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My email address: sr1220@ic.ac.uk Slides based off: Helena Milton-Jones Acute Respiratory Shruti Rajendra MedEd Y3 Written Exam Lectures 2025SESSION STRUCTURE Aetiology History Presentation Investigations Management = Gold Standard = High YieldSESSION CONENT Conditions: • Acute bronchitis • Influenza • Pulmonary embolism (PE) • Pneumothorax • Acute respiratory distress syndrome (ARDS) • Respiratory arrest • COVID-19 (summary slide) SBA 1 Lucy is a 12-year-old girl who has presented to her GP accompanied by her mother with a dry cough and shortness of breath. She says it has lasted 5 days and she’s taken some time off school. She has been feeling generally unwell although doesn’t have a fever. She has no known drug allergies and no medical history of note, although had a similar cough last winter. What should the GP do? A) Advise her mother to give her paracetamol at home and make sure she’s well hydrated B) Prescribe a 7-day course of amoxicillin C) Prescribe a 7-day course of doxycycline D) Prescribe inhaled corticosteroids E) Refer to A&E for a chest x-ray Acute Bronchitis Definition: Infection of the bronchi, upper respiratory tract infection (URTI) Aetiology: Usually a viral infection, although may be bacterial Typical organisms: Less commonly • Rhinovirus caused by: • Parainfluenza • Mycoplasma • Influenza A or B pneumoniae • Respiratory syncytial • Bordetella pertussis virus • Chlamydia • Coronavirus pneumoniae Acute bronchitis Risk factors: Smoking Cystic fibrosis COPD Acute Bronchitis Signs and Symptoms: Non-productive or minimally Dyspnoea productive cough - Results from chest pain or - High or prolonged fever tightness with breathing suggests pneumonia - May last weeks - Wheezing Acute Bronchitis Investigations: CXR is usually only indicated if: Diagnosis is based on clinical ➢Findings suggestive presentation following ➢Elderly patients examination and history. ➢Persistent cough >6 weeks ➢History of COPD, lung pathology Sputum MCS usually has no role, unlike in pneumonia Acute Bronchitis Management: In patients with underlying lung pathology (eg. COPD, asthma): In otherwise healthy patients: ➢ Oral antibiotics ❖ Amoxicillin – 7 days) ➢Paracetamol and ibuprofen as required ❖ Doxycycline (if penicillin allergy) – 7 days ➢Hydration If cough persists for > 2 weeks: ➢Inhaled corticosteroids Inhaled beta-2 agonists (eg. salbutamol) may be useful if the patient is wheezing. Antitussives can be prescribed if cough is interfering with sleep. SBA 1 Lucy is a 12-year-old girl who has presented to her GP accompanied by her mother with a dry cough and shortness of breath. She says it has lasted 5 days and she’s taken some time off school. She has been feeling generally unwell although doesn’t have a fever. She has no known drug allergies and no medical history of note, although had a similar cough last winter. What should the GP do? A) Advise her mother to give her paracetamol at home and make sure she’s well hydrated B) Prescribe a 7-day course of amoxicillin C) Prescribe a 7-day course of doxycycline D) Prescribe inhaled corticosteroids E) Refer to A&E for a chest x-ray Influenza Definition: Acute respiratory tract infection caused by seasonal influenza A or B virus transmitted through inhalation of infected respiratory droplets Aetiology: • Single-stranded RNA genome • Haemagglutinin (H antigen) – binding and entry of virus into tracheobronchial epithelial cells • Viral replication occurs • Neuraminidase (N antigen) – helps mature virus to escape • Peak viral shedding occurs in first 48-72 hours, declines and undetectable within 10 days Influenza Risk factors: Aged ≥65 years Aged 6 months – 5 years Pregnancy Chronic respiratory conditions Chronic kidney disease Diabetes Immunocompromised Healthcare workers Influenza Signs and symptoms: Have a higher suspicion of influenza in winter months and at-risk groups who are unvaccinated Fever, myalgia, malaise Cough Sore throat Cervical lymphadenopathy Influenza Investigations: Influenza is a clinical diagnosis * Viral culture is definitive test for laboratory diagnosis, but takes 3-10 days for results to be reported, so is not often used for initial clinical management. It is used for confirming screening tests and for public health surveillance. Management: st 1 line: Bed rest, OTC antipyretics and analgesia (paracetamol and ibuprofen) High risk group: Consider antiviral therapy (eg. oseltamivir) *must present ≤48 hours after first symptoms for antiviral therapy to be effective Hospitalised patients: Antiviral therapyAcute Bronchitis: SUMMARY SLIDE Aetiology: Risk factors: Investigations: Smoking, chronic lung Clinical diagnosis: Infection of the conditions (COPD, CF) Indications for CXR: bronchi, upper Thorough examination • Findings suggestive of respiratory tract and history infection (URTI) Differentials: pneumonia Sputum MCS usually • Elderly patients ✶ Usually, viral over ✶ Pneumonia not indicated • Persistent cough lasting weeks bacterial infection • History of lung pathology ✶ Asthma History: Management: Complications: • Cough Conservative: Regular paracetamol, ibuprofen, hydration ✶ Pneumonia • Sore throat • Dyspnoea ✶ Chronic bronchitis • Cervical Medical ✶ Sinusitis lymphadenopathy • Fever • Malaise Influenza: SUMMARY SLIDE Aetiology: Risk factors: Investigations: Acute respiratory Elderly, infants, Clinical diagnosis: Indications for CXR: tract infection pregnancy, chronic Thorough examination • Findings suggestive of diseases, NHS workers and history caused by seasonal pneumonia influenzaA or B Differentials: Sputum MCS usually • Persistent cough lasting ✶ Transmitted via weeks respiratory ✶ Pneumonia not indicated • History of lung pathology droplets ✶ Bronchitis History: Management: Complications: Conservative: Regular paracetamol, ibuprofen, hydration ✶ Pneumonia • Non-productive or minimally productive cough Medical ✶ High risk group: Consider antiviral therapy (eg. • Dyspnoea oseltamivir) *must present ≤48 hours after first symptoms for antiviral therapy to be effective • Mild fever ✶ Hospitalised patients:Antiviral therapy SBA 2 Rachel is a 24-year-old female who underwent a recent salpingectomy for an ectopic pregnancy. Today she awoke breathless, with pleuritic chest pain and haemoptysis. She has been taking the COCP for 5 years. A pulmonary embolism was suspected. CTPA identified filling defects within the pulmonary vasculature with pulmonary emboli. Her recent observations are: How should Rachel be managed? Temp: 37.4°C a)Anticoagulation HR: 122 bpm b)Thrombolysis BP: 105/78 c)Embolectomy RR: 22 d)Respiratory Support SaO 2 93% on RA e)TED stockings Pulmonary Embolism (PE) Definition: a blockage in one of the pulmonary arteries in the lungs One or more emboli, usually arising from a Venous Thromboembolism thrombus formed in the veins, are lodged in and obstruct the pulmonary arterial system, causing severe respiratory dysfunction Embolus Pulmonary Embolism Deep Vein Thrombosis Pulmonary Embolism (PE) Risk factors: Mnemonic: CT, s'il vous plaît C T S V P ▪ Cancer ▪ Trauma ▪ Stasis ▪ Varicose ▪ Pill (OCP) ▪ Chemo ▪ Time (age) ▪ Surgery veins ▪ Pregnancy ▪ Cardiac ▪ Thrombocytosis ▪ Factor S ▪ Virchow’s ▪ Puerperium Failure ▪ Travel (long deficiency Triad ▪ Previous VTE ▪ COPD haul flight) ▪ Factor V ▪ Polycythaemia ▪ deficiency Leiden ▪ depositionn Why? Because you will be asking the radiologist for a CTPA Pulmonary Embolism (PE) Signs and symptoms: Presentation depends on the severity of PE Pleuritic chest pain Dyspnoea Collapse (if severe) Pulmonary Embolism (PE) Signs and symptoms: Acute Massive PE Acute Small PE Chronic PE Sudden complete occlusion of Sudden incomplete Chronic occlusion of pulmonary artery occlusion of pulmonary pulmonary artery microvasculature ▪ Collapse ▪ Pleuritic chest pain ▪ Exertional ▪ Central crushing pain ▪ Haemoptysis Dyspnoea ▪ Severe dyspnoea ▪ Dyspnoea On ECG ▪ S Q T pattern ▪ Sinus tachycardia 1 3 3 Buzzword ▪ Right axis deviation (RAD) for written ▪ Right bundle branch block (RBBB) exam Note: CXR can show Westermark’s Sign (high +ve pred. value, occurs in 10% of cases) Pulmonary Embolism (PE) S1Q3T3 pattern: Westermark’s Sign: Hypovolaemia distal to the pulmonary artery that has been occluded Indicative of RV strain, and therefore, suggestive of PE by tinfarction. This increases the translucency of the region.d Pulmonary Embolism (PE) Investigations: Well’s Score is used to estimate risk of PE and determines the patient should be investigated * You need to know when and why the Well’s score is used for the written exam Well’s Score: Previous DVT/PE 1.5 CTP A Evidence of DVT 3 ≥5 High Risk Stasis 1.5 Well’ s Cancer 1 Opinion is PE 3 Score ≤4 D-dimer Rhythm Raised (>100) 1.5 Low Risk Exsanguination (Haemoptysis) 1 Pulmonary Embolism (PE) Management: Management depends on whether the patient is haemodynamically stable or not Are they haemodynamically stable (ie. SBP <90 mmHg) YES NO Sub-acute/Chronic PE Massive PE ▪ Respiratory support ▪ stspiratory support ▪ Anticoagulation ▪ 1ndine: UFH heparin infusion ▪ 2 line: Thrombolysis ▪ 3 line: Embolectomy Anticoagulants: ▪ DOACs/Heparin for 5 days IV Thrombolytics (fibrinolytics): ▪ Warfarin for 3 months ▪ Alteplase ▪ Streptokinase ▪ rt-PA Pulmonary Embolism (PE) Venous thromboembolism (VTE) prevention: *VTE encompasses both DVT and PE NICE guidelines state everyone must be VTE risk assessed within 24 hours of hospital admission. A standard checklist is: ▪ Mechanical: Compression stockings (TED stockings) ▪ Pharmacological: Low-molecular-weight heparin (eg. tinzaparin) “TEDs & Tinz” SBA 2 Rachel is a 24-year-old female who underwent a recent salpingectomy for an ectopic pregnancy. Today she awoke breathless, with pleuritic chest pain and haemoptysis. She has been taking the COCP for 5 years. A pulmonary embolism was suspected. CTPA identified filling defects within the pulmonary vasculature with pulmonary emboli. Her recent observations are: How should Rachel be managed? a)Anticoagulation Temp: 37.4°C b)Thrombolysis HR: 122 bpm BP: 105/78 c)Embolectomy RR: 22 d)Respiratory Support SaO 2 93% on RA e)TED stockings Pulmonary embolism (PE): SUMMARY SLIDE Aetiology: Risk factors: Investigations: A blockage in one of ✶ Stasis (bed bound IfWell’s score < 4: ECG: S1Q3T3 pattern, the pulmonary arteries patient, recovering D-dimer RAD, RBBB, tachycardia in the lungs, usually from surgery, long arises from a venous IfWell’s score ≥4: CT CXR: Westermark’s sign thrombus haul flight) pulmonary angiogram (CTP A) (rare but high sensitivity) ✶ Acute massive ✶ Oral contraceptive ✶ Acute small pill ✶ Chronic ✶ Pregnancy scan insteadTPA in pregnancy, doV/Q History: Management: Complications: Acute massive • Collapse ✶ If haemodynamically stable: Respiratory support, ✶ Reoccurrence • Central crushing chest anticoagulation pain ✶ Fondaparinux/heparin for 5 days; warfarin/DOAC for 3 • Severe dyspnoea ✶ Cardiac arrest Acute small months • Haemoptysis ✶ If haemodynamically unstable (SBP < 90): • Dyspoea Thrombolysis (IV alteplase) is first line, embolectomy ✶ Pulmonary • Pleuritic chest pain hypertension is second line Chronic ✶ VTE prevention: Compression stockings, LMWH eg. • Exertional dyspnoea enoxaparin, tinzaparin SBA 3 Lanky Schmidt is a tall, 29-year-old male. He has presented toA&E after feeling short of breath whilst playing basketball. He has right sided pleuritic chest pain. He is a non- smoker and is otherwise healthy with no underlying medical conditions. A chest radiograph shows a right sided pneumothorax 8mm in diameter. How should the medical team proceed? a)Reassure and discharge with outpatient review b)Observe for 6 hours and give oxygen c)List for elective Surgical Pleurodesis d)Needle Aspiration and give oxygen nd e)Immediate wide bore cannula insertion at 2 intercostal space Pneumothorax Definition: an abnormal collection of air in the pleural space between the lung and the chest wall Normal intrapleural pressure is -5 to 28 cm H O Traumatic pneumothorax Spontaneous pneumothorax Damage to parietal pleura Damage to visceral pleura Pneumothorax Classifying pneumothoraxes: PRIMARY or SECONDARY? COPD Cystic fibrosis Primary – young and otherwise healthy patieSecondary – pre-existing lung pathology; elderly Pneumothorax Risk factors for primary pneumothorax: Male Smoking Marfan’s Syndrome Pneumothorax Signs and symptoms: Presentation depends on the severity of pneumothorax Pleuritic chest pain Dyspnoea Collapse if severe Pneumothorax Investigations: CXR – Look for loss of lung markings (may see line where they stop; air is black on x-ray) Pneumothorax Management: Lung Dx OR 50+ Old Smoker? Primary No Secondary Yes >2cm OR >2cm OR SoB? SoB? No Yes No Yes Discharge & Needle Between 1- OPD review aspiration: 2cm? Chest drain Successful? No Yes No Yes Observation Observation Needle Chest drain and O and O aspiration: 2 2 Successful? No Yes Chest drain Observation and O 2 Pneumothorax Tension pneumothorax – medical emergency ONE WA Y VALVE Lung Compression ▪ Severe Dyspnoea ▪ Tracheal Deviation (away from lesion) ▪ Silent chest, hyperresonance, reduced expansion(on lesioned side) Contralateral Mediastinal Shift ▪Decreased venous return and cardiac output ▪Hypotension, tachycardia, neck vein distension Severe hypotension caused by obstructive shock is what causes death Pneumothorax Management of tension pneumothorax: Insert large bore cannula (orange or nd grey) in 2 ICS, MCL nd to avoid the neurovascular bundle of the 2 rib.rior region of 2 ICS) in order SBA 3 Lanky Schmidt is a tall, 29-year-old male. He has presented toA+E after feeling short of breath whilst playing basketball. He has right sided pleuritic chest pain. He is a non- smoker and is otherwise healthy with no underlying medical conditions. A chest radiograph shows a right sided pneumothorax 8mm in diameter. How should the medical team proceed? a)Reassure and discharge with outpatient review b)Observe for 6 hours and give oxygen c)List for elective surgical pleurodesis d)Needle Aspiration and give oxygen nd e)Immediate wide bore cannula insertion at 2 intercostal space Pneumothorax: SUMMARY SLIDE Aetiology: Risk factors: Investigations: CXR: Loss of lung markings (look An abnormal collection Male sex, smoking, for line where lung markings stop) of air in the pleural Marfan’s syndrome space between the lung and the chest wall Differentials: Bloods: FBC, clotting screen ✶ Primary (young, (correct clotting abnormalities healthy) ✶ Asthma before inserting chest drain) ✶ Secondary (elderl, lung disease ✶ PE History: Complications: Management: • Sudden pleuritic ✶ Primary pneumothorax: Discharge and organise ✶ Pulmonary oedema chest pain OPD review if <2cm and no SOB, needle aspiration if • Dyspnoea >2cm or SOB, chest drain if unsuccessful ✶ ARDS • Ipsilateral reduced breath sounds ✶ Secondary pneumothorax: Needle aspiration if <2cm • Ipsilateral (chest drain if unsuccessful), immediate chest drain if hyperinflation >2cm • Hypoxia ✶ T ension pneumothorax: Wide bore cannula, 2 nd ICS, MCL SBA 4 Which of the following most accurately describes ARDS? a)Hyaline Membrane Disease b)Type 2 Respiratory failure due to acute lung injury c)Non-Cardiogenic Pulmonary Oedema d)Respiratory distress secondary to severe sepsis e)Long-term respiratory sequelae of childhood rheumatic fever SBA 5 Mr Smith, a 60-year-old man, presents with acute onset shortness of breath, fever and cough. He is given intravenous antibiotics and high flow oxygen, but his respiratory status declines over the next 24 hours. A chest x-ray reveals bilateral diffuse infiltrates. He has no history of cardiac failure. ou quickly transfer him to the intensive care unit where he is intubated. Given the most likely diagnosis, what would you expect to hear on auscultation of Mr Smith’s lungs? a) Normal breath sounds b) Wheeze c) Bilateral fine crackles d) Bilateral coarse crackles e) Stridor Acute Respiratory Distress Syndrome (ARDS) Definition: Non-cardiogenic pulmonary oedema Berlin Criteria: 1)No alternative cause for pulmonary oedema (eg. cardiac failure) 2)Rapid onset < 1 week 3)Dyspnoea 4)Bilateral signs on chest x-ray Very common in ICU Acute Respiratory Distress Syndrome (ARDS) ARDS is caused by hypoxaemic acute lung injury Sepsis Pneumonia Ventilation Severe burns Transfusion Acute pancreatitis reactions Drug overdose COVID-19Acute Respiratory Distress Syndrome (ARDS) Aetiology: The body responds with a profound inflammatory response ++ Vascular Permeability ++ Alveolar Oedema Alveolar Collapse Acute Respiratory Distress Syndrome (ARDS) Investigations: CXR Bilateral, diffuse opacities Normal ARDS patient Acute Respiratory Distress Syndrome (ARDS) Management: Refer to ICU Respiratory Arrest Definition: Respiratory arrest is a state in which a patient stops breathing but maintains a pulse Respiratory arrest and cardiac arrest are two different conditions. While respiratory arrest indicates a cessation of breathing, cardiac arrest indicates a lack of heart function. treated promptly. cause the other to occur if it is not Management: Perform ACLS as appropriate + bleep crash team and ICU for mechanical ventilation Acute Respiratory Distress Syndrome (ARDS): Aetiology: Berlin criteria: Investigations: SUMMARY SLIDE ✶ No alternative cause for Non-cardiogenic pulmonary oedema eg. cardiaclateral, diffuse opacities pulmonary oedema failure ✶ Dyspnoeaset < 1 week ✶ Bilateral signs on CXRloods: ABG (type 2 respiratory Profound inflammatory failure) response increasing vascular permeability Differentials: Sputum culture: Identify cause and alveolar collapse ✶ COVID-19 eg. pneumonia Risk factors: ✶ Acute heart Blood culture: Identify cause eg. failure sepsis ✶ Sepsis ✶ Mechanical ventilation ✶ Burns Management: Complications: ✶ Acute pancreatitis ✶ Transfusion reactions ✶ Drug OD ✶ Refer to ICU for intubation, ventilation etc ✶ Death (mortality ✶ COVID-19 between 30-50%) ✶ Consider proning to improve oxygenation ✶ Ventilator associated History: lung injury or ✶ Dyspnoea pneumonia ✶ Tachypnoea ✶ painr, cough, pleuritic chest ✶ Multiple organ failure COVID-19: SUMMARY SLIDE Aetiology: Differentials: Investigations: A potentially severe acu✶ Pneumonia RT -PCR: Positive for SARS-CoV- respiratory infection caused 2 viral DNA by coronavirus severe acute respiratory syndrome Pulse oximetry: Low oxygen coronavirus 2 (SARS-CoV-2) saturation if moderate/severe RNA virus, multiple variantsfluenza Bloods: ABG, FBC,TFTs, glucose, SARS-CoV-2 attaches to CRP , ESR, cardiac biomarkers, ACE2 receptor on target host coagulation screen, U&Es cells.ACE2 is highly ✶ Common cold expressed in upper and lower CXR/Chest CT: Ground glass respiratory tract, but also in opacity, consolidation myocardial, renal epithelial, Complications: enterocytes and endothelManagement: cells of multiple organs ✶ ARDS Mild/moderate COVID-19: Bed rest, paracetamol, History: ibuprofen, maintain hydration, monitor O2 sats ✶ Thrombosis (due to Severe COVID-19: Hospital admission, oxygen therapy, hypercoagulable state) ✶ Dyspnoea ✶ Fever VTE prophylaxis, dexamethasone, remdesivir, IL-6 ✶ Cough inhibitor eg. tocilzumab OR Janus kinase (JAK) inhibitor ✶ Post COVID-19 ✶ Altered smell and taseg. barictinib, consider ICU admission for ventilation, syndrome (long ✶ Headache ✶ GI disturbances ECMO etc COVID) SBA 4 Which of the following most accurately describes ARDS? a)Hyaline Membrane Disease c)Non-Cardiogenic Pulmonary Oedemao acute lung injury d)Respiratory distress secondary to severe sepsis e)Long-term respiratory sequelae of childhood rheumatic fever SBA 5 Mr Smith, a 60-year-old man, presents with acute onset shortness of breath, fever and cough. He is given intravenous antibiotics and high flow oxygen, but his respiratory status declines over the next 24 hours. A chest x-ray reveals bilateral diffuse infiltrates. He has no history of cardiac failure. You quickly transfer him to the intensive care unit where he is intubated. Given the most likely diagnosis, what would you expect to hear on auscultation of Mr Smith’s lungs? a) Normal breath sounds b) Wheeze c) Bilateral fine crackles d) Bilateral coarse crackles e) Stridor