Respiratory for PACESCases for finalsMonday 8th October 2012Dr James MilburnDr Chris Kyriacou

OutlineSigns to be seen in examination, both expected and miscellaneousCommon cases we had/are to be expected in the examHx and ExIxMx

Respiratory ExamEnd of bed inspectionGeneral ExamChestInspectionPalpationPercussionAuscultationAdded extras

Inspection (End of bed)Observe patient breathless/comfortableLook at surroundings inhaler/oxygen/nebulisers etcUse of accessory musclesCachexic

General ExaminationHandsFaceNeckLegs

Hands

Hands

Hands

HandsClubbingBronchiectasis, CF, Carcinoma, Fibrosing alveolitis4 signs - FACEFlucance of nail bedAngle lossCurvature of nailExpansion of terminal phalynxTar stainingSmall muscle wastingLung Ca pressure on brachial plexus

HandsHPOAPeriosteal inflammation in distal ends of long bonesPrimary lung Ca, MesoFlap/Tremor CO2 retentionFine tremor from 2-agonistsPulseRate and rhythmBoundingCyanosis

Face

Face

FacePlethoricSecondary polycythaemia, SVC obstructionHorners (Ptosis, miosis, anhydrosis)Pancoasts, (Demyelination, Carotid aneurysm)Anaemia Central cyanosisMouth Halitosis/Thrush

NeckLymphadenopathyJVP

Legs

Inspection - Chest

Inspection - Chest

Inspection - Chest

Inspection - Chest

Inspection - Chest

Inspection - Chest

Inspection Chest

Inspection - ChestShapeBarrel-chested (AP>Lateral)Excavatum/CarinatumScarsDilated veinsAsk them to take deep breathReduced expansionSymetrical

PalpationTracheaApexExpansionVocal fremitus

PercussionFlat Pleural effusion (thigh)Dull Lobar pneumonia (liver)ResonantHyper-resonant Emphysema/PneumothoraxTympany Large pneumothorax (puffed out cheek)

AuscultationCracklesNature of cracklesFine Oedema/Fibrosis (velcro)Coarse BronchiectasisTimingEarly insp COPD/BronchitisMid-late Fibrosis/OedemaClear on coughing? Yes - ?bronchiectasisNo Fibrosis/Oedema

AuscultationWheezeInspiratory/ExpiratoryFixed monophonic - Bronchial CaPolyphonic - AsthmaPleural rubVocal resonance

AuscultationBreath soundsVesicular Insp longer than expBronchial Exp longer than insp

Causes of bronchial breath soundsConsolidationCollapseFibrosis

Back of chestRepeat

Added Extras to offerSatsTemp chartSputum potPEFRCVS exam

Case 1Mrs Jones is 40 yr old women who presents with a chronic coughPlease take a history

HistoryCough for last 2 years although now worseningNo diurnal variationNo obvious exacerbating factorsProductive of around -1 cupful of foul-smelling green sputum dailyOccasional flecks of blood mixed in with sputumHad 3 chest infections in the last 6 monthsNo weight loss

History2 years ago could walk several miles with no SOBDuring exacerbation is

HistoryPMH,Laparoscopic cholecystectomy 2007Whooping cough ~1970

FH,Nil of note

Drugs and Allergies, NilNKDA

SH,Legal secretary for last 15yrs no hx of asbestos exposureEx-smoker for 5 years in her 20sMinimal drinkerNo petsNo recent travel

Differentials

DifferentialsBronchiectasisMost likely from pertussis as childCF unlikely though screen in

ExaminationOn examination the patient was clubbed and had coarse inspiratory crackles bilaterally R>L

Not dyspnoeic at rest and no use of accessory muscles.A/E and expansion equalNo wheeze

InvestigationsBedsideBloodsImagingSpecial tests

Bedside

BedsideSputumPEFRSatsTemperature

Bloods

Bloods

BloodsFBC Anaemia (chronic disease/haemoptysis)Polycythaemia (secondary to hypoxia in more advanced cases)Raised WCC if infectionEosinophilia if ABPAInflammatory markers ESR/CRPU&EsRenal dysfunction due to amyloid depositionSerum immunoglobulinsGenotyping/Sweat test

Imaging

Imaging

Imaging

ImagingCXRFlattened diaphragmsTramlines from thickened bronchial wallsCystic shadows

CT/HRCTSignet ringsBronchial wall thickening

Management

ManagementConservativeMedicalSurgical

ConservativePostural drainageChest physiotherapyPulmonary rehabOscillating positive expiratory devices (Acapella)

MedicalCheck for reversibility with 2-agonistsSaline nebs Vaccinations

Little/No role for:Steroids (unless concurrent asthma/COPD)Human DnaseLeukotriene agoinstsMethylxanthines

MedicalAntibioticsSputum sample before antibioticsChoose abx depending on previous sensitivitiesIf previously cultured Pseudomonas need oral cipro or other IV abxConsider low dose macrolides if >3 exacerbations/yearMacrolides have anti-inflammatory effect

SurgicalIndicated if localised disease or massive haemoptysisLobectomyPneumonectomy

Viva-esque QuestionsMain organisms responsible for infection in bronchiectasis?

H.influezae, S.pneumoniae, Staph aureus, Pseudomonas, anaerobes

Viva-esque QuestionsMain organisms responsible for infection in bronchiectasis?What are the main causes of bronchiectasis?

H.influezae, S.pneumoniae, Staph aureus, PseudomonasCongenital CF, Kartageners, YoungsPost-infection (childhood) Measles, pertussis, TB, BronchiolitisPost-infection (adult) Severe pneumonia, TBAutoimmune RA, UCObstruction ( localised) Tumour, Forgien body, lymph nodeIdiopathicImmunocomp Primary hypogammaglobulinaemiaTraction bronchiectasis Secondary to fibrosis

Viva-esque QuestionsMain organisms responsible for infection in bronchiectasis?What are the main causes of bronchiectasis?What are the complications of bronchiectasis?

Viva-esque QuestionsInfectionRespiratory failureBrain abscess (haematogenous spread of infection)Amyloidosis (renal failure)Pneumothorax

Viva-esque QuestionsMain organisms responsible for infection in bronchiectasis?What are the main causes of bronchiectasis?What are the complications of bronchiectasis?What is the definition of bronchiectasis?

Viva-esque Questions4.Persistent progressive condition characterised by dilated thick-walled bronchi. Typically >1.5x the diameter of the accompanying arteriole

Viva-esque QuestionsMain organisms responsible for infection in bronchiectasis?What are the main causes of bronchiectasis?What are the complications of bronchiectasis?What is the definition of bronchiectasis?What are the different morhpological subtypes of bronchiectasis

Viva-esque questionsCylindrical (uniform calibre and parallel walls)Varicose (uncommon bead like appearance)Cystic (severe form where cyst like bronchi extend to pleural surface)

6. What is Kartagners syndrome?

6. Dextrocardia, Bronchiectasis, Chronic sinusitis

Case 2Mr Singh has complained of shortness of breathPlease take a history

HistoryWorsening over last 3 monthsNow exercise tolerance

HistoryPMH,HTNDMHypercholesterolaemia

Drugs and allergies,NKDAAmlodipineIndapamideMetforminGlicazide

HistoryFH,Nil of note

SH,Ex-smoker (20 pack years)Around 8 cans strong lager a dayNo travel/petsLives with wife and 2 children

Examination

ExaminationAppears dyspnoeic at restReduced chest expansionB/L lower zoneStony dull to percussionAbsent breath soundsReduced vocal resonance

No obvious signs of wt lossNo lymphadenopathyNo tracheal deviation

Differentials

DifferentialsPleural effusionSecondary to HFSecondary to cirrhosisMalignancy

PE Fibrosis

Investigations

Bedside

BedsidePEFRSats

Bloods

BloodsFBCBNPU+ELFTs CRPLDHBNPThyroid Function Tests

ImagingCXREchoUSS for guiding drainageCT (with contrast)/CTPA if ?PE

Imaging

ImagingCXRBlunting of costophrenic anglesIf larger then opacity with concave upper margin Meniscus signEven bigger...complete white out +/- mediastinal shiftElevated hemidiaphragm if subpulmonic effusion

What is this....

Pleural fluid analysisTransudate 35g/L25-35g/LExudative if:Ratio of pleural fluid to serum protein >0.5Ratio of pleural fluid to serum LDH >0.6Pleural fluid LDH > 2 thirds of the upper limits of normal serum value

Pleural fluid analysisGlucose

Management

ManagementConservativeMedicalSurgical

ManagementConservative

ManagementMedicalBAD ALS (for management of heart failure)-blockersACEiDigoxinARBsLoop diureticsSpirinolactone

Pleurodesis if malignant

ManagementSurgicalDrainageRe-inflation oedemaPleurodesis

Intercostal SpaceRibIntercostalNerves and VesselsIntercostal MusclesLungDiaphragmFluid (or air) free in the pleural cavity

Viva-esque questionsComplications of chest tube drainage

Viva-esque questionsOrgan damageLymphatic drainage chylothoraxLong thoracic nerve of bellRarely arrythmias

Viva-esque questions2. What are the common causes of a exudative effusion

Viva-esque questions2. PRISM PERAInfectionSLEMalignancy

Viva-esque questions3. What are the common causes of transudative effusions

Viva-esque questions3.The failuresCardiac failureNephrotic syndromeCirrhosisFailure to eat Malabsorption

Viva-esque questions4. How big does an effusion have to be before it can be seen on CXR

4. 175-200mls blunting of C-P angle

Case 3Mrs Smith is a 30 year old female who has come in with a long standing coughPlease take a history

HistoryCough for last 6 months, remained relatively constantUnproductive of any sputum or bloodShe says she has a constant tightness of the chestBegun to notice some weight loss

HistorySince the cough began, she has felt more lethargic with polyarthralgiaHas recently begun to feel breathless, even at restChest pain noted central, constant, throbbing, relieved by paracetamolNoticed that her eyes feel very itchy and dry

HistoryPMH,Recurrent conjunctivitis 2011-12

FH,Nil of note

Drugs and Allergies, NilNKDA

SH,Minimal drinker and non smokerNo pets, No recent travelWork - waitress

Differentials

DifferentialsSarcoidosisYoung, femalePast history of non-pulmonary manifestation of sarcoidCause of apical pulmonary fibrosis

Malignancy rule out as weight loss noted, but non smoker, youngExtrinsic allergic alveolitis no occupational exposureTB another cause of pulmonary fibrosis but no foreign travel

Examination

Lupus pernioDuskyPurpleFace, Fingers, Feet

InspectionPlaques noted on skinPercussion, Palpation NAuscultationEnd inspiratoryFine cracklesAPICAL

Erythema nodosumPanniculitis

Viva-esque questions1. What is sarcoidosis?

Viva-esque questions1. A Multisystem, granulomatous diseaseOf unknown causeScattered collections of granulomasMixed inflammatory cellsNon-caseating, epithelioid

Viva-esque questions2. What % of patients with sarcoidosis have pulmonary involvement?

Viva-esque questions2. 90%Bilateral hilar lymphadenopathyPulmonary infiltratesFibrosis

Viva-esque questions3. What are the causes of APICAL pulmonary fibrosis?

Causes of apical pulmonary fibrosisB BorelliosisR RadiationE Extrinsic allergic alveolitisA Ankylosing spondylitisS SarcoidT Tuberculosis

Case 4Mrs Jenkins is a 65 year old female who has noticed she gets breathless after walking 50 yardsPlease take a history

HistoryHer breathlessness was first noted 6 months ago, which began after walking 500 yardsOver the last 2 months this has reduced to 50 yardsChronic cough for about 2 yearsProductive of white sputumAlways has pain in both her hands, but she puts it down to everyday wear and tear. Has not sought medical attention

HistoryPMH,HypertensionHypercholesterolaemia

FH,Mother suffered from arthritis

Drugs and Allergies, AmlodipineSimvastatinNKDA

SH,Minimal drinker and non smokerHas 2 catsNo recent travelWork retired lawyer

Differentials

DifferentialsRheumatoid arthritisOlder femaleBilateral long standing small joint arthralgiaCause of basal pulmonary fibrosis

Malignancy rule out as no weight loss noted, non smokerDrug induced worsening SOB not usually associated with CCB and StatinsScleroderma/CREST no other extra-pulmonary signs notedAsthma highly unlikely for age, no diurnal variation

Examination

PIP and MCP affectedElbow nodules

AuscultationEnd inspiratoryFine cracklesBASAL

Viva-esque questions1. What are the pulmonary complications of rheumatoid arthtitis?

Pulmonary complications of RAPleural effusionNodular lung diseasePULMONARY FIBROSISPulmonary vasculitisAlveolar haemorrhageObstructive pulmonary diseaseInfection

Viva-esque questions2. What are the BASAL causes of pulmonary fibrosis?

Causes of basal Pulmonary FibrosisD DrugsABCA AsbestosisR Rheumatoid arthritisS Scleroderma/Systemic sclerosisI Idiopathic pulmonary fibrosis

Viva-esque questions3. What three findings constitute Feltys syndrome?

PLUS Neutropenia

PLUS Rheumatoid arthritis

Investigating Pulmonary fibrosis

BedsideSputum?TB AFBSatsTemperatureResp rate

Bloods

Imaging

Investigating?

Special testsFEV1?FVC?FEV1/FVC ratio?Restrictive or obstructive?Why?

Lung functionFEV1 ReducedFVC ReducedFEV1/FVC ratio same or increasedRestrictiveWhy? Decreased lung complianceOther causes: Obesity, pregnancy, air trapping in COPD (mixed picture), paralysis/muscle weakness

Management

ManagementConservativeMedicalSurgical

ConservativeOxygen supportPulmonary rehab

MedicalCorticosteroidsLow dose prednisoloneMonths in durationN-AcetylcisteineSildenafilPirfenidone

SurgicalLung transplantDependant onSeverity of pulmonary fibrosisPatient healthPotential improvement

Case 5Mr Patel is a 75 year old male with long term shortness of breathTake a history

HistorySOB began 15 years ago, and has been worsening gradually sinceNow SOB at rest, although previously only on exertionAssociated chesty coughProductive of ++ sputumWith associated wheezeNo weight loss

HistoryPMH,Nil relevant

FH,Nil of note

Drugs and Allergies, SalbutamolSeretide (salmeterol + fluticasone)NKDA

SH,Started smoking at 25Continues to smoke 20 a dayDrinker in the past, now quit

Differentials

DifferentialsCOPDProgressive, irreversible airway obstructionCough, SOB, WheezeLong term smoker

Pneumonia unlikely, as no acute pathologyAsthma unlikely due to age and ++ sputum

Examination

InspectionBarrel chestUse of accessory musclesRaised RRPalpationReduced expansionPercussionHyper-resonanceAuscultationQuiet breath sounds

Viva-esque questions1. The term COPD constitutes chronic bronchitis and emphysema. How would you recognise each COPD subtype clinically?

Chronic Bronchitis vs EmphysemaObesityFrequent, productive coughAccessory muscle useRhonchiWheezingCor pulmonale signsOedemaCyanosis Thin, barrel chestLittle/no coughPURSED LIP breathing and accessory muscle useTRIPOD sitting positionHyper-resonanceWheezingQuiet HS

Investigations

BedsideSputumMucoidMacrophages typicallySatsTemperatureResp rate

BloodsFBCRaised PCVU+ENa 147a1ATBNP?

ABGpH 7.40PO2 8.3CO2 5.2BE +1HCO3 23.4

Investigations?

Lung functionFEV1?FVC?FEV1/FVC ratio?Restrictive or obstructive?Why?

Lung functionFEV1 lowFVC normalFEV1/FVC ratio reduced, LESS than 0.7ObstructiveWhy? Decreased expiratory flowOther causes? Asthma

Investigations

Management Chronic COPD

ConservativeSmoking cessationEducationNRTVareniclineBupropionPhysiotherapy

MedicalInitialSABA (Salbutamol) or SAMA (Ipratropium) prnIf SOB continues or 2+ exacerbationsFEV1 >50% (Mild COPD)Add LABA (Salmeterol) OR LAMA (Tiotropium)If LAMA, STOP SAMAFEV1

MedicalPO theophyllinePO Carbocisteine? Oral steroid trial? Alpha tocopherol ? Beta carotene

Viva-esque questions2. When should long term oxygen therapy be considered in COPD?

Long term oxygen therapyPaO2

LTOTSupplemental oxygen for at least 15hours per dayGreater benefits if 20 hours per dayReduces hospital admissions and frequency of exacerbations

SurgicalBullectomyLVRSLung transplantation

Acute exacerbations of COPD

InvestigationsSputumPurulentNeutrophils

3. What organisms commonly can cause an acute exacerbation of COPD?

S. pneumoniaeH. influenzaeM. catarrhalisP. aeruginosa

InvestigationsBloodsFBCU+E - ? Effect of theophyllineCRPABGpH 7.30PO2 7CO2 7.2BE -10HCO3 12

Treatment - ExacerbationsOxygen sats 88-92% - why not higher?AntibioticsDependant on organismNebulised bronchodilatorsOral Prednisolone, to continue as part of rescue packageIV aminophyllineNIV?

Non invasive ventilationPersistent hypercapnic ventilatory failureT2RF No response to medical therapy

BIPAP can then be used

Case 6Mr Baldwin is a 15 year old boy whose mother is worried about a longstanding coughPlease take a history

HistoryCough has lasted around 1 year, worse in the evenings and in the morningsMr Baldwin has mentioned he feels a band around his chest when he needs to cough, which is dry and hackingWhen this happens, it leaves him very breathless and wheezy

HistoryAlso known to have hayfever and eczema, something that his father also suffers from

DifferentialsAsthmaCardinal features - Wheeze, SOB, CoughUsually diurnal reversible and variable airflow obstructionAssociated atopy and family history

Aspergillosis unlikely as no trigger identified, not diurnal

ExaminationInspectionRaised RRPalpationHyperinflated chestPercussionHyper-resonanceAuscultationExpiratory polyphonic wheeze bilaterally

Investigations

BedsidePEFRDiary of symptoms/Peak flow

BloodsSerum precipitins

Hyperinflation

Imaging

Special testsSpirometry obstructive pictureUsually >15% improvement in FEV1 following SABA or steroid trial

Skin prick testing

Management of chronic asthma

Viva-esque questions1. What are the aims of asthma treatment, and what guidelines are they based on?

Viva-esque questions1. British thoracic society guidelines; no daytime symptoms, no exacerbations, no rescue medications, lung function >80% predicted

ConservativeRemoval of any allergens

Patient education

MedicalStep 1Inhaled SABA prnStep 2Add inhaled steroid 200-800micrograms/dayStep 3Add inhaled LABA +/- increase inhaled steroid up to 800micrograms/dayStep 4Increase inhaled steroid up to 2000micrograms/day +/- leuotriene receptor antagonist, beta agonist PO, MR TheophyllineStep 5Add long term oral prednisolone

Acute exacerbation of asthmaModeratePEFR 50-75%SeverePEFR 33-50%Life threateningPEFR

InvestigatingBedsidePEFRSputumBloodsFBC, UE, CRP, culturesABG, especially in life threatening

Management of acute asthmaOxygenNebulised salbutamol and ipratropiumPrednisolone 50mg PO OD/Hydrocortisone 100mg IV QDSCall a senior!IV Magnesium 1.2-2g infusionIV Salbutamol or IV aminophyllineIf numbers not improving ITU!

SummarySigns common and miscellaneousCasesBronchiectasisPleural EffusionPulmonary fibrosisCOPDAsthma

Visible as a tightening of the sternomastoid and strap muscles of the neck or as a transient hollowing behind the clavicles with inspiration.Also seen as an elevation of the clavicles with inspiration*Resp causes of clubbing Lung Ca, Meso, Fibrosing alveolitis, Bronchiectasis, CF, Empyema*Tar staining*Peripheral cyanosis*Rounded face due to long term steroid use in a patient with chronic obstructive airways disease, with facial plethora due to secondary polycythemia

*Horners miosis and ptosis*Thrush from steroid useHalitosis from bronchiectasis*Lung transplant scar - clamshell*Thoractomy lobectomy, pneumonectomy*VATS scars*Pectus excavatum if severe can restrict lung capacity*Dilated veins in a patient with SVC obstruction

*Kyphosis*Radiation tatoo*Barrel-chested from chronic retention*Fremitus vibration absent in pneumothorax/increased in consolidatino*due to opening and closing of airways containing secretions in regions of lung deflated to residual vol*Fixed monophonic due to airflow limitation through single airway*If not mixed in with sputum ?PE*COPD without smoking history very unlikely ?alpha1-antitrypsin*Cystic shadows and tram lines*Signet ring. Bronchiole larger than accompanying arteriole*No malar flush, No signs of RA, Stigmata of liver disease*Haematinics if Fe def anaemia will exacerbate problme. Same for hypoythy. LFts for serum proteinBNP CCF

*Echo for ejection fraction - CCFUs to guid drainage

*Blunting of costophrenic angle*Hydropneumothorax. Horizontal fluid level on erect CXR...can be seen following chest drain insertion of effusion*Beware re-inflation oedema***Not dyspnoeic at rest no use of accessory muscles.

**A/E and expansion equal

*Sarcoidosis is a multisystem granulomatous disease. This means there are scattered collections of mixed inflammatory cells (granulomas) affecting many different parts of the body. Characteristically these are non-caseating epithelioid granulomas (a pathological description distinguishing sarcoidal granulomas from the caseating or cheese-like granulomas seen in tuberculosis). Sarcoidosis usually starts in the lungs or lymph nodes in the chest. It is thought that inflammation of the alveoli (tiny sac like air spaces in lungs where carbon dioxide and oxygen are exchanged) is the start of the disease process in the lungs. This may either clear up on its own or lead to granuloma formation and fibrosis (scarring). Over 90% patients have some type of lung problem. Once considered a rare disease, sarcoidosis is now the most common of the fibrotic lung disordersOther commonly affected organs (i.e. outside the lungs) include the following: Skin 20-35% Eye 20-30% Liver 30-40% Heart 5-25% Nervous system 1-5% Musculoskeletal 2-38%Sarcoidosis is a multisystem granulomatous disease. This means there are scattered collections of mixed inflammatory cells (granulomas) affecting many different parts of the body. Characteristically these are non-caseating epithelioid granulomas (a pathological description distinguishing sarcoidal granulomas from the caseating or cheese-like granulomas seen in tuberculosis). Sarcoidosis usually starts in the lungs or lymph nodes in the chest. It is thought that inflammation of the alveoli (tiny sac like air spaces in lungs where carbon dioxide and oxygen are exchanged) is the start of the disease process in the lungs. This may either clear up on its own or lead to granuloma formation and fibrosis (scarring). Over 90% patients have some type of lung problem. Once considered a rare disease, sarcoidosis is now the most common of the fibrotic lung disorders**Borelliosis borellia, spirochete phylum, vector borne disease, tics and lice cause Lyme diseaseRadiation Radiotherapy for lung CaEAA Hypersensitivity pneumonitis diffuse granulomatous inflammation of the lung parenchyma in people sensitised by repeated inhalation of organic antigens in dusts (eg from dairy or grain products, animal dander and protein and water reservoir vapourisers)Ank Spond axial skeletal inflammatory disease form of spondyloarthritis chronic inflammatory arthritisSarcoidTB*Rheumatoid arthritischronic systemic inflammatory disorder that damages the joints of the body. Classic symptoms of rheumatoid arthritis include joint swelling, deformity, pain, weakness, and stiffness of the smaller joints such as those of the hands, wrists, elbows, knees, ankles and feet. These are referred to as the articular manifestations of the disease. When rheumatoid arthritis affects other organs of the body these are known as extra-articular manifestations *Rheumatoid nodules - Most common extra-articular feature of RA

Rheumatoid hands symmetrical deforming arthopathy, PIP and MCP joints, nodules at elbows, swan neck, boutonnieres, subluxation and ulnar drift

Decreased bibasal sounds pleuritic pain, dyspnoea, coughLocalised wheezing asymp but can be cough + haemoptIncresed RR, club, creps basally Bilateral basilar rates sobConsolidation, rales haemoptysis

*Amiodarone, Bleomycin, CyclophosphamideIPF cryptogenic fibrosing alveolitis most common cause of pulmonary fibrosis*Feltys syndrome:Rheumatoid arthritisSplenomegalyNeutropenia*Anaemia- Granulomatous, ACDWcc raisedHypercalcaemiaAnaemia sarcoid, chronic diseaseWCC TBHypercalcaemia sarcoidLFT - sarcoid

*CXR reticular nodular shadowing in a basal distributionDx basal pulmonary fibrosis

ReducedReducedSame or increasedRestrictiveDecrease lung complianceObesity, pregnancy, air trapping in COPD (mixed picture), paralysis/muscle weakness*

BIOPSYPatchwork pattern of interstitial scarring, honeycomb changes, fibroblast foci

*PR education about PF, PE, breathing exercises, nutritional advice, psychological support, social network

*

NAC antioxidant slow progressionSildenafil used as vasodilator secondary to pulmonary hypertension, secondary to the pulmonary fibrosisPirfenidone antifibrotic can get photosensitivity rash to this

*Lung TP how bad condition, how fast deteriorating, age and general health, how condition will improve after transplant, whether donor lung available

*Tripod position in patients with Emphysema, oxygen, sputum pot, sats probe, wt loss, pursed lips (maintain PEEP law of laplace), ensure?Switching insertion of pec major? CO2 retention flap

OxygenBarrel chest of hyperinflation with resulting reduced expansion

*Cor pulmonale = pulmonary hypoertension causing right heart failureSputum CB: mucoid, macros

BNP vasodilator intermediate, cant differentiate between CHF and COPDBloods retain sodiumA1AT if less than 11, between 3 and 7, younger emphysema

*Low paO2 with some compensation

Hyperexpansion, depressed diaphragm, increased retrosternal space, swinging heartFEV1 lowFVC normalReduced, less than 70%ObstructiveLung capacity normal, but decrease in expiratory flow Asthma

FEV1 lowFVC normalReduced, less than 70%ObstructiveLung capacity normal, but decrease in expiratory flow Asthma

CT thoraxHyperlucency diffuse hypovasc and bullae formationVarenicline option for smokers who have expressed desire to quit smokingOnly as part of behavioural support programme*Nebuliser trial

*Mucolytics separate from processOral steroid trial 30mg Pred /day for 2 wks FEV>15%

*Bulla on CT, and SOB FEV 20%, po225, HR>110Lifethreatening PaO2 92% aim4-6 hourlyIf not improving within 15-30 min or lifethreateningNebs every 15minInfusion over 20min of magnesium*