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And right uh we're live now, Hello can everyone hear me can you actually say whether they can hear me, yeah, we can see in here, you know okay um and just one question can, they answer questions if they want to yeah in the chat, okay, cool all right hello, everyone thank you for joining me whoever is joining me on this friday afternoon and giving up your spare time on friday. My name is yvonne, I'm kind enough to our uh West Middlesex last year, I wasn't trying Cross, I was an imperial so very familiar with whatever you're going through um. And I'm here to speak about respiratory. I want to make this as interactive as possible of a zoom um And I want to make this short, sweet and clear okay. I won't teach you everything, but hopefully it's going to be a nice refresh in and remind you of a few acute things that you need to know for respiratory, So, in terms of pace, is I'm not gonna focus too much, but it's it's an exam that has a limited scope. Um There's three types of sounds that people can have um a few scars, so focus on them, learn their indications, management complications of those, and you'll probably be fine okay, so that's in terms of like places, but I won't focus too much on that following that. Yeah, I just already kind of set this. The two categories I'm going to go about is infections and acute shortness of breath for all of these are very very like common you all encounter them in both your exams and next year, so here we can start um we I have questions. I don't know if you guys are brave enough to answer uh on the chat, but we'll go through them in a bit so first you can take a piece of paper write them down and then we'll discuss them. I'll give you guys 45 seconds, mhm, ok going on to the next one. Okay uh continue that's okay. I know some of you are giving answers. Um I think it's better to like point them down and say them, um but I'll also come and give you the answers. At the end, okay well, thank you for participating. Please engage with me it's quite odd to feel to speak in the screen. I'm not sure if any of you have done it 10 more seconds all right moving on okay, so first we're going to be talking about cap it is a but yeah first we're gonna be talking about cap community acquired pneumonia. Here. We have two examples lobar is when the pneumonia the inflammation consolidation any kind of like water you want to kind of use is in, locate in one of the lobes. You also have bronchopneumonia, where it's more patchy rather than everywhere rather than lobar. For example, Covid is more of a bronchopneumonia rather than labor, and I think Covid is also more peripheral but pneumonias. Ultimately is when you have a consolidation on a chest radiograph, It's not when you have a chest infection per se and that's a sign of lobar pneumonia bit closer up okay. So in terms of pathogens, the most common lobar pneumonia is strep pneumonia, is the most common in um community and then you have different organisms for bronchopneumonia. I won't focus too much on the list because it's quite boring and you probably have done it on path, but it is here for you to have a look if you're interested later now. I want some participation okay. If you keywords that are always coming up of that emissary. Recently it was in finals it was in path you would be handed by this for life. Um So russ disputes in what's what pathogen is it yes, okay because it's pdf. I can't really show the answers, so I'm just gonna leave it like that um post influenza, but you're correct the step pneumonia for anyone who's not seeing the codes yes, staff oils, excellent alcoholics early either hemoptysis, ease or read current jealous sputum collapse, ciel excellent, and then this is more of a less commonly known when we have hughes, a bacteria, and pepticol doctors. What kind of pneumonia is caused by that. What kind of presentation is usually, it's aspiration pneumonia basically just to it's not something I'm sure you need to know, but I think it's useful to know. These are all pathogens that I found in the mouth in the saliva, so basically if you're aspirating, they're the most likely to cause um aspiration pneumonia. What's the organism that's more common COPD and bronchiectases yes, haemophilus influenza and then uh one of our typical ones uh a typical is dry cough, a thermal multiform um which is basically like just kind of like red rashes like circular, circular um it's hyponatremia, but but don't be yes. Micro plasma is correct, uh an autoimmune hemolytic anemia, then which conditions are associated with Pneumocystis geo virgie otherwise known as PCP Yeah, so it is hiv, but it's also immuno, suppressed. Um So if you have any other kind of immunosuppressive condition can also cause that and then we have our typical again, but associated with air conditioning, water, hypernatremia in life opinion, regional excellent and last are common um Question about birds. Yeah It's pataki yeah Chlamydia pataki. I can't pronounce it properly, I blame it on my accent. It's all right, we'll move on okay um moving on um curb 65. Um It's useful to know it's confusion usually, am am t. S. Based yuri above seven, respiratory rate about 30 BP below 90 or diastolic 60 and h so I'm going through a bit of fast, assume that you don't want to go too much too telling it. Investigation. Wise you always need to start with the basics. So at bedside, you're gonna do your examinations. If they're presenting with chest pain, probably gonna do any ct as well, just exclude other stuff. Then you go for your blood's you're looking for your inflammatory markers and then you also take your cultures in terms of cultures, your culture, anything that you can you're trying to find the source of infection, so you go blood, saliva, sputum, and urine okay. You um do you urine antigens, legionella and your cocoa and that's you also do your chest x ray okay, so basically accepted screen that you're gonna find a lot in f, one you need to find the source of infection okay. This involves obviously your examination your bloods and then is it a blood infection, is it just infection, a urine infection um or chest infection and if you still can't find what's going on you go for your typical and that's when you do urinate antidotes uh. Um In terms of antibiotics, I had a question in that in my antibiotics always depends on trust guidelines, but for your typical community acquired pneumonia, you usually are going to start with amoxicillin and if they are, if they are penicillin allergic, you're gonna do clarithromycin, instead, if it's moderate severity, you're gonna go with amoxicillin and clarithromycin and if it's severe depending on your credit score, you're gonna go with jeff, jackson plus clarithromycin, okay, These are trust line dependent um actually have something nice. I can send you guys give me a moment uh because you can't see the notes of my slides, will coat pace that for reference the guidelines, I'm gonna send through our in, pierre guidelines so um nhs mpl, so it depends as I said trust dependent, but they're pretty um listen, I like him to you always doing yeah, I'll send it to you afterwards okay. So in terms of hospital acquired pneumonia, it's a pneumonia that kind of starts after 48 hours of being hospital. Also, if someone lives in a care home or hospice or anything of that sort where you have a lot of fail. Patient's basically um It's also called Canasa Hospital acquired what's different is you need to do different antibiotics. In imperial it used to be if it's oral or mild, you give doxycycline and if it's severe, you give co-trimoxazole again that's um trust dependent, but I think it's good to have an idea of what kind of antibiotics they might have to do depending on severity, okay so bronchiectases, what is bronchiectases um broncos, is basically your airways ecstasies. Ecstasies basically means that enlargement um in greek, so it's a dilation of your bronch. I, this can be due to many reasons but basically because you're like alveola. You lose elasticity and it can be caused by do too many things. Barrick, are infections or severe infections can result in that um your presentation is usually recurrent pneumonias. You have a lot of sputum production and high pitched inspiratory squeaks clapping as well, which is different from your copd in terms of causes, um It can be due empathic, okay, who don't really know why can be post infectious, so if someone has a very serious like child infection, when they're really young, they can develop on practices um. And then immunocompromised people. Also we have more genetic rare stuff statistic fibrosis is really associated primary cellular disease, connective tissue disorders, and all of us if you think about it connective tissue disorders, you lose your elasticity. Therefore, you're more likely to have this permanent dialectic bronchitis okay. Um You can have bronchiectasis with copd okay um but at the, as at the end of it, breaking a copd alone would not cause clubbing okay. In terms of investigations, sputum is really important, so your sputum cultures uh the only thing that you can definitely diagnose it is a high resolution city um and then you can have your spirometry, so, parliament function tests, as well as testing for are weird and wonderful causes. Most of the time you have a sort of direction of where your investigation need to go, depending on the clinical presentation management wise, so basically if it's an acute exacerbation, give antibiotics sure story of it okay. If they have persistent or resistant organism is, um you might think that you have pseudomonas, so you give, Iv, so you probably there you give you like take a planning or less elite, however, at that point, you asking micro advice okay into the chronic management. Uh It's also like this is quite relevant for paces as well because bronchiectases can come up. People are quite stable, so they're really good patient's to come up in paces. Um So lifestyle wise chest physiotherapy is kind of good to know what it is. Um apart from like it's basically trying to get the mucus out of it. You can also have things to like help you you know basically strengthen your lungs and it's usually a thing that it has like a few like is it kind of a tube and has three balls and you have to like basically blow through it and try to get the balls moving upwards and you have to do it every couple of hours. It's something that just to visit therapists sometimes do with people who have different kind of respiratory conditions and that's to like basically exercise the lungs you can have bronchodilators. Obviously, it's like salbutamol one, the same newco active agent because bronchiectasis has a lot of mucus and that can clog up and kind of feel uncomfortable. Um You can have basically hypertonic saline, uh which is 3% sodium chloride basically, and it's like so beautiful nebulizers, the nebulizer you put it through your mouth and it basically produces humidifies your lungs okay and makes you cough it up okay. There's um knock and as a system which also used or like brum, brum hexedine and urge justine, which are new biologic agents that usually seen with either bronchiectases, sometimes with copd patient's, uh and there is the option of surgical, however, it's most likely only if it's localized on one aspect of the lung otherwise, um there's no real point having a lot of people who had lobectomies for bronchiectases, but it's something to be aware um In a pace case you would go with conservative, medical and surgical management and explain those okay, So going back to our questions, uh so a few of your answers and it is lobar pneumonia. Uh We have a productive course is rusty color, so we're thinking more strep pneumonia almost common thing, reduced air entry is a sign it doesn't have to be car cause per se and then we have raised inflammatory markets and a chest x ray, which shows um our consultation which is in a lobar distribution. Any questions about this one okay. Moving on our second question, this was a bit tricky because you need to be aware of guidelines, but there's also a few hints okay you have someone who has a very high kept 65. If I remember correctly, is roughly four out of five, yes because the age, the confusion I didn't do a, didn't give you an m. T. S. High respiratory rate high area, so it has a score of four or five on Cape 65 so we're talking about severe infection, okay, so if we're talking about severe infection strategically saying it's probably not going to be oral antibiotics so go to the ivies, there's no suggestion that this is a weird and wonderful kind of um infection. They're presenting to any so, it's more likely to be community acquired community acquired is gonna be careful rather than uh co-trimoxazole, but that's a way of like going through the question any questions for this all right and yes uh in terms of kept jackson um you can, I know there is um there is some kind of similarity between penicillins and follow sports. No there is uh well you have to probably give it under a lot of supervision, okay, but there is often that people who are penicillin allergic. They have a rash you follow sports are different enough to give um with kind of safety, you do it on a regular basis, or someone yesterday I was seeing a cellulitis and we couldn't give flublok sicilian you know cellulitis most commonly stuff areas, so you're gonna check with flu clocks. Uh You couldn't get cloxacillin. They had a rash when they had you know penicillins. We give them distraction, they're fine um So you can you need to monitor them and you need to know what kind of reaction they had. If they have Andre, Dhiman okay proper anaphylaxis, then maybe maybe you do concerned about it, but typically you can yes. So very few people Very few people actually have cross reactivity and cross reactivity, counts if they're actually anaphylactic. Um Most people who say they have penicillin allergy, It's not very true but yeah. It's the same question in past meant interesting, fair enough passman is copying me obviously um but yes um it's it's possible to give kept Jackson's follow sports are slightly different. It's tricky but nothing in medicine in black and white and then following on with the next question. Um High resolution CT is probably the most likely way of establishing bronchiectases. You can see that or these. I don't know if you can see my miles, probably can't see my mouth, but the black holes on the left side of the lung uh and large and there's a white kind of like, surrounding, dies pretty much pathognomonic of uh bronchitis, okay moving to breathlessness. Everyone happy am I going too slow too fast or okay All right, thank you, thank you very much, hopefully, but I feel free to criticize me. I am not often this any answers for this, one good that's correct, but we'll go into it what this is a bit of a difficult one okay, but what is this what is wrong with this. E. C g. Not really um it doesn't actually have from my understanding, okay apart from s one q 3 83 um Sinus tiki is one of them T wave inversion is okay um yeah very good, so it's just to be mindful s one q three t three we like it. In questions definitely know about it, you'll be like it would be a waste not to know it about it, but commonly it doesn't pes, don't really present with s one q three t three unless someone is really like unwell. They often present with sinus tiki or tea working version, and we'll go into why so we are talking about peace. As you correctly established. Presentation wise is usually pleuritic chest pain, pleuritic, meaning when you're breathing in difficulty to breathe, breathing fast and you can have hemodynamic compromise but not always present. Okay signs of DVT always present Sometimes presents are always um and signs of DVT means basically a red, swollen, cough, okay, painful, tender um Investigations Wise you have your d dimer is, but as we know, d dimer are not very specific so if it's negative, you definitely don't have a p, but a positive result can be because of infection, cancer, inflammation In general, um so not a very specific test. Ct pa is a gold stander. Echo is there to show us a right ventricular strain, does anyone know why you would have a right ventricular strain in a p. Yeah, um exactly so because if you have a clot basically in your like lungs and you're like pulmonary. You know vascular chair of your lungs. It means that nothing can go through is like more pressure and therefore your heart has more like you know resistance to pump across, Therefore it causes right ventricular strain. Your chest x ray is mostly to exclude anything else there are some weird wonderful like things they're not gonna come up in your exams. Um a vq scan is a ventilation profusion scan um um with pe, is what happens is you have a clot in your blood supply. It means that your perfusion which is basically your blood supply is reduced. Your lungs can still have oxygen, but because there's no blood through a section of your lungs, it means that the blood is not oxygenated okay, that's why there is a mismatch between the ventilation which is fine and the perfusion which is not fine because you have a clot and yes, I'll get onto the e. C. G. Next, so e. C. G. We've already discussed it. I am following with this next slide. Um So you have a right ventricular strain pattern is t wave inversions in v one and before, and some of the inferior leads um and right axis deviation as well as um one of your colleagues has pointed so that's how right particular strain presents. This is another like um you can have also st depression, uh but usually it's in the precordial leads as we said, we want to be three and then fear leads. Um um Sometimes any questions about that as I said no about us one, q three, t three, but also be aware that it's not the only way it presents and that's commonly in really really bad situations okay moving on. Um We have a few kind of scores and people love scoring things because I think it gives them some safety um There's another score that I have don't have mentioned here, but we use in clinical practice and it's Perk score has anyone heard of Perks score, I hadn't heard of it, but Perk score is excellent very much you're doing better than I was. Um Perks score wise um is usually for people who are younger and it's to rule out a p. Really useful in your e. D. S. Like placements um I don't know if it comes up in finals per se, but really good to use in your like e. D. Placements medical, legally kind of safe, but commonly, we're gonna use well score that's definitely gonna show up in your exams in some way or other, um And we have our two levels well score, I'm not gonna go through in too much detail because I think it's rather pointless, but in terms of your pe, you have if you have to score about four, you basically will go with ct p. A. If it's a score less than four you go with and you suspected you go with the edema and then ctp okay, that's basically the gist of it. Um interesting question because I I personally did this the written exams close Altenburg, um I would say have a rough idea like spend two or three minutes on it, um but I wouldn't learn it off by hand. I think if they do ask you for it, it's pointless knowledge no one remembers it off the top of the head, so I don't assume that they will ask, but have a rough kind of like understand, I don't think they will score you. Uh They might ask you whether is a ct pa indicated or not. So know roughly, yeah not a very specific answer I'm sorry, but in terms of management okay, so if someone has confirmed or even suspected, t. E, you treat okay, we like to say that we're gonna do a ct pa first, but it doesn't always happen in your practice, so if you can get a ct p. A. U. Treat okay very few, unless they have a bleed in the head, which is getting a bit of a tricky territory, you would um treat them with anticoagulants. Typically is apixaban, rivaroxaban, and oxygen. Um I pick somebody and the doxepin, I think it's twice a day, River oxygen is once a day. Um They have different, slightly different users depending on renal function. I would have learned too much about them. Usually. If you have a, you know provoke divinity, so you know all of your like risk factors for your like peace and DVTS, I'm not going to go through them, but if you have like someone oh you know, they are on the all conceptive peel. They wanted a long flight and hadn't surgery for some sort um. And they got you know a p, they don't need to be for more than three months on anticoagulants, but if you don't know why someone has a p, or if it's because of cancer, we'll just basically a state that won't change anytime fast uh You give them for six months, at least okay uh for pregnancy. You're gonna give low molecular weight heparin by that, I mean enoxaparin injections, um Because we know that enoxaparin is safe in pregnancy um renal failure. If they have a low e. G. F. Of less than 15, then you're probably gonna go with either low molecular weight heparin or unfractionated heparin's and sore this is in terms of like being hemodynamically stable, okay, that means that they're not you know the BP is fine. They're not unwell, okay. If they are unstable, so they're like heart rate's 130. Their BP is dropping by the minute. Um Then you have an unstable person okay, so you give them high flow auction. You give them flu presentation you're trying to like basically fooling bowlers you're trying to maintain the BP and you might consider Basso active agent suppressors. Those are your like basically alpha one agonists, which basically constrict um your vessels, your artists, and then increase the BP. You wouldn't do this as a foundation level. You probably get I t you to do this, but you need to be aware of it. Um exams In terms of anticoagulants, you will give your infusions uh of heparin. I don't think you need to know the numbers of it, but you need to know that you give an infusion. Second lies, you're like clot busters, so at the place, step to kindness and so on but first line is I have prayed, infusion okay and then after the stable, you go and switch them to your dogs as we discussed before, um which are usually or apixaban, rivaroxaban, and so on, as I said low molecular weight heparin, you usually mean an ox, a pair in and in terms of v. K, is vitamin k antagonist, is your warfarin, not the choice, they're not the typical choice for like p prevention, but it's more like for example when someone had a human rogic stroke, okay, um which basically means you know bleeding in the brain um and you need to have more of a type regulation of between your you know clotting and your uh dissolving the clot um Then you probably will go for warfarin. Otherwise, it's too much of a fast with having to do your eye on ours and so on okay um So it is the oxygen uh anyone want to know anyone do you have any questions as to why is your oxygen, so they're pretty stable. They're not human, dynamically unstable, okay, so you don't need an infusion. Uh We have a reason why it's causing it, so we're gonna go with dogs were not gonna wait for the ct p. A. Because they could die in the meantime. Um If I'm very frankly honest and you don't really have an occupying 40 mg is prevention, does not treatment does um and you would probably go with dogs over low molecular weight heparin unless you had a reason for it. Next, question it is a bit of a cheeky one this one. I remember when I first wrote the question, I said the man and you can see that on the chest x ray, it's not a man, so I got up to the two women any more takers, no understanding is not shifted. Um In this case, it is actually be, but well let's go through it because I think there is quite a bit about to talk about uh So obviously this know obviously this is a pneumothorax okay um and in terms of uh presentation, again, shortness of breath is quite common one um chest pain against pleuritic, usually, one sided reduced breath sounds because if you have a rash like if you have basically a space where there's no long, there's no air coming in. Therefore, it's gonna be reduced and then for a similar reason, it's gonna be hyper resonant because um sound travels faster tension pneumothorax. Um It's you're probably gonna be hemodynamically unstable always. Um you're gonna have you know higher tachypnea, tacky cardiac you're gonna have reduced situations. It's gonna be you're not gonna saturate 98% if you're gonna have tension human works, and it's trickle deviation, I mean shaky is never 100% straight because I as I get the point of like is this a shifted media standard, um but it needs to be significantly more than that, so we have primary and secondary is different types of definition, primary basically means there's no reason for it, It just happens usually marfanoid types of people tall, thin, skinny, um and then secondary is basically you have some kind of like lung condition uh that makes your lungs most sensitive and can cause any more thorax and our number one investigation chest x ray, but you could do bloods just basically exclude other causes of like you know pleuritic chest pain and uh so on, but ultimately if you just accept that will define um your your chances your your diagnosis. So if you diagrams uh primary it depends, if you have copd, secondary, but if it's you just smoking like if you're like it's quite common like 25 or 20 year old, you know guys usually um stereotyping much, but that's medicine, um who if you're smokers, the lungs are not damaged as of now, but they in the tall and skinny that usually can cause it, but that's primary, it's just a risk factor for it. Secondary. Is well, If you smoke for years and you have copd, or you have lung cancer or anything else like that then it's secondary. So in terms of different types of pneumothorax, I think maybe, I'm patronizing you maybe, I'm not, but I think at this diagram is quite nice. I stole it from hiking, the smith, uh colleague of Mine is about year, but what happens is when you have a pneumothorax. You have a whole okay, so it can be either on the outside bit, it means that air is coming into the pleural space is and that's what's causing the new orthorexia or you can have a whole insight. Your like lungs themselves and then again is leaking from your lungs to the pleural space okay and your primary is a secondaries. Uh You know and two more tickets spontaneous. All of these pneumothorax usually uh two way valves okay, which mean as you breathe in airs, goes into the space as you breathe out. Air also can come from the pleural space out into the lungs, um sorry danielle also smoking is considered primary unless they have copd, if they have copd, if you like smoking has caused lung damage, then it's considered secondary. Okay. Uh Following that in terms of tension pneumothorax we hear is always a one way valve, one way valve, but what does it actually mean again. I'm not sure if I'm patronizing you, but I think it was, it was useful to know basically what we have is teligent seem orthotics, you have a way of going out of the lung so, from the lungs into the pleural space, but there's no way that the air can then come back into the lungs, so what happens is you breathe in air goes into the pleural space. Pneumothorax grows without the air stays in your pleural space. You take another breath more air goes into the pool space, which basically means that you accumulate air in your pleural space and there's no way for you to go out, so then it builds this tension. Obviously, because you have pressure in a close cavity, then that pushes everything else on the way does that make sense. What do you mean by one way valve fingers crossed any questions okay following that management wise, it depends again whether someone is hemodynamically stable and what kind of pneumothorax they have. If they're not hemodynamically stable, you basically do a minute emergency needle decompression and then you do it just uh drain. If they are stable, then it depends on the size of the pneumothorax. If it's primary, secondary, and so on, I will not go through the diagram because I feel like you can read it in your spare time, um but it's a useful diagram from BMJ to know okay all right in terms of traumatic and nontraumatic traumatic, basically, you go for open thoracostomy is done by cardio thoracic, it's an emergency and then you do just train. If it's non traumatic, then you need an immediate decompression um and that's a large bore cannula. It used to be the second intercourse space, midclavicular line, uh but now it's mostly prefer to do it in the safe triangle, so basically 4th 5th intercourse space in the middle of the red line okay and high flow auction just to maintain basically the reason you're putting high flow oxygen is to maintain your airways as open as possible, so olivia about chest drains. I'm not going to pretend, I'm an expert, but I definitely have done your exams and they did in the images uh instruments Kind of station should have a chest pain to me and they were like what is this. I was smart enough to know what a chest train was, but they were like okay, what is what does it mean when it's sing, swinging, and bubbling, so then I was a little bit intimidated, okay, so what happens is the chest drain you um put some water okay. The water creates a positive pressure usually, I think it's plus 2 kg pascal's, I'm not gonna go into the physics of it too much. If you remember your lungs in the pleural space, has a negative pressure is usually minus five. It's minus eight when you take a deep breath in, because basically you die from goes down, you expand your lungs and therefore the negative pressure is greater, so the air can come from the environment, which has, I think in like zero killer pascal's or one clip ask, I'm not sure my physics and it comes into your lungs, so what happens is you uh put a bit of water creates a bit of positive pressure okay and then you put it on the floor okay, so anything that's below the gravity below that the actual chest just so that the gravity is um allowing for air from the negative pressure to go to the positive pressure okay, so when it's bubbling, it means that air is coming out from the chest into the jane, okay When it's swinging, it just means that is when you take a deep breath I/O the pressure changes, so that kind of causes the swinging okay, but it doesn't actually mean that air is coming out of the thorax anymore uh into the drain, so you need to always be swinging basically because you're always taking breathing. If it's not swinging in my means that it's clotted, blocked in some kind of way and that's uh when you know that your jane is not really working, I have a nice link about chest physio, uh physio, didio, that says about chest trains, but you can further look at it if you want to okay. Uh In terms of this church, um you safety let them if they're short of breath, they can need to come back, they cannot dive anymore so unfortunately, for those for divers, um you're not allowed to travel for one week because they're flying. You know basically going high up, increases pressures in the lungs and then you need to stop smoking in terms of surgical management that exists about pneumothorax. Um It's not very common but it's also usually there's something kind of persistent and recurring new orthotics, so you kind of think about it, you have to record to me or bats that's usually done by your cardiothoracic surgeons uh and if you cannot do surgical management usually, people who are elderly frail, they might have new orthodox because they have cancer and it might be like multilobular waited and whatnot you do chemical pleurodesis is what is this is basically it's either used with tuck or they can do plasma as well um and that irritates the lining of the plural and that basically sticks the two you know the visceral and the thoracic close sticks them together. You know to avoid basically having this air space in between them. Um answering the question in the chat yes, it has to bubble until the pneumothorax resolves very well and sit there. Um Yeah, so our question here, I don't know if you can see they, I don't know if you can can you see my mouse, probably not in the top right, okay in the top right corner of the chest x ray. Um If you zoom in a bit to see it, um you can see that there's no landmarking is going to the edge and you can see around the three third rep, k cage that there's a line going down that's your pneumothorax, they're um it looks like it's more than two centimeters but I guess it's a little bit hard to not for sure, but we also know that the patient is breathless, okay, so if you look at your like diagram breathlessness um in primary uh and more than two centimeters would um basically elite onto an aspiration using a large bore cannula okay. Uh Aspiration using a large bore cannula is not the same as the compression decompression is um using basically it's an immediate thing when they have tension in orthotics okay. Yeah In terms of um orthodox, you probably have to repeat your a chest x ray after six weeks to also see if it's resolved okay, okay. Our last question for the day hanging with with me, I'm going to probably be downing 15 minutes if you can handle that much with me, uh I'll cut back to the uh to your question in libit, but in terms of this, um it is b and I'll go onto why is that in terms they were talking about plural effusions, um what is it, it's a fluid collection in the plural area basically uh it's usually as always short of breath truly chest pain, cough. In terms of examination, stony dullness, reduce breath sounds, and you can hear like reduce vocal parameters because sound doesn't travel very well in fluid and then chest x ray is probably the most likely investigation. You can also do approval ultrasound. There are some words that have um basically an ultrasound um and you can have a look uh I don't have any images at this point, but basically you see a lot of like um black, basically stuff there because of the fluid. Uh In terms of pre hospira ation, it's you set a needle you basically use the ultrasound you set a needle into the pleural effusion area uh and then you send different tests and that's identify what kind of pleural effusion it is and in terms of separating them is Lights criteria um I was a little bit mean and asked you some like in the previous question expected, expected you to be able to kind of roughly calculate using Lights criteria, so yeah what you compare is between your pleural fluid what you aspirate okay and then your serum okay serum is basically a blood test okay to simplify things, so you have your pleural fluid protein to serum protein, so it means like your aspiration to your like blood column thing and if the pleural fluid protein is more than 0.5 and also your lactate dehydrogenase more than 0.6. Um It's part of the criteria as well as the pleural fluid like the d. Hydrogen is being greater than two thirds of the normal. Two of the three okay um Yes, So it was exciting even the previous question okay but two of the three are fine to qualify for the criteria and what it tells us is if it fulfills the last criteria is an executive okay executive is because of inflammation okay and that inflammation is what raises the protein and the lactaid, the hydrogen iss um usually, that's your infection, your cancer, your autoimmune stuff okay because obviously autoimmune or inflammatory, transitive is uh due to increased pressure from the basically blood vessels, hydrostatic pressure, or low proteins in the, which is the oncotic pressure and that's your failures. So always remember your failures, heart failure, liver failure, um and we know failure can also like no not really in this case but your failures and hypoalbuminemia, So in terms of management, it depends on what is caused. The main thing is your congestive like your heart, feeling stuff okay. It means that you have too much pressure and it is like reduce, that you use your loop diuretics, okay, you have furosemide it to get rid of it. If it's no no so life because here is only for um plural effusions uh for acetic, is more like sag more than 11 and stuff like that which I right now. I don't remember on top of my head, but it's different criteria, similar concept, but different criteria, so in terms of your infective causes, um you have basically give antibiotics um unless if it's m. P, m, uh m. P. E. Mails, basically you have a lot of pass in your pleural fluid um in your pleural area and that needs to be drained. Because no matter how much antibiotics you give you cannot remove the pass so malignant If you have cancer, uh it doesn't mean it's lung cancer you can have malignant pleural effusions and they are quite recurrent um So you can do the whole like three o'clock synthesis. Um If they have no which is as I said cardiothoracic kind of like attitude. If you have poor prognosis also with a good prognosis, you can give the poor odysseys which we said before, it's either with talk or plasma, which irritates the lungs and basically the pleural space and filled it together to do the pleurodesis. You have to have a chest training, so what happens with you when you have a chest rate in, uh is inside the pleural space, so if you insert talk or um or plasma usually, it's done. I've done it with because I did the rest job. Last year, it basically sticks it together, not always successful, but that's the concept. So in this question, the protein was more than 0.5, it was actually 0.66 and the like that they had to resonate was more than 0.6, so we have two of the um you know Lights criteria being fulfilled and said it was olivia mean to expect you to remember the Lights criteria, but we're here to challenge you. Um I don't expect necessary that it will be as cruel in the exams, but better to be prepared uh and in this case, you have an basically um executive poor effusion and the only cause that we have here. That's usually infection or as I said infection on campuses autoimmune, but out of the options, antibiotics is the most suited. Um I'm gonna speak a little bit about a few extra stuff because we have a little bit of time and I think I can potentially push your brains and your attention for a little bit more um so what is acute respiratory distress syndrome is when you have pulmonary edema, so fluid is in your lungs, so what have been discussing out pleural effusions where fluid was in the pleural space. Okay, so pulmonary edema is because you have fluid in your lungs and it's not cardiogenic what we in cardiogenic heart failure, for example, will cause pulmonary edema. Uh There's no acute respiratory distress syndrome uh that's heart failure. Uh You like cute onset is bilateral uh and respiratory failure, which is not explained by card. Of course, you do your ab, GS chest x rays um and then you manage them from an 80 assessment and most likely they're gonna end up in i. T. U, so going there for the auction and peep peep is positive experience ori, um positive something, pressure, remember the e, but what is explain a little bit respiratory failures. We have type one and type two type one your auction is both of both of them. Your auction is low okay, respiratory failure, I mean the auction is low so p. A. 02 is less than eight and it can only be done by n. A. B. g v b g one show is like not replicable. It's like doesn't tell you what's your arterial oxygen content top pain Top one is because you have a ventilation perfusion mismatch, so we said the pamela embolism is an example of that uh pneumonia can be example of that because if you have obviously consolidation and inflammation in your lungs, it means that there is a perfusion issue. There is like uh diffusion problem, so there's no able to gas exchange and therefore it ends up having a low auction and then also your chance um which are your like weird and wonderful cardiac conditions, which I want to focus too much on it. Type two okay apart from low auction, is like to remember, there's two things going wrong, so you have low oxygen and high carbon dioxide okay uh that's more than six um and what happens is basically your I'll be like it's not having a good time uh and they cannot excrete ceo, to this. That space usually happens with copd, uh so pulmonary disease, kind of kind of causes uh drugs can cause uh that such as like you know uh morphine a periods because they reduce your ventilation, so you they just your respiratory rate let's say because you get tired and everything kind of like slows down. Um Similar concept with motor neurone disease, uh basically what this is is your lungs are not able to excrete CO2 and most of the time if that's in a severe kind of form, um you can give them n i. V. N. I. V is bipap okay. In this case, the n. I. V can be a lot of things, but n i v, in this case will be bipap, where um you have um basically it's a way of getting rid of um CO2 out of you like lungs okay, where see pop, doesn't do that, see part is there's just like positive pressure and it's usually used for people who don't retain carbon dioxide okay, so type one respiratory failure could be people who have obstructive sleep apnea, which means that they need to be of more pressure for air to get into their lungs because they have something that's like stopping them from breathing, um whereas by pub would typically be used for those who are retaining um basically carbon dioxide, which is acidic that's what I have to say about those two things. Any questions, I think that they lost the bed to be honest, yeah that's the last of it, so I hope this wasn't too fast um and it was a good division of everything that kind of like happens. Not everything things that happen in the spirit. Ori, um Medicine, I am very happy to be contacted if you have any questions about exams life f one f two. I don't always have a very um the best answers, but I have one answer um. And I have yeah so the in terms of like the last question about aspiration and decompression, aspirating okay um is done in more of a controlled way, So you go whether it's a pneumothorax, uh whereas the compression you just go for a safe triangle is basically the main difference um what is it okay, so um you're aspirating and you're using a cannula okay and you can like remove some of the oxygen okay, uh whereas decompression is where is it um is it a needle decompression um yes, so is not necessarily with the cannula uh first of all, and I think it's less controlled, I'm not 100% able to clarify the answer, um but I think my understanding is it's with the cannula you cope is basically more is it like odd, sound guided and you can do it um rather than just check a bigger needle into safe triangle, that's my understanding of it, which is more of an emergency, less kind of like guided, more likely less time to think about it, but yeah um hope this same answer your question, I don't think that was the best explanation, um but yeah any questions. I don't know if you have my email, and I can't I can't I can't actually mhm