The document presents case studies of patients with respiratory conditions, focusing on COPD and asthma management. It details diagnostic features, pharmacological treatments, and management approaches for acute exacerbations, including oxygen therapy and invasive interventions. Additionally, it highlights classifications such as GOLD staging for COPD and emphasizes the importance of monitoring blood gas values in patients.

1. Respiratory Cases
Dr G Abraham

2. Case 1
• A 75 year old gentleman living in the community is
being assessed for home oxygen. His ABG on room air
is as follows:
• pH: 7.36 (7.35-7.45)
• pO2: 8.0 (10–14)
• pCO2: 7.6 (4.5–6.0)
• HCO3: 31 (22-26)
• BE: +5 (-2 to +2)
• Other values within normal range

3. Case 1
• Respiratory acidosis
with full metabolic
compensation
(chronic)
• Note no acidemia –
pH normal
• Seen in chronic lung
disease, eg COPD

4. COPD
• Describe the diagnostic features of COPD.
• What are the investigations required for
diagnosis?
• Describe the staging of COPD.
• What pharmacological treatments are
available?

5. GOLD Staging of COPD
Classification FEV1 of predicted
Mild >80%
Moderate 50-79
Severe 30-49
Very severe <30%

7. Pharmacological Treatments in COPD
SABA or SAMA
FEV1
<50%
>50%
LAMA or
LABA +ICS
(Seretide)
LABA
(Salmeterol)
or LAMA
(Tiotropium)

8. Other considerations in medical
management of COPD
• Persistent exacerbations require combinations
of long-acting medications.
• Oral theophylline.
• Longterm oxygen therapy
• Diuretics

9. Case 2
• A 65 year old lady is admitted with acute shortness of
breath, cough, fever and malaise. She is known to have
COPD and a previous discharge letter says he is a CO2
retainer. ABG on air shows:
• pH: 7.10 (7.35-7.45)
• pO2: 6.0 (10–14)
• pCO2: 7.6 (4.5–6.0)
• HCO3: 35 (22-26)
• BE: -5 (-2 to +2)
• Other values within normal range

10. Case 2 CXR

11. Case 2
• Describe your approach to management.
• Discuss oxygen therapy.

12. Management of acute exacerbations
• Nebulisers – Salbutamol/ipratropium
• IV Hydrocortisone
• Antibiotics – Benzylpenicillin/Clarithromycin
Commonest pathogen s.pneumoniae,
h.influenzae
• IV Aminophylline 250 mcg loading dose, then
infusion at 500 mcg/kg/h
• BiPAP (Bilevel pressure support ventilation)
• Intubation and ventilation

13. Oxygen administration

14. Oxygen therapy
• Aim sats 88-92% and Pa02 of >8kPa. Assess
changes in PaCO2.
• Nasal cannulae – Flow rate 1-4L
• Delivers Fi02 of 24-40%
• Venturi mask – often preferred in COPD as
gives precise FiO2 at high flow rates.
• Colour coded.

16. Case 3
• A 23 year old girl with known asthma presents
to the GP with some daytime wheeze and
limitation in her exercise capacity over the last
3 months.
• DHx: Salbutamol accuhaler 200 mcg prn/qds

18. Case 3 – Answers to MCQ
• 1 – Inhaled corticosteroid with prn SABA
• 2 – LABA
• 3 - LAMA

19. 2016 BTS guidelines: Asthma
management
• 1) Use combination of steroid and short -acting
steroid inhaler
• 2) Add LABA in combination preparation.
• 3) Increase inhaled steroid dose. Discontinue
LABA if no response. Consider oral drugs from
other groups.
• 4) Leukotriene receptor antagonists,
theophylline, LAMA, increase steroid dose to
maximum.
• Consider specialist referral at this stage.

21. Case 4

23. Interstitial Lung Disease – A quick
guide
• Umbrella term.
• Consider:
• 1) Idiopathic interstitial pneumonias of which
usual interstitial pneumonia is commonest type
(also known as idiopathic pulmonary fibrosis)
• 2) Interstitial lung disease of known cause –
connective tissue disease, drug related, dusts
which may be organic or inorganic.
• 3) Granulomatous interstitial lung disease –
sarcoidosis.

25. Cases 5-6

26. References
• Hsu C, Wu Y, Lin H, et al Indicators of
haemothorax in patients with spontaneous
pneumothorax Emergency Medicine Journal
2005;22:415-417.
• Radiopedia.org
• Passmedicine.com