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Top Tips on Respiratory On-Calls
Dr Manish Pagaria Consultant Respiratory and Critical Care Medicine
Royal College Tutor for Medicine
Dudley Group of Hospitals NHS FT
23rd July 2016,
Fast Bleep the Doctor, RCP, London
Objectives
O Burden of disease
O How to recognise the problem?
O How to manage the problem?
Percentage of hospital admissions
Percentage of death
Projected proportion of deaths due to leading respiratory causes.
O Percentage of deaths worldwide 2008 2015 2030
O Lower respiratory infections 6.1 5.5 4.2
O COPD 5.8 6.6 8.6
O Trachea/bronchus/lung cancer 2.4 2.8 3.4
O Tuberculosis 2.4 1.6 3.4
O % of deaths in WHO European region 2008 2015 2030
O Lower respiratory infections 2.3 2.2 1.9
O COPD 2.5 2.7 3.2
O Trachea/bronchus/lung cancer 3.9 3.9 4.1
O Tuberculosis 0.8 0.7 0.4
Source: World Health Organization World Health Statistics 2011.
Projected disability-adjusted life-years (DALYs) lost due to leading respiratory causes
O Percentage of DALYs worldwide 2008 2015 2030
O Lower respiratory infections 5.4 4.6 3.2
O COPD 2.3 2.7 3.8
O Trachea/bronchus/lung cancer 0.9 1.0 1.4
O Tuberculosis 2.0 1.6 1.1
O % of DALYs in WHO European region 2008 2015 2030
O Lower respiratory infections 1.5 1.3 1.0
O COPD 2.0 2.0 2.2
O Trachea/bronchus/lung cancer 2.2 2.2 2.6
O Tuberculosis 1.2 1.1 0.6
Source: World Health Organization World Health Statistics 2011.
Immediate Assessment
How to recognise the problem?
O History
O Symptoms
O Importance of the HPC
O Examination
O Investigation
Symptoms
O Dyspnoea
O Chest pain
O Haemoptysis
Symptoms
O Dyspnoea
O Chest pain
O Haemoptysis
Dyspnoea: Pattern of Onset
O Sudden
O Pneumothorax
O PTE
O Aspiration
O Cardiac event –
arrhythmia, MI
O Over hours / days O Asthma
O Pneumonia
O Pulmonary oedema
O Intermittent O Asthma
O Hyperventilation
O Progressive O COPD
O IPF
O Pleural effusion
O Anaemia
O LVF
O Pulmonary hypertension
Symptoms
O Dyspnoea
O Chest pain
O Haemoptysis
Chest pain
O Myocardial ischaemia
O Pericardial pain
O Respiratory
O Oesophageal
O Musculoskeletal
Chest pain - 1
O Myocardial ischaemia O central
O radiating to the jaw / arm(s)
O squeezing / crushing / heavy weight
O aggravated by exertion
O relieved by rest / GTN
O associated autonomic features
Chest pain - 2
O Myocardial ischaemia
O Pericardial pain O Retrosternal
O Pleuritic
O relieved by sitting forward
O worse on swallowing, twisting and with sternal pressure
Chest pain - 3
O Myocardial ischaemia
O Pericardial pain
O Respiratory O typically not central
O pleuritic
Chest pain - 4
O Myocardial ischaemia
O Pericardial pain
O Respiratory
O Oesophageal O Retrosternal
O heart burn
O can be indistinguishable from cardiac pain
Chest pain - 4
O Myocardial ischaemia
O Pericardial pain
O Respiratory
O Oesophageal
O Musculoskeletal O Localised
O associated with tenderness
Symptoms
O Dyspnoea
O Chest pain
O Haemoptysis
Haemoptysis
0
5
10
15
20
25
Other Points from History
O Don’t overlook the rest of the history
O PMH -e.g. previous DVT
O Drug history -e.g. new medications
O Smoking
O Occupation e.g. baker, farmer, asbestos exposure
O Pets especially birds
O Family History
Examination
O Do not make the diagnosis from the history
alone
O It is negligent not to examine a patient with
new symptoms
O Follow the gold guide of inspection,
palpation, percussion and auscultation
Examination
O Wheeze
O Asthma / COPD
O Heart failure
O Anaphylaxis
O Foreign body
O Stridor
O Foreign body
O Epiglottitis
O Anaphylaxis
O Crackles O Pulmonary oedema
O Fibrosis
O Pneumonia
O Bronchiectasis
O Clear chest O PTE
O Pneumothorax
O Hyperventilation
O Metabolic acidosis
O Anaemia
O Drug overdose
Investigation
O Bloods
O FBC, U&E, CRP
O Trop, Ddimer
O ABG
O CXR
O ECG
D-dimer Assay (Pulmonary Embolism)
O Quantitative ELISA based assays (e.g. VIDAS) have
sensitivity of ~ 95%
O But specificity poor
O The only useful D-dimer result is a negative one
O Chance of having had a PTE with negative D-dimer is
O low clinical probability 0.7 –2%
O moderate clinical probability5%
O high clinical probability >15%
PIOPED II AJM 2006
D-dimer Assay
O It should not be done:-
O As a screening test on all general medical
patients
O In high probability cases
Arterial Blood Gases
NORMAL VALUES
O pH: 7.35 – 7.45
O pO2: 10 – 14kPa
O pCO2: 4.5 – 6kPa
O Base excess (BE): (-2) – (+2) mmol/l
O HCO3: 22 – 26 mmol/l
How to interpret an ABG
O Look at the patient !!!
O Review history and examination findings.
O What is the pO2 – how much oxygen was your patient on when the
gas was taken?
O What is the pH?
O What is the pCO2?
O What is the HCO3 and base excess?
O Is the patient compensating?
O What are the other values? Ensure that you look at all other figures
on the gas.
How to present an ABG
O State that this is an arterial blood gas sample (rather than venous).
O State the patients name and outline history/pertinent examination
findings.
O State the time the sample was taken and how much oxygen the patient
was on at the time.
O Present your findings: e.g. this showed type one respiratory failure with
a p02 of 7
O Present any abnormal findings or important negatives from the rest of
the values.
O A one line summary of your findings.
ABG done on 2l O2 for Mr JS with COPD who came in with SOB, it
shows partially compensated T2RF with pH 7.21, pCO2 14.5, pO2 8.5,
HCO3 45.
Question
O An increase in ventilation leads to:
(a) a rise in pCO2 and pO2
(b) a fall in pCO2 and pO2
(c) a rise in pCO2 and a fall in pO2
(d) a fall in pCO2 and a rise in pO2
(e) a rise in pCO2 and no change in pO2
Answer
O D
Increase in ventilation ‘blows off’ more CO2 (leading to a fall in
pCO2) and replenishes the alveolar oxygen, leading to an
increase in alveolar O2 and therefore arterial pO2, although
the O2 saturation of the blood may alter very little.
Question
O VQ mismatching leads to:
(a) a rise in pCO2 and pO2
(b) a fall in pCO2 and pO2
(c) a rise in pCO2 and a fall in pO2
(d) a fall in pCO2 and a rise in pO2
(e) no change in pCO2 and a fall in pO2
Answer
O E
In VQ mismatch with respect to CO2 content, the high content
of blood from underventilated areas is balanced by the low
content from overventilated areas. However in the case of O2,
the low content of blood from underventilated areas cannot be
compensated for by an equivalent increase in the O2 content
of blood from the overventilated areas.
Question
O A 24 ♀, day 3 post
cholecystectomy
complaining of SOB.
ABG on Room Air:
pH: 7.49
pCO2: 3.9 kPa
pO2: 7.5 kPa
sHCO3: 22 mmol/l
BE: -1
O2 sats: 97%
O What is the most likely
diagnosis
(a) Pulmonary embolism
(b) Anxiety
(c) Opiate overdose
(d) Excessive vomiting
(e) pneumonia
Answer
O A
This is type 1 respiratory failure. The PO2 is low with a low CO2.
The accompanying alkalosis is a response due to the patient blowing off CO2
due to her likely high respiratory rate.
The (A-a) gradient is increased(7.6), implying a problem within the lungs
(affecting V/Q matching) which anxiety cannot explain.
(A-a) gradient = PAO2 – PaO2
= PIO2 – (PaCO2/0.8) – PaO2
Normal (A-a) gradient is < 2
Question
O A 75 ♀ with COPD, admitted
with SOB.
ABG on 2l O2:
pH: 7.25
pCO2: 12.26 kPa
pO2: 7.8 kPa
sHCO3: 40.3 mmol/l
BE: +9
O What does the ABG show
(a) Metabolic acidosis
(b) Respiratory Acidosis
(c) Compensated Respiratory
Acidosis
(d) Partially compensated
Respiratory Acidosis
O This is Acute on Chronic Type 2 respiratory failure.
O Note that the HCO3 is raised in this patient despite the abnormal pH.
O This would indicate that the patient normally retains CO2 and has a
chronically raised HCO3.
O The drop in pH represents the normal mechanisms of compensation being
over whelmed.
O This is one of the cases where having an old ABG from a previous admission
can be useful.
O Oxygen administration in this group is a complicated issue. 100% oxygen
makes subsets of COPD patients retain CO2, decreasing respiratory drive
and worsening hypoxia and hypercapnia.
CXR
O White CXR
O Pneumonia
O Pulmonary oedema
O Pleural effusion
O Pulmonary fibrosis
O Pulmonary hge
O Black CXR
O COPD
O Asthma
O Pneumothorax
O Pulmonary embolism
O normal
RLL Consolidation
Pleural Effusion
Pulmonary Oedema
LUL Collapse
LUL collapse
LLL Collapse
Situs Inversus
Pulmonary Haemorrhage
LLL abscess
Bullous emphysema
Bullous emphysema
Pneumothorax
COPD
TB Thoracoplasty
Summary
O Most common respiratory problems faced during on-
call
O Assessment of the sick patient
O Recognizing the problem
O Some aspects of management
Any Questions?
“Complex is easy,
Simple is much harder to achieve –
but much more important”
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