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1
Q

What are common indications for a VATS procedure?

A

Wedge resection (segmentectomy)
Decortication (RA, chronic infection, mesothelioma)
Bullectomy
Lobectomy
Recurrent PTX

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2
Q

What are the benefits of VATS?

A

Smaller incision
Reduced pain
Reduced wound complications
Redued length of stay

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3
Q

What are the possible indications for a lobectomy?

A

Lung cancer
Aspergilloma
TB
Lung abscess

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4
Q

Ix for Lung cancer?

A

Staging CT TAP
Tissue diagnosis
Functional imaging (PET CT)
Working up patient for surgery

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5
Q

How would you assess fitness for surgery?

A

Full lung function tests including transfer factor assessment
Cardiopulmonary excercise testing

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6
Q

What FEV1 would you want the patient to have if they were having a lobectomy/pneumonectomy?

A

Lobectomy = 1.5L
Pneumonectomy = 2L

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7
Q

What is the VO2 max threshold that offers a good post-op outcome?

A

VO2 Max 15ml/kg/min

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8
Q

What are the histological subtypes of lung cancer?

A

SC (20%)
NSCLC - adenocarcinoma, squamous, large cell, neuroendocrine tumours

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9
Q

What are the treatment options for lung cancer?

A

SC - chemoradiotherapy, palliative chemotherapy
NSCLC - curative surgical treamtent, adjuvant chemoradiotherapy

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10
Q

What are the clinical signs differences between a pneumonectomy and lobectomy?

A

Lobectomy
Trachea may not be deviated
Normal/reduced breath sounds
Percussion note normal

Pneumonectomy
Trachea always deviated
towards
Absent breath sounds
Dull percussion note

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11
Q

What are respiratory causes of clubbing?

A
  1. ILD
  2. Chronic suppurative lung disease (CF, abscess, bronchiectasis)
  3. Lung cancer
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12
Q

What are the indications for surgical management of pneumothorax?

A
  1. Persistent air leak
  2. Inadequate lung expansion
  3. Recurrent pneumothorax
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13
Q

What is the management of a pneumothorax?

A

Primary
<2cm and asymptomatic - discharge and repeat CXR
>2cm or symtomatic - aspiration. If aspiration fails, chest drain

Secondary
Chest drain if: >50y, >2cm, SOB
If 1-2cm aspirate followed by chest drain if not resolved.
If <1cm = oxygen and admit for 24 hours

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14
Q

What improvement would you expect when performing peak flow following bronchodilator therapy in asthma?

A

Improvement in 200ml on peak flow, or an improvement by 15%

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15
Q

How do you treat asthma?

A
  1. Step wise approach
  2. SABA
  3. SABA + ICS
  4. SABA + ICS + LTRA
  5. SABA + ICS + LTRA + LABA
  6. Switch ICS/LABA For MART that includes a low dose ICS
  7. Consider introducing theophylline / LAMA
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16
Q

How do you treat COPD?

A
  1. SABA or SAMA
  2. If asthmatic features: LABA + ICS. If no asthmatic features: LABA + LAMA
  3. LAMA + LABA + ICS (Trimbow)
  4. Consider theophylline
  5. Consider carbocisteine
  6. Consider PDE4 inhibitors (roflumilast)
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17
Q

What causes upper lobe fibrosis?

A

Coal pneumoconiosis
Hypersensitivity pneumonitis
Ank spond
ABPA
Radiation
TB
Silicosis
Sarcoidosis

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18
Q

What causes lower zone fibrosis

A

MTX and other drugs
Asbestos
IDiopathic Pulmonary Fibrosis!!!!
Scleroderma and other connective tissue diseases

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19
Q

Differential for bibasal crepitations?

A

Bronchiectasis (coarse and clear with coughing)
Bilateral pneumonias
Congestive heart failure (elevated JVP)
Fibrosis (fine)

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20
Q

How do you investigate fibrosis?

A
  1. Bloods: ESR, RF, ANA
  2. CXR
  3. ABG
  4. Lung function tests (restrictive picture)
  5. Bronchoalveolar lavage (excludes infection, and Ly/Neu ratio
  6. HRCT
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21
Q

HRCT findings

A

Widespread: NSIP - autoimmune > steroids
Bi-basal subpleural honeycombing: UIP > pirfenidone
Apical: Sarcoid, ABPA, TB, Langerhann’s

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22
Q

What are the CT findings of IPF?

A

Groundglass changes = alveolitis
Honeycombing = fibrosis

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23
Q

What are the spirometry findings of fibrosis?

A
  1. Reduced FEV1
  2. Reduced FVC
  3. Preserved/high FEV1/FVC ratio
  4. Reduced TLC
  5. Reduced transfer factor
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24
Q

Rx for ILD?

A
  1. MDT
  2. Treat underlying connective tissue disorder
  3. If groundglass = steroids
  4. IPF: anti-fibrotic agent pirfenidone/ninetanib
  5. Transplant
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25
CTDs that cause ILD?
RA, SS, SLE, Dermatomyositis
26
What are the idiopathic causes for ILD?
Sarcoidosis IPF Bronchioloitis Obliterans NSIP (most connective tissue diseases) - reversible groundglass inflammation (steroid responsive) Usual interstitial pneumonitis (RA) - end stage pulmonary fibrosis and more difficult to treat. Similar pattern to IPF, and ongoing trials looking at anti-fibrotics
27
Broadly speaking, how can we categorise interstitial lung disease?
1. Idiopathic 2. Connective tissue disease 3. Occupational 4. Drug exposure
28
What specific treatments are available for NSIP?
1. Immunosuppression (steroids, Aza, MMF)
29
What is the life expectancy of ILD?
2-5 years, rate is variable
30
What is the gene affected in CF?
1. AR 2. CFTR gene mutation Chr 7 = defective CFTR protein. Commonest delta F508 (PH508del) 3. Increased salt excretion 4. Thicker mucus affecting respiratory, digestive, reproductive systems
31
Complications of CF?
1. Multi-system disease 2. Bronchiectasis 3. Pancreatic insufficiency 4. Infertility 5. Liver failure, gallstones, kidney stones
32
How do you manage CF?
1. MDT 2. Regular physiotherapy positional drainage/enhanced breathing techniques 3. Nebulised mucolytics (DNAse) 4. Nebulised prophylactic abx (tobramycin for pseudomonas) 5. Azithromycin 6. Pancreatic enzyme replacement 7. Nutritional supplementation if unable to meet caloric needs (may have PEG) 8. CFTR receptor modulators (ivacaftor)
33
Microbiology of CF lung disease?
1. Different patients have different microbiomes 2. Pseudomonas Aeriginosa 3. Berkholderia and mycobacterium absceses is an absolute contra-indication in transplant and carries a poor prognosis
34
Resp comps of CF
ABPA PTX Haemoptysis (may be massive or chronic) Hypoxia Sinus disease and nasal polyps Chronic infection - pseudomonas or Burkholderia cenecipacia or mycobacaterium
35
What are the pre-requisites for lung transplant?
1. >50% risk of death within 2 years if transplant not performed 2. >80% likelihood of surviving 90 days post-transplant 3. >80% 5-year survival from gen med perspective provided adequate graft function
36
What common conditions are lung transplants performed for?
1. ILD (usually single) 2. CF (usually double) 3. COPD (40% of transplants) 4. Pulmonary vascular diseases
37
What are the complications of lung transplant?
1. Hyper-acute rejection 2. Hyper-acute graft dysfunction (ischaemic reperfusion) 3. Chronic rejection (bronchiolitis obliterans syndrome) 4. Infections 5. Malignancy - PTLD/skin
38
Types of immunosupression in lung transplant?
1. Steorid 2. Calcineurin inhibitor 3. Nucleotide blocking agent (MMF/aza) 4. Prophylactic antibiotic
39
What is the COPD BODE index?
FEV1 (% of predicted) 6 minute walk distance MRC Dyspnoea scale Estimates 4 year survival
40
What are the contraindications to lung transplant?
BMI >35 Untreated other organ system Unstable critical condition Chest wall deformity Substance misuse Poor adherence
41
Post- lung transplant mortality?
20% at 1 year 50% at 5 years
42
What is yellow nail syndrome?
1. Bronchiectasis 2. Pleural effusions 3. Lymphoedema changes with coughing 4. Dystriphic, discoloured, thickened nails
43
How would you investigate someone with bronchiectasis?
1. Routine bloods 2. HIV, Ig, Aspergillus serology, CF, Rheumatoid serology 3. Sputum analysis (gen, fungus, mycobacterium) 4. CXR 5. Spiro 6. HRCT 7. Saccharine ciliary motility test: Kartagener's
44
What are the radiological findings of bronchiectasis?
CXR: tramlines and ring shadows CT: Signet ring sign (thickened dilated bronchi that are larger than the adjacent vascular bundle)
45
Management of bronchiectasis?
1. MDT 2. Postural drainage 3. Hypertonic saline 4. Long-term antibiotics 6. Sputum culture guided IV abx 7. Neublised antibiotics in pseudomonas 8. Vaccination - pneumococcal and annual influenza
46
Causes of bronchiectasis?
Congenital: CF, Kartagener's Childhood infections: Measles, TB Immune over-activity: ABPA, IBD Immune under-activity: HypoG, CVID Aspiration: GORD, alcohol (RLL)
47
Amongst patients who dont smoke, what is the most common lung cancer histology?
Adenocarcinoma
48
What targeted treamtent in NSCLC do you know of?
EGFR (osimertinib) ALK (repotrectinib) PD-L1 (nivolumab)
49
what paraneoplastic syndromes do you know if in small cell lung cancer?
LEMS ACTH SIADH
50
What will you send your pleural sample off for if you have a unilateral pleural effusion?
1. pH 2. Protein 3. LDH 4. Cell count and cytology 5. Gram stain + AFB staining 6. Culture
51
What is Light's criteria
<25g/L: transudate >36g/L: exudate 25-35g/L: apply Light's criteria Exudate if: Pleural:Blood protein ratio >0.5 Pleural:Blood LDH ratio >0.6 Pleural LDH >2/3 the upper limit of normal blood levels Transudate: Heart Failure Liver failure Nephrotic syndrome Hypothyroidism Meig's syndrome Exudate: Infection Malignancy CTD Pancreatitis Yellow nail syndrome PE Dressler's
52
What other assays are useful when investigating a pleural effusion?
Low glucose in pleural = infection, malignancy, oeseopheal rupture Very low glucose = RA High amylase in pancreatitis Cell count = higher WCC with neutrophilia in paraneumonic; lymphocytosis in TB
53
What specific investigations would you conduct for upper zone fibrosis?
Spirometry Echocardiogram ABG Broncheoalveolar lavage (looking for lymphocytosis) IgG antibodies (precipitins)
54
What is cor pulmonale?
Right heart failure due to respiratory disease that causes pulmonary vasoconstriction.
55
What are the causes of pulmonary hypertension?
1. LVSD 2. Respiratory causes - asthma, COPD, ILD 3. PAH 4. Thrombo-embolic disease 5. MISC - eg. lymphangiomatosis
56
What is the difference between OSA and OHS?
OSA - Weak airway muscles, most common on obese individuals. Loud snoring in an obese individual. Rx CPAP+/- NIV in overlap syndrome. Diagnosis is made with sleep studies. OHS - Only affects obese individuals. Impaired diaphragmatic/chest wall movement in sleep - slow/shallow breathing. Importantly, these individuals also experience hypoventilation whilst awake, which differentiates it from OSA. However this is much overlap. Raised pCO2 whilst awake is key to diagnosis.
57
How do you grade COPD?
FEV1/FVC must be <0.7 FEV1 >80% = mild FEV1 50-80% = mod FEV1 30-50% = sev FEV1 <30% = v sev
58
DDX for bilateral lower zone creps?
ILD (does not clear with cough) Heart failure B/L pneumonia Bronchiectasis (clear with cough)
59
How do you differentiate creps in bronchiectasis and ILD?
The characteristics of the creps in bronchiectasis change with coughing
60
What bronchiectasis syndromes do you know?
1. ABPA 2. Yellow Nail syndrome 3. Primary ciliary dyskinesia 4. Young syndrome 5. Kartagener's syndrome 6. Chediak-Higashi (AR, chronic granulomatous disease of the lung)
61
What types of smoking cessation do you know?
1. NRT - short courses 2. Varinecline - partial nicotinic receptor agonist. CI self-harm/suicide/pregnancy/breastfeeding. 3. Buprenorphine - nicotinic receptor antagonist, norepinephrine and dopamine re-uptake inhibitor. CI pregnancy/breastfeeding.
62
What clinical feature would most likely suggest chronic lung transplant rejection?
Bronchiolitis obliterans producing an obstructive lung defect.
63
Inclusion criteria for LTOT?
Non-smoker PaO2<7.3 or PaO2<8 with features of polycythaemia, peripheral oedema, PHTN
64
What are the features of EGPA?
1. Asthma 2. Eosinophilia 3. Paranasal sinusitis 4. Mononeuritis multiplex 5. pANCA + in 60%
65
What are the features of GPA?
Not eosinophilic Epistaxis, crusting, sinusitis Haemoptysis RPGN Saddle shaped nose deformity Vasculitic rash, CN lesions cANCA in 90%
66
What is the treatment of GPA?
1. Steroids 2. Cyclophosphamdie (90% response rate) 3. Plasma exchange
67
What are the clinical features of cystic fibrosis?
1. Small stature 2. Clubbing 3. Purulent cough 4. Coarse crackles and wheeze (bronchiectatic) 5. Pancreatic exocrine dysfunction 6. Pancreatic endocrine dysfunction 7. Distal intestinal obstruction in adults, meconium ileus in children 8. Seminal vesicles - male intertility 9. Fallopian tubes - reduced female fertility
68
What do you know about the genetics of CF?
1. AR 2. Chromosome 7 - CFTR gene, commonest and most severe is delta F508 (70%) 3. Incidence of 1 in 2500
69
What are the principles of treatment of CF?
1. MDT 2. Physiotherapy - postural drainage is critical 3. Pancrease, fat soluble supplements 4. Mucolytics (DNAse) 5. Double lung transplant 6. Gene therapy 7. CFTR potentiators (caftors - lumacaftor, ivacaftor)

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