Phase 2 Stephen Lau & George Lam

Respiratory Phase 2 Stephen Lau & George Lam The Peer Teaching Society is not liable for false or misleading information…

Outline • Pulmonary Embolism • Pneumothorax • Pneumonia • Pleural Effusion The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Causes of PE • Thrombus (DVT, ?) • ? • ? • ? The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Causes of PE • Thrombus (DVT, AF) • Fat • Air • Bacterial Vegetation (EC) The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Causes of VTE • ? • ? • ? The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Causes of VTE • Change in Blood Flow • Immobility  Post-Op, Paralysis • Obesity • Pregnancy • Change in Blood Vessel • Smoking • HTN • Change in Blood Constituent • Dehydration • Malignancy • High Oestrogen • Polycythaemia • Nephrotic Syndrome • Inherited  Protein C/S Deficiency, Factor VLeiden The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Classification of Clinical Presentation The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Classification of Clinical Presentation • Acute  Sudden • Massive  Cardiogenic Shock (SBP < 90 mmHg or ↓ ≥ 40 mmHg for > 15 min) • Submassive  No Shock • Chronic  Gradual P HTN The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Sx – Submassive The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Sx – Submassive • Acute SOB  • Pleuritic Chest Pain  • Cough  • Haemoptysis  • Wheeze  • Tachycardia  • Tachypnoea  The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Sx – Submassive • Acute SOB  ↓ PaO2 /↑ PaCO2 (due to V/Q mismatch + opening of AV collaterals) • Pleuritic Chest Pain  Inflammatory Rxn Irritates Parietal Pleura • Cough  ?Fluid Extravasation • Haemoptysis  Lung Infarction • Wheeze  Bronchospasm • Tachycardia  ↓ PaO2 /↑ PaCO2 • Tachypnoea  ↑ PaCO2 The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Sx – Massive The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Sx – Massive • Shock Sx  • ↑ JVP  • Accentuated P2  The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Sx – Massive • Shock Sx  ↓ LV Pre-Load = ↓ CO • ↑ JVP  RHF • Accentuated P2  Delayed RV Emptying The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • 70 y/o man day 4 post-THR developed sudden-onset SOB and pleuritic chest pain 2h ago. SOB occurs at rest and worse on exertion. No associated leg pain/swelling, cough, haemoptysis or wheeze. • No PMH asthma/COPD, DVT/PE. 20 Pack Years. • Ex • T 37.0, HR 110, BP 120/80, RR 24, SaO2 93%. • JVP 2 cm. HS normal, no Murmur. • Trachea central. Scattered creps @ lung base. • Mild calf tenderness. The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • DDx • Submassive PE  • PTX  • Acute Pulmonary Oedema/ARDS  • Pneumonia  • Sepsis  • MI  • Arrhythmia  The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • DDx • Submassive PE  D-Dimer, Leg USS • PTX  CXR • Acute Pulmonary Oedema/ARDS  CXR • Pneumonia  FBC, CXR • Sepsis  FBC, Lactate, Blood Culture, CXR • MI  ECG • Arrhythmia  ECG The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Ix • FBC • LFT  ?Liver Mets/Ca • U&E  ?Renal Function (?Shock) • Clotting  ?Hypercoagulable • D-Dimer • ABG • Blood Culture • CXR • Leg USS • ECG The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Ix • D-Dimer • If +ve, next step? • If –ve? • ABG • PaO2 • PaCO2 • CXR • 3 Signs • ECG • What is the pathognomonic arrhythmia? The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Ix • D-Dimer • If +ve, next step? CTPA or V/Q Scan • If –ve? Not PE • ABG  T1RF • PaO2  Low • PaCO2  Low • CXR **COMMONLY NORMAL • Decreased Vascular Markings • Dilated PA • Wedge-Shaped Infarction • Pleural Effusion • ECG • What is the pathognomonic arrhythmia? • S1Q3T3  Deep S (I), Q (III), T Inversion (III) The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Mx of Submassive PE (SBP > 90 mmHg) • Initial • Long-Term The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Mx • Initial • O2 • 1) LMWH SC (Enoxaparin, Dalteparin) • / Fondaparinux • / UFH • 2) IVC Filters • Long-Term • Mobilization • TED Stockings • Warfarin PO for ≥ 3 Months  INR 2-3 The Peer Teaching Society is not liable for false or misleading information…

Pulmonary Embolism • Causes of PE • Risk Factors for VTE  Virchow’s Triad • Clinical Presentation • Acute  Massive/Submassive • Chronic • DDx of Acute SOB • Ix of Acute SOB • Ix Results of PE • Mx of Submassive PE The Peer Teaching Society is not liable for false or misleading information…

Pneumothorax • Types The Peer Teaching Society is not liable for false or misleading information…

Pneumothorax • Types • Tension • Non-Tension • Spontaneous • Primary  No Lung Pathology (but probably small blebs) • Secondary  Lung Pathology (esp. COPD bullae) • Traumatic The Peer Teaching Society is not liable for false or misleading information…

Pneumothorax • 2 Symptoms • 4 Examination Signs of Non-Tension PTX • Which Side has PTX? The Peer Teaching Society is not liable for false or misleading information…

Pneumothorax • 2 Symptoms • SOB • Pleuritic Chest Pain • 4 Examination Signs of Non-Tension PTX • Tracheal Deviation Towards Side • ↓ CE Affected Side • ↑ PN • ↓ BS • Which Side has PTX? • Left The Peer Teaching Society is not liable for false or misleading information…

Pneumothorax • Mx of Small Primary Spontaneous PTX? • Mx of Large Primary Spontaneous PTX? • Mx of Small Secondary Spontaneous PTX? • Mx of Large Secondary Spontaneous PTX? • Where Do You Stick the Cannula? The Peer Teaching Society is not liable for false or misleading information…

Pneumothorax • Mx of Small Primary Spontaneous PTX? • Observe • Mx of Large Primary Spontaneous PTX? • 1) Aspiration • 2) Chest Drain • Mx of Small Secondary Spontaneous PTX? • 1) Aspiration • 2) Chest Drain • Mx of Large Secondary Spontaneous PTX? • Chest Drain • Where Do You Stick the Cannula? • 2nd Intercostal Space, Mid-Clavicular Line The Peer Teaching Society is not liable for false or misleading information…

Pneumonia - Basics • Signs and Symptoms of Acute Lower Respiratory Tract Infection. • Radiographic Change The Peer Teaching Society is not liable for false or misleading information…

Pneumonia - Basics • Causative Organisms • Pathogens • Streptococcus pneumoniae • Klebsiella pneumoniae • Haemophillus influenzae • Staphlylococcus aureus • Pseudomonas aeruginosa • Atypical Pathogens • Chlamydia pneumoniae • Mycoplasma pneumoniae • Legionella pneumophillia The Peer Teaching Society is not liable for false or misleading information…

Types of Pneumonia Hospital and Community Acquired • Hospitalization for more than 2 days in the last 90 days • IV therapy, chemotherapy, or wound care in last 30 days • Residence in care home or long term care • Attendance in hospital in the last 30 days. The Peer Teaching Society is not liable for false or misleading information…

Clinical Evaluation - Symptoms • Fever • Pleuritic Chest Pain • Haemoptysis • Sputum Production ( purulent) • Dyspnea • Cough • Fever/Rigors The Peer Teaching Society is not liable for false or misleading information…

Clinical Evaluation - Signs • Febrile • Raised Respiratory Rate • Reduced SpO2 • Crackles • Bronchial Breathing • Dullness on percussion The Peer Teaching Society is not liable for false or misleading information…

Diagnosis - Investigations • Bloods • ABG • FBC • CRP • WCC + Differential • Anaemia • U/E • LFT The Peer Teaching Society is not liable for false or misleading information…

Diagnosis - Investigations • Scoring System • Confusion • Urea • Respiratory Rate • Blood Pressure <90mmHg systolic • <65 years of age • Imaging • CXR The Peer Teaching Society is not liable for false or misleading information…

Treatment • Antibiotics • Amoxicillin / Flucoxacillin (if S. aureus suspected) • Oxygen • Fluids • Analgesia The Peer Teaching Society is not liable for false or misleading information…

Pneumonia – Clinical Scenario 1 A 54-year-old smoker with multiple comorbidities (diabetes, hypertension, coronary artery disease) presents with a 2-day history of a productive cough with yellow sputum, chest tightness, and fever. Physical examination reveals a temperature of 38.3°C (101°F), BP of 150/95 mmHg, heart rate of 85 bpm, and a respiratory rate of 20 breaths per minute. His oxygen saturation is 95% at rest; lung sounds are distant but clear, with crackles at the left base. CXR reveals a left lower lobe infiltrate. The Peer Teaching Society is not liable for false or misleading information…

Pleural Effusion - Basics • Fluid that occupies the space between the visceral and parietal pleural • Transudate • Disruption of hydrostatic and oncotic forces across pleural membrane • Exudate • Increases permeability of the pleural surface The Peer Teaching Society is not liable for false or misleading information…

Pleural Effusion - Basics • Common Causes of Transudate • Heart Failure • Cirrhosis • Hypoalbuminaemia • Peritoneal Dialysis • Nephrotic Syndrome • Hypothyroidism The Peer Teaching Society is not liable for false or misleading information…

Pleural Effusion - Basics • Common Causes of Exudate • Pneumonia • Malignancy • Pulmonary Infarction (Embolism) • Autoimmune • Pancreatitis • TB The Peer Teaching Society is not liable for false or misleading information…

Pleural Effusion - Symptoms • Shortness of Breath on Exertion • Cough • Pleuritic Pain • PMHx of smoking, asbestos exposure • PMHx of any previously mentioned diseases The Peer Teaching Society is not liable for false or misleading information…

Pleural Effusion - Signs • Dullness to percussion • Tracheal centrality • Vocal Fremitus • Asymmetric Chest Expansion • Reduced Breath Sounds The Peer Teaching Society is not liable for false or misleading information…

Diagnosis - Investigations • CXR – PA/Lateral • Thoracentesis (Chest Drain) • Diagnostic in up to 75% of cases • Protein • LDH • Cholesterol • Cytology • Glucose • RBC/WBC/pH • Cultures • Pleural Ultrasound • FBC/CRP/Culture The Peer Teaching Society is not liable for false or misleading information…

Treatment • Treat the cause • Thoracentesis • Pleurodesis The Peer Teaching Society is not liable for false or misleading information…

Pleural Effusion – Clinical Case 1 • A 70-year-old women presents with slowly increasing dyspnoea. She cannot lie flat without feeling more short of breath. She has a history of HTN and osteoarthritis, and she has been taking NSAIDs with increasing frequency over the previous few months. On physical examination, she appears dyspnoeic at rest, her BP is 140/90 mm Hg, and pulse is 90 bpm. Her jugular venous pressure is elevated to the angle of the jaw. The left lung field is dull to percussion with decreased air entry basally. Crackles are heard in the right lung field and above the line of dullness on the left. Lower extremities have pitting oedema to the knee. The Peer Teaching Society is not liable for false or misleading information…

Phase 2 Stephen Lau & George Lam