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12.12.21 Teaching notes

Pleural effusion
  • Make sure you do serum LDH and protein as well as a diagnostic tap
    • Need to calculate ratios
    • Serum values may well be low
  • Draining fluid too quickly can cause re-expansion pulmonary oedema
    • Drain 1 litre at a time, then clamp and rest for an hour
  • Types of effusion
    • Serous fluid (hydrothorax)
    • Blood (haemothorax)
    • Chyle (chylothorax)
      • White/milky appearance
      • Leakage from blocked thoracic duct
      • Lymphoma / Iatrogenic
    • Pus (empyema)

BTS asthma guidelines

  • GOLD guidelines (see PDF below)
  • Most important info on TTO, to guide A+E at next admission:
    • ABG when well (e.g. CO2 of 10 may be fine)
    • Treatment ceiling
  • Subdued breath sounds
  • Only ever give steroids for an exacerbation under antibiotic cover
  • 28% venturi mask
  • Prognosis:
    • B - BMI
    • O - Obstruction
    • D - Dyspnoea
    • E - Exercise tolderance
  • Only ever give oral steroids as maintenance therapy together with inhalers
    • cf Asthma
  • Surgical treatments:
    • Lung transplant
    • Volume reduction therapy

  • Archaic term
  • Definition:
    • 3 months of cough + white sputum
    • For 2 consecutive years

BODE Index

VariablePoints on BODE Index
FEV1 (% predicted)≥6550-6436-49≤35
6-Minute Walk Test (meters)≥350250-349150-249≤149
MMRC Dyspnea Scale0-1234
Body Mass Index>21        ≤21

MRC Dyspnoea Scale

 0 Breathless only with strenuous exercise
 1 Short of breath when hurrying on the level or walking up a slight hill
 2 Slower than most people of the same age on the level because of breathlessness or have to stop for breath when walking at my own pace on the level
 3 Stop for breath after walking about 100 meters or after a few minutes at my own pace on the level
 4 Too breathless to leave the house or I am breathless when dressing

  • Ehlers–Danlos syndrome (EDS)
    • Group of inherited connective tissue disorders, caused by a defect in the synthesis of collagen (Type I or III)
    • Predisposes to spontaneous pneumothorax
    • As does Marfan's
  • BTS classification
    • Primary
      • Small (<2 cm) => Conservative management
      • Large (>2 cm) => Aspirate with syringe
    • Secondary
      • Small (<2 cm) => Aspirate with syringe, Chest drain if required
      • Large (>2 cm) => Chest drain

  • Laryngeal oedema => Higher -ve pressures in lung => Pulmonary oedema after extubation
  • Pleurodesis - Deliberately inflame the pleura, so they stick together
  • Less than 3-4 fingerbreadths between suprasternal notch and cricothyroid cartilage
  • 2 cm pneumothorax (BTS "Small") is equivalent to 50% volume loss
Kieran Gillick,
21 Dec 2012, 10:33