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Rhiannon Coulter Peershare 2024 Respiratory Medicine Need to know – whistle stop tour Asthma COPD Pneumonia Lung cancer Lung fibrosis Pneumothorax Pleural OSCEs effusionAsthma Obstructive lung condition – Risk factors: personal or family history of atopy, *OSCE – eczema FEV1/FVC <70% and hay fever* Diagnosis: spirometry with Symptoms: cough worse at night, bronchodilator reversibility (>12% dyspnoea, wheeze and chest or increase in 200ml) or FENO tightness testing (40 parts per billion)Asthma managementAcute asthmaAcute asthma management ABCDE APPROACH AND OXYGEN 15L NON SALBUTAMOL – NEBULIZED SENIOR HELP (ANSWER TO REBREATHER MASK IF IF LIFE THREATENING, ALL OSCE ACUTELY UNWELL PATIENTS ARE ACUTELY STANDARD PRESSURIZED SCENARIOS) UNWELL AND HYPOXIC METERED DOSE INHALER OTHERWISE SEVERE – IV MAGNESIUM CORTICOSTEROID 40-50 IPRATROPIUM BROMIDE IN SULPHATE, IV MG PREDNISOLONE ORALLY SEVERE OR LIFE AMINOPHYLLINE, CONTINUE FOR 5 DAYS THREATENING INTUBATION AND VENTILATIONCOPD Symptoms: productive Investigations: post CXR: hyperinflation, flat cough, dyspnoea, wheeze bronchodilator spirometry hemidiaphragm, need to FEV1/FVC less than 70%. do to exclude lung cancer Severity indicated by FEV1COPD – stable management Number 1 = smoking cessation Annual influenza and one off pneumococcal vaccine Pulmonary rehab Step wise management COPD exacerbations Infective vs non infective Infective = green sputum, fever, commonly H.influenza Increase from baseline of usual symptoms Management: increase bronchodilator, oral prednisolone (30mg 5 days), if infective amoxicillin, consider admission and tailored oxygen therapy. COPD patients prone to type 2 respiratory failure (low oxygen, high CO2 on ABG), resp acidosis 7.25-7.35 consider NIV (BiPap)Pneumonia Symptoms: cough, Signs: low SpO2, sputum, fever, tachycardia, coarse plpain, SOBhest creps Low Na+ CURB 65!!! Investigations: Confusion (new CXR, FBC, U&E, onset), urea >7, RR Red currant jelly CRP, sputum >30, BP (systolic culture <90, diastolic ,60) age >65.Pneumonia • CAP vs HAP (>48 hours from hospital admission) • Review all with CXR at 6 weeks post infection • Common OSCE with CXR – always state check drug allergy status and follow local trust microbiology guidelines for treatment • Management based on CURB65 score • 0-1 = home on oral amoxicillin • >2 = hospital based care with IV anitibiotics • >3 = consider ICULung cancer • RED FLAG symptoms: hemoptysis, any of the following for >3 weeks: shoulder enlarged lymph nodes, persistent cough • Examination: fixed wheeze, supraclavicular lymphadenopathy, clubbing • Investigation: CXR, CT, bronchoscopy, PET scanning, bloods may show raised platelets • Management specialized don’t need to know in detail Idiopathic pulmonary fibrosis typically seen 50 – 70. Features include progressive exertional SOB, bibasal fine end inspiratory crepitations on auscultation, dry cough and clubbing. Spirometry: restrictive picture (FEV1 normal / decreased, FVC decreased, FEV1/FVC increased) Idiopathic pulmonary Impaired gas exchange, reduced TLCO fibrosis CT is gold standard and will have honeycomb appearancegh resolution Management: pulmonary rehab, stop smoking, oxygen therapy, if suitable lung transplant. Lung fibrosis Differentiate for MCQ causes of upper zone and lower zone.Pneumothorax • STEP 1 – symptomatic? If no symptomsconservativecare regardlessof size • Step 2 – assess for high risk characteristics • If high risk characteristicsinsert chest drain • If no high risks then choice of intervention • Safetyfor intervention is 2cm laterally on CXR or any size on CT which can be accessed with radiological support • Discharge: do not smoke, can fly 1 week post chext x ray, never scuba dive. • Review CXRs • Life threatening • Clinical features: acute onset of dypnoea, pleuritic chest pain, tachypnoea • Signs: hyperresonance on percussion, diminished T ension breath sounds on the affected side, tracheal pneumothorax deviation, hypotension and tachycardia • Clinical diagnosis • Management: insert cannula into second intercostal space in midclavicular line in affected side and place chest drain after.Pleural effusions • Features: SOB, non productive cough or chest pain. Findings: dullness to percussion, reduced breath sounds, reduced chest expansion • Transudate vs exudate • Transudate = failures <30g/L protein • 3H – heart failure, hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption), hypothyroidism • Exudate = inflammation >30g/L protein • PINTS – pulmonary embolis, infection (pneumonia most common), neoplasia, TB, SLE / RAPleural effusion investigation and management • Chest X ray • Pleural aspiration – send fluid for pH, protein, LDH, cytology and microbiology • Light’s criteria – if protein level between 25-35 apply Exudate if pleural fluid protein divided by serum protein >0.5 Pleural fluid LDH dividedby serum LDH >0.6 Pleural fluid LDH more than 2/3s the upper limits of normal serum LDH - If fluid is purulent a chest drain needs inserted or if pH is less than 7.2Pulmonary embolismPE treatment Treatment = DOAC for everyone bar severe renal impairment <15ml/min then LMWH Length = 3 months if provoked, 6 months if unprovokedOSCEs • 1: interpret chest x rays. Previous stations: pneumonia CXR and management, pulmonary function tests and CXR • 2: respiratory exam – read carefully! • 3: Resp history: COPD (smoking, previous infections), asthma (triggers, atopy), lung cancer (red flag features), TB (night sweats, travel history and contact with TB) • 4: Explanation of asthma / COPD – unlikely more 4 year / final year • Top tips: social history very important!!! Ask about impact on life and managing at home and ICEQuestion 1 • A 65-year-old man is seen in the clinic with a 2-year history of progressively worsening shortness of breath on exertion and a dry cough. He has had no haemoptysis and does not smoke or drink. The patient worked in an office for the last 30 years. • His pulse is 85 bpm, his respiratory rate is 16 /min, and he is afebrile. On auscultation, fine crackles are heard over both lung bases. He has finger clubbing. A chest x-ray is unremarkable. • Based on these features, what is the most likely diagnosis? 1. Asbestosis 2. Hypersensitivitypneumonitis 3. COPD 4. Idiopathic pulmonary fibrosis 5. Non-small cell lung cancerQuestion 1 • A 65-year-old man is seen in the clinic with a 2-year history of He has had no haemoptysis and does not smoke or drink. The patientcough. worked in an office for the last 30 years. • His pulse is 85 bpm, his respiratory rate is 16 /min, and he is afebrile. On auscultation, fine crackles are heard over both lung bases. He has finger clubbing. A chest x-ray is unremarkable. • Based on these features, what is the most likely diagnosis? 1.Asbestosis 2.Hypersensitivity pneumonitis 3.COPD 4.Idiopathic pulmonary fibrosis 5.Non-small cell lung cancerQuestion 2 • A 55-year-old man presents with a history of hoarseness of voice lasting >2 months. He has also noted feeling more tired than usual and has lost some weight over the same time. • He has a 20-pack-year history of smoking and a recent chest x-ray was clear. • Which investigation is likely to be diagnostic in this case? • A. Throat examination B. CTchest C. MRI head & neck • D. Chest X-ray E. Ultrasound neckQuestion 2 • A 55-year-old man presents with a history of hoarseness of voice lasting >2 months. He has also noted feeling more tired than usual and has lost some weight over the same time. • He has a 20-pack-year history of smoking and a recent chest x-ray was clear. • Which investigation is likely to be diagnostic in this case? • A. Throat examination B. CT chest C. MRI head & neck • D. Chest X-ray E. Ultrasound neckQuestion 3 • A 55-year-old gentleman has had some pulmonary function tests carried out, after presenting to the respiratory clinic with breathlessness. His results are as follows: • FEV1 – 60% predicted, 65% predicted post salbutamol FVC – 95% predicted FEV1/FVC – 0.63 What is the most likely diagnosis? 1.Pulmonary oedema 2.Asthma 3.PulmonaryFibrosis 4.Emphysema 5.Pulmonary FibrosisQuestion 3 • A 55-year-old gentleman has had some pulmonary function tests carried out, after presenting to the respiratory clinic with breathlessness. His results are as follows: • FEV1 – 60% predicted, 65% predicted post salbutamol FVC – 95% predicted FEV1/FVC – 0.63 What is the most likely diagnosis? 1.Pulmonary oedema 2.Asthma 3.Pulmonary Fibrosis 4.COPD 5.SarcoidosisQuestion 4 • pain. He is alert and orientated with HR 106, RR 34, SpO2 94%, BP 96/56, temp 38. His bloods are as follows: • CRP 50 Urea 6.6 Please calculate this patients CURB-65 score. • A. 1 • B. 2 • C. 3 • D. 4 • E. 5Question 4 • A 67 year old man has attended ED following 3 days of fever, breathlessness and chest pain. He is alert and orientated with HR 106, RR 34, SpO2 94%, BP 96/56, temp 38. His bloods are as follows: • WCC 16 Urea 6.6 Please calculate this patients CURB-65 score. • A. 1 • B. 2 • C. 3 • D. 4 • E. 5Question 5 • A 34-year-old presents complaining of episodic shortness of breath. This is particularly noted whilst at work where he describes feeling wheezy and having a tendency to cough. A diagnosis of occupational asthma is suspected. Which one of the following is the most appropriate diagnostic investigation? 1.Skin prick test 2.Specific IgE 3.FeNO 4.Serial peak flow measurements at work & home 5.Chest X-rayQuestion 5 • A 34-year-old presents complaining of episodic shortness of breath. This is particularly noted whilst at work where he describes feeling wheezy and having a tendency to cough. A diagnosis of occupational asthma is suspected. Which one of the following is the most appropriate diagnostic investigation? 1.Skin prick test 2.Specific IgE 3.FeNO 4.Serial peak flow measurements at work & home 5.Chest X-ray Not covered Interpreting pulmonary ABGs CXRs function testsGOOD LUCK Any questions please ask!