A MEDED LECTURE Acute Resp - PowerPoint Presentation

1. A MEDED LECTUREAcute RespHelena Milton-Joneshm5118@ic.ac.uklMENTI CODE: 8364 0463

2. SESSION STRUCTUREConditions:PneumoniaBronchitisPulmonary embolism (PE)PneumothoraxAcute respiratory distress syndrome (ARDS)COVID-19 (summary slide)

3. SESSION STRUCTUREHistoryAetiologyPresentationInvestigationsManagement

4. SBA 1Which of the following organisms is a recognised cause of hospital acquired pneumonia?Streptococcus pneumoniaePseudomonas aeruginosaHaemophilus influenzaeLegionella pneumophilia Chlamydophila psittaciMENTI CODE: 8364 0463

5. PneumoniaDefinition: Infection of the alveoli in the lungs (lower respiratory tract infection, LRTI)Community acquired pneumonia (CAP) = pneumonia acquired within the communityHospital acquired pneumonia (HAP) = pneumonia which has occurred 48 hours after hospital admission

6. PneumoniaCommon causes of CAPStreptococcus pneumoniaeMycoplasma pneumoniaeHaemophilus pneumoniae Atypical organismsMycoplasma pneumoniaeLegionella pneumophiliaChlamydia psittaciChlamydia pneumoniaeCommon causes of HAPStaphylococcus aureusPseudomonas aeruginosaKlebsiellaAspiration pneumoniaAnaerobes from gut flora*Beware in stroke patientsCausative organisms:Streptococcus pneumoniae is most common cause of CAP (39%)- previous exam question

7. PneumoniaRisk factors:Pet birds – Chlamydia psittaciRecent travelImmunocompromisedFaulty air conditioning - Legionella Smoking

8. PneumoniaSymptoms:Typical organismsFeverSOBProductive cough (yellow/ green sputum)Pleuritic chest painAtypical organismsDry coughHeadacheDiarrhoeaMyalgiaHepatitisConfusion (legionella)

9. PneumoniaSigns:Typical signsInspectionRespiratory distressCyanosisPalpationReduced chest expansionPercussionDull percussion over areas of consolidationAuscultationBasal coarse crepitationsBronchial breathingIncreased vocal resonanceAtypical signsMycoplasma pneumoniaTransverse myelitis (inflammation of spinal cord)Erythema multiforme (round lesions with bullseye appearance)Associated with autoimmune haemolytic anaemiaLegionellaHyponatraemiaAbnormal LFTsWhat will we find?

10. PneumoniaInvestigations:Bedside testsSputum MCSBloodsFBC (high WCC)CRP (high)ABG (type 1 respiratory failure)Invasive testsPleural fluid MCS via thoracentesisImaging-CXR (consolidation with fluid level)What next?Investigations for atypical organismsMycoplasma pneumoniaBlood film (red cell agglutination with cold agglutinin)LegionellaUrinary antigensLFTs

11. PneumoniaCXRLobar pneumonia – consolidation within one lobeBronchopneumonia –consolidation all over the lungs* Examiners often show CXR of lobar pneumonia in OSCE and ask for differentials

12. PneumoniaCURB-65 assesses the severity of a patient’s pneumonia and determines treatmentRespiratory rate > 30Confusion ≤ 8 (AMTS)*Urea > 7mmol/LSBP < 90mmHgAge > 65Treatment optionsScore of 1 = GP + oral antibioticsScore of 2 = A&E + IV antibioticsScore of ≥3 = Hospital admission + IV antibiotics + consider ITUCAP antibioticsTypical organisms = amoxicillinCo-amoxiclav if severeAtypical organisms = clarithromycin*Commonly, amoxicillin & clarithromycin given together if causative organism not yet identifiedManagement:* Need to know how to calculate CURB-65 score for written exam*AMTS = Abbreviated Mental Test scoreHAP antibioticsStaph aureus: flucloxacillinMRSA: vancomycinPseudomonas: tazocin + gentamicin (tazosin = tazobactam + piperacillin)Anaerobes: metronidazole & amoxicillin

13. PneumoniaManagement:If patient has penicillin allergy, give doxycyclinePneumocystis jiroveci – pneumonia in HIV patients, give co-trimoxazole (trimethoprim + sulfamethoxazole)

14. SBA 1Which of the following organisms is a recognised cause of hospital acquired pneumonia?Streptococcus pneumoniaePseudomonas aeruginosaHaemophilus influenzaeLegionella pneumophilia Chlamydophila psittaciMENTI CODE: 8364 0463

15. Aetiology: Investigations: Pneumonia: SUMMARY SLIDEHistory: Typical:FeverSOBProductive cough (yellow/ green sputum)Pleuritic chest painCausative organisms: Infection of the alveoli in the lungs (lower respiratory tract infection, LRTI)CAP = acquired in the communityHAP = acquired 48 hours after hospital admissionBloods: FBC, CRP, ABG (type 1 resp failure) Management: Sputum MCS: Identify causative organismPleural fluid MCS: Via thoracentesisAssess severity using CURB-65 scoreScore of 1 = GP + oral antibioticsScore of 2 = A&E + IV antibioticsScore of ≥3 – Hospital admission, IV antibiotics + consider ICUCAP:Typical organisms – amoxicillin (doxycycline if penicillin allergy)Atypical organisms – clarithromycinHAP:If staph aureus: flucloxacillin; If MRSA: vancomycin; If pseudomonas: tazocin + gentamicin (tazosin = tazobactam + piperacillin); For anaerobes: metronidazole & amoxicillinComplications: ARDSPleural effusionCAP:Streptococcus pneumoniae (most common)HAP:Staphylococcus aureusPseudomonas aeruginosaKlebsiellaAtypical organisms:Legionella pneumophilia (AC)Chlamydia psittaci (birds)Mycoplasma pneumoniaeMycoplasma pneumoniae: Blood film (red cell agglutination)Legionella: Urinary antigens,LFTs, U&Es (hyponatraemia) CXR: Consolidation (lobar or bronchopneumonia?)Atypical:Dry coughHeadacheDiarrhoeaMyalgiaHepatitisConfusion (legionella)SepsisDifferentials: Bronchitis, bronchiectasis, lung cancer

16. SBA 2Lucy is a 12-year-old girl who has presented to her GP accompanied by her mother with a dry cough and shortness of breath. She says it has lasted 5 days and she’s taken some time off school. She has been feeling generally unwell although doesn’t have a fever. She has no known drug allergies or medical history of note, although had a similar cough last winter. What should the GP do?Advise her mother to give her paracetamol at home and make sure she’s well hydratedPrescribe a 7-day course of amoxicillin Prescribe a 7-day course of doxycyclinePrescribe inhaled corticosteroidsRefer to A&E for a chest x-rayMENTI CODE: 8364 0463

17. Acute bronchitisDefinition: Infection of the bronchi, upper respiratory tract infection (URTI)Aetiology: Usually a viral infection, although may be bacterialTypical organisms:RhinovirusParainfluenzaInfluenza A or BRespiratory syncytial virusCoronavirusLess commonly caused by:Mycoplasma pneumoniaeBordetella pertussisChlamydia pneumoniae

18. Acute bronchitisRisk factors:COPDCystic fibrosisSmoking

19. Acute bronchitisSigns and symptoms:Nonproductive or minimally productive cough- May last weeksDyspnoeaResults from chest pain or tightness with breathingWheezingMild fever* High or prolonged fever suggests pneumonia

20. Acute bronchitisInvestigations:CXR is usually only indicated if:Findings suggestive of pneumoniaElderly patientsPersistent coughHistory of COPD, lung pathologySputum MCS usually have no role, unlike in pneumoniaDiagnosis is based on clinical presentation following examination and history

21. Acute bronchitisManagement:In otherwise healthy patients:Paracetamol and ibuprofen as requiredHydrationIf cough persists for > 2 weeks:Inhaled corticosteroidsIn patients with underlying lung pathology eg. COPD, asthma:Oral antibioticsAmoxicillin (7 days)Doxycycline if penicillin allergy (7 days)Inhaled beta-2 agonists eg. salbutamol may be useful if patient is wheezingAntitussives can be prescribed if cough interfering with sleep

22. SBA 2Lucy is a 12-year-old girl who has presented to her GP accompanied by her mother with a dry cough and shortness of breath. She says it has lasted 5 days and she’s taken some time off school. She has been feeling generally unwell although doesn’t have a fever. She has no known drug allergies or medical history of note, although had a similar cough last winter. What should the GP do?Advise her mother to give her paracetamol at home and make sure she’s well hydratedPrescribe a 7-day course of amoxicillin Prescribe a 7-day course of doxycyclinePrescribe inhaled corticosteroidsRefer to A&E for a chest x-rayMENTI CODE: 8364 0463

23. Aetiology: Investigations: Acute bronchitis: SUMMARY SLIDEHistory: Non-productive or minimally productive coughDyspnoeaMild feverDifferentials: PneumoniaAsthmaInfection of the bronchi, upper respiratory tract infection (URTI)Usually, viral over bacterial infectionSputum MCS usually not indicated Management: Clinical diagnosis: Thorough examination and historyConservative: Regular paracetamol, ibuprofen, hydration MedicalIf wheeze: Salbutamol inhalerIf cough disturbing sleep: AntitussivesIf cough persists > 2 weeks: Inhaled corticosteroids (can give oral if severe) Underlying lung pathology: Amoxicillin (doxycycline if penicillin allergy)Complications: PneumoniaChronic bronchitisIndications for CXR:Findings suggestive of pneumoniaElderly patientsPersistent cough lasting weeksHistory of lung pathologyRisk factors: Smoking, chronic lung conditions (COPD, CF)Sinusitis

24. SBA 3Rachel is a 24-year-old female who underwent a recent salpingectomy for an ectopic pregnancy. Today she awoke breathless, with pleuritic chest pain and haemoptysis. She has been taking the OCP for 5 years. A pulmonary embolism was suspected. CTPA identified filling defects within the pulmonary vasculature with pulmonary emboli. Her recent observations are:Temp: 37.4°CHR: 122 bpmBP: 105/78RR: 22SaO2: 93% on RAHow should Rachel be managed?AnticoagulationThrombolysisEmbolectomyRespiratory SupportTED stockingsMENTI CODE: 8364 0463

25. Pulmonary embolism (PE)Venous Thromboembolism Deep Vein ThrombosisPulmonary EmbolismEmbolus Definition: a blockage in one of the pulmonary arteries in the lungsOne or more emboli, usually arising from a thrombus formed in the veins, are lodged in and obstruct the pulmonary arterial system, causing severe respiratory dysfunction

26. Pulmonary embolism (PE)CTSVPCancerChemoCardiac FailureCOPDFactor C deficiencyTraumaTime (age)ThrombocytosisTravel (long haul flight)StasisSurgeryFactor S deficiencyVaricose veinsVirchow’s TriadFactor V LeidenPill (OCP)Pregnancy PuerperiumPrevious VTEPolycythaemiaParaprotein depositionMnemonic: CT, s'il vous plaîtWhy? Because you will be asking the radiologist for a CTPARisk factors:

27. Pulmonary embolism (PE)Signs and symptoms:Pleuritic chest painCollapse if severeDyspnoeaPresentation depends on the severity of PE (more on next slide)

28. Pulmonary embolism (PE)Signs and symptoms:Acute Massive PEAcute Small PEChronic PESudden complete occlusion of pulmonary arterySudden incomplete occlusion of pulmonary arteryChronic occlusion of pulmonary microvasculatureCollapseCentral crushing painSevere dyspnoeaPleuritic chest painHaemoptysisDyspnoeaExertional DyspnoeaOn ECGS1Q3T3 patternRight axis deviation (RAD)Right bundle branch block (RBBB)Sinus tachycardiaNote: CXR can show Westermark’s Sign (high +ve pred. value, occurs in 10% cases)Buzzword for written exam

29. Pulmonary embolism (PE)S1Q3T3 pattern:Westermark’s Sign:Indicative of RV strain and therefore suggestive of PE Hypovolaemia distal to the pulmonary artery that has been occluded by the PE. Blood cannot reach this region causing ischaemia and infarction. This increases the translucency of the region.

30. Pulmonary embolism (PE)Previous DVT/PE1.5Evidence of DVT3Stasis1.5Cancer1Opinion is PE3Rhythm Raised (>100)1.5Exsanguination (Haemoptysis) 1Investigations:≥4<4ScoreLow RiskHigh RiskThe Well’s Score is used to estimate risk of PE and determines how we should investigateWell’s Score:* You know know when and why the Well’s score is used for the written exam

31. Pulmonary embolism (PE)Management:Management depends on whether the patient is haemodynamically stable or notAre they haemodynamically stable?i.e. SBP <90 mmHgYESNOSub-acute/Chronic PEMassive PERespiratory supportAnticoagulationAnticoagulants:Fondaparinux/Heparin for 5 daysWarfarin for 3 monthsRespiratory support1st line: Thrombolysis2nd line: EmbolectomyIV Thrombolytics (fibrinolytics):AlteplaseStreptokinasert-PA

32. Pulmonary embolism (PE)Venous thromboembolism (VTE) prevention:NICE guidelines state everyone must be VTE risk assessed within 24 hours of hospital admission. A standard checklist is:Mechanical: Compression stockings (TED stockings)Pharmacological: Low-molecular-weight heparin (eg. tinzaparin)“TEDs & Tinz”*VTE encompasses both DVT and PE

33. SBA 3Rachel is a 24-year-old female who underwent a recent salpingectomy for an ectopic pregnancy. Today she awoke breathless, with pleuritic chest pain and haemoptysis. She has been taking the OCP for 5 years. A pulmonary embolism was suspected. CTPA identified filling defects within the pulmonary vasculature with pulmonary emboli. Her recent observations are:Temp: 37.4°CHR: 122 bpmBP: 105/78RR: 22SaO2: 93% on RAHow should Rachel be managed?AnticoagulationThrombolysisEmbolectomyRespiratory SupportTED stockingsMENTI CODE: 8364 0463

34. Aetiology: Investigations: Pulmonary embolism (PE): SUMMARY SLIDEHistory: Acute massiveCollapseCentral crushing chest painSevere dyspnoeaRisk factord: Stasis (bed bound patient, recovering from surgery, long haul flight)Oral contraceptive pillPregnancyA blockage in one of the pulmonary arteries in the lungs, usually arises from a venous thrombusAcute massiveAcute smallChronicIf Well’s score ≥4: CT pulmonary angiogram (CTPA)Management: If Well’s score < 4: D-dimer* Don’t do CTPA in pregnancy, do D-dimer insteadIf haemodynamically stable: Respiratory support, anticoagulationFondaparinux/heparin for 5 days; warfarin/DOAC for 3 monthsIf haemodynamically unstable (SBP < 90): Thrombolysis (IV alteplase) is first line, embolectomy is second lineVTE prevention: Compression stockings, LMWH eg. enoxaparin, tinzaparinComplications: ReoccurrenceAcute smallHaemoptysisDyspoeaPleuritic chest painChronicExertional dyspnoeaECG: S1Q3T3 pattern, RAD, RBBB, tachycardiaCXR: Westermark’s sign (rare but high sensitivity)Cardiac arrestPulmonary hypertension

35. SBA 4Lanky Schmidt is a tall, 29-year-old male. He has presented to A+E feeling short of breath. He has right sided pleuritic chest pain. He is a non-smoker and otherwise healthy. A chest radiograph shows a right sided pneumothorax 8mm in diameter. How should the medical team proceed?Reassure and discharge with outpatient reviewObserve for 6 hours and give oxygenList for elective Surgical PleurodesisNeedle Aspiration and give oxygenImmediate wide bore cannula insertion at 2nd intercostal spaceMENTI CODE: 8364 0463

36. PneumothoraxDefinition: an abnormal collection of air in the pleural space between the lung and the chest wallTraumatic pneumothoraxDamage to parietal pleuraSpontaneous pneumothoraxDamage to visceral pleuraNormal intrapleural pressure is -5 to -8 cm H2O

37. PneumothoraxClassifying pneumothoraxes: PRIMARY or SECONDARY?Primary - young and otherwise healthy patientSecondary - pre-existing lung pathology. elderlyCOPDCystic fibrosis

38. PneumothoraxRisk factors for primary pneumothorax:MaleMarfan’s SyndromeSmoking

39. PneumothoraxInvestigations:CXR – Look for loss of lung markings (may see line where they stop, air is black on x-ray)

40. PneumothoraxManagement:PrimarySecondaryYesYesYesYesYesYesNoNoNoNoNoNo

41. PneumothoraxONE WAY VALVETension pneumothorax – medical emergencyLung CompressionSevere Dyspnoea Tracheal Deviation (away from lesion)Silent chest, hyperresonance, reduced expansion(on lesioned side)Mediastinal ShiftHypotensionTachycardiaSevere hypotension is what causes death

42. PneumothoraxManagement of tension pneumothorax:Insert large bore cannula (orange or grey) in 2nd ICS, MCLPlace the needle just above the third rib (inferior region of 2nd ICS) in order to avoid the neurovascular bundle of the 2nd rib.

43. SBA 4Lanky Schmidt is a tall, 29-year-old male. He has presented to A+E feeling short of breath. He has right sided pleuritic chest pain. He is a non-smoker and otherwise healthy. A chest radiograph shows a right sided pneumothorax 8mm in diameter. How should the medical team proceed?Reassure and discharge with outpatient review Observe for 6 hours and give oxygenList for elective Surgical PleurodesisNeedle Aspiration and give oxygenImmediate wide bore cannula insertion at 2nd intercostal spaceMENTI CODE: 8364 0463

44. Aetiology: Investigations: Pneumothorax: SUMMARY SLIDEHistory: Differentials: AsthmaPEAn abnormal collection of air in the pleural space between the lung and the chest wallPrimary (young, healthy)Secondary (elderly, lung diseaseBloods: FBC, clotting screen (correct clotting abnormalities before inserting chest drain)Management: CXR: Loss of lung markings (look for line where lung markings stop)Primary pneumothorax: Discharge and organise OPD review if <2cm and no SOB, needle aspiration if >2cm or SOB, chest drain if unsuccessfulSecondary pneumothorax: Needle aspiration if <2cm (chest drain if unsuccessful), immediate chest drain if >2cm Complications: Pulmonary oedemaARDSSudden pleuritic chest painDyspnoeaIpsilateral reduced breath soundsIpsilateral hyperinflationHypoxiaTension pneumothorax: Wide bore cannula, 2nd ICS, MCLRisk factors: Male sex, smoking, Marfan’s syndrome

45. SBA 5Which of the following most accurately describes ARDS?Hyaline Membrane DiseaseType 2 Respiratory failure due to acute lung injury Non-Cardiogenic Pulmonary OedemaRespiratory distress secondary to severe sepsisLong-term respiratory sequelae of childhood rheumatic feverMENTI CODE: 8364 0463

46. Acute respiratory distress syndrome (ARDS)Definition: Non-cardiogenic pulmonary oedemaBerlin Criteria:No alternative cause for pulmonary oedema eg. cardiac failureRapid onset < 1 weekDyspnoeaBilateral signs on CXRVery common in ICU

47. ARDS is caused by hypoxaemic acute lung injuryDrug overdoseCOVID-19VentilationSevere burnsSepsisPneumoniaTransfusion reactionsAcute pancreatitisAcute respiratory distress syndrome (ARDS)

48. Aetiology: The body responds with a profound inflammatory response++ Vascular Permeability ++Alveolar OedemaAlveolar CollapseAcute respiratory distress syndrome (ARDS)

49. Normal Acute respiratory distress syndrome (ARDS)ARDS patientInvestigations: CXRBilateral, diffuse opacities

50. Acute respiratory distress syndrome (ARDS)Management: Refer to ICU

51. SBA 5Which of the following most accurately describes ARDS?Hyaline Membrane DiseaseType 2 Respiratory failure due to acute lung injury Non-Cardiogenic Pulmonary OedemaRespiratory distress secondary to severe sepsisLong-term respiratory sequelae of childhood rheumatic feverMENTI CODE: 8364 0463

52. Aetiology: Investigations: Acute respiratory distress syndrome (ARDS): SUMMARY SLIDERisk factors: Differentials: COVID-19Acute heart failureNon-cardiogenic pulmonary oedemaProfound inflammatory response increasing vascular permeability and alveolar collapseSepsisPneumoniaMechanical ventilationBurnsAcute pancreatitisTransfusion reactionsDrug ODCOVID-19Bloods: ABG (type 2 respiratory failure)Management: CXR: Bilateral, diffuse opacitiesSputum culture: Identify cause eg. pneumoniaRefer to ICU for intubation, ventilation etc Complications: Death (mortality between 30-50%)Ventilator associated lung injury or pneumoniaMultiple organ failureBlood culture: Identify cause eg. sepsisConsider proning to improve oxygenation Berlin criteria: No alternative cause for pulmonary oedema eg. cardiac failureRapid onset < 1 weekDyspnoeaBilateral signs on CXRHistory: DyspnoeaTachypnoeaFever, cough, pleuritic chest pain

53. Aetiology: Investigations: COVID-19: SUMMARY SLIDEDifferentials: PneumoniaInfluenzaA potentially severe acute respiratory infection caused by the novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)RNA virus, multiple variantsSARS-CoV-2 attaches to ACE2 receptor on target host cells. ACE2 is highly expressed in upper and lower respiratory tract, but also in myocardial, renal epithelial, enterocytes and endothelial cells of multiple organsPulse oximetry: Low oxygen saturation if moderate/severeManagement: RT-PCR: Positive for SARS-CoV-2 viral DNABloods: ABG, FBC, TFTs, glucose, CRP, ESR, cardiac biomarkers, coagulation screen, U&EsMild/moderate COVID-19: Bed rest, paracetamol, ibuprofen, maintain hydration, monitor O2 satsComplications: ARDSThrombosis (due to hypercoagulable state)Post COVID-19 syndrome (long COVID)CXR/Chest CT: Ground glass opacity, consolidationSevere COVID-19: Hospital admission, oxygen therapy, VTE prophylaxis, dexamethasone, remdesivir, IL-6 inhibitor eg. tocilzumab OR Janus kinase (JAK) inhibitor eg. barictinib, consider ICU admission for ventilation, ECMO etcHistory: DyspnoeaFeverCoughAltered smell and tasteHeadacheGI disturbancesCommon cold

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