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1
Q

Signs of pulmonary fibrosis (6)

A

Clubbing
Central cyanosis
Tachypnoea
Fine end inspiratory crackles
Signs of autoimmune disease - RA, SLE, systemic sclerosis
Signs of treatment - cushingoid
Discoloured skin - amiodarone

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2
Q

Investigations for pulmonary fibrosis - bloods (3)

A

ESR
Rheumatoid factor
ANA

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3
Q

What will you see on CXR in pulmonary fibrosis? (3)

A

Reticulonodular changes
Loss of definition of heart border
Small lungs

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4
Q

Results of lung function tests in pulmonary fibrosis (3)

A

FEV1/FVC >0.8 (restrictive)
Low TLC
Reduced TLco and Kco

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5
Q

What investigations would you do for pulmonary fibrosis? (7)

A

Bloods: FBC, CRP, ESR, RhF, ANA
CXR
ABG
Lung function tests
Bronchoalveolar lavage
HRCT
Lung biopsy

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6
Q

Findings on HRCT in pulmonary fibrosis (3)

A

Bibasal subpleural honeycoming - UIP
Widespread groundglass - NSIP (autoimmune association)
Apical - sarcoidosis, ABPA, old TB, hypersensitivity pneumonitis, langerhans cell histiocytosis

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7
Q

Which diseases cause apical fibrosis ? (8)

A

Sarcoidosis
Radiation
ABPA
Ankylosing spondylitis
Old TB
Hypersensitivity pneumonitis
Histoplasmosis - fungal infection
Langerhans cell histiocytosis

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8
Q

What are treatment options for pulmonary fibrosis? (4)

A

Immunosuppression eg NSIP
Pirfenidone - UIP when FEV1 50-80%
NAC
Single lung transplant

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9
Q

Prognosis of pulmonary fibrosis - Highly cellular with ground glass infiltrate with response to immunosuppression

A

80% 5 year survival

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10
Q

Prognosis of pulmonary fibrosis - honeycombing on CT, no response to immunosuppression

A

80% 5 year mortality

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11
Q

What are causes of basal pulmonary fibrosis? (4)

A

UIP
Asbestosis
Connective tissue disease
Aspiration

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12
Q

Signs of bronchiectasis (8)

A

Cachexia
Tachypnoea
Clubbing
Mixed character crackles that alter with coughing
Occasional squeaks and wheeze
Sputum +++
Cor pulmonale - leg swelling, raised JVP, RV heave, loud P2
Yellow nail syndrome

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13
Q

Investigations for bronchiectasis (8)

A

Sputum culture and cytology
CXR - tramlines, ring shadows
HRCT - signet ring sign (thickened dilated bronchi larger than adjacent vascular bundle)
Immunoglobulins - hypogammaglobulinaemia
Aspergillus RAST or skin prick
Rheumatoid serology
Saccharine ciliary motility test - kartageners
Genetic screening - cystic fibrosis

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14
Q

Causes of bronchiectasis - congenital (2)

A

Kartageners
Cystic fibrosis

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15
Q

Causes of bronchiectasis - childhood infection (2)

A

Measles
TB

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16
Q

Causes of bronchiectasis - immune (2 over active, 2 under active)

A

ABPA
IBD associated
Hypogammaglobulinaemia
CVID

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17
Q

Causes of bronchiectasis (5)

A

Congenital - kartageners/CF
Childhood infection - measles/TB
Immune over activity - ABPA/ IBD
Immune under activity - hypogammaglobulinaemia/CVID
Aspiration - alcoholics, GORD, stroke

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18
Q

Treatment for bronchiectasis (5)

A

Chest physio
Abx for exacerbations
Low dose azithromycin 3 times per week long term
Bronchodilators/ICS if airflow obstruction
Surgery for localised disease

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19
Q

Complications of bronchiectasis (4)

A

Recurrent infections
Cor pulmonale
Secondary amyloidosis
Massive haemoptysis

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20
Q

Signs of old TB (6)

A

Chest deformity / absent ribs
Thoracoplasty scar
Tracheal deviation towards fibrosis
Reduced expansion
Dull percussion but present tactile vocal fremitus
Crackles and bronchial breathing

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21
Q

Historical treatment for TB (6)

A

Plombage - polystyrene balls
Phrenic nerve crush
Thoracoplasty - rib removal, lung not resected
Apical lobectomy
Recurrent medical pneumothoraces
Streptomycin

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22
Q

Side effects of TB drugs (4)

A

Isoniazid - peripheral neuropathy and hepatitis
Rifampicin - hepatitis and increased contraceptive pill metabolism
Ethambutol - retro bulbar neuritis and hepatitis
Pyrazinamide - hepatitis

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23
Q

What to council TB patients before starting treatment regarding side effects (5)

A

If jaundice - stop tablets and call nurse
If red becomes less bright - call nurse
If tingling in toes - tell dr at next visit
Secretions will turn orange / red - don’t wear contacts
If on OCP - use barrier contraception

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24
Q

Signs of lobectomy (5)

A

Reduced expansion and chest wall deformity
Thoracotomy scar
Central trachea
If lower lobectomy - dull percussion note lower zone, absent breath sounds
If upper lobectomy - normal or hyper-resonant percussion upper zone, dull percussion at base - elevated diaphragm

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25
Signs of pneumonectomy (7)
Thoracotomy scar Reduced expansion on side of op Trachea deviated to side of op Dull percussion note through hemi thorax Absent tactile vocal fremitus beneath scar Bronchial breathing in upper zone Reduced breath sounds in rest of hemi thorax
26
Signs of single lung transplant (3)
Thoracotomy scar Normal exam on side of scar Clinical signs on opposite side
27
Indications for single lung transplant (2)
COPD Pulmonary fibrosis (“Dry” lung conditions)
28
Signs of double lung transplant (1)
Clamshell incision
29
Indications for double lung transplant (3)
CF Bronchiectasis Pulmonary HTN (“Wet” lung conditions)
30
Signs of COPD on inspection (4)
Nebuliser or inhalers at bedside Sputum pot Dyspnoea Pursed lips
31
Signs of COPD in hands (3)
CO2 retention flap Bounding pulse Tar stained fingers
32
Chest signs in COPD (4)
Hyper expanded lungs Percussion note resonant Expiratory polyphonic wheeze Reduced breath sounds at apices
33
Signs of cor pulmonale (5)
Raised JVP Ankle oedema RV heave Loud P2 Pansystolic murmur of TR
34
Causes of clubbing - chest (7)
Bronchial carcinoma Bronchiectasis Cystic fibrosis Lung abscess /empyema Mesothelioma Idiopathic pulmonary fibrosis TB
35
Causes of COPD (3)
Smoking Industrial dust exposure (apical) Alpha 1 anti trypsin (basal)
36
Spirometry result in COPD
Low FEV1 FEV1/FVC ratio <0.7 obstructive Gas transfer low T CO
37
GOLD classification of COPD
GOLD 1 - mild: FEV1 ≥80% predicted GOLD 2 - moderate: 50% ≤ FEV1 <80% predicted GOLD 3 - severe: 30% ≤ FEV1 <50% predicted GOLD 4 - very severe: FEV1 <30% predicted
38
Treatment of COPD (9)
Smoking cessation / NRT Mild - Beta agonists Moderate - Tiotropium and beta agonist Severe - Moderate plus ICS if no pneumonia Pulmonary rehab Nutrition Vaccinations - pneumococcal and influenza LTOT Surgical - bullectomy, endobronchial valve replacement, lung reduction surgery, single lung transplant
39
LTOT inclusion criteria (4)
Non smoker PaO2 <7.3 on air PaCO2 does not rise excessively on O2 PaO2 <8 if cor pulmonale
40
COPD exacerbation prognosis
15% in hospital mortality
41
Wheezy chest differential (4)
COPD/asthma Granulomatous polyarteritis Rheumatoid arthritis (obliterative bronchiolitis) Post transplant - chronic rejection
42
Signs of pleural effusion (6)
Asymmetrically reduced expansion Trachea or mediastinum displaced away from side of effusion Stony dull percussion note Absent tactile vocal fremitus Reduced breath sounds Bronchial breathing above
43
Signs to indicate cause of pleural effusion - cancer (3)
Clubbing Lymphadenopathy Mastectomy - breast cancer
44
Signs that indicate cause of pleural effusion - heart failure (2)
Raised JVP Peripheral oedema
45
Signs that indicate cause of pleural effusion - chronic liver disease (3)
Leuconychia Spider naevi Gynaecomastia
46
Signs that indicate cause of pleural effusion - renal failure (1)
AV fistula
47
Causes of chronic pleural effusion (5)
Cancer Congestive heart failure Chronic liver disease Chronic renal failure Connective tissue disease
48
Signs of cause of pleural effusion - connective tissue disease (2)
RA hands Butterfly rash of SLE
49
Causes of a dull lung base (6)
Effusion Consolidation - bronchial breathing and crackles Collapse - tracheal deviation, reduced breath sounds Lobectomy - reduced lung volume Pleural thickening - similar to pleural effusion but normal tactile vocal fremitus, scars from VATs pleuradesis Raised hemidiaphragm - hepatomegaly
50
Causes of a transudative pleural effusion (3)
CCF Renal failure Liver failure
51
Causes of exudative pleural effusion (4)
Neoplasm Infection Infarction Inflammation - RA/SLE
52
What pleural effusion aspirate findings suggest exudate? (4)
Protein: >35g/L or lights criteria Pleural fluid albumin/plasma albumin >0.5 LDH: effusion LDH/plasma LDH >0.6 Or >2/3 normal value
53
What pleural effusion aspirate findings are suggestive of empyema? (3)
Exudate Low glucose pH <7.2
54
What is an empyema?
Collection of pus in pleural space Most frequently anaerobes, staph and gram negatives Associated with bronchial obstruction - carcinoma, recurrent aspiration, poor dentition, alcohol dependence
55
What is the treatment for empyema? (4)
Pleural drainage IV abx Intrapleural DNAse plus TPA Surgical decortication
56
Clinical signs of lung cancer (11)
Cachexia Clubbing Tar staining Lymphadenopathy Tracheal deviation - if collapse or effusion Reduced expansion Dull percussion - if collapse or effusion Absent tactile vocal fremitus - if effusion or increased resonance if consolidation Auscultation - crackles or reduced breath sounds Hepatomegaly if mets Bony tenderness if mets
57
What signs of lung cancer treatment might you find? (3)
Lobectomy scar Radiotherapy burn Radiotherapy tattoo
58
What are complications of lung cancer? (9)
SVCO Recurrent laryngeal nerve palsy Horners sign Wasted small muscles of hands Gynaecomastia Lambert Eaton myasthenia Dermatomyositis SIADH Hypercalcaemia
59
What are the different types of lung cancer and how common? (5)
Squamous 35% Small (oat) 24% Adeno 21% Large 19% Alveolar 1%
60
How do you diagnose lung cancer? (7)
CXR: collapse, mass, hilar lymphadenopathy CT thorax Induced sputum cytology Biopsy by bronchoscopy if central Percutaneous CT guided needle if peripheral lesion and FEV1 >1L Staging CT/EBUS/thoracoscopy/PET Lung function tests for operability assessment
61
What is important for staging of different lung cancers?
Non small cell - TNM staging to assess operability Small cell - assess limited or extensive disease
62
What is ideal FEV1 value for lobectomy and pneumonectomy?
Lobectomy FEV1 >1.5L Pneumonectomy >2L
63
What might bloods show in lung cancer that show complications? (6)
Deranged LFTs - mets Hypercalcaemia - mets or non small cell Low Hb - mets Raised PTHrP - non small cell Raised ACTH - small cell SIADH - small cell
64
What are treatment options for lung cancer - non small cell? (4)
Surgery - lobectomy or pneumonectomy Radiotherapy Chemo - eGFR positive - erlotinib MDT approach
65
What are treatment options for small cell lung cancer? (2)
Chemo MDT approach
66
What are palliative treatment options for lung cancer and its complications ? (5)
Dex and radiotherapy for brain mets or SVCO Stent for SVCO Radiotherapy for haemoptysis, bone pain, cough Chemical pleurodesis for effusion Opiates for pain, cough
67
What are signs of CF? (8)
Small stature Clubbed Tachypnoea Sputum pot with purulent sputum Hyperinflated chest with reduced expansion Coarse crackles and wheeze Portacath or Hickman lines/scars PEG
68
What are the genetics of CF?
1/2500 live births Autosomal recessive Chromosome 7q CFTR gene Chloride channel Delta 508 deletion most common
69
What is the pathophysiology of CF and which organs does it affect?
Secretions thickened and block lumens of various structures: Bronchioles - bronchiectasis Pancreatic ducts - loss of endo and exocrine function Gut - distal intestinal obstruction syndrome in adults Seminal vesicles - male infertility Fallopian tubes - reduced female fertility
70
What are investigations for CF? (3)
Screened at birth- heel prick - low immunoreactive trypsin Sweat test - Na >60 Genetic screening
71
What can cause a false positive sweat test for CF?
Hypothyroidism Addisons
72
What are treatments for CF? (9)
Physiotherapy - postural drainage and active cycle breathing Abx for infections Pancrease Fat soluble vitamin supplements Mucolytics- nebulised DNAse Immunisations Double lung transplant Gene therapy under development Kaftrio for certain mutations
73
What is the prognosis in CF?
Median survival 35 years but rising If double lung transplant - 50% survival at 5 years Poor prognosis if burkholderia cepacia infection
74
What are signs of pneumonia? (8)
Tachypnoea Oxygen requirement Sputum pot with purulent or rusty sputum Reduced expansion Dull percussion note Focal coarse crackles Increased vocal resonance Temperatures
75
What investigations would you do for pneumonia? (6)
CXR: consolidation with air bronchogram, effusion Bloods: raised WCC, CRP, urea, atypical serology, immunoglobulins Blood cultures Sputum culture Atypical serology in urine - legionella, pneumococcal antigens Haemoglobulinuria
76
Which pneumonia causes cold agglutinins leading to haemolysis?
Mycoplasma
77
What are most common organisms causing CAP? (4)
Strep pneumoniae 50% Mycoplasma pneumoniae 6% Haemophilus influenzae - COPD Chlamydia pneumoniae
78
What are first line abx for pneumonia? (2)
Penicillin or cephalosporin + Macrolide
79
What bugs might immunosuppressed people be at risk of causing pneumonia and what are treatments? (4)
Fungal - amphotericin Multi resistant mycobacteria Pneumocystis carinii- co-trimox or pentamidine CMV - ganciclovir
80
What bug commonly causes pneumonia post influenza and what is treatment?
Staph aureus - flucloxacillin
81
What are complications of pneumonia? (4)
Lung abscess - Staph aureus, klebsiella, anaerobes Para pneumonic effusion or empyema Haemoptysis Septic shock and organ failure
82
What are risk factors for asthma? (10)
Atopy FH of asthma or atopy Inner city environment Socio-economic deprivation Obesity Prematurity and low birth weight Viral infections in early childhood Smoking Maternal smoking Early exposure to broad-spectrum antibiotics
83
What are investigations for asthma? (6)
Peak flow diary Spirometry with reversibility testing FeNO - elevated levels suggest inflammation CXR to exclude other causes if atypical FBC for eosinophilia Allergen testing IgE
84
What are steps for managing asthma? (9)
Identify and remove triggers, remember occupational SABA only if intermittent and mild Add ICS if frequent symptoms Add montelukast +/- LABA Increase steroid dose Change to MART Add LABA if not before +/- SR theophylline Oral steroids Omalizumab if IgE mediated poorly controlled
85
What is the most likely underlying pathology of a pancoasts tumour?
Squamous cell carcinoma
86
What are respiratory indications for VATS? (5)
Lobectomy/Wedge resection/segmentectomy Bullectomy / volume reduction Recurrent pneumothorax pleurodesis Decortication/pleurectomy Biopsy
87
What are BTS guidelines for pneumothorax?
If patient is symptomatic, do they have high risk characteristics? If yes, then drain If no and pneumothorax large enough (>2cm), patient can choose conservative, ambulatory device or therapeutic aspiration If aspiration does not resolve it, then drain
88
What are indications for pleurodesis? (3)
Malignant pleural effusion Recurrent or persistent pneumothorax Recurrent pleural effusion
89
What are causes of airflow obstruction ? (4)
Asthma COPD Bronchiectasis Obliterative bronchiolitis: viral, pollutants, graft vs host
90
What defines reversible airflow obstruction?
FEV1 200ml or 15% change in response to bronchodilation
91
Who can have anti fibrotics in IPF?
FVC 50-80% predicted
92
Which bacteria confers poor prognosis in cystic fibrosis?
Burkholderia cepacia Rapid decline in lung function, contraindication to transplant
93
What is the most common cause of chronic lung transplant rejection?
Bronchiolitis obliterans
94
What are contraindications to lung transplant? (10)
History of malignancy in last 5 years Untreatable significant other organ dysfunction Uncorrected atherosclerotic disease Acute illness Chronic infection with resistant organisms Chest wall or spinal deformity BMI >35 Non adherence to therapies Poor functional status Substance abuse: alcohol, smoking
95
Which condition carries worst prognosis for lung transplant?
ILD
96
What are signs of hyper inflation on examination? (7)
Prolonged expiration Tracheal tug Cricosternal distance less than 3 finger widths Indrawing of inter and subcostal spaces Reduced expansion Quiet breath sounds Hyper resonance to percussion
97
What respiratory involvement can occur in rheumatoid arthritis? (8)
ILD - UIP or NSIP Treatment related ILD Pulmonary nodules Pleural effusion Pleuritis Obliterative bronchiolitis Infections related to immunosuppression Raised hemidiaphragm
98
What does groundglass appearance on CT suggest?
Inflammation - likely to respond to steroids/immunosuppressants
99
What does honeycomb appearance on CT mean?
Fibrosis Not ammenable to steroids /immunosuppressants

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