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Rapid review - Respiratory Froher Yasin, Hannah Lin,Stella Watkins RespSocx EdMedSocCase 1 Liz, a 16 yr old female, presents toA&E with a 5 dayhistoryof productivecough. The sputum is thick and yellow. She haschest pain withfever,chills andmalaise. Upon examination, you findreducedchest expansion on the rightside and hearcoarse crackles. She has a past medicalhistory of asthma What isthedifferential diagnosis? What investigations would youlike to perform?Pneumonia Symptoms: ● Fever, cough,sputum(quantity,colour), dyspnoea, chest pain(maybepleuritic) Signs: ● Fever, tachycardia,reducedbreathsounds, coarsecrackles, bronchial breathing,dullpercussion,increased vocal resonance,reducedchestexpansion Diagnosis: ● Clinicalpicture andCXR signs of consolidationInvestigations of pneumonia ● Bedside: general obs, ECG, sputumculture ● Bloods: FBC, U&Es, CRP,ABG ● Imaging: CXR Scoring system: ● CRB65 in primarycare ● CURB65 in secondary careCauses of pneumonia: ● Non-infective: idiopathicinterstitial pneumonia ● Infective: bacterial (most common), mycobacterial, viral,fungal● Strep pneumonia:high fever, rapid onset, herpeslabialis ● Haemophilus influenza:common in COPD patients ● Staph aureus:occursfollowing influenza ● Mycoplasma pneumonia:youngerpatients,prolongedonset,erythema multiform, erythemanodosum, coldautoimmunehaemolyticanaemia/ITP ● Legionella:spreadclassically throughair-conditioningunits, drycough, lymphopenia, hyponatraemia,deranged LFTs ● Pneumocystis jiroveci:seeninHIV patients, drycough,exerciseinduced desaturationManagement ● Oxygen ● Antibiotics ● Appropriate place for care (CURB-65 score) ● RepeatCXRAcute bronchitis ● Symptoms:cough, sore throat, rhinorrhoea, wheeze ● Signs:normal chestexamination, wheeze, low-grade fever ● Investigations:typically aclinicaldiagnosis, CRP ● Management: analgesia,good fluid intake, antibiotic therapy ○ Only ifsystemicallyunwell, CRP >100 (CRP 20-100 offer delayed prescription), pre-existing co-morbidities ○ Doxycycline first line(Amoxicillin as alternativeif contraindicated, e.g., children/pregnant women)Lung Abscess ● Mostcommonlyoccurs secondary toaspiration pneumonia. Often polymicrobial cause:staph aureus,Klebsiella,pseudomonasaeruginosa ● Symptoms: similar topneumonia, fever, productivecough,chestpain, dyspnoea ● Signs: dullpercussion, bronchial breathing, clubbing ● Investigations:CXR, sputum culture, blood culture ● Management:intravenous antibiotics,if not resolving percutaneous drainagemay be required, in rarecases surgical resectionCase 1 continued Liz presents to A&E again. Thistime she is extremely breathless,wheezingand her cough is not responding to hersalbutamolinhaler. On examination, her oxygen sats are 90%, she hasa heartrateof 50bpm, herchest is silentandshe is exhausted What isthedifferential diagnosis? WhyisLiz more likely to develop this?Acute asthma Features: ● Worsening dyspnoea,wheeze, coughnot respondingto salbutamol ● Can be triggered byrespiratory tract infectionAcute asthma management ● Investigations:ABG if spO2 <92%,CXR (only if indicated) ● Management: ○ Admission ○ Oxygen ○ Salbutamol nebuliser ○ Ipratropium bromide nebuliser ○ Hydrocortisone IV ororal prednisolone ○ Magnesium sulfate IV/magnesium sulfatenebuliser ○ Aminophylline/IV salbutamol ● Discharge and follow-up: ○ Chest and improve inhaler technique ○ PEFR>75% ○ Stable on discharge medication for 12-24 hoursAsthma ● Symptoms: cough(typically worse at night),wheeze/chesttightness,dyspnoea ● Signs: expiratory wheeze onauscultation, reduced PEFR ● Important history points:diurnalvariation in symptoms,atopy(asthma,atopic dermatitis, allergic rhinitis), triggers(coldair, exercise,allergies - pets,smoking, infection), occupational? ● Investigations: ○ Spirometry: obstructive (FEV1/FVC <70%), bronchodilator reversibility (improvement of more than 12% FEV1 and morethan 200ml volume increase) ○ FeNO ○ CXRAsthma management in adults 1. SABA 2. SABA + low-dose ICS 3. SABA + low-dose ICS + LTRA 4. SABA + low-dose ICS+ LABA (+LTRA) 5. Low-dose ICS MART therapy added to SABA +/-LTRA 6. Moderate-dose ICS 7. High-dose ICS / LAMA/ theophylline + SPECIALIST REVIEW Also important to : ● Check and improve inhaler technique ● Education and asthma plan ● Review management of asthma and ensure good control ● Stepping down treatmentCase 1 continued even more Liz presents a year later to her doctor. This time with jaundice and ascites. Following investigations, she is diagnosedwith liver cirrhosis Sheisreferred to specialists whoperform an A1AT concentration, whichcomes backlow What isyour differential?Alpha-1 antitrypsin deficiency ● Classically causes COPDemphysema in young,non-smokers ● TheA1AT gene is locatedonchromosome 14 andinheritedinanautosomal recessive/co-dominant fashion ● Alleles classified by electrophoresismobility -Mfornormal, Sfor slow, Z forvery slow ● Homozygous PiSS has50% A1ATconcentration,PiZZ has 10% A1AT concentration ● Features:disease manifestationtypically occurs in PiZZ ○ Lungs: panacinar emphysema, mostly lower lobes ○ Liver: cirrhosis, hepatocellular carcinoma, cholestasisin children ● Investigations:A1AT concentration, obstructivepicture,genesequencing ● Management: no smoking, supportive bronchodilators/physiotherapy, IV A1AT concentrate, surgery (lung volume reduction/transplant)COPD ● Symptoms:cough (oftenproductive),dyspnoea,wheeze,in severecases cor pulmonale ● Important historypoints:smoking (packyears),familyhistory(A1AT deficiency) ● Signs:barrel chest, hyperresonance on percussion,wheeze, asterixis ● Investigations:spirometry (FEV1/FVC <70%),post-bronchodilatorspirometry, CXR (hyperinflation, bullae, flat hemidiaphragm), FBC, BMI calculation, Pulse oximetry (may be CO2 retainers!), ABG, A1AT concentration (if deficiency suspected)COPD ManagementBreakCase 2 Paulis a 66 year old man attends ED with a 2 day historyof chestpainthat isworseon inspiration andhaemoptysis. He is recovering froma falldowna flightofstairs 3weeks ago,where he sustained a fracture to hisleft tibia. He tells you he has beenstruggling with mobility since then and mostly sits orlies in bed at home. He denies any fever, lethargy, night sweats orweight loss. Differentials?66M, pleuritic chest pain, haemoptysis Trachea/bronchus Vascular ● Malignancy ● PE ● Bronchitis ● AVM ● Bronchiectasis ● Airway trauma ● Aortic aneurysm ● Trauma ● Foreign body Other Lung parenchyma ● Pulmonary endometriosis ● Lung abscess ● Pneumonia - bacterial or viral ● Coaguloapathy eg. leukaemia ● TB ● Drugs- anticoagulants, thrombolytics ● Fungal infection ● Bleeding of alternative origineg. ● Goodpastureʼs syndrome haematemesis Mostlikely +why?66M, pleuritic chest pain, haemoptysis Trachea/bronchus Vascular ● Malignancy ● PE ● Bronchitis ● AVM ● Bronchiectasis ● Airway trauma ● Aortic aneurysm ● Trauma ● Foreign body Other Lung parenchyma ● Pulmonary endometriosis ● Lung abscess ● Pneumonia - bacterial or viral ● Coaguloapathy eg. leukaemia ● TB ● Drugs- anticoagulants, thrombolytics ● Fungal infection ● Bleeding of alternative origineg. ● Goodpastureʼs syndrome haematemesisCase 2 Paulis a 66 year old man attends ED with a 2 day historyof chestpainthat isworseon inspiration andhaemoptysis. He is recovering froma falldowna flightofstairs 3weeks ago,where he sustained a fracture to hisleft tibia. He tells you he has beenstruggling with mobility since then and mostly sits orlies in bed at home. He denies any fever, lethargy, night sweats orweight loss. Differentials? Most likely + why? What dowe wantto do for thispatientinitially?Initial Mx A to E!!! Call forhelp/informseniors Full Hx and examinationPulmonary embolism - presentation Symptoms: Our patient on examination: ● Chest pain ● Dyspnoea T: 37.5 ● Haemoptysis HR: 110 Signs: RR: 20 ● Hypoxia Chest clear ● Tachycardia ● Tachypnoea CalvesSNT ● Chest - classically clear, may be crackles What mightyouwant to do next?2-level PE Wells score 0-4: D-dimer→ CTPA ifpositive >4: CTPA → if negative ? In pregnancy ? What other investigationswouldyou do?Pulmonary embolism - investigations Bedside- basic obs, ECG Bloods-FBC, U&Es, LFTs,CRP,D-dimer Imaging - CXR, CTPA Management?Pulmonary embolism - management Immediate supportive - oxygenifhypoxic Haemodynamic instability ● Thrombolysis Stable ● Anticoagulation withDOACs ○ Provoked → 3 months ○ Unprovoked → 6 monthsCase 2 continued Paulreturns to ED a few years laterafter returning fromafamilyweddinginIndia. He hashad ongoing haemoptysis for4 weeks, with the blood mixed in with yellowsputum. Hehasbeen feeling gradually moreunwell, and nowhefeelsbreathless upon walking up thestairs. His appetite has reduced, and he has lost 6.5kgin thelast 2months. He said he hasnʼt measured his temperature, but has experienced intermittentnight sweats. When asking his ideas, concernsand expectations,hetells you he thinks itʼsʻthat pulmonary thing againʼ. Do you agree? If not, what do youthink this is?TB ● Causative organism = ? ● Mx of acute pulmonary TB:RIPE ○ Rifampicin ○ Stain? ○ Isoniazid 6months ● Risk factors:? ○ Pyrazinamide ● Types: active, latent, secondary, miliary, ○ Ethambutol 2months pulmonary, extrapulmonary ○ ʻ4for 2then2for4ʼ ● Presentation: ● Side effects of Tx: ○ Lethargy ○ Rifampicin:P450 inducer,orangesecretions, ○ Fever, nightsweats thrombocytopenia ○ Weightloss ○ Isoniazid:neuropathy,drug-inducedlupus ○ Cough± haemoptysis ○ (gout), arthralgiaotoxic,hyperuricaemia ○ Lymphadenopathy ○ Ethambutol:opticneuritis ○ Erythemanodosum ● Other Mx considerations: ● Ix: sputum, blood cultures, CXR ○ Isolateon ward ○ CXRfindingsinclude consolidation,pleural ○ Test forotherinfectiousdiseases effusion, hilarlymphadenopathy,cavitation ○ Test contacts (typicallyupperzone),ʻmilletseedsʼ ○ NotifyPublicHealth ○ SpecialistMDT1 2 3 4BreakCase 3 Markis a 55 year old male smokerpresentsto you (a GP) with painfulmuscles, difficultywalking upthe stairs, fatigueand adry mouth. Upon questioning, you find out thatthe muscle pain/weaknessseems toimprove ashe exercises. Whatdo we think the diagnosis is? Whatunderlying condition does this imply?Lambert-Eaton syndrome A syndrome associated with smallcell lungcancer(although canbeindependent asan autoimmune condition) - Duetoantibody against presynapticvoltage gated calciumchannels Key features: - Repeated muscle contractionleadsto increasedmusclestrength - Autonomic symptoms: dry mouth,impotence, difficultymicturating - Limb-girdle weaknessSubtypes of Lung cancer - NSCLC (80%) - SCLC(15/20%) - Adenocarcinoma(35%) - Mostlysmokers - Most commonoverall - Earlymetastasis - Commoninnon-smokers - Mostcommonlungcancertocause - Likely aperipherallesion paraneoplasticsyndromes - Squamous cell(30%) - Associatedwith smoking - Associatedwithclubbing - Associatedbyparathyroid hormone-relatedprotein (PTHrP) secretion - Most likelytobecavitating - Large cell (15%) - Usuallyperipheral - May secrete beta-hCGA note on smoking Thingsyou need to ask in a history -esp.If concerned aboutlung cancer? - Agestarted, numberof cigarettesa day, duration - Calculate “pack-years” =packs of 20 smoked/dayxyearssmoked - “Ismoke 10 a day and have donefor 20 years” = 10 packyears - Risk reduces to the level of anon-smokerafter13yearsSymptoms/History of Lung Cancer ● Common presentations: ● SVC obstruction ○ Shortness of breath ○ Facial swelling ○ Persistentcough ● Pancoasttumour ○ Chest pain ○ Recurrent laryngeal nerve palsy ○ Constitutionalsymptoms: ● Paraneoplastic syndromes… fatigue/weightloss ○ HaemoptysisAnotherway of thinking about symptoms: Local effects: Invasion/ compression effects: - Cough - Pleural effusion and SOB -> Pleural invasion - Haemoptysis - Bronchial obstruction- recurrent - Chest pain -> Invasioninto chest wall pneumonia/collapse - Hoarseness -> Recurrent laryngeal nerve - Raised hemidiaphragm -> Phrenic nerve - Wasting of small muscles of hand -> Brachial Effect ofmetastatic spread plexus - Horner syndrome -> Sympathetic - Depends onlocation of metastasis involvement - SVC obstruction -> great vessels obstructed Paraneoplastic effects - NextslideParaneoplastic syndromes Seen in SCLC Seen inNSCLC - ACTH ->Cushings - In squamous cell carcinoma: PTHrP - HIgh levelsof cortisol - Hypokalaemia, Hypertension,Alkalosis secretion - Hypoglycaemia, muscle weakness - Hypercalcemia - ADH - In adenocarcinoma - gynaecomastia - Hyponatraemia - LambertEaton syndrome(antibody to voltage gated calcium channels) - Proximal weaknessReferral guidelines ● ReferforCXR if:(within 2W) ○ >40 +2 unexplainedsymptomsORsmoker +1unexplainedsymptoms ■ Weight loss ■ Fatigue ■ Shortnessofbreath ■ Cough ■ Chest pain ● Referforcancerpathway 2WW if: ○ CXR findingssuggestiveoflungcancer ○ >40+unexplained haemoptysisInvestigations ● Bloods ○ Paraneoplasticsyndromes ○ Raisedplatelets ● Imaging ○ CXR/CT ○ PETscan - metastases? ● Bronchoscopy ○ To take a biopsy ○ Can beguided by endobronchialUS ● Thoracocentesis ○ Pleural fluid- Largemass in rightupperzone Signs of lung canceron X-ray - This increaseddensityarea- shouldmakeyouthink either - Focal lesion - Widened mediastinum - infectionorcancer lymph node - In thiscase -wellcircumscribed massnotfollowingobvious involvement fissure lines -hintingtowards - Pleural effusion diagnosisofcancer - Atelectasis (partial - Atbase ofrightlung-pleural collapse) effusionpresent - ConsolidationImageshowsa malignant pleural effusion - Yellow arrow indicatesthehorizontalfissure - Lack ofbreastshadow onthe left (normal breast shadow shown by orangearrows)1stimage: Large cavitation lesionseenin upper-mid right lung A wall is present withan air-fluidlevel within 2nd image: Right upper lobe cavitylesion- airfluid levelpresentCannonballmetastases - Large,well-circumscribed, roundpulmonary metastases - Classically secondary to renal cell carcinomaManagement NSCLC: SCLC: - 20%suitable for surgery - Most offered combo radiotherapy and - CI: metastasis, FEV1 < 1.5l, malignant chemotherapy pleural effusion, vocal cord paralysis, - Surgery if early stage disease, however SVC obstruction,Hilar involvement often present metastatic - If not for surgery: Radiotherapy, poor chemoresponseSummary Our top tips! ● Learn management of acutescenarios, eg. anaphylaxis, acute asthma ● Learn simple scoring systems eg. CURB-65, have an idea of Wells score (also applies togen med eg. GCS) ● For SBAs, rememberA toE and distinguish between initial and definitive management ● Learn the paraneoplastic syndromes and their symptoms ● Goodto have anidea of antibioticchoice, if in doubt in OSCE, say ʻrefer to localguidelinesʼ Things we havenʼt covered today but important for revision: Pulmonaryfibrosis Pneumothorax Cysticfibrosis Respiratory failure (types1 and 2) Bronchiectasis Pleural effusion Lung functiontests+ interpretatiGP presentations eg.tonsillitisFeedback