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Welcome to this um CSI case tutorial today. We'll be looking at um this case of uh breathlessness. I think it's Mister Philip Craven, who you probably already visited in first year. So the first task revolves around, first of all, in terms of like the clinical aspect comorbidities with CO PD. And in terms of like CSI focus, the focus here is gonna be on statistics. You've probably seen them all on your questions now on your exam and they can be quite annoying, but if you have like the right approach to them, they're basically free marks. Um So as you would have had in your um in your in person sessions, um So here we have a list of quite a few er common comorbidities associated with CO PD. And really what I'm trying to make you guys look at here is less. So the comorbidities because that's something you can read upon and potentially it won't really be us questions about that, although you might do and there's common ones, for example, like coronary heart disease, um heart failure that are all linked with CO PD, which we'll also look at a little bit later in this presentation. But in terms of the sta statistical side, it's very important to get yourself comfortable with key terms. For example, Publix big term, um how like how pre prevalent it is in the population, how many cases there are? And when you see a graph like this, which you've already seen, the bigger the circle indicates in that selected population, so that group of people, the bigger the circle, the greater the number And then statistical significance is very important. So essentially, are we confident that this didn't happen due to chance was as an actual, like an actual conclusion? And we can see here in this particular um circumstance, everything within the dotted line circle uh counts as statistically significant and it's gotta be fully within it. And then finally, we're looking at the closer it is to the center, the stronger we have the association of that particular comorbidity having with death, you can look even further. And I think that there, there is a key in here somewhere denoting that the different colors have are different types of. So the red colors are your, I believe that your cardiac comorbidities. Well, the pink ones are more specific to just female health and then the green ones, I believe that they're respiratory ones. Um So that's why we're looking at. Now, I wanna look at a separate question, another one and essentially which behavior in this is most significantly associated with jealousy in dogs. And OK, So it's a bit of the graph has been cut out, but that's fine. So from the four that we can see which behavior is most significantly associated with jealousy in dogs and this left axis would be the ratio. So the higher it is the more likely it is to be significantly associated. And the bottom axis is just telling you the different behaviors. So what we find is that when you see a question like this, what you really wanna be looking at is first of all the hazard ratio. So how related is this variable X to the incidence of the actual ratio? And as we can see, the higher it is, the more you can consider that variable link to the original question that we're asking. So the higher the bar is the more likely um the dog is showing a yellow sign and then we're also looking for statistical significance. So if we look at um these stars at the top, they're denoting how statistically significant it is if you look down at the bottom as well on the bottom left of it. So therefore, we're looking for the greatest hazard. So the highest bar which is also statistically significant and that would be the behavior which demonstrates the most um jealous like that. W which work, which shows that a job is showing jealousy uh for its owner. So I have to like summarize everything I've just said essentially when you're looking at any of these statistical questions, always look, first of all, if it's statistically significant or not, that'll save you a lot of time once you figure that out, um I remember anything. So if P is less than 0.05 you're statistically significant after you've looked at that, then you want to move on to the greatest association or hazard ratio or whatever it is. So by anything above one, you're showing a positive association towards whatever the variable is, anything less and it's a negative association. Then in terms of the second task, um this was pretty much centered around x-rays and x-rays is a very, very important thing to get good at. And while this lecture won't just be an x-ray lecture, I'll give you guys a few useful tips on how to like efficiently read x-rays. So x-rays or the proper term for it is radiographs. As many doctors will point out to you, there's three pneumonics or two mnemonics and one sort of approach that we can use uh before any of this, it would have been useful if I used a radiograph with patient details on it, I think good practice and also free marks at any station when you get to your third year and your asks, you always wanna confirm the patient details. So that is looking at the name or hospital number, looking at the date of birth. Um You want to look what x-rays actually been ordered and if you're doing the right one, there's no use if someone's broken their leg, if you're taking an X ray of their chest, you know, something like that. And also if it's something that's like a recurring issue, you might want to potentially consider looking what other X rays are available. So you can sort of think what's happened in the past and you might be able to almost predict what is going on right now. But then once you've done all of that, once you've done all the, the good practice side of things, a very common mnemonic is ripe. So you want to check if this x-ray is adequately rotated. So you wanna ensure that these clavicles uh in line with each other um position is very, very important. So you want to make sure that the person is positioned correctly, that you can see the heart, the different markers, exposure is also very important. So you wanna ensure that the X ray is adequately exposed to make sure that you can see all the structures that you're looking for. And then all that and that is essentially that right mnemonic is to check if this is an adequate x-ray. If this is something that can be examined in terms of actually examining the x-ray, then you're gonna move on to ABCD ea being for airways. So this is essentially looking at the trachea, trachea can become deviated in various different conditions. So you wanna be looking at that and you wanna be looking at B which is your breathing. So now you're looking at your lung fields and then see you move on to cardiac causes. So for that, you're looking at, you know, the outline of your heart, is there anything that's changed with that D is very important? So this is your diaphragm that can tell you a lot of things in particular. You wanna be looking for the actual shape of the diaphragm. Is it a nice curve? You're gonna be looking at the corners. So the hemi diaphragms, you wanna be seeing if there's a nice, essentially, if you can visualize it properly or if it's moved up down and then to be really thorough, we can also consider um and then finally ease everything else. So with e you're looking for potential like pacemakers, like any leads on the patient. Um And in terms of the thoroughness, then you'll be looking at the zonal approach. So you can consider, you can split the lung into essentially six zones. So the right and left, upper zone, right and left, middle zone, and the right and left, lower zone. And you essentially wanna go systematically through these zones and ensure they're all uh patent and there's no consolidation or any sort of uh tumors in these areas. So OK, fine. So the current radiograph we're looking at is one of a patient with CO PD and some common signs are, first of all, is hyperinflation. So, you can see that both of these lung fields are hyper expanded, they're bigger than they usually should be. You can see bully. So these patches are very dark areas and the multiple areas of these can be present. Then finally, another very common sign of it is a flattened diaphragm. So a diaphragm instead of having it's nice curve, I'm not sure if you can see my cursor, but a normal diaphragm will have a nice sort of concave curve to it look, but this is a lot more flat. So now I want you guys to have a look at this other x-ray and then I'll give you guys maybe like let's say two minutes to have a look at it. And if anyone wants to type any phone you see in the chat and we'll look at it together, start time. But in the meantime, if anyone has, has a question or anything, just just put it in the chat. OK? And let's have a look at this x-ray then. So this was a lung cancer x-ray. And the main finding here was in this left middle zone where you can see this mass opacity, which is most likely um just a tumor. Um something that's important to remember in terms of when you see a consolidate an opacity, sorry, like this is in pediatrics. So in kids, you can often pneumonia can present a lot like this. So you might look at a child's x-ray with a cough fever and all of that and what might look like lung cancer. You've got to think of the context and um pediatric pneumonia can present like this sort of lobar like lobar looking like consolidation around here. So, but most likely this is taken from an adult x-ray. This is a a lung cancer x-ray. So similarly, if we look at this X ray here, I'll just give maybe like a minute for you guys to look at it and think about what could be happening over here. OK? 10 more seconds. OK? So this x-ray was showing you perfusion. So you can see this massive whitening of the lower left um uh zone. And in addition to that, there's something that we call the meniscus sign. So if you remember back to like titrations and a level chemistry, um you used to, you read from the bottom of the meniscus, right? The meniscus like the slight dipping and you can see the base of the well, the visible lung of what you can actually see because the rest of it's filled up with fluid. You can see this almost like meniscus looking like sign. Fantastic. So before we move on, has anyone got any questions about x-rays? Anything else that they wanna ask? OK. I'll take that as a no um ABG S. So this is really, really important. I think there's one thing to super focus on and get good at because it'll save it. Make your life so much easier later on in other exams is to get good at reading ABG S. Um, so I say ABG simplified. This is more of like a system for you guys to use when you're reading A B GSI. Think when, whenever you're looking at it, it's a lot of numbers. It's a lot of letters. It can be quite daunting, but this is why it's so important to have a system in your head and how to do it. And once you figure it out a system, it's just about practice, practice, practice. So I'll, I'll talk you guys through how I essentially approach an ABG. And also we'll look at some examples. The first thing that I always like to do is look at the oxygen status because what's gonna cause the most harm to patient is hypoxemia. I mean, that is the most like time critical thing to do. So you wanna check if they're being oxygenated correctly and you'll see a lot of different um unit. So this is given in millimeters per of mercury, but you can also get it in past scales, for example, but whatever it is, just check um like check with the rangers and if it's in normal ranges and you know the normoxemic and then there's no more worry about that. So I like to just get that done at the start, clears your mind. Next thing you wanna look at straight away is the ph so is this patient's ph lower or is it too high? And you can see in this example, the patient's ph is low, it's below this, um, range and the ranges. Um, if you guys hadn't al also already realized are always given to you, er, when the machine prints it out, you always see the ranges. So you don't have to memorize these values, although you're gonna look at it so much that some of you will just, you'll just end up just learning it through osmosis basically. So after you've reread the Ph, you wanna look at what's actually causing this Ph, so we're given two values, we're given the CO2 and we're given the HC 03. So the first thing I always check that because this is what changes before the HC 03, this is almost instant is you wanna check the CO2. So we can see in this patient, the CO2 seems to be um yeah, it seems to be fine. But we can see then after that, we're gonna check the HC 03. And now we can see in this patient, the HC 03 has dropped and that gives us an indication of what type of acidosis this is, I call this an acidosis because um if the PH has dropped bloods become more acidic, therefore, acidosis as the PH H increases alkalosis. So now we can definitely say that this is a metabolic acidosis and that's because the ph has dropped heo three has dropped. Therefore, because the HO three is what's causing it, it's become a metabolic cause while the respiratory cause of it would be the CO2, which is essentially how much CO 02 is your lungs clearing. What you can quite often see, uh when the ph is a little bit closer to normal. So maybe 7.2 is quite extreme. But if we're looking at a seven point um we just go back to the screen. So you can see 7.35 to 7.45 is normal. If it's on the borderline of normal, then the body can be trying to partially compensate, your body will actively fight to try and fix it ph imbalance. And there's multiple different mechanisms that can do it. So if we look at here, we can see that in the last one, we had a metabolic acidosis. The way your body is trying to try and compensate the acidosis is try and bring on a respiratory alkalosis. Now, the way it does that is essentially it controls your rate of breathing. So if you increase your rate of breathing, you can see that you're breathing out more CO2. But if you decrease it, you're breathing out less CO2. Now because we're in an acidotic state, your body wants to create, wants to get rid of more CO2. Therefore, it's gonna try and just get rid of more by breathing faster. And that's how you can see in certain patients different sides, but we won't look into that too much. Um But it's just for interesting. And then I, if I just leave it on the slide for a little bit, you can see there's different, essentially. If you were in a respiratory alkalosis, then metabolically, you're gonna try and enter into a slight acidosis and you're gonna try and clear the HC 03 in order to bring yourself back to normalcy. And then if you get to a state where a patient has a normal ph, but the CO2 or the HC 03 is deranged, then we can say that you have to sort of work backwards and say the body's fully compensated, but this is what previously would have been happening. So we're gonna have a look at a few examples now of um A BD report. So if I pause it again for like another minute or so, um do people wanna have a go at summarizing this A G report? Ok. So it's been a minute, let's go through this um ABG report. Uh So what we can see here is that first of all, the ph is low. So, OK. Well, first of all, obviously look at the PH O2 that's low. So you wanna give the patient oxygen to make sure that they don't suffer any damages of hypoxemia. Then if we look at the, in terms of the blood chemistry, the ph is low. So we know that this patient is an acidosis. Then we look down, we look at the CO2, the CO2 is high. Therefore, we now know it's a respiratory acidosis. Then the next thing we're gonna look at is the HC 03 and this is normal. Therefore, the body hasn't actively tried to compensate yet. Therefore, we can say with confidence this is respiratory acidosis with no compensation on a background of hypoxemia because of his low past P AO two. Um Here is another example, I'll just wait, pause for another minute if anyone's just doing it in their own time and then after that, we'll go through this again together. Um OK, it's been another minute. Um So I hope that you guys have been doing it. Um Honestly feel free to message in the chat, whatever you think it is, this is a place to make, you know, mistakes and learn from you. And like, II remember when I was learning it, it's making the mistakes and then fixing it. Then when you practice, you realize how you're actually doing it properly. And then this is this A BD is one of the things where you just have to keep practicing and you're good at it. Um So once again, here, we can check that again. So this is interesting, the oxygen's actually high, which probably means the patient might have come, come in with low oxygen and they've been put on oxygen to keep them at a certain level. This is just what my thinking is not 100% sure why this is high. But first of all, if we look at the P the Ph here is low. So respiratory acid uh sorry. So we know we're in acidosis. Then for this one, we can look down at the HC 03 and we can see that this is also low. And when this is low, we know it's a metabolic acidosis. And then the PA CO2 here is slightly low. And this is because the body is trying to compensate via a respiratory mechanism. It's trying to get rid of the CO2. What we can say with this is this is a metabolic acidosis with partial respiratory compensation. But no what happens when your body, your body can't try and compensate forever. You know, otherwise there wouldn't be any need for, you know, breathing support, there wouldn't be any need to fix balances. So eventually, when your body just can't compensate for so long, you enter respiratory failure. And there's two types that you guys have to know. Type one, which is hypoxemic, not of oxygen. This can be treated with CPAP and then type two hypercapnic, which means not only is there low oxygen, there's also high CO2, your body's struggling to get that CO2 up. This can be treated with N IV, which uh can also be known as BIPAP. Um And we'll look at see if I can buy in a little bit more detail just a bit later, but I'll pause on the sli for a bit so you guys can make any notes or whatever. Um What we're looking at here are the main causes of type one and also type two and CO PD, as we can see here is more associated with type two respiratory failure. If there's any terms here that no one understands, um feel free to drop in the chat and I can explain to the best of my knowledge, pause it for a few more seconds and then keep going on. Oh, right. Oh, I should have paused here. Um So if you guys don't mind, we'll take a a just a quick little pit stop scan, the QR code, leave some feedback. It really helps the society and myself um for future lectures. So now this is task 43 combined together and we're gonna be looking at the management of CO PD. Now, now the initial management always and this is something that's almost universal across medicine apart from maybe A&E where things are super quick or an ICU where it's quite late stage. But in the majority of the hospital, you're always gonna be trying to look at non pharmacological or non surgical interventions first. Um Now, with AC O now, especially like useful for AC O PD patient with considering stop smoking is a massive thing. Um Smoking's one of the biggest risk factors and like causative factors for CO PD. So every patient who is um whether, what, whatever stage of CO PD they're in, you want to essentially get them to stop smoking, cos it, it, it improves the um prognosis massively, you want to offer nutritional support. Sure that the patient is um adequately, uh, got the correct vitamins and eating properly because when you're always like that, I don't know when people are under the weather, your appetite off a bit. And when you already compound that with this chronic illness, it can lead to awful outcomes. Offer the flu vaccine cos consider CO PD. Um in CO PD, your, your lung has its own microbiome. Your lung has its own closed environment. Right? In CO PD, when there's always a sort of pseudoinflammatory state, it can get what you can mean when you get infections, it can get even worse. So it's very important that these patients with CO PD, avoid getting any kind of flu like symptoms um when possible. And then finally, you can offer them pulmonary rehabilitation to see if they can um improve their status quo whatsoever without the need for any kind of drugs whatsoever. Yeah. Now, um when we're looking at actual pharmacological management in CO PD, there's a, there's a stepwise approach and, well, this is a good place to start what you'll actually find when you get to GP placement. And in the community is people with CO PD often have a good relationship with their GP. And it might not be just as step unlike step like like this, it might be a little bit more on a trial basis if this works for some patients, this works for other patients. But when you're learning, I think it's a very good bet to learn it like this. So the step one, the first step with CO PD, you always want to offer a short acting base agonist or short term antimuscarine Muar agent. Um so a Sabra or LMA and then if that's not working, you wanna change the S to an L or a labra, a lama. So instead of it being short acting, it's a little bit more long acting, it stays in the lungs for a bit longer. And finally, if their daily symptoms are affecting their activities of daily living, um which is something that you guys will touch on in LMA, then you wanna consider a steroid. So, Aic s but as you probably, as you may know, or you may not know steroids when they're used over a prolonged time in a chronic disease, like this can have their own set of side effects. So this is hopefully avoided and, and that's why it is towards the end. But some people, it's quite common to be used. Actually, the other aspect to CO PD that you wanna consider is so that those previous two slides were more about your daily maintenance of your like chronic background. CO PD. How are exacerbations treated cos that's a big part of CO PD management. So patients often present very unwell with oxygen. SATS are gonna be quite low. So oxygen um quite often by 24% O2 by a vary mask, a venturia mask is this piece of apparatus that you'll start to see around the hospital. Um It's pacing the patient to ensure that they're adequately oxygenated. So if anyone's interested, I mean, there's different levels of like oxygen support that you can give a patient and a venturia is further like it's not right at the start, but it's somewhere towards the middle where um you're giving them a fairly decent amount of oxygen, you also wanna consider giving antibiotics. So traditionally, it's amoxicillin first line, but then a lot of people can have an amoxicillin allergy. So doxycycline can also be used. And then once furthermore, if they're also allergic to Doxycycline, you can also offer uh Clarithromycin. Um So those are the three ones that you really wanna be thinking about and you also wanna be thinking about um like a rescue steroid or bronchodilator. So increasing the dosage so that their lungs essentially relax a little bit and the airways clear up so they can breathe a bit more easily. And then finally, after all of those interventions is not working, then you wanna consider you more your slightly more invasive breathing sport. So for CO PD, you often go straight to N IV. Otherwise known as bipap. So we'll just take a little minute to consider CPAP versus bipap. So in CPAP, we can see there's only, there's one essential way of in CPAP, there's only support on inhalation. While in bipap, there's support in both ways, inhalation and exhalation like this next slide will show. So when you're breathing in, in CPAP, it's helping your body get oxygen in and when you have type one respiratory failure, while CPAP is very much used, um you have this hypoxemia. So you need, your body needs help getting oxygen in. But then in CO PD with where it's typically type two respiratory failure, not only does your body need help getting the oxygen, it also needs help clearing the CO2 away. So that's why BIPAP is used where the support, not only when it's breathing in, also support on this breathing out. And that was quite a simplified explanation. It, it, it can be uh a bit more of a complicated topic. So it's probably important. I mean, if anyone has any questions, I'll be happy to try and answer them if you put them in the chat, but it's also something that's worth reading up on fine. So um question time. So we're gonna have a look at a little scenario here. So patient's arrived at a local A&E he's got a history of CO PD and he's coughing up yellow and green sputum. He's complaining of shortness of breath and he's concerned about his underlying CO PD. How would you manage the patient? So, stick a timer for about a minute and then if we just share the pole. Perfect. Yeah. Mm. A few more responses, guys. And we'll move on. Right. Let's make one. Um So the correct answer was C and then whoever put B once again, I it's not completely wrong because depending on the hospital and the doctor, they might decide to introduce um Bipin. So I guess d is more correct than me. Cos you'd also give steroids, but you'd very, very rarely unless the person was really, really ill. And in that case, why were they not in the hospital earlier? That's the question to ask her N IV straight away. So that's something to consider. But yeah, that's, and then finally tough. Six. Why are his ankles swollen? He's got CO PD. Why? Why has he got swollen ankles? This can be explained by someone called corporal mona. I don't know if anyone's heard about that. Now, in this, you get this back up of blood in the venous system of things. So if you, if you picture like a traffic jam, um because of a road closure, the cars are beginning to move more slowly because there's this conge congestion of cars because a part of the road's been closed, right? There's less space and then some cars will also deviate off that road off that motorway to take other routes to get to that final destination and you see something very similar happen here. So first of all, why is there a closure of the road? Why is there this blockage in the body? Well, CO PD can lead to alveolar hypoxia. Meaning there's this, there's a whole lot of gunk and um phlegm and just inflammation in a person with CO PD lungs, fibrotic tissue. This can mean that the alveoli aren't properly ventilated, they enter this hypoxic state and the body's not gonna keep beating a dead horse in terms of this alveoli. So it's gonna reduce the blood supply to this alveoli because there's poor ventilation. Um and therefore you get an increase in the vascular resistance because there's less blood flow in total. And when you get this increased vascular resistance, there's more, there's more, there's more pressure in the system. Therefore, you get pulmonary hypertension. And because of this hypertensive state, essentially, this goes out in, this essentially goes to the disarray. So usually fluid enters the interstitium. So between the blood vessels and the skin and then it also enters back in. But now because of the hypertension, more fluid enters the interstit then gets reabsorbed. And that's how you get this edema. And if we just bring that all together, you can see that we start off with the alveolar alveolar hypoxia, like I mentioned before, which leads to the pulmonary basal constriction due to er inadequately ventilated um alveoli. And therefore you get a greater pulmonary vascular resistance when this happens, you know, large scale when it happens to multiple alveoli, which therefore leads to hypertension, pulmonary hypertension. This increases the right ventricular afterload and ultimately contributes to right ventricular failure. And then eventually you get peripheral edema which is the swelling of the ankles and the feet. So final question during right ventricular heart failure, which phenomenon directly causes this. So if we just take a few minutes to have a bit of a tricky question, that one. So the correct answer is a the pulmonary vascular resistance we were talking about that reduced blood flow is caused by this resistance. It's not the hypoxia because that doesn't directly cause it or it isn't necessarily the intended effect. The afterload might affect the right hand side of the atrium, but not the left hand side. And finally, in terms of part D or the edema occurs after the blood flow occur. So it can't necessarily cause to reduce blood flow. But that um that brings us to the end guys. Um Thanks a lot for listening. And um once again, has anyone got any questions? If not? Um Thank you very much for listening and coming and enjoy the rest of your weeks. No worries. Thank you.