A chest x-ray of a patient with sarcoidosis shows bilateral hilar lymphadenopathy (BHL) but is otherwise normal.
What chest x-ray stage does this correspond to?
Correct Answer B: There is no one diagnostic test for sarcoidosis and hence diagnosis is still largely clinical. ACE levels have a sensitivity of 60% and specificity of 70% and are therefore not reliable in the diagnosis of sarcoidosis although they may have a role in monitoring disease activity. Routine bloods may show hypercalcaemia (seen in 10% if patients) and a raised ESR.
Sarcoidosis: investigation:
A chest x-ray may show the following changes:
Other investigations*:
*The Kveim test (where part of the spleen from a patient with known sarcoidosis is injected under the skin) is no longer performed due to concerns about cross-infection.
A 45-year-old female develops pleuritic chest pain following a hysterectomy 10 days ago. Low molecular weight heparin is given initially and CTPA confirms a pulmonary embolism. There is no previous history of venous thromboembolism.
How long should the patient be warfarinized for?
Correct Answer C: As this patient has a temporary risk factor for a thromboembolic event the recommended period of anti-coagulation is 3 months.
Pulmonary embolism management:
The NICE guidelines of 2012 provided some clarity on how long patients should be anticoagulated for after a pulmonary embolism (PE). Selected points are listed below.
Low molecular weight heparin (LMWH) or fondaparinux should be given initially after a PE is diagnosed. An exception to this is for patients with a massive PE where thrombolysis is being considered. In such a situation unfractionated heparin should be used.
Thrombolysis:
A 69-year-old man with chronic obstructive pulmonary disease (COPD) presents to the Emergency Department with dyspnoea. Three days ago he was started on amoxicillin and prednisolone by his GP. Since arriving in the department he has been given back-to-back nebulized salbutamol and ipratropium bromide. The oxygen concentration has been titrated to 28% to achieve a saturation of 88-92%. Due to his poor response to treatment an aminophyline infusion is started. Thirty minutes later, his arterial blood gases show the following (taken on 28% oxygen):
What is the most appropriate next step in management?
Correct Answer D: Intravenous magnesium sulphate is useful in acute asthma, rather than COPD. Giving intravenous hydrocortisone is unlikely to make any difference given that he has had three days worth of prednisolone already.
Non-invasive ventilation: The British Thoracic Society (BTS) published guidelines in 2002 on the use of non-invasive ventilation in acute respiratory failure. Following these the Royal College of Physicians published guidelines in 2008.
Non-invasive ventilation - key indications:
Recommended initial settings for bi-level pressure support in COPD:
A 65-year-old female with a history of chronic obstructive pulmonary disease (COPD) is reviewed in the Emergency Department. She has presented with a sudden worsening of her dyspnoea associated with haemoptysis.
What is the most suitable initial imaging investigation to exclude a pulmonary embolism?
Correct Answer D: Pulmonary embolism - CTPA is first-line investigation.
It is still common in UK hospitals, despite guidelines, for a ventilation-perfusion scan to be done first line.
Pulmonary embolism investigation: 2012 NICE guidelines: All patients with symptoms or signs suggestive of a PE should have a history taken, examination performed and a chest x-ray to exclude other pathology.
If a PE is still suspected a two-level PE Wells score should be performed:
Clinical probability simplified scores:
If a PE is 'likely' (more than 4 points) arrange an immediate computed tomography pulmonary angiogram (CTPA). If there is a delay in getting the CTPA then give low-molecular weight heparin until the scan is performed.
If a PE is 'unlikely' (4 points or less) arranged a D-dimer test. If this is positive arrange an immediate computed tomography pulmonary angiogram (CTPA). If there is a delay in getting the CTPA then give low-molecular weight heparin until the scan is performed.
If the patient has an allergy to contrast media or renal impairment a V/Q scan should be used instead of a CTPA.
CTPA or V/Q scan?
The British Thoracic Society (BTS) published guidelines back in 2003 on the management of patients with suspected pulmonary embolism (PE). Key points from the guidelines include:
D-dimers:
ECG:
V/Q scan:
CTPA:
A 70-year-old man who is known to have chronic obstructive pulmonary disease (COPD) is admitted to the Medical Admissions Unit with a suspected infective exacerbation of COPD.
What should the target oxygen saturations be until blood gases are available?
Correct Answer C: The British Thoracic Society published guidelines on emergency oxygen therapy in 2008. The following selected points are taken from the guidelines. Please see the link provided for the full guideline.
In patients who are critically ill (anaphylaxis, shock etc) oxygen should initially be given via a reservoir mask at 15 l/min. Hypoxia kills. The BTS guidelines specifically exclude certain conditions where the patient is acutely unwell (e.g. myocardial infarction) but stable.
Oxygen saturation targets:
Management of COPD patients:
Situations where oxygen therapy should not be used routinely if there is no evidence of hypoxia:
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