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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
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
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
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
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
MedicalPO theophyllinePO Carbocisteine? Oral steroid trial? Alpha tocopherol ? Beta carotene
Viva-esque questions2. When should long term oxygen therapy be considered in COPD?
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
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*