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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5. Pulmonary Embolism Causes of VTE ?
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6. 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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7. Pulmonary Embolism Classification of Clinical Presentation
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8. 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
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9. Pulmonary Embolism Sx – Submassive
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10. Pulmonary Embolism Sx – Submassive Acute SOB  Pleuritic Chest Pain 
Cough 
Haemoptysis 
Wheeze 
Tachycardia 
Tachypnoea 
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11. 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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12. Pulmonary Embolism Sx – Massive
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13. Pulmonary Embolism Sx – Massive Shock Sx  ↑ JVP  Accentuated P2 
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14. 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 lung base.
Mild calf tenderness.
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16. 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.
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17. Pulmonary Embolism DDx Submassive PE  PTX 
Acute Pulmonary Oedema/ARDS 
Pneumonia 
Sepsis 
MI 
Arrhythmia 
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18. 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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19. Pulmonary Embolism Ix FBC LFT  ?Liver Mets/Ca
U&E  ?Renal Function (?Shock)
Clotting  ?Hypercoagulable
D-Dimer
ABG
Blood Culture
CXR
Leg USS
ECG
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20. 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?
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21. 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)
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22. Pulmonary Embolism Mx of Submassive PE (SBP > 90 mmHg) Initial
Long-Term
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23. 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
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24. 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
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25. Pneumothorax
Types
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26. Pneumothorax Types Tension Non-Tension Spontaneous Traumatic
Primary  No Lung Pathology (but probably small blebs)
Secondary  Lung Pathology (esp. COPD bullae)
Traumatic
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27. Pneumothorax 2 Symptoms 4 Examination Signs of Non-Tension PTX
Which Side has PTX?
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28. 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
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29. 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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30. 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
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31. Pneumonia - Basics
Signs and Symptoms of Acute Lower Respiratory Tract Infection.
Radiographic Change
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32. 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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33. 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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34. Clinical Evaluation - Symptoms
Fever
Pleuritic Chest Pain
Haemoptysis
Sputum Production ( purulent)
Dyspnea
Cough
Fever/Rigors
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35. Clinical Evaluation - Signs
Febrile
Raised Respiratory Rate
Reduced SpO2
Crackles
Bronchial Breathing
Dullness on percussion
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36. Diagnosis - Investigations
Bloods
ABG
FBC
CRP
WCC + Differential
Anaemia
U/E
LFT
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37. Diagnosis - Investigations
Scoring System
Confusion
Urea
Respiratory Rate
Blood Pressure <90mmHg systolic
<65 years of age
Imaging
CXR
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38. Treatment Antibiotics Oxygen Fluids Analgesia
Amoxicillin / Flucoxacillin (if S. aureus suspected)
Oxygen
Fluids
Analgesia
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39. 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.
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40. 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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42. Pleural Effusion - Basics
Common Causes of Exudate
Pneumonia
Malignancy
Pulmonary Infarction (Embolism)
Autoimmune
Pancreatitis TB
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43. 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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44. Pleural Effusion - Signs
Dullness to percussion
Tracheal centrality
Vocal Fremitus
Asymmetric Chest Expansion
Reduced Breath Sounds
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45. 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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46. Treatment Treat the cause Thoracentesis Pleurodesis
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47. 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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