An elderly patient with a history of chronic obstructive pulmonary disease is admitted following an infective exacerbation. The posterior anterior (PA) chest x-ray on admission shows a unilateral pleural effusion.
Which one of the following is the most useful next line investigation?
Correct Answer D: Ultrasound is recommended by the British Thoracic Society as it increases the likelihood of successful pleural aspiration and is sensitive for detecting pleural fluid septations.
The British Thoracic Society (BTS) produced guidelines in 2010 covering the investigation of patients with a pleural effusion.
Imaging:
Pleural aspiration:
Light's criteria was developed in 1972 to help distinguish between a transudate and an exudate. The BTS recommend using the criteria for borderline cases:
Other characteristic pleural fluid findings:
Which one of the following markers is most useful for monitoring the progression of patients with chronic obstructive pulmonary disease?
Correct Answer D:
COPD: investigation and diagnosis:
NICE recommend considering a diagnosis of COPD in patients over 35 years of age who are smokers or ex-smokers and have symptoms such as exertional breathlessness, chronic cough or regular sputum production.
The following investigations are recommended in patients with suspected COPD:
The severity of COPD is categorized using the FEV1*:
Measuring peak expiratory flow is of limited value in COPD, as it may underestimate the degree of airflow obstruction.
*Note that the grading system has changed following the 2010 NICE guidelines. If the FEV1 is greater than 80% predicted but the post-bronchodilator FEV1/FVC is < 0.7 then this is classified as Stage 1 - mild
**Symptoms should be present to diagnose COPD in these patients.
A 24-year-old male is admitted with acute severe asthma. Treatment is initiated with 100% oxygen, nebulized salbutamol and ipratropium bromide nebulizers and IV hydrocortisone. Despite initial treatment there is no improvement.
What is the next step in management?
Correct Answer B: Current guidelines do not support the routine use of non-invasive ventilation in asthmatics.
Asthma: acute severe:
Patients with acute severe asthma are stratified into moderate, severe or life-threatening:
British Thoracic Society guidelines:
A 29-year-old man presents to the Emergency Department with dyspnoea. He has no past medical history of note other than a fractured ankle five months ago. On examination he has reduced breath sounds on the left side. The trachea is central and oxygen saturations are 98% on room air. A chest x-ray shows a pneumothorax on the left-side with a 3.5cm rim of air. There is no midline shift.
What is the most appropriate initial management?
Correct Answer A: The British Thoracic Society (BTS) guidelines would advocate aspiration in this scenario given the absence of a secondary cause, for example asthma. In accordance with the BTS oxygen guidelines there are no indications to give oxygen.
Pneumothorax:
The British Thoracic Society (BTS) published updated guidelines for the management of spontaneous pneumothorax in 2010. A pneumothorax is termed primary if there is no underlying lung disease and secondary if there is.
Primary pneumothorax:
Recommendations include:
Secondary pneumothorax:
Iatrogenic pneumothorax:
A 24-year-old heroin addict is admitted following an overdose. He is drowsy and has a respiratory rate of 6 / min.
Which of the following arterial blood gas results (taken on room air) are most consistent with this?
Correct Answer C: This patient is likely to have developed a respiratory acidosis secondary to hypoventilation.
Respiratory acidosis:
Respiratory acidosis may be caused by a number of conditions:
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