Which of the following factors is least useful in assessing patients with a poor prognosis

in community-acquired pneumonia?ia

A.A Mini-mental score 6/10ia

B.A Raised ureaia
x C.A White blood cell count of 22
D.A Respiratory rate of 30ia
E.A Aged 75 years oldia
Next question
The white blood cell count is least useful of the above in predicting mortality in patients
with community-acquired pneumonia. The rest of the answers are part of the CURB-65
criteria
Pneumonia: prognostic factors
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CURB-65 criteria of severe pneumonia
• Confusion (abbreviated mental test score < 8/10)he
• Urea > 7 mmol/Lhe
• Respiratory rate >= 30 / minhe
• BP: systolic < 90 or diastolic < 60 mmHghe
• age > 65 yearshe

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Patients with 3 or more (out of 5) of the above criteria are regarded as having a severe
pneumonia
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Other factors associated with a poor prognosis include:
• presence of coexisting diseasehe
• hypoxaemia (pO2 < 8 kPa) independent of FiO2he
Which one of the following is responsible for farmer's lung?ia

A.A Aspergillus clavatusia

x B.A Micropolyspora faeni
C.A Thermophilic actinomycetesia
D.A Mycobacterium aviumia
E.A Avian proteinsia
Next question
Micropolyspora faeni causes farmer's lung, a type of EAA
Extrinsic allergic alveolitis
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Extrinsic allergic alveolitis (EAA) is a condition caused by hypersensitivity induced lung
damage due to a variety of inhaled organic particles. It is thought to be largely caused by
immune-complex mediated tissue damage (type III hypersensitivity) although delayed
hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic
phase
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Examples
• bird fanciers' lung (avian proteins)he
• farmers lung (spores of Micropolyspora faeni)he
• malt workers' lung (Aspergillus clavatus)he
• mushroom workers' lung (thermophilic actinomycetes)he
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Presentation
• acute: occur 4-8 hrs after exposure, SOB, dry cough, feverhe
• chroniche

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Investigation
• CXR: upper lobe fibrosishe
• BAL: lymphocytosishe

• blood: NO eosinophiliahe
Which one of the following causes of lung fibrosis predominately affect the upper zones?
ia

A.A Bleomycinia
B.A Rheumatoid arthritisia
C.A Cryptogenic fibrosis alveolitisia
D.A Methotrexateia
x E.A Extrinsic allergic alveolitis
Next question
Lung fibrosis
sqweqwesf erwrewfsdfs adasd dhe
It is important in the exam to be able to differentiate between conditions causing
predominately upper or lower zone fibrosis. It should be noted that the more common
causes (cryptogenic fibrosing alveolitis, drugs) tend to affect the lower zones
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Fibrosis predominately affecting the upper zones
• extrinsic allergic alveolitishe

• coal worker's pneumoconiosis/progressive massive fibrosishe

• silicosishe
 • sarcoidosishe

• ankylosing spondylitis (rare)he

• histiocytosishe
• tuberculosishe

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Fibrosis predominately affecting the lower zones
• cryptogenic fibrosing alveolitishe
• most connective tissue disorders (except ankylosing spondylitis)he
• drug-induced: amiodarone, bleomycin, methotrexatehe
• asbestosishe

A chest x-ray of a patient with sarcoidosis shows bilateral hilar lymphadenopathy but is
otherwise normal. What chest x-ray stage does this correspond to?ia

A.A Stage 0ia

x B.A Stage 1
C.A Stage 2ia
D.A Stage 3ia
E.A Stage 4ia
Next question
Sarcoidosis CXR
•1 = BHL
•2 = BHL + infiltrates
•3 = infiltrates
•4 = fibrosis

Sarcoidosis: investigation
sqweqwesf erwrewfsdfs adasd dhe
There is no one diagnostic test for sarcoidosis and hence diagnosis is still largely clinical.
ACE levels have a sensitivity of 60% and specificity of 70% and are therefore not
reliable in the diagnosis of sarcoidosis although they may have a role in monitoring
disease activity. Routine bloods may show hypercalcaemia (seen in 10% if patients) and a
raised ESR
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A chest x-ray may show the following changes:
• stage 0 = normalhe

• stage 1 = bilateral hilar lymphadenopathy (BHL)he

• stage 2 = BHL + interstitial infiltrateshe
• stage 3 = diffuse interstitial infiltrates onlyhe
• stage 4 = diffuse fibrosishe

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Other investigations
 • spirometry: may show a restrictive defecthe
• tissue biopsy: non-caseating granulomashe
• gallium-67 scan - not used routinelyhe
A 24-year-old male with no past medical history presents to the Emergency Department
with pleuritic chest pain. There is no history of a productive cough and he is not short of
breath. Chest x-ray shows a right-sided pneumothorax with a 1.5cm rim of air and no
mediastinal shift. What is the most appropriate management?ia

A.A Immediate 14G cannula into 2nd intercostal space, mid-clavicular lineia
x B.A Dischargeia
C.A Aspirationia
D.A Intercostal drain insertionia
E.A Admit for 48 hours observationia
Next question
Pneumothorax
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The British Thoracic Society (BTS) published guidelines for the management of
spontaneous pneumothorax in 2003. A pneumothorax is termed primary if there is no
underlying lung disease and secondary if there is
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Primary pneumothorax
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Recommendations include:
• if the rim of air is < 2cm and the patient is not short of breath then discharge should
be consideredhe
• otherwise aspiration should be attemptedhe
• if this fails then repeat aspiration should be consideredhe
• if this fails then a chest drain should be insertedhe
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Secondary pneumothorax
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Recommendations include:
• if the patient is > 50 years old and the rim of air is > 2cm and the patient is short of
breath then a chest drain should be inserted. he
• otherwise aspiration should be attempted. If aspiration fails a chest drain should be
inserted. All patients should be admitted for at least 24 hourshe
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Iatrogenic pneumothorax
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Recommendations include:
• less likelihood of recurrence than spontaneous pneumothoraxhe
• majority will resolve with observation, if treatment is required then aspiration
should be usedhe
 • ventilated patients need chest drains, as may some patients with COPDhe
A 46-year-old female with a history of rheumatoid arthritis is investigated due to
progressive shortness of breath. She is currently treated with methotrexate and ibuprofen.
The following results are obtained from spirometry:
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FEV1/FVC 45%

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What is the most likely cause of the dyspnoea?ia

x A.A Bronchiolitis obliterans

B.A Methotrexate pneumonitisia
C.A Pulmonary fibrosisia
D.A Caplan's syndromeia
E.A Lung canceria
Next question
The spirometry reveals an obstructive picture which would be in keeping with
bronchiolitis obliterans
Rheumatoid arthritis: pulmonary manifestations
sqweqwesf erwrewfsdfs adasd dhe
A variety of respiratory problems may be seen in patients with rheumatoid arthritis:
• pulmonary fibrosishe
• pleural effusionhe

• pulmonary noduleshe
• bronchiolitis obliteranshe
• complications of drug therapy e.g. methotrexate pneumonitishe
• pleurisyhe

• Caplan'ssyndrome - massive fibrotic nodules with occupational coal dust

exposurehe
• infection (possibly atypical) secondary to immunosuppressionhe
A 74-year-old woman with thyroid cancer is admitted due to shortness of breath. What is
the best investigation to assess for possible compression of the upper airways?ia

A.A Arterial blood gasesia

B.A Forced vital capacityia
C.A Transfer factoria
D.A Peak expiratory flow rateia
x E.A Flow volume loop
Next question
Flow volume loop is the investigation of choice for upper airway compression
Flow volume loop
sqweqwesf erwrewfsdfs adasd dhe
A normal flow volume loop is often described as a 'triangle on top of a semi circle'
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Flow volume loops are the most suitable way of assessing compression of the upper
airway
Which one of the following is characteristic of Mikulicz's syndrome?ia

A.A Erythema nodosumia

x B.A Enlargement of the parotid glands
C.A Cholestatic jaundiceia
D.A Urethral dischargeia
E.A Goitreia
Next question
Mikulicz's syndrome is a type of sarcoidosis characterised by enlargement of the parotid
and lacrimal glands
Sarcoidosis
sqweqwesf erwrewfsdfs adasd dhe
Sarcoidosis is a multisystem disorder of unknown aetiology characterised by non-
caseating granulomas. It is more common in young adults and in people of African
descent
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Features
• acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever,
polyarthralgiahe
• insidious: dyspnoea, non-productive cough, malaise, weight losshe
• skin: lupus perniohe
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Syndromes associated with sarcoidosis
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Lofgren's syndrome is an acute form of the disease characterised by bilateral hilar lymphadenopathy
(BHL), erythema nodosum, fever and polyarthralgia. It usually carries an excellent prognosis
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In Mikulicz's syndrome there is enlargement of the parotid and lacrimal glands due to sarcoidosis,
whilst in Heerfordt's syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis
secondary to sarcoidosis
A 52-year-old man with a history of hepatitis B infection presents with fever and
polyarthralgia associated with a right foot drop. Examination reveals BP 180/100. What
is the most likely diagnosis?ia

A.A Churg-Straus syndromeia

B.A Hepatocellular carcinomaia
C.A Systemic lupus erythematousia
x D.A Polyarteritis nodosa
E.A Giant cell arteritisia
Next question
Polyarteritis nodosa
sqweqwesf erwrewfsdfs adasd dhe
Polyarteritis nodosa (PAN) is a vasculitis affecting medium-sized arteries with
necrotizing inflammation leading to aneurysm formation. PAN is more common in
middle-aged men and is associated with hepatitis B infection
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Features
• fever, malaise, arthralgiahe
• hypertensionhe

• mononeuritis multiplex, sensorimotor polyneuropathyhe

• haematuria, renal failurehe
• testicular painhe
• abdominal pain (e.g. from mesenteric ischaemia)he
• ANCA negative in > 90%
A 23-year-old female who is 28 weeks pregnant presents with shortness-of-breath and
right-sided pleuritic chest pain. A diagnosis of pulmonary embolism is suspected. What is
the most appropriate investigation to confirm the diagnosis?ia

A.A Computed tomographic pulmonary angiographyia

B.A Echocardiogramia
x C.A Ventilation-perfusion scan
D.A D-dimeria
E.A MRI thoraxia
Next question
Pregnancy: DVT/PE investigation
sqweqwesf erwrewfsdfs adasd dhe
D-dimer is of limited use in the investigation of thromboembolism as it raised in
pregnancy. Ventilation-perfusion scanning involves minimal exposure to the fetus and is
therefore the investigation of choice
A 24-year-old male is admitted with acute severe asthma. Treatment is initiated with
100% oxygen, nebulised salbutamol and ipratropium bromide nebulisers and IV
hydrocortisone. Despite initial treatment there is no improvement. What is the next step
in management?ia

A.A IV aminophyllineia
x B.A IV magnesium sulphate
C.A IV salbutamolia
D.A IM adrenalineia
E.A IV adrenalineia
Next question
Asthma: acute severe
sqweqwesf erwrewfsdfs adasd dhe
Management
• ABChe

• 100% O2he
• nebulised salbutamol + ipratropium bromidehe
• oral prednisolone or IV hydrocortisonehe
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British Thoracic Society guidelines 2003 (updated 2004)
• magnesium sulphate recommended as next step for patients who are not responding
(e.g. 1.2 - 2g IV over 20 mins)he
• little evidence tosupport use of IV aminophylline (although still mentioned in
management plans)he
• if no response consider IV salbutamolhe
Which one of the following interventions is most likely to increase survival in patients
with COPD?ia

A.A Home nebulisersia

B.A Tiotropium inhaleria
C.A Long-term steroid therapyia
x D.A Smoking cessation
E.A Long-term oxygen therapyia
Next question
Whilst long-term oxygen therapy may increase survival in hypoxic patients, smoking
cessation is the single most important intervention in patients with COPD
COPD: long-term management
sqweqwesf erwrewfsdfs adasd dhe
Factors which may improve survival in patients with stable COPD
• smoking cessation - the single most important intervention in patients who are still
smoking he
• long term oxygen therapy in patients who fit criteria he
• lung volume reduction surgery in selected patients he
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Non-invasive ventilation has been shown to effective in the management of patients with
acute respiratory failure
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Anticholinergic agents (e.g. tiotropium) have been shown in some studies to be superior
to beta 2 agonists in COPD, and are therefore sometimes used as first line therapy
A 52-year-old man is admitted to hospital with breathlessness and fever. He has no
significant past medical history of note. A chest x-ray reveals right lower lobe
consolidation. Arterial blood gases on air are as follows:
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pH 7.39
pCO2 4.6 kPa
pO2 9.2 kPa

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What is the most suitable antibiotic therapy?ia

A.A Oral co-amoxiclavia

B.A Oral ciprofloxacinia
x C.A Oral amoxicillin + erythromycin
D.A IV ceftriaxone + clarithromycinia
E.A Oral co-amoxiclav + metronidazoleia
Next question
The 2001 British Thoracic guidelines recommend oral amoxicillin with an oral macrolide
as first line treatment for hospitalised patients with non-severe CAP
Pneumonia: community-acquired
sqweqwesf erwrewfsdfs adasd dhe
Streptococcus pneumoniae is the most common cause of community-acquired pneumonia
(CAP)
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Characteristic features of pneumococcal pneumonia
• rapid onsethe
• high feverhe

• pleuritic chest painhe

• herpes labialishe
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Antibiotic choices
• hospitalized non-severe CAP, first line: oral amoxicillin + macrolidehe
A 22-year-old man presents to his GP complaining of episodic wheezing whilst playing
rugby and a nocturnal cough. Which one of the following is the most appropriate way to
confirm a diagnosis of asthma?ia

x A.A Serial peak expiratory flow measurements

B.A Spirometryia
C.A Histamine stimulation testia
D.A Methacholine stimulation testia
E.A A trial of inhaled steroids with FEV1 measurements before and afteria
Next question
Asthma: diagnosis in adults
sqweqwesf erwrewfsdfs adasd dhe
The 2005 British Thoracic Society guidelines states that a diagnosis of asthma should be
considered in patients with typical symptoms, for example:
• episodic wheezehe

• shortness of breathhe
• coughhe

• chest tightnesshe

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Signs may or may not be present, for example:
• wheeze: diffuse, bilateralhe
• tachypnoeahe

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Additional information may also be useful:
• personal or family history of asthma or atopyhe
• history of worsening after NSAIDs or beta-blockershe
• recognised triggers e.g. pollen or dusthe
• pattern and severity of symptoms and exacerbationshe
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In terms of objective measurements the 2005 BTS guidelines recommend the following:
• diurnal variation % = [(Highest – Lowest PEFR) / Highest PEFR] x 100he
• greaterthan 20% diurnal variation on >= 3 days in a week for 2 weeks on peak
expiratory flow diaryhe
• otherobjective measures listed in the guidelines include a trial of a short acting beta
2 agonist, trial of prednisolone or a decrease in FEV1 following exercisehe
A 55-year-old man is referred by his GP to the medical admissions unit. He recently
returned from a holiday in Italy and has failed to respond to a course of co-amoxiclav for
a suspected lower respiratory tract infection. Chest x-ray shows bilateral infiltrates.
Bloods are as follows:
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Na+ 122 mmol/l
K+ 4.3 mmol/l
Urea 8.4 mmol/l
Creatinine 130 µmol/l

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What is the likely diagnosis?ia

A.A Goodpasture's syndromeia

x B.A Legionella pneumonia
C.A Pneumocystis carinii pneumoniaia
D.A Pulmonary eosinophiliaia
 E.A Mycoplasma pneumoniaia
Next question
Legionella
sqweqwesf erwrewfsdfs adasd dhe
Legionnaire's disease is caused by the intracellular bacterium Legionella pneumophilia. It
is typically colonizes water tanks and hence questions may hint at air-conditioning
systems or foreign holidays. Person-to-person transmission is not seen
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Features
• flu-like symptomshe

• dry coughhe

• lymphopeniahe

• hyponatraemiahe

• deranged LFTs he
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Diagnosis
• urinary antigenhe

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Management
• treat with erythromycinhe
A 62-year-old female is admitted with a suspected infective exacerbation of COPD. A
chest x-ray shows no evidence of consolidation. What is the most likely causative
organism?ia

A.A Pseudomonas aeruginosaia

x B.A Haemophilus influenzae
C.A Staphylococcus aureusia
D.A Streptococcus pneumoniaeia
E.A Moraxella catarrhalisia
Next question
COPD: acute management
sqweqwesf erwrewfsdfs adasd dhe
The most common organisms which cause infective exacerbations of COPD are:
• Haemophilus influenzae (most common cause)he
• Streptococcus pneumoniaehe
• Moraxella catarrhalishe
Which one of the following is true regarding anti-tuberculous therapy?ia

A.A Rifampicin is a potent liver enzyme inhibitoria

B.A Pyrazinamide should be added to therapy after 8 weeksia
 C.A Major side-effects of pyrazinamide include peripheral neuropathyia
x D.A Visual acuity should be checked before starting ethambutol
E.A Rifampicin works by inhibiting DNA synthesisia
Next question
Rifampicin is a potent liver enzyme inducer. It works by inhibiting RNA synthesis in
bacteria. Pyrazinamide should be given for the first two months of therapy - side-effects
include hepatitis and gout. Peripheral neuropathy is a side-effect of isoniazid
Tuberculosis: drug therapy
sqweqwesf erwrewfsdfs adasd dhe
The standard therapy for treating active tuberculosis is:
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Initial phase - first 2 months (RIPE)
• Rifampicinhe

• Isoniazidhe

• Pyrazinamidehe

• Ethambutol (the 2006 NICE guidelines now recommend giving a 'fourth drug' such
as ethambutol routinely - previously this was only added if drug-resistant
tuberculosis was suspected)he
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Continuation phase - next 4 months
• Rifampicinhe

• Isoniazidhe

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The treatment for latent tuberculosis is isoniazid alone for 6 months
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Patients with meningeal tuberculosis are treated for a prolonged period (at least 12
months) with the addition of steroids
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Directly observed therapy with a thrice weekly dosing regimen may be
indicated in certain groups, including:
• homeless people with active tuberculosishe
• patients who are likely to have poor concordancehe
• all prisoners with active or latent tuberculosishe
A 49-year-old male with a past history of alcohol excess presents to the Emergency
Department due to fever and shortness of breath. Chest x-ray reveals a cavitating lesion
in the right middle zone. What is the most likely causative organism?ia

x A.A Klebsiellaia
B.A Bartonellaia
C.A Pneumococcusia
D.A Coxiella burnetiiia
E.A Haemophilus influenzaeia
Next question
Klebsiella pneumonia (Friedlander's pneumonia) typically occurs in middle-aged
alcoholic men. Chest x-ray features may include abscess formation in the middle/upper
lobes and empyema. The mortality approaches 30-50%
CXR: cavitating lung lesion
sqweqwesf erwrewfsdfs adasd dhe
Differential
• tuberculosishe

• lung cancer (especially squamous cell)he

• abscess (Staph aureus, Klebsiella and Pseudomonas)he
• Wegener's granulomatosishe
• pulmonary embolismhe
• rheumatoid arthritishe

• aspergillosis, histoplasmosis, coccidioidomycosishe

A 24-year-old female with a history of anxiety is taken to the Emergency Department
following an acute onset of shortness of breath. On examination the chest is clear to
auscultation but the respiratory rate is raised at 40 breaths per minute. A diagnosis of
hyperventilation secondary to anxiety is suspected. Which of the following arterial blood
gas results (taken on room air) are consistent with this?ia

A.A pH = 7.56; pCO2 = 2.9 kPa; pO2 = 10.1 kPaia

B.A pH = 7.24; pCO2 = 8.4 kPa; pO2 = 12.7 kPaia
C.A pH = 7.34; pCO2 = 2.7 kPa; pO2 = 15.4 kPaia
x D.A pH = 7.54; pCO2 = 2.4 kPa; pO2 = 14.1 kPa
E.A pH = 7.54; pCO2 = 4.9 kPa; pO2 = 13.3 kPaia
Next question
Hyperventilation will result in carbon dioxide being 'blown off', causing an alkalosis
Respiratory alkalosis
sqweqwesf erwrewfsdfs adasd dhe
Common causes
• anxiety leading to hyperventilationhe
• pulmonary embolismhe
• salicylate poisoning*he

• CNS disorders: stroke, subarachnoid haemorrhage, encephalitishe

• altitudehe

• pregnancyhe
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*salicylate overdose leads to a mixed respiratory alkalosis and metabolic acidosis. Early stimulation
of the respiratory centre leads to a respiratory alkalosis whilst later the direct acid effects of
salicylates (combined with acute renal failure) may lead to an acidosis
Each one of the following may result in bronchiectasis, except:ia
 A.A Kartagener's syndromeia
x B.A Amyloidosisia
C.A Selective IgA deficiencyia
D.A Lung canceria
E.A Allergic bronchopulmonary aspergillosisia
Next question
Amyloidosis does not cause bronchiectasis per se, but may be seen in bronchiectasis as a
consequence of chronic inflammation and infection
Bronchiectasis: causes
sqweqwesf erwrewfsdfs adasd dhe
Bronchiectasis describes a permanent dilatation of the airways secondary to chronic
infection or inflammation. There are a wide variety of causes are listed below:
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Causes
• post-infective: tuberculosis, measles, pertussis, pneumoniahe
• cystic fibrosishe

• bronchial obstruction e.g. lung cancer/foreign bodyhe

• immune deficiency: selective IgA, hypogammaglobulinaemiahe
• allergic bronchopulmonary aspergillosis (ABPA)he
• ciliary dyskinetic syndromes: Kartagener's syndrome, Young's syndromehe
• yellow nail syndromehe
A 62-year-old man who is investigated for haemoptysis is found to have squamous cell
lung cancer. Which one of the following is a contraindication to surgery?ia

A.A Pleural effusionia

x B.A Superior vena caval obstruction
C.A Haemoptysisia
D.A Hypercalcaemiaia
E.A Enlarged mediastinal lymph nodesia
Next question
Contraindications to lung cancer surgery include SVC obstruction, FEV < 1.5,
MALIGNANT pleural effusion, and vocal cord paralysis
If one of the options was 'malignant pleural effusion', rather than just 'pleural effusion'
(which may be reactive), then this would also be a contraindication
Lung cancer: non-small cell management
sqweqwesf erwrewfsdfs adasd dhe
Management
• only 20% suitable for surgeryhe
• mediastinoscopy performed prior to surgery as CT does not always show
mediastinal lymph node involvementhe
 • curative or palliative radiotherapyhe
• poor response to chemotherapyhe
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Surgery contraindications
• assess general healthhe
• stage IIIb or IV (i.e. metastases present)he
• FEV1 < 1.5 litres is considered a general cut-off point*he
• malignant pleural effusionhe

• tumour near hilumhe

• vocal cord paralysishe
• SVC obstructionhe

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* However if FEV1 < 1.5 for lobectomy or < 2.0 for pneumonectomy then some
authorities advocate further lung function tests as operations may still go ahead based on
the results
Which one of the following is a contraindication to surgical resection in lung cancer?ia

A.A Haemoptysisia
B.A FEV 1.9 litresia
C.A Histology shows squamous cell canceria
x D.A Vocal cord paralysis
E.A Calcium = 2.84 mmol/Lia
Next question
Contraindications to lung cancer surgery include SVC obstruction, FEV < 1.5,
MALIGNANT pleural effusion, and vocal cord paralysis
Lung cancer: non-small cell management
sqweqwesf erwrewfsdfs adasd dhe
Management
• only 20% suitable for surgeryhe
• mediastinoscopy performed prior to surgery as CT does not always show
mediastinal lymph node involvementhe
• curative or palliative radiotherapyhe
• poor response to chemotherapyhe
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Surgery contraindications
• assess general healthhe
• stage IIIb or IV (i.e. metastases present)he
• FEV1 < 1.5 litres is considered a general cut-off point*he
• malignant pleural effusionhe
 • tumour near hilumhe
• vocal cord paralysishe
• SVC obstructionhe

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* However if FEV1 < 1.5 for lobectomy or < 2.0 for pneumonectomy then some
authorities advocate further lung function tests as operations may still go ahead based on
the results
A 67-year-old female is referred to the acute medical unit with an infective exacerbation
of COPD. Despite maximal medical therapy the arterial blood gases continue to show
type II respiratory failure. You are asked to consider non-invasive ventilation. At what pH
is the patient most likely to receive benefit from non-invasive ventilation?ia

A.A pH 7.13ia
B.A pH 7.18ia
C.A pH 7.23ia
x D.A pH 7.29
E.A pH 7.37ia
Next question
The evidence surrounding the use of NIV in COPD shows that patients with a pH in the
range of 7.25-7.35 achieve the most benefit. If the pH is < 7.25 then invasive ventilation
should be considered if appropriate
Non-invasive ventilation
sqweqwesf erwrewfsdfs adasd dhe
The British Thoracic Society (BTS) published guidelines in 2002 on the use of non-
invasive ventilation in acute respiratory failure
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Non-invasive ventilation - key indications
• COPD with respiratory acidosis pH 7.25-7.35he
• type IIrespiratory failure secondary to chest wall deformity, neuromuscular disease
or obstructive sleep apnoeahe
• cardiogenic pulmonary oedema unresponsive to CPAPhe
• weaning from tracheal intubationhe

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Recommended initial settings for bi-level pressure support in COPD
• EPAP: 4-5 cm H2Ohe

• IPAP: 12-15 cm H2Ohe

• back up rate: 15 breaths/minhe

• Back up I:E ratio: 1:3he
Each one of the following paraneoplastic features is often seen in squamous cell cancer,
except:ia

A.A Lambert-Eaton syndrome

 x

B.A Hyperthyroidismia
C.A Hypertrophic pulmonary osteoarthropathyia
D.A Hypercalcaemiaia
E.A Clubbingia
Next question
Paraneoplastic features of lung cancer
• squamous cell: PTHrp, clubbing, HPOA
• small cell: ADH, ACTH, Lambert-Eaton syndrome

Lambert-Eaton syndrome occurs almost exclusively in small cell lung cancer

Lung cancer: paraneoplastic features
sqweqwesf erwrewfsdfs adasd dhe
Small cell
• ADHhe

• ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and

muscle weakness are more common than buffalo hump etche
• Lambert-Eaton syndromehe
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Squamous cell
• PTH-rphe

• clubbinghe

• hypertrophic pulmonary osteoarthropathy (HPOA)he

• hyperthyroidism due to ectopic TSHhe
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Adenocarcinoma
• gynaecomastiahe

A 35-year-old female with sarcoidosis is started on a course of prednisolone. Which one

of the following is a suitable indication for commencing steroid therapy in such patients?
ia

A.A Bilateral hilar lymphadenopathyia

B.A Arthralgiaia
x C.A Hypercalcaemiaia
D.A Serum ACE > 120 u/lia
E.A Erythema nodosumia
Next question
Sarcoidosis: management
sqweqwesf erwrewfsdfs adasd dhe
Sarcoidosis is a multisystem disorder of unknown aetiology characterised by non-
caseating granulomas. It is more common in young adults and in people of African
descent
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Indications for steroids
• hypercalcaemiahe
• worsening lung functionhe
• eye, heart or neuro involvementhe
Which one of the following is least associated with Kartagener's syndrome?ia

A.A Male infertilityia

B.A Recurrent sinusitisia
x C.A Malabsorptionia
D.A Dextrocardiaia
E.A Bronchiectasisia
Next question
Kartagener's syndrome
sqweqwesf erwrewfsdfs adasd dhe
Kartagener's syndrome (also known as immotile ciliae syndrome) was first described in
1933 and most frequently occurs in examinations due to its association with dextrocardia
(e.g. 'quiet heart sounds', 'small volume complexes in lateral leads')
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Features
• dextrocardia or complete situs inversushe
• bronchiectasishe
• recurrent sinusitishe

• infertility in male patients (secondary to immotile ciliae)he

A 57-year-old female presents to the Emergency Department with shortness of breath and
pleuritic chest pain. She has no past medical history of note and enjoys good health.
Investigations reveal a non-massive pulmonary embolism. What is the recommended
length of warfarinisation for this patient?ia

A.A 6 weeksia
x B.A 3 months
C.A 6 monthsia
D.A 12 monthsia
E.A Life-longia
Next question
Pulmonary embolism: management
sqweqwesf erwrewfsdfs adasd dhe
The British Thoracic Society (BTS) published guidelines in 2003 on the management of
patients with suspected pulmonary embolism (PE)
he earaer aeraer asdsadas eerw dssdfsselleds
Key points from the guidelines include:
he earaer aeraer asdsadas eerw dssdfsselleds
Anticoagulation
• low molecular weight heparin (LMWH), rather than unfractionated heparin (UFH),
should be used routinely in patients with suspected pulmonary embolism. This
reflects the equal efficacy and safety of LMWHs as well as their ease of use.
Exceptions include patients with a massive PE or in situations where rapid
reversal of anticoagulation may be necessaryhe
• warfarinisation: the standard duration of anticoagulation is 4-6 weeks* if temporary
risk factors are present, 3 months for the first idiopathic PE and at least 6 months
for other situationshe
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Thrombolysis
• thrombolysis is now recommended as the first-line treatment for massive PE. Other
invasive approaches should be considered where appropriate facilities existhe
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*the 2005 British Committee for Standards in Haematology guidelines suggest at least 3 months
anticoagulation in this situation, based on a 2004 study. It is therefore possible these guidelines may
soon change
A 54-year-old woman is noted to have a pleural effusion on CXR. Which one of the
following would typically cause a transudate?ia

A.A Tuberculosisia
B.A Pneumoniaia
x C.A Nephrotic syndrome
D.A Yellow nail syndromeia
E.A Pulmonary embolismia
Next question
Pleural effusion
sqweqwesf erwrewfsdfs adasd dhe
Exudate (> 30g/L protein)
• infection: pneumonia, TB, subphrenic abscesshe
• connective tissue disease: RA, SLEhe
• neoplasia: lung cancer, mesothelioma, metastaseshe
• pancreatitishe
• pulmonary embolismhe
• Dressler's syndromehe
• yellow nail syndromehe
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Transudate (< 30g/L protein)
• heart failurehe
 • hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)he
• hypothyroidismhe

• Meigs' syndromehe
Which one of the following is least recognised in polyarteritis nodosa?ia

x A.A ANCA positive

B.A Hypertensionia
C.A Mononeuritis multiplexia
D.A Pyrexiaia
E.A Renal failureia
Next question
Polyarteritis nodosa
sqweqwesf erwrewfsdfs adasd dhe
Polyarteritis nodosa (PAN) is a vasculitis affecting medium-sized arteries with
necrotizing inflammation leading to aneurysm formation. PAN is more common in
middle-aged men and is associated with hepatitis B infection
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Features
• fever, malaise, arthralgiahe
• hypertensionhe
• mononeuritis multiplex, sensorimotor polyneuropathyhe
• haematuria, renal failurehe
• testicular painhe
• abdominal pain (e.g. from mesenteric ischaemia)he
• ANCA negative in > 90%he
Which of the following features is associated with a good prognosis in sarcoidosis?ia

A.A Insidious onsetia

B.A Splenomegalyia
C.A Disease in black peopleia
D.A Stage III features on CXRia
x E.A Erythema nodosum
Next question
Sarcoidosis: prognostic features
sqweqwesf erwrewfsdfs adasd dhe
Sarcoidosis is a multisystem disorder of unknown aetiology characterised by non-
caseating granulomas. It is more common in young adults and in people of African
descent. Sarcoidosis remits without treatment in approximately two-thirds of people
he earaer aeraer asdsadas eerw dssdfsselleds
Factors associated with poor prognosis
 • insidious onset, symptoms > 6 monthshe
• absence of erythema nodosumhe
• extrapulmonary manifestations: e.g. lupus pernio, splenomegalyhe
• CXR: stage III-IV featureshe
• black peoplehe

A 30-year-old female with a past history of asthma presents to the Emergency

Department with shortness of breath. Chest x-ray shows a right-sided pneumothorax with
a 1.5cm rim of air and no mediastinal shift. What is the most appropriate management?ia

A.A Admit for 48 hours observationia

B.A Intercostal drain insertionia
x C.A Aspirationia
D.A Dischargeia
E.A Immediate 14G cannula into 2nd intercostal space, mid-clavicular lineia
Next question
Pneumothorax
sqweqwesf erwrewfsdfs adasd dhe
The British Thoracic Society (BTS) published guidelines for the management of
spontaneous pneumothorax in 2003. A pneumothorax is termed primary if there is no
underlying lung disease and secondary if there is
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Primary pneumothorax
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Recommendations include:
• if the rim of air is < 2cm and the patient is not short of breath then discharge should
be consideredhe
• otherwise aspiration should be attemptedhe
• if this fails then repeat aspiration should be consideredhe
• if this fails then a chest drain should be insertedhe
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Secondary pneumothorax
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Recommendations include:
• if the patient is > 50 years old and the rim of air is > 2cm and the patient is short of
breath then a chest drain should be inserted. he
• otherwise aspiration should be attempted. If aspiration fails a chest drain should be
inserted. All patients should be admitted for at least 24 hourshe
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Iatrogenic pneumothorax
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Recommendations include:
• less likelihood of recurrence than spontaneous pneumothoraxhe
 • majoritywill resolve with observation, if treatment is required then aspiration
should be usedhe
• ventilated patients need chest drains, as may some patients with COPDhe
Which one of the following is least associated with a false positive sweat test in the
diagnosis of cystic fibrosisia

x A.A Diabetes mellitus

B.A Hypothyroidismia
C.A G6PDia
D.A Malnutritionia
E.A Ectodermal dysplasiaia
Next question
Cystic fibrosis: diagnosis
sqweqwesf erwrewfsdfs adasd dhe
Sweat test
• patient's with CF have abnormally high sweat chloridehe
• normal value < 40 mEq/l, CF indicated by > 60 mEq/lhe
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Causes of false positive sweat test
• malnutritionhe

• adrenal insufficiency he
• glycogen storage diseaseshe

• nephrogenic diabetes insipidus he

• hypothyroidism, hypoparathyroidismhe
• G6PDhe
• ectodermal dysplasiahe

Which one of the following causes of lung fibrosis predominately affect the lower zones?
ia

x A.A Methotrexate
B.A Sarcoidosisia
C.A Coal worker's pneumoconiosisia
D.A Ankylosing spondylitisia
E.A Extrinsic allergic alveolitisia
Next question
Lung fibrosis
sqweqwesf erwrewfsdfs adasd dhe
It is important in the exam to be able to differentiate between conditions causing
predominately upper or lower zone fibrosis. It should be noted that the more common
causes (cryptogenic fibrosing alveolitis, drugs) tend to affect the lower zones
he earaer aeraer asdsadas eerw dssdfsselleds
Fibrosis predominately affecting the upper zones
• extrinsic allergic alveolitishe
• coal worker's pneumoconiosis/progressive massive fibrosishe
• silicosishe
• sarcoidosishe

• ankylosing spondylitis (rare)he

• histiocytosishe

• tuberculosishe
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Fibrosis predominately affecting the lower zones
• cryptogenic fibrosing alveolitishe
• most connective tissue disorders (except ankylosing spondylitis)he
• drug-induced: amiodarone, bleomycin, methotrexatehe
• asbestosishe

Which one of the following conditions is most associated with lupus pernio?ia

A.A Rheumatoid arthritisia

B.A Malariaia
C.A Tuberculosisia
D.A Amyloidosisia
x E.A Sarcoidosisia
Next question
Sarcoidosis
sqweqwesf erwrewfsdfs adasd dhe
Sarcoidosis is a multisystem disorder of unknown aetiology characterised by non-
caseating granulomas. It is more common in young adults and in people of African
descent
he earaer aeraer asdsadas eerw dssdfsselleds
Features
• acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever,
polyarthralgiahe
• insidious: dyspnoea, non-productive cough, malaise, weight losshe
• skin: lupus perniohe
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Syndromes associated with sarcoidosis
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Lofgren's syndrome is an acute form of the disease characterised by bilateral hilar lymphadenopathy
(BHL), erythema nodosum, fever and polyarthralgia. It usually carries an excellent prognosis
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In Mikulicz's syndrome there is enlargement of the parotid and lacrimal glands due to sarcoidosis,
whilst in Heerfordt's syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis
secondary to sarcoidosis
A 62-year-old man with a history of recurrent lower respiratory tract infections is
diagnosed as having bilateral bronchiectasis following a high resolution CT scan. What is
the treatment of choice for symptom control?ia

A.A Postural drainageia

B.A Prophylactic antibioticsia
C.A Surgeryia
x D.A Physical training
E.A Mucolytic therapyia
Next question
Symptom control in non-CF bronchiectasis - physical training rather than postural
drainage
This is a very tough question as all of the above options have been used in the
management of bronchiectasis. However, the only option with an evidence base is
physical training (e.g. inspiratory muscle training) for patients with non-cystic fibrosis
bronchiectasis. Please see the Clinical Evidence link - any comments?
Bronchiectasis: management
sqweqwesf erwrewfsdfs adasd dhe
Bronchiectasis describes a permanent dilatation of the airways secondary to chronic
infection or inflammation. After assessing for treatable causes (e.g. immune deficiency)
management is as follows:
• physical training (e.g. inspiratory muscle training)he
• postural drainagehe
• antibiotics for exacerbations + long-term rotating antibiotics in severe caseshe
• bronchodilators in selected caseshe
• immunisationshe

• surgery in selected cases (e.g. localised disease)he

Each one of the following predisposes to the development of obstructive sleep apnoea,
except:ia

A.A Acromegalyia
x B.A COPDia
C.A Amyloidosisia
D.A Obesityia
E.A Hypothyroidismia
Next question
Sleep apnoea causes include obesity and macroglossia
Obstructive sleep apnoea/hypopnoea syndrome
sqweqwesf erwrewfsdfs adasd dhe
Predisposing factors
 • obesityhe
• macroglossia: acromegaly, hypothyroidism, amyloidosishe
• large tonsilshe
• Marfan's syndromehe
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Consequence
• daytime somnolencehe

• hypertensionhe
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SIGN guidelines for the diagnosis and management of patients with OSAHS were
published in 2003
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Assessment of sleepiness
• Epworth Sleepiness Scale - questionnaire completed by patient +/- partnerhe
• Multiple SleepLatency Test (MSLT) - measures the time to fall asleep in a dark
room (using EEG criteria)he
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Diagnostic tests
• sleep studies - ranging from monitoring of pulse oximetry at night to full
polysomnography where a wide variety of physiological factors are measured
including EEG, respiratory airflow, thoraco-abdominal movement, snoring and
pulse oximetryhe
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Management
• weight losshe

• CPAP is first line for moderate or severe OSAHShe

• intra-oral devices (e.g. mandibular advancement) may be used if CPAP is not
tolerated or for patients with mild OSAHS where there is no daytime sleepinesshe
• limited evidence to support use of pharmacological agentshe
Which one of the following is least associated with the development of COPD?ia

A.A Cadmium exposureia

B.A Smokingia
C.A Coal dustia
x D.A Isocyanatesia
E.A Alpha-1 antitrypsin deficiencyia
Next question
COPD: causes
sqweqwesf erwrewfsdfs adasd dhe
Smoking!
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Alpha-1 antitrypsin deficiency
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Other causes
• cadmium (used in smelting)he
• coalhe
• cottonhe

• cementhe
• grainhe

Which of the following is not a recognised cause of pulmonary eosinophilia?ia

A.A Churg-Strauss syndromeia

B.A Sulphonamidesia
x C.A Extrinsic allergic alveolitis
D.A Loffler's syndromeia
E.A Allergic bronchopulmonary aspergillosisia
Next question
Pulmonary eosinophilia
sqweqwesf erwrewfsdfs adasd dhe
Causes of pulmonary eosinophilia
• Churg-Strauss syndromehe
• allergic bronchopulmonary aspergillosis (ABPA)he
• Loffler's syndromehe
• eosinophilic pneumoniahe

• hypereosinophilic syndromehe
• tropical pulmonary eosinophiliahe
• drugs: nitrofurantoin, sulphonamides he
• less common: Wegener's granulomatosishe
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Loffler's syndrome
• transient CXR shadowing and blood eosinophiliahe
• thought tobe due to parasites such as Ascaris lumbricoides causing an alveolar
reactionhe
• presents
with a fever, cough and night sweats which often last for less than 2
[Link]
• generally a self-limiting diseasehe
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Tropical pulmonary eosinophilia
• associated with Wuchereria bancrofti infectionhe
A 54-year-old man is admitted with suspected pulmonary embolism. He has no past
medical history of note. Blood pressure is 120/80 mmHg with a pulse of 90/min.
Following treatment with low-molecular weight heparin, what is the most appropriate
initial lung imaging investigation to perform?ia

A.A Pulmonary angiographyia

B.A Echocardiogramia
C.A MRI thoraxia
D.A Ventilation-perfusion scania
x E.A Computed tomographic pulmonary angiography
Next question
CTPA is the first line investigation for PE according to current BTS guidelines
This is a difficult question to answer as both computed tomographic pulmonary
angiography (CTPA) and ventilation-perfusion scanning are commonly used in UK
clinical practice. The 2003 British Thoracic Society (BTS) guidelines, however,
recommended that CTPA is now used as the initial lung imaging modality of choice.
Pulmonary angiography is of course the 'gold standard' but this is not what the question
asks for
Pulmonary embolism: investigation
sqweqwesf erwrewfsdfs adasd dhe
The British Thoracic Society (BTS) published guidelines in 2003 on the management of
patients with suspected pulmonary embolism (PE)
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Key points from the guidelines include:
• computed tomographic pulmonary angiography (CTPA) is now the recommended
initial lung-imaging modality for non-massive PE. Advantages compared to V/Q
scans include speed, easier to perform out-of-hours, a reduced need for further
imaging and the possibility of providing an alternative diagnosis if PE is excluded
he
• if the CTPA is negative then patients do not need further investigations or treatment
for PEhe
• ventilation-perfusion scanning may be used initially if appropriate facilities exist,
the chest x-ray is normal, and there is no significant symptomatic concurrent
cardiopulmonary diseasehe
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Some other points
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Clinical probability scores based on risk factors and history and now widely used to help
decide on further investigation/management
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D-dimers
• sensitivity = 98% but poor specificityhe
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V/Q scan
• sensitivity = 98%; specificity = 40% - high negative predictive value, i.e. if normal
virtually excludes PEhe
 • can be used in pregnancyhe
• othercauses of mismatch in V/Q include old pulmonary embolisms, AV
malformations, vasculitis, previous radiotherapyhe
• COPD gives matched defectshe
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CTPA
• peripheral emboli affecting subsegmental arteries may be missedhe
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Pulmonary angiography
• the gold standardhe
• significant complication rate compared to other investigationshe
Which one of the following conditions is associated with the development of gout?ia

x A.A Lesch-Nyhan syndrome

B.A Osteogenesis imperfectaia
C.A Fanconi syndromeia
D.A Di George syndromeia
E.A Turner's syndromeia
Next question
Gout: predisposing factors
sqweqwesf erwrewfsdfs adasd dhe
Impaired excretion
• drugs: diuretics, low-dose aspirinhe
• renal failurehe
• lead toxicityhe
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Increased production
• myeloproliferative/lymphoproliferative disorderhe

• cytotoxic drugshe
• severe psoriasishe

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Lesch-Nyhan syndrome
• hypoxanthine-guanine phosphoribosyl transferase deficiencyhe
• inheritance = x-linked recessivehe
• features: gout, renal failure, learning difficulties, head-banginghe
Which one of the following is most characteristic of type 1 renal tubular acidosis?ia

A.A Hyperkalaemiaia
B.A Osteomalaciaia
 C.A Decreased bicarbonate reabsorption in the proximal tubuleia
D.A Raised anion gap metabolic acidosisia
x E.A Renal stones
Next question
Osteomalacia is more commonly seen in type 2 renal tubular acidosis
Renal tubular acidosis
sqweqwesf erwrewfsdfs adasd dhe
All three types of renal tubular acidosis (RTA) are associated with hyperchloraemic
metabolic acidosis (normal anion gap)
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Type 1 RTA (distal)
• inability to generate acid urine (secrete H+) in distal tubulehe
• causes hypokalaemiahe
• complications include nephrocalcinosis and renal stoneshe
• causes include idiopathic, RA, SLE, Sjogren'she
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Type 2 RTA (proximal)
• decreased HCO3- reabsorption in proximal tubulehe
• causes hypokalaemiahe
• complications include osteomalaciahe
• causesinclude idiopathic, as part of Fanconi syndrome, Wilson's disease, cystinosis,
outdated tetracyclineshe
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Type 4 RTA (hyperkalaemic)
• causes hyperkalaemiahe
• causes include hypoaldosteronism, diabeteshe
A 35-year-old patient with a history of asthma and epilepsy presents with haemoptysis
and a worsening of his asthma. Blood tests reveal an eosinophilia and a positive pANCA.
Which of the following drugs is most likely to have precipitated the likely diagnosis?ia

x A.A Montelukastia
B.A Phenytoinia
C.A Sodium valproateia
D.A Prednisoloneia
E.A Sodium cromoglycateia
Next question
This patient probably has Churg-Strauss syndrome, which is associated with the use of
leukotriene receptor antagonists
Churg-Strauss syndrome
sqweqwesf erwrewfsdfs adasd dhe
Overview
 • an ANCA associated small-medium vessel vasculitishe
• associated with the use of leukotriene receptor antagonistshe
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Features
• asthmahe

• blood eosinophilia (e.g. > 10%)he

• paranasal sinusitishe

• mononeuritis multiplexhe
• pANCA positive in 60%
A 65-year-old life-long smoker with a significant past history of asbestos exposure is
referred to the respiratory clinic with haemoptysis. What is his increased risk of lung
cancer given the history?ia

A.A 5ia
B.A 10ia
x C.A 50ia
D.A 500ia
E.A 1,000ia
Next question
Lung cancer: risk factors
sqweqwesf erwrewfsdfs adasd dhe
Smoking
• increases risk of lung ca by a factor of 10he
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Other factors
• asbestos - increases risk of lung ca by a factor of 5he
• arseniche
• radonhe

• nickelhe
• chromatehe

• aromatic hydrocarbonhe
• cryptogenic fibrosing alveolitishe
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Factors that are NOT related
• coal dusthe
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Smoking and asbestos are synergistic i.e. if smoker with asbestos exposure risk = 50 times that of
normal
Which one of the following conditions is least associated with HLA-B27?ia
 A.A Reiter's syndromeia
B.A Psoriatic arthritisia
C.A Ankylosing spondylitisia
x D.A Crohn's disease
E.A Sacroilitisia
Next question
There is an indirect association between HLA-B27 and Crohn's as some patients may
develop enteropathic arthritis, but this is the least common association of the above
Seronegative spondyloarthropathies
sqweqwesf erwrewfsdfs adasd dhe
Common features
• associated with HLA-B27he
• rheumatoid factor negative - hence 'seronegative'he
• peripheral arthritis, usually asymmetricalhe
• sacroilitishe

• enthesopathy: e.g. Achilles tendonitis, plantar fasciitishe

• extra-articular
manifestations: uveitis, pulmonary fibrosis (upper zone),
amyloidosis, aortic regurgitationhe
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Spondyloarthropathies
• ankylosing spondylitishe
• psoriatic arthritishe

• Reiter's syndrome (including reactive arthritis)he

• enteropathic arthritis (associated with IBD)he
A 58-year-old man is investigated for a chronic cough and is found to have lung cancer.
He enquires whether it may be work related. Which one of the following is most likely to
increase his risk of developing lung cancer?ia

A.A Isocyanatesia
B.A Soldering flux resinia
x C.A Passive smoking
D.A Coal dustia
E.A Polyvinyl chlorideia
Next question
Whilst many chemicals have been implicated in the development of lung cancer passive
smoking is the most likely cause. Up to 15% of lung cancers in patients who do not
smoke are thought to be caused by passive smoking
Lung cancer: risk factors
sqweqwesf erwrewfsdfs adasd dhe
Smoking
 • increases risk of lung ca by a factor of 10he
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Other factors
• asbestos - increases risk of lung ca by a factor of 5he
• arseniche

• radonhe
• nickelhe

• chromatehe
• aromatic hydrocarbonhe

• cryptogenic fibrosing alveolitishe

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Factors that are NOT related
• coal dusthe
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Smoking and asbestos are synergistic i.e. if smoker with asbestos exposure risk = 50
times that of normal
Which one of the following is not part of the diagnostic criteria of acute respiratory
distress syndrome (ARDS)?ia

A.A Bilateral infiltrates on CXRia

B.A Non-cardiogenicia
C.A pO2/FiO2 < 200 mmHgia
x D.A Respiratory rate > 24/min
E.A Acute onsetia
Next question
ARDS
sqweqwesf erwrewfsdfs adasd dhe
Basics
• acute respiratory distress syndromehe
• caused by increased permeability of alveolar capillaries leading to fluid
accumulation in alveoli i.e. non-cardiogenic pulmonary oedemahe
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Criteria (American-European Consensus Conference)
• acute onsethe

• bilateral infiltrates on CXRhe

• non-cardiogenic (pulmonary artery wedge pressure needed if doubt)he
• pO2/FiO2 < 200 mmHghe
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Causes
 • infection: sepsis, pneumoniahe
• massive blood transfusionhe
• traumahe
• smoke inhalationhe

• pancreatitishe
• cardio-pulmonary bypasshe
A 63-year-old man presents to the respiratory out-patients department with shortness of
breath. Investigations reveal a fibrosing lung disease. A sputum sample however is
positive for acid-fast bacilli. Which of the following may have predisposed him to
developing tuberculosis?ia

A.A Cadmiumia
B.A Coal dustia
C.A White asbestos fibresia
D.A Blue asbestos fibresia
x E.A Silicaia
Next question
Silicosis
sqweqwesf erwrewfsdfs adasd dhe
Silicosis is a risk factor for developing TB (silica is toxic to macrophages)
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Features
• fibrosing lung diseasehe

• 'egg-shell' calcification of hilar lymph nodeshe

Which type of hypersensitivity reaction predominates in the acute phase of extrinsic
allergic alveolitis?ia

A.A Type Iia

B.A Type IIia
x C.A Type III
D.A Type IVia
E.A Type Via
Next question
Although it is known that the pathogenesis of extrinsic allergic alveolitis involves a type
IV (delayed) hypersensitivity reaction, a type III hypersensitivity reaction is thought to
predominate, especially in the acute phase
Extrinsic allergic alveolitis
sqweqwesf erwrewfsdfs adasd dhe
Extrinsic allergic alveolitis (EAA) is a condition caused by hypersensitivity induced lung
damage due to a variety of inhaled organic particles. It is thought to be largely caused by
immune-complex mediated tissue damage (type III hypersensitivity) although delayed
hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic
phase
he earaer aeraer asdsadas eerw dssdfsselleds
Examples
• bird fanciers' lung (avian proteins)he
• farmers lung (spores of Micropolyspora faeni)he
• malt workers' lung (Aspergillus clavatus)he
• mushroom workers' lung (thermophilic actinomycetes)he
he earaer aeraer asdsadas eerw dssdfsselleds
Presentation
• acute: occur 4-8 hrs after exposure, SOB, dry cough, feverhe
• chroniche

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Investigation
• CXR: upper lobe fibrosishe
• BAL: lymphocytosishe

• blood: NO eosinophiliahe
Which one the following statements regarding asbestos is not correct?ia

x A.A Pleural plaques are premalignant

B.A Asbestosis typically affects the lower zonesia
C.A Crocidolite (blue) asbestos is the most dangerous formia
D.A Severity of asbestosis is related to the length of exposureia
E.A Mesothelioma may develop following minimal exposureia
Next question
Asbestos
sqweqwesf erwrewfsdfs adasd dhe
The severity of asbestosis is related to the length of exposure. This is in contrast to
mesothelioma where even very limited exposure can cause disease. Asbestosis typically
causes lower lobe fibrosis. Crocidolite (blue) asbestos is the most dangerous form
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Other features
• pleural thickeninghe
• pleural plaques also seen (not premalignant)he
What is the most appropriate first-line antibiotic in the treatment of Mycoplasma
pneumonia?ia

A.A Benzylpenicillinia
B.A Ceftriaxoneia
C.A Ampicillinia
 x D.A Erythromycinia
E.A Ciprofloxacinia
Next question
Mycoplasma pneumoniae
sqweqwesf erwrewfsdfs adasd dhe
Mycoplasma pneumoniae is a cause of atypical pneumonia which often affects younger
patients. It is associated with a number of characteristic complications such as erythema
multiforme and cold autoimmune haemolytic anaemia. Epidemics of Mycoplasma
pneumoniae classically occur every 4 years. It is important to recognise atypical
pneumonias as they may not respond to penicillins or cephalosporins
he earaer aeraer asdsadas eerw dssdfsselleds
Features
• flu-like symptoms classically precede a dry coughhe
• bilateral consolidation on x-rayhe
• complications may occur as belowhe
he earaer aeraer asdsadas eerw dssdfsselleds
Complications
• cold agglutins (IgM) may cause an haemolytic anaemia, thrombocytopeniahe
• erythema multiforme, erythema nodosumhe
• meningoencephalitis, Guillain-Barre syndromehe
• bullous myringitis: painful vesicles on the tympanic membranehe
• pericarditis/myocarditishe
• gastrointestinal: hepatitis, pancreatitishe
• renal: acute glomerulonephritishe
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Diagnosis
• Mycoplasma serologyhe

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Management
• erythromycin/clarithromycinhe
Each one of the following is a known cause of occupational asthma, except:ia

A.A Isocyanatesia
x B.A Cadmiumia
C.A Soldering flux resinia
D.A Flouria
E.A Platinum saltsia
Next question
Asthma: occupational
sqweqwesf erwrewfsdfs adasd dhe
Causes
• isocyanateshe

• platinum saltshe
• soldering flux resinhe
• glutaraldehydehe

• flourhe
• epoxy resinshe
• proteolytic enzymeshe
Which one of the following is least associated with bronchiectasis?ia

A.A Hypogammaglobulinaemiaia
B.A Allergic bronchopulmonary aspergillosisia
C.A Measlesia
D.A Cystic fibrosisia
x E.A Sarcoidosisia
Next question
Traction bronchiectasis may be seen in some rare cases of stage IV pulmonary
sarcoidosis but this is the least strong association of the five options
Bronchiectasis: causes
sqweqwesf erwrewfsdfs adasd dhe
Bronchiectasis describes a permanent dilatation of the airways secondary to chronic
infection or inflammation. There are a wide variety of causes are listed below:
he earaer aeraer asdsadas eerw dssdfsselleds
Causes
• post-infective: tuberculosis, measles, pertussis, pneumoniahe
• cystic fibrosishe
• bronchial obstruction e.g. lung cancer/foreign bodyhe
• immune deficiency: selective IgA, hypogammaglobulinaemiahe
• allergic bronchopulmonary aspergillosis (ABPA)he
• ciliary dyskinetic syndromes: Kartagener's syndrome, Young's syndromehe
• yellow nail syndromehe
A 45-year-old female with a 30 pack-year history of smoking is admitted to the
Emergency Department with shortness of breath. Arterial blood gases taken on room air
are as follows:
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pH 7.49
pCO2 2.9 kPa
pO2 9.4 kPa

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Which one of the following is the most likely diagnosis?ia

A.A Salicylate overdoseia

B.A Chronic obstructive pulmonary diseaseia
x C.A Pulmonary embolism
D.A Vomitingia
E.A Anxietyia
Next question
Pulmonary embolism needs to be excluded. Hyperventilation secondary to anxiety would
not cause hypoxia
Respiratory alkalosis
sqweqwesf erwrewfsdfs adasd dhe
Common causes
• anxiety leading to hyperventilationhe
• pulmonary embolismhe
• salicylate poisoning*he

• CNS disorders: stroke, subarachnoid haemorrhage, encephalitishe

• altitudehe
• pregnancyhe
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*salicylate overdose leads to a mixed respiratory alkalosis and metabolic acidosis. Early stimulation
of the respiratory centre leads to a respiratory alkalosis whilst later the direct acid effects of
salicylates (combined with acute renal failure) may lead to an acidosis
Which one of the following is responsible for malt workers' lung?ia

x A.A Aspergillus clavatus

B.A Avian proteinsia
C.A Mycobacterium aviumia
D.A Thermophilic actinomycetesia
E.A Micropolyspora faeniia
Next question
Aspergillus clavatus causes malt workers' lung, a type of EAA
Extrinsic allergic alveolitis
sqweqwesf erwrewfsdfs adasd dhe
Extrinsic allergic alveolitis (EAA) is a condition caused by hypersensitivity induced lung
damage due to a variety of inhaled organic particles. It is thought to be largely caused by
immune-complex mediated tissue damage (type III hypersensitivity) although delayed
hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic
phase
he earaer aeraer asdsadas eerw dssdfsselleds
Examples
• bird fanciers' lung (avian proteins)he
 • farmers lung (spores of Micropolyspora faeni)he
• malt workers' lung (Aspergillus clavatus)he
• mushroom workers' lung (thermophilic actinomycetes)he
he earaer aeraer asdsadas eerw dssdfsselleds
Presentation
• acute: occur 4-8 hrs after exposure, SOB, dry cough, feverhe
• chroniche
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Investigation
• CXR: upper lobe fibrosishe

• BAL: lymphocytosishe
• blood: NO eosinophiliahe
Which one of the following is least associated with the development of acute respiratory
distress syndrome (ARDS)?ia

A.A Acute pancreatitisia

B.A Massive blood transfusionia
x C.A Anterior myocardial infarction
D.A Smoke inhalationia
E.A Sepsisia
Next question
ARDS criteria
• acute onset
• bilateral infiltrates on CXR
• non-cardiogenic
• pO2/FiO2 < 200 mmHg

ARDS
sqweqwesf erwrewfsdfs adasd dhe
Basics
• acute respiratory distress syndromehe
• caused by increased permeability of alveolar capillaries leading to fluid
accumulation in alveoli i.e. non-cardiogenic pulmonary oedemahe
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Criteria (American-European Consensus Conference)
• acute onsethe

• bilateral infiltrates on CXRhe

• non-cardiogenic (pulmonary artery wedge pressure needed if doubt)he
• pO2/FiO2 < 200 mmHghe
he earaer aeraer asdsadas eerw dssdfsselleds
Causes
• infection: sepsis, pneumoniahe
• massive blood transfusionhe
• traumahe
• smoke inhalationhe

• pancreatitishe
• cardio-pulmonary bypasshe
A 26-year-old man is referred to the respiratory clinic due to episodic shortness-of-breath
and wheeze. He brings with him a peak flow diary given to him by his GP. What is the
cut-off value which would support a diagnosis of asthma?ia

A.A Greater than 15% diurnal variation on >= 7 days in a week for 2 weeksia
x B.A Greater than 20% diurnal variation on >= 3 days in a week for 2 weeks
C.A Greater than 15% diurnal variation on >= 5 days in a week for 2 weeksia
D.A Greater than 15% diurnal variation on >= 5 days in a week for 4 weeksia
E.A Greater than 10% diurnal variation on >= 3 days in a week for 2 weeksia
Next question
Asthma: diagnosis in adults
sqweqwesf erwrewfsdfs adasd dhe
The 2005 British Thoracic Society guidelines states that a diagnosis of asthma should be
considered in patients with typical symptoms, for example:
• episodic wheezehe
• shortness of breathhe
• coughhe
• chest tightnesshe

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Signs may or may not be present, for example:
• wheeze: diffuse, bilateralhe
• tachypnoeahe

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Additional information may also be useful:
• personal or family history of asthma or atopyhe
• history of worsening after NSAIDs or beta-blockershe
• recognised triggers e.g. pollen or dusthe
• pattern and severity of symptoms and exacerbationshe
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In terms of objective measurements the 2005 BTS guidelines recommend the following:
• diurnal variation % = [(Highest – Lowest PEFR) / Highest PEFR] x 100he
 • greaterthan 20% diurnal variation on >= 3 days in a week for 2 weeks on peak
expiratory flow diaryhe
• otherobjective measures listed in the guidelines include a trial of a short acting beta
2 agonist, trial of prednisolone or a decrease in FEV1 following exercisehe
Which one of the following antibiotics is most associated with pulmonary fibrosis?ia

A.A Linezolidia
B.A Streptomycinia
x C.A Nitrofurantoinia
D.A Tetracyclineia
E.A Piperacillinia
Next question
Amiodarone & methotrexate are common causes of lung fibrosis
Drugs causing lung fibrosis
sqweqwesf erwrewfsdfs adasd dhe
Causes
• amiodaronehe
• cytotoxic agents: busulphan, bleomycinhe
• anti-rheumatoid drugs: methotrexate, sulfasalazine, goldhe
• nitrofurantoinhe

Each one of the following features is seen in extrinsic allergic alveolitis, except:ia

A.A Upper lobe fibrosisia

x B.A Eosinophiliaia
C.A Pyrexiaia
D.A Coughia
E.A Dyspnoeaia
Next question
Extrinsic allergic alveolitis
sqweqwesf erwrewfsdfs adasd dhe
Extrinsic allergic alveolitis (EAA) is a condition caused by hypersensitivity induced lung
damage due to a variety of inhaled organic particles. It is thought to be largely caused by
immune-complex mediated tissue damage (type III hypersensitivity) although delayed
hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic
phase
he earaer aeraer asdsadas eerw dssdfsselleds
Examples
• bird fanciers' lung (avian proteins)he
• farmers lung (spores of Micropolyspora faeni)he
• malt workers' lung (Aspergillus clavatus)he
 • mushroom workers' lung (thermophilic actinomycetes)he
he earaer aeraer asdsadas eerw dssdfsselleds
Presentation
• acute: occur 4-8 hrs after exposure, SOB, dry cough, feverhe
• chroniche
he earaer aeraer asdsadas eerw dssdfsselleds
Investigation
• CXR: upper lobe fibrosishe
• BAL: lymphocytosishe
• blood: NO eosinophiliahe
Which one of the following respiratory disorders is least associated with rheumatoid
arthritis?ia

A.A Exudative pleural effusionsia

x B.A Emphysemaia
C.A Caplan's syndromeia
D.A Lower zone pulmonary fibrosisia
E.A Bronchiolitis obliteransia
Next question
Rheumatoid arthritis: pulmonary manifestations
sqweqwesf erwrewfsdfs adasd dhe
A variety of respiratory problems may be seen in patients with rheumatoid arthritis:
• pulmonary fibrosishe
• pleural effusionhe
• pulmonary noduleshe

• bronchiolitis obliteranshe
• complications of drug therapy e.g. methotrexate pneumonitishe
• pleurisyhe
• Caplan'ssyndrome - massive fibrotic nodules with occupational coal dust
exposurehe
• infection (possibly atypical) secondary to immunosuppressionhe
A 19-year-old male with no past medical history presents to the Emergency Department
with anterior chest pain and shortness of breath. Blood pressure is 110/80 mmHg and his
pulse is 84 bpm. The chest x-ray is reported as showing a 50% pneumothorax with no
mid-line shift. What is the most appropriate management?ia

A.A Intercostal drain insertionia

B.A Immediate 14G cannula into 2nd intercostal space, mid-clavicular lineia
C.A Dischargeia
 D.A Admit for 48 hours observation and repeat chest x-rayia
x E.A Aspirationia
Next question
Pneumothorax
sqweqwesf erwrewfsdfs adasd dhe
The British Thoracic Society (BTS) published guidelines for the management of
spontaneous pneumothorax in 2003. A pneumothorax is termed primary if there is no
underlying lung disease and secondary if there is
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Primary pneumothorax
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Recommendations include:
• if the rim of
air is < 2cm and the patient is not short of breath then discharge should
be consideredhe
• otherwise aspiration should be attemptedhe
• if this fails then repeat aspiration should be consideredhe
• if this fails then a chest drain should be insertedhe
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Secondary pneumothorax
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Recommendations include:
• if the patient is
> 50 years old and the rim of air is > 2cm and the patient is short of
breath then a chest drain should be inserted. he
• otherwise aspiration should be attempted. If aspiration fails a chest drain should be
inserted. All patients should be admitted for at least 24 hourshe
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Iatrogenic pneumothorax
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Recommendations include:
• less likelihood of recurrence than spontaneous pneumothoraxhe
• majoritywill resolve with observation, if treatment is required then aspiration
should be usedhe
• ventilated patients need chest drains, as may some patients with COPDhe
A 52-year-old female is admitted with a suspected lower respiratory tract infection.
Investigations are as follows:
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Chest x-ray Right lower lobe consolidation
Urinary Legionella antigen Positive

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What is the most appropriate antibiotic therapy?ia

A.A Tetracyclineia
 B.A Ceftriaxoneia
C.A Co-amoxiclavia
D.A Vancomycinia
x E.A Clarithromycinia
Next question
Legionella
sqweqwesf erwrewfsdfs adasd dhe
Legionnaire's disease is caused by the intracellular bacterium Legionella pneumophilia. It
is typically colonizes water tanks and hence questions may hint at air-conditioning
systems or foreign holidays. Person-to-person transmission is not seen
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Features
• flu-like symptomshe
• dry coughhe
• lymphopeniahe

• hyponatraemiahe
• deranged LFTs he
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Diagnosis
• urinary antigenhe
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Management
• treat with erythromycinhe
What is the first line treatment in allergic bronchopulmonary aspergillosis?ia

A.A Itraconazoleia
B.A Nebulised pentamidineia
C.A Fluconazoleia
D.A Cyclophosphamideia
x E.A Prednisoloneia
Next question
Allergic bronchopulmonary aspergillosis
sqweqwesf erwrewfsdfs adasd dhe
Allergic bronchopulmonary aspergillosis results from an allergy to Aspergillus spores. In
the exam questions often give a history of bronchiectasis and eosinophilia.
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Features
• bronchoconstriction: wheeze, cough, dyspnoeahe
• bronchiectasis (proximal)he
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Investigations
 • eosinophiliahe
• flitting CXR changeshe
• positive radioallergosorbent (RAST) test to Aspergillushe
• positive IgG precipitins (not as positive as in aspergilloma)he
• raised IgEhe

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Management
• steroidshe

• itraconazole is sometimes introduced as a second line agenthe

How often do epidemics of Mycoplasma pneumonia tend to occur?ia

A.A Every 4 monthsia

B.A Every 2 yearsia
x C.A Every 4 years
D.A Every 8 yearsia
E.A Every 20 yearsia
Next question
Mycoplasma pneumoniae
sqweqwesf erwrewfsdfs adasd dhe
Mycoplasma pneumoniae is a cause of atypical pneumonia which often affects younger
patients. It is associated with a number of characteristic complications such as erythema
multiforme and cold autoimmune haemolytic anaemia. Epidemics of Mycoplasma
pneumoniae classically occur every 4 years. It is important to recognise atypical
pneumonias as they may not respond to penicillins or cephalosporins
he earaer aeraer asdsadas eerw dssdfsselleds
Features
• flu-like symptoms classically precede a dry coughhe
• bilateral consolidation on x-rayhe
• complications may occur as belowhe
he earaer aeraer asdsadas eerw dssdfsselleds
Complications
• cold agglutins (IgM) may cause an haemolytic anaemia, thrombocytopeniahe
• erythema multiforme, erythema nodosumhe
• meningoencephalitis, Guillain-Barre syndromehe
• bullous myringitis: painful vesicles on the tympanic membranehe
• pericarditis/myocarditishe

• gastrointestinal: hepatitis, pancreatitishe

• renal: acute glomerulonephritishe

he earaer aeraer asdsadas eerw dssdfsselleds

Diagnosis
 • Mycoplasma serologyhe
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Management
• erythromycin/clarithromycinhe
A 56-year-old man is admitted with type II respiratory failure secondary to COPD but
fails to respond to maximal medical therapy. It is decided that a trial of non-invasive
ventilation in the form of bi-level pressure support should be given. What are the most
appropriate initial settings for the ventilator?ia

x A.A IPAP = 12 cm H2O; EPAP = 5 cm H2O

B.A IPAP = 15 cm H2O; EPAP = 15 cm H2ia
C.A IPAP = 50 cm H2O; EPAP = 20 cm H2Oia
D.A IPAP = 20 cm H2O; EPAP = 50 cm H2Oia
E.A IPAP = 5 cm H2O; EPAP = 12 cm H2Oia
Next question
Non-invasive ventilation
sqweqwesf erwrewfsdfs adasd dhe
The British Thoracic Society (BTS) published guidelines in 2002 on the use of non-
invasive ventilation in acute respiratory failure
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Non-invasive ventilation - key indications
• COPD with respiratory acidosis pH 7.25-7.35he
• type II respiratoryfailure secondary to chest wall deformity, neuromuscular disease
or obstructive sleep apnoeahe
• cardiogenic pulmonary oedema unresponsive to CPAPhe
• weaning from tracheal intubationhe

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Recommended initial settings for bi-level pressure support in COPD
• EPAP: 4-5 cm H2Ohe
• IPAP: 12-15 cm H2Ohe

• back up rate: 15 breaths/minhe

• Back up I:E ratio: 1:3he
Which one of the following is least associated with a coin lesion on chest x-ray?ia

A.A Hydatid cystia

B.A Harmatomaia
C.A Abscessia
D.A Lung canceria
x E.A Miliary tuberculosis
Next question
CXR: coin lesions
sqweqwesf erwrewfsdfs adasd dhe
Coin lesions
• malignant tumour: lung cancer or metastaseshe
• benign tumour: harmatomahe

• infection: pneumonia, abscess, TB, hydatid cysthe

• AV malformationhe

Which one of the following is associated with a poor prognosis in patients with
community-acquired pneumonia?ia

A.A Diastolic blood pressure 65 mmHgia

B.A Sodium 131 mmol/lia
x C.A Urea 12 mmol/l
D.A White blood cell 27 * 109/lia
E.A Respiratory rate 25/minia
Next question
Pneumonia: prognostic factors
sqweqwesf erwrewfsdfs adasd dhe
CURB-65 criteria of severe pneumonia
• Confusion (abbreviated mental test score < 8/10)he
• Urea > 7 mmol/Lhe
• Respiratory rate >= 30 / minhe
• BP: systolic < 90 or diastolic < 60 mmHghe
• age > 65 yearshe
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Patients with 3 or more (out of 5) of the above criteria are regarded as having a severe
pneumonia
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Other factors associated with a poor prognosis include:
• presence of coexisting diseasehe
• hypoxaemia (pO2 < 8 kPa) independent of FiO2he
Which one of the following is the most common type of lung cancer in the UK?ia

A.A Small cellia

x B.A Squamous cell
C.A Adenocarcinomaia
D.A Large cellia
E.A Carcinoidia
Next question
Tricky question. It is well known that the incidence of adenocarcinoma is rising in
comparison to the other types of non-small cell lung cancer. Indeed, adenocarcinoma is
now the most common type of lung cancer in the USA. In Europe however squamous cell
cancer remains the most common subtype
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Reference
he earaer aeraer asdsadas eerw dssdfsselleds
Janssen-Heijnen, M.L. and J.W. Coebergh, The changing epidemiology of lung cancer in
Europe. Lung Cancer, 2003. 41(3)
Lung cancer: types
sqweqwesf erwrewfsdfs adasd dhe
Lung cancer
• squamous: c. 35%he
• adenocarcinoma: c. 30%he
• small (oat) cell: c. 15%he
• large cell: c. 10%he
• other c. 5%he
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Other tumours
• alveolar cell carcinoma: not related to smoking, ++sputumhe
• bronchial adenoma: mostly carcinoidhe
A 52-year-old male is admitted to hospital with a temperature of 38.2 C and a 3 days
history of a productive cough. He has been generally unwell for the past 10 days with flu-
like symptoms. Chest x-ray shows left lower zone consolidation. What is the likely
causative organism?ia

A.A Moraxella catarrhalisia

B.A Fusobacteriumia
C.A Klebsiellaia
x D.A Staphylococcus aureus
E.A Chlamydia pneumoniaeia
Next question
Preceding influenza predisposes to Staphylococcus aureus pneumonia
Pneumonia: community-acquired
sqweqwesf erwrewfsdfs adasd dhe
Streptococcus pneumoniae is the most common cause of community-acquired pneumonia
(CAP)
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Characteristic features of pneumococcal pneumonia
• rapid onsethe
• high feverhe

• pleuritic chest painhe

• herpes labialishe
he earaer aeraer asdsadas eerw dssdfsselleds
Antibiotic choices
• hospitalized non-severe CAP, first line: oral amoxicillin + macrolidehe
A 49-year-old female is admitted to the Emergency Department with shortness of breath.
On examination the pulse is 114 bpm with blood pressure 106/66 mmHg, temperature
37.7ºC and respiratory rate 30/min. Examination of the cardiorespiratory system is
unremarkable with a peak expiratory flow rate of 280 l/min. Arterial blood gases on air
reveal:
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pH 7.41
pCO2 4.0 kPa
pO2 7.2 kPa

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Following the initiation of oxygen therapy, what is the next most important step in
management?ia

A.A IV aminophyllineia
B.A IV hydrocortisoneia
x C.A Low molecular weight heparin
D.A IV fluidsia
E.A IV co-trimoxazoleia
Next question
Type 1 respiratory failure in a tachycardic, tachypnoeic female with an absence of chest
signs points towards a diagnosis of pulmonary embolism
Pulmonary embolism: management
sqweqwesf erwrewfsdfs adasd dhe
The British Thoracic Society (BTS) published guidelines in 2003 on the management of
patients with suspected pulmonary embolism (PE)
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Key points from the guidelines include:
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Anticoagulation
• low molecular weight heparin (LMWH), rather than unfractionated heparin (UFH),
should be used routinely in patients with suspected pulmonary embolism. This
reflects the equal efficacy and safety of LMWHs as well as their ease of use.
Exceptions include patients with a massive PE or in situations where rapid
reversal of anticoagulation may be necessaryhe
• warfarinisation: the standard duration of anticoagulation is 4-6 weeks* if temporary
risk factors are present, 3 months for the first idiopathic PE and at least 6 months
for other situationshe
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Thrombolysis
• thrombolysis is now recommended as the first-line treatment for massive PE. Other
 invasive approaches should be considered where appropriate facilities existhe
he earaer aeraer asdsadas eerw dssdfsselleds
*the 2005 British Committee for Standards in Haematology guidelines suggest at least 3 months
anticoagulation in this situation, based on a 2004 study. It is therefore possible these guidelines may
soon change
Each one of the following is associated with bronchiectasis, except:ia

A.A Cystic fibrosisia

x B.A Down's syndrome
C.A Pertussisia
D.A Hypogammaglobulinaemiaia
E.A Young's syndromeia
Next question
Bronchiectasis: causes
sqweqwesf erwrewfsdfs adasd dhe
Bronchiectasis describes a permanent dilatation of the airways secondary to chronic
infection or inflammation. There are a wide variety of causes are listed below:
he earaer aeraer asdsadas eerw dssdfsselleds
Causes
• post-infective: tuberculosis, measles, pertussis, pneumoniahe
• cystic fibrosishe
• bronchial obstruction e.g. lung cancer/foreign bodyhe
• immune deficiency: selective IgA, hypogammaglobulinaemiahe
• allergic bronchopulmonary aspergillosis (ABPA)he
• ciliary dyskinetic syndromes: Kartagener's syndrome, Young's syndromehe
• yellow nail syndromehe
Which one of the following conditions is most likely to cause upper lobe lung fibrosis?ia

A.A Rheumatoid arthritisia

B.A Cryptogenic fibrosing alveolitisia
C.A Dermatomyositisia
D.A Systemic sclerosisia
x E.A Ankylosing spondylitis
Next question
Lung fibrosis
sqweqwesf erwrewfsdfs adasd dhe
It is important in the exam to be able to differentiate between conditions causing
predominately upper or lower zone fibrosis. It should be noted that the more common
causes (cryptogenic fibrosing alveolitis, drugs) tend to affect the lower zones
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Fibrosis predominately affecting the upper zones
 • extrinsic allergic alveolitishe
• coal worker's pneumoconiosis/progressive massive fibrosishe
• silicosishe
• sarcoidosishe
• ankylosing spondylitis (rare)he
• histiocytosishe
• tuberculosishe

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Fibrosis predominately affecting the lower zones
• cryptogenic fibrosing alveolitishe
• most connective tissue disorders (except ankylosing spondylitis)he
• drug-induced: amiodarone, bleomycin, methotrexatehe
• asbestosishe

A 35-year-old female presents with shortness of breath. The following blood gases are
obtained on room air:
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pH 7.54
pCO2 1.8 kPa
pO2 12.4 kPa

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Which one of the following is the least likely cause?ia

x A.A Opiate overdose

B.A Pulmonary embolismia
C.A Pregnancyia
D.A Encephalitisia
E.A Anxietyia
Next question
The question asks for the least likely cause of a respiratory alkalosis. Salicylate, not
opiate, poisoning is associated with a respiratory alkalosis. Opiate overdose would lead to
respiratory depression and hence a respiratory acidosis
Respiratory alkalosis
sqweqwesf erwrewfsdfs adasd dhe
Common causes
• anxiety leading to hyperventilationhe
• pulmonary embolismhe

• salicylate poisoning*he

• CNS disorders: stroke, subarachnoid haemorrhage, encephalitishe

• altitudehe
 • pregnancyhe
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*salicylate overdose leads to a mixed respiratory alkalosis and metabolic acidosis. Early
stimulation of the respiratory centre leads to a respiratory alkalosis whilst later the direct
acid effects of salicylates (combined with acute renal failure) may lead to an acidosis

Which of the following is not a feature of Lofgren's syndrome?ia

A.A Bilateral hilar lymphadenopathyia

B.A Polyarthralgiaia
x C.A Insidious onset
D.A Feveria
E.A Erythema nodosumia
Next question
Lofgren's syndrome
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Lofgren's syndrome is an acute form sarcoidosis characterised by bilateral hilar
lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia.
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It typically occurs in young females and carries an excellent prognosis
Which one of the following is least associated with a cavitating lung lesion?ia

A.A Klebsiella infectionia

x B.A Sarcoidosisia
C.A Lung canceria
D.A Tuberculosisia
E.A Histoplasmosisia
Next question
CXR: cavitating lung lesion
sqweqwesf erwrewfsdfs adasd dhe
Differential
• tuberculosishe
• lung cancer (especially squamous cell)he
• abscess (Staph aureus, Klebsiella and Pseudomonas)he
• Wegener's granulomatosishe
• pulmonary embolismhe
• rheumatoid arthritishe
• aspergillosis, histoplasmosis, coccidioidomycosishe
A chest x-ray of a patient with sarcoidosis shows bilateral hilar lymphadenopathy
accompanied with interstitial infiltrates. What chest x-ray stage does this correspond to?ia
 A.A Stage 0ia
B.A Stage 1ia
x C.A Stage 2
D.A Stage 3ia
E.A Stage 4ia
Next question
Sarcoidosis CXR
•1= BHL
•2= BHL + infiltrates
•3= infiltrates
•4= fibrosis

Sarcoidosis: investigation
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There is no one diagnostic test for sarcoidosis and hence diagnosis is still largely clinical.
ACE levels have a sensitivity of 60% and specificity of 70% and are therefore not
reliable in the diagnosis of sarcoidosis although they may have a role in monitoring
disease activity. Routine bloods may show hypercalcaemia (seen in 10% if patients) and a
raised ESR
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A chest x-ray may show the following changes:
• stage 0 = normalhe
• stage 1 = bilateral hilar lymphadenopathy (BHL)he
• stage 2 = BHL + interstitial infiltrateshe
• stage 3 = diffuse interstitial infiltrates onlyhe
• stage 4 = diffuse fibrosishe
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Other investigations
• spirometry: may show a restrictive defecthe
• tissue biopsy: non-caseating granulomashe
• gallium-67 scan - not used routinelyhe
Each one of the following is typically seen in Legionella pneumonia, except:ia

A.A Dry coughia

x B.A Lymphocytosisia
C.A Hyponatraemiaia
D.A Flu-like symptomsia
E.A Deranged liver function testsia
Next question
Legionella
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Legionnaire's disease is caused by the intracellular bacterium Legionella pneumophilia. It
is typically colonizes water tanks and hence questions may hint at air-conditioning
systems or foreign holidays. Person-to-person transmission is not seen
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Features
• flu-like symptomshe
• dry coughhe
• lymphopeniahe

• hyponatraemiahe
• deranged LFTs he
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Diagnosis
• urinary antigenhe
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Management
• treat with erythromycinhe
A 60-year-old female with a history of COPD presents to the Emergency Department
with shortness of breath. Blood pressure is 120/80 mmHg and he pulse is 90 bpm. The
chest x-ray shows a pneumothorax with a 2cm rim of air and no mediastinal shift. What
is the most appropriate management?ia

x A.A Intercostal drain insertion

B.A Dischargeia
C.A Admit for 48 hours observation and repeat chest x-rayia
D.A Immediate 14G cannula into 2nd intercostal space, mid-clavicular lineia
E.A Aspirationia
Next question
Pneumothorax
sqweqwesf erwrewfsdfs adasd dhe
The British Thoracic Society (BTS) published guidelines for the management of
spontaneous pneumothorax in 2003. A pneumothorax is termed primary if there is no
underlying lung disease and secondary if there is
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Primary pneumothorax
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Recommendations include:
• if the rim of
air is < 2cm and the patient is not short of breath then discharge should
be consideredhe
• otherwise aspiration should be attemptedhe
• if this fails then repeat aspiration should be consideredhe
 • if this fails then a chest drain should be insertedhe
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Secondary pneumothorax
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Recommendations include:
• if the patient is
> 50 years old and the rim of air is > 2cm and the patient is short of
breath then a chest drain should be inserted. he
• otherwise aspiration should be attempted. If aspiration fails a chest drain should be
inserted. All patients should be admitted for at least 24 hourshe
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Iatrogenic pneumothorax
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Recommendations include:
• less likelihood of recurrence than spontaneous pneumothoraxhe
• majoritywill resolve with observation, if treatment is required then aspiration
should be usedhe
• ventilated patients need chest drains, as may some patients with COPDhe
Churg-Strauss syndrome is associated with each one of the following, except:ia

A.A Asthmaia
x B.A Lymphocytosisia
C.A Paranasal sinusitisia
D.A Mononeuritis multiplexia
E.A pANCAia
Next question
Churg-Strauss syndrome
sqweqwesf erwrewfsdfs adasd dhe
Overview
• an ANCA associated small-medium vessel vasculitishe
• associated with the use of leukotriene receptor antagonistshe
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Features
• asthmahe
• blood eosinophilia (e.g. > 10%)he
• paranasal sinusitishe

• mononeuritis multiplexhe
• pANCA positive in 60%he
A 63-year-old man is noted to have a pleural effusion on CXR. Which one of the
following would typically cause a transudate?ia

A.A Pancreatitisia
 B.A Pneumoniaia
C.A Yellow nail syndromeia
x D.A Hypothyroidismia
E.A Dressler's syndromeia
Next question
Pleural effusion
sqweqwesf erwrewfsdfs adasd dhe
Exudate (> 30g/L protein)
• infection: pneumonia, TB, subphrenic abscesshe
• connective tissue disease: RA, SLEhe
• neoplasia: lung cancer, mesothelioma, metastaseshe
• pancreatitishe
• pulmonary embolismhe

• Dressler's syndromehe
• yellow nail syndromehe
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Transudate (< 30g/L protein)
• heart failurehe
• hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)he
• hypothyroidismhe

• Meigs' syndromehe
Which one of the following complications is least recognised following Mycoplasma
pneumoniae infection?ia

x A.A Myasthenia gravis

B.A Erythema multiformeia
C.A Bullous myringitisia
D.A Meningoencephalitisia
E.A Haemolytic anaemiaia
Next question
Mycoplasma pneumoniae
sqweqwesf erwrewfsdfs adasd dhe
Mycoplasma pneumoniae is a cause of atypical pneumonia which often affects younger
patients. It is associated with a number of characteristic complications such as erythema
multiforme and cold autoimmune haemolytic anaemia. Epidemics of Mycoplasma
pneumoniae classically occur every 4 years. It is important to recognise atypical
pneumonias as they may not respond to penicillins or cephalosporins
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Features
 • flu-like symptoms classically precede a dry coughhe
• bilateral consolidation on x-rayhe
• complications may occur as belowhe
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Complications
• cold agglutins (IgM) may cause an haemolytic anaemia, thrombocytopeniahe
• erythema multiforme, erythema nodosumhe
• meningoencephalitis, Guillain-Barre syndromehe
• bullous myringitis: painful vesicles on the tympanic membranehe
• pericarditis/myocarditishe
• gastrointestinal: hepatitis, pancreatitishe
• renal: acute glomerulonephritishe
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Diagnosis
• Mycoplasma serologyhe

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Management
• erythromycin/clarithromycinhe

A 57-year-old man with a history of COPD is admitted to hospital with worsening

shortness-of-breath. On examination blood pressure is 124/88 mmHg with a respiratory
rate of 18 / min. A chest x-ray reveals left lower lobe consolidation. Arterial blood gases
on air are as follows:
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pH 7.37
pCO2 5.5 kPa
pO2 9.1 kPa

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What is the most suitable antibiotic therapy?ia

A.A Oral co-amoxiclavia

B.A Oral levofloxacinia
x C.A Oral amoxicillin + erythromycin
D.A IV ceftriaxone + clarithromycinia
E.A Oral co-amoxiclav + metronidazoleia
Next question
The 2001 British Thoracic Society pneumonia guidelines do not make specific
recommendations for patients with COPD. Whilst COPD may obviously affect the
severity of the episode there is limited evidence to suggest that the causative organisms
are different. Oral amoxicillin with an oral macrolide is therefore first line treatment for
hospitalised patients with non-severe CAP
Pneumonia: community-acquired
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Streptococcus pneumoniae is the most common cause of community-acquired pneumonia
(CAP)
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Characteristic features of pneumococcal pneumonia
• rapid onsethe
• high feverhe
• pleuritic chest painhe

• herpes labialishe
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Antibiotic choices
• hospitalized non-severe CAP, first line: oral amoxicillin + macrolidehe
Each one of the following features are associated with Wegener's granulomatosis,
except:ia

A.A Haemoptysisia
B.A Saddle-shape nose deformityia
C.A Epistaxisia
x D.A Asthmaia
E.A Glomerulonephritisia
Next question
Wegener's granulomatosis
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Wegener's granulomatosis is an autoimmune condition associated with a necrotizing
granulomatous vasculitis, affecting both the upper and lower respiratory tract as well as
the kidneys
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Features
• upper respiratory tract: epistaxis, sinusitis, nasal crustinghe
• lower respiratory tract: dyspnoea, haemoptysishe
• glomerulonephritis ('pauci-immune', 80% of patients)he
• saddle-shape nose deformityhe

• also: vasculitic rash, eye involvement (e.g. proptosis), cranial nerve lesionshe
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Investigations
• cANCA positive in > 90%, pANCA positive in 25%he
• chest x-ray: wide variety of presentations, including cavitating lesionshe
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Management
• steroidshe
 • cyclophosphamide (90% response)he
• plasma exchangehe

• median survival = 8-9 yearshe

Which one of the following is not a contraindication to surgical resection of a bronchial
adenocarcinoma?ia

A.A Malignant pleural effusionia

x B.A FEV 1.6 litres
C.A Vocal cord paralysisia
D.A SVC obstructionia
E.A Stage IIIbia
Next question
Contraindications to lung cancer surgery include SVC obstruction, FEV < 1.5,
MALIGNANT pleural effusion, and vocal cord paralysis
Lung cancer: non-small cell management
sqweqwesf erwrewfsdfs adasd dhe
Management
• only 20% suitable for surgeryhe
• mediastinoscopy performed prior to surgery as CT does not always show
mediastinal lymph node involvementhe
• curative or palliative radiotherapyhe
• poor response to chemotherapyhe
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Surgery contraindications
• assess general healthhe
• stage IIIb or IV (i.e. metastases present)he
• FEV1 < 1.5 litres is considered a general cut-off point*he
• malignant pleural effusionhe

• tumour near hilumhe

• vocal cord paralysishe
• SVC obstructionhe
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* However if FEV1 < 1.5 for lobectomy or < 2.0 for pneumonectomy then some authorities advocate
further lung function tests as operations may still go ahead based on the results
A 25-year-old man is referred due to pain and swelling in his knees and ankles. On
examination he has a painful, erythematous rash on his legs. The following results are
obtained:
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Rheumatoid factor Negative
ESR 94 mm
Chest x-ray Hilar lymphadenopathy
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What is the most likely outcome?ia

A.A Improvement following a course of prednisoloneia

B.A Scarring and ulceration of skinia
x C.A Spontaneous improvement
D.A Progressive arthritisia
E.A Renal replacement therapy in 20 years timeia
Next question
The majority of patients with sarcoidosis get better without treatment
This man has an acute form of sarcoidosis. There are no indications for steroid therapy
and his symptoms will resolve spontaneously in the majority of cases
Sarcoidosis: prognostic features
sqweqwesf erwrewfsdfs adasd dhe
Sarcoidosis is a multisystem disorder of unknown aetiology characterised by non-
caseating granulomas. It is more common in young adults and in people of African
descent. Sarcoidosis remits without treatment in approximately two-thirds of people
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Factors associated with poor prognosis
• insidious onset, symptoms > 6 monthshe
• absence of erythema nodosumhe
• extrapulmonary manifestations: e.g. lupus pernio, splenomegalyhe
• CXR: stage III-IV featureshe
• black peoplehe
Non-invasive ventilation (NIV) is least likely to be successful in which one of the
following scenarios?ia

A.A COPDia
B.A Chest wall deformityia
C.A Obstructive sleep apnoeaia
D.A Weaning from tracheal intubationia
x E.A Bronchiectasisia
Next question
The British Thoracic Society recommend that whilst a trial of NIV may be undertaken in
bronchiectasis it should not be used routinely as its effectiveness is likely to be limited by
excessive secretions
Non-invasive ventilation
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The British Thoracic Society (BTS) published guidelines in 2002 on the use of non-
invasive ventilation in acute respiratory failure
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Non-invasive ventilation - key indications
• COPD with respiratory acidosis pH 7.25-7.35he
• type II respiratoryfailure secondary to chest wall deformity, neuromuscular disease
or obstructive sleep apnoeahe
• cardiogenic pulmonary oedema unresponsive to CPAPhe
• weaning from tracheal intubationhe

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Recommended initial settings for bi-level pressure support in COPD
• EPAP: 4-5 cm H2Ohe
• IPAP: 12-15 cm H2Ohe

• back up rate: 15 breaths/minhe

• Back up I:E ratio: 1:3he
Which one of the following is responsible for mushroom workers' lung?ia

x A.A Thermophilic actinomycetes

B.A Micropolyspora faeniia
C.A Avian proteinsia
D.A Mycobacterium aviumia
E.A Aspergillus clavatusia
Next question
Thermophilic actinomycetes causes mushroom workers' lung, a type of EAA
Extrinsic allergic alveolitis
sqweqwesf erwrewfsdfs adasd dhe
Extrinsic allergic alveolitis (EAA) is a condition caused by hypersensitivity induced lung
damage due to a variety of inhaled organic particles. It is thought to be largely caused by
immune-complex mediated tissue damage (type III hypersensitivity) although delayed
hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic
phase
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Examples
• bird fanciers' lung (avian proteins)he
• farmers lung (spores of Micropolyspora faeni)he
• malt workers' lung (Aspergillus clavatus)he
• mushroom workers' lung (thermophilic actinomycetes)he
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Presentation
• acute: occur 4-8 hrs after exposure, SOB, dry cough, feverhe
• chroniche

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Investigation
 • CXR: upper lobe fibrosishe
• BAL: lymphocytosishe

• blood: NO eosinophiliahe
Which one of the following interventions is most likely to increase survival in patients
with COPD?ia

A.A Home nebulisersia

B.A Prophylactic antibiotic therapyia
C.A Pulmonary rehabilitationia
D.A Long-term steroid therapyia
x E.A Long-term oxygen therapy
Next question
After smoking cessation, long-term oxygen therapy is one of the few interventions that
has been shown to improve survival in COPD
COPD: long-term management
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Factors which may improve survival in patients with stable COPD
• smoking cessation - the single most important intervention in patients who are still
smoking he
• long term oxygen therapy in patients who fit criteria he
• lung volume reduction surgery in selected patients he
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Non-invasive ventilation has been shown to effective in the management of patients with acute
respiratory failure
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Anticholinergic agents (e.g. tiotropium) have been shown in some studies to be superior to beta 2
agonists in COPD, and are therefore sometimes used as first line therapy
Each one of the following is a risk factor for lung cancer, except:ia

A.A Radonia
B.A Cryptogenic fibrosing alveolitisia
x C.A Coal dust
D.A Asbestosia
E.A Arsenicia
End session
Lung cancer: risk factors
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Smoking
• increases risk of lung ca by a factor of 10he
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Other factors
 • asbestos - increases risk of lung ca by a factor of 5he
• arseniche

• radonhe
• nickelhe
• chromatehe

• aromatic hydrocarbonhe
• cryptogenic fibrosing alveolitishe
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Factors that are NOT related
• coal dusthe
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Smoking and asbestos are synergistic i.e. if smoker with asbestos exposure risk = 50
times that of normal
Which one of the following types of lung cancer is most associated with cavitating
lesions?ia

A.A Carcinoidia
B.A Large cellia
C.A Small cellia
x D.A Squamous cell
E.A Adenocarcinomaia
Next question
Whilst the other types of lung cancer may cause cavitating lesions, it is most commonly
seen in squamous cell cancer
CXR: cavitating lung lesion
sqweqwesf erwrewfsdfs adasd dhe
Differential
• tuberculosishe
• lung cancer (especially squamous cell)he
• abscess (Staph aureus, Klebsiella and Pseudomonas)he
• Wegener's granulomatosishe
• pulmonary embolismhe
• rheumatoid arthritishe
• aspergillosis, histoplasmosis, coccidioidomycosish
Key points from session

ARDS criteria
• acute onsethe

• bilateral infiltrates on CXRhe

 • non-cardiogeniche
• pO2/FiO2 < 200 mmHghe
Amiodarone & methotrexate are common causes of lung fibrosis
Aspergillus clavatus causes malt workers' lung, a type of EAA
Contraindications to lung cancer surgery include SVC obstruction, FEV < 1.5,
MALIGNANT pleural effusion, and vocal cord paralysis
Sarcoidosis CXR
•1= BHLhe
•2= BHL + infiltrateshe
•3= infiltrateshe
•4= fibrosishe
The majority of patients with sarcoidosis get better without treatment
Thermophilic actinomycetes causes mushroom workers' lung, a type of EAA