Respiratory for PACES Cases for finals Monday 8th

Respiratory for PACES Cases for finals Monday 8th

Respiratory for PACES Cases for finals Monday 8th October 2012 Dr James Milburn Dr Chris Kyriacou Outline Signs to be seen in examination, both expected

and miscellaneous Common cases we had/are to be expected in the exam Hx and Ex Ix Mx Respiratory Exam

End of bed inspection General Exam Chest

Inspection Palpation Percussion Auscultation Added extras Inspection (End of bed)

Observe patient breathless/comfortable Look at surroundings inhaler/oxygen/nebulisers etc Use of accessory muscles Cachexic General Examination

Hands Face Neck Legs

Hands Hands Hands Hands

Clubbing Bronchiectasis, CF, Carcinoma, Fibrosing alveolitis 4 signs - FACE

Flucance of nail bed Angle loss Curvature of nail Expansion of terminal phalynx Tar staining Small muscle wasting Lung Ca pressure on brachial plexus

Hands HPOA Periosteal inflammation in distal ends of long bones Primary lung Ca, Meso Flap/Tremor CO2 retention

Fine tremor from 2-agonists Pulse Rate and rhythm Bounding Cyanosis

Face Face Face Plethoric Secondary polycythaemia, SVC obstruction

Horners (Ptosis, miosis, anhydrosis) Pancoasts, (Demyelination, Carotid aneurysm) Anaemia Central cyanosis Mouth Halitosis/Thrush Neck

Lymphadenopathy JVP Legs Inspection - Chest Inspection - Chest

Inspection - Chest Inspection - Chest Inspection - Chest Inspection - Chest

Inspection Chest Inspection - Chest Shape Barrel-chested (AP>Lateral) Excavatum/Carinatum

Scars Dilated veins Ask them to take deep breath Reduced expansion Symetrical Palpation

Trachea Apex Expansion Vocal fremitus


Flat Pleural effusion (thigh) Dull Lobar pneumonia (liver) Resonant Hyper-resonant Emphysema/Pneumothorax Tympany Large pneumothorax (puffed out cheek) Auscultation Crackles

Nature of crackles Fine Oedema/Fibrosis (velcro) Coarse Bronchiectasis Timing Early insp COPD/Bronchitis Mid-late Fibrosis/Oedema

Clear on coughing? Yes - ?bronchiectasis No Fibrosis/Oedema Auscultation Wheeze Inspiratory/Expiratory Fixed monophonic - Bronchial Ca

Polyphonic - Asthma Pleural rub Vocal resonance Auscultation Breath sounds Vesicular Insp longer than exp

Bronchial Exp longer than insp Causes of bronchial breath sounds Consolidation Collapse Fibrosis Back of chest

Repeat Added Extras to offer

Sats Temp chart Sputum pot PEFR CVS exam Case 1

Mrs Jones is 40 yr old women who presents with a chronic cough Please take a history History Cough for last 2 years although now worsening No diurnal variation No obvious exacerbating factors

Productive of around -1 cupful of foul-smelling green sputum daily Occasional flecks of blood mixed in with sputum Had 3 chest infections in the last 6 months No weight loss History

2 years ago could walk several miles with no SOB During exacerbation is <50yards No fever/night sweats No chest pain History PMH,

Laparoscopic cholecystectomy 2007 Whooping cough ~1970 FH, Nil of note Drugs and Allergies, Nil NKDA SH,

Legal secretary for last 15yrs no hx of asbestos exposure Ex-smoker for 5 years in her 20s Minimal drinker No pets No recent travel Differentials

Differentials Bronchiectasis Most likely from pertussis as child CF unlikely though screen in <40 Chronic infection

COPD very unlikely without FH of 1-antitrypsin TB rule out, no foreign travel, no known exposure Malignancy rule out, no wt loss, non-smoker etc Fibrosis not dry cough, no occupational risk

Examination On examination the patient was clubbed and had coarse inspiratory crackles bilaterally R>L Not dyspnoeic at rest and no use of accessory muscles. A/E and expansion equal No wheeze

Investigations Bedside Bloods

Imaging Special tests Bedside Bedside

Sputum PEFR Sats Temperature

Bloods Bloods Bloods FBC Anaemia (chronic disease/haemoptysis) Polycythaemia (secondary to hypoxia in more advanced

cases) Raised WCC if infection Eosinophilia if ABPA Inflammatory markers ESR/CRP U&Es Renal dysfunction due to amyloid deposition

Serum immunoglobulins Genotyping/Sweat test Imaging Imaging Imaging

Imaging CXR Flattened diaphragms Tramlines from thickened bronchial walls Cystic shadows CT/HRCT

Signet rings Bronchial wall thickening Management Management Conservative Medical

Surgical Conservative

Postural drainage Chest physiotherapy Pulmonary rehab Oscillating positive expiratory devices (Acapella) Medical

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?

1. H.influezae, S.pneumoniae, Staph aureus, Pseudomonas 2. Congenital CF, Kartageners, Youngs Post-infection (childhood) Measles, pertussis, TB,

Bronchiolitis Post-infection (adult) Severe pneumonia, TB Autoimmune RA, UC Obstruction ( localised) Tumour, Forgien body, lymph node Idiopathic Immunocomp Primary hypogammaglobulinaemia Traction bronchiectasis Secondary to fibrosis

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



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

Glucose <3.3mmol/L Malig/Ra/SLE/TB pH <7.2 Malig/Ra/SLE/TB Increased LDH Malig/Ra/SLE/TB Increased amylase pancreatitis/Carcinoma/Bacterial pneumonia/Oesophageal rupture Management

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

travel Examination Lupus pernio Dusky Purple Face, Fingers, Feet

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

Pleural effusion Nodular lung disease PULMONARY FIBROSIS Pulmonary vasculitis Alveolar haemorrhage

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

Rhonchi Wheezing Cor pulmonale signs Oedema Cyanosis Thin, barrel chest Little/no cough

PURSED LIP breathing and accessory muscle use TRIPOD sitting position Hyper-resonance Wheezing Quiet HS

Investigations Bedside Sputum Mucoid Macrophages typically Sats

Temperature Resp rate Bloods FBC Raised PCV U+E

Na 147 a1AT BNP? ABG

pH 7.40 PO2 8.3 CO2 5.2 BE +1

HCO3 23.4 Investigations? Lung function

FEV1? FVC? FEV1/FVC ratio? Restrictive or obstructive? Why?

Lung function

FEV1 low FVC normal FEV1/FVC ratio reduced, LESS than 0.7 Obstructive Why? Decreased expiratory flow Other causes? Asthma

Investigations Management Chronic COPD Conservative Smoking cessation Education NRT

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

Inspection Raised RR Palpation Hyperinflated chest Percussion Hyper-resonance

Auscultation Expiratory polyphonic wheeze bilaterally Investigations Bedside PEFR

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

Step 1 Inhaled SABA prn Step 2 Add inhaled steroid 200-800micrograms/day Step 3

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

Bronchiectasis Pleural Effusion

Pulmonary fibrosis COPD Asthma

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