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Dr Ahmed Fadil Bilal Dr Danyal UsmanZara, a 15 year old girl attends GP with a one month history of cough and shortness of breath. Zara says she gets a really bad cough at night time and states that her cough gets really bad when she plays badminton in has been fit and well.istory includes eczema, apart from this she Which of the following would confirm the likely diagnosis? A. FEV1/FVC> 0.8 B. FeNO < 20 ppb C. Chest X-ray D. FEV1/FVC < 0.7 E. Serum TryptaseZara, a 15 year old girl attends GP with a one month history of cough and shortness of breath. Zara says she gets a really bad cough at night time and states that her cough gets really bad when she plays badminton in has been fit and well.istory includes eczema, apart from this she Which of the following would confirm the likely diagnosis? A. FEV1/FVC> 0.8 B. FeNO < 20 ppb C. Chest X-ray D. FEV1/FVC < 0.7 E. Serum Tryptase Asthma Cough - often worse early morning/night time, on exercise, colder weather Diurnal Variation Shortness of Breath Expiratory Wheeze & “Tight Chest” History of Atopy – Eczema, Hay-fever Asthma Diagnosis FractionalExhaled Nitric Oxide (FeNO) Level of Nitrous Oxide = Level of inflammation FeNO ≥ 40 ppb: supports a diagnosisof asthma in Adults FeNO ≥ 35 ppb: supports a diagnosisof asthmain Children Asthma Diagnosis Spirometry FEV1/FVC: < 70% FEV1: reduced, FVC: Normal or reduced Asthma Diagnosis BronchodilatorReversibilityTest Improvement in FEV1 by ≥12 % Or increase in volume by ≥200ml Yaseen, 23-year-oldmale comes to A&E with shortness of breath. He mentions that he is an On respiratoryexamination,he is alert and orientatedbut is unable to completesentenceswhile speaking. ObservatThere is audible expiratory wheezeon lung auscultation.94%, T: 36.3 Which of the followingis the most likely diagnosis? A. Pneumothorax B. Anaphylaxis C. Life-threatening asthma D. Acute severe asthma E. Acute exacerbation of COPD Yaseen, 23-year-oldmale comes to A&E with shortness of breath. He mentions that he is an On respiratoryexamination,he is alert and orientatedbut is unable to completesentenceswhile speaking. ObservatThere is audible expiratory wheezeon lung auscultation.94%, T: 36.3 Which of the followingis the most likely diagnosis? A. Pneumothorax B. Anaphylaxis C. Life-threatening asthma D. Acute severe asthma E. Acute exacerbation of COPD Asthma Moderate Severe Life-threatening Symptoms Speech Can’tcomplete Silentchest,cyanosis, normal full sentences poor respiratory effort, exhaustion,confusion RR > 25/min RR RR < 25/min RR > 25/min HR >110 HR >110 SATS ≥ 92% < 92% < 92% PEFR 50%-75% 33%-50% <33% Life Threatening Asthma 33: PEFR <33% predicted 92: Sats <92% Cyanosis 33, 92 CHEST: Hypotension Exhaustion Silent chest TachycardiaZareena, 32-year-oldfemale is in A&E resus with asthma attack, She is so short of breath she cant complete full sentences in one breath, still wheezy despite back to back nebulisers. Observations: RR: 27/min, BP: 115/75mmHg, HR: 100/min, O2 SATS: 95%, T: 37.2 Which of the followingis the most likely diagnosis? A. Pneumothorax pH 7.37 (7.35-7.45) pO2 10.1 (>9 kPa) B. Anaphylaxis pCO2 4.9 (4.7-6.0kPa) C. Life-threatening asthma Base Excess 1.1 (-2to 2) Lactate 1.9 (<2 mmol/L) D. Acute severe asthma E. Acute exacerbation of COPDZareena, 32-year-oldfemale is in A&E resus with asthma attack, She is so short of breath she cant complete full sentences in one breath, still wheezy despite back to back nebulisers. Observations: RR: 27/min, BP: 115/75mmHg, HR: 100/min, O2 SATS: 95%, T: 37.2 Which of the followingis the most likely diagnosis? A. Pneumothorax pH 7.37 (7.35-7.45) pO2 10.1 (>9 kPa) B. Anaphylaxis pCO2 4.9 (4.7-6.0kPa) C. Life-threatening asthma Base Excess 1.1 (-2to 2) Lactate 1.9 (<2 mmol/L) D. Acute severe asthma E. Acute exacerbation of COPD Life Threatening Asthma 33, 92 CHEST: 33: PEFR <33% predicted 92: Sats <92% Cyanosis Hypotension Exhaustion Silent chest Tachycardia Normal CO2 on Asthma Blood Gas = BAD (Exhaustion) Fahad, 25 year old male engineer has come to GP due to worsening dry cough, has asthma and is on salbutamol inhaler, othave been getting worse and is using the blue inhaler more frequently at work.noticed that his symptoms What would be useful in helping you treat Fahad? A. CTPA B. ECG C. Exercise tolerance test D. Spirometry E. Peak Flow Diary Fahad, 25 year old male engineer has come to GP due to worsening dry cough, has asthma and is on salbutamol inhaler, othave been getting worse and is using the blue inhaler more frequently at work.noticed that his symptoms What would be useful in helping you treat Fahad? A. CTPA B. ECG C. Exercise tolerance test D. Spirometry E. Peak Flow Diary Occupational Asthma Social history – Work, hobbies as possible trigger Symptoms better on weekend / time off work PEFR diary at work and away from work Asthma Peak Flow Diary - Diurnal Variation Fatima, 22 year old female accountant comes to see GP about her asthma, she has been using the Salbutamol She is currently prescribed a Short Acting Beta Agonist reliever inhaler and a Low-dose Steroid preventor inhaler. What would be the most appropriate management? A. Switch SABA for LABA B. LeukotrieneReceptorAntagonist C. Mediumdose Steroid D. Maintenance & Reliver Therapy E. MuscarinicAntagonist Fatima, 22 year old female accountant comes to see GP about her asthma, she has been using the Salbutamol She is currently prescribed a Short Acting Beta Agonist reliever inhaler and a Low-dose Steroid preventor inhaler. What would be the most appropriate management? A. Switch SABA for LABA B. LeukotrieneReceptorAntagonist C. Mediumdose Steroid D. Maintenance & Reliver Therapy E. MuscarinicAntagonist Asthma Stepwise Management SABA SABA + low dose ICS SABA + low dose ICS + LTRA SABA + low dose ICS + LABA +/- LTRA SABA + low dose ICS + MART +/- LTRA Increase Steroid Dose…Sumaya, 16 year old female has been recovering on the respiratory ward following an acute severe asthma attack. Which of the following criteria must be met for the patient to be safely discharged? A. After one dose of Amoxicillin B. Clear chest X-ray C. Stops smoking D. Peak expiratoryflow >75% best or predicted E. After clear CTPASumaya, 16 year old female has been recovering on the respiratory ward following an acute severe asthma attack. Which of the following criteria must be met for the patient to be safely discharged? A. After one dose of Amoxicillin B. Clear chest X-ray C. Stops smoking D. Peak expiratoryflow >75% best or predicted E. After clear CTPA Asthma Management Discharge Criteria • Been stable on their discharge medication (no nebulisers or oxygen) for 12–24 hours • Inhaler technique checked and recorded • PEFR >75% of best or predicted Kishan, a 30 Year old male bricklayer presents to A&E with chest pain and shortness of breath that came on suddenly this evening while at work. He states he has never felt like this before, no trauma and has never been so short of breath. He is a very heavy smoker, smokes two packets a day cince he was 16. Observations: RR: 26/min, BP: 115/75mmHg, HR: 80/min, O2 SATS: 93%, T: 36.3 What is the treatment? A. Salbutamol Nebuliser B. Adrenaline C. Chest Drain D. Magnesium Sulphate E. IV AmoxicillinChan, a 30 Year old Male bricklayer presents to A&E with chest pain and shortness of breath that came on suddenly this evening while at work. He states he has never felt like this before, no trauma and has never been so short of breath. He is a very heavy smoker, smokes two packets a day cince he was 16. Observations: RR: 26/min, BP: 115/75mmHg, HR: 80/min, O2 SATS: 93%, T: 36.3 What is the treatment? A. Salbutamol Nebuliser B. Adrenaline C. Chest Drain D. Magnesium Sulphate E. IV Amoxicillin Pneumothorax Pneumothorax = Air within pleural space Short of breath Pleuritic chest pain (pain worse on inspiration) Reduced air entry & breath sounds Hyper-resonant percussion Tracheal deviation AWAY from pneumothoraxPneumothoraxPneumothorax The size of a pneumothorax should be measured at the level of the hilum (‘b’ in diagram, NOT ‘a’)Chan, a 30 Year old Male bricklayer presents to A&E with chest pain and shortness of breath that came on suddenly this evening while at work. He states he has never felt like this before, no trauma and has never been so short of breath. He is a very heavy smoker, smokes two packets a day cince he was 16. Observations: RR: 26/min, BP: 115/75mmHg, HR: 80/min, O2 SATS: 93%, T: 36.3 Where should the Chest Drain be inserted? A. Cubital fossa nd B. Midclavicular 2 intercostal space C. At the angle of the lowest rib D. Safe Triangle E. Midaxillary4 intercostalspaceChan, a 30 Year old Male bricklayer presents to A&E with chest pain and shortness of breath that came on suddenly this evening while at work. He states he has never felt like this before, no trauma and has never been so short of breath. He is a very heavy smoker, smokes two packets a day cince he was 16. Observations: RR: 26/min, BP: 115/75mmHg, HR: 80/min, O2 SATS: 93%, T: 36.3 Where should the Chest Drain be inserted? A. Cubital fossa nd B. Midclavicular 2 intercostal space C. At the angle of the lowest rib D. Safe Triangle E. Midaxillary4 intercostalspaceChest Drain Safe TriangleSaifuldin, a 40 Year old Male jocky is brought to A&E after falling off his horse in his north Wales farm, He is struggling to breath and looks extremely distressed. Assessment of airway: Reduced air entry on the right side, trachael deviation to the left. What is the most appropriate management? A. Immediatechest x-ray B. Needledecompression C. 5 rescue breaths D. Chest drain E. CT – PulmonaryAngiogramSaifuldin, a 40 Year old Male jocky is brought to A&E after falling off his horse in his north Wales farm, He is struggling to breath and looks extremely distressed. Assessment of airway: Reduced air entry on the right side, trachael deviation to the left. What is the most appropriate management? A. Immediatechest x-ray B. Needledecompression C. 5 rescue breaths D. Chest drain E. CT – PulmonaryAngiogram Tension Pneumothorax No investigation. IMMEDIATE needle decompression nd Midclavicular 2 intercostal spaceYasamin, a 35 year old female attends A&E with sudden shortness of breath and chest pain that started suddenly this evening, particularly worse on inspiration She has just got back from visiting only current medication she takes is combined oral contraceptive pill.l impairment and Observations: RR: 24/min, BP: 115/75mmHg, HR: 115/min, O2 SATS: 93%, T: 36.6 What investigation is needed to confirm most likely diagnosis? A. CTPA B. Troponin C. V/Q scan – Pregnancy& Renal Impairment D. D-Dimer E. Chest X-rayYasamin, a 35 year old female attends A&E with sudden shortness of breath and chest pain that started suddenly this evening, particularly worse on inspiration She has just got back from visiting only current medication she takes is combined oral contraceptive pill.l impairment and Observations: RR: 24/min, BP: 115/75mmHg, HR: 115/min, O2 SATS: 93%, T: 36.6 What investigation is needed to confirm most likely diagnosis? A. CTPA B. Troponin C. V/Q scan – Pregnancy & Renal Impairment D. D-Dimer E. Chest X-ray Pulmonary Embolus Short of breath Pleuritic chest pain (pain worse on inspiration) Haemoptysis Tachycardia Crackles/Fever Travel / Immobility Dehydration Estrogen hormone therapy - COCP Clotting disorder (Thrombophilia)Wells’ Score PE Suspected = Do Wells’ Score Wells > 4 = PE Likely Straight to CTPA Wells 4 or less D-dimer PE Management Direct Oral Anticoagulant - DOAC Apixaban / Riveroxaban DOAC as soon as diagnosis suspected pregnancy / renal impairment -> Low Molecular Weight Heparin Provoked = 3 months DOAC Unprovoked or Cancer = 6 months DOACPulmonary embolism rule-out criteria (PERC) PERC rule helps to justify not investigating (not doing D-dimer) for low suspicion PE. Must score 0 for criteria Avoid false positive D-Dimer and unnecessary CTPAHamza and Humost common ECG finding in patients presenting with a PE?r asks them what is the A. Right Bundle Branch Block B. S1Q3T3 C. T wave inversion D. Widespread ST elevation E. Sinus TachycardiaHamza and Humost common ECG finding in patients presenting with a PE?r asks them what is the A. Right Bundle Branch Block B. S1Q3T3 C. T wave inversion D. Widespread ST elevation E. Sinus Tachycardia ECG’s Sinustachycardia ECG’s S1Q3T3+ RBBB + RightaxisdeviationCheng is a 69 year-old male who attends his GP complainingof 6 months hx SOB, with occasional productive year pack hx.The GP decides to order spirometry to aid the diagnosis. The results are as follows:x reveals 36 FEV1/FVC 0.68 FEV1 82% of his predicted FEV1. What is the likely diagnosis? A. Lung fibrosis B. Asthma C. COPDstage1 D. COPDstage2 E. COPDstage3Cheng is a 69 year-old male who attends his GP complainingof 6 months hx SOB, with occasional productive year pack hx.The GP decides to order spirometry to aid the diagnosis. The results are as follows:x reveals 36 FEV1/FVC 0.68 FEV1 82% of his predicted FEV1. What is the likely diagnosis? A. Lung fibrosis B. Asthma C. COPD stage1 D. COPDstage2 E. COPDstage3 Chronic Obstructive Pulmonary Disease Two Pathologies Smoker AAT deficiency • Chronic bronchitis: Productive cough for at Occupational risk least 3 months for 2 consecutive years • Emphysema: Structural lung changes causing abnormal airspace enlargement in the bronchioles ClassicClinicalSymptoms ClassicClinicalSigns • Cough (usually productive) • Dyspnoea • Coughing yellow sputum  IECOPD • Pursed lip breathing • Breathlessness,wheeze • Use of accessarymusclesto • Weight loss, fatigue, ankle swelling breathe (RSHF 2 to pulmonary HTN – cor pulmonale) • Coarsecrackles Diagnosing COPD: GOLD Criteria Post-bronchodilator Severity FEV1 (of predicted) FEV1/FVC Stage 1 - Mild** > 80% < 0.7 Stage 2 - Moderate 50-79% < 0.7 Stage 3 - Severe 30-49% < 0.7 Stage 4 - Verysevere < 30% < 0.7Diagnosing COPD 1. Lung hyperinflation Investigations to consider 2. Flattened hemidiaphragms • FBC may show polycythaemia 3. Bullous changes 4. Barrel chest shape • CRP/ESR raised if infection 5. Increased broncho vascular marking (if • Sputum culture: To identify organisms if p.HTN) 6. Cardiomegaly if RH strain sputum is persistently present and purulent • ECG AF, RBBB P pulmonale, RAD. • ABG to assess baseline/ type of respiratory failure  often T2RF  require BiPAP // • BNP and echocardiogram to exclude heart failure and pulmonary hypertension Panacinar/Lower lobe destruction - pure AAT deficiency. • Serum alpha-1 antitrypsin low in AAT deficiency test in those age < 40 years or with Centrilobular a family history. destruction/upper lobe emphysema is seen in • HRCT can show some of the damage and smokers dilatation of the airways and bullae A 70 year-old male named Yousaf attends his GP after 6 months after his diagnosis of COPD. Despitebeing started on a salbutamolinhaler,he still complainsof breathlessness.Yousaf is havingto use his inhaler daily and is strugglingwith certainactivities, such as walkingup the stairs. His FEV1 (forced expiratory volumein 1 second)is 55% and his bloodeosinophilcount is within the normalrange. A. Continuesalbutamol B. Long-actingbeta-2agonist(LABA)+ inhaledcorticosteroid(ICS) C. Long-actingbeta-2agonist(LABA)+ long-actingmuscarinic antagonist(LAMA) D. Aminophylline E. Long-actingbeta-2agonist(LABA)+ long-actingmuscarinic antagonist(LAMA)+ inhaled corticosteroid(ICS) A 70 year-old male named Yousaf attends his GP 6 months after his diagnosis of COPD. Despitebeing started on a salbutamolinhaler,he still complainsof breathlessness.Yousaf is havingto use his inhaler daily and is strugglingwith certainactivities, such as walkingup the stairs. His FEV1 (forced expiratory volumein 1 second)is 55% and his bloodeosinophilcount is within the normalrange. A. Continuesalbutamol B. Long-actingbeta-2agonist(LABA)+ inhaledcorticosteroid(ICS) C. Long-actingbeta-2agonist(LABA)+ long-actingmuscarinic antagonist(LAMA) D. Aminophylline E. Long-actingbeta-2agonist(LABA)+ long-actingmuscarinic antagonist(LAMA)+ inhaled corticosteroid(ICS) COPD Management Class Example Stable COPD Short Acting Beta Agonist Salbutamol Short Acting Muscarinic Ipratropium bromide SABA/SAMA Antagonist Steroid Responsiveness Long Acting Beta Agonist Salmeterol/ Formoterol No Yes Long Acting Muscarinic Tiotropium Antagonist Inhaled Corticosteroid Fluticasone/ Budesonide LABA + LAMA LABA + ICS LABA + LAMA + ICS Trellegy Ellipta: fluticasone, umeclidinium, and vilanterolAlso Azithromycin prophylaxis but ECG must be done. consider: to rule out QT prolongation prior use lung volume reduction surgery in selected patients One off pneumococcal vaccine and annual influenza vaccine Respiratory specialist nurse are critical in community management for rehabilitation, education and support on discharge. Rescue packs are key. LTOT if PO2 <7.3kPa, or <8kPa with secondary polycythaemia, peripheral oedema, pulmonary hypertension. Contraindicated in smokers as oxygen has to be used 15 hours a day. Acute COPD Management common cause) of exacerbation O SHITE (a) Using Oxygen O xygen (88-92%) • Give controlled oxygen i.e 24- 28% (venturi S albutamol 2.5-5mg 4hrly 15mins to avoid type 2 respiratory failure (hypercapnia) H ydrocortisone 200or PO Pred 30mg Ipratropium 500mcg 4hly • Can adjust target range 94-98% if pCO2 is normal on ABG T heophylline (aminophylline / ECG + Senior)• Use non-invasive ventilationpatients E scalate (pH<7/35or PCO>6kPA)ic respiratory failure (a) ntibiotic(amoxicillin orclarithromycinor doxycycline) if clinically seen to have infection e.g. spiking fever // crackles// produc sputumAlys, an 83 yo female presentswith her son to the GP. Her son complainsthathis motherhas been more disorientatedover the past day. He has seen her cough green sputumwhich has been happeningfor past 5 days. The GP takesher observations which reveals: RR 26, BP 84/55, temp 37.8, O2 sats of 94% on room air.What is the most appropriate next step to takein Karen’s management? A. Oral antibiotics and send home with safety netting B. Admit to hospital for IV antibiotics C. Safety net and review again if becoming worse D. Takebloods from her to calculate Urea E. Takea sputum cultureAlys, an 83 yo female presentswith her son to the GP. Her son complainsthathis motherhas been more disorientatedover the past day. He has seen her cough green sputumwhich has been happeningfor past 5 days. The GP takesher observations which reveals: RR 26, BP 84/55, temp 37.8, O2 sats of 94% on room air.What is the most appropriate next step to takein Karen’s management? A. Oral antibiotics and send home with safety netting B. Admit to hospital for IV antibiotics C. Safety net and review again if becoming worse D. Takebloods from her to calculate Urea E. Takea sputum culture Pneumonia Scoring Systems Community Secondary care C- Confusion(AMT ≤8) C- Confusion(AMT ≤ 8) R- Respiratoryrate ≥30 U- Urea > 7.0 B- Blood pressure ≤ 90 systolicorratoryrate ≥ 30 ≤60 diastolic B- Blood pressure≤ 90 systolic or ≤ 60 diastolic 65- Age ≥ 65 65- Age ≥ 65 Pneumonia Pneumonia Classic Clinical Classic Clinical Signs • Expiratory wheeze • Infection of air spacesSymptoms and surroundingtissue • Fever • Tachypnoea of the lung. • Dull percussion note • Malaise • Reduced breath sounds • Bronchial breathing (transmission • Cough of bronchialsounds to Hospital Acquired (purulent peripheries due to consolidation) • Onset >48hrsafter sputum) • Coarse crepitations admission • Tachycardia • Post operative, ITU / • Dyspnoea • Hypotension Air conditioned/ • Confusion Intubated • Pleuritic pain • CyanosisPneumonia CXRAtypical Pneumonia CXR XRAY Findings • patchy infiltrates often bilateral in distribution, • interstitial patterns of lung pathology • pneumaotceles. • Ground glass opacification They are less commonly associated with lobar consolidations and complicated parenchymal findings such as empyema and ARDS. Additional points for severity - Hypoxaemia - WCC >20 - Multi love involvement - Positive blood cultures Pneumonia Management • ABCDE approach • Consider Sepsis  Give 3 (O2, IV fluid bolus, IV broad spectrum antibiotics)  Take 3 (blood cultures, lactate, monitor urine output) • Antibiotic therapy based on local guidance. Guided by severity (CURB score) and whether hospital/ community acquired. CAP CURB65 0 or 1 1 Line: Amoxicillin 2ndLine: Doxycycline CURB65 2 or more Amoxicillin + Clarithromycin 2ndLine: Doxycycline or Co-trimoxazole HAP If mild or moderate start with amoxicillin or doxycycline (tetracycline) clarithromycin if allergic. If severe: co-trimoxazole Send sputum for - Amoxicillin is narrow spec MC&S as soon as - Co-Amoxiclav is broad spec possible in order to switch to targeted therapyWhich of the following organisms is responsible for the majority of community acquired pneumonias? A. Haemophilusinfluenzae B. Staphylococcus aureus C. Streptococcus pneumoniae D. Pneumocystisjirovecii E. Klebsiella pneumoniaeWhich of the following organisms is responsible for the majority of community acquired pneumonias? A. Haemophilusinfluenzae B. Staphylococcus aureus C. Streptococcuspneumoniae D. Pneumocystisjirovecii E. Klebsiella pneumoniaeCommonly Tested Microorganisms Streptococcus mostcommon causeof CAP. Cold sores (HSV) pneumoniae Haemophilus influenzae mostcommon causeof COPD exacerbation Staphylococcusaureus Influenza pneumonia, IV drug use or central line. Staph A is part of skin flora and nasal cavity hence it can get into bloodand lungs. If MRSA i.e. S.A is resistant then it can be difficult to treat. Klebsiella pneumoniae Alcoholics and diabetic patient red currant jelly sputum Lower lobe – air sac Chlamydiapsittaci transmittedfrombirds, hepatosplenomegaly, rosespotson abdomen,hepatitis and renalfailure Pneumocystisjiroveci HIV, desaturationwhilstexercising Ground glass opacification treatment w/ co- trimoxazole (often long term prophylaxsis needed) Legionella ↓NA+ and derangedLFTs Urinary antigen to diagnose In wet locations- ventilation- curise ships, conferences, intubation Mycoplasmapneumoniae pneumoniae- Erythema multiforme,younger patients, haemolyticanaemia,myocarditis– if patienthasnew chestpain on chest infection– do serologyto lookformycoplasma Cold agglutination – look uprdhat this means Children and young adults – 1/3 have no coughPatient present to GP with increasing breathlessness over the past month on background of dry cough for 6 months. O/E there is decreased vocal resonance and deviation of the trachea to the right. No other abnormalities seen on cardiovascular, abdominal or peripheral examination. Smoking hx of 30 years. What is the next step in management given CXRAY? A. Start abx and referre him under the 2WW cancer pathway B. Therapeutic tap w/ results sent for MCS C. High flow oxygen + IV furosemide + catheter D. Needle decompression + MET call E. IV antibiotics + fluids + Sputum culture + admitSabrina present to GP with increasing breathlessness over the past month on background of dry cough for 6 months. O/E there is decreased vocal resonance and deviation of the trachea to the right. No other abnormalities seen on cardiovascular, abdominal or peripheral examination. Smoking hx of 30 years. What is the next step in management given CXRAY? A. Start abx and referre him under the 2WW cancer pathway B. Therapeutic tap w/ results sent for MCS C. High flow oxygen + IV furosemide + catheter D. Needle decompression + MET call E. IV antibiotics + fluids + Sputum culture + admit Pleural Effusion Summary One of the following present: Exudates >30g/L  Abdominalinfections, abscess, ascites,  Meigs syndrome, pancreatitis  Churg-Straussdisease,lupus, rheumatoid Effusion protein/serumprotein ratio greaterthan arthritis, Wegenergranulomatosis 0.5  Oesophageal perforation(raised amylase)  Lung abscess, bacterial pneumonia, fungal Effusion LDH/serumLDH ratio greater than 0.6 disease,parasites, tuberculosis (low glucose)  Acute respiratory distresssyndrome(ARDS) Effusion LDH level greater than two-thirdsthe  Asbestosis, pancreatitis, radiation, upper limitof the laboratory's reference range of sarcoidosis,uremia serum LDH  malignancy,  Pulmonary embolism  infarction of blood Lights vessel down stream  protein and blood leak  lymphoma, leukemia,mesothelioma, Criteria paraproteinemia One of the following present: Transudate <30g/L  Cerebrospinal fluid (CSF) leak into pleural space Effusion protein/serumprotein ratio less than 0.5  Heart failure, Liver failure, Nephrotic syndromeand Hypoalbuminemia Effusion LDH/serumLDH ratio less than 0.6  Iatrogenic: Misplaced catheter into lung Effusion LDH level less than two-thirds the upper  Peritoneal dialysis limitof the laboratory'sreference range of serum LDHACE! Asthma Pathophysiology Clinical Features Management Asthma is the resultof airway • Symptoms:Cough (worse at 1) SABA inflammation,intermittent airflow night), dyspnoea, chesttightness 2) SABA + low dose ICS obstruction, and bronchial 3) SABA + ICS+ LABA hyperresponsiveness which leads to • Signs: Expiratory wheeze, 4) SABA + ICS+ LABA+ LTRA an increasein airway resistance. tachypnoea 5) SABA + MART + Low dose ICS+/- LTRA a) If ineffe,increasedose of ICS Diagnosis Life threatening asthma Acute management FeNO:≥ 40 ppb 33, 92 CHEST OSHITME Spirometery:Obstructivepattern, 33: PEFR <33% predicted Oxygen FEV1/FVCratio < 70% 92: Sats <92% Bronchodilatorreversibility: Cyanosis Salbutamol Improvement in FEV1 by ≥12 % or Hypotension Hyrdocortisone Theophylline increase in volumeby ≥200ml Exhaustion MagnesiumSulphate Silent chest Escalate TachycardiaACE! Chronic Obstructive Pulmonary Disease Pathophysiology Clinical Features Management Repeat injury leads to chronic • Symptoms:Chroniccough 1) SAMA/SABA inflammationcausing: Airway (usually productive), 2a) If no asthmatic features:LABA + remodelling, Mucous production, breathlessness, wheeze LAMA Loss of alveolar spaces, Vascular bed 2b) If asthmatic features:LABA+ ICS changes (causing pulmonary • Signs: Dyspnoea, pursed lip 3) LABA+ LAMA+ ICS hypertension). breathing, wheeze, coarse Can consider Azithromycin,LTOTand crackles,barrel chest lung reduction volumesurgery Investigations Acute management Spirometry+ post-bronchodilator OSHITE(a) reversibilitytest- FEV1:FVC<0.7 Oxygen (88-92% with venturimask) Salbutamol Hyrdocortisone/prednisolone CXR (hyperinflationand flattened Ipratropium diaphragm) Theophylline Antibiotics Consider BiPAPand chest physioACE! Pneumothorax Management Pathophysiology Clinical Features • Primary: discharge if rim of air <2cm and no • Symptoms:Dyspnoea, pleuritic SOB,otherwise aspirate (chest drain if chest pain usually unilateral failure) A collection of air within the pleural • Secondary: >50 with rim of air >2cm – chest drain space. • Signs: Normal if small, tracheal 1-2cm – aspirate deviation, reduced chest <1cm – O2 and admit expansion and breath sounds, • Tension: – large bore 14-16G needle, insert hyper-resonantpercussion into 2nd Intercostal space midclavicular line. Aetiology Investigations Long Term Avoid air travel until 1 weekpost x- Firstline: ErectPAchest x-ray. Risk factors:Smoker,tall, slim, male, raycheck confirmingfull resolution Marfansyndrome,presenceof FBC and clotting: to determine if Scuba diving is typically underlyinglung diseases there is any clotting abnormalities prior to inserting chest drain permanentlyavoidedACE! Pulmonary Embolism Pathophysiology Clinical Features Management • Symptoms: Dyspnoea, pleuritic • 1 line: DOAC, provoked = Based on Virchow’s triad: chest pain, cough, haemoptysis, 3months, unprovoked = 6months nd 1. Venous stasis leg pain + swelling • 2 line: LMWH or unfractionated 2. Endothelial injury heparin 3. Hypercoagulablestate • Signs: Tachycardia, Low grade • If haemodynamicallyunstable: fever, syncope Consider thrombolysis • If recurrent PE’scanconsiderIVCfilter Wells score Investigations Risk factors • Age 1 line: CTPA • Obesity If ≤4 then PE is unlikely, do D-dimer 2 line: V/Qscan if renal impairment • Familyhistory of VTE and if positiverequestCTPA • Pregnancy or pregnant • Immobility/hospitalisation Chestx-ray: usually normal, used to • Malignancy If >4 then PE is likely,request CTPA exclude other diagnoses • Blood clotting disorders and startpatienton anticoagulation • COCP ECG: sinus tachycardia, S1Q3T3, • Hormonal replacementtherapy RBBB and Right axis deviationACE! Pneumonia Pathophysiology Management Clinical Features • Symptoms: Productive cough, • Low severityCAP: 5 days Inflammationof the parenchyma of dyspnoea, pleuritic chest pain, amoxicillin the lung mostcommonly due to malaise, fever • ModerateseverityCAP: infection. Causes include bacteria, Amoxicillinand clarithromycin7- viruses, fungi and parasites. • Signs: Reduced breath sounds, 10 days coarse crepitations,dull • High severityCAP: IV co- percussionnote, tachycardia, amoxiclavand clarithromycin7-10 confusion days Organisms Investigations Scoring systems • Streptococcuspneumoniae-most C- Confusion commoncause Imaging:Chestx-ray consolidation U- Urea > 7.0 (in hospital) • Haemophilusinfluenzae-COPDpatients • Staphylococcusaureus-following Bloods:FBC (neutrophila= bacterial R- Respiratory rate > 30 influenza infection),U&E,CRPused to monitor tx B- Blood pressure <90 systolic or <60 • Klebsiellapneumoniae-Alcoholics response, blood cultures diastolic • Chlamydiapsittaci-transmittedbybirds 65- Age>65 • Pneumocystisjiroveci-HIV patients Microbiology:Sputumculture,urine • Legionella-foreigntravel, ↓NA+ antigentestingACE! Pleural Effusion Pathophysiology Management Clinical Features An abnormal collectionof fluid • Symptoms:Breathlessness,non- productivecough,pleuritic chestpain • Treatunderlyingcause within the pleural space. • Chestdrainfor drainage Fluid may enter the pleural space due to:↑vasculaturepermeability, • Signs:Reduced chest expansion, • Indwellingpleuralcatheter if ↑ microvascularpressure or reduced breath sounds,stony dull recurrentpleuraleffusions percussion,reduced vocal resonance • Pleurodesis(e.gbleomycin)to ↓plasma oncoticpressure and tracheadeviation away from the reducefluidaccumulation side of the effusion Transudate causes Investigations Exudative causes PAand lateral CXR: Blunting of An extravascular fluid with high An extravascular fluid withhigh protein proteincontent(> 30 g/L) costophrenicangles,trachealdeviation content (> 30 g/L) away from effusion,opacity • Infection:Pneumonia Pleural ultrasound:usefulfor locating • Connectivetissue disease • Heart failure (mostcommon) area for thoracentesis • Neoplasia:Lung cancer, breast cancer • Hypoalbuminemia (e.g. Liver Pleuralparacentesis & analysis: • Pancreatitis disease, nephrotic syndrome) Determineif fluid is transudateor • Pulmonaryembolism exudate. If difficult to differentiate use • Hypothyroidism Lightscriteria. • Dressler’ssyndromeACE! Lung Cancer Pathophysiology Clinical Features NSCLC Management Lungmalignancies are dividedby the cell types responsible: • If stage IIIC or below: Surgery 1. Non-smallcell lung carcinoma (NSCLC) • Symptoms:Weight loss, (lobectomy)+/- chemotherapy a) Adenocarcinoma (most common, can haemoptysis, cough, malaise, cause gynaecomastia) hoarseness b) Squamous cell (locatedcentrally) • Radiotherapy isoften a palliative c) prognosis,can secreteB-HCG)lly,poor treatmentbut radical • Signs: Stridor, lymphadenopathy, 2. Small cell lung carcinoma (SCLC)(cancause wheeze, clubbing, dull percussion radiotherapycan be given with Cushingssyndrome,Hyponatremia,lambert-Eaton curative intent in early disease syndrome) Urgent referral Investigations SCLC Management Urgent2 weekreferral via cancerpathway • Surgeryis only an option in <5% if: CXR: may show suspiciousopacity of cases in T1/2 N0 disease • CXR findingsaresuggestiveof lung Tissue biopsyvia bronchoscopy cancer Cytology • Chemotherapy (platinum based • >40yrswithnewhaemoptysis • >40yrswith2 non-haemoptysisredflag CTAP/PET:for determiningTNM therapy) symptomif nonsmoker stagingof malignancy: • Radiotherapy ismostly used for • >40yrswith1 non-haemoptysisredflag palliativerelief. symptomif nonsmokerACE! Interstitial lung disease Management Pathophysiology Clinical Features A group of disorders causing chronic • Symptoms:Dry cough, fatigue, Pulmonary Rehabilitation inflammationand/or progressive dyspnoea. Antifibrotic (e.g pirfenidone) fibrosis.Cycles of parenchyma injury can lead to abnormal wound healing • Signs: inspiratorycrackles, Oxygenforsymptomaticrelief causing fibrosis. clubbing, acrocyanosis Lung transplant Investigations fibrosisbe vs lower lobe Pulmonaryfunctiontests:Restrictive pattern UpperLobe LowerLobe CXR: reticularopacities CHARTS Idiopathic Coal worker’s pneumoconiosisSLE CT scan:honeycombing Histiocytosis Abestosis Ankylosing spondylitis Drugs: FBC (anaemia), U+Es, TFTs,HbA1c, Radiation Amiodarone Tuberculosis Bleomycin lipids Silicosis/sarcoidosis Methotrexate