 Her pulmonary function tests show normal spirometry but a decreased

gas transfer factor (Tlco, transfer factor for carbon monoxide) and a de
creased transfer coefficient (Kco).
 Isolated decreases in gas transfer (TLCO and KPO) are typical of
pulmonary vascular diseases such as vasculitis without pulmon
ary haemorrhage and recurrent pulmory embolus.
 Upper zone fibrosis typically occurs in ;CHARTS HP
 A 33-year-old man is found to have strongly positive Aspergillus precipi
tins in his blood and complains of a cough with intermittent bloody sp
utum. He has a business working as a builder, particularly involved in r
enovating farm houses and barns.
 Chronic pulmonary aspergillosis; Aspergillus precipitins (IgG antibodies
to Aspergillus) are typically found in chronic pulmonary aspergillosis
(which can include the presence of an aspergilloma)
 Allergic bronchopulmonary aspergillosis; It is associated with
wheeze, sputum plugs, eosinophilia and fleeting CXR infiltrate.
Haemoptysis can occur, but this is less commonly found whe
n compared to CPA
 A 49-year-old woman with ulcerative colitis becomes breathl
ess and develops a dry cough.
 low flow rates at low lung volumes is suggestive of a small-air
way (ie bronchiolar) problem. In combination with the gas tra
nsfer finding the diagnosis is bronchiolitis. Expiratory thoracic
high-resolution computed tomography classically reveals a m
osaic pattern compatible with gas trapping.
 Idiopathic pulmonary haemosiderosis tends to occur in younger peopl
e and is characterised by pallor, weakness, lethargy, dry cough and occ
asional haemoptysis. There are no abnormal immunological features.
Gas transfer is elevated as blood is already in the alveolar space.
 A 70-year-old man with chronic bronchitis is admitted with dy
spnoea and peripheral cyanosis. Arterial blood gases show: p
H 7.38, PaO2 5.3 kPa (40 mmHg) and PaCO2 6.0 kPa (45 mmH
g). He is given 40% oxygen by face mask. Within 10 minutes hi
s condition worsens and his respiratory rate falls. Repeat arter
 ial blood gases show: pH 7.24, PaO2 11.6 kPa (82 mmHg), PaC
O2 8.4 kPa (63 mmHg).
 What is the next step in his management?
A. Initiate mechanical ventilation
B. Decrease the fraction of inspired oxygen
 Decrease the fraction of inspired oxygen; Patients with advan
ced chronic obstructive pulmonary disease (COPD) are at risk
of developing acute respiratory failure. Oxygen therapy is effe
ctive in reversing the hypoxaemia of respiratory failure, but o
xygen administration can lead to hypercapnia. The optimal int
ervention therefore is to reduce the inspired oxygen and re-ch
eck the ABG.
 Mechanical ventilation would be considered only after medic
al therapy was maximised and non-invasive ventilation was tr
ied without success.
 42-year-old salesman was admitted with a diagnosis of pneu
monia, He is allergic to erythromycin. Blood investigations sho
wed hyponatraemia and a slight rise in the level of liver amin
otransferases. On the 5th day after starting medication he bec
ame acutely jaundiced and his liver aminotransferase levels b
ecame very high,he also complained of reddish discoloration
of his urine, though dipstick testing did not show haematuria.
He has been treated with combination therapy for presumed
Legionella.
 This patient has Legionella pneumonia and so rifampicin was
prescribed. However, rifampicin is a hepatic-enzyme inducer a
nd its use can lead to acute jaundice, with a rise in liver amino
transferases.
 Cryptogenic pulmonary eosinophilia: This patient has eosinop
hilia and associated pulmonary signs, but no indications of dr
ug involvement or malignancy. He has cryptogenic pulmonary
eosinophilia. Systemic features can occur in this condition, inc
 luding: malaise weight loss fever raised ESR asthma (in aroun
d 50%) . A chest X-ray showed extensive symmetrical, homog
enous shadowing affecting all the peripheral lung field. The di
sease responds to steroid treatment, which needs to be conti
nued for about 1 year.
 Which one of the following statements about cystic fibrosis (C
F) is true?
 Allergic bronchopulmonary aspergillosis is a recognised com
plication, occurring in 15% of adult CF patients.
 Cushing syndrome in small cell carcinoma does not manifest cl
assically by buffalo hump, striae or central obesity. Its presenc
e is suspected by arterial hypertension, hyperglycaemia, hypo
kalaemia, alkalosis and muscle weakness. Chemotherapy is th
e treatment of choice.
 A 22-year-old man presented with shortness of breath, an incr
ease in sputum production and a temperature of 37.9 °C. He s
uffers from recurrent chest infections three or four times a yea
r, wheelchair-bound since the age of 12 years. He grew up in f
oster care but found out that his uncle died young, wheelchai
r-bound. There are coarse crackles bilaterally and a chest X-ray
shows signs of bronchiectasis. Hypogammaglobulinaemia in at
axia telangiectasia.
 YOUNGAGE, RECURRENT INFECTION,
ATAXIA=Hypogammaglobulinemia in ataxia talengiectasia.
 A thin 24-year-old man complains of constant daytime sleepin
ess. He mentions involuntary naps, often in the middle of activ
ity, which occur suddenly and without warning. He also cause
d an accident when he fell asleep while driving home from wo
rk. NARCOLEPSY=Treatment involves the use of central nervou
s system stimulants such as modafinil to allow daytime functio
ning.
 A 58-year-old smoker with chronic bronchitis was treated with
antibiotics for a right upperlobe bronchopneumonia by his GP.
After 6 weeks he was readmitted to hospital. The chest Xray s
hows signs of a pneumonia in the same place. Bronchial carcin
oma with post-stenotic pneumonia. Non -resolving pneumoni
a is an indication of bronchogenic carcinoma. An ill-defined ho
mogeneous or patchy consolidation in a segmental or non-seg
mental distribution might be an indication of bronchogenic car
cinoma.
 A 50-year-old woman is admitted with a dry cough, shortness
of breath and a 2-week history of intermittent fevers. chest X-r
ay shows patchy shadowing at her right lower lobe, with an air
bronchogram. She is started on antibiotics for community-acq
uired pneumonia, improves clinically and is discharged after t
wo days. You see her in clinic three months later, when she tell
s you that she is no better. Computed tomography (CT) finding
s are characteristic, with multiple patchy alveolar opacities, w
hich often spontaneously migrate=CRYPTOGENIC ORGANIZING
PNEUMONIA.
 The major sub-types of aspergillosis are:
 Aspergilloma – usually asymptomatic, sometimes mild haemo
ptysis
 Invasive aspergillosis – fever, cough with copious sputum prod
uction, and pleuritic chest pain
 Allergic pulmonary aspergillosis – productive cough, wheeze,
and shortness of breath
 Chronic pulmonary aspergillosis – chronic productive cough an
d shortness of breath.
 Pancreatic insufficiency, which is present in approximately 85
% of adults with cystic fibrosis, is most characteristic of cystic
fibrosis (CF).
 A positive tuberculin test in a patient with chronic sarcoidosis i
s suggestive of active tuberculosis.
 Which of the following is the main limiting feature of spiral co
mputed tomographic (CT) scanning for pulmonary embolism.
 CT angiography is less accurate for imaging peripheral emboli i
n the subsegmental arteries.
 Hospital-acquired pneumonia, the third most common hospit
al-acquired infection after urinary tract infections and wound i
nfections is treated with combination therapy. A third-genera
tion cephalosporin with an aminoglycoside is the current Britis
h Thoracic Society (BTS) recommendation.
 A 75-year-old woman visits your chronic obstructive pulmonar
y disease (COPD) clinic for review. Her blood gases were check
ed at her last visit 2 months ago when she was relatively well,
and you check them again today. Her PaO2 on air on both occa
sions was 6.8 kPa. There is no CO2 retention on 28% O2. To he
r credit, she did succeed in stopping smoking 6 months ago. Sh
e is maintained on combination inhaled steroid and long-actin
g ß2-agonist therapy. What is the next management step most
likely to improve her prognosis?
 Studies have shown that at least 15 hours of oxygen therapy p
er day is required to reduce the pulmonary hypertension assoc
iated with COPD, to treat the underlying pathology of incipien
t right heart failure and to improve survival.
 Staphylococcal pneumonia only occurs after a preceding viral i
llness. Patchy areas of consolidation occur that eventually bre
ak down into abscesses. Pneumothorax, pleural effusion and e
mpyema are common in staphylococcal pneumonia.Clinical fe
atures of severe pneumonia include a respiratory rate > 30/mi
n, diastolic blood pressure < 60 mmHg, confusion, involvemen
t of more than one lobe, low albumin concentration, white cel
l count > 20 × 10 9/l or less than 1 × 10 9/l, and renal dysfuncti
 on. Treatment: fulminant staphylococcal pneumonia, as in this
case, carries a high mortality. Standard therapy would be intra
venous cefuroxime and clarithromycin, with added flucloxacilli
n for suspected Staphylococcus aureus pneumonia.
 Theophylline is indicated in the treatment of chronic asthma
when symptoms are still not controlled despite inhaled cortico
steroids, long-acting ß-agonists and leukotriene receptor anta
gonists.
 A 49-year-old man with unexplained cough undergoes bronch
oscopy and transbronchial biopsy. Histology shows evidence o
f neutrophil infiltrate, but there is no evidence of granulomas.
Which is the most likely diagnosis?
 Polyarteritis nodosa (PAN) affects medium-sized arteries and t
he infiltrate is composed of neutrophils; granulomas are absen
t. However, PAN affecting the lungs is rare but histologically is
the best answer here as it is the only option that does not give
granulomas.
 A 34-year-old woman, who is a non-smoker, is found to have
moderate hypoxaemia on blood gas analysis, with a Pao2 of 7.
9 kPa. Lung function tests confirm normal lung volumes but a
reduced Tlco at 45% of predicted.
 Pulmonary arteriovenous (AV) malformations cause right-to-le
ft shunts, so reducing Tlco values and provoking hypoxaemia.
 The functional criteria for pneumonectomy are therefore: Forc
ed expiratory volume in 1 s (FEV1) of > 2 l FEV1 > 50% of the o
bserved forced vital capacity Normal partial pressure of arteri
al CO2 (PaCO2) with the patient at rest.
 A 40-year-old man complains of increasing shortness of breath
and his chest X-ray shows an elevated hemidiaphragm on the l
eft side; no other abnormalities are seen. What is the most lik
ely investigation to elucidate the mechanical reason for his sh
ortness of breath?
 The diagnosis of unilateral paralysis, suggested by asymmetric
elevation of the affected hemidiaphragm on X-ray, can be confi
rmed by fluoroscopy.
 Which of the following cell types is the most important antige
n-presenting cell during sensitisation? Dendritic cells.
 A 45-year-old businessman returns to the UK from Texas. Shor
tly after arriving back he develops an acute illness with subste
rnal ache, arthralgia and breathlessness. A chest X-ray shows s
oft pulmonary infiltrates in the upper lobes and mild mediasti
nal widening. What is the most likely diagnosis?
 Histoplasmosis is the most common systemic mycosis in North
America. About 5% of patients have pleural effusions. Arthralg
ia occurs in about 10% of patients.
 A 30-year-old woman is admitted with a history of recent upp
er respiratory tract infection and subsequent progressive lowe
r-limb weakness. Examination confirms loss of her lowerlimb r
eflexes and grade 4/5 power in her arms. Which of the followi
ng lung function tests would be most useful for assessing her r
espiratory muscle reserve? Guillain–Barré syndrome. The most
important and reproducible bedside lung function test to perf
orm in such a patient is the forced vital capacity (FVC). This wil
l detect respiratory muscle involvement earlier than arterial bl
ood gases or the peak expiratory flow rate (PEFR).
 Pneumocystis pneumonia can present with a normal X-ray or
bilateral interstitial shadowing, which is often perihilar in distr
ibution.
 A 74-year-old man presents to the clinic complaining of increa
sed shortness of breath. He has smoked 40 cigarettes per day f
or the past 30 years. Medications include diclofenac and parac
etamol for joint pain. He comes to the clinic with a chest X-ray
from his GP which shows a spiculated left hilar mass. What wo
 uld the classical respiratory findings over the abnormal area b
e? Whispering pectoriloquy is a sign of consolidation.
 The combination of ceftazidime and tobramycin is the antibio
tic regimen of choice for the treatment of cystic fibrosis exacer
bations in patients with Pseudomonas aeruginosa.
 A 32-year-old man with a 2-year history of asthma diagnosed
and managed by his GP now presents with weight loss, abdom
inal pain, diarrhoea and petechial skin changes. During the pas
t week he has become increasingly lethargic with associated fe
elings of nausea. Other past history of note includes an episod
e of foot drop, which occurred 3 months ago. The chest X-ray s
hows bilateral pulmonary infiltrates and urinalysis shows bloo
d ++ and protein ++.CBC shows EOSINOPHIIA.
 The clinical picture seen here is very suggestive of eosinophilic
granulomatosis with polyangiitis, which is commonly associate
d with antimyeloperoxidase antibodies.
 A 33-year-old woman with cystic fibrosis dies while awaiting a
lung transplant. She undergoes a post-mortem examination in
cluding a biopsy of the respiratory epithelium. Which of the fo
llowing cells is likely to be found on the surface of the respirat
ory epithelium? Neutrophils.
 A 44-year-old woman who is known to have brittle asthma is a
dmitted to the Emergency Department. She is started on a Ven
turi mask designed to deliver 40% O2. How does the Venturi
mask achieve this? Air entrainment.
 A 62-year-old heavy smoker comes to the Emergency Departm
ent with a persistent cough and severe shortness of breath me
aning that he is unable to lay down flat in bed. He has a histor
y of hypertension and chronic obstructive pulmonary disease
(COPD) and a previous inferior myocardial infarction. On exam
ination his BP is 155/72 mmHg, pulse is 80 bpm and regular. H
e has coarse crackles and wheeze consistent with his diagnosis
 of chronic obstructive pulmonary disease (COPD) on auscultati
on of the chest. You can feel supraclavicular lymphadenopath
y=small-cell lung cancer progresses rapidly enough to move fr
om no changes on CXR to significant changes within only 3 mo
nths.
 The desaturation on minimal exercise, dry cough, elevated LD
H and perihilar changes on chest X-Ray (CXR) fit with a diagnos
is of Pneumocystis jirovecii pneumonia.
 This patient has Superior Vena Cava (SVC) obstruction as a res
ult of extrinsic compression from an underlying bronchial carci
noma. A NICE review has concluded that stenting offers a grea
ter degree of success in terms of relief of symptoms resolving
SVC obstruction than radiotherapy.
 Which of the following vitamins is it most important to supple
ment in cystic fibrosis? Cystic fibrosis results in malabsorption
of fat, therefore vitamin supplements for fat-soluble vitamins
are recommended. These include vitamins A, D, E and K.
 You suspect bronchiectasis. Which of the following is the most
logical next step? serum immunoglobulins= both to look for el
evated IgE (consistent with possible allergic bronchopulmonar
y aspergillosis (ABPA)), and immunoglobulin deficiency (both I
gA and IgG subclass deficiencies are possible) are a reasonable
next step investigation.
 This woman in all likelihood has a viral exacerbation of her ast
hma. As such the most appropriate intervention is a course of
oral steroids (Prednisolone), with instruction to use ten puffs o
f her salbutamol via a spacer at home in lieu of a nebuliser.