1. Pulmonary Embolism Dr Felix Woodhead Consultant Respiratory Physician

2. Pulmonary Embolism Part of VTE Potentially fatal Can complicate hospital admission Preventable Tests poor

3. Risk factors Surgery –Abdominal –Lower limb Obstetric Malignancy Previous VTE

4. Clinical Probability Wells score Geneva criteria Is a major risk factor present? =1 Is there no other explanation? =1 Score: –2: High probability –1: Intermediate probability –0: Low probability

5. D-dimer Only useful if NEGATIVE ↑ by many things (including pregnancy and infection) Used only after assessment of clinical probability –Not used if high clinical probability

6. Imaging CTPA in most places V/Q –only if normal CXR and no cardiopulmonary disease –Intermediate scan requires follow-up imaging (CTPA) Doppler USS if DVT (no need for resp imaging)

7. Screening for thrombophilia/cancer Thrombophilic abnormality occurs in 25-50% VTE Usually interacts with environment (esp oestrogens), and risk is multiplicative Does not predict risk of recurrence Screen for cancer with bloods, clinical picture and CXR only

8. Treatment Thrombolysis only in massive PE (circ collapse) Thrombolysis controversial if RV impairment Anticoagulate with LMWH then warfarin for –4-6/52 if associated with temporary risk factor –3/12 if no risk factor (BTS), US recommend 6/12 ?unfractionated heparin initial bolus

9. Pulmonary Arterial Hypertension Dr Felix Woodhead Consultant Respiratory Physician

10. Findings Exertional breathlessness Exertional chest pain and presyncope Normal radiology if idiopathic Normal PFTs if idiopathic ↑ systolic PAP on echo only if TR

11. Defined by RHC mPAP –> 25 mmHg at rest (normal 12-16 mmHg) –> 30 mmHg on exertion Cardiac Output Cardiac Index (=CO/height 2 ) Pulmonary Vascular Resistance

12. Causes Left ventricular impairment (PCWP > 15) –LVF –Mitral valve disease Increased pulmonary blood flow (L→R shunt) → Eisenmenger’s syndrome Hypoxaemia (cor pulmonale) Chronic Thromboembolic (CTEPH) HIV CTD (SSc etc) Idiopathic (IPAH)

13. Investigations PFTs CTPA Echo (± bubbles) 6 minute walk Right Heart Catheter (traditional) pulmonary angiogram

14. Treatment Treatment of associated causes –LV disease –O2 for cor pulmonale Warfarin (for all) Calcium channel blockers – little used now Endothelin receptor blockers – Bosentan, sitaxentan PDE4 antagonists – Sildenafil etc Prostaglandins –Nebulised –Continuous IV via Hickman line

15. Sleep medicine Dr Felix Woodhead Consultant Respiratory Physician

16. Obstructive sleep apnoea/hypopnoea Sx Periodic reduction of airflow at night Caused by ostruction (cf central apnoea) due to reduced muscle tone in a suceptible airway (obesity) Apnoea : no airflow for 10 s Hypopnoea : ≤ 50% airflow in 10 s AHI (apnoea/hypopnoea index) = no of events/hr AHI –5-14 = mild –15-30 = moderate –>30 = severe

17. Symptoms Sleepiness (daytime hypersomnolence) –Epworth Sleepiness Score Witnessed apnoeas Nocturia Hypertension Reduced concentration Reduced libido Tendency to cor pulmonale, esp in COPD

18. Diagnosis Overnight oximetry –Good screening esp in obese –Cannot be used to exclude OSAHS Limited PSG –Useful initial test in young, non-obese Full PSG

19. Treatment Only if symptomatic AHI >15, desat index >10/hr Nasal CPAP –fixed –Autotitrating device

20. Domiciliary NIV For ventilatory failure Other treatments –Low flow O 2 (with care) –Treatment of sleep disordered breathing Hallmark of ventilatory failure is ↑pCO 2