Check for reversibility with 2-agonists Saline nebs Vaccinations
Little/No role for: Steroids (unless concurrent asthma/COPD)
Human Dnase Leukotriene agoinsts Methylxanthines Medical Antibiotics Sputum sample before antibiotics Choose abx depending on previous sensitivities
If previously cultured Pseudomonas need oral cipro or other IV abx Consider low dose macrolides if >3 exacerbations/year Macrolides have anti-inflammatory effect Surgical Indicated if localised disease or massive haemoptysis
Lobectomy Pneumonectomy Viva-esque Questions 1. Main organisms responsible for infection in bronchiectasis? 1. H.influezae, S.pneumoniae, Staph
aureus, Pseudomonas, anaerobes Viva-esque Questions 1. Main organisms responsible for infection in bronchiectasis? 2. What are the main causes of bronchiectasis?
Viva-esque Questions 1. Main organisms responsible for infection in bronchiectasis? 2. What are the main causes of bronchiectasis? 3. What are the complications of bronchiectasis? Viva-esque Questions
3. Infection Respiratory failure Brain abscess (haematogenous spread of infection) Amyloidosis (renal failure) Pneumothorax Viva-esque Questions 1. Main organisms responsible for infection in
bronchiectasis? 2. What are the main causes of bronchiectasis? 3. What are the complications of bronchiectasis? 4. What is the definition of bronchiectasis? Viva-esque Questions 4. Persistent progressive condition characterised by dilated thick-walled
bronchi. Typically >1.5x the diameter of the accompanying arteriole Viva-esque Questions 1. 2. 3. 4.
5. Main organisms responsible for infection in bronchiectasis? What are the main causes of bronchiectasis? What are the complications of bronchiectasis? What is the definition of bronchiectasis? What are the different morhpological subtypes of bronchiectasis
Viva-esque questions 5. Cylindrical (uniform calibre and parallel walls) Varicose (uncommon bead like appearance) Cystic (severe form where cyst like bronchi extend to pleural surface) 6. What is Kartagners syndrome?
6. Dextrocardia, Bronchiectasis, Chronic sinusitis Case 2 Mr Singh has complained of shortness of breath Please take a history
Worsening over last 3 months Now exercise tolerance <10 yards Dry cough and pain on coughing Sleeps with 3 pillows No haemoptysis No weight loss
History PMH, HTN DM Hypercholesterolaemia
Drugs and allergies, NKDA Amlodipine Indapamide
Metformin Glicazide History FH, Nil of note SH,
Ex-smoker (20 pack years) Around 8 cans strong lager a day No travel/pets Lives with wife and 2 children Examination Examination
Appears dyspnoeic at rest Reduced chest expansion B/L lower zone Stony dull to percussion Absent breath sounds Reduced vocal resonance No obvious signs of wt loss
No lymphadenopathy No tracheal deviation Differentials Differentials Pleural effusion Secondary to HF
Secondary to cirrhosis Malignancy PE Fibrosis Investigations
Bedside Bedside PEFR Sats Bloods
FBC BNP U+E LFTs CRP LDH
BNP Thyroid Function Tests Imaging
CXR Echo USS for guiding drainage CT (with contrast)/CTPA if ?PE Imaging
Imaging CXR Blunting of costophrenic angles If larger then opacity with concave upper margin Meniscus sign Even bigger...complete white out +/- mediastinal shift Elevated hemidiaphragm if subpulmonic effusion
What is this.... Pleural fluid analysis Transudate <25g/L protein Exudate >35g/L 25-35g/L Exudative if: Ratio of pleural fluid to serum protein >0.5
Ratio of pleural fluid to serum LDH >0.6 Pleural fluid LDH > 2 thirds of the upper limits of normal serum value Pleural fluid analysis
Management Conservative Medical Surgical Management Conservative
Management Medical BAD ALS (for management of heart failure)
-blockers ACEi Digoxin ARBs Loop diuretics
Spirinolactone Pleurodesis if malignant Management Surgical Drainage Re-inflation oedema
Pleurodesis Rib Lung Intercostal
Nerves and Vessels Intercostal Muscles Intercostal Space Fluid (or air) free in the pleural cavity
Diaphragm Viva-esque questions 1. Complications of chest tube drainage Viva-esque questions 1. Organ damage Lymphatic drainage chylothorax
Long thoracic nerve of bell Rarely arrythmias Viva-esque questions 2. What are the common causes of a exudative effusion Viva-esque questions
2. PRISM PE RA Infection SLE Malignancy Viva-esque questions
3. What are the common causes of transudative effusions Viva-esque questions 3. The failures Cardiac failure
Nephrotic syndrome Cirrhosis Failure to eat Malabsorption Viva-esque questions 4. How big does an effusion have to be before it can be seen on CXR
4. 175-200mls blunting of C-P angle Case 3 Mrs Smith is a 30 year old female who has come in with a long standing cough Please take a history History
Cough for last 6 months, remained relatively constant Unproductive of any sputum or blood She says she has a constant tightness of the chest Begun to notice some weight loss History
Since the cough began, she has felt more lethargic with polyarthralgia Has recently begun to feel breathless, even at rest Chest pain noted central, constant, throbbing, relieved by paracetamol Noticed that her eyes feel very itchy and dry History
PMH, Recurrent conjunctivitis 2011-12 FH, Nil of note Drugs and Allergies, Nil NKDA SH,
Minimal drinker and non smoker No pets, No recent travel Work - waitress Differentials Differentials Sarcoidosis
Young, female Past history of non-pulmonary manifestation of sarcoid Cause of apical pulmonary fibrosis Malignancy rule out as weight loss noted, but non smoker, young Extrinsic allergic alveolitis no occupational exposure TB another cause of pulmonary fibrosis but no foreign
Inspection Plaques noted on skin Percussion, Palpation N Auscultation End inspiratory Fine crackles
APICAL Erythema nodosum Panniculitis Viva-esque questions 1. What is sarcoidosis?
Viva-esque questions 1. A Multisystem, granulomatous disease Of unknown cause Scattered collections of granulomas Mixed inflammatory cells Non-caseating, epithelioid Viva-esque questions
2. What % of patients with sarcoidosis have pulmonary involvement? Viva-esque questions 2. 90% Bilateral hilar lymphadenopathy Pulmonary infiltrates Fibrosis
Viva-esque questions 3. What are the causes of APICAL pulmonary fibrosis? Causes of apical pulmonary fibrosis
B Borelliosis R Radiation E Extrinsic allergic alveolitis
A Ankylosing spondylitis S Sarcoid T Tuberculosis Case 4 Mrs Jenkins is a 65 year old female who has noticed she gets breathless after walking 50 yards
Please take a history History Her breathlessness was first noted 6 months ago, which began after walking 500 yards Over the last 2 months this has reduced to 50 yards Chronic cough for about 2 years
Productive of white sputum Always has pain in both her hands, but she puts it down to everyday wear and tear. Has not sought medical attention History PMH,
Hypertension Hypercholesterolaemia FH, Mother suffered from arthritis Drugs and Allergies, Amlodipine Simvastatin NKDA
SH, Minimal drinker and non smoker Has 2 cats No recent travel Work retired lawyer Differentials
Differentials Rheumatoid arthritis Older female Bilateral long standing small joint arthralgia Cause of basal pulmonary fibrosis Malignancy rule out as no weight loss noted, non smoker Drug induced worsening SOB not usually associated with
CCB and Statins Scleroderma/CREST no other extra-pulmonary signs noted Asthma highly unlikely for age, no diurnal variation Examination PIP and MCP affected Elbow nodules
Auscultation End inspiratory Fine crackles BASAL Viva-esque questions 1. What are the pulmonary complications
of rheumatoid arthtitis? Pulmonary complications of RA
Obstructive pulmonary disease Infection Viva-esque questions 2. What are the BASAL causes of pulmonary fibrosis? Causes of basal Pulmonary Fibrosis
D Drugs ABC
A Asbestosis R Rheumatoid arthritis S Scleroderma/Systemic sclerosis I Idiopathic pulmonary fibrosis Viva-esque questions 3. What three findings constitute Feltys syndrome?
PLUS Neutropenia PLUS Rheumatoid arthritis Investigating Pulmonary fibrosis
Bedside Sputum ?TB AFB Sats Temperature Resp rate
Bloods Imaging Investigating? Special tests
FEV1? FVC? FEV1/FVC ratio?
Restrictive or obstructive? Why? Lung function
FEV1 Reduced FVC Reduced FEV1/FVC ratio same or increased Restrictive Why? Decreased lung compliance
Other causes: Obesity, pregnancy, air trapping in COPD (mixed picture), paralysis/muscle weakness Management Management Conservative Medical
Surgical Conservative Oxygen support Pulmonary rehab Medical Corticosteroids
Low dose prednisolone Months in duration N-Acetylcisteine Sildenafil Pirfenidone Surgical
Lung transplant Dependant on Severity of pulmonary fibrosis Patient health Potential improvement Case 5 Mr Patel is a 75 year old male with long
term shortness of breath Take a history History SOB began 15 years ago, and has been worsening gradually since Now SOB at rest, although previously only on exertion Associated chesty cough Productive of ++ sputum
With associated wheeze No weight loss History PMH, Nil relevant FH,
Nil of note Drugs and Allergies, Salbutamol Seretide (salmeterol + fluticasone) NKDA SH, Started smoking at 25 Continues to smoke 20 a day
Drinker in the past, now quit Differentials Differentials COPD Progressive, irreversible airway obstruction Cough, SOB, Wheeze
Long term smoker Pneumonia unlikely, as no acute pathology Asthma unlikely due to age and ++ sputum Examination Inspection
Barrel chest Use of accessory muscles Raised RR Palpation Reduced expansion Percussion
Hyper-resonance Auscultation Quiet breath sounds Viva-esque questions 1. The term COPD constitutes chronic bronchitis and emphysema. How would
you recognise each COPD subtype clinically? Chronic Bronchitis vs Emphysema Obesity Frequent, productive cough Accessory muscle use
Varenicline Bupropion Physiotherapy Medical Initial
SABA (Salbutamol) or SAMA (Ipratropium) prn If SOB continues or 2+ exacerbations FEV1 >50% (Mild COPD) Add LABA (Salmeterol) OR LAMA (Tiotropium) If LAMA, STOP SAMA FEV1 <50% (Moderate-Severe COPD)
Add LABA/Steroid combo (Seretide salmeterol + Flixotide; Symbicort formeterol + beclomethasone) If exacerbations continue Maximise inhaled therapy with LABA/steroid combo + LAMA + SABA Medical
PO theophylline PO Carbocisteine ? Oral steroid trial ? Alpha tocopherol ? Beta carotene
Viva-esque questions 2. When should long term oxygen therapy be considered in COPD? Long term oxygen therapy PaO2 <7.3 PaO2 7.3-8.0 AND Secondary polycythaemia
Nocturnal hypoxaemia sats <90% Peripheral oedema Pulmonary hypertension LTOT Supplemental oxygen for at least 15hours per day Greater benefits if 20 hours per day
Reduces hospital admissions and frequency of exacerbations Surgical Bullectomy LVRS Lung transplantation
Acute exacerbations of COPD Investigations Sputum Purulent Neutrophils 3. What organisms commonly can cause an acute
exacerbation of COPD? S. pneumoniae
H. influenzae M. catarrhalis P. aeruginosa Investigations Bloods FBC U+E - ? Effect of theophylline
pH 7.30 PO2 7 CO2 7.2 BE -10 HCO3 12 Treatment - Exacerbations
Oxygen sats 88-92% - why not higher? Antibiotics Dependant on organism
Nebulised bronchodilators Oral Prednisolone, to continue as part of rescue package IV aminophylline NIV? Non invasive ventilation Persistent hypercapnic ventilatory failure
T2RF No response to medical therapy BIPAP can then be used Case 6 Mr Baldwin is a 15 year old boy whose mother is worried about a longstanding
cough Please take a history History Cough has lasted around 1 year, worse in the evenings and in the mornings Mr Baldwin has mentioned he feels a band around his chest when he needs to cough, which is dry and hacking
When this happens, it leaves him very breathless and wheezy History Also known to have hayfever and eczema, something that his father also suffers from Differentials
Asthma Cardinal features - Wheeze, SOB, Cough Usually diurnal reversible and variable airflow obstruction Associated atopy and family history Aspergillosis unlikely as no trigger identified, not diurnal Examination
Diary of symptoms/Peak flow Bloods Serum precipitins Imaging Hyperinflation
Special tests Spirometry obstructive picture Usually >15% improvement in FEV1 following SABA or steroid trial Skin prick testing Management of chronic asthma
Viva-esque questions 1. What are the aims of asthma treatment, and what guidelines are they based on? Viva-esque questions 1. British thoracic society guidelines; no daytime symptoms, no exacerbations, no
rescue medications, lung function >80% predicted Conservative Removal of any allergens Patient education Medical
Add inhaled LABA +/- increase inhaled steroid up to 800micrograms/day Step 4 Increase inhaled steroid up to 2000micrograms/day +/- leuotriene receptor antagonist, beta agonist PO, MR Theophylline Step 5 Add long term oral prednisolone
Acute exacerbation of asthma Moderate PEFR 50-75% Severe PEFR 33-50%
Life threatening PEFR <33% Investigating Bedside PEFR Sputum
Bloods FBC, UE, CRP, cultures ABG, especially in life threatening Management of acute asthma
Oxygen Nebulised salbutamol and ipratropium Prednisolone 50mg PO OD/Hydrocortisone 100mg IV QDS
Call a senior! IV Magnesium 1.2-2g infusion IV Salbutamol or IV aminophylline If numbers not improving ITU! Summary Signs common and miscellaneous Cases
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