Respiratory

Question 1

5 Respiratory causes of clubbing

Answer 1

1. Lung carcinoma (but usually not small cell)
2. Chronic suppurative lung disease such as bronchiectasis, lung abscess, empyema, CF
3. IPF, asbestosis
4. Mesothelioma
5. Mediastinal diseases such as thymoma, lymphoma, carcinoma

Question 2

Name 5 conditions in which clubbing DOES NOT occur

Answer 2

1. COPD
2. Sarcoidosis
3. Extrinsic allergic alveolitis
4. Coal worker’s pneumoconiosis
5. Silicosis

Question 3

Describe hypertrophic pulmonary osteoarthropathy and its causes

Answer 3

Characterized by presence of periosteal inflammation at the distal ends of long bones, wrists, ankles, metacarpal and metatarsal bones.

Clubbing and associated tenderness in the involved areas.

Causes:

1. Primary lung carcinoma
2. Mesothelioma

Question 4

What is tracheal tug?

Answer 4

When the finger resting on the trachea feels it move inferiorly with each inspiration. This is a sign of gross overexpansion of the chest due to airflow obstruction.

Question 5

3 causes of kyphoscoliosis

Answer 5

1. Idiopathic (80%)
2. Marfans syndrome
3. Poliomyelitis

Question 6

What is thoracoplasty and why was it performed?

Answer 6

Removal of large number of ribs on one side of the chest to achieve permanent collapse of the affected lung. Causes severe chest deformity. Used to be done for TB management but now no longer performed.

Question 7

What indicates a diaphragmatic paralysis on clinical exam?

Answer 7

Paradoxical inward motion of the abdomen during inspiration when the patient is SUPINE.

Question 8

Where is the upper level of the liver on percussion located at during clinical exam?

Answer 8

Usually at 5th rib in the right MCL.

If the chest is resonant below this level, it is a sign of hyperinflation.

Question 9

Describe forced expiratory time

Answer 9

Time taken by a patient to exhale forcefully and completely through the open mouth after taking a maximum inspiration. Usually 3 seconds or less. Note any audible wheeze or cough.

Increased FET indicates airway obstruction.

Question 10

Light’s criteria for pleural effusion

Answer 10

Exudate if:

Pleural/serum protein >0.5
Pleural LDH >2/3 ULN
Pleural/Serum LDH >0.6

Question 11

4 causes of bronchial breath sounds

Answer 11

1. Lobar pneumonia
2. Localized fibrosis or collapse
3. Above a pleural effusion
4. Large lung cavity

Question 12

Causes of bronchiectasis

Answer 12

Divided into congenital and acquired:

1. Congenital:
   CF
   Primary ciliary dyskinesia
   Congenital hypogammaglobulinaemia
2. Acquired:
   - Infections in childhood (TB, pneumonia, measles, whooping cough)
   - ABPA
   - Localized obstruction - adenoma, foreign body
   - RA, sjogrens syndrome
   - Recurrent aspiration

Question 13

Spirometry and suitability for pneumonectomy

Answer 13

If FEV1 >1.5L, this indicates that the patient could tolerate a pneumonectomy. A post operative FEV1 of 1 L or more is usually considered the minimum that will be tolerated.

Question 14

Reversibility in spirometry

Answer 14

Increase in FEV1 OR FVC of 15% and at least 200 mL

Question 15

Differential diagnosis to COPD

Answer 15

1. Asthma - suggested by nocturnal symptoms, rapid response to treatment such as steroids, family history of allergy, eosinophilia in the sputum, reversibility of obstruction
2. Bronchiectasis - daily sputum production recurrent chest infections, clubbing

Question 16

Treatment of alpha 1 antitrypsin deficiency

Answer 16

Can consider replenishing the missing anti-protease which re-establishes antineutrophil elastase protection for the lower lung zones. Administered IV every week or monthly

Usually indicated only if A1AT levels <11 umol/L.

Question 17

When would you consider operative management of COPD?

Answer 17

Consider lung transplant if severe COPD <65 age with no other significant comorbidities without previous thoracic surgery

LVRS are now less performed as lung function continues to deteriorate after resection (despite initial symptomatic benefit), and this operation was combined with an intensive rehabilitation and exercise program which may in itself account for the improvement.

Question 18

Diagnosis of OSA

When is treatment for OSA shown to be effective?

Answer 18

Apnoeic spells >10 seconds and at least 5 events per hour must be recorded over several hours

Mild = 5 - 15
Moderate 16-30
Severe = >30

PaO2 monitoring over night can also be considered in patients with typical features of the condition - a positive test (several significant desaturation episodes/hr) is enough to justify treatment, however negative result does not rule out the diagnosis.

Treatment for OSA is effective in at least moderate OSA (AHI >15) - reduces symptoms, improves blood pressure and quality of life. In milder OSAs, it does improve daytime somnolence but less evidence of QoL or cognitive impairment improvement, and no evidence of impact on BP.

Question 19

Causes of pulmonary infiltrates and eosinophilia

Answer 19

PLATE:

Prolonged pulmonary eosinophilia due to drugs (sulphonamides, sulfasalazine, penicillin, isoniazid)

Loeffler’s syndrome

ABPA

Tropical (microfilaria)

EGPA

Question 20

Complications of cystic fibrosis

Answer 20

GI - difficulty maintaining weight, pancreatic insufficiency, constipation, bowel obstruction (due to defective water excretion into the bowel)

Heat exhaustion in hot weather - loss of large amount of salt in their sweat

Cardiac - cor pulmonale

Jaundice and variceal bleeding - focal biliary cirrhosis and PTHN can occur

Diabetes

Resp: major haemoptysis requiring bronchial artery embolization

Azoospermia in male leading to infertility

Question 21

Diagnosis of CF

Answer 21

Sweat chloride >70 mmol/L suggests CF in adult

Question 22

Management of CF

Answer 22

1. Intensive and repetitive physiotherapy, use of flutter valve, postural drainage
2. Influenza/pneumococcal vaccine
3. Assessment and management of malabsorption - pancreatic enzyme supplements, vitamin supplements, frequent small meals
4. dornase alfa nebulizers (Human recombinant DNAse) to help degrade the concentration of DNA in the sputum reducing sputum viscosity and allow better clearance of pulmonary secretion.

Question 23

Indications for lung transplantations in COPD, CF/bronchiectasis, ILD, pulmonary hypertension

Age criteria for lung transplant:

Answer 23

COPD - FEV1 <25% predicted, PaCO2 >55 mmHg

CF/Bronchiectasis - FEV1 <30% or complications such as cachexia, severe haemoptysis, or PacO2 >50mmHg, PaO2 <55mmHg

ILD - progressive symptoms, DLCO <60%

Pulmonary hypertension - NYHA class III or IV symptoms, pulmonary artery pressure >55 mmHg

Age criteria:
Unilateral <65
Bilateral <60
Heart and lung <55

Question 24

Complications post lung transplant

Answer 24

1. Rejection - early rejections are common and treated with prednisone. Symptoms of early rejection include malaise, fever, dyspnoea and cough. Transbronchial biopsy is performed if there are any suspicion of rejection and to allow accurate diagnosis.
2. Infection - most common cause of death due to combination of immunosuppression, impaired ciliary activity. Commonly CMV, adenovirus, influenza A. Patients now receive routine 3 months prophylactic antibiotics, antiviral and antifungal treatment.
3. Immunosuppressant side effects- metabolic complications, osteoporosis, peripheral neuropathy.
4. Bronchiolitis obliterans - more common with burden of acute rejection episodes and HLA mismatch. Gradual onset dyspnoea, fatigue and cough.
5. Disease recurrence - sarcoidosis, idiopathic ILD.

Question 25

UIP vs NSIP pattern

Answer 25

UIP pattern

1. Subpleural and basal predominance
2. Reticular abnormality
3. Honeycombing and traction bronchiectasis

NSIP pattern

1. Immediate subpleural sparing
2. Ground glass opacities
3. Traction bronchiectasis