Académique Documents
Professionnel Documents
Culture Documents
Dr Anand V Joshi
Pulmonary Medicine
ANATOMY AND
PHYSIOLOGY
Introduction
For effective gas exchange
A. Lungs
B. Neuronal Input
C. Muscles of the chest wall
D. The circulatory system
Tracheobronchial Tree
Pulmonary vasculature
Ans: The V:Q ratio is greater in apical than basal segments of the lung
when upright and at rest.
Mediastinum
www.radiologymasterclass.co.uk
nswer: Consolidation of the left lower lobe will elevate the left hemidiaphragm
Ans: Bronchoscopy
LUNG FUNTION
Spirometry
DLCO
VO2(Exercise testing)
Methacholine challenge
(Bronchoprovocation tests)
Polysomnography
Overnight oximetry
ECG, 2-D Echo
Spirometry
Helpful in differentiating between obstructive and
restrictive lung disorders
Grading severity
Detecting early lung disease
Assess the effect of medication (reversibility)
Measure progress in disease treatment
As a part of pre aesthetic checkup
Parameters
FVC
FEV1
FEV1/FVC or FEV1/FVC
PEFR
FEF 25-75
VT, TLC, RV, FRC
Interpretation
FEV1/FVC < 80% - obstructive
FEV1/FVC < 80% & > 65% - Mild
obstruction
< 65% & > 50% - Moderate
< 50% & > 35% - Severe
< 35%
- Very severe
Interpretation
FEV1 is reduced due to decreased airflow, in turn due to
narrowed airways
FVC is also reduced, as gas is trapped behind the
narrowed bronchi
FEV1 < 1 lit is likely to have dyspnoea
FEV1 < 0.5 lit is likely to be breathless at rest & possibly
respiratory failure
FEV1 < 2 lit is unlikely to cause breathlessness due to
airway disease, except on vigorous excercise
Interpretation
FEV1/FVC > 100% Restrictive defect
Lung volumes to evaluate for Emphysema
PFT only gives a pattern
To be correlated by the physician
Spirometry
Spirometry
Spirometry
Spirometry
Characterizes the lesion:
A-Location of the lesion:
Intrathoracic
Extrathoracic
B-Behavior of the lesion during rapid inspiration and expiration:
Fixed
Variable
Variable Intrathoracic Lesion: Tracheomalacia & Intratracheal tumor.
Variable Extrathoracic Lesion: Vocal cord paralysis, Goiter, and Tumor
Intra or Extrathoracic Fixed Lesion: Tracheal stenosis & surgical stricture, and
compressing mass.
Spirometry
Spirometry
DLCO
DLCO measures the ability of the lungs to
transfer gas from inhaled air to the red blood
cells in pulmonary capillaries
The DLCO is designed to reflect properties of
the alveolar-capillary membrane
Strong affinity of Hb for CO, combined with
the enormous capacity of the red cell mass to
absorb CO, make the uptake of CO less
dependent on cardiac output.
Uses
DD of airways obstruction & lung volume
restriction
Screening for mild (early) interstitial lung
disease (ILD)
Detection of pulmonary vascular disease
Disability/impairment evaluations for ILD or
COPD
Follow-up for ILD/ Need for o2 therapy
1.6 L
pH
7.35
paCO2
6kPa (45mmHg)
paO2
7.2kPa (55mmHg)
69) A 60-year-old female presents with recent onset dyspnoea and noisy
breathing.
Her chest x ray showed right deviation of the trachea due to a retrosternal
goitre.
Which of the following tests is most useful in the assessment of airflow
obstruction due to the goitre?
a) Flow volume curve
b) Forced expiratory flow volume in one second
c) Forced vital capacity
d) Peak expiratory flow rate
e) Residual volume
A 19-year-old man with recurrent admissions to hospital for exacerbations of his asthma attends
the Emergency department with a short history of increasing breathlessness and cough.
On examination he is obviously dyspnoeic and wheezy and becoming exhausted. His respiratory
rate is 16 breaths per minute, his HR is 125 bpm (sinus tachycardia) and his PEFR is 30%
predicted.
An arterial blood gas is taken and the results are as follows:
pH - 7.43 (7.36-7.44)
pO2 - 7.3 kPa (11.3-12.6)
pCO2 - 5.2 kPa (4.7-6.0)
Using the details above what severity is this patient's exacerbation?
A.
B.
C.
D.
E.
ASTHMA
Definition
Asthma is a chronic inflammatory
disease of the airways characterized
by
1)variable and recurring symptoms
2)reversible airflow obstruction
3)bronchospasm
Spirometry
Other tests
CXR
2-D ECHO
Skin atopy
IgE Rast to common allergens
Newer tests; exhaled nitric oxide,
breath condensate cytokines, and
analysis of induced sputum
Differential
Vocal Cord Dysfunction -involuntary closure
of the vc, during inspiration
Central airway obstruction- goitre, vascular
rings
COPD
Bronchiectasis
ABPA
Cardiac asthma
Pulmonary Embolism
Sarcoidosis
Allergic alveolitis
Eosinophillic syndromes
Exercise-induced asthma
Episodic bronchoconstriction following exercise
Prevalence varies from 7 to 20% in the general and
upto 80% in asthmatics
Minute ventilation rises with exercise
Triggered by the large volume of relatively cool & dry
air inhaled during vigorous activity.
Occupational asthma
Work place - immunologic or non-immunologic stimuli
Reactive airways dysfunction syndrome (RADS) or irritant-induced
asthma
5 to 25% of adult asthma
Low molecular wt. (Isocyanates) and high molecular wt. (flour)
antigens
Intensity of exposure, antigen property, host factors, such as atopy,
cigarette smoking, and genetic predisposition
Spirometry at work place and during the day-off
Stepwise Tx
38) Which one of the following is correct regarding long acting beta-2
agonists?
a) Are beneficial in acute viral croup.
b) Become less effective over time (tolerance).
c) Can be used to prevent activity-induced symptoms
d) Protect against allergen challenge for up to 48 hours.
e) Should not be used in association with erythromycin.
60) A 15-year-old boy presented with wheezing when playing football and
nocturnal cough.
Which is the best test to confirm the underlying condition?
a) A trial of inhaled corticosteroids
b) A trial of inhaled salbutamol
c) A trial of oral corticosteroids
d) Serial peak expiratory flow rate measurements
e) Spirometry alone
73) An elderly man with a history of asthma, congestive heart failure, and
peptic ulcer disease is admitted with bronchospasm and rapid atrial
fibrillation.
He is given nebulised salbutamol frequently, a loading dose of oral digoxin,
and oral prednisolone. His regular medications are continued. 24 hours after
admission his plasma potassium is noted to be 2.8 mmol/l.
Which of his medications is most likely to have caused this abnormality?
a) ACE inhibitor
b) Digoxin
c) Ranitidine
d) Salbutamol
e) Spironolactone
Ans: Salbutamol
COPD
Definition
CLINICAL PRESENTATION
History
Physical Findings
Predominant emphysema
"pink puffers, thin and
noncyanotic at rest and have prominent use of accessory
muscles
supplemental
RISK FACTORS
Cigarette Smoking
CXR
Characteristic features in lung parenchyma
Rapidly tapering vascular shadows
Increased radiolucency of the lung
Flat diaphragm
Long, narrow heart
Increased retrosternal airspace on a lateral
radiograph
Bullae are due to locally severe disease
Prominent hilar vascular shadows
Cardiac enlargement due to pulmonary hypertension
and cor pulmonale (secondary to hypoxia
CT
CT has greater sensitivity and specificity for
emphysema, but not chronic bronchitis
Centriacinar emphysema - preferentially in the
upper lobes
Panacinar emphysema - involves the lung
bases and involves the entire secondary
pulmonary lobule
Centri-acinar
Pan-lobular
Bullae
Interpretation in COPD
FEV1/FVC ratio less than 0.70
Severity
Symptoms
Spirometry
At Risk
Mild
IIA
Moderate
III
Severe
IV
Very
Severe
Management
The only intervention which has proven
benefit in arresting the disease is
smoking cessation
The fall in lung function
stabilises/plateaus when patient quits
smoking
Mx of Exacerbation
Controlled O2 inhalation (risk of CO2 retention secondary to lack
of hypoxic drive)
Antibiotics (sputum c/s), Steroids
Nebulised bronchodilators
Non-invasive ventilation (BiPAP)
Invasive mechanical ventilation
8.5kPa
(4.7-6.0)
PH
7.3
(7.36-7.44)
21) In which of the following have randomised controlled trials shown that
long term oxygen therapy (LTOT) reduces mortality?
a) Asthma
b) Cor pulmonale due to chronic airflow obstruction
c) Cryptogenic fibrosing alveolitis
d) Cystic fibrosis
e) Pulmonary sarcoidosis
The reduction in birth weight is related to the number of cigarettes smoked per
Bronchiectasis
Definition
Etio-pathogenesis
Congenital
Acquired
Congenital
Ciliary dyskinetic syndrome
Young syndrome
Cystic fibrosis
William campbell syndrome (Bronchomalacia)
Mounier-kuhn syndrome
Swyer James syndrome
Yellow nail syndrome
Acquired
Types
Cylindrical
Follicular
Cystic
Wet & Dry (Bronchiectasis sicca)
Clinical features
Persistent cough with mucopurulent sputum
Haemoptysis, sometimes massive (bronchial arterial
bleed)
SOB
Wheeze
Pleuritic pain
Weight loss/fever/weakness/tiredness
Clubbing
Cyanosis & plethora
Mid-inspiratory crackles (localized)
Severe case with cor pulmonale & RVF
Spirometry
Obstruction
Restrictive defect
Combined
Special tests
Sweat chloride test for CF
Genetic analysis for CF
Saccharin test for ciliary dyskinesia
Electron microscopy of sperm tail & cilia
Peripheral eosinophillia
Serum IgE, Aspergillus precipitins
Radiology
CXR;
1) Sensitivity < 50%
2) Evidence of dilated bronchi
3) Appearance consistent with volume
loss
4) Ring Shadow (End-on view),
5) Signet ring appearance
6) Parallel line (Tram track appearance)
CT
Gold standard
HRCT
1 to 1.5 mm cuts
Better localisation
Replaced bronchography
Treatment
Antibiotics
Check for Pseudomonas colonisation
Gram ve cover (Ceftazidime, Ciprofloxacin)
Gram +ve cover (Amox+clavulanic acid)
Prolonged course; 2 weeks, preferably IV
Nebulised Tobramycin for prevention and long term
Cyclical antibiotics (3 antibiotics, alternating every
month)
Surgery
Localised disease
Destroyed lobe
Haemoptysis (recurrent and massive)
Colonisation with resistant organisms like MAI
complex
40) The parents of a child with cystic fibrosis (CF) consult you wishing to
know what is the risk of their next child being a carrier of the condition.
Which one of the following percentages is the correct risk?
a) 0%
b) 25%
c) 50%
d) 75%
e) 100%
Ans: 50%
61) A 68-year-old man presents with a one month history of dyspnoea and a 3
kg weight loss.
On examination there were signs of a large left pleural effusion, confirmed on
chest x ray.
Pleural fluid analysis revealed:
Protein
38 g/L
Cytology
Infection Pneumonia,
empyema, pleuritis, viral disease
Autoimmune Rheumatoid,
SLE
Vascular PTE
Cardiac Pericarditis,
CABG
Respiratory Haemothorax,
Chylothorax
Abdominal Subphrenic
abscess
Transudate (systemic illness)
(Low protein <30g).
Liver Ascites,
Cirrhosis
Renal
Glomerulonephritis,
Nephrotic syndrome
Ovarian Meigs
syndrome
CURB-65 score
C: confusion present (abbreviated mental test score <8/10)
U: (plasma) urea level >7 mmol/L
R: respiratory rate >30/min
B: systolic BP <90 mmHg; diastolic BP <60 mmHg
65: age >65
1 point for each of the above:
Score 01: Treat as outpatient
Score 2: Admit to hospital
Score 3+: Often require ICU care
Mortality rates increase with increasing score.
Other markers of severe community- acquired pneumonia
Chest X-ray: more than one lobe involved
Other co-morbidities
Pharmacology of penicillins
Mechanism of action
Penicillins comprise a - lactam ring which binds this transpeptidase required for cross linking
peptidoglycans, thus inhibiting cell wall production.
Uses
Four groups:
1. Standard penicillin (e.g. benzyl penicillin, phenoxymethyl penicillin) : streptococcus ( pneumonia
and sore throat)
2. Antistaphylococcal penicillin (e.g. flucloxacillin): staphylococcal pneumonia.
3. Aminopenicillins (e.g. ampicillin, amoxicillin) : Broad spectrum (Gram-ve + Gram+ve). Used to treat
CA-LRTI/URTI (e.g. infective exacerbation of COPD, community-acquired pneumonia).
4. Antipseudomonal penicillins (e.g. piperacillin, azlocillin) : Broader spectrum with pseudomonas
included. (e.g. in patients with cystic fibrosis or with hospital-acquired pneumonia)
Pharmacokinetics
Water soluble; hence given intravenously.
. Rapidly excreted by the kidney, hence usually given at least 34 times daily.
Main side-effects
. Hypersensitivity ; Gastrointestinal upset
. Clostridium difficile diarrhoea (aminopenicillins)
. Rash in patients with EpsteinBarr virus infection (aminopenicillins)
nswer: A positive tuberculin skin test develops within two weeks of infection
Primary tuberculosis
When M. tuberculosis reaches the pulmonary alveoli it:
Invades alveolar macrophages and replicates
Is taken up by (but does not replicate in) dendritic cells and is transported to local lymph nodes
A few bacteria may escape into the blood stream
Infection causes a local inflammatory reaction at infected sites and forms granuloma that contains the
infection. THIS IS PRIMARY INFECTION
Possible outcomes at this stage include:
Eradication of infection and healing, sometimes with calcification
Latent infection - immune system develops memory cells (2-10 weeks from Primary infection)
Failure of the immune process, resulting in widespread dissemination throughout the body, causing
miliary TB
In the lung, the site of primary infection is the periphery of the lung (subpleural) in the mid or upper
zones.
Ghons focus - The small area of granulomatous inflammation seen on chest X-ray
Ghons complex - conjunction with hilar lymphadenopathy.
A patient with primary TB is usually not unwell and may not know they have been infected until they
have a chest X-ray or develop postprimary TB. They are not infectious.
Reactivation tuberculosis
The majority of TB cases are due to reactivation
of latent infection.
The initial contact usually occurred many years or
decades earlier.
In patients with HIV infection newly acquired TB
infection is also common.
Factors implicated in the reactivation of latent TB
HIV co-infection
Immunosuppressant therapy
Diabetes mellitus
End-stage chronic kidney disease
Malnutrition
Ageing
Diagnosis of Active TB
Diagnosis of Latent TB
Tuberculin skin test (TST)
A positive result is indicated by a delayed hypersensitivity reaction evident 4872 hours after the
intradermal injection of purified protein derivative (PPD) resulting in:
1. A raised indurated lesion >6 mm diameter in non- vaccinated adults
2. A raised indurated lesion >15 mm in BCG-vaccinated adults.
False negative (anergic) TSTs :Immunosuppression , HIV infection (CD4+ <200/mm3), sarcoidosis,
drugs (chemotherapy, anti-TNF therapy, steroids), extremes of age.
False positives : Cross-reactivity with non-tuberculous mycobacteria (NTM) and BCG vaccination.
Interferon-gamma release assays (IGRAs)
. IGRAs detect T-cell secretion of interferon-gamma (IFN-) following exposure to M tuberculosisspecific antigens (ESAT-6, CFP-10,).
. The test does not differentiate between active and latent infection.
. However, it is highly specific compared with the TST and has a similar or better sensitivity.
Ans: Tuberculosis
People who should be treated for latent TB infection (after excluding active
TB)
People aged 35 years with positive TST or IGRA
Healthcare workers with positive TST or IGRA
Patients commencing anti-TNF therapy with positive IGRA HIV-positive
people with positive IGRA
People with evidence of previous TB on chest X-ray and
inadequate treatment.
64) A 28-year-old man who had been diagnosed two weeks previously with
tuberculosis of the mediastinal lymph nodes and who had been started on
chemotherapy with rifampicin, isoniazid and pyrazinamide was admitted
because of the increasing dyspnoea and stridor.
Chest x ray showed compression of both main bronchi by carinal lymph node
enlargement.
What is the next step in management?
a) Mediastinoscopy and biopsy
b) Refer for tracheal stent insertion/tracheostomy
c) Refer for urgent CT scan of the mediastinum
d) Start corticosteroids
e) The addition of ethambutol
66) A 28-year-old man had been treated for pulmonary tuberculosis with
rifampicin, isoniazid, pyrazinamide and ethambutol for four weeks.
Pre-treatment liver function tests (LFTs) were normal but his most recent
investigations revealed:
Serum total
98 mol/l (0-18)
bilirubin
Serum alanine
620u/l
(5-45)
aminotransferase
Serum aspartate
450 u/l
(5-45)
aminotransferase
Serum alkaline
720 u/l
(40-110)
phosphatase
Which one of the following is the most appropriate next step?
a) Stop all treatment
b) Stop ethambutol
c) Stop isoniazid
d) Stop pyrazinamide
e) Stop rifampicin
Ans: Stop all treatment
Investigations :
Management :
LYMPHADENOPAT
HY
58) A 26-year-old man with a history of alcohol and drug abuse was
admitted with a 14 day history of fever, cough and fatigue.
He was emaciated. His temperature was 39.4C. Cervical and axillary
lymphadenopathy were present. Chest x ray revealed bilateral areas of
pulmonary shadowing.
Which of the following is the most likely diagnosis?
a) Alcoholic cardiomyopathy
b) Pneumococcal pneumonia
c) Pneumocystis pneumonia
d) Pulmonary tuberculosis
e) Tricuspid endocarditis
Pneumocystis jiroveci
Pneumocystis pneumonia (PCP) is one of the most common opportunistic infections.
It affects Immunosuppressed - long-term corticosteroids, monoclonal antibody therapy, methotrexate
for autoimmune disease, post-solid organ transplantation or stem cell transplantation, HIV; those at
particular risk have CD4 counts <200/mm3.
Pneumocystis jiroveci is found in the air, and pneumonia arises from re-infection rather than
reactivation of persisting organisms acquired in childhood.
Clinically, the pneumonia with a high fever, breathlessness and dry cough, rapid desaturation on
exercise or exertion.
The typical CXR is of a diffuse bilateral alveolar and interstitial shadowing - butterfly pattern, Other
includes localized infiltration, nodules, cavitation , pneumothorax, or Photo negative X-ray .
Diagnosis should be confirmed by indirect immunofluorescence on induced sputum or
bronchoalveolar lavage fluid.
First-line treatment of PCP is with high-dose co-trimoxazole . Respiratory failure responds very
well to steroids.
Ans: Histoplasmosis
CAVITY IN LUNG
Cancer
Autoimmune (Wegeners, RA)
Vascular (septic emboli)
Infectious (Tb, Abscess)
Trauma
Young (bronchogenic cyst, laryngotracheal
papillomatosis)
59) What is the most likely cause of upper lobe fibrosis on chest x ray?
a) Ankylosing spondylitis
b) Cryptogenic fibrosing alveolitis
c) Rheumatoid arthritis
d) Scleroderma
e) Systemic lupus erythematosus
B roncho-pulmonary aspergillosis
R adiation fibrosis
E xtrinsic allergic alveolitis
A nkylosing spondylitis
S ilicosis
T uberculosis
X Histiocytosis-X
Whatcausesahoarsevoice?
Soundismadeduringspeechbychangesinair
pressureinthelarynx,whichcausethevocalcords
tosnaptogether.Ahoarsevoicecanbecausedby
thefollowing.
Laryngealorvocalcordlesions
Laryngitis(e.g.viralinfection,
smoking,acidreflux)
Voiceoveruse
Inhaledsteroids
Vocalcordnodules
Laryngealcarcinoma
Damagetonervesthatsupplythelarynx
Lungcancer
Thyroidsurgery
Thyroidcancer
Dissectionofthethoracicaorta
from the head and upper limbs to the heart. Causes facial congestion, upper limb oedema and headaches. (S
on of the pupil of the eye on the affected side (miosis).Sunken eye (enophthalmos) and reduced sweating of t
Mostly localised
Adenocarcinoma and Large cell carcinoma
presents at peripheral nodule or masses
squamous-cell carcinoma is the most common
to cavitate, followed by adenocarcinoma and
large cell carcinoma.
Multiple cavitary lesions are rare,seen in
multifocal bronchoalveolar cell carcinoma.
Responds poorly to chemotherapy .
Surgery can be curative for patients with
localized disease
Mostly disseminated
Typically central mass
Small cell carcinoma is never known to
cavitate.
Grows fast, therefore initially is responsive to
chemotherapy.
Metastasizes early, therefore surgery has no
role in the management of this condition
74) A 58-year-old man presents with weight loss and haemoptysis. He has
smoked most of his life.
On examination he is clubbed and has clinical evidence of right pleural
effusion. His serum calcium is 3.2 mM (2.2-2.6 mmol/l). A bone scan is normal.
From which of the following histological type of lung cancer is he most likely to
suffer?
a) Adenocarcinoma
b) Large cell carcinoma
c) Mesothelioma
d) Small cell carcinoma
e) Squamous cell carcinoma
Active cigarette smoking ,Overall, the risk of lung cancer is increased 13 times. A
person who has a 40 pack year smoking history over 20 years has a 6070 times
greater risk of lung cancer than a non-smoker.
Risk factors for lung cancer other than active cigarette smoking
Environmental smoke exposure (passive smoking)
Marijuana and cocaine smoking
Occupational carcinogens, including: asbestos arsenic chromium petroleum products and tar
Why Smoking ?
Bronchi are normally lined by cuboidal epithelium. If the epithelium is subjected to
repeated damage or irritation (e.g. by cigarette smoking) it may change its form to
squamous epithelium to withstand this (metaplasia). Early malignant changes
(dysplasia) may arise during this process which may progress to cancer (neoplasia)
Small cell lung cancer arises from endocrine cells in the lung which are
members of the APUD system (amine precursor uptake and
decarboxylation).
Small cell tumours comprise 2030% of lung cancers and are rapidly
growing and highly malignant.
These tumours have usually metastasized, either overtly or occultly, at the
time of presentation.
As the tumour cells have an endocrine origin they often secrete hormones
which have systemic effects.
47) A 60-year old man with a history of non-small cell lung cancer was treated
with a right lower lobectomy 12 months ago.
He had an chest and abdominal CT scan one month ago which revealed
hepatic mass lesions and hilar lymphadenopathy. He now presents with
malaise and fatigue.
Protein +++ His results show:Urinalysis
24 hour urine
2.7 g/24hr
protein
Serum urea
30 mmol/L
(2.5-7.5)
Serum creatinine
450 mol/L
(60-110)
A renal biopsy shows focal deposition of IgG and C3 with a granular pattern.
What is the most likely diagnosis?
a) Goodpasture's syndrome
b) Membranous glomerulonephritis
c) Minimal change glomerulonephritis
d) Nodular glomerulosclerosis
e) Rapidly progressive glomerulonephritis
Lien, Y.-H. H. & Lai, L.-W. (2010) Pathogenesis, diagnosis and management of paraneoplastic glomerulonephritis
Nat. Rev. Nephrol. doi:10.1038/nrneph.2010.171
y, clinically evident N2 disease (discovered preoperatively) and IIIB disease that can be inc
( if performance status and general medical condition are reasonable)
ollowed by RT,
53) In which of the following cases of lung cancer would surgical resection of
the tumour be a reasonable therapeutic option?
a) A 56-year-old woman with an adenocarcinoma of the right lung. CT scan
shows enlarged lymph nodes in the right and left hilum. PFTs show an FEV1
of 2.25 L. (55% predicted).
b) A 59-year-old man who is found at bronchoscopy to have a tumour in the
right mainstem bronchus extending to within 1 cm of the carina. Pulmonary
function tests (PFTs) show an FEV1 of 2.1 litres (65% of predicted normal).
c) A 62-year-old lady with a small peripheral mass who has elevated liver
enzymes and a computed tomography (CT) scan showing probable metastatic
deposits in the liver. Lung function tests show an FEV1 of 3.5 litres (80% of
predicted normal).
d) A 70-year-old man with a right lower lobe tumour 2 cm in diameter with no
evidence of regional adenopathy or distant spread of disease. Lung funcion
studies show an FEV1 of 0.8 litres (28% predicted).
e) A 71-year-old man with a 3 cm tumour obstructing the right lower lobe
bronchus. Lung function tests show an FEV1 of 2.1 L. (60% predicted).
Ans: A 71-year-old man with a 3 cm tumour obstructing the right lower lobe
bronchus. Lung function tests show an FEV1 of 2.1 L. (60% predicted).
ns: Overall lung cancer survival is less than 15% at five years.
Prognosis
Unfortunately, compared with some other types of cancer, the outlook for lung
cancer is not very good.
The statistics we have here are for all types of lung cancer in England and
Wales.
Overall, 30% will survive for 1 year or more after they are diagnosed.
Around 10% will survive for 5 years or more.
And about 5% will survive for 10 years or more after they are diagnosed.
Pleural plaques :
These are benign calcified patches of pleural
thickening.Usually asymptomatic.
Asbestosis :
Mild to moderate symptomatic Inflammation and
fibrosis of the lung parenchyma ; Occurs 2030
years after exposure.
Lung cancer :
Asbestos exposure increases the risk of small
cell and non-small cell lung cancer by several
times in both smokers and non-smokers
Pleural mesothelioma :
Highly malignant Pleural tumour with Mean
survival from diagnosis is 814 months.
Mean time interval is 41 years
sensitivity pneumonitis
spread diffuse inflammatory reaction in both the small airways of the lung and the alveoli.
en triggers, like microbial spores contaminating vegetable matter (e.g. straw, hay, mushroom compost).
rette smokers have a lower risk of developing the disease due to decreased antibody reaction to the ant
lly fever, malaise, cough and shortness of breath come on several hours after exposure to the causative
e end- inspiratory crackles and wheezes throughout the chest.
res of idiopathic pulmonary fibrosis
Investigations
Chest X-ray : Fluffy nodular shadows, streaky shadows, in the upper zones. Later, honeycomb lung occurs.
High-resolution CT : Reticular and nodular changes with ground glass opacity.
Lung function tests : Restrictive ventilatory defect with a decrease in carbon monoxide gas transfer.
Peripheral smear : PMN leucocyte count is raised in acute cases. Eosinophilia is not a feature.
Blood Antibodies : Poor specificity. Pigeon fanciers have precipitating IgG antibodies against pigeon protein
and droppings . Precipitating antibodies are evidence of exposure, not disease.
Bronchoalveolar lavage : Increased T lymphocytes and granulocytes.
Ans: Methotrexate
Ans: Amiodarone
Hoarseness
( Pneumoconiosis - coal
worker, asbestosis,
silicosis + Rheumatoid
lung disease )
Asymptomat
ic
is means the accumulation of dust in the lungs and the reaction of the tissue to its presence. It is main
plant material is ensiled, it begins to ferment. Oxygen used in fermentation combines with nitrates in the
Extrinsic Allergic Alveolitis aka Hypersensitivity pneumonitis. Predominantly involve apices, but
other areas are also involved, causing wide spread end inspiratory crackles and wheeze.
Typically fever, malaise, cough and shortness of breath come on several hours after exposure to
the causative antigen. Thus, a farmer forking hay in the morning may notice symptoms during the
late afternoon and evening with resolution by the following morning.
It is more common for the individuals to trigger asthma from inhalation of antigens from a variety
of mites that infest stored grain and other vegetable material.
Ans: Sulphasalazine
Investigations
Chest X-ray - glass appearance, irregular reticulonodular shadowing (in the lower zones) and a
honeycomb.
High-resolution CT scan (HRCT) bilateral changes involving the lower lobes. Subpleural reticular
pattern, ground glass, honeycombing,thick-walled cysts 0.52 cm in diameter in terminal and
respiratory bronchioles, and traction bronchiectasis.
Respiratory function tests : Restrictive pattern with reduced FVC, the FEV1 to FVC ratio is normal
to high (with both values being reduced). DLCO reduced. PEFR may be normal.
Blood gases : hypoxaemia, with normal or low PaCO2 owing to hyperventilation.
Blood tests. ANA & RA are present in one-third of patients. ESR is mildly elevated.
masses several centimetres in diameter, almost invariably in the upper lobes and sometimes having necrotic
pical destruction and disruption of the lung, resulting in emphysema and airway damage.
w a mixed restrictive and obstructive ventilatory defect with loss of lung volume, irreversible airflow limitation a
ss (or even develop) after exposure to coal dust has ceased and may lead to respiratory failure.
Ans: Sarcoidosis
Sarcoidosis is a common disease of unknown aetiology that is often detected by routine chest X-ray.
The peak incidence is in the 3rd and 4th decades, with a female preponderance.
Immunopathology
Typical sarcoid granulomas consist of epithelioid cells, macrophages and lymphocytes, mainly T cells.
Tuberculin test is negative. Lymphopenia - Low T cells but slightly increased B cells
BAL shows increased cells with lymphocytes predominance
Transbronchial biopsies show infiltration of the alveolar walls and interstitial spaces
Its not a pre malignant state or immunosuppresed state.
Clinical features
Sarcoidosis can affect many different organs of the body.
Respiratory symptoms or abnormalities (without symptoms) found on chest X-ray (50%).
Fatigue or weight loss (5%), peripheral lymphadenopathy (5%) and fever (4%).
Stage I: bilateral hilar lymphadenopathy (BHL) alone
Stage II: BHL with pulmonary infiltrates
Stage III: pulmonary infiltrates without BHL
Stage IV: fibrosis.
Investigations
Imaging. Chest X-ray. High-resolution CT .
Full blood count. mild normochromic, normocytic anaemia with raised ESR.
Serum biochemistry. High serum calcium and hypergammaglobulinaemia.
Transbronchial biopsy is positive in 90% of cases . Non-caseating granulomas in extrapulmonary.
Serum angiotensin-converting enzyme (ACE) level is raised in 75% of patients. Other d/d
lymphoma, pulmonary tuberculosis, asbestosis and silicosis.Assesses disease activity and response to
treatment.
Lung function tests show a restrictive lung defect .Decreased TLC, FEV 1 and FVC, and gas transfer.
Lung function is usually normal with extrapulmonary disease or only having hilar LNAP.
Treatment
1. No Treatment : Hilar LNAP, Infiltrates on CXR and Normal lung function. Just follow up 3-6 months.
2. Corticosteroids :
1. No Improvement for 6 months of follow up in above cases
2. Abnormal Lung function
3. Deteriorating lung function
4. Eye, Hypercalcemia, Eythema nodosum, Heart and CNS involvement
Prognosis
Mortality is 10%
Lung function and DLCO are best guide for the progress
An 18-year-old woman presents with red, tender lumps on her shins and arthralgia.
Chest x ray shows bilateral hilar lymphadenopathy and clear lung fields.
A clinical diagnosis of sarcoidosis is made.
Which one of the following is the most appropriate management plan?
a) 24 hour urinary calcium measurement
b) Follow up appointment with chest x ray in three months
c) Mediastinoscopy and lymph node biopsy
d) Skin biopsy
e )Thoracic CT scan
A 60-year-old woman was referred to the rapid access lung cancer clinic after having a chest x
ray which she was told was abnormal. She reported feeling unwell for the past six weeks with
lethargy, intermittent fever and myalgia. She noticed that she became more breathless on
exertion and had difficulty climbing steep hills.
She had one episode of haemoptysis which she attributed to nose bleeds, which she was
experiencing frequently. She had a 40 pack/year smoking history and kept no pets at home. She
was a retired nurse and had worked in the NHS for 40 years.
On examination she looked unwell and had a temperature of 38.4C. Her blood pressure was
elevated at 160/100 mmHg, pulse 100 beats per minute and oxygen saturations of 94% on room
air. On palpation of the carotid pulse, she had marked tenderness of her right carotid artery.
There was no palpable lymphadenopathy in her cervical, axillary or inguinal regions. Her heart
sounds were normal with no audible murmurs. Respiratory examination revealed vesicular
breath sounds which were of normal intensity. There was no audible wheeze or crepitations.
Abdominal examination was normal.
A repeat chest radiograph revealed alveolar shadowing in the right upper lobe. The previous
chest radiograph, which she brought with her to clinic, showed alveolar shadowing in the right
mid-zone.
INVESTIGATIONS
Haemoglobin :
115 g/L (115-165)
Serum sodium
140 mmol/L
(137-144)
Serum urea
13.7 mmol/L
(2.5-7.5)
Anti-nuclear antibody
Positive
Perinuclear-ANCA
(pANCA)
Negative
Serum potassium
4.2 mmol/L
(3.5-4.9)
Serum creatinine
170 mol/L
(60-110)
Cytoplasmic-ANCA
(cANCA)
Positive
Anti-GBM
Negative
Neutrophils 6.4 109/L (1.5-7) ; Lymphocytes 2.0 109/L (1.5-4.0); Monocytes 0.8 109/L
(0-0.8:Eosinophils 0.7 109/L (0.04-0.4) ;Basophils 0.1 109/L (0-0.1)
Platelets 500 109/L (150-400)
ESR (Westergren) 100 mm/1st hour (0-15)
ms, clinical signs and laboratory findings are classical of Wegener's granulomatosis.
causing vasculitis (causing carotid artery tenderness), Wegener's is also a cause of migrating alveolar
SR, renal dysfunction and positive C-ANCA are also in keeping with the diagnosis.
also be raised in Wegener's granulomatosis.
and cough, which has been increasing over the last two weeks.
uating joint pains and had a couple of episodes of sinusitis over the last one year. He had no family histo
n 10 L oxygen.
Hb
128 g/L
(130 - 180)
Na+
136 mmol/L
(137 - 144)
WBC
11.5 109/L
(4 - 11)
K+
5.7 mmol/L
(3.5 - 4.9)
Platelets
452 109/L
(150 - 400)
Urea
42.7 mmol/L
(2.5 - 7.5)
CRP
56 mg/L
(< 10)
Creatinine
650 mol/L
(60 - 110)
Urinalysis
Protein ++
Blood +++
Nitrates negative
Leucocytes negative
Chest x ray
Anti-GBM antibodies
c-ANCA
positive
He deteriorates and is intubated on ITU and also received renal replacement therapy.
Given the most likely diagnosis, what course of treatment should be commenced?
A.
B.
C.
D.
E.
Goodpastures syndrome
Its Autoimmune antibodies targeting lungs and kidneys.
Symptoms : URTI , Cough and intermittent haemoptysis, Anaemia, although massive bleeding may
occur.
The chest X-ray shows transient blotchy shadows that are due to intrapulmonary haemorrhage.
The features usually precede the development of an acute glomerulonephritis by several weeks or
months.
The course of the disease is variable: some patients spontaneously improve while others proceed to
renal failure.
It is due to a type II cytotoxic reaction driven by antibodies directed against the basement
membrane of both kidney and lung. It has been proposed that there is a shared antigen.
ANCA may be positive.
An association with influenza A2 virus has been reported.
Treatment is with corticosteroids.
Dramatic improvement has been seen with plasmapheresis to remove the autoantibodies.
33) A 57-year-old male is admitted with acute dyspnoea and chest pain. A
pulmonary embolism (PE) is confirmed.
Which of the following is a recognised feature of a significant pulmonary
embolism?
a) An arterial pH less than 7.2
b) An increase in serum troponin levels
c) Blood gases show increased pCO2 on air
d) Normal D-dimer levels
e) Reduced plasma lactate levels
Pulmonary embolism
Massive PE :
SBP <90 mmHg or a drop by 40 mmHg for a period >15 minutes
Associated elevated JVP
NATURAL HISTORY
Prognosis
Right ventricular (RV) dysfunction :
Two-fold increase in PE-related mortality
Brain natriuretic peptides :
Six-times increased mortality with BNP >100 pg/mL and 16-times with an NTproBNP >600 ng/L
DVT :
Coexisting DVT are at increased risk for mortality
Troponin :
Elevated levels are associated with an increased risk of death
RV thrombus & Hyponatraemia :
Increased mortality
Pathophysiology
Most PE arise deep venous system of the
lower extremities
Also originate in the right heart or the
pelvic, renal, or upper extremity veins
Iliofemoral veins are the source of most
clinically recognized PE (50-80%)
Calf vein thrombi - only 20 to 30 % cause PE,
others resolve spontaneously.
Smaller thrombi more likely to produce
pleuritic chest pain
Only 10% PE cause infarction
Risk factors
Immobility
Surgery within the last 3 months,
Stroke
Paraplegia
Hx of venous thromboembolism (Hypercoagulable
states)
Malignancy
Central venous instrumentation within the last
three months
Chronic heart disease
Obesity (BMI 29 kg/m2),
Heavy cigarette smoking (>25 cigarettes per day)
Hypertension
Presentation
Dyspnoea at rest or with exertion
(sudden)
Pleuritic chest pain
Cough
Orthopnea
Calf or thigh pain
Wheezing
Tachypnea, Tachycardia, Accentuated
P2 , jugular venous distension
Diagnosis
History
ABG - hypoxaemia and respiratory alkalosis
ECG - Sinus tachy, S1Q3T3 pattern, RV strain,
new incomplete RBBB, atrial arrythmias
Troponin (30-50%)
BNP - raised
2-D ECHO - Acute cor pulmonale, PAH
D-Dimer - Good sensitivity and NPV, but poor
specificity and PPV
High in infections, malignancy, recent
surgery
Imaging
CXR : Normal, plate-like atelectasis, oligaemia,
effusion
V/Q scan : Perfusion defects
Pulmonary angiogram : Gold standard
CTPA : 98% accuracy
CTPA
Treatment
Anti-coagulants (LMWH, Warfarin); 6
months or longer for recurrent PE
Thrombolysis, rarely
Prevention of DVT
IVC filter
Throboendarterectomy
Treat underlying cause
Ans: Hypersomnolence
Who is at risk?
Obesity
Craniofacial abnormalities
Upper airway soft tissue abnormalities
Potential risk factors include heredity, smoking,
nasal congestion, and diabetes
Severity
Based on Apnea Hyponea Index (AHI)
Mild : AHI between 5 and 15 respiratory events/hr of
sleep
Moderate : 15 and 30 respiratory events/hr of sleep
Severe : AHI greater >30 respiratory events/hr of
sleep
and/or a saturation below 90% for more than 20%
of the total sleep time.
Complications
Hypertension
CHF
Depression
Arrythmias, IHD, Death
Worsening asthma
Nasal congestion, Conjunctivitis
Treatment
Behavioural modifications (wt. reduction, alcohol, avoid
sedatives, drugs)
Positive airway pressure (CPAP, BiPAP)
Oral appliances (Mandibular advancement splints)
Surgery (UPPP, tonsillectomy, adenoidectomy, polyp and
sinus surgery, palatal advancement)
Haemoglobin
17.0 g/dl
(13.0-18.0)
PaO2
13.0 kPa
(11.3-12.6)
SaO2(using an
85%
(>95)
oximeter)
What is the most likely diagnosis?
a) Argyria
b) Cyanotic congenital heart disease
c) Haemochromatosis
d) Methaemoglobinaemia
e) Methylene blue poisoning
Ans: Methaemoglobinaemia