Resp. ~ Short Answer

Question 1.

A 22 year old woman with a past history of asthma presents with her first spontaneous right pneumothorax estimated to be around 25% of lung volume.

A.) What type of pneumothorax is this?

Show Answer

Secondary spontaneous pneumothorax

(1 mark)

B.) How large is this pneumothorax?

Show Answer

Small; 25% equates to about 1 cm from thoracic apex to the cupola of the lung

(1 mark)

 C.) List ALL the options for treating a pneumothorax

Show Answer

  • Conservative
    • Observation only either as outpatient or inpatient
    • O2 therapy + observation
  • Invasive
    • Single aspiration and remove cannula
    • Small pneumocatheter aspiration (14F), clamp, leave in for 6 hours, if no recurrence d/c with follow-up
    • Small pneumocatheter aspiration (14F) leave to drain and admit
    • Small to moderate ICC insertion, aspiration then leave to drain and admit
  • Further procedures
    • As above AND
      • Video-assisted thorascopic surgery
      • Pleurodesis

(5 marks)

 D.) What are the treatment options in this patient?

Show Answer

  • Conservative
    • Observation only either as outpatient or inpatient
    • O2 therapy + observation
  • Invasive
    • Single aspiration and remove cannula
    • Small pneumocatheter aspiration (14F), clamp, leave in for 6 hours, if no recurrence d/c with follow-up
    • Small pneumocatheter aspiration (14F) leave to drain and admit

(3 marks)

 

E.) Pick 3 of those options and discuss the pros and cons of each

Show Answer

  • Conservative
    • Observation only either as outpatient or inpatient
      • Pros
        • Non-invasive
        • No pain
      • Cons
        • Likely to take a long time to resolve (20 days)
        • Does not address symptoms
        • Contraindicated if secondary pneumothorax or significant ain
        • Risk of further expansion/tension
      • O2 therapy + observation
        • Pros
          • Non-invasive
          • No pain
          • Resolution 3-4 x faster than no O2
        • Cons
          • Admission required
          • Still chance to accumulation and tension
          • Does not address symptoms
          • High chance recurrence in secondary pneumothorax
        • Invasive
          • Single aspiration and remove cannula
            • Pros
              • Resolution pneumothorax + symptoms
              • Simple procedure
              • No ongoing pain from catheter left in

 

  • Cons
    • If re-accumulates will need second procedure
    • Higher chance of re-accumulation in secondary pneumothorax
    • Painful + invasive
    • Scarring
    • complications
  • Small pneumocatheter aspiration (14F), clamp, leave in for 6 hours, if no recurrence d/c with follow-up
    • Pros
      • Resolution pneumothorax + symptoms
      • Simple procedure
      • If re-accumulates can leave catheter in to drain
    • Cons
      • Higher chance of re-accumulation in secondary pneumothorax
      • Painful + invasive
      • Scarring
      • Discharge
      • Small catheter do could block
      • complications
    • Small pneumocatheter aspiration (14F) leave to drain and admit
      • Pros
        • Resolution pneumothorax + symptoms
        • Simple procedure
        • If re-accumulates can leave catheter in to drain
        • Safe, patient admitted
        • Can have definitive procedure as inpatient if needed
      • Cons
        • Painful + invasive
        • Scarring
        • Requires admission
        • Small catheter so could block
        • complications

(9 marks)

F.) What would be your approach be in this patient and why?

Show Answer

BTS Guidelines for 1-2 cm or breathless

  • Aspirate with 16-18 G cannula
  • If < 2.5 L aspirated and lung back up
  • Admit with high low O2 and observe 24 hours

OR

  • Pleurocatheter and aspiration
  • High flow O2
  • Admit under respiratory for observation

(4 marks; reasonable approach)

Author: J Haire

 


 

Question 2.

A 12 year old girl with cystic fibrosis presents unwell with a fever and acute shortness of breath.

Her observations are:

Temp 38.2oC

PR 130 per min

BP 100/60 mmHg

RR 30 per min

O2 Sat 91% room Air

A Chest X-ray reveals bilateral patchy consolidation and a 20% left sided pneumothorax.

 A.) What are the problems that need to be addressed in this child?

Show Answer

  • Sepsis
  • Respiratory source
  • Likely atypical infection given cystic fibrosis e.g. Pseudomonas
  • Hypoxia secondary to infection + pneumothorax
  • Pneumothorax likely to expand given underlying disease so needs drainage
  • Child so need to manage fear and likely will need procedural sedation for ICC

(6 marks)

 B.) How would you prioritise these problems?

Show Answer

  1. Sepsis
    • Resuscitate
    • Early antibiotics
  2. Hypoxia
    • High flow O2
    • Insert ICC
  3. Simultaneous
    • Analgesia
    • Reassurance
    • Calm environment

(3 marks)

C.) How would you address the sepsis?

Show Answer

  • Resuscitate with fluids
    • 2 x 20 G IVC
    • 20 ml/kg (Wt.= 3 x 12 + 7 = 43) = approx. 800 mls fluid bolus
  • Aims
    • HR < 100 bpm
    • BP > 100 systolic
    • CRT < 2 secs centrally
    • Lactate clearance > 10% or normalisation
  • Early antibiotics
    • Consult with patients’ respiratory physician + ID
    • Likely broad spectrum with pseudomonas cover e.g. piperacillin + clavulanate AND gentamicin

(6 marks)

 D.) How would you insert the ICC?

Show Answer

  • Under ketamine procedural sedation
    • Maintain respiration AND BP
    • Analgesic too
    • 5mg/kg boluses
    • 2 experienced physicians (sedation + procedure)
  • Left ICC
    • 14-16 G
    • 4th intercostal space mid-axillary line
    • LA infiltration
    • Attach to underwater seal

(4 marks)

E.) How would you address the child’s anxiety?

Show Answer

  • Optimal analgesia
    • IN fentanyl initially
    • IV morphine
  • Calm environment
  • Distraction
    • TV
    • Games
  • Carer with child at all times
  • Nurse dedicated to child and family and managing this aspect of care

(4 marks)

F.) Who would you consult regarding this child?

Show Answer

  • Child’s respiratory physician
  • Paediatrics
  • PICU
  • ID

(3 marks)

G.) Where is this child’s disposition?

Show Answer

PICU

(1 mark)

Author: J Haire

 


 

Question 3.

A 55 year old man presents to the emergency department with chest pain and shortness of breath following vomiting four hours earlier.
On examination the patient is distressed by chest pain.

An erect chest X-ray is performed.

Respiratory Xray 1 Short Answer

 

A.) Describe the abnormalities in this x-ray

Show Answer

  • R sided pneumothorax
    • Large (> 2cm)
  • No radiographical signs of tension
    • Mediastinum not displaced
  • s/c emphysema in neck bilaterally
  • no pneumomediastinum
  • right sided pleural effusion
    • meniscus right costophrenic angle

(3 marks; bold + 1)

B.) What is the likely diagnosis in this patient?

Show Answer

Boerhaave’s syndrome

(1 mark)

C.) List the other differentials

Show Answer

  • Spontaneous pneumothorax
    • Primary
    • Secondary

(2 marks)

D.) Assuming the most likely diagnosis, what is your immediate management?

Show Answer

  • O2 to maintain O2 sats > 95%
  • IV fluids to treat sepsis
  • Broad spectrum IV antibiotics
    • Ampicillin, gentamicin, metronidazole
  • Drainage of pneumothorax
    • Pneumocatheter or ICC
  • Referral to surgery immediately

(4 marks)

E.) What investigations can be done to make the diagnosis?

Show Answer

  • Oesophogram with gastrograffin (not barium)
  • CT scan with

(2 marks)

F.) What is the degree of mortality associated with this condition?

Show Answer

  • High (35%)
  • Increases with delayed diagnosis

(1 mark)

Author: J Haire

 


 

Question 4.

A 35 year old homeless man presents with two months of increasing cough. He has no other medical past history.

 Respiratory Xray 2 Short Answer

 A.) Describe the abnormalities in this x-ray

Show Answer

  • R upper zone cavitating lesion
  • R lower zone consolidation

(2 marks)

B.) What is the broad differential diagnosis for these abnormalities?

Show Answer

  • Infectious
  • Malignancy
  • Rheumatological diseases
    • Wegners granulomatosis
    • Sarcoidosis
  • Bronchiolitis obliterans organising pneumonia
  • Langerhans cell histiocytosis

(3 marks; bold + 1)

C.) What is your differential for infectious causes of these types of lesions?

Show Answer

  • Infectious
    • Necrotising pneumonias/lung abscess e.g. Strep, Hib, Staph, Klebsiella
    • Actinomycosis
    • Nocardia
    • Meliodosis
    • TB
    • Fungi
      • Aspergillosis
    • Aspiration pneumonia

(3 marks)

D.) How would you investigate this further to get a definitive diagnosis?

Show Answer

  • Sputum cultures including acid-fast
  • CT scan
  • CT-guided aspirate/biopsy

(3 marks)

Author: J Haire

 


 

 

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