Phase 2 Stephen Lau & George Lam

Phase 2

Stephen Lau & George Lam

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• Pulmonary Embolism• Pneumothorax• Pneumonia• Pleural Effusion


Outline

• Causes of PE– Thrombus (DVT, ?)– ?– ?– ?


Pulmonary Embolism

• Causes of PE– Thrombus (DVT, AF)– Fat– Air– Bacterial Vegetation (EC)


Pulmonary Embolism

• Causes of VTE– ?•

– ?•

– ?•


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


Pulmonary Embolism

• Classification of Clinical Presentation


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


Pulmonary Embolism

• Sx – Submassive


Pulmonary Embolism

• Sx – Submassive– Acute SOB – Pleuritic Chest Pain – Cough – Haemoptysis – Wheeze – Tachycardia – Tachypnoea


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


Pulmonary Embolism

• Sx – Massive


Pulmonary Embolism

• Sx – Massive– Shock Sx – ↑ JVP – Accentuated P2


Pulmonary Embolism

• Sx – Massive– Shock Sx ↓ LV Pre-Load = ↓ CO – ↑ JVP RHF– Accentuated P2 Delayed RV Emptying


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 creps @ lung base.– Mild calf tenderness.


Pulmonary Embolism

• DDx– Submassive PE – PTX – Acute Pulmonary Oedema/ARDS – Pneumonia – Sepsis – MI – Arrhythmia


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


Pulmonary Embolism

• Ix– FBC– LFT ?Liver Mets/Ca– U&E ?Renal Function (?Shock)– Clotting ?Hypercoagulable – D-Dimer– ABG– Blood Culture– CXR– Leg USS– ECG


Pulmonary Embolism

• Ix– D-Dimer

• If +ve, next step?• If –ve?

– ABG• PaO2

• PaCO2

– CXR• 3 Signs

– ECG• What is the pathognomonic arrhythmia?


Pulmonary Embolism

• Ix– D-Dimer

• 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)


Pulmonary Embolism

• Mx of Submassive PE (SBP > 90 mmHg)– Initial– Long-Term


Pulmonary Embolism

• Mx– Initial

• O2

• 1) LMWH SC (Enoxaparin, Dalteparin)– / Fondaparinux– / UFH

• 2) IVC Filters

– Long-Term• Mobilization• TED Stockings• Warfarin PO for ≥ 3 Months INR 2-3


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


Pulmonary Embolism

• Types


Pneumothorax

• Types– Tension– Non-Tension

• Spontaneous– Primary No Lung Pathology (but probably small blebs)– Secondary Lung Pathology (esp. COPD bullae)

• Traumatic


Pneumothorax

• 2 Symptoms• 4 Examination Signs of Non-Tension PTX• Which Side has PTX?


Pneumothorax

• 2 Symptoms– 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


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?


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?– 1) Aspiration– 2) Chest Drain

• Mx of Large Secondary Spontaneous PTX?– Chest Drain

• Where Do You Stick the Cannula?– 2nd Intercostal Space, Mid-Clavicular Line


Pneumothorax

• Signs and Symptoms of Acute Lower Respiratory Tract Infection.

• Radiographic Change


Pneumonia - Basics

• Causative Organisms– Pathogens

• Streptococcus pneumoniae• Klebsiella pneumoniae• Haemophillus influenzae• Staphlylococcus aureus• Pseudomonas aeruginosa

– Atypical Pathogens• Chlamydia pneumoniae• Mycoplasma pneumoniae• Legionella pneumophillia


Pneumonia - Basics

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.


Types of Pneumonia

• Fever• Pleuritic Chest Pain• Haemoptysis• Sputum Production ( purulent)• Dyspnea• Cough• Fever/Rigors


Clinical Evaluation - Symptoms

• Febrile• Raised Respiratory Rate• Reduced SpO2• Crackles• Bronchial Breathing• Dullness on percussion


Clinical Evaluation - Signs

• Bloods– ABG– FBC• CRP• WCC + Differential• Anaemia

– U/E– LFT


Diagnosis - Investigations

• Scoring System– Confusion– Urea– Respiratory Rate– Blood Pressure <90mmHg systolic– <65 years of age

• Imaging– CXR




Treatment

• Antibiotics– Amoxicillin / Flucoxacillin (if S. aureus suspected)

• Oxygen• Fluids• Analgesia

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.


Pneumonia – Clinical Scenario 1

• 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


Pleural Effusion - Basics

• Common Causes of Transudate

– Heart Failure– Cirrhosis– Hypoalbuminaemia– Peritoneal Dialysis– Nephrotic Syndrome– Hypothyroidism



• Common Causes of Exudate

– Pneumonia– Malignancy – Pulmonary Infarction (Embolism)– Autoimmune– Pancreatitis– TB



• Shortness of Breath on Exertion• Cough• Pleuritic Pain• PMHx of smoking, asbestos exposure• PMHx of any previously mentioned diseases


Pleural Effusion - Symptoms

• Dullness to percussion• Tracheal centrality• Vocal Fremitus• Asymmetric Chest Expansion• Reduced Breath Sounds


Pleural Effusion - Signs

• 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



• Treat the cause

• Thoracentesis

• Pleurodesis


Treatment

• 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.


Pleural Effusion – Clinical Case 1

Phase 2 Stephen Lau & George Lam

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