Respiratory Lecture 7 Dr Azeem Alam, MBBS BSc (Hons) Surgical AFP - - PowerPoint PPT Presentation

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Respiratory Lecture 7 Dr Azeem Alam, MBBS BSc (Hons) Surgical AFP - - PowerPoint PPT Presentation

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Respiratory Lecture 7 Dr Azeem Alam, MBBS BSc (Hons) Surgical AFP Guys and St. Thomas Hospital admin@bitemedicine.com www.bitemedicine.com www.facebook.com/biteemedicine @bitemedicine Content reviewed on 21/04/2020. 1 Learning

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Respiratory

1

Lecture 7

admin@bitemedicine.com www.bitemedicine.com www.facebook.com/biteemedicine @bitemedicine

Dr Azeem Alam, MBBS BSc (Hons) Surgical AFP Guy’s and St. Thomas’ Hospital

Content reviewed on 21/04/2020.

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Learning objectives

  • 2 respiratory topics: Pneumothorax and Pulmonary Embolism
  • Case-based discussion(s) to identify the top differentials and why
  • Theory to cover pathophysiology, diagnostic criteria, investigations and

management

  • Quiz (Mentimeter and multi-step SBAs)

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Case 1

History A 23-year-old male presents with sudden onset left-sided chest pain and shortness of breath after meeting his friends. He is usually fit and well. On examination, there is left-sided hyper-resonance on percussion and diminished breath sounds. Observations HR 114, BP 120/82, RR 26, SpO2 92%, Temp 37.2°C.

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Pathophysiology

Definition: accumulation of air within the pleural space Spontaneous occurs without trauma

  • Primary pneumothorax: without underlying pulmonary disease
  • Secondary pneumothorax: complication secondary to underlying pulmonary

disease Traumatic pneumothorax

  • Penetrating or blunt injury to the chest, including iatrogenic causes

Tension pneumothorax (EMERGENCY)

  • Intrapleural pressure exceeds atmospheric
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Pathophysiology

Primary spontaneous Pathogenesis Spontaneous rupture of a subpleural bleb Typical presentation Young, tall, healthy, male presenting with sudden

  • nset breathlessness and

chest pain Underlying lung disease? No Risk factors

  • Tall, slender, young

(20-30)

  • Smoking
  • Marfan syndrome
  • Family history
  • Diving or flying

(2)

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Pathophysiology

Secondary spontaneous Pathogenesis Rupture of damaged pulmonary tissue Typical presentation Middle-aged patient with COPD presenting with sudden onset breathlessness and chest pain Underlying lung disease? Yes: occurs due to ruptured bleb or bullae secondary to lung disease Risk factors

  • Underlying lung

disease: COPD, asthma, lung cancer

  • Tuberculosis
  • Pneumocystis

jirovecii

(3)

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Pathophysiology

Tension (emergency) Pathogenesis

  • Air is forced to enter

the thoracic cavity without any means

  • f escape
  • Results in a ‘one-

way-valve’ Typical presentation Ventilated patient suddenly becomes breathless and acutely unwell Underlying lung disease? Yes/no: usually occurs in ventilated or trauma patients Risk factors

  • Mechanical

ventilation

  • Trauma
  • Iatrogenic: central

line insertion, biopsy

(4)

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Clinical features

Symptoms Signs Sudden onset pleuritic chest pain Tachycardia and tachypnoea Sudden onset dyspnoea Cyanosis Hyper-resonance ipsilaterally Reduced breath sounds ipsilaterally Hyperexpanded chest ipsilaterally: associated with tension pneumothorax Contralateral tracheal deviation and circulatory shock in tension pneumothorax

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Differentials

Pneumothorax Pulmonary embolism Pneumonia

  • SOB
  • Pleuritic chest pain
  • SOB
  • Pleuritic chest pain
  • Haemoptysis
  • Pain / swelling in one leg
  • SOB
  • Pleuritic chest pain
  • Productive cough
  • Fever
  • Any age
  • Primary spontaneous
  • Secondary spontaneous
  • Tension
  • Risk factors for

thromboembolism

  • Obesity
  • Prolonged bed rest
  • Pregnancy
  • Malignancy
  • Usually middle-aged or

elderly

  • More common with

underlying lung disease Confirmed on CXR ECG usually non-specific, but sinus tachycardia and S1Q3T3 Usually confirmed on CXR

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Investigations

Imaging

  • Chest x-ray: visible visceral pleural edge with no lung margins peripheral to this
  • CT chest: gold-standard imaging method but not routinely performed

Bedside

  • ECG: exclude a cardiac cause

Bloods

  • Arterial blood gas: may demonstrate respiratory failure

Additional points

  • Other investigations will depend on the aetiology
  • ALL patients require a repeat CXR after intervention
  • Tension pneumothorax: decompress prior to imaging if high clinical suspicion
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13 (5)

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14 (6)

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15

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(5)

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(5)

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Management: spontaneous

  • Needle aspiration: 2nd intercostal space midclavicular line
  • Chest drain: 5th intercostal space mid-axillary line; triangle of safety
  • Remember to always insert above the upper border of the rib
  • High-flow oxygen
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Management: tension

  • EMERGENCY: high-flow oxygen and urgent needle decompression
  • Aspirate: 14G cannula at the 2nd-3rd intercostal space midclavicular line
  • After decompression: chest drain insertion
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Chest drain insertion

Base of axilla Lateral edge of latissimus dorsi Lateral edge of pectoris major Nipple or 5th intercostal space

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Chest drain insertion

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Management: recurrent pneumothoraces

Options

  • Open thoracotomy and pleurectomy: lowest recurrence rate (1%)
  • VATS pleurectomy: lower morbidity than open
  • Surgical chemical pleurodesis: less popular now

Indications for referral to a thoracic surgeon First contralateral pneumothorax Second ipsilateral pneumothorax Bilateral spontaneous pneumothorax Persistent air-leak despite chest drain High risk professions: e.g. pilots Pregnancy

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Top decile question

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Management: follow-up

Flying

  • Patients can fly 1 week post check CXR as long as the pneumothorax has resolved

Diving

  • Avoid indefinitely until the patient has had a definitive bilateral surgical

pleurectomy, post-operative CT chest and normal lung function tests

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Recap

  • Pneumothorax is classified as primary or secondary spontaneous, or tension
  • Patients present with dyspnoea and pleuritic chest pain
  • The most important initial investigation is a CXR
  • Tension pneumothorax is an emergency, requiring immediate aspiration
  • Management is either conservative, or with oxygen, aspiration or drainage
  • There are numerous surgical options for recurrent pneumothoraces
  • Patients must be offered discharge advice regarding flying and diving
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Case 2

History A 65-year-old female presents with sudden onset shortness of breath and pleuritic chest pain. She has a history of a right-sided mastectomy for breast cancer, 1 year ago. She has a BMI of 27. Observations HR 125, BP 85/60, RR 28, SpO2 89%, Temp 37.7°C

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Pathophysiology

Definition: obstruction of the pulmonary vasculature secondary to an embolus

  • Virchow’s triad
  • Often secondary to deep vein thrombosis
  • Embolus dislodges and migrate to the lung circulation
  • Obstructed pulmonary vasculature ⟶ increased pulmonary vascular resistance
  • Can result in arrhythmias, pulmonary infarction, cor pulmonale and cardiac

arrest

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Pathophysiology

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Clinical features

Symptoms Signs Pleuritic chest pain Tachypnoea and tachycardia Dyspnoea Hypoxia Cough or haemoptysis Deep vein thrombosis: swollen, tender calf Fever Pyrexia Syncope: a red flag symptom Hypotension: SBP < 90mmHg suggests massive PE Elevated JVP: suggests cor pulmonale Right parasternal heave: suggests right ventricular strain

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Differentials

Pneumothorax Pulmonary embolism Pneumonia

  • SOB
  • Pleuritic chest pain
  • SOB
  • Pleuritic chest pain
  • Haemoptysis
  • Pain / swelling in one leg
  • SOB
  • Pleuritic chest pain
  • Productive cough
  • Fever
  • Any age
  • Primary spontaneous
  • Secondary spontaneous
  • Tension
  • Risk factors for

thromboembolism

  • Obesity
  • Prolonged bed rest
  • Pregnancy
  • Malignancy
  • Usually middle-aged or

elderly

  • More common with

underlying lung disease Confirmed on CXR ECG usually non-specific, but sinus tachycardia and S1Q3T3 Usually confirmed on CXR

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Case 2

History A 65-year-old female presents with sudden onset shortness of breath and pleuritic chest pain. She has a history of a right-sided mastectomy for breast cancer, 1 year ago. She has a BMI of 27. Observations HR 125, BP 85/60, RR 28, SpO2 89%, Temp 37.7°C

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Wells score

Wells Two-Level PE Score Clinical feature Points Clinical signs and symptoms of a DVT 3.0 PE is number 1 diagnosis or equally likely 3.0 Tachycardia (>100 BPM) 1.5 Immobilisation for more than three days or surgery in the previous four weeks 1.5 Previous, objectively diagnosed PE or DVT 1.5 Malignancy with treatment within the last 6 months, or palliative 1.0 Haemoptysis 1.0

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Investigations

Bedside

  • ECG: sinus tachycardia (most common); RBBB and right axis deviation; S1Q3T3

Bloods

  • ABG: may demonstrate respiratory failure

Imaging

  • CXR: typically normal, although a wedge-shaped opacification can be seen
  • ECHO: assess for right ventricular strain in massive PE

Specialist tests: depends on Wells score

  • CTPA is performed if high probability (Wells score > 4) or
  • D-dimer performed if low probability (Wells score ≤ 4)
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(8)

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(9)

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Investigations

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Further investigations: unprovoked PE

Investigations for cancer

  • All patients: full set of blood tests, CXR, and urinalysis
  • Patients > 40 years old: CT abdomen and pelvis should be considered

Investigations for thrombophilia

  • Antiphospholipid antibodies: considered in people who have an unprovoked PE
  • Hereditary thrombophilia: considered in people who have an unprovoked PE and a

first-degree relative who has had a DVT

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Management

Massive PE

  • Thrombolysis: e.g. alteplase

Non-massive PE

  • Anticoagulation:
  • Oral anticoagulation: warfarin or DOAC for 3 months if provoked, or 6 months if

unprovoked

  • LMWH used for 6 months in cases of active cancer

Alternative treatments

  • Inferior vena cava filter: consider in patients with recurrent PEs, despite

anticoagulation

  • Surgical embolectomy: when thrombolysis has failed or is contraindicated
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Recap

  • A pulmonary embolism presents with dyspnoea and pleuritic chest pain
  • Risk factors can be remembered using Virchow’s triad
  • A massive PE can cause cor pulmonale and rapid deterioration
  • Initial investigations include ABG, ECG, CXR, D-dimer, CTPA and ECHO for a massive PE
  • Patients with an unprovoked PE require further investigations
  • Management options include thrombolysis, DOAC, LMWH or specialist interventions
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Top decile question

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Further information

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References

1. OpenStax College / CC BY (https://creativecommons.org/licenses/by/3.0). https://upload.wikimedia.org/wikipedia/commons/0/0d/2313_The_Lung_Pleurea.jpg 2. Mileny ES Colovati, Luciana RJ da Silva, Sylvia S Takeno, Tatiane I Mancini, Ana R N Dutra, Roberta S Guilherme, Cláudia B de Mello, Maria I Melaragno and Ana B A Perez / CC BY (https://creativecommons.org/licenses/by/2.0) 3. National Heart Lung and Blood Institute / Public domain 4. Royalty—free stock illustration from Shutterstock. 5. James Heilman, MD / CC BY (https://creativecommons.org/licenses/by/3.0) 6. Photographed by User Clinical Cases 00:42, 7 November 2006 [<a href="https://creativecommons.org/licenses/by-sa/2.5">CC BY-SA 7. Egmason / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0). https://upload.wikimedia.org/wikipedia/commons/e/e2/Endothoracic_fascia.svg 8. James Heilman, MD / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0). https://upload.wikimedia.org/wikipedia/commons/b/bd/Sinustachy.JPG 9. James Heilman, MD / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0). https://upload.wikimedia.org/wikipedia/commons/4/4e/Cardiogram_indicating_right_bundle_branch_block_ with_tachycardia.jpg

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