#DAVIDSON_REVIEW
#RESPIRATORY_MEDICINE 1
(N.B.Respiratory medicine এর জন্য physiology লাগবে।আজকের টপিক এ anatomy & physiology
আছে যেটা Davidson থেকে দেওয়া। অবশ্য পড়তে হবে।Davidson থেকে যে টপিক টাই পড়বেন চেষ্ট করবেন
সম্পূর্ণ টপিক টা একবার রিডিং দেওয়ার। তাহলে বুঝতে সুবিধা হবে।পরের বার পড়ার সময় সব না পড়ে গুরুত্বপূর্ণ
লাইন/টপিক পড়বেন।)
Page 546 - 556
Page 547 **********
Fig 17.2 *
Box 17.3 *********
CT/PET/BRONCHOSCOPY/THORACOSCOPY ***
Box 17.4 *********
@ Page 547
+ SBA
খুবই গুরুত্বপূর্ণ। সবকিছু পড়তে হবে।কিন্তু গুরত্ব দিতে হবে যে পয়েন্ট গুলো Dx এ হেল্প করবে।
IMPORTANT
COPD **
+ Hyperinflated ‘barrel’ chest, Reduced breath sounds – wheeze, low flat diaphragm
PULMONARY FIBROSIS ***
+ Fine late inspiratory crackles at bases *** (SBA)
+ Small lungs, high diaphragm, FINGER CLUBBING
CONSOLIDATION/PNEUMONIA ***
+ Percussion Dull
+ Auscultation BRONCHIAL BREATH SOUNDS and↑vocal resonance ***
+ Pleural rub if pleurisy
COLLAPSE ***
+ Percussion - Dull
+ Auscultation -↓BREATH SOUNDS
+ X-ray - Deviated trachea to site of lesion
PNEUMOTHORAX *********
+ Percussion - Resonant or hyper-resonant on
+ Auscultation - Absent breath sounds on + Deviation of trachea to opposite side
+ Tachycardia and hypotension
In short : Resonant/Hyper resonance + Absent/Diminished breath sound
PLEURAL EFFUSION *****
+ Percussion - Stony dull
+ Auscultation Absent breath sounds and vocal resonance
IMPORTANT FOR ANATOMY & PHYSIOLOGY
*** The acinus is the gas exchange unit of the lung (SBA) and comprises branching respiratory
bronchioles and clusters of alveoli
** The alveoli are lined with flattened epithelial cells (type I pneumocytes) and a few, more
cuboidal, type II pneumocytes
** Type ll produce surfactant, which is a mixture of phospholipids that REDUCES SURFACE
TENSION and COUNTERACTS THE TENDENCY OF ALVEOLI TO COLLAPSE under
surface tension
** Type II pneumocytes can divide to reconstitute type I pneumocytes after lung injury
@ Fig 17.2
** The more distal bronchioles are collapsible, but held patent by surrounding ELASTIC
TISSUE
** The unit of lung supplied by a TERMINAL BRONCHIOLE is called an acinus
* The bronchiolar wall contains smooth muscle and elastin fibres
*** Gas exchange occurs in the alveoli, which are connected to each other by the PORES OF
KOHN
* Both the pulmonary artery (carrying desaturated blood) and the bronchial artery (systemic
supply to airway tissue) run ALONG THE BRONCHUS
* The venous drainage to the left atrium follows the INTERLOBULAR SEPTA
* Elastin fibres allow the lung to be easily distended at physiological lung volumes, but collagen
f ibres cause increasing stiffness as full inflation is approached
** Elastin fibres in alveolar walls maintain small airway patency
*** The respiratory motor neurons in the posterior medulla oblongata are the origin of the
respiratory cycle (SBA)
** Central chemoreceptors in the VENTROLATERAL MEDULLA SENSE THE PH of the
cerebrospinal fluid (CSF) and are indirectly STIMULATED BY A RISE IN ARTERIAL PCO2
** The carotid bodies sense hypoxaemia but are MAINLY ACTIVATED BY ARTERIAL PO2
values below 8 kPa (60 mmHg)
* Muscle spindles in the respiratory muscles sense changes in mechanical load
** Vagal sensory fibres in the lung may be stimulated by stretch,inhaled toxins or disease
processes in interstitium
** Hypoxia constricts pulmonary arterioles and airway CO2 dilates bronchi
* Cigarette smoke increases mucus secretion but reduces mucociliary clearance
** Airway secretions contain an array of antimicrobial peptides (such as defensins,
immunoglobulin A (IgA) and lysozyme), antiproteinases and antioxidants
*** α1-antitrypsin regulates neutrophil elastase, and deficiency of this may be associated with
premature emphysema.
@ Box 17.3
+ SBA & MCQ
+ খুব গুরুত্বপূর্ণ। Direct question or Scenario Dx এ লাগবে।
+ সব পড়তে হবে
IMPORTANT (সব গুরুত্বপূর্ণ কিন্তু এগুলো এক্টু বেশি)
* Multiple nodule
* Ring/Tramline /Tubular shadow
* Cavitations (Remember Staphylococcus & Klebsiella)
* Reticular/Nodular/Reticulonodular
* Increased translucency
* Hilar abnormality
@ CT ***
* Provides detailed images of the pulmonary parenchyma, mediastinum, pleura and bony
structures
** In cases of suspected lung cancer, CT is central to both diagnosis and staging
*** HRCT in - diffuse parenchymal lung disease,airway thickening, bronchiectasis and
emphysema
*** CT pulmonary angiography (CTPA) has become the investigation of choice in the diagnosis
of pulmonary thromboembolism (SBA)
** Radioisotope-based ventilation–perfusion scan - pre-operative assessment of patients being
considered for lung resection and assessment of pulmonary hypertension
@ PET ***
** Quantify the rate of GLUCOSE metabolism by cells
*** Indication:
+ staging of mediastinal lymph nodes and distal metastatic disease in lung cancer and
investigation of pulmonary nodules
+ differentiate benign from malignant pleural disease & extent of extrapulmonary disease in
sarcoidosis
@ BRONCHOSCOPY *
+ trachea and the first 3–4 generations of bronchi may be inspected using a flexible
bronchoscope
+ diagnosis of bronchocentric disorders such as sarcoidosis and diffuse malignancy
@ THORACOSCOPY
*** GOLD STANDARD for evaluation of pleural interface, characterisation of complex pleural
effusion, and identification of exudate and haemorrhage, as well as the analysis of superior
sulcus tumours, as it enables more accurate staging
*** To distinguish large airway narrowing from small airway narrowing, spirometry data are
plotted as flow/volume loops
@ BOX 17.4
+ SBA
+ খুব বেশি গুরুত্বপূর্ণ
Obstructive - Asthma,COPD,Emphysema
Restrictive - Fibrosis
Obstuctive & Restrictve এর feture আলাদা ভাবে পড়বেন
REMEMBER
FEV1
Obstructive ↓↓↓
Restrictive ↓
FVC
Obstructive ↓
Restrictive ↓↓↓
FEV1/FVC
Obstructive ↓↓
Restrictive →/↑↑
TLC/RV
Obstructive↑
Restrictive↓
EXPLANATION:
Obstructive & Restrictive ২ টাতেই FEV1 & FVC কমে।কিন্তু obstructive FEV1 বেশি কমে &
restrictive এ FVC বেশি কমে। সো FEV1/FVC ratio টা obstructive এ কমে গেলেও restrictive এ
Normal থাকে অথবা বেশি হয়।
Obstructive এ lung expansion এ কোন সমস্যা থাকে না।সো RV/TLC কমে না বরং Expiration এ বাধা
থাকায় আরো বেশি হয়।
Restrictive এ lung expansion করতে বাধা পাই।সো RV/TLC কমে যায়।
#DAVIDSON_REVIEW
#RESPIRATORY_MEDICINE 2
PAGE 556 - 567
Box 17.5 *
Box 17.6 ***
Box 17.7 ***
Box 17.8 *****
Box 17.9 *****
Box 17.10 **
Box 17.11 ***
Box 17.12 *****
Box 17.13 *****
Box 17 14 ***
Box 17.15 *
Box 17.16 **********
Box 1.18 *****
Bx 17.5
***** COPD, Asthma,Lung cancer,TB, Bronchiectasis, Pneumonia, Pulmonary edema,
Interstitial fibrosis এর clinical feature / Cough এর character পড়বেন। Scenario dx এ কাজে লাগবে।
Box 17.6
+ Acute / Chronic আলাদা করে পড়বেন
+ Cardiac/Respiratory cause দেখলেই পারা যাবে।Reading only.
*** ভাল করে পড়বেন others cause গুলো।
Box 17.7
+ MCQ
*** High score,Co2<4.5%,Digital / perioral paraesthesia
Box 17.8
+ MCQ
+ GIT & Others ভাল করে পড়তে হবে
+ 10% - Congenital/familial,90% - Pathological
***** REMEMBER :
COPD & SARCOIDOSIS - No clubbing
Box 17.9
+ MCQ
+ CVS cause ***
*** REMEMBER
+ Acute bronchitis not chronic
+ Repeated small hemoptysis- highly suggstive of cancer
+ Massive / Catastrophic hemoptysis - Bronchiectasis & intracavitary mycetoma
Box 17.11
+ MCQ
+ Risk of malignancy কি কি আছে?Both patients & Nodule character
+ Remember : Coal dust is not a risk factor
Box 17.12
+ MCQ
+ Common cause আলাদাভাবে পড়তে হবে
+ * চিহ্ন দেওয়া গুলো bilateral effusion করে
BOX 17.13
+ MCQ
+ Exudate, Transudate, Chyle - Cause
+ Blood stained - cause
IMPORTANT
+ TB - MTB in fluid (20%), (+) biopsy (80%), ADA(+)
+ Malignancy - Blood stained, (+) biopsy (40%)
+ PE - Blood stained,RBC,Eosinophil
*** RA - Cholesterol,Low glucose
+ A. Pancreatitis - Blood stained,Amylase
Page 564 investigation
*** Features suggesting empyema are a fluid glucose of less than 3.3 mmol/L (60 mg/dL),
lactate dehydrogenase (LDH) of more than 1000 IU/L, or a fluid pH of less than 7.0 (H+ > 100
nmol/L)
Box 17.16
+ SBA & MCQ
+ Type 1/2, Acute/Chronic আলাদা ভাবে পড়তে হবে।
+ O2,Co2,H+,Co2 level পড়তে হবে
(এই বক্সটা কিছুটা সহজ করার জন্য আলাদা পোস্ট দিব ইং শা আল্লাহ্)
*** Most common cause of Chronic type 2 failure - COPD
*****Features of Co2 retention
• Warm periphery
• Bounding pulse
• Flapping tremor
• Delirium
Box 17.18
+ MCQ
+ Combined heart lung transplantation
- Eisemenger syndrome, Primary pulmonary hypertension not responding to drug
#DAVIDSON_REVIEW
#RESPIRATORY_MEDICINE_3
PAGE 567 - 581
Box 17.19 ***** (SBA in JAN 2020)
Box 17.22 **********
Box 17.23 ***
Box 17.24 ***
Fig 17.25 ***
Box 17.26 *****
Box 17.27 ***
Box 17.28 * (Only name)
Box 17.30 *****
Box 17.31 *****
Box 17.32 ***
Asthma ***
COPD ***
Bronchiectasis *****
Cystic fibrosis *****
ASTHMA
*** Typical symptoms include recurrent episodes of wheezing, chest tightness, breathlessness
and cough
***** Aggravating drug : Beta-blockers, even when administered topically as eye drops,aspirin
and (NSAIDs),oral contraceptive pill, cholinergic agents and prostaglandin F2α. Betel nuts
contain arecoline, methacholine
** Prior to discharge, patients should be stable on discharge medication (nebulised therapy
should have been discontinued for at least 24 hours) and the PEF should have reached 75% of
predicted or personal best
BOX 17.19
+ SBA & MCQ
Remember :
+ Criteria তে % & ml ২ টাই থাকতে হবে Not or
Box 17.21
+ PG F2@ should be used with caution. All others are safe
BOX 17.22
+ MCQ mainly
+ Scenario দিয়ে কোন Category জানতে চাওয়া হতে পারে
+ পরিক্ষা & বাস্তব জীবনে ২ জায়গায় কাজে লাগবে।
BOX 17.24
+ Risk factor গুলোর শুধু নাম পড়তে হবে।
+ Remember 2 infection - Adenovirus & HIV
FIG 17.25
+ Systemic & Pulmonary কি কি change হয়
Box 17.26
+ FEV1 % & Category
COPD
** Chronic bronchitis (cough and sputum for at least 3 consecutive months in each of 2
consecutive years) and emphysema (abnormal permanent enlargement of the airspaces distal to
the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis
*** Cigarette smoking represents the most significant risk factor for COPD
* It is unusual to develop COPD with less than 10 pack years
***** Finger clubbing is not a feature of COPD
* Pink puffers’ and ‘blue bloaters’. The former are typically thin and breathless, and maintain a
normal PaCO2 until the late stage of disease. The latter develop (or tolerate) hypercapnia earlier
and may develop oedema and secondary polycythaemia
*** younger patients with predominantly BASAL EMPHYSEMA α1-antitrypsin should be
assayed.
* Presence of emphysema is suggested by a low gas transfer
*** Severity of COPD may be defined in relation to the post-bronchodilator FEV1 (SBA)
*** Smoking cessation remains the only strategy that impacts favourably on the natural history
of COPD
*** Bronchodilator therapy is central to the management of breathlessness (SBA)
** Patients with predominantly upper lobe emphysema, preserved gas transfer and no evidence
of pulmonary hypertension may benefit from lung volume reduction surgery (LVRS),
BOX 17.30
+MCQ mainly
+ সবগুলোই পড়তে হবে
*** For SBA
# Kartagener syndrome - Bronchiectasis +Sinusitis + Transposition of viscera
# Cystic fibrosis - Malabsorption + DM + Infertility
# Allergic bronchopulmonary aspergillosis - Bronchiectasis + Asthma
BOX 17.31
+ SBA Scenario
Clue
Chronic cough + Copious sputum + Coarse crakles +/- heamoptysis
*** TB is the most common cause of Bronchiectasis (SBA)
CYSTIC FIBROSIS
** Autosomal recessive (SBA)
*** Mutations affecting a gene on the LONG ARM OF CHROMOSOME 7 (SBA)
which codes for a CHLORIDE CHANNEL (SBA) known as cystic fibrosis transmembrane
conductance regulator (CFTR) (SBA)
** increased sodium and chloride content in sweat and increased resorption of sodium and water
from respiratory epithelium
* INV : sweat electrolyte testing and genotyping
*** Most men with CF are infertile due to FAILURE of DEVELOPMENT OF THE VAS
DEFERENS (SBA) PAGE 582 - 593
***** Respiratory medicine এর সবচেয়ে গুরুত্বপূর্ণ অংশ।
***** Pneumonia & TB খুব খুব ভাল করে পড়তে হবে
Box 17.35 ***
Box 17.36 *
Fig 17.32 *****
Box 17.37 **
Box 17.38 *****
Box 17.39 *****
Box 17.40 ***
Box 17.41 ***
Box 17.42 *
Box 17.44 **
Box 17.45 ***
Box 17.47 ***
Box 17.48 **********
Box 17.49 ***
Box 27.50 ***
Fig 17.37 ***
Box 17. 53 **********
Box 27.54 **
Box 17.35
+ MCQ
Box 17.36
+ MCQ
+ Causes of atypical pneumonia টা পড়বেন (From micro)
Fig 17.32
+ VVI
+ Scenario থাকতে পারে যেখানে CURB 65 এর এক/একাধিক পয়েন্ট থাকবে। Scoring করে mx কি হবে
জানতে চাওয়া হতে পারে?
Box 17.38
+ MCQ
+ Marker of severity লেখা ৫ টা পয়েন্ট আছে।VVI
+ Severity এর marker scenario তে থাকতে পারে।প্রশ্ন হতে পারে Dx or Mx? Severe এর mx Box 17.40
তে আছে।
Box 17.40
+ SBA
+ Only name of drug & route
+ Scenario তে possible organism এর clue থাকতে পারে
*** Staphylococcus, Mycoplasma, legionella,Severe
Box 17.41
+ MCQ
PNEUMONIA :
***** Clinical feature - Characters of cough,sputum,pain
***** Young + Hemolytic Anemia + Jaundice - Mycoplasma pneumoniae
*** Elderly + Previous lung disease - Haemophilus influenzae
***** Local outbreak in hotel/Hospital/Industry + H/O travel + Hyponatraemia - Legionella
pneumophila
*** Previous influenza/ Viral illness / Multiple cavitation - Staphylococcus aureus
** H/O alcohol abuse - Klebsiella
*** Herpes lebialis +/- Rusty sputum - Streptococcus pneumoniae
* Farm workers, Hide factory workers - Coxiella burnetii ( Q fever)
* Birds (often parrots) - Chlamydia psittaci ( psittacosis)
** Sewage workers,farmers,animal handlers & vets - leptospiral pneumonia
* Anthrax (wool-sorter’s disease) -workers exposed to infected hides, hair, bristle, bonemeal &
animal carcases.
*** When suppurative pneumonia or a pulmonary abscess occurs in a previously healthy lung,
the most likely infecting organisms are Staph. aureus or K. pneumoniae
*** Lemierre’s syndrome is a rare cause of pulmonary abscesses - anaerobe Fusobacterium
necrophorum
TUBERCULOSIS
+ Gohn focus, Gohn complex?
*** Post-primary pulmonary TB - most frequently pulmonary and characteristically occurs in the
apex of an upper lobe, where the oxygen tension favours survival of the strictly aerobic organism
*** Lymph nodes are the most common extrapulmonary site of disease (SBA)
* Cervical and mediastinal glands are affected most frequently, followed by axillary and
inguinal. The nodes are usually painless and initially mobile but become matted together with
time
*** The spine is the most common site for bony TB (Pott’s disease), which usually presents with
chronic back pain and typically involves the lower thoracic and lumbar spine. The infection
starts as a discitis and then spreads along the spinal ligaments to involve the adjacent anterior
vertebral bodies, causing angulation of the vertebrae with subsequent kyphosis.
***** The major differential diagnosis is malignancy, which tends to affect the vertebral body
and leave the disc intact.
** TB can affect any joint but most frequently involves the hip or knee
*** Gold standard for drug sensitivity test - Culture
*** Latent TB - TST (Children) & IGRA (HIV)
** IGRA more specific
*** BCG vaccine - live,highly immunogenic, intradermally, shouldn’t be given in
immunosuppressed
** Drug resistant TB
*** Atypical mycobacteria name
Box গুলো সব mainly MCQ.
Box 17.53
+ ************* Vvvvvvvvviiiiiu
+ সবকিছু লাগবে
#DAVIDSON_REVIEW
#RESPIRATORY_MEDICINE 5
MUST TO READ / MOST IMPORTANT TOPIC
Box 17.64
Lung cancer
Sarcoidosis
Idiopathic pulmonary fibrosis
PAGE 596 - 610
Box 17.56 ***
Box 17.58 *
Box 17.59 **
Box 17.60 (Clinical criteria/CT finding)
Box 17.62 ***
Fig 17.48 ***
Box 17.63 ***
Box 17.64 **********
Fig 17.49 *****
Box 17.68 *****
Box 27.69 *
Fig 27.59 **********
Box 17.72 ***
Box 17.73 ***
For scenario based SBA:
Lung cancer *****
Sarcoidosis *****
Idiopathic pulmonary fibrosis *****
Box 27.56
+ MCQ
+ just remember any cause of immunosuppression
+++ Remember 2 diseases associated with ABPA - Asthma & Proximal Bronchiectasis (17.58)
Box 27.62
*** Most common (Adenocarcinoma) - SBA
BOX 17.64
+ SBA & MCQ
+ Need to remember all
+ Q: Scenario based SBA / Endocrine features/ Neurological features
Some clue for SBA:
+++ Smoker + Chronic cough + low Na -> SIADH -> SCLC
+++ Lung cancer + Hypercalcaemia -> Squamous cell carcinoma
+++ Lung cancer / Chronic cough + Weakness -> Myasthenia / LES / Polymyositis
Box 17.68
+ SBA Scenario dx
***** Cough, Crakles, Clubbing, Radiology
Fig 17.59
+ SBA & MCQ
LUNG CANCER
***** SCLC - SIADH/Hyponatremia, Cushing, Dermatomyositis
*** Squamous cell carcinoma - Hypercalcemia
** Cigarette smoking - most important cause
*** Metastasis commonly to - Liver, bone,brain, adrenal,skin
***** Highly suggstive - Change in smokers cough / Hemoptysis in smoker / Monophonic
unilateral wheeze failing to clear with cough / Pneumonia that recurs at same site or responds
slowly
*** Pancoast’s syndrome (pain in the inner aspect of the arm, sometimes with small muscle
wasting in the hand) indicates malignant destruction of the T1 and C8 roots in the lower part of
the brachial plexus by an apical lung tumour
IDIOPATHIC PULMONARY FIBROSIS
*** Old age + Dry, persistent cough + Clubbing + bi basal Fine late inspiratory Crakles +
Radiological findings
** Rx - Pirfenidone or nintedanib
SARCOIDOSIS
***** Cough + Hypercalcemia + Mediastinal mass + Erythema nodosum + Neuropathy
*** Non caseating granulomatous disease, less in smoker, more in black, association with
common variable immunodeficiency
** 90% affecting lung
*** Löfgren’s syndrome – an acute illness characterised by erythema nodosum, peripheral
arthropathy, uveitis, bilateral hilar lymphadenopathy (BHL), lethargy and occasionally fever – is
often seen in young women
*** Pleural disease is uncommon and FINGER CLUBBING IS NOT A FEATURE
*** Lymphopenia is characteristic and liver function tests may be mildly deranged.
*** Hypercalcaemia may be present (reflecting increased formation of calcitriol – 1,25-
dihydroxyvitamin D – by alveolar macrophages) - SBA
** Bronchoscopy - ‘cobblestone’ appearance of the mucosa
*** Bronchoalveolar lavage - INCREASED CD4:CD8 T-CELL RATIO.
** Characteristic HRCT appearances include reticulonodular opacities that follow a
perilymphatic distribution centred on bronchovascular bundles and the subpleural areas
***** The occurrence of erythema nodosum with BHL on chest X-ray is often sufficient for a
confident diagnosis, without recourse to a tissue biopsy
*** Indication of prednisolone - hypercalcaemia, pulmonary impairment, renal impairment and
uveitis. Sunlight may precipitate hypercalcaemia
#DAVIDSON_REVIEW
#RESPIRATORY_MEDICINE 6
PAGE 610 - END
Box 17.74 *
Box 17.75 *****
Box 17.76 **
Box 17.79 ***
Box 17.80 *
Box 17.81 ** (Farmer's lung)
Box 17.83 *****
Fig 17.66 *****
Box 17.85 ***
Box 17.87 *
Box 17.88,89,90 ***
Fig 17.73 ***
Box 17.92 ***
Important topic
Pulmonary embolism *****
Pulmonary hypertension ***
Pneumothorax **********
Box 17.74
MUST TO KNOW
RA - Bronchiectasis, effusion, Pulmonary fibrosis (Most Common pulmonary manifestation ***)
SLE - Effusion, Shrinking lung (***),most serious manifestation - Acute alveolitis (***)
SS - Bronchiectasis, hidebound chest (***)
DM/PM- Lung cancer
GP - Epistaxis,crusting, subglottic stenosis
Box 17.75
+ MCQ
+ Extrinsic, Intrinsic cause, Drugs (***)
+++ Churg strauss features
Box 17.76
+ MCQ
+ Important but difficult (Don't spend much time as it's mcq)
+ ARDS, Pulmonary eosinophilia (***)
Box 17.80
+ Coal dust,silica, asbestos - Occupation, Characteristic features
PNEUMOCONIOSIS
+ Silica - highly fibrogenic
+ Iron,tin, barium - inert
+ Beryllium - Interstitial granulomatous disease like sarcoidosis
SILICOSIS
+ Egg shell pattern calcification
+ Increased risk of TB,COPD,Lung cancer
HYPERSENSITIVITY PNEUMONITIS
+ Both type 3 &4 immunological mechanism
Fig 17.64 *
MESOTHELIOMA
*** Malignant,plreura/peritoneum, asbestos exposure,fatal
BOX 17.53
+SBA
***** Acute massive PE (C/F,ECG,ABG)
(এইটাই বেশি আসে।বাকি ২ টা পারলে পড়ে রাখবেন)
*** Most common ECG finding - Sinus tachycardia & anterior T inversion
*** Increased alveolar-arterial oxygen gradient
** D dimer - high negative predictive value
***** Investigation - CTPA (SBA)
** DIURETICS & VASODILATORS - should be avoided
PULMONARY HYPERTENSION
+ At least 25 mm Hg,measured by right heart catheterization
+ Respiratory failure due to intrinsic pulmonary disease is the most common cause of PH (***)
+ Primary pulmonary hypertension (PPH) - predominantly affects women aged between 20 and
30 years
+ Elevation of the JVP (with a prominent ‘a’ wave if in sinus rhythm), a parasternal heave (right
ventricular hypertrophy), accentuation of pulmonary component of 2nd heart sound & a right
ventricular third heart sound
+ Echocardiography provides a non-invasive estimate of the PAP
+Nitrates should be avoided owing to the risk of hypotension, and β-blockers are poorly
tolerated. Cyclizine can aggravate PH and should also be avoided.
SLEEP APNEA
+ Recurrent occlusion of the pharynx during sleep, usually at the level of the soft palate.
Inspiration
+++ Risk factors - Male,Obesity, alcohol, acromegaly, sedaives, hypothyroidism. Association
with metabolic syndrome, insulin resistance,type 2 DM
PNEUMOTHORAX
+++ Risk - Smoking,tall,apical subpleural bleb
BOX 17.90
+ McQ/SBA
FIG 17.73
*** Indication of tube
• Tension pneumothorax
• Chronic lung disease
• > 2.5 L aspiration/pneumothorax persistence
• >15% hemithorax/significant dyspnea+ >50 yr age
*********
Severe Respiratory distress + No physical sign / CXR normal +/- features of shock -> Pulmonary
embolism -> CTPA
Respiratory distress + Absent/Reduced breath sound + Hyperresonance -> TENSION
PNEUMOTHORAX -> CXR
