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I A C n a e e - o e e p t RESPIRATORY CORE y C n t n CONDITIONS s By Ina Ko Imperial College Healthcare Trust 28 November 2022 – 6pm BRITISH INDIAN MEDICAL @ BRITISHINDIANMEDICASSOCIATION @BINDIANMEDICS @ BIMA ASSOCIATION 1 BIMA Clinical SeriesM A n a e s C e e Pneumothorax p t y o i n Pneumonia s COVID-19 Asthma Session plan COPD 2B M A i c l e e - o e R p a o y o d i n s PNEUMOTHORAX Pneumothorax refers to condition where air enters the pleural space 3B M C n a s i s C r Pneumothorax – background and presentation R s r o • Categorisation: y o Tension vs non-tension d o s Primary vs secondary • Risk factors Primary – male, young, tall, slim Secondary – smoking, FHx, CTD, chest trauma, medical procedures, pulmonary disease (e.g. asthma, COPD, CF) • Presentation SOB, pleuritic chest pain, unequal chest expansion, ↑ percussion Tension – deviated trachea, distended neck veins 4I A C n a e e - o e e p t y T ension pneumothorax – management C n t n • A-E approach s Key steps in B Breathing – supplemental O2, emergency decompression, nd Needle or cannula into 2 ICS, mid clavicular line on the affected sign • Note: if LOC or no signs of life → CPR • Admit + senior support • Insert chest drain • Follow up – chest x-ray 2 weeks after discharge 5B A C n a s e s C e Pneumothorax – e p a r investigations C n i o • Bedside s Vital signs Respiratory examination • Bloods ABG • Imaging CXR • Specialist https://radiopaedia.org/cases/34235/studies/35507?lang=gb&referrer=%2Farticles 6 %2Fpneumothorax%3Flang%3Dgb%23image_list_item_10989432I A C i l Pneumothorax - management e s C r R s a Assess SOB Admit + o Primary and size Secondary assess SOB C & size n i n s No SOB and SOB or Assess No SOB, No SOB, SOB or < 2cm >2cm Assess < 1cm 1-2 cm > 2cm Discharge + Treatment Aspirate Treatment 24 hrs high Aspirate Chest drain CXR in 2/52 flow O2 Chest drain Chest drain 7B M C n a s i s C r R s r o SBA: y o d o s • A 48 year old male attends A&E with shortness of breath. On arrival to A&E his observations are: 94% on room air, respiratory rate of 24, heart rate of 110,blood pressure is 110/80, temperature is 37. On examination he has a central trachea, reduced breath sounds and increased percussion on the left with unequal chest expansion. He has no significant past medical history. • What is the most appropriate management? a) Needle aspiration of the right chest b) Reassurance and discharge c) Admission for observation d) Needle aspiration of the left chest e) Needle decompression of the right chest 8B M C n a s i s C r R s r o SBA: y o d o s • A 48 year old male attends A&E with shortness of breath. On arrival to A&E his observations are: 94% on room air, respiratory rate of 24, heart rate of 110,blood pressure is 110/80, temperature is 37. On examination he has a central trachea, reduced breath sounds and increased percussion note on the left with unequal chest expansion. He has no significant past medical history. • What is the most appropriate management? a) Needle aspiration of the right chest b) Reassurance and discharge c) Admission for observation d) Needle aspiration of the left chest e) Needle decompression of the right chest 9B M A C n a s i s C o e e p a o Questions? y o d t n s 10B M A i c l r s - o e e p a r C o d o s PNEUMONIA Refers to infection of lung parenchyma 11I A C i l e e - o Pneumonia - background e s r o • Categorisation: y o d Typical vs atypical o s Community vs hospital acquired Special cases: aspiration, immunocompromised • Risk factors Immunocompromise, previous pneumonia, lung conditions, age, smoking, IVDU (S. Aureus), travel • Presentation of typical CAP Cough +/- sputum, SOB, chest pain (pleuritic), fever, malaise 12M A l c s i Key pathogens – typical s o e e Pathogen Key features i o y o Streptococcus pneumoniae • Most common bacterial cause d o • Rusty coloured sputum s • Lobar usually • Associated with cold sores Haemophilus influenza • Smoking • COPD Moraxella Catarrhalis • Smoking, immunocompromised Staphylococcus Aureus • Recent viral infection (e.g. flu) • Cavitation on CXR Klebsiella pneumoniae • Alcoholism • Elderly • Haemoptysis • Cavitation 13I A C i l e Key pathogens – atypical s C r R Pathogen Key features s a o C n Legionella pneumophilia • Travel, air conditioning, water tower i n • Hepatitis features s • Low sodium Mycoplasma pneumonia • University/boarding school • Dry cough • Arthralgia • +ve cold agglutinin • Derm Sx – popular rash, erythema multiforme • Associated AIHA Chlamydia psittiaci • Bird keeping 14M C n a e s C e e r o Pneumonia investigations C n i s Specialist and Bedside Bloods Imaging scoring • Observations • ABG – if • CXR • CURB-65 • Respiratory hypoxic • Viral screen examination • FBC + CRP • Urinary • Sputum • U&Es antigen cultures • LFTs 15B M A i c l e e - o e Lobular vs bronchopulmonary pneumonia R p a o y o Lobular pneumonia Bronchopulmonary pneumonia d i n s 16I A C i Antimicrobial treatment l e s Mild-moderate Moderate-severe C r amoxicillin or clarithromycin co-amoxiclav + clarithromycin R s a Pneumonia o C n (CAP) i n management s Supportive care Ventilatory Oxygen IV fluids Analgesia support as required Once resolved consider a chest x-ray a few weeks after recovery, consolidation can mask an underlying pathology e.g. cancer 17I A l c l r s C SBA: e e p a • A 66 year old man presents to his GP with an ongoing cough. He reports 4 days of y C productive cough, with a 2 day history of fever and malaise. He denies d i haemoptysis, any travel or TB contacts. He has hypertension, which is well s controlled with amlodipine. He is penicillin allergic. On examination he has reduced air entry at the left base with coarse crackles audible. He is orientated. His respiratory rate is 24, his oxygen saturations are 95% and his blood pressure is 115/86. • What is the most appropriate management? a) Conservative management b) Admission to A&E for further assessment c) Clarithromycin for 5 days d) Chest x-ray and then review e) A moxicillin for 5 days 18I A l c l r s C SBA: e e p a • A 66 year old man presents to his GP with an ongoing cough. He reports 4 days of y C productive cough, with a 2 day history of fever and malaise. He denies d i haemoptysis, any travel or TB contacts. He has hypertension, which is well s controlled with amlodipine. He is penicillin allergic. On examination he has reduced air entry at the left base with coarse crackles audible. He is orientated. His respiratory rate is 24, his oxygen saturations are 95% and his blood pressure is 115/86. • What is the most appropriate management? a) Conservative management b) Admission to A&E for further assessment c) Clarithromycin for 5 days d) Chest x-ray and then review e) A moxicillin for 5 days 19B M A i c l r s - o e e p a r C o d o s COVID-19 Viral respiratory infection caused by SARS-CoV-2 coronavirus 20I A C i l e COVID-19 - background s C r R • Pathophysiology s a o Binds to ACE2 via spike protein C n Causes host disease via direct cell death, infection i n induced hypercoagulability and inflammation s Key host mediators – IL-6, IL-10, G-CSF and TNF-alpha • Risk factors Area of high transmission, older, male, co-morbidities (DM, CKD, lung pathology) • Presentation Fever, cough, SOB, altered sense of taste or smell, headache Hypoxia, especially silent hypoxia 21I A l c l r s C Bedside e e p • Examination + observations a y • Rapid antigen test (LFT) C d i Bloods s • ABG • FBC, clotting, U&E, LFT, CRP • Blood cultures and lactate Imaging COVID-19 • CXR – ground glass opacity, bilateral investigations Specialist or scoring • Real-time PCR – diagnostic 22M A l Infection precautions c s i s o Oxygen + ventilatory e e support i o y o d Acute infection Corticosteroids – o dexamethasone s Anti-virals – remdesivir, ritonavir Monoclonals – tocilizimab, sarilumab COVID-19 management Long COVID Rehabilitation Prevention Vaccination 23B M A C n a s i s C o e e p a o Questions? y o d t n s 24B M C n c s r s C o R s i t y C n t n s Asthma Asthma is a chronic inflammatory airway disease characterised by reversible airway obstruction with airway hypersensitivity and bronchial inflammation 25I A C n a Very common condition e e - o e IgE mediated bronchoconstriction e p t Asthma - y C background n Risk factors t n s • FHx, atopy, LBW, hygiene hypothesis Presentation • Episode SOB, dry cough, chest tightness, wheeze Key features in history • Atopy • Previous attack severity + treatment • Triggers • compliance 26I A C n Asthma is overall a clinical diagnosis a e e - o Bedside e e p • Respiratory examination t Asthma – y • Observations C investigations; n t Bloods n diagnostic s • FBC Imaging • CXR – exclude other pathology Specialist and scoring • Lung function test with bronchodilator trial • Peak flow diary • FeNO • Skin prick testing for allergens 27I A C i l e Asthma management - chronic e - o e s r o y o d o s Aims of treatment Conservative • no daytime symptoms • Inhaler technique • no night-time waking due to asthma • Compliance • no need for rescue medication • Safety net and clear instructions for acute • no attacks attacks • no limitations on activity • Trigger avoidance • normal lung function (FEV1 and/or PEF > • Smoking cessation 80% predicted or best) • Medication review • Minimal side effects from medications 28I A C i Short-acting beta-agonist (SABA) l • Salbutamol e reliever inhaler s C r R Add low dose inhaled • SABA + ICS s corticosteroid (ICS) BD a • Low does < 400 micrograms budesonide or equivalent o C n i Add leukotriene receptor • SABA + ICS + LTRA n antagonist (LTRA) • e.g. Montelukast, PO s Add Long-acting beta-agonist • SABA + ICS + LABA + LTRA (LABA) • e.g. salmeterol (inhaled) Switch LABA/ICS to maintenance and reliever therapy which has low- • MART + LTRA dose ICS Increase dose of ICS steroids to • Medium dose is 400-800 micrograms budesonide medium dose • MART/LABA with medium dose ICS + LRTA • May consider high dose ICS (> 800 mcg) Referral to specialist • Biologics – omalizumab, mepolizumab 29M C n a e Asthma management – acute s C e e r o C n i s Moderate Severe Life-threatening • Increasing symptoms • PEF 33-50%RR > 25 • Altered consciousness • PEF 50-70% /min • Cyanosis or normal • No features of severe • HR > 110/min Pa CO2 acute asthma attack • Inability to complete • Hypotension or sentences in one Hypoxia breath • Exhaustion • Silent chest • Threatening PEF < 33% 30I A C i l e s C r R s a o Asthma – management, acute C n i n s Step 1 Step 3 Step 4 Step 5 Step 6 Step 7 •High flow oxygen •Salbutamol, •Ipratropium •Steroids oICU support •Intubation bromide •aim 94-98% •5mg •Prednisolone oIV Magnesium •Monitor vitals •Nebulised •nebuliser •40-50mg sulphate (1st line) •0.5mg 4-6 hourly oIV aminophylline •Monitor ABG •5 days •Monitor PEF infusion oIV salbutamol 31I A C n a e e - o SBA: e e p t • A 28 year old female attends for her annual asthma review. She is currently on a ICS + SABA y C therapy. She reports she has had 2 asthma attacks in the last 8 weeks, both resolving with n t burst SABA therapy. She has also been waking at night with a dry cough. On examination her n s chest is clear with no wheeze, her observations are all normal. She has no other past medical history of note. • What is the next most appropriate step? a) Add montelukast b) S end her for review in A&E c) Assess inhaler technique and compliance d) Ask patient to monitor peak flows for 2 weeks e) N o further change in management required 32I A C n a e e - o SBA: e e p t • A 28 year old female attends for her annual asthma review. She is currently on a ICS + SABA y C therapy. She reports she has had 2 asthma attacks in the last 8 weeks, both resolving with n t burst SABA therapy. She has also been waking at night with a dry cough. On examination her n s chest is clear with no wheeze, her observations are all normal. She has no other past medical history of note. • What is the next most appropriate step? a) Add montelukast b) S end her for review in A&E c) Assess inhaler technique and compliance d) Ask patient to monitor peak flows for 2 weeks e) N o further change in management required 33B M A C n a s i s C o e e p a o Questions? y o d t n s 34B M C n c s r s C o R s i t y C n t n s COPD Chronic, progressive lung disorder characterised by irreversible airflow obstruction 35M A l c Chronic obstructive pulmonary s i s o disease e e i • Associated with: o y Chronic bronchitis o d Emphysema o s • Risk of CO2 retention • Strongly associated with smoking history • Very common, 2% diagnosed each year, progressive disease • Presentation Chronic cough +/- sputum SOB Haemoptysis Recurrent chest infections 36M A n a e COPD - investigations s C e e p t y o i n s Specialist or Bedside Bloods Imaging scoring • Vitals • ABG - in acute or • CXR • Spirometry • Sputum MC&S monitoring • Echocardiogram • Obstructive • ECG • FBC picture • PEFR - • CRP • FEV1 < 80%, • Alpha-1 anti- • FEV1:FVC < trypsin level 0.7 37M A i c s COPD – long term management e - o e s r o C n t n s Conservative Medical Surgical • Smoking cessation • Inhalers • Bullectomy • Flu and pneumococcal • Rescue packs • Lung volume reduction vaccines • Long term oxygen surgery • Pulmonary therapy rehabilitation • Chest physio • Annual review 38I A l c SABA or SAMA l r s C • Symptoms relief e e • Salbutamol or ipratropium bromide p a COPD – long y C term Assess for asthmatic features d i s management • Previous asthma diagnosis or atopy; ↑ eosinophils, FEV1 > 400ml variability, diurnal variation in PEFR (>20%), steroid responsive • If asthmatic → LABA + ICS • No asthmatic features → LAMA + LAMA LAMA + LABA + ICD • 3 month trial Specialist referral 39M A i c s e - COPD – Exacerbations management o e s r o C n t n s Assess Nebuliser Steroids Antibiotics Senior r/v • A-E • Salbutamol • Prednisolone • If evidence of • HDU/ICU • Set sats target • Ipratropium • 30mg PO infection • IV bromide • 5 days • Amoxicillin aminophylline • Doxycycline • NIV – BiPAP • Clarithromycin • Intubation 40I A C i l e e - SBA: o e s r • A 67 year old man presents to A&E with a 3 day history of productive cough and worsening o y shortness of breath. He is known to have COPD and started his rescue pack yesterday but o d has not been improving. He has previously been admitted to HDU for COPD exacerbations o s requiring BiPAP. On arrival to A&E his saturations were 86% on room air, respiratory rate of 30, heart rate of 125, blood pressure of 121/96 and temperature of 37.9. He appears to be slightly confused. The junior doctor in A&E starts him on treatment for acute exacerbation and as part of the work up takes an ABG. • What disturbance is likely to be seen on the ABG? a) Type 1 respiratory failure b) Respiratory acidosis c) Type 2 respiratory failure d) Hypoxia e) Normal ABG 41I A C i l e e - SBA: o e s r • A 67 year old man presents to A&E with a 3 day history of productive cough and worsening o y shortness of breath. He is known to have COPD and started his rescue pack yesterday but o d has not been improving. He has previously been admitted to HDU for COPD exacerbations o s requiring BiPAP. On arrival to A&E his saturations were 86% on room air, respiratory rate of 25, heart rate of 125, blood pressure of 121/96 and temperature of 37.9. He appears to be slightly confused. The junior doctor in A&E starts him on treatment for acute exacerbation and as part of the work up takes an ABG. • What disturbance is likely to be seen on the ABG? a) Type 1 respiratory failure b) Respiratory acidosis c) Type 2 respiratory failure d) Hypoxia e) Normal ABG 42B M A C n a s i s C o e e p a o Questions? y o d t n s 43THANK YOU FOR LISTENING ANY QUESTIONS BIMA Clinical SeriesB M C n c s r s C o R s i t References y C n t n 1. https://www.ncbi.nlm.nih.gov/books/NBK559090/ s 2. https://www.bsuh.nhs.uk/library/wp-content/uploads/sites/8/2020/06/BTS-pneumothorax-guideline.pdf 3. https://www.nice.org.uk/guidance/ng138/resources/pneumonia-communityacquired-antimicrobial- prescribing-pdf-66141726069445 4. https://www.nice.org.uk/guidance/ng138/resources/visual-summary-pdf-9130723021 5. https://www.nice.org.uk/guidance/conditions-and-diseases/respiratory-conditions/covid19 6. https://www.thebottomline.org.uk/?s=COVID 7. https://cks.nice.org.uk/topics/asthma/ 8. https://www.nice.org.uk/guidance/ng115 45