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Resp Flashcards

1
Q

FEV1 definition?

A

forced expiratory vol in 1 sec

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2
Q

an increase of ? or more in ? 10-20 mins after inhalation of short-acting B2 agonist is compatible with diagnosis of asthma

A

increase of 15% or more in FEV1

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3
Q

name 2 interstitial lung diseases

A 
asbestosis, silicosis etc
drug induced
hypersensitivity pneumonitis
TB, viral, fungi
GORD
sarcoid
RA, SLE, SS, UC
idiopathoic pulm fib
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4
Q

kyphoscoliosis

A

deformity of the spine

curvature in sagittal AND coronal plane

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5
Q

describe FEV1 and FVC in obstructive lung disease

A

FEV1/FVC less than 80%

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6
Q

describe FEV1 and FVC in restrictive lung disease

A

FEV1/FVC >80%

lung volume reduced, most air blown out in 1st second as airways not narrowed

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7
Q

2 conditions under umbrella term of COPD

A

chronic bronchitis

emphysema

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8
Q

bronchiectasis - most obstructive or restrictive?

A

mostly obstructive but can get some restrictive scarring

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9
Q

describe bronchiectasis

A

dilated bronchi w/ pool secretions

copious purulent sputum

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10
Q

3 atopic conditions

A

hay fever
asthma
eczema

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11
Q

major complications of bronchoscopy

A

pneumonia
pneumothorax
heamorrhage

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12
Q

stridor definition

A

harsh vibrating noise when breathing, caused by obstruction of windpipe or larynx

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13
Q

presentation of PE

A

breathlessness/haemoptysis
pleuritic chest pain

acute massive: v. sudden circulatory collapse, life-threatening emergency

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14
Q

describe pleuritic chest pain

A

hurts when patients breathes in or coughs

pain from pleura due to infarct

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15
Q

causes of acute breathlessness

A

asthma
pneumonia
PE
pneumothorax

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16
Q

How many lobes in L and R lungs?

A

left lung 2

right lung 3

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17
Q

normal areas to show up on PET scan

A

heart
kidneys
bladder

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18
Q

what is the CURB-65 score?

A

scoring system in community acquired pneumonia - home Abx/ hospital Abx/ mortality

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19
Q

what are the 5 criteria of CURB-65 score?

A 
confusion
urea >7
resp rate >30
BP >90/60
age >65
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20
Q

RA & the lungs - complications with immunosuppression?

A

PCP

TB reactivation with anti-TNF

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21
Q

lung problems caused by RA

A 
pleural effusions
fibrosing alveolitis
bronchiectasis
obliterative bronchiolitis
methotrexate > lung fibrosis
immunosuppression > TB/PCP
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22
Q

Guillain–Barré syndrome definition

A

acute neuropathy
usually inflammatory demyelinating
often preceded by resp infection [CMV, EBV]
limb weakness, resp failure

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23
Q

ABPA [allergic bronchopulmonary aspergillosis] definition

A

hypersensitivity/exaggerated immune response to aspergillus fungus
[often asthma/ CF patients]

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24
Q

what is goodpastures’s syndrome?

A

antibodies to type 4 collagens in basement membrane of lung & kidney after some viral infections

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25
myaesthenia gravis
autoimmune muscle weakness without atrophy defect in ACh at neuromuscular jn.s
26
how do diffuse parenchymal lung diseases present?
SOB on exertion | persistent non-productive cough
27
how does sarcoidosis present & appear on CXR
skin or eye lesions coughing/SOB bilateral hilar lymphadenopathy &/or pulmonary infiltrations
28
treatment of sarcoidosis
[just hilar lymphadenopathy > no Tx] prednisolone steroid sparing/long-term: methotrexate/azathioprine/cyclophosphamide
29
treatment for wegener's granulomatosis
remission with corticosteroids and cyclophosphamide [plasmapheresis] 2nd line: rituximab
30
treatment for microscopic polyangiitis
corticosteroids | immunosuppressive drugs: azathioprine, cyclophosphamide
31
treatment for churg-strauss syndrome
corticosteroids | immunosuppressive drugs: azathioprine, cyclophosphamide
32
microscopic polyangiitis causes what in relation to the kidney?
haematuria proteinuria renal failure
33
2 main organs affected by microscopic polyangiitis
lungs | kidneys
34
3 main areas affected by wegener's granulomatosis lesions
lungs kidneys upper resp tract
35
diagnosis of microscopic polyangiitis
renal biopsy | serum pANCA
36
cANCA is associated with which disease?
wegener's
37
pANCA is associated with which diseases?
microscopic polyangiitis churg-strauss IBD
38
what 3 things make up the triad of Churg-Strauss syndrome?
eosinophilia asthma systemic vasculitis [peripheral nerves & skin]
39
which infections may trigger Guillain-Barre syndrome?
campylobacter jejuni EBV CMV
40
Management of Guillain-Barre syndrome
IV immunoglobulin [reduce paralysis duration & severity] heparin [reduce thrombosis risk] physio [prevent contracture]
41
diagnosis of Guillain-Barre syndrome
clinical features | nerve conduction studies [slow motor conduction]
42
mciroorganism that causes PCP
pneumocystis jirovecii
43
individuals susceptible to PCP [opportunistic infection]
on immunosuppressive drugs HIV cancer organ transplant
44
scoring system for PE/ DVT
Wells
45
frothy white-pink sputum indicates what ?
pulmonary oedema
46
commonest organism to cause CAP & one other typical
strep pneumoniae | haemophilus influenzae
47
individuals/ conditions at risk of aspirating
``` stroke M gravis bulbar palsy post ictal intoxicated reflux/ achalasia poor dental hygiene ```
48
give 4 symptoms of pneumonia
``` SOB pleuritic chest pain fever/rigors cough w/sputum malaise anorexia haemoptysis ```
49
give 4 clinical signs of pneumonia
``` pyrexia ^RR dull chest percussion creps / pleural rub / bronchial breathing tachycardia hypoTN confusion cyanosis ```
50
how will the curb65 score affect how you give your Abx?
0-1 home Tx, PO unless vomiting 2 hospital, PO unless vomiting >2 IV 3 = severe - consider ITU
51
Mx of pneumonia
``` ABx O2 VTE prophylaxis IV fluids [analgesia if pleurisy] ```
52
complications of pneumonia
``` pleural effusion empyema [in pleura] abscess [in lung] resp failure sepsis brain abscess pericarditis myocarditis cholestatic jaundice ```
53
Abxs for severe pneumonia (curb65>3) e.g.
co-amox + clarithromycin OR e.g. cefuroxime + clarith IV
54
Abxs for aspiration pneumonia
IV cephalosporin e.g. cefuroxime | + metronidazole
55
at risk groups who should have a pneumococcal vaccine
imm comp - AIDS, chemo, steroids DM [non- diet controlled] >65 liver/ heart/ renal/ lung chronic disease
56
commenest patient groups for pneumonia
``` elderly post splenectomy alcoholics immunosuppressed HF lung disease ```
57
Mx of type 1 resp failure as a complication of pneumonia
high flow O2 60% ABGs consider ITU if hypoxia not improving with O2 or PaCO2 >6 aim for sats 94-98%
58
pneumonia can lead to AF in the elderly. Usually resolves with Tx of the pneumonia. What drugs may be needed to slow the ventricular response rate in the short term
BB, digoxin
59
walled cavity and fluid level seen on xray. cough, fever, foul smelling purulent sputum. diagnosis?
lung abscess
60
describe the pathology of bronchiectasis
chronic inflammation of bronchi + bronchioles leads to dilatation
61
causes of bronchiectasis
``` CF post infection [bronchiolitis, pneumonia, measles] RA UC bronchial tumour/ foreign body ```
62
Sx of bronchiectasis + signs
cough ^^^ purulent sputum haemoptysis clubbing inspiratory creps, wheeze
63
name 3 complications of bronchiectasis
``` pneumonia pleural effusion pneumothorax haemoptysis cerebral abscess amyloidosis ```
64
CXR findings in bronchiectasis
thickened bronchial walls [tramline/ring shadows] | cystic shadows
65
give 4 Ix in bronchiectasis
``` sputum CXR spirometry [obstructive] high res CT bronchoscopy CF sweat test ```
66
Mx of bronchiectasis
chest physio/ airway clearance ABx [based on sensitivities] bronchodilators [neb salb]
67
genetic cause of CF
``` auto rec mutation of CFTR gene on chromosome 7 a Cl- channel. Leads to ^Cl- secretion + Na+ absorption across airway epithelium. Leads to bronchiectasis. ```
68
how is CF diagnosed?
newborn screening sweat test- Na + Cl common genetic mutations screen faecal elastase
69
list 4 complications on CF
``` meconium ileus pancreatic insuff steattorhoea pancreatitis [acute/chron] DM infective exac haemop resp failure male infertility nasal polyps clubbing ```
70
Tx of CF
``` fat soluble vitamins panc enzyme replacement chest physio bronchodilators mucolytic nebs Abx lung transplant [new mutation specific therapies] ```
71
small cell lung cancers arise from what type of cells
endocrine (Kulchitsky)
72
of small and non-small cell lung cancers, which is the commoner and which is often disseminated at presentation/ worse porgnosis
NSCLC more common (80%) | SCLC often disseminated at presentation
73
name 4 Sx of lung cancer
``` cough haemoptysis SOB weight loss chest pain recurrent/not resolving pneumonia lethargy anorexia back pain ```
74
name 3 examination findings in lung CA
supraclavicular/axillary lymph node enlargement cachexia CHEST: none/ consolidation/ effusion/ collapse METS: hepatomeg/ bone tenderness/ confusion/ fits
75
CXR findings in Lung CA
``` peripheral nodule consolidation hilar enlargement pleural effusion bony involvement collapse ```
76
list 4 local and 4 systemic/metastatic complications of Carcinoma of bronchus
``` LOCAL: recurrent laryngeal nerve palsy phrenic nerve palsy SVC obstruction horners syndrome rib erosion pericarditis AF ``` ``` mets: brain, bone, liver, adrenals hypercalcaemia cushings anaemia neuro: myopathy, neuropathy, cerebellar degeneration ```
77
describe the difference between type 1 and type 2 resp failure
type 1 = low O2, normal CO2 | type 2 = low O2 and high CO2
78
why do you aim for lower O2 targets in type 2 resp failure
if you give them lots of O2, then the CO2 keeps rising which just worsens the resp acidosis
79
what non invasive ventilation do you use in type 1 and type 2 resp failure
type 1 - CPAP | type 2 - bipap [need to draw out CO2 as well as driving O2 in]
80
what Ix might you consider in lung CA
``` CXR pleural fluid aspiration + cytology sputum cytology biopsy [lymph node/ bronchoscopy/ peripheral] CT/PET [staging] lung fn test bone scan [mets] ```
81
clinical features of mesothelioma
``` SOB chest pain weight loss clubbing pleural effusion [mets - lymphadenopathy, hepatomeg, bone pain] ```
82
differentials of lung nodule on CXR
``` malignancy - prim/mets infection granuloma abscess arterio-venous malformation carcinoid tumour cyst foreign body skin tumour e.g. seb wart ```
83
non metastatic extrapulm manifestations of bronchial CA - endocrine
``` ectopic secretion of hormones by the tumour: cushings (ACTH) dilutional hyponatraemia (ADH) hypercalcaemia (PTH) gynaecomastia (HCG) ```
84
non metastatic extrapulm manifestations of bronchial CA - neuro
cerebellar degeneration myopathy polyneuropathy myasthenic syndrome
85
non metastatic extrapulm manifestations of bronchial CA - vascular/ haem
thrombophlebitis migrans anaemia DIC
86
Mx of NSCLC
lobectomy radiotherapy + chemo for more advanced cetuximab
87
what manifestations/ complications of palliative SCLC might be helped by palliative radiotherapy?
``` SVC obstruction haemoptysis bronchial obstruction bone pain cerebral mets ```
88
give 5 aspects of SCLC Mx
``` surgery in less advanced chemo + radio if well enough palliative care SVC stent tracheal stent dexamethasone pleural drainage analgesia antiemetics bronchodilators antidepressants ```
89
what is allergic bronchopulmonary aspergillosis
type 1 + 3 hypersens rn. to aspergillus fumigatus. affects asthmatics and CF. Caused constriction then bronchiectasis
90
Mx of allergic bronchopulmonary aspergillosis
pred bronchodilators for asthma itraconazole bronchoscopic aspiration of mucus plugs
91
difference between asthma and copd
asthma is reversible
92
asthma Sx
``` SOB wheeze chest tightness cough [often nocturnal] sputum precipitants e.g. exercise /allergens ```
93
asthma precipitants
``` cold air exercise emotion allergens [house dust mite, pollen, fur] infection smoking/passive pollution NSAIDs BBs ```
94
what time of day is it commoner for asthmatics to have worse peak flow
morning
95
examination findings/signs in asthma
``` ^RR wheeze [audible + auscult] hyperinfated chest ^resonance on percussion reduced air entry ```
96
signs that indicate a life threatening asthma attack
``` silent chest confusion cyanosis exhaustion bradycardia ```
97
clinical features that increase probability of asthma
``` wheeze chest tightness SOB diurnal precipitants:exercise, cold, allergens aspirin/BB induced Hx of atopy FH of asthma/atopy wheeze on auscult low peak flow eosinophilia ```
98
Ix in asthma
``` peak flow/ spirom CXR sputum culture FBC/U&E/CRP cultures ABG ```
99
what might an ABG show in asthma attack
normal or low O2 + low CO2 [hypervent] a normal or raised CO2 indicates failing resp effort > HDU/ITU
100
differentials of asthma
``` obstruction [foreign body/ CA] pneumothorax LRTI COPD pulm oedema ["cardiac asthma"] SVC obstruction PE bronchiectasis obliterative bronchiolitis ```
101
lifestyle Mx of asthma
weight loss stop smoking avoid allergens
102
Mx of chronic asthma, stepwise
1. salbutamol inhaler PRN 2. beclometasone inhaler od 3. salmeterol inhaler BD / ^beclo dose try montelukast (LRA), oral theophylline 4. ^steroid, oral theoph, oral B2 ag, oral monte 5. PO pred od
103
in asthma, when would you move from PRN salb to step 2 (inhaled steroid)?
used more than od | night time Sx
104
side effects of B2 agonists [salbutamol]
``` tachyarrhythmias hypokalaemia tremor anxiety [long acting - paradoxical bronchospasm] ```
105
mouth should be rinsed after using inhaled steroids for asthma. Why?
prevent oral candidiasis
106
aminophylline, metabolised to theophylline, has a narrow therapeutic ratio. What SEs?
``` arrhythmia GI upset fits anxiety tremor ```
107
if IV aminophylline is used in acute asthma, what Ix should you do after administration [bearing in mind its narrow therapeutic ratio]
ECG | theophylline levels
108
COPD Sx
cough sputum SOB wheeze
109
signs in COPD
``` wheeze ^RR accessory muscles hyperinflation reduced expansion resonant/hyperres cyanosis quiet breath sounds ```
110
complications of COPD
``` infective exacerbation polycythaemia resp failure cor pulmonale [oedema] pneumothorax carcinoma ```
111
Ix in COPD
``` FBC [^haematocrit] CXR CT ECG [R hypetrophy] ABG [low O2 +/- ^CO2] spirom ```
112
CXR signs in COPD
``` hyperinflation flat hemidiaphragms large central pulm arteries reduced peripheral vascular markings bullae ```
113
Mx of chronic stable COPD
``` SABA/SAMA [ipratropium] LABA LAMA ICS home O2 CPAP/BIPAP ``` SMOKING CESSATION flu + pneumococcal vaccines
114
what happens to the lungs in acute resp distress syndrome
^cap permeability > oedema
115
pulmonary causes of ARDS
``` pneumonia aspiration inhalation vasculitis injury/contusion ```
116
non-pulmonary causes of ARDS
``` sepsis/shock/haemorrhage/DIC multiple transfusions pancreatitis ALF trauma head injury burns eclampsia drugs [aspirin/heroin] ```
117
clinical features of ARDS
^RR cyanosis tachycardia crackles
118
Ix for ARDS
``` CXR FBC, U+E, clotting, amylase, CRP, LFT cultures ABG sputum pulm artery catheter [cap wedge pressure] ```
119
diagnostic criteria for ARDS
1. acute onset 2. CXR - bilateral infiltrates 3. refactory hypoxaemia
120
what is pulmonary capillary wedge pressure?
estimate of LA pressure | measured by placing balloon catheter in pulm. artery
121
Mx of ARDS
``` admit ITU treat cause e.g. sepsis O2, CPAP intubate + ventilate inotropes [dobutamine] vasodilators blood transfusion ```
122
what is pneumoconiosis
industrial lung disease ass. with dust e.g. coal miners
123
give signs / Sx of hypoxia
``` SOB restlessness agitation confusion central cyanosis ```
124
give 4 signs/sx of hypercapnia
``` headache peripheral vasodilatation tachycardia bounding pulse tremor/flap papilloedema confusion drowsy coma ```
125
Ix in respiratory failure
``` ABG CXR FBC, U+E, CRP sputum cultures spirometry ```
126
where do PEs usually arise from?
a venous thrombosis in the pelvis or legs
127
risk factors for PE
``` recent surgery (especially abdo/pelvic, hip/knee replacement) thrombophilia e.g. antiphospholipid syndrome leg fracture prolonged bed rest / reduced mobility malignancy pregnancy/post partum COCP, HRT previous PE ```
128
PE Sx
SOB pleuritic CP haemoptysis dizzy, syncope
129
PE signs
``` tachypnoea pyrexia cyanosis pleural rub tachycardia hypoTN ^JVP pleural effusion [DVT- red hot swollen leg] ```
130
Ix in PE
``` FBC, U+E, clotting, D-dimer ABG [low O2, low CO2] CXR CTPA ECG ```
131
CXR findings in PE
``` may be normal oligaemia of affected segment dilated pulmonary artery linear atelectasis small pleural effusion wedge shaped opacity/ cavitation [rare] ```
132
ECG findings in PE
``` may be normal tachycardia RBBB RV strain [R axis deviation, dominant R wave, inverted T wave or ST depression V1-V4] (rarely SIQIIITIII) ```
133
PE Mx
``` O2 morphine + antiemetic LWWH/ fondaparinux fluid bolus if low BP vasopressors e.g. dobutamine/noradrenaline thrombolysis [alteplase] long term anticoag [noac] VC filter ```
134
what ix.s might you carry out in a Pt with an unprovoked PE [unknown cause]
?malignancy - breast exam and mammography, CXR FBC, Ca2+, LFTs urinalysis abdo-pelvic CT antiphospholipid + thrombophilia testing if FH +ve
135
name 5 causes of pneumothorax
``` spontaneous [young thin men] asthma, COPD TB pneumonia lung abscess carcinoma CF lung fibrosis sarcoidosis marfans/EDS trauma iatrogenic [biopsy/line] ventilation ```
136
presentation of pneumothorax
may be asymptomatic sudden onset SOB, pleuritic CP asthma/COPD sudden deterioration hypoxia
137
examination findings in pneumothorax
^resonance [percussion] reduced air entry/ breath sounds reduced expansion tracheal deviation in tension
138
Mx pneumothorax
aspiration chest drain O2 in secondary
139
what is the difference between transudate and exudate pleural effusions?
protein concentration | transudate less, exudate more protein
140
what do you call a) pus in the pleural space. b)blood in the pleural space. c) blood and air in the pleural space ?
a) empyema b) haemothorax c) haemopneumothorax
141
causes of transudate pleural effusion
^ venous pressure: [HF, constrictive pericarditis, fluid overload] low blood protein: [nephrotic syndrome, cirrhosis, malabsorption] hypothyroidism
142
causes of an exudate pleural effusion
pneumonia, TB pulmonary infarction RA, SLE bronchogenic carcinoma, mets, lymphoma, mesothelioma
143
Sx of pleural effusion
asymptomatic or | dyspnoea, pleuritic CP
144
exam findings in pleural effusion
``` reduced expansion stony dull to percussion diminished breath sounds may be bronchial breathing above effusion large > tracheal deviation ```
145
Ix in pleural effusion
CXR US aspiration pleural biopsy
146
CXR findings in pleural effusion
blunting of costophrenic angles | larger > water-dense shadows with cancave upper border
147
Mx of pleural effusion
drainage pleurodesis [with talc] surgery treat the cause
148
define obstructive sleep apnoea
``` intermittent closure/collapse of pharyngeal airway causing apnoeic episodes during sleep terminated by partial arousal ```
149
presentation of ob. sleep apnoea
``` falling asleep during the day loud snoring poor sleep quality morning headache reduced libido nocturia reduced cognitive performance ```
150
complications of obstructive sleep apnoea
pulm HTN type 2 resp failure HTN
151
investigations in obstructive sleep apnoea
video recording pulse ox polysomnograph [during sleep: O2, airflow, ECG, abdo wall movement, EMG chest]
152
sleep apnoea Mx
``` weight loss stop smoking + alcohol mandibular advancement device CPAP surgery [polyectomy/tonsillectomy] rarely ```
153
causes of cor pulmonale [name 4]
COPD, bronchiectais, pulm fibrosis, asthma, resection PE, vasculitis, pulm HTN, ARDS myasthenia gravis, MND, stroke kyphosis, scoliosis sleep apnoea
154
most common age range, gender and ethnicity affected by sarcoidosis
20-40 female african-caribbean
155
clinical features of sarcoidosis. | Name 2 for acute sarcoidosis, 2 for pulmonary, 5 non-pulmonary.
acute: fever, erythema nodosum, hilar lymphadenopathy,polyarthralgia pulm: SOB, dry cough, CP ``` non-pulm: lymphadenopathy hepatosplenomeg uveitis/conjunctivitis/glaucoma terminal phalynx bone cysts bells palsy/neuropathy/mengingitis/space-occ lesion erythema nodosum renal stones hypercalcaemia arrhythmia/cardiomyopathy ```
156
bloods findings in sarcoidosis
``` ^ESR lymphopenia ^LFTs ^ACE ^Ca2+ ^imm.glob.s ```
157
what findings in 24 hours urine in sarcoidosis
^ urine ca2+
158
CXR findings in sarcoidosis
``` bilat. hilar lymphadenopathy infiltrates fibrosis bulla pleural ```
159
Ix in sarcoidosis
``` CXR ECG lung Fn tests bloods: ESR, FBC, LFT, Ca2+, imm.globs tissue biopsy bronchoalveolar lavage transbronchial biopsy UA bone xray CT/MRI ```
160
results found on tissue biopsy in sarcoidosis [lung/liver/lymph node/skin nodule]
non-caseating granulomata
161
Mx of sarcoidosis
acute: bed rest, nsaids pred 4-6 weeks severe: IV methylpred/ methotrex/ hydroxychloroquine/ciclosporin/ cyclophosphamide anti TNFa lung transplant
162
name 4 differentials for graulomatous disease
``` TB, leprosy, syphilis sarcoidosis fungi [cryptococcus] primary biliary cholangitis extrinsic allergic alveolitis vasculitis: GCA, polyarteritis nodosa, wegeners] crohns silicosis ```
163
differentials of bilateral hilar lymphadenopathy on CXR
``` sarcoidosis TB, mycoplasma lymphoma pneumoconiosis mets mediastinal tumour ```
164
Sx of interstitial lung disease | + spirometry picture
dry cough SOB restrictive
165
name 3 causes of intersitial lung disease
occupational: asbestos, silica drugs: nitrofurantoin, amiodarone hypersensitivity rn [pneumonitis] infection: TB, fungi, viral GORD idiopathic pulmonary fibrosis
166
give some systemic disorders which cause, or are associated with, interstitial lung disease
``` RA, SLE, systemic sclerosis, sjogrens sarcoidosis UC renal tubular acidosis autoimmune thyroid disease ```
167
Mx of extrinsic allergic alveolitis
remove allergen give o2 PO pred
168
differentials for upper zone fibrotic shadowing on CXR
``` TB hypersensitivity pneumonitis ank spond radiotherapy progressive massive fibrosis ```
169
Sx of idiopathic pulmonary fibrosis
``` dry cough SOB malaise weight loss arthralgia ```
170
signs of idiopathic pulm. fibrosis
cyanosis fine end-resp creps clubbing
171
complications of idiopathic pulm. fibrosis
resp faulire | ^risk of lung CA
172
Ix for idiopathic pulm. fibrosis
``` ABG CRP imm glob ANA, Rh. factor CXR, CT spirom bronchoalveolar lavage lung biopsy ```
173
Mx of idiopathic pulm. fibrosis
``` O2 pulmonary rehab opiates palliative lung transplant ```
174
Differentials for bilateral hilar lymphadenopathy
Lymphoma (primarily hodgkins) Sarcoidosis Silicosis TB
175
metabolic disturbace caused by aspirin od
resp alkalosis [hyperventilaiton]
176
can APTT be used to monitor unfractionated heparins and LMWH
yes for unfractionated because its intrinsic, not for LMWH which act on factor Xa
177
causes of COPD other than smoking
industrial exposures e.g. coal dust, grain/flour, silica | alpha-1-antitrypsin deficiency

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