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Teaching Frontier UKMLA Series 5 Respiratory Medicine Learning Objectives Knowledge Objectives Understand the pathophysiology, clinical features, and management of key respiratory conditions, including asthma, COPD, pneumonia, and pulmonary embolism. Recognize red-flag symptoms in respiratory presentations that require urgent investigation or referral. Learn the principles of respiratory failure (Type I and II) and their initial management. Skills Objectives Interpret key respiratory investigations, including chest X-rays, arterial blood gases (ABG), and spirometry results. Apply clinical scoring systems (e.g., CURB-65 for pneumonia, Wells score for PE) to guide diagnosis and management. Demonstrate an understanding of oxygen delivery systems and indications for escalation of care.Part 1Asthma Hyper-reactivity of the airways with PATHOPHYSIOLOGY chronic inflammation leading to variable airflow obstruction Family history Smooth muscle Atopy constriction Childhood bronchiolitis Childhood smoke Subepithelial layer inflammation exposure Premature birth Mucous secretion Low birth weight Airway narrowing Genetics i.e. ADAM33 polymorphism TYPE EXAMPLES Asthma Hyper-reactivity of the airways with House dust, pollen, chronic inflammation leading to variable ALLERGENS animal airflow obstruction dander/feathers Smooth muscle constriction Pollution, smoke, cold AIRBORNE air, thunderstorms, Subepithelial layer mould/damp inflammation DRUGS NSAIDs, beta-blockers Mucous secretion Airway narrowing INFECTIONS URTI, acute bronchtiis FOODS Sulphites ACTIVITY ExerciseAsthma Acute Chronic Severe breathlessness, chest tightness, Intermittent/persistent wheeze, chronic wheeze, cough , difficulty speaking cough, shortness of breath (on exertion), symptom variation PEFR 50-70%, normal Moderate speech, O2 >92% Home/GP PEFR 33-50%, cannot Peak Expiratory Flow Rate (PEFR) is the complete sentences, RR Hospital maximum speed of expiration, Severe >25, HR >110 mand reflects the large airway flown), capacity Life PEFR <33%, spO2 <92%, silent chest, cyanotic, Hospital Threatening bradycardic, confusedAsthma Plan Acute Re-assess every 15 minutes Nebulised salbutamol every 15- Oxygen (sats >94%) 30 minutes ECG for arrhythmias Nebulised salbutamol 5mg Magnesium sulfate 1.2 - 2g IV over Nebulised ipratropium 20 minutes 0.5mg/6h Hydrocortisone 100mg IV or Prednisolone 40-50mg POAsthma Acute Oxygen (sats >94%) Nebulised salbutamol 5mg ICU Nebulised ipratropium 0.5mg/6h Hydrocortisone 100mg IV or Prednisolone 40-50mg POAsthma Acute Plan Nebulised salbutamol every 4 - Oxygen (sats >94%) 6h (+ipratropium if started) Prednisolone 40 - 50mg PO OD Nebulised salbutamol 5mg for 5 - 7 days PEFR >75% - ?home Nebulised ipratropium 0.5mg/6h Hydrocortisone 100mg IV or Prednisolone 40-50mg POAsthma Chronic 1 SABA 2 SABA + ICS 3 SABA + ICS or LABA 4 SABA + ICS + LTRA 5 SABA + ICS or LABA + LTRA NICE GuidanceA 35-year-old man with a history of asthma presents to his GP with worsening MCQ symptoms over the past month. He reports daily wheezing, waking up at night twice a week with breathlessness, and using his salbutamol inhaler multiple times per day. He is currently prescribed a short-acting beta-agonist (salbutamol) and a low-dose inhaled corticosteroid (ICS). What is the most appropriate next step in his asthma management? A) Increase the dose of inhaled corticosteroid (ICS). B) Add a long-acting beta-agonist (LABA) to his current treatment. C) Prescribe a leukotriene receptor antagonist (LTRA). D) Start oral prednisolone. E) Refer for emergency secondary care assessment.A 35-year-old man with a history of asthma presents to his GP with worsening MCQ symptoms over the past month. He reports daily wheezing, waking up at night twice a week with breathlessness, and using his salbutamol inhaler multiple times per day. He is currently prescribed a short-acting 1 SABA beta-agonist (salbutamol) and a low-dose inhaled corticosteroid (ICS). 2 What is the most appropriate next step in SABA + ICS his asthma management? 3 A) Increase the dose of inhaled SABA + ICS or LABA corticosteroid (ICS). B) Add a long-acting beta-agonist (LABA) 4 SABA + ICS + LTRA to his current treatment. C) Prescribe a leukotriene receptor 5 SABA + ICS or LABA + LTRA antagonist (LTRA). D) Start oral prednisolone. E) Refer for emergency secondary care assessment.A 24-year-old woman presents to the MCQ Emergency Department with worsening shortness of breath, wheezing, and chest tightness. She has a history of asthma and uses a salbutamol inhaler as needed but reports using it every 2-3 hours for the past day. On examination, she is speaking in short sentences, has a respiratory rate of 28 breaths per minute, and a heart rate of 112 bpm. Oxygen saturation on room air is 91%, and her peak expiratory flow rate (PEFR) is 180 L/min (40% of predicted). What is the most appropriate next step in her management? A) Administer a short course of oral antibiotics. B) Prescribe a leukotriene receptor antagonist. C) Start nebulized salbutamol and ipratropium bromide, along with oral prednisolone. D) Administer intravenous aminophylline. E) Arrange for immediate intubation and mechanical ventilation.A 24-year-old woman presents to the Emergency Department with worsening MCQ shortness of breath, wheezing, and chest tightness. She has a history of asthma and This patient is experiencing a severe acute asthma uses a salbutamol inhaler as needed but reports using it every 2-3 hours for the past exacerbation based on her symptoms (inability to day. On examination, she is speaking in speak full sentences, increased respiratory rate, short sentences, has a respiratory rate of tachycardia, reduced oxygen saturation, and PEFR 28 breaths per minute, and a heart rate of <50% of predicted). 112 bpm. Oxygen saturation on room air is 91%, and her peak expiratory flow rate (PEFR) is 180 L/min (40% of predicted). What is the most appropriate next step in The appropriate initial management in such a case her management? includes: A) Administer a short course of oral Nebulized bronchodilators: Salbutamol (a short- antibiotics. acting beta-2 agonist) and ipratropium bromide (a B) Prescribe a leukotriene receptor antagonist. short-acting muscarinic antagonist) are first-line C) Start nebulized salbutamol and ipratropium bromide, along with oral treatments to relieve airway obstruction. prednisolone. Corticosteroids: Oral prednisolone is essential to D) Administer intravenous aminophylline. reduce airway inflammation. E) Arrange for immediate intubation and mechanical ventilation.A 24-year-old woman presents to the MCQ Emergency Department with worsening shortness of breath, wheezing, and chest tightness. She has a history of asthma and uses a salbutamol inhaler as needed but reports using it every 2-3 hours for the past day. On examination, she is speaking in PEFR 50-70%, normal short sentences, has a respiratory rate of Moderate speech, O2 >92% Home/GP 28 breaths per minute, and a heart rate of 112 bpm. Oxygen saturation on room air is PEFR 33-50%, cannot 91%, and her peak expiratory flow rate Severe complete sentences, RR Hospital (PEFR) is 180 L/min (40% of predicted). What is the most appropriate next step in >25, HR >110 her management? A) Administer a short course of oral Life PEFR <33%, spO2 <92%, silent chest, cyanotic, Hospital antibiotics. Threatening bradycardic, confused B) Prescribe a leukotriene receptor antagonist. C) Start nebulized salbutamol and ipratropium bromide, along with oral prednisolone. D) Administer intravenous aminophylline. E) Arrange for immediate intubation and mechanical ventilation. Chronic Obstructive Pulmonary Disease (COPD) Heterogenous mix of pathological changes to the lungs, with it being a leading cause of morbidity and mortality worldwide. Emphysema Chronicbronchitis Bronchiolotitis Chronic Obstructive Pulmonary Disease (COPD) Risk Factors Smoking Vaping ↓Alpha-1 anti- Pollution trypsin Occupation Childhood Asthma ↓Socioeconomic Chronic Obstructive Pulmonary Disease (COPD) Chronic Obstructive Pulmonary Disease (COPD) Symptoms Productive cough (usually morning) Exertional dyspnoea (developing into at rest dyspnoea) Sputum production (worse with exacerbations) Exposure to risk factors Signs Barrel chest Hyper-resonance Reduced breath sounds Wheeze and crackles Chronic Obstructive Pulmonary Disease (COPD) Symptoms Productive cough (usually morning) Exertional dyspnoea (developing into at rest dyspnoea) Sputum production (worse with exacerbations) Exposure to risk factors Signs Barrel chest Hyper-resonance Reduced breath sounds Wheeze and crackles Chronic Obstructive Pulmonary Disease (COPD) Investigations Spirometry CXR CT thorax Pulse oximetry + ABGs ECG + echocardiograms Sputum MC&S Chronic Obstructive Pulmonary Disease (COPD) Spirometry Air forcefully exhaled FEV1 in 1 second <80% Max air forcefully FVC exhaled after a deep ↓ breath FEV1/FVC % of FVC of expired <70% after 1 second TLCO Transfer factor for CO <80% Chronic Obstructive Pulmonary Disease (COPD) Spirometry Chronic Obstructive Pulmonary Disease (COPD) CXR Chronic Obstructive Pulmonary Disease (COPD) CT Chronic Obstructive Pulmonary Disease (COPD) ABG m e “pink puffer”“blue bloater” ’ to c o A B G e r! PaO2 Low Low lat PaCO2 Normal High PathophysiologV/Q mismatch Alveolar hypoventilation Geeky Medics Chronic Obstructive Pulmonary Disease (COPD) ECG’s and Echo Life in the Fast Lane Drugs.com Chronic Obstructive Pulmonary Disease (COPD) Sputum MC&S (IE-COPD) Haemophilus influenzae Moraxella caterrhalis Streptococcus pneumoniae Chronic Obstructive Pulmonary Disease (COPD) Treatment NICE Guidance Chronic Obstructive Pulmonary Disease (COPD) Treatment NICE Guidance Chronic Obstructive Pulmonary Disease (COPD) Treatment NICE GuidanceA 72-year-old man with COPD presents with worsening cough, purulent sputum, and MCQ breathlessness for the past 4 days. He reports feeling more fatigued than usual and is struggling to perform daily activities. His medications include a long-acting beta- agonist (LABA) and a long-acting muscarinic antagonist (LAMA). Examination reveals coarse crackles in the right lower lung field and a respiratory rate of 22 breaths per minute. His oxygen saturation is 91% on room air. What is the most appropriate management for this patient? A) Add a short course of oral prednisolone and antibiotics. B) Increase the dose of his LABA and LAMA. C) Prescribe nebulized bronchodilators and monitor at home. D) Admit for intravenous antibiotics and oxygen therapy. E) Refer for long-term oxygen therapy (LTOT).A 72-year-old man with COPD presents with worsening cough, purulent sputum, and MCQ breathlessness for the past 4 days. He reports feeling more fatigued than usual and This patient has an infective exacerbation of COPD is struggling to perform daily activities. His (IECOPD), as indicated by increased breathlessness, medications include a long-acting beta- agonist (LABA) and a long-acting muscarinic purulent sputum, and systemic fatigue. The presence of antagonist (LAMA). Examination reveals purulent sputum suggests a possible bacterial infection. coarse crackles in the right lower lung field and a respiratory rate of 22 breaths per Standard management of a mild to moderate IECOPD minute. His oxygen saturation is 91% on room air. What is the most appropriate includes: management for this patient? Oral corticosteroids: A 5-day course of prednisolone A) Add a short course of oral prednisolone (e.g., 30 mg/day) to reduce airway inflammation. and antibiotics. Antibiotics: If purulent sputum is present, antibiotics B) Increase the dose of his LABA and LAMA. C) Prescribe nebulized bronchodilators and such as amoxicillin, doxycycline, or clarithromycin are indicated to target bacterial pathogens (e.g., monitor at home. D) Admit for intravenous antibiotics and Haemophilus influenzae, Streptococcus oxygen therapy. pneumoniae). E) Refer for long-term oxygen therapy (LTOT).Which of the following is the most likely MCQ bacterial cause of this patient’s exacerbation? A) Pseudomonas aeruginosa B) Streptococcus pneumoniae C) Staphylococcus aureus D) Haemophilus influenzae E) Klebsiella pneumoniaeWhich of the following is the most likely bacterial cause of this patient’s MCQ exacerbation? The most common bacterial pathogens associated with A) Pseudomonas aeruginosa acute exacerbations of COPD (AECOPD) are: B) Streptococcus pneumoniae 1.Haemophilus influenzae – the most frequent cause of C) Staphylococcus aureus community-acquired exacerbations. D) Haemophilus influenzae E) Klebsiella pneumoniae 2.Streptococcus pneumoniae – another common pathogen in COPD exacerbations. 3.Moraxella catarrhalis – especially in more severe COPD cases. In this patient, the absence of recent hospitalizations and significant antibiotic use makes Haemophilus influenzae the most likely cause, as it frequently colonizes and infects the airways in stable and exacerbating COPD patients.Which of the following is the most likely bacterial cause of this patient’s MCQ exacerbation? Why Not the Other Options? A) Pseudomonas aeruginosa A) Pseudomonas aeruginosa: Typically seen in patients B) Streptococcus pneumoniae with frequent exacerbations, prior hospitalizations, or C) Staphylococcus aureus structural lung disease (e.g., bronchiectasis). D) Haemophilus influenzae E) Klebsiella pneumoniae B) Streptococcus pneumoniae: A plausible option but less common than Haemophilus influenzae in AECOPD. C) Staphylococcus aureus: Rarely causes AECOPD, more associated with pneumonia or post-viral infections. E) Klebsiella pneumoniae: Usually associated with nosocomial infections or patients with significant immunosuppression.Part 2 Case Discussion 47 year old male smoker, presented to ED with worsening haemoptysis, breathlessness and chest pain. He mentioned that he has been unwell with cough and fever since his vacation in Maldives 5 days ago. Differentialdiagnosis? By setting Community acquired (CAP) Hospital acquired (HAP) Pneumonia Ventilator associated pneumonia (VAP) By cause Bacterial Viral Fungal Chemical inhalation Idiopathic/interstitial pneumonia By area Lobar pneumonia; inflammation of entire pulmonary lobe Broncho-pneumonia; sacttered around bronchi & bronchioles Pneumonia (CAP) Bacterial Typical Atypical Mycoplasma pneumoniae; Ix PCR sputum serology Streptococcus pneumoniae complications including most common erythema multiform, Steven Johnson syndrome, Haemophilus influenzae meningoencephalitis, GBS common in COPD Chlamydophila pneumoniae Staphylococcus aureus c. pneumonia, c. trachoma's, c. often in IVDU, following psittacci (usually infects birds) influenza or underlying disease Moraxella catarrhalis Legionella pneumophila thrives in water reservoir blood test; hyponatraemia, lymphopenia, deranged LFT Ix urine/antigen culturePneumonia (HAP) HAP; >48hrs after admission Escherichia coli Klebsiella pneumoniae Pseudomonas aeruginosa common in bronchiectasis, CF, ITU infection, post- surgery green coloured sputum Streptococcus pneumoniae, Staphylococcus aureus (including MRSA). Polymicrobial Pneumonia Symptoms and signs Complications Flu-like symptoms Septicaemia Breathlessness Respiratory Failure Chest pain, pleuritic pain AF Cough Pleural effusion Fever Pericarditis and myocarditis Haemoptysis Lung abscess, empyema Investigation Pulse Oximetry: low O2 Bloods: raised wcc and crp, urea CXR: a positive CXR would show new consolidation Serology screening for atypical pneumonia Sputum culture Pneumonia Right middle lobe pneumonia Left lobar pneumoniaCommunity Acquired Pneumonia (CAP) CURB 65 C - Confusion 1 U - Urea (Level ≥7mmol/L) 1 R - RR ≥30/minute 1 B - BP ≤90mmHg (systolic) or 1 ≤60mmHg (diastolic) 65 - patient ≥65 y/o 1 0-1 Low risk consider OP management 2 Consider admission vs close OP Antibiotic selection is Trust Specific! management BMJ Best Practice 3-5 Admission, manage as severeMary is a 63y/o lady in ED with SOB, cough productive of green sputum, acute confusion, MCQ and fever. She is normally fit and well and takes no regular medications. Examination and investigation result are: vital signs: RR 24, BP 93/66, T 38.5 coarse crackles to right mid zone Abbreviated mental test score 7 urea - 8.1mm/L Based on her CURB-65 score, what is the most appropriate course of action? A) admission to care of the elderly ward B) admission to ICU C) admission to the Medical Respiratory Ward D) discharge with antibiotics and clinic follow up in. 6 weeksMary is a 63y/o lady in ED with SOB, cough productive of green sputum, acute confusion, MCQ and fever. She is normally fit and well and The correct answer is (C) admission to the takes no regular medications. Medical Respiratory Ward CURB - 65 is a tool to assess 30-day mortality Examination and investigation result are: vital signs: RR 24, BP 93/66, T 38.5 in CAP. coarse crackles to right mid zone The CURB - 65 criteria below with the criteria Abbreviated mental test score 7 triggered by Mary under underlined which urea - 8.1mm/L shows she has a score of 2 and therefore (B) and (D) are both incorrect Based on her CURB-65 score, what is the most appropriate course of action? A) admission to care of the elderly ward Geriatrics generally caters to patients ages 65 or over, so with Mary beig 63 and generally fit and well, this is not the most B) admission to ICU appropriate ward for her C) admission to the medical respiratory ward D) discharge with antibiotics and clinic follow up in. 6 weeksA 25-year-old man has presented to the hospital you work at with muscle aches, MCQ cough, and diarrhoea over the last 3 days. His partner tells you he was completely well earlier in the week and even had the energy to fix their water storage unit on his own. His observations reveal he is pyrexial. A) Mycoplasma pneumoniae His admission blood tests are as follows: B) Streptococcus pneumoniae Haemoglobin: 120 g/L MCV: 92fL C) Legionella pneumophillia WCC: 14.6 x109/L Platelets: 312 x109/L D) Escherichia coli Sodium: 124mmol/L Potassium: 3.9mmol/L E) Salmonella typhi Urea: 12.4mmol/L Creatinine: 229 μmol/L The diagnosis is confirmed by urinary antigen testing. Which organism is most likely to have caused this presentation? MCQ The bacterium legionella pneumophilia is the cause of Legionnaires’s disease. A) Mycoplasma pneumoniae Signs and symptoms of Legionnaires’s B) Streptococcus pneumoniae disease include cough, SOB, fever, muscle pains, AKI, hyponatraemia and headaches. C) Legionella pneumophillia Nausea, vomiting and diarrhoea may also occur. Symptoms often begin two to ten days D) Escherichia coli after exposure. E) Salmonella typhi Legionella antigens can be detected in the urine of those affected. Classically Legionella is transmitted via contaminated water reservoirs such as air conditioning systems, water storage units or cooling towers. Pulmonary Embolism (PE) Virchow’sTriad Definition PE is a thrombus that has travelled through the venous system to the pulmonary artery - usually this is a consequence form a DVT.Pulmonary Embolism (PE) Risk factors Pulmonary Embolism (PE) Symptoms Dyspnoea 50% S Haemoptysis Pleuritic chest pain 39% T Syncope or pre-syncope Features of DVT Cough 23% Q Fever Signs S1Q3V3 Tachypnoea 21% Tachycardia Hypotension Remember!!! Elevated jugular venous Most common ECG findings in pressure Hypoxia PE is sinus tachycardia Pleural rub Pulmonary Embolism (PE) ImportanceofaWells’Score Prior to commencing a set of investigations the main thing that needs to be done is a Wells’ Score! Image taken from: https://ebmcalc.com/BMJ_English_Prod/PulmonaryEmbRisk.htmPulmonary Embolism (PE) Nice.orgPulmonary Embolism (PE) Remember!!! CTPA is the preferred investigation for confirmation of PE. D-Dimer is an exclusion investigation, it is NOT a diagnostic tool. Nice.orgPulmonary Embolism (PE) CTPA CXR usually normal in PE patientPulmonary Embolism (PE) Treatment Nice.orgPulmonary Embolism (PE) Treatment Important points on PE treatment Start interim anti-coagulant if investigation result is not available in 4 hours Measure baseline FBC, U&E and LFT, PT and APTT but start anticoagulation before results are available and review within 24 hours Offer anticoagulation for at least 3 months. After 3 months (3 to 6 months for active cancer) assess and discuss the benefits and risks of continuing, stopping or changing the anticoagulant with the person. Pulmonary Embolism (PE) Treatment Treatment failure PE with haemodinamic instability/massive PE If anticoagulation treatment fails: check adherence Offer continuous UFH infusion address other sources of and consider thrombolytic hypercoagulability therapy increase the dose or change to Other invasive approach an anticoagulant with a should be considered where different mode of action appropriate facilities exist Nice.orgA 45 y/o woman presents to ED with 1 episode MCQ of haemoptysis. She is worried that she may have had a pulmonary embolism (PE), as her husband had one last year and she is on the combined oral contraceptive pill. Her heart rate is 90bpm and her SpO2 is 97%. What is the most appropriate investigation to order? A) CT pulmonary angiography (CTPA) B) ECG C) D-dimer D) V/Q perfusion scan Before ordering any investigation it is important to calculate this patient’s Well’s MCQ A 45 y/o woman presents to ED with 1 episode score, which can be remembered as: of haemoptysis. She is worried that she may have had a pulmonary embolism (PE), as her E: embolism hx (previous VTEs) - 1.5 husband had one last year and she is on the M: malignancy (active or treated in past 6 combined oral contraceptive pill. months) - 1 B: bed-rest (> 3 days) or surgery (in the Her heart rate is 90bpm and her SpO2 is past 4 weeks) - 1.5 97%. O: oral blood/haemoptysis - 1 L: legs affected (see later) What is the most appropriate investigation to I: increased HR (>100) - 1.5 order? S: signs of DVT (leg swelling, pain on palpitation) - 3 A) CT pulmonary angiography (CTPA) M: most likely to be PE - 3 B) ECG She score 1 for haemoptysis. She has 1 risk factor and no further convincing signs or C) D-dimer symptoms, her husband medical history is unlikely to be of significance thus, she does D) V/Q perfusion scan not scare for PE most likely. Type 1 ↓O2 Respiratory -CO2 Failure Type 2 When the respiratory system fails to maintain adeqaute O2 and/or removal of CO2, leading to ↓O2 hypoxia, hypercapnia or both ↑CO2 ↑ WOB ↑RR → 15L NRB → ABGRespiratory Failure Pulmonary Vascular Type 1 Disease Airway Diseases PE COPD Pulmonary Hypertension Problems w/ O2 exchange Asthma Right-to-left shunts i.e. Ventilation/Perfusion mismatch (V/Q mismatch) 15L NRB Treat underlying cause Interstitial lung diseases Pulmonary fibrosis Sarcoidosis Call for Senior help Alveolar Infiltrates Pneumonia Pulmonary Oedema ARDS Respiratory Failure Type 2 Centrally Opiates/BDZs/sedatives/narcotics, Obesity , Brain stem CVA, Encephalitis Alveolar hypoventilation w/ reduced respiratory drive/effort or muscle failure Chest Wall Thoracoplasty, Kyphoscoliosis, NIV Obesity Treat underlying cause Neuromuscular Muscular dystrophy, MND, Cervical cord lesion, Myasthenia Gravis, Obstructive Call for Senior help COPD, Acute Asthma, Bronchiectasis Guillan-Barre syndrome, or CF, Severe OSA Diaphragmatic paralysis Respiratory Failure Type 2 Centrally Opiates/BDZs/sedatives/narcotics, Obesity , Brain stem CVA, Encephalitis Alveolar hypoventilation w/ reduced respiratory drive/effort or muscle failure Chest Wall Thoracoplasty, Kyphoscoliosis, NIV Obesity Treat underlying cause Neuromuscular Muscular dystrophy, MND, Cervical cord lesion, Myasthenia Gravis, Obstructive Call for Senior help COPD, Acute Asthma, Bronchiectasis Guillan-Barre syndrome, or CF, Severe OSA Diaphragmatic paralysisPart 3CXR Image Quality interpretation Rotation Inspiration Mostimportanttocheck The 5-6 anterior ribs, lung apices, Patient details: name, date of both costophrenic angles and the birth and identification lateral rib edges should be visible. number. Date and time the film was Projection Note if the film is AP or PA taken Previous imaging: useful for Exposure comparison. The left hemidiaphragm should be visible to the spine, and the vertebrae should be visible behind the heart. CXR Interpretation Airway: trachea, carina, bronchi and hilar ABCDEapproach structures. Breathing: lungs and pleura. Cardiac: heart size and borders. Diaphragm: including assessment of costophrenic angles. Everything else: mediastinal contours, bones, soft tissues, tubes, valves, pacemakers and review areas. CXR Interpretation Airway: trachea, carina, bronchi and hilar structures. Trachea Carina and Bronchi Inspect the trachea for evidence of important landmark when assessing deviation nasogastric (NG) tube placement ABCDEapproach Hilar Structures Each hilar also has a collection of lymph nodes which aren’t usually visible in healthy individuals The hilar are usually the same size, so asymmetry should raise suspicion of pathology CXR Interpretation Breathing: lungs and pleura. ABCDEapproach Lungs Inspect the lung zones ensuring that lung markings are present throughout. Increased airspace shadowing in a given area of a lung field may indicate pathology (e.g. consolidation/malignant lesion). Pleura The pleura are not usually visible in healthy individuals. If the pleura are visible it indicates the presence of pleural thickening which is typically associated with mesothelioma. CXR Interpretation Cardiac: heart size and borders. Diaphragm: including assessment of costophrenic ABCDEapproach angles. Heart size should occupy no more than 50% of the thoracic width, This rule only Costophrenic angle applies to PA chest X-rays (as AP films The right hemidiaphragm is, in most exaggerate heart size) cases, higher than the left check if free gas is present under diaphragm (often as a result of bowel perforation) costophrenic blunting, can indicate the presence of fluid or consolidation in the area Heart Borders CXR Interpretation Everything else: mediastinal contours, bones, soft tissues, tubes, valves, pacemakers and review ABCDEapproach areas. Bones and soft tissue Mediastinal contour Assess if any fracture or haematoma Aortic knuckle; reduced definition of contours can occur in the context of an aneurysm. Aortopulmonary window (This space can be lost as a result of mediastinal lymphadenopathy) Miscellaneous Tubes, valves and pacemakers CXR Interpretation Airway: trachea central, carina and bronchi normal ABCDEapproach and no hilar abnormalities. Breathing: clear lung fields and no pleura abnormalities. Cardiac: normal heart size and visible borders. Diaphragm: normal costophrenic angles, no other abnormalities of the diaphragm Everything else: normal mediastinal contours, no bony or soft tissues abnormalities Impression: Normal CXR CXR excercise 88M bed-bound male patient with b/g of Parkinson’s Disease presented from care home with worsening abdominal pain and distention, 2/52 of constipation and no vomiting. Riggler sign also known as the double-wall sign gas is outlining both sides of the bowel wall Airway Breathing Cardiac Diaphragm Everything elseCXR excercise 20y/o male brought in by ambulance to ED resus with gunshot wound to the chest. He is breathless and not maintaining oxygen despite 15L highflow. Airway Breathing Cardiac Diaphragm Everything elsePart 4 ABG’s A simple but incredibly useful tool to quickly assess an unwell patient It can tell us the O2 and CO2 levels Any electrolyte disturbances And the Hb status Not only used for Respiratory Failure, but also in acid-base disorders i.e. sepsis, renal failure, DKA, excess vomiting etc ABG’s To start, always rememberABG’s Step 1; Look at the pH. Is it high? or low? ABG’s Step 1; Look at the pH. Is it high? or low? Step 2; Is it a Respiratory or Metabolic cause? ABG’s Step 1; Look at the pH. Is it high? or low? Step 2; Is it a Respiratory or Metabolic cause? ABG’s Step 1; Look at the pH. Is it high? or low? Step 2; Is it a Respiratory or Metabolic cause? ABG’s Step 1; Look at the pH. Is it high? or low? Step 2; Is it a Respiratory or Metabolic cause? ABG’s Step 1; Look at the pH. Is it high? or low? Step 2; Is it a Respiratory or Metabolic cause? ABG’s Step 1; Look at the pH. Is it high? or low? Step 2; Is it a Respiratory or Metabolic cause? Step 1; Look at the pH. Is it high? or low? Step 2; Is it a Respiratory or Metabolic cause? ABG’s Step 3; Look at i.e. T1RF or T2RFh? or low? Step 1; Look at the pH. Is it high? or low? Step 2; Is it a Respiratory or Metabolic cause? ABG’s Step 3; Look at i.e. T1RF or T2RFh? or low? Step 1; Look at the pH. Is it high? or low? Step 2; Is it a Respiratory or Metabolic cause? ABG’s Step 3; Look at i.e. T1RF or T2RFh? or low? Step 1; Look at the pH. Is it high? or low? Step 2; Is it a Respiratory or Metabolic cause? ABG’s Step 3; Look at i.e. T1RF or T2RFh? or low? Step 1; Look at the pH. Is it high? or low? Step 2; Is it a Respiratory or Metabolic cause? ABG’s Step 3; Look at i.e. T1RF or T2RFh? or low? Step 1; Look at the pH. Is it high? or low? Step 2; Is it a Respiratory or Metabolic cause? ABG’s Step 3; Look at i.e. T1RF or T2RFh? or low?Thank you for listening and engaging!Teaching Frontier UKMLA Series 6 ENT