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Acute respiratory conditions Srushti Bhat Clinical Fellow Cardiothoracic SurgeryAbout meT opics covered:  Pulmonary embolism (PE)  Pneumonia  Acute asthma  Pneumothorax  Pleural effusion1. A 28-year old patient presents with productive cough over last 5 days. He had fever as well as breathing difficulty on exertion in the past 2 days. Observations: T 38.2, BP 100/60, HR 90, RR 20, Sats 95% on air. On examination sputum is green coloured, there is reduced air entry on left lower base associated with some crepitations. Sputum culture shows gram positive diplococci. What is the most likely organism responsible? a) Mycoplasma pneumoniae b) Streptococcus pneumoniae c) Staphylococcus aureus d) Pneumocystis jeroveci e) Mycobacterium tuberculosisAnswer: Streptococcus pneumoniae • Diagnosis: Community acquired pneumonia • Points in favour: • Differentials: • Investigations: • CXR- • Management:2. A 19-year old football player suddenly fell to the ground during a match. He was found to be short of breath and complained of right-sided chest pain. His observations: apyrexial, HR 102, BP 92/58, RR 26/min, Sats 90% on air. On auscultation, there is reduced air entry on the right. What will be the most likely next step? a) Chest Xray b) Chest drain on left side c) Chest drain on right side d) Needle thoracocentesis on right side e) Needle thoracocentesis on left sideAnswer: Needle thoracocentesis on the right side • Diagnosis: Tension pneumothorax • Points in favour: • Investigations: CXR- • Management- Emergency setting: Hospital setting:3. A young motorcyclist presents to A&E with sudden onset shortness of breath. Going through his records you realise that he was discharged 1 week ago after undergoing a surgery for fractured femur. His past history is otherwise unremarkable. He was fit and active prior to his injury. Obs: apyrexial, HR 100, BP 100/60, RR 20, Sats 92% air. You perform a chest Xray. What is the most likely diagnosis? a) Fat embolism b) Pulmonary oedema c) Chronic Obstructive Pulmonary Disease (COPD) d) Pulmonary embolism e) PneumoniaAnswer: Pulmonary embolism • Points in favour: • Investigations: • ECG- • Bloods- • CXR- • Definitive: CTPA (not for fat embolism) • Management:4. A 40 year old woman undergoes oesophageal dilatation for longstanding dysphagia secondary to benign peptic stricture. She develops sudden onset breathlessness and starts feeling unwell. Her observations are stable except for RR 26/min. What is the most likely chest x-ray appearance? a) Normal chest Xray b) Free mediastinal gas c) Pneumothorax d) Haemothorax e) PneumoniaAnswer: Free mediastinal gas (Pneumomediastinum) • Diagnosis: Oesophageal perforation • Points in favour: • CXR findings: • Management: Feeding regimen-Mediastinal contents The Middle Mediastinum - Borders - Contents - TeachMeAnatomy Superior Inferior- Inferior- Middle Inferior- Posterior Anterior Organs • Thymus Thymus • Heart • Oesophagus • Trachea (child) • Pericardium • Oesophagus Arteries • Aortic arch • Ascending aorta • Thoracic aorta • Brachiocephalic • Pulmonary trunk trunk • Pericardiophrenic • Left common carotid arteries • Left subclavian Veins & lymphatics • SVC • SVC • Azygos vein • Brachiocephalic vein • Azygos vein • Hemiazygos • Thoracic duct • Pulmonary veins • Thoracic duct • Pericardiophrenic arteries Nerves • Vagus • Phrenic • Vagus nerve • Left recurrent laryngeal • Cardiac nerves • Phrenic5. A 55 year old woman presents to A & E with severe wheeze and persistent dry cough. She says it started a few hours ago when she was hoovering the house. Past history – asthma, hypertension, hypothyroidism. She takes regular oral steroids. Her obs: apyrexial, BP 110/70, HR 98, RR 24/min, Sats 92% air. She is able to provide a history but feels very exhausted. On auscultation: widespread wheeze over all areas. What is the most appropriate immediate management? a) Nebulisation with salbutamol and ipratropium bromide b) Nebulisation with steroids c) Hydrocortisone 100 mg IV d) Oral prednisolone e) Nebulisation with adrenalineAnswer: Nebulisation with salbutamol + ipratropium bromide • Diagnosis: Acute exacerbation of asthma • Trigger: dust • Points in favour: • Diagnosis: • Management:6. A 58 year old woman presents with worsening shortness of breath over last few hours. Her past medical history reveals mitral stenosis, diabetes (diet controlled). She is not on any regular medications. Obs: apyrexial, HR 92, BP 90/65, RR 22, Sats 90% on air. There are widespread crackles bilaterally. She has a displaced apex beat and a systolic murmur. You start her on oxygen and perform a chest Xray. What will be your next management plan? a) Give IV fluids b) IV furosemide c) IV Antibiotics d) Nebulised salbutamol e) Nebulised salineAnswer: IV furosemide • Diagnosis: Mitral stenosis  Left ventricular failure  pulmonary oedema • Points in favour: • Investigations: ABG • Management:7. An 80 year old man was brought by his daughter due to progressively worsening shortness of breath over the past week. He was apyrexial but his mobility was greatly reduced to dyspnoea. He is an ex-smoker and worked at a cement factory. Obs: stable. On examination: right side reduced air entry mid-lower zone. You perform an ABG and a chest Xray. Which of the following do you think is correct? pH 7.48 pO2 11.2 pCO2 2.8 HCO3- 24 a) Pneumonia and metabolic acidosis b) Pulmonary embolism and respiratory alkalosis c) Pulmonary oedema and metabolic alkalosis d) Pulmonary Tuberculosis and metabolic acidosis e) Pleural effusion and respiratory alkalosisAnswer: Pleural effusion and respiratory alkalosis • Points in favour: • Causes: • Investigations: • CXR findings: • Management:Exudate vs Transudate8. A young man presents to his GP with symptoms of severe cough at night. He says he hasn’t slept in the last few days to this and he is unable to work during the day. You look at his previous history. He is a known asthmatic and takes high dose inhaled steroids and salbutamol when required. Which of the following medications will benefit him? a) Leukotriene receptor antagonist b) Increase dose of inhaled corticosteroid c) IV corticosteroid d) PO corticosteroid e) Inhaled long acting b2 receptor agonists Answer: Leukotriene receptor antagonist • Diagnosis: Nocturnal symptoms of asthma • Investigations: • Management: BTS guideline alongside9. A 66 year old man with a known history of emphysema is brought to the A & E by ambulance. He is acutely breathless and can barely speak. He has a RR 40 breaths/minute, a pulse rate of 130 beats/minute, BP 80/60. Air entry is poor on the left and inaudible on the right and his trachea is deviated to the left. What is the single most appropriate immediate action? a) Insert a chest drain into the left pleural cavity b) Insert a chest drain into the right pleural cavity c) Insert an Endotracheal tube d) Insert a wide bore needle into the left pleural cavity e) Insert a wide bore needle into the right pleural cavityAnswer: Insert a wide bore needle into the right pleural cavity • Diagnosis: Tension (spontaneous) pneumothorax • Points in favour: • Investigations: • Management: