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Hi, everyone. Good evening. I'm Viv. I'm one of the f on cos at mind the bleep. Um Welcome to tonight's talk, which will be covering, covering respiratory. Um Just a few things before we get started with the talk, a few disclaimers and a little bit of signposting to what resources we have available. So, I'm part of the F one team at mind the bleep alongside my colleagues, Ramer and Manish. Um And we run lots of different things in including this series. Um So the aim of this series is just to support you with on call shifts. So, what we've tried to do is get a variety of seniors from different backgrounds to run talks on common presenting complaints that you might see on an on call. Um So this week obviously is on respiratory and we've had some already, you're on Gastro on cardio. Um And most of our sessions run at this time on a Tuesday. Um Just a few disclaimers. So, um all of our content is, is intended to be viewed only by medical professionals. Um and that applies to anyone watching this recording at the moment. All of the cases used today and in all of our, in all of our webinars have been anonymized. Um and any resemblance to any actual person is unintentional. Um But we do try our best with all of our webinars to make sure they're accurate. Um But there may be some inaccuracies despite our best efforts, um or things might come out, become out of date. So if you do notice anything that you think is accurate, um just let us know either during the session or if you're watching the recording as a comment. Um We've got a slightly lengthier list of disclaimers that you can access on that link below. So mind the bleep.com dash disclaimers. Um So, as mentioned, we've done quite a few of these sessions already. I think today is our eighth session. Um And we've got one next week which covers ABG. Um So Zeng's kindly produced um a session today on some respiratory presenting complaints. And next week we've got um Mark Bailey who's a respiratory consultant who'll just be going over ABG S. Um So we sort of split them up into two little segments. And then later this month, we've got a session on tackling wellbeing, um which is obviously a very important thing to be aware of as, as a newly qualified resident doctor. Um Just to note that next week's talk will be on a Monday. So most of our sessions on a Tuesday, but next week will be on a Monday, right speaking very quickly. Um, just so that you're all aware, we've obviously got a website. Mind the bleep, it's got lots and lots of articles covering lots of different themes. Um, and we have a specific tab at the top called Fy One. and that's where you'll get Fy one specific, er, resources if anyone here is a medical student. Um, we've also got a medical student tab and other tabs as well. Um, That QR code is for all of the whatsapp groups. So if you're part of a Deanery and you're not in the Deanery whatsapp group, then you can scan that code and join the correct Deanery chat and we try and advertise all of our, of our webinars for this series and other series through those. Um an easy thing to do is to just follow us on medal. So the platform we're on at the moment um and then you'll be notified of, of events that are coming up and that way you definitely won't miss any right. I will just stop showing my slides. Um So I'll just present Zheng Ya, who's an fy two doctor working in Scotland. Um So at the very north of the country, um she's had a previous respiratory job as an F one, so she knows the struggle. Um And she's collated a few different patient presentations based on this. Um All of our, all of the webinars in this series are quite interactive as some of you may know if you've attended them. Um, so definitely be using the chat. Um, this is probably gonna be a little bit more chat heavy than poll heavy. Um, so please do not feel to feel afraid to send anything in the chat. Um, and hopefully we'll finish a little bit early. Um, and we'll also have a chance for you to submit any questions you have. So if you've got any questions, submit them through, um And I'll be reviewing them and we'll either answer them at the end or we'll interrupt to answer depending on what the question is. Um So just to check, everyone can see saying slides I can. So hopefully that's all. Ok. Um And I will hand over to her. Cool thanks with. Um So yeah, as I said, I'm Zang. I'm one of the F twos. Um I have to disc like just disclaim that I'm not a special consultant or registrar. I've just done a job in respiratory in my first job in F one which was really, really interesting. Um saw lots of presentation but also thought that this is quite, quite a stressful situation if you get bleed to see someone in respiratory distress. Um So we can just jump straight into some cases. So you got a bleep. Um And it's a 62 year old male who has dropped her stats to 78%. The nurses just found out about this when they did their observations round. Um, you ask a few more questions and they say, oh, she's in hospital because of an infective exacerbation of CO PD. And they actually know her quite well because it's her fifth time with them this year. Uh And you get the rest of her observations and they're here. So she's Nique um at 25 breaths per minute has a heart rate of 90 BP of 100 and 48/85 and has a temperature of 37.9. So if everyone wants to pop in the chat, what other information they would like from the nurse just while they're on the phone with the nurse, just write them in the chart. Um Just think about what information would be useful for you before you see the patient. Yeah, quite a few people want to get ABG S and the target saturation, which is useful. What are some other things you would like to know? Um That's, that's happening on the ward just now. So a quick way to think about this is probably um like because people are, people are all taught to give handovers in SBAR format. So our nurses, so if you think about it in the SBAR format as well, like you've got a bit of the, you've got the situation here, you've got the background that she has COPD and is in hospital with IEC O PD. Um I think the next thing I probably want to know, is, is, you know, if they started oxygen as Jess has correctly said there, if they started oxygen. Um And then I think I probably the next thing I will say is just put her on some nebulizers and I'm, I'm going to head over just now. Ok. So we'll go to the next slide. Um, your eye on the ward. She's me is just getting in there as you arrive. Uh So you start your A two E assessment as any good doctor would um her airways pa she's fine. Um But in B you notice that she's sitting in a tripod position, um she's working really hard to breathe and she's just speaking short sentences to you. Um You take out a stethoscope and have a listen to the chest. There is equal chest expansion but you, you are hearing lots and lots of wheeze. So what would you do next? And we're stopping at B because there are lots of problems at B. Um So we're not moving on. OK. Yup. A chest x-ray. That is definitely going to be informative. Yeah. And we'll start oxygen. Yeah, because it doesn't say here in B that she's on oxygen and also doesn't say here what oxygen level she's at. So I'll probably pop on the pulse oximeter on her finger and just keep it there as we go just to keep an eye on it. Yeah, we can do an ABG. You can get another check of the new score if you want steroids is a shout. Yeah. So those are all good, good like suggestions, logical. Um I think I would probably, you know, once we get started on the nebulizers because nebulizers does take a while to run through. So you just have some time where the patient is sitting there before the next thing can happen. You can get a chest X ray, you can get the portable x-ray so that can be on the way. So II would then have, have a few minutes um which I would use to sit down at the computer, try and have a look through the notes. Get a bit more of information cause she's been in hospital maybe for a couple of days now getting treated for CO PD. So I would want to know what treatment she's currently on, on that front. Like are they giving her any antibiotics? What are they giving her? What's her nebulizer regime? Is she on regular? You know, is, or is, is, has she actually just been taken off the regular? And that like, and now she's deteriorating again? Um And is there any escalation plans? You know, if someone is, does she have comorbidities? Yeah, like any prior itu should be a candidate. That's exactly what I'm thinking about here because you wanna think about if, if your ward level treatment is not working, where would you go from here? Would it be N IV? And would it be more than just the ward. Um, is there any DNA CPR put in place, that kind of thing. Um, all good thoughts to think about and you get the chest x-ray. This is a chest x-ray. Would anyone try to describe what they see in this x-ray? Just write it in the chart. What are your thoughts? Yeah, it's a barrel chest. And does anyone want to say what barrel chest means? Yeah, it's, it's definitely a hyperinflated lungs. You can see about like 10 to 11 ribs here. Um But yeah, there's no trache deviation, there's no cardiomegaly. Um So I would say about, about chest x-rays. We're not like we're not radiologists and, you know, most people aren't trying to be a radiologist, but a few things that I do look out for when I sort of provisionally review a chest X ray before the formal report comes through are things that would change my initial management. Um So things like a pneumothorax, you wouldn't want to miss like a pleural effusion, pulmonary edema, consolidation, obvious things. Um sometimes you see broken bones on the chest X ray as well. Um And, and, and something that isn't respiratory but is a really important thing not to miss on a chest x-ray would be some free guests on a chest X ray, which quite interestingly happened this over this weekend on the night shift. Um Someone had free guests under the diaphragm that's not a respiratory issue, but I would definitely call a senior and treat the person and not just, not just move on for that. Um Some areas I would specifically look at on a chest X ray um would be the apices um in the apex of the lungs. I would, I would zoom in on the computer um and have a good look because there are things there that can hide in there and just get missed just because it's in the corner. Um and a good way to look for to, to make sure there's no consolidation. You should also probably just follow the heart borders on both sides. Um Make sure that it's going down smoothly following the contours of the heart. If there's any sort of bumps or like the line just doesn't look smooth, then there there may be a consolidation just hiding there behind the heart or it could be in front of the heart. Um But yeah, I think what people have written here are mostly correct like hyperinflation, a fles and diaphragm, but there's no consolidation and the lung markings look fine. Um I think the costophrenic angle is OK on the right side. Um That's not really jumping out to me if there's a blunting, but we're gonna move on. Um This is just a slide to summarize what you would do with CO PD. You will, you know, when, when you see the patient, I think most of us do this unconsciously. Um You see the clinical signs, you know, you, you, you see the patient tripoding and just speaking to you in short sentences, you might not be necessarily consciously thinking about it. But these are all things that contribute to how worried we are about a patient. Um You will see how they present and these are just clinical signs that are useful and obviously listening to the chest. Um hearing a wheeze would be a giveaway for a COPD slash asthma. Um But those are like, those are the things that would make you think about it. And you know, we have a past medical history of CO PD. You can also, you can also start going down the CO PD route when they have a past medical history. Um, they usually would have a wheeze, but there are some patients who don't have a wheeze. Um uh and for investigations like, like we already talked about chest x-ray, that's really useful. Um Obviously the ones that the, the one that I've had up here, that's just a typical CO PD chest X ray, which we, you would get in lots and lots of patients. Um But a chest X ray is also used to rule out other causes. That's not CO PD that could be making someone breathless as well. Um ABG um that's really useful, especially if you have sort of serial gasses. Uh One when the patient just started deteriorating and one after you, you've given them some oxygen um just because that sort of comparison will show how well they're responding to nebulizers and some noninvasive oxygen. Um And if they're still not responding to just sort of mask or nasal cannula, you can take that and speak to someone about putting them on N IV, which should be bipap for CO PD patient. Um You could, you know, you could see things like how acidotic they are. Um And what's the PO two P CO2 like? Um There are also other blood tests which can suggest clues of other causes like if they're having an infection um or if they've just suddenly all of a sudden become really, really anemic, then you need to start thinking about non respiratory causes. So it's always useful to just get some blood tests off. Um If you have any doubts and then sputum cultures and throat swabs. These are things that won't help you urgently in the time that you are there. Um But it will be really, really useful for the patient in their onwards journey of trying to get a treatment that's right for them. Uh If it's infective cause. Um So yeah, um immediate management giving, giving them oxygen to help you need to have a target saturation. If, if in any doubt, just put them on the high oxygen and then you can dial it back once they're a bit more stable and put them on a vary um a saba and Asama nebulizer which would be sabutal and ipratropium um is what we use. Uh, you can give them both at the same time in the same nebulizer mask and you can give them back to back. Um, a typical thing that people do and really unwell people is just giving them three back to back and then coming back to reassess the response after that or you can just give one if you're not too, too worried about them, just give one, see if that opens up their airway. Um And then go from there, we give steroids, prednisoLONE. Um But bear in mind that's not, that's not gonna work immediately like a nebulizer. It probably takes a few hours, I think six hours that it starts to kick in. Um But it is important that we start them on that and not just resolve their wheeze and walk away and continue with your night. Uh You should start the steroids um and antibiotics if there's an infective component to this, get senior help. If um you're real worried about them, if they're not improving with treatment, especially if they become more drowsy, become more fatigued. Um Definitely important to give the senior a call and get them to come and have a look and escalation options. You have N IV, which should be BIPAP um And speaking to critical care and getting that assessment, even if you think they're not a candidate for, for HD or ICU, get critical care down to give you that, you know, that assessment and, and it will show that you've, you've gotten them considered and then they're not for it. It's not appropriate. It's really useful for the patient for the next doctor who sees the patient. So then they know that this conversation and this discussion has been had. Um, and I've not built a separate case for asthma. I've just sort of tagged it along to this because it's, it can be kind of similar, but there are some differences in that your patient can be possibly younger. Um because a lot of them are younger, they can be less comorbid asthma could be their only medical condition and they can be quite generally fit and healthy um when they're not having an acute asthma attack. Um but when you examine them, you want to be really worried if they have a low oxygen level, especially, you know, when you give them oxygen and the oxygen levels are still dropping, that's, that's really worrying along with a silent chest or a normal respiratory rate or even worse, a low respiratory rate rate cause those are all signs of life threatening asthma. Um because it just, it, it essentially showing there reduced respiratory effort um when they should be trying to breathe really hard because their airways are so tight. Um And for asthma, the sort of difference in investigation is like quite often we will get a peak flow. Now this is more useful if you have a baseline peak flow number from the patient. A lot of patients actually would say, I don't know, I, I've not checked that in five years, but that's fine. You still get it and write it down um cause you can still use that to sort of assess their improvement later on once they've had some treatment. Um and then there's also ABG that you get for asthma, you would, you, you'd like particularly want to look out for a normal or high P CO2. Um Otherwise, it will most likely show type one respiratory failure, which is going to be a low po two and a high, sorry, a, a low PO two with a low P CO2. Um But you have an ABG talk next week, so it won't go too much into detail, but really like II just want to highlight that a normal P CO2 in asthma is, is not OK. That's life threatening asthma. Um OK. Um And a chest X ray and asthma, I don't always jump to get that myself. Um But I would if they're not responding to initial treatment or if you suspect something else like a pneumothorax or consolidation. OK. Um Yeah, that's just II just wouldn't jump to get x-ray for every asthma patient myself cause it's uh it's probably not going to add too much to the treatment cause you're just gonna treat them with nebulizers or inhaler through um the spacer. Um So it's the same salbutamol or apotropina, you can do that as well. Um starting on steroids and you wanna get senior help again early. Um If it's life-threatening asthma or if they're just not responding to treatment and um for life threatening asthma, you wanna get ICU down to see them cause there's a potential that they'll go into sort of peri arrest and then need ventilation, need intubation and ventilation. Those are just sort of basic things that I think like at my level and your level at F one that you would be expected to do. Um Obviously there are advanced treatment like IV myself and Aminophylline, but that is not, that is not our decision. What you need to do is to escalate the seniors and then they can guide you from there and that's an X ray of someone who might have asthma. Would anyone like to point out what they're seeing here? What do we think? Don't, don't think too hard into it. Just the first thing that you think, what was your first impression? Just don't, don't overthink it. Yeah, exactly. It looks normal. Um It's I I'm not, I'm not trying to put in a trick question, but that's just how chest x rays would look for most asthma patient, they will look normal. Um So yeah, let's, let's, let's just move on. II OK. Um So new patient, second patient, you get another bleep and the nurse opens with this patient has a use of six. So you gotta come and see them. Um So they have a respiratory rate of 94% on 3 L of oxygen. A pressure rate of 20 a BP of 100 and 5/75. A heart rate of 110 and a temperature of 35 38.5. And this is 75 year old Alex who actually has been needing 2 L of oxygen since he came out of surgery yesterday because he actually came in two nights ago after he had a fall and sustained a right neck of femur fracture. He's otherwise recently fit before this admission, he just has hypertension and type two diabetes in his past medical history. And he actually walks his do dog every day before he had fallen and so has no complaints about his exercise tolerance prior. Ok. Um So you get a bit more information about him, you come down to do his A two E assessment. Um And on arrival, you like before you even get in the room, you can hear him coughing and when you get there, you see a few tissue just on his bedside table and it is kind of has some mucky green sputum. Um, he's maintaining his own airway. Um, he's not working too, too hard to breathe, but because he's, that's because the nurses have already turned up his oxygen. He's now at 4 L and he's saturating quite well. 96% on that. So he's not working too hard to breathe, but you can hear some crackles at the base of his right lung. Um, and the, the rest of the sort of examination um on, on sea, he's a bit tachycardic, but he's quite well perfused. Not, not too concerned, there's no ankle edema. Um And d he might be a little confused. Um You, you find that he's not or in at a time and place. Um but his pupils are equal and reactive and his abdomen is soft and we're, we're not concerned about the surgical wound. Um So what, what would you do next? Yeah, you can certainly do a sputum culture, but that's not really going to come back today or tomorrow. It's not gonna help you out. Now, a chest X ray is going to be useful and yeah, pneumonia is something to think about sepsis. Six. That's also reasonable given that we have ops looking like that people thinking about pneumonia wanting a chest X ray and need antibiotics. Yeah, all very sensible. Um The chest X ray, you know, you can probably get them, get him down to the radiography department rather than asking for a possible um Since he's now OK, on the 4 L of oxygen, um something that no one has mentioned that I would probably do um not urgent but I would probably do soon is an E CG as well. Um He's tachycardic. So I wanna, I wanna have a, have a look at what rhythm he's doing. And yeah, I would, I would, I would put a cannula in um get some blood and blood cultures off and give him some IV fluids. If you feel that's appropriate, it might, it might help with this tachycardia. But I think the sepsis six is probably the summary of that. There's one more thing that nobody has uh said about to show you that as well. Yeah, that's a good shout. Sophie stop antihypertensive. That's a good shout. Yeah. Blood glucose. That's well done. Um Yeah, he, he's confused and he is type two diabetic. I would, I would check his blood glucose. It's a quick test. Um And it's a good thing to exclude. Ok. Yeah, it's probably not anything to do with the blood glucose. His current state is probably not caused by that, but it's good to, it's good to check that and, and keep that in your mind. So that says chest X ray. And what do we think? Yes, anyone wants to just comment the obvious problem with this chest X ray. Yeah, there's a, there's a whopping consolidation in the right lower zone. OK. I'm, I'm not too worried about the trachea. Um It's probably just an element of rotation there. But yeah, that, that's a, that's so that is a wing consolidation which would confirm most people's suspicion that this is a pneumonia um which would make you, you know, quite confident to start some antibiotics for pneumonia. It is, it is like worth noting that sometimes chest x-ray won't, won't show a consolidation even even if someone has pneumonia, particularly if you've taken this x-ray in the early stages. Um, but you know, his, his history and presentations all very congruent with the pneumonia. Um, so I would still treat with pneumonia antibiotics even if this chest X ray was a normal x-ray and move on to the next. So just a little bit about pneumonia. I think most of us are quite familiar with pneumonia and how to treat it. Um, but pneumonia is split into these different subtypes which would change what antibiotics you would use based on your local guidelines. Um If it's a community acquired pneumonia, a curb, the CB 65 score is really useful, um which should require you checking some blood tests. Ok. Um But that's, that's useful in Rera and telling you what level of antibiotics you need to give this person. Um, our guy, I think a lot of people have said that this would be a hospital acquired pneumonia, which would be right because he's been in hospital more than 48 hours. And that's important distinguishing thing to make because it changes what antibiotics you want to use. It. It's usually different from community acquired aspiration pneumonia. You would want to think about that. Just a lot, a lot of that suspicion for aspiration pneumonia will come from the history. Um, if they have a history of choking, of dysphasia, swallowing, swallowing difficulties, um, having seen, seen salt, um, for swallowing difficulties, having a modified diet, those kind of things or in stroke patients who just maybe just came into hospital. A miss it with a stroke, you would, you would think about aspiration pneumonia. Again, there's different antibiotics for that. And then you've got your odd and wonderful atypical fungal pneumonia, um, which would probably only be seen more in smokers, immunocompromised people. Um people who has traveled to exotic places or have lived there. Um The telltale signs for this will be the odd non respiratory features. Um like having diarrhea, having deranged LFT S hyponatremia, having a rash. Um The main things with like um un under atypical, I think would be like lesion and mycoplasma, that kind of thing. Um But I don't think the f one who is the first to see a deteriorating patient at this point, like you would be expected to think about this. I've just put it there for, for completeness since we're talking about pneumonia. Um But yeah, the, the treatment was already talked about A two E and then antibiotics, sepsis six, you know, and escalating antibiotics. If it's someone who has already received a good amount of a starting point, antibiotic and they're still deteriorating, then there are some that at that point you will come in and you probably step it up right. And then next next, next day, next two days, um you work and then two nights later, you are bleeped again to see someone who is not maintaining their saturations on 4 L, you arrive and find that actually it's Alex from a couple of nights ago. So, you know, this guy, um so you're not asking the same questions about what his background, you, you already know him. So you jump straight into an A three assessment. Um This time um under B he's saturating only 90% on 4 L oxygen when he was saturating quite well on that two nights ago. Now, he's got crackles at the base and middle zone of his right lung. There's some crackles in his left lung base and he's clammy, he's tachycardic 100 40 BPM. His BP is at 90/60 has no murmurs um but still has some moist mucous membranes. But you notice that now he's, he's got an ankle edema um on his right. That's, that's larger than the left. And the last E CG he had was when you requested it. Um last time when you saw him that that was just sinus rhythm. Um and the, the, the he's confused. So, um and this time you've already got ABM that's normal. So you don't have to check that again. Uh Temperature is normal now, um and the rest of E is still unconcerning, nothing to talk about and you read through the notes. Um and find that in the past couple of days he has been on his antibiotics but they actually, the, the staff actually hasn't been able to wean him off the oxygen even though they've tried a few times to turn him down to 3 L. But he's not, he's just not been coping and now he's dropped his saturation even on 4 L. So, are we worried, what are we gonna do? Lots of answers coming through? Yeah, chest x-ray E CG an ABG getting some bloods, all very useful things, all very sensible. Um That's what I would do. And a few people are worried about pe which is, which is definitely the thing to think about. Someone wants to consider atypical screen results. That's, that's also useful. But I think, yeah, like II would worry about pe myself um because he's, he's got this presentation of having persistent oxygen requirement, actually increasing oxygen requirement despite being on appropriate treatment for, for a chest infection, which is what we thought he had. Um And he's actually, you know, under under sea, he's, he's getting more sort of circulatory, pressed with a, with a high heart rate and a low BP. Um and he's got multiple risk factors for it. He's had a recent long bone fracture, a recent injury which immobilized him. He's had an operation for this and he's also had sepsis. Ok. So there are, there are multiple risk factors I think um if you calculated his well score, it probably be something like six. which would, which would mean, which would mean that like people that say it's ad dimer, I would say that that that's actually inappropriate. If you ask me, um, in someone who's high risk for a pe, you should do a DD, you should, shouldn't do ad dimer, you should go straight to a C TPA. The D dimer is a really useful rule out test for people who are unlikely to have a DVT or PE is used as a rule out test for low risk pe patients. Um, but in high risk patients, you absolutely want a C TPA. Um I don't know how well versed people are with the risk assessment score. Um But do people know about what risk assessment scores are used in pe just put them in the chat? Yeah. Well, score. Is there anything else? Yeah, that's perk score as well. Um So I think in this case, there's a well score and perk score are both used um for pe, but I think in this case, well, score is probably the more relevant one, the perk score is like a rule out criteria. Um That would like that you would use for someone who you don't think pe is the case, but you just want to be sure of that kind of thing. Um It just basically tells you whether or not you need to do ad dimer or not. Um But in his case, I would, I would go for a C TPA. Um, because I think the most likely thing here is, is pe and so, so pe um, the clinical signs for it, you, you look out for any signs of DVT, um, tachycardia dyspnea and ple chest pain hemoptysis. Just, they're, they're just like quite nonspecific if you look at them in isolation. But, uh, you know, when someone's breathless and, and they have a high heart rate, I would immediately have to think about pe and have to think about reasons of why I shouldn't consider pe um someone's asking, do you often meet resistance from fasting radiologists or requesting CT A without the dimer? Um I don't, I don't think so. Um I think especially if you have a good case of how it's really likely like he's got, he's, he broken a bone and he's been in the hospital, he's had an operation which would raise ad dimer anyways. Like they like a good radiologist should not give you resistance to get a C TPA without ad dier because that, that D di one is just delaying things. And even if that's low, he still has all these clinical signs. He's got a swollen leg that is bigger than the other. He's had all this history. He's got a continuing and increasing oxygen requirement. II don't think a good radiologist should say no. Um And I think if they said no or someone presenting like this, you should absolutely stand your crown and fight them. Uh Because it, it makes no sense to reject that. Um Yeah, I don't know what else to say. They shouldn't say no if you've got someone like this. Um Yeah, carry on um E CG. So, so I think we all know like, do we all know that like the most likely E CG you will get for someone with P is Sinus tachycardia. Um So like, don't expect to see S one Q three T three in everyone. Um Those are for the past me. Um But sinus tachycardia is most common. Um But things you do want to look out for, you still want to look at their E CG because you wanna look out for a right heart strain pattern, which would be at wave inversion in V one to V four, at least 23 A VF. So the inferior leads um and having a right bundle branch block a right axis deviation. Um because those will make you more worried about, about the heart um in the case of a pe which would prompt you to get a more urgent ech echocardiogram. Um cause otherwise, I think patients usually at least at least here in Edinburgh. Um we tend to get the echocardiogram at their checkup appointment. So like six months down the line when they're getting followed up. Um But if they're showing signs of right heart strain, that would prompt prompt you to request an echo earlier um during the admission rather than later on. And yeah, there's the question about D dimer versus C TPA um in low risk patients, then absolutely do the D dimer. Uh But if they have a high well score and then it's C TPA A DDO is not appropriate and P score is useful for people who pe is not that likely but is in the differential and you just, you, you want to stratify your risk. And in general, um yeah, I've talked about that but um if in, in general, if pe is likely, but C TPA is not available immediately, either because of logistics or you know, because you have other pressing issues to do with that patient besides getting them away from the ward into a CT scanner. Um You can, you should still start anticoagulation based on your clinical suspicion. Um give them some anticoagulation and then worry about the CT PA later. You shouldn't let the C TPA delay your treatment. Um which, which would, which sometime mean, you know, in in ambulatory patient, you would give them doac and get them to come back for C TPA during working hours. That could be something you do. Um But uh we're not talking about ambulating patients. Now we're talking about in hospital. Um So in hospital, your options still include DOAC or it could be a therapeutic dose of low molecular weight heparin. Um or in more unwell people or people who are actively arresting it will be thrombolysis. Um The, the consideration of doac and, and low Me Heparin, like that's not a decision that F one has to make. But um usually, I think the rationale of using one over the other is how unstable, how hemodynamically unstable you think this person is going to be or how precarious their heart um like their cardiac output is going to be like to how much right heart strain they're having. Because if you have Doac within the first uh with, within the last 48 hours, then you're not able to have thrombolysis. Ok. So Doac in the past 48 hours is a contraindication for thrombolysis. So if you think someone's likely to start developing, you know, like hemodynamic instability or worse go into cardiac arrest because of their pe then don't give them Doac give them a little mole Heparin so that they have the possibility of getting thrombolysis. But if they're, they're quite stable, then just give them the doac, it's way easier, there's no injection. Um And that's usually sort of like a quicker thing to get people way home as well. OK. Pe is done. Um And we move on to last case um which is case three. So we have a 90 year old Margaret who is having an increasing oxygen requirement since yesterday, she's now needing 3 L of oxygen and is saturating 92% which on her target saturation that's actually fine for her. Um The nurse just called you because uh the they're, they're hearing noisy breathing as well every time they walk past and obviously the, the amount of oxygen she's needing is going more like higher and higher. But her other observations are otherwise normal. She's kind of just pleasantly snoozing in her bed. She's been in hospital for three months, so no one actually can tell you why she's in hospital in the first place, but we know that she's waiting for a twice daily package of care you arrive um You see Margaret um and, and you do an A two E assessment as usual. So her SP O2 is 92% on 3 L. Um Rest rate of 19 B breaths per minute. There's no cyanosis, equal chest expansion and crackles at both the bases. She is quite well perfused. She's got a systolic murmur um and she has some pitting edema on both her knees. Um Well, to, to just below both her knees, she's alert when you, when you, when you sort of wake her up, but she's confused. She doesn't know where she is, but we don't know sort of how new this is. Um otherwise she's fine. So by this point, you're quite, you're quite smooth with your respiratory assessment. So you, you get a chest X ray and you get the nurses to take some bloods and then you just sit down to read her notes. While all that's happening and you're waiting for the x-ray to come back. You find that her Furosemide actually was suspended four days ago because her bloods uh showed an AK I which is fine. But the problem is this hasn't been reviewed again since then. And because, because it's been a bank holiday weekend and we're not having another consultant around until tomorrow and we know she's just waiting for a package of care. So she's not one of those people that get daily medical review on the Jerry Sword, um which is quite typical. So what's, what's your top differential? Um What's gonna be the question you put in in your chest X ray request? Ok. Absolutely. Everyone's saying something along the lines of pulmonary edema and heart failure and everyone's spot on. That's right. That's exactly what we want to think about here. Um And this uh this would be what her x-rays could look like. There's just two examples. Um Anyone wants to describe them, anyone jumping at the chance to show off their um ABCD E for pulmonary edema? No, no more. Well, I I probably would also be one of those people that don't to point out the sort of pulmonary edema signs like battling um curly bee lines. Um But I mean, I would just call this a fluffy chest x-ray cause that's what it looks like um like cause cause fluid looks white on X ray as we know. Um And there is white everywhere, right? Someone's saying there's curly bee lines, curly bee lines are basically sort of fluid in between the lung lobes. They're interstitial fluid. Um Yeah. Um fluid in the horizontal fissure. That's also the same thing. Um And like some of these fluff would be fluid in the alveoli. Um If you have, if you spot the costophrenic angle, especially on the, on the left of the picture on the right, that's got a cusic angle blunting. So that will be pleural effusion that's fluid as well. Um So it's essentially you're just seeing fluid everywhere with pulmonary edema. So what's what, what are you gonna do next when you see this x-ray, what is, what is the first treatment? OK. People want to start furosemide or shall we say restart? Because she should have been on furosemide. Yeah. Interesting people that people are saying fluid balance and checking renal function. That's all all useful. But yeah, it's, it's essentially going to be loop diuretic is your first thing that you're gonna prescribe. It can be IV it can be oral um you know, sometimes elderly patients and this maybe not the most con conducive to get an IV access into them, but ideally one IV furosemide um or it could be bumetanide um in, in some patients where you don't really want to put them through needles and things, you could just restart the oral furosemide. It's all about balance, I suppose in the geriatric population but loop diuretic would be the treatment that would, that would treat this chest X ray presentation. So we'll talk a bit about fluid overload with pulmonary edema. Um Although it's not a lung problem that's led to a respiratory distress, it's, it's mostly a heart problem that led to respiratory distress. But you will get called about this, you know, like the, the nurses will bleep you and said that someone has dropped their sets or are struggling to breathe. So that's why I've included it in the respiratory talk. Um even though it's not technically a respiratory disease, it's pulmonary edema, but it's caused by something else. Um So clinical clues, uh they would be dyne pink, frothy sputum. We all know that um orthopnea, parasal, nocturnal dyspnea, tachycardic technique having a race JVP, they don't have to have all of the above. They could have none of the above, but there's just some clues. Um and, and non respiratory clues or fluid overload would be edema. It could be ankle or sacral if this is someone who is spending most of their time lying in bed, um, abdominal distension, ie and ascites. Um weight gain with, you know, no apparent reason why they should gain weight, history of heart failure, ischemic heart disease, having a structural heart disease that's known et cetera. Um A pe could, could give you fluid overload because that causes heart failure and investigations that you would do. The first thing would be the chest X ray that, that will give you the diagnosis. Um You would take some bloods that's really useful for the renal function. Um, and some blood gas if they're struggling to breathe and they're just not saturating despite the oxygen that you're giving you take, take a blood gas to just quantify how hypoxemic they are. Um I would echo someone, I would, I would suggest an echo to the senior and um if it's to, to, to like a senior, if, if it's someone who's not known to have a cardiac background, like you just, if it's someone that you just think it surely not like he's got heart failure, um then they might want to echo the person cause maybe there's something new that has happened inside the heart. Um management as we said, look diuretic. Um It's the first thing usually we use IV furosemide. Um And it's use to take the blood because you wanna monitor the renal function. I think someone did mention that you want to check renal function. Um especially if you're putting someone on IV diuretics is uh you, you would, you would want to check the renal function very frequently and you want a careful fluid balance um with their urine output and regular ways. Um As someone has said, you want to check the fluid balance um because that tells you if they're responding to the treatment or not, because if they're not responding, then you're gonna need to step it up. Um which I know it's quite hard to get sometimes um especially in understaff medical wards, like getting the nurses to do fluid balance charts are, is is is difficult because they are so busy. Um Quite often times, I just, I just explain my rationale to the nurses why I want fluid balance on this particular person. Um because quite a lot of times, I think a lot of patients are put on fluid balance and may when maybe some of them don't really need that. And over time nurses just feel like I'm checking, I'm I'm doing this fluid balance chart, but it's not like any doctor looks at it anyways. So I would, I would sort of explain to the nurses quite nicely, like, oh really important for, for, for this, for Margaret that we check her weight and check her urine output with her fluid intake. Um It's not just for the dieticians, ok? And then after that, I thought we have a bit of fun um and spot some pneumothoraces. Um at the end, if anyone wants to shout which site they think the pneumothorax is in this one's an obvious one to start us off. Just a quick left or right would do. That's it. That's the left. So it, it's completely collapsed essentially as there's no lung markings. It's a good X ray to look at if you didn't understand what people meant when they said there's no lung markings cause the left thorax has no lung markings in it. And there's quite a clear line of plural, sort of pleural line where the lung has entirely collapsed into. And then the next one, same thing again, say which side the pneumothorax is on? Yeah, it's left. Um, can everyone see it? I don't think there's a pointer thing that I can do, um, to show you where the lung has, has sort of dropped down to, but can everyone see it? Um I think most people can, um, unfortunately, I should have put in a slight to sort of put arrows on where the lung marking has sort of dropped down to. Um, but yeah, with, with pneumothorax, um, the important thing is to recognize it on the chest X ray. This one's not showing attention. So, you know, you might or might not be able to figure that out on just by, just by auscultation by examination. Um You see it on the, on the X ray and then how you treat. It depends a lot on the size of it. It depends on how symptomatic the person is and depends on the etiology. Um As in, you know, if this is, this is caused by a cause that is not reversible. Like cancer, it's going to keep recurring, then you probably want to do something about it because it's probably not going to resolve itself. Like, uh you know, much like a spontaneous pneumothorax probably would Um But again, the F one, you probably, you probably aren't required to make that decision whether or not you treat the pneumothorax um or not. But essentially, if they don't treat the pneumothorax and decide to let itself resolve, the patient will get a follow up chest X ray to confirm resolution. And then the last one which is a lot more subtle. Um which is why I've zoomed in on the apices for people to see if anyone wants to say which side this pneumothorax is on. Mhm We're having some disagreements about this which is fair. Um It's not an obvious one and it's not a big one. This one's in the apex. I found this chest X ray just to say that like just remember to look at the apex and something quite useful to do when you look at the apex um is to just zoom in and compare the two apices to each other and just have a look and see if they're different. But this pneumothorax is on the left again, they're all on the left today. Um And I've put some arrows there. So hopefully you're now able to see where the lung the like the pleural line has dropped to. So the pleural line should be like a thin white line is what you're looking for. Ok. Um And then I think that about concludes us, but just like a few more other things um that could cause respiratory distress. Um that's a bit more like, sort of, not common but important to know. Um, there's airways, anaphylaxis which, you know, recognize it, you know, the moment you recognize it you should just grab the IM adrenaline and, and just give it to the person. Even, even if it's not an, a anaphylaxis, you know, like the IM adrenaline is not gonna kill that person. Um, they're probably gonna feel a bit weird and a bit agitated for a bit, but it's not gonna kill them. So if there's suspicion about anaphylaxis and, and you know, this airway airway problem, rather than a breathing problem first, then just give the uh II M adrenaline if someone is choking on someone, um, if they're, if they're still conscious and still talking to, you, get them to cough as much as they can and then do your back blows, um, abdominal thrust. Um And that's not working if they start sort of not coping so well, like get the suction suction tube out from the wall. Um, see if there's like, get them to open their mouth, try to see if there's anything you can grab. And then, um the last one, like if someone's having like a like drop set spot, having a low or on the likes of borderline, low respiratory rate have a look in their pupils. Um, make sure they're not just sort of overdosing a little bit on opioids, it can happen to older people or just happen to people on the ward who have just been taking liberties of their PRN or. Um, so that can happen. Um, but yeah, that's, that's just a few more things to talk about and that's it. Uh, thanks for.