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• In idiopathic pulmonary fibrosis, lung expansion (and therefore FVC) and lung elasticity (and therefore FEV1) are reduced, leading to a normal or increased FEV1/FVC ratio. There is reduced diffusion per alveolar volume, hence the reduced transfer factor and transfer coefficient.
• Cystic fibrosis is a restrictive lung disease with reduced transfer factor due to incomplete alveolar expansion, but a normal transfer coefficient as it corrects for alveolar volume.
• Common causes of lobar collapse include:

  • lung cancer (the most common cause in older adults)
  • asthma (due to mucous plugging)
  • foreign body

  The general signs of lobar collapse on a chest x-ray are as follows:

  • tracheal deviation towards the side of the collapse
  • mediastinal shift towards the side of the collapse
  • elevation of the hemidiaphragm
• Mesothelioma is a cancer of the pleura due to asbestos exposure
• Adenocarcinoma of the lung is associated with gynaecomastia.
• Squamous cell lung cancers can secrete parathyroid hormone-related peptide which causes hypercalcaemia.
• Lung cancer: paraneoplastic features

  Small cell

  • ADH
  • ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc
  • Lambert-Eaton syndrome

  Squamous cell

  • parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia
  • clubbing
  • hypertrophic pulmonary osteoarthropathy (HPOA)
  • hyperthyroidism due to ectopic TSH

  Adenocarcinoma

  • gynaecomastia
  • hypertrophic pulmonary osteoarthropathy (HPOA)
• Ciprofloxacin may be used in the management of hospital-acquired pneumonia.Co-amoxiclav is used to treat hospital-acquired pneumonia. Doxycycline is used to treat community acquired pneumonia.Flucloxacillin is used in staphylococci suspected community-acquired pneumonia.
• Respiratory alkalosisCommon causes

  • anxiety leading to hyperventilation
  • pulmonary embolism
  • salicylate poisoning (mixed respiratory alkalosis and metabolic acidosis)
  • CNS disorders: stroke, subarachnoid haemorrhage, encephalitis
  • altitude
  • pregnancy
• Parallel line shadows (often called tram-lines) are common in bronchiectasis and indicate dilated bronchi due to peribronchial inflammation and fibrosis.
• Syncope from aortic stenosis is usually exertional. It is associated with a poor prognosis. It is usually thought to be secondary to the heart producing a nearly fixed cardiac output due to the narrowness of the aortic valve.
• Heart failureA history of ischaemic heart disease or hypertension may be presentOrthopnoea and paroxysmal nocturnal dyspnoea are characteristicBibasal crackles and a third heart sound (S3) are the most reliable features of left-sided failureRight heart failure causes peripheral oedema and a raised JVP
• Chronic obstructive pulmonary disease Seen invariably in smokersChronic productive cough is typicalFeatures of right heart failure may be seen
• Asthma Cough, wheeze and shortness of breath are typicalSymptoms are often worse at night and may be precipitated by cold weather or exerciseAssociated with hay fever and eczema
• Aortic stenosis Chest pain, SOB and syncope seen in symptomatic patientsAn ejection systolic murmur radiating to the neck and narrow pulse pressure are found on examination
• Recurrent pulmonary emboli There may be a history of predisposing factors e.g. Malignancy. Pleuritic chest pain and haemoptysis may be seen but symptoms are often vague. Tachycardia and tachypnoea are common in the acute situation. Symptoms of right heart failure may develop in severe cases
• Lung cancer Normally seen in smokersHaemoptysis, chronic cough or unresolving infection are common presentationsSystemic symptoms e.g. Weight loss and anorexia
• Pulmonary fibrosis Progressive shortness of breath may be the only symptomFine bibasal crackles are typicalSpirometry shows a restrictive pattern
• Bronchiectasis Affected patients may produce large amounts of purulent sputumPatients may have a history of previous infections (e.g. Tuberculosis, measles), bronchial obstruction or ciliary dyskinetic syndromes e.g. Kartagener's syndrome
• Anaemia There may be a history of gastrointestinal symptomsPallor may be seen on examination
• The main 2 indications for surgery in bronchiectasis are uncontrollable haemoptysis and localised disease.
• All adults suspected to have asthma should have both spirometry with a bronchodilator reversibility test and a fractional exhaled nitric oxide (FeNO) test. A negative result on spirometry does not exclude asthma as a diagnosis and should be further investigated.
• Severe asthma would have a PEFR of 33-50% of best or predicted. Life-threatening asthma would have a PEFR of less than 33% of best or predicted. Near-fatal asthma does not use PEFR in its classification. Instead, it is classified as an increased PaCO2 level and the need for critical care support (i.e. mechanical ventilation).
• An increased concentration of haematocrit also known as polycythaemia can occur due to long-term hypoxia that is present in COPD. This results in increased erythropoietin production by the kidneys causing haemoglobin levels to rise.
• A reduced platelet count, known as thrombocytopenia, has many causes including decreased production (e.g. vitamin B12 or folic acid deficiency), increased destruction (e.g. disseminated intravascular coagulation) or as a side effect of medication (e.g. methotrexate).
• A raised platelet count, known as thrombocythemia, can be caused by infection, malignancy or any form of inflammation.
• A reduced white cell count, known as leukopenia, can be caused by acute infection or more serious things like HIV or malignancy.
• A reduced concentration of haemoglobin, known as anaemia, has many causes including iron deficiency or vitamin B12 or folic acid deficiency.
• Acute pancreatitis is known to precipitate ARDS. ARDS is characterised by bilateral pulmonary infiltrates and hypoxaemia. Note that pulmonary oedema is excluded if there is normal pulmonary capillary wedge pressure.
• Silicosis is a chronic lung disease caused by inhaling large amounts of silica dust over many years. Dyspnoea, dry cough and chest x-ray findings of upper lobe shadowing and egg-shell calcification of hilar nodes are features of silicosis. Miners are especially at risk of inhaling silica dust, the cause of silicosis.
• Asbestosis is a lung condition caused by prolonged exposure to asbestos. Nowadays, people most at risk are in construction trades, such as demolition workers, plumbers and electricians. Symptoms of asbestosis include cough, shortness of breath, wheezing and fatigue; chest x-ray may show opacities with a fine reticular or a honeycomb appearance, typically in the lower lobes.
• Hypersensitivity pneumonitis is inflammation and damage of the lungs caused by an allergic reaction to inhaled antigens such as fungi/mould, avian droppings/feathers, plant proteins or chemicals like paint hardener. Symptoms of hypersensitivity pneumonitis include cough, shortness of breath, tiredness and weight loss. There may be non-specific abnormalities on chest x-rays. In someone with hypersensitivity pneumonitis, you would expect to find a history of exposure to the aforementioned antigens.
• Idiopathic pulmonary fibrosis is lung fibrosis that occurs with no known cause. It can present with dyspnoea and cough however, fibrosis would predominantly be in the lower lung zones.
• Symptoms of lung cancer include cough, haemoptysis, dyspnoea, chest discomfort, weight loss and fatigue. Primary lung cancer typically appears as a unilateral mass on a chest x-ray.
• Small cell lung cancers can be responsible for independent secretion of ACTH, causing Cushing's syndrome, causing central weight gain, buffalo hump, moon facies and skin thinning. Small cell lung cancers are frequently responsible for paraneoplastic syndromes including syndrome of inappropriate ADH secretion (SIADH), Lambert-Eaton syndrome and Cushing's syndrome.
• Cushing's syndrome occurs due to hypercortisolism, and the most common cause is exogenous corticosteroid administration. The term Cushing's disease is reserved for cases involving an ACTH-secreting pituitary adenoma.
• Adenocarcinoma is not associated with paraneoplastic Cushing's syndrome but has been associated with hypertrophic osteoarthropathy (HPOA).
• Mesothelioma has been associated with asbestos exposure, and may cause symptoms of restrictive lung disease.
• Squamous cell carcinoma is associated with the paraneoplastic syndrome relating to hypercalcaemia of malignancy, due to its secretion of parathyroid hormone-related peptide (PTHrP)
• Symptoms of suspected asthma


  • Family history of atopy
  • Wheeze
  • Shortness of breath
  • Dry cough at night