Resp

Question 1

Fibrotic crackles in upper zones

Answer 1

Fibrotic crackles in upper zones - consider: TB, ankylosing spondylitis, radiation induced fibrosis and possibly extrinsic allergic alveolitis, sarcoidosis, silicosis and coal-workers’ pneumoconiosis.

Question 2

Fibrotic crackles in lower zones

Answer 2

Consider: cryptogenic fibrosing alveolitis, drugs, connective tissue disease.

Question 3

Fine end inspiratory crackles

Answer 3

Left ventricular failure, pneumonia and fibrosis (Rheumatoid arthritis, SLE, systemic sclerosis, cryptogenic fibrosing alveolitis, extrinsic allergic alveolitis, drugs (amiodarone, methotrexate, sulphasalazine and cyclophosphamide)) and bronchiectasis.

Question 4

Extra-articular features of Rheumatoid arthritis

Answer 4

Episcleritis
Scleritis
Pulmonary fibrosis
Pleural effusions
Pericarditis
Splenomegaly in Felty’s syndrome
Glomerulonephritis

Question 5

Differentials for VATS

Answer 5

Wedge resection of pulmonary nodule
Lobectomy
Pleurodesis or pleurectomy 
Bullectomy 
Lung biopsy

Question 6

Management of primary pneumothorax (breathless)

Answer 6

ABCDE
Resuscitation with immediate decompression if clinical signs of tensioning
Aspiration can be considered up to 2.5L - if fully resolved / <2cm can be d/c’ed and f/u OP
Chest drain
Surgical if persistant air leak

Question 7

Treating Idiopathic Pulmonary Fibrosis

Answer 7

MDT approach
Steroids
Pirfenidone

Question 8

Interstitial lung disease ddx

Answer 8

Peripherial/facial signs of CTD - SS, RA, SLE
Clubbing - IPF more likely (esp if age >50)
AF/PPM - consider drugs such as amiodarone, methotrexate
Basal vs apical fibrosis have slightly different aetiologies
Idiopathic - IPF, sarcoid, COP
Occupational exposure - birds (EAA), asbestos, silicosis, berylosis

Question 9

Interstitial lung disease spirometry

Answer 9

Reduced TLC
Reduced FEV1 but preserved FEV1/FVC ratio
Reduced fransfer factor

Question 10

Investigating ILD

Answer 10

Bloods incl FBC, U&E, LFTs, CRP
CXR
ECG / ECHO - pulmonary hypertension
ABG - resting PO2 to guide LTOT
HRCT - honeycombing (fibrosis), ground glass shadowing for alveolitis and therefore response to steroids/immunosupression
Bronchoscopy + BAL +/- endobronchial or transbronchial biopsy
Or lung biopsy in cases of diagnostic difficulty

Question 11

Dermatomyositis

Answer 11

From top: Heliotrope rash
Malar rash and nasolabial folds
Shawl sign
Gottrons papules and calcinosis
Shoulder and pelvic girdle weakness

Question 12

IPF prognosis

Answer 12

> 5yr 20-30%; median 2-3 years
Poor prognostic criteria - age, dyspnoea, rapid decline in pulmonary function, low ET tolearance, co-existing pulmonary disease, exertional desaturation

Question 13

Management of CF

Answer 13

MDT in specialist centre
Physiotherapy for mucous clearance (postural drainage, enhanced breathing techniques, exercise)
Mucolytics (like recombinant DNase, hypertonic saline) - nebulised
Nebulised antibiotics
Regular oral azithromycin therapy and may need regular IV Abx
Pancreas - creon and fat solube vitamins, PEG tubes may be required for nutritional support (catabolic state)
Pseudomonas colonisation and burholderia colonisation (burkholderia is absolute CI to lung Tx)
Can get diabetes (usually insulin), liver disease, constipation and obstruction, gallstones, renal stones, osteopenia, infertility, nasal polyps.
B/L lung Tx - FEV1<30%, poor ET, PTH, high exacerbation frequency, NIV, large volume haemoptysis despite embolisation

Question 14

CF

Answer 14

AR inheritance
Mutation in chr 7 in defective CFTR gene, most common - delta F508,
50% homozygous, 90% heterozygous
Bronchiectasis (classically upper lobes more affected) + clubbing, catabolic state and signs of nutritional deificency.
Long term venous access - e.g. portacath (upper chest, lateral chest)
Can be on LTOT
Median life expectancy into 40s and 50s
CFTR modulating therapies for eligible patients.
All infants in UK - guthrie test, immunoreative trypsin.

Question 15

Indication for lung transplant

Answer 15

Indications:
>50% risk of death within 2 years
>80% likelihood of surviving 90 days post transplant
>80% likelihood of 5 year post Tx survival
*
Bilateral (Better prognosis, about 7.5 years median), Suppurative lung disease like CF and bronchiectasis usually, pulmonary vascular disease or pulmonary fibrosis less often
Single lung (classic) - COPD/ ILD

Question 16

Anti-rejection medication in lung transplant

Answer 16

Calcineurin inhibitor: Ciclosoprin (old), Tacrolimus (tremor, diabetes)
Nucleotide blocking agent: Mycophenylate/Azathioprine
Steroids - cushings
Prophylaxis of opportunistic infection

Question 17

Complication of lung transplants

Answer 17

Hyperacute rejection
Acute rejection
Opportunistic infection - mycobacterial, fungal, viral, bacterial
Chronic rejection - Bronchiolitis obliterans
Post transplant lymphproliferative disease (most common in 1st year post Tx) and skin malignancy
SE from anti-rejection medication

Question 18

CI to lung Tx

Answer 18

Malignancy within 5 years or previous 2 years if low risk recurrence
Heart liver kidney and brain dysfunction
Uncorrected atherosclerotic disease
Acute illnesses
Chronic infection with highly resisstant organisms - mycobacterium abscesses, burkholderia
Spinal deformities
BMI at extremes
Smoking / drug use
Mental health conditions precluding compliance with medication or follow up
Relative - age >65 (single), BMI <17 / BMI >30, microbiological profiles

Question 19

COPD on examination

Answer 19

Obstructive lung diseases - ask patient to expire fully

Important to mention signs of respiratory failure, pulmonary hypertension and cor pulmonate

Question 20

COPD staging

Answer 20

Spirometry, FEV1
Mild - >80%
Moderate 50-79
Severe 30-49
Very severe <30

Question 21

Classifying COPD

Answer 21

FEV1/FVC <0.70 (must for obstructive disease)
GOLD criteria
1. Classifying severity (spirometry, FEV1)
2. Symptoms - Modified British Medical Research Council (mMRC) or COPD assessment test (CAT)