Respiratory - Level 2

Question 1

Definition of asthma?

Answer 1

• Respiratory condition associated with reversible airway inflammation and hyper-responsiveness

Question 2

Classification of asthma?

Answer 2

o	Extrinsic (Atopy)
	Allergens identified by positive skin prick to common inhaled allergens

o Intrinsic
 No definitive external cause is identified and often develops in middle age

Question 3

Pathology of asthma?

Answer 3

o Usually reversible either spontaneously or treatment
o 1. Airway narrowing
 Smooth muscle contraction, thickening of airway wall by cellular infiltration and inflammation
 Secretions within the airway
o 2. Inflammation
 Mast cells, eosinophils, T cells, dendritic cells cause IgE production and release of histamine, prostaglandin D2, leukotriene C4
o 3. Remodelling
 Hypertrophy and hyperplasia leading to more mucous secreting goblet cells

Question 4

Epidemiology of asthma?

Answer 4

• 10-15% of people develop asthma in 2nd decade of life
• More common in developed world
• 15% of asthma induced at work

Question 5

Risk factors of asthma?

Answer 5

• FHx of atopic disease
• Respiratory infections in infancy
• Tobacco smoke
• Low birth weight
• Social deprivation
• Inhaled particulates

Question 6

Aetiology of asthma?

Answer 6

• Atopy
  o Defined as people who readily develop IgE antibodies
  o Genetic and environmental predispose to asthma
  o Increased responsiveness of airways to stimuli – provocation tests induce a response (histamine)

Question 7

Precipitating factors of asthma?

Answer 7

• House dust mite and its faeces
• Viral infections
• Cold air
• Exercise
• Irritant dust, vapours, fumes (cigarettes, perfume, exhaust)
• Emotion
• Drugs (Aspirin, beta-blockers)

Question 8

Symptoms of asthma?

Answer 8

• Wheezing attacks
• SOB
• Chest tightness
• Cough (nocturnal)
• Sputum

Question 9

Features characteristic of asthma?

Answer 9

• Intermittent and worse at night – diurnal variation
• Quantify exercise tolerance
• Disturbed sleep
• Often have atopy – hayfever, eczema
• Any pets, feathers, job
• Days per week of school/work

Question 10

Signs of asthma?

Answer 10

• Tachypnoea
• Audible wheeze
• Hyperinflated chest
• Hyper-resonant percussion
• Decreased air entry
• Reduced chest expansion

Question 11

Investigations of asthma - if suspected asthma?

Answer 11

• If <5 – treat based on symptoms and review child regularly, if still symptoms at 5, carry out objective tests
• If >5 and unable to perform objective tests – continue to treat and try redoing test every 6-12 months

Question 12

Investigations of asthma in children 5-17 years - initial investigations to perform?

Answer 12

o Offer spirometry to all if diagnosis of asthma considered
 FEV1/FVC <70% if positive tests for obstructive airway disease

o Bronchodilator Reversibility test
 Consider if obstructive spirometry (FEV1/FVC <70%)
 Positive test if >12% increase in FEV1

Question 13

Investigations of asthma in children 5-17 years - when to diagnose asthma?

Answer 13

o Obstructive spirometry and positive BDR

o FeNO >35ppb and positive PEFR variability

Question 14

Investigations of asthma in children 5-17 years - tests if diagnosis of asthma uncertain and what is a positive result?

Answer 14

o FeNO
 If normal spirometry or obstructive spirometry with negative BDR test
 35ppb or more is positive test

o Monitor PEFR variability for 2-4 weeks
 If normal spirometry o robstructive spirometry with negative BDR test and FeNO >35ppb
 >20% variability is positive test
o Refer for specialist assessment if obstructive spirometry, negative BDR and FeNO <35ppb

Question 15

Investigations of asthma in children 5-17 years - when to refer to specialist?

Answer 15

o Refer for specialist assessment if obstructive spirometry, negative BDR and FeNO <35ppb

Question 16

Investigations of asthma in children 5-17 years - when to suspect asthma?

Answer 16

o FeNO >35 with normal spirometry and negative PEFR variability
o FeNO >35 with obstructive spirometry but negative BR with no variability on PEFR
o Normal spirometry, FeNO <35 and positive PEFR
o Review diagnosis after 6 weeks of treatment by repeating any abnormal tests

Question 17

Investigations of asthma in adults - objective tests to perform?

Answer 17

o FeNO
 >40ppb is positive test

o Spirometry
 FEV1/FVC <70% is positive result of obstructive spirometry

o Bronchodilator Reversibility Test (BDR)
 If obstructive spirometry (FEV1/FVC <70%), positive result is >12% improvement of FEV1 with increase in volume of >200ml

Question 18

Investigations of asthma in adults - diagnose asthma when?

Answer 18

o FeNO >40ppb with either positive BDR or positive PEFR variability or bronchial hyperreactivity
o FeNO between 25-39 and positive bronchial challenge test
o Positive BDR and positive PEFR variability irrespective of FeNO level

Question 19

Investigations of asthma in adults - tests to perform if diagnosis uncertain?

Answer 19

o PEFR variability for 2-4 weeks (>20% variability is positive test)
 If uncertainty and FeNO test and have either:
• Normal spirometry
• Obstructive spirometry with BDR positive but FeNO <39

o Direct bronchial challenge with histamine or methacholine if normal spirometry and either:
 FeNO >40ppb with no PEFR variability
 FeNO <39 with PEFR variability
 PC20 (provoking concentration to induce 20% reduction in FEV1) of 8mg/ml or less is positive result

Question 20

Investigations of asthma in adults - when to suspect asthma?

Answer 20

• Suspect Asthma if obstructive spirometry and:
  o Negative BDR and either FeNO >40 or FeNO 25-39 and positive PEFR
  o Positive BDR, FeNO 25-39 and negative PEFR
  o Treat patients and review diagnosis after 6-10 weeks by repeating spirometry

Question 21

Management of asthma - general advice?

Answer 21

• Weight loss
• Stop smoking
• Avoid triggers
• Annual flu vaccine
• Check inhaler technique and PEFR 2x a day

Question 22

Management of asthma - medications - under 5s - step 1?

Answer 22

o SABA with 8-week trial of paediatric moderate dose ICS

 If symptoms >3x per week, causing waking at night or not controlled on SABA alone

Question 23

Management of asthma - medications - under 5s - step 2?

Answer 23

o After 8 weeks, stop ICS treatment:
 If symptoms resolved then reoccurred within 4 weeks of stopping ICS – restart at paediatric low dose maintenance therapy
 If symptoms resolved but reoccurred beyond 4 weeks after stopping ICS – repeat 8-week trial of paediatric moderate dose of ICS

Question 24

Management of asthma - medications - under 5s - step 3?

Answer 24

o If unresolved on paediatric low dose maintenance therapy:

 Add LTRA

Question 25

Management of asthma - medications - under 5s - step 4?

Answer 25

o If unresolved on ICS and LTRA: |  Stop LTRA and refer to specialist

Question 26

Management of asthma - medications - child >5 and adults - step 1?

Answer 26

o Step 1 |  PRN SABA – Salbutamol alone if infrequent

Question 27

Management of asthma - medications - child >5 and adults - step 2?

Answer 27

o Step 2 (if >3 doses PRN SABA, drugs not working, woken) |  Add low dose ICS (beclomethasone) 400mcg starting dose

Question 28

Management of asthma - medications - child >5 and adults - step 3?

Answer 28

``` Step 3 (if >3 doses PRN SABA in week, drugs not working, woken)  Add a LTRA and assess in 4-8 weeks - if not controlled, discuss benefit (stop or continue) (NICE Step 3) ```  Add LABA (salmeterol) either fixed dose or MART - if good response - continue (BTS Step 3) • If benefit of LABA but inadequate, increase beclomethasone dose 800mcg • If no response to LABA, stop LABA and increase beclomethasone dose 800mcg

Question 29

Management of asthma - medications - child >5 and adults - step 4?

Answer 29

o Step 4 (if >3 doses PRN SABA, drugs not working, woken)  Trials of: • Increase inhaled corticosteroid 2000mcg • Add SR theophylline, LAMA

Question 30

Management of asthma - medications - child >5 and adults - step 5?

Answer 30

o Step 5 (if >3 doses PRN SABA, drugs not working, woken)  Referral to specialist  Oral prednisolone  Steroid sparing – methotrexate, ciclosporin

Question 31

Management of asthma - when to refer immediately?

Answer 31

- Immediately if occupational asthma suspected

Question 32

Management of asthma - follow up?

Answer 32

- Annually - 4-8 weeks after medication change or start - Long-term/Frequent steroid tablets need BP, HbA1c, cholesterol and vision tested every 3 months

Question 33

Management of asthma - self-management plan?

Answer 33

- Increased dose of ICS for 7 days when asthma deteriorates (quadruple dose)

Question 34

Doses of ICS in asthma - adults?

Answer 34

o < or equal 400mcg budesonide or equivalent = low dose o 400mcg – 800mcg budesonide or equivalent = moderate dose o >800mcg budesonide or equivalent = high dose

Question 35

Doses of ICS in asthma - child <16?

Answer 35

o < or equal 200mcg budesonide or equivalent = low dose o >200mcg – 400mcg budesonide or equivalent = medium dose o >400mcg budesonide or equivalent = high dose

Question 36

Definition of COPD?

Answer 36

- Characterised by airflow obstruction due to combination of obstructive bronchiolitis and emphysema, resulting from enhanced inflammatory response - FEV1 <80% predicted; FEV1/FVC <0.7

Question 37

Pathology of COPD?

Answer 37

 Chronic bronchitis • Airway narrowing due to hypertrophy and hyperplasia of mucous secreting glands and oedema • Change to columnar epithelium • Sputum production for 3 months of 2 successive years  Emphysema • Dilatation and destruction of lung distal to terminal bronchioles • Loss of elastic recoil

Question 38

Classes of COPD?

Answer 38

o Type 1 Respiratory Failure (Pink puffers)  Normal paO2, PaCO2  Emphysema predominantly, breathless not cyanosed o Type 2 Respiratory Failure (blue bloaters)  Low PaO2, High PaCO2  Chronic bronchitis – cyanosed develop cor pulmonale and rely on hypoxic drive

Question 39

Epidemiology of COPD?

Answer 39

- In UK, 3 million people living with COPD - Cigarette smoking in 90% of cases - 10-20% of the over 40s - Age of onset >35 years

Question 40

Risk factors of COPD?

Answer 40

- Cigarette smoking - Exposure to pollutants o Mining, building, chemical industries - Air pollution - Alpha-1-antitrypsin deficiency

Question 41

Symptoms of COPD?

Answer 41

- Productive, white/clear sputum cough - Progressive breathlessness - Wheeze - Frequent exacerbations - Weight loss, fatigue

Question 42

Signs of COPD?

Answer 42

- Cyanosed - Flapping tremor - Tachycardia - Accessory muscles used - Hyperinflated chest - Reduced expansion - Reduced breath sounds - Wheeze - Hyper resonant percussion - Cor Pulmonale – peripheral oedema, raised JVP, systolic parasternal heave

Question 43

When to diagnose COPD clinically?

Answer 43

- >35 years old - Risk factor present - Typical and other symptoms o Exertional SOB, chronic cough, regular sputum production, frequent winter bronchitis, wheeze

Question 44

Asssessment of COPD?

Answer 44

- MRC Dyspnoea scale o 1 – not troubled by breathlessness except strenuous o 2 – SOB when hurrying or walking up slight hill o 3 – Walks slower than contemporaries due to breathlessness, must stop when at own pace o 4 – stops for breath about 100m or few minutes o 5 – Too breathless to leave house, breathless when dressing - Symptoms of anxiety or depression - Calculate BMI - Arrange spirometry, CXR, FBC

Question 45

Investigations to perform in COPD?

Answer 45

Post-bronchodilator spirometry - Reduced FEV1, FEV1/FVC <0.7, PEFR - Reversibility <20% post-bronchoscopy CXR o Hyperinflation (>6 anterior ribs seen above diaphragm MCL) o Flat hemidiaphragm FBC BMI

Question 46

Classification criteria in COPD?

Answer 46

Diagnosis – GOLD Criteria - Mild – FEV1 ≥80% of predicted - Moderate – FEV1 50-79% of predicted - Severe – FEV1 30-49% of predicted - Very Severe – FEV1 <30% of predicted

Question 47

When and what additional tests can be used in COPD?

Answer 47

- Sputum culture – if sputum persistently present or purulent - Serial home PEFR – exclude asthma - ECG & Echo – any cardiac disease or pulmonary hypertension suspected - CT – investigate signs that other lung diagnosis present, abnormal CXR, suitability for lung volume reduction procedures - Alpha-1-antitrypsin – if early onset, minimal smoking or FHx

Question 48

Management of COPD - general advice?

Answer 48

- Stop smoking – offer smoking cessation - Yearly influenza and pneumococcal vaccine - Encourage exercise - Flying – need to assess whether fit to fly or refer to respiratory specialist, carry inhalers in hand luggage, inform airport/transport, avoid smoking and alcohol

Question 49

Management of COPD -self management plan?

Answer 49

o Lifestyle – diet, exercise (at own level, to become a little out of breath), smoking cessation o Recognise early sign of exacerbation o Supply of rescue Abx and corticosteroids if worsens  If had exacerbation within last year and competent to take them

Question 50

Management of COPD -pulmonary rehab?

Answer 50

- Pulmonary rehabilitation if MRC dyspnoea scale grade 3 or more o Do not offer if unable to walk or have unstable angina or recent MI - Chest physio if lots of sputum

Question 51

Management of COPD - when to step up from SABA to Step 2?

Answer 51

Remain breathless or exacerbations depite:  Offered smoking cessation advice  Optimal non-pharmacological management and relevant vaccines  Using SABA

Question 52

Management of COPD - when to step up from Step 2 to triple therapy?

Answer 52

 Acute episodes of worse symptoms caused by COPD exacerbations (hospitalisation or 2 moderate exacerbations per year)  Adversely impacting on QoL

Question 53

Management of COPD -step 1?

Answer 53

o PRN SABA (salbutamol) or SAMA (ipratropium bromide)

Question 54

Management of COPD - step 2 if no asthmatic features or not steroid responsive?

Answer 54

o Add LABA + LAMA | o Discontinue SAMA if having LAMA

Question 55

Management of COPD - step 2 if asthmatic features (previous asthma diagnosis, high blood eosinophils, FEV1 variation over time >400mls, >20% PEFR variability)?

Answer 55

o Add LABA plus ICS combination (never just ICS, Seretide (salmeterol & fluticasone)/Symbicort(formoterol & budesonide)

Question 56

Management of COPD - step 3?

Answer 56

o Add LABA + LAMA + ICS |  If no asthmatic features – trial 3 month and if no improvement, move back to LABA + LAMA

Question 57

Management of COPD - oral therapy?

Answer 57

- Oral theophylline or aminophylline if still symptomatic or cannot use inhalers - Mucolytic if chronic cough with sputum - If cor pulmonale – furosemide diuretic - Prophylactic antibiotics (azithromycin) - Long-term oral corticosteroids

Question 58

Management of COPD - follow up?

Answer 58

- In very severe (FEV1 <30%), twice a year - In mild, moderate or severe, once a year - Consists of: spirometry, BMI, MRC scale, O2 sats, symptom control, drug treatment, inhaler technique, referral

Question 59

Management of COPD - when to refer to respiratory?

Answer 59

- Haemoptysis - Worsening/Severe COPD – FEV1<30% or decline - Cor pulmonale - Person <40 - MDT for physiotherapy, social care, OT, dietetic

Question 60

Management of COPD - when is pulmonary rehab and chest physio?

Answer 60

o Pulmonary rehab if MRC 3 or above, or acute hospitalisation – can improve QoL, usually 2-3 sessions/week for 6-12 weeks – physical training, education, nutrition o Chest physio for excessive sputum

Question 61

Management of COPD - specialist treatments - oxygen?

Answer 61

``` When to refer  O2 <92% on air  FEV1 <30%  Cyanosis  Secondary polycythaemia  Peripheral oedema and raised JVP ``` Cannot smoke when on oxygen Measure ABG on 2 occasions at least 3 weeks apart:  LTOT if PaO2 <7.3 or 7.3-8.0 and secondary PCV, peripheral oedema or pulmonary hypertension Ambulatory Oxygen  If exercise desaturations

Question 62

Management of COPD - specialist treatments - lung volume reduction?

Answer 62

o Bulllectomy if breathless and CT scan shows bulla occupying >1/3 of hemithorax o Refer to repiratory for surgery if:  Severe COPD (FEV1 <50) and breathless despite optimal medical treatment  Do not smoke  Can complete 6-minute walk distance of at least 140m o Can have lung transplant

Question 63

Management of COPD - end stage COPD?

Answer 63

End-Stage FEV1<30% - Unresponsive to treatment - Discuss with palliative care team to relive symptoms and improve quality of life

Question 64

Prognosis of COPD?

Answer 64

- Progressive and accounts for 5% of deaths each year | - Mortality rate 3-4% in hospital

Question 65

Complications of COPD?

Answer 65

- Poor QoL - Depression/Anxiety - Cor pulmonale (caused by pulmonary hypertension) - Frequent chest infections - Polycythaemia - Lung cancer

Question 66

Definition of primary and secondary spontaneous pneumothorax?

Answer 66

- Primary spontaneous pneumothorax occur in previously healthy individuals - Secondary spontaneous pneumothorax occur in >50 years and significant smoking history or evidence of underlying lung disease on exam or CXR

Question 67

Causes of spontaneous pneumothorax?

Answer 67

o Spontaneous – ruptured subpleural bullae (young thin man) o Chronic lung disease – asthma, COPD, CF, lung fibrosis, sarcoidosis o Infection – TB, pneumonia, lung abscess o Traumatic – iatrogenic o Carcinoma o Marfan’s, Ehlers-Danlos syndrome

Question 68

Symptoms of spontaneous pneumothorax?

Answer 68

o Can be asymptomatic o Unilateral sudden-onset pleuritic chest pain o SOB

Question 69

Signs of spontaneous pneumothorax?

Answer 69

o Tachycardia, tachypnoea o Reduced expansion o Hyper-resonance to percussion o Diminished breath sounds

Question 70

Severe signs of spontaneous pneumothorax?

Answer 70

o Unable to speak, low SpO2 o Think tension pneumothorax o If not tension, emergency CXR and senior doctor review

Question 71

Initial management of spontaneous pneumothorax?

Answer 71

``` Monitor pulse, SpO2, BP IV access High flow O2 ABG (if no sign of tension pneumothorax) Erect CXR  Loss of lung markings  Measure rim of air by chest wall to lung edge at level of hilum CT Scan  In subacute setting for assessing bullous disease in stable patient ```

Question 72

Interventions performed in primary spontaneous pneumothorax?

Answer 72

 If not SOB and rim of air on CXR <2cm – discharge and OPD F/U in 2/4 weeks  If SOB and/or rim of air on CXR >2cm – Aspiration 16-18G cannula (<2.5L) • If successful – discharge and OPD F/U in 2-4 weeks • If not successful – Seldinger Chest Drain 8-14Fr

Question 73

Interventions performed in secondary spontaneous pneumothorax?

Answer 73

 If rim of air >2cm or SOB on CXR – Seldinger Chest drain 8-14Fr  If not SOB & rim of air 1-2cm on CXR – Aspiration 16-18G cannula • If unsuccessful – Seldinger Chest Drain 8-14Fr • If successful – Admit with high-flow oxygen and observe for 24 hours  If not SOB and rim of air <1cm on CXR - admit, high-flow O2 and observe for 24 hours

Question 74

Whent to get surgical advice in spontaneous pneumothorax?

Answer 74

o If bilateral pneumothoraces, lung fails to expand after drain insertion, 2 or more previous pneumothoraces on same side o Options – open thoracotomy and pleurectomy or video-assisted thoracoscopy (VATs) or talc pleurodesis

Question 75

Discharge information in spontaneous pneumothorax?

Answer 75

o Patients without SOB and PSP consider discharge o Give verbal and written instruction to return if symptoms worsen o Do not fly and diving not allowed o Appointment with respiratory physician in 2-4 weeks

Question 76

When to remove chest drain in spontaneous pneumothorax?

Answer 76

o Refer to respiratory physician within 24h of admission | o Remove 24 hours after cessation of air leak without clamping

Question 77

Definition of pleural effusion?

Answer 77

- Lungs covered with visceral pleura and chest wall and pericardium covered with parietal pleura - Excessive accumulation of fluid in pleural space - Detected on x-ray when >300ml present, clinically if >500ml

Question 78

Risk factors of pleural effusion?

Answer 78

o CHF o Pneumonia o Malignancy o Recent CABG/MI

Question 79

Aetiology of pleural effusion - transudate? ( protein <30g/L)

Answer 79

```  Cardiac Failure  Liver Failure – cirrhosis  Constrictive Pericarditis  Fluid Overload  Nephrotic Syndrome  Hypothyroidism  Meig’s syndrome ```

Question 80

Aetiology of pleural effusion - exudate? ( protein >30g/L)

Answer 80

```  Pneumonia  TB  Pulmonary infarction  RA  SLE  Malignancy – lung/breast cancer  Lymphoma  Pancreatitis ```

Question 81

Symptoms of pleural effusion?

Answer 81

o Often asymptomatic o SOB (extertional) o Cough o Pleuritic chest pain

Question 82

Signs of pleural effusion?

Answer 82

``` o Decreased expansion o Stony dull percussion o Diminished breath sounds o Tactile vocal fremitus and decreased vocal resonance o Tracheal deviation away from side ```

Question 83

Investigations of pleural effusion?

Answer 83

- Bloods as appropriate o FBC, BNP, ESR, CRP, albumin, amylase, TFTs, blood cultures - ABG - CXR o Blunt costophrenic angles  Dense haemogenous shadows o Mediastinal Shift - Ultrasound o Aids diagnosis and guiding of chest drain/aspiration

Question 84

How to aspirate pleural effusion? What to send for?

Answer 84

 Percuss upper border of effusion and go 1-2 ICS below it |  Send for cultures (AAFB, M, C &S), biochemistry (protein, glucose, LDH), cytology, pH

Question 85

When to aspirate pleural effusion?

Answer 85

 Clinical picture suggests exudate |  NOT FOR TRANSUDATE OR BILATERAL PLEURAL EFFUSIONS

Question 86

Pleural aspiration- appearance features?

Answer 86

 Clear, straw – transudate, exudate  Turbid – empyema, pneumonia  Red – trauma, malignancy, infarction

Question 87

Pleural aspiration- cytology features?

Answer 87

 Neutrophils – PE, pneumonia  Lymphocytes – TB, malignancy, RA, SLE, Sarcoidosis  Mesothelial – mesothelioma, infarction  Multinucleated – RA

Question 88

Pleural aspiration- chemistry features?

Answer 88

 Transudate - <25g/L  Exudate - >35g/L • 25-35g/L – use lights criteria  Glucose <3.3, pH<7.2, LDH (pleural:serum >0.6) – empyema, malignancy, TB, RA, SLE

Question 89

Pleural aspiration- immunology features?

Answer 89

 RF – RA  ANA – SLE  Complement levels low – RA, SLE, malignancy, infection

Question 90

What is Light's criteria in pleural effusion?

Answer 90

- Light’s Criteria when protein between 25-35g/L, exudate if…. o Pleural fluid to serum protein ratio >0.5 or o Pleural fluid to serum LDH ratio >0.6 or o Pleural fluid LDH concentration >2/3 upper limit of normal for serum LDH

Question 91

Further testing to perform in pleural aspiration?

Answer 91

``` - If aspiration does not give diagnosis, refer to chest physician and consider: o CT o Pleural Biopsy o Bronchoscopy o Thoracoscopy ```

Question 92

Management of pleural effusions - cause?

Answer 92

o CHF – IV/oral furosemide, physiotherapy, chest drain and oxygen o Infective – Abx, chest drain, physio, oxygen o Empyema – Tube thoracostomy

Question 93

Management of pleural effusions -drainage?

Answer 93

- Pleural aspiration - Chest Drain o No more than 1.5 litres drained – fluid shift risk o If malignant effusion and recurrent – insert PleureX drain

Question 94

Management of pleural effusions - when to pleurodesis?

Answer 94

o If recurrent malignant effusions | o Tetracycline/bleomycin/talc

Question 95

Management of pleural effusions -when to perform surgery?

Answer 95

o Pleurodectomy/pleuroperitoneal shunts | o If persistent collections of fluid, usually malignancy

Question 96

Definition of lung cancer?

Answer 96

- Tumours usually arise from epithelium of large and medium sized bronchi (rarely lung parenchyma)

Question 97

What is Small Cell Lung Cancer (15%)? Associated syndrome?

Answer 97

 Highly aggressive, rapidly growing tumours  Usually metastasised prior to diagnosis  Can be very responsive to chemotherapy but relapse rapidly  Prognosis poor  Associated with paraneoplastic syndromes • SIADH (hyponatraemia) • Cushing’s syndrome (ACTH production) • PTH – hypercalcemia • HCG - gynecomastia • Lambert Eaton Myaesthenia syndrome (LEMS)

Question 98

What are the types of non-small cell lung cancer (85%)? Locations?

Answer 98

 Squamous cell carcinoma (42% of NSCLC) • Often central, close to bronchi and can present with bronchial obstruction • Closely linked to cigarette smoking • SCC can secrete PTHrp leading to hypercalcaemia  Adenocarcinoma (39% of NSCLC) • Often peripheral • More frequent in women, non-smokers and previous asbestos exposure • Associated with mutation in EGFR and ALK  Large Cell carcinoma (8% of NSCLC) • Less differentiated and metastasise early  Others • Carcinoid, mesothelioma, sarcoma, lymphoma

Question 99

Spread of lung cancer?

Answer 99

- Spread to brain, bone, liver and adrenal

Question 100

Epidemiology of lung cancer?

Answer 100

- 3rd most common cancer in UK - Men > Women - 1 in 13/15 - Accounts for 22% of cancer related deaths in UK

Question 101

Risk factors of lung cancer?

Answer 101

``` o Genetics o Cigarette smoking o Increased age o COPD o Industrial exposure to asbestos, chromium, arsenic and iron oxide o Exposure to radiation ```

Question 102

Symptoms of lung cancer?

Answer 102

``` o Cough o Haemoptysis o Dyspnoea o Chest Pain o Recurrent pneumonia o Lethargy, anorexia, weight loss ```

Question 103

Signs of lung cancer?

Answer 103

``` o Cachexia o Anaemia o Clubbing o Lymph nodes (axilla, supraclavicular) o Consolidation, collapse, effusion (often unilateral) ```

Question 104

Metastases of lung cancer?

Answer 104

``` o Bone tenderness o Hepatomegaly o Confusion o Fits o Focal CNS signs o Proximal myopathy ```

Question 105

Complications of lung cancer?

Answer 105

``` o Recurrent laryngeal/phrenic nerve palsy o SVC obstruction o Horner’s syndrome (Pancoast tumour)  Partial ptosis, miosis, anhidrosis o Pericarditis, AF o DIC o Dermatomyositis o Acanthosis Nigricans ```

Question 106

Initial investigations of lung cancer?

Answer 106

CXR o Round shadow, edge fluffy or spiked o Cavitation, lobar, collapse, pleural effusion (unilateral) CT chest and upper abdomen o Assess extent of local and distant disease, TMN staging PET scan o Used in operable disease to check for distant metastases Bronchoscopy o Fibre-optic or rigid bronchoscopy allows visualisation, biopsy and bronchial washing o Endo-bronchial ultrasound used to biopsy lymph nodes Trans-thoracic biopsy

Question 107

Further investigations of lung cancer?

Answer 107

- Pulmonary Function Tests o Assess underlying lung function - Cardiopulmonary Exercise Testing o Important for patients considered for surgical resection to ensure fitness

Question 108

When to refer on lung cancer pathway in primary care?

Answer 108

o >40 and unexplained haemoptysis | o >40, cough, fatigue, SOB, chest pain, weight loss (≥1 if smoker, ≥2 if non-smoker)

Question 109

Management of SCLC - if limited stage?

Answer 109

radical radiotherapy

Question 110

Management of SCLC - if palliative?

Answer 110

o Chemotherapy  Mainstay of treatment, very chemo-sensitive, responds within days  SVCO and MSCC treated with chemotherapy  Most patients will relapse and die from chemo-resistant progression ``` o Radiotherapy  Highly radio-sensitive  Three indications: • Treatment of primary tumour o Thoracic radiotherapy as consolidation or concurrent treatment • Prophylactic cranial irradiation • Palliative ``` o Surgery  Early dissemination so surgery inappropriate mostly  Patients usually require adjuvant chemo/radiotherapy

Question 111

Management of NSCLC - surgery for Stage 1/2?

Answer 111

o Stage 1/2 managed with surgical excision (30%) o Lobectomy preferred over pneumonectomy due to mortality risk o Adjuvant chemotherapy and radiotherapy used if able to/positive margins

Question 112

Management of NSCLC - radiotherapy?

Answer 112

o Patients with early stage not suitable for surgery o Radical radiotherapy for stage 1/2  Continuous, hyper-fractionated accelerated radiotherapy (CHART) given TDS for 12 days o Concurrent chemo-radiotherapy given in Stage 2/3

Question 113

Management of NSCLC - chemotherapy?

Answer 113

o Mainstay for metastatic/locally advanced disease used in combinations (Carboplatin/Gemcitabine) o Dependent on histological subtype:  Biologic Therapy: • Patients positive for EGFR, ROS-1 and ALK – TKI (Afatinib and Crizotinib)  Immunotherapy: • Pembrolizumab for advanced NSCLS with high PDL1 expression

Question 114

Management of NSCLC - SABR?

Answer 114

o Early NSCLC located peripherally given stereotactic ablative body radiotherapy (SABR)  Delivers <5 very large doses of radiotherapy to small volume around tumour

Question 115

Follow up in lung cancer?

Answer 115

- Primary care follow-up according to MDT review - Specialist appointment 6 weeks after treatment completion - CT scan at 1 year and 2 year then discharged

Question 116

Prognosis of SCLC?

Answer 116

o Extremely poor prognosis with median survival 2-4 months – improved to 6-12 months with chemotherapy o Prognostic Factors – extent at presentation, number of mets, performance status, degree of weight loss

Question 117

Prognosis of NSCLC?

Answer 117

o Without treatment, prognosis short 3-6 months | o If suitable for treatment and targeted therapies, survival can be improved by 1-2 years