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Hi, everyone. I hope you guys can hear me. Ok. Um If somebody could just pop a message in the chart that they can hear me. Ok, cool. Ok, thank you. So today's topic is going to be about infective exacerbation of CO PD asthma and pneumonia. So basically it's the first one. Ok, thank you. So this is the first one in our Respiratory medicine series. So these are like some of the most common presentations that you guys will see, um, especially like in the emergency department or in the acute medical unit. So they're, they're really good to go over and I'm glad many of you are here and joining. So thank you for that. Just for reference. Next week, we'll be going over pulmonary embolism. So again, another really high yield important topic. So, um it would be great if you guys can tune in for that as well. So yeah, um I'll make a slide. I hope you guys can see my slides. Ok? Any, any issues just um, put a message in the chat. Ok? So we're going to be starting off with a case and then we'll be discussing the main things. So for us, we, we like to focus more on how you're going to clock this patient. What will you see in their history? How will they present, how will, you know, it's this disease? Not that one and how will you manage it? And what, what investigations will you do? Just really like the most important stuff that you'll need when actually practicing in the UK. Um, because obviously when we studied abroad it's been very different. We learn very theory based. Um I'm assuming many of you guys also studied Bulgaria, Roma Romania, like um European countries. So there, it's more like, oh what's the pathophysiology? What's the, it's, it's very specific, whereas here, it's more important to know how you actively manage it and how you can actually find it. So that'll come with time and experience. But this is giving you a lot of hopefully a lot of the tools and skills so that you'll already have some ideas in mind and be better prepared. So we'll start off with a case and then we'll return to that same case at the end. It's more to gauge what what your guys' understanding is and to see if um how the presentation helps and if we can get better um at dealing with the case. So to start off with. So here is the have a 75 year old male who's experiencing breathlessness and also has a cough and they were beaver. Um If anybody knows what the acronym Beaver stands for, you can put that in the chart as well and then this is their ABG. So I guess we could break this up. So we know it's a 75 year old male. They're having breathlessness and a cough. So, what kind of diseases? What differentials are you guys thinking about? I know this is a re topic but you can say whatever you're thinking it would just be good to, to gauge where, where you're at with this. Um Just give me your thoughts in the chat. I'll give you guys a couple of minutes for that. Thank you. Yes, that was my next question. Yeah, brought in by the ambulance. Thank you. So elderly male, breathlessness, coughing, dyspnea. What, what is like high on our radar? Absolutely. Yep. Yep. Very fitting is the title for our talk. But yes, absolutely. All of those. Definitely. What else? Yep. Thank you, Nikita. Yeah. Could be ap anything else? Yeah. Could be heart failure. Yeah. Yeah. Some patients um, can present with atypical M I symptoms like the shortness of breath. Yeah, see, I think we've got some good ground there. Um ok. Now guys, let's have a look at the ABG. So this is, um, this is the ABG of that patient. So what can you tell me about the results? Maybe you can comment like on the individual things if you want or just give like an overall conclusion just to see where you guys are at with ABG interpretation. This is something we're gonna be covering in our talk as well. It's just to see how much your understanding is now. Mhm. Mhm. Very good. Very good, amazing, amazing, very good, well done. Yeah. So um definitely type two resp failure, hypoxemia, hypercapnia, respiratory acidosis with partial metabolic compensation. Yeah. Very good, very good. All very good. Um I'm really happy with that. It shows like good understanding. All good. So OK, let's move on and then we'll come back to the case at the end. See if there's anything else we want to add. Ok, so going off of the symptoms that recognize that cough, what, what sort of questions are important for us to ask, to distinguish um what is the patient having? Because the whole point is like, OK, they've come in, they're breathless, they've got a cough. What could this be? And you, you, yeah, you can do scans, you can do this that but your history is very, very important. So what, what are you going to ask this patient? How are you going to narrow down which one they're having? Yes. Really? Yeah. Is the cough productive? Nice question. What else? Yeah. Hemoptysis. Yeah. So that's like blood in the sputum fever. Absolutely. The color of the sputum. Yeah. If anyone was here for last week's talk as well, there were some, there's a lot of crossover with some of the questions. So particularly about the breathlessness because in heart failure they have similar signs with the breathlessness. So if you can remember any of those questions, they would be good as well um In this as well. Mhm Yeah. Fine. Do they have edema? Yeah. Could it be related to the heart failure? Good. Yeah. Good guys. Go back to the basics. Go back to the absolute basics. They've come in with a cough and they've come in with shortness of breath. If you have that patient in front of you, what are you going to ask them? Yeah. Good. When does it happen? Is there anything that's causing it? Have they, have they noticed their symptoms get worse, um, when they're going up the stairs when they, you know, exert themselves? Yeah. Good. Exertional dyspnea. How long have they been having the symptoms? Yeah. Very good in he, yeah. Do they use extra pillows? Yep. Yeah. Any other questions or shall I move on? Chest pain? Yes. Very important. They've got a cough. They've got dyspnea. Yeah. Very important to ask about associated symptoms. Like chest pain is the cough productive, dry. Yeah. Palpitations. Yes. So, um, fever, chest pain, all of these, uh, as a side thing are important to ask. Syncope. Yeah. You can ask all of these. Ok, if they were. Yep. Yep. So, that would be like the paroxysmal nocturnal dyspnea. Yeah. More for heart failure. Good. Mhm. Fine. Ok. I think we've covered like, a lot of the questions just give me one second guys and then we'll go on to um the next spot. Ok. So we've covered a lot of this stuff. So here I know this looks like a very extensive list, but I promise you all of this is important. Plus when you're asking the actual history, you don't realize how much you're saying as well. So, um don't worry that we didn't get a lot of this. That's obviously the whole point of the talk. So somebody mentioned, how long have they been having this shortness of breath? Obviously, very important. Is this their first episode? I don't think anybody mentioned that we need to know, have they had this before? Um Is this something they chronically suffer from? Is this the first time next one? Is this the first time admitted to hospital with this issue? If you've got an IEC O PD patient or um even ac a patient, sometimes you'll notice they've had multiple hospital admissions with that exact same complaint. They could literally the amount of times you'll see someone who's come in maybe a few months ago and had um the exact same complaints and then you'll see a chest X ray from a few months ago. Um And it's just like, it's so obvious that this could be possibly what we're looking at again. So this is why it's very important to know have they had admissions for that problem before. So a lot of the times what you can do is you can go into their previous admissions just on like on the internet, on the um like every hospital is different, but you'll have a way to see basically. And then you can see like um maybe a discharge summary of their last visit and on that it will show you. Yeah, they came in with this, they were treated with this whatever. Um So yeah, that's a very important point. So we need to know their past medical history. Do they have known CO PD? It would be a huge giveaway if we know they've got a known CO PD. This could very well be an exacerbation of that CO PD. If they're a known asthmatic, this could be an acute asthma exacerbation. Do they have a history of malignancy if it's somebody who's quite elderly? And they've got, I don't know, like, um, maybe liver cancer and they've got, um, known metastases, like, could this be related to the known Mets that they've got in the lung, giving them that dyspnea, giving them that cough, for example. So, again, important to know past medical, um, what medications are they currently taking at home? Sometimes just looking from their medications, you can know what they have if they're on steroids at home. If they're on antibiotics, like that's already giving you some, some ideas of, of possible po possible things that they could be suffering from? Ok. Have they been seen in hospital previously or have they been seen by the respiratory clinic because this patient is presenting with what could be, obviously, it could be cardiac as well. But we're gonna rule out rest like mainly like first. So unless obviously they've got really obvious like heart failure signs, they've seen, they've been seen by heart failure nurses, whatever, then you can go down that route. But have, if they've been seen by the rest clinic before, then that's something you need to look at. So because when you present, for example, if you're in A&E and you are presenting this to the consultant, they're gonna say, ok, have they had this problem before? What was done because, ok, yeah, they've been seen by the clinic. But what actions did they put in? Did the clinic put in? We're going to start them on XYZ these steroids, these antibiotics and the clinic might even have given a follow up. Um Like if the patient deteriorates, we will do this if they like, they might give you some advice which you could follow during your clerking or which the consultant will want to know about. So make sure you check um old hospital clinic letters. Ok, if they have a known disease. So how do they routinely manage it at home? So what I mean by that, is it medicated? Are they on just medications alone or is um some patients have like um a CPAP or a bipap machine at home? So that's um, like what we call noninvasive ventilation. So some of them, like they self administer it, they're completely fine managing their, um co PD, their respiratory diseases at home. They've got the machines, the technology at home, they're, they're compliant. The family knows about it. So it's important to ask how they manage their disease at home. Um Of course, do they smoke? Which we didn't mention, but it's extremely important question that is very related to a lot of um lung pathologies. Cap COPD, especially, um also malignancy. So make sure you're asking about their smoking also. Um Something that we spoke about last week with the heart failure topic. So how far can the patient walk before they start to feel breathless? This is important, not only like to, to know what the, what the disease could be, but it helps us to establish what is the baseline. So if they say at home, I'm able to completely walk independently. I don't need a frame, I'm completely fine. And then in hospital, they, I don't know, maybe let's say like worst case scenario, they've, they've been bedbound, they, they can't even get out like physio can't get anywhere with them. So that's showing like quite a big deterioration in their baseline. And obviously our aim when they're in hospital is to bring them back as close to their physical cognitive baseline as we can. Um, within reason, within reason. Um If it's something chronic, like you can't expect one hospital admission to, to suddenly correct everything. So within reason, um, but definitely like our aim, especially if they've had like, like maybe slightly reduced mobility if we treat them and they start to feel better, which a lot of patients will say they do after a few days of their management, they'll say that they're feeling better. And then obviously you've, you've successfully gotten them close to their baseline, but this is very important, generally speaking, um to know where they're at, consider that age. So, um sometimes like maybe asthma exacerbations, it could be in somebody who's younger, not always, but it's important to consider the patient's age if they're old frail, like um they're very like prone to infections as well. So that's just another thing to bear in mind most of the times from what I've seen anyways in these um respiratory diseases, it's usually more elderly and geriatric patients you're dealing with anyways. Um Yeah, I think somebody said this question. So are they producing sputum, what color is it? How much are they producing? Um Also very important, any associated symptoms which somebody mentioned. And I think I touched on this earlier, but make sure you check the GP records before you see these patients. Sometimes you'll go right and you'll have all of these questions you want to ask and the patient is maybe they're delirious, maybe they're confused, maybe they're like poor hearing. Um Honestly, the amount of times this happens, it's, yeah, Um, so then you won't be able to get like the best history out of them. So it's important to look at all of these things typically when you're larking. Um, I think we Anisa did it in the first talk as well. You, you will already have such a good idea of what's going on with the patient before you go to see them purely based off their medical history, what A&E have said and their GP record. Um, so look through their record, see what repeat medications they're on. Look at their past medical history, look what clinics they've seen all of the things I've mentioned before. But, um, yeah, like make sure, you know, as well when you start a new hospital, how to access the GP records because that's, that's very important. So you can be like best equipped when you're seeing a new patient because you can't, you're not always going to get that perfect, amazing history. A lot of the times they'll be elderly. Um, yeah, yeah. Um, they might have a rescue pack prescribed from the GP. So, um, what I need to mean by that is sometimes the patient will feel like they, they might have that exacerbation in the community. Ok. They might be having that cough, that shortness of breath. Um, and then they might have seen the GP and they might have given them like five days of, um, medications like steroids, antibiotics. We're gonna go over medication anyways. But if the GP has already prescribed them some, you don't need to give them the full course, you can just give like what's left. So if they've been prescribed two days already, you just need to give them three days and they should have already had those two days if that makes sense. Um But yeah, I think we mentioned that as well at some point. Ok, I hope that makes sense. Any questions just pop in the chat. So now moving on to physical exam. So what are we going to look for on the physical exam? Excuse me? So in like, so we're going down the lines more of respiratory here. So in rest cases, how, what, what sort of assessments do we do on patients to assess the respiratory system? Yeah. Mhm. I hold it. What, what, what sort of sounds can we hear on a quotation? Mhm. Inspect the trachea? Is it central, is the tracheal deviation? Yeah. Good. Yeah. One of the first things is um is there equal chest expansion or is there more expansion on one side? Yeah. Use of accessory muscles. Ok. So basically when you look at them from the end of the bed, how do they look from the end of the bed is an important question. Um How are they using their accessory muscles? Um crackles usually bilateral. Yep. Yep. So do they have crackles? Um symmetry. Yeah. Is there a wheeze good. So wheeze crackles any other um chest sounds. Yeah, and this is help for you guys. Yeah. Creps, which is, which is crepitations. Um We'll get into that as well. Anything else guys from the Yeah, to slip inspect per Yeah. Good. Ok, I'll show you guys what we've got here then. Um Yes, just have a read of that, just giving you. Ok. So in the physical exam, bronchi as well. Yeah, good. So in the physical exam for us patients, we'll do the typical. So we'll it's called like an end of the bed. So we'll assess the patient from the end of the bed. So I think somebody mentioned, are they using the accessory muscles? What it means by that? Are they having to use like their um trapezius, stenocladum mastoid? Do they look like they're like really visibly struggling for basic breathing? Um Do they have signs of labored breathing? Do they appear in respiratory distress? Are they having any abnormal airway sounds? So remember from the A two E, do they have like grunting? Um abnormal breathing? Sounds like, could there be some obstruction there? Are they cyanotic? Very important? Are they sometimes you'll go and you'll see these things and they seem ok on the exam. Um And then when you go and talk to them, like they're literally struggling to get full sentences out if that happens, make sure you write that down guys. Um like the patient is easily tiring, not able to complete full sentences like all of that is part of your um examination. You might think it's like trivial and not important, but you should absolutely write it down. That's part of your exam. Um is that equal chest expansion on both sides on inspection and palpation? So, um the main thing, to be honest with the rest of the exam is looking from the end of the bed and then going straight to chest expansion and a quotation. Those are like the main things um flapping tremor clubbing. Yes. So like a lot of these things like we in practice, to be honest, I'm not sure um in niece's case, but to be honest, like most of the times we will look more like if the patient has clubbing and is very prominent, I would say yes. But otherwise sometimes like you won't always notice these things or they might not be as obvious, like I would say as a junior, especially like just get good at um like knowing like to auscultate them, knowing who really does visibly appear sick and somebody yeah, like knowing who you want to ask. Um sorry who you want to escalate and ask her to. Um because obviously as a junior, your main thing is I need to look at this patient, I need to manage them until I see them again with the consultant. And if there's anything acute that I'm really worried about, I need to speak to my or speak to a senior as soon as possible. Ok. Um So yeah, on a quotation. So there's a few different things. Um all of these um you guys will hear at some point, I can assure you. So first one is crackles and I know like sometimes it can be difficult like in med school, like you, we don't really see patients that much and it can be hard to identify chest sounds, but the more, the more you listen to, I can guarantee you, um you'll get better. And also guys, this is like a little tip. Um Sometimes the patient will have been seen like if you're in um A&E, so usually they'll be seen by A&E team, ok? And then they'll discharge them and they'll say, yeah, the medics can see them. So sometimes the A&E team might have put, oh, they're very wheezy or something and if you're on like quite comfortable or maybe you wouldn't have recognized before that it's a wheeze and they've put in the history, it's wheezy when you auscultate them. If you can like also hear that wheeze, make like a mental note and then at least you'll know for yourself for all of future reference how a wheeze sounds and I can guarantee the more you listen to chass like the better you will get at it. So, um don't worry too much about that. Um Obviously just know what's clear and what's not? Ok. Um So yeah, is there any crackles? So crackles suggesting fluid. So, could this be heart failure or congestive or could this be um a cap and fluid? So cap is community acquired pneumonia. Um So that's like crackles. So, as your, he said, so they can be unilateral, they can be bilateral as well. Are there reduced breathing sounds? Could there be some consolidation? Could the patient um do they have a wheeze? So usually it's like an um expiratory wheeze but um some can have an inspiratory wheeze as well. So, are they wheezy important, important to mention that? Um And do they have any crepitations? So, crepitations, you can hear them um a lot in CO PD because the pathology of CO PD is um like when you have chronic bronchitis. So it's an obstructive disease by default, right? Obstructive airway disease. And in chronic bronchitis, you'll have that inflammation and there will be a lot of sticky mucus accumulation. So that sticky mucus when that builds up, that is what you, why you hear the cramps. So again, like these, these um couple of sounds are like the most common things that you will hear and als always make sure that you're not just looking at one side, you're listening to both and like, don't be scared to ask the patient like to keep breathing in and out, like really make sure you get comfortable with examining them and doing your best with that. Um Yeah. OK. I think we can move on to that Ok. Next question. So, what investigations should we be doing in these patients? So, we're, we're suspecting. Maybe they've got AC O PD exacerbation. Maybe they've got a cap, what, what sort of investigation should we be doing in these patients and why? There's no such thing as a silly answer. Just whatever you're thinking you can just put it down. Yeah. Sputum culture. If they're producing Sputum. Definitely chest X ray. Blood and swing cultures. Yes. ABG. Yes. Very good. Oh Yeah. Very good. Legionella urinary antigens. Very, very good. Thank you. Somebody said bloods as well. Yeah, good. So FP CCR P for infection. Very good cultures. Yeah. Um chest X ray, ECG to rule out cardiac cause is very good that you mentioned the E CG as well. That's important. Mhm Because then even if later down the line, the patient deteriorates, at least we've got an ECG for comparison if you don't take that EC G there. Um and then later on the patient like gets worse or something, you're not gonna have something to compare to. You might have one from years ago um or you like, you're not in trouble but it's just good to have the ECG. So you've got something for um like the most recent comparison. OK. I think we've got the majority of them. That was good. OK. So um we're going to order a chest X ray. Um we'll order an ABG as somebody said, full blood's good. Somebody said sputum culture. Um Yeah, this is an important, like additional thing to mention a lot of patients, they might come in and be presenting as septic. Um and then they might have an underlying. So they're, they're presenting with infection, but it might be secondary to um another pathology. So it might be sepsis secondary to a cap or sepsis secondary to um IEC O PD. So it's important that you always have um sepsis in the back of your mind because like um obviously with the government as well, like how big of a thing sepsis was and how many people it can kill. Like it's always important to have that on your radar. So, can anyone tell me what the sepsis six are? Yeah. What exactly? Yeah. Take three, give three. But what? Yes. So give um oxygen usually high flow, give IV fluids, give antibiotics. Usually they'll be broad spectrum antibiotics. And then when you've taken the cultures, you can switch the antibiotics depending on the sensitivities that come back from the cultures. Very good. So those are all what you give and then you take a urinary output um in the form of a urinary catheter. Usually um taking a lactate good and also taking blood cultures. Yeah. Very good. Very good. Thank you. Also, just to mention as well, a lot of nurses um will, will keep um sepsis very. What's the word like? Sometimes they'll have already started the sepsis six when you come, like, you might just need to do um cultures and the lactate, for example, like, they, they'll already have started them. You might need to prescribe the antibiotics, but they'll already be starting like the oxygen um asking you to do the fluids. So it's not like, um, because when nurses do observations, um, like they do regular news scores, regular observations, so it might flag up there. Oh, this patient could be preseptic and then they'll come to you. They'll be like doctor like this patient could have sepsis. Um And then obviously you can like quickly look over the notes, look at the vitals and if it is um that that's the case, then you can um begin the sepsis six. But yeah, like just to mention that nurses are also very aware of this and we'll usually begin um with the 76 as well. Ok. So going specifically to pneumonia now. So um I mention cap a lot. So cap is community acquired pneumonia and cap is hospital acquired pneumonia. Obviously, the difference being in the name one is when they've recently been discharged from hospital. So it could be hospital related. One is purely in the community, so not hospital related usually. Um and we'll go into management for that later as well. So typical pneumonia findings on the chest x-ray, it will usually show some form of consolidation or some kind of hazy opacities. So you guys can see here, I don't know if you can see my pointer, but where the arrow is this area, um this patient in the right upper lobe has got like consolidation. OK. So um we call it like dense opacity or you can call it a hazy opacification. Um And the next point is always try to ha um compare to an older chest X ray because um a lot of the times this patient has been coming in for the same thing. So, um or sometimes they'll have a normal chest X ray previously and you can see like how bad this one is in comparison. It's um like consultants will usually ask you, do we have a previous one for comparison and they like to see it side by side. So it's just something to have in mind. Um We already mentioned with disputing culture and then we can wait for the results and we can switch them to a better antibiotic. What I mean by that is it'll come back saying that this um this microbe is um resistant to, I don't know Clarithromycin or something. So if you're giving Clarithromycin, like it's not gonna be very helpful. So, but they're sensitive to Coamoxiclav or they're sensitive to something else. So then you can switch it to whatever they're sensitive to, which will um help hopefully to make them feel better. OK. Um But like I said, usually you'll start broad and depending on the results, you'll switch to more um narrow spectrum antibiotics. Ok. Um We will also on the bloods. Um somebody mentioned blood, so we will monitor the C RP, we'll monitor the white cell count and also the neutrophils. So whenever you get a set of bloods, ok? And you're thinking about a bacterial infection. So PAP is bacterial, right? So if you're thinking of some bacterial infection, the CRP obviously is a key marker for inflammation. But if you're thinking bacteria always look at the white cells. If they're high. Again, that's like alarm bells for bacterial and especially neutrophils. If they are high as well, then it's like a giveaway. This is likely um bacterial etiology and the consultant will always agree with you if you say that. So they'll, they'll be happy if you're pointing out these things because that's like literally what they're looking for as well. Um And then in viral, if you're suspecting viral infection, like um if somebody's come in, maybe they've got a query flu, um you'll be looking and they'll usually have reduced lymphocytes and that's like a telltale sign that they could have like flu or some, some viral pathology going on. OK. And then also consider the need for viral swabs and urinary antigens. So we have like a set panel. So it'll cover HIV legionella, pneumococcal respiratory syncytial virus. And then especially now in this uh in the winter period, we all to cover flu and COVID. So this isn't something you guys have to do. You'll just have to print off the forms a lot of the times or you can just tell the nurse, like, um can you do um a COVID sample or can you test this patient for flu and they'll just do that quickly? It's just a quick respiratory swab. Um But again, it's, it's good to ask for that. You don't have to do it in every single patient, but it depends, obviously, like, obviously now with it being winter, if you've got elderly patients with a lot of these signs, I would say you can do it. Um, things like HIV, like take it depending on your clinical judgment. And if you think th if this patient's becoming in a lot for the same thing, you might be thinking, is there something else underlying, are they immunosuppressed and maybe, then you'll want to do like all of these atypical antigen screening tests? Um, but yeah, again, you don't have to physically do them yourself. You just print out the forms and give it to one of the nurses. Ok. Next thing. So now we have the C 65 score. So does anybody know what this score is? Um, any ideas what any of it stands for would be good to know we're gonna cover it anyways. But does anybody know? Oh, and what disease do we use it? Mhm. Yeah. It's related to pneumonia. Definitely. Yeah. Yeah. So, basically, yeah, it's like a combination of those two answers. Let me show you guys, ok, so the curb 65 score is when you, when when you're thinking pneumonia for a patient and you want to explain how severe the pneumonia is. You use the curb 65 score. So this is just like a score that we talk about and nobody really uses it. Like this is very like if you're thinking pneumonia, this score should absolutely be something you're thinking about in your clocking. Um and mentioning as well, it's all about like covering yourself as well. Like I'll go into that anyways. So C 65. So it stands for confusion. Um Urea nitrogen, more than 19 respirate above 30 systolic BP, less than 90/60 at age over 65. So you absolutely don't need to know all of this off by heart. Just go on um MD CALC, which I've recommended a lot to you before. Um and just go on the curb 65 score and then if they've got it like each one is one point and then you can um like tally their total curb 65 score and then um use the algorithm on the right. So basically um it says here, so you'll use the confusion, the respirate blah, blah and then if they've got ac 65 score of zero, this is OK. I don't think we have it on ours. So I think it depends what, what trust you're working on as well. Um That's good. To know it would be helpful to have it. So yeah, if they have, if they have a like low low curb score like zero, then they like suitable for home treatment. So you could start them on treatment and they could go home. Um The next score is ac score of one or two, they might need hospital referral and assessment as well. And then ac three or four, this is high mortality, urgent hospital admission. So that's what the algorithm says. OK. But I would say, and I think a degree as well that you should always use your clinical judgment with this. So somebody might have ac score of one, but they might be very sick. They might be like um constantly requiring oxygen or um maybe the query septic. So their clinical condition might not reflect on their curb score if that makes sense. So if you genuinely feel like they are very sick, you could put like c score one. So usually like with a curb of one, you might on oral antibiotics. OK? But you feel like this patient's CRP is extremely high and you think they benefit more from IV antibiotics. So as long as you're documenting clearly, why you're doing something and why you're worried about this patient, nobody will say anything to you. And if anything, they'll be happier that you started them on the IVS because you can always switch from IV to oral. You can always what we call them down from IV to oral medications. OK? But at least if you start them on IV and if their clinical condition improves and they do get better, you've used your clinical judgment and you've helped um that patient. I hope that makes sense guys. So, C score is a very useful score and in terms of the algorithm, use it with a pinch of salt, always use it alongside your own clinical judgment. Um Yeah, I hope that makes sense. And if I, if I'm going too fast, please let me know. OK. The next thing we're gonna do is we're gonna talk a little bit about ABG S. So I know that um a lot of you may not have done ABG S like when we studied abroad, but when we come back, like I can guarantee you the amount of ABG S that because it's not something that nurses do. It's usually always what the doctors do and nine times out of 10, it'll go to like it's a junior job. So um if there's one skill like to like slowly like watch videos, um get more confident, it's a B GSI would say, especially if you work in emergency medicine, obviously, blood stuff. Yeah. Um Definitely ABG S as well. So um make sure you've watched a video, make sure you understand the general procedure. It's extremely straightforward guys. Um and male CS. OK? Um Yeah, it's extremely straightforward and once you've done one or two, like, you'll be completely fine. Um I was in like um A&E and one of the consultants was like, um go do this ABG and I'd never done one before and I was absolutely terrified. So I just went to one of my colleagues, like, um somebody who I assumed had a lot more experience than me. Um And I just asked him like, I've never done this. ABG. Could you please help me? Um So then we went together to see the patient and he explained it quite well. So obviously, like you'll, you'll go um in the area and he basically explained, like you need to palpate the pulse. So um like palpate the radial pulse, make sure you can feel it if you can't feel the pulse, right? Don't, don't try to go for the ABG, like if they've got a weak pulse and you're not 100% sure. I always ask a senior to do it. Um But if the patient's got quite a strong pulse and you're quite confident, then you can go for it. That's the main tip I would give with ABG S. Um And after that, like it was OK. So just um make sure, yeah, or you can do a VBG as well. It depends because like in my case, like he said, um like this patient was having um I think he was thinking about breast failure and he had COPD. So in that case, the consultant was like do an ABG but if you have an option to do a VBG, yeah, do a VBG. It's easier. Um But I'm just saying like because in our choice, a lot of the nurses could also do VBG S if you asked. Um But yeah, like it depends on what's the situation at the time. But if you are asked to do the ABG, like try and get like confident doing those. Um Yeah, so as it says here, so they're usually often done in acutely unwell patients to monitor their condition. So if knowing how to interpret them is important, but again, you can always ask for help if you're not completely sure about the ABG. OK, so the interpretation that I'm doing here is exactly the same as the A S interpretation. Um I think it's a very good approach that they use. So I've used the same one. So the first thing is how is the patient? So you need to know a little bit of a brief history context. So what did they come in with? Did they have coughing shortness of breath? Are we, do they have a history of COPD? Is that why we're doing this? Have they recently had a cardiac arrest? Like because that can give, that can already give you some idea if we're expecting them to be acidotic or alkalotic. Um If they've been having really profuse um severe vomiting, again, that might give us an idea if they've been on loads of opioids that might help. Also, it's it's good to have some general context. So the next thing are they hypoxemic? So somebody mentioned earlier about hypoxemia. So the the partial pressure of oxygen should be 10, less than inspired air. So roughly for reference, a room air is about 21% oxygen. So that would give us like um like roughly around like 8 to 10, something like that for oxygen like around 10. So if the patient, the main point to know with this, right, if a patient is on like a lot of supplemental oxygen and their SATS are low. So like 15, that could indicate some underlying issue even though 15 could be seen as normal if they were on room air because they're taking that supplemental oxygen and their SATS are still quite low. That's why that's in what case you should be more worried if that makes sense. OK. The next thing. So how is the Ph so normal is of course from 7.35 to 7.45. Again, you don't have to memorize these, they'll be on the um the the references will be there, but I think Ph is a good one to know. Um So the more acidic they are, the more the hydrogen ions, the more alkalotic, the less the hydrogen ions are present. So um go in this order. Um and you want hopefully you shouldn't miss anything. Next thing is you look at the partial pressure of carbon dioxide. So if you have an abnormal partial pressure of CO2, check the value and compare it with the PH. So what I mean? So if you've got someone who's having a low ph less than 7.35 so they're acidemic. OK. And they've got a raised pso two more than six, this is likely respiratory acidosis. So why is that? So obviously, they've got the acidosis because we've looked at the PH it's low. And then why is it respiratory? Because the P CO2 is high? So if they're retaining a lot of CO2, OK, they'll have um so if they're not ventilating as much. So, in cases where they're hypo ventilate, they will have um re retention of CO2 and then they'll end up with a high um CO2. I hope that makes sense. So like the ABG we saw at the start that was um as somebody said, like breast acidosis and a similar presentation to this. Um So yeah, and then on the flip side, if we've got a high ph like more than 7.45 so that's alkalemia. And if the CO2 is low, reduce P CO2, less than 4.7 that's likely respiratory alkalosis. Why? Because they're not keeping that CO2, they're blowing it off, they're getting rid of the CO2 faster than what we need. So, supply and demand, there is an imbalance there. So, did anyone have any ideas, like what cases we could see respiratory alkalosis. So there will be alkalotic and they'll be blowing off that CO2. So what like maybe just one example um of where they could have this if anyone has any ideas. Yeah. Good. Yeah. Yeah. Yeah. So in those cases, that's OK. So in those cases because they're going to be what we say, hyperventilating, right? So anything, basically anything that causes excessive ventilation, they can present with a spiritual alkalosis. So, anxiety pe Yes, absolutely. OK. Next, we would look at the bicarb and the base excess. So if the PH is less than 7.35 um you, you should look, is there a base deficit or is the bicarb reduced? Um So basically, you know, we have like the base excess and normal is from minus 2 to 2. So if this patient is having um like a low amount of the base deficit and their bicarb is reduced, that's probably th that's clearly showing that there is some metabolic aspect going on here that's making them acidotic. So, metabolic acidosis, um obviously they could have some respiratory compensation but if their back up and the base excess are low um way out of range, then it's like primary metabolic acidosis. Um So like w when can we see metabolic acidosis? What, what are like the most obvious examples for metabolic acidosis? Yes. Good. Yeah. DKA diarrhea. Yeah. Yeah. Absolutely. Yeah. Divertic ketosis doses. Yeah. These are like, um, typical examples. Um, basically cases where you're gonna have excessive hydrogen ions and you're going to be, um, losing the bicarb. Ok. And then the next one we have ph, more than 7.45. So again, um, yeah, you can see it in like sepsis starvation. Um, things like that. It's, it's kind of related with the DK A as well. Yeah, you could, yeah. Um, so if they have a higher ph, um, look at the base excess, look at the bicarb, are they high? So if they're producing more, if this, if they have a higher Ph and the bicarb and these things are also higher, this is um, metabolic alkalosis, right? Primary metabolic alkalosis. Again, you can look for some compensation. But if the alkalotic and the base excess and that stuff is way out of whack, then you'll know it's more likely metabolic alkalosis. Um, again, does anybody wanna give like maybe one course, I know, I keep asking the same thing but it's because, um, this is why like the history will help you a lot and you can already explain. Yeah. Good man. Yeah. Vomiting. They can have profuse vomiting in metabolic alkalosis cases also like, um, certain medications like antacid use, they might, um, have a raised bicarb. Cushing's. Um, I'm not, maybe I'm not sure about that one, off the top of my head, but probably I'm not, I'm not 100% sure about that. One. yeah, the main one is like excessive vomiting, antacids, things like that. Certain medications. Um, yeah. Ok. So generally speaking, if the base excess is more negative than minus two, so it's like more like negative, it's metabolic acidosis and if the base excess is more than two, it's more likely metabolic alkalosis. Um, so that's step five. And then the final thing is to look at the other, other values because from a blood gas, you're not just gonna get the Ph the PC two, you'll also get electrolytes. So the, the good thing about a blood gas, you can get the results really quickly. Um Like you might be doing ABG S like literally every 15 minutes or every 10 minutes honestly. So, um just to see how the patient's doing, how they're responding to treatment, um making sure they're not deteriorating further. So, um it gives you a really quick idea of the electrolytes as well. So, are they hyponatremic? You can look at the potassium, the chloride, calcium. Also the hemoglobin glucose lactate. All of these markers are so important if they're um hypoglycemic, if there's anemia on there. Um a lot of CO PDC O PD patients, they can have um affected hemoglobin as well. Also the lactate, you can um make a note of that as well. Lactate, obviously being important for end organ um dysfunction and like it's a good marker of how unwell the patient is. Um They'll mention it in hand are actually like, oh they have a lactate of, I don't know, 10 or something. Um So yeah. OK. Next thing we're gonna talk about, I think a lot of people are familiar with this because they were mentioning in the ABG which was really good um at the start of the case. So um I know it's really close to two and it's a mix. Yeah, so I believe there's a thing depending. Um and easy. You can maybe explain this by me. But I think they look at the oxygen, the po two from what I've seen because sometimes they'll do an ABG and then they'll look at the oxygen, they'll say no, this is a um a venous sample. But um yeah, maybe at least I could mention as well about that. But I think you look at the oxygen level um to know whether it's arterial or venous, but I don't know the exact specifics of that part. Yeah. Yeah. You look, you would look at the oxygen. Yeah. Um OK. So type one versus type two RS failure. So um if we have a look at the top ABG. OK. So OK. So typic typical A BNA. OK. So this patient, um this patient has a ph of 7.29. So they're acidotic, right? And then if we look at the CO2, the CO2, um it's close to normal. OK. Um The SAS are 84. So they're hypoxic because um normally we're looking for above 90 right? So the S ATS are, they're hypoxic and then if you look at the bicarb and the base excess, so they're, they're more um like it's more negative than minus two. So they're producing less of the bicarb and the base excess. Right? So that's a metabolic acidosis. Ok. But because the CO2, um because the CO2 is normal, this is classed as a type one respiratory failure. So the the main difference when you're going between type one and type two resp failure is looking at the um CO2. So type one will be what we call normal capn. The main issue for type ones is they'll just have that hypoxia. OK? Whereas in type two, if we look at the ABG below again, we've got acidosis because normal is 335 to 45, right? So they've got 12, so 7.12. So they're acidotic. Also, in this case, the CO2 is high, a value of 8.5. I know we don't have the references here. Sorry about that, but a value of C uh 8.5 is high for the CO2. So this is a CO2 retainer. And um so this is what we call like hypercapnic um respiratory failure. And that is the definition like type two respiratory failure. So type two resp failure, there will be hypercapnic, high CO2 and there will be hypoxic as well. So low CO2, sorry low oxygen, high CO2. Again, their SAS are OK. They're 92%. It depends if they've got known CO PD and it says here they've got known CO PD. So if they've got known copds ATS 88 to 92 are acceptable for that patient. So that's what we call scale two or type two resp failure. So if a patient has type two resp failure, we will keep their SATS usually between 88 to 92%. That's their target um saturations and we'll put them on what's called scale two. OK. That's what that's talking about. So you might hear a lot men, that's what that means. Um And then if they're on like um scale one, it's just like the normal one like aiming um roughly 94 to 98% sats. So obviously, um this first patient is very hypoxic and will need like more um like a high flow supplemental oxygen as well. But I hope that makes clear the difference between type one and type two resp failure. Um And what like what, what the meaning and how that will reflect on the ABG. OK. Moving on to management. So just off the bat, can anybody say so maybe like for ac or for asthma or CO PD and any of them, what sort of medications will we use? Um And what are the key if, if you know of any of the differences? If not, it's OK, you can just give, like, the medication groups that we typically use. Um, and that would be fine just to see, like, what your understanding is for that part. Like, how can we manage, um, like a cat, for example. Yeah. Inhalers. Yeah. What else? Yeah. Good. Antibiotics. Mhm. Very good steroids. Yeah. Good. We've got the main ones. Thank you guys. Um, yeah. Co Amox Antibiotic. Yeah. Oh, so I've got some criteria and then we'll go to the management. Sorry. Um So what criteria do we use when keeping patients in hospital? So as a rule of thumb, generally we consider emergency admission in patients who have severe breathlessness if someone's extremely breathless and you're not sending them home um inability to cope at home. So they've got these symptoms and they're also not coping at home. That's a very important one, especially if they're elderly and frail. We, we have a duty of care. We can't just put, throw them back into the community. They'll just come back in again with the same admission. OK? Um Poor or deteriorating, general condition and significant comorbidities. So if they have a lot of the times in elderly patients, you're not going to be treating them for one thing. You, you like they'll have 11 thing and then they'll have like comorbidity, heart failure, pacemaker, all of these other things. So you're not just treating what they have at the moment. You're making sure that you, you optimize the management for the other diseases as well. Um Let me just see. Yes, long term oxygen therapy. Good also. Um Cortisone nebs. Yeah. Yeah, absolutely. All good suggestions. Thank you guys. Um Yeah. So also if they have rapid symptom onset, so if this is a sudden exacerbation, a again, we need to keep an eye on them because that could get worse at any point if they have acute confusion. So some patients, if they're very elderly and they've got chronic confusion or chronic um dementia, we can't expect them to make a full 360 in hospital. It's just not, it's not possible. Um But if they're acutely confused, they might come in with a next of kin who says I've never seen them like this before. They're so confused. Um Then in that case, you might, you might want to keep them in do the full um confusion screen. Yeah, delirium. Yeah. Um You do the full confusion screen, you'll see what's causing these symptoms and this confusion. Um, cyanosis if their um oxygen sites less than 90 or if they're requiring oxygen. So if they have a new oxygen requirement um in hospital, you need to keep them in as well. Also, if they've, if they've had um, so what we call like refractory symptoms. So if they're not responding to conventional therapy, um or they're having multiple admissions and they've already had conventional therapy. Um, or maybe they've had like a rescue pack from the GP and they're completely not responding to it. In all of those cases, we're going to keep the patients in. Ok. So this isn't like the only criteria, this is just like a general rule of thumb um for you guys to understand, but again, use your clinical judgment as well. Um But this gives you like some idea because I feel like a lot of these things unless we speak about the, you wouldn't, we wouldn't know like I wouldn't know if somebody's got acute confusion. Like I'd just say like, yeah, they were confused or something like I wouldn't always know that's the reason we need to keep them in. So um and also like the inability to cope at home like in the UK social um admissions are such a big thing. Um and making sure you don't just dump the patient back into the same condition like a lot of the times there's entire wards dedicated just for elderly people on social admissions um where you're still waiting for a package of care. So um they're very big on that here. Yeah. Ger geriatrics. Yeah, exactly. Ok. Ok. Similarly, so this is criteria, general criteria for discharge. So when we say weaned off oxygen, it means that they had an oxygen requirement, we kept them on oxygen and then slowly, slowly we reduced their oxygen and now they're, they've been off oxygen for um a good period of time. They're no longer symptomatic. That's, that's what its class as they've been successfully weaned off the oxygen. Um We'd also look for stable ABG S so um not like really, like really thrown off acidotic alkalotic good CO2 now. Um Yeah, we'd look for that. We'd look like they've been off their nebs for at least 24 hours um or at least for a good period of type. Again, you don't have to make these decisions guys, like for um criteria for discharge, usually, the consultant will say I'm happy to discharge this patient based on XYZ criteria. Um And you just go with that, like the, the consultants always going to us usually, um they will give their management um especially as juniors, like we don't really have to make those like big decisions. Um Also if they've been stepped down to oral. So if somebody's on IV, obviously they're not going home, you need to make sure they've been switched down to oral and that they're tolerating the oral. OK. Um And also are they at their baseline physically or cognitively within reason, as I said? Um Yeah, these are some of the main criteria that we look for. OK. Now going on to um management. So for CO PD and asthma, the management is more or less identical for um exacerbations. OK? So it varies. So always make sure you check your trust guidelines. So um I know like, like we always say that but you literally just log on to your computer and the first thing that will come up is the internet and you can literally just type in. So internet is like specific for every hospital. OK? Each trust has their own like guidelines, everything um collated into this internet. So you can type in like CP or um co PD exacerbation and it'll give you the guidelines for your trust. So if you follow those, obviously, you can't go wrong if you're not sure about something, you can cross check it with the B NBN F. But nine times out of 10 people just use the trust guidelines. OK. So generally for COPD asthma, we'll start on beta agonists. So this is the inhalers we were talking about. So um we'll start on um salbutamol. Um It might be P RN. So P RN means when the patient wants, when the patient needs, um they can take the or you might have the patient in, in my trust. We've used like what we call back to back nebs. So keeping them on constant nebulizers, basically. Um this is used usually in extremely, extremely unwell patients, uh very hypercapnic, very acutely unwell. We use them then. So yeah, beta agonists are usually like one of the cornerstones in these patients. Also ipratropium bromide. So this is again, another nebulizer. Um yeah, always push nebs. OK. The next thing is steroids. So um usually we'll go for oral um steroids. So 30 mg. Um po is oral prednisoLONE OD is once daily uh and it's usually a five day course, obviously with it being steroids, you need to be really careful if you're not sure about anything. Always check your trust guidelines and go off the course that they've said. Ok, like usually for steroids, there'll be a short course. You don't want to keep them on that for a very long time. Ok. Um So yeah, if they're having breathlessness and it's causing interference in their daily activities, we'll also give them steroids. If they're um producing sputum as well, you can consider antibiotics or sometimes people will just generally start them on antibiotics as well. Um Again, check your guidelines, but what I've seen is first choice usually amox um 500 mg, TD S3 times a day for five days or DOXY 200 mg on day one and then step it down to 100 mg daily for af for the rest of the five day course or Clarithro BD twice a day for five days. So know is how most of them are like five day courses. So always make sure you're not just going for a week or two weeks, like make sure you're checking the duration. It's important. Um This was what the Anissa mentioned earlier about the rescue pack. So if they've had a rescue pack prescribed, they won't need the full five day course. You might just need to check how many days they've already had from the GP and prescribe the remainder Ok. And then the most, most important, please make sure you ask for allergies. So, allergies, you can see them, um, for us when we go on E PMA, like on medication prescribing at the top, you can see if they've got allergies also in the clerking. Um, you should be able to see if they've got allergies as well. So definitely make sure, or you can check the GP record or ask the patient, like there's so many different ways to check the allergies. Um Sometimes the patient might not know, like if it's an old one, they'll just be like, oh yeah, I assume so. And then you will check the prescribing thing and they have like a penicillin allergy or something. So as the patient, we'll also check as well, um cause you do not want to be prescribing them something that they're allergic to or they've had a reaction to in the past. Ok. Um I apologize about how small this is. Um So this is for acute asthma exacerbation. So this is not the same as the previous slide that was just like for people who are having. Um So it was like IEC O PD and like a general asthma presentation that was that management, this is in like acute asthma exacerbations like the ones which are like neo ftal, severe life threatening in those cases. We use these, the reason why I'm not gonna dwell on this too much is because as a junior, you are, like, I'll be honest, I haven't seen this at all. Um, I haven't managed an acute asthma attack in Ed because usually this will already have been managed by paramedics and by the emergency team straight when the person comes into hospital. And because I'm, I'm not, I'm not the emergency team, I'm the medics. Like once they've seen emergency, um, usually this patient will be escalated to a senior, like a reg or somebody more senior. Um And you won't really have to be, um handling them. That being said it's still important to know what the main medications are. So, um I'll make sure that I put this on the recordings that you guys, I'll send the slides as well so you guys can have a look. Um I just search like a L SA LS has got a really good section in their book. Um, if you wanna have a look at acute asthma attack, but a lot of the management is similar. It's like steroid therapy, higher doses, et cetera. But um I just wanted to mention that like as a junior, you usually won't be seeing a lot of these cases. Um If any, it'll be the previous slide or a cap or something. Um Yeah, it's usually more senior. Ok? And then for community acquired pneumonia or cap. So typically we'll do the curb score like we talked about before curb 65 score, we'll start them on their antibiotics. Um So usually what you'll do, um, you'll see, you'll go see the patient, you'll see them with the consultant. They'll say I want you to start this is this medication? So you'll go and you'll prescribe it on the, um, prescribing system and then just mention to them nurses, I've prescribed this, uh, I prescribed meds and fluids for this patient. Please. Can you um, give it to them and they'll happily do that. Ok. Um That's just like how it works because I always used to think like they'll be prescribed it and then what like how do I make sure they're getting it? Like you just mentioned it to one of the nurses. Um In A&E I found that the nurses are very good, generally speaking, um very helpful and very on it compared to what? So um yeah, um you might want to do a sputum culture if they're productive, producing sputum. So again, just print the form, give it to some one of the nurses. Um and the exact same thing for the viral swabs antigens. You just need to make sure you're printing the forms. It's a lot of admin. Um But yeah, that's, that's junior doctors for you. Um Yep. Ok. So this is the medical management for a lot of different types of pneumonias um and a lot of different types of infections. So these are um like one trust guidelines. So I would say always just refer to your old individual trust guidelines. This is just one for reference. So typically for ac um I hope you guys can see it. Ok? Or maybe like just zoom in a bit. Um But usually for community acquired, we'll do the C 65 and if it's mild, we'll go for Amox or if they're allergic, we'll go for Clarithro or Doxy. So it's the same as the other slide really. If it's moderate again, we'll go for amoxicillin plus Clarithro. Um, and if they're allergic, we'll go for the other options and if it's very severe we'll go for Comox. Um, plus, uh, Clarithromycin. Um, so, yeah, bas basically each, depending how severe the pneumonia is, the medications will change. But it's usually a variation of those medications which we talked about, um, for community acquired and you just need to prescribe them exactly as the guidelines say and tell one of the nurses. That's it. Like, it's, it's not like too difficult at all guys. Um, yeah, so this is for a trust. Um, we use your individual trust guidelines. This is just like I was giving you an example. So you're not like, ok, what medications for reference? Like just as a rough idea, but again, use your own specific trust guidelines. Um, so that's for a cap and then if you, um, if you were recently discharged, if the patient was recently discharged from hospital, um, I think we've said like roughly like a week to 10, if they've had a recent discharge. Um, then we can say it's a hap hospital acquired pneumonia instead. Um, and in that case we'll follow slightly different meds. Um, so if it's mild, moderate severe, we've got other medications that we use. Um, a lot of other times it's similar, but in the severe one we would go for like a pip taz. Um. Yeah. Sorry. Yeah. Or if they've been in the hospital a few days then it'll be a hap as well. Yeah, thank you. Um, so that's cases for hospital acquired pneumonia. Um, and then we have like, if you're suspecting in patients, you know, thinking that they've had an aspiration. Um, I personally haven't seen this but I know a niece said she's seen quite a lot of it. Um, she's seen a lot of the aspiration types, I think maybe like if you've got um, elderly patients where, um, they're struggling with swallowing or maybe like query stroke, uh, maybe in those cases, like you can see more aspiration type pneumonias. Um, so again, those are treated with slightly different antibiotics. Um, yeah, so it's just like you can, you can zoom in on this basically and have a look what they treated for and then the others are not relevant for us. That's cellulitis and uti S. Um, and how you manage that. But, um, I hope that makes sense. So basically you'll always have guidelines that you can refer to. Um, and they'll break down each of the individual types like community hospital. Um So basically, when you start, just make sure you know how to access the trust guidelines. Um and just have a fiddle around, make sure you've seen the most common ones, I would say this. Um knowing these particular ones is quite important, like knowing where to see these cause you're gonna see a lot of cellulitis, a lot of caps, um a lot of UTI S. So this is quite high yield for this, I would say. Um Yeah, I hope that makes sense. Ok. And then just to finish guys kind of tying all of our management in together, um for the final like management in the plan. So usually medical management. So you'll go with the consultant. Yeah, and they might say you need to prescribe IV co mo for this many days, uh, oral predone for this many um salbutamol blah, blah, blah. So once you finish seeing that patient, obviously you're gonna do the most important jobs, right? Always do your medications first. Your medications are a top priority um, in the patients because that like if you haven't prescribed something that's on you, that's, that's like that's your job. You need to do that straight away. So make sure that you're actively doing the medications for the patients. The next thing is ABG S again, usually doctors do them. So if the consultant specifically asks for ABG S, um, make sure you're doing them um, chest X ray, all you need to do for that is just go in the system. Um m make sure you know how to request imaging and order the chest X ray. Sometimes they ask you for clinical details, but if it asks you for clinical details, you you'll know them already because you've seen and clocked that patient. So just go um go through the clocking history and make sure that you can um give like some ideas for the because treat like when you're requesting a chest X ray, make sure you give all of the main reasons relevant. So yeah, you might, you, you talk about the cough, the breathlessness they don't wanna know like like don't give unnecessary information is what I'm saying. Make sure you're giving the most relevant details so that they can't refuse your chest x-ray if that makes sense. Um But that's another story anyways, I don't think I've had one refused but I know people who have. So yeah, um next one is EC GS. So um I think somebody mentioned earlier, always get a baseline E CG. It's a very good thing to have in case they have some cardiac issues down the line. Get a full set of bloods, including C RP if they've had any hemoptysis, get um coagulation. I nr make sure you're getting those bloods as well. Speech and culture. We said um consider a respiratory referral. So make sure also when you first start that you know how to do a referral. So each trust is different. Um What, what I've seen you just do an ere referral like an online referral. Um So you put in all of the electronic uh sorry, you put in all of the clinical details and it'll go straight to um the the relevant team. Um and sometimes they'll like randomly email you and be like, yeah, um we received this referral, we request this. Um So yeah, like make sure that if you have referrals, I would say they're another important job like alongside meds, if there's urgent referrals, make sure I'm putting in the relevant details um on discharge or if a patient's had a new asthma diagnosis or exacerbation, make sure you're mentioning that on the um discharge summary, like it's something that the GP and all future clinicians who will deal with this patient have to know. Um So make sure you put that down um in the plan, make sure you put what target sets you're aiming for. So this is that scale one, scale two. So if you're aiming for scale two, you're going for 88 to 92. So make sure you specifically write it down so that there's no confusion with the nurses because you're not gonna be the one who's going there and changing the oxygen doing all of that. It's the nursing team, right? So make sure you've made it very clear otherwise they'll come and ask you um also put that you're aiming to wean the patient off the oxygen. So if they've started and they've got an oxygen requirement, um then you can just put, once clinical condition improves, aim to wean off the oxygen because you don't want to keep patients on oxygen unnecessarily. Um Or for two extensive, extensive periods of time when it's not required. Um Another really useful resource is CO PD and asthma nurses. So if people came to last week, they'd know that we have um heart failure nurses, they're really good. Like to optimize um medical management. We also have COPD and asthma nurses. So they can be really helpful, they can come in hospital or they can see the patient in the community and they can be really helpful like with inhaler education because sometimes people are having constant exacerbations because they're not using their inhalers properly or they don't know like when to breathe in, breathe out when to pump the inhaler. So obviously, like as doctors, we've got a lot of stuff to do if you can explain it to the patient and you've got enough time, go for it, but some days are so hectic. Um you might not always have that chance. So this referral will always cover that um club score like we've said, um it is simple but put in the plan whether the patient is being admitted or not, usually the consultant will say I wanna admit this patient um viral swabs as we've said, if they're frequent attenders, very old, very young. Um It's something we've mentioned in earlier talks, I think in the very first talk Anisa, did she talked about feelings of care? Um Is this patient for full es in itu? Um Is this patient just for ward based care? Um Are they quite frail, would they not benefit from CPR? Do they have a respect form in place all of those things important to consider? Um And then just the final thing to be aware of if somebody needs further management for their respiratory condition. Um so they can go up to AM U which is like an acute medical unit. Um And then re obviously, if they've got a rest thing and you want rest input, respiratory can come to the ward to see the patient or if you've got enough beds and respiratory, this patient can be moved to respiratory because you've already worked out that it's likely respiratory causes for this patient. Like the bloods have proved it the symptoms, the chest X ray, the clinical history, past medical history, all of it has pointed to res respiratory. So um usually they won't say no in that case, but also if you've done ABG S everything else. Um Yeah, you can refer them to rest or rest. We'll see them on AM U. So um I think that is everything. Oh God, I forgot to put the, oh my God, that's so bad. I'm gonna go back to the first light. Um Sorry, my bad. So we're gonna go back to the case which I forgot to put in at the end. OK. So I know this is a bit repetitive. But if we could please um go back to this case again knowing what we know. So we've got this patient who's breathless with a cough. Um They've come in from an ambulance and this is their ABG. So what kind of questions are we going to be asking? And what are we thinking about this case? So let, let's go from the start. So what, what kind of questions on the history are we going to ask this patient? I promise we're almost done though. Sorry that it's a bit repetitive. Yeah. Onset of the breathlessness and the cough. Past medical history. Mhm. Do they have known? COPD? Yeah. Smoke. Very good. Very good. Yeah. On set. Yeah. Mhm. Any medications are they having the shortness of breath on exertion? Yeah. Good. Mhm. Chronic shortness of breath, predictive cough, sudden timing. Mhm. Wheezing progression. Mhm. Mhm. Yeah. ABG showing type two resp good. Um What did we say like about GP records? What was important to check there? Mhm. Past medical history. Yes. What else specifically on GP records? Yeah. Previous episodes inhalers. Long term oxygen at home. Good old chest X ray. Mhm. Yeah. Rescue pap. Mhm. And also remember um if they've been seen in all of the um clinic in, in all clinics and stuff as well? Ok, good. OK. Moving on guys. So how would we manage this um patients? Let's come up with a bit of a plan. So how are we gonna manage this patient? What is our plan? So remember like the last stuff we talked about medical stuff, just whatever you can remember if you can jot that down. Yeah. Oxygen, oxygen inhalers, antibiotics, steroids. Yeah, antibiotics. A three assessment, nebulized salbutamol. Yeah. OK. I need to settle. So let's say if this patient has no consolidation on the Oh Yeah, I need to go ahead. Sorry guys. Um So this case, you breathless cough, we know that his ABG is showing in type two respiratory failure um and bicarbonate level and usually you see type two respiratory failure in patients with COPD. Let we don't like the history taking of CO PD. Um He'll have been seen by A&E they will have done a chest xray already. You just need to look at, not order it just look, look at it, make sure that there's no consolidation. Um No, nothing like that. So the chest X ray is clear. Um But the type two they're obviously requiring oxygen um that was already started by A&E it's not something that you need to start, they're already on oxygen. Um So what, what would the plan? Ok. This patient you already know it's if there's no, you got to look at the bloods, you're making sure that there's no bacter. You have raised white cell counts, neutrophils on bloods. But it doesn't mean this patient has a cap because they have a background of COPD. You should always have an IE COPD or asthma in, in the back of your mind. Um They don't have a consolidation on chest X ray. So we're thinking of IE COPD. Uh and the plan here would be basically to try and wean them off the oxygen and we get them started on a five day course of antibiotics. And we would push nebs whilst they're in hospital and give them steroids. And that would be dependent on whether or not they've received a recent rescue pack. Um So with regards to the antibiotics, if someone's really unwell and clinically, you feel like they would benefit from IVS. Um So remember your plan is a reflection of how the patient is at the time you are seeing them. Um And when the consultant post takes the patient, our goal as juniors is to make sure that they're able to be stepped down and discharged by the time they post it. So if you start that patient on IV S there's no harm because it's essentially you're going in with intense treatment. By the time the consultant post takes this patient, they will have received even like one dose of IV treatment, they'll have had some in A&E as well. And the consultant might look at, you know, this patient, they might have improved clinically and might be like, ok, we can set this patient down to oral antibiotics and get them home. So your goal essentially is to bridge the gap between A&E and the consultant who's post taking. So if, if, if he looks really unwell, start them on ivs uh with the intention of stepping down later. But if you see this patient and you're actually like, ok, you know what, let's wean him off oxygen and see how he goes. And if he's weaned off and you're, and he's able to take oral medication, we can always put them on oral antibiotics and as soon as they're off the oxygen, we can get them home. Um But if, if they do look unwell, start them on ivs and then just review to step down to oral once they of oxygen and they're feeling a little bit better and the consultant can always like, sort of, they have that option, like if you've treated them with IVS initially, it helps the consultant be able to basically get them medically fit for discharge. Um So that's it. I ACPC O PD and asthma is really, really easy to treat. Um if they're really, really unwell, that's the only reason why they would usually be in the hospital. Respiratory team don't like to admit chest infections just like that. So if someone has a consolidation on their chest X ray and they have a cap, it does not mean, they are staying in, they could totally go home with cap. Um It just depends on their clinical situation. I wanted to add the Sputum culture earlier. Um Sputum culture results don't come back straight away. They take a couple of days. So that's the reason why we start them on broad spectrum antibiotics initially. Um So, and you can have a look at the Sputum culture later, but it, it doesn't really help if we discharge the patient and sent them home before that. But what would help is if they've come in with repetitive chest infections, have a look through their previous microbiology, if they've had previous sputum cultures. Um And there's like a specific organism that keeps coming up like multiple times and you can see the sensitivities, just look through the sensitivities and, and, and pick out like an antibiotic that you think it is the best for this patient. Like it's sensitive to, to most of the strains this patient has been infected with in the past because you're basically optimizing what this patient could be infected with. Uh And you're putting them on the best antibiotic for them and you can essentially um get the patient home if you put them on the right antibiotic initially. So definitely have a look at that then with the HIV test. Um make sure you ask for consent before you get a HIV test sent uh sent off again. It depends on the patient like I don't think a 75 year old male would be the best patient to ask for a HIV test. But if it's someone who's in his forties and he keeps coming in with recurrent chest infections, he's quite young. You want to do a HIV test? So, your sputum culture, your HIV test. Don't forget. Your viral swabs always do viral swabs and nurses do not like viral swabs. It means that the patient may or may not need to go into a side room and side rooms are always, it's, it's really hard to, to have a side room available in the first place, but I'm pushed to get viral swabs done. Then additionally, what, what other things did we mention? Sputum culture, viral swabs, uh the urine antigens, make sure the nurses are aware of and always write very clearly what the um targets sets should be on the clocking sheet. Because the number of times I've had nurses come to me saying my patients desaturating and it's because they're on scale one and they have a background of COPD which is inaccurate. They should be scale two. and they're not desaturating, that's just their oxygen requirement level is lower. Um So you need to double check that and make sure you've written it on the clocking sheet um and make sure they're weaning them off as well. Or when you go to see the patient, you can turn down the oxygen um slowly and just make sure that they are weaned off and, and to be honest, I have a consultant who likes to just turn the oxygen off completely. Um, and he just sees how they go. Like if they're desaturating, you can always restart the oxygen you whilst you're there and you're clocking them, you're taking history, just turn the oxygen off. Have a look at what they're doing. Put the sats probe on their finger, see how they go. If they're desaturating quite fast, you might want to keep them on it for a bit longer. Um But, but otherwise you can just see how they go and they might not require it. Usually by the time A&E have referred the patient over, they've been on oxygen for a while, uh the ABG S will have improved. So you, you kind of just need to get them off the oxygen and have them on oral antibiotics so that we can declare them fit from a respiratory perspective and get them home. Um But again, if they're unwell, definitely start them on ivs and allow the consultant to step them down and get them home and if they're really unwell, they'll probably need shifting to au uh but most chest infections, they tend to go home. That's IC O PD asthma and pneumonias. They, they are the three infections that we can start them on orals and get them home. Um Anything else, any other questions that you guys might have? I want to add with regards to the aspiration pneumonia. So I think someone's already mentioned the type of patients we would suspect an aspiration for. So the reason why I asked someone to include hospital acquired and aspiration pneumonia in the, the presentation is because whilst you might not be, well, to be honest, you can be clocking a hospital acquired pneumonia and aspiration pneumonia. But, um, sorry, I was just reading the comments, I'll get back to that. Um A lot of the times you are bleeped when you're on call, if you're the ward sho or F one, it's usually an sho level job. Uh You can get bleeped to see these patients. Uh So you might go to see a patient who the nurse is saying has started desaturating or they feel really unwell and the patient actually might say to you, you know what I've, I've started to get this cough and I've been coughing up some sputum or I just feel really unwell or if they're elderly, the most common complaint will be um delirium and it's usually high proactive delirium and some nurses may confuse it with all patients unresponsive. Can you come and see them and you'll get worried, you'll, you'll basically run to go and see the patient. They're not, they, they don't have a low G CS. You should check their G CS, but it's usually hypoactive delirium in these patients. Um go assess them and basically always get a chest X ray for them because you want to rule out hap in any of these patients. Um So even if it's not a respiratory complaint, always have hap in the back of your mind. And if they have like a consolidation of the chest X ray, start them on the antibiotics for hap, it's very common for especially elderly patients to pick up a hospital acquired pneumonia in the hospital. And you've also got aspiration pneumonia. Typically it's with, um, stroke patients or patients that have problems with their swallow. Uh So usually the nurse will give you a bit of background to these patients if they bleak you to see them. And it'll usually be like, oh, you know, like they're choking their food. So anyone that basically mentions choking or if you're clar someone and they mention choking, that's when you want to start thinking along the lines of aspiration. Uh, and an important thing for their management is the medications. So for their medications, you can put them on IV antibiotics, but you need to, um, sorry, I keep getting phone calls. Um, you need to have a look at their regular medications and you can't just prescribe them as they are because they shouldn't be taking anything orally. You need to have these patients nil by mouth. So keep that in mind anyone with an aspiration pneumonia, get a chest X ray for them, keep them nil by mouth, start them on IV antibiotics. Um, and they're regular medications it needs to be prescribed. But in the form of a liquid or, um, if the patient has an NG tube and for whatever reason, I think the meds can be crushed. So, what I like to do is basically go to the pharmacist and I go through like the medications with them and I'll be like, ok, can you tell me which one of these, can I switch to, like, liquid form and they'll be able to tell you like, what's available in liquid form or any, any other alternatives. So, a lot of elderly patients are on Apixaban for af, that's something, it's a critical medication. And that, for example, you can switch to collecting if someone's nail by mouth instead, um, other critical medications like, uh, antiepileptics or patients that have dementia and they're on memantine. These are medications that absolutely need to be like Parkinson's meds. They absolutely need to be given and they can't be missed. Uh, so keep that in mind when you're clocking your patients, but anyone with aspiration pneumonia, you need to make sure that they are still receiving these medications in whatever form like IV or, or a liquid form. And it's good to speak to the pharmacist about them. Um, yeah, if they're ill by mouth, that means you need to prescribe IV fluids, especially if it's overnight. Like you need maintenance fluids and you should always add on to your plan to have the salt team to assess this patient in the morning, if they've been made nail by mouth or whenever they're able to. So the salt team is, it's the speech and language, language therapist. And they basically assess patients that have like a choke or like usually elderly patients with dementia always have a salt referral. Um, but they should assess the swallow and basically rule out whether or not is it a medical cause, are they struggling to swallow? Is, is there a foreign body? What's actually going on with this patient? Are we thinking of aspiration pneumonia? And they can actually go ahead and if they think that there's something wrong, do like a video fluoroscopy. Uh just to basically assess the swallowing and it depends on, on what they advise. Usually in elderly patients, they, they're also able to modify like diets. Uh so they might switch like solid foods to something like mash or something that's easier for them to swallow. Um That's really important because it, it helps prevent aspiration pneumonia in the first place. And stroke patients can have problems with their swallow. We already know that, but just keep in mind that salt team needs to have, they need to have uh a referral form sent to them in order to come and assess the patient, anyone that you're clocking, uh if you suspect aspiration, you should always keep salt in the back of your mind. Uh with regards to N IV because someone's commented about uh bipap adjustment and CPAP adjustment. So that's not something we have to worry about as juniors. Um I guess if, if you are into respiratory medicine, you could read more about it. But basically N IV decisions are made by the consultant or a reg um more specifically a respiratory wedge. So, like I personally, I've never really dealt with N I vi just know that if I had a patient to clock and we needed to make a decision about like someone with IC O PD and they're quite bad. They're deteriorating. We've put in a DNA or we've let the family know like he's basically going to die. Uh You put them on um N IV, but it's, it's not going to be me and you that put them on an IV, it's going to be something you have to discuss with a senior. Uh You absolutely have to discuss it with the respiratory team and the consultant on call or the medical registrar and they would need to then make that decision for an IV. It's not, it's not something that we're expected to do at all. Does anyone else have any questions? By the way, patients with like chest infections, UTI S, they can deteriorate very fast. So, as much as you sort of see a 75 year old male with IE COPD and think, you know what? They don't need a DNA or we could probably get them on orals and send them home. You'd be surprised how fast they can deteriorate. Um, I've, I've not very recently, I've had a patient with a UTI who sort of started going downhill quite fast. Um, so just keep that in the back of your mind when you're doing sees of care, it doesn't matter how mild the illness is. Like, you must always do a DNA off her guys. If you have any questions, feel free to, uh, sort of just put it into the chart. But otherwise I think someone's explained it quite well and I've noticed that you guys are, you're able to do your plans for respiratory a lot better. Um There's a few chest X ray courses on I think it's BMJ. You should go through those. So you're able to basically see what collapsed pneumothorax. Um the different consolidations, what's what's the pneumonia? You'll be surprised how many patients get admitted with cap and they don't actually have a consolidation on chest X ray. Um But definitely look at BMJ for the chest X ray course, go through your ABG S as well. Uh Let me see if I can find it, make sure you can interpret your chest X rays because the report doesn't come up until a lot later and that's no use to you or me. So you need to be able to read a chest X ray. Um More recently though, they are introducing a I interpretation to chest X rays, which is a lot faster than getting a report from a radiologist. Um, that's in my hospital but I'm not sure what's going on everywhere else. But you still as a doctor, you need to be competent to read chest x-rays. It's the bare minimum. I think. So. I think the take home from, from this topic is anyone with a chest infection? The goals are to wean them off oxygen and get them on oral antibiotics to get them home In summary, any other questions? Um Guys just mindful of time. Um Thank you all so much for coming. Um If you could please do the feedback form for us, that would be really, really great. Um And you'll get your certificate automatically when you do that. Um It really helps us a lot. I promise you, we look through all of them um and make sure that we're following up on what you guys say. Um So please do that. Thank you all for coming. As I said, next week, we'll continue the second part of the re series. So we'll be covering pulmonary embolism. Um Yes, we are CPD approved. Yeah, so it'll, it will be on your certificate. So the more talks you go to the more CPD points you accumulate as well. Um And yeah, that is everything. Thank you for coming. I hope it was helpful and hopefully we'll see you guys again. Thank you. I'll stay around in case anybody has any questions, but you're free to go. No, worries. So, I think with the next one it's with, um Hamza. So he's the f one on the team. Um, we would need to confirm with him first because we all work full time. So it'll be depending on what his rota is next week. He might be on nights, he might be on long days. I'm not sure. So we'll try and clarify that as soon as we're able to and put it on the chat. Yeah, I'm just explaining. It's another doctor that's doing the next talk. So it would depend on his shifts next, his shift pattern next week. But as soon as he's told us, we'd let you know on the chat. So all the talks are on Medal. So all the previous talks, including today's, they, they are recorded and on meal, you should be able to have a look at them.