Respiratory Disorders
Disease Condition Pneumothorax, Causes, Sign and Symptoms, Pathophysiology, Types, Assessment and Dignostic Test, Management
By HIREN GEHLOTH For Nursing Students Medical Surgical Nursing
LAUGH A LOT IT CLEARS THE LUNGS
TEACHING IS ONE PROFESSION THAT CREATE ALL OTHER PROFESSION
this is my presentation of pneumothorax that I presented in my gen medicine class, I includes investing and management only of pneumothorax
best of luck
Respiratory Disorders
Disease Condition Pneumothorax, Causes, Sign and Symptoms, Pathophysiology, Types, Assessment and Dignostic Test, Management
By HIREN GEHLOTH For Nursing Students Medical Surgical Nursing
LAUGH A LOT IT CLEARS THE LUNGS
TEACHING IS ONE PROFESSION THAT CREATE ALL OTHER PROFESSION
this is my presentation of pneumothorax that I presented in my gen medicine class, I includes investing and management only of pneumothorax
best of luck
International Lung Symposium on Pleural Diseases, Manila 2019.
Practice changing clinical trials in pleural diseases from 2017 to 2019 by Dr. Gary Lee.
EMGuideWire's Radiology Reading Room: Spontaneous PneumothoraxSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Spontaneous Pneumothorax and is brought to you by Elizabeth Olson, MD, and Janet Lorenz, NP.
EMGuideWire's Radiology Reading Room: PneumomediastinumSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Pneumomediastinum and is brought to you by Jacob Leedekerken, MD and Chelsea Wilson, MD.
Dr. Escobar’s CMC X-Ray Mastery Project: December CasesSean M. Fox
Drs. Daniel Escobar, Angela Pikus, and Alex Blackwell are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Blunt hemothorax
- Pulmonary contusion
- Lung Cancer with Bone Metastases
- Pneumomediastinum
- Pneumopericardium
Similar to Spontaneous pneumothorax: Are we treating the patient or the xray? (20)
As presented at EUSEM 2015, this presentation discusses how venous blood gas analysis fits into clinical care in emergency departments. The evidence is correct as of Sept 2015
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Getting research going in emergency departments can be hard but it is vitally important for improving healthcare. This presentation gives tips and strategies for building a research culture. Taking the first step is often the hardest part!
Arterial blood gases in ED: Rest in Peace?kellyam18
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Are venous and arterial blood gas analysis interchangeable in ED assessment o...kellyam18
Ever wondered if you can use a venous blood gas instead on an arterial analysis to guide management of patients with acute respiratory disease in the eemergency department? This presentation will try to answer the key questions including does my patient have acute respiratory failure, is my patient a CO2 retainer, do I need to provide additional ventilatory support and is my treatment working.
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Errors in clinical decision making in the emergency department can be fatal! Through case studies, this presentation explores the factors contributing to error and strategies to overcome them.
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Venous and arterial blood gas analysis in the ED: What we know and what we don'tkellyam18
This presentation delivered at the International Conference on Emergency Medicine in Dublin summarises agreement between venous and arterial blood gas parameters and utility of venous blood gas analysis in emergency department clinical practice. It also highlights important gaps in our knowledge on this topic.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
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Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
2. Permission
This presentation may be used freely for
educational purposes
It is the responsibility of the user to ensure that
the content is up to date and relevant to their
practice environment
4. Objectives
To review current evidence-based
guidelines for management of
spontaneous pneumothorax
To discuss the practical challenges in
managing spontaneous
pneumothorax
5. Before we start ...
According to recent guidelines, which
of the following should be the main
determinant of ED therapeutic
intervention in primary spontaneous
pneumothorax?
A. Pneumothorax size
B. Presence or absence of significant
breathlessness
C. Previous spontaneous
pneumothorax
D. Occupation
6. Mike
Aged 19
Onset of pleuritic
chest pain yesterday
Mildly SOB on
exertion only
Smoker, no other
past history
At rest, pulse 60, O2
sat 98% (on room
air), other vital signs
normal
7. What would you do?
A. Large bore intercostal catheter
(ICC) and underwater-seal drain
(UWSD)
B. Small bore ICC and Heimlich
valve/ UWSD
C. Aspirate
D. Nothing –conservative
management with outpatient followup
E. Admit to ED observation ward for
oxygen therapy
8. Would this xray change your
mind?
Same history,
symptoms and
vital signs
9. Epidemiology
Primary spontaneous pneumothorax
is a disease of the young
Peak incidence late teens/ twenties
Male> Female; about 4:1
Smoking is a major risk factor
10. Clinical features
Chest pain: 90%
Sharp, dull
Dyspnoea- but can be transient
Presentation delayed > 24 hours in
>50% of patients
Signs
Resonant chest
Reduced breath sounds
May be subtle depending on size, chest
wall thickness, etc.
11. Imaging
Chest xray
Erect CXR is highly sensitive for clinically
relevant pneumothorax
Expiratory films add little and should be
avoided
Supine films are of little use
CT
Highly sensitive and can identify other
pathology
Concern that overcalls clinically irrelevant
pneumothorax
Ultrasound
Used in trauma and increasing accepted in
non-trauma
12. A question of size?
No international agreement on size
definitions!
Australia and UK
Small: <2 cm rim around lung (measured at
hilum)
US
Small: <3cm inter-pleural distance at apex
US
method
UK and Australian
method
13. International variation in
guidelines
Guideline Year Definition of
‘large’
pneumothora
x
Management
recommendation for
‘large’ pneumothorax
in stable patient
British Thoracic
Society
2010 >2cm
interpleural
distance at
hilum
Conservative if minimal
symptoms, otherwise
aspiration
American
College of
Chest
Physicians
2001 >3cm apical
interpleural
distance
Pleural catheter insertion
(small bore or ICC) with
UWSD
Belgian Society
for
Pulmonology
2005 Interpleural gap
along entire
length of lateral
chest wall
Aspiration or pleural
catheter insertion with
USWD/valve
Therapeutic
guidelines
(Australia)
2014 >2cm
interpleural
distance at
Aspiration
14. International variation in
opinions
Region/count
ry
Year
of
repo
rt
Comment
Wales 2000 Small PT not breathless only 50% would
treat conservatively.
Initial treatment of moderate/large: 75%
would aspirate
USA 1997 20% PSP in well young patient:
conservative 52%; aspirate 14%, pleural
catheter 31%
Czechoslovaki
a
2008 First PSP: 69% pleural catheter, 6%
aspiration
Switzerland 2006 Stable first large PSP: High consensus
for insertion pleural catheter; no support
for conservative
Wales: Yeoh et al, Post Grad Med J; USA: Baumann et al, Chest;
Czech: Stolz et al, Rozhl Chir; Switz: Kuester et al, Interact
Cardiovas Thorac Surg
15. International variation in
practice
Country/
Region
Size Year
of
repor
t
Conservati
ve
Aspiratio
n
Pleural
catheter
drainage
Hong
Kong
(N=12)
Large 2009 2% 18% 80%
Australia
(N=19)
Large 2008 10% 17% 72%
UK (N=1) Large 2002 0% 75% 25%
Singapore
(N=1,
SGH)
All 2004 35% 18% 47%
HK: Chan et al, HK Med J; Aus: Kelly et al, Int Med J; UK: Mendis et al,
Post Grad Med J; Sing: Ong et al, Eur JEM.
16. Different perspectives
Multiple speciality groups involved:
Emergency physicians
Respiratory physicians
Thoracic surgeons
General physicians
General surgeons
Evidence of variation in practice and
opinion
EP and respiratory physicians are more
comfortable with conservative management
General physicians and surgeons favour
pleural drainage as initial intervention
17. What does this tell us?
There is international and inter-
disciplinary lack of consensus regarding
management strategies
The various national guidelines are not
being followed
There is variation in how the available
evidence is being interpreted
Same evidence, different recommendations
18. The evidence
Evidence base is NOT strong
Factors to consider:
Type of pneumothorax: primary or
secondary
Clinical evidence of respiratory
compromise, in particular significant
breathlessness
Size: Pneumothoraces resolve at a rate of
approximately 1.25 to 2.2% of the volume
of hemithorax per day.
Age: Evidence suggests that aspiration is
less successful in patients aged over 50.
Availability of followup
19. Emergent drainage
Who?
Patients with severe respiratory
compromise
Patients with shock
How?
14G IV catheter
Small bore catheter (e.g. Cook’s) via
Seldinger technique
Definitive treatment required
20. Problems with IV catheter emergent
drainage
Traditional recommendation has been
14G, 5cm needle in second intercostal
space
Radiological studies:
24-42% of people have chest wall
thickness at 2ICS >5cm.
Chest wall thickness increases steadily
with BMI
Cadaver study:
Average chest wall thickness >4cm
Only 58% of 14G, 5cm needles entered
pleural space
21. Solutions
Use a longer needle
Go straight for a
Seldinger-type kit
Quick
Has long needle
Connects directly to
drainage so no
secondary procedure
required
22. Minimal symptoms
Evidence supports conservative
treatment irrespective of size on xray
Re-absorb at rate of 1.5-2.3%
hemithorax/ day
Can be managed at home!
Follow-up
Weekly is safe (some use 2-4 weekly)
Caveat: for early presenters (<24
hours), may be prudent to check in 4-6
hours and next day
23. Key questions
What is the risk of progression to tension
pneumothorax?
Negligible –none reported in literature
How long should I keep the patient in ED
or observation ward?
If symptoms >24 hours, no need to observe
If symptoms <24 hours, most would re-xray after
4-6 hours ‘just in case’ – not evidence-based
How do I arrange appropriate follow-up?
Very important, but depends on local factors
24. Symptomatic
Main indication for intervention is
presence of significant
breathlessness
Options
Aspiration
Catheter drainage
Small bore
Large bore
Pigtail catheters / similar
25. Aspiration
Usually performed using a small catheter
inserted by Seldinger technique
Aim is to convert a large pneumothorax
to a small one
Success = rim <2cm and resolution of
breathlessness without re-accumulation
over 4-6 hours
Success rate 50-80%
26. Predictors of failure
Much less likely to be successful if
patient aged >50 years
If you have aspirated >3 litres,
success unlikely
Connect to Heimlich valve or UWSD
27. Key questions
What site should be used?
Second ICS mid-clavicular line or 4 ICS
mid axillary line
How long should I observe the
patient after successful drainage?
4-6 hours is probably enough
Need to check no re-accumulation
28. Catheter drainage
Small bore catheters (5-16F) are as effective
as large catheters
Many inserted by Seldinger-type approach
Success rate 65-95%
Suction does not improve outcome and
should be avoided
Trocars should not be used
Complication rate of ‘traditional’ open catheter
insertion 5-10% (excludes persistent air leak).
29. Key questions
Where should I insert a pleural
catheter?
If using small catheter, either anterior or
lateral is fine
If using large catheter, lateral side
preferred for aesthetic and comfort
reasons
Are large bore catheters really
‘out’?
Yes!
No evidence of benefit, more
30. Surgery
About 10% of patients require
surgical intervention
Indications:
persistent air leak after 2-7 days
recurrent pneumothoraces
airline pilots, frequent plane travelers
and divers
contralateral or bilateral
pneumothoraces and
pregnancy
31. Ambulatory management
options
Country/
region
Year
of
report
Study
design
Findings
Singapore 2011 RCT Aspiration vs mini chest tube. No
difference in outcome; ~50%
discharge from ED
France 1 2014 Case
series
Pigtail catheter + valve. 78%
success rate
France 2 2014 Case
series
Pigtail catheter + valve, 83%
success rate; 60% treated as
outpatients
Canada 2009 Case
series
Small bore catheter + valve; 81%
discharged from ED; 60%
managed totally as outpatients
Japan 2014 Case
series
Small bore catheter + valve; 94%
success rate
Singapore: Ho et al, Am J Emerg Med 2011; France 1: Voisin et al, Ann Emerg med 2014;
France 2: Massongo et al, Eur Respir J, 2014; Canada: Hassani et al, Acad Emerg Med 2009;
Japan: Karaskai et al, Thorac Cardiovasc Surg
All
concluded
outpatient
management
was safe.
32. The bottom line
If asymptomatic/ minimal symptoms,
conservative management as
outpatient is safe
Aspiration is worth a try in young
patients
If a pleural catheter is indicated, a
small (or pigtail catheter) is as good
as a large catheter
Outpatient management with pigtail
catheter and valve is safe in selected
patients
33. Recurrence
Up to 50% after first pneumothorax
Greatest risk in first year
Up to 70% after subsequent
pneumothorax
34. Revisiting
Which of the following is the main
determinant of ED therapeutic
intervention in primary spontaneous
pneumothorax?
A. Pneumothorax size
B. Presence or absence of significant
breathlessness
C. Previous spontaneous
pneumothorax
D. Occupation
35. Revisiting
Which of the following is the main
determinant of ED therapeutic
intervention in primary spontaneous
pneumothorax?
A. Pneumothorax size
B. Presence or absence of
breathlessness
C. Previous spontaneous
pneumothorax
D. Occupation
36. Did you change your mind?
Aged 19
Onset of pleuritic
chest pain yesterday
Mildly SOB on
exertion
Smoker, no past
history
At rest, pulse 60, O2
sat 98% on room air
37. Did you change your mind?
Same history,
symptoms and
vital signs
38. Did you change your mind?
Same history, symptoms
and vital signs
I would treat both of
these conservatively
as outpatients
39. Question #1
23 year old man
50% pneumothorax with minimal
symptoms
Past history of ipsilateral PSP a year
ago
What is the preferred treatment option?
40. Question #1
No intervention needed in ED
Refer to thoracic surgery team for
definitive procedure (can be as
outpatient)
41. Question #1a
Same history
Pneumothorax ~70% and significant
breathlessness
What should be done?
42. Question #1a
This is an evidence free zone
Definitive procedure recommended as
likelihood of further recurrence is very
high (>70%)
Options:
Aspirate – if successful, home for semi-
elective thoracic surgical procedure
Small bore/pigtail catheter – as outpatient/
inpatient
Primary thoracoscopy without ED
intervention
43. Question #2
Can I send a patient home with a
pigtail (similar) catheter and one
way valve in situ?
44. Question #3
Is it safe to observe (treat
conservatively) a young patient
with large first PSP who has
minimal symptoms?
45. Question #3
The evidence says ‘YES’
Require:
Sensible patient
Access to appropriate followup
Means of return to hospital if gets worse
46. Question #4
What advice should I give about
work, flying and return to sport?
47. Question #4
Evidence-free zone
Return to work is OK as long as
symptoms are resolved
Air travel should be avoided until full
resolution confirmed by xray
Most airlines have a rule requiring 1 week
after full resolution
Sports are OK
Caveat: reasonable to avoid sports with
extreme exertion or contact until full
resolution
48. Question #5
Are there trials comparing
aspiration / small bore catheter
management with traditional large
bore pleural catheter management
for clinically significant outcomes?
49. Question #5
Clinically significant outcomes
Requirement for hospital admission
Requirement for secondary procedure
Requirement for surgery
Recurrence
50. Question #5
Aspiration vs. chest tube
Cochrane review (CD 004479)
No difference in immediate success rate, early
failure rate, duration of hospitalisation, one year
success rate and number of patients requiring
pleurodesis at one year.
Aspiration had lower admission rate
Small vs. Large pleural catheters
Several RCT comparing small and large
catheters show similar outcomes
(methodological issues)
Large bore catheters inserted by ‘open’
technique may have higher complication
rate
52. Research opportunity
Do defined high risk features identify patients
who require definitive surgical intervention for
radial fracture?
Instability markers: age >60, intra-articular,
osteoporosis, dorsal angulation >20%, ulna
fracture, dorsal comminution, radial shortening
>3 instability markers, outcome was better with
surgery
53. What is involved?
Reviewing medical records for demographics,
mechanism of injury and instability markers
Reviewing xrays/ reports for instability markers
Participating in interpretation of data
54. What is in it for me?
Taste of research
Opportunity to be published
Opportunity to present at local / national
conferences