respiratory for paces
DESCRIPTION
Respiratory for PACES. Cases for finals Monday 8 th October 2012 Dr James Milburn Dr Chris Kyriacou. Outline. Signs to be seen in examination, both expected and miscellaneous Common cases we had/are to be expected in the exam Hx and Ex Ix Mx. Respiratory Exam. End of bed inspection - PowerPoint PPT PresentationTRANSCRIPT
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Respiratory for PACES
Cases for finals
Monday 8th October 2012
Dr James Milburn
Dr Chris Kyriacou
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Outline• Signs to be seen in examination, both expected
and miscellaneous• Common cases we had/are to be expected in the
exam– Hx and Ex
– Ix
– Mx
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Respiratory Exam• End of bed inspection• General Exam• Chest
– Inspection– Palpation– Percussion– Auscultation
• Added extras
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Inspection (End of bed)
• Observe patient – breathless/comfortable• Look at surroundings –
inhaler/oxygen/nebulisers etc• Use of accessory muscles• Cachexic
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General Examination
• Hands
• Face
• Neck
• Legs
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Hands
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Hands
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Hands
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Hands
• Clubbing– Bronchiectasis, CF, Carcinoma, Fibrosing alveolitis– 4 signs - FACE
• Flucance of nail bed• Angle loss• Curvature of nail• Expansion of terminal phalynx
• Tar staining• Small muscle wasting
– Lung Ca pressure on brachial plexus
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Hands
• HPOA– Periosteal inflammation in distal ends of long bones– Primary lung Ca, Meso
• Flap/Tremor– CO2 retention– Fine tremor from β2-agonists
• Pulse– Rate and rhythm– Bounding
• Cyanosis
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Face
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Face
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Face• Plethoric
– Secondary polycythaemia, SVC obstruction
• Horner’s (Ptosis, miosis, anhydrosis)– Pancoast’s, (Demyelination, Carotid aneurysm)
• Anaemia • Central cyanosis• Mouth – Halitosis/Thrush
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Neck
• Lymphadenopathy
• JVP
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Legs
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Inspection - Chest
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Inspection - Chest
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Inspection - Chest
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Inspection - Chest
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Inspection - Chest
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Inspection - Chest
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Inspection Chest
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Inspection - Chest
• Shape– Barrel-chested (AP>Lateral)– Excavatum/Carinatum
• Scars• Dilated veins• Ask them to take deep breath
– Reduced expansion– Symetrical
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Palpation
• Trachea
• Apex
• Expansion
• Vocal fremitus
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Percussion
• Flat – Pleural effusion (thigh)• Dull – Lobar pneumonia (liver)• Resonant• Hyper-resonant – Emphysema/Pneumothorax• Tympany – Large pneumothorax (puffed out cheek)
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Auscultation
• Crackles– Nature of crackles
• Fine – Oedema/Fibrosis (velcro)• Coarse – Bronchiectasis
– Timing• Early insp – COPD/Bronchitis• Mid-late – Fibrosis/Oedema
– Clear on coughing? • Yes - ?bronchiectasis• No – Fibrosis/Oedema
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Auscultation
• Wheeze– Inspiratory/Expiratory– Fixed monophonic - Bronchial Ca– Polyphonic - Asthma
• Pleural rub• Vocal resonance
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Auscultation
• Breath sounds– Vesicular – Insp longer than exp– Bronchial – Exp longer than insp
• Causes of bronchial breath sounds– Consolidation– Collapse– Fibrosis
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Back of chest
• Repeat
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Added Extras to offer
• Sats• Temp chart• Sputum pot• PEFR• CVS exam
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Case 1
• Mrs Jones is 40 yr old women who presents with a chronic cough
• Please take a history
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History
• Cough for last 2 years although now worsening– No diurnal variation– No obvious exacerbating factors
• Productive of around ½-1 cupful of foul-smelling green sputum daily
• Occasional flecks of blood mixed in with sputum• Had 3 ‘chest infections’ in the last 6 months• No weight loss
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History
• 2 years ago could walk several miles with no SOB
• During exacerbation is <50yards• No fever/night sweats• No chest pain
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HistoryPMH,• Laparoscopic cholecystectomy 2007• Whooping cough ~1970
FH,• Nil of note
Drugs and Allergies, • Nil• NKDA
SH,• Legal secretary for last 15yrs no hx of asbestos exposure• Ex-smoker for 5 years in her 20’s• Minimal drinker• No pets• No recent travel
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Differentials
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Differentials
• Bronchiectasis– Most likely from pertussis as child– CF unlikely though screen in <40
• Chronic infection
• COPD – very unlikely without FH of α1-antitrypsin• TB – rule out, no foreign travel, no known exposure• Malignancy – rule out, no wt loss, non-smoker etc• Fibrosis – not dry cough, no occupational risk
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Examination
• On examination the patient was clubbed and had coarse inspiratory crackles bilaterally R>L
• Not dyspnoeic at rest and no use of accessory muscles.• A/E and expansion equal• No wheeze
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Investigations
• Bedside
• Bloods
• Imaging
• Special tests
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Bedside
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Bedside
• Sputum
• PEFR
• Sats
• Temperature
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Bloods
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Bloods
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Bloods
• FBC – Anaemia (chronic disease/haemoptysis)– Polycythaemia (secondary to hypoxia in more advanced
cases)– Raised WCC if infection– Eosinophilia if ABPA
• Inflammatory markers – ESR/CRP• U&E’s
– Renal dysfunction due to amyloid deposition• Serum immunoglobulins• Genotyping/Sweat test
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Imaging
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Imaging
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Imaging
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Imaging
• CXR– Flattened diaphragms
– Tramlines from thickened bronchial walls– Cystic shadows
• CT/HRCT– Signet rings– Bronchial wall thickening
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Management
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Management
• Conservative
• Medical
• Surgical
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Conservative
• Postural drainage• Chest physiotherapy• Pulmonary rehab• Oscillating positive expiratory devices
(Acapella)
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Medical
• Check for reversibility with β2-agonists• Saline nebs • Vaccinations
• Little/No role for:– Steroids (unless concurrent asthma/COPD)– Human Dnase– Leukotriene agoinsts– Methylxanthines
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Medical• Antibiotics
– Sputum sample before antibiotics– Choose abx depending on previous sensitivities– If previously cultured Pseudomonas need oral cipro or other IV
abx– Consider low dose macrolides if >3 exacerbations/year
• Macrolides have anti-inflammatory effect
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Surgical
• Indicated if localised disease or massive haemoptysis
• Lobectomy
• Pneumonectomy
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Viva-esque Questions
1. Main organisms responsible for infection in bronchiectasis?
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1. H.influezae, S.pneumoniae, Staph aureus, Pseudomonas, anaerobes
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Viva-esque Questions
1. Main organisms responsible for infection in bronchiectasis?
2. What are the main causes of bronchiectasis?
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1. H.influezae, S.pneumoniae, Staph aureus, Pseudomonas2. Congenital – CF, Kartagener’s, Young’s
Post-infection (childhood) – Measles, pertussis, TB, BronchiolitisPost-infection (adult) – Severe pneumonia, TBAutoimmune – RA, UCObstruction ( localised) – Tumour, Forgien body, lymph nodeIdiopathicImmunocomp – Primary hypogammaglobulinaemiaTraction bronchiectasis – Secondary to fibrosis
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Viva-esque Questions
1. Main organisms responsible for infection in bronchiectasis?
2. What are the main causes of bronchiectasis?
3. What are the complications of bronchiectasis?
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Viva-esque Questions
3. Infection
Respiratory failure
Brain abscess (haematogenous spread of infection)
Amyloidosis (renal failure)
Pneumothorax
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Viva-esque Questions
1. Main organisms responsible for infection in bronchiectasis?
2. What are the main causes of bronchiectasis?
3. What are the complications of bronchiectasis?
4. What is the definition of bronchiectasis?
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Viva-esque Questions
4. Persistent progressive condition characterised by dilated thick-walled bronchi. Typically >1.5x the diameter of the accompanying arteriole
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Viva-esque Questions
1. Main organisms responsible for infection in bronchiectasis?
2. What are the main causes of bronchiectasis?
3. What are the complications of bronchiectasis?
4. What is the definition of bronchiectasis?
5. What are the different morhpological subtypes of bronchiectasis
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Viva-esque questions
5. Cylindrical (uniform calibre and parallel walls)
Varicose (uncommon – bead like appearance)
Cystic (severe form where cyst like bronchi extend to pleural surface)
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6. What is Kartagner’s syndrome?
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6. Dextrocardia, Bronchiectasis, Chronic sinusitis
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Case 2
• Mr Singh has complained of shortness of breath
• Please take a history
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History
• Worsening over last 3 months• Now exercise tolerance <10 yards• Dry cough and pain on coughing• Sleeps with 3 pillows• No haemoptysis• No weight loss
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HistoryPMH,• HTN• DM• Hypercholesterolaemia
Drugs and allergies,• NKDA• Amlodipine• Indapamide• Metformin• Glicazide
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History
FH,• Nil of note
SH,• Ex-smoker (20 pack years)• Around 8 cans strong lager a day• No travel/pets• Lives with wife and 2 children
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Examination
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Examination
• Appears dyspnoeic at rest• Reduced chest expansion• B/L lower zone
– Stony dull to percussion– Absent breath sounds– Reduced vocal resonance
• No obvious signs of wt loss• No lymphadenopathy• No tracheal deviation
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Differentials
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Differentials
• Pleural effusion– Secondary to HF– Secondary to cirrhosis– Malignancy
• PE
• Fibrosis
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Investigations
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Bedside
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Bedside
• PEFR
• Sats
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Bloods
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Bloods
• FBC• BNP• U+E• LFTs • CRP• LDH• BNP• Thyroid Function Tests
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Imaging
• CXR
• Echo
• USS – for guiding drainage
• CT (with contrast)/CTPA if ?PE
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Imaging
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Imaging• CXR
– Blunting of costophrenic angles– If larger then opacity with concave upper margin –
Meniscus sign– Even bigger...complete white out +/- mediastinal shift– Elevated hemidiaphragm if subpulmonic effusion
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What is this....
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Pleural fluid analysis
• Transudate <25g/L protein• Exudate >35g/L• 25-35g/L
– Exudative if:• Ratio of pleural fluid to serum protein >0.5
• Ratio of pleural fluid to serum LDH >0.6
• Pleural fluid LDH > 2 thirds of the upper limits of normal serum value
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Pleural fluid analysis
• Glucose <3.3mmol/L– Malig/Ra/SLE/TB• pH <7.2 – Malig/Ra/SLE/TB• Increased LDH – Malig/Ra/SLE/TB• Increased amylase – pancreatitis/Carcinoma/Bacterial
pneumonia/Oesophageal rupture
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Management
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Management
• Conservative
• Medical
• Surgical
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Management
• Conservative
![Page 89: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/89.jpg)
Management
• Medical– BAD ALS (for management of heart failure)
• Β-blockers• ACEi• Digoxin• ARBs• Loop diuretics• Spirinolactone
– Pleurodesis – if malignant
![Page 90: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/90.jpg)
Management
• Surgical– Drainage
• Re-inflation oedema
– Pleurodesis
![Page 91: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/91.jpg)
Intercostal Space
Rib
IntercostalNerves and Vessels
Intercostal Muscles
Lung
Diaphragm
Fluid (or air) free in the pleural cavity
![Page 92: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/92.jpg)
Viva-esque questions
1. Complications of chest tube drainage
![Page 93: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/93.jpg)
Viva-esque questions
1. Organ damage
Lymphatic drainage chylothorax
Long thoracic nerve of bell
Rarely arrythmias
![Page 94: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/94.jpg)
Viva-esque questions
2. What are the common causes of a exudative effusion
![Page 95: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/95.jpg)
Viva-esque questions
2. PRISM
PE
RA
Infection
SLE
Malignancy
![Page 96: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/96.jpg)
Viva-esque questions
3. What are the common causes of transudative effusions
![Page 97: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/97.jpg)
Viva-esque questions
3. ‘The failures’Cardiac failureNephrotic syndromeCirrhosisFailure to eat – Malabsorption
![Page 98: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/98.jpg)
Viva-esque questions
4. How big does an effusion have to be before it can be seen on CXR
![Page 99: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/99.jpg)
4. 175-200mls blunting of C-P angle
![Page 100: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/100.jpg)
Case 3
• Mrs Smith is a 30 year old female who has come in with a long standing cough
• Please take a history
![Page 101: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/101.jpg)
History
• Cough for last 6 months, remained relatively constant
• Unproductive of any sputum or blood
• She says she has a constant ‘tightness of the chest’
• Begun to notice some weight loss
![Page 102: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/102.jpg)
History
• Since the cough began, she has felt more lethargic with polyarthralgia
• Has recently begun to feel breathless, even at rest
• Chest pain noted – central, constant, throbbing, relieved by paracetamol
• Noticed that her eyes feel very itchy and dry
![Page 103: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/103.jpg)
HistoryPMH,• Recurrent conjunctivitis – 2011-12
FH,• Nil of note
Drugs and Allergies, • Nil• NKDA
SH,• Minimal drinker and non smoker• No pets, No recent travel• Work - waitress
![Page 104: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/104.jpg)
Differentials
![Page 105: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/105.jpg)
Differentials
• Sarcoidosis– Young, female– Past history of non-pulmonary manifestation of sarcoid– Cause of apical pulmonary fibrosis
• Malignancy – rule out as weight loss noted, but non smoker, young
• Extrinsic allergic alveolitis – no occupational exposure• TB – another cause of pulmonary fibrosis – but no foreign
travel
![Page 106: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/106.jpg)
Examination
![Page 107: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/107.jpg)
• Lupus pernio– Dusky– Purple– Face, Fingers, Feet
![Page 108: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/108.jpg)
• Inspection– Plaques noted on skin
• Percussion, Palpation – N
• Auscultation– End inspiratory– Fine crackles– APICAL
![Page 109: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/109.jpg)
• Erythema nodosum– Panniculitis
![Page 110: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/110.jpg)
Viva-esque questions
1. What is sarcoidosis?
![Page 111: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/111.jpg)
Viva-esque questions
• 1. A Multisystem, granulomatous disease– Of unknown cause– Scattered collections of granulomas
• Mixed inflammatory cells• Non-caseating, epithelioid
![Page 112: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/112.jpg)
Viva-esque questions
• 2. What % of patients with sarcoidosis have pulmonary involvement?
![Page 113: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/113.jpg)
Viva-esque questions
• 2. 90%– Bilateral hilar lymphadenopathy– Pulmonary infiltrates– Fibrosis
![Page 114: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/114.jpg)
Viva-esque questions
• 3. What are the causes of APICAL pulmonary fibrosis?
![Page 115: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/115.jpg)
Causes of apical pulmonary fibrosis
• B – Borelliosis• R – Radiation• E – Extrinsic allergic alveolitis• A – Ankylosing spondylitis• S – Sarcoid• T – Tuberculosis
![Page 116: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/116.jpg)
Case 4
• Mrs Jenkins is a 65 year old female who has noticed she gets breathless after walking 50 yards
• Please take a history
![Page 117: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/117.jpg)
History
• Her breathlessness was first noted 6 months ago, which began after walking 500 yards
• Over the last 2 months this has reduced to 50 yards
• Chronic cough for about 2 years– Productive of white sputum
• Always has pain in both her hands, but she puts it down to ‘everyday wear and tear’. Has not sought medical attention
![Page 118: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/118.jpg)
HistoryPMH,• Hypertension• Hypercholesterolaemia
FH,• Mother ‘suffered from arthritis’
Drugs and Allergies, • Amlodipine• Simvastatin• NKDA
SH,• Minimal drinker and non smoker• Has 2 cats• No recent travel• Work – retired lawyer
![Page 119: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/119.jpg)
Differentials
![Page 120: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/120.jpg)
Differentials
• Rheumatoid arthritis– Older female– Bilateral long standing small joint arthralgia– Cause of basal pulmonary fibrosis
• Malignancy – rule out as no weight loss noted, non smoker• Drug induced – worsening SOB not usually associated with
CCB and Statins• Scleroderma/CREST – no other extra-pulmonary signs noted• Asthma – highly unlikely for age, no diurnal variation
![Page 121: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/121.jpg)
Examination
![Page 122: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/122.jpg)
• PIP and MCP affected• Elbow nodules
• Auscultation– End inspiratory– Fine crackles– BASAL
![Page 123: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/123.jpg)
Viva-esque questions
• 1. What are the pulmonary complications of rheumatoid arthtitis?
![Page 124: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/124.jpg)
Pulmonary complications of RA
• Pleural effusion• Nodular lung disease• PULMONARY FIBROSIS• Pulmonary vasculitis• Alveolar haemorrhage• Obstructive pulmonary disease• Infection
![Page 125: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/125.jpg)
Viva-esque questions
• 2. What are the BASAL causes of pulmonary fibrosis?
![Page 126: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/126.jpg)
Causes of basal Pulmonary Fibrosis
• D – Drugs– ABC
• A – Asbestosis
• R – Rheumatoid arthritis
• S – Scleroderma/Systemic sclerosis
• I – Idiopathic pulmonary fibrosis
![Page 127: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/127.jpg)
Viva-esque questions
• 3. What three findings constitute Felty’s syndrome?
![Page 128: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/128.jpg)
PLUS Neutropenia
PLUS Rheumatoid arthritis
![Page 129: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/129.jpg)
Investigating Pulmonary fibrosis
![Page 130: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/130.jpg)
Bedside
• Sputum– ?TB – AFB
• Sats• Temperature• Resp rate
![Page 131: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/131.jpg)
Bloods
![Page 132: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/132.jpg)
Imaging
![Page 133: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/133.jpg)
Investigating?
![Page 134: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/134.jpg)
Special tests
• FEV1?
• FVC?
• FEV1/FVC ratio?
• Restrictive or obstructive?
• Why?
![Page 135: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/135.jpg)
Lung function
• FEV1 Reduced• FVC Reduced• FEV1/FVC ratio same or increased• Restrictive• Why? Decreased lung compliance• Other causes: Obesity, pregnancy, air trapping in COPD (mixed
picture), paralysis/muscle weakness
![Page 137: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/137.jpg)
Management
![Page 138: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/138.jpg)
Management
• Conservative
• Medical
• Surgical
![Page 139: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/139.jpg)
Conservative
• Oxygen support
• Pulmonary rehab
![Page 140: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/140.jpg)
Medical
• Corticosteroids– Low dose prednisolone
• Months in duration• N-Acetylcisteine• Sildenafil• Pirfenidone
![Page 141: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/141.jpg)
Surgical
• Lung transplant– Dependant on
• Severity of pulmonary fibrosis• Patient health• Potential improvement
![Page 142: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/142.jpg)
Case 5
• Mr Patel is a 75 year old male with long term shortness of breath
• Take a history
![Page 143: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/143.jpg)
History• SOB began 15 years ago, and has been worsening gradually
since
• Now SOB at rest, although previously only on exertion
• Associated chesty cough– Productive of ++ sputum– With associated wheeze
• No weight loss
![Page 144: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/144.jpg)
HistoryPMH,• Nil relevant
FH,• Nil of note
Drugs and Allergies, • Salbutamol• Seretide (salmeterol + fluticasone)• NKDA
SH,• Started smoking at 25• Continues to smoke 20 a day• Drinker in the past, now quit
![Page 145: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/145.jpg)
Differentials
![Page 146: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/146.jpg)
Differentials
• COPD– Progressive, irreversible airway obstruction
• Cough, SOB, Wheeze• Long term smoker
• Pneumonia – unlikely, as no acute pathology• Asthma – unlikely due to age and ++ sputum
![Page 147: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/147.jpg)
Examination
![Page 148: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/148.jpg)
• Inspection– Barrel chest– Use of accessory muscles– Raised RR
• Palpation– Reduced expansion
• Percussion– Hyper-resonance
• Auscultation– Quiet breath sounds
![Page 149: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/149.jpg)
Viva-esque questions
• 1. The term COPD constitutes chronic bronchitis and emphysema. How would you recognise each COPD subtype clinically?
![Page 150: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/150.jpg)
Chronic Bronchitis vs Emphysema
• Obesity• Frequent, productive
cough• Accessory muscle use• Rhonchi• Wheezing• Cor pulmonale signs
– Oedema– Cyanosis
• Thin, barrel chest• Little/no cough• PURSED LIP breathing
and accessory muscle use
• TRIPOD sitting position• Hyper-resonance• Wheezing• Quiet HS
![Page 151: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/151.jpg)
Investigations
![Page 152: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/152.jpg)
Bedside
• Sputum– Mucoid– Macrophages typically
• Sats• Temperature• Resp rate
![Page 153: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/153.jpg)
Bloods
• FBC– Raised PCV
• U+E– Na 147
• a1AT• BNP?
![Page 154: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/154.jpg)
ABG
• pH 7.40• PO2 8.3• CO2 5.2• BE +1• HCO3 23.4
![Page 155: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/155.jpg)
Investigations?
![Page 156: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/156.jpg)
Lung function
• FEV1?• FVC?• FEV1/FVC ratio?• Restrictive or obstructive?• Why?
![Page 157: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/157.jpg)
Lung function
• FEV1 low• FVC normal• FEV1/FVC ratio reduced, LESS than 0.7• Obstructive• Why? Decreased expiratory flow• Other causes? Asthma
![Page 158: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/158.jpg)
Investigations
![Page 159: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/159.jpg)
Management – Chronic COPD
![Page 160: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/160.jpg)
Conservative
• Smoking cessation– Education– NRT– Varenicline– Bupropion
• Physiotherapy
![Page 161: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/161.jpg)
Medical• Initial
– SABA (Salbutamol) or SAMA (Ipratropium) prn
• If SOB continues or 2+ exacerbations– FEV1 >50% (Mild COPD)
• Add LABA (Salmeterol) OR LAMA (Tiotropium)– If LAMA, STOP SAMA
– FEV1 <50% (Moderate-Severe COPD)• Add LABA/Steroid combo (Seretide – salmeterol + Flixotide; Symbicort – formeterol + beclomethasone)
• If exacerbations continue– Maximise inhaled therapy with LABA/steroid combo + LAMA + SABA
![Page 162: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/162.jpg)
Medical
• PO theophylline
• PO Carbocisteine
• ? Oral steroid trial
• ? Alpha tocopherol ? Beta carotene
![Page 163: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/163.jpg)
Viva-esque questions
• 2. When should long term oxygen therapy be considered in COPD?
![Page 164: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/164.jpg)
Long term oxygen therapy
• PaO2 <7.3• PaO2 7.3-8.0 AND
– Secondary polycythaemia– Nocturnal hypoxaemia – sats <90%– Peripheral oedema– Pulmonary hypertension
![Page 165: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/165.jpg)
LTOT
• Supplemental oxygen for at least 15hours per day
• Greater benefits if 20 hours per day
• Reduces hospital admissions and frequency of exacerbations
![Page 166: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/166.jpg)
Surgical
• Bullectomy
• LVRS
• Lung transplantation
![Page 167: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/167.jpg)
Acute exacerbations of COPD
![Page 168: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/168.jpg)
Investigations• Sputum
– Purulent– Neutrophils
• 3. What organisms commonly can cause an acute exacerbation of COPD?
![Page 169: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/169.jpg)
• S. pneumoniae• H. influenzae• M. catarrhalis• P. aeruginosa
![Page 170: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/170.jpg)
Investigations• Bloods
– FBC– U+E - ? Effect of theophylline– CRP
• ABG– pH 7.30– PO2 7– CO2 7.2– BE -10– HCO3 12
![Page 171: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/171.jpg)
Treatment - Exacerbations• Oxygen – sats 88-92% - why not higher?• Antibiotics
– Dependant on organism
• Nebulised bronchodilators• Oral Prednisolone, to continue as part of rescue package• IV aminophylline• NIV?
![Page 172: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/172.jpg)
Non invasive ventilation
• Persistent hypercapnic ventilatory failure– T2RF
• No response to medical therapy
• BIPAP can then be used
![Page 173: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/173.jpg)
Case 6
• Mr Baldwin is a 15 year old boy whose mother is worried about a longstanding cough
• Please take a history
![Page 174: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/174.jpg)
History
• Cough has lasted around 1 year, worse in the evenings and in the mornings
• Mr Baldwin has mentioned he feels a ‘band’ around his chest when he needs to cough, which is dry and hacking
• When this happens, it leaves him very breathless and wheezy
![Page 175: Respiratory for PACES](https://reader035.vdocuments.net/reader035/viewer/2022081506/568146b5550346895db3d822/html5/thumbnails/175.jpg)
History
• Also known to have hayfever and eczema, something that his father also suffers from
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Differentials
• Asthma– Cardinal features - Wheeze, SOB, Cough– Usually diurnal reversible and variable airflow obstruction– Associated atopy and family history
• Aspergillosis – unlikely as no trigger identified, not diurnal
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Examination
• Inspection– Raised RR
• Palpation– Hyperinflated chest
• Percussion– Hyper-resonance
• Auscultation– Expiratory polyphonic wheeze bilaterally
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Investigations
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Bedside
• PEFR
• Diary of symptoms/Peak flow
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Bloods
• Serum precipitins
• Hyperinflation
Imaging
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Special tests
• Spirometry – obstructive picture– Usually >15% improvement in FEV1 following
SABA or steroid trial
• Skin prick testing
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Management of chronic asthma
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Viva-esque questions
• 1. What are the aims of asthma treatment, and what guidelines are they based on?
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Viva-esque questions
• 1. British thoracic society guidelines; no daytime symptoms, no exacerbations, no rescue medications, lung function >80% predicted
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Conservative
• Removal of any allergens
• Patient education
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Medical• Step 1
– Inhaled SABA prn
• Step 2– Add inhaled steroid 200-800micrograms/day
• Step 3– Add inhaled LABA +/- increase inhaled steroid up to 800micrograms/day
• Step 4– Increase inhaled steroid up to 2000micrograms/day +/- leuotriene receptor antagonist, beta agonist PO, MR
Theophylline
• Step 5– Add long term oral prednisolone
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Acute exacerbation of asthma
• Moderate– PEFR 50-75%
• Severe– PEFR 33-50%
• Life threatening– PEFR <33%
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Investigating
• Bedside– PEFR– Sputum
• Bloods– FBC, UE, CRP, cultures– ABG, especially in life threatening
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Management of acute asthma• Oxygen• Nebulised salbutamol and ipratropium• Prednisolone 50mg PO OD/Hydrocortisone 100mg IV QDS• Call a senior!• IV Magnesium 1.2-2g infusion• IV Salbutamol or IV aminophylline• If numbers not improving ITU!
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Summary
• Signs – common and miscellaneous• Cases
– Bronchiectasis
– Pleural Effusion
– Pulmonary fibrosis
– COPD
– Asthma