Phase 2

1

Respiratory

• Phase 2
• Stephen Lau George Lam

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2
Outline

• Pulmonary Embolism
• Pneumothorax
• Pneumonia
• Pleural Effusion

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3
Pulmonary Embolism

• Causes of PE
• Thrombus (DVT, ?)
• ?
• ?
• ?

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4
Pulmonary Embolism

• Causes of PE
• Thrombus (DVT, AF)
• Fat
• Air
• Bacterial Vegetation (EC)

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Pulmonary Embolism

• Causes of VTE
• ?
• ?
• ?

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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

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Pulmonary Embolism

• Classification of Clinical Presentation

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Pulmonary Embolism

• Classification of Clinical Presentation
• Acute ? Sudden
• Massive ? Cardiogenic Shock (SBP lt 90 mmHg or ?
  40 mmHg for gt 15 min)
• Submassive ? No Shock
• Chronic ? Gradual P HTN

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Pulmonary Embolism

• Sx Submassive

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Pulmonary Embolism

• Sx Submassive
• Acute SOB ?
• Pleuritic Chest Pain ?
• Cough ?
• Haemoptysis ?
• Wheeze ?
• Tachycardia ?
• Tachypnoea ?

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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

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Pulmonary Embolism

• Sx Massive

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Pulmonary Embolism

• Sx Massive
• Shock Sx ?
• ? JVP ?
• Accentuated P2 ?

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Pulmonary Embolism

• Sx Massive
• Shock Sx ? ? LV Pre-Load ? CO
• ? JVP ? RHF
• Accentuated P2 ? Delayed RV Emptying

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15
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 _at_ lung base.
• Mild calf tenderness.

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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 _at_ lung base.
• Mild calf tenderness.

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Pulmonary Embolism

• DDx
• Submassive PE ?
• PTX ?
• Acute Pulmonary Oedema/ARDS ?
• Pneumonia ?
• Sepsis ?
• MI ?
• Arrhythmia ?

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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

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Pulmonary Embolism

• Ix
• FBC
• LFT ? ?Liver Mets/Ca
• UE ? ?Renal Function (?Shock)
• Clotting ? ?Hypercoagulable
• D-Dimer
• ABG
• Blood Culture
• CXR
• Leg USS
• ECG

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Pulmonary Embolism

• Ix
• D-Dimer
• If ve, next step?
• If ve?
• ABG
• PaO2
• PaCO2
• CXR
• 3 Signs
• ECG
• What is the pathognomonic arrhythmia?

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21
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)

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Pulmonary Embolism

• Mx of Submassive PE (SBP gt 90 mmHg)
• Initial
• Long-Term

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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

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Pulmonary Embolism

• Causes of PE
• Risk Factors for VTE ? Virchows Triad
• Clinical Presentation
• Acute ? Massive/Submassive
• Chronic
• DDx of Acute SOB
• Ix of Acute SOB
• Ix Results of PE
• Mx of Submassive PE

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Pneumothorax

• Types

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Pneumothorax

• Types
• Tension
• Non-Tension
• Spontaneous
• Primary ? No Lung Pathology (but probably small
  blebs)
• Secondary ? Lung Pathology (esp. COPD bullae)
• Traumatic

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Pneumothorax

• 2 Symptoms
• 4 Examination Signs of Non-Tension PTX
• Which Side has PTX?

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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

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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?

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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

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Pneumonia - Basics

• Signs and Symptoms of Acute Lower Respiratory
  Tract Infection.
• Radiographic Change

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Pneumonia - Basics

• Causative Organisms
• Pathogens
• Streptococcus pneumoniae
• Klebsiella pneumoniae
• Haemophillus influenzae
• Staphlylococcus aureus
• Pseudomonas aeruginosa
• Atypical Pathogens
• Chlamydia pneumoniae
• Mycoplasma pneumoniae
• Legionella pneumophillia

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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.

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Clinical Evaluation - Symptoms

• Fever
• Pleuritic Chest Pain
• Haemoptysis
• Sputum Production ( purulent)
• Dyspnea
• Cough
• Fever/Rigors

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Clinical Evaluation - Signs

• Febrile
• Raised Respiratory Rate
• Reduced SpO2
• Crackles
• Bronchial Breathing
• Dullness on percussion

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Diagnosis - Investigations

• Bloods
• ABG
• FBC
• CRP
• WCC Differential
• Anaemia
• U/E
• LFT

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Diagnosis - Investigations

• Scoring System
• Confusion
• Urea
• Respiratory Rate
• Blood Pressure lt90mmHg systolic
• lt65 years of age
• Imaging
• CXR

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Treatment

• Antibiotics
• Amoxicillin / Flucoxacillin (if S. aureus
  suspected)
• Oxygen
• Fluids
• Analgesia

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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 38.3C (101F), 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.

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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

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41
Pleural Effusion - Basics

• Common Causes of Transudate
• Heart Failure
• Cirrhosis
• Hypoalbuminaemia
• Peritoneal Dialysis
• Nephrotic Syndrome
• Hypothyroidism

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Pleural Effusion - Basics

• Common Causes of Exudate
• Pneumonia
• Malignancy
• Pulmonary Infarction (Embolism)
• Autoimmune
• Pancreatitis
• TB

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Pleural Effusion - Symptoms

• Shortness of Breath on Exertion
• Cough
• Pleuritic Pain
• PMHx of smoking, asbestos exposure
• PMHx of any previously mentioned diseases

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Pleural Effusion - Signs

• Dullness to percussion
• Tracheal centrality
• Vocal Fremitus
• Asymmetric Chest Expansion
• Reduced Breath Sounds

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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

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Treatment

• Treat the cause
• Thoracentesis
• Pleurodesis

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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.

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