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Respiratory For FinalsT opics Covered: • Asthma • COPD • TB • Pleural Effusions • Lung Malignancy • Pneumonia • Interstitial Lung Disease • Pneumothorax • Pulmonary Embolism Q U E S T I 1 N A 46 year old male comes in with acute shortness of A CPAP breath. On inspection, the patient is visibly uncomfortable, and can not complete his sentences. The B BiPAP patient is quickly given oxygen, NEB salbutamol, IV Hydrocortisone and NEB Ipratropium along with IV MgSO4. On auscultation, the chest sounds quiet. The C NEB Adrenaline patient’s ABG results are shown below: pH- 7.38 D PO Prednisolone O2- 9.3KPa CO2- 4.8KPa E Invasive Mechanical Ventilation HCO3- 25 mmol/l Given the likely diagnosis, what is the most appropriate ANSWER ON THE ZOOM POLL next step in the management of this patient. Q U E S T I 1 N A 46 year old male comes in with acute shortness of A CPAP breath. On inspection, the patient is visibly uncomfortable, and can not complete his sentences. The B BiPAP patient is quickly given oxygen, NEB salbutamol, IV Hydrocortisone and NEB Ipratropium along with IV MgSO4. On auscultation, the chest sounds quiet. The C NEB Adrenaline patient’s ABG results are shown below: pH- 7.38 D PO Prednisolone O2- 11KPa CO2- 4.8KPa E Invasive Mechanical Ventilation HCO3- 25 mmol/l Given the likely diagnosis, what is the most appropriate ANSWER ON THE ZOOM POLL step in the management of this patient. Asthma Pathophysiology Clinical Features • Reversible airway obstruction • Secondary to hypersensitivity reaction to non harmful stimuli e.g • Attacks of SOB pollen, dust mite faeces. • Nocturnal cough • Eosinophil mediated • Hay fever, asthma, eczema hypersensitivity reaction. ID rId3 was not found in the file. Diagnosis Treatment • Spirometry- Obstructive with • INH Salbutamol bronchodilator reversibility • INH ICS • FeNO- indicated inflammation in • LTRA the airways • LABA • Peak Flow - diurnal variation • MART?? Asthma Attack Moderate Severe • SpO2 < 92% PEF 33-50% best or predicted • SpO2 > 92% Can't complete sentences in one PEF > 50% best or predicted breath Heart rate > 125/min Respiratory rate > 30/min Use of accessory neck muscles Life Threatening Treatment • SpO2 < 92% PEF < 33% best or predicted • Oxygen Silent chest • NEB Salbutamol Poor respiratory effort • IV hydrocortisone Altered consciousness Cyanosis Asthma Important Pts 1 2 3 Children under the age of 5 Remember: O SHIM TE for not diagnosed with asthma: acute exacerbations of Atopic Triad: Hay fever, as may be viral induced asthma Exzema, Asthma wheeze, or small airways INV may be required which may resolve with age Q U E S T I O2N A 55 year old male presents to his GP complaining of a A Strep Pneumonie productive cough, which he describes to be green in colour. He also mentions that over the past 5 years or B Staph Aureus so he is becoming progressively short of breath on exertion to the extent where now he can only walk on flat ground as any incline makes him very breathless. C Pseudomonas Aeruginosa He also mentions that he has had a cough for quite a while now, but the mucus is usually clear. Given the D Pneumocystis Jerovicii likely diagnosis, what organism is responsible for this patient’s condition? E Haemophilus Influenza B ANSWER ON THE ZOOM POLL Q U E S T I O2N A 55 year old male presents to his GP complaining of a A Strep Pneumonie productive cough, which he describes to be green in colour. He also mentions that over the past 5 years or B Staph Aureus so he is becoming progressively short of breath on exertion to the extent where now he can only walk on flat ground as any incline makes him very breathless. C Pseudomonas Aeruginosa He also mentions that he has had a cough for quite a while now, but the mucus is usually clear. He has a 40 D Pneumocystisis Jerovicii pack year smoking history. Given the likely diagnosis, what organism is responsible for this patient’s E Haemophilus Influenza B condition? ANSWER ON THE ZOOM POLL COPD Pathophysiology Clinical Features • Smoking is the most common • Progressive SOB cause • Productive cough- usually clear, • Irreversible airway obstruction non purulent • Comprises of Chronic Bronchitis and Emphysema • Pursed lip breathing • Auscultation- Wheeze Diagnosis Treatment • Spirometry- Obstructive with no • SABA/SAMA bronchodilator reversibility • SABA + LABA + LAMA • CXR- Hyperinflated lungs- • SABA + LABA+ ICS flattened hemidiaphragms • SABA + LABA + LAMA + ICS COPD: Important Pts 1 2 3 LTOT: Patients with a PO2 of less than 7.3 or between 7.3-8 For COPD exacerbations Acute Exacerbations: and: with no production of REMEMBER O SHIT Secondary Polycythaemia purulent sputum, NIV Pulmonary Hypertension prednisolone for 5 days in the first choice treatment Peripheral Oedema Q U E S T I O3N A 57 year old male presents to A&E with productive A Manteux test cough and haemoptysis. The patients observations show that he has a temperature of 38.9 degrees, a B Blood cultures respiratory rate of 33 breaths per minute and a pulse rate of 88 beats per minute. He mentions that he is a doctor by profession and just spent a month in rural C 3 early morning sputum samples India, helping charity clinics. On examination there is no calf tenderness or swelling present. Given the likely D CTPA diagnosis, what is the gold standard investigation for this condition. E Duplex Ultrasound ANSWER ON THE ZOOM POLL Q U E S T I O3N A 57 year old male presents to A&E with productive A Manteux test cough and haemoptysis. The patients observations show that he has a temperature of 38.9 degrees, a B Blood cultures respiratory rate of 33 breaths per minute and a pulse rate of 88 beats per minute. He mentions that he is a doctor by profession and just spent a month in rural C 3 early morning sputum samples India, helping charity clinics. On examination there is no calf tenderness or swelling present. Given the likely D CTPA diagnosis, what is the gold standard investigation for this condition. E Duplex Ultrasound ANSWER ON THE ZOOM POLL TB Pathophysiology Clinical Features • Cause by Mycobacterium • Productive Cough Tuberculosis • Haemoptysis • Fever • Latent- Caseating granulomas • ALL IN ACTIVE TB • Opportunistic in nature Diagnosis Treatment • ACTIVE - 3 Early morning sputum • For active TB: RIPE samples sent for MC&S • For Latent TB:Isonizid for 6 • LATENT- Manteux test or IGRA months or R+I for three months TB: Important Pts 1 2 3 Always ensure that you R- Orange secretions ACTIVE TB: RIPE for 2 rule out TB in patients from I- Peripheral Neuropathy months followed by R+I for TB endemic regions for P- Gout a further 4 months example the Indian Subcontinent E- Optic Neuritis Q U E S T I O4N A 78 year old female has been transferred to the A Pneumonia respiratory ward to investigate her shortness of breath. On examination, there is a dull percussion note over the B COPD right and left lower zones, with diminished breath sounds and reduced vocal resonance over these areas as well. She has a past medical history C Mesothelioma hypercholesterolaemia, has had 2 previous myocardial infarctions and was recently diagnosed with bilateral D Heart Failure knee osteoarthritis. Given the information above which of the following is the most likely cause of her E Squamous Cell Carcinoma findings? ANSWER ON THE ZOOM POLL Q U E S T I O4N A 78 year old female has been transferred to the A Pneumonia respiratory ward to investigate her shortness of breath. On examination, there is a dull percussion note over the B COPD right and left lower zones, with diminished breath sounds and reduced vocal resonance over these areas as well. She has a past medical history C Mesothelioma hypercholesterolaemia, has had 2 previous myocardial infarctions and was recently diagnosed with bilateral D Heart Failure knee osteoarthritis. Given the information above which of the following is the most likely cause of her E Squamous Cell Carcinoma findings? ANSWER ON THE ZOOM POLL Pleural Effusions Pathophysiology Clinical/ Exam Features • Collection of fluid in the pleural • SOB space. • Dull percussion note • Reduced Vocal resonance • Can be due to malignancy, organ • Reduced breath sounds over those failure or infection zones Diagnosis Treatment • Usually a pleural aspirate is taken, to check its pH, this is to determine • CXR will show blunting of the the cause of the infection. costophrenic angle • Chest drains may be required to • Meniscal sign may be seen drain large effusions, or infected effusions as well. • Pleurodesis • Exudative Vs Transudative • Bilateral Vs Unilateral Pleural Effusions: • Remember the examination signs!! Things to consider • Pleural Aspiration- pH <7.2- Infection?? • Rapid removal of flui- Re-expansion Pulmonary OedemaPleural Effusions Q U E S T I O 5 A 78 year old male presents to the GP complaining of A Adenocarcinoma abdominal pain and constipation. Recently he had an admission due to kidney stones. On examination, there B Squamous Cell Carcinoma is a monophonic wheeze over the right middle zone. He also mentions that he has lost about 2 stone in weight over the last month or so. He also admits to smoking 40 C Giant Cell Carcinoma cigarettes a day for the past 50 years. What is the most likely cause of this patient’s condition. D Mesothelioma E Small CellCarcionma ANSWER ON THE ZOOM POLL Q U E S T I O5N A 78 year old male presents to the GP complaining of A Adenocarcinoma abdominal pain and constipation. Recently he had an admission due to kidney stones. On examination, there B Squamous Cell Carcinoma is a monophonic wheeze over the right middle zone. He also mentions that he has lost about 2 stone in weight over the last month or so. He also admits to smoking 40 C Giant Cell Carcinoma cigarettes a day for the past 50 years. What is the most likely cause of this patient’s condition. D Mesothelioma E Small Cell Carcinoma ANSWER ON THE ZOOM POLL Adenocarcinoma Small Cell Lung Cancer Squamous Cell Usually affects the Very aggressive, Most common in lung peripheries quickly smokers metastasizes Most common Affects large Lung cancer in SIADH airways (Central) non-smokers Ectopic ACTH PTHrP Interestingly most of those who get it Lambert Eaton are smokers Mesothelioma 1 2 3 Usually associated with Poor prognosis, Video Usually large unilateral Assisted Thoracoscopy asbestos exposure. pleural effusions are a sign. could be used to take Can receive compensation These are exudative biopsies of the pleural OCCUPATION Hx essential lining Q U E S T I O 6 A 38 year old male presents to the A&E with severe A COPD shortness of breath on exertion. He has previously undergone treatment forHogdkin’slymphoma. The B Buerger’sdisease patient is afebrile, has never smoked and if fine at rest. Given the above information, what is the most likely diagnosis. C Alpha -1 Antitrypsin deficiency D Asthma E Pulmonary fibrosis ANSWER ON THE ZOOM POLL Q U E S T I O 6 A 38 year old male presents to the A&E with severe A COPD shortness of breath on exertion. He has previously undergone treatment forHogdkin’slymphoma. The B Buerger’sdisease patient is afebrile, has never smoked and if fine at rest. Given the above information, what is the most likely diagnosis. C Alpha -1 Antitrypsin deficiency D Asthma E Pulmonary fibrosis ANSWER ON THE ZOOM POLL Drug Induced: Nitrofurantoin Systemic disease: Idiopathic Bleomycin RA Methotrexate Pulmonary Fibrosis Desaturation on Fine end inspiratory CT- gold standard to exertion crackles Dx Pulmonary Fibrosis- Cheat Sheet Remember the causes for upper lobe fibrosis: • C- Coal workers pneumoconiosis • H- Histiocytosis • A- Ankylosing spondylitis • R- Radiation • T- TB • S- Sarcoidosis • Classically Patients with PF are fine at rest and become greatly breathless on exertion. https://radiopaedia.orgarticles/idiopathic pulmonary-fibrosis Pulmonary Fibrosis Pathophysiology Clinical Features • Fibrotic changes- collagen deposition in the interstitium of the • Exertional dyspnoea • Dry cough lung. • Causes a restrictive picture Diagnosis Treatment • Mostly supportive • HRCT • LTOT • CXR could show shadowing • Lung transplantation • Restrictive spirometry taste • Nintedinib Q U E S T I O7N A 46 year old male comes in complaining left sided A Urgent CXR chest pain. On examination the patient has reduced breath sounds on the left, with a hyper resonant B Chest drain insertion percussion note. He has a past medical history of COPD. Given the likely diagnosis, what is the next step in the management of this patient. C Urgent pericardiocentesis D Urgent needle decompression E Aspiration ANSWER ON THE ZOOM POLL Q U E S T I O7N A 46 year old male comes in complaining left sided A Urgent CXR chest pain. On examination the patient has reduced breath sounds on the left, with a hyper resonant B Chest drain insertion percussion note. He has a past medical history of COPD. Given the likely diagnosis, what is the next step in the management of this patient. C Urgent pericardiocentesis D Urgent needle decompression E Aspiration ANSWER ON THE ZOOM POLL • Borders of the triangle of Safety: Lateral border of the pec mthor, border of the Lat Dorsi, apex of axilla, 5 intercostal space • Tracheal deviation awayTension Pneumothorax: pneumothorax Important • Do not wait for CXR in patients with points tension pneumothoraxes • Hyper resonant percussion note • Bullae rupture in COPD, tall thin individuals could result in pneumothoraxBASED ON BTS 2010 GUIDELINES SPONTANEOUS PNEUMOTHORAX BILATERAL ABCDE ASSESSMENT CHEST DRAIN AGE > 50 & SMOKING HISTORY OR EVIDENCE OF LUNG DISEASE SECONDARY PRIMARY SIZE >2cm AND/OR SIZE >2cm AND/OR BREATHLESS BREATHLESS CONSIDER DISCHARGE & REVIEW IN ASPIRATE ASPIRATE SIZE 1-2cm OUTPATIENTS ADMIT SUCCESS? GIVE HIGH FLOW (SIZE < 2cm & CHEST DRAIN SUCCESS? O2 breathing improved) (SIZE < 1cm) OBSERVE Q U E S T I O8N A 46 year old patient comes with to the GP presenting A Amoxicillin with a fever and shortness of breath. The patient has normal oxygen saturations of 96% at rest however it B Clarithromycin drops significantly to 88% on movement. The patient has poorly controlled HIV. Given the likely diagnosis, what is the drug of choice to treat this condition. C Co -trimoxazole D Meropenem E Piperacillin and tazobactam ANSWER ON THE ZOOM POLL Q U E S T I O8N A 46 year old patient comes with to the GP presenting A Amoxicillin with a fever and shortness of breath. The patient has normal oxygen saturations of 96% at rest however it B Clarithromycin drops significantly to 88% on movement. The patient has poorly controlled HIV. Given the likely diagnosis, what is the drug of choice to treat this condition. C Co -trimoxazole D Meropenem E Piperacillin and tazobactam ANSWER ON THE ZOOM POLL Pneumonia 1 2 3 Remember CURB 65: Score 0- Home treatment CAP- < 48 hours post Score 1- Assess the Risk Admission Atypical Pneumonias may Score of 2 above- HAP> 48 hours post have completely normal CXRs!!! Hospitalise admission Score 3,4- High risk- ITU? • Alcoholic/ Diabetic with cavitating lesion- Klebsiella- Carbapenems • May present with atypical chest pain, Pneumonia: radiating to the back Things to • In children with lobar pneumonia, typical signs may be absent, always watch out consider for RESP DISTRESS • Post 5 days in hospital, if HAP usually Abx given to cover pseudomonas • Can cause SIADH and thus hyponatremiaMycoplasma. Pneumonie LEGIONELLA P. JEROVOCII ATYPICAL HYPONATREMIA HIV ERYTHEMA MULTIFORME A/C COMMON CAUSE EXERTIONAL DESTATURATION MACROLIDE MACROLIDE IF PO2< 9.3- STEROIDS CAUSES GBS CO- TRIMOXAZOLE S AUREUS STREP PNEUMONIE Haemophilus Influenza POST VIRAL INFECTION MOST COMMON CAUSE OF CAP COPD HAP- POST 48HRS ADMISSION CURB SCORE DEPENDANT TX BRONCHIECTASIS USUALLY AMOXICILLIN, CLARITHROMYCIN QUICK OVERVIEW- CYSTIC FIBROSIS • CFTR CHANNEL DEFECT: • RESPIRATORY; • VISCOUS SECRETIONS • BEFORE 12- S AUREUS • AFTER 12- PSEUDOMONAS • CLOGGING OF DUCTS E.G PANCREAS, VAS DEFERENS • CHEST PHYSIO • PROPHYLACTIC ABX It is important to note the CF patients can present with meconium ileus at birth- failure to pass the first stool. Signs of pancreatic insufficiency too are common: pale stools, due to fat malabsorption Q U E S T I O9N A 48 year old female presents to the emergency A V/Q Scan department with dyspnoea, and left sided chest pain. She has recently returned from the Bahamas, and B CTPA mentions that she did have some leg tenderness after that. Her blood pressure is 85/40. Given the likely diagnosis, what is the next step in her management. C Anticoagulation with apixaban D IV steptokinase E CXR ANSWER ON THE ZOOM POLL Q U E S T I O9N A 48 year old female presents to the emergency A V/Q Scan department with dyspnoea, and left sided chest pain. She has recently returned from the Bahamas, and B CTPA mentions that she did have some leg tenderness after that. Her blood pressure is 85/40. Given the likely diagnosis, what is the next step in her management. C Anticoagulation with apixaban D IV streptokinase E CXR ANSWER ON THE ZOOM POLL Pulmonary Embolism 1 2 3 Usually if provoked- Calculate a 2 level well’s 3months of anticoagulation If Haemodynamically score: e.g Apixaban Unstable- Thrombolyse!! Greater than 4- CTPA If unprovoked- 6 months 4 or less- D- dimer For cancer patient- 3-6 months • Long haul flights, cancer, thrombophilia, immobility • If they have a PFO- DVT could lead to Pulmonary stroke Embolism: • If CTPA is negative- proximal vein USS to rule out DVT Things to consider • If CTPA after 4 hours- start anticoagulation with DOAC • VTE prophylaxis essential in hospital patients usually LMWH used for this PLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK! @OSCEazyOfficial @osceazyofficial OSCEazy Osceazy@gmail.com