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Question 1

Signs of COPD in the hands

Answer 1

CO2 retention flap
Tar staining
Bounding pulse

Question 2

Signs of hyper expansion seen in a patient with COPD

Answer 2

 ↓ cricosternal distance
 Loss of cardiac dullness on percussion
 Palpable liver edge

Question 3

What are signs of cor pulmonale?

Answer 3

 ↑JVP
 Left parasternal heave: RV hypertrophy
 LoudP2±S3
 MDM of pulmonary regurg
 Ascites and pulsatile hepatomegaly
 Peripheral oedema

Question 4

Definition of COPD

Answer 4

Is used to define two conditions:

Chronic bronchitis: Cough productive of sputum on most days for ≥3mo on ≥2 consecutive years

Emphysema: Histological description of alveolar wall destruction with air collapse and air trapping

Question 5

4 features you would see on spirometry of a patient with COPD?

Answer 5

 ↑ TLC and residual volume (RV)
 FEV1 <80%
 FEV1:FVC <0.7
 ↓ transfer factor

Question 6

How can you determine the prognosis of a patient with COPD?

Answer 6

Bode index

Looks at:
 BMI
 Obstruction: FEV1
 Dyspnoea: MRC score
 Exercise capacity: 6 min walk

Question 7

Gold Classification COPD

Answer 7

Global Initiative for Obstructive Lung Disease) - allows you to tailor therapy to the patient

Looks at:

 mMRC dyspnoea score (modified medical research council)
 Airflow limitation
 No. of exacerbations per year

Question 8

Conservative management of COPD (4)

Answer 8

MDT
 GP, dietician, physio, resp physician, specialist nurses
 Regular review 1-2x / yr

Smoking Cessation: single most important intervention
 Specialist nurse and support programme
 Nicotine replacement therapy
 Varenicline: partial nicotinic agonist

Pulmonary Rehabilitation Therapy
 Tailored exercise programme
 Disease education
 Psychosocial support

Co-morbidities
 Nutritional assessment and dietary support
 CV risk Mx
 Vaccination: pneumococcal and seasonal influenza

Question 9

Medical Management of COPD

Answer 9

Principal Therapies
 Anti-muscarinics: short- or long-acting
 β-agonists: short- or long-acting
 Inhaled corticosteroids: in combination ̄c β-B

Other Therapies
 Theophylline or Roflumilast: PDIs 
 Carbocisteine: mucolytic
 Home emergency pack for acute exacerbations 
 LTOT

Question 10

Surgical Management of COPD

Answer 10

 Used for recurrent pneumathoraces or large bullae

 Bullectomy
 Lung reduction surgery (removing damaged parts of the lungs)

Question 11

Definition of asthma

Answer 11

Episodic, reversible airway obstruction due to bronchial hyper-reactivity to a variety of stimuli.

Question 12

Conservative management of Asthma

Answer 12

M TAME

General
 MDT: GP, specialist nurses, respiratory physician
 Technique for inhaler use
 Avoidance: allergens, smoke (ing), dust
 Monitor: Peak flow diary (2-4x/d)
 Educate
        Liaise  ̄c specialist nurse 
        Need for Rx compliance 
        Emergency action plan

Question 13

Management of acute asthma exacerbations

Answer 13

Immediate

1. Sit-up
2. 100% O2 via non-rebreathe mask (aim for 94-98%)
3. Nebulised salbutamol (5mg) and ipratropium (0.5mg) 4. Hydrocortisone 100mg IV or pred 50mg PO (or both) 5. Write “no sedation” on drug chart

Life threatening
 Inform ITU
 MgSO4 2g IVI over 20min
 Nebulised salbutamol every 15min (monitor ECG)

IV Rx if No Improvement in 15-30min:
 Nebulised salbutamol every 15min (monitor ECG)
 Continue ipratropium 0.5mg 4-6hrly
 MgSO4 2g IVI over 20min
 Salbutamol IVI 3-20ug/min
 Consider aminophylline
          Load: 5mg/kg IVI over 20min
          Monitor Levels
ITU for intubation

Question 14

What are some of the causes of PF?

Answer 14

Upper (PENTA):
 Pneumoconiosis: Coal, Silica
 Extrinsic allergic alveolitis
 Negative, sero-arthropathy (ank spond)
 TB
 Aspergillosis : ABPA

Lower (STAIR):
 Sarcoidosis (mid zone)
 Toxins: BANS ME
 Asbestosis
 Idiopathic pulmonary fibrosis
 Rheum: RA, SLE, SS, Sjogren’s, PM/DM

TOXINS (BANS ME):
 Bleomycin, Busulfan
 Amiodarone
 Nitrofurantoin
 Sulfasalazine
 MEthotrexate

Question 15

Spirometry results for PF?

Answer 15

 ↓TLC ̧ ↓RV, ↓FEV and ↓FVC
 FEV1:FVC >0.8
 ↓ transfer factor

Question 16

Management of PF

Answer 16

MDT: GP, pulmonologist, physio, psych, palliative care,
specialist nurses, pts. family

Anti fibrotic: e.g. perfenidone

Rx specific cause:
 EAA: steroids
 Sarcoidosis: steroids
 Connective tissue disease: steroids

Supportive care:
Stop smoking: single most beneficial strategy Pulmonary rehabilitation
LTOT
Symptomatic: anti tussive such as codeine phosphate

Question 17

Ddx for bronchiectasis

Answer 17

COPD
Asthma
Pneumonia

Question 18

Causes of bronchiectasis

Answer 18

Congenital
 CF
 PCD / Kartagener’s
 Young’s: azoospermia + bronchiectasis
 Hypogammaglobulinaemia: XLA, CVID, SAD

Acquired
 Idiopathic
 Post-infectious: pertussis, TB, measles
 Obstruction: tumour, foreign body
 Associated: RA, IBD (esp. UC), ABPA

Question 19

Ix for bronchiectasis

Answer 19

Sputum

Blood
 FBC: ACD
 Serum Ig: may do provocative testing
 Aspergillus: RAST, precipitins, ↑IgE, eosinophilia  RA: anti-CCP, RF, ANA

Spirometry
 Obstructive

HRCT
 Signet ring sign: thickened dilated bronchi + smaller adjacent vascular bundle
 Pools of mucus in saccular dilatations

CXR
 tramlines and ring shadows (bunch of grapes)

Question 20

Management of bronchiectasis

Answer 20

Conservative
 MDT: GP, pulmonologist, physio, dietician, immunologist
 Physio: postural drainage, active cycle breathing, pulmonary rehabilitation

Medical
 Abx
 Exacerbations: e.g. cipro for 7-10d
 May use prophylactic azithromycin
 Bronchodilators: nebulised β agonists
 Treat underlying cause
 CF: DNAase, pancreatin (Creon), ADEK vitamins
 ABPA: Steroids
 Immune deficiency: IVIg
 Vaccination: flu, pneumococcus

Surgical
 May be indicated in severe localised disease or obstruction

Question 21

Organs affected by CF

Answer 21

 Bronchioles → bronchiectasis
 Pancreatic ducts → DM, malabsorption
 GIT → Distal Intestinal Obstruction Syndrome
 Liver → gallstones, cirrhosis
 Fallopian tubes → ↓ female fertility
 Seminal vesicles → male infertility

Question 22

Causes of pleural effusion

Answer 22

Transudate

• CCF
• Renal failure
• ↓ albumin
• Hypothyroidism
• Meig’s syn.

Exudate

• Infection: pneumonia, TB -Ca:1O or2O
• Inflammation: RA, SLE
• Infarction: PE
• Trauma

Question 23

What are the types of lung malignancy?

Answer 23

Non-Small Cell Lung Cancer
SCC: 35%
 Highly related to smoking 
 Centrally located
 PTHrP → ↑ Ca2+

Adenocarcinoma: 25%
 RF: female non-smokers
 Peripherally located
 80% present ̄c extrathoracic mets

Large-cell: 10%

Small Cell Lung Cancer: 20%
       Highly related to smoking
       Central location
       80% present  ̄c advanced disease
       Ectopic hormone secretion

Question 24

Outline the CURB 65 score and how would you interpret the result

Answer 24

Severity: CURB-65 (only if x-ray changes)

 Confusion (AMT ≤8) 
 Urea >7mM
 Resp. rate >30/min 
 BP <90/60
 ≥65

Score
0-1 → home Rx
2 → hospital Rx
≥ 3 → consider ITU

Question 25

How do you treat TB and what are some of the side effects of the drugs?

Answer 25

 RMP: hepatitis, orange urine, enzyme induction
 INH: peripheral sensory neuropathy, ↓PMN
 PZA: hepatitis, arthralgia (CI: gout, porphyria)
 EMB: optic neuritis → loss of colour vision first

Question 26

Causes of obstructive lung disease

Answer 26

Asthma
COPD
Bronchiectasis
Bronchiolitis obliterans
Alpha 1 Antitrypsin deficiency

Question 27

Causes of restrictive lung disease

Answer 27

Pulmonary fibrosis
Asbestosis
Sarcoidosis

Acute respiratory distress syndrome
Infant respiratory distress syndrome
Kyphoscoliosis e.g. ankylosing spondylitis
Neuromuscular disorders
Severe obesity

Question 28

Causes of apical lung fibrosis

Answer 28

C- Coal worker's pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis

Question 29

Causes of lower lobe lung fibrosis

Answer 29

Sarcoid 
Toxins 
Asbestosis
Idiopathic PF
Rheumatological

Most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
Drug-induced: amiodarone, bleomycin, methotrexate

Question 30

Ddx for coarse crackles

Answer 30

Pneumonia
Bronchiectasis (can be mixed)
Pulmonary oedema

Discontinuous, brief, popping sounds. They have also been described as a bubbling sound. More common during inspiration.

Question 31

Ddx for fine end-inspiratory crackles

Answer 31

Fine end-inspiratory crackles are associated with pulmonary fibrosis

Brief, discontinuous, popping sounds that are high-pitched. Similar to wood burning in a fireplace. More commonly heard during inspiration.

Question 32

How can you tell the difference between fine and coarse crackles?

Answer 32

Fine are usually smaller airways and normally on inspiration

Coarse usually on inspiration and expiration and may change if you ask the patient to cough

Question 33

Features O/E of lung collapse?

Answer 33

Trachea deviation towards affected side
Reduced breath sounds
Dull to percussion

Question 34

4 causes of pulmonary hypertension?

Answer 34

Chronic thromboembolic disease/recurrent PEs
Chronic lung disease
Congenital heart disease
Left sided heart disease
HTN

Question 35

Causes of trachea pulled toward the white-out on xray?

Answer 35

Pneumonectomy
Complete lung collapse e.g. endobronchial intubation
Pulmonary hypoplasia

Question 36

Causes of Trachea pushed away from the white-out on xray?

Answer 36

Pleural effusion
Diaphragmatic hernia
Large thoracic mass

Question 37

Causes of trachea central on white-out CXR?

Answer 37

Consolidation
Pulmonary oedema (usually bilateral)
Mesothelioma

Question 38

Causes of exudative pleural effusion?

Answer 38

The Boys In the NYPD Choir were singing Exudate:

TB
Infection (pneumonia, abscess)
Neoplasm
Yellow nail syndrome
PE, Pancreatitis
Dressler's syndrome
Connective tissue: RA & SLE

Question 39

Findings on lung function test of restrictive conditions?

Answer 39

Reduced FEV1
Significantly reduced FVC
Normal/increased FEV1/FVC ratio

Question 40

Findings on lung function test of obstructive conditions?

Answer 40

FEV1 - significantly reduced
FVC - reduced or normal
FEV1% (FEV1/FVC) - reduced