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Hello. Um my name is a if you didn't, if you weren't online yesterday. Um I'm finally you Scotty student. So I did my um MLA in June last year. Um I am gonna talk about respiratory today, so I've kind of done a similar thing to yesterday where I'm gonna go through conditions, kind of the main things that you should be looking for in the questions and then um we'll go through some questions as well. Um Hopefully a lot of it's gonna be fairly straightforward and things that you remember, but I guess hopefully it's gonna be useful as it just kind of help refresh your memory a wee bit. So I hope everyone can see that. So we'll start with ABG revision. So um this is just kind of like the basics of what I think is useful to know if you go to do your finals and kind of what you're looking for. And so knowing the difference which is between type one and type two respiratory failure. So for type one, remember, you're just looking at the oxygen level if they're hypoxic and type two is when you're looking at the oxygen level and CO2. So the oxygen is going to be low and CO2 is going to be high and then just remember that they might be compensating as well. So if the ph is normal, then they're compensating. Whereas if it's decompensated, it would mean that the PH is um abnormal. So, respiratory acidosis, you would look at CO2 first. Um you're looking for the CO2 to be raised if it's respiratory. Um and then if there's some raised bicarbonate that shows that you know, there's some compensation, respiratory alkalosis. So this would be if you're hyperventilating or you've got a pe um you'd have low CO2. I think metabolic acidosis is slightly more complicated because you have the different types. So you can have normal anion gap and a raised a anion gap. So for respiratory uh sorry metabolic acidosis, remember you're looking for low ph and then um you would see that the bicarb was low to check the anion gap. Remember you're just adding up the positives and then taking away the negatives. Um If it's normal, I think, I think for when I did finals, I pretty much just remembered these three conditions so that at least I could kind of spot them in a question. Um So renal tubular acidosis, Addison's and diarrhea. And I think they're some of the main ones to remember for normal anion gap, metabolic acidosis. And then if you've got metabolic acidosis, you can, where the anion gap is raised you can kind of rule out those three and it could be any of these other things. So lactate DKA and renal failure or if they've got kind of um toxicity from um drugs and then metabolic alkalosis is when you've got low Ph and you'd have high bicarbonate. And then this one is caused by vomiting, diuretics, hypokalemia, primary hyperaldosteronism and Cushing's. Um So hopefully that's all stuff that you've sort of know and have been looking at. So we'll just do a quick question. Um, I will let you read it or will I read it? I'll read it. Um, so a 65 year old gentleman with a history of CO PD, he's got worsening shortness of breath and productive cough. He describes increase in sputum production with the sputum color changing from clear to yellow. And then here's his ABG based on this information. What does his arterial blood gas show? So I'll give you a minute to look at the, um, blood gas and then I can start a poll to, for you to answer. So, hopefully that has worked. Can you let me know Adam if that worked? Yeah, it's working. But, um, and then what do I need to click on to, to see the answers to the poll? Uh, it should just be in the little pull section on the next to the messages. If you can't see it, I can, you know. Ok, cool. It'll be down in the bottom if you cool down. Yeah. Yeah, I see you now. Thanks. Mhm. Ok. So we've got a few answers. So most people went for a, so this is type two respiratory failure. So if we look at the oxygen level, you can see that he's, his oxygen is low, he's hypoxic. And then you can also see that the CO2 is raised. So that tells you it's type two. I think that acute on chronic. So if we look at the question, you can see that he's got a history of COPD and that's, that would suggest he's got a chronic respiratory problem. And then, but on top of that, he's got this worsening, shortness of breath and productive cough um with purulent sputum. So I think, I think it's just worth remembering to read the question as well. So don't try and find all the answers in the ABG and you can kind of work out some of it from the question as well. Um So my basic A PT um revision was that I would look at the Ph first, look at CO2 next to see if it's um gonna be respiratory or metabolic and then kind of go to bicarb blast. And then if you're thinking about respiratory failure, make sure you're checking the oxygen. Um And then I would just advise that you learn some of the main causes of each type so that if you see something in a question, you kind of automatic like if you see um yeah, pe or hyperventilation, you can kind of automatically know what that might be any question. So, um I've got a bit about like asthma CO PD and then restrictive lung diseases as well. So just to start with, um we'll have a look at the differences between obstructive and restrictive disease. So when you do spirometry, you can work out the differences between obstructive and restrictive. So, obstructive, you would see that the ratio F EV one to F EC would be less than 70%. Um And that's your asthma and COPD and then in restrictive disease, both of them would be reduced, but the F EV one to F EC ratio would be over 70%. So that's kind of the first thing you would look at if you're, if you get given the spirometry results and you can also have mixed disease where there's a bit of both going on. Hopefully, in that case, they, they're gonna make it obvious what, what they're, what they're wanting you to work out from that. Um So for chronic asthma, so this is just a kind of over overview of your kind of treatment ladder for asthma. Um Again, it's probably stuff that you've looked at. I apparently they've actually changed the guidelines um since even since I did the exam. So I think in the past year they've changed it. So step one now would be that you'd use an I CS or A lab for symptom relief. Step two is to use low dose mark. So that's your I CS and laba like a combination inhaler and step three. Would you just increase that dose? Step four, you're going to check the feno and for eosinophils. And if they're raised, you might refer them to a specialist. If they're normal, you could try uh LTR A or a lama in addition to your MT and then if you're going any further than that, you're going to refer them to a specialist. Um, these are your symptoms for acute asthma and then we'll go on to what the acute asthma management would be. So your acute asthma symptoms, you're trying to work out whether it's moderate severe life threatening or it can be near fatal. Um, I know that past med quite likes asking you these questions. I think, I mean, I think it's probably is useful to know, um because it's going to help, help you to work out how to manage them. So I think even remembering a couple of, couple of the um criteria for each um level is quite useful. Um So if so, II guess moderate is less important. So if it's severe, it's gonna be between your pe if your peak flow will be between 33 and 50 they're not gonna be able to complete sentences. At that point, they're gonna have a raised respirate and a raised pulse and then for it to be life threatening the peak flow would be less than 33. Um sats are also gonna be low at this stage. The CO2 is likely to still be normal. Um But you could start getting some confusion, hypertension and then near fatal is when your C or two starts to go up. Um So that's something you need to have a look at. If they give you a ABG and then your treatment for acute asthma is gonna be, you're gonna give them oxygen, you need to give them salbutamol. So you can give that through a nebulizer. We're gonna give them steroids and remember you need to continue the steroids for at least five days. Um If it's not, if they're not kind of responding or it is a severe asthma attack, then we might give them ipratropium bromide. The next step would be IV magnesium sulfate. And then the next step would be it for intubation um with acute asthma as well. Remember they need to be stable for 12 to 24 hours. So if they've, if the question says that they've shown up in A&E and we've treated them and they're getting better, um Don't just send them home until we know that they're going to be stable. Um You also need to check inhaler technique before they go home and that their peak flows greater than 70%. So, don't get um Yeah, I think I've definitely seen questions where that somebody has come to A&E and they've kind of stabilized and then it's just remember you need to do some things before you send them home. You're not just gonna let them go. Um So moving on to CO PD. So it's just remembering as well. So for COPD, you're always going to tell them they need to stop smoking if you can, they need to get their vaccines. So the flu and pneumococcal vaccines and then the other thing you can do that's not drugs would be pulmonary rehab. Um So I think just remembering that these things that you would advise for patients before you start using um inhalers. Um And then these are just the different steps. So remember for CO PD, you'd start with a saba or a sama and then you're gonna look at whether there's asthmatic features or not. If there's no asthmatic features, then we know it's not gonna respond to a steroid. So we would give them a laba lama. Um if they were on salbutamol before we changed that to Asama as they kind of um relief, like immediate relief therapy. And then if there's asthmatic features, we can add I CS. Um the kind of step four here is when you're kind of, you've already kind of used up all your treatment options, you might add oral theophylline. Um I remember sometimes some people end up on long term antibiotics if um if they're kind of having recurring infections. But that, yeah, that would be a kind of serious severe case. Um, and then your acute management. So if you've got somebody like we had in the last question, that's got a, um, acute infection on top of the COPD and the common causes are going to be hemo infl strep pneumonia and more. Um, and then 30% of the time it could be viral, but most of the time it's going to be bacterial, which is why we'd give them antibiotics. Um Your management would be that you would tell them to keep using their blue inhaler. We're gonna give them prednisoLONE again for five days. And if we think it's bacterial infection, we would give them amoxicillin or Clarithromycin or Doxycycline. If they're allergic um for severe exacerbations, they might need to come into hospital to get oxygen. Remember you're 88 to 92 A A and for COPD patients will be through a venturing mask and they might need to get nebulized S or oh, I was meant to say Sabba sorry or Sama. Um they might need to get IV steroids depending on how um severe severe the exacerbation is. Um and then IV theophylline and they might need bipap in kind of worst case scenario. So we've got another question here. So as a 52 year old man comes to acutely short of breath, unable to complete full sentences. Sitting in tripod position suffers from asthma. This is his second attack this year, he is pale and distressed and then he's got a bilateral wheeze. And so that's his odds there and then he's got his ABG here. And the question is what's the most worrying finding? So I will let you have a quick look and then I can start the poll again. So that should be the pole open now. OK. So most of you have said b so that's the correct one. So it's just remembering that if you look at the CO2, that's kind of the most, um It's one of the most important things to look at. So if the CO2 starts to go up, you know that they're getting tired and they're not able to, to get rid of the CO2. Um I think the next closest answer was that these are unable to complete full sentences and I think that that one is one of the criteria for severe rather than life threatening or you're fatal. Um So I guess just, yeah, hopefully, look at all the different criteria and try and get, get some of it into your brain. Um I've got another question. So a 28 year old woman who's got pain on swallowing, well controlled asthma using salbutamol and a steroid uh inhaler and then she's got white plaques in her mouth. An anti fungal oral suspension is prescribed. But what are we going to do to help manage? Um with regards to her beclomethasone inhaler. This was from one of the like UK MLA past papers so it's kind of related to asthma management but um slightly different angle, start the pull there good. Um So most people have gone for d so, um she's basically, has got oral thrush from using a steroid inhaler and we've treated it. But then what we're going to say to help this um to help stop it happening again. Um So using the volume spacer can help kind of disperse it. Um The next, I think a couple of people have said a so I don't, I think the dry powder can kind of get stuck in the back of your throat and just kind of cause the same problems. Um ok, good. Well done. Um So just to bear in mind for the MLA, remember to look at the different stages of asthma and COPD, try and get the different treatment steps into your mind. Um Remember to look for asthmatic features in COPD if it's asking what the next step is, they might have mentioned that they've got kind of asthmatic features. Um and I'll help you differentiate, which is the right answer. Um And then remembering they need to be stable for at least 12 hours before they leave hospital. Um ok. So if we go on to some restrictive lung diseases, so, interstitial lung diseases, inflammation and fibrosis of the lung tissue. And then the one that we need to be aware of mostly is idiopathic pulmonary fibrosis. Um So this is the one where you would get by basal fine expiratory crackles and you can also get finger clubbing. And if you do act, you're gonna see the ground glass appearance. Um So the, the prognosis for this isn't very good, but you can use these drugs. So pirfenidone and um to help slow progression. Um So yeah, I II just learned that as I was making this presentation. So there we go. Um Other ones, other forms of interstitial lung disease include secondary pulmonary fibrosis. So this is one once caused by drugs. So just be aware that if you're on amiodarone, cyclophosphamide methotrexate nitrofur, for example, and you might need to do chest x rays um to check that they've not got pulmonary fibrosis as a consequence of that drug. Um Another example is hypersensitive pneumonitis. So this is your allergic reactions. So this is a bird fanciers lung farmer lung, I think, I mean, just if you see slightly weird things in a question, like they own lots of canaries, then maybe highlight it and just bear it in mind if you're, when you're going to your answers, um cryptogenic organizing pneumonia. So it's similar to pneumonia, but it's with focal consolidation. Um I think that one's probably less, less common, like less likely to come up and then asbestosis. So if it mentions any kind of job where they might have been exposed to asbestos and, and they could end up with lung fibrosis and remember there's a link to mesothelioma with that. Um bronch bronchiectasis. So the permanent bronchodilation, your key features that you're going to look for in questions are if they've had um mainly if they've got productive cough and lots of sputum coming out. Um or they say they've had recurrent chest infections over the year and they can also have weight loss and finger clubbing. And I think sometimes they can also have hemoptysis. So I know that you're kind of looking for red flags for lung cancer. But just remember that those kind of things can also refer to other, other conditions as well. Um When you were listening to the chest, you're gonna hear scattered wheeze squeaks and crackles and to investigate, you might do sputum cultures. So the big ones for bronchiectasis would be hemo hemo infl and Pseudomonas. Um management is gonna be that they need to get their vaccines. So getting their flu pneumococcal vaccines, you might do um chest physio, you could give them long term antibiotics if it's, if it's a recurring problem for them, um they might also end up on a laba, they might need O2 oxygen and then they might need surgery or a lung transplant in the kind of worst case sarcoidosis. So that's your chronic granulomatous disorder. Your typical patient is gonna be a 20 to 40 year old black female with a dry cough. I was meant to say short of breath, sorry. Um and erythema erythema dosing. Um So a kind of subtype I think is if you look for this triad for Lofgren syndrome. So if they've got ery meningo bilateral hilar lymphadenopathy and polyarthralgia, that's the kind of three things you're looking for for that. If that's one of the answers in the question, maybe you can go back and, and see if, if they've got those three things um for your diagnosis, remember it's the ace that would be raised, they can also have hypercalcemia. You're going to do a chest X ray and you would do a higher A CT. Um Remember as well as sarcoidosis, it can um have, you can have problems with kind of all the, all your other organs. Um But I think especially remember if you've got someone with a cough who's also got these like nodules on their shins, then it's gonna be quite likely be sarcoid. Um Management is conservative and it's just mild. They might need to get steroids, they might need to get methotrexate um lung transplant if it's very severe. So we've got a 60 year old man with six months of dry cough, increasing short of breath previously fit and well, nonsmoker, his temperature is it a pulse is normal. Um SATS are 89 on air and he's got finger clubbing. Cardiac exam is normal and chest exam reveals by basal crepitations. So I'll give you a minute to have a look and then I'll start the poll good. So most people have gone for idiopathic pulmonary fibrosis. Um, so the dry cough, shortness of breath, finger clubbing, hypoxia and the bi basal crepitations are all, um, suggested suggestive of I PF. Um I think a couple of people had gone for bronchiectasis. Um I think that just remember you looking for, um, increased sputum production and kind of more likely to have an infection with that well done 22 year old woman who's got worsening shortness of breath and a productive cough. Um, she's coughing up 4 to 5 tablespoons of sputum per day. She had childhood pneumonia and recurrent chest infections. She has also coughed up blood on two occasions many years ago and they just got scattered by basal wheeze and coarse inspiratory crackles. I'll give you a minute to look through the answers and then I'll start the poll. Ok. So well done. Most people went for bronchiectasis. So just coughing up a lot of sputum. And then remember there's also links to childhood pneumonia or, um, I think if they've had childhood whooping cough as well as another one, if they mention that in a question that can be linked to bronchiectasis. Um And I guess, yeah, I just don't get distracted by the coughing up blood on two occasions. Um, because that can be other things other than lung cancer. Good. 52 year old man has got four weeks of joint pain fever and weight loss. He's a nonsmoker. It's got no significant medical history. Exam is unremarkable and he's hypercalcemic. Um oh, I think that I have missed the end of that, but it's meant to say that the plasma parathyroid hormone is normal. What's the most likely diagnosis? Start? Pull there? Ok. So this is interesting. This one's a bit more split. Most people have gone for sarcoidosis. Um So I think, oh, hold on, I missed some of the question. That's why very did it mention lymphadenopathy? No. Um OK. Well, so sorry if I've missed some of the question then um I'm sorry if you didn't get the right answer because that was my fault. Um So most likely it's sarcoid doses. So we can see, remember that um it can affect other organs. So um and you can get hypercalcemia with it as well. Um Yeah. Um sorry, I can give you a minute to read through the, the um the answer description there, but I think that was partly my fault because I've missed some of the question. Um So just as kind of things we're looking for on imaging for what we've just spoken about. So bronchiectasis on a chest X ray, you would get tram track capacities and ring shadows for IDP. Um I don't think that's dear, I'm so sorry. This is not II made so many typos that's not meant to say IDP. It's meant to say idiopathic pulmonary fibrosis is when you look at the high risk CT and you get ground glass appearance and then sarcoidosis is when you get highlight lymphadenopathy and you would see that on the chest X ray, but also on the CT. Um and you might also get pulmonary nodules. So I think with a lot of these respiratory questions because it's quite easy to get confused as a lot of them have similar symptoms. So it's just kind of remembering what the, what the key things you're looking out for for each condition is. So I've just got a wee bit on pneumonia. Um So somebody's got a productive cough fever, hemoptysis, pruritic chest pain, they might have delirium, they could be acutely unwell. Um So remember you need to look at their obs and examination as well. Um On examination, they could have bronchial breath sounds and they might have focal ch crackles and it could be Delta Percos. Your score for this is your curb 65. So you're looking at a confusion, um confusion, you respirate and BP and that if they're over 65 for mortality and the score goes from 0 to 3. So three being higher risk and zero being less risk. Most common causes are strep pneumonia and he influenza. And I remember you can have atypical causes as well. And so a five year old woman who's got shortness of breath associated with productive cough, chest x rays. Done. What does the chest X ray show? I'll give you a minute to look at it. I think when I looked at the, um, past papers for the MLA as well. There are quite a few, um, chest x rays or there was a chest CT as well. So I think definitely have a look at a few just so you kind of know what you're looking at as well. But I think a lot of the time you can work out most of the answer from the questions stem and then the imaging usually just helps kind of reinforce what you might already be thinking. So, don't panic. If you are not good with imaging, we'll start the pool there. Hopefully, this was quite a nice straightforward one for most people. So I've got right middle lobe pneumonia. So we can kind of tell from the question, um or she's got shortness of breath and productive cough. So that suggests that she's got that sort of infection. And then if we look at the chest X ray, you can see on the right side that there's kind of an area of consolidation that's in the, in the middle of the lung. Um So that kind of that helps you, helps you choose that answer so well done everybody. Um So just quickly to go through your atypical causes of pneumonia. Um So legionella is one that they quite like to put in question. So just remember if it's anybody that's been on holiday recently, um and they might have um had the air conditioning on that's um that's something to look out for in questions. You can also get hyponatremia with that. Uh chlamydia sachi. I don't know how you say that it is from birds. So they mentioned birds and then they've got kind of a pneumonia. It could be that one. Mycoplasma pneumonia is also associated with erythema multiform. Um And then you've got chlamydophyllum pneumonia, which is more likely in school age Children and then Coxiella burnetti, which is linked to animal body fluids. So, if they mention like a farmer or somebody that works with animals and he's got pneumonia, it could be that one. And then on a chest X ray, you're looking for areas of consolidation and it might have some kind of effusions as well. So that is me, I can rattle through that fairly quickly. Is there any questions?