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Hello, everyone. Good evening. Thank you for joining us tonight. Uh, my name is Angus. I'm a junior doctor currently working at Wigan. I'm Foundation Year one, currently approaching the end of my stint and acute medicine. I think I have two weeks left. Um, I'm here to talk to you tonight about asthma and COPD More specifically about the acute recognition investigation and management of acute asthma and COPD in a kind of out of hours hospital setting. Um, and we're also gonna be exploring kind of the world beyond those two conditions. So what to do when you've tried everything and the asthma slash COPD isn't getting any better. So we'll have a look at the slides or just start from the first slide. So, like I said, we're looking at acute asthma, acute COPD and beyond. Um, I I appreciate, uh, a little bit more difficult to interact with these kind of online presentations when you can't use your microphone. But I really appreciate, um, some good engagement in the chat. I think for the last chat, when I was last teaching, when I was doing a session on falls, we had some really good engagement. So I'm looking forward to more of the same. So these are the aims for the session. Like I said, how to recognize acute asthma, acute COPD, the kind of signs and symptoms that you might expect to see. Uh, here, how to investigate these presentations. Looking more a kind of out of our setting how to manage these presentations. So that's both in terms of acute management on first presentation, but also how you might, uh, change management To help avoid acute flares of these two conditions, we're going to be talking a little bit about knowing when to escalate, because that's an important part of your job as a foundation. Year one, trainees, Um, and also some instances of where to be cautious. Just so I've got a good idea of the kind of the audience of the chat. If you could just pop in kind of whether you're in medical school, whether your post medical school and if you are in medical school, kind of, uh, the year that you are in, that would be really helpful just so that I know that I'm pitching it at the right level for you guys. So I appreciate it's early on in the presentation to be asking you to engage, but good to start early. Okay, so we've got 50 of Madison, fourth year medicine. Excellent. So the the concept, the prospect of out of our shifts might be weighing on your mind a little bit. I know it was for me when I was 1/5 year medic. Um, when I was in my final year. So hopefully this will help to put your mind at ease and give you a kind of system of how to approach these kind of presentations out of hours. So, asthma, How? What kind of what the signs and symptoms. The cardinal signs and symptoms that you might Your respiratory clinical educator. Good grief. OK, so I'm there's a respiratory clinical educator in the teaching, so I'll be, uh I've got nurse practitioners. Excellent. So this will be important for you. Um, but I'm I'm gonna be under pressure from a respiratory clinical educator. Um, being in the teaching, So cardinal signs and symptoms of asthma. What? What? What are the kind of features that you might expect people to, you know, present with and again, just put your answers in the chat okay? Yeah. Thank you. New era. Thank you, Tanisha. So, yeah, we've got shortness of breath. We've got wheeze. So these are kind of clinical features as well that I've I've I've included in the in the slide, so we've got reversible broncho constriction. That's kind of like a clinical feature. But it's Diane or cough Diana wheeze and the shortness of breath as well, which I haven't. That's that's what comes from the Broncho constriction. So what are some common triggers for asthma? So Beverly's just said short sentences as well. So that's kind of jumping the gun with something that we'll be talking about in just a few slides time. So, Tony, she has mentioned dust and pollens. And yeah, we've also got pets cold weather, another good couple of triggers for acute asthma. And it can also be triggered by exercise as well, so you can get exercise induced Broncho construction. Excellent. So then COPD COPD is a little bit different from asthma. It'll affect a different category of patient's, which is something that we'll talk about again in a couple of slides. And COPD really is a syndrome of or constellation of symptoms, uh, chronic bronchitis. and emphysema are the two conditions, which, uh combined to create this kind of, uh, progressively worsening disease or irreversible disease. Um, how do we define chronic bronchitis? This is a classic kind of medical school question. This is more to to get you thinking about the more chronic stage as well of COPD, despite the focus on the, uh, the acute setting tonight. Anyone? So it's, uh so it's defined as three months of symptoms of chronic of bronchitis symptoms, and it's got to be in two consecutive years. So that's kind of how we define chronic bronchitis. However, like I said, so quite close. Tunisia. Yeah, so it's It's the It's the bronchitis for three months for two consecutive years, but again, blow tres Yes, we'll be talking about floaters as well. Beverly. However, we are going to be talking more about an acute situation tonight. Um, so you are bleak to see a patient. He's a 24 year old male admitted with an acute exacerbation of asthma, which kind of gives the game away. Past medical history includes Xmas and hay fever. He's got an allergy to capped under, and he's currently working as an apprentice carpenter. So as you can see here, we've got an established diagnosis of asthma. Unless you're in a pediatric setting, Uh, you know, the first presentation of asthma being acute is somewhat rare. We've got a bit in the past medical history about the kind of hypersensitivity syndrome. So, you know, people with hay fever and eczema more commonly might have asthma as well. You've got specific triggers. So allergy to capped under and some occupational exposures as well, which might prove to be a trigger, too. So you've been bleak to see them because they're short breath. What signs and symptoms would indicate a moderate asthma attack. So this is a kind of categorization process, and this is going to be important for management. So, yeah, we've got low oxygen. Saturations got shortness of breath, coughing with sputum. I mean, it certainly could be coughing, um, plus or minus sputum. So chest pain and tightness is a really good one. Yep. Using accessory muscles. That's a very good thing to look at. And it's something that will be discussing. So this is your kind of mild to moderate categorization. So, Beverly yeah, that's a great point. Talking about peak flow, so it's not about it's more. About 50% predicted. It's more about the how they are doing in comparison to their baseline more than looking at, uh, a fixed peak flow number. So, for example, if their usual peak flow measurements are 400 then the peak flow measurement of 2 50 might be thinking about a mild or moderate asthma attack. So it's kind of shortness of breath that's limiting activity, Still able to talk in phrases or sentences. Um, but we're thinking about accessory muscles a little bit more, Um, when the patient prefers to be sitting or two lying because they're trying to get that weight of all our abdominal, uh, contents off of the diaphragm just to ease that breathing, Um, and you might get that accessory muscle use and then, yeah, we've already spoken about hypoxia, Uh, and you also get some tachycardia as well, but probably below 1 20. You're thinking about mild to moderate. So with that in mind, what signs and symptoms would indicate a severe asthma attack. So, yeah, we've got oxygen saturations of less than 90 heart rate above 1 20. I think Osama is kind of clocked onto the to the pattern that might be about to emerge. If we look at the previous slide, we can kind of see trends and where this might go if it's severe, so a severe attack. So we're talking about peak expiratory flow. 50% predicted of personal, best or equal to or under disk near at rest. So this is where they're sat still or well, yeah, they'll probably be sat up at this point rather than lying down like we've already discussed. Um, But it will be at rest. They might sit hunched forward, sort of tripoding trying to really brace those the threat Sick cage to help breathing so they might not be talking phrases or sentences anymore. It might just be simple words. They might be agitated, sweaty, clammy diaphoretic. Uh, they might again, accessory muscle use very well spotted this arm. And we've got a trend of over 90% kind of under 90% here. Respiratory rate that's climbing and also a heart rate that's climbing. So when you're called to see a patient and you see some of these signs, you know there's an acute presentation of asthma going on. However, you know you might not be too concerned at this point. Osama has asked if he's he can ask a question. He absolutely can go. Go ahead. Will the patient develop kyphosis Mm kyphosis of Of which of which spine? Because the thoracic spine is already in kyphosis. Yeah, and the cervical and lumbar spine already in law Dose ISS. So they will we they will be kyphotic. Anyway, um So where we need to start being really aware is what signs and symptoms might indicate a life threatening asthma attack. Why do you think it's important that we differentiate between mild, moderate and severe at one end of the spectrum, But then life threatening at the other side besides the obvious? Of course. How will this change our management? Is this going to make us escalate sooner? Perhaps the answer is yes. It would definitely make us escalate sooner if we If we see signs and symptoms that might point towards a life threatening asthma attack, then we're probably going to be escalating the situation to a senior doctor much sooner than we would with mild to moderate or severe. So these are the kind of features that you might see in a severe asthma attack. Um, the peak experience your flow of 25% predicted. Obviously, if someone is having a severe, life threatening asthma attack, asking them to do a peak flow might not necessarily be the kindest or most appropriate thing to do. However, if the patient is able to do it, then that's a different question. But, um, perhaps this peak Xperia Torrey Flow reading might be a bit more theoretical than it is practical in this situation, because if they're to dispute to speak, the chances are they're probably going to be to dispute, to do a peak flow. Um, they might have altered mental status. It might be cyanotic, peripherally and centrally. They'll have an inability to Maine respiratory effort. So this is a really important sign to to think about, because if you are attending a patient who is having a severe asthma attack and they're very short of breath, are very tech it, Nick, if that respiratory effort starts to drop, it's not a very, uh, reassuring sign you might you know, you might think, Oh, well, the respiratory rate is dropping. Maybe they're improving, but actually it's a sign that they're tiring. And this is a very, very important time to get senior escalation and even start talking to. I see you potentially, um, so absent breath sounds again. That's just from tiring, minimal or no relief from frequently inhaled sub Sabas, which are short acting Byetta agonists, and they might have bradycardia or hypertension. So the reason why you want to be able to categorize acute asthma is so that you know when to escalate on the flip side. So we've spoken a little bit about asthma, and now we're going to speak a little bit about COPD. So as compared to our asthma presentation, the age range is a little bit different. So now we're thinking about people who are probably, uh, 40 years old and above. Realistically, it's going to be more towards the end of the kind of 60 70. Um, their reason for admission is cough and generally unwell. They've got a past medical history of ischemic heart disease and peripheral vascular disease. There was 37 Pacquiao smoking history and they used to work in the mines, so we've got a lot of risk factors for COPD, particularly your smoking history and occupational exposure. This is something that you still see, um, in hospital and in the community, particularly around the peak district, which is relevant for people who are studying in Manchester or, um, Derby Sheffield anywhere like that. Um, you will still see patient's who have had occupational exposure from from mine work. So how does an acute exacerbation of COPD present? So we've already spoken about blue bloat Ear's. We've got the flip side of that as well. Which is, you think? Puffers. These are kind of not necessarily that useful clinically, but a good teaching tool to demonstrate the different kind of presentations of chronic COPD. But how does an acute exacerbation of COPD present give it another couple of moments so actually similarly to asthma they might present with shortness of breath they might present with coughing with sputum, some chest pain, some tightness again, use of accessory muscles. Um, peak flow readings might not be as relevant with our COPD patient's or unless they have features that might indicate they've got asthma as well, which is entirely possible. Um, but yeah, that kind of cough, shortness of breath, chest pain, chest tightness. They're all as relevant for our COPD presentation as they are for our estimate presentation. So we've got a cough. It may be productive generally, if it's a non infective exacerbation of of COPD. Sorry, then disputes and maybe sort of white in color. Um, if it's infective, then it might be a bit more purulent closer to sort of yellowy green streaks of blood as well. Maybe present as well in sputum. They might be wheezy or they're almost definitely going to be wheezy. I'll be short of breath, lower limb swelling that That's an interesting point. That's something that we're definitely going to talk about in a moment, Beverly. But thank you for bringing that up. They might be pre req sick, so if it's an effective exacerbation of COPD, then they might have a fever as well. Again. We've already spoken about chest pain dyspnea as short of breath tachycardia, tachypnea and hypoxia. So they might be a bit cyanosed as well if they're having an acute flare of COPD. And I said there can be effective and non infective exacerbations of COPD, and the management changes a little bit, but not drastically, but that's something that will cover soon. So how does that presentation of COPD pose a diagnostic challenge, and this is a very important point, and it's something that will be discussing shortly. And Beverly is kind of already touched on it a little bit talking about lower limb swelling. It's something that will come back to Don't worry, there will be answers to that question, but just keep it in the back of your mind as we're talking about COPD and just keep some of these symptoms in mind as well. So yeah, we've got we've got a suggestion of similar to congestive heart failure. So again you're thinking on the right tracks you are thinking on the right tracks. There's a lot of similarities to a lot of other presentations that will be talking about. What's important in COPD, though, is much like recognizing a life threatening asthma attack. We need to recognize some signs of impending respiratory failure. So what are some of these signs of impending respiratory failure to watch out for? And these can be lean from the history rather than and sometimes the examination as well. But some of these points can be cleaned from the history, too. Any ideas? It's absolutely fine, if not give it another mouth breathing. I mean, I'm mouth very sometimes at the end of the night shift when I'm very stressed, I start mouth breathing to just sit there, kind of panting a little bit. So retraction. Retraction of what? Tunisia hunger. I haven't heard it phrased quite like that. But yet Blueish. Yeah. So some of these So that, you know, we've got some signs of air hunger that? Yeah, they're kind of gasping for air, I suppose. Yeah. Super sternal notch. Uh, um, not sure What? So what? What do you What? What exactly are you referring to when you say suprasternal notch is that you get that kind of sucking in? Just at the thoracic inlet is that you're kind of talking about Anyway, we'll move on. So it's change in mental status, so they might be drowsy. They might be confused. Um, yeah. So yeah, you bang on the money, then with the, uh, super stone or notch. But they might also have change in mental status in the history. They might talk about morning headaches. They might have daytime somnolence, which basically sleepiness during the daytime because they haven't really had an opportunity to have a good amount of sleep. So the kind of fatigue accessory muscle use. These are, um I think what we've spoken about with retraction of the super sternal notch as Tunisia very expertly brought up and you might have a paroxysmal movement of the abdomen. So this is kind of belly breathing that looks. It looks incredibly irregular. Once you've seen it once, you'll you'll know exactly what I'm talking about. It's quite hard to describe, but you get this, um, kind of belly breathing, which doesn't quite line up with how you would expect someone, someone's abdomen to move as their breathing. It's a sign of respiratory distress and potentially impending respiratory failure. So if you arrive, um, and with our 63 year old lady and she's a bit drowsy, um, she's clearly fatigued. She's kind of sat up tripoding like we've already spoken about those arms fixed forwards, creating a really strong, uh, thoracic cage to assist in breathing. And if there's this kind of paroxysmal movement of the abdomen, then you can kind of start to be a little bit more concerned that they're having quite severe, uh, exacerbation of COPD. So you've taken a lovely and thorough history. What is your next step? I mean, I say you've taken a lovely if you're able to take a lovely and thorough history provided they're not having a life threatening asthma attack. And you don't have time for a history. But what comes after History? Physical examination. Perfect. Yeah. What examination are you going to perform? It's four. AM on a Saturday morning. Your what examination are going to perform for this patient that you think is having an acute asthma or acute COPD exacerbation. So we've got respen CV, so, yeah, you're definitely going to want to do, uh, respiratory and cardiovascular exam. But we're in an acute situation. What a cute examination would you like to do? And this is going to be the benchmark, the hallmark of every, uh, acute presentation that you're bleeped to see out of hours. You're always going to take a history if you're able to if it's clinically, uh, appropriate. But you're also going to do an exam that you're going to get incredibly used to doing over and over again. Guys, it's an A to a 80 exam. So you do a history, if again, if it's clinically appropriate. And you do an 80. Because while you do want to focus on the respiratory system with asthma and COPD and you are going to want to do a bit of a cardiovascular exam as well, you're gonna 80 always, always 80. Because that way, we're not going to miss anything, and you have a structured approach to every acute presentation. So what kind of things are we going to look for in a A for airway? So we're gonna be wanting to make sure that they're maintaining their own airway. And you can sort of mention any kind of added airway sounds, any strider or starter as well. So that's the kind of whistling or snoring sound that might indicate, um, some sort of obstruction be. What would we be looking for? And B for breathing what the three components of every rising full chest Yet So we've looked at the rise in the fall of the chest. We've looked for any accessory muscle use. We feel for the trachea to make sure it's central. It's in the midline because even though they've got a history of COPD or asthma, doesn't necessarily mean that there's not another underlying condition that might have affected the trachea and deviated it. And as always, we're going to check expansion percussion and auscultation. What are we going to check for and see for circulation. So we're gonna check Pulse? Yep. Peripheral pulse. Capillary refill. Perfect. So yeah, BP, heart rate. We're going to get a full set of basic Hobbs. The lovely thing about working in a hospital is that when someone bleeps you and you say hi, what's the problem? And they say, Oh, I think this patient's having an acute exacerbation of COPD. You can say, Can you please get a full set of observations before I get there so that when you arrive, you already have that information in hand? So do they have stertorous breathing? Yep. Um, that's Yeah, that was very relevant for our for our be, um in. See, we're going to look at JVP. Always check the JVP. I think I'm going to have to do a full on a full on teaching session on the JVP because it's such a gloriously important sign. Um, we are going to check the pulse. We can do radio radio delay if we have any concerns we can check collapsing or bounding if there's a murmur as well. Um, and we're going to listen to the heart and we're going to We'll already have listened to lung fields in breathing, so but we can check for peripheral edema as well, though that comes into Annie Really d. Of course, it's just your classic pupils. Are they equal and reactive? G. C s of 15 and then is everything else or And that's pretty much everything else. See if it's relevant. You go for top detail. Um, including an Abdo exam. So this is where we can now move on. So we've we've done our history. We've done a lovely examination, and now we can manage our acute exacerbation of asthma and COPD. Now, luckily, there is a very, uh, useful, slightly rude pneumonic memory device that we can use to remember how to manage acute asthma and COPD when all you have to do is flip around a couple of these letters, uh, to give a very sort of handy memory aid to remembering the acute management. Does anyone have any idea what these letters stand for? And quite helpfully, they're done in their done in a kind of relative order of, um a relative order that would be useful in terms of order, of escalation too. So not only will this help you to remember the components, but also the order in which to do them. And oh, is a nice, easy one. Oh, it's for oxygen. Perfect. So if they're hypoxic, the first thing that we're gonna do is give them some oxygen. How do you target saturations differ in COPD and for bonus points, Why do you target saturations different COPD? Tanisha is jumping the gun. She's moved on to us, so Yeah, excellent. We so Yeah. 88 to 92% is the target saturations that we aim for in COPD. Does anyone know why higher flows can depress breathing? Exactly. So with COPD, their chronic retainers of carbon dioxide. Anyway, so they lose that drive. Exactly. They're used to a relatively higher level of CO2. So they lose their hipper kapnick drive of respiration and they rely more on their hypoxic drive. If we remove that kind of hypoxic state that chronic hypoxic state, then, uh, it can decrease their respiratory drive. So as we've already said salbutamol is a short acting beta beta two agonist. And how would we give salbutamol if someone's having an acute management of asthma? Does anyone know how we would administer salbutamol? NEBs? Exactly. So we can give oxygen and salbutamol at the same time through a nebulizer, and we can do the same with I, which is ipratropium too. And does anyone know what the next letter is? H hydrocortisone. Yeah. So this is when we start thinking about steroids so we can give Hydrocortisone IV. But if the patient is able to tolerate it, then a course of prednisolone orally is equally as equally as good, as long as they can tolerate it. Obviously, if this person is in respiratory failure, then it's probably hydrocortisone. That's probably going to be used. Um, I I actually attended an acute exacerbation of COPD on my night shifts about a week ago. I was reluctant to give Prednisolone at first because it was three in the morning, and it probably, you know, I wasn't exactly going to help the patient sleep necessarily. But I still have to give it, um because it's always a balance of risk versus benefit, and I think the risk of having an acute exacerbation of COPD probably outweighed the risk of having a bit of a poor night's sleep. This is where the acute management of asthma and COPD 10 This is kind of where they drift apart, so t theophylline or aminophylline in useful in COPD and an asthma. But this is really where we get a deviation for the next one. So everything from oh through to t they're all factors that we can consider in the management uh, for, um COPD theophylline and, um, an offline. I wouldn't personally start those myself. It's something that a more senior doctor would have to make the decision on. So everything up to there, I would say, is the perfect management level as an F one on the wards during the night shift. As long as you've done those things, I don't think anyone can hold it against you. The offline is something to consider when you know you're discussing with the registrar. You know about escalation, M. Does anyone know what M stands for? And from here on, this is kind of acute management of asthma over COPD magnesium sulfate. Yeah, exactly. So magnesium sulfate. So it is indicated in acute management of asthma, again not to be initiated by an F one. This is very much a senior registrar consultant level decision. Um, but yeah, it's got a good evidence based for asthma. There's absolutely no evidence for its, uh, benefit in COPD. And as with every acute presentation respiratory, cardiovascular, whatever the case may be, One of the most important parts of your management as an F one is always going to be e, which is you can tell me what he stands for. It's escalate. So for me personally, I always like to discuss it with someone more senior. Even if I feel like I've managed the patient well and they are now stable. I always like to run the decisions that I've made past at least the S H O that I'm working with just to make sure that I've ticked all the boxes, I've done all the right things. And there's nothing extra to consider because even even though we can be the most confident F one in the world, um, we're still learning. It's not been that long since medical school, and we should never really be making decisions. Uh, offer our own back that haven't really been discussed, at least with someone a bit more senior with a bit more insight, because we might be missing something. So you stabilize the patient. Congratulations. You've managed the acute asthma or COPD attack. The S h O has turned up, and they have asked you whether you've ordered all the relevant investigations. So what investigations would you order? Uh, any ideas? I'll give it another few seconds. I really appreciate the engagement so far, guys. Keep it up. So I always used to get a bit flustered when someone would ask me about what investigations I would order up until the point that someone introduced me to an incredible system Bedside Bloods imaging. So this is how I structure how I would want to investigate a, uh, a patient that I'm seeing, whether that's out vows on the ward or in A and e clerking. I always think about what tests I want to order at the bedside, what blood's I'd like to get. And then finally, what imaging might be approach appropriate in this clinical situation? So, in terms of bedside, So yeah, E c g. We've got So Andrew's off so we've got to niche. So Tunisia's offered up CBC. Uh, is that capillary blood? Perhaps I'm not sure exactly what CBC stands for. Andrew Higgins has offered up chest X ray E C G Blood's ABGs. All very relevant. Yeah. So these are the bedside tests that I thought of, So peak flows for asthma. Uh, and E C G s. Now, why might an egg be important? And again, this is kind of thinking back to when we were talking about the diagnostic. Um, how COPD presentations can create a diagnostic challenge. Any thoughts about why we might think about ordering an E c G? If not, that's fine. We'll move on and we'll come back to it. Just keep it ticking over in the back of your mind. So, yeah, we're starting to think about ruling out some things so possible. Flu testing? Yeah. Peak experience, The flow. Yeah. So Blood's. These are the kind of things that are relevant for our acute presentation of asthma or COPD. There are obviously additional blood tests that you would order. Uh, if you had any sort of concern about anything else that might be going on. But these are the ones that I can think of for asthma and COPD. And I would welcome anyone who can think of additional tests that I may have left out or forgotten here. But why? Why is a full blood count important? What kind of things would be would we be looking at on a full blood count? So Ashley's offered up an excellent excellent point that I'm really happy that we're going to get to cover so people with COPD might have polycythemia. Um and it's one of the indications. So it's part of a few things that could make us think about whether we need to introduce home oxygenation for someone with COPD and polycythemia is one of them. So that's great. It's kind of a reaction, uh, from your hypoxic state that your your body starts creating extra red blood cells to try and deal with it. So, Andrew Yeah, exactly. White blood cells and neutrophils. So we're going to be looking at, uh and eosinophil is as well. Yeah, so? So if we're thinking about asthma, yeah, eosinophils are important. White blood cells and neutrophils will help us kind of point towards whether this is an infective exacerbation of asthma or an effective exacerbation of COPD. And that's something that CRP will help us with as well, obviously, A. C B, G V B G A B G. That's going to give us an idea of how the blood gases are doing, Um, and whether someone's in type one type two respiratory failure, uh, quite an important part of the V b g A B G. When we're thinking about COPD as well is that the bicarb might be bicarb might be deranged, deranged. Sorry, because obviously it takes a little bit of time for the bicarb to start having an effect. Uh, so the bicarb would be raised because they'd be in a sort of constant hyper kapnick state if they're in type two respiratory failure. So the bicarb might rise as a result as well. Does anyone know why I would include a U and E in my kind of standard screen of an acute exacerbation of COPD or asthma? Okay, there's a particular value that I'd be looking at. This is particularly giving you a few more clues. This is particularly if we're thinking about an infective exacerbation, so I'd be looking at the urea Does anyone know why I'd be looking at the urea? So you rear forms part of the curb score. Have we heard of the carbs School? See you are B. Yes. Great. So we have heard of it. So the curb score for those that don't know is how we start thinking about how severe um, a presentation of pneumonia might be. So this is a scoring system which can be used, which includes C, which is confusion. You, which is urea are, which is respirator? It and B, which is BP. And then you've got 65 on the end. So the curb scores important, uh, trust that I work in because it determines, um, what kind of antibiotic therapy that we're going to give? Obviously, in the community, it's more about whether this patient is going to need admission for, um, their chest infection. But in a hospital setting, at least at Wigan, where I'm working, they use it to determine what antibiotic therapy they use as part of their um, it's part of their guidelines. So that's just something to think about. So I think I think it's a urea over seven. I've gotten so used to using the calculator. I'm way out of exam mode. I think a urea over seven is what would score you one on the curb. Score. So what? Imaging. So we've spoken a bit about bedside. We've spoken a bit about blood's. What imaging would would you order If you're thinking that there might be an acute exacerbation of asthma or COPD, and this is not a trick question, it's as easy as you think it is. Yeah, we'll be wanting to order a lovely chest X ray. Um, if it's a non infective exacerbation. Yeah, there's a little bit of additional radiation exposure, but if there's an acute infective exacerbation of asthma or COPD, then you might be able to see some congestion. But there's also some other things that you might see that might point you towards a different diagnosis. So these are just some additional points in management of COPD that you can put at the end of your plan or considering including so see COPD Nurse review. Obviously, this might not happen out of hours, but this is something that we can definitely consider for the day team when they come into hospital, so carbon cystine is something that it's a medication that is used to help with, um, kind of secretions. Um And so So I'm just going back to the chat of just seeing Yeah, make sure no pneumothorax on the chest X ray and yeah, you can also see bully sometimes on the chest x ray as well. Um, so that's that's actually really That's actually a really good and important point because obviously a sequela of someone having, uh, COPD is that they have these bully which can rupture. And although it might, it might present, like an acute exacerbation of COPD, it might be something very different. Um, just going back to this. So carba cystine is used help with secretions associated with COPD can use antibiotics according to local trust guidelines, and you can use morphine and lorazepam. Now, this is a really, uh, quite interesting thing that I've seen on the wards and that I discussed with one of the respiratory consultants the other day. Why might we use morphine or lorazepam if someone's having an acute exacerbation of COPD? Yeah, so yeah, Andrew, you're buying on the money. So when someone is having an acute exacerbation of COPD or asthma. They become very short breath. They become hypoxic and this is going to make them very anxious. They're going to hyperventilate more azeem Exactly. And they're gonna get stuck in this really nasty cycle where they might not actually necessarily need broncodilator therapy necessarily. But it's more that they're in a kind of downward spiral of anxiety, hyperventilation and agitation and actually a little bit of morphine. So we're talking sort of 1.25 to 2.5, Um uh, of Oramorph or lorazepam, Not 0.5 mg, I am IV. That might be enough just to help break that cycle of anxiety and hyperventilation and just help them to get on top of their symptoms a little bit better. So we've done all this. We've taken a fantastic history. We've done a really lovely thorough examination, and we're gonna move on to this. I promise I'm gonna be ending soon. I I realize that we're coming up to an hour, but, um, if you just bear with me because we just got a couple more little bits to get through, um, so your bleeped to see them again, they're not improving. Despite your inventive interventions, are still wheezy. What's your thoughts? What do you do next? So, yeah, escalate. You're definitely going to escalate. But before you escalate, is there anything that you might consider? So we've got some back to back Nab's so they're still wheezy. So you're thinking, OK, there's still some Broncho constriction. Maybe we can give them some more NAB's. So actually patient's with COPD, they're gonna be wheezy. No matter how many NEBs you give them, there's there's a There's a good probability that they're still going to be wheezy despite all your interventions. So you might you'll be giving them oxygen salbutamol, ipratropium, prednisolone, hydrocortisone, the works. But they're still probably going to be a bit wheezy, even if they're over the acute exacerbation. So they're still wheezy. They're still unsettled. They're still Yeah, so again, yeah, we could think about escalating, but in terms of medications, um, but we also want to consider that there might be something else going on as well. So we've already touched on this a little bit. So when we've spoken about the bully, the pneumothorax on chest X ray, when we've spoken about the E. C G as well as a bedside test. These are all things that we need to be thinking about, because if this patient with COPD they're still desaturating, they're still not still not quite right. And something something isn't quite fitting. Then we need to start thinking about other things, and this is again, is where leg swelling comes in as well. So these are things that we want to think about rolling out, because if we remember, if we think back to the symptoms chest tightness, shortness of breath, these are all things that could appear in acute coronary syndrome, pulmonary embolism, pneumonia, sometimes gastro esophageal reflux disease as well and pneumothorax as well. So if someone still isn't improving, then we really need to start thinking about ruling some of these other important things out. So a. C s. Obviously, we'll think about things like proponents and an egg. Um P A. We can start thinking about D dimer a lovely well score for PE and then using those to get a nice clinical indication of whether you need to send this patient for CT P A and perhaps give them treatment dose of low molecular weight heparin God. This will likely come from the symptoms I've yet to see an acute exacerbation of COPD that is actually just gastroesophageal reflux disease. But it's not unheard of a pneumothorax. So again, this is something that will show up, hopefully show up quite nicely on a chest X ray. And that's how you do all these out. I'm aware that I didn't didn't let you guys do the thinking on that, But I'm also aware that I've taken up enough of your Wednesday evening. So thank you very much for listening. This is my email. Feel free to get in contact with me about anything to do with, uh, medical school s J t. Um, ranking your positions, whatever. Whatever it might be and more than I have people to get for you to get in contact with me. Uh, just drop me an email, and I'll do my best to get back to you as soon as I possibly can. Um, I hope you'll have had have learned something. That's the aim of that. That's the name of the game, The aim of the game, and I Yeah. And, uh, I hope you have a lovely rest of your Wednesday evening. Thank you very much. for attending. If anyone has any questions, I'll hang around for a for a short while, Uh, and we'll try to help as much as I can. And also, I'd really value feedback. Um, you'll come to you come to learn the importance of feedback. When? When you're working. Um, so, yes, very much appreciate it. All right, guys, if everyone's filled in, the feedback will be ending this session now. Thank you so much, Angus. It was a really helpful session. Oh, you're welcome. You're more than welcome. Everybody All right? I'll end the broadcasting now. Thank you so much for joining us. And I will have another lecture for you guys next week. On Wednesday, same time.