Pulmonology

Question 1

What is Bronchiectasis?

Answer 1

The irreversible and abnormal dilatation of the bronchi

Question 2

What is the pathophysiology of Bronchiectasis?

Answer 2

Cycles of bronchial inflammation/infection and inadequate clearance of secretions/airway obstruction/impaired host immune defenses

Question 3

What causes Bronchiectasis?

Answer 3

Congenital
Acquired (children)
Acquired (adults)

Review notes

Question 4

What are common causative pathogens associated with bronchiectasis?

Answer 4

Pseudomonas aeruginosa, S. aures, H influenze, TB

Question 5

How does Bronchiectasis present? What are the examination findings

Answer 5

1. Chronic cough with copious purulent sputum
2. Haemoptysis
3. Dyspnea
4. Non-specific (wt loss, anorexia, malaise)
5. Pleuritic chest pain

O/E: clubbing, coarse inspiratory crepitations/ crackles, wheeze

Question 6

How is Bronchiectasis investigated?

Answer 6

1. CBC
2. CXR: tram track lines
3. HRCT (most sensitive): tram-track lines, signet ring
4. Sputum cultures
5. Serum Ig levels
6. Sweat chloride test
7. Spirometry
8. Bronchoscopy

Question 7

How is a patient with Bronchiectasis managed?

Answer 7

Conservative: Physiotherapy

Medical Mx: Abx, Inhaled bronchodilators & Steroids, Vaccinations (Influenza, Pneumococcal)

Surgical Mx: Excision of affected areas if confined to a single lobe or segment on CT

Question 8

What is the FEV1 (Forced Expiratory Volume in 1 second)?

Answer 8

This is the maximum volume of air that can be forcefully expired within 1 second after maximal inspiration. It is normally >/= 80%

Question 9

What is the Forced Vital Capacity?

Answer 9

The maximum volume of air that can be forcefully expired after maximal inspiration

Question 10

What is the FEV1//FVC?

Answer 10

Ratio of FEV1 to FVC expressed as a percentage. This is normally 75-80%

Question 11

What is Obstructive Lung Disease?

Answer 11

A lung disordet that results in increased resistance to airflow due to narrowing of airways

Question 12

What is restrictive lung disease?

Answer 12

Impaired ability of the lungs to expand due to reduced lung compliance

Question 13

Define COPD

Answer 13

COPD is a common, progressive, non-reversible disorder characterized by airway obstruction

N.B Spirometry needed for diagnosis

Question 14

What are the risk factors for COPD?

Answer 14

1 factor is Smoking!!!

Environmental: Air pollution, occupational exposure (silica, cadmium), Exposure to biomass fuel for cooking

Demographic factors: Age, FH, Male sex, H/o childhood respiratory infections, Low SES

Others: Alpha 1 antitrypsin deficiency, airway hyperactivity

Question 15

Define Chronic Bronchitis

Answer 15

(Defined clinically:) Productive cough on most days for at least 3 consecutive months in each of 2 consecutive years

Obstruction is due to narrowing of the airway lumen by thickening of the mucosa and excess mucus production

Question 16

Define Emphysema

Answer 16

(Defined pathologically):
Enlarged air spaces distal to the terminal bronchioles with destruction of the alveolar walls; no obvious fibrosis

Decreased elastic recoil of lung parenchyma causes decreased expiratory driving pressure, airway collapse & air trapping

Question 17

What are the types of Emphysema?

Answer 17

Centriacinar: typical form seen in smokers. primarily affects upper lung zones

Panacinar: acounts for 1% of emphysema cases. Alpha 1 antitrypsin deficiency. Primarily lower lobes

Question 18

What is a “pink puffer”?

Answer 18

A thin patient
Predominant emphysema
C/o severe dyspnea (use of accessory muscles of respiration esp on exertion)
Pursed lip breathing
Cough is rare. Oedema and polycythemia absent

Question 19

What are examination findings of “pink puffers”?

Answer 19

Hyperinflated chest
Hyperresonant PN
Prolonged expiration
Decr BS

Question 20

What are laboratory features of “pink puffers”?

Answer 20

Decr FEV1
Decr FEV1/FVC

Incr TLC (hyperinflation)
Incr RV (gas trapping)

Question 21

What is noted on CXR for “pink puffers”?

Answer 21

Hyperinflation, flattened diaphragms, diminshed vascular markings, decr heart shadow

Question 22

What is a “blue bloater”?

Answer 22

Patient with predominantly chronic bronchitis

Cyanotic but not breathless

Question 23

What are the examination features of a “blue bloater”?

Answer 23

Cyanosis (due to hypoxemia and hypercapnea)
Polycythemia
Peripheral Oedema from RVF (cor pulmonale)
Prolonged expiration
Coarse creps, wheeze

Question 24

What is noted on CXR for “blue bloaters”?

Answer 24

Increased vascular markings

Enlarged heart with cor pulmonale

Question 25

What is cor pulmonale?

Answer 25

Right sided heart failure due to a pulmonary process

Question 26

What are the physical examination findings of cor pulmonale?

Answer 26

``` Increased P2 Tricuspid Regurg Murmur Jugular Venous distention with a large V wave Hepatomegaly Ascites Oedema ```

Question 27

What is a bulla?

Answer 27

A sharply demarcated area of emphysema measuring >/= 1cm in diameter and possessing a wall <1mm thick

Question 28

What investigations should be carried out for COPD?

Answer 28

Blood CBC: anemia, polycythemia Alpha 1-antitrypsinase Imaging: CXR (hyperinflation; R/o Lung ca, CCF) HRCT (high specificity for diagnosing emphysema as bullae can be outlined) Spirometry: Permanent Obstructive pattern (post-bronchodilator FEV1/FVC <70%) ECG: RAH, RVH (cor pulmonale

Question 29

Differentials for COPD include:

Answer 29

Chronic Asthma TB Bronchiectasis CCF

Question 30

What are the complications of COPD?

Answer 30

``` Polycythemia due to hypoxia Pulmonary HTN from vasoconstriction Pulmonale (cor pulmonale) Pneumothorax due to ruptured emphysematous bullae Chronic Hypoxemia ```

Question 31

What is the GOLD staging system?

Answer 31

System to indicate the severity of COPD in relation to post bronchodilator FEV1 Stage I (mild) Stage II (moderate) Stage III (severe) Stage IV (very severe

Question 32

What is the GOLD staging system?

Answer 32

System to indicate the severity of COPD in relation to post bronchodilator FEV1 Stage I (mild): FEV1 >/= 80% of predicted Stage II (moderate): FEV1 50-79% of predicted Stage III (severe): FEV1 30-49% of predicted Stage IV (very severe): FEV1 <30% of predicted or FEV1 <50% predicted if respiratory failure present

Question 33

What is the GOLD staging system?

Answer 33

System to indicate the severity of COPD in relation to post bronchodilator FEV1 Stage I (mild): FEV1 >/= 80% of predicted Stage II (moderate): FEV1 50-79% of predicted Stage III (severe): FEV1 30-49% of predicted Stage IV (very severe): FEV1 <30% of predicted or FEV1 <50% predicted if chronic respiratory failure present

Question 34

How is COPD managed?

Answer 34

A. Prolong Survival 1. Smoking Cessation 2. Vaccination: Influenza, Pneumococcal 3. Home Oxygen (LTOT) B. Symptomatic Relief 1. Bronchodilators (Mild: SABA, anti-cholinergics; Mod-Severe: LABA, anticholinergics) 2. Corticosteroids 3. Surgical (LVRS--resection of emphysematous parts of lung, or lung transplant) 4. Patient education, eliminate respiratory allergens/irritants, exercise rehabilitation to improve physical endurance, Diet

Question 35

What is the Criteria for Long Term Oxygen Therapy in patients with COPD? How should LTOT be administered?

Answer 35

ABG measured in clinically stable patients (non-smoker) on optimal medical therapy on at least 2 occasions 3 weeks a part: 1. PaO2 <55mmHg on room air 2. PaO2 <60mmHg with polycythemia or pulmonary oedema/HTN May also be given to terminally ill patients. It should be administered for at least 15h/day at 2-4Lto achieve a PaO2 of at least 60mmHg

Question 36

What mechanisms can be employed to help patients with smoking cessation?

Answer 36

1. Nicotine replacement 2. Bupropion 3. Varenicline (oral selective nicotine receptor partial agonist)

Question 37

What is an acute exacerbation of COPD?

Answer 37

This is sustained worsening (>24-48h) of symptoms and deterioration of lung fxn. Usually triggered by a viral/bacterial URTI, air pollution

Question 38

Mx of Acute Exaerbation of COPD?

Answer 38

1. ABCs (start with 24-28% Oxygen) 2. SaO2 target of 88-92% 3. Bronchodilators 4. Systemic corticosteroids 5. Abx if evidence of bacterial infection 6. Physiotherapy

Question 39

What is the BODE index?

Answer 39

This is a prognostic index for risk of death in COPD: BMI<21 Obstruction (FEV1) Dyspnea (MRC scale) Exercise capacity

Question 40

What are the extrapulmonary features of COPD?

Answer 40

1. Increased circulatory inflammatory markers 2. Muscular weakness 3. Wt loss due to altered fat metabolism 4. Impaired salt and water excretion--> peripheral oedema 5. Increased prevalence of osteoporosis