Respiratory Long Case

Question 1

Bronchiectasis (History)

Answer 1

1. Aetiology (congenital, acquired)
2. Presentation
3. Triggers
4. Investigations
   - FBE, ESR
   - IgG levels
   - test for CF
   - sputum culture
   - CXR
   - Pulmonary function tests
   - HRCT
5. Management
   - treat underlying disease
   - general advice - smoking, vaccines
   - physiotherapy
   - postural drainage
   - bronchodilators
   - antibiotics
   - prophylaxis
   - resection, transplantation
6. Complications
   - pneumonia
   - empyema
   - abscess
   - cor pulmonale
7. Impact

Question 2

Cystic fibrosis

Answer 2

1. Diagnosis
   - screening/sweat test
2. Family history
3. Presentation
   - nasal
   - pulmonary
   - pulmonary hypertension
   - gastrointestinal
   - pancreatic
   - diabetes
   - malabsorption
4. Investigations
   - FBE, UEC, LFT
   - sputum
   - CXR
   - HRCT
   - pulmonary function test
   - Hba1c
   - faecal elastase
5. Management
   - CFTR modulators
   - Physiotherapy
   - Inhaled DNAse, hypertonic saline
   - vaccinations
   - oral azithromycin
   - bronchodilators
   - inhaled glucocorticoids
   - inhaled tobramycin
   - treatment of exacerbations
   - croon
   - vitamin supplementation
6. Complications
   - infertility
   - haemoptysis
   - pulmonary hypertension
7. Impact, supports
8. Prognosis
9. Transplantation

Question 3

COPD (History)

Answer 3

1. Risk factors (smoking, occupation, a1AT)
2. Presentation (triggers, MRC dyspnoea scale)
3. Investigations (CXR, HRCT, PFT)
4. Management
   - Confirm Dx/Severity
   - Optimize - ICS/LAMA/LABA, technique, rehab
   - Prevent deterioration - smoking, vaccines, LTOT
   - Develop action plan - antibiotics?
   - eXacerbations - steroids
   Surgical
5. Complications
   Cor Pulmonale
6. Impact
7. Prognosis/transplant

Question 4

Sleep Apnoea (History)

Answer 4

1. Risk factors (obesity, male, neurological)
2. Presentation (ESS, triggers - ETOH, sedatives, associations - HTN, T2RF, pulmonary HTN)
3. Differentials (poor hygiene, shift work, drugs, depression, narcolepsy, idiopathic)
4. Investigations (sleep study, TTE, TSH)
5. Management (weight reduction, address drugs/ETOH, CPAP, surgical)
6. Complications (driving, T2RF)
7. Impact (mood, work)

Question 5

Asthma (History)

Answer 5

1. Diagnosis (how and when)
2. Risk factors (family history, atopy, obesity)
3. Triggers (environmental ie. Cigarettes, Aeroallergens, Pollution, infections, medications, stress, exercise)
4. Severity (frequency of puffer use, PFT, hospitalizations)
5. Investigations
6. Complications (pneumonia, atelectasis, pneumothorax)
7. Management (trigger avoidance, bronchodilators, ICS/LABA, monoclonal antibodies)

Question 6

Sarcoidosis

Answer 6

1. Risk factors
   - age, family history
2. Presentation
   - respiratory - ILD/BHL
   - erythema nodosum
   - uveitis/sicca
   - lymphadenopathy
   - neuropsychiatric
   - fever, weight loss, arthralgia
   - hypercalcaemia
   - cardiac
3. Investigations
   - FBE, ESR
   - serum ACE
   - CXR
   - CT chest
   - pulmonary function test
   - bronchoscopy + biopsy - non caseating granuloma
   - biopsy involved organs
4. Management
   - steroids - 12 months
   - steroid sparing - MTX, aza, HCQ
5. Complications
   - ILD
   - medication SE
6. Outlook

Question 7

Interstitial Lung Disease

Answer 7

1. Diagnosis
2. Risk factors
   - connective tissue disease
   - occupational exposures
   - pets
   - smoking
   - drugs (MTX, nitrofurantoin, amiodarone)
3. Presentation
   - systemic symptoms
   - dyspnoea, cough
   - exercise tolerance
   - extra-pulmonary manifestations
4. Investigations
   - XRAY, HRCT
   - PFTs
   - aetiology biopsy?
   - blood tests
5. Management
   - underlying cause
   - smoking cessation
   - infection prevention
   - treat GORD
   - pulmonary rehab
   - O2 therapy
   - steroids?
   - antifibrotics?
   - monitoring
6. Complications
   - pulmonary hypertension
   - current exercise tolerance
7. Outlook
   - trajectory of illness
   - lung transplantation
   - if end stage - palliative

Question 8

ILD (Examination)

Answer 8

1. Clubbing
2. Signs of systemic disease
3. Signs of severity - pulmonary hypertension
4. Distribution of fibrosis on auscultation
5. Side effect of treatment (steroids)

Question 9

Pulmonary Hypertension

Answer 9

1. Diagnosis
2. Aetiology
   - primary arterial hypertension
   - left heart disease
   - pulmonary disease
   - CTEPH
   - miscellaneous (haematological, vasculitis, sarcoidosis, CKD on HDx)
3. Presentation
   - NYHA class
   - dyspnoea/cough
   - underlying disease
4. Investigations
   - TTE
   - CXR
   - HRCT, PFTs
   - V/Q scan
   - Right heart catheter for confirmation/severity ax
   - 6MWT (predicts survival)
5. Management
   - treat underlying cause
   - oxygen therapy
   - endothelin receptor antagonist, PDE5 inhibitors, iloprost
   - calcium channel blockers
   - diuretics
6. Complications
   - complications of therapy
7. Outlook
   - heart/lung transplant
   - functional ax
   - prognosis

Question 10

Lung Cancer

Answer 10

1. Risk factors
   - smoking
   - occupational
2. Presentation
   - pulmonary symptoms
   - B symptoms
3. Investigations
   - CXR/CT
   - PET/staging
   - bronchoscopy/transthoracic biopsy
   - histology
   - PFT (resectability)
4. Management
   - curative vs non-curative
   - resection/chemo/radiotherapy
   - ?prophylactic cranial radiation
   - ?immunotherapy
5. Complications
   - complications of therapy
   - current symptoms - fatigue, paraneoplastic dx
   - ECOG
6. Impact
   - plan for future/deteriorating function/end of life
   - future treatment plan

Question 11

Tuberculosis

Answer 11

1. Diagnosis
   - how and when diagnosed
2. Risk factors
   - HIV
   - immunodeficiency
   - malnutrition/alcohol
   - country of birth, family history
3. Presentation
   - pulmonary symptoms
   - extra-pulmonary dx
   - acquisition history
4. Investigations
   - latent TB test
   - primary/reactivation TB - TB PCR, sputum culture, pleural biopsy, MDR testing
   - imaging - CT
   - HIV/hepatitis serology
5. Management
   - HRZE (2 mo), HR (4 mo)
   - ?moxifloxacin (MDRTB, CNS TB, or renal/liver issue)
   - drug interactions
   - adherence
6. Complications
   - side effects of medications
   - MDRTB
7. Outlook
   - isolation (2/52 usually)
   - impact on family
   - impact on occupation
   - prophylaxis for family

Question 12

Lung Transplantation

Answer 12

1. Underlying disease/diagnosis
   - indication
   - time on waitlist
2. Transplantation
   - single/double/re-do/multi-organ
   - matching/CMV
   - perioperative course
3. Monitoring
   - rejection
   - infection
   - bronchial anastomosis stenosis
   - biopsies/PFTs
4. Management
   - follow-up
   - medications
   - prophylaxis
5. Complications
   - medication side effects
   - vaccinations
   - bone health
   - malignancy screen
   - CVD profile
6. Outlook
   - impact/success/QOL
   - mental health
   - function
   - recurrence

Question 13

Lung transplant (indication/CI)

Answer 13

1. Indications
   - COPD
   - CF
   - ILD
   - Class III or IV pulmonary hypertension
   - Eisenmenger’s
2. Contraindications
   - age > 65
   - comorbidities
   - uncontrolled infection
   - malignancy
   - colonisation with Burkoulderia, mycobacterium abscesses
   - smoking/EOTH excess
   - increased BMI
   - compliance issues