Resp Quickfire

Question 1

Pleural analysis
a) Light’s criteria
b) Milky consistency
c) Straw coloured/ammonia smell
d) Empyema biochemistry
e) Causes of bloody tap
f) Cause of black pleural fluid
g) causes of low pH
h) If clinical history fits with transudates, should you still sample?
i) What would be suggestive of malignancy

Answer 1

a) Light’s criteria for exudate:
- Pleural protein > 0.5x serum protein
- Pleural LDH > 0.6x serum LDH or >2/3 ULN for serum LDH

b) Chylothorax - high pleural cholesterol
Pseudochylothorax - normal pleural cholesterol (e.g. caused by TB)

c) Urinothorax

d) Exudate, low pH, low glucose, high WCC, high LDH, purulent fluid

e) Trauma, malignancy, infection

f) Aspergillus niger, melanoma, other malignancy

g) pH < 7.2 is seen with empyema. Can also be low with tuberculosis, malignancy, collagen vascular disease or oesophageal rupture (Boerhaave’s)

h) - No, try treating cause and assess for improvement
- If no improvement, or if could be exudate - send pleural sample (always send 50mls for protein, cytology, LDH, gram stain, culture)

i) Exudative + high protein (>30) + bloody tap (consistently across multiple taps)

Question 2

PE
a) treatment duration
b) thrombolysis indications

Answer 2

Provoked PE - 3 months if provoking factor no longer present and patient is stable

PE provoked by malignancy - 6 months

Unprovoked PE - review at 3 months risk/benefit, but likely to recommend continuing long-term

Recurrent PE - lifelong

b) Thrombolysis:
- Massive PE (circulatory collapse) - must be confirmed by bedside ECHO (right heart strain*) or CTPA if stable
- 50mg alteplase IV (+/- invasive thrombus fragementation)

*ECG findings:
- ST depression/TWI in V1-V3, and inferior leads (especially lead III)
- Right axis deviation

Question 3

Asthma
a) 3 questions for assessing good control
b) adult treatment pathway

Answer 3

a) 1. Have you had symptoms during the day/ needed to use your SABA?
2. Has your asthma interfered with usual activities, including have you had to take time off work due?
3. Have you been waking up at night with coughing/wheezing?

b) Treatment pathway:
1. SABA for symptoms
2. Low-dose ICS (for anyone with daytime symptoms >3x per week or night-time symptoms 1x per week)
3. Leuko-TRI… Add LTRA (oral, take at night) - trial for 4-8 weeks
4. Add LABA (stop LRTA if no response)
5. Switch to MART* therapy (budesonide/formoterol or beclometasone/formoterol)
6. Increase steroid dose to moderate
7. 3 options:
- Add LAMA (triple therapy - Trelegy, Trimbow)
- Add theophylline
- Increase steroid dose to high
8. Oral steroids

*Maintenance and reliever therapy:
- Contains ICS + formoterol (which has LABA and SABA action)
- Hence can be used as maintenance and reliever

Question 4

Eosinophilia

Answer 4

Allergy (including drug eruption)
Allergic bronchopulmonary aspergillosis
Asthma
Eosinophilic folliculitis
Parasite
Vasculitis - EGPA (Churg Strauss)

Question 5

Transfer factor
a) What is DLCO (TLCO)? Equation for DLCO
b) Principles
c) What conditions increase, decrease and do not affect the DLCO?
d) Clinical use of DLCO
e) What effect does recent smoking, and high altitude have on DLCO?

Answer 5

a) DLCO = TLCO
DLCO: diffusion capacity of CO
TLCO: transfer capacity of CO
KCO: diffusion rate of CO
VA: ventilation surface area

DLCO = VA x KCO

b) CO is inhaled and due to high affinity for Hb, all of it should diffuse and end up on Hb. DLCO measures the ability of CO to diffuse into the blood and end up on Hb
Calculated as % predicted CO

c) DLCO reduced by:
- anything that reduces surface area for diffusion (e.g. emphysema, intrinsic restrictive lung disease i.e. fibrosis), or
- reduced perfusion (e.g. systolic HF, PAH, PE, anaemia, pulmonary AVM*)

*Pulmonary AVMs cause right-to-left shunting from PA to PV, bypassing the lung, hence reducing lung perfusion

DLCO increased by:
- anything that increases perfusion (e.g. left-to-right shunt, diastolic HF, exercise, polycythaemia, old pulmonary infarction* and haemorrhage)
- Also increased in pneumonectomy (if corrected for lung volumes)
- Perforated eardrum causes very high DLCO, as some of the administered CO enters the blood via perforation

*Due to increased blood flow to functional areas of the lung

DLCO is unaffected by:
- Asthma, bronchitis (but emphysema reduces it)
- Extrinsic restrictive lung disease

d) - Lung Ca: if DLCO <60%, pneumonectomy has poor prognosis; if <40%, pneumonectomy will not be offered
- PAH: isolated reduction in DLCO with normal lung volumes
- Intrinsic restrictive lung disease: DLCO is usually the first parameter to decrease, before lung volumes
- Particularly, patients on medications like amiodarone, bleomycin, methotrexate and nitrofurantoin should have DLCO monitoring

e) Recent smoking:
- Additional COHb so less capacity for CO binding on testing
- Hence, this reduces DLCO
(so patients told no smoking for 24h pre-test)

High altitude:
- Lower PaO2, so less oxygen competing for Hb
- Hence, increased capacity for CO to bind to Hb –> increased DLCO

Question 6

Atraumatic pneumothorax management
a) Primary vs secondary pneumothorax - define
b) Management of secondary pneumothorax
c) Management of primary pneumothorax
d) If bilateral PTX or haemodynamically unstable…
e) Long term advice

Answer 6

a) Secondary:
- Age >50 and smoker, or
- Known underlying lung disease

Primary spontaneous:
- Most common in tall young men (basketballers, Marfan’s, etc.)
- Usually due to rupture of apical blebs (gas balls)

b) Secondary pneumothorax management:
>2cm or breathless –> chest drain (8-14 Fr)
1-2cm –> aspirate no more than 2.5L –> once <1cm, admit for 24h observation and high flow oxygen*
<1cm –> admit for 24h observation and high flow oxygen*

*unless contraindicated - CO2 retainers

c) Primary pneumothorax management:
>2cm or breathless –> aspirate no more than 2.5L (16 or 18G cannula)
–> if fails, chest drain.
–> If successful (<2cm and not SOB), discharge and review in OPD 2-4 weeks.
<2cm and not breathless –> consider discharge and review in OPD 2-4 weeks.

d) Immediate chest drain (irrespective of primary/secondary)

e) - No smoking, no diving
- No flying for 2 weeks after full resolution

Question 7

Long-term oxygen therapy
a) ABG samples to be taken when?
b) PaO2 threshold for considering LTOT (in COPD, but also in other respiratory disease)
c) Other criteria for considering at higher PaO2
d) How long should oxygen be given for generally?
e) Below what FEV1 level in COPD should assessment for LTOT be considered?
f) Absolute contraindication to LTOT

Answer 7

a) 2 samples, 3 weeks apart, during clinical stability

b) PaO2 < 7.3 kPa

c) PaO2 7.3 - 8.0 kPa in the context of 3 Ps:
- Polycythaemia (secondary)
- Peripheral oedema (cor Pulmonale)
- Pulmonary hypertension
- Or, overnight hypoxaemia (SpO2 <90% for 30% of the night)

d) At least 15 hours per day - mortality benefit seen

e) FEV1 < 30% predicted

f) Current smoker (offer smoking cessation interventions first)

Question 8

COPD management
a) Treatment pathway, including add-on therapies
b) What are “asthmatic features”
c) Significant type/number of exacerbations
d) Who to consider rescue pack in
e) What is in a rescue pack
f) Advice for acute exacerbation
g) Pulmonary rehab

Answer 8

a) Management:
1. If breathless/exercise limitation: SABA or SAMA (Atrovent i.e. ipratropium)

2. If continued SOB or exacerbations despite SABA:
   - Combined LABA/LAMA if no asthmatic features (e.g. Ultibro)
   - Combined LABA/ICS if asthmatic features present like reversibility/diurnal variation/eosionophilia/atopy (e.g. Fostair, Seretide, Symbicort
3. If continued symptoms affecting QoL or frequent exacerbations:
   - TRiple therapy: LABA/LAMA/ICS (e.g. TRimbow, TRelegy)
   - Note: if no asthmatic features, trial this inhaler for 3 months - if no response, go back to LABA/LAMA
4. If symptoms persisting, consider referral and add-on therapies, including:
   - Mucolytics (e.g. carbocisteine)
   - Slow-release theophylline
   - Oral prednisolone
   - Prophylactic antibiotics (e.g. azithromycin 500mg three times per week, trial for 6-12 months - must check LFTs and ECG at baseline and after 1 month)
   - Phosphodiesterase-4 (PDE₄) inhibitors (e.g. roflumilast, cilomilast)
   - Nebulised therapy
   - LTOT

b) - Previous secure diagnosis of asthma or atopy
- Eosinophilia
- Substantial variation in FEV1 over time (at least 400 ml)
- Substantial diurnal variation in peak flow (at least 20%)

c) Two in a year, or one severe (requiring hospitalisation)

d) Those with 2+ exacerbations per year (know how to recognise an exacerbation)

e) Prednisolone 30mg (7 - 14 day supply)
- Amoxicillin 500mg TDS, or doxycycline 100mg OD, or clarithromycin 500mg BD, or antibiotic based on sputum culture (5 day supply)

f) In acute exacerbation:
- increase frequency of SABA/SAMA
- take steroids if more breathless
- take antibiotics if sputum changes colour or increases in thickness/volume
- notify GP

g) - For anyone who has significant breathlessness (usually MRC grade 3+)
- Contraindicated in unstable angina or recent ACS

Question 9

Lung cancer differentiation
a) Location
b) Breakdown of different types (%)
c) Associated features

Answer 9

a) and b)
- Adenocarcinoma (40%) - more peripheral
- Squamous cell (30%) - more Sentral, intra-bronchial (earlier symptoms)
- Small cell (15%) - more Sentral (perihilar mass), more rapid progression and present late, poor prognosis
- Large cell (10%) - outer edge, grow rapidly and present late
- Carcinoid (5%)

c) Squamous cell
- commonly has hypercalcaemia from bone or mets or before metastasising as a result of PTH-rP production (endogenous PTH will be low)
- Gynaecomastia
- Hyperthyroidism

Small cell
- Ectopic ADH secretion causing SIADH and hyponatraemia
- Ectopic ACTH secretion causing Cushing’s syndrome
- Lambert-Eaton myasthenic syndrome - 60% have SCLC. Presents with gradual onset proximal muscle weakness, diminished reflexes and improvement in power with repeated movements. Caused by antibodies to voltage-gated calcium channels (pre-synaptic membrane
- Peripheral neuropathy

Adenocarcinoma
- HPOA most common in this subtype
- Also most associated with dermatomyositis

Carcinoid
- Not associated with smoking, younger patients

Question 10

Mesothelioma
a) Chromosome abnormality commonly found
b) Risk of pleural drainage

Answer 10

a) Loss of tumour-suppressor material from Chromosome 22

b) Seeding of tumour along the track

Question 11

Radiation lung injury
a) Early form - diagnosis and management
b) Late form

Answer 11

a) Radiation pneumonitis
- Occurs in the days-weeks following radiation
- Presents with pleurisy, SOB, mild inflammatory response (low-grade temp, mild leukocytosis, etc.), pleural rub
- CXR shows patchy infiltrates
- Rx: high dose steroids + PCP prophylaxis.
If ARDS or failing to respond - IV methylpred + broad spectrum ABx

b) Radiation fibrosis
- Occurs after around 6 months post-radiation

Question 12

Surgical treatment of lung Ca
a) Functional criteria for pneumonectomy (FEV1, FVC, PaCO2, DLCO)
b) Mediastinal lymph nodes

Answer 12

a) FEV1 > 2L and FVC >1.5L
Normal PaCO2 at rest
DLCO >60% generally (if <40% definitely not for surgery)

b) If <1mm, unlikely to be malignant, PET scan is best way of differentiating inflammatory vs malignant

Question 13

FeNO testing
a) What is it?
b) Positive test value, and confounding factors
c) Indications for FeNO testing
d) Alternatives for asthma diagnosis

Answer 13

a) Fraction of exhaled nitric oxide
- surrogate marker of airways inflammation (thought to be due to eosinophil mediated inflammation)

b) Age 5-16: FeNO level of ≥35 ppb
Age 17+ : FeNO >40

Factors that may increase FeNO: male, high nitrate diet, current infection/rhinitis/allergen exposure

Factors that may decrease FeNO: children, smoking, treatment with ICS/oral steroid/LTRA

c) Symptoms suggestive of asthma, but negative spirometry and/or negative peak flow variability:
- If FeNO positive, asthma can be diagnosed

d) Spirometry + reversibility
Peak flow diary
Bronchial challenge e.g. histamine, mannitol –> test for sensitivity of airways
Serum eosinophils, serum IgE, skin prick testing

Question 14

Flow-volume loops
a) Obstructive lung disease (and effect of SABA)
b) Restrictive lung disease
c) Upper airway obstruction (e.g. laryngeal tumour, tracheal stenosis, goitre)
d) Variable extra-thoracic obstruction
e) Variable intra-thoracic obstruction

Answer 14

a) Obstructive (asthma/COPD):
- Reduced PEFR
- Normal inspiration with coving of expiration curve (looks like church with steeple)
- Increased residual volumes (due to hyper-expansion)

SABA leads to increased PEFR and reduced coving if good reversibility (i.e. asthma)

b) Restrictive:
- Reduced lung volumes (including residual volume)
- Reduced PEFR
- No coving, normal expiration

c) UA obstruction:
- Flattening of inspiration and expiration curves
- Increased residual volumes

d) Variable extra-thoracic obstruction:
- Restricted inspiratory phase

e) Variable intra-thoracic obstruction
- Restricted expiratory phase

Question 15

Sarcoidosis
a) Typical features
b) CXR findings
c) Diagnosis
d) Staging
e) Treatment

Answer 15

a) - Cough, SOB, erythema nodosum, hypercalcaemia
- May have general unwellness
- Most common in African middle-aged people
- Lofgren syndrome: triad of bilateral hilar LN, arthralgia and erythema nodosum
- Ocular involvement common: dry eyes, uveitis
- CNS involvement in 2%

b) Hilar lymphadenopathy, upper lobe granulomas

c) - Initially CXR, then CT chest to demonstrate granulomas/ alveolitis
- May do a biopsy - skin (if lesions present) or transbronchial biopsy (via bronchoscopy) for non-caseating granulomas
- Raised serum ACE in 60%

d) - Stage 0: clear CXR
- Stage 1: Bilateral hilar LN
- Stage 2: Bilateral hilar LN and interstitial infiltrates
- Stage 3: diffuse interstitial disease
- Stage 4: advanced fibrosis

e) - Pulmonary - Treat if symptomatic or stage 2 or above
- Also treat if hypercalcaemia
Or if there is ocular, CNS or cardiac involvement
- Steroids, then steroid sparing agents

Question 16

Chest drain troubleshooting
a) What does bubbling indicate?
b) What does swinging indicate?
c) If still swinging but no longer bubbling, what does this indicate?
d) If bubbling but lung not re-inflated on CXR, what needs doing?
e) What position should bottle be in relative to insertion site?

Pleural effusions.
f) Maximum drainage of effusions per hour, and why
g) When to remove effusion chest drain
h) If empyema, how to prevent blockages

Answer 16

a) Air moving from pleural space into the bucket (resolving pneumothorax)

b) Drain is in contact with the pleural space as moves with inspiration/ expiration (correct positioning)

c) Likely pneumothorax has resolved - all air has finished coming out so no more bubbling, but still swinging as drain is in contact with the pleural space

d) There may be fluid in the space, so ?needs suctioning

e) Must always be below

f) - 1.5L/hour (should be clamped once it drains 1.5L and then unclamped after a couple of hours)
- Drainage of more than this risks re-expansion pulmonary oedema (mortality around 20%)

g) When drainage is <200mls/day

h) Regular flushes of drain

Question 17

Young person with cough, haemoptysis, but no extra-pulmonary features and normal immunology

Answer 17

Idiopathic pulmonary haemosiderosis

Question 18

CF
a) Sweat test positive result

Answer 18

a) Chloride >60: positive (98% sensitive)
Chloride 30-60: indeterminate - proceed to CFTR gene testing

Question 19

Alpha-1-antitrypsin deficiency
a) Genotypes - normal to worst prognosis
b) vs classical COPD
c) Why is RV/TLC ratio increased?

Answer 19

a) PiMM = normal (100% A1AT activity)
PiSS = 60% activity (asymptomatic)
PiMZ 60% activity (asymptomatic)
PiSZ = 40% activity (symptoms)
PiZZ = 15% activity (severe symptoms, early onset - liver disease in infants, emphysema in young adults)

b) Lower lobe emphysema more commonly and occurring at younger age

c) Residual volumes high due to gas trapping

Question 20

Severe haemoptysis
a) Most common targets for embolisation

Answer 20

a) Bronchial artery 90%, pulmonary artery 5%

Question 21

Carbon monoxide poisoning
a) Oxygen saturations
b) How should you further investigate

Answer 21

a) May be normal as most probes cannot distinguish oxyhaemoglobin from carboxyhaemoglobin

b) ABG - look at HbO2 and HbCO (if present)

Question 22

Lung cancer metastatic sites

Answer 22

Your Brain and your BALLS
- Brain
- Bone
- Adrenal
- Lung
- Liver
- Skin

Question 23

Phrenic nerve palsy

Answer 23

• Supine FVC markedly reduced
• Nocturnal hypoventilation, daytime sleepiness, morning headaches, etc.

Question 24

Reversibility testing
a) When to do in COPD
b) When to do in asthma
c) Significant value for reversibility
d) How is it performed

Answer 24

a) - Age < 35
- Non-smoker
- Significant diurnal symptoms/nocturnal symptoms
- Spirometry inconclusive
(note - generally in COPD, diagnosis based on symptoms and spirometry)

b) - Low suspicion but other conditions excluded (may include PPI trial), or intermediate probability
- High suspicion but poor response to treatment
(note - usually in high suspicion there is no need to do reversibility testing, just proceed to treatment trial)

c) FEV1 >15% or >200ml (if >400ml, virtually diagnostic of asthma)

d) - FEV1 checked before and after 400mcg inhaled SABA
- Or trial of 2/52 oral steroids or 6/52 inhaled steroids (FEV1 checked before and after trial)

Question 25

HPOA
a) Associated cancer
b) Clinical features
c) Diagnosis

Answer 25

a) Non-small cell lung cancer (especially squamous cell)

b) Long bone pain + finger clubbing

c) Isotope bone scan
- Increased uptake on long bones, periarticular surfaces, and sometimes mandible and scapula

Question 26

NIV
a) Indications
b) Contraindications

Answer 26

a) - Acute or chronic hypercapnic respiratory failure
- AECOPD where hypercapnic AND acidotic (i.e. decompensated T2RF)

b) Airway:
- Airway compromise
- Facial trauma/burns/surgery
- Copious secretions - control first
- Vomiting - control first

Breathing:
- Pneumonia (unless COPD and not for intubation)
- Asthma
- Undrained pneumothorax (would need chest drain first)

Circulation:
- Haemodynamic instability (unless in HDU)

Disability:
- Confusion/agitation/low GCS (unless caused by hypoxia/hypercapnia)

Exposure:
- Recent UGI surgery (risk of anastomotic breakdown)
- Bowel obstruction

Question 27

Pneumothorax: needle aspiration procedure
a) Check indication and contraindications
b) Consent for complications
c) Equipment needed
d) Landmark
e) Procedure

https://www.youtube.com/watch?v=j_UGBS-Kp2I

Answer 27

a) Indications:
- Spontaneous primary pneumothorax if breathless or >2cm at hilum
- Spontaneous secondary pneumothorax if size 1-2cm and not breathless

Contraindications:
- Haemodynamic instability or tension pneumothorax
- Bilateral pneumothorax
- Traumatic pneumothorax
- Secondary pneumothorax if breathless or >2cm at hilum
- Bleeding diathesis

b) - Failed procedure (proceed to ICD) - especially in very muscular or fat patients (may need longer cannula)
- Infection
- Bleeding
- Damage to lung parenchyma
- Air embolism
- Subcutaneous emphysema
- Persistent air leak (proceed to ICD)

c) - Sterile drape, gloves, gown, mask, chlorhexidine
- 1% lidocaine, short and longer needle, and 10ml syringe
- 16 or 18G cannula, drip connector, 3-way tap, 50ml luer lock syringe
- Ensure adequate patient monitoring and analgesia

d) 2nd intercostal space, mid-clavicular line (adjacent to sternal notch)
- Ensure to inject LA and insert cannula directly ABOVE rib

e) - Prepare area
- Inject subcutaneous LA with small needle and 10ml syringe
- Then inject into deeper layers with longer needle, perpendicular to the skin, aspirating all the while as you go deeper. When you penetrate the pleura, gas bubbles will appear in the 10ml syringe. At this point, stop advancing and withdraw the needle making note of the depth (compare next to cannula)
- Then use same technique to advance a 16/18G cannula into the pleural space. Gas bubbles will appear in the LA fluid in the 10ml syringe. At this point, advance another few millimetres so cannula tip is definitely within pleural space
- Remove needle and 10ml syringe, and ensure to cover the opening of the cannula with your thumb to prevent air entry
- Attach tubing with 3-way tap* to the cannula. Use 50ml luer lock syringe to gently aspirate air from the pleural space
- Turn the 3-way tap to block it from the pleural space and open it to ambient air - then you can push the air out of the syringe into the ambient air
- Count the number of syringes evacuated
- Continue until no further air aspirated or until 2.5L aspirated (aspiration of more than this implies an air leak)
- Apply sterile dressing
- Symptoms should improve post-procedure
- Post-aspiration CXR should show resolved PTX. If still breathless or >2cm (or >1cm in secondary PTX), proceed to chest drain

*Ensure this is positioned correctly. Never have the pleural space connected to the ambient airs

Question 28

COPD severity

Answer 28

FEV / FVC ratio < 70% for all stages (necessary for COPD diagnosis)

Severity classified on basis of %predicted FEV1 post-bronchodilator:
- >80% = stage 1 (mild)*
- 50-79% = stage 2 (moderate)
- 30-49% = stage 3 (severe)
- <30% = stage 4 (very severe)**

*Symptoms should be present to diagnose COPD in mild airflow obstruction

**If FEV1 <50% but in respiratory failure, they would also be classified as very severe

Question 29

IECOPD management
a) Who needs to be admitted?
b) Essential investigations
c) Management for all
d) Management of hypercapnic AECOPD

Answer 29

a) - Severe SOB, cyanosis, SpO2 <90%
- Confused, drowsy
- On LTOT/ severely poor condition
- Severe comorbidities, frailty, poor social support
- Rapid onset, worsening peripheral oedema
- ABG: pH <7.35, pCO2 7+
- Significant CXR changes

b) - Bloods (inc theophylline level if taking)
- ABG
- CXR
- ECG
- Sputum sample
- Blood cultures if pyrexial

c) 1 hour of maximal medical therapy:
- back-to-back nebulisers of salbutamol + ipratropium
- stat dose PO prednisolone 30mg/ IV hydrocortisone 100mg
- consider IV theophylline
- consider antibiotics
- controlled oxygen therapy to target saturations

d) - Keep SpO2 88-92%
- If remain acidotic (pH < 7.35) and hypercapnic (pCO2 >6.5) after 1 hour of maximal medical therapy, consider NIV trial unless contraindicated
- May need to intubate* if NIV not tolerated/ ineffective / contraindicated

*Note - COPD patients generally do quite well if intubated even if seemingly frail - consider ceiling of care closely

Question 30

Acute mountain sickness
a) Lake Louise features
b Features of HAPO and Rx
c) Features of HACO and Rx

Answer 30

a) Gain in altitude and headache plus one of:
- Nausea and vomiting
- Insomnia
- dizziness
- fatigue and weakness

b)

c) Ataxia, drowsiness
- Immediate descent, oxygen and IV dexamethasone. Acetazolamide

Question 31

Chest drain insertion
a) Indications and contraindications
b) Consent for complications
c) Equipment
d) Landmarks
e) Procedure

https://www.med.scot.nhs.uk/simulation/the-mastery-programme/guidewire-intercostal-drain

Answer 31

a) Indications:
- Primary spontaneous PTX where needle aspiration fails to reduce size to <2cm or still breathless
- Secondary spontaneous PTX if breathless, >2cm or after failed needle aspiration
- Unilateral pleural effusion causing breathlessnesss – insert drain to relieve symptoms and aid diagnosis
- Empyema
- Bilateral pleural effusions if decompensated despite optimal medical management
- Tension pneumothorax after needle decompression
- Palliation of breathlessness in malignant pleural effusions
- To facilitate pleurodesis

Contraindications:
- Local infection
- Coagulopathy

b) - Failure of procedure
- Pain
- Infection
- Bleeding
- Damage to surrounding structures
- PTX if for an effusion

c) - Sterile drape, gloves, gown, mask, chlorhexidine
- 1% lidocaine, short and longer needle and 10ml syringe
- Chest drain kit - introducer needle, 10ml syringe, guidewire, scalpel, dilator, chest tube*, gauze, dressing
- Sutures, needle holder, scissors
- Chest drain sample tubes (if effusion)
- Chest drain bottles
- Ensure adequate patient monitoring and analgesia

*size will depend on indication:
- Small bore Seldinger (8-14 Fr) - spontaneous pneumothorax
- Large bore surgical drains (20 Fr +) - traumatic pneumothorax/haemothorax/ malignant effusion
- Very large bore (36 Fr+) - empyema

d) Ask patient to put hand behind head to expose triangle of safety:
- Superior: base of axilla
- Lateral: latissimus dorsi
- Medial: pectoralis major
- Inferior: 5th intercostal space, mid axillary line

e) - Prepare area
- Inject LA to subcutaneous area
- Then inject LA to deeper tissues (ABOVE the rib), aspirating as you go deeper until pleura is met. Remove this needle, making a note of the pleura depth
- Put this needle next to the introducer needle so you know how far to insert the introducer
- Then insert the introducer needle, with a second 10ml syringe attached, holding needle with your left finger/thumb and steadying your left hand on the patient.
- Aspirate as you advance until the resistance reduces and you have gas bubbles (or pleural fluid) in the syringe. At this point, advance a further 0.5-1cm
- Remove the syringe, (if pleural effusion, ensure pleural fluid is flowing freely), then occlude the entrance with your thumb
- Insert the guidewire using Seldinger technique, there should be no resistance to this. Leave around 10cm at the end of the guidewire
- Then remove the introducer needle
- Incise the skin with blunt end of scalpel blade facing the wire. Have a gauze ready for any oozing blood
- Next insert the dilater to the safety marker, using a 90-degree rotational movement. Hold the guidewire in place. Remove the guidewire using the same rotatory motion
- Next insert the tube over the guidewire, ensuring never to lose the guidewire
- Once the guidewire is visible at the proximal end of the tube, hold the guidewire at this end and insert the tube to depth of approx 10-12cm
- Then remove the guidewire from the tube and the stiffening rod from within the tube
- At this point, if pleural samples need taking, connect 50/60ml syringe
- Then connect up tubing to the underwater seal
- Secure tube in place with 1 suture above the tube and then wrapping the stitch around the tube
- Place two pieces of gauze which have been incised to their middle, one on top of the other in the opposite orientation
- Remove drape
- Then apply adhesive dressing over the top
- Communicate to the nursing staff about chest drain management
- Request post-procedure CXR

Question 32

Hepatopulmonary syndrome
a) What is it?
b) Signs on examination
c) Confirming diagnosis
d) Management

Answer 32

a) Portal hypertension (usually in context of chronic liver disease) causing pulmonary vasodilation and AV shunts, which lead to V/Q mismatch and hypoxia

b) - Worsening of SOB and hypoxia when moving from supine to upright position
- Clubbing, cyanosis, telangiectasia

c) - Contrast enhanced ECHO (agitated saline), or
- Lung perfusion scanning

d) Liver transplant
(don’t respond to diuretics, TIPS not indicated)

Question 33

30 year old man presents with worsening dental pain, submandibular swelling, trismus, difficulty speaking and SOB. Generalised swelling seen under the tongue
a) Diagnosis
b) Management

Answer 33

a) Ludwig’s angina
- Cellulitis/abscess of sublingual/submandibular tissues, usually from dental infection, that rapidly cause life-threatening airway obstruction

b) - Call anaesthetist for immediate intubation - may have difficulty with direct laryngoscopy due to trismus so may need fibreoptic nasal intubation or FONA
- IV antibiotics + steroids
- CT neck with contrast once airway secure - if surgical target identified, refer for drainage

Question 34

Post- heart and lung transplant, presents with increasing SOB and obstructive picture on spirometry

Answer 34

Bronchiolitis obliterans - can be due to transplant rejection or CMV infection post-transplant. Responsible for over 50% deaths post-transplant after the first year

Question 35

Acute asthma: staging (adults)
a) Moderate
b) Severe - any one of…? (PUFF)
c) Life-threatening - any one of…? (PORSCHE)
d) Near-fatal

• Note: in children, there is no moderate, only acute severe and acute life-threatening (criteria broadly map onto adult acute severe and life-threatening)

Answer 35

a) Increasing symptoms, PEF >50–75% best/predicted, no features of acute severe asthma

b) PEF 33-50% best/predicted,
Unable to talk in complete sentences,
Fast breathing (RR 25+),
Fast heart rate (HR 110+)

c) PEF < 33% best/predicted,
Oxygen low (SpO2 <92% / PaO2 <8 kPa) or CO2 ‘normal’
Reduced consciousness
Silent chest
Cyanosis
Hypotension
Exhaustion/altered GCS
-Also: arrhythmia

d) T2RF: Raised PaCO2 and/or requiring mechanical ventilation