Respiratory

Question 1

Causes lower lobe pulmonary fibrosis

Answer 1

asbestosis
idiopathic pulmonary fibrosis
drugs- methotrexate/ bleomycin
CTD- SLE, rheumatoid arthritis

Question 2

causes of upper lobe pulmonary fibrosis

Answer 2

sarcoidosis
silicosis
ankylosing spondylitis
coal workers pneumoconiosis
ABPA
radiation
TB

Question 3

what are the main treatments available for pulmonary fibrosis

Answer 3

immunosuppression- corticosteroids, cyclophosphamide
antioxidants- NAC
supplemental oxygen
lung transplantation
anti-fibrotics- perfinidone (little evidence), nintedinib

non specific intersistitial pneumonia- steroids + immunosuppressives

Question 4

what factors contribute to a lack of response to steroids in lung fibrosis

Answer 4

male sex
severity of symptoms
neutrophilia on BAL
predominant honeycombing on CT scan

Question 4

which disorders have a high lymphocyte count BAL

Answer 4

organising pneumonia
sarcoidosis
hypersensitivity pneumonitis

Question 5

indications for a VATS procedure

Answer 5

lobectomy, wedge resection, bullectomy, treatment of recurrent pneumothoraces

Question 6

what are the benefits of a VATs over open thoractomy

Answer 6

smaller incision- less pain, reduced wound complication, shorter healing time, shorter hospital admission

Question 7

what are the indications for a lobectomy or pneumonectomy

Answer 7

lobectomy: malignancy (peripheral), malignant nodules, abscesses (or wedge resection), aspergilloma, localised bronchiectasis

pneumonectomy: malignancy (central), bronchiectasis, trauma, TB

Question 8

how would you investigate a patient with suspected lung cancer

Answer 8

staging CT (TAP)
broncosopy/ EBUS
tissue diagnosis with biopsy
functional imaging like PETCTh

Question 9

how would you assess someone’s respiratory fitness for surgery

Answer 9

full history and examination
lung function test
cardiopulmonary exercise testing

Question 10

if you were performing a lobectomy/ pneumonectomy what FEV1 would you want

do you know of a VO2 max that offers the best post op prognosis

Answer 10

Lobectomy- FEV1 of 1.5L
pneumonectomy- FEV1 of 2L

VO2 max of at least 15ml/kg/min

Question 11

what are the different histological cell types of lung cancer

Answer 11

2 types
small cell (20%) and NSCLC (80%)
NSCLC- adenocarcinoma/ squamous cell/ large cell lung cancer/ neuroendocrinea

Question 12

what are the treatment options for small cell and non small cell lung cancer

Answer 12

NSCLC Management

Stage I/II MFFS- surgical resection:
curative obectomy (with hilar and mediastinal lymph node resection/sampling)

Radiotherapy: Is first-line for those with stage I-III disease who are not suitable for surgery. This treatment is given with curative intent.

Chemotherapy:
Is offered to those with stage III or IV disease to improve survival and quality of life.

Combination therapy:
Adjuvant chemotherapy should be offered to patients who have undergone a complete resection
Adjuvant radiotherapy is offered to patients who have had a incomplete resection of their tumour
All patients with stage I-III disease who are not suitable for surgery should be considered for chemoradiotherapy

SCLC Management

Surgery is rarely used and only considered in very early stage I disease - SCLC is disseminated at presentation in almost all patients. The majority of SCLC patients are treated with chemotherapy in combination with radiotherapy.

Question 13

indication for a lobectomy/ pneumonectomy

Answer 13

malignancy
bronchiectasis
empyema
TB
cystic fibrosis

Question 14

what is COPD

Answer 14

progressive and irreversible airway obstruction due to chronic bronchitis/ emphysema, most commonly associated with smoking, but also with A1AT deficiency and coal dust

Question 15

what is bronchitis

Answer 15

bronchitis is a clinical diagnosis- patients have a cough productive of sputum on most days for 3 months for 2 consecutive years

Question 16

what is emphysema

Answer 16

abnormal and permanent enlargement of air spaces distal to terminal bronchioles associated with wall destruction

Question 17

what are the most common pathogens in acute infective exacerbations of COPD

Answer 17

strep pneumonia
haem influenza
moraxella cattarhalish

Question 18

how would you manage an acute IECOPD

Answer 18

1- controlled oxygen with aim saturations based on whether or not they are a CO2 retainer which can be ascertained from an ABG
2) bronchodilators via nebuliser
3) abx- commonly doxycycline
4) steroids
5) NIV if any evidence of type 2 respiratory failure

Question 19

what are the causes of a pleural effusion

Answer 19

transudative (protein level <30g/L)
heart failure
liver failure
renal failure
hypothyroidism
hypoalbuminaemia

exudative (protein level >30g/L)
infective- pneumonia/ TB/ subphrenic abscess
malignancy - primary lung/ metastatic
connective tissue disease- rheumatoid arthritis, systemic lupus erythematosus
pancreatitis
pulmonary embolism
Dressler’s syndrome
yellow nail syndrome

Question 20

what causes a haemorrhagic pleural effusion

Answer 20

malignancy, chest trauma, PE, TB

Question 20

what are the causes of low glucose in pleural fluid

Answer 20

malignancy, empyema, TB, RA, SLE, oesophageal rupture

Question 20

what are the lights criteria for exudate

Answer 20

lights criteria is used when the pleural protein level is between 25 and 35
exudate is when:
pleural protein: serum protein >0.5
pleural LDH: serum LDH > 0.6
pleural fluid LDH more than two-thirds the upper limits of normal serum LDH

Question 20

when would you drain a pleural effusion

Answer 20

pH <7.2, frank pus, not amenable to medical management

Question 21

what are the complications of draining a pleural effusion

Answer 21

pneumonia pneumothorax haemothorax re-expansion pulmonary oedema

Question 22

what is the composition/ appearance of normal pleural fluid

Answer 22

pH 7.6 protein <1 WCC <1000 LDH <50% serum level glucose similar to plasma concentration

Question 23

what are the common conditions for which patients have a lung transplant

Answer 23

single lung transplant- COPD/ bronchiectasis is the most common double lung transplant- cystic fibrosis/ bronchiectasis

Question 24

what are the indications of a lung transplant

Answer 24

Patient must have chronic end stage respiratory disease and meet 2 criteria 1) 50% risk of death within 2 years if lung transplant is not performed 2) >80% risk survival at least 90 days post transplant 3) >80% likelihood of 5 year post transplant survival from a medical perspective

Question 25

what are the complications following a lung transplant

Answer 25

rejection- acute or chronic phase can lead to bronchiolitis obliterans and is the leading cause of death in the first year post transplant immunosuppresion- malignancy, steroid use, nephrotoxicity, susseptibility to infection

Question 26

what are contraindications to a lung transplant

Answer 26

malignancy - in the past 5 years infection- mycobacterium/ burkholdia in the past organ dysfunction unsuitability for surgery

Question 27

what is bronchiectasis

Answer 27

bronchial airway dilation, destruction and inflammation

Question 28

what are the causes of bronchiectasis

Answer 28

congenital- kartageners, cystic fibrosis childhood infection- measles, TB immune overactivity- RA, SLE, IBD immune underactivity- hypogammaglobinaemia, AIDS aspiration- GORD/ alcoholics

Question 29

what are complications of bronchiectasis

Answer 29

pneumonia pneumothorax respiratory failure pulmonary hypertension

Question 30

what pathogens most commonly affect patients with bronchiectasis

Answer 30

staph aureus strep pneumonia Hib pseudomonas aeruginosa klebsiella aspergillus

Question 31

what do you know about cystic fibrosis

Answer 31

autosomal recessive condition characterised by a defect in the CFTR gene on chromosome 7. respiratory manifestations are of asthma, bronchiectasis, recurrent infections GI- malabsorption and pancreatic insufficiency infertility

Question 32

what is yellow nail syndrome

Answer 32

disorder characterised by slow growing, curved and thickened yellow nails. Other features include exudative pleural effusions, bronchiectasis, sinusitis and lymphoedema

Question 33

what are the radiological findings of bronchiectasis

Answer 33

CXR- tramlines and ring shadows HRCT- signet ring sign- thickened dilated bronchi

Question 34

what is the management of bronchiectasis

Answer 34

MDT approach medical- mucolytic therapy- hypertonic saline nebuliser, carbocisteine, bronchodilators, steroids infections to be treated with a 2 week course- sputum samples chest PT annual vaccination- pneumococcal, influenza smoking cessation surgery- if not resolving with medical therapy

Question 35

how to qualify severity of patients COPD by spirometry

Answer 35

obstructive picture therefore FEV1/FVC ratio <0.8 FEV1 compared to predictive number and if >80%- mild 50-80%- moderate 30-50%- severe <30%- very severe

Question 36

classes of drugs for COPD

Answer 36

inhaled corticosteroids SABA/LABA SAMA/ LAMA

Question 37

what is cor pulmonale

Answer 37

Right sided heart failure secondary to respiratory disease chronic hypoxia leads to pulmonary vasodilation and pulmonary hypertension mainstay of treatment- long term oxygen (16 hours a day), diuretics for congestion

Question 38

management of long term COPD

Question 39

rheumatoid related lung diseases

Answer 39

ILD bronchiectasis pleural effusions raised hemidiaphragm (nerve involvement from vasculitis) obliterans bronchitis pulmonary nodules (no signs)

Question 40

UIP vs NSIP

Answer 40

Whilst most connective tissue associated with interstitial lung disease is due to NSIP, in rheumatoid this is not the case and UIP is more common. UIP is associated more with end stage pulmonary fibrosis and is more difficult to treat than NSIP which shows more ground glass type changes on HRCT, which is felt to be more associated with inflammation and potentially reversible with steroids or immunosuppression. The prognosis of the UIP type interstitial lung disease in rheumatoid arthritis is worse than NSIP and is similar to that of idiopathic pulmonary fibrosis