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Respiratory
Hugo Duncan-DuggalQuestion 1:
A 67-year-old women from Pakistan, presents to ED
with a 1-week history of shortness of breath, a
productive cough and a fever.
She has a PMH of eczema and hypertension, she has What is the most likely causative organism?
never smoked but does disclose with you that she
drinks about 2 bottles of wine a day. She has not A – Mycobacterium tuberculosis
recently left the country and lives at home with family
who are all well. B - Legionella pneumophillia
Obs: C - Mycoplasma pneumoniae
HR 95
BP 138/95 D - Streptococcus pneumoniae
Sats 92% on air
RR 23 E – Klebsiella pneumoniae
Temp 38.0
You order a chest x-ray which shows cavitating lesions
in the right upper zone.Question 1:
A 67-year-old women from Pakistan, presents to ED
with a 1-week history of shortness of breath, a
productive cough and a fever.
She has a PMH of eczema and hypertension, she has What is the most likely causative organism?
never smoked but does disclose with you that she
drinks about 2 bottles of wine a day. She has not A – Mycobacterium tuberculosis
recently left the country and lives at home with family
who are all well. B - Legionella pneumophillia
Obs: C - Mycoplasma pneumoniae
HR 95
BP 138/95 D - Streptococcus pneumoniae
Sats 92% on air
RR 23 E – Klebsiella pneumoniae
Temp 38.0
You order a chest x-ray which shows cavitating lesions
in the right upper zone.T opic 1: Pneumonia
Features:
Signs – changes on auscultation, cyanosis (severe),
confusion (severe)
• Bedsidetions:
• Obs, sputum sample, urinary sample, ECG
• Bloods
• FBC, U&Es, CRP, blood cultures
• Imaging
• CXRT opic 1: Pneumonia
Organism Typical or Atypical Exam clues
Streptococcus pneumoniae Typical Most common, 80% of CAPs
Haemophilus influenzae Typical Common in patients with
COPD
Staphylococcus aureus Typical Seen after initial influenza
infection, cavitating lesion on
CXR
Legionella pneumophila Atypical Infected air-conditioning
units, low sodium (SIADH)
Mycoplasma pneumoniae Atypical Erythema multiforme (target
lesions), neuro symptoms in
some patients
Chlamydophila pneumoniae Atypical Chronic pneumonia in school
age children
Coxiella burnetii Atypical Animal bodily fluids –
farmers with flu-like illness
Chlamydia psittaci Atypical From infected birds – parrot
ownersQuestion 2:
A 32-year-old man presents to the emergency
department complaining of chest pain, this started last
night and has not improved today. The pain is sharp What is the most appropriate next step in
and worse on inspiration. management for this patient?
PMH: Bronchiectasis and he smokes 20 cigarettes / day. A - Give oxygen and admit for 24 hours monitoring
On examination he appears breathless B - Insert chest drain
Obs: C - Attempt needle aspiration
HR 125
BP 132/91 D - Reassure and discharge with outpatient review in 2-
RR 24/min 4wks
Sats 92% on room air
Chest x-ray shows a pneumothorax with a 3cm rim of E - Reassure and discharge with lifestyle advice
air.Answer 2:
A 32-year-old man presents to the emergency
department complaining of chest pain, this started last
night and has not improved today. The pain is sharp What is the most appropriate next step in
and worse on inspiration. management for this patient?
PMH: Bronchiectasis and he smokes 20 cigarettes / day. A - Give oxygen and admit for 24 hours monitoring
On examination he appears breathless B - Insert chest drain
Obs: C - Attempt needle aspiration
HR 125
BP 132/91 D - Reassure and discharge with outpatient review in 2-
RR 24/min 4wks
Sats 92% on room air
Chest x-ray shows a pneumothorax with a 3cm rim of E - Reassure and discharge with lifestyle advice
air.• If haemodynamically compromised = chest drain
• Triangle of safety for chest drain = 5 ICS, midaxillary
line, anterior axillary line
• Follow up – all patients require a follow up 2-4wks
later:
• Stop smoking to reduce risk of further episodes
• BTS advise not to fly until one week post check
x-ray
• Scuba diving – should be permanently avoidedQuestion 3:
Bill is a 67-year-old man recovering on the orthopaedic
ward after a total hip arthroplasty.
He tells you that he has a sharp chest pain when
What is the most likely underlying cause of this
breathing in and has become more short of breath and patients pleural effusion?
developed a cough over the last 48hrs.
A – Lung malignancy
Bill has a 35-pack year smoking history and has had a
previous myocardial infarction in 2014.
B – Pneumonia
On examination he has reduced breath sounds on the
bilaterally and a dullness to percussion. C – Pancreatitis
A chest x-ray demonstrates a moderate bilateral pleural D – Congestive cardiac failure
effusion.
E – Asthma
A pleural tap is conducted, which reveals a protein level
of 2.5 g/L.Answer 3:
Bill is a 67-year-old man recovering on the orthopaedic
ward after a total hip arthroplasty.
He tells you that he has a sharp chest pain when What is the most likely underlying cause of this
breathing in and has become more short of breath and patients pleural effusion?
developed a cough over the last 48hrs.
A – Lung malignancy
Bill has a 35-pack year smoking history and has had a
previous myocardial infarction in 2014. B – Pneumonia
On examination he has reduced breath sounds C – Pancreatitis
bilaterally and a dullness to percussion.
D – Congestive cardiac failure - Transudative pleural
A chest x-ray demonstrates a moderate bilateral pleural effusion
effusion
A pleural tap is conducted, which reveals a protein level E – Asthma
of 2.5 g/L.T opic 3: Pleural effusion
Collection of fluid in the pleural space.
Features:
• Shortness of breath
• Dullness to percussion over the effusion
• Reduced breath sounds
• Tracheal deviation away from effusion (in very large
effusions)
Investigations:
• Bedside:
• Obs, sputum sample, ECG
• Bloods:
• FBC, U&Es, CRP, blood cultures
• Imaging:
• CXR, USS, CT
• Special tests:
• Pleural aspirate analysisT opic 3: Pleural effusion
Transudate vs Exudate:
• Classified according to protein concentration
• Transudate almost always associated with an
imbalance of fluid or protein
• Exudate usually due to specific pleural pathology
and inflammation
Light’s criteria:
• Used to establish exudative effusion using protein or
LDH
• Used when protein content is borderline (25-35 g/L)
• An exudate is likely if at least one of the following is
present:
• Pleural fluid protein / serum protein >0.5
• Pleural fluid LDH / serum LDH >0.6
• Pleural fluid LDH more than 2/3 the upper
limits of normal serum LDHT opic 3: Pleural effusion
Feature Potential diagnosis
Low glucose Rheumatoid arthritis, TB
Raised amylase Pancreatitis, oesophageal perforation
Heavy blood staining Mesothelioma, PE, TB, trauma
Purulent (clear but with pH less than 7.2) Pleural infection (empyema)
Milky fluid ChylothoraxQuestion 4:
Which of the following conditions is most
A 62-year-old man presents to the respiratory clinic likely to have caused the patients symptoms
after being referred by his GP for persistant shortness and CT findings?
of breath and a dry cough. He has not smoked for 25
years but does have a 20-pack-year smoking history
from when he was younger. A – Tuberculosis
Systemically he is well but symptoms have been getting B – Coal workers pneumoconiosis
worse over the last 8 months.
On examination he has bibasal fine end-inspiratory C – Idiopathic pulmonary fibrosis
crackles and finger clubbing.
D – Sarcoidosis
A high-resolution CT scan shows a ground glass
appearance to the lower zones of the lungs bilaterally.
E – Hypersensitivity pneumonitisAnswer 4:
Which of the following conditions is most
A 62-year-old man presents to the respiratory clinic likely to have caused the patients symptoms
after being referred by his GP for persistant shortness and CT findings?
of breath and a dry cough. He has not smoked for 25
years but does have a 20-pack-year smoking history
from when he was younger. A – Tuberculosis
Systemically he is well but symptoms have been getting B – Coal workers pneumoconiosis
worse over the last 8 months.
On examination he has bibasal fine end-inspiratory C – Idiopathic pulmonary fibrosis
crackles and finger clubbing.
D – Sarcoidosis
A high-resolution CT scan shows a ground glass
appearance to the lower zones of the lungs bilaterally.
E – Hypersensitivity pneumonitisT opic 4: Interstitial lung disease
• Umbrella term for many conditions that cause
inflammation and fibrosis of the lung parenchyma.
• This involves the replacement of elastic functional tissue
with non-functional scar tissue.
Features
• Shortness of breath, dry cough, fatigue
• IPF specific - Bibasal fine end-inspiratory crackles, finger
clubbing
Diagnosis
• High resolution CT – honeycomb appearance
• Spirometry
Management
• Remove/treat underlying cause
• Stop smoking
• Physiotherapy and pulmonary rehab
• Pneumococcal and flu vaccine
• Lung transplantT opic 4: Interstitial lung disease
Spirometry interpretation
• Method of assessing lung function by measuring
volume of air patients can expel from the lungs.
• Differentiates between obstructive and restrictive
airway disorders. Obstructive pattern:
• Reduced FEV1 (<80% of predicted normal)
Obstructive – COPD, asthma, emphysema, • Reduced FVC (to a lesser extent than FEV1)
bronchiectasis • FEV1/FVC ratio reduced (<0.7)
Restrictive – fibrotic lung disease, pulmonary oedema, • Test for reversibility with bronchodilator can be
skeletal abnormalities useful if considering asthma
Restrictive pattern:
• Can also be used to monitor disease severity • Reduced FEV1 (<80% of predicted normal)
• FEV1 = volume exhaled in first second with forced • Reduced FVC (<80% of the predicted normal)
expiration (>80% predicted) • FEV1/FVC ratio normal (>0.7)
• FVC = total volume of air that can be forcibly exhaled
in one breath (>80% predicted)
• FEV1/FVC = ratio expressed as a percentage (>0.7)T opic 4: Interstitial lung disease
Causes of Pulmonary fibrosis
• Can be split into causes of upper or lower zone fibrosis
Lower zone (RASIO) Upper zone (CHARTS)
• Coal-worker pneumoconiosis
• Rheumatoid arthritis
• Asbestosis • Hypersensitivity pneumonitis:
• SLE, scleroderma and Sjogren's syndrome • Bird fancier's lung
• Farmers lung
• Idiopathic pulmonary fibrosis (most common cause) • Malt workers lung
• Other (including drugs): • Ankylosing spondylitis
• Amiodarone
• Methotrexate • Radiation (e.g. for breast cancer)
• Nitrofurantoin • Tuberculosis
• Sarcoidosis and silicosisQuestion 5:
A 21-year-old woman presents to the emergency
department with sudden onset dyspnoea. Her
symptoms started 1.5hrs ago.
Which feature from the history, examination and
On examination, she is unable to talk in full sentances investigations indicates that she is having a life-
and she has a widespread bilateral wheeze. She has no threatening asthma exacerbation?
rash.
A – Her inability to talk in full sentances
You carry out some observations, a peak flow reading
and an ABG. B – Her oxygen saturations
Peak flow: 240 (her usual best is 600) C – The widespread bilateral wheeze
Obs: ABG D – Her peak flow result
• HR 117
• RR 29 pH 7.39 (7.35-7.45) E – Her pCO2
• BP 125/82 pCO2 5.5 kPa (4.5-6.0)
• Temp 36.5
• Sats 94% pCO2 10.0 kPa (10-14)Answer 5:
A 21-year-old woman presents to the emergency
department with sudden onset dyspnoea. Her
symptoms started 1.5hrs ago.
Which feature from the history, examination and
On examination, she is unable to talk in full sentances investigations indicates that she is having a life-
and she has a widespread bilateral wheeze. She has no threatening asthma exacerbation?
rash.
A – Her inability to talk in full sentances
You carry out some observations, a peak flow reading
and an ABG. B – Her oxygen saturations
Peak flow: 240 (her usual best is 600) C – The widespread bilateral wheeze
Obs: ABG D – Her peak flow result
• HR 117
• RR 29 pH 7.39 (7.35-7.45) E – Her pCO2
• BP 125/82 pCO2 5.5 kPa (4.5-6.0)
• Temp 36.5
• Sats 94% pCO2 10.0 kPa (10-14)T opic 5: Acute asthma
Moderate Severe Life-threatening Near-fatal
PEFR >50-75% PEFR 33 - 50% PEFR <33% Raised pCO2
Normal speech Unable to complete Exhaustion, poor Requiring mechanical
sentances in one breath respiratory effort (silentventilation with raised
chest), cyanosis, inflation pressures
arrhythmia, hypotension
Saturations >92% Saturations <92% SpO2 <92%
Increasing symptoms HR >110 Altered consciousness /
confusion
RR >25 PaO2 <8 kPa
Normal pCO2 (4.6 – 6.0
kPa)
https://www.brit-thoracic.org.uk/document-library/guidelines/asthma/bts-sign-guideline-for-the-management-of-asthma-2019/Topic 5: Acute asthma
“O.S.H.IT.M.E”
HighYieldMedicsQuestion 6:
A 57-year-old man attends his GP for a general check-
up. He is a heavy smoker with 55 pack years and drinks
about 10 pints most weekends.
You send him to the hospital for further investigations,
He reports that he has had a continuous cough for his CXR shows a right hilar mass suspicious for
about 3 months and has begun to cough up some malignancy.
blood. He has also noticed his face has become rounder What is the most likely diagnosis?
and he has put on about 10kg of weight. He mentions
noticing some purple lines appearing on the skin of his A – Metastatic deposits
abdomen too.
He has no significant PMH and is not on any regular B – Adenocarcinoma of the lung
medications.
C – Squamous cell lung cancer
On examination he struggles to get up out of the chair, D – Small cell lung cancer
he has a persistent cough, but his chest is clear and
heart sounds are normal. All other examination findings E – Mesothelioma
are normal apart from his BP which is raised.Answer 6:
A 57-year-old man attends his GP for a general check-
up. He is a heavy smoker with 55 pack years and drinks
about 10 pints most weekends.
You send him to the hospital for further investigations,
He reports that he has had a continuous cough for his CXR shows a right hilar mass suspicious for
about 3 months and has begun to cough up some malignancy.
blood. He has also noticed his face has become rounder What is the most likely diagnosis?
and he has put on about 10kg of weight. He mentions
noticing some purple lines appearing on the skin of his A – Metastatic deposits
abdomen too.
He has no significant PMH and is not on any regular B – Adenocarcinoma of the lung
medications.
C – Squamous cell lung cancer
On examination he struggles to get up out of the chair, D – Small cell lung cancer
he has a persistent cough, but his chest is clear and
heart sounds are normal. All other examination findings E – Mesothelioma
are normal apart from his BP which is raised.T opic 6: Lung Cancer
Features:
Symptoms – Fever, malaise, haemoptysis, dyspnoea,
cough, weight loss, recurrent pneumonia
Signs – Stridor, wheeze, lymphadenopathy
(supraclavicular), clubbing
Investigations:
• Bloods
• FBC
• U&Es
• LFTs
• Calcium/Bone profile
• Imaging
• CXR
• CT chest
• PET-CT
• CT head (screen for mets)T opic 6: Lung Cancer
Extrapulmonary manifestations
• Recurrent laryngeal nerve palsy
• Phrenic nerve palsy
• Superior vena cava obstruction
• Horner’s syndrome
• SIADH
• Cushing’s syndrome
• Hypercalcaemia
• Limbic encephalitis
• Lambert-Eaton myasthenic syndromeQuestion 7:
A 75-year-old man is recovering from hip fracture
surgery 4 days ago. You are called to go and assess him Given the likely diagnosis, what is the most
as the nurse reports he has become acutely short of appropriate diagnostic investigation to perform?
breath. He also describes some chest pain since this
morning that is sharp and worse on inspiration.
A – CTPA
You note in his notes that he has a history of CKD stage
5 and type 2 diabetes. B – Echocardiogram
C – V/Q perfusion scan
On examination his chest is clear, and his observations
are as follows: D – D-dimer
• Heart rate: 120/min
• Respiratory rate: 23/min
• Temperature: 37.5 E – Chest x-ray
• Blood pressure: 110/85Answer 7:
A 75-year-old man is recovering from hip fracture
surgery 4 days ago. You are called to go and assess him Given the likely diagnosis, what is the most
as the nurse reports he has become acutely short of appropriate diagnostic investigation to perform?
breath. He also describes some chest pain since this
morning that is sharp and worse on inspiration.
A – CTPA
You note in his notes that he has a history of CKD stage
5 and type 2 diabetes. B – Echocardiogram
C – V/Q perfusion scan
On examination his chest is clear, and his observations
are as follows: D – D-dimer
• Heart rate: 120/min
• Respiratory rate: 23/min
• Temperature: 37.5 E – Chest x-ray
• Blood pressure: 110/85T opic 7: Pulmonary Emboli
Risk factors:
• Immobility
• Recent surgery
• Long-haul flight
• Malignancy
• Pregnancy
Presentation:
Symptoms: SOB, cough, haemoptysis, pleuritic chest
pain, leg swelling
Signs: Tachycardia, tachypnoea, hypotension, low grade
fever
Diagnosis:
• CXR
• Wells score
• Likely - perform a CTPA or alternative imaging
• Unlikely – perform a d-dimer, and if positive,
perform CTPA
• If haemodynamically unstable à immediate
thrombolysisT opic 7: Pulmonary Emboli
Treatment
• First line treatment is with
DOAC drugs
• Length of treatment:
• Unprovoked = 6 months
• Provoked = 3 months
• Haemodynamic instability -
thrombolysisThings covered:
What we have covered: Other topics to look over
Pneumonia COPD
Pneumothorax Tuberculosis
Pleural effusion Sarcoidosis
Interstitial lung disease Chronic asthma
Acute asthma Cystic fibrosis
Lung cancer / Paraneoplastic syndromes
Pulmonary emboliThank you!
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