Resp + X-rays

Question 1

Case
60-year-old man presents with sudden onset SOB. PMH of COPD on symbicort (long acting corticosteroid) and tiotropium (mAChR (beta) antagonist). Tachycardic (110bpm), raised JVP, reduced breath sounds, scattered wheezing crepitations, peripheral oedema and sats of 80% A. FBC: Hb 8.5, WCC 12, plt 300
Most likely Diagnosis?

Answer 1

Sudden onset suggests Pneumothorax, and PE unlikely due no risk factors
and prescence COPD increases chance of pneumothorax

Question 2

What are the associated symptoms of breathlessness?

Answer 2

Cough?
Sputum?
Haemoptysis?
Wheeze?
Creps?
Fever?

Question 3

Conditions based on onset, if it is sudden (seconds)

Answer 3

Pneumothorax (bullus that has burst)
PE - perfusion issues
Foreign body (blockage of airway)

Question 4

Conditions based on onset, if it is subacute (minutes/hours)

Answer 4

Airways (inflammation/obstruction) - exacerbation of asthma or COPD
Chest infection (pus) - pneumonia
Acute heart failure (fluid)

Question 5

Conditions based on onset, if it is chronic (days/weeks)

Answer 5

Any of the above that is chronic and not resolving
Interstitial lung disease (pulmonary fibrosis)
Malignancy/large pleural effusions
Neuromuscular (Guillain-Barré)
Anaemia/thyrotoxicosis

Question 6

Pneumothorax management

Answer 6

1. Is it primary or secondary?
   - Primary-> usually in tall, thin, healthy man with no other PMH
   - Secondary-> to underlying lung condition (this case COPD)
2. Is it >2cm or <2cm?
   - Primary <2cm: discharge and repeat CXR
   - Primary and >2cm or SOB: aspiration with large-bore cannula and if unsuccessful -> chest drain
   - Secondary and <2cm: aspiration with large-bore cannula
   - Secondary >2cm or SOB: chest drain

Question 7

What do after aspiration or chest drain?(prescribing)

Answer 7

Aspirating and chest drains require regular analgesia - paracetomol 1g or ibuprofen

Question 8

Location for aspiration and chest drain

Answer 8

Aspiration: 2nd ICS MCL

Chest Drain Insertion: 4-6th ICS MAL

Question 9

How to determine axis on ECG?

Answer 9

1. Look at I and II – is either overall negative?
   a. Yes = there is axis deviation
2. Look at avL – is it overall positive?
   a. Yes = left axis deviation
   b. No = right axis deviation

Question 10

Management of patient with PE

Answer 10

Start patient with LMWH
Then carry out a CT pulmonary angiogram
When PE is confirmed start Warfarin and continue with LMWH until the INR is in the therapuetic stage (3-5days)
Carry on Warfarin for at least 3 months
Do not thrombolyse UNLESS haemodynamically compromised

Question 11

What does FEV1/FEV show

Answer 11

if less than 70% then obstructive picture

If greater than 70% then restrictive picture

Question 12

What are the types opacities on a CXR?

Answer 12

Interstitial or alveolar fluffy shadowing 
Reticular nodular shadowing (lines with dots)
Homogenous shadowing (fluid)
Masses/coin lesions/cavitations

Question 13

Causes of Interstitial or alveolar fluff shadowing?

Answer 13

Fluid - heart failure (oul. oedema) bilateral
Pus - pneumonia unilateral
Blood - pulmonary haemorrhage in vasculitis (rare)

Question 14

Cause of reticular nodular shadowing

Answer 14

pulmonary fibrosis

Question 15

Causes of homogenous shadowing

Answer 15

Bilateral = pleural effusion
Unilateral = lung removal, pleural effusion

Question 16

Cause of masses/coin lesions/cavitation

Answer 16

tumours, granulomas, abscesses
Inflammatory nodules
TB - cavitating coin lesions

Question 17

Presenting Chest-Xray in regards to quality, what needs to be mentioned?

Answer 17

Rotation - distance between the spinous processes and medial ends of clavicles should be the same
Inspiration - 7 ribs anteriourly
Penetration - look at the vertebrae/spine, too white=under penetrated
Projection - AP/PA?

Question 18

What is a CPAP and when is it used?

Answer 18

apply continuous positive airway pressure – helps to splint airways open and improve oxygenation e.g. in pneumonia (pus) and heart failure (pulmonary oedema- fluid) clogging alveolar space

Question 19

What is a BiPAP and when is it used?

Answer 19

continuous baseline pressure (as above) + every time patient takes a breath, you apply a higher pressure (inspiratory positive airway pressure). Additional airway pressure helps ventilation. Used if not blowing off enough CO2- Respiratory Acidosis/ T2RF (helps to blow off CO2 through increased ventilation)