Respiratory

Question 1

Types of lung cancer

Answer 1

Small cell vs NSCLC
NSCLC:
- Squamous most common
- Adeno - classically nonsmoker
- Large
Small cell often metastatic at presentation, almost all smoking

Question 2

Small cell lung cancer management

Answer 2

• Few surgical options given usually presents with advanced disease
• Therefore chemo+/-immunotherapy
• Some evidence for prophylactic cranial irradiation
• Small cell often produces polypeptide hormones e.g. ACTH

Question 3

Lung cancer pathology options

Answer 3

• Sputum cytology (very low sens, better w central lesions)
• VATS
• Bronchoscopy + direct or EBUS. EBUS better for staging as lesion + nodes can be accessed
• Transthoracic needle asp.

Question 4

Lung cancer central vs peripheral lesions

Answer 4

Central - squamous, small, large
Peripheral - Adeno

Question 5

eGFR mutation in lung cancer relevance

Answer 5

• Site for targeted TK targeted therapy
• More likely positive in low/no smoking pts

Question 6

ECOG performance status

Answer 6

Eastern Coop Onc group
0 - Fully active
5 - deceased

Question 7

VATS indications

Answer 7

Wedge resection (good for benign lesions e.g. aspergillus)
Bullectomy
Lung biopsy
Recurrent PTx
Lobectomy

Question 8

VATS vs thoracotomy scars

Answer 8

Thoracotomy:
- Large (15-20cm) lateral chest wall scar
- Possibly drain scar also
VATS
- 3 scars that triangulate
- 3-6cm scar on lateral wall largest

Question 9

Benefits of VATS over thoracotomy

Answer 9

Smaller incision -> reduced healing time, bleeding

Question 10

Lobectomy indications

Answer 10

Lung cancer
Aspergilloma
TB

Question 11

Lobectomy/pneumonectomy workup

Answer 11

PFTs inc transfer factor and exercise testing.
FEV1 >1.5L for lobectomy, >2L for pneumonectomy
VO2 max >15ml/kg/min

Question 12

Respiratory causes of clubbing

Answer 12

• Lung cancer
• Chronic suppurative conditions - bronchiectasis, abscess, CF
• Interstitial lung disease

Question 13

Signs to distinguish lobectomy from pneumonectomy

Answer 13

Pneumonectomy:
- trachea deviated
- unilateral reduced expansion
- dull hemothorax
- absent tactile fremitus beneath the scar
- Bronchial breathing in upper zones may be present
Lobectomy:
- Trachea central if old
- Lower - dull lower zone with abs breath sounds
- Upper - Hyper-resonant upper zone

Question 14

Single lung transplant indications

Answer 14

“Dry lung”
- COPD
- Fibrosis

Question 15

Double lung transplant indications

Answer 15

“Wet lung”
- CF
- Bronchiectasis
- Pulmonary hypertension

Question 16

VATS indications resp

Answer 16

• Lung resection (wedge/lobe/segment)
• Bullectomy
• Pleural drainage/pleurodesis
• Diagnostic

Question 17

PTx management

Answer 17

Asymptomatic - nothing
High risk features - chest drain if >2cm
Symptomatic, no HRF, sufficient size - aspirate, drain or conservative

Persistent >24-48h? Recurrent? Consider pleurodesis/pleurectomy

Question 18

PTx high risk features

Answer 18

• Sig desat
• HD instab
• Bilat
• Underlying lung disease
• Haemoptx

Question 19

Asthma chronic management

Answer 19

1- AIR therapy - anti-inflammatory reliever (formoterol/ICS) PRN
2 - MART - same inhaler regular
3 - MART higher dose
4 - Ref to specialist or LTRA (montelukast) or LAMA (e.g. tiotropium)

Question 20

Role of FeNO in asthma diagnosis

Answer 20

• FeNO = Fraction exhaled nitric oxide
• NO in parts per billion
• Raised NO demonstrates airway inflammation as inflammatory cytokines induce NO synthase. NO has a role in negative feedback of bronchoconstriction
• > 50ppb supportive of asthma dx

Question 21

Asthma investigation

Answer 21

(Progress if each step normal)
1 - Eosinophils or FeNO
2 - Spirometry (FEV1:FVC<0.7) with reversibility
3 - PEFR diary with variability (>20%)
4 - Bronchial challenge

Question 22

BTS asthma spirometry results

Answer 22

• Reversibility PEFR 12% and FEV1 200ml more than baseline