Short & Long Cases in Clinical Medicine Harendra Nath Sarker
INDEX
×
Chapter Notes

Save Clear


Respiratory SystemCASE 1

 
PLEURAL EFFUSION
 
Scenario
Dull pain and heaviness of chest.
 
Instruction
  • Examine the chest
  • Examine the chest from back
  • Examine the chest from front.
 
Proceed as Follows
  1. Address the patient as your custom “Hi, Hello, Assalamualaykum” and introduce yourself.
  2. Maintain 3Ps (Permission, Position and Proper exposure).
  3. Look at the patient (from head to toe) and surroundings, and spend a few seconds to get any clue, e.g. patient may be dyspnic, tachypnic and may have a bandage over chest (aspiration site).
  4. Inspect the chest from side and head or foot end and observe shape, movement, needle puncture or biopsy mark, engorged vein, scar mark and any other abnormality.
    Note: This patient has diminished movement on right side [think the causes of unilateral diminished movement (Box 1.1)].
  1. Palpate the trachea to ascertain its position. Palpate apex beat, and assess expansibility and vocal fremetus.
    Note: This patient has trachea and apex beat shifted to the left and reduced expansibility and vocal fremetus on right side) [think causes of deviated trachea opposite to the side of pathology (Box 1.2)].
  1. Percuss over midclavicular and midaxillary line and notice percussion note, presence of normal cardiac and liver dullness
    Note: Percussion note is dull (stony) from 4th and 3rd space downward along midclavicular and midaxillary lines, respectively [think about causes of dullness on percussion (Box 1.3)].
  1. Auscultate chest along midclavicular and midaxillary line and listen breath sound and any added sound sounds. Assess vocal resonance.
    Note: Breath sound and vocal resonance are diminished on right side [Think about causes of diminished breath sound and vocal resonance (Box 1.4)].
  1. Examine back of the chest by inspection, palpation, percussion and auscultation.
  2. Do the relevant examination to find out the cause— appearance (cachexia—malignancy and TB, toxic-empyema), temperature (TB, pneumonia and empyema), clubbing (malignancy and empyema), nicotine stain (malignancy), lymph nodes (malignancy, TB and lymphoma), rheumatoid hands (rheumatoid arthritis), and malar rash (SLE).
24
 
Schematic Diagnosis
Chest examination
Inspection
↓ movement on right side (pathology on right Side)
Palpation
Trachea shifted to left (pleural effusion or pneumothorax)
Percussion
Stony dull on right side (pleural effusion)
Auscultation
↓ breath sound and vocal resonance (support pleural effusion)
Final diagnosis
Right-sided pleural effusion
Q. What are your findings?
A. Patient is not dyspneic. Movement and expansibility are reduced on right side. Apex beat and trachea are shifted to left. Percussion note is stony dull. Breath sounds and vocal resonance are diminished on right side. No added sound is present.
Q. What is your diagnosis?
A. Right-sided pleural effusion.
Q. Which findings may be found above the level of pleural effusion?
A. Bronchial breath sound, increased vocal resonance and whispering pectoriloque.
Q. Why is this not pneumothorax?
A. It is not pneumothorax as percussion note is stony dull; in pneumothorax it should be hyperresonant.
Further discussion—Read long case “Pleural Effusion”.
 
PNEUMOTHORAX
 
Scenario
Sudden onset of right-sided chest pain.
 
Instruction
  • Examine the chest
  • Examine the chest from front.
 
Proceed as Follows
  1. Address the patient as your custom “ Hi, Hello, Assalamu alaykum” and introduce yourself and tell your role.
  2. Maintain 3Ps (Permission, Position and Proper exposure).
  3. Look at the patient (from head to toe) and surroundings, and spend a few seconds to get any clue, e.g. patient may be dyspnic, tachypnic and cyanosed.
  4. Inspect the chest from side and head or foot end and observe shape, movement, needle puncture or biopsy mark, engorged vein, scar mark and any other abnormality.
    Note: This patient has diminished movement on right side [think the causes of unilateral diminished movement (Box 1.1)].
  5. Palpate the trachea to ascertain its position. Palpate apex beat and assess expansibility.
    Note: This patient has trachea and apex beat shifted to the left and reduced expansibility on right side [think causes of deviated trachea opposite to the side of pathology (Box 1.2)].
  6. Percuss chest along midclavicular and midaxillary line and notice percussion note, presence of normal cardiac and liver dullness.
    Note: Percussion note is hyperresonant on right side along midclavicular and midaxillary lines [think about causes of hyperresonant percussion note (Box 1.5)]
  1. Auscultate chest along midclavicular and midaxillary line and listen breath sound and any added sounds. Assess vocal resonance.
    Note: Breath sound and vocal resonance are diminished on right side. Also look for features of underlying diseases (vesicular breath sound with prolonged expiration—COPD, coase crepitations—bronchiectasis, fine crepitations unaltered after coughing—interstitial lung disease). (Think about causes of diminished breath sound and vocal resonance in spite of hyperresonant percussion note (Box 1.6)].
  1. Examine back of the chest by inspection, palpation, percussion and auscultation.
  2. Do the relevant examination to find out the cause— clubbing (malignancy, bronchiectasis and interstitial lung disease), nicotine stain (COPD, malignancy— smoking a common cause) and JVP (tension pneumothorax).
25
 
Schematic Diagnosis
Chest examination
Inspection
↓ movement on right side (pathology on right side)
Palpation
Trachea shifted to left (pleural effusion or pneumothorax)
Percussion
Hyperresonant on right side (right pneumothorax)
Auscultation
Absent or ↓ breath sound and vocal resonance (pneumothorax)
Final diagnosis
Right-sided pneumothorax
Q. What is your diagnosis?
A. Right-sided pneumothorax.
Q. What are the points in favor of your diagnosis?
A. Diminished movement, expansibility and vocal fremitus are present on right side. Trachea and apex beat are shifted to left side. Percussion note is hyperresonant. Breath sound and vocal resonance are diminished.
Q. Why is this not giant bulla?
A. In bulla, no mediastinal shifting is present, i.e. trachea and apex beat are in normal position.
Q. Why is this not pleural effusion?
A. In pleural effusion, percussion note is stony dull.
Q. What is pneumothorax?
A. Pneumothorax is the presence of air in the pleural space.
Q. What are the definitive signs of pneumothorax?
A. Hyperresonant percussion note and diminished/absent breath sound.
Q. What are the causes of pneumothorax? Or classify pneumothorax.
A. Classification of pneumothorax
  1. Spontaneous:
    • Primary
      • No evidence of overt lung disease
      • Rupture of:
        1. A small subpleural emphysematous bulla.
        2. Pleural bleb.
        3. The pulmonary end of a pleural adhesion.
    • Secondary
      • Underlying lung disease, most commonly COPD and TB; asthma, lung abscess, pulmonary infarcts, and bronchogenic carcinoma.
  2. Traumatic:
    • Iatrogenic (e.g. following thoracic surgery or biopsy, pleural fluid aspiration)
    • Chest wall injury.
Q. What are the types of spontaneous pneumothorax?
A. The types of spontaneous pneumothorax are:
  • Closed type
  • Open type
  • Tension (valvular) type.
Q. Is there any evidence of tension pneumothorax?
A. No.
Q. What are the features of tension pneumothorax?
A. The features of tension pneumothorax are:
  • Severe chest pain
  • Severe and progressive dyspnea
  • Shifting of mediastinum
  • Features of shock (cyanosis, hypotension, and tachycardia).
Q. How will you investigate the patient?
A. Investingation include:
  • X-ray chest PA view
  • Rarely, CT scan of chest
  • Others—to detect cause of secondary spontaneous pneumothorax.
Q. When is CT scan necessary in pneumothorax?
A. CT scan is necessary:
  • To differentiate a pneumothorax from complex bullous disease
  • When surgical emphysema is present and obscure underlying structure.
Q. How will you treat this patient?
A. As there is no evidence of pneumothorax, I would like to do chest X-ray and then arrange management according to severity of pneumothorax.
Q. How will you treat small primary spontaneous pneumothorax?
A. In patients who have minimal symptoms and have a rim of air 2 cm on CXR, pneumothorax normally resolves without intervention and can be allowed to go home with a repeat CXR in 7–10 days. They should be given clear written advice to return if they develop breathlessness.
Q. How will you treat medium or large primary spontaneous pneumothorax?
A. Percutaneous needle aspiration of air which can be repeated once; if failed, intercostal tube drainage.
Q. How will you treat secondary spontaneous pneumothorax?
A. Treatment of secondary spontaneous pneumothorax includes:
  • 26 All patients with secondary spontaneous pneumothorax should be hospitalized for observation
  • Observation alone is only recommended with small pneumothorax (<1 cm) or isolated apical pneumothorax in asymptomatic patients
  • If age <50 years, asymptomatic or a small pneumothorax (rim of air <2 cm) they should be aspirated. If successful, they should be observed for 24 hours prior to discharge. If unsuccessful, then they will require an intercostal tube drain
  • If age >50 years, symptomatic or a large pneumothorax (rim of air >2 cm), an intercostal tube drain should be inserted.
Q. How will you treat tension pneumothorax?
A. Treatment of tension pneumothorax includes:
  • High flow oxygen
  • Immediate insertion of a large bore cannula into the second intercostal space along mid-clavicular line on the affected side which will allow time for preparation of intercostal tube drainage
  • Prompt insertion of an intercostal tube drain connected with underwater seal.
Q. What is the most important predictor of re-expansion pulmonary edema?
A. Delayed treatment; the greater the length of time the lung has remained collapsed, the greater the risk of re- expansion pulmonary edema.
Q. What is the rate of resolution/reabsorption of a spontaneous primary pneumothorax?
A. The rate of absorption is 1.22–1.8% of the volume of hemithorax per day.
 
PULMONARY FIBROSIS
 
Scenario
Breathlessness on moderate exertion.
 
Instruction
  • Examine the chest
  • Examine the chest from front.
 
Proceed as Follows
  1. Address the patient as your custom “ Hi, Hello, Assalamu alaykum” and introduce yourself and tell your role.
  2. Maintain 3Ps (Permission, Position and Proper exposure).
  3. Look at the patient (from head to toe) and surroundings, and spend a few seconds to get any clue, e.g. stooped posture in ankylosing spondylitis, rheumatoid hands.
  4. Inspect the chest from side and head or foot end and observe shape, movement, scar mark, radiation scar and any other abnormality.
    Note: This patient has flattening of right upper chest, diminished movement on right side [think the causes of focal flattening of chest (Box 1.7).
  1. Palpate the trachea to ascertain its position. Palpate apex beat and assess expansibility.
    Note: This patient has trachea and apex beat grossly shifted to the right and reduced expansibility on right upper part [think causes of deviated trachea to the same side of pathology (Box 1.8).
  1. Percuss chest along midclavicular and midaxillary line and notice percussion note, presence of normal cardiac and liver dullness.
    Note: Percussion note is impaired on upper part of right side along midclavicular line up to 4th space.
  2. Auscultate chest along midclavicular and midaxillary line and listen breath sound and any added sounds. Assess vocal resonance.
    Note: Breath sound is low pitched bronchial and vocal resonance is increased on right upper part. Cracklesare present in the same area which altered after coughing [think about causes of bronchial breath sound (Box 1.9)].
  1. Examine back of the chest by inspection, palpation, percussion and auscultation.
  2. Do the relevant examination—clubbing, nicotine stain, lymph nodes and scar marks.
 
Schematic Diagnosis
Chest examination
Inspection
Flattening and ↓ movement on right upper part (pathology on right upper part)
27
Palpation
Trachea shifted to right (pleural fibrosis or collapse)
Percussion
Dull on right upper part (pleural fibrosis or collapse)
Auscultation
Bronchial breath sound and ↑vocal resonance (pleural fibrosis or collapse with patent bronchus)
Crepitations in right upper part (pulmonary fibrosis)
Final diagnosis
Right apical fibrosis
Q. Present your case.
A. Examination of chest reveals that there is flattening of upper part of right side of chest with diminished movement and expansibility. Trachea and apex beat are grossly shifted to right, percussion note is impaired, breath sound is low pitched bronchial, vocal resonance is increased and crackles on auscultation in above mentioned area. Patient is not breathless at rest.
Q. What is your diagnosis?
A. Right-sided apical fibrosis.
Q. Why is this not collapse?
A. All these features may be present in long standing collapse but presence of crepitations favor diagnosis of fibrosis.
Q. What is the underlying cause and why?
A. Most probably, tuberculosis as it is the commonest cause of unilateral apical fibrosis.
Q. What are the causes of upper lobe fibrosis?
A. Causes of upper lobe fibrosis are—Mnemonic (T-SCAR)
  • T—Tuberculosis
  • S—Silicosis, sarcoidosis
  • C—Coal worker's pneumoconiosis
  • A—Ankylosing spondylitis and allergic broncho­pulmonary aspergillosis
  • R—Radiation
Q. What are the causes of lower lobe fibrosis?
A. Causes of lower lobe fibrosis are—Mnemonic (B-RASIO)
  • B—Bronchiectasis
  • R—Rheumatoid arthritis
  • A—Asbestosis
  • S—Scleroderma
  • I—Idiopathic pulmonary fibrosis
  • O—Others (drugs—bleomycin, busulphan, nitrofurantoin, methotrexate, amiodarone)
Further discussion—Read long case “Pulmonary Tuberculosis”.
 
COLLAPSE OF LUNG
 
Scenario
Cough with hemoptysis.
 
Instruction
  • Examine the chest
  • Examine the chest from front.
 
Proceed as Follows
  1. Address the patient as your custom “ Hi, Hello, Assalamu alaykum” and introduce yourself and tell your role.
  2. Maintain 3Ps (Permission, Position and Proper exposure).
  3. Look at the patient (from head to toe) and surroundings, and spend a few seconds to get any clue, e.g. cachexia, cough, sputum pot, ptosis (Horner's syndrome) (carcinoma bronchus).
    Note: The patient is cachetic.
  4. Inspect the chest from side and head or foot end and observe shape, movement, scar mark, radiation scar and any other abnormality.
    Note: This patient has diminished movement on right side.
  5. Palpate the trachea to ascertain its position. Palpate apex beat and assess expansibility.
    Note: This patient has trachea and apex beat grossly shifted to the right and reduced expansibility on right side [Think causes of deviated trachea to the same side of pathology (Box 1.8)]
  6. Percuss chest along midclavicular and midaxillary line and notice percussion note, presence of normal cardiac and liver dullness.
    Note: Percussion note is dull on right side along midclavicular line from infraclavicular space downward.
  7. Auscultate chest along midclavicular and midaxillary line and listen breath sound and any added sounds. Assess vocal resonance.
    Note: Breath sound is absent and vocal resonance is diminished on right side. No added sound is present. There is high pitched bronchial breath sound in right supraclavicular space which is transmitted from deviated trachea.
  8. Examine back of the chest by inspection, palpation, percussion and auscultation.
    Note: Percussion note is dull, breath sound is absent and vocal resonance is reduced on right side.
  9. 28Do the relevant examinations—clubbing, nicotine stain, hypertrophic osteoarthropathy, lymph nodes, Horner's syndrome, features of superior vena caval obstruction and hepatomegaly (secondaries).
    Note: Clubbing, nicotine stain and right supraclavicular lymph nodes are present.
 
Schematic Diagnosis
Chest examination
Inspection
↓ movement on right side (pathology on right side)
Palpation
Trachea and apex beat shifted to right (pleural fibrosis or collapse)
Percussion
Dull on right side (pleural fibrosis or collapse)
Auscultation
Absent breath sound and ↓vocal resonance (collapse with obstructed bronchus—central collapse)
Final diagnosis
Right-sided collapse of lung
Q. Please tell your findings.
A. Patient is cachetic and breathless at rest. Chest examination reveals that there is diminished movement with reduced expansibility on right side of chest. Trachea and apex beat are grossly shifted to right, percussion note is dull, breath sound is absent, vocal resonance is decreased on right side. There is high- pitched bronchial breath sound in right supraclavicular space which is transmitted from deviated trachea. On relevant examination, clubbing, nicotine stain and right supraclavicular lymph nodes are present.
Q. What is your diagnosis?
A. Right-sided lung collapse due to bronchial carcinoma.
Q. Why is this not a case of pleural effusion?
A. In large pleural effusion, trachea and apex beat are shifted to the opposite side; in small pleural effusion, trachea and apex beat are in normal position. Yet pleural effusion is possible but there must be underlying collapse.
Q. May it be fibrosis?
A. Unlikely, as there are clubbing, nicotine stain and right supraclavicular lymphadenopathy but no flattening of chest, crowding of ribs, drooping of shoulder and crepitations on the affected side.
Q. What are the types of collapse?
A. Collapse are of following types:
  1. Etiological—two types of collapse
    • Compression collapse—due to pleural effusion, pneumothorax
    • Absorption collapse—bronchial obstruction due to any cause. Air is absorbed distal to obstruction and affected part collapse.
  2. Anatomical:
    • Central collapse—main bronchus is completely obstructed (all the signs will be collapsed, breath sound and vocal resonance are absent or reduced).
    • Peripheral collapse—main bronchus is patent (bronchial breath sound and increased vocal resonance).
Q. What are the causes of collapse?
A. Common causes include:
  • Malignancy
  • Mucus plugs (asthma, COPD, bronchiectasis, cystic fibrosis)
  • Foreign body
  • Tuberculosis
  • Extrinsic compression by hilar lymphadenopathy (sarcoidosis, tuberculosis).
Q. How will you investigate the patient?
A. Investigations must included the following:
  • X-ray chest PA view and right lateral view
  • CT scan of chest
  • Bronchoscopy and biopsy
  • CBC and ESR
  • Sputum for malignant cells.
  • USG of whole abdomen
  • CT scan of brain and abdomen
  • Isotope bone scan.
Q. How can you differentiate collapse from fibrosis radiologically?
A. These are as follows:
In collapse—X-ray shows homogenous opacity with lobar or segmental shape. Evidence of bronchial obstruction may be seen.
In fibrosis—nonhomogenous opacity with ring shadow due to dilatation of bronchi within fibrosis may be seen.
Q. What is middle lobe syndrome?
A. Middle lobe syndrome is the recurrent or persistent collapse of right middle lobe.
Further discussion—Read long case “Bronchial Carcinoma”.
29
 
CONSOLIDATION OF LUNG
 
Scenario
Cough, fever and chest pain.
 
Instruction
  • Examine the chest
  • Examine the chest from front.
 
Proceed as Follows
  1. Address the patient as your custom “Hi, Hello, Assalamu alaykum” and introduce yourself and tell your role.
  2. Maintain 3Ps (Permission, Position and Proper exposure).
  3. Look at the patient (from head to toe) and surroundings, and spend a few seconds to get any clue, e.g. ill and toxic.
    Note: The patient is ill and toxic.
  4. Inspect the chest from side and head or foot end and observe shape, movement, scar mark, radiation scar and any other abnormality.
    Note: This patient has diminished movement on right side.
  5. Palpate the trachea to ascertain its position. Palpate apex beat and assess expansibility.
    Note: This patient has trachea and apex beat in normal position and reduced expansibility on right side.
  6. Percuss chest along midclavicular and midaxillary line and notice percussion note, presence of normal cardiac and liver dullness.
    Note: Percussion note is woody dull on right side along midclavicular line from 2nd to 4th space.
  7. Auscultate chest along midclavicular and midaxillary line and listen breath sound and any added sounds. Assess vocal resonance.
    Note: Breath sound is bronchial and vocal resonance is increased on right side. There are few crepitations which altered after coughing.
  8. Examine back of the chest by inspection, palpation, percussion and auscultation.
  9. Do the relevant examinations—temperature, clubbing.
 
Schematic Diagnosis
Chest examination
Inspection
↓ movement on right side (pathology on right side)
Palpation
Trachea and apex beat normal in position (consolidation, lung abscess)
Percussion
Dull on right side (consolidation)
Auscultation
Bronchial breath sound and ↑vocal resonance (consolidation, lung abscess)
Absence of clubbing, presence of fever suggest consolidation
Final diagnosis
Right-sided consolidation of lung
Q. What is your physical diagnosis?
A. Right-sided consolidation (resolution stage).
Q. What are the points in favor of your diagnosis?
A. Diminished movement on right side with reduced expansibility, trachea is central in posision, percussion note is woody dull, breath sound is bronchial and vocal resonance is increased on right side. There are few crepitations which altered after coughing. Patient is febrile.
Q. What is the underlying etiology?
A. Pneumonia.
Q. What are the causes of consolidation?
A. The causes of consolidation are:
  • Bacterial pneumonia
  • Pulmonary infarction
  • Alveolar cell carcinoma
  • Tubercular consolidation.
Q. What are the clinical types of pneumonia?
A. Clinical types of pneumonia are:
  • Community-acquired pneumonia
  • Hospital-acquired pneumonia
  • Suppurative pneumonia, and aspiration pneumonia
  • Pneumonia in immunocompromised hosts.
Q. What are the common organisms causing community-acquired pneumonia (CAP)?
A. The common organisms are:
  • Streptococcus pneumoniae
  • Mycoplasma pneumoniae
  • Legionella pneumophila
  • Chlamydia pneumoniae
  • Haemophilus influenzae
  • Staphylococcus aureus.
Q. What type of sputum occurs in pneumonia?
A. Rusty sputum.
Q. What does ‘rusty sputum’ indicate?
A. It indicates pneumonia due to Streptococcus pneumoniae.
Q. What are the pathological stages of pneumonia?
A. Four stages:
  1. Stage of congestion
  2. Stage of red hepatization
  3. 30 Stage of grey hepatization
  4. Stage of resolution.
Q. When are crepitations present in consolidation?
A. During stages of resolution.
Q. What investigations will you do?
A. Investigations are:
  • Blood for TC, DC, ESR and Hb%—neutrophilic leukocytosis
  • C-reactive protein (CRP)
  • X-ray chest PA view
  • Sputum for Gram stain and C/S
  • Blood culture
  • Pneumococcal antigen detection in serum or urine
  • Arterial blood gas analysis.
Q. When CXR findings will appear in case of pneumonia?
A. After 12–18 hours of onset of symptoms.
Q. What is the radiological finding in consolidation?
A. Homogenous opacity with air bronchogram.
Q. When does signs of consolidation appear in pneumonia?
A. Usually after 2 days of onset of symptoms.
Q. How can you assess severity of pneumonia?
A. We can assess severity of pneumonia by using CURB-65 score.
Q. What is CURB-65?
A. CURB–65 is:
  • Confusion
  • Urea >7 mmol/L
  • Respiratory rate >30/min
  • Blood pressure (systolic 90 mm Hg or diastolic 60 mm Hg)
  • Age >65 years (Score 1 point for each feature).
Q. What is severe pneumonia?
A. Score 3 or more indicates severe pneumonia.
Q. How can you treat CAP?
A.
  • Oxygen—maintaining the PaO2 ≥8 kPa (60 mm Hg) or SaO2 ≥92%
  • Maintain fluid balance
  • Antibiotic treatment—prompt administration of antibiotics improves outcome.
Antibiotic treatment for CAP:
Uncomplicated CAP
  • Amoxicillin 500 mg 8-hourly orally or if patient is allergic to penicillin
  • Clarithromycin 500 mg 12-hourly orally or
  • Erythromycin 500 mg 6-hourly orally.
  • If Staphylococcus is cultured or suspected
  • Flucloxacillin 1–2 g 6-hourly IV plus
  • Clarithromycin 500 mg 12-hourly IV.
Severe CAP
  • Clarithromycin 500 mg 12-hourly IV or
  • Erythromycin 500 mg 6-hourly IV plus
  • Co-amoxiclav 1.2 g 8-hourly IV or
  • Ceftriaxone 1–2 g daily IV or
  • Cefuroxime 1.5 g 8-hourly IV or
  • Amoxicillin 1 g 6-hourly IV plus flucloxacillin 2 g 6-hourly IV.
Duration of treatment—7–10 days (up to 14 days).
Q. How long it takes for radiological resolution?
A. Usually 4 weeks but may take long time, even months.
Q. What are the causes of slow or delayed resolution?
A. The causes are as follows:
  • Incorrect clinical or microbiological diagnosis
  • Inappropriate selection of antibiotic or inadequate dose
  • Development of complication
  • Hidden bronchial obstruction (bronchial carcinoma, adenoma)
  • Immunosuprresion (DM, lymphoma, leukemia, multiple myeloma, HIV).
Q. What are the complications of pneumonia?
A. The complications of pneumonia are:
  • Pleural effusion
  • Empyema
  • Lung abscess
  • Hemoptysis
  • Pneumothorax
  • Distant abscess, e.g. brain abscess
  • Septicemia.
Q. What is hospital-acquired pneumonia (HAP)?
A. Hospital-acquired or nosocomial pneumonia refers to a new episode of pneumonia occurring at least 2 days after admission to hospital.
Q. What are the organisms involved in hospital-acquired pneumonia (HAP)?
A.
  • In early-onset HAP (within 4–5 days of admission), the organisms are same as CAP.
  • In late-onset HAP—Gram-negative bacteria [e.g. Escherichia, Pseudomonas and Klebsiella species), Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus (MRSA)] and anaerobes.
Q. How can you treat HAP?
A. The treatment of HAP includes:
  • A third-generation cephalosporin (e.g. cefotaxime) with an aminoglycoside (e.g. gentamicin) or meropenem or a monocyclic β-lactam (e.g. aztreonam) and flucloxacillin.
    31 These antibiotics are all given intravenously, at least initially
  • Physiotherapy is important in those who are immobile or old
  • Adequate oxygen therapy, fluid support and monitoring are essential.
Q. What is aspiration pneumonia?
A. Aspiration pneumonia is characterized by destruction of the lung parenchyma by the inflammatory process after the inhalation of septic material during operations on the nose, mouth or throat, under general anesthesia, or of vomitus during anesthesia or coma.
 
COLLAPSE/CONSOLIDATION OF LUNG (MASS LESION)
 
Scenario
Cough with hemoptysis in a cachectic man.
 
Instruction
  • Examine the chest
  • Examine the chest from front.
 
Proceed as Follows
  1. Address the patient as your custom “ Hi, Hello, Assalamu alaykum” and introduce yourself and tell your role.
  2. Maintain 3Ps (Permission, Position and Proper exposure).
  3. Look at the patient (from head to toe) and surroundings, and spend a few seconds to get any clue, e.g. cachexia, cough, sputum pot, ptosis (Horner's syndrome) and swollen face, neck and upper chest with engorged veins (SVC obstruction) (carcinoma bronchus).
    Note: The patient is cachectic.
  4. Inspect the chest from side and head or foot end and observe shape, movement, scar mark, radiation mark and any other abnormality.
    Note: This patient has diminished movement on left side.
  5. Palpate the trachea to ascertain its position. Palpate apex beat and assess expansibility.
    Note: This patient has trachea and apex beat normal in position and reduced expansibility on left side.
  6. Percuss chest along midclavicular and midaxillary line and notice percussion note, presence of normal cardiac and liver dullness.
    Note: Percussion note is dull on left side along midclavicular line from 2nd space to 5th space and resonant below this.
  7. Auscultate chest along midclavicular and midaxillary line and listen breath sound and any added sounds. Assess vocal resonance.
    Note: Breath sound and vocal resonance is diminished on left side in the above mentioned area. No added sound is present.
  8. Examine back of the chest by inspection, palpation, percussion and auscultation.
  9. Do the relevant examinations—clubbing, nicotine stain, hypertrophic osteoarthropathy, wasting of small muscles of hands, lymph nodes (cervical and axillary), Horner's syndrome, features of superior vena caval obstruction and hepatomegaly (secondaries).
    Note: Clubbing, nicotine stain and a hard left supraclavicular lymph node are present.
 
Schematic Diagnosis
Chest examination
Inspection
↓ movement on left side (pathology on left side)
Palpation
Trachea and apex beat normal in position (consolidation)
Percussion
Dull in limited area on left side (consolidation or collapse)
Auscultation
↓ breath sound and vocal resonance (collapse with obstructed bronchus— central collapse)
Cachexia, clubbing, nicotine stain, a hard supraclavicular lymph node
Final diagnosis
Left-sided collapse—consolidation (mass lesion) of lung
Q. Present your case.
A. Patient is cachetic and breathless at rest. Chest examination reveals that there is diminished movement with reduced expansibility on left side of chest. Trachea and apex beat are normal in position, percussion note is dull on left side along midclavicular line from 2nd space to 5th space and resonant below this. Breath sound and vocal resonance are diminished on left side in above mentioned area. On relevant examination, clubbing, nicotine stain and a hard left supraclavicular lymph node are present.
Q. What is your diagnosis?
A. Left-sided mass lesion due to bronchial carcinoma.
Q. Why is this not pleural effusion?
A. In pleural effusion, trachea and apex beat are shifted to the opposite side.
32
Q. Why is this not consolidation?
A. In consolidation, there is bronchial breath sound, increased vocal resonance.
Q. Why is this not collapse?
A. In collapse, trachea and apex beat are shifted to the same side.
Further discussion—Read long case “Bronchial Carcinoma”.
 
LUNG ABSCESS
 
Scenario
Cough with profuse purulent sputum.
 
Instruction
  • Examine the chest
  • Examine the chest from front.
 
Proceed as Follows
  1. Address the patient as your custom “Hi, Hello, Assalamu alaykum” and introduce yourself and tell your role.
  2. Maintain 3Ps (Permission, Position and Proper exposure).
  3. Look at the patient (from head to toe) and surroundings, and spend a few seconds to get any clue, e.g. ill-looking and toxic, sputum pot.
    Note: There is sputum pot at bed side containing purulent sputum.
  4. Inspect the chest from side and head or foot end and observe shape, movement, scar mark, radiation scar and any other abnormality.
    Note: This patient has diminished movement on right side.
  5. Palpate the trachea to ascertain its position. Palpate apex beat and assess expansibility.
    Note: This patient has trachea and apex beat in normal position and reduced expansibility on right side.
  6. Percuss chest along midclavicular and midaxillary line and notice percussion note, presence of normal cardiac and liver dullness.
    Note: Percussion note is dull on right side along midclavicular line from 2nd to 4th space and 3rd to 6th space along midaxillary line.
  7. Auscultate chest along midclavicular and midaxillary line and listen breath sound and any added sounds. Assess vocal resonance.
    Note: Breath sound is bronchial and vocal resonance is increased with aegophony on right side. There are numerous coarse crepitations which altered after coughing in above mentioned area. Remember causes of coarse crepitations—see Box 1.10.
  1. Examine back of the chest by inspection, palpation, percussion and auscultation.
  2. Do the relevant examinations—temperature, clubbing. Note: Raised temperature and clubbing are present.
 
Schematic Diagnosis
Chest examination
Inspection
↓ movement on right side (pathology on right side)
Palpation
Trachea and apex beat normal in position (consolidation, lung abscess)
Percussion
Dull on right side (consolidation, lung abscess)
Auscultation
Bronchial breath sound and ↑vocal resonance (consolidation, lung abscess)
Coarse crepitations and clubbing suggest lung abscess
Final diagnosis
Right-sided lung abscess
Q. What is your physical diagnosis?
A. Right-sided lung abscess.
Q. What are the points in favor of your diagnosis?
A. Diminished movement on right side with reduced expansibility, trachea is central in position, percussion note is dull, breath sound is bronchial and vocal resonance is increased on right side. There are numerous coarse crepitations which altered after coughing. Clubbing is present and patient is febrile.
Q. Why is this not consolidation?
A. As clubbing is present in addition to coarse crepitations, though crepitation may occur in resolution stage of consolidation.
Q. Why is this not bronchiectasis ?
A. In bronchiactasis, diminished movement, expansibility, dull percussion note, bronchial breath sounds and increased vocal resonance are usually absent (may occur if associated with consolidation; these features are also absent in small lung abscess which may mimic bronchiectasis).
33
Q. What is lung abscess? What is suppurative pneumonia?
A. Lung abscess is a large localized collection of pus, or a cavity lined by chronic inflammatory tissue, from which pus has escaped by rupture into a bronchus.
Suppurative pneumonia is characterized by destruction of the lung parenchyma by the inflammatory process and microabscess formation is a characteristic histological feature.
Q. What are the causes of lung abscess?
A. These are as follows:
  • Aspiration of infected material (commonest cause)—after the inhalation of septic material during operations on the nose, mouth or throat, under general anesthesia, or of vomitus during anesthesia or coma
  • Alcoholism, achalasia of cardia
  • Obstruction by bronchial carcinoma, adenoma, foreign body
  • Infection in pulmonary infarction (by Streptococcus pneumoniae, Staph aureus, H. influenzae)
  • Spread from surrounding infection—liver abscess, subphrenic abscess
  • Hematogenous spread from distant focus (pelvic abscess, salpingitis).
Q. What are the common organisms causing lung abscess?
A. Strep pneumoniae Type 3, Staph aureus, Klebsiella pneumoniae, Strep pyogenes, H. influenzae and, in some cases, anaerobic bacteria.
Q. What are the characteristics of sputum in lung abscess?
A. If the sputum is kept in a bottle, there are three layers (as in bronchiectasis):
  1. Lower—sediment (epithelial debris, bacteria)
  2. Middle—thick liquid
  3. Upper—frothy.
Q. What are the differential diagnoses?
A. These are as follows:
  • Consolidation (resolution stage)
  • Bronchiectasis
  • Pulmonary tuberculosis.
Q. What investigations will you do?
A. The investigations are:
  • CBC (leukocytosis)
  • X-ray chest (cavitary lesion with fluid level)
  • Sputum examination—Gram staining, culture and sensitivity test (both aerobic and anaerobic), AFB and malignant cell
  • CT scan of the chest
  • Bronchoscopy (to exclude mass, foreign body).
Q. How will you treat lung abscess ?
A. Emperical antibiotic therapy with amoxicillin and metronidazole should be given after sending sputum for culture and sensitivity and then change antibiotic according to culture and sensitivity result if necessary. Treatment should be continued for 4–6 weeks.
Q. What are the complications of lung abscess?
A. The complications are:
  • Pleurisy
  • Empyema
  • Cerebral abscess
  • Bronchiectasis
  • Amyloidosis (rare)—in chronic cases.
 
BRONCHIECTASIS
 
Scenario
Cough with profuse purulent sputum.
 
Instruction
  • Examine the chest
  • Examine the chest from back.
 
Proceed as Follows
  1. Address the patient as your custom “Hi, Hello, Assalamu alaykum” and introduce yourself and tell your role.
  2. Maintain 3Ps (Permission, Position and Proper exposure).
  3. Look at the patient (from head to toe) and surroundings, and spend a few seconds to get any clue, e.g. sputum pot.
    Note: There is sputum pot at bed side containing purulent sputum.
  4. Inspect back of chest from above and side and observe movement, needle puncture mark.
  5. Palpate back to see expansibility and vocal fremitus.
  6. Percuss back over lung apices and scapular line.
  7. Auscultate back over lung apices and scapular line to listen breath sound, vocal resonance and added sound.
    Note: Both inspiratory and expiratory coarse crepitations altered after coughing are present at right lower chest. Remember causes of crepitations altered after coughing—see Box 1.11 and cause of unilateral basal crepitations—see Box 1.12.
34
zoom view
Fig. 1.1: Clubbing
  1. Examine chest from front as usual, i.e inspection, palpation, percussion and auscultation.
  2. Do the relevant examinations—temperature, clubbing (Fig. 1.1).
    Note: Clubbing is present.
 
Schematic Diagnosis
Chest examination from back
Inspection
Normal
Palpation
Normal
Percussion
Normal
Auscultation
Breath sound and vocal resonance normal, coarse crepitations altered after coughing at right lung base (bronchiectasis)
Clubbing supports diagnosis of bronchiectasis
Final diagnosis
Right-sided bronchiectasis
Q. What is your diagnosis?
A. Right-sided bronchiectasis.
Q. What are the points in favor of your diagnosis?
A. Presence of clubbing and coarse crepitations altered after coughing at right lung base support the diagnosis.
Q. Why is this not consolidation?
A. Presence of clubbing and absence of bronchial breath sound and increased vocal resonance exclude consolidation.
Q. Could it be lung abscess?
A. May be, both clubbing and coarse crepitations are found in lung abscess but other features like dull percussion note, bronchial breath sound and increased vocal resonance may be absent in small lung abscess.
Q. Where is the commonest site of bronchiectasis?
A. Left lower lobe and lingula.
Q. What is bronchiectasis?
A. It is the abnormal permanent dilatation of one or more bronchi with destruction of bronchial wall proximal to the terminal bronchioles.
Q. What are the causes of bronchiectasis ?
A. Causes are:
  • Congenital:
    • Cystic fibrosis
    • Ciliary dysfunction syndromes—primary ciliary dyskinesia (immotile cilia syndrome), Kartagener's syndrome (sinusitis and transposition of the viscera)
    • Primary hypogammaglobulinemia.
  • Acquired: Children
    • Pneumonia (complicating whooping cough or measles)
    • Primary TB
    • Inhaled foreign body.
  • Acquired: Adults
    • Suppurative pneumonia
    • Pulmonary TB
    • Allergic bronchopulmonary aspergillosis complicating asthma
    • Bronchial tumors.
Q. What are the components of Kartagener's syndrome?
A. Dextrocardia, bronchiectasis, and sinusitis or frontal sinus agenesis.
Q. What are the types of bronchiectasis?
A. These are three types:
  1. Cylindrical
  2. Fusiform
  3. Saccular or cystic (more severe form).
Q. What is dry bronchiectasis (bronchiectasis sicca)?
A. It is a type of bronchiectasis in which cough is nonproductive but associated with recurrent hemoptysis, which may be severe. Common cause is tuberculosis involving upper lobe.
Q. Why does hemoptysis occur in bronchiectasis?
A. It is due to bronchial wall hypertrophy, so mucosa becomes friable, slough out on coughing, capillary 35 opens and bleeding occurs. Erosion of hypertrophic bronchial artery may result in massive hemoptysis.
Q. What are the characteristics of sputum in bronchiectasis?
A. If sputum is kept in a bottle or glass, there are three layers:
  1. Lower—sediment (epithelial debris, bacteria)
  2. Middle—thick or liquid
  3. Upper—frothy.
Q. What are the causes of foul smelling sputum?
A. Bronchiectasis and lung abscess.
Q. What is the cause of the fetid sputum?
A. Anaerobic infection is the cause of fetid sputum.
Q. If anaerobic organism infection, how will you treat the case?
A. By using metronidazole.
Q. What will be the color of sputum of Pseudomonas infection?
A. Greenish sputum.
Q. How wil you investigate the case?
A. The investigations are as follows:
  • Sputum for bacteriological and mycological examination
  • X-ray chest PA view
  • HRCT.
Q. What are the radiological findings?
A. The radiological findings are:
  • May be normal
  • Linear shadow (tramline)
  • Ring shadow
  • Multiple small cavities with or without fluid level.
Q. What is the definitive investigation for bronchiectasis?
A. High-resolution CT scan is the definitive investigation for bronchiectasis.
Q. What are the complications of bronchiectasis ?
A. The complications are as follows:
  • Infection—pneumonia, pleurisy, pleural effusion or empyema (common organisms are Staphylococcus aureus, Haemophilus influenzae, Pseudomonas aeruginosa)
  • Lung abscess
  • Respiratory failure
  • Pulmonary hypertension and cor-pulmonale
  • Brain abscess
  • Amyloidosis.
Q. How will you treat bronchiectasis?
A. Treatments of brochiectasis are:
  • Postural drainage—keeping the affected side up and percuss over the affected part with cupped hand
  • Antibiotic if infection— amoxicillin commonly used
  • Chest physiotherapy
  • Inhaled bronchodilators and corticosteroids if airflow obstruction
  • Surgical treatment—lobectomy, heart lung transplantation.
Q. What is postural drainage?
A. Coughing maintaining position of the body to keep affected part of lung up and clab with cupped hand.
Q. What are the indications of surgery?
A. Indications of surgery are:
  • Young patient
  • Unilateral and localized to a single lobe or segment.
 
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
 
Scenario
Cough and breathlessness.
 
Instruction
  • Examine the chest
  • Examine the chest from front.
 
Proceed as Follows
  1. Address the patient as your custom “Hi, Hello, Assalamu alaykum” and introduce yourself and tell your role.
  2. Maintain 3Ps (Permission, Position and Proper exposure).
  3. Look at the patient (from head to toe) and surroundings, and spend a few seconds to get any clue, e.g. breathless at rest, tachypnea, O2 cylinder at bed side, sputum pot, inhaler device, pursed lip breathing.
    Note: The patient is breathless at rest, tachypneic and has pursed lip breathing.
  4. Inspect the chest from side and head or foot end and observe shape, suprasternal and supraclavicular recession, prominent accessory muscles of respiration, intercostal indrawing, subcostal recession, movement, and any other abnormality.
    Note: This patient has barrel chest, intercostal indrawing and diminished movement on both sides.
  5. Palpate the trachea to ascertain its position. Palpate apex beat and assess expansibility and vocal fremitus. Measure cricosternal distance (normal 3 cm) and tracheal tug.
    36Note: This patient has trachea in central position but cricosternal distance is reduced, apex beat is impalpable and symmetrically reduced expansibility on bothsides.
    Causes of bilateral reduced movement and expansibility—see Box 1.13.
  1. Percuss chest along midclavicular and midaxillary line and notice percussion note, presence of normal cardiac and liver dullness.
    Note: Percussion note is hyperresonant on both sides and liver and cardiac dullness are obliterated.
  2. Auscultate chest along midclavicular and midaxillary line and listen breath sound and any added sounds. Assess vocal resonance.
    Note: Breath sound is vesicular with prolonged expiration and low or medium pitched rhonchi and few crepitations which altered after coughing.
    Causes of vesicular breath sound with prolonged expiration— see Box 1.14.
  1. Measure forced expiratory time (FET): Ask the patient to take a deep breath in and then breathe out as hard and fast as he/she can untill the lungs are empty. Normally a person should be able to empty the lungs in less than 6 seconds. An FET >6 seconds demonstrates airflow obstruction.
  2. Examine back of the chest by inspection, palpation, percussion and auscultation.
  3. Do the relevant examinations: Congested eyes (polycythemia), cyanosis, nicotine stain (smoking), clubbing (absence—important negative sign), flapping tremor (type II respiratory failure), temperature (infective exacerbation), and features of corpulmonale (palpable and loud P2, raised JVP, enlarged tender liver and pitting pedal edema).
 
Schematic Diagnosis
Chest examination
Inspection
↓ movement on both sides (pathology on both sides)
Palpation
Trachea central, apex beat impalpable and ↓ expansibility on both sides (COPD, asthma, ILD)
Percussion
Hyperresonant on both sides with obliteration of liver and cardiac dullness (COPD, asthma)
Auscultation
Vesicular breath sound with prolonged expiration and low- or medium-pitched rhonchi (COPD)
Presence of pursed lip breathing, nicotine stain and reduced cricosternal distance support diagnosis of COPD.
Final diagnosis
Chronic obstructive pulmonary disease
Q. Present your case?
A. This patient is breathless at rest. There is pursed lip breathing, nicotine staining but no clubbing and flapping tremor. JVP is not elevated. Chest is barrel shaped, movement and expansibility are symmetrically reduced, trachea is central with a reduced cricosternal distance but apex beat is impalpable. The percussion note is hyperresonant throughout both lung fields, obiterating the carciac and liver dullness. The breath sound is vesicular with prolonged expiration. There are low- or medium-pitched rhonchi and few crepitations. There is no evidence of corpulmonale. The forced expiratory time (FET) is greater than 6 seconds.
Q. What is your diagnosis?
A. Chronic obstructive pulmonary disease (COPD).
Q. How can you define COPD, chronic bronchitis, and emphysema?
A. These are as follows:
  • COPD: Progressive and irreversible (or partially reversible) airflow obstruction due to chronic bronchitis or emphysema
  • Chronic bronchitis: Cough productive of sputum on most days for successive 3 months during 2 consecutive years (a clinical diagnosis)
  • Emphysema: Abnormal and permanent enlarge-ment of air spaces distal to the terminal bronchioles 37 associated with destruction of their walls without obvious fibrosis (a pathological diagnosis)
Q. How can you define airflow abstruction?
A. Airflow obstruction is defined as FEV1 80% predicted and FEV1/FVC 70%.
Q. What are differences between chronic bronchitis and emphysema?
A. Differences between chronic bronchitis and emphysema:
Feature
Chronic bronchitis
Emphysema
Diagnosis
A clinical diagnosis
A pathological diagnosis
Appearance
Blue bloater
Pink puffer
Cyanosis
Prominent
Absent
Hyperinflation
+
++
Dyspnea
+
++
Cor-pulmonale
++
+
Inspiratory drive
Reduced
Present
Further discussion—Read long case ‘COPD’.
 
INTERSTITIAL LUNG DISEASE
 
Scenario
Progressive breathlessness.
 
Instruction
  • Examine the chest
  • Examine the chest from back.
 
Proceed as Follows
  1. Address the patient as your custom “Hi, Hello, Assalamu alaykum” and introduce yourself and tell your role.
  2. Maintain 3Ps (Permission, Position and Proper exposure).
  3. Look at the patient (from head to toe) and surroundings, and spend a few seconds to get any clue, e.g. breathless at rest or minimal exertion, O2 cylinder at bed side, inhaler device, rheumatoid hands, tight shiny skin of face and pinced nose (systemic sclerosis).
    Note: The patient is breathless on minimal exertion.
  4. Inspect the chest from side and head or foot end and observe shape, movement, and any other abnormality. Note: This patient has symmetrically diminished movement on both sides.
  5. Palpate the trachea to ascertain its position. Palpate apex beat and assess expansibility and vocal fremitus. Measure cricosternal distance (normal 3 cm).
    Note: This patient has trachea and apex beat in normal position, cricosternal distance is not reduced and symmetrically reduced expansibility on both sides.
  6. Percuss chest along midclavicular and midaxillary line and notice percussion note, presence of normal cardiac and liver dullness.
  7. Auscultate chest along midclavicular and midaxillary line and listen breath sound and any added sounds. Assess vocal resonance.
  8. Examine back of the chest by inspection, palpation, percussion and auscultation.
    Note: The percussion note is dull and vocal fremitus is reduced at both bases. On auscultation, there are fine end inspiratory crackles at both bases which do not alter after coughing. Causes of end inspiratory crepitations—see Box 1.15.
  1. Do the relevant examinations: Cyanosis (central and peripheral), nicotine stain, clubbing, purpura (steroid), smooth shiny and tight skin of face, sclerodactyly, atrophic nails, and evidence of Raynauds phenomenon, rheumatoid hands, lymph nodes (sarcoidosis), and features of corpulmonale (palpable and loud P2, right parasternal heave, raised JVP, enlarged tender liver and pitting pedal edema). NB. This patient has clubbing and central cyanosis. Causes of clubbing with cyanosis—see Box 1.16.
 
Schematic Diagnosis
Chest examination
Inspection
↓ movement on both sides (pathology on both sides)
Palpation
Trachea, apex beat normal in position and ↓ expansibility on both sides (COPD, asthma, ILD)
Percussion
Normal in front but percussion note is dull and vocal fremitus is reduced at both bases (ILD)
38
Auscultation
Normal vesicular breath sound and fine end inspiratory crackles at both bases which do not alter after coughing (ILD)
Presence of clubbing and central cyanosis support diagnosis of ILD
Final diagnosis
Interstitial lung disease
Q. Present your case?
A. This patient is breathless on minimal exertion. There is clubbing and central cyanosis. JVP is not elevated. Chest movement and expansibility are symmetrically reduced, trachea and apex beat are normal in position. The percussion note is dull and vocal fremitus is reduced at both bases. On auscultation, there are fine end inspiratory crackles at both bases which do not alter after coughing. There is no evidence of pulmonary hypertension.
Q. What is your diagnosis?
A. Interstitial lung disease (ILD).
Q. What are the causes of chronic interstitial lung disease?
A. The causes of interstitial lung disease are:
  • Idiopathic pulmonary fibrosis (cryptogenic fibrosing alveolitis)
  • Rheumatological diseases:
    • Rheumatoid arthritis
    • Systemic sclerosis
    • Systemic lupus erythematosus (SLE)
    • Polymyositis
    • Dematomyositis
    • Mixed connective tissue disease
    • Ankylosing spondylitis.
  • Eosinophilic lung disease
    • Drugs (nitrofurantoin imipramine, and sulphasalazine)
    • Aspergillosis.
  • Inhaled agents
    • Extrinsic allergic alveolitis
    • Silicosis, bryliosis.
  • Drugs: Amiodarone, nitrofurantoin, busulphan, bleomycin, methotrexate
  • Radiation fibrosis
  • Sarcoidosis
  • Vasculltis—polyarteritis nodosa, Churg-Strauss syndrome, etc.
Q. Why does end-inspiratory crepitation occur in interstitial lung disease?
A. In interstitial lung disease, alveoli remain collapsed. During forceful inspiration, sudden opening of collapsed alveoli produces crepitations at the end of respiration.
Q. How can you differentiate from that of left ventricular failure?
A. In left ventricular failure, end-inspiratory crepitation alters after coughing but that of ILD does not.
Q. How will you investigate a patient with interstitial lung disease?
A. These are as follows:
  • Blood tests
    • FBC with ESR
    • Rheumatoid factor
    • Autoimmune profile [ANA, ENA (extractable nuclear antigen), ANCA (anti-neutrophil cytoplasmin antibody), anti-GBM (anti- glomerular basement membrane antibody)]
    • Immunoglobulins
    • Creatine kinase
    • Precipitins
    • Serum ACE
  • Arterial blood gas analysis
    Type 1 respiratory failure
  • X-ray chest PA veiw
    • Bilateral basal reticulonodular infiltrates
    • In advanced cases, marked destruction of the lung parenchyma giving rise to a honeycomb appearance
    • Bilateral hilar lymphadenopathy (sarcoidosis)
    • Calcified pleural plaques (asbestosis).
  • Lung function tests
    • Reduction in lung volumes [total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV)]
    • Restrictive pattern of defect [forced expiratory volume/forced vital capacity (FEV1/FVC) >70%]
    • Reduced gas transfer factor and gas transfer coefficient.
  • High-resolution computed tomography (HRCT)
  • Magnetic resonance imaging (MRI)
  • Bronchoalveolar lavage
  • Lung biopsy
    • Fibreoptic bronchoscopy with transbronchial lung biopsy (berylliosis, silicosis, sarcoidosis, hypersensitivity pneumonitis, lymphangitis carcinomatosa)
    • Video-assisted thoracoscopic lung biopsy/open lung biopsy (idiopathic pulmonary fibrosis, connective tissue disease, vasculitis, histiocytosis).
Q. How would you mange this patient?
A. Management includes:
  1. General measures:
    • Smoking cessation
    • 39Removal of underlying cause:
      • Discontinuation of offending drugs
      • Remove from inhalational exposure
    • Treatment of respiratory infections promptly
    • Long-term oxygen therapy.
  2. Immunosuppressive therapy
    • All patients should receive a course of oral steroid if no contraindications (prednisolone 40 mg daily for 6 weeks)
    • If the response is good, then continue. Optimal duration of therapy is not known, but treatment for 1–2 years is suggested
    • If response to steroids is not good, then discontinue and taper over 1 week
    • In steroid non-responders, azathioprine, methotrexate, or cyclophosphamide may be used.
  3. Anti-fibrotic therapy
    • Colchicine and D penicillamine may be used in specific cases including idiopathic pulmonary fibrosis.
  4. Surgery
    • Single or double lung transplantation in advanced disease.
Q. What are the complications of interstitial lung disease?
A. Complications of interstitial lung disease are as follows:
  • Respiratory failure
  • Pulmonary hypertension
  • Cor-pulmonale
  • Chest infection
  • Carcinoma of the lung.
Q. What is the prognosis?
A. The clinical course is unpredictable. The median survival is 3–5 years from the onset of symptoms.
Q. What do you know about the ATS/ERS classification for idopathic pulmonary fibrosis?
A. The ATS/ERS classification for idopathic pulmonary fibrosis is:
  • Acute interstitial pneumonia (AIP)
  • Usual interstitial pneumonia (UIP)
  • Nonspecific interstitial pneumonia (NSIP)
  • Desquamative interstitial pneumonia (DIP)
  • Lymphoid interstitial pneumonia (LIP)
  • Respiratory bronchiolitis-interstitial lung disease (RB-ILD)
  • Cryptogenic organizing pneumonia (COP).