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Symptoms: dyspnoea (graded by the mMRC scale), cough (acute, chronic over 8 weeks), sputum (purulent in infection or bronchiectasis), haemoptysis (cancer, tuberculosis, bronchiectasis, pulmonary embolism), wheeze and pleuritic chest pain. Examination: inspection (respiratory rate, use of accessory muscles, cyanosis, clubbing), palpation (tactile fremitus), percussion (dull in consolidation and effusion; hyperresonant in emphysema and pneumothorax) and auscultation (vesicular breath sounds; wheeze in airway narrowing; crackles in fluid, fibrosis or pneumonia; bronchial breathing in consolidation; absent sounds in effusion or pneumothorax).

Spirometry: FEV1, FVC and FEV1/FVC. Obstructive pattern: FEV1/FVC below 0.70 (asthma, COPD, bronchiectasis); reversibility after bronchodilator is characteristic of asthma. Restrictive pattern: reduced FVC and total lung capacity with normal or high ratio (interstitial and chest wall disease). Diffusing capacity for carbon monoxide (DLCO) is reduced in emphysema, fibrosis and pulmonary vascular disease. Peak flow shows variability in asthma. Arterial blood gas: PaO2, PaCO2, pH and bicarbonate identify respiratory failure and acid-base disturbance. Pulse oximetry gives SpO2 (below 90 percent is significant hypoxaemia). Six-minute walk test measures exercise tolerance.

1. Which percussion note is found in pleural effusion? 2. Define obstructive spirometry. 3. What does DLCO measure? 4. Which breath sound indicates consolidation?

1. Stony dullness. 2. FEV1/FVC below 0.70. 3. The efficiency of gas transfer across the alveolar-capillary membrane. 4. Bronchial breathing.

Definition: chronic inflammatory airway disease with variable symptoms (wheeze, breathlessness, chest tightness, cough) and variable expiratory airflow limitation. Phenotypes: allergic (type 2 eosinophilic), non-allergic, exercise-induced, occupational, aspirin-exacerbated. Diagnosis: history plus documented variability: bronchodilator reversibility (FEV1 rise of 12 percent and 200 mL), peak flow variability, bronchial challenge, exhaled nitric oxide and eosinophils. Treatment: inhaled corticosteroid-containing regimens (ICS-formoterol as needed or maintenance), add-on LABA, LAMA, leukotriene antagonists, and biologics (omalizumab, mepolizumab, benralizumab, dupilumab) in severe asthma; trigger avoidance, inhaler technique and written action plan.

Diagnosis: post-bronchodilator FEV1/FVC below 0.70 with exposure history (smoking). Assessment: symptom scores (mMRC, CAT) and exacerbation history (GOLD A, B, E groups). Management: smoking cessation, vaccination (influenza, pneumococcus), LAMA/LABA dual bronchodilation as the mainstay, adding an ICS if eosinophils are 300 per microlitre or more or there are frequent exacerbations, pulmonary rehabilitation, long-term oxygen if PaO2 is 55 mmHg or below, non-invasive ventilation for chronic hypercapnia, lung volume reduction and transplantation in selected patients. Exacerbation: bronchodilators, prednisolone for 5 days, antibiotics if purulent sputum, oxygen titrated to 88-92 percent.

Causes: post-infectious, cystic fibrosis, primary ciliary dyskinesia, immunodeficiency, allergic bronchopulmonary aspergillosis, tuberculosis and obstruction. Features: chronic productive cough with large volumes of purulent sputum, recurrent infections, haemoptysis; crackles and clubbing. Diagnosis: HRCT (signet ring sign: bronchus wider than its accompanying artery, tram-track lines). Colonisation with Pseudomonas aeruginosa worsens prognosis. Treatment: airway clearance physiotherapy, antibiotics for exacerbations, long-term macrolides or inhaled antibiotics in frequent exacerbators, treatment of the cause.

1. State the criteria for bronchodilator reversibility. 2. What is the mainstay of COPD pharmacotherapy? 3. Which oxygen saturation target is used in COPD exacerbations? 4. What is the HRCT sign of bronchiectasis?

1. FEV1 rise of at least 12 percent and 200 mL. 2. LAMA/LABA dual bronchodilation (ICS added if eosinophilic or frequent exacerbations). 3. 88-92 percent. 4. Signet ring sign (bronchus larger than the accompanying artery) and tram-tracks.

ILD comprises more than 200 conditions: idiopathic (IPF, non-specific interstitial pneumonia), connective tissue disease-related, hypersensitivity pneumonitis, sarcoidosis, drug-induced and occupational (asbestos, silica). Evaluation: history of exposure and drugs, examination (fine bibasal crackles, clubbing), spirometry (restrictive, low DLCO), HRCT (UIP pattern: subpleural honeycombing and traction bronchiectasis), autoimmune serology, bronchoalveolar lavage and biopsy if needed. IPF: progressive fibrosis, median survival 3-5 years; antifibrotics (nintedanib, pirfenidone) slow decline; transplantation.

Signs: dullness, reduced breath sounds, reduced tactile fremitus, blunted costophrenic angle on X-ray; ultrasound guides sampling. Transudates: heart failure, cirrhosis, nephrotic syndrome. Exudates (Light criteria): infection (parapneumonic, empyema: pH below 7.2, low glucose, pus), malignancy (cytology positive; may need thoracoscopy), pulmonary embolism, tuberculosis (lymphocytes, high adenosine deaminase). Treatment: treat the cause, therapeutic drainage for symptoms, chest drain for empyema, pleurodesis or indwelling catheter for recurrent malignant effusion.

Type 1: hypoxaemia with normal or low PaCO2 (pneumonia, pulmonary oedema, ARDS, embolism). Type 2: hypercapnia with hypoxaemia (COPD, neuromuscular disease, obesity hypoventilation, drugs). Management: treat the cause; controlled oxygen; high-flow nasal oxygen; non-invasive ventilation for hypercapnic failure and cardiogenic oedema; intubation and mechanical ventilation, with lung-protective settings (low tidal volume) in ARDS and prone positioning in severe cases.

Community-acquired pneumonia: S. pneumoniae most common; atypicals; viruses. Diagnosis: symptoms, chest X-ray consolidation, CRP, blood cultures and urinary antigens in severe cases. Severity: CURB-65. Treatment: amoxicillin for mild disease, plus a macrolide for moderate and severe disease, 5-7 days. Hospital-acquired and ventilator-associated pneumonia involve Gram-negatives and MRSA. Complications: parapneumonic effusion, empyema, lung abscess, sepsis.

Types: adenocarcinoma, squamous cell carcinoma, small cell lung cancer. Presentation: cough, haemoptysis, dyspnoea, weight loss, recurrent pneumonia, paraneoplastic syndromes (SIADH, hypercalcaemia, Lambert-Eaton), superior vena cava syndrome, Pancoast tumour. Diagnosis: CT, bronchoscopy or CT-guided biopsy, PET-CT, mediastinal staging (EBUS). Treatment: surgery (early NSCLC), chemoradiotherapy, targeted therapy for EGFR, ALK, ROS1 mutations, immunotherapy (PD-1/PD-L1 inhibitors); limited-stage small cell cancer treated with chemoradiation. Screening with low-dose CT in high-risk smokers reduces mortality.

1. What HRCT pattern defines IPF? 2. How do you distinguish a transudate from an exudate? 3. Name the two types of respiratory failure. 4. Which targeted therapies are used in lung adenocarcinoma? 5. What antibiotic is first-line for mild community-acquired pneumonia?

1. Usual interstitial pneumonia pattern: subpleural honeycombing and traction bronchiectasis. 2. Light criteria: pleural/serum protein above 0.5, pleural/serum LDH above 0.6, or pleural LDH above two thirds of the upper serum limit indicates an exudate. 3. Type 1 (hypoxaemic) and type 2 (hypercapnic). 4. EGFR, ALK and ROS1 inhibitors. 5. Amoxicillin.