Respiratory

Obstructive Pulmonary Disease

1. Asthma

a) What is asthma?
• Chronic inflammatory disorder of the airways. It is characterized by recurrent episodes of dyspnea, cough
and wheeze caused by reversible airway obstruction

b) What are the factors that lead to airway narrowing?

• Bronchial muscle contraction
• Mucosal swelling/inflammation (mast cell & basophil degranulation)
• Increased mucous production

c) Clinical features
• Wheezing, Chest tightness, Breathlessness & Cough
• Tachypnea
• Hyperinflated chest
• Hyper-resonant percussion
• Reduced air entry

d) Points to diagnosis and Points against diagnosis

Increase Probability of Asthma Decrease Probability of Asthma

• Wheeze, SOB, Chest tightness
• Diurnal variation
• Response to exercise, allergen & cold air
• Symptoms after aspirin or β-blockers
• History of atopy
• Family history of atopy/asthma
• Widespread wheeze heard on auscultation
• Unexplained low FEV1 of PEF
• Unexplained peripheral blood eosinophilia
*no. of cigarettes smoked per day/20 x no. of years smoked
• Prominent dizziness, Lightheadedness, Tingling
• Chronic Productive cough with no wheeze
• Normal examination when symptomatic
• Change in voice
• Symptoms with colds only
• Significant smoking history (>20 pack year)
• Cardiac disease
• Normal PEF when symptomatic

e) What are the precipitants

• Cold air
• Exercise
• Emotion
• Allergen (e.g. house dust mites, pollen,fur)
• Infection
• Smoking & passive smoking
• Pollution
• NSAIDs
• β-blockers

f) Diagnosis
• Clinical + History + Lung function test
• Spirometry
- FEV1 ≥ 12% (and 200 mL) increase following administration of a bronchodilator/trial of
glucocorticoids. Greater confidence is gained if the increase is >15% and >400 mL
- > 20% diurnal variation on ≥ 3 days in a week for 2 weeks on PEF(Peak Expiratory Flow) diary
- FEV1 ≥ 15% decrease after 6 mins of exercise
• Peak flow meter
• AHR challenge tests
• High-resolution CT scan à Useful to detect bronchiectasis
• Full blood count – Eosinophilia
g) Differential diagnosis
• Pulmonary edema (cardiac asthma)
• COPD
• SVC obstruction (wheeze/dyspnea not episodic)
• Pneumothorax
• Pulmonary embolism
• Bronchiectasis
• Obliterative bronchiolitis (suspect in elderly)

h) Management
Acute
• Oxygen
• High doses of inhaled bronchodilators (short acting β2-agonists)
• Systemic glucocorticoids à Reduces inflammatory response (e.g. Prednisolone(Po), Hydrocortisone (IV))

Chronic
• β-adrenoceptor agonists (e.g. Short – Salbutamol, Long – Salmeterol, Formoterol)
• Corticosteroids
• Aminophylline (Inhibit phosphodiesterase à ↑cAMP à ↓ Bronchoconstriction)
• Anticholinergics (e.g. Ipratropium, Tiotropium)
• Cromoglicate (mast cell stabilizer)
• Leukotriene receptor antagonists (e.g. Montelukast (Po), Zafirlukast)
• Anti-IgE monoclonal antibody (e.g. Omalizumab)
2. Chronic Obstructive Pulmonary Disease (COPD)

a) What is COPD?
• COPD is a common progressive disorder characterized by airway obstruction (FEV1 < 80%, FEV1/FVC
<70%)

b) Spirometry results
FEV1 FVC FEV1/FVC ratio
Normal >80% >80% 75 – 80%
Restrictive <80% <70% >70% normal
Obstructive <80% Normal/Low <70%

c) List down COPD

• Emphysema
• Chronic Bronchitis

d) Differences between Emphysema & Chronic Bronchitis

Emphysema COPD Chronic Bronchitis

Abnormal permanent enlargement of the Definition Abnormal permanent enlargement of the
airspaces distal to terminal bronchioles airspaces ≥3 consecutive months in each of 2
consecutive years
Pink Puffers Appearance Blue Bloaters
Rare Infection Common
Rare Cor Pulmonale Common
Hyperinflation, Small heart Radiology Prominent vessels, Large heart

e) Risk factors for development of COPD

Environmental Factors Host Factors

• Tobacco smoke • Genetic factors
• Indoor air pollution (cooking in confined areas) - ↓ ⍺1-antitrypsin
• Occupational (coal dust, silica, cadmium) • Airway hyperactivity
• Low birth weight
• Lung growth (childhood infections, maternal smoking)
• Infection (Adenovirus à lung damage, HIV à Emphysema)
• Low socioeconomic status
• Cannabis smoking

f) Clinical Features
• Cough & Sputum
• Dyspnea
• Wheeze
• Tachypnea
• Use of accessory muscles (Inspiration – SCD, Pect. Minor, Scalene; Expiration – Abdominals)
• Hyperinflation
• ↓ cricosternal distance (< 3cm)
• ↓ expansion
• Resonant percussion
• Quiet breath sounds (e.g., bullae)
• Cyanosis
• Cor Pulmonale

g) Differential Diagnosis
• Chronic asthma
• Tuberculosis
• Bronchiectasis
• Congestive Cardiac Failure
h) Modified Medical Research Council Dyspnea Scale

Grade Degree of Breathlessness related to activities

0 No breathlessness, except with strenuous exercise
1 Breathlessness when hurrying on the level of walking up a slight hill
2 Walks slower than contemporaries on level ground because of breathlessness or has to stop for
breath when walking at own pace
3 Stops for breath after walking about 100m or after a few minutes on level ground
4 Too breathless to leave the house, or breathless when dressing and undressing

i) Investigations
• FBC - ↑ PCV (packed cell volume), r/o anemia, document polycythemia, predominantly basal emphysema
• Chest X-ray – r/o cardiac failure, lung cancer
- Hyperinflation
- Flat hemidiaphragms
- Large central pulmonary arteries
- ↓ Peripheral vascular markings
- Bullae
• CT
• ECG – Right Atrial & Ventricular hypertrophy (Cor Pulmonale)
• ABG – PaO2 +/- Hypercapnia
• Spirometry
- Obstructive + Air trapping

j) Management
• Reducing exposure to noxious particles & gases
• Bronchodilators
- Mild à Short-acting bronchodilators
- Moderate/Severe à Long-acting bronchodilators
• Combined inhaled glucocorticoids & bronchodilators
• Oral glucocorticoids
• Pulmonary rehabilitation
- Exercise
- Physical training
- Disease education
- Nutritional counselling reduces symptoms
- Improve health status & enhance confidence
• Oxygen therapy
• Surgical intervention
- Bullectomy
- Lung Volume Reduction Surgery (LVRS)
• Palliative care
• Edema: Diuretics
• Mucolytics: Chronic productive cough
• Flu & pneumococcal vaccinations
3. Bronchiectasis

a) What is Bronchiectasis?
• Abnormal dilatation of the bronchi
• Chronic suppurative airway infection with sputum production, progressive scarring & lung damage

b) Causes

Congenital Acquired : Children Acquired : Adults

• Cystic fibrosis
• Primary ciliary dyskinesia
• Kartagener’s syndrome
• Primary
hypogammaglobulinaemia
• Severe infections in infancy
(whooping cough, measles)
• Primary TB
• Inhaled FB
• Suppurative pneumonia
• Pulmonary TB
• Allergic bronchopulmonary
aspergillosis complicating asthma
• Bronchial tumours

c) Clinical features

Signs Symptoms
• Unilateral or Bilateral • Chronic Cough
• Crackles heard over affected areas (sputum) • Sputum
• Locally diminished breath sounds • Pleuritic pain
• Clubbing • Hemoptysis
• Infective exacerbation
• Halitosis

d) Investigations
• Sputum culture
- Pseudomonas aeruginosa
- Staphylococcus aureus
- Aspergillus
• Chest X-ray (advanced)
• CT - Thickened dilated airways
• Screening test for ciliary dysfunction syndrome
- Measure time taken for saccharin pellet from anterior chamber of the nose to reach pharynx (<20min)

e) Management
• Physiotherapy
• Antibiotic therapy
• Surgical treatment
4. Cystic Fibrosis

a) What is Cystic Fibrosis?

• Common fetal genetic disease that causes production of thick & sticky mucous
• The genetic defect causes increased sodium chloride content in sweat and increased sodium & water from
respiratory epithelium

b) Clinical Features
• Bronchiectasis (childhood)
• Infection of the lungs (P.aeruginosa, Stenotrophomomonas maltophilia)
• Progressive lung damage
• Infertile (Male)

c) Diagnosis
• Clinical picture (Bowel obstruction, Failure to thrive, Steatorrhea, Chest symptoms in young child)
• Sweat electrolyte testing
• Genotyping
• Immunoreactive trypsin & genetic testing (Neonatal screening)

d) Complications of Cystic Fibrosis

Respiratory GI & Hepatic Others

• Hemoptysis • Malabsorption & Steatorrhea • DM
• Nasal polyps • Distal IO syndrome • Male infertility
• Progressive airway • Biliary cirrhosis • Osteoporosis
obstruction • Gallstones • Arthropathy
• Respiratory failure • PT, Varices & Splenomegaly • Delayed puberty

e) Management
Respiratory
• Oral antibiotics – Infection
• Bronchodilators & Glucocorticoids – Asthma
• Lung transplant

Non-respiratory
• Supplemental feeding (nasogastric, gastrotomy)
• Insulin therapy

Respiratory Tract Infection

5. Upper Respiratory Tract Infection

a) Give examples of UTI

• Coryza (Common cold) - Rhinovirus
• Acute pharyngitis
• Acute tracheobronchitis

b) Clinical features of Coryza

• Nasal discharge
• Sneezing
• Cough
• Hoarse voice

c) Clinical features of Rhinosinusitis

• Nasal congestion
• Nasal discharge
• Facial pain
• Loss of smell
6. Pneumonia

a) What is Pneumonia?
• Acute lower respiratory tract illness characterized by inflammation of the lung parenchyma and abnormal
alveolar filling with fluid (Consolidation & Exudation)

b) Types of pneumonia and their causes

Typical : Streptococcus pneumoniae, Staphylococcus aureus, Klebsiella pneumoniae

Atypical : Mycoplasma, Legionella, Chlamydia
CAP : Streptococcus pneumoniae, Staphylococcus aureus, Klebsiella pneumoniae,
Morazella catarrhalis, Haemophilus influenzae, Adenovirus, CMV, Coronaviruses
HAP : Staphylococcus aureus, Klebsiella, Pseudomonas
Aspiration : Stoke, Esophageal diseases, Low conscioussness

c) Factors Predisposing to Pneumonia

• Cigarette smoking
• URTI
• Alcohol
• Glucocorticoid therapy
• HIV

d) Clinical Features of Pneumonia

• Fever
• Rigors & Shivering
• Malaise
• Cough
• Purulent sputum
• ↓ expansion, dull percussion, ↑ tactile vocal fremitus, bronchial briefing

e) Clinical Features of Suppurative Pneumonia

• Cough
• Pleural pain
• Foul sputum
• High remittent pyrexia
• Clubbing (10-14 days)
• Pleural rub

f) Differential Diagnosis
• Pulmonary infarction
• Pulmonary TB
• Pulmonary edema
• Pulmonary eosinophilia
• Malignancy: Bronchioalveolar Cell Carcinoma

g) How to determine the severity of Pneumonia

CURB – 65
• Confusion
• Urea : >7mmol
• Respiratory rate : <30/min
• Blood pressure : <90mmHg
• Age : ≥65
h) Complications of Pneumonia
• Para-pneumonic effusion
• Empyema
• Retention of sputum causing lobar collapse
• DVT & Pulmonary embolism
• Pneumothorax (especially Staphylococcus aureus)
• Ectopic abscess formation (especially Staphylococcus aureus)
• ARDS, renal failure, multi-organ failure
• Suppurative pneumonia
• Arrhythmias
• Pyrexia due to drug sensitivity
• Hepatitis, pericarditis, myocarditis, meningoencephalitis
• Septicemia
• Respiratory failure

i) Investigations
• Assess oxygenation: O2 Saturation
• Blood test – FBC, U&E, LFT, CRP
• Chest X-ray
- Lobar or multilobar infiltrates
- Cavitation
- Pleural effusion
• Urinalysis
• Viral serology
• Pleural fluid culture
• Bronchoscopy
• Bronchoalveolar lavage

j) Management
• Antibiotics
• Oxygen
• IV fluids
• VTE prophylaxis
• Analgesia for pleurisy
7. Tuberculosis

a) What is TB
• Infection caused but Mycobacterium tuberculosis

b) Clinical features

Systemic Features Pulmonary

• Low-grade fever • Cough (dry then productive)
• Anorexia • Pleurisy
• Weight loss • Hemoptysis
• Malaise • Pleural effusion
• Night sweats • Miliary TB
• Clubbing (bronchiectasis) - Discrete foci of granulomatous tissue
• Erythema nodosum throughout the lung

Extra-Pulmonary

Tuberculous lymphadenitis • Painless enlargement of cervical or supraclavicular lymph nodes

GI TB • Colicky abdominal pain
• Vomiting
• Bowel obstruction (bowel wall thickening)
• Stricture formation
• Inflammatory adhesions
• Caseation necrosis (differentiate from Crohn’s disease)
• Absence of transmural fissures (differentiate from Crohn’s disease)
Spinal TB • Local pain & bony tenderness (weeks to months)
• Slow, insidious progression
• Bony destruction, vertebral prolapse & soft tissue abscess
CNS TB • Foci of infection in brain
- Enlarge à Tuberculoma
- Rupture à Meningitis
• Headache
• Meningitism
• Confusion
• Seizures
• Focal neurological deficit
GU TB • Chronic/Intermittent/Silent
• Dysuria
• Frequency
• Loin pain
• Haematuria
• Sterile pyuria
• Genital ulceration
Cardiac TB • Pericardium
- Pericarditis, Pleural effusion, Constrictive pericarditis
• Myocardial involvement
- Arrhythmia, Heart failure, Ventricular aneurysm, Outflow obstruction
Skin • Red-brown, ‘apple-jelly’ nodules
c) Diagnosis
Ø Imaging & lab tests but confirmed by isolating Mycobacterium tuberculosis from clinical samples
Ø AFB smears & cultures from clinical specimens
- ≥2 sputum specimens (≥1 early morning specimen)
- Gastric lavage/ bronchoscopy in patient who is not suitable for sputum induction
- EPTB – tissue of fluid from affected sites for cytology/histopathological examination & culture

• Mantoux test (Purified Protein Derivative)

• Nucleic Acid Amplification Tests (NAAT)
• Fluorescence Microscopy
• Line Probe Assay – detect-resistant TB (rifampicin & isoniazid resistance)
• Xpert MTB/RIF
• Imaging
- Chest X-ray
- CT
- High Resolution CT
- MRI

d) Management

• Health education
• New cases
- 6 month regimen ( 2 months daily EHRZ + 4 months daily HR)
- E-Ethambutol, H-Isoniazid, R-Rifampicin, Z-Pyrazinamide, S-Streptomycin (1st line drugs)
• Maintenance phase
- Intermittent drug regimen designed for Directly Observed Therapy (DOT)
• Fixed-dose combinations (FDC)
- Incorporate 2 or more drugs in single tablet & offer reduction in number of pills need to be consumed
• Optimal duration of treatment
- Pulmonary TB : 6 months
- EPTB should be treated with anti-TB treatment ≥6 months
- Bone TB : 6-9 months
- Joint TB : 9-12 months
- Streptomycin should be used instead of ethambutol in adult TB meningitis
• Corticosteroid - TB meningitis & TB pericarditis
• Renal failure patients
- Adjust frequency for pyrazinamide & ethambutol
- Avoid streptomycin
Respiratory Diseases caused by Fungi

8. Allergic Bronchopulmonary Aspergillosis

a) What is Allergic Bronchopulmonary Aspergillosis?

• Result of a hypersensitivity reaction to germinating fungal spores in the airway wall

b) Clinical features
• Fever
• Breathlessness
• Cough productive of bronchial casts
• Worsening asthmatic symptoms

c) Factors predisposing to pulmonary fungal disease

Systemic Factors Local Factors
• Haematological malignancy • Tissue damage by suppuration or necrosis
• HIV • Alteration of normal bacterial flora by antibiotic
• DM therapy
• Chronic alcoholism
• Radiotherapy
• Glucocorticoids, Cytotoxic chemotherapy,
Biologic therapies & other immunosuppressant

d) Diagnostic features
• Asthma
• Proximal bronchiectasis
• Positive skin test for Aspergillus fumigatus
• ↑ total serum IgE (>1000ng/mL)
• ↑ Aspergillus fumigatus specific IgE or IgG
• Peripheral blood eosinophilia (>0.5 x 109/L)
• Presence or Hx of CXR abnormalities
• Fungal hyphae of Aspergillus fumigatus on microscopic examination of sputum

e) What is it usually mistaken as radiologically?

• Pneumonia

f) Management
• Regular therapy with low-dose oral glucocorticoids
• Specific anti-IgE monoclonal antibodies
• Prednisolone
• Physiotherapy
• Bronchoscopy – remove impacted mucus & ensure prompt re-inflation
9. Invasive Pulmonary Aspergillosis

a) What is Invasive Pulmonary Aspergillosis

• Complication of profound neutropenia caused by drugs (especially immunosuppressive agents) &/or
disease

b) Clinical features
• Severe necrotizing pneumonia
• Immunocompromised patient (Fever, Pleural pain, Haemoptysis, Pleural rub)
• Thrombosis & infarction
• Tracheobronchial fungal plaques & ulceration

c) Risk factors for Invasive aspergillosis

• Neutropenia • Cytotoxic chemotherapy
• Solid organ or allogeneic stem cell • Advanced HIV
transplantation • Severe COPD
• Prolonged high-dose glucocorticoid • Critically ill patients on ICU
therapy • Chronic granulomatous disease
• Leukaemia & other haematological
malignancies

d) Investigation
• Culture of diseased tissues (definitive diagnosis)
• PCR – Detect Aspergillus cell-wall components in blood or BAL fluid & Aspergillus DNA

e) Management
• Voriconazole
• Second-line agents : Liposomal amphotericin, Caspofungin, Prosaconazole, Isavuconazole
• Patient at risk should be managed in rooms with high-efficiency particulate air filters and laminar air flow
• Wear a mask when out of hospital room
• Primary Prophylaxis – Posaconazole or Itraconazole

Tumours of the lung

10. Primary Tumours of the Lung

a) What is the most important cause of Lung cancer?

• Cigarette smoking

b) Common cell types in lung cancer

• Adenocarcinoma
• Squamous
• Small-cell
• Large cell

c) Causes of large bronchus obstruction

• Common
- Lung cancer or Adenoma
- Enlarged tracheobronchial LN
- Inhaled FB (especially Right)
- Bronchial casts or plugs consisting of mucus or blood clot
- Collections of mucus or mucopus retained in the bronchi as a result of ineffective expectoration

• Rare
- Aortic aneurysm
- Giant left atrium
- Pericardial effusion
- Congenital bronchial atresia
- Fibrous bronchial stricture
d) Clinical features
• Cough
• Haemoptysis (especially central)
• Breathlessness (diaphragmatic paralysis)
• Pain & nerve entrapment (lung apex cancer à Horner’s syndrome (ptosis, miosis, anhidrosis)
• Mediastinal spread
- Esophagus à Dysphagia
- Pericardium à Arrhythmia, Pericardial effusion
- SVA obstruction à swelling of the neck & face, Conjunctival edema, Headache
- L. recurrent laryngeal nerve à vocal cord paralysis, Voice alteration, Bovine cough
- Supraclavicular LN à enlarged
• Metastatic spread
- Focal neurological defects, Epileptic seizures, Personality change
- Bone pain
- Jaundice
- Skin nodules
• Finger clubbing
• Hypertrophic Pulmonary Osteoarthropathy (periostitis – distal tibia, fibula, radius,ulna)
• Non-metastatic extrapulmonary effects

Endocrine Neurological Other

• SIADH • Polyneuropathy • Digital clubbing
• Ectopic ACRH secretion • Myelopathy • Hypertrophic Pulmonary Osteoarthropathy
• PTH • Cerebellar • Nephrotic syndrome
• Carcinoid syndrome degeneration • Polymyositis & Dermatomyositis
• Gynecomastia • Myasthenia • Eosinophilia

e) Investigation
• Imaging
- Chest X-ray (Lobar collapse/Mass lesions/Effusion/Malignant rib destruction)
- CT (Reveal mediastinal or metastatic spread, Helpful for planning biopsies)
• Biopsy & Histopathology (bronchoscopic washings & brushings, sputum cytology, pleural aspiration)

f) Common Radiological Presentations of Lung Cancer

1) Unilateral hilar enlargement à Central tumour/hilar glandular

involvement
2) Peripheral pulmonary opacity
3) Lung, lobe or segmental collapse
4) Pleural effusion
5) Widening of upper mediastinum à Paratracheal lymphadenopathy
6) Enlarged cardiac shadow à Malignant pericardial effusion
7) Raised hemidiaphragm à Phrenic nerve palsy
8) Osteolytic rib destruction à Metastatic spread

g) Management
• Surgery
• Radiotherapy
• Chemotherapy
• Laser therapy & stenting
• General aspects (Effective communication, Pain relief, Attention to diet)
11. Tumors of the Mediastinum

a) Causes of mediastinal mass

Superior Anterior Posterior Middle
• Retrosternal goiter • Retrosternal goiter • Aortic aneurysm • Lymphoma
• Thymic tumour • Thymic tumour • Foregut duplication • Lung cancer
• Dermoid cyst • Dermoid cyst • Paravertebral • Sarcoidosis
• Lymphoma • Lymphoma abscess • Bronchogenic cyst
• Aortic aneurysm • Aortic aneurysm • Neurogenic tumour • Hiatus hernia
• Persistent left • Ferm cell tumour • Esophageal lesion
superior vena cava • Pericardial cysts
• Prominent left • Hiatus hernia
subclavian artery through diaphragm

b) Clinical features of malignant mediastinal invasion

Trachea & Main Bronchi • Stridor, Breathlessness, Cough, Pulmonary collapse

Esophagus • Dysphagia, Esophageal displacement or Obstruction on barium
swallow examination
Phrenic nerve • Diaphragmatic paralysis
Left Recurrent Laryngeal nerve • Paralysis of left vocal cord with hoarseness & bovine cough
Sympathetic nerve • Horner’s syndrome (ptosis, anhidrosis, miosis)
SVC • SVC obstruction
- Non-pulsatile distension of neck veins
- Subconjunctival edema
- Edema and cyanosis of head, neck, hands & arms
- Dilated anastomotic veins on chest wall
Pericardium • Pericarditis +/- Pericardial effusion

c) Investigations
• Chest X-ray
- Benign : Sharply circumscribed mediastinal opacity
• CT/MRI – investigayion of choice for mediastinal tumours
• Bronchoscopy
• Biopsy guided by endoscopic ultrasound (posterior mediastinum)
• Mediastinoscopy under GA
• Surgical exploration of chest, with removal of part or all of the tumour

d) Management
• Surgical removal – Benign mediastinal tumours
Diseases of the upper airway

12. Diseases of the nasopharynx

a) Allergic rhinitis
• Episodes of nasal congestion, watery nasal discharge and sneezing
• May be seasonal or perennial
• Due to an immediate hypersensitivity reaction in the nasal mucosa
• Seasonal antigens include pollens , responsible for hay fever
• Perennial antigens include house dust, fungal spores or animal dander, physical or chemical irritants, e.g.
pungent odours or fumes, including strong perfumes, cold air and dry atmospheres.

b) Clinical features
• Frequent sudden attacks of sneezing, last for a few hours
• Profuse watery nasal discharge
• Nasal obstruction
• Starting and watering of eyes and conjunctival irritation

c) Investigation
• Skin hypersensitivity tests with the relevant antigen - positive in seasonal allergic rhinitis but are less
useful in perennial rhinitis.

d) Management
• Thorough dust removal from the bed area, leaving a window open and renewing old pillows
• Avoidance of pollen and antigens from domestic pets
• Medications
- Antihistamine - loratadine
- Sodium cromoglicate nasal spray
- Glucocorticoid nasal spray- beclometasone dipropionate, fluticasone, mometasone or budesonide
• Iimmunotherapy (desensitization)- risk of serious reactions
• Ipratropium bromide, administered into each nostril 3 times daily.

13. Laryngeal disorders

a) Causes of chronic laryngitis

• Repeated attacks of acute laryngitis
• Excessive use of the voice, especially in dusty atmospheres
• Heavy tobacco smoking
• Mouth-breathing from nasal obstruction
• Chronic infection of nasal sinuses

b) Clinical features
• Hoarseness or loss of voice (aphonia)
• Throat irritation and spasmodic cough.
• Other causes of chronic hoarseness include use of inhaled glucocorticoid treatment, tuberculosis,
laryngeal paralysis or tumour.

c) Investigation
• Chest X-ray - may reveal unsuspected lung cancer or pulmonary tuberculosis
• Laryngoscopy - to exclude a local structural cause.

d) Management
• Rest voice completely.
• Smoking should be avoided
Interstitial & Infiltrative Pulmonary Disease

14. Diffuse Parenchymal Lung Disease

a) What is Diffuse Parenchymal Lung Disease

• Heterogenous group of conditions affecting the pulmonary parenchyma (interstitium) and/or alveolar
lumen

b) Clinical Presentation
• Cough (Usually dry, persistent & distressing)
• Breathlessness (Usually slowly progressing , Insidious onset, Acute)

c) Examination Findings
• Crackles (typically bilateral & basal)
• Clubbing
• Central cyanosis & signs of RHF

d) Radiological Findings
• Chest X-ray • High-resolution CT
- Small lung volume - Ground glass changes
- Reticulonodular shadowing - Reticulonodular shadowing
- Honeycomb cysts
- Traction bronchiectasis

e) Pulmonary function
• Restrictive ventilatory defect • Exercise test
- Reduced lung volumes - Assess exercise tolerance
- Impaired gas transfer - Exercise-related fall in SaO2

f) Conditions that mimic parenchymal lung disease

• Infection • Malignancy
- Viral pneumonia - Leukemia & lymphoma
- Pneumocystis jirovecii - Lymphangitic carcinomatosis
- Mycoplasma pneumoniae - Multiple metastases
- TB - Bronchoalveolar carcinoma
- Parasite (e.g. filariasis) • Pulmonary edema
- Fungal infection • Aspiration pneumonitis

g) Investigation
• Laboratory investigation
- FBC : Sarcoid (lymphopenia), Pulmonary eosinophilia (eosinophilia), Drug reactions,
Hypersensitivity pneumonitis (Neutrophilia)
- Calcium levels : Elevated in Sarcoid
- LDH : Elevated in active alveolitis
- Serum ACE : Sarcoid
- ESR & CRP
- AI screen : Anti-CCP & Other autoantibodies à Connective tissue disease
• Radiology (see (d))
• Pulmonary function (see (e)
• Bronchoscopy
- BAL (Sarcoid, Drug-induced pneumonitis, Pulmonary eosinophilia, Hypersensitivity pneumonitis,
Organizing pneumonia)
- Transbronchial biopsy (Sarcoidosis, Malignancy, Infection)
- Bronchial biopsy (Sarcoid)
• Video-assisted thoracoscopic lung biopsy
- Asbestos à Asbestosis, Silica à Occupational fincrosing lung disease
• Liver biopsy (Sarcoidosis)
• Urinary calcium excretion (Sarcoidosis)
Idiopathic Interstitial Pneumonias

15. Idiopathic Pulmonary Fibrosis

a) What is Idiopathic Pulmonary Fibrosis

• IPF is defined as progressive fibrosing interstitial pneumonia of unknown cause, occurring in adults and
associated with the histological or radiological pattern of Usual Interstitial Pneumonia (UIP)

b) Clinical features
• Old (>50 years)
• Progressive breathlessness
• Non-productive cough
• Finger clubbing
• Bi-basal fine late inspiratory crackles (like unfastening Velcro)

c) Investigations
• Chest X-ray
- Bilateral lower lobe & subpleural reticular shadowning
• High-Resolution CT
- Patchy, predominantly peripheral, subpleural & basal reticular pattern
- Honeycombing cysts (advanced)
- Pleural plaques à Asbestosis
• Pulmonary function test
- Restrictive defect with reduced lung volumes & gas transfer
• Dynamic tests
- Document exercise tolerance
- Demonstrate exercise induced arterial hypoxemia
• Bronchoscopy
• Lung biopsy à diagnostic uncertainty or with atypical features

d) Management
• Anti-fibrotic agent (e.g., pirfenidone)
- Those on pirfenidone should avoid direct exposure to sunlight
• Tyrosine kinase inhibitor (e.g. nintedanib)
- Nintedanib à Diarrhea
• Medication for GE reflux
• Advise to stop smoking
• Influenza & pneumococcal vaccination
• Pulmonary rehabilitation with ambulatory oxygen
• Lung transplantation
• Broad spectrum antibiotics + Glucocorticoids
• Avoid use of high-dose steroids
16. Sarcoidosis

a) What is Sarcoidosis\
• Multisystem granulomatous disorder of unknown aetiology characterized by the presence of non-caseating
granulomas

b) Clinical features
• Asymptomatic
• Respiratory & constitutional symptoms
• Erythema nodosum & arthralgia
• Ocular symptoms
• Skin sarcoid (including lupus pernio)
• Superficial lymphadenopathy
• Others
- Hypercalcemia
- Diabetes insipidus
- Cranial nerve palsies
- Cardiac arrhythmias
- Nephrocalcinosis (due to hypercalciuria)

c) Complications
• Bronchiectasis • Pulmonary hypertension
• Aspergilloma • Cor Pulmonale
• Pneumothorax

d) Investigations
• FBC – Lymphopenia
• LFT
• Calcium levels – Hypercalcemia (especially when exposed to strong sunlight)
• Serum ACE
• Chest radiology – used to stage sarcoid
• Bronchoscopy – Cobblestone appearance of mucosa
• HRCT – reticulonodular opacities that follow a perilypmhatic distribution, centered on bronchovascular
bundles and the subpleural areas

e) Chest X-ray changes in Sarcoidosis

Stage I: • Often asymptomatic

Bilateral hilar lymphadenopathy,
BHL (usually symmetrical);
paratracheal nodes often enlarged
Stage II:
BHL and parenchymal infiltrates
Stage III:
Parenchymal infiltrates without BHL
Stage IV:
Pulmonary fibrosis
f) Management
• May associate with erythema nodosum and arthralgia.
• Majority of cases resolve spontaneously within 1 year
• Breathlessness and cough
• Majority cases resolve spontaneously
• Less likely to resolve spontaneously
Cause progression to:
• ventilatory failure
• pulmonary hypertension
• cor pulmonale
*BHL – Bilateral Hilar Lymphadenopathy

• NSAIDs (presented with acute illness and erythema nodosum)

• Systemic corticosteroid for 6 months (no organ damage)
• Prednisolone (hypercalcemia, pulmonary impairment, renal impairment and uveitis)
• Methotrexate, azathioprine and the use of specific tumour necrosis factor (TNF)-α inhibitors (patients with
severe disease)
• Single lung transplant (selected patient)
Pulmonary Vascular Disease

17. Pulmonary Embolism

a) What is Pulmonary Embolism?

• Pulmonary embolism is a blockage in one of the pulmonary arteries in your lungs

b) Signs & Symptoms

Signs Symptoms
• Pyrexia • Acute breathlessness
• Cyanosis • Pleuritic chest pain
• Tachypnea • Haemoptysis
• Tachycardia • Dizziness
• Hypotension • Syncope
• ↑ JVP
• Pleural rub

c) Investigations
• FBC, U&E, Baseline clotting, D-dimers
• ABG - ↓PaO2 & ↓PaCO2
• Chest X-ray
- Oligemia of affected segment
- Dilated pulmonary artery
- Linear atelectasis
- Small pleural effusion
- Wedge-shaped opacities
• ECG
- Tachycardia
- RBBB
- Right ventricular strain (Inverted T waves from V1 – V4)
• USG of leg +/- CT pulmonary angiogram

d) Management
• General measures
- Sufficient oxygen
- Circulatory shock – IV fluids, Plasma expander
- Avoid vasodilators & diuretics
- Opiates to relieve pain & distress
- External cardiac massage for hypotensive patients
• Anticoagulation
• Thrombolytic & surgical therapy
- Massive PE + Cardiogenic shock
• Caval filters
- For patients contraindicated with anticoagulation
- Used until anticoagulation can be safely initiated
18. Pulmonary Hypertension

a) What is Pulmonary Hypertension?

• Pulmonary hypertension is defined as a mean Pulmonary Arterial Pressure (PAP) of ≥25 mmHg at rest

b) Classification
Pulmonary Arterial Hypertension
Pulmonary Venous Hypertension
Pulmonary HTN a/w disorders of
respiratory system +/- hypoxemia
Pulmonary HTN due to chronic
thromboembolism
Miscellaneous
• Primary Pulmonary HTN
• Secondary to
- Connective tissue disease
- Congenital systemic to pulmonary shunts
- Portal HTN
- HIV infection
- Drugs & toxins
- Persistent pulmonary HTN in newborn
• Left-sided atrial or ventricular heart disease
• Left-sided valvular heart disease
• Pulmonary veno-occlusive disease
• Pulmonary capillary haemangiomatosis
• COPD, Diffuse parenchymal lung disease
• Sleep-disordered breathing
• Alveolar hypoventilation disorders
• Chronic exposure to high altitudes
• Neonatal lung disease
• Alveolar capillary dysplasia
• Severe kyphoscoliosis
• TE obstruction of the proximal pulmonary arteries
• In situ thrombosis
• Sickle-cell disease
• Inflammatory conditions
• Extrinsic compression of the central pulmonary veins

c) Clinical Features
• Breathlessness
• Chest pain
• Fatigue
• Palpitation
• Syncope
• Elevation of JVP (prominent ‘a’ wave if sinus rhythm)
• Loud S2

d) Investigations
• ECG – Right ventricular strain pattern
• Chest X-ray – enlarged pulmonary vessels
• Transthoracic echocardiography
• Right heart catheterization – Pulmonary haemodynamics, Measure vasodilator responsiveness

e) Management
• Diuretic therapy – RHF
• Supplemental oxygen
• Anticoagulation
• Digoxin – Atrial
• Avoid nitrates & β-blockers, Cyclizine
• Phosphodiesterase V inhibitors (Sildenafil,Tadalafil)
• High-dose calcium channel blockers
• Surgery
- Double-lung transplantation
- Pulmonary thrombo-enterectomy
- Atrial septostomy
Pleural Effusion

19. Pleural Effusion

a) What is Pleural Effusion

• Accumulation of serous fluid within the pleural space

b) Clinical Assessment
• Asymptomatic
• Pain on inspiration
• Pleural rub (Pleurisy)
• Breathlessness (insidious onset)

c) Causes
Common Uncommon
• Pneumonia • Post-MI syndrome
• Tuberculosis • Connective Tissue Diseases* (e.g. SLE & RA)
• Malignant disease • Hypoproteinemia* (e.g. nephrotic syndrome, liver failure, malnutrition)
• Pulmonary infarction* • Acute Rheumatic Fever
• Cardiac failure* • Uremia*
*may be bilateral
d) Investigation
• Radiological
Ø Erect PA chest film
- Blunting of the costophrenic angle
- Simulated elevated hemidiaphragm (sub pulmonary effusion)
Ø Ultrasound
- Clear hypoechoic space à Transudate, Floating densities à Exudate
- Septation à Evolving empyema or resolving haemothorax
Ø CT scanning
- Indicated when malignant disease is suspected

• Pleural Aspiration & Biopsy

Causes Appearance of Fluid Type of Fluid
Tuberculosis Serous, usually amber-coloured
Malignant Disease
Pulmonary Infarction Serous, often blood-stained
Rheumatoid Disease Serous Exudate
Turbid if chronic
SLE Serous
Acute Pancreatitis Serous or blood-stained
Obstruction of Thoracic Duct Milky Transudate
Cardiac Failure Serous, Straw-straw coloured Chyle

e) Management
• Therapeutic aspiration
• Treat underlying causes (e.g., heart failure, pneumonia, pulmonary embolism, subphrenic abscess)

f) Type 1 (Lung Problem) vs Type 2 (Pump Problem) Respiratory failure

20. Empyema

a) What is Empyema?
• Accumulation of frank pus in the pleural space which may be thin or thick

b) What are the complications?

• Bronchopleural fistula
• Pyopneumothorax
• Empyema necessitans (Subcutaneous abscess or sinus)

c) Clinical features
Systemic Local
• Pyrexia (High & remittent) • Pleural pain
• Rigors, sweating, malaise & weight loss • Breathlessness
• PMN leukocytosis, ↑CRP • Cough
• Sputum (copius purulent à empyema rupture)
• Clinical signs of pleural effusion

d) Investigations
• Chest X-ray
- Empyema: D-shaped shadow against inside of chest wall
- Pyopneumothorax : horizontal ‘fluid level’ marks the air/liquid interface
• USG
- Shows the position of the fluid, extent of pleural thickening, single or multilocated, any fibrin &
debris
- Identify optimal site for aspiration
• CT
- Provides information on the pleura, lung parenchyma & patency of major bronchi
- Identify optimal site for aspiration
• Cultures
• Biopsy
• Histology
• NAAT

e) Management
• Aspiration of pus
• Empirical antibiotic treatment (e.g. co-amoxiclav(IV) or Cefuroxime + Metronidazole)
• Surgical intervention
Pleural disease

21. Pneumothorax

a) What is Pneumothorax?
• Presence of air in the pleural space
• Can occur spontaneously or trauma to the lung or chest wall

b) Classification

• Spontaneous
Primary Secondary
• No history of lung disease • Underlying lung disease, commonly COPD &
• Air escapes from the lung into the pleural TB, and sometimes in asthma, lung abscess,
space through a rupture of a small pleural pulmonary infarcts, lung cancer and all forms
bleb, or the pulmonary end of a pleural of fibrotic & cystic lung disease
adhesion
• Smoking, tall stature and the presence of
apical subpleural blebs are risk factors

• Traumatic
• Iatrogenic (e.g. following thoracic surgery or biopsy) or chest wall injury

Closed Pneumothorax Open Pneumothorax Tension Pneumothorax

• The communication
between the airway and the
pleural space seals off as the
lung deflates and does not
re-open.
• The mean pleural pressure
remains negative,
spontaneous reabsorption of
air and re-expansion of the
lung occur over a few days
or weeks
• Infection uncommon
• The communication fails to
seal, air continues to pass
freely between bronchial tree
and pleural space
• Infection from the airways
into the pleural space, leading
to empyema.
• Commonly seen following
rupture of emphysematous
bulla, tuberculous cavity or
lung abscess into the pleural
space.
• The communication between the
airway and pleural space acts as one-
way valve, allowing air to enter the
pleural space during inspiration but not
to escape on expiration.
• Large amounts of trapped air
accumulate progressively in the pleural
space and intrapleural pressure rises to
above atmospheric levels, causing
mediastinal displacement towards the
opposite side, with compression of the
opposite normal lung and impairment
of systemic venous return, causing
cardiovascular compromise
c) Clinical features
• Sudden onset of unilateral pleuritic chest pain
• Breathlessness
• Decreased or absent breath sounds in larger pneumothorax (>15% of the hemithorax)
• Resonant percussion note
• Marked tachycardia, hypotension, cyanosis and tracheal displacement in tension pneumothorax

d) Investigations
• Chest X-ray
- Sharply defined edge of deflated lung with complete translucency (no lung markings)
- Extent of any mediastinal displacement
- Reveal any pleural fluid or underlying pulmonary disease
• CT

e) Management
• Primary pneumothorax (lung edge <2cm from chest wall, not breathless) - resolves without intervention.
• Moderate or large spontaneous primary pneumothorax- percutaneous needle aspiration of air
• Secondary pneumothorax - intercostal tube drainage (fourth, fifth or sixth intercostal space, mid-axillary
line, connected to underwater seal or one-way Heimlich valve)
• Tension pneumothorax- insertion of a blunt cannula into pleural space
• Supplemental oxygen
• Recurrent spontaneous pneumothorax - aspiration or tube drainage, Surgical pleurodesis