Title: COPD/Asthma/Pneumonia/Pulmonary fibrosis

Ddx:
Acute exacerbation of asthma
Acute exacerbation of COPD
Pneumonia
Acute bronchitis
Bronchiectasis
Lung carcinoma
CCF
PE

Ddx for PE:

- PE
- Pneumothorax
- Acute exa. COPD
- ACS
- A.Fib
- Acute pulmonary oedema
- Myocarditis
- Pericarditis

Ddx for ILD:

- Pulmonary fibrosis (sarcoidosis, amyloidosis, pulmonary vasculitis,
occupational lung disease)
- Lung carcinoma
- Mesothelioma
- Pulmonary hypertension
- Acute COPD
- Acute asthma
- CCF/RVF

Ddx for lung carcinoma:

- Pneumonia
- Exa COPD
- Parapneumatic effusion
- TB
- Mesothelioma
- Metastatic lung disease

Common presentation: Dyspnoea/Cough

1. When did it start? (dyspnoea)

2. What were you doing when you it started?
3. Have this happened before?
4. Did it start gradually or suddenly?
5. Was it constantly there or comes and go?
6. (Intermittent) How long did it last when it was there?
 7. Did you feel breathless when sitting down? When you were walking on a
flat floor? When you are walking up the stairs/up a hill? When you were
running?
8. How far could you walk when you first had this problem? How far can you
walk now? When did it start to get worse?
9. Any particular time of the day that it gets worse?
10. Is there anything that brings it on or makes it worse? For example,
exercise, cold air, pollen, dust, furry animals, or exposure to work place?
11. Anything that makes it better? For example sitting down, inhalers or
avoid exposure from work place? (I use inhaler does your inhaler helps
to relieve it this time?)
12. Associated symptoms:

Respiratory sx:
I. Cough:
- when did it start?
- Any particular time of the day you would cough?
- is it a dry cough or did you cough up any phlegm?

II. Sputum:
- how much sputum would you cough up?
- Whats the colour of sputum?
- Any change in the colour?
- Any particular time of the day you would cough up more
sputum?

III. Haemoptysis:
- did you cough up any blood?
- How much blood would you cough up?
- Whats the colour of the blood?

IV. Any wheeziness?

V. Any fever?
VI. Any night sweats?
VII. Any hoarseness of voice?
VIII. Any weight loss? / Any loosening of pants?
- how much weight did you lose? / what size did you wear last
time and now?
- Over what period of time did you lose your weight?
IX. Do you have any allergy to any thing?
X. Any lethargy/fatigue? Any backpain or joint pain? (Malignancy)

Cardiovascular symptoms:

I. Any chest pain? (SRTCOPDSARA) Did you get chest pain when
breathing in?
II. Orthopnea? How many pillows do you sleep at night? (>2)
III. PND?
IV. Any swelling in the legs?
 V. Any pain at the back of your legs?
VI. Any heart racing? (Palpitations)
VII. Any dizziness?
VIII. Any faintness? Did you lose your consciousness?
IX. Any headache?
X. Any n/v?
XI. Any sweating?

Risk Factors:

1. Smoking:
- Do you smoke?
- How long have you been smoking?
- How much do you smoke every day?
- (have you smoked before?)
- (when did you give up?)
- (how much did you smoke before you gave up?)

2. Drinking:
- Do you drink?
- What do you drink?
- How often do you drink?
- How many units do you drink weekly?

3. History of asthma/copd
- Have you ever been diagnosed with asthma/copd?
- When were you diagnosed?
- Are you taking any inhalers? Which inhalers? Whats the dose?
Any change in the dose? How often do you use your inhalers?
Did it help? Do you use the correct technique for the inhaler?
- Do you use any oxygen at home?
- Do you do any chest physiotherapy? What do you do? How
often do you do chest physio?
- Do you use any peak-flow meter at home? Whats your average
reading?
- Any admission to hospital for COPD/Asthma? When was the
last time?
- How long did you stay in the hospital?
- Did they give you oxygen? Did it help?
- Did you get any nebulizer? Did it help?
- Any recurrent chest infections? How often do you get chest
infections in a year?
- Do you have to be admitted into hospital for chest infections?
- How long were you on the antibiotic course?
- Do you get influenza vaccination every year?

4. Anyone in the family with COPD/Asthma/Any lungs disease?

5. Iv drug use? Close contact with anyone sick recently? (pneumonia)
 6. Hx of malignancy/ radiation therapy ?
7. Exposure to asbestos, heavy metals or other toxins?
8. RF for PE
- Recent immobilization/ laung-haul flight
- Sugery within the last 3/12
- Hx of DVT/PE
- Malignancy
- OCP/HRT
- Trauma/injury
- Hx of CRF/CLF/CCF

If they had a transplant ask :

how many days out
where you put on bypass
Do you know how much blood lost
Where you transfused
How long did it take for them to wake you up?
Wound Healing well ?

Social History:

1. Who lives with you at home?

2. Are you coping well at home?
3. Are bedroom and toilet upstairs or downstairs? Any difficulties going up
to bedroom or toilet?
4. Who does the shopping, cleaning and cooking?
5. Do you need any helps at home? Is there any social worker comes to your
house? Any meals on wheel?
6. Are you working or studying? Do you have to missed work or school due
to your illness? How often? How many days?
7. Does your illness affect your daily activity?

Disease Symptoms / Features

- chronic cough, >3months for
COPD 2 consecutive years
- sputum
- SOB (progressive)
- Wheeze (gradually)
- >35yo
- heavy smoker for long term

Asthma - non productive cough

- wheeze
 - SOB sudden onset and on
exertion (intermittent)
- Diurnal variation- worse at
night/early morning
- Allergy (exercise, cold,
pollen, dust)
- Hx of GORD
- Hx of eczema
Pneumonia - Productive cough
- Mucopurulent/purulent
sputum
- Haemoptysis
- Dyspnea
- Pleuritic CP
- Fever, rigor
- Fatigue
- Myalgia/arthralgia
- n/v
- Headaches
TB - Haemoptysis
- Fever, night sweats
- Weight loss
- Recent travel/contact with
patient known for TB
Pulmonary Fibrosis - Persistent dry cough
- SOB on exertion
- Malaise
- Weight loss
- Arthralgia
CF - Productive cough
- A lot of sputum
- Haemoptysis
- Recurrent chest infections
- GORD (heartburn etc)
- Constipation
- Weight loss, slow weight
gain
- Diabetes
- Stools hard to
flushed/floating stools
- Liver failure (jaundice etc)
- Osteoporosis/osteopenia
- Young , Caucasian,
nonsmoker,
Bronchiectasis - Persistent cough
- Purulent sputum
- Intermittent haemoptysis
Pulmonary oedema - Cough
- Frothy sputum (pinkish)

PE
Lung Ca
Dry cough ACEi, Pul. Fibrosis, Sinusitis, asthma, GORD
Investigations:
Disease Investigations
COPD 1. Peak Expiratory Flow
2. PFT- spirometry (obstructive
defect), reversibility, lung
volumes, DLCO
3. ABG T1RF/T2RF, hypoxia,
hypercapnoea
4. Bloods FBC, CRP, U&E, LFTs,
pANCA (churg strauss), IgE, RAST
Asthma,BNP, blood cultures
5. Sputum for microscopy, culture
and sensitivity
6. Viral serology, TB cultures
7. Skin Prick Testing (asthma)
8. CXR hyperinflated lungs,
flattened diaphragm and bullae
9. HRCT Thorax enlarged air
spaces, air trapping and bullae
10. ECG for signs of straining to rt
heart tall p wave, RBBB, RVH
11. ECHO
Asthma Same as COPD
- SOB
- Haemoptysis
- Acute SOB
- Pleuritic CP
- Dizziness, syncope
- Swelling, redness, pain in
legs
- Cough
- Haemoptysis
- SOB
- Hoarseness (T1)
- Chest pain
- Weight loss, anorexia
- Bone pain
- Recurrent LRTI
Management
1. Assess ABC, check vitals, take focused hx
and exam
2. Controlled O2 therapy, saO2 88-92%,
about 24%-28% of O2/2-4L via nasal
prongs
3. Nebulized bronchodilator of SABA +/-
ipratropium bromide (combivent)
4. Nebulized saline to aid airway clearance
5. Oral prednisolone or iv hydrocortisone
6. +/- oral or iv abx if suspect infection/
positive culture
7. Chest physiotherapy to aid airway
clearance
8. Reassess (ABG, O2 sat, physical exam)
9. If no improvement, repeat nebulized
bronchodilator and consider iv infusion
of aminophylline
10. If no improvement, pH<7.35, PO2
>6.5kPa, RR>30 consider NIV (biPAP)
11. If no improvement, pH<7.26 and PO2
keeps on increasing, alert the
anaesthetist and ICU for intubation and
mechanical ventilation
1. Assess ABC/vitals/HX/Exam
 2. Give O2 to achieve O2 sat > 90% (95% in
children)
3. Nebulized Salbutamol 5mg up to every
15mins (if life-threatening) and attached
telemetry to monitor for any
hypokalaemia
4. If insufficient, adds nebulized
ipratropium bromide 0.5mg every 20
mins for x3, then PRN every 3hrs
5. If insufficient, adds oral prednisolone
40mg-60mg OD then taper, or iv
hydrocortisone 200mg stat then 100mg-
200mg QDS
6. If insufficient, consider iv magnesium
sulphate 1-2g over 15-20mins
7. If insufficient, alert the anaesthetist and
ICU for intubation and mechanical
ventilation
8. Assess patient regularly after each
intervention and every 1-2hrs initially,
looking at ;
- O2 sat
- PAO2
- improvement in PEFR
- physical exam
9. Admit if no improvement after 4-6hrs
10. Discharged if PEFR >60% with
improvement on oral/inhaled medication
11. Discharged patient on ;
- inhaled bronchodilator
- oral prednisolone
- consider combined inhaler
(seretide, symbicort)
- educate patient on taking
medication appropriately,
review action plan and follow-
up.

Pneumonia 1. ABG 1. O2
2. ECG 2. Antimicrobial therapy, initially empiric,
3. Bloods FBC, u&e,LFTs, blood thereafter as per culture sensitivities
culture 3. Saline nebulisers +/- bronchodilator
4. Sputum culture, ZN, TB culture nebulisers if concomitant obstructive
5. Viral serology airways disease
6. Mycoplasma serology 4. +/- oral prednisolone/iv hydrocortisone
7. Legionella urinary antigen if COPD/Asthma component
8. CXR 5. Anti-pyretics
9. CT thorax 6. +/- IVF
10. Bronchoscopy, bronchial 7. Oxygen therapy as appropriate
 washing/BAL 8. Chest physiotherapy/ACBT
11. Dx/Tx pleural aspiration under 9. Non-invasive ventilation-CPAP/BiPAP if
US-guidance Type 1/Type 2 respiratory failure,
respectively
Curb-65 (diagnosis): admit if score 2 or 10. Therapeutic pleural aspiration/pleural
more. drain for parapneumonic effusions
- Confusion 11. NIV unit/HDU/ICU management as
- Urea > 7mmol/L required
- RR>30
- SBP <90, DBP
<60mmHg
- Age >65

PE 1. ABG hypoxia, hypocapnia, resp 1. Assess ABC/vitals/Hx/Exam

alkalosis, 2. Give 100% O2
T1RF 3. IV access, IV fluids
2. ECG n/sinus 4. Morphine 10mg iv + antiemetics
tachy/RAD/RBBB/S1Q3T3
5. If critically ill with massive
3. Bloods - FBC, u&e, CRP, ESR, troponin,
d-Dimers, BNP, LFTs
haemotysis/cardiogenic
4. Screen for thrombophilia shock/haemoynamic instability
antithrombin 3, protein c/s, factor V immediate thrombolysis (if no CI)
leiden, antiphospholipid ab, anti- rtPA, streptokinase, alteplace
cardiolipin ab, lupus anti-coagulant 6. LMWH first 24hr, x5days
5. CXR atelectasis, pleural effusion - Tinzaparin 175iu/kg od sc
6. CTPA filling defect - Enoxaparin 1mg/kg bd sc or
7. V/Q scan CXR must be normal. 1.5mg/kg od sc
8. ECHO - increased RV size, decrease RV - Simultaneous warfarin and
function, tricuspid regurgitation monitor INR
7. IV unfractioned heparin if
- Persistent hypotension SBP<90
- Increased risk of bleeding
- Morbid obesity
8. IVC filter if failed/CI to AC therapy
- Percutaneously via femoral or
jugular vein
- Placed below renal veins
9. Embolectomy if CI to thrombolysis
surgically or catheter
10. Conservative
- TED stockings
- Hydration
- Mobilization
11. Long term, warfarin/NOAC
- 6 months
- lifelong if recurrent
PE/thrombophilia
- DVT prophylaxis Tinzaparin
3500u od sc/ Enoxaparin 40mg od
sc
Bronchiectasis - Refer CF
- HRCT (gold standard)
Bronchial diameter
1.5times greater than
adjacent pulmonary A
(signet ring sign)
Lack of bronchial tapering
Bronchial wall thickening
(tram lines)
1. Fluoroquinolone x 7-10/7 , if no hx of
recurrent exa/ positive culture
2. Dual abx
3. Physiotherapy
4. Iv fluids
5. Mucolytics
6. Inhaled bronchodilators
7. Iv hydrocortisone
8. Long term
- Oral macrolide x3 weekly for
>4/52 if relapsed >3/yr
- Nebulized 0.9% or 7% saline
- Pulmonary rehab

ILD 1. ABG 1. O2 therapy

2. ECG 2. Prednisolone 1mg/kg/day for NSIP and
3. FBC, U&E, LFTs, Serum CCP (in mod-severe, taper over 6-
Ca/Albumin, ESR, CRP 12mths)
4. CXR 3. Pirfenidone for IPF (steroid harmful in
5. Sputum for AFB, TB culture IPF)
6. PFTs-restrictive ventilatory 4. Methylprednisolone iv 9rapidly prog) or
defect, reduced lung volumes, azathioprine if failed steroids in CCP
reduced DLCO 5. Smoking cessation
7. High-Resolution CT Thorax (HRCT 6. Pulmonary rehab
Thorax) 7. Influenza vaccination
8. Serum ACE, Rheumatoid Factor, 8. +/- lung transplant
Anti-CCP Abs, Anti-scl 70 Abs,
ANA, ds DNA, anti-centromere,
ANCA, anti-GBM Abs
9. Echocardiogram
10. Bronchoscopy + endobronchial
biopsy (EBBx)/ transbronchial
biopsy (TBBx)
11. Surgical biopsy

Lung cancer 1. FBC, U&E, LFTs, Ca/Albumin, LDH, Management depends on:
ESR, CRP - Histology
2. ABG - Staging
3. Sputum Cytology - ECOF performance
4. CXR - Comorbidities
5. PFTs- spirometry, reversibility, - MDT discussion
lung volumes, DLCO
6. CT Thorax/Liver/Adrenals 1. Limited Stage SCLC
7. a. Chemotherapy plus Thoracic
8. PET/CT Radiotherapy
i. Platinum-based chemotherapy +
- Assesses metabolic activity etoposide
of primary lesion +/- b. Prophylactic cranial irradiation
clarifies/identifies sites of 2. Extensive Stage SCLC
 metastatic disease
9. Bronchoscopy
10. Bronchial washings, bronchial
brushings, bronchoalveolar
lavage, endobronchial biopsy
11. Endobronchial Ultrasound and
Trans-Bronchial Needle
Aspiration of mass/lymph node
(EBUS-TBNA)
- Stages mediastinal disease
12. Pleural ultrasound
13. Pleural aspiration under
ultrasound guidance
14. CT-/US-guided biopsy of a
peripheral
lung/liver/adrenal/neck lesion
15. Endoscopic Ultrasound (EUS)
16. Liver Ultrasound
17. Radioisotope Bone Scan
18. CT Brain/MRI Brain
a. Palliative Chemotherapy
i. Can increase survival from 2
months to 10 months
b. Whole Brain Radiotherapy for brain
metastases
c. Palliative Care
3. Stage I, II or III treatment modalities
include
o Surgery
o Chemotherapy (platinum-doublet) +/-
bevacizumab (VEGF-inhibitor)
o +/- Pemetrexed (Alimta ) only if non-
squamous subtype
o Radiotherapy/Stereotactic RT
o Tyrosine-Kinase Inhibitors if EGFR
mutation-positive
Erlotinib, gefitinib
o ALK tyrosine kinase inhibitor if ALK
fusion oncogene positive
crizotinib
4. Stage IV (Advanced)
o Palliative Chemotherapy
o Bisphosphonates iv for bone metastases
Inhibits osteoclasts
o Metastatectomy-brain, adrenal

Questions:
1. What are the side effects of long-term steroids?
- Thin skin
- Muscle wasting
- Easy bruising
- Poor wound healing
- DM
- Infection
- Low mood, depression, psychosis
- Acne, cushingoid facial
- Central obesity
- Hypertension
- GI ulcers/PUD
- Osteoporosis

2. What are the criteria for longterm oxygen therapy?

- paO2 7.3 kPa
- paO2 < 8kPa with
 clinical evidence of pulmonary hypertension (clinical signs of
cor pulmonale/right heart failure) or
echocardiogram showing a mean Pulmonary Artery Pressure
(mPAP) > 20 mmHg

3. What are the management for smoking cessation?

o Physician advice, group support
o Nicotine Replacement
o Varenicline partial agonist of the 42 subtype of the nicotinic
acetylcholine receptor, 12 week course, caution in
depression
o Buproprion Inhibits dopamine reuptake
o Electronic cigarettes Limited safety data on side effects/lung health

4. Antibiotic choices for pneumonia:

Mild Community-Acquired Pneumonia:

Amoxicillin 500 mg 1 gram tds po
Moderate to Severe Community-Acquired Pneumonia and any
patient with undelrying cardiovascular or respiratory illness:
1st line: Co-amoxiclav 625 mg tds po and Clarithromycin 500 mg bd po
2nd line if penicillin-allergic: Levofloxacin 500 mg od po OR Moxifoxacin
400 mg od po
Severe Community-Acquired Pneumonia
1st line: Co-amoxiclav 1.2g tds iv AND Clarithromycin 500 mg bd po
OR 3rd generation Cephalosporin eg Cefuroxime 1.5 g tds iv AND
Clarithromycin 500 mg bd po
2nd line: iv Fluoroquinolone eg Levofloxacin 500 mg bd iv
Hospital-Acquired/Healthcare-Acquired Pneumonia
Ist line: Piperacillin/Tazobactam 4.5 g tds iv
(Reduced to 4.5 g bd iv if Creatinine Clearance < 30 ml/min)