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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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