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Respiratory Presentation

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Respiratory Presentation

  1. 1. Respiratory
  2. 2. Lung Volumes Inspiratory Reserve Volume Inspiratory Reserve Volume Vital Capacity Total Lung Capacity Tidal Volume Tidal Volume Expiratory Reserve Volume Functional Residual Capacity Residual Volume Residual Volume
  3. 3. Spirometry Volume Time FEV1 FVC
  4. 4. Alternatively… Volume (L) Flow(L/sec) Inspiration Expiration
  5. 5. Mechanics
  6. 6. Gas Exchange
  7. 7. Control of Respiration Pontine Controll • Pneumotaxic centre • Apneustic centre Medullary Control • Dorsal respiratory group • Ventral respiratory group
  8. 8. Investigations – Blood Tests • Full Blood Count • Urea & Electrolytes • Thyroid Function Tests • Arterial Blood Gas • Blood Cultures
  9. 9. Investigations - Imaging • Chest X-ray • CT scan • Ultrasound • Bronchoscopy • Pulmonary Angiography • MRI
  10. 10. Investigations - Others • Spirometry • Biopsy • Pleural biopsy • Bronchoalveolar lavage • Video assisted Thoracoscopy • Sputum analysis • Pleural fluid aspirate & analysis • Exercise testing • Genetic testing
  11. 11. A 24-year old known IV drug abuser is bought into A&E unconscious. His respiratory rate is 4/min and his SaO2 is 85% on air.
  12. 12. Respiratory Acidosis pH = 7.21 PaCO2 = 11.9 PaO2 = 8.2 HCO3 - = 26 Base Excess = 1
  13. 13. With Partial Metabolic Compensation pH = 7.31 PaCO2 = 9.8 PaO2 = 9.9 HCO3 - = 34 Base Excess = 8
  14. 14. Compensated pH = 7.37 PaCO2 = 6.7 PaO2 = 10.9 HCO3 - = 34 Base Excess = 8
  15. 15. Management Approaches Ventilation Pharmacology Oxygen Invasive Non-Invasive Vs Bronchodilators Respiratory Stimulants Drug Antagonists Bicarbonate
  16. 16. A 34-year old woman with known anxiety disorder is bought in to A&E after a major panic attack. Her respiratory rate is 32/min.
  17. 17. Respiratory Alkalosis pH = 7.47 PaCO2 = 3.2 PaO2 = 16 HCO3 - = 22 Base Excess = -1
  18. 18. With Partial Metabolic Compensation pH = 7.47 PaCO2 = 3.7 PaO2 = 13.7 HCO3 - = 10 Base Excess = -13
  19. 19. Fully Compensated pH = 7.4 PaCO2 = 4.2 PaO2 = 12.6 HCO3 - = 12 Base Excess = -12
  20. 20. Management Approaches Treat underlying disorder
  21. 21. Respiratory Failure Type 1 A 26-year old female comes in following a sudden collapse. She is a known asthmatic. She is tachypnoeic, tachycardic, normotensive, apyrexic and her SaO2 is 89% on air. An arterial blood gas is performed. The results are below:- pH - 7.36 PaO2 - 7.6 PaCO2 - 5.6 HCO3 - - 24 Base Xs - -1
  22. 22. Causes
  23. 23. Management • Treat underlying cause • Give O2 to correct hypoxia • Consider assisted ventilation
  24. 24. Respiratory Failure Type 2 A 56-year old ex-smoker is bought into A&E. She is responsive to voice and her breathing is laboured. She is a known COPD patient. An ABG reveals the following: pH - 7.32 PaO2 - 7.6 PaCO2 - 7.6 HCO3 - - 26 Base Xs - -2
  25. 25. Causes • Asthma/COPD/Pneumonia • Sedative Drugs • Cord lesion, Myasthenia Gravis, Guillain-Barré • Flail Chest/Kyphoscoliosis
  26. 26. Management • Underlying cause • O2 Therapy • ABG monitoring • Ventilation/Intubation
  27. 27. Asthma A 12- year old is bought to the GP. His mother says he complains of chest tightness during PE and he has recently started coughing throughout the night. He has not been feeling unwell at all recently and had eczema as a child. His brother is a diagnosed asthmatic.
  28. 28. Spirometry • Recommended in ALL adults • Recommended in children if able to do test and have a probability of asthma
  29. 29. What it looks like… Volume (L) Flow(L/sec)
  30. 30. Managing A New Presentation In Children Lifestyle Advice SABA ± Corticosteroid Referral to Respiratory Paediatrician Leukotriene Receptor Antagonist LABA Increase Steroids Under 2 2-5 Over 5
  31. 31. Managing A New Presentation In Adults SABA • 200- 800mcg Inhaled Steroid LABA Increase Steroid/Add 4th Drug • Up to 2000mcg/day Daily Steroid Table
  32. 32. Stepping Down Treatment • SLOWLY • Make sure patient feels Asthma is well controlled • Advise exacerbations may occur • Step down steroid dose 20-30% every 3-months
  33. 33. Asthma A 21-year old female presents to A&E with a 3-day history of shortness of breath and wheezing. This is not relieved by her inhaler. It is disturbing her sleep and she cannot concentrate in her university classes. She has been asthmatic since childhood and takes a regular corticosteroid inhaler.
  34. 34. Assessing Severity Moderate Severe Life-threatening PEF > 50% best or predicted Speech normal RR < 25 / min Pulse < 110 bpm PEF 33 - 50% best or predicted Can't complete sentences RR > 25/min Pulse > 110 bpm PEF < 33% best or predicted Oxygen sats < 92% Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma
  35. 35. Investigations • FBC • U&Es • PEAK FLOW • ABG • CXR • All the rest – LFTs, Glucose etc.
  36. 36. Do they need admitting? Yes • Life-threatening • Severe asthma that doesn’t respond rapidly • Moderate who have a factor that warrants a lower threshold No • Severe asthma that respons rapidly • Moderate asthma
  37. 37. Managing an Admission • High Flow O2 • Salbutamol Nebuliser • Give the first dose of a course of prednisolone/IV hydrocortisone • Monitor PEFR and O2 sats to determine response to treatment • Nebulised Ipratropium Bromide • IV Magnesium Sulphate • IF STILL NO RESPONE IV SALBUTAMOL
  38. 38. Managing a Patient Who Does NOT Need Admission • Steroid course • Do NOT prescribe antibiotics unless indicated • Use SABA - 2 puffs every 2 minutes up to 10 puffs • Repeat every 10-20 minutes and reassess • Advice to monitor PEFR and symptoms • Consider initiating montelukast if over 2 years • Follow up within 24 hours either with GP or respiratory physician and 1 week later
  39. 39. COPD A 52-year old presents to her GP with increasing breathlessness when she’s walking that’s been coming on over the past year. She has noticed a dry cough more recently since September, alongside feeling very lethargic. She has smoked 50 cigarettes a day for the past 25 years of her life. You note last Winter and the Winter previous she was treated for bronchitis.
  40. 40. Investigations • Post-Bronchodilator Spirometry • Chest X-ray • Full Blood Count • Body Mass Index
  41. 41. Diagnosis & Assessing Severity Post-bronchodilator FEV1/FVC FEV1 (of predicted) Severity < 0.7 > 80% Stage 1 - Mild** < 0.7 50-79% Stage 2 - Moderate < 0.7 30-49% Stage 3 - Severe < 0.7 < 30% Stage 4 - Very severe
  42. 42. Managing Stable COPD General Smoking Cessation Annual Influenza Vaccine One-Off Pneumococcal Vaccine Bronchodilators SABA/SAMA First-line FEV1>50% - LABA/LAMA FEV1<50% - LABA+ICS/LAMA Next Steps If taking LABA, add ICS If taking LABA + ICS, add LAMA Oral Theophylline Mucolytics Cor Pulmonale Loop Diuretic Consider for LTOT Nutrition Dietician if BMI <20 or >25 Nutritional Supplements if BMI <20
  43. 43. Oxygen Criteria Long-Term Oxygen Therapy Ambulatory Oxygen Therapy Short-Burst Oxygen Therapy Severe Airflow Obstruction People on LTOT who wish to have O2 outside the home If not appropriate for LTOT Cyanosis Polycythaemia Peripheral Oedema Raised JVP PaO2 ≤ 92% on air
  44. 44. Acute Exacerbations • Assess and decide to admit • Follow Hospital-at-home scheme if possible • Follow instructions on oxygen alert card • Administer oxygen • 100% OR 28% venture mask 4L/min and titrate
  45. 45. Treatments • Increase bronchodilator use and give via nebuliser • 30mg Prednisolone daily for 7-14 days • Give antibiotics if sputum purulent or clinical signs of pneumonia • Amoxicillin 500mg TDS OR Doxycycline 200mg then 100mg OD for 5 days • OR Erythromycin 500mg QDS/Clarithromycin 500mg BD for 5 days
  46. 46. Bronchiectasis A 32-year old presents with a cough that has been ongoing for several months. She produces green-sputum daily, but doesn’t feel feverish. She does not ave a history of smoking. You note when she was younger she was hospitalised with pneumonia and has previously cultivated Pseudomonas in her sputum. On examination you observe her fingers are clubbed, and hear coarse crackles during early inspiration.
  47. 47. Investigations • Chest X-ray • High resolution CT • Cystic fibrosis testing • Antibody deficiency • Immunological disorder investigations • Bronchoscopy • 24-hour pH monitorin
  48. 48. Management • Physical inspiratory muscle training • Postural Drainage • Immunisations • Bronchodilators • Antibiotics • Dependent on previous sputum results & Local Guidelines
  49. 49. Smoking Cessation Varenicline Nicotine Replacement Therapy Bupropion
  50. 50. Pleural Fluid Analysis Transudate Exudate Main causes Increased hydrostatic pressure, Decreased colloid osmotic pressure Inflammation Appearance Clear Cloudy Protein content < 25 g/L > 29 g/ fluid protein serum protein < 0.5 > 0.5 Difference of albumin content with blood albumin > 1.2 g/dL < 1.2 g/dL fluid LDH upper limit for serum < 0.6 or < ⅔ > 0.6 or > ⅔ Cholesterol content < 45 mg/dL > 45 mg/dL
  51. 51. ↑ ↓ pH Empyema/Cancer Glucose Cancer/Bacterial Infection/Rheumatoid Pleuritis Amylase Oesophageal Rupture, Pancreatic Pleural Effusion, Cancer Cytology If neg:- thorascopy/needle biopsy Gram staining Culture and test for TB if indicated
  52. 52. Community-Acquired Pneumonia A 53-year old male is bought into A&E with dyspnoea and fever coming on over the last day. He has started coughing up purulent sputum. He is in pain when he breathes in. He has recently returned from holiday in France and is noted to have an ulcerated lesion on his upper lip. On examination you find decreased chest expansion on the right hand side, dullness to percussion, bronchial breathing and coarse inspiratory crackles.
  53. 53. Aetiology Organism • Pneumococcus • Haemophilus • Staphylococcus • Klebsiella • Pseudomonas History • Most common. Commonly reactivates herpes • Most common infective exacerbation of COPD • Commonly occurs after the flu • Classically in alcoholic • Common in CF and bronchiectasis
  54. 54. Aetiology Organism • Mycoplasma • Legionella • Chlamydophila • Pneumocystis jiruveci History • Epidemics. Flu-like symptoms with dry cough • Colonises water tanks. Typically post travel. Anorexia, D&V, hepatitis, renal failure • Biphasic illness – pharyngitis, hoarseness, otitis followed by cough • Causes pneumonia in immunosuppressed
  55. 55. Investigations
  56. 56. • Full blood count • Urea & Electrolytes • C-reactive protein • Blood cultures • Sputum C&S • Arterial Blood Gas
  57. 57. Assessing Severity • Mini-mental score of 6/10 • Urea of 11.4 mmol/L • C-reactive protein of 154 • Respiratory Rate of 30 • Aged 75 • Blood Pressure 87/65 • Mini-mental score of 6/10 • Urea of 11.4 mmol/L • C-reactive protein of 154 • Respiratory Rate of 30 • Aged 75 • Blood Pressure 87/65
  58. 58. Management • Low – Moderate Severity CAP • Oral Amoxicillin ± macrolide if admitted • High Severity CAP • IV Co-amoxiclav + clarithromycin • Cefuroxime + clarithromycin • Cefotaxime + clarithromycin • Oxygen & analgesia
  59. 59. Hospital-Acquired Pneumonia A 72-year old female is in hospital following a traumatic injury resulting in a hip replacement. 48 hours after her operation she becomes breathless and has a high- grade fever. A chest x-ray performed shows acute changes compared to an X-ray the FY1 took in A&E.
  60. 60. Complications • Respiratory Failure • Hypotension • Atrial Fibrillation • Pleural Effusion • Empyema • Lung Abscess • Septicaema • Pericarditis • Jaundice
  61. 61. Tuberculosis An 18-year old female smoker attended her GP complaining of a cough. It’s been ongoing for about 4 weeks and yesterday she coughed up blood. She has noticed some weight loss and at night she’s been waking up with the sheets soaked. She rarely comes to the GP and lives in a council block of high-rise flats.
  62. 62. Investigations • General ones • CXR • Three sputum samples for microscopy, sensitivities and culture
  63. 63. Management • Rifampacin • Isoniazid • Pyrazinamide • Ethambutol 2 Months initial phase 4 months continuation
  64. 64. Pharmacology • Rifampacin • Inhibits bacterial DNA dependent RNA polymerase preventing transcription • Potent liver enzyme inducer (decreases action of warfarin) • Hepatitis, orange secretions • Flu-like symptoms
  65. 65. Pharmacology • Isoniazid • Inhibits mycolic acid synthesis • Peripheral neuropathy (give with Vitamin B6) • Hepatitis, agranulocytosis • Liver enzyme inhibitor (increases action of warfarin)
  66. 66. Pharmacology • Pyrazinamide • Converted into pyrazinoic acid which inhibits fatty acid synthase • Hyperuricaemia causing gout • Hepatitis
  67. 67. Pharmacology • Ethambutol • Inhibits arabinosyl transferase which polymerises arabinose into arabinan • Optic neuritis • Dose needs adjusting in patients with renal impairment
  68. 68. Pneumothorax under Tension A 22-year old male presents with right sided chest pain and difficulty breathing. You note he is extremely tall and has arachnodactyly. The pain is worth on breathing in and his PaO2 is 95% on room air. You notice the right side of his chest isn’t expanding fully, and is hyper-resonant on percussion. You hear no air entry on the right hand side either. His apex beat is laterally displaced.
  69. 69. • Aspirate • 2nd Intercostal space, mid-clavicular line • Large bore needle with syringe attached, partially filled with saline • Remove plunger to allow air to bubble through saline • Insert chest drain • Follow protocol, STERILE procedure • Insert 4th-6th intercostal space anterior-mid axillary line
  70. 70. Primary Pneumothorax NOT under tension CXR SOB and/or rim of air > 2 cm on CXR Aspiration successful? Repeat aspiration Chest drain Consider discharge with outpatient monitoring NO NO NO YES YES YES
  71. 71. Secondary Pneumothorax NOT under tension CXR SOB and/or rim of air >2cm on CXR and age >50 Rim of air <1 cm Chest drain Aspirate Admit for 24 hours and give O2 NOYES YESNO
  72. 72. Carbon Monoxide Poisoning A 73-year old gentleman is bought in to the GP by his son-in-law after a few weeks being very confused and unsure where he is. He has also had headaches for the past few weeks. On examination he has a low-grade pyrexia and has abnormally pink mucosa. His son-in-law asks for some pills for a headache he woke up with this morning. He stayed in the same house last night.
  73. 73. Cystic Fibrosis A 3-year old is bought in with diarrhoea and shortness of breath. He has been vomiting up thick green sputum and struggling to clear his throat. On examination you notice a small rectal prolapse and that his weight has dropped two centiles. Looking back through his notes you see he has been treated for several chest infections within the past year.
  74. 74. Investigations • Sweat testing • Molecular genetic testing • Faecal elastase • Spirometry • Sputum microbiology • General tests
  75. 75. Management • Chest • Regular physiotherapy • Antibiotics • Mucolytics • Bronchodilators • GI tract • Pancreatic enzyme replacement • Vitamin ADEK • Ursodeoxycholic acid
  76. 76. Other Management • Screen for CF-related diabeters • Screen and treat osteoporosis • Arthritis • Sinusitis • Vasculitis • Fertility & genetic counselling
  77. 77. Advanced Disease • O2 • Diuretics • NIV • Lung transplantation • Liver transplantation
  78. 78. Lung Cancer A 56-year old female presents with a 3 week history of shoulder pain, shortness of breath and haemoptysis. She has a 30-pack year history. On examination there is nail bed fluctuation and cervical lymphadenopathy. You refer her urgently for a chest x-ray.
  79. 79. Type of Lung Cancer Squamous = 35% Adenocarcinoma = 30% Small Cell = 15% Large Cell = 10% Other = 5%
  80. 80. Features of Small Cell Lung Cancer • Usually central • Arise from APUD cells • Associated with ectopic ADH & ACTH secretion • Hyponatremia • Cushing’s syndrome • Hypokalemic alkalosis • Lambert-Eaton syndrome
  81. 81. Management of Small Cell Lung Cancer • Chemotherapy & Radiotherapy • Extensive disease = palliation • Surgery only appropriate for debulking
  82. 82. Features of Non-Small Cell Lung Cancer • Squamous cell cancer • Typically central • Ectopic PTH secretion causing hypercalcaemia • Hypertrophic pulmonary osteoarthropathy • Adenocarcinoma • Most common in non-smokers • Located on periphery
  83. 83. Management of Non-Small Cell Lung Cancers • Excision if no metastatic spread • Chemotherapy ± radiotherapy for advanced disease
  84. 84. Staging Tumour Description TX Malignant cells in bronchial secretions TIS Carcinoma in situ T0 None evident T1 <3cm in lobar or distal airway T2 >3 cm and >2cm distal to carina or ANY size if pleural involvement T3 Involves chest wall, diaphragm, mediastinal pleura, pericardium or <2cm from carina T4 Involves mediastinum, heart, great vessels, trachea, oesophagus
  85. 85. Staging Nodes Description N0 None involved N1 Peribronchial and/or ipsilateral hylum N2 Ipsilateral mediastinum/subcarinal N3 Contralateral mediastinum or hilum, scalene or supraclavicular
  86. 86. Staging Metastases Description M0 None M1 Distant metastases
  87. 87. Superior Vena Cava Obstruction A 72-year old female comes for review. She has a history of small cell lung cancer for which she has recently completed a course of chemotherapy. Over the past week she has become more short of breath and has noticed some facial swelling. She also has a headache. You notice she has distended neck veins although examination of the chest reveals nothing further.
  88. 88. Interstitial Lung Disease A 44-year old male presents with a history of exertional breathlessness and dry cough that’s been on and off for a few months. On examination he is apyrexic and has no crackles, but you do hear widespread abnormal air entry and breath sounds. You refer for a chest x-ray which returns with interstitial shadowing, and refer him for a HRCT scan and spirometry.
  89. 89. Sarcoidosis • Multisystem granulomatous disorder of unknown cause • Cause of erythema nodosum • Hilar lymphadenopathy, dry cough, dyspnoea, polyarthralgia • Hepato/splenomegaly, keratoconjunctivitis sicca, uveitis, glaucoma, bells palsy, lupus pernio, nodules, cardiomyopathy, hypercalcaemia • Raised ESR, LFTs, ACE, Ca2+, immunoglobulins • Bed rest, NSAIDs in acute sarcoidosis • Steroid therapy if parenchymal lung disease, uveitis, hypercalcaemia, neurological/cardiological involvement
  90. 90. Goodpasture’s Syndrome • Acute glomerulonephritis and pulmonary alveolar haemorrhage • Autoimmune disease • Type II hypersensitivity • Chills & fever, nausea & vomiting, weight loss, chest pain, pulmonary haemorrhage, haematuria, AKI, arthralgia • Anti-glomerular basement membrane antibodies are diagnostic • Plasmapharesis, immunosuppression, remove identifiable causes
  91. 91. Kartagener’s Syndrome • Autosomal recessive syndrome • Defects in structure and function of sensory and motile cilia • Situs inversus, abnormal frontal sinuses (causing sinusitis and bronchiectasis), primary ciliary dyskinesia • Upper respiratory symptoms, otitis media, COPD/bronchiectasis/recurrent pneumonia • Medical – antibiotics, bronchodilators, mucolytics, physiotherapy, vaccination • Surgery – tympanostomy tubes, endoscopic sinus surgery, lobectomy

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  • MohamedNagar1

    Jan. 21, 2018
  • SamaRajashekharreddy

    Mar. 26, 2019
  • RavindraNayak10

    Apr. 28, 2020

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