Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hi, everybody. We're just gonna wait for other people to join before we get started. So, um, just hold on for a few more minutes, please. I've just seen a question on the chart about um, if the slides are available after the session and they should be, yeah, we'll have the recording up and then, um, as Rard said, we'll, we can also e email them to you as well. Ok. So it looks like we've got a few more people, which is good. So we'll just get started. Um, so, hi everybody. I'm Kat. Um, he'll be one of the presenters for you today and we've also got a as well who will also be present. Um, so welcome to our fifth episode uh for our teaching series on the UK MLA. Er, today we'll be covering everything respiratory, uh which is a very big topic. So we've just really focused on the high yield things that commonly come up in your exam. Ok. Uh, just a quick aside, just a reminder about who we are teaching. Frontier is a project that was started up by resident doctors, um who are all passionate about teaching. We all understand what you're all going through in the run up to your exams. Um, we want to pass on our knowledge to those coming through the medicine training pathway. So we put together this series to aid in your revision and to help you with coming up to those finals. Um, and there's a lot to cover for these final exams and we understand that. So we're trying to pass on um, some really high yield stuff to you to get you through these exams and starting, um, your first job as a doctor. So today, um, we're gonna be covering um, some chronic conditions, some acute conditions and uh some uh key investigations for respiratory. Um, these are your learning objectives for today, we split them up into your knowledge, ones and your skills. Um We've also set it up into three parts for you as well. Just so, you know, where you're at, we're gonna be starting off with your chronic conditions, moving on to your acute, followed by, um, investigations. So part one, starting off with our chronic. Um, so we're gonna start with asthma. It's a really common condition. Um, both here in the UK and worldwide. Um I'm sure we all probably know someone with asthma at least one person. Um, if not yourself. Um, so just breaking it down into the actual pathophysiology of the condition. Um, here I've put a, um, cross section or bronchial. So sort of showing you what happens within the airways of someone um with uh asthma. Um sorry, just give me one second. Yeah. Um So in asthma, it's a uh chronic condition. Um it essentially uh has multiple contributing factors that I've listed here on the screen. So going from family history all the way down to genetics, um and all these contributing factors that lead to a chronic inflammation of someone's airway um leading to variability in their airflow um uh with acute exacerbations of their condition. Um The most common uh contributing factors are those with a strong family history of asthma. Um So you'll find that in your history taking um someone that might have other underlying conditions such as um eczema. So here we've got ap um as well as those who've had exposure to smoke um at a young age. So, uh uh if they live in a household of um parents who smoke or other family member here, um it isn't an exhaustive list. It's, there's probably a lot more triggers than this, but the most common triggers um for asthma. So I've split them up into um different types. So we've got our allergens, our airborne triggers. We've got drugs, infections, foods and even activity. So some people um can get asthma exacerbations due to exercise. Um So that's just something to bear in mind. Um So with asthma, it's not just a chronic condition, as I'm sure we all know, people tend to get acute exacerbations of their condition due to the triggers that I've just mentioned. Um So this can be split up into three severities. Um We've got moderate, we have severe and we have life life threatening. Um Unfortunately, for your exam, you're just gonna have to remember um how we distinguish these three types, which is um all of this information here. I've highlighted the key part to know which is to do with someone's peak flow. Um So what I'd recommend for your revision is trying to make flashcards with um this information in to help you with remembering these um ways to distinguish if someone's in a moderate severe or life threatening, um acute asthma exacerbation. OK. Um It's a really common question in the UK MLA. It's a really easy one that they can give you um if they give you um uh a patient presenting with severe breathlessness, a wheeze, they have a cough, they can't speak properly and they give you a few extra little tidbits. So they tell you that their peak flow is about 55% let's say, um and they might ask you how severe is this person's um asthma? Um So just bear that in mind. Ok. Um What I'd recommend as well is sort of focusing on if you really struggle with knowing with your peak flows, um how severe the asthma exacerbation is, is sort of learning the cut offs. So knowing that we need to focus on the lower cutoff numbers. So for example, if we get someone with peak flows of 50 above, we know they're having a moderate exacerbation. Um, if they have 33 and above, they're having a severe 33 and below, they're having um, a life threatening um, asthma attack. Ok. So try and make some flash cards or some an cards that really focus on those numbers. Um So when we get these patients with the acute asthma exacerbation, um the first thing we need to do is give them oxygen straight away. Um We need to help them as much as we can with keeping those saturations up as they're probably, definitely already struggling as it is with getting enough um air into their lungs. So we need to try and help as much as we can. Um Whilst this is happening, what we can also do is some medicines for them to sort of dilate their airways and try and um reverse that um acute asthma can't talk acute asthma exacerbation. Um So for example, what we start off with is salbutamol. So hopefully before they've come to hospital, they've already had their blue inhaler, they've already had a few puffs. Um But that's a short and quick, it's not a constant um inhalation of, of the medicine. So what we do is we set it up in something called a nebulizer. So it looks like an oxygen mask, but it's got this little um uh circular pocket underneath that we put the salbutamol in and it's going through with the oxygen and it looks like, um, a mist going to someone's face and it's just constant salbutamol that with every breath that is breathing in over about a five minute or so period, um, sort of get as much of the medicine into their lungs as possible. Um, whilst that's happening, we can set up another medicine so we can start them with ipratropium, which is, um your um other medicine that we can give someone as their long term asthma therapy. Um Again, we set it up as a nebulizer. So through the mask, if that's not working, we can then move on to giving them um some steroids as well. So, steroids is to help reduce the inflammation that they're experiencing. So, whilst these two here are opening up their airways, um this is gonna reduce any inflammation that they're experiencing. So we can either do an IV um or an oral if they're still able to um speak to us. But if they're really struggling, we'd wanna give it in an IV form. Ok. Uh Whilst this is happening, um we need to be continually assessing our patient. Um So every 15 minutes, um we wanna be doing the observations just checking to see how they are. Um We can continue with the salbutamol as well every 15 to 30 minutes. If we're still struggling with um uh trying to uh reverse this exacerbation, we can keep doing this salbutamol. Um and due to the fact that salbutamol has got the side effects of tachycardia. So they get a really fast heart rate. We wanna do an E CG to make sure this, this person hasn't got any um arrhythmias as well. Um And we can also give another medicine, um magnesium sulfate IV. Um this is another um bronchodilator. So opening up that person's airway to really help um them if they're struggling, if we're finding that none of this is helping. Um Obviously, we should have already got senior support at this point. Um But we also want to get in contact with the anesthetist and ICU because this person might need to be intubated. Um if the airway is just not um opening up and we're really struggling. Um So we wanna get them down and on onto the A&E for example, as soon as we can to help if everything that we've just done. So all of this here, it has helped um we wanna continue to keep them in the hospital just to keep an eye on them because they could again go into another asthma attack. We wanna continue with this salbutamol. So we'll be prescribing it every 4 to 6 hours. Um And if we did ipratropium, we'll put that on the prescription as well. Cos that clearly helped, we also want to continue with the steroids because even though that first dose might might have temporarily reduced the inflammation, we really wanna make sure that those airways aren't as inflamed as they were when that person came in. So, we'll keep that for about u up to a week after this exacerbation. Um, and how do we know that they're ready to go home? Well, one, they've not had a further attack since they've been with us. Um, and we'll also be doing their peak flows every day. We wanna make sure that, um, it's over 75% of their predicted value before we're happy to send them home. Ok. We make sure that person's safe and they're not gonna have a have another attack um when we discharge them in terms of the management, um sort of long term, um every person um get started on a saber, which is that blue inhaler um Altol. Um that uh you'll see a lot of people have in their pockets, they'll have multiple ones that they'll have with them at all times. Um After that, it's just um a series of chopping and changing different medications. So adding in a steroid, adding in a long acting um beta agonist, um adding a leukotriene receptor agonist, et cetera, et cetera. Um until we find what works for them and how do we know that we need to move through this algorithm is if we're finding that the patient is either using their medication too much, um Or they're still saying that they're waking up in the night with a cough. Um or they feel a more wheezy than usual. Um, that's how we know that we need to change their, their medication because the last thing we want is to not have the correct medication for them and that they go into an acute asthma attack. Ok. Um, this is the nice guidelines, um, that I took, this is the most up to date one, actually, this is from 2024. Um, so again, unfortunately, this is something you have to remember for your exams. It's a really easy question that they could give you asking you. Um, uh, what medication should we add on next for this patient? Um, so again, I'd really recommend making some, um, flash cards to help you with, um, knowing the, the steps of what medications to add. Um, and also applying it with actual question banks too. I'd really recommend doing that. Ok. So we're just gonna move on to our MC QS. Now, um, Richard's gonna put some options in the chat fuel to choose from if he's able to do that. So it's gonna pop up in a minute. But I just want you all to read this question and this is a very UK MLA style, um, question. Um, and once the poll is up, I want you to click what you think the answer might be. Ok, the polls in the chart you guys want to choose in terms of, um, deciding if they need to move down the ladder for an acute asthma exacerbation. Um, I think it would be, um, literally within five minutes if you're sort of noticing this person, it's, it's still not helping. I would just move on as quick as, as you can, with getting on to the next medication because you don't want to be waiting, let's say 15 minutes and then they're now, um, in a severe or life threatening, um, asthma exacerbation. Ok. But you'd be having senior support with you this whole time. He'll be talking you through the steps. But um, you want to be doing it within a five minute period. Ok. So it looks like we've got all the answers. I'm just gonna give you the answer now. So again, this is what I just do. So the answer is b we're gonna be adding on the Long Acting Beta agonist to their current treatment. So they've had their salbutamol, they've had the steroid. Um So the next step is adding on um the um long acting Beta agonist. Ok. No, so it looks like most of you got that right? Which is really good, well done. Um I've got another M CQ after this, but we're gonna skip over it as we haven't got a lot of time today. Ok. So, um I'd recommend um download, downloading the um powerpoint slides uh for when they get sent out. Ok. Uh So moving on to CO PD. Um this is an umbrella term for a few conditions that can be in combination. Um And they can all e every single person is different in terms of severity of, of these different combinations of these conditions here. So, we've got emphysema, we've got chronic bronchitis, bronchiectasis and nonreversible asthma as well. Um Again, this is a worldwide um really common condition that a lot of people have. Um in terms of risk factors, smoking is the leading risk factor for developing COPD. Um, after that, it's mostly lifestyle. So people either Vape um or genetics. So someone might have a genetic condition where they have um a reduction in this particular enzyme. Um or it might be due to their job as well. So they could work in a factory, they could have worked in a foundry, something that exposes them to a lot of um, smoke, um and inhalation products. Um This here is just a really brief overview of how it develops. Um Essentially it is a chronic insult to the lungs. Repeated activation of someone's immune system. Lots of inflammatory cytokines are, are then produced by the body, um causing constant damage and remodeling to the lungs leading to those conditions. Um, that I mentioned, um, how do we know that we have someone with CO PD? Well, if the history doesn't give it away in terms of they're a smoker, the certain job that they might have, this person might be telling you that they've got this chronic productive cough that's getting worse um, they are short of breath, that's also getting worse. So it might be, even if they're doing some cleaning, they can't breathe properly. Um, and they might also point out they're really wheezy or they feel a bit crackly too. Um, when you examine them, some people have this sign, it's called the barrel chest. Um, essentially it does get a really pronounced chest shape and it looks like a barrel as I've pointed out here. Um This happens just due to the fact that people with CO PD, they get a lot of trapped air in their lungs. So the lungs get really big, get really hyper expanded. Um I'll show you a few chest x rays where that's found. Um, and therefore the actual chest changes to accommodate for the size of the lungs. Um This is the same reason that we get sort of the hyper resonance to percussions when we're going over someone's chest and tapping away, it sounds really hollow. Um Again, just due to the fact that we've got all this trapped air in there. Um, and they also get reduced breath sounds as well due to the fact they can't get, you know, deep breaths in. Um, they get really wheezy due to the airway narrowing from the changes of the sort of emphysema chronic bronchitis. Um, and they can also get crackles as well that can either due to be due to an infection or they might have bronchi as well. Um, so here I've put some sounds on. So, um, if you download the powerpoint, you can listen to these yourself. They're just on youtube. Really good to listen to if you've not heard it before. Um, here's a list of the investigations that we want to do to sort of support, um, the diagnosis if we have an inkling that this person might have CO PD when they first come to us. Um, so the first one is spirometry, it's sort of an in an, in detailed picture of the efficiency of a person's lungs. Um, you might have seen this before. You might have not, you might, you might have been taught about it before. Um, but I've just broken down the definitions of what each of these parts mean and the values that we're looking for in someone with COPD as well. Ok. Um, so the amount of air that they can force out in one second is less than 80% but the amount of air they could force out, um, if you let them to continue exhaling is a lot less than what they can exhale in one second as well. It just gets worse and worse, essentially, it just slows down rapidly as they breathe out. Um, so this is what the picture will look like an exam. They might give you this and ask you if someone's got an obstructive picture or a restrictive picture. That's a, a question that they like or they might even give you um some values for each of these and ask you if this person has got CO PD or not. Ok. Um Here's a chest X ray. So, like I mentioned earlier, they get really hyperinflated lungs. These are absolutely huge. You can see that here and it also flattens their diaphragm because the lungs are taking up so much space. You can see that there IMA will cover chest X rays in a bit though. So she might go a bit more detail for you. Um CT S, you won't be asked to interpret Act for your exam, but this is just showing you what emphysema looks like in someone's lungs. This is someone who smokes and this is someone who vapes. Um It's coming really common now. Um And this is what it looks like as well. So, emphysematous changes here. Um ABG S are also a very useful tool. Um I'll talk about it a bit later, why we need to do it for CO PD. Um But CO PD patients can be subdivided into these two categories. II think we're trying to move away from these two definitions now. Um But they're either a type one, they're either in type one respiratory failure due to them being hypoxic or they're even in type two respiratory failure due to the fact that they're both hypoxic and they have a lot of CO2 in their lungs because they can't breathe all out due to all the changes. Um Some of them can also develop heart changes. Um I'm not gonna go into too much detail, but this is a, just to remind you, we might need to do an E CG for someone with CO PD or they might even need an echo. Um And they also get frequent infections too. Um This one here, haemophilus influenza is the most common cause, ok, for um infections in Co PD. Um, so just bear that in mind. That's a, a nice little question that might give you in the exams. Um and also their treatment somewhat similar to asthma, but the main thing to take away is that we need to tell them to stop smoking. That's the, that's the first step. Ok? Just bear that in mind. They love that as a question. Um And here is the step wise for, for that um treatment to, again, please do some um flash cards for this. Um and do some applied question banks too. So we probably don't have time to do M CK and is very aware that we only have an hour. But again, um please, uh do download this powerpoint, go through it yourself and read the explanations as well when they come through. So just moving on to a now who will be covering the acute uh conditions for respiratory to be aware of? Ok. All right. So can, can you hear me? Ok. Yeah, we can hear you. Yeah. OK. So let's start with case discussion first. So we have just to throw it out there. Um 47 years old smoker went to Ed there's hemoptysis, so breathlessness and some chest pain as well. So he mentioned that he has been unwell with, with cough uh from coming in from vacation. So if there's anyone wanted to put it on the chart, any differential diagnosis that uh we're thinking of with this presentation, same, right? Any differentials patient with hemoptysis S OB and chest pain, acute presentation, it doesn't look like we have any responses yet. No, not yet. There we go. Yeah. TV. That's good. Good. All right. So with this case, again, we need to have a look. Uh, this is a respiratory symptoms, pneumonia, pe that's good. And um it's, it is acute as well, but there's not much about background here. There's not much about uh other uh information whether he's had these uh symptoms before a few months back. Uh uh other symptoms like loss of weight. So, uh that's good that pe can cause hemoptysis, breathlessness, chest pain, pneumotox T BTB is a longstanding uh condition but can also cause hemoptysis and breathlessness. Uh part of the differential diagnosis with hemoptysis, very uh famous as well and uh pneumonia and pe as well. Yeah, thank you very much. So, go ahead with uh next slide. So, pneumonia, pneumonia. This is a very common condition for patient uh presenting in the hospital. It's also common in um, any, um, the exam question. So let's try to approach, uh by, uh, putting pneumonia into like, uh boxes. So the, it is by setting, we have community called pneumonia hospital called pneumonia and ventilator associated pneumonia. So the difference between this, uh C AP and H AP is the bugs and also the treatment as well. And it can also be divided by which is a bacterial. We'll speak about this later on uh as well in the slides, viral causes such as um adenovirus, um COVID SARS, um influenza as well. Fungal. Usually, in fact, like uh immunocompromised patient, uh HIV chemical inhalation, idiopathic uh or interstitial pneumonia. This is noninfective causes uh for example, from complication of immuno uh sorry IE and also like rheumatoid arthritis and also a complication from medication like amiodarone. So it can also be divided by area. So, lobar pneumonia, this is uh usually inflammation of the entire pulmonary lobe and also bronchial pneumonia, which is just catheter consultation. Uh on the x-ray, we can go to next one. So this is a community called pneumonia. It is further divided into typical and atypical pneumonia in the questions. Sometimes they do ask what kind of organism that cause the pneumonia. So, on these uh slides, I put uh some uh points to differentiate between uh each uh organism basically. So we have typical pneumonia which is a common pneumonia. Uh We have strep pneumonia. This is the most common uh in an individual h influenza. Uh, we've talked about this before. Common in COPD, soft aureus is common in IBD patient and for typical pneumonia. So, mycoplasma pneumonia, what uh is difference between this, um, pneumonia? Uh compared to the other is the complication. There's skin complication like erythema multiforme, which is the target sign there on the picture. Uh, patient can have Steven Johnson syndrome and uh Anit and Guillainbarre cell syndrome as well. So, with atypical pneumonia, we have added investigation. So for uh mycoplasma, we add uh sputum serology, mycoplasma, sputum serology. And um the other famous uh bugs for typical pneumonia is the legionella pneumophilia. So usually this bug drives in water. Uh They will usually put some question like patient one to somewhere with air conditioning and then come in uh back sick, for example. So the other thing uh points for the gene to uh remember is uh they can cause different uh surgery range t and also hyponatremia and sometimes uh kidney injury as well. So, uh the investigation for legionella is the urine or antigen and just to throw in there, um chlamydia pneumonia, there's like a strain as well, uh which is chlamydia sit, this is usually uh infect birds. So those um who do bird watching or um patient who have pet birds at home and tried to put in a typical screening as well. A patient came in with like um respiratory symptoms. Ok. So for hospital acquired pneumonia. Um, usually we will diagnose patient with a heart if, uh, there is more than 48 hours uh, of inpatient visit. So, uh the organism is different as well uh from cap uh, other than the strep pneumonia and also uh stuff areas. So, for uh the other organism, e coli clsa and pseudomonas. Pseudomonas is famous as well because, um, ventilator ventilator associated with pneumonia can be because of pseudomonas And uh usually, um they will give green um sputum. All right. So let's go towards symptoms of pneumonia. Um, the most common symptoms is flu like symptoms. Patient coming in with a sore throat, uh runny nose, myalgia, tiredness, breathlessness, uh is one of the common symptoms as well. Chest pain, pruritic pain, cough, productive, cough fever and hemoptysis. So, what will we do for this patient coming in with a respiratory presentation? First, we need to know how it are they doing with uh, in terms of oxygenation? If they are maintaining oxygen? Well, then probably patient is not too affected by uh pneumonia. Um, so blood as well, there will be raised in inflammatory infection marker, white cell and CRP and urea is important for the crib score. We'll go through that in a bit and uh chest X ray wise, the most common uh x-ray uh findings for pneumonia is consolidation, uh ification and um added serology for the typical screening. So, not every patient need to have like the typical screening. So those patient who has not um improved with, for example, antibiotic causes in GP. Uh we do uh put uh give them a typical screening patient with who are immunocompromised with background of like p other pulmonary disease, like COPD, for example, uh lung malignancy and other patient with risk factor. Uh we will uh give them a typical pneumonia screen and lastly is the sputum culture. So um there's a few complication of pneumonia there. So, uh pneumonia, if it's not um responded with the antibiotic, it can cause uh pulmonary abscess and this pulmonary abscess, if it's been there for a while, it can cause empyema. So, empyema, it's depends on if there's collection, uh and pockets of empyema will go to thoracic uh for surgeries can uh be cured just by antibiotic. All right, then let's go to the X ray. So these are the example of x-ray for patient with the pneumonia. The first one is, as you can see, there's like some consolidation there and opacification on the middle right lobe and then the left one is the lobar pneumonia. So, uh there's upper lobe and uh lower lobe is all infected and you can see plenty of the trophic angle as well. We'll do some chest X ray interpretation uh going towards the end. So let's go ahead. So one thing uh to take home from pneumonia um is the curb 65. So this is the famous question for pneumonia. Other than the uh types of bugs and uh differences between them. Curb 65 is important. So see is confusion. That's one mark urea more than seven, that's one mark. Uh respiratory rate, more density is one mark and low BP, less than 90 systolic and less than 60 diastolic is one mark as well. And 65 is patient is more than 65 years old. So this will affect management. So 0 to 1, usually, patient can be given antibiotic and be managed in the community. Uh if patient is scoring two, so the GP or any community doctor, urgent treatment care uh needs to consider whether we need to admit this patient. And this is depending basically uh on patient case to case basis itself. If patient is really unwell or if the patient is uh an elderly with no carers uh in terms of like uh living away as well uh from the hospital, then it's better to admit patient if not to uh follow up closely. And if patient is going 3 to 5 with the C 65 this patient must be admitted and usually needs to be uh reviewed by the ICU doctor as well. Cause pneumonia uh can kill um a lot of patient in the ICU mostly from pneumonia uh in terms of like medical um presentation. OK. Uh Just to throw it out there as well, uh there's antibiotic on there on the um but because antibiotic is it will depend on every trust. So I'm not going to um talk about it. The community require pneumonia, usually amoxicillin if the patient is not allergic for penicillin. But the hospital like going towards admission, it's going to be local guidelines. So, all right. So let's go to one of these M CQ. Um R will put Paul in a minute. So Mary, she's a 63 year old lady coming in with S ob shortness of breath, some cough, productive of green sputum. She is also confused with fever. So she is normally feel unwell. And uh on examination, respiratory high 24 BP is a bit on the lower side. 9366 temperature is high 38.5. So on examination, there's scars crackles on the right mid zone and the A MT score is seven, less than eight is usually we considered as confused. So, urea is 8.1. So based on the curb 65 score, what is the most appropriate course of action if yeah, if you want to answer on the uh multiple sorry on the pool. Yeah, so I can see that. Uh Yeah. So if we go to the next the answer is C was it C So let's have a look. Uh Ba Mary, Mary, isn't it? So Mary is confused. So scoring seven and also the urea is high 8.1. So that's two. scoring two, the BP is not lower than 90 systolic and the diastolic is not lower than 66. So, yeah. Yeah. All right. There's further explanation there if you wanted to have a look. Um, why, why not on, uh, care of elderly? It's because patient age and basically patient is, uh, usually fit and well. All right. Do we? This one? Yeah. Ok. So, going ahead with, uh pulmonary embolism, this is also one of the, um, common presentation in hospital as especially if the patient has been uh inpatient for a long time. They might develop like either pneumonia or pe depending on uh where they are like a patient who has had surgery and has been in patient for a while. They, most of them, not, not most of them, but some of them can develop the um, so definition of uh pulmonary embolism is basically a thrombus that went up to the um, artery of the lung, sorry, not artery. Yeah. Uh and then dislodged there. So these clots, it develops in this uh systemic circulation. It goes up uh to the right artery and goes to the right ventricle and uh through the pulmonary artery and it will get dislodged on the arteries of the lungs. So, um, that's how the pe developed and we chose try. It's very important for pe basically, this is why a patient is prone to uh getting the clots. So, um, endothelial injury, this can, this can um, aggravate, sorry, basically, uh the tissue factor for the clotting system, hyper, everything is sticky there and stasis, everything is sticky in there as well. So high risk of getting uh clots, let's go ahead. So risk factor again, if patient based on the virtual trial is patient has hypercoagulable state increase in stasis. And also um uh any injury in the vessels that, that increase the risk of patient with the pe for example, the uh the common one malignancy, hypercoagulable state pregnancy, uh hyper state and also stasis as well. In terms of like the veins, uh because of mass effect and the swelling in the leg. Um inflammatory and sepsis, uh increase the he will state as well in terms of stasis and a because the uh heart is not pumping um as it should, that can cause uh clots to develop uh venous insufficiency can cause stasis and also immobility or um postoperative um period where patient does not um walk around like uh their baseline. So that can give uh increase the risk of stasis and also vascular injury, any indwelling catheter in the veins, any injury, even though like a simple cannulation, venu puncture, um and other um prostheses in the heart, like uh heart valve and stuff. All right. So, symptoms of pe uh the most common symptoms is dyspnea, which is breathlessness. Patient can also come in with hemoptysis, pruritic chest pain, which is uh pain while taking a deep breath, uh syncope and presyncope. This is usually for a patient with massive pe and uh wanting to point towards uh PE as well if patient has had DVT or features of DVT, which is leg swelling, um redness or tenderness of the leg, um cough and fever and the signs uh usually tachypnea, tachycardia, um elevated JVP hypotension in very unwell patient with massive pe and hypoxia and pleural love. So there's ECG on there just wanted to uh point it out as well that pe the most common ecg findings is tachycardia. But this S one, Q three and V three is famous uh ECG, it's very rare. It's uh for those massive pe with right heart strain, but they usually ask about this as well. So the S one Q three V three, if you have the, have a look on the ECG, so that's uh your um wave, the P wave QR SNT. So for S one, there's obvious S wave in the in lead one and for Q three, obvious Q wave in lead three and also T inversion in lead three. OK. But remember uh there's a trick question sometimes uh don't go straight away for S one Q three V three have if they ask for like common um ECG findings in pe it's gonna be tachycardia. All right, thanks. So, like pneumonia, crib score is very important for pe well, score is very important. Um Basically, if you want to request for CT P, if you put well score me more than four or more than 4.4 you'll get the CTPA done screen. So, uh, what's in the well scores? So, symptoms of DVT that points, uh, for three and then if there is no other diagnosis other than pe, uh, you'll score three as well. So, going down, if tachycardia 1.5 immobilization or previous, uh, surgery, 1.5 previous DVT or PE is 1.5. And, um, the other points are for hemoptysis. And, uh, if there's a new, uh, presence in malignancy, basically malignancy is active malignancy or any malignancy within the past six months. Ok. So more than four is, uh, the cut off point. If it's less than four, then it is unlikely to be pe if it's more than four, then it is likely to be pe, so you go through your investigation or management based on this. So if we go down the table there, um, well, score less than four points, it is pe unlikely. So, what we do in this patient is, uh, do a ddimer blood test. If it is available in the next four hours, that's fine. Just wait for the result. If it's not available in the next four hours, start patient on um, therapeutic, uh, anticoagulant. If there is no other risk factors such as bleeding, uh, or like subarachnoid hemorrhage or something like that. So, if the D dime is negative, then we can rule out a pe, if it's positive, then we go ahead with CT P and this is the same case uh for a patient who has had more than four points um in the well score. So go straight away for CTB. So if it's CTP positive and um continue with the anticoag like um the D dimer, if CTPA is not available, CTPA result is not available in the next four hours. We start patient with the anticoagulant straight away. If there's no other risk factor and uh we'll rereview uh with the CTPA result. If the CTPA result is negative, then stop the anticoagulant. If it's positive, then continue. And again, if the CTP is negative, if patient has um features of DVT, for example, patient who were in, let's say orthopedic ward uh has had a total knee replacement and uh one leg is more swollen than the other side. So we do the uh DVT ultrasound scan, sorry, Doppler. All right. So yeah, CTP is the preferred investigation. Um D dime is only exclusion and D dime is very, it's nonspecific as well. So it can be high in patient with uh after surgery can be high with a patient with infection. So don't do D dimer for a patient after surgery, go straight away with the CTP even though well, scar is uh on the lower side. Ok. So this is CT pa uh features of patient with PE, if you can see on the first picture, there's like the hypodense area. Um point there this is a massive sle pe and, and then the second one, if you can see the part where is um hyperdense uh with the, that's actually pulmonary artery, the one that goes like this, that's the pulmonary artery. And you can see at the end of the pulmonary artery, there's a hypodense area which is the massive clot for the pe there. All right. So treatment for pe this goes based on um every trust guideline as well. But according uh but nice guidelines or any question asking, what is the best treatment? First line treatment for pe is going to be do? All right. But it will uh defer depends on patient um renal impairment. And also if there's any um malignancy or antiphospholipid as well. So, but the first line is going to be do and that's not usually the case in hospital, they will put patient under low molecule weight, heart brain first and then upon. Mhm. Oh, I don't know what's happened there again. All right. All right. So important points start anticoagulant uh within four hours. If the CTP will not be overnight, it's if it's gonna be tomorrow, make sure you start uh the low milk weight heparin or any like uh based on the trust guideline, uh make sure measure the uh baseline F BCU and E LFT and COAG. Um and this patient who we started, who has pe continued the treatment for three months and those with cancer are usually six months and rereview afterwards whether we need to continue with the um treatment next one. So, treatment failure, usually because of adherence uh address uh other causes. And if so, if it's uh patient is adhered, we need to increase the dose of anticoag or change it. And pe with um unsta in unstable patient, massive pe do with sudden um emboli offered uh unfractured heparin and also thrombolysis in a certain hospital who does em bullectomy then discuss with the IR radiology. All right. So this M CQ, let's do one quickly. And this is the well scar 45 year old with hemoptysis. Uh she is worried because her husband has pe and she is on cop heart rate is 90 beats and her sp two is normal. Any appropriate investigation to order going forward. So well, score. Is there great. Yeah. So D dimer and the answer is c the reason for that is because of the hemoptysis. So cop patient has risk, but that doesn't mean that uh other diagnosis of pe is unlikely. So she doesn't scar the, the 2nd 2nd part, which is an alternative diagnosis. She doesn't score just because she has risk factor and um, her husband having pe history of pe has nothing to do with her. Let's go ahead. Next one. Ok. Is cat. Ok. Sorry, everyone, I didn't expect that to happen. Ok. All right. Where are we up to now? Um I think we're just finishing the pe so let's go with the uh the resp failure. Yeah, let me just uh my screen again. Ok. Yeah, you guys can see that. Ok, so sorry guys, we are gonna be overrunning today. Really sorry. But as I said at the start, this is a really big topic and a lot of this is really important for your final exam. So please just go again over the explanation and there's like uh tips as well for you to remember the well score there just go back. I I'm not going to Yeah. Ok. Ok. So moving on to respiratory failure, um this is um sort of what we start to suspect in someone who comes to us with an increased work of breathing. Um So they look like they're really struggling to get their breath in and they're breathing really fast. So we want to see actually how much oxygen does that person have in their blood. Ok. This condition is subdivided into two. So like I said with COPD, so it's a type one or a type two. The way to remember is type one has one problem um which is they have low oxygen and type two has two problems. They have low oxygen and lots of CO2 in their blood. So hypoxic and hypercapnic just as a way to remember. Um So when someone does come to you with, with these symptoms, so increased work of breathing, we give them oxygen straight away then we do an ABG because um just one thing to remember is hypoxia kills. If, if you take anything away from this is um low oxygen is gonna kill someone. Ok. So it's type one switch failure. Um This is a problem with the oxygen exchange. So either we have a problem with the ventilation. So how much air they're getting in or we have a problem with the perfusion. So the um blood going around in the lungs or the body. Ok. Um I've indicated here how it can be subdivided. So there could be a problem with the airway. So they might have COPD or asthma, they might have a problem with the vasculature. So they could have a pa as I just mentioned, um they could have some pulmonary hypertension or a shunt in their heart as well. Um They could also have um interstitial lung disease such as fibrosis or sarcoidosis, um or they could have some problems um at the alveolar level. So they could have a pneumonia, they could have some edema in their lungs or it could be an acute respiratory distress syndrome. Um That's just a nice way to sort of subdivide it and remember it. So it's gonna be a problem either with how much oxygen they're getting in or the blood. All right. So again, we started them on some high flow oxygen. We're gonna find out what the underlying cause is. Once I've got that ABG and I know they're in um type one. So they're hypoxic. Um we're gonna find out what the cause is and then we're gonna start the further investigation to get some senior help. Type two. is a problem with um hypoventilation. So they're not getting enough oxygen um in um there could be multiple points at which there is a problem. So again, I've subdivide it for you all to remember. So, starting from the top, working our way down. So we could have a problem with someone's brain. So someone could have taken a lot of opioids, um, or you could have had um a brain injury and that's affected the respiratory um uh drive. So if they're not, they have, if their brain's not working properly due to either too much opioids or due to brain damage, um, they're not gonna have that drive to breathe, they're not gonna get that oxygen in and they're not gonna get rid of that CO2. So they're gonna be hypoxic and they're gonna have a lot of CO2 in their blood. So they'll be hypercapnic. Um, we can also have a problem with their chest wall. So someone might have had a recent um, chest surgery. So they might have had thoracic surgery. They're gonna be in immense pain, they're not gonna want to breathe properly. So one, they're not gonna get oxygen in two, they're not gonna get CO2 out. So it'll be hypoxic and hypercapnic, um, similar scoliosis. This can affect rib expansion. So again, they're not getting good inhalations in and breathing out properly. We can also have a problem um at the muscles. So someone in terms of the intercostal muscles or the diaphragm, so I've put all the multiple causes here, there's probably more than this. These are just common ones to know. Guillain Barre, um really important to know. So, um I think we'll cover this probably in a, in a gi talk potentially. Um But I can imagine this would be a really nice exam question if they gave you someone with ascending weakness. Um You really want to be worried about the muscle of the diaphragm because if that's not working, um they're gonna stop breathing. Um And again, we can have some lung problems. So CO PD an acute asthma exacerbation, et cetera, um that can um lead them to not getting enough oxygen in and um not getting the CO2 out. All right. Um For these people. Um, obviously, as I said, at the beginning, everyone is gonna be put in a 15 L non Reef Brief mask, which is like high flow oxygen, but I wanna get an ABG straight away because if someone um, has got any of these problems and they're not getting rid of CO2. If I'm giving them loads of oxygen, they're gonna be making even more CO2 and they can't get rid of it. And when we've got CO2 at really high levels, it's toxic to someone. Um So I want to try and stop the high flow oxygen and I want to instead give them a noninvasive mask. So this is what they look like and this really helps patients with getting rid of the CO2 and, and allowing them to be doing gas exchange properly just due to positive pressures. Um I'm not going to do any teaching on it today, but I'd recommend going to look up what positive pressure, noninvasive ventilation does and why it's so important for someone with type two respiratory failure. Um Again, I want to find out what the cause is going through all of this and then getting senior help. Um but this is really important for someone who has got COPD. Um because if they are actually someone who retains a lot of CO2 and I've started giving them high flow oxygen because they've come in um with infection. Um I'm actually gonna cause more harm than good. So we're gonna move on to part three now. So this is us going over our investigation. So again, we're gonna go back to IMA she's gonna talk you through chest X rays. So again, guys, we're gonna run over time but please bear with us. This is really important. Ok. So x-rays, most common thing, most important thing we need to do is uh check, we got the right patient uh date uh of the X ray that we want. And also if uh there's any previous imaging that we can compare. So basically image quality uh rotation, make sure the clavicle is uh asymmetrical inspiration. We need to see around like 5 to 6 waves in there. And also make sure that both trophic angle is in the image uh projection, whether it's AP or PA. So pa uh is the better view because we can see the uh basically, we can uh view the heart of the heart deck in ap the heart will be slightly bigger uh and exposure as well. All right, let's go to the next one. So there's ABCDE approach. So a is airway breathing cardiac diaphragm and everything else next slide. So anyway, here, we can need to have a look on the trachea, whether it's central, uh if it's pushed to one side, then that means uh either there's mass effect from like um hemor X or like um s right from the uh adjacent lung because of like uh lung collas, something like that. So, Carina uh that's important as well. It's one of the important in NG. It will usually dissect the carina going down towards the diaphragm and uh bronchus uh as well. So, and the hilar structure there, usually in patient uh well, patient, we can't really see the lymph nodes but uh the lymph nodes is obvious, then there might be pathology there. And um regarding the hilar, usually the blood vessel, the um area of the blood vessel, it's usually symmetrical. Uh If it's not the same size, then again, uh it can be pathological, then, all right. So b this is breathing. So this is where we review the lung fields and also the pleura. So lung have a look at the lung, make sure the lung um marking is all the way towards the edge if there is no lung marking towards the edge. So, um we just make sure there's no pneumothorax. Um based on the history, any trauma, then you might need to uh raise that. And also any consolidation is also uh based on looking at, at the lung fields and pleura as well. Uh Usually we can't see any pleura uh but in patient with mesothelioma, for example, there can be uh visible pleura like uh the picture, the small picture uh at the side there. OK. So c and we're, we're uh covering C and D in this uh slide. So C is the cardiac, so heart size in pa A pa uh x-rays uh review the heart size, but it's not uh you can't re actually review the heart size in ap x-ray. So it should not be more than 50% of the lung fields. Yeah. OK. Uh There's small uh picture over there, uh which shows uh it is more than 50% of the lung fields then uh that shows that uh there is some cardiomegaly going on and also heart border as well. We need to be able to see the heart border. If we can't really see the heart border, there might be consolidation or um some inflammation uh around that area that suggests um infection. So, costophrenic angle, this is very important. Um If it's blunting, then it uh suggests there's some pure effusion, maybe some bloods as well. Uh hemato and um with the diaphragm, the other important thing is to make sure there is no air under the diaphragm and any um if you can't see the diaphragm properly, uh then there might be consideration. Usually the right diaphragm is higher and it's just because of the liver. All right. And then last thing is everything else. So with everything else, have a look on the medinal. Uh usually there um there's a knuckle if it's not defined, uh that might suggest aneurysm because it doesn't have like this low, the, the dip on the uh and also uh bones and soft tissue have a look. If there is, especially in patient with trauma, might need to pay special attention with the bone just to make sure there is no fracture, uh rib fracture. And the other thing is um like wires and pacemakers and G two, you need to um comment on that as well if you're interpreting chest x-ray. So let's go to the next one. So this is a, this uh is a normal chest X ray. So have a look on the uh report like trachea is central, um lung, feels normal cardiac, uh normal diaphragm, uh sharp costophrenic angle and everything else is OK. Let's do one chest x-ray exercise, maybe the next one. OK. If anyone wants to put it in the chart, uh the most striking thing you can do that as well, but I'm just going to go through a two E for this patient just because we are running out of time. So airway wise, trachea is not, it doesn't look central that looks like it's deviated towards the right. So uh we're thinking of like mass effect uh from the left lung. So um can't really see the carina and um the bronchus there. And in terms of breathing the lung failed, the left lung is completely wiped out. Um based on the um based on the sorry, based on the uh male brought in by ambulance and gunshot wound. So, there is history of trauma there. So we're thinking whether this is hemato uh uh other than like hemato in terms of like uh trauma. So cardiac angle can really see the cardiac angle diaphragm there is blunting on the right uh diaphragm post the angle on the left side. And this is not a very good x-ray as well because the we can see the diaphragm on the right side. All right. So this chest X ray actually uh shows like uh hemopneumothorax with some um mass effect on the left side. All right, to ABG now. OK. So we'll quickly go through ABG S. So I know we've, I've touched on it a few times in the presentation, but I just want to give you some quick tips on how to read it. Um, as it, again, this is a really common question in both your written exam and at your OSK as well. And they love this in OSK. Give you an ABG. Um So I've tried to break it down, step by step um in what and how I would recommend to read it. Um And, and how you should really note down the results as you go to sort of help you with your overall interpretation of an ABG. Um So really useful tool really quick. It literally comes back in minutes as soon as you hand it over to someone and it goes to the machine, it comes back literally within five minutes from wherever they've come. Um It gives you so much information so it can tell you um how much oxygen a person has in their blood, how much CO2 they have in their blood, any electrolyte disturbances. So if someone comes in with a cardiac arrest really useful. Um and also um someone's hemoglobin status um as well if we just want a really quick picture because if you send off someone's FBC, that's gonna take over an hour to come back if the lab's working well that day. Um So it's really good. Um And it's not only used for respiratory failure, we can also use it for a multitude of other conditions. So I've just listed a few here. Um And what else we can use it for? So, again, really good if you want to assess someone for sepsis, if they're also struggling to breathe too, um to start off with, this is a Pneumonic that um is really useful um in terms of remembering um what picture that you're looking at. So we'll go through the different disorders you can have for an ABG, but it's the Pneumonic Rome. So, respiratory opposite, metabolic equal. Um and essentially, it's to do with the CO2 levels in regard to the PH or the um HO three in terms of the PH as well. So, in respiratory um conditions, if the ph is up, the C two will be down, if it's down, it will be up. So sort of the reverse. Whereas in metabolic conditions, if the ph is up, this will be up. If the ph is down, this will be down. OK. So just bear that in mind. So when we're looking at an ABG, the first thing I want to do is I want to look at the P CO I wanna know if someone's acidotic or if they're alkalotic. Um So it, it will usually tell you. So if I go back to slide one, so this is the PH result here. So it's 7.25. It gives me the range. So I know that the person's acidotic and ABG also like to tell you if it's low or high, which is very nice of them to do. Um So once I've done my step one, I'll move on to my step two. So I want to know if someone is in a respiratory acidosis or alkalosis or if someone's in a metabolic acidosis or alkalosis. So I want to then look at their CO2 and their bicarb. OK. So here I've put again, as I've said in the Pneumonic, if someone's in um respiratory acidosis, um their uh CO2 will be high. All right. So, just remembering that Pneumonic all the way over here um in terms of um things that cause these um different conditions. So, if someone is acidotic and um it looks like their CO2 is gone up, um I'll be thinking that they've got a problem with ventilation. Um So they're retaining a lot of CO2 which is making them acidotic. So, again, similar to when I presented earlier about um uh type one and type two, we've got things at the brain that can cause this, we've got problems with the muscles or the chest wall um as well or if someone's got intubation, we've not optimized the intubation properly because remember that will brief for them. Um If someone's alkalotic, um it might mean that they are blowing off too much CO2. So the ph has gone up but the CO2 has gone down. So, um, they could be having a panic attack so they're breathing really rapidly. They're blowing off loads of CO2, um, or due to pain. A lot of people breathe really fast around them when they're in pain. Um, I've put all the other reasons here as well. Um, pe, they breathe quite quickly because they haven't got, um, they have something blocking, um, the um fusion, um et cetera and pneumothorax as well. Um For metabolic causes um metabolic acidosis, they're gonna have a low Ph and a low bicarb. There are two causes for this. So either someone who's got too much acid in their body or they're not able to get rid of it as quickly as possible. Um Here, if you want, um when you get the slides, you can go through my explanations. These are from a little thing that I've made. But um you then need to look at the i the ion gap. So if I get up the ABG again, it should be on here. No. So the base excess thing is this one here. So you wanna be looking at this um or calculating it yourself. So if you download the slides, I've written, I've literally put the explanation for you. But if you want to know if someone's got too much acid or they can't get rid of the acid, you need to be looking at this to help you decide what the cause is. If someone's got a high a, an ion gap, you'll be thinking they're in DK A. So they could be diabetic type one. They could have lactic acidosis or they could be in renal failure. But if it's normal, um and um will be then thinking they've got diarrhea, um or they could have an underlying endocrine disorder such as Addison's disease. And I've put these two pictures there as well to help you understand, if someone, um, has got a high ph of the alkalotic and a high bicarb, um, I'll be thinking that they've got not a lot of, um, uh, uh proton in their, in their blood, but they've got a lot of bicarb in their blood. So they could be losing it either through vomiting or diarrhea. So you get acid secretions, um, in your vomit and in, um, your stool, um, or it could be due at the kidneys. It could be a problem there or we could have caused it with medications. Um, this is the syndrome that is called, if it, if we've caused it with medications, um, we've also got compensation. So the body will try its best to try and reverse um, these problems. So it doesn't like to be acidotic, it doesn't like to be alkalotic. Um, so it's gonna try its best. So if we've got a respiratory acidosis, the kidneys are gonna kick in and it's gonna start making loads of bicarbs to try and counteract the fat, there's so much carbon dioxide in the body. Um and the reverser if they're alkalotic, same for if it's a metabolic cause, um the lungs will kick in and it will try, it's best to try and um get rid of this excess bicarb. Um So this is compensation. So with compensation, your um your bicarb and your carbon dioxide are gonna go the same way. So if one's low, the other is low, but unfortunately, to make things more confusing, you can also get a mixed picture. Um ABG so someone could be in respiratory and metabolic acidosis. Um I've put the causes here. So someone could be in cardiac arrest and it could be in multi organ failure, secondary to sepsis, for example. Um if we've got the, the acidotic all around, um but if they're alkalotic, um it, it will be due to these reasons and you'll know it's mixed because if um your CO2 is up, your bicarb will be down. Whereas if it's compensated, they'll be going in the same way. So if one's up the others up, if one's down the other's down, if it's mixed, one will be up, one will be down. OK. That's just how you need to remember it. That took me a long time in med school to get my head around. Um So there might be a bit me your exam and give you something like that and expect you to know what could have caused it. But I think it'd be really rare if they did that. Um, I've also put a few scenarios on here. Um, I'll, I'll just go through this first one with you. Um, there's no, I haven't put any multiple choice questions with it. Um, so this is a 63 year old lady. She's short of breath. She seems really drowsy. And you've put her on 10 L of oxygen. You've done an ABG, she's put her on quite a lot of oxygen and it shows you that she's got a low oxygen level. So she's hypoxic. She's got a low ph. So she's acidotic. She's got a high CO2. Um and her bicarb is normal. So if we go for our steps, so step one, I want to know the ph. So as I said, she's acidotic. So we'll make a note of that in step two. I've noted that she's got a high CO2. So that means um that we've got a respiratory opposite. So low ph, but a high CO2. So I know she's respiratory acidotic. But as we've pointed out, we've also seen that she's got low oxygen, so she's hypoxic. So again, going back to her respiratory failures earlier, this lady is in respiratory acidosis with hypoxia. So it's secondary to a type two respiratory failure. This could be due to COPD, could be due to um our brain problem, um could be due to a muscle problem or due to a chest wall problem. OK. So again, you can see how I've used those steps to get down to the root cause. Um, on this presentation, I've put loads of, um, work through ABG S here. You can see. So I'd really recommend um doing our feedback, downloading the presentation um to work through it yourself and sort of, um, read through the explanations as to why. Um, this is, um, this ABG is the way it is. Ok? So sorry about the whistle stop tour and um running over guys, but thank you so much for engaging with us. Um And coming today, we really, really appreciate it. Um Here, I've got the QR code. If you want to scan, please, um, you'll get a certificate of attendance which you can use for your portfolio um to show that you want to be learning and, and getting better for your exams. Ok. So I'd really appreciate that. Um, and ARDS also put the link in the chart if you want to use that if you can't, um, can, can put your emails on the, on the chat as well. So we can send the uh slides to anyone who wants to slides, put your emails on the chat because I don't think it goes automatically with the feedback, isn't it? Yeah, it won't go as fast feedback. Ok. So hopefully you've all scanned that or you've used the one in the chat. Um So just as a little reminder for next week we've got our series six, episode six next week about Ent. Um, and we're really lucky that a registrar for Ent has come next week to teach you all. Um, so please, I really recommend attending, um, as it's a, it's a big topic. Um, and yeah, just very lucky to get a registrar to come and teach you also. I'd recommend. Yes, you can put it in the either feedback form or, uh, in the comment section. Thank you, everyone. Yeah, thank you guys. Hopefully that's been helpful for you. Yes. Ok. All right. So we're gonna end the live now, but thank you so much for coming and good luck with your exams and we'll see you next week. Yeah, if you can, if you have not had time to put, uh, your email in there, just put it in the feedback form, uh, just comment there, uh, your email and then we'll send it off. Thank you the