This medical teaching session covers respiratory topics from diagnosing and treating asthma. We'll review things like diagnostic tests such as fractional exhaled nitric oxide and spirometry, peak flow diary as well as the asthma stepwise management. The talks will focus on answering common questions asked on exams and will provide a good refresher for medical professionals. Join us on Thursdays and Sundays for the upcoming sessions and brush up on your respiratory knowledge.
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Learning objectives

Learning Objectives: 1. Describe the clinical features and diagnosis of asthma in a medical setting 2. Recognize the difference between acute severe asthma and life threatening asthma 3. Identify when peak flow monitoring is indicated in the management of asthma 4. Apply the stepwise approach in managing an asthma patient 5. Identify the criteria that must be met for a patient to be safely discharged from the respiratory board following an acute severe asthma attack
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continue. Awesome. So we have people join. We've got Q and A. No, because I haven't started yet, have I? Did you started? You started with Some people are joining now. Oh, good, because they're good. Hello, guys. Thanks for joining. We're just waiting for everyone to join, and we'll start in a bit. All right, guys, Just joining a couple minutes. We'll just started a couple of minutes. And you want people to join? Okay, I think we're going to start now. Yeah. Okay, guys, welcome to the, uh, series SBA Progress Test teaching today. We're going to be going over some respiratory teaching. This is the second talk of our series. We've got some more talks coming up every Thursday and Sunday in the coming weeks. So we start off with The first question is, are a 15 year old girl attends the GP with a woman history of a cough, shortness of breath, and she says that she gets a really bad cough specifically at nighttime states that her cough gets really bad as well. When she's doing sports in school with badminton. Her past medical history includes asthma. And apart from this, she's fitting well, which of the following would help confirm the most likely diagnosis. We launched the pool. All right, so we've got some good answers coming in. Okay, so most people answer the D. Some people were confused with a. So the correct answer here is D. So this is showing a obstructive picture, which is asthma, and you get an F. U B one of the F B C of less than 0.7. So with asthma, you get a cough often worse in the early mornings or later on at night, and it can be exacerbated by exercise. Or call the weather Winter times. And it's called diurnal variation, where you get a difference in the symptoms throughout the day. You get shortness of breath and the typical expiratory wheeze because of the obstructive nature of the condition, and you get a tight chest feeling sometimes. It's also associated with patients who have a history of asthma or other activities such as hayfever. Some of the diagnostic tests, the more new ones include a fractional exhaled nitric oxide test, and all this means is that it's correlated to the level of the nation inside the lungs. And if you need to know. For example, if it's the result is 40 or above, then this is a diagnostic for asthma and adults or if it's 35 or above this diagnostic of asthma and Children. And these are more objective, definitive tests to get a diagnosis of asthma and those over the age of five years old. Now you can also do other tests like the spyrometry. You get an F E V one, which is the Force expiratory volume in one second over the functional vital capacity, and that would show a ratio of less than seven less than 70%. So with this, as you see in the diagram there, just a quick recap you get with a normal picture, you get that full, functional, vital capacity. With a restrictive picture, you get a restriction of the lungs so you can't use all of that functional capacity that functional vital capacity is reduced. So that's why it's called a restrictive, uh, airway disease. But with obstructive, you're not having any restriction rather than just getting an obstruction. So it's taking you longer more time to get a full use of that full, functional, vital capacity, and that's why it leads to that reduced FPV one, but a more normal, slightly reduced FBC. Other tests include the bronchodilator reversibility test so you can do the spirometry and then if the HPV one increases by 12% or increases in volume by 200 millimeters after giving them the bronchodilators. So such as the salbutamol inhaler that is indicative of asthma diagnosis as well. To move on to our second question, you have seen a 23 year old male comes to Amy with shortness of breath. He mentions that his asked him he has asthma, he has asthma. And he gets a bad cough at night. Uh, this time of year, winter respiratory examination. He is alert orientated, but is finding it difficult to speak to you is unable to complete sentences while speaking. Those are his observations. And there's an audible exploratory online occupation. Which of the following is the most likely diagnosis? It was the prograf. Sorry. What did you watch it? Yeah, I'll just launch. I can just Okay, Okay. All right. So most people answered, uh, directly there, which is the acute severe asthma participation is finding it difficult to complete sentences now. Asthma the way that acute asthma is, uh, identify spread into moderate, severe or life threatening or internal. For example, if you can complete sentences, then this means it's at least severe or worse for life threatening asthma. You can have other things, including silent chest cyanosis for respiratory effort, socially or confusion. If you get any of these, then this makes it a life threatening asthma, and their shots will be below 92. Or their peak expiratory flow rate is less than 33% of their best of predicted. The way to remember that is the acronym 33 92 chest. So 33 is the peak flow rate. Less than 33% of their best are predicted. The shots will be less than 92%. And if they have any of the following diagnosis hypertension, exhaustion, silent test or tachycardia? No, we're going to the same question. Zarina, 32 year old female, is in a any research with asthma attacks. She's so short of breath she can complete full sentences. The one breath still be easy. Despite back to back nebulizers, Which of the following is the most likely diagnosis? You know, the whole I said the day I think you should have the port that most of all I'm using that. Just let me just share it Doesn't let me start it or bend it. Thank you. There were some answers coming in all right in the hole there. So about 70% of people thought that this is an acute severe asthma. But the actual answer here is a life threatening asthma. Now, although the patient she can complete, uh, in full sentences can't complete what they're saying in full sentences, then, uh, this is still a life threatening because they are showing some signs of life threatening asthma, which is the exhaustion, because if they are normalizing so to look at their CO2 is 4.9. You'd expect them to be blowing off that CO2 because if they're high respiratory rate, if they're not, then this is showing that they are getting exhausted. And there this is a very bad sign and showing your life that he asked me This often comes up in exams. Okay, we'll come to the next question I had a 25 year old male engineer has come to gp do to worsening dry cough as asthma and his own salbutamol inhaler, otherwise feeling well and does not have any other past medical history, has noticed that his symptoms have been getting worse and he's using the blue inhaler more frequently at work. What would be useful in helping you treat for her? You can share the pole, so just give it a minute for people to get the answers in. Okay? You and you ended when you think that's fine. All right. Okay, so everyone just put an answer. If you don't know, obviously, just try and have an educated guess. I'll put that in schools. Mhm. That's it. 10 seconds left. Okay, we'll send it there. All right. Great. So most people answer the correct answer their peak flow diary. In this case, we're worried about something like occupational asthma because from the social history what to do with work there. So if you find that in the questions I was talking about work or talking about a hobby or recently moving or starting a new kind of work when you were a little odd occupational asthma and this often comes with symptoms which are better on time from work so when they're on holiday or on the weekends and what you want to get is a peak flow diary, uh, of them at work and away from work. And compare that the Victoza is also very useful and just diagnosing asthma in general and seeing how patients are getting on different treatments. This is how one could look like. So you get diarrhea variation. You get changes in the peak expiratory flow rate, uh, different times of the day. So, for example, in this, uh, patient, we get a reduced peak flow in the mornings compared to the later on in the day, and you can see that this is a general trend. And then suddenly, once you stop the treatment, it's they get away more increase in their peak flow, showing that they have asthma and that this treatment is working. Okay, we're going to move on to the next question about my 22 year old female accountant comes to see the GP about her asthma. She has been using the salbutamol inhaler 3 to 4 times a week for the past month and feels her asthma is getting worse. She's currently prescribed the short acting beta agonist, salbutamol, blue inhaler and a low dose steroid preventer. Inhaler, which is the brown inhaler, would be the most appropriate management for this patient. Getting a little wide spread answers here. One guy's clueless. Don't worry if your clothes we'll go for it now. Okay? All right. Hopefully go over. That question now is in the hole there. So there was a split between B A, c and D and you? So much for everything. So the correct answer here is be a leukotriene receptor antagonist is the next step to try. So this is the asthma stepwise management. This is all you need to know. For example, this these five steps, most questions you can ask about, like the third or the fourth step. Um, you start off with the Sabbath. Short acting beta agonist, salbutamol, blue inhaler. Then you add a Another inhaler is low dose inhaled cortical steroid. Okay, so that's the preventer. So the relievers, the Blue Sabbath, the, uh, preventer one is the low dose inhaled cortical steroid and the brown one. And then you can third step, try and try and stop the antagonist. And if that doesn't work, you can try a long acting beta agonist, such as like Salmeterol, which is the first step that doesn't work. We can try a maintenance and reliever therapy, which involves having a steroid, which with a fast acting level, which means it's a Elavil. But that starts acting quickly and ask for a longer period of time as compared to solve you to more like for for medical, for example. Then after that, you can just do increasing the steroid of the maintenance and relieve the therapy, the mark, or increasing the steroid and fix this regime. You hardly get asked about that. That's more specialists. You just asked me to ask about the first five steps most of the time and all the time. So the next question somebody. A 16 year old female has been recovering on the respiratory board following an acute severe asthma attack. Which of the following criteria must be met for the patient to be safely discharged? Okay, Virtually every everyone got that one right. So with without the correct answer is deep. So peak flow rate of 75% of predicted it needed, and most importantly as well you need to check their inhaler technique. This comes up as well because it's useless to the regime or change the treatment or do anything else. If the patient is just not using the inhaler properly, and if they're struggling with that, you can just add an aero chamber, especially for younger people like Children as well. And they must have been stable and not only the nebulizers oxygen for at least 12 hours. Okay, move on to the next question. Shine. A 50 year old male, Brickley represents the and you with the chest pain and shortness of breath that came on suddenly this evening while at work. The States they have never felt like this before, he says. No, trauma has never been short of breath in his life, and he's, but he's a very heavy smoker. He smokes two packets a day since he was 16, goes to his observations, and this is his chest X ray. What is the treatment for this patient? So this is a real patient. I saw him Monday, obviously different name and different stuff, but this is his actual X ray. All right, good answers. Most people have got this one right. The correct answer is just a dream So this is a big pneumothorax. So with the methotrexate just means they're within the flu of space. Isn't gonna be short of breath. Could be a dirty chest pain, maybe reduced air entry and bread sounds when your auscultated you because you're going to hear a hyper resident percussion. All that space is filled with air. So when you're tapping is going to be a resident. Okay, If it was filled with fluid, like in an infusion or the consolidation, then it will be dealt to percussion, and that's the difference there. And the trachea will be deviating away from the pneumothorax. Pays attention Pneumothorax. This is the algorithm for it. So for spontaneous pneumothorax. So for example, one that's not been caused by trauma, like playing rugby or fallen off a ladder or some sort of trauma. So spontaneous pneumothorax you look at is this a primary or secondary secondary means that there's a risk factors such as above the age of 50 with smoking history, evidence, underlying lung disease, Then this will be a second. If you don't have any of these things. No smoker know lung disease, then looking at looking at primary pneumothorax. Now you sent me for X ray. If the size is above two centimeters or they're symptomatic, they're breathless, then you wanna aspirated it. If the aspiration is successful, you just charge them with the GP to repeat the chest X story in two weeks' time and make sure it's resolved. If the aspiration fails and the heart is still above two centimeters when you go into chest strain in case of a secondary pneumothorax, this one has those risk factors. It's worse, so if it's above two centimeters, you go straight to chest brain rather than aspirating, and emphasize is between one and two centimeters. Then you can admit them okay and more to them and observed. But they must be admitted with the second one. You can just send them home if, if, um if the size is 1 to 2 centimeters, then you aspirated. So if it's less than one centimeter, then you just admit them and observe. But if it's between 1 to 2 centimeters, you want to go in to observe to aspirate it, and if that doesn't work, then you go straight away. The chest train that does work, then go again to aspirate it. But The point is, secondary one. It's above two centimeters. You go straight to chest train, the primary one. It's above two centimeters to aspirate, and the way that it's measured is like this. So, for example, in here you can see this diagram to be measured at the level of the highland in Britain measured at this level in America. They measured at the eight cc, and that's just something for you that you don't even know that. But it's just something cool. All right. Now, China 50 year old male basically represents again and, uh, you know, get asked, where should you place the chest? The train. You can share the pole. Okay, we'll get some 50 50 split here No more People are saying the right one yet, So there's some people answering between B, d or E. Let's stop that one there. So most most people got a right. Well, have you got the right? Is this safe triangle for chest rain? And the borders of that is basically underneath the arm pits of the base of the axilla down to the fifth intercostal space. It's around the nipple line, and the other edges are the lateral edge of the Pectoralis Major and the other muscle on the bike, which is, uh, dismissed. Dorsey. That's a safe triangle. Now we got another patient safety in a four year old male jockey has brought any after falling off his horse in his North Wales farm. He was struggling to breathe and looks extremely distressed. These are observations and assessment of his airway. Tell this reduced air entry on the right side and it's tricky is deviated to the left. What is the most appropriate management for this patient? That was the whole and most people get this. All right, Now we're going to stop that one there. Yeah, Most people get that one right there. Needle decompression. So in this case, you go into the medical literature. Second intercostal space. So this is for attention in the thorax. There's no investigation. You shouldn't be sending this one to a chest X ray. But that's what the chest X ray would look like. What actually kill deviation and the way you do? The needle decompression is just above the rib, so that can sometimes be asked where you put the needle. You put it just above the rib because of the bus teacher that ones underneath the rib. All right. Just give me a 35 year old female attends a any with sudden shortness of breath and chest pain that started suddenly this evening. Particularly worse on inspirations of pleuritic. And she just got back from visiting family in Australia has a past medical history of severe renal impairment and only kind of medication she takes is combined or contraceptive. Those are observations. One investigation is needed to confirm the most likely diagnosis. Okay, so most people, uh, concert it was split between. So we're going to split between a and see some D and e. The majority people chose a is the wrong answer. The correct answer is a VQ scan. So if the patient has renal permanent or they're pregnant, then we go for a VQ scan instead of the CT P. A. Most likely diagnosis here is a pulmonary ambulance. Also, we did have some pleuritic chest pain was the inspiration shortness of breath hemoptysis or coughing up blood. A fast heart rate can sometimes be associated. Some crackers, the fever and the lung a risk factors include travel. So this patient, they got a long half life from Australia. The mobility, dehydration, estrogen hormone therapy like the combined or conceptive pill or other hormonal therapy containing estrogen, the ones that just contain for just strong. Those ones are not respective for memory embolism, and they are obviously a clotting disorder. Now, with a P E. If you suspect that you do a well score, this looks at these parameters and you can calculate score there. So you look at the clinical science symptoms of a DVT and is it your number one diagnosis or, equally likely, your number one diagnosis like tide with another differential? Is the heart rate more than 100 a tachycardia? Has there been immobilization? How do they have a previous P e r D u T? Are you coughing up any blood chemistry of the malignancy in the last six months? Or the palliative they total of the score? If it's above four, you don't do a d dimer. You just go straight to a CT pa or a VQ scan case of pregnant or third. But either way, if this was the case, you start treatment straight away when you suspect that you don't wait for them to have a scan and then start the treatment. You have to start treatment immediately. That would be the immediate management. This would be just to confirm the diagnosis or to rule it out. And then if you hold it out, then you can stop treating for PT. And if the world is four or less than you do a d dimer. If the D dimer is positive, then you're going to do the scan, the CT or the week. You a scan? If. But the d dimer thing about it is that it's very sensitive but not specific, it can be falsely elevated due to infection or other problems. Now, with the management, the new management nice guideline is to start a direct oral anticoagulant. So don't worry about what you see on placement. Just remember this for your exams as a direct all anticoagulants and apixaban or overactive on. The really function needs to be good, for this needs to be above a day for about 30 or so, and you need to start it straight away immediately. When you when you expect the diagnosis, you don't wait for a scan. If they're pregnant or having a payment would you use Use low molecular weight heparin like enoxaparin. If it's a provoked, be so you know, because they just had a long, long flight or for another reason. You know the reason why then it's three months of dog. If you don't know why, Unprovoked, they haven't been a mobile or anything or had recent surgery or anything like that or they have a history of cancer. Then you need to use six months of P treatment. This is something This is something called the perc. Uh, right here, This is just something to help you avoid ending up doing, uh, diver, for patients Who you who you don't really suspect to be, but you don't know or you don't know what to do, but they must be below the age of 50. This is more for for like, uh, work than actually for exams. And it only fits if the score is completely zero. So they're below 50 and they score zero. These other points, then you can just not do a d dimer and leave that leave. The problem is, um, to one side and think about your other most likely diagnosis that you have on your preference is like a pleurisy or something else. Okay, so the medical students hands are saying are on placement A Me. The doctor asked to them What is the most common issues you're finding in patients with a P E. And have the whole give you some good answers there. Okay. Anyone else want to answer? Okay, that one there. Okay. So most people got to write some people thought it was B. You know, I know you can associate it with this s Q 3 to 3 t three things, but it's very rare. It's not the most common finding. The most common is it's a Sinus tachycardia. Okay, that's the most common one. So just get normally. See GI normal Q waves, period, everything normal T waves. But all you have is that it's a psychologist or a fast heart rate. This s 123 t three thing. Basically, what it means is a indeed one. So it's one. We're gonna have a downward big s wave. You're gonna have some, uh, changes in the three big Q wave and the T wave inversion and someone to find the branch block right on the black box. Sometimes Okay, now we're gonna move on to the second part. Okay? Thank you. So my name's Daniel. I'm, uh, an F one working up in North Wales. So I'm just going to be doing the remainder of the talk. Just bear with me while I project the slides. Uh huh. Ahmed, can you see just the slides? Or you can probably see the whole presents of you right now. How does that work? Now? I see. Just a slight Good, good, good. Okay, guys. Right. So let's go on to another SBA. So can you see the full thing, including the top? You can see everything. All right. So check is a 69 year old male who attends his GP complaining of six month history of shortness of breath with occasional productive cough of white sputum. So he currently takes ramipril for hypertension and insulin on a background of type one diabetes. His social history reveals that he has a 36 pack year history. And so the GP decides to order a spirometry to aid the diagnosis. So the results are as follows. So the key points are the F E V one. Fvc ratio is not 10.68 And the F E V one is 82% of his predicted FPV one. So, given that information provided, what is the most likely diagnosis? Okay, so that is a pretty resounding choice. We also seem to think is COPD, which is good. Maybe we should have made the question a bit harder. That's okay. Uh huh. Okay, fine. So I think we can send it there because it's pretty unanimous, so Yeah, absolutely right. Umm Ahmed, can you see the thing in the window there? How? What do you mean, which one? The, uh hang on. Because for me, it's a bit, uh all I can see the slides. Okay. Can you can come. Okay, fine. Um, all right, so yeah, that's right. So the correct answer here is see which is COPD and we're categorizing. It is stage one. So essentially, you all seem to know what to pick up on in the question, but just to kind of go through it. What we have here is someone who's presenting with the history of chest symptoms. So some shortness of breath, and he's producing some sputum. So we've ordered spirometry. And so the key point here is the HPV one fvc ratio is 10.68. So essentially the threshold for determining whether we're looking at an obstructive pathology versus a restrictive pathology is no 0.7. So if it's less than 4.7, then we know it's something obstructive such as asthma or COPD. And that just means that it's a problem with flow rather than a problem with capacity, which is the case with restrictive, uh, lung condition So we can rule out lung fibrosis. And then when it comes to thinking, is it asthma or COPD? Then essentially, in this question, I think, based on the risk factors here, this is an older patient, and this is someone who is who has extensive smoking history. So based on those two findings, it would guide us more towards COPD rather than asthma. So I can ask a question. So if you'd like to contribute on the chat, um, what additional investigation could we order in order to distinguish if we were thinking Okay, this could be asthma or COPD. There is a particular test that we could do in the GP, which could help us in that regard, So if you just put it on the chat. Does anyone want to have a stab at that? Okay, it's disabled. Okay. Do you want to just put it here? That's fine. Just just put it in the queue and a section. Sorry, we'll sort sort it out for next time. So it's just one simple investigation that we can do, Which I don't think, um, I did mention, um, so Yeah, exactly. So that's right. Um, so it's a broncodilator reversibility test. So the key difference between asthma and COPD is the COPD. Um it's characterized by irreversible obstructive lung disease. Okay, so COPD is basically an umbrella tim, which covers to pathology so that these can occur on their own. But commonly what we see is chronic bronchitis and emphysema together. And that's what makes the diagnosis of COPD. So chronic bronchitis just refers to productive cough, which we can think of what's happening for at least three months for two consecutive years. And then the other part of it is emphysema, which is basically like a structural change in the lungs, which results in increased, uh, kind of capacity of the airways, actually of the alveoli. Sorry. Um, so the risk factors for that as we touched on, would be a smoker. Also, there is a genetic condition called alpha one antitrypsin deficiency, which can come up in exams. I don't believe it's very common, but essentially that would predispose. The patients are having more like emphysematous change and, lastly, occupational risk factors. So, for example, if someone has had a lot of secondhand exposure to smoke as a result of their job, so the symptoms that we classically see would be a cough, which is, you know, it can be productive so they could be producing either some white or clear sputum. If they were producing colored sputum like yellow or green, then that would be more in line with ineffective or acute exacerbation of COPD. The other symptoms we see would be some breathlessness, which tends to be exertionally in nature, and the patient can be a bit wheezy as well. If the patient's having symptoms such as weight loss, fatigue and ankle swelling, then that could indicate uh, that could indicate a secondary, um, pathology going on, which is, uh, could be as a result of right sided heart failure due to pulmonary hypertension, which can be caused by COPD. So basically it means that there is a resistance to the right side of the heart as it's pumping out into the pulmonary vessels going into the lungs, and that's causing strain on the right side of the heart. And it's basically losing its effectiveness. And that's why you get the back flow into the systemic circuit, which results in ankle swelling. For example, you also see like a raised JVP, for example. Okay, so the clinical signs that you'd see would be shortness of breath. Uh, there's a type of breathing called purse lip breathing, which you can see the use of accessory muscles. So, for example, that's like intercostal muscles and your trapezius muscles. And lastly, on auscultation, you can find some coarse crackles, Um, so just going to the next slide. So when we think about COPD, we can categorize it based on the gold criteria, and that helps us, uh, stage it, basically based on whether it's mild, moderate, severe or very severe. And essentially, what we do is we look at the F E V one and obviously as a percentage of the predicted, uh, target. So that's based on the patient's age. and height, I believe. And essentially, if it's above 80% then it's a mild disease. If it's 50 to 79% it's moderate and then 30 to 49 would be severe and less than 30% would be very severe. So there are certain guidelines that we can use to guide the management. I believe that there's gold criteria, guidelines and nice criteria guidelines. So the ones I believe that tend to be tested more in our exams is based on the nice criteria. But there are overlaps with both. Okay, so and as you can see with the F E V one fvc ratio, that's always going to be less than 1.7 because it's an obstructive condition, okay, and another point to mention is just that. Obviously, if someone presents in a hospital setting and it's they, they're giving either severe or very severe presentation. That's when you'd, uh, as a matter of urgency, like to inform your senior rather than waiting Okay, So when it comes to diagnosing COPD, naturally we'd want to do a series of investigations. So we do some routine bloods and then order a chest X ray. As we would anyone presenting with chest symptoms such as shortness of breath or chest pain? Um, not that we have that here, but it's just a routine test. So could we just have some input on the chat as to some findings from this particular E c G, which would suggest COPD. So just put it in the queue and a function. Yeah, so, yeah, Hyperinflation, absolutely. Anything else. Barrel chest? Yep, so that's good. So definitely that's something like a sign we can see as well. From the end of the bed you should be. You can see if a patient has a barrel chest. Okay, that's fine. So essentially, these are the type of findings that we look for. So as you guys said, lung hyperinflation, so typically on on an X ray, should be able to see about seven ribs. But if you count these up, you'll be able to see in excess of that, so that's basically indicating that there's some hyperinflation going on. You can also see the The diagrams here are flattened, Um, and then there's a few other changes. So, for example, we can see some bullous changes barrel chest shape. As someone said um there are some increased kind of markings here that you can see, but also, there is actually, like, decreased opacity. So essentially, this is more black looking, so that's a key finding from COPD on an X ray. Um, And then, as I mentioned before, if there is any strain on the right side of the heart and that would show cardiomegaly But we can't see that in this case. Okay, so there are a few other changes that you could see. So, for example, if someone has, um um, an alpha one antitrypsin deficiency, you see some destruction of the lower lobes. Um, and if they have kind of, uh, either centrilobular changes, which means kind of central or upper lobes changes, then that would be more in keeping with emphysema. So just to run through some of the investigations that we do, um, so routine blood. So F B c. You know, the CRP um, fbc may see some polycythemia so essentially raised hemoglobin, um, may see a raised CRP or es are so they're basically inflammatory markers. The patient's having a productive cough should always culture dispute, and particularly if you're suspecting an effective exacerbation, so that you can basically guide your antibiotic therapy. So in any one presenting the chest symptoms, you want to do an EKG as well, because they could be having like, a cardiac cause of exertion or breathlessness such as angina, so that would be a valid differential. Here, an ABG is very important. So anyone presenting acutely with any shortness of breath is really important to just get an ABG. And in particular, we'd be looking at the oxygen levels in the, um in the arterial blood and the CEO too as well to see whether they're retaining um, any CO2. Okay, so there's a few other tests. They're so bmp would be, uh, in keeping with heart failure. Um, And then, if we were suspecting a genetic abnormality, then we can do genetic testing for Alpha one antitrypsin deficiency. Okay, so next question, a 70 year old male named Yusuf attends the GP after six months being diagnosed with COPD. Despite being started on the albuterol inhaler, he still complains of breathlessness. Yusuf is having to use his inhaler daily and is struggling with certain activities such as walking up the stairs. So his FPV one is 55% and his blood using a viral count is within the normal range. So, out of these options, what do you think is the next step in his management? Okay, so I can see that the two most popular answers are B and C. They're pretty much tied. Okay, so that's been about a minute. So I'll send it there. So yeah, you guys are definitely on the right lines. So the correct answer here is See? So it's a long acting beta agonist in combination with a long acting muscarinic antagonist. So basically, I'll explain that in the next slide. So this is basically based on the nice criteria. As I mentioned, there are different criteria you can use, but I think nice guidelines always just the safe, uh, example of the kind of, uh, management guidelines that you can follow. So this is a kind of simplified version just to kind of clarify what exactly is going on? So in anyone with COPD, firstly, you want to start them on kind of short acting therapy in case they're symptomatic. So, uh, commonly would be a short acting beta agonist or a short acting muscarinic antagonist. So I put a table here just showing the examples of those drugs. So, for example, that would be either salbutamol or hypertropia Enbrel mind? I think another important point to kind of just touch on for your exams is that the medicine name is one thing, But then the inhaler name is another. So, for example, uh, I just put my pointer on. So this over here, as I'm sure a lot of you know, is, uh, salbutamol pump. But, uh, patients may refer to this as Ventolin, basically, because that's the name of the inhaler. So similarly, each of these will have, uh, you know, a name for the exact inhaler. This you so you don't need to really learn every single one of the exams. But I think these are the more important ones. Just to have an awareness in case it comes up in in placement or, um, or even on, like, GP records. They can just have the inhaler name rather than the, uh, the actual name of the medicine. So it's good to be aware of, So Okay, so, back to the flow chart. So, uh, that's the first step. Now, if the patient is still symptomatic despite having the short acting therapies. Then you basically consider whether there is features of steroid responsiveness or basically any asthmatic features. So those will be, for example, diurnal variation. If the patient is more symptomatic at certain times of the day, Um and you can actually test that with spirometry. So if there is a greater than 10% I believe variation throughout the day, then that would be more in keeping with asthma features. So they still have COPD. But we we call this like, uh, like, uh, as it says, steroid responsiveness. Um, other example would be looking at the NFL. So if they have eosinophilia meaning high eosinophil count and that would be also like a feature more in keeping with, like, asthma. So if they do have some of those features, then you would go ahead and give them a lab A in combination with an inhaled corticosteroid, as you would if it was an asthma patient. And so, um, an example of that would be a cell natural, uh, and then an inhaled corticosteroid to be like fluticasone. Um, and this combination pumps that they can give for that, um and then if they didn't have any of those features, which is the case in the question we start them on a labor and a llama, and as you can see, examples of a llama would be tiotropium. It's important to mention that if they are taking a llama, then they shouldn't also be on Osama as well just because you don't want to combine those two. So in that case, they would be on a Sabah, a lotta and a llama. And then, if they are still symptomatic, despite those therapies, then you move on to basically third line treatment, which would be, uh, combining the Sabbath, which they have for this symptomatic episodes in combination with the lab, a llama and an ice DS. So, um, quite a few drugs there, Um, and it's important. One key inhaler to just know about is called Trelegy. So, uh, that, I believe, has been tested in, um, in one of the card. If progresses questions, you just have to have an awareness. That trilogy is this kind of last line therapy here, and quite a few patients are on that. So it's a good thing to know. Okay, uh, and as I said the Trelegy is just a combination of these different drugs. Uh, fine. So, um, other aspects of managing patient with COPD so you can consider azithromycin. So that's more for patients with recurrent infected exacerbations. And there's certain strict criteria as to whether patients should be on that. Um, patients should have an EKG done prior because azithromycin is a beauty prolonging agent so it can make them more risk for long QT syndrome. And that can lead to V. F and stuff like that. So should be cautious with that. There are surgical options as well. So uh, in kind of severe refractory cases, you could consider lung volume reduction surgery, um, routine things like giving the pneumococcal vaccine and annual influenza vaccine because it's been shown that patients often times are presenting with effective exacerbation of COPD on a background of flu. Uh, so if you get them vaccinated, you just make it less likely for them to present um, and then also consider the MG T. So there's respiratory specialist nurses in the community. Um, there's pulmonary rehabilitation therapy and simple things like smoking cessation and just general education for patients about their condition and the patients with recurrent exacerbations. You can also give rescue PACs, which basically consist of a short course of steroids, which the patient can keep at home. And I believe it also has some nebulizers as well. Uh, in case they should need it if they have an effective exacerbation and then lastly, long term oxygen therapy can be prescribed with if it's within these criteria, uh, and important to know that it's contraindicated in smokers. Okay, so just to talk about managing an acute exacerbation of COPD or it's also called an effective exacerbation. So there are so there's this pneumonic that you can use. So there's an overlap with asthma management. Um, so I'm not going to say the actual words keep it clean. But starting off, we'll give the patients oxygen. Um, because patients have patients with COPD, we do think about controlling the oxygen within the range of 88 to 92% and that's just because we patients can be quote unquote CO2 retainers. Um, but it's important to remember that any patient who's presenting, you know, acutely unwell. If they are kind of clinically unstable, then you just give them 15 liters you kind of stabilize them first. And then only after that, you consider eventually mask. So always just use your judgement there, because oftentimes questions can try and catch you out. Uh, just putting in COPD, but just important to remember that if they are acutely and well, they're, you know, the statin in the seventies, for example, Just give them 15 liters because that's, uh, you know, the risk of developing hypercapnia, which is high CO2 and so to retainers like that's a lesser risk than them having like hypoxia. Basically. Okay, so the next important point is giving salbutamol. We can give that in a nebulized form, and then essentially, it just goes through similar to the asthma management. So in an acute setting that is so giving hydrocortisone or prednisolone. So steroids, um, further hypertropia NEBs And then at that point that I would say that that's at the level of, like, a junior s h O level. So at that point, then you'd want to escalate to your seniors. You think about giving Theopylline. Um and then if there is, this is on a background of an infection, then you definitely want to start them on antibiotics. Okay, so just to recap the oxygen therapy, Uh, as I said, if the patient isn't, um, you know, very hypoxic. Say they do have, uh, sats, you know, in the in the eighties. Say, um then you can give them oxygen via Venturi mask and you aim for 88 to 92% and you would want to do an, uh, an ABG, um, and that can allow you to establish whether they are so two retainer. And then once you know whether they are or not, then you can adjust as necessary. Okay, so next question. So Alice is an 83 year old female presenting with her son to the GP. Her son complains that that his mother has been more disorientated over the past day. He has seen her green sputum, which has been happening for the past five days. The GP takes her observations, which revealed an elevated sorry. Her respiratory rate of 22 26 BP is 84 55 a temperature of 37.802 SATs 94 on air. So what is the most appropriate next step to take in Alex's management? sorry. Just launched the pole. Uh huh. Okay, so I think someone just asked how long is the session? So we'll go on. Uh, hopefully it shouldn't be too much longer. Um, if someone could drop the feedback form in the chat right now, um, that would be appreciated. Okay, so and the pole there. So it seems like there's pretty much agreement that it's B, which is the correct answer. Okay, there we go. So you were admitted to hospital for intravenous antibiotics, So the diagnosis here would be a patient with pneumonia, so basically an infection in the lungs. So there's two key scoring systems which we use to stratify the severity of pneumonia, and it also guides the treatment. So in the community, we basically take one component out of that. So it's just the cr be 65 score and in secondary care, we can, um, just get your area. So draw some blood, send that off, and then establish if the urea is elevated. So the C stands for confusion. So you can either just use your clinical judgment or if there's any. If you're unsure, then you can use, like a test such as the abbreviated mental status test. Um, the respiratory rate if they are to keep nick so over 30 over over or equal to 30 if they are hypertensive. So the BP, if it's less than 90 or 60 diastolic and then the age. So if they are 65 or older. So okay, so the pneumonia is basically an infection of the air spaces and surrounding tissue of the lung. So we also in addition to curb scoring, we would classify pneumonias based on whether they are acquired in the community or if they are hospital acquired. So if the patient is developing pneumonia, um, greater than 48 hours into a hospital admission, then it's classified as hospital acquired. And some causes for that could be post operatively. The patient is basically they have some kind of respiratory distress. Um, then that can cause pneumonia to develop. Or, for example, if they've been in the I t. U. And they've had some, uh, mechanical ventilation, or it could be due to airconditioning or intubation. And there are risk factors for developing pneumonia, so classic symptoms that you'd expect to see would be things that would be typical for an infection. So, for example, fever. Uh, you'd expect to see a cough, which is productive sputum, so it can be yellow or green in color. Uh, the patient can be having malaise as well. So just generally lethargic, and then they can be short of breath and having some pain, which is pleuritic in nature. So essentially, if they breathe in, then they have pain. A focal point that would point to what you call a pleuritic chest pain. Um, signs that you see So you could think about it in terms of what you can see on inspection of the patient generally. So you'd expect to see someone who's taking ethnic their breathing a lot. Or at a high rate of breath, you may hear a wheeze from the end of the bedside on percussion. You get a dull percussion note due to, uh, kind of, uh, fluid in the lungs if you like. Uh, you could also see on oscal or hear on auscultation some coarse reputations in the lungs and then a few other things as well. So as you mentioned hypertension, uh, tachycardia, confusion and sinosis. So if they're blue around the lips on the tongue, so that would be indicating hypoxia. Okay, So, similarly to the COPD X ray. Should we just have some people in the chat, Uh, saying what we think is going on with this X ray? Oh, there we go. So, yeah. You know, see? All right. Yeah. So, someone saying increased capacity in the right lower zone? Yeah, that's correct. So essentially, um, when we look at a chest X rays, we can There's like, an A B C D E approach. So airways a stands for airways. We just look at the daycare. We can see that in this patient, it's central B stands for breathing. So we just look at the lung field. So I would say the most striking abnormality, as you guys have said, here is some opacity in the right lower zone here. Probably confined to the right lower lobe. Um, so the right lung consists of three lobes, which illustrated here. So 12 and three is the lower lobe, and the the left lung consists of two lobes, which is the left upper lobe of the left lower lobe. Um, And then just to go through that approach. So let's see which stands for cardio, the cardiac contours. So here I would say, on the on the left side, it's within the normal limits. On the right side, it is kind of obstructed by that capacity that we were talking about. D stands for diaphragm so we can see the to hemidiaphragm arms and then e stands for everything else. So are there any bony pathology? Is any fractures going on any E c g leads or any artifacts on the X ray that we can make out? So I don't think that's the case here. So in summary, I would say that this is a This is showing a consolidation in the right lower lobe, uh, in keeping with pneumonia. Okay, So just to mention atypical pneumonia would be basically defined as pneumonia caused by, like, an atypical pathogen, which will go through, uh, a couple of slides. But that would show, uh, appearance, which is more patchy throughout the lungs rather than confined to one specific lobe. So don't be put off by that. So that's that. So, yeah, they're patchy infiltrates, which often are bilateral, um, and other points to look for, which would indicate a severe atypical pneumonia would be if there's hypoxia. If there's a high white cell count, there's multi lobe involvement and positive cultures. So when it comes to managing pneumonia, always manage any acute condition and 80 approach. It's important to consider sepsis in a patient presented with infection, whether it's a chest infection or if it's a urinary tract, for example, it could be your oh, sepsis or abdominal. Always have sepsis in the back of your mind. Um, so if the patient is using high the hypertensive tachycardic, those should be the kind of red flags that make you think about it. The sepsis six is the protocol that should be done in the first hour after identifying sepsis, so that involves giving three and taking three. So you give oxygen. You give a fluid bolus of crystalloids. So, for example, 500 miles of 9.9% saline or Hartmann's. It's another alternative, and then you give IV broad spectrum antibiotics. So in the hospital I'm working now. We just give tax season, and then we take three. So take blood cultures. We take lactate so you can take an ABG would be useful in this case or you can get VBG as well. Um, and then you monitor the urine output, which can involve catheterizing the patient. Um, and then we need to start this patient on antibiotics. So obviously, if if we've thought about sepsis and it's being started on terazosin, and that's fine, because it's a broad spectrum antibiotic as broad cover. If we haven't done the steps this protocol and we just think it's a relatively uncomplicated pneumonia, then we'd prescribe antibiotics, which would be based on local guidelines. So if you get this app called Micro Guide, it's very good and just telling you the different, uh, antibiotics given in the trust that you're in. So I've just taken these for the best to like North Wales Trust. This is basically what it says so based on the curb score. So if it's zero or one, then you can give amoxicillin or doxycycline. Um, and if it's two or more, then you can give amoxicillin in combination with clarithromycin just for a broader cover, Um, and as a second line alternative, you could give doxycycline or co-trimoxazole. If it's a hospital acquired pneumonia, then you consider whether it's mild or moderate, and it gives you certain criteria for that. Um, but essentially, you start with amoxicillin or toxic cycling. Um, and if it's severe, then you can give co-trimoxazole. Well, basically consult with microbiology. So always in an exam setting. I think it's safe to say just a consult with local guidelines is very important as well. To check if a patient has any allergies, particular antibiotics, because they will always be an alternative that it suggests they are allergic. Um, and lastly, just if there is an uncertainty, then you can consult with microbiology. Okay. And another important point is, uh, these guidelines emphasize sending, uh, sputum sample if you can get one for, um, CNs. Um so, basically culture and sensitivities. So you do that as soon as possible. It takes a few days to grow. But then when you have the answer for that, then it tells you specifically which antibiotics would be effective for that case, and then you can switch over. Okay, so which of the following organisms is responsible for the majority of community acquired pneumonia? Yeah. Okay, So the majority of people said c, which is the correct answer. Okay. So well done. So, essentially for exams. There is. Um I would say that this is very high yield information to know is basically the different organisms microorganisms causing different pneumonias and, uh, the key features in the SBA to look out for, um, to just help you to answer the question. So, um, these are the main ones that I would suggest to know about. So starting with strep pneumonia, so that would be the most common cause of a community acquired pneumonia. Um, and then just to go through the list quickly. So haemophilus influenza would be most common cause of COPD exacerbation staph aureus would be most commonly someone is having, uh, pneumonia in the background of flu. Um, also in someone who's having IV drug use or if they have a central line in, uh, and as it says here, staph, staph or is just part of the skin for us always. Just think, you know, how can it be linked to the particular condition? Um, Klebsiella is associated with alcoholics and diabetics, and the key thing they say in the question is that there will be some red current gel, a sputum, or if they just mentioned red sputum, um, which isn't hemoptysis this, then it's probably klebsiella, um chlamydia, Stasi. Um so when we talk about atypical pneumonias, essentially these types of organisms so klebsiella, chlamydia, PCP, legionella and mycoplasma. So chlamydia status is commonly associated with birds, and there's some other key features here, which is good to know. Um, PCP is basically a type of pneumonia associated with people who have HIV. So, as you know, there are immunocompromised and particularly vulnerable to that organism. And I believe that they do take prophylactic co-trimoxazole if they have a CD four count below a certain threshold. Um, and on that you see ground glass of classification on imaging. Legionella would be in a case if you see hyponatremia in the question someone having pneumonia and you can see that in someone who has recently come back from a holiday or they've been associated. They've been around with, like, air conditioning units. And you can basically get, uh, get released in those 80 units, Uh, and lastly, mycoplasma. So the way I tend to remember that is just that they have this specific rash of erythema multiform. Um, and as it says, there's a few other features there. So being a younger patient. They might have a huma lytic and anemia, and also, it can be associated with myocarditis. Um, but honestly, I think the key point there is this erythema multiform rash. Okay, so I think this is the last question. So patient presents the GP with increasing breathlessness over the past month on background of a dry cough. For six months on examination, there's decreased vocal residence and deviation of the year to the right. No other abnormalities are seen on cardiovascular abdominal peripheral examination. Patient has a smoking history of 30 years. What is the next step in the management given the chest X ray. Okay, Very good. So because the time is getting on, I think I'll just cut the pole there. But the people who did answer on the right lines definitely. So it's be so Yeah, The answer. There is a therapeutic tap with the results sent for M. C and s. So culture and sensitivity. So essentially, what we see here is a very, very obvious, uh, pleural effusion on this chest X ray. Um, I shouldn't say it's very obvious. So the obvious thing on the chest x ray is this left sided opacity, which we can see in the left, middle and lower zones. So I would say what gives it away as a pleural effusion versus a pneumonia, for example, is this curvature here? So we call this a meniscus, and that basically shows that there is fluid in the lung and it's it's giving the appearance of the meniscus. So basically, you need to do a tap, which means that you just draw some of that fluid out, and you send it for, um, for for sensitivities. Um, so just to summarize what we need to know about pleural effusions is, according to the lights criteria, which is commonly tested and commonly asked about, to be honest. So there's two categories basically of pleural effusions. It can either be exudative or transitive. So if there is an inflammatory process, which can lead to a protein leak into the lungs and that causes that causes fluid to accumulate, that basically causes an exudative, um, pleural effusion. And that is basically more associated with like a bacterial, of course. So what you'll see when you um when you analyze the pleural effusion is that it has a higher protein content, so there's different ways to quantify that. So you can do protein fusion, protein to serum protein ratio, or ldh ratio. But essentially, um, there's a greater amount of protein, which indicates more bacteria present. And there's some There's many differentials for that. But the the key things are, you know, it's caused by infections, abscesses, Um, and obviously, this is a long list, but you need to correlate it with the other clinical symptoms. So, for example, if someone is having, um, you know, a pleuritic chest pain history of, uh, DVT, um, it's more keeping a pulmonary embolism. Then that would be the cause of the infusion. So it would be secondary to a P. Um, I would say this is pretty high yield to know, to be honest, um, and then the other cause would be a transitive. So as opposed to being a bacterial cause, um, it could just be an accumulation of fluid, which is caused by an increased hydrostatic pressure. So an increased pressure, uh, in the capillaries, um, in combination with the decreased oncotic plasma pressure, which basically means that there's less protein, um, holding fluid inside the vessels. Um, so basically, that's just those criteria they reflected, but with a lower protein concentration and causes of a transitive pleural effusion would be things like heart failure. Um, liver failure, Nephrotic syndrome, hyper album anemia. Um, it could also be acrogenic. So, for example, if you misplaced a a pulmonary catheter, um, so, yeah, I think those are the key. Key wants to know. So that's it's basically, um, thank you everyone for coming. And thank you for staying to the end. I've noticed that there is an issue that you guys have pulled up with the feedback form so we'll try and get that sorted as soon as possible. Um, yeah. Sorry about that, guys. If you just fill out the Google form that we just sent you with your email and we'll send you the correct, uh, be back from later on so that you can access the recording and all the slides, and we'll be sending out the cardiology stuff now. Today as well. Thank you. Thank you, everyone. I'll just have a look to see if there are any questions. Um, okay. So I'll just So we have these slides on the end just for you guys too Quick Recap on the main conditions. Um okay. And I'll just pull up the QR code as well. So the middle, the middle one doesn't work, so the QR code, I don't think it will work. Oh, I see. Okay, there's one question Where ask you what should you improve? But it doesn't actually get you to fill that out a solution. We're just gonna just put a Google form out to collect the emails, and we'll put it on Facebook later on the correct form. Okay, guys. And hopefully see you on Sunday for gastroenterology teaching every Sunday and Thursday. Yeah, There we go. Okay. Thank you, everyone. Thank you, and goodnight.