Acute exacerbation of COPD

 AE of COPD is characterized by worsening of respiratory symptoms (cough, wheeze and dyspnea) more than usual day to day variation and requires changes in the medications.

Pathophysiology of breath sounds

 Normal breath sounds originate from the larynx .When the sound leaves the larynx it travels down the trachea and then divides when the airway divides. Some sound must be transmitted through the lung parenchyma but most travels down the airway. Eventually the sound travels along airways of different lengths and therefore becomes out of phase. Next it arrives in the respiratory bronchioles and alveoli and then gets transmitted through the chest wall to your stethoscope. The fat layer filters out much of the high frequency sound (above 4 kHz). The resulting sounds are much softer (because the sound has effectively been diluted throughout the whole of the lungs). There is no gap between inspiration and expiration (because all of the sound has become out of phase and therefore 'filled in' the gap. Finally, the first third of expiration is now the only part that is audible because the latter two-thirds are much quieter.

Reference: Chamberlain

Bronchiectasis

 Bronchiectasis is derived from Greek roots, bronchion meaning windpipe and ektasis is stretching out.

Bronchiectasis is present when one or more Bronchiectasis are abnormally and permanently dilated.

Reference: Crofton and Douglas page 794

Bronchiectasis is an entity characterized pathologically by airway inflammation and permanent bronchial dilatation 

Clinically by cough,sputum production,and exacerbations with recurrent respiratory tract infections.

Reference: Fishman edition 6 page no 862

Drugs causing breathlessness

 DRUGS CAUSING ORGANISING PNEUMONIA

1.Amiodarone

2.Amphotericin B

3.Carbamazepine

4.Cephalosporins

5.Coacine

6.Gold salts

7.Interferon alpha

8.Minocycline

9.Nitofurantoin

11.D-Penicillamine

12.Phenytoin

13.Rituximab

14.Sotalol

15.Sulfasalazine/Mesalamine

DRUGS CAUSING INTERSTITIAL INFILTRATES/FIBROSIS:

1.Amiodarone

2.Beta adrenargic blockers

3.Carbamazepine

4.Gold salts

5.Hydralazine

6.Methotrexate

7.Penicillins

EOSINOPHILIC LUNG DISEASE

1.ACE inhibitors

2.Amiodarone

3.Amphotericin B

4.Carbamazepine

5.Cephalosporins

6.Erythromycin

7.Ethambutol

8.Isoniazid

9.Minocycline

10.Methotrexate

11.Nitofurantoin

12.NSAIDS

13.PAS

14.Tetracycline

15.Trazadone

IDSA sinusitis management

 

Gram positive bacilli and Gram negative cocci

 Gram positive bacilli

Spore forming

Aerobic- Bacillus

Anaerobic- Clostridium 

Non spore forming

Filamentous 

Nocardia(weakly acid fast) ,actinomyces

Non filamentous

Listeria,corynebacterium

Gram negative cocci

Neisseria ,Moraxella

Gram negative coccobacilli

Hemophilus influenza

Upper vs lower respiratory tract

 Upper respiratory tract is arbitrarily regarded as that part above cricoid cartilage. It includes nose,pharynx,paranasal sinuses,eustachian tube, larynx.

Lower respiratory tract extends from trachea

Reference - Crofton page 4

Muscles of respiration

 Muscles of inspiration 

1.Diaphragm

2.External intercostal muscle 

Acessory Muscles of inspiration 

1.Sternocleidomastoid

2 Scalene Muscles

3.Trapezius

4 Pectoralis major and minor

Muscles of expiration

 Only during forced expiration 

1.Internal intercostal

2.subcoastalis

3.External oblique

4.Internal oblique

5.Rectus abdominis

3.Transverse abdominis

Complication of tb

 Local complications 

1. Bronchiectasis 

2 Hemoptysis 

3.Fungal ball

4.TB endobronchitis ,tracheitis

5.calcification of lungs

6.scar carcinoma

7.obstructive airway disease

8.secondary pyogenic infection

9.non tuberculosis mycobacteria

Pleural complications 

Chronic empyema 

Acute empyema

Fibrothorax

Spontaneous pneumothorax 

Systemic complications 

1.secondary amyloidosis

2.chronic type 1 and type 2 respiratory failure.

3.pulmonary hypertension 

4.chronic cor pulmonale 

High grade and low grade fever

 Low-grade: 37.3 to 38.0 C (99.1 to 100.4 F)

High-grade: 39.1 to 41 C (102.4 to 105.8 F)

Ref:Islam MA, Kundu S, Alam SS, Hossan T, Kamal MA, Hassan R. Prevalence and characteristics of fever in adult and paediatric patients with coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis of 17515 patients. PLoS One. 2021;16(4):e0249788

Exacerbation of COPD

 Exacerbation of COPD

An exacerbation of COPD is a sustained worsening of the patient's condition, from the stable state and beyond normal day-to-day variations that is acute in onset and may warrant additional treatment in a patient with underlying COPD.

Ref:ERS -COPD exacerbations: definitions and classifications

Epworth sleepiness scale

 It is a questionnaire for assessing the degree of subjective sleepiness 

Parameters

1.sitting and reading 

2.watching TV

3.sitting inactive in public place

4.as a passenger in car for an hour 

5.sitting and talking to someone 

6.sitting quietly after lunch without alcohol 

7.sitting in a car,in traffic for few minutes 

Score

0- never doze

1- slight chance of dozing 

2.moderate change of dozing

3.high chance of dozing

Score 0-24

A score more than 10 is considered abnormal.

ECG changes

 P mitrale-

seen in left atrial enlargement

 broad p wave occupying >0. 11 sec in lead 2 or biphasic in V1

P pulmonale -

 seen in right atrial enlargement 

Tall p wave > 2.5 mm in lead 2

LVH - 

1.sum of s waves in lead V1 and sum of R wave in lead V6 more than 35 mm

2.S wave in V1 20mm or more in depth

3.R wave in V6 more than 25 mm

Right axis deviation

P wave negative in in lead 1 and positive in lead 3

Left axis deviation

P wave  positive in lead 1 and negative in lead 3

Normal axis 

P wave positive in lead 1 and positive in lead 3

Bronchial artery Anatomy

 Bronchial arteries most commonly originate from the descending thoracic aorta between the levels of t5 and t6 vertebral bodies but can originate anywhere between t2 to t7 level.

80% of individuals have a right Bronchial artery that arises as a common intercostobronchial trunk from the posterolateral aspect of thoracic aorta.the other Bronchial arteries arise from the  anterolateral aspect of the thoracic aorta.

Four classic branching patterns are there:

2 on the left and 1on the right arising as an intercostobronchial trunk (ICBT)-40%

1 on the left and 1 ICBT on the right -20%

2 on the left and 2 on the right -20%

1 on the left and two on the right -20%

Anomalous Bronchial arteries found in upto 35% of the individuals,may arise from aortic arch,intercostal arteries,internal mammary arteries,thyrocervical trunk,costocervical trunk,brachiocephalic artery,subclavian artery.

Anuria and oliguria definition

 Anuria- no urine or urine output less than 50ml / day

Oliguria- Urine output less than 400ml / days

Puddle Sign

 Puddle sign is an percusso auscultatory test  detecting small amounts of ascites—as small as 120 ml . Patient is examined in knee elbow position . Tap the flank while moving the stethoscope from umbilicus towards frank. Sudden tympanic sound is the edge of ascites.

Emphysema and chronic bronchitis definition

 Emphysema- Abnormal, permanent enlargement of the airspaces distal to the terminal bronchiole, accompanied by destruction of their walls.

Chronic bronchitis-chronic cough and sputum production for at least 3 months per year for two consecutive years, in the absence of other conditions that can explain these symptoms .

Reference 

Fishman 6 th edition

Gold 2024

Cobbs angle

The Cobb angle is the most widely used measurement to quantify the magnitude of spinal deformities, especially scoliosis, on plain radiographs. 

Scoliosis is a lateral spinal curvature with a Cobb angle of >10° 4. The Cobb angle technique can also assess the degree of kyphosis or lordosis in the sagittal plane

Lines are then drawn along the endplates (or the pedicles if the endplates are not properly visualized ), and the angle between the two lines, where they intersect, is measured.

Reference 

Fritz Hefti. Pediatric Orthopedics in Practice. (2007) ISBN: 9783540699644.

Breath sounds: Mechanism

 Normal breath sounds originate from the larynx. When the sound leaves the larynx it travels down the trachea and then divides when the airway divides. Eventually the sound travels along the airways of different lengths and therefore becomes out of phase. Next it arrives in the respiratory bronchioles and the alveoli and then get transmitted through the chest wall to your stethescope. The fat layer filters out much of the higher frequency (4 kHz). The resulting sounds are much softer (because the sounds has effectively been diluted throughout of the whole lungs). There is no gap between the inspiration and the expiration because the sound has become out of phase and therefore filled in the gap. Finally, the first third of expiration is now only part that is audible because the latter two thirds are much quieter. 

Reference: Chamberlain’s symptoms and signs in clinical medicine, 13th edition, page no:97

Cough- aggravating factors

 Pneumonic: PDFCE

P3

Pollen 

Pollution

Posture

D2

Drugs

Diurnal variation 

F

Food

C2

Common cold

Cold weather

E1

Exercise 

Exacerbation of ILD

 Acute exacerbation of ILD is defined as

 1) a previous or concurrent diagnosis of ILD 2) unexplained worsening of dyspnoea within the past 30 days

3) high-resolution computed tomography (HRCT) with new bilateral ground-glass opacity or consolidation; and 

4) exclusion of alternative causes, including pulmonary infection by endotracheal aspirate or bronchoalveolar lavage

Reference:journal for IPF

ORTHOPNEA and PND

 Dyspnoea on lying flat

It is a sign of advanced heart failure

Lying flat increases venous return and in patients with left ventricular impairment may precipitate pulmonary edema.

Lying flat causes a steep increase in left atrial and pulmonary capillary pressure resulting in pulmonary congestion and severe dyspnea.

This severity can be graded by number of pillows used at night.eg -three pillow orthopnea

Causes 1.Biventricular failure 

PND-Paroxysmal nocturnal dyspnea

Sudden breathlessness waking the patient from sleep.caused by accumulation of alveolar fluid.patient may choke or gasp for air , patient open windows in an attempt to relieve their stress

Causes 1.Left heart failure

2.cardiomyopathy

3.Aortic valve disease

Reference -Macleod edition 13 page 102

Celcius to Fahrenheit

Celcius to Fahrenheit= (9/5*celcius)+32

Fahrenheit to celcius=( Fahrenhei-32)*5/9

Pain sensitive areas in lungs

 1) Parietal pleural

2) Visceral pain pathway - triggered by various stimuli - receptors concentrated over bronchial bifurcation & upper airways - Causes retrosternal burning sensation

3) Diaphragmatic pain - Radiated to ipsilateral shoulder due to phrenic nerve irritation

4) Pain from chest wall.

Postitional variation of chest pain

 Positional variation in chest pain

Pain aggreavted in supine position

Pericarditis

Gerd

Angina

Pain aggrevated on lying  on the  pathology side

Pleuritic pain

Ref: Harrison

Atypical pneumonia- causes

1. Mycoplasma:

M. pneumoniae

2. Chlamydophila:

C.psittaci, C.pneumoniae

3. Bacteria:

Legionella spp., F. tularensis, Y.pestis, B.anthracis

4. Fungi:

Histoplasma, Blastomyces, Coccidiodes, Pneumocystis

5. Aspiration pneumonitis:

Sterile or mixed upper respiratory and oral flora

6. Viral agents:

Influenza, adenovirus, respiratory syncitial virus, parainfluenza virus, metapneumovirus, varicella zoster, measles, EBV, CMV, Hantavirus

7. Rickettsia:

C. burnetti

REFERENCE: Fishman’s 6th edition, pg no-2120

Collapse Radiologic signs

 Direct signs

1.Displacement of interlobar fissures

2.Crowding of vessels and bronchi

Indirect signs

1.local increase in opacity

2.elevation of hemidiaphragm

3.displacement of the mediastinum

4.compensatory over inflation

4 Approximation of the ribs

5.Absence of  an air bronchogram(resorption atelectasis only)

6.Absence of visibility of interlobar artery(in lower lobe atelectasis only)

Reference -Fraser volume 1 page 529

Sherwood jones classification

 Sherwood jones classification

Grade 1a Able to do housework or job with

moderate difficulty

Grade 1b Carrying out job or housework with

great difficulty

Grade 2a Confined to chair or bed but able to get

up with moderate difficulty

Grade 2b Confined to chair or bed but able to get

up with great difficulty

Grade 3 Totally confined to chair or bed

Grade 4 Moribund

Foul smelling sputum

 Foul smelling sputum suggests anaerobic bacterial infection.

It occurs in Bronchiectasis,lung abscess and empyema.

In Bronchiectasis a change of sputum taste may indicate infective exacerbation.

REF- Macleod's , page no- 141,13th edition 

Diseases associated with cattles

 Brucellosis

Bovine Tb

Q fever

Rabies

Prion diseases

 NYHA CLASSIFICATION OF BREATHING DIFFICULTY

CLASS                                              SYMPTOMS

CLASS 1                        No limitation of physical activity, Ordinary physical activity does not cause                                                  undue fatigue, palpitations or breathing difficulty

CLASS 2                        Slight limitation of physical activity. Comfortable at rest but Ordinary physical                                              activity cause  undue fatigue, palpitations or breathing difficulty

CLASS 3                       Marked limitation of physical activity. Less than ordinary activities cause fatigue,                                         palpitations and breathing difficulty

CLASS 4                       Unable to carry out any physical activity without discomfort. Symptoms are                                                 present even at rest.

Fever Patterns

 Sustained/Continuous fever:Persistent rise in temperature with minimal(<1C)diurnal variation.eg- Pneumonia, meningitis,UTI,brucella

Intermittent fever: Exaggeration of normal circadian rhythm.If the variation between high and low is extremely large it is called hectic.eg-Deep seated infection,abscesses,malignancy,kala-azar,drug fever.

Remittent fever: Temperature spikes fall daily with diurnal variation of >2 degree celsius,but doesn't touches baseline.eg-Tuberculosis,infective endocarditis,

Relapsing fever:Febrile episodes seperated by intervals of normal temperature .eg-malaria,borrelia,lymphoma.

If it occurs daily,it is called quotidian fever.cause- plasmodium falciparum.

Double quotidian fever when there are 2 spikes of fever everyday,once in morning and once in evening.causes-miliary tuberculosis 

If it occurs every 48 hrs- tertian fever.causes-plasmodium falciparum,ovale and vivax.

If it occurs every 72 hrs- quartan fever.cause-plasmodium malariae.

Inverse fever -Temperature rises in the early hours of morning rather than evening.some cases of  military tuberculosis

REFERENCE -HUTCHISON'S 24th edition,Page no-144.

Causes of PND & Orthopnea

 Causes of PND: 

Left ventricular failure 

Mitral stenosis 

Causes of Orthopnea:

Pulmonary edema

Sleep apnea

Hypothyroidism

Copd 

Ascites 

Pleural effusion

Anxiety 

Definition of emphysema

 Abnormal permanent dilatation of air spaces distal to terminal bronchioles accompanied by destruction of alveolar walls and without obvious fibrosis.

Periorbital edema in renal disease

  In acute or chronic renal failure, periorbital edema occurs ,when Na intake exceeds kidneys’ ability to excrete Na secondary to marked reductions in glomerular filtration.Sodium retention causes periorbital edema.

Referrence- Harrison 20th edition

Chronic Bronchitis and Emphysema

 Chronic Bronchitis is defined as cough and sputum for atleast 3 consecutive months in each of 2 consecutive years.

Emphysema is abnormal permanent enlargement of the air spaces distal to the terminal bronchioles accompanied by destruction of their walls.

Refference -Robbin's pathology.

Eosinophilic bronchitis - BHR

 Bronchial hyperreactivity is absent in Eosinophilic bronchitis and is present in asthma

Reference: Murray and Nadel’s textbook of respiratory medicine, 7th edition