Lungs: Restrictive Intrinsic Conditions - Pulmonary Fibrosis, Sarcoidosis, Asbestosis, Pneumonia

Question 1

IPF

-presentation

Answer 1

45+
Persistent SOB on exertion, dry cough
Bilateral inspiratory crackles
Clubbing
Restrictive spirometry

Question 2

IPF

-triggers and exposures

Answer 2

Idiopathic

Drug induced

• chemo
• methotrexate
• amiodarone
• nitrofurantoin

Environmental

• asbestos, orgnaic dust
• hay, straw, grain
• bird poo

AI
-RA, SLE, Sjogrens, scleroderma, dermatomyositis, polymyositis

Question 3

IPF

-investigations

Answer 3

Clinical diagnosis with the support of lung function tests and imaging
LFTs - spirometry, gas transfer => restrictive intrinsic lung problem
Scans
-CXR => interstitial lung markings
-CT => reticular honeycombing, traction bronchiectasis

Procedures done if still unsure - broncheolar lavage, lung biopsy

Question 4

IPF management

• conservative
• medical
• surgical

Answer 4

MAINLY SUPPORTIVE

• Pulmonary rehabilitation
• Oxygen therapy
• Smoking cessation

Nintedanib
Pirfenidone

Lung transplantation/palliative care

Question 5

Upper lung fibrosis causes

Lower lung fibrosis causes

Answer 5

Upper

• Coal worker
• Histiocytosis/hypersensitivity pneumonitis
• AS
• Radiation
• TB
• Silicosis (rocks, soil)/sarcoidosis

Lower

• IPF
• Most connective tissue AI cond MINUS AS
• Drugs - amiodarone, bleomycin (chemo), methotrexate
• Asbestosis

Question 6

What is sarcoidosis

• epidemiology
• etiology
• pathophysiology

Answer 6

Women
Young adults

Mix of genetic and environmental

AI => non caseating granulomas on lungs and skin
Can be acute or chronic

Question 7

Sarcoidosis

-acute presentation

Answer 7

Loefgren syndrome - acute, mild, self limiting
Bilateral hilar lymphadenopathy
Erythema nodosum
Arthritis

SOB, persistent dry cough
Tender swollen LN

Question 8

Sarcoidosis

-investigations, diagnosis

Answer 8

Clinical diagnosis of exclusion

• Restrictive spirometry
• High Ca, ACE, CRP
• CXR - bilar hilar lymphadenopathy
• Lung biopsy - non caseating granulomas

Question 9

Sarcoidosis

-management

Answer 9

Acute episodes can be self limiting
NSAIDs/CS depending on severity
-may also use methotrexate, azathiopurine, HCQ = LFTs needed to assess impacts

If end stage lung disease - lung transplants considered

Question 10

What 4 lung problems can asbestos exposure cause

• presentation
• management

Answer 10

Pleural plaques - benign (20-40 years latent)

Asbestosis - severity linked to length of exposure

• lower lung fibrosis => SOB, low exerecise tolerance
• conservatively managed

Mesothelioma - limited exposure can cause disease

• SOB, chest pain, pleural effusions
• v aggressive => palliative chemo

Lung cancer

Question 11

Pneumonia

-epidemiology and etiology

Answer 11

Young children/elderly
IC

Droplet inhalation
Haematogenous

Question 12

Pneumonia

-presentation

Answer 12

Dyspnoea
Purulent/clear sputum
Cough
Fever

High RR,
Hypotension, pyrexia (systemic inflammation)
Crackles, increased VR (exudate and consolidation)
Central cyanosis/confusion (hypoxemia)

Question 13

Pneumonia

-investigations, diagnosis

Answer 13

DEFINITIVE - CXR
IDENTIFY ORGANISM
-Blood, sputum culture
-Viral PCR
-Atypical serology 
-Urine AG (legionella, pneumococcal)

ABG - PO2
FBC
U&E, LFT, CRP

Question 14

CURB65

-interpretation of results

Answer 14

Confusion AMTS<8
Urea >7
RR >30
BP systolic<90 diastolic<60
65 

0-1 home
2 admission considered
3-5 urgent admission, maybe ITU

Question 15

Pneumonia

-management

Answer 15

Empirical broad spec ABx in 4hrs

0-amox
1-2-amox+clarithromycin
3-5-coamox+clarythromycin

Question 16

Most common causative organism for pneumonia

• presentation
• management

Answer 16

S pneumonia - amox

• acute, high fever
• pleuritic pain, cold sores

Question 17

2nd most common causative organism for pneumonia
-management

Causative organism of pneumonia post influenza
-management

Causative organism of pneumonia in alcoholics
-presentation

Answer 17

Viral - management depends on virus

S aureus - fluclox

Klebsiella pneumonia - red currant sputum

Question 18

What are some causes of atypical pneumonias

How are they different from other pneumonias

Answer 18

Slow onset, flulike
Dry cough, fatigue, substernal chest pain
Often no physical exam findings => CXR looks worse than patient
Extrapulmonary features

Mycoplasma pneumonia - culture, serology

• younger people
• neuro and systemic symptoms (rashes)

Chlamydophila pneumonia - culture and serology
-Mild symptoms

Legionella - urine AG
-Severe pneumonia with a high mortality

CAN ALL BE MANAGED WITH ERYTHROMYCIN

Question 19

Common causes of aspiration pneumonia

• location
• bacteria involved

Answer 19

Foreign materials entering bronchial tree

• poor dentition
• dysphagia
• prolonged hospitalisation, surgery
• unconscious

S pneumonia, aureus, H influenza, P aeruginosa, sterile (pneumonitis)

Question 20

Fungal causes of pnuemonia

• epidemiology
• presentation
• causative organism, management

Answer 20

HIV, IC

• SOB
• dry cough
• fever
• v few chest signs

Aspergillus - amphotericin
PCP (HIV) - cotrimoxazole + CS

Question 21

Complications of pneumonia

Answer 21

Sepsis
ARDS
Parapneumonic effusion, empyema
Cavitations
MI

Question 22

Follow up 6wks after pneumonia

Prevention of pneumonia

Answer 22

CXR if

• smoker
• 50+
• symptomatic to check for lung cancer

Pneumonia, flu vaccine