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P-PALS YEAR 3 RESPIRATORY TEACHING Daisie Edgerley andAnanya Banerjee – Pneumonia Thingswewill – Tuberculosis – Asthma cover – ABG A 32 year old has a productive cough for the last 5 days. Her cough is productive of green sputum.She has a fever andSOB on exertion. On examination there is reduced air entry and crepitations heard at the right lower base.What are the likelyX ray findings? A – Hyperinflated lungs with a flat diaphragm Pneumonia B –Opacification in the right lower zone C –Cardiomegalyand interstitial oedema D – Meniscus shaped opacification in the right lower zone E – normalX-Ray – Typical – Culturable ongramstain – More classic presentation Pneumonia– – Atypical Classification – Not culturable on gram stain – Non-specific presentations (myalgia, gradual onset) Community-acquired – Streptococcuspneumoniae (T) – Haemophilus influenzae (T) – Mycoplasmapneumoniae (A) – Legionella pneumonia (A) Pneumonia– Classification Hospital-acquired–Onset 48 hours after admission – Staphylococcus aureus (T) – Pseudomonas aeruginosa (A) – Klebsiella pneumoniae (T) – Aspiration pneumonia – Pneumonia afterinhalingforeign materials – Viral Pneumonia– – InfluenzaA Classification – Varicellazoster virus – Cytomegalovirus – Fungal – PneumocystisJirovecii – SOB – Productive cough – Colourless, greenor rustcolouredsputum – Fever – Sepsis (do a septic screen) – Pleuritic chest pain Pneumonia– Presentation – Delirium – Haemoptysis (rare) – Examination – Tachycardiatachypnoea, hypoxia, and hypotension – Reduced chestexpansion – Bronchialbreathing, course crackles and dullpercussion – Increased vocalfremitus – Blood tests – RaisedWCC, raisedCRP,U+Es to guide management – Oxygen saturations – ABG – Blood cultures Pneumonia– Tests – ECG (may developAF) – ChestX-ray – Consolidation in zones – changes may not appear quickly – Sputum sample – Urinary antigen testing for Legionnaires’ – CURB-65score – assesses the mortality of the infection – Can underestimate the risk in young patients and overestimate the risk inCKD patients CURB-65 Clinical Feature Points C Confusion 1 U Urea >7 mmol/L 1 R RR ≥30 1 Pneumonia– Systolic BP < 90 mmHg B Diastolic BP ≤60 mmHg 1 Management 65 Age ≥65 1 CURB-65 30-day Score RiskGroup mortality Management 0-1 1 1.5% Low risk, consider home treatment 2 2 9.2% Probably admission vs close outpatient management 3-5 3 22% Admission, manage as severe – Treatment (usually antibiotics) depends onCURB-65score and local guidelines – Amoxicillin – Clarithromycin Pneumonia– Management – Consider fluids, oxygen and pain relief – Bloods,X-Ray, sputum culture and follow up appointment – Cough lasting longer than 3 weeks – Haemoptysis – Fever Tuberculosis Presentation – Night sweats – Tiredness and fatigue – Loss of appetite – MantouxTest Diameter of IndurationPositivity Interpretation <6 mm Negative–No significant Previously unvaccinated Latent hypersensitivityto individuals may be given Tuberculosis tuberculin protein the BCG 6-15mm Positive–HypersensitiveShould not be given Diagnosis to tuberculin protein BCG. May be due to previousTB infection or BCG >15mm Strongly positive– Suggests tuberculosis Strongly hypersensitiveinfection to tuberculin protein – ChestX-Ray – Upperzonecavitation – Bilateral hilarlymphadenopathy – Sputum smear – 3samples Active – Stained using theZiehl-Neelsenstain for acid-fastbacilli – Sensitivity 50-80% Tuberculosis – Sputum culture Diagnosis – Gold standard – Can be used to assess drugsensitivities – Takes 13weeks – Nucleic acid amplification tests – Takes 2448 hours – More sensitive than a smear, but less sensitive than a cultureTuberculosis CXR – 3 months of isoniazid with pyridoxine and rifampicin Latent Tuberculosis OR Management – 6 months of isoniazid with pyridoxine – Initial phase for 2 months – Rifampicin – Isoniazid – Pyrazinamide Active – Ethambutol Tuberculosis – Continuation phase for 4 months Management – Rifampicin – Isoniazid – Give 4 for 2, then 2 for 4 – Rifampicin – Red/orangesecretions – Hepatitis – Isoniazid – Peripheral neuropath–prevent with pyridoxine (Vitamin B6) Tuberculosis – Hepatitis DrugSide – Agranulocytosis Effects – Pyrazinamide – Gout – Hepatitis – Arthralgia andmyalgia – Ethambutol – Optic neuritis – A 46 year old patient is on quadruple therapy (rifampicin, isoniazid, ethambutol and pyrazinamide) for a confirmed diagnosis of pulmonary tuberculosis. He presents to his respiratory follow up complaining that his vision has deteriorated, more specifically colours appear less vivid.Which medication change would you make? Tuberculosis – A –Stop rifampicin – B –Stop isoniazid – C –Stop ethambutol – D –Stop pyrazinamide – E –Stop pyridoxine Source: Passmedicine – A 32-year-old male presents to his general practitioner having had several episodes of blood-streaked sputum production. He reports, on further questioning, to have noticed that his clothes are fitting more loosely and he often wakes up in the night soaked through with sweat and needs to change his pyjamas.On examination, theGP notices some cervical lymphadenopathy.Cardiorespiratory examination is unremarkable. He has a known history of HIV and is compliant with antiretroviral therapy.TheGP explains she wishes to perform further investigations for tuberculosis. Tuberculosis What is the most appropriate diagnostic test for this patient for active disease? – A –ChestX-Ray – B – Interferon gamma release assay (IFGA) blood test – C – Mantoux skin test – D –Sputum culture – E –Sputum microscopy Source: Passmedicine – A 64-year-old Bangladeshi man presents to theGP with blood- stained sputum and breathlessness.On further questioning, he notes fatigue, weight loss and some sweating in the night.TheGP takes sputum samples and sends the man for a chestX-ray. Given this initial management, what other investigation must be requested in this patient? Tuberculosis – A –Urinalysis – B – Pleural aspiration – C – High-resolution computed tomography (HRCT) chest – D – Lumbar puncture – E – HIV test Source: Passmedicine Chronic inflammatory disease of the airways 3 components: Asthma – Reversible and variable airflow obstruction – Airway hyper-responsiveness to stimuli – Inflammation of the bronchi – Wheeze – SOB – Dry cough – Chest tightness(especially in the morning) – Symptoms worse at night (less cortisol – less immunosuppression) – Any previous hospital admissions? Asthma– – Adherence to treatment/inhaler technique – Ask about triggers (exercise, weather, pets) Presentation – Associated conditions(hay fever, eczema) Toassess severity 1. Difficulty sleeping 2. Symptoms during the day 3. Affecting daily activity – Low birth weight – Family history – Smoking exposure Asthma–Risk Factors – Obesity – Deprivation – Other conditions in atopic triad – Oxygen saturations – PEF measurement (20% diurnal variability) – Spirometry - FEV1/ FVC ratio <70% indicates obstruction – FEV1 improvement of 12% with bronchodilator indicative of asthma. – FeNO testing to detect eosinophilia >40ppb suggestive of asthma – Blood test and chest x ray to rule out infection Asthma– Investigation Examination: – Increased work of breathing, use of accessory muscles, audible wheeze – Fine tremor (salbutamol use) – Oral candidiasis (steroid inhaler) – Polyphonic expiratorwheezeLong-Term Management ofAsthma Source: BTS Guidelines Treatment ABCDE approach • Oxygen Acuteasthma • Salbutamol • Hydrocortisone attack • Ipratropium • Theophylline • Magnesium • Escalate to ICU OHSH*T ME – Personalised asthma action plan – Peak flow diaries – Annual asthma review Asthma– – Smokingcessation Management – Vaccinations – Weightloss – Avoid asthma triggers – Which of the following features suggest a life threatening acute attack – A – 33-50% of predicted PEF – B – RR over 30 breaths/min Asthma – C – HR > 125 BPM – D –Oxygen sats < 92% – E – Difficulty completing full sentences – A 40 year old man is presenting with an acute exacerbation of asthma. His Peak expiratory flow rate is 210 litres per minute. His usual average is around 600 litres per minute.What level of exacerbation is this man experiencing. – A- mild Asthma – B – moderate – C –Severe – D – Life threatening – E – Near fatal 1. Is the patient hypoxaemic? – Normal PaO 210kPa on roomair 2. What is the pH? – Acidotic if the pH <7.35 – Alkalotic if the pH >7.45 ABG 3. What is the PaCO ?2 – Respiratory acidosis if the P2CO>6kPa Interpretation – Respiratory alkalosis if the P2CO<4.7kPa 4. What is the bicarbonate level and base excess? – Metabolic acidosis if the bicarbonate <22mmol/l or a base excess <- 2mmol/l – Metabolic alkalosis if the bicarbonate >26mmol/l or a base excess >+2mmol/l 5. Is there any compensation? Respiratory Failure – Type 1 – Oxygen PaO 2s reduced ABG – CO 2s low ornormal Interpretation – Type 2 – Oxygen PaO 2s reduced – CO 2s high – You are asked to review -year-oldfemale who wasadmittedwith shortness of breath.On your arrival, the patient appears drowsy and is on 10Lofoxygenviaamask. – You perform an ABG, which reveals the following results: – PaO 2 7.0kPa (11-13 kPa) – pH:7.29 (7.35 –7.45) ABG – PaCO 2 9.1kPa(4.7 –6.0kPa) Interpretation – HCO 3: 26(22 –26 mEq/L) – Base excess: +1 (-2to+2) 1. What does theABG show? 2. What type of respiratory failure is shown? Source: Geeky Medics – A 22-year-old female is brought intoA&E by ambulance with a 5-day history of vomiting and lethargy.When you begin to talk with the patient you note that she appears disorientated and looks clinically dehydrated.At present, you are unable to gain any further details, but the patient looks very unwell from the end of the bed.You gain IV access, send off a routine panel of bloods and commence some fluids. You ask the nurse to check the patient’s observations and she notes an increased respiratory rate, low blood pressure and tachycardia.You perform an ABG on the advice of your registrar.The results of theABG are shown below (the patient was not on oxygen when this was taken). ABG – PaO 2 13 kPa (11– 13 kPa) – pH: 7.3 (7.35 – 7.45) Interpretation – PaCO 2 4.1 kPa (4.7 – 6.0 kPa) – HCO 3: 13 (22– 26 mEq/L) – BE: -4 (-2 to +2) 1. What does theABG show? 2. What investigations would you order given the likely diagnosis? Source: Geeky Medics – significant dyspnoea and a wheeze.Theparamedics report that his HR was 110 BPM, respiratoryrate 24/minute,SpO 94% on room air,BP 115/84 mmHg and temperature 37.3ºC. 2 – The nurse in theEmergency Department repeats his observations and 126, BP 115/78 mmHg. He is distressed and unable to talk in fullHR sentences.AnABG is performed. – PaO 2 9 kPa (11 – 13 kPa) ABG – pH: 7.36 (7.35 – 7.45) Interpretation – PaCO 2 4.8 kPa (4.7 – 6.0 kPa) – HCO 3: 25 (22 – 26 mEq/L) – BE: 0 (-2 to +2) 1. What does theABG show? 2. What is the likely diagnosis? 3. What would you do next?