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Okay. Hi, everyone. Thanks for joining us this evening. Um, this evening, we've got Doctor Hannah Booth, who's going to be going through respiratory, um, covering all things that will come up in final year exams and just hitting that high yield stuff for your revision. Hand over to you, Hannah. Hi, everyone. Um, yeah. So as live said, I'm Hannah. I'm taking an F three year. I'm working in north east of England, just working in a and e at the minute. And I'm going to be covering respiratory with you today. Um, this is just a slide from the sponsor Wesleyan. Um, so that they helped to prepare you for the transition to your first year of foundation year. Um, with advice and support so you can scan the QR code for more information there. This is just a bit of an outline of the session. Obviously, respiratory is a huge topic, so I will try my best to cover as much of it as I can, but obviously, it's not gonna be possible to cover everything in kind of just less than an hour. But I will try my best. So, um, I thought before we get into kind of the nitty gritty of different conditions that it would make sense to start with. Your kind of core someone of your core knowledge for respiratory, which is your lung function tests. Um, so your lung function tests are basically just a way that you can objectively measure a patient's lung function. So, um 22 measurements that you get. So the first of these measurements is your F E V one with your forced Xperia Torrey volume in one second. This basically just means it's the amount of air that a person can blow out of their lungs in one second. Um, and this is the measurement that will be reduced in obstructive lung conditions like COPD and asthma. Um, your FEC is your forced vital capacity, which is the total volume of air that someone can breathe out after they've taken full inspiration. And this is the measurement that's usually reduced in restrictive lung conditions. Um, so when we think about obstructive lung disease, um, this can be diagnosed when the F E V one value is less than 75% of the F V C. If this pattern is recognized on your lung function, test, then you can go on to perform reversibility testing. So this is when you give a bronco dilator so usually sell. But, um um, to the patient to see whether that change can be reversed. Um, in asthma, Obviously, that is reversible in COPD. It's not reversible. Then, when we think about restrictive lung disease is the pattern that we see is that both the F E V one, um, and the FEC are equally reduced. So, um, the ratio stays above 90%. So that's kind of how you can tell the difference between those those patterns. So moving on to asthma, I thought, would be a good place to start is probably one of the largest topics in respiratory. So I thought it makes sense to kind of get it out of the way first. Um so asthma is a chronic inflammatory condition with episodic exacerbations of broncho constriction. And as I've already said, it's one of your obstructive airways disease is there are a number of different symptoms or clinical features that should make you suspicious of a diagnosis of asthma in a patient. Um, these are breathlessness, dry cough, and we've, um, is most specifically uh, the symptoms often have what's called diurnal variation. Um, so they're often worse. At nighttime, people find nighttime wheeze, nighttime coughing fits. Um, there's often a history of other coexisting ATP or atopic conditions, things like asthma, hay fever and other allergies to other things. And there's often a history of ATP in family members as well. Um, there are separate guidelines between Nice and BTS, the British Thoracic Thoracic Society, about how to diagnose asthma. But the general consensus is that you, um, based on the clinical features, you have a suspicion. Then you should organize spyrometry for that patient with reversibility testing. Um, if you're still not sure, once you've got the results of the spyrometry, then you can give the patient a peak flow meter and ask them to complete a peak flow diary. So they measure their own peak flow at home several times a day over a period of 2 to 4 weeks. And that should kind of help with your diagnosis. If we move on to management. I'm sure probably everyone has seen this before, So this is the B T s, um, step wise approach to asthma management. Um, it's worth noting that the nice guidelines do differ ever so slightly, but they basically follow the same the same pattern. So your first step is going to be a short acting beta two agonist, which is your blue salbutamol inhaler. I've got a little photo of it there. Um, this is your reliever inhaler. So patient's use this as and when they're getting symptoms and you can monitor how often they're needing their inhaler based on how often they're requesting prescription prescriptions of it. Um, the sub use one inhaler takes effect within 15 minutes, and the effects can last for 2 to 4 hours. Um, after use, and then your next step. If your patient's having ongoing troublesome symptoms, um, then you're moving on to adding in a regular inhaled corticosteroid. So this is, for example, the one that I've put there is your brown inhaler. You're you're beclomethasone inhaler. Um, these also get called preventer medication. So these are something that you use regularly, um, to try and prevent symptoms and exacerbations as well as your salbutamol to use as and when. If that's still not helping, then you're going to look at adding in one of your long acting beta two agonists. So, for example, that's something like salmeterol on. Um, they work in the same way as your, um, Sabir's, but to cause airway Brunk to cause bronchial dilation. But they obviously have a longer, um, duration of Axion. You can combine if you know, if you get into that point and you think that that's that's going to be the right level for the patient, then you can combine. Um, the two inhalers. So the the inhaled cortical steroid and the labor into one. And these are things like, um, Foster or Symbicort those kind of inhalers. Once you're getting on to step four, you're going to be adding in an extra agent. So you've got a choice here. You can use a leukotriene receptor antagonist things like montelukast, which is the most commonly used you can add in, um theophyl in trouble with theophylline, as it has a very narrow therapeutic window. And it requires monitoring has to be taken at the same time twice a day every day. Um, on the other option is a long acting muscarinic antagonist or a llama. So examples of that are things like Tia Tropea. Um um, the last thing to think about in terms of asthma management and not to forget about is counseling on lifestyle factors, particularly things like smoking and exercise is super important. They are eligible for a flu jab every year. Everyone with asthma and they should all have an individualized asthma management plan from their GP or practice nurse. Um, so yeah, that's management moving on to kind of acute asthma, which is a super important topic within asthma. This is when there's a really rapid deterioration in symptoms. Um can be triggered by, um, infection amongst a number of different things. Um, patient's will often have, uh, significant breathlessness. They have increased work of breathing, um, including the use of accessory muscles and ticket. Nia, When you listen to their chest, they should have a symmetrical xperia torrey wheeze. In a worst case scenario, they might actually end up having reduced breath sounds or what's called a silent chest. Um, the green amber and red boxes that I've put up there are how we think about grading the severity of an asthma attack, and they're quite commonly come up in S B A s, or they did when I did exams. Um I'm not going to read it all out. You can read it yourselves. But the main thing is the peak flow values and what they indicate in terms of the severity of the asthma attack and then recognizing that an asthmatic who's not talking who's got a silent chest, who's making really poor respiratory effort is a very bad sign. Um, the other way that you can tell the severity of asthma attacks is by getting an arterial blood gas or an A B G from your patient in the initial stages of an asthma attack. They'll be tack it, Nick. So they'll be breathing really fast, working hard to breathe. They'll be blowing off all that excess CO2 while they're doing that. So on there a, B G, their arterial CO2 levels will be slightly low, and this will result in a respiratory alkalosis ISS. Once they're starting to become tired, they're not working as hard to breathe. They can't keep it up, Um, and their respiratory rate is slow in a bit. Then their CO2 starts to rise. At this stage, we would call it inappropriately normal. It suggests that they're tiring basically. And then once you get past that point, the CO2 can actually start to rise and result in a respiratory acidosis when they're really not working hard at all. Um, that's the point that you're going to start thinking about critical critical care input or actually, ideally, before that point, trying to recognize it early. So what do we do if someone's coming to hospital and they're having an acute asthma attack? Um, so the first line is obviously going to be, um, nebulized short acting broncho dilators. So this is salbutamol and ipratropium. You can give these in a mixed nebulizer at the same time, just helps to get it in quicker to them. We also want to be given steroids, So if the patient is alert, they're able to take oral medications. Then you can give oral prednisolone. B N F recommends 40 mg once daily for at least five days. Um, this generally doesn't have any impact on their initial presentation. It helps to reduce airway inflammation later on down the line. Basically, um, if the patient's not alert or you've got concerns about them taking the oxygen off to take all the medications anything like that. Then you can give IV hydrocortisone just just the same thing. Basically, Um, obviously, if the patient is desaturating on air, then you're going to want to give them oxygen therapy to try and keep their SATs within the target range. The 94 to 98%. Um, B T s states that if there's been an inadequate response to the initial nebulizers, then you can give a dose of IV magnesium. Um, this has kind of a mixed bronchodilatation re anti inflammatory effect. Um, once you get into that point again, you're thinking about escalation. So in all cases, early recognition of sick patient's because they can deteriorate really quickly. Um, an early escalation to h D you or I t u as needed. So moving on to COPD um, on that table at the top, there is your m r. C diff near scale. I'm not gonna go through all of that with you, but it is worth knowing, and I seem to remember it coming up on exams that I've done in the past. Um so COPD similar to asthma in the It's an obstructive lung disease, but it doesn't have the reversibility that asthma has. So it's a it's a progressive degenerative condition. Um, almost all cases of COPD are linked to smoking or significant passive smoking for people that used to work in pubs where everyone was smoking all the time. Um, the clinical features that suggest a diagnosis of COPD they're going to be chronic breathlessness, productive cough, wheeze and people are presenting with recurrent chest infections. Once you've got these symptoms in someone who's a smoker or been a smoker, they need to be referred for spyrometry to try and confirm the diagnosis. So, um, once once you've done that and you actually have the f e V one value, um, you can work out the severity of the COPD according to the the second table there, so it just goes through. Obviously, everyone with COPD, which is an obstructive lung disease, has the reduced F E V one to V C ratio, which is less than 70% but then, depending on their actual F E V one value will give you the severity score ing of the COPD. Um, other investigations that you might want to consider in people with COPD are going to be things like sputum cultures during exacerbations To get an idea of what books They're growing in their chest. Um, to help guide kind of antibiotic management for future exacerbations things like chest X rays. So the chest X ray at the bottom there is the most common thing that you see in COPD, which is just hyperinflated lung fields. Um, we call it hyperinflated when you've got more than six anterior ribs or more than 10 posterior ribs visible above the level of the diaphragm on the chest X ray. So moving on to management stone in a step wise approach similar to, um, asthma, so same as asthma. Your first step is your Sabbath, which is your salbutamol, your blue inhaler, which is used as and when for symptoms. Your second step depends on whether they have any steroid responsive features. So if there are, then you use a combination of a lab er and an inhaled corticosteroid such as foster. If there aren't, then you can use a lab er and a llama such as your Ulta bro breeze healer. Um, the next stage after that is to combine whichever one you weren't already using, um, into that. So that's like your trim bow, and then the final stage. If you're getting into that, is really your kind of more specialist respiratory treatments. These are things like your or theophylline, which I've already mentioned has a very narrow therapeutic window. And then, um, Carba Sistine, which acts as a mucolytic to help kind of break up the mucous so that these patient's can cough it up. And then you getting towards things like home nebulizer machines if they need them home oxygen if it's required, and then long term prophylactic prophylactic antibiotics, Um, such as azithromycin. So like asthma. COPD. You get acute exacerbations um, the exacerbations that COPD patient's experience usually increase in frequency and severity with the length of time that they've had to COPD for. As I've already said, it's It's a progressive condition, um, the symptoms that they're going to present with our obviously fairly obvious. They get acute worsening of their breathlessness sputum production. Usually they'll say it's changed in color, so you know, I normally get white sputum and it's now dark green, and they get worsening wheeze. It's important to try and recognize how it's how the exacerbation is affecting them. So what's their normal exercise tolerance when they're well, um, what is it that they can do now? What is what are they being limited by? Um, in terms of investigating these patient's, you're going to want to do a chest X ray to look for signs of infection signs of pneumonia that might be triggering their exacerbation again. You want to going to want to do blood tests so again to look for your infection markers, and then it's important to do an A P G on pretty much everyone presenting to hospital with an acute exacerbation of the COPD. So if the if the result comes back as a low p o tomb with a normal P CO2, then that would show a type one respiratory failure if the result has a raised P CO2 above the normal level but a raised bicarb and a normal pH that suggests that this chronic type two respiratory failure, because they've had time to raise their bicarb to kind of counteract it, and it's resulted in a normal pH. Um, these are the patient's that are at risk of deterioration. If we give them too much, too much oxygen or uncontrolled oxygen therapy. So these are the patient's whose target oxygen saturations should be strictly 88 to 92%. Any oxygen that you're given to these patient's should be given via controlled oxygen therapy. So that's the Venturi masks that are just in the top right corner so that you know exactly what percentage of oxygen they're giving. They're getting Sorry. Um, finally, the last thing that the A B G might show is a raised PCO, too. But they've become acidotic with it that suggests that there type two respiratory failure is decompensated, so their body is not dealing with it. And that's when you're starting to think that they might need, um, an IV to help clear that CO2 out. I'm not gonna have time to go through M N I V today because it's a whole topic in itself, but it's worth reading up on. Yeah, um, so how do we manage patients' when they're having an acute exacerbation of COPD? So if you're in a G p surgery, um, then you would give prednisolone. So usually you give 30 mg slightly less than asthma for 5 to 7 days, and then antibiotics if there's evidence of infection. So purulent, sputum, fevers, that sort of thing. If they're ill enough to have presented to hospital, then you're similar to, um, asthma. You're going to be thinking about your nebulized bronchodilators again. Salbutamol and ipratropium. You can give them together. Um, be aware of the side effects so salbutamol can cause headaches, tremors, tachycardia with overuse, um, to just to be aware of, you're gonna want to give them steroids similar to last time. So I said, you can give oral prednisolone or if they're too unwell to manage that. You can give IV hydrocortisone as well again antibiotics if there's evidence of infection. And that will be based on, um, local trust guidelines, but also based on the patient's previous, um, sputum culture results, so that when that's when that becomes really useful to help guide their antibiotic management, if you're concerned about them not being able to expectorate sputum very well, or you think they might have a bit of mucus plugging, then you can ask the chest physio to come and see them to try and help with that. That might be causing them more hypoxia. And then, as I've already said. Worst case scenario, you think kind of starting? Um, an IV if they've got decompensated Type two respiratory failure. So moving on to pneumonia. So pneumonia is just a chest infection with evidence of focal consolidation on a chest X ray like the one in the corner. There's different classifications of pneumonia, which are fairly self explanatory. So community acquired pneumonia is those which are required in the community. Hospital. Acquired are those that develop more than 48 hours after admission to hospital so into a hospital. Stay an aspiration. Pneumonia happens after someone has inhaled foreign material. Usual food into the lungs again. Symptoms fairly straightforward. So they're going to complain of breathlessness, productive cough. They often have fevers, get pleuritic chest pain. They can get him, opt icis and then delirium. You know anyone with any kind of infection can end up with that, Um, then when you assess the patient, then you'll be able to pick up on their signs so they might be to Katnik. They might be taking cardiac. They might have a fever. They might have hypoxia and be requiring oxygen therapy. They can be confused, and in severe infections, they can end up with hypotension, and that's sort of heading towards your sepsis. Um, when you ask, will take their chest. You might have some bronchial breathing. They can have focal course crackles at the site of where the pneumonia is, and if you because their chest it'll be dull at the site of the pneumonia. So just looking at organisms that can cause pneumonia. These are the common organisms. So most common is strep pneumonia. Um, that causes 50% of all pneumonias. Closely followed by him awful is which is 20%. Um, the rest of them I'm not going to go through them all, but they make good, um, kind of SBA questions because they've got specific for each. Um, so your legionella is your infected water supplies. Then you've got your Coxiella, which is typically farmers and that sort of thing, and then your PCP at the bottom, which is usually related to patient's with HIV. They often have night sweats and a non productive cough. So it's worth just kind of going through all of those and working out which patient group they fit with because they make nice sp a questions so great in the severity of pneumonia. We look at a curb 65 score, so this, as the table says up there, this is your confusion. Uh, urea being higher than seven. A respiratory rate of 30 or higher, a BP so systolic less than 90 or diastolic less than 60. And then, if they're over the age of 65 they score. One point for each of those to the maximum score is five, and that kind of correlates to how the patient's managed managed and the antibiotics that they might receive. So trusts will have different policies on that, but it's usually related to their Curb 65 score when we're investigating someone with suspected pneumonia. Obviously important things to do a chest X ray to see the radiological evidence of it. Blood tests. So your full blood count is going to give you your white cell count and your CRP. Those are your your kind of inflammatory markers, and then your using these are going to give you your your ear so that you can calculate your curb 65 score. And then I've already mentioned the importance of trying to culture the sputum as well, and then management is varies according to area and trust policy, Um, and then obviously other things. If they need an oxygen, give them oxygen. If they're scoring for sepsis, then initiate the sepsis. Six. All of those kind of things. Yeah, moving on to pleural effusion So you can kind of differentiate between an infusion and consolidation, because in an infusion you've got blunting of the cost of phrenic angle on that side or both sides. If it's bilateral, um, larger effusion such as this one, you can see a meniscus so kind of a nice fluid line there where the fluid sitting, um, similarly, if it's a really large effusion, then the trickier and potentially the mediastinum might be pushed away from the side of the infusion as well. And you'll see that on a chest X ray. Um, as with all things respiratory patient's are likely to complain of breathlessness. This might be slightly different with the fusions because it's likely to be significantly worse when the patient lies flat. This is because, obviously, with gravity, the fluid's going to shift to kind of the back of the lung. It's gonna cover a much larger volume of the lung um so they're going to feel much worse when they're lying down. When you examine them and have a listen to their chest, they're gonna have reduced breath sounds, obviously, because nowhere is going to get shifted in that area. It's gonna be dull, uh, to percussion with the fluid in there as well. And as I've said, you might get that trickle deviation if it's a particularly large effusion, um, managing these patient's same things again. So if the oxygen levels alone, you're gonna give them oxygen. Um, And if they've got concurrent infection because you can get effusions along with pneumonias called parapneumonic effusions, then you're gonna want to manage their, um, manage their infection, obviously, with antibiotics and those sorts of things. Um, if the infusion is small, um, and not causing any any troublesome symptoms, then they can be managed conservatively. If the infusions large or they're getting significant symptoms or they've got really high oxygen requirement, then you can aspirate the pleural fluid. Um, and I've included the table up there. Um, that shows what your aspirate is going to show you. So you send it off for testing and based on the protein levels of your aspirate that you get will depend on your you know, the causes of the of the effusion. So I usually just think of x x u negative X as bad things. So it cancers your infections, and then your transit dates are your kind of heart failure. Low albumin, those kind of things. Um, when you aspirate the pleural fluid, it's obviously investigating. Um, and it's therapeutic. They will feel better, but the fluid can obviously re accumulate, depending on what's causing it. Um, so the kind of definitive management is going to be insertion of a chest rain to make sure all that fluid is gone. So pneumothorax. So this is basically where it shouldn't be. Um, so it's in the pleural space, so they're potential space between the lung and the chest wall. Um, there are a number of causes. They can be spontaneous so often in your exams. This will be a tall young man who's fit and well playing sports of some kind who gets sudden onset breathlessness and chest pain. That's the kind of spontaneous pneumothorax. Um, you can get iatrogenic new math or it ease, so you know when you're trying to do a lung biopsy or any kind of fiddling around in that area can cause that, obviously, trauma car accidents. Those kind of things can result in new math authorities. And then underlying lung conditions can put people increased risk. So things like fibrosis, COPD, all of those things and again they're going to present with breathlessness and chest pain. It's usually quite sudden onset and severe, depending on the size of the pneumothorax, they may have hypoxia as well. Um, and obviously, as you can see, that's a very big pneumothorax on not Chest X, right. But essentially, you've got no lung markings between the lung tissue and the chest wall. And if it's particularly large or it's a tension pneumothorax, then you can get tricky. Well, deviation and mediastinal shift away because it's going to push everything away from the side that the pneumothorax is, um, in terms of how we manage them. So, um, if so, when we measure the size of the pneumothorax, so we measure it kind of horizontally at the level of the hilum. So from the lung edge to the inside of the chest wall, we measure that distance. If it's less than two centimeters, and the patient's not breathless, then they don't necessarily need any immediate treatment. They usually get followed up within a couple of weeks, and they usually spontaneously resolve. If the patient is breathless or they're needing oxygen or it's larger than two centimeters in size there, then they need, um, aspirating, Um, if the patient is unstable with it or they have bilateral pneumonia. Thor it ease, for example, um, most commonly either in trauma or underlying lung disease. Or they've got a history of previous new moth authorities. Then they'll need a surgical trust train inserting to make sure that it's going to be properly drained just a quick bit on a tension pneumothorax. Um, so I've just put that photo up there just to remind you that it's, you know, usually young, tall, skinny males in your exams. So attention pneumothorax is specifically there is a one way valve created that basically means that air is getting into the pleural space, but it can't get back out. So every time that patient is taking a breath, air is going into that pneumothorax, and it cannot escape back out. So it's just getting bigger with every breath that they're taken and this can. This is more likely to cause the trick eel deviation and the mediastinal shift away from the side because it's a huge pneumothorax and it's fatal if it's if it's not recognized and treated. If it's an emergency situation, this so, um, the initial management, which is what you quote is you're going to insert a large bore cannula into the second intercostal space in the midclavicular line. Um, that's not definitive management. That's just kind of release the tension, um, and then moving forward. Then they're going to need a surgical chest rain to again to properly drain it. Um, I've put that photo at the bottom. That's your triangle of safety. Um, for when you're when chest trains are being inserted. Um, so that's between the fifth intercostal space, the anterior axillary line, and then the midaxillary line. That's your like triangle of safety. You want to go in just above that rib because you've got the neuro neuro vascular bundle that runs just below each rib, so you want to go just above to make sure that's not being damaged. Um, moving on to pee is pulmonary emboli, So a pa is a blood clot in the pulmonary arteries. It blocks the blood flow to the long tissue basically, and it can result in right sided heart stream. There are several factors risk factors for developing PS um, that are listed there. The only ones that are included in your well score are periods of immobility, recent surgery, previous PS and cancer on active treatment. Um, symptoms that people present with our breathlessness, pleuritic, chest pains or chest pain. That's worse on inspiration. They might have him opt Icis. Um, as well. That's another one of the things in your well score. Um, in terms of signs, they're commonly tachycardic. If it's a very large pa, they might be hypoxic, and their BP might be affected so they might end up with hypertension. It's worth noting that you can get a low grade fever as well with P s and then the next little bit. There is just how to interpret your well score. So if they're well, score is more than four. You don't need to do a d dimer on them. You can just straight request um, ct P A. If they're well, score is four or less then you would request a d dimer on this patient just a little bit on D dimer. So they're sensitive, but not very specific. It's all, um, they can be raised for a load of different reasons. So infection, malignancy, loads of things. Um, so they are good to rule out peace. So if they're negative, then you can pretty safely rule out a pa. But if it's positive, it doesn't necessarily mean that that patient has a pa. It can be raised for a number of different reasons. Um, so that's just worth bearing in mind. So as we've already spoken about investigating for a pa, So if you're either got a high well score or you've got a positive d dimer, um, then your first line is gonna be your CT p. A. Um, that's according to Nice. Um, the other option is something called a VQ scan. Um, this can be used in certain situations. Um, such as patient's that are allergic to ct contrast. Obviously, they can't have a CT then, in that case, because it uses contrast if they have severe renal impairment of people with severe AKI can't have, um, ct contrast, so that would be the option for them. And people like pregnant women who are more susceptible to the effects of radiation. Um, they would use a B to scam in that situation as well. Um, managing PS So again, if they are needing oxygen, give them oxygen. If they've got chest pain, give them pain, relief, all the usual things. And and then obviously the management of appearing is going to be anti coagulation. Um, first line would be a Duac. So things like, um apixaban rivaroxaban um they are the preferred therapies. If there's no contraindications because they don't need, um monitoring basically, um, patient's that are unable to take those would go on to warfarin, but it obviously needs to be, um, tightly monitored to make sure they stay within their therapeutic window. Um, and then people, so particularly pregnant women. The only anti coagulant that's licensed for use in pregnant women is tins apart. So if it's a pregnant woman, that would be what you would use for them. Um, the length of treatment depends on whether there is a cause for the pa. Um, so if there's an obvious reversible cause, then you would usually treat them for three months. If there is, you're not sure what the cause is or they've got an irreversible cause. So thrombophilia or that kind of thing that you're not going to be fixing, Um, then it's going to be longer than three months, and then if they've got active cancer that's triggered it, then it's usually six months duration in that scenario, just touching on kind of the more emergency side of P. So you can get massive peas or bilateral peas, and they're the ones that become often become hemodynamically unstable. So you've got high oxygen requirement. They're very tiki cards. Can they drop their BP as well in those situations, then you're going to be thinking, once you've confirmed your diagnosis, would this patient be suitable for thrombolysis? So as long as there's no Contra indications and the benefits outweigh the risks, then you can thrombolysis them. So that's using something like Alter place. Um, you would not be making that decision that would definitely be one of your seniors. Um, and these patient's have to go to a higher level care, So h d you afterwards to be monitored more closely after you from belies them because, obviously that there are high risk of bleeding. And then, um, the last topic is interstitial lung disease that I'm going to cover today. This in itself is a huge topic. So by no means is this all the information that you need to know, but I've tried to condense it. Um, so you've got different kind of, uh, conditions within interstitial lung disease. It's kind of a blanket term. Um, so you've got pulmonary fibrosis is kind of the first one, and then within your that you've got different causes. So it idiopathic pulmonary fibrosis, Um, clues in the name. And there's no specific cause for it. Patient's usually present with kind of progressive, chronic breathlessness. They often have a dry cough. Um, and these are one of the conditions that can cause finger clubbing. And when you listen to their chest, they get the find the very fine crackles usually start the bases, and then as the disease progresses, you can hear it throughout their chest. Um, that chest X ray there is is a chest X ray from someone with idiopathic pulmonary fibrosis. Um, it's a not a very nice condition. Um, as I say, it's progressive from diagnosis. There's an average life expectancy of somewhere between two and five years. Um, there's no cure for it. Unfortunately, there are some medications that I've listed there that can help to slow disease progression. But they're not curative. They are expensive treatments, and patient's have to fit into specific criteria to be to qualify for those treatments on the N. H s, um, patient's will often end up in the later stages on home oxygen therapy. Some patient's may get lung transplants Um, but there's only a very small window within the condition when this can be done, and it obviously depends on patient suitability and the availability of organisms. Organ organs Sorry, um, moving on then your other courses of fibrosis. So you've got drug induced fibrosis, so it's probably worth trying to remember the main drugs that can cause that because that again, that's something nice and easy that can come up in, um, in SBS, and then the last one is kind of secondary to other diseases. So rheumatoid arthritis and Lupus, those kind of things, and then moving on to hypersensitivity pneumonitis. This is basically a hypersensitivity reaction, um, to some sort of allergen in the environment. Um, the kind of gold standard diagnosis for this is your bronchoalveolar lavage. And then when you test it, you'll get raised lymphocytes and mast cells in there that are released in response to the to the allergen in the lungs. So these are things like your bird fancy as long farmers lung mushroom work as long. All of those kind of things again, there's no specific treatment steroids help to reduce any inflammation. And then the main thing is, um, avoiding the allergen, basically which often people who keep pigeons and things aren't very keen to do, then your next one is, uh, your cryptogenic organizing pneumonias to So this is much less common. I don't think I've ever seen this. Um, it can be idiopathic or it can be triggered by those things listed there. So pretty much anything. Radiation, toxins, infection. Um, the gold standard diagnosis for this is among biopsy. Um, and again, management is just with steroids to try and reduce the inflammation. The last bit on there is, um, asbestosis. So obviously this is patient's who have a known exposure to asbestos or who have worked in high risk environments So shipyard workers, that sort of thing. Um, they get kind of the fibrosis effect, and they also get the oncogenic effect. So this is hinting at your, um, mesothelioma. I'm not covering lung cancer. And you know, part of that is mesothelioma because I think there's a separate oncology session, so I haven't gone into that. Um, but along those lines, you get kind of the the effect of the exposure usually delayed by several decades. Um, and it's kind of a dying, dying out thing because obviously we don't use asbestos anymore, So it's kind of in the very older generations and actually in probably 10, 20 years, we probably won't see it all. Hopefully. So just moving on to some quick questions just to stop you there. Hannah. There's been a few questions in the chat. I've answered a few, but I don't know if you want to add anything almost about when would you increase the dose of a steroid inhaler? And is the chest drain used to the management of spontaneous first tension you with Rx the same and another one on ground glass? What causes ground glass changes on the chest X ray? Let's have a look so mhm I was just about to answer the ground glass appearance ones. Basically, the fibrotic tissue damage within the lungs from the disease is just the classic appearance test X ray. But it's just the damaged and the heart and lungs. Basically, yeah, pretty much. And it's often commented on on CT scans as well. They get that kind of ground glass changes. And, yeah, like you said, um, the steroid inhaler. I don't know if that's related to asthma or COPD, but that's kind of included in your set for of your if you kind of BTS guidelines. So once you've got to, you're adding in your lab. Er so you've got your, uh, Sabir, you've got your inhaled corticosteroid, and then you've got your labs as well. Then the next step after that, you can either add in your fourth agents. That's when we were talking about the leukotriene receptor agonists and that sort of thing. Or you can try increasing the steroid inhaler. Then, um, what are the other questions? Chest trains. So yeah, so chest trains are the same. So you've got two different types of chest trains. You've got a seldinger um, and a surgical chest drain. Um, let me just that questions disappeared, but yeah, it's gonna be that is the same same chest drain, Basically, for both. Um, I think that's everything. Cool. Shall we move on to, um, the S B A s, then? So I'm not going to read them out to you. I'm just going to put them up, give you some time to answer them, and then we'll kind of go through them at the end or one at a time. I'll give you another five seconds. So it looks like Let's have a look at people's answers. So it's kind of split. Most people seem to have put lung cancer and then everyone else kind of similar, um, for the pulmonary fibrosis. So, um, the answer to this one was pulmonary fibrosis. So, um, what I was hinting at here is this kind of progressive breathlessness. He doesn't have a significant smoking history that's been mentioned. Um, he has lost a little bit of weight, which is very common in people that have fibrosis. Their reserves just get less and less and less, and they lose a lot of weight. Um, the thing about traveling to Australia was just a red herring. But the big giveaway is the examination findings. So those fine crackles by baselli point to your diagnosis of, um, fibrosis there. Um, fine. We'll go on to the next one, so I'll give you a little bit of time to read that and answer. Yeah, yeah. Mhm. Mhm. Okay, I think most people have answered that one now, Um, So most people have gone for, um, chest X ray, which is the right answer. So this lady is a smoker with hemoptysis iss. Um, any smoker with a mop desist particularly given her slightly advanced age, has earned themselves a two week wait. Referral for an urgent chest x ray, um, to investigate for potential lung cancer. Um, fine. Um, what else did you go answer to that one. Okay, we will move them maybe a few minutes or so to answer this. It's definitely another thing. Okay. Mhm. Mhm. Uh, remember? Yeah. You can get just okay. Can you go? Come in. Mhm. Cool. Last few seconds. Uh, fine. Um, So most people have gone for, um, where am I, um, gone for COPD, which is the right answer. Um so her. If you calculate her f e v 12 f fvc ratio for Sheila, it comes at less than 70% which suggests some sort of obstructive lung disease. Um, so that's what I was getting out with that question. Um, and her symptoms fit with that as well. Um, so she's worsening breathlessness. She's got this chronic cough, and she's got quite significant smoking history. Um, so that one was, uh, COPD. I'll move on. This one is Sheila as well, but it's a bit shorter. Um, so I'll give you a minute or so to answer it. Mhm cool. Last few seconds. So, um, most people have gone from moderate, which is right. Um, it just depends whether or not people were new, that table that showed earlier. So once you've got their f e v one V c score, then that just gives you the diagnosis of COPD or confirms the diagnosis of CAPD. But then, when you're working out her severity, that's based only on her f. U V one score. So her, uh, f e V one works out to be 65% of predicted, so that puts her into the moderate category. So moderate falls between 50 and 80%. So that's where she sits. So that was good. Well done for knowing that. And then, um, last question is a bit longer, so I'll give you a minute or so to answer. Cool. A few more seconds. Fine. I think most people have answered. So, um, most people seem to have put legionella for this one, which is the right answer. A few people have gone for the the other ones. So, um, as I was talking about earlier, um, with your organisms, this is how I was saying that it fits really nicely into SBS because they have very specific set of things related to each one. So this one was getting at legionella. So it's commonly kind of younger people who've been on holiday caused by kind of dodgy air conditioning vents, dodgy water supplies, that sort of thing. Um, And then, um, the thing that you get with legionella is it causes SIADH, so they get low sodium. So that's why I've put his sodium results there. Um, so yeah, that says, um, that's his most most likely organism for him. I think that was the last one. Yeah. So that was the last question, Um, that I've just put the next session up there that's been organized, which is the oncology session on the 20th of February. I think, um, there is a QR code there for you to scan, um, to, uh, to get, um to give feedback on the session. Um And then if you, um, submit feedback for the session, then you'll get a certificate of attendance for the session that you can then use for portfolios and stuff like that. Uh, thanks, Hannah. That was great. If everyone can fill in their feedback form either by scanning the QR code or I'll put a link in the chat now, just help with planning future sessions and for Hannah's feedback for a portfolio. And you all get a certificate of attendance as well, if you if you feel in the feedback, which also looks great on your portfolio's as well for the future. And just I think there's one question in the group chat. Hannah, there was something. Does I bs mean inflammatory bowel disease. So I B s is usually irritable bowel syndrome might IBD for inflammatory bowel disease, then one on bronchiectasis and bronculitis. So, uh, so Moraxella Moraxella I never actually what you say it is common in people immunocompromised patient's and patient's with COPD. Um, I think that's what she's getting up there. Yeah, bronculitis. I guess it's more common in pediatrics. And bronchiectases is also kind of the part of the COPD package, I guess. Yeah, you're young kids, so I'm just asking to go over the last question again. Sorry. Yeah. Yeah, last right. And I just answered that back. So, um yeah. So this is your what I was talking about with the specific organisms relating to specific people. So it's commonly, um, the answer to this one was legionella. So e, um, so this is a young patient who's traveled abroad, um, to a hotel abroad. They're the kind of patient's that you usually get given in the S p. A s for, um, if the answer is going to be legionella. So it's dodgy. Air conditioning vents, dodgy water supplies. Um, that's where kind of legionella is colonized. And that's why people pick it up from, um And then I was mentioning that the kind of specific thing relating to Legionella is an organism is that it can cause SIADH, and then they get the low sodium. So if they give you their blood tests, it's a young person. They've traveled abroad and they've got a low sodium in the blood test that should all kind of point towards, um, Legionella. The other things that I put in there were just things to try and try and kind of. Well, they were just red herrings, really? So it's. That's why I put in the thing about rhonchi light as it isn't actually relevant to the diagnosis at all. And then the eye bs think I think that's already answered is irritable bowel syndrome. Cool. I think that's all the questions. Um, yeah, great. Hannah, Thank thanks for joining everybody. That was really good. Session cool.