Chronic Breathlessness

Question 1

What are the constituent parts of the conduction zone of the respiratory system? (4)

Answer 1

Trachea, bronchi, bronchioles, terminal bronchioles.

Question 2

What are the constituent parts of the respiratory zone of the respiratory system? (3)

Answer 2

Respiratory bronchioles, alveolar ducts, alveoli.

Question 3

What is responsible for the sympathetic innervation of bronchiolar smooth muscle?

Answer 3

Noradrenaline acting on beta receptors to cause bronchodilation.

Question 4

What is responsible for the parasympathetic innervation of bronchiolar smooth muscle?

Answer 4

Acetylcholine acting on muscarinic receptors to cause bronchoconstriction.

Question 5

Describe the functions of the two types of alveolar cells.

Answer 5

Type I Alveolar Cells - gas exchange between the alveoli and capillaries.
Type II Alveolar Cells - secrete surfactant to lower surface tension.

Question 6

What system does NICE recommend using to objectively assess breathlessness?

Answer 6

Medical Research Council (MRC) Dyspnoea Scale

Question 7

What cardiac pathology classically causes breathlessness with lightheadedness?

Answer 7

Aortic stenosis

Question 8

What is a ‘pack year’?

Answer 8

A way of identifying an individual’s exposure to tobacco over time, calculated by (no. cigarettes smoked per day/20) x no. years they have smoked for.

Question 9

What are the hallmark symptoms of COPD? (5)

Answer 9

Shortness of breath, chronic cough, sputum production, winter exacerbations, wheeze.

Question 10

What is the gold standard investigation for diagnosing and grading COPD?

Answer 10

Spirometry

Question 11

Describe a COPD natural history.

Answer 11

1. Progressive decline in lung function.
2. Progressive dyspnoea and disability.
3. Right ventricular failure (‘cor pulmonale’)
4. Exacerbations become more frequent and contribute to morbidity and disability.

Question 12

What is ‘cor pulmonale’? (6 steps)

Answer 12

Hypoxia —> pulmonary arterial vasoconstriction—> increased resistance to blood flow through lungs —> increased pulmonary artery pressure —> right ventricular hypertrophy—> right ventricular failure (aka cor pulmonale)

Question 13

What characteristics of COPD are seen histologically? (3)

Answer 13

Goblet cell hyperplasia, airway narrowing (partly through inflammation, partly through scarring of bronchial wall, partly through mucus production) and alveolar destruction (normal alveoli replaced by functionless holes).

Question 14

What does premature airway collapse result in?

Answer 14

Air becoming trapped in the lungs.

Question 15

In what patients should nicotine replacement therapy be considered?

Answer 15

Anyone who is tobacco-dependent and over 11 years old.

Question 16

What is bupropion?

Answer 16

A noradrenaline dopamine reuptake inhibitor used to aid smoking cessation in nicotine-dependent patients.

Question 17

What is varenicline (Champix)?

Answer 17

A nicotine receptor partial agonist used to aid smoking cessation.

Question 18

What oral add ons can be prescribed to help manage COPD day to day?

Answer 18

Oral theophylline (bronchodilator)
Carbocisteine (mucolytic)

Question 19

What oral add ons can be prescribed to help manage COPD exacerbations? (2)

Answer 19

-Oral corticosteroids (prednisolone 30mg/OD for 5 days)
-Oral antibiotics

Question 20

What are the NICE guidelines on when home oxygen therapy should be offered to a patient?

Answer 20

Patient with paO2 less than 7.3 on air.
OR
paO2 7.3 - 8.0 on air and either secondary polycythaemia, peripheral oedema, or pulmonary hypertension.

Question 21

Name three inhaled corticosteroids.

Answer 21

Fluticasone
Beclometasone
Budesonide

Question 22

What are the clinical features of hypercapnia? (5)

Answer 22

Altered mental state
Dilated pupils
Flushed skin
Asterixis
Bounding pulse

Question 23

What signs on a chest x-ray might suggest COPD? (5)

Answer 23

Flattened diaphragm, nipple shadows, smaller heart size, hyperinflated lungs, horizontal ribs.

Question 24

What respiratory conditions are associated with nail clubbing?

Answer 24

-Lung cancer
-Suppurative lung diseases (diseases that result in chronic lung infection such as bronchiectasis, cystic fibrosis)
-Interstitial lung diseases.

Question 25

What investigations need to be conducted to confirm a diagnosis of interstitial lung disease (ILD)? (2)

Answer 25

-High resolution CT scan (can show basal fibrosis, honey-combing and traction bronchiectasis).
-Spirometry (restrictive pattern)

Question 26

What is the term ‘interstitial lung disease’?

Answer 26

A umbrella term used for over a hundred different conditions affecting the lung parenchyma.

Question 27

What lung sound is an indicative feature of fibrotic lung disease?

Answer 27

Bi-basal, fine, end-inspiratory crepitations.

Question 28

What is sarcoidosis?

Answer 28

A type of lung fibrosis that has an unknown cause, in which immune cells form clumps called granulomas in various organs, including the lungs.

Question 29

What are the five categories of known causes of interstitial lung disease (ILD)?

Answer 29

Occupational (asbestosis/silicosis)
Environmental (hypersensitivity pneumonities [pigeons/birds])
Immune (connective tissue disease (RA; systemic sclerosis))
Smoking (DIP and RB-ILD)
Drugs (any!)

Question 30

What are the two main pathological categories used to describe interstitial lung diseases (ILDs)?

Answer 30

Primarily inflammatory (may eventually lead to fibrosis if left unchecked)
Primarily fibrotic

Question 31

What treatments are suggested for Idiopathic Pulmonary Fibrosis? (3)

Answer 31

-Antifibrotics (Pirfenidone and Nintedanib) - don’t actually impact symptoms but slow disease progression.
-Pulmonary rehabilitation (education and physiotherapy)
-Oxygen therapy assessment

Question 32

What is Lofgrens Syndrome?

Answer 32

An acute form of sarcoid, more common in females.

Question 33

How is pulmonary sarcoidosis staged?

Answer 33

Stage 0 - normal chest x-ray
Stage I - hilar adenopathy alone
Stage II - hilar adenopathy with parenchymal involvement
Stage III - parenchymal involvement alone
Stage IV - pulmonary fibrosis

Question 34

What are the aims of managing sarcoidosis? (3)

Answer 34

-Preventing end organ damage/dysfunction (ECG, urinary calcium, LFTs, screen for eye and neurological symptoms)
-Maintaining quality of life
-Preventing impact on life expectancy

Question 35

What are tram-track opacities on a chest x-ray?

Answer 35

Dilated airways seen in the longitudinal plane.

Question 36

What are ‘ring opacities’ on a chest x-ray?

Answer 36

Dilated airways seen end-on.

Question 37

What is bronchiectasis?

Answer 37

A chronic condition in which the bronchial walls become thickened and inflamed, leading to a build-up of excess mucus which can make the lungs vulnerable to infection; the bronchial tree becomes abnormally and irreversibly dilated.

Question 38

What is the diagnostic imaging of choice for bronchiectasis?

Answer 38

High resolution CT scan.

Question 39

What is a ‘sail sign’ seen on a chest x-ray?

Answer 39

A dense triangular opacity overlying the cardiac shadow.

Question 40

What is a ‘sail sign’ on a chest x-ray indicative of?

Answer 40

In an adult, left lower lobe collapse with subsequent left upper lobe hyper-expansion.

Question 41

Give an overview of the stepwise treatment of COPD using inhaled therapies.

Answer 41

Step 1: SABA or SAMA as required.
Step 2: for no asthmatic features, dual therapy LABA and LAMA. For asthmatic features, dual therapy with LABA and ICS.
Step 3: triple therapy with LABA, LAMA and ICS.

Question 42

What class of drug is aminophylline?

Answer 42

Phosphodiesterase inhibitor.