RESPIRATORY MEDICINE

CLINICAL ENTITIES ALGORITHM

PULLING LESIONS NO PUSH/ PUSHING LESION

PULL
COLLAPSE FIBROSIS Consolidation PLEF PNEUMOTHORAX
PERCUSION Dull Impaired Dull Stony dull Hyper resonant/
Tympanic
Auscultation Breath BS Bronchial BS BS decreased/ absent
sounds (BS) decreased breathing decreased/
absent absent
CXR White and White Air White with Hyper transluecent are
homogenous heterogenous bronchogram meniscoid with compressed lung
(no air) (less air) fluid level margin

Absent BS right side with mediastinal pull to Right upper lobe consolidation
same side Clinical bronchial breathing
Right pleural effusion Left pneumothorax
Clinically dull note

 A pt with SOB underwent spirometry with reduced Fev1 /Fvc ratio:

Ans: Obstructive pattern.

Fev1/FVC ratio

LOW<0.7 Normal/ increased

Obstructive FVC < 80%

Bronchodilator Reversibility: increase Fev1 > normal restrictive

12% after SABA Inhalation

extrinsic RLD Intrinsic RLD

+ -
KYPHOSCOLIOSIS, fibrosis , ILD
NEUROMUSCULAR Occupational Lung
asthma COPD DISORDER diseases

 A pt with Respiratory Failure post operatively + TYPE OF RESP FAILURE??

- Type III Respiratory failure

RESPIRATORY FAILURE
TYPE 1 TYPE 2 TYPE 3 TYPE 4
Hypoxemic Hypercapnic Due to lung Due to
Diffusion defect/ (mneumonic – COPD) atelectasis hypoperfusion of
decrease O2 associated respiratory
transfer with general muscles
anesthesia
1. Severe Central-narcotics /Brainstem injury Perioperative Shock Related
pneumonia Obstructive Foreign body/ Severe Resp failure
2. ARDS COPD
3. Fibrosis/ ILD Peripheral – muscle weakness –
4. pulmonary GBS, MG, polio
embolism Diaphragmatic injury
 In type I RF, mechanical ventilation is given at 6-

8ml/kg body weight (normal is 10 ml/kg body wt)

Q) A 30y/o presented with features of acute

pancreatitis. Few days later developed dyspnea.

His CXR is shown below

 Diagnosis ARDS (due to indirect causes) as

CXRAY shows B/L pulmonary infiltrates

ARDS:

 Severe pneumonia is the m/c/c of ARDS (direct)

 Diagnostic criteria/ BERLIN 2012 CRITERIA

1. Acute SOB within 1 wk

2. CXR: B/L diffuse infiltrates

3. Non cardiogenic pulmonary edema

4. PaO2/ FiO2 < 300mmHg

 Rx:

- Low tidal volume mechanical ventilation (4-8ml/kg) = 6ml/kg

 - PEEP to improve oxygenation

- Other options : ECMO (extracorporeal membrane oxygenation) and if ot improving

then prone ventilation

Q) Acute SOB + Hemoptysis + Chest pain + hypotension in young female on OCPS

 Ans: massive pulmonary embolism

PULMONARY EMBOLISM

MASSIVE PE/High risk :Shock SUB MASSIVE PE: Normal MINIMAL PE: Normal BP +
+RV dysfunction BP + RV dysfunction normal RV function
Stabilize & Anticoagulation Anticoagulant : If worsening Anticoagulation.
Definitive Rx: Thrombolysis > Thrombolysis
surgical thrombectomy.
 RV function is assessed by 2D ECHO

Q) A young female with unexplained SOB with high Pulmonary arterial pressures on 2D echo.

No evidence of left heart disease / lung disease/ CTD/ Drug/toxin related/genet etiology

 Idiopathic pulmonary HTN/ group I PAH

I D IO PA T HIC P ULM O NA RY HTN

Vasoreactivity Test at RHC (right heart catheterisation) to NO inhalation

Reduction of mPAP >10 mm Hg

YES NO

CCBS ADVANCED RX

NON HIGH RISK high risk (class IV NYHA SOB)

endothelin receptor antagonist + PDE5I ERA + PDE5I + i/v prostacylcin

 ERA (endothelin receptor antagonists) – bosentan

 PDE5 inhibitors – sildenafil

 NYHA class IV SOB is SOB at rest