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Respiratory Phase 2 Stephen Lau & George Lam
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Outline Pulmonary Embolism Pneumothorax Pneumonia Pleural Effusion
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Pulmonary Embolism Causes of PE Thrombus (DVT, ?) ?
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Pulmonary Embolism Causes of PE Thrombus (DVT, AF) Fat Air
Bacterial Vegetation (EC) The Peer Teaching Society is not liable for false or misleading information…
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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 The Peer Teaching Society is not liable for false or misleading information…
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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 < 90 mmHg or ↓ ≥ 40 mmHg for > 15 min) Submassive No Shock Chronic Gradual P HTN The Peer Teaching Society is not liable for false or misleading information…
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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 The Peer Teaching Society is not liable for false or misleading information…
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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 The Peer Teaching Society is not liable for false or misleading information…
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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 The Peer Teaching Society is not liable for false or misleading information…
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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 lung base. Mild calf tenderness. The Peer Teaching Society is not liable for false or misleading information…
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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 lung base. Mild calf tenderness. The Peer Teaching Society is not liable for false or misleading information…
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Pulmonary Embolism DDx Submassive PE PTX
Acute Pulmonary Oedema/ARDS Pneumonia Sepsis MI Arrhythmia The Peer Teaching Society is not liable for false or misleading information…
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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 The Peer Teaching Society is not liable for false or misleading information…
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Pulmonary Embolism Ix FBC LFT ?Liver Mets/Ca
U&E ?Renal Function (?Shock) Clotting ?Hypercoagulable D-Dimer ABG Blood Culture CXR Leg USS ECG The Peer Teaching Society is not liable for false or misleading information…
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Pulmonary Embolism Ix D-Dimer ABG CXR ECG If +ve, next step? If –ve?
PaO2 PaCO2 CXR 3 Signs ECG What is the pathognomonic arrhythmia? The Peer Teaching Society is not liable for false or misleading information…
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Pulmonary Embolism Ix D-Dimer ABG T1RF CXR **COMMONLY NORMAL ECG
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) The Peer Teaching Society is not liable for false or misleading information…
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Pulmonary Embolism Mx of Submassive PE (SBP > 90 mmHg) Initial
Long-Term The Peer Teaching Society is not liable for false or misleading information…
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Pulmonary Embolism Mx Initial Long-Term O2
1) LMWH SC (Enoxaparin, Dalteparin) / Fondaparinux / UFH 2) IVC Filters Long-Term Mobilization TED Stockings Warfarin PO for ≥ 3 Months INR 2-3 The Peer Teaching Society is not liable for false or misleading information…
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Pulmonary Embolism Causes of PE Risk Factors for VTE Virchow’s Triad
Clinical Presentation Acute Massive/Submassive Chronic DDx of Acute SOB Ix of Acute SOB Ix Results of PE Mx of Submassive PE The Peer Teaching Society is not liable for false or misleading information…
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Pneumothorax Types The Peer Teaching Society is not liable for false or misleading information…
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Pneumothorax Types Tension Non-Tension Spontaneous Traumatic
Primary No Lung Pathology (but probably small blebs) Secondary Lung Pathology (esp. COPD bullae) Traumatic The Peer Teaching Society is not liable for false or misleading information…
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Pneumothorax 2 Symptoms 4 Examination Signs of Non-Tension PTX
Which Side has PTX? The Peer Teaching Society is not liable for false or misleading information…
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Pneumothorax 2 Symptoms 4 Examination Signs of Non-Tension PTX
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 The Peer Teaching Society is not liable for false or misleading information…
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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? The Peer Teaching Society is not liable for false or misleading information…
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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? Mx of Large Secondary Spontaneous PTX? Chest Drain Where Do You Stick the Cannula? 2nd Intercostal Space, Mid-Clavicular Line The Peer Teaching Society is not liable for false or misleading information…
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Pneumonia - Basics Signs and Symptoms of Acute Lower Respiratory Tract Infection. Radiographic Change The Peer Teaching Society is not liable for false or misleading information…
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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 The Peer Teaching Society is not liable for false or misleading information…
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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. The Peer Teaching Society is not liable for false or misleading information…
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Clinical Evaluation - Symptoms
Fever Pleuritic Chest Pain Haemoptysis Sputum Production ( purulent) Dyspnea Cough Fever/Rigors The Peer Teaching Society is not liable for false or misleading information…
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Clinical Evaluation - Signs
Febrile Raised Respiratory Rate Reduced SpO2 Crackles Bronchial Breathing Dullness on percussion The Peer Teaching Society is not liable for false or misleading information…
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Diagnosis - Investigations
Bloods ABG FBC CRP WCC + Differential Anaemia U/E LFT The Peer Teaching Society is not liable for false or misleading information…
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Diagnosis - Investigations
Scoring System Confusion Urea Respiratory Rate Blood Pressure <90mmHg systolic <65 years of age Imaging CXR The Peer Teaching Society is not liable for false or misleading information…
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Treatment Antibiotics Oxygen Fluids Analgesia
Amoxicillin / Flucoxacillin (if S. aureus suspected) Oxygen Fluids Analgesia The Peer Teaching Society is not liable for false or misleading information…
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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 38.3°C (101°F), 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. The Peer Teaching Society is not liable for false or misleading information…
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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 The Peer Teaching Society is not liable for false or misleading information…
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Pleural Effusion - Basics
Common Causes of Transudate Heart Failure Cirrhosis Hypoalbuminaemia Peritoneal Dialysis Nephrotic Syndrome Hypothyroidism The Peer Teaching Society is not liable for false or misleading information…
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Pleural Effusion - Basics
Common Causes of Exudate Pneumonia Malignancy Pulmonary Infarction (Embolism) Autoimmune Pancreatitis TB The Peer Teaching Society is not liable for false or misleading information…
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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 The Peer Teaching Society is not liable for false or misleading information…
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Pleural Effusion - Signs
Dullness to percussion Tracheal centrality Vocal Fremitus Asymmetric Chest Expansion Reduced Breath Sounds The Peer Teaching Society is not liable for false or misleading information…
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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 The Peer Teaching Society is not liable for false or misleading information…
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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. The Peer Teaching Society is not liable for false or misleading information…
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