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Question 1

Bronchiectasis

Medications & Management?

Question 2

Differentials for basal crepitations

Answer 2

Lower zone interstitial lung disease / pulmonary fibrosis
Bronchiectasis - clear on coughing
Pulmonary oedema

Question 3

Causes of ILD/Pulmonary fibrosis

Answer 3

Upper zone:
* Silicosis
* Tuberculosis
* Ank Spond, sarcoidosis
* ABPA, Extrinsic allergic alveolitis
* Radiation

Lower zone:
* Asbestosis
* Rheumatoid arthritis, SLE, scleroderma, Sjogren’s
* Idiopathic pulmonary fibrosis
* Drugs - MTX, amiodarone

Question 4

ILD: Definitive Ix?

Answer 4

High resolution CT scan
* Honeycombing
* Reticular shadowing
* Ground glass
* Volume loss

Question 5

ILD: Management

Answer 5

Conservative
* Smoking cessation
* Remove causative allergen/medication (if applicable)
* Pulmonary rehabilitation
* Claim compensation e.g. asbestos
* Vaccines

Medical:
* Tx underlying cause
* Manage complications - Abx for infective exacerbations
* Steroids
* Immunosuppressants e.g. azathioprine
* Antioxidants e.g. NAC
* Pirfenidone - anti fibrotic
* Long term O2 therapy

Surgical:
* single/double lung transplant

Question 6

Signs of Right HF

Answer 6

Hepatomegaly, ascites
Peripheral oedema
Raised JVP

Question 7

Criteria for steroid Tx in sarcoidosis

Answer 7

Pulmonary fibrosis - symptomatic stage 2/3 +
Uveitis
Neurological involvement
Cardiac - constrictive pericarditis?
Hypercalcaemia

Question 8

Management of scleroderma

Answer 8

Conservative
- Currently no cure: psychological?
- monitor BP, renal function, annual echo, spirometry

Medical
- immunosuppressive regimes: IV Cyclophosphamide (organ involvement, progressive skin disease)
- Anfibrotic tyrosine kinase inhibitor
- ACEi, ARB (prevent renal crisis)

Question 9

Bronchiectasis radiological findings

Answer 9

Signet ring
Tram line and ring shadows (thickened bronchial walls)

Question 10

Bronchiectasis Ix

Answer 10

Sputum: culture

CXR/HRCT

Specialist
Spirometry: obstructive
Bronchoscopy - locate site of haemoptysis, exclude obstruction, obtain samples for culture
Serum immunoglobulins
CF sweat test
Aspergillus precipitins
Skin prick RAST, IgE

Question 11

Management of bronchiectasis

Answer 11

Conservative
- smoking cessation
- physio: airway clearance

Medical
- mucolytics
- Abx (oral ciprofloxacin)
- more than 3 exacerbations = prophylactic Abx

Surgery
- control localised disease or severe haemoptysis

Question 12

Management of stable COPD

Answer 12

Conservative
- smoking cessation
- pulmonary rehab
- flu, pneumococcal vaccines

Medical
1. SABA / SAMA
2a. NO Evidence of steroid responsive? LABA + LAMA
2b. Evidence of steroid responsiveness? LABA + ICS
3. Still Sx? Triple therapy (LAMA + LABA + ICS)?
4. Specialist
- LTOT
- Prophylactic Abx: criteria???

Surgical
- Lung volume reduction, transplant
- indications: recurrent pneumothoraces, isolated bullous disease

Question 13

Indications for LT O2 therapy

Answer 13

Clinically stable non smoker on maximum medical Tx

PaO2 <7.3 on 2 occasions 3 weeks apart
OR PaO2 7.3-8.0 and pulmonary HTN, polycythaemia, peripheral oedema, nocturnal hypoxia

Question 14

Indications for specialist referral

Answer 14

Uncertain diagnosis, suspected severe COPD, rapid decline in FEV1
Cor pulmonale
Bullous lung disease (assess for surgery)
Assessment for oral steroids, nebuliser, LTOT
<10 yr pack history OR age <40yo
Sx disproportional to LFT
Frequent infections (exclude bronchiectasis)

Question 15

Paraneoplastic syndromes in lung cancer

Answer 15

Small cell
- SIADH
- ACTH: Cushing’s syndrome
- Lambert Eaton

Squamous
- PTH-rp

Adenocarcinoma
- hypertrophic pulmonary osteoarthropathy
- gynaecomastia

Question 16

Indications for Chest drain

Answer 16

Drain air, blood, pus

• pneumothorax
• haemopneumothorax - wide bore
• pleural effusion
• empyema