This on-demand teaching session provides an in-depth look at how to manage patients with complicated breathing conditions including COPD, asthma, and pneumonia. You'll learn how to differentiate between these conditions and get comprehensive insight into essential clerking history and physical exam findings. We'll delve into key aspects of the physical exam such as respiratory distress signs, abnormal breathing sounds, chest expansion, and more. The session also covers crucial investigations such as CXR, ABG, full set of bloods, and sputum culture. You'll gain understanding of pneumonia findings, CURB-65 scoring system, and ABG interpretation. Plus, we'll outline how to determine whether a patient needs to be admitted to hospital or discharged. Finally, we'll discuss the medical management of COPD and asthma, specifically focusing on the type of medications to administer, methods of delivery, and durations of course. This is an invaluable class for medical professionals who diagnose and treat respiratory conditions.
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IE COPD, asthma + pneumonia Sumran ImtiazContents - Case - Clerking - Physical exam findings - Investigations - Management - CaseCase 75M Breathlessness Cough BIBA See the ABG here- thoughts? Clerking history What questions are important for us to ask to distinguish if the patient is having one of these? Bonus Q: How can we distinguish between the 3 diseases individually?Clerking history- what symptoms do we look for? - Duration of SOB - Is this their first episode? Or chronically suffer from this? - Is this their first time admitted to hospital with this issue? Or have they had multiple hospital admissions with this same complaint? - Past medical history? Known COPD/asthma? H/o malignancy? - Medications they are currently taking @ home - Have they been seen in hospital/by the respiratory clinic? - If known disease, how do they routinely manage it @ home? - Do they smoke? (VERY IMPORTANT) - How far can you walk before feeling breathless? Helps to establish baseline and current condition. Aim is to bring them back to their baseline - Consider their age - Are they producing any sputum? What color is it and how much? (IMP) - Associated symptoms: fever, chest pain - Make sure you have checked the GP records before seeing these patients as these can hold valuable information re. pt PMH, especially if they are a poor historian or non compliantPhysical exam What should we be noting from physical exam?Physical exam - Do the usual respiratory physical exam: end of the bed assessment, use of accessory intercostal muscles, signs of labored breathing, does the pt appear in respiratory distress, grunting, abnormal breathing sounds, cyanosis, easily tiring and not completing full sentences. - Is there equal chest expansion on both sides on inspection and palpation - On auscultation, are there any: Crackles (fluid= CAP as more congestion/HF) Reduced breathing sounds Wheeze (asthma) Crepitations (COPD- obstruction and mucus accumulation) - Bonus Q: how will you manage those signs?What investigations should we do?Investigations - CXR: why? - ABG: why? - Full set of bloods: FBC UEs LFTs and CRP - Sputum culture - Follow sepsis 6 if they are query septic - Some can have sepsis presentation secondary to a respiratory pathology - What are the sepsis 6?Pneumonia findings - CXR showing consolidation/ hazy opacities - ALWAYS try to compare to an older CXR as this can be their baseline - Sputum culture: wait for the microscopy and sensitivity results and can switch the pt to a better abx - Monitor the CRP, WCC and neutrophils (bacterial infection) - Consider the need for viral swabs/urinary antigens: HIV, legionella, pneumococcal, RSV etc and also flu/COVID, especially in WinterCURB-65 score Is anyone familiar with this? Any ideas what it stands for or why we use it?CURB-65 scoring system Use your clinical judgement!ABG interpretation - Good for everyone to watch videos and understand the basic procedure - Drs usually do the ABGs on the ward/A & E and they can be done very often in acutely unwell patients to monitor their condition - Knowing how to interpret them is essential but you can always ask for help - 6 step approach (ALS) - 1) How is the patient: have brief history/context - 2) Are they hypoxaemic: PaO2 should be 10 less than inspired air (room air is 21% O2 for ref) E.g. if a pt is on 40% oxygen and sats are 15kPa this could indicate underlying issue - 3) What is the pH? Normal arterial blood is 7.35-7.45. The more acidic, the more the H ions and the more alkalotic, the less H ions present.ABG interpretation - 4) Check the paCO2 If there is abnormal paCO2, check the value and compare it with the pH. pH <7.35 (acidaemia) + raised PaCO2 (>6)= likely resp. acidosis pH >7.45 (alkalaemia) + reduced PaCO2 (<4.7)= likely resp alkalosis. Bonus: when can we see such scenarios occur? 5) Check the bicarbonate/base excess pH <7.35: is there a base deficit (<-2) or is the bicarbonate reduced (<22): likely metabolic acidosis. Could have a resp component depending on CO2. pH >7.45: is there a base excess >2 OR is the bicarbonate increased >26: likely metabolic alkalosis - Generally: BE more negative than -2 is met. acidosis and BE >2 is met alkalosis 6) Other values to consider - Assess the electrolytes: Na, K, Cl, Ca. Check Hb, glucose and lactate.Type 1 vs Type 2 respiratory failure - Also known as Scale 1 vs Scale 2How are we going to manage these conditions? - What medications will we use? - Are there other things aside from medications we can consider? - What are the key differences in the management between each of the 3 conditions e.g. how to treat a CAP differently to IE COPD?Criteria to keep patients in hospital We would usually consider emergency admission in the following cases: - Severe breathlessness - Inability to cope @ home - Poor/deteriorating general condition inc. significant comorbidities - Rapid symptom onset - Acute confusion/impaired consciousness - Cyanosis - Oxygen sats <90% on pulse oximetry or requiring oxygen to maintain sats - Failure of exacerbation to respond to therapyCriteria for discharge Weaned off oxygen Stable ABGs Off nebs for 24h Stepped down to oral abx Are they at their baseline physically/cognition?Medical management IE COPD/asthma - Varies for each according to the guidelines - Generally speaking: Beta agonists- administer depending on the severity e.g. back to back nebs/ PRN Salbutamol nebs etc Ipratropium bromide (nebulised anticholinergic) 30mg PO Prednisolone OD for 5 days if breathlessness causing interference in daily activities Consider abx if there is sputum- first choice usually Amoxicillin 500mg TDS 5 days OR Doxycycline 200mg on day 1 then 100mg daily for 5 day course total OR Clarithromycin 500mg BD for 5 days Check if the patient had a rescue pack prescribed by the GP- if had a 5 day course of steroids and on day 3, only need 2 more MAKE SURE YOU ASK FOR ALLERGIES!Medical management- acute asthma exacerbation - Usually, this will have been handled by ED or the reg will be handling it - It is more of a senior matterMedical management- CAP - Calculate CURB score - Oral/IV abx - IV fluids (prescribe and inform the nurse) - Sputum culture (print the form) - Viral swabs/ urinary antigens (nurses do this- just print the request)Further management to mention in the plan - Medical management usually first and the most urgent - ABGs - CXR - ECG - Bloods (inc CRP and also coag if hemoptysis) - Sputum culture if producing any - Consider a respiratory referral for input - Must mention asthma exacerbation on d/c or if new diagnosis - Aim for target saturations of x - Aim to wean off oxygen (if they currently have an oxygen requirement) once condition improves - COPD/asthma nurses e.g. re. inhaler education in community or in hospital - CURB score - Admitting the patient or not - Viral swabs if indicated (very elderly/very young pt/ frequent attender to ED) - Consider ceilings of care - Pts requiring further management can go to AMU-- resp can come to the ward to see them OR can move them to respiratoryThank you!! Any questions?
