Chest Diseases & COPD + Acute Kidney Injury PDF

# Chest diseases Dr. SAHAR SHAWKY ## Outline: * Symptoms of chest diseases * Common chest diseases * Investigations for chest diseases # Anatomy of respiratory system * Respiratory system starts by the nose then pharynx, trachea, bronchi and lung * Respiratory system above the bronchi called upper respiratory tract, below them called lower respiratory tract ## Anatomy of the Lower Respiratory System A diagram showing a cross-section of the lower respiratory system, with the following labels: * Trachea * Bronchioles * Main bronchi * Left * Right * Bronchus * Rigid because of C-shaped cartilage rings * Capillary * Attenuated epithelium * Alveola space * Acinus * Alveolus * Capillaries # Respiratory symptoms * Dyspnea * Cough * Haemoptysis * Cyanosis * Chest pain * Wheezy chest # Dyspnea * Definition: Subjective sensation of shortness of breath often exacerbated by exertion * Causes include: * Acute: Foreign body, pneumothorax, acute asthma, pulmonary embolism, pulmonary edema * Sub acute: Asthma, pneumonia, pleural effusion * Chronic:COPD, ILD, Anemia, heart failure # Haemoptysis * Definition: Cough of red blood * Causes: * Infection: Pneumonia, TB, lung abscess * Neoplastic: Primary or secondary * Vascular: Pulmonary embolism * Mitral stenosis * Coagulopathy # Chest pain * Causes: * Cardiac: Myocardial ischemia, pericarditis, dissecting aortic aneurysm * Pleurisy * Esophageal: GERD, esophageal spasm * Musculoskeletal: Fracture rib, myositis * Skin: Herpes zoster # Pneumonia * Definition: An acute lower respiratory tract illness associated with fever, symptoms and signs in the chest, and abnormality in the chest X ray * Classification: * Community acquired pneumonia * Aspiration pneumonia * Hospital acquired: after 48 hours after admission * Pneumonia in immuno compromised pt # Clinical picture * Symptoms: Fever, rigor, cough, malaise, purulent sputum, haemoptysis and pleuritic pain * Signs: Fever, cyanosis, confusion, tachypnea, tachycardia, hypotension and chest signs of pneumonia and pleurisy # Investigation To establish diagnosis and identify pathogen and assess the severity include: 1. CXR: Lobar pneumonia or bronchopneumonia (patchy) 2. ABG:To detect 02 satuation 3. Sputum examination and culture 4. Blood culture # Management * Patient education and explanation * Rest and cessation of smoking * Oral Antibiotics if mild and IV if severe * Oxygen supply * Analgesic for pleural pain * ICU admission if respiratory failure or severe # Complication * Lung abscess * Pleural effusion * Respiratory failure * Septacemia and shock # Asthma * Definition: Recurrent episodes of dyspnea, cough and wheeze caused by reversible airways obstruction * Three factors lead to: * Bronchial muscle contraction * Mucosal swelling * Increase mucous production # Clinical picture * Symptoms: Intermittent dyspnea, wheezy chest, cough. * Signs: Tachypnea, audible wheeze in severe attack, inability to complete sentence, pulse >110, respiratory rate >25. * Life threatening attach: silent chest, cyanosis, bradycardia, exhaustion, confusion # Investigation * CXR (no abnormal detected) * ABG (hypoxemia, hypercabnea) * Pulmonary function (obstructive pattern) # Treatment of asthma 1. Lifestyle modification: Help quit smoking, avoid precipitant 2. Inhaled short acting B2 stimulant 3. Inhaled corticosteroid 4. Cortisone systemically 5. Theophyline 6. Long acting B2 stimulant, given only with inhaled steroid # Acute severe asthma * Start treatment immediately * Sit pt up and high flow oxygen * Neuplizer by Salbutamol 5 mg and ibratropium * Hydrocortisone 100 mg + theophyline IV infusion * CXR and ABG * Monitor improving by oximetry * If respiratory failure ventilate # Chronic obstructive pulmonary disease (COPD) * Definition: COPD is common progressive disorder characterized by airway obstruction with little or no reversibility * It include emphysema and chronic bronchitis ## Definition of COPD * COPD is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. * Its pulmonary component is characterized by airflow limitation that is not fully reversible. * The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases. ## INFLAMMATION IN COPD A diagram showing inflammation in COPD, with the following labels: * Small airway disease * Airway inflammation * Airway remodeling * Parenchymal destruction * Loss of alveolar attachments * Decrease of elastic recoil ***AIRFLOW LIMITATION*** ## Diagnosis of COPD A diagram showing the diagnosis of COPD, with the following labels: * **SYMPTOMS** * cough * sputum * dyspnea * **EXPOSURE TO RISK FACTORS** * tobacco * occupation * indoor/outdoor pollution ***SPIROMETRY*** ## Differential Diagnosis: COPD and Asthma | COPD | ASTHMA | |--------------------------------------------|------------------------------------------------------------| | Onset in mid-life | Onset early in life (childhood) | | Symptoms slowly progressive | Symptoms vary from day to day | | Long smoking history | Symptoms at night/early morning | | Dyspnea during exercise | Allergy, rhinitis, and/or eczema also present | | Largely irreversible airflow limitation | Family history of asthma | | | Largely reversible airflow | # Investigation for respiratory disease * Sputum examination and culture and zeil nelson stain * Pulse oximetry * Arterial blood gases * Pulmonary function test * Chest xray # Arterial blood gases * The heparinised blood is taken from the radial artery or femoral artery and the PH, pao2, paco2 are measured using an automated analyser. * Uses: * Acid base balance * Oxygenation * Co2 level # Acute kidney injury By / Dr Abdelrahman El Braky Lecturer of Internal medicine ## Agenda * Definition & Stages * Cause * Clinical picture * Evaluation * Treatment ## Normal Values * Normal serum creatinine: * For adult men: 0.74 to 1.35 mg/dL (65.4 to 119.3 micromoles/L) * For adult women: 0.59 to 1.04 mg/dL * Normal serum urea: around 6 to 24 mg/dL (2.1 to 8.5 mmol/L) * Normal urine output: 0.5 to 1.5 cc/kg/hour * For healthy adult individual: around 2000 cc per day ## Definition & Stages 1. Increase in sCr ≥0.3 mg/dL (≥26.5 µmol/L) within 48 hours; or 2. Increase in sCr≥1.5 times baseline, which is known or presumed to have occurred within the prior 7 days; or 3. Urine volume <0.5 mL/kg/h for 6 hours. AKI is staged for severity according to the following criteria: | Stage | sCr | Urine volume | |-------|--------------------------------------|---------------------------------------------------| | 1 | 1.5-1.9 times baseline OR ≥0.3 mg/dL (≥26.5 µmol/L) absolute increase in sCr | Urine volume <0.5 mL/kg/h for 6-12 hours | | 2 | sCr≥2.0-2.9 times baseline | Urine volume <0.5 mL/kg/h for ≥12 hours | | 3 | sCr≥3.0 times from baseline OR increase in sCr to 24.0 mg/dL(≥353.6 µmol/L) OR Initiation of renal replacement therapy OR, In patients <18 years, decrease in eGFR to <35 mL/min per 1.73 m2 | Urine volume <0.3 mL/kg/h for ≥24 hours OR Anuria for ≥12 hours | * sCr-serum creatinine, eGFR estimated glomerular filtration rate ## RIFLE CRITERIA | Risk | Non-oliguria | Oliguria | Specificity | |-----------------------------------------|---------------------------------------------------------------------------|----------------------------------------|---------------------------------------------------------------------------------------| | Abrupt (1-7) days decrease ( >25% in GFR, or serum creatinine x 1.5 sustained) | | Decreased UO relative to fluid input | AKI- earliest time point for provision of RRT | | Injury | Adjust creatinine or GFR decrease >50% serum creatinine x 2 | UO <0.5 mg/kg/hx6h | | | Failure | Adjust creatinine or GFR decrease> 75% serum creatinine × 3 or serum creatinine >4 mg when acute increase 0.5 mg% | UO <0.5 mg/kg/h x 12 h | | | | | UO <0.5 mg/kg/hx 12 h, Anuria x 12 h | | | Loss | Irreversible AKI or persistent AKI >4 weeks | | | | | | | | | ESRD | ESRD >3 months | | | ## Phases of Acute Kidney Injury | Phase | Features | Duration | |---------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------| | Onset phase | Common triggering events: significant blood loss, burns, fluid loss, diabetes insipidus Renal blood flow of normal Tissue oxygenation 25% of normal Urine output below 0.5 mL/kg/hour | Hours to days | | Oliguric (anuric) phase | Urine output below 400 mL/day, possibly as low as 100 mL/day Increases in blood urea nitrogen (BUN) and creatinine levels Electrolyte disturbances, acidosis, and fluid overload (from kidneys inability to excrete water) | 8 to 14 days or longer, depending on nature of AKI and dialysis initiation | | Diuretic phase | Occurs when cause of AKI is corrected Renal tubule scarring and edema Increased glomerular filtration rate (GER) Daily urine output above 400 mL Possible electrolyte depletion from excretion of more water and osmotic effects of BUN | 7 to 14 days | | Recovery phase | Decreased edema Normalization of fluid and electrolyte balance Return of of normal | Several months to 1 year | ## Risk Factors 1. CKD (eGFR <60 ml/minute/1.73 m²) 2. Age >75 years 3. Atherosclerotic peripheral vascular disease 4. Cardiac failure 5. Liver disease 6. Diabetes mellitus 7. Nephrotoxic drugs, eg * NSAIDS * Aminoglycosides 8. Hypotension (compared to baseline blood pressure) * Hypovolaemia * Primary cardiac cause * Antihypertensive medication 9. Sepsis * CKD - chronic kidney disease, eGFR estimated glomerular filtration rate; NSAID - non-steroidal anti-inflammatory drug. ## Causes | Prerenal | Intrarenal | Postrenal | |--------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------| | Dehydration* | Intrinsic renovascular disease Hypertensive emergency Small vessel vasculitis TTP/HUS Glomerular disease Post-infectious glomerulonephritis | (Obstructive uropathy/nephropathy) Ureteral obstruction (usually requires bilateral obstruction) Neurogenic bladder Urinary tract infection Medications Benign prostatic hypertrophy (BPH)* | | Heart failure (a.k.a. cardiorenal syndrome) | Tubulointerstitial disease Acute tubular necrosis (ATN)* (causes: sepsis, meds, contrast, rhabdo, prolonged prerenal AKI) Acute interstitial nephritis (AIN) | | | Liver failure (a.k.a. hepatorenal syndrome) | | | | | | | ## Clinical picture of AKI | Uremia | Electrolyte imbalance | Acidosis | Volume overload | |----------------------------------------------------|-----------------------------------------------------------------|---------------------------------------------------|-----------------------------------------| | Fatigue | Hyperkalemia | Arrhythmia | Dyspnea | | Lethargy | Hypo or hypernatremia | Air huger | Orthopnea | | Confusion | | | Lower limb edema | | Anorexia | | | | | Nausea | | | | | Vomiting | | | | | Cramps | | | | | Pruritus | | | | | Hiccups | | | | ## Clinical picture - **SIGNS & SYMPTOMS -** | Oliguric Phase | Diuretic Phase | Recovery Phase | |-----------------------------------------------------------------------------------|--------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------| | Oliguria - <400mL/day; occurs within 1-7 days of kidney injury | Gradual ↑ in urine output- 1-3 L/day, may reach 3-5 L/day | Begins when GFR Increases | | Urinalysis-caste, RBCs, WBCs, op gr fixated at 1.010 | Hypovolemia, Dehydration | BUN and Creatinine Levels Plateau, then ↓ | | Metabolic Acidosis | Hypotension | | | Hyperkalemia and Hyponatremia | BUN and Creatinine Levels Begin to Normalize | | | Elevated BUN and Creatinine | | | | Fatigue & Malaise | | | ## Evaluation & Management ### History * **Personal history:** Age - old age (dehydration), habits of medical importance - NSAID abuse * **Complaint:** Nausea, vomiting, hiccup, SOP, LL swelling, .....etc * **HPI:** Onset course duration, old labs * **Other systems affection (CVS, GIT......** * **Past history:** DM, HTN, Hx of urological operations * **Drug History:** Nephrotoxic drugs ### Examination * Blood pressure, respiratory rate * Conscious level * Lower limb edema: level bilateral pitting degree * Chest auscultation: signs of congestion - FBC * Cardiac auscultation: uremic pericarditis ### Acute Renal Failure Symptoms * Loss of appetite * Shortness of breath * Irregular heartbeat * Chest pain or pressure * Decreased urine output * Edema ## Overview of Treatment for AKI | Prerenal | Intrarenal | Postrenal | |-----------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------| | Correct hemodynamic derangements - If low preload → IV Fluids - If high preload → Diuretics - If low contractility → Afterload reduction (not ACEIs) +/- inotropes - Hepatorenal syndrome → Treat underlying liver disease, ?Octreotide + midodrine + albumin | Treat the underlying disease - ATN→ No specific treatment - AIN → Consider steroids if not improving with discontinuation of causative medication | Relieve obstruction - Ureteral obstruction → nephrostomy tube(s) and/or ureteral stent(s) - Neurogenic bladder → Intermittent straight cath or long-term Foley - UTI→ Antibiotics +/- temp Foley catheter - Medications → Stop meds - BPH → a blockers + temporary Foley catheter | * Copyright © Strong Medicine - Dr. Eric Strong ## Indication of Hemodialysis in AKI | Acute Kidney Injury (Indications for dialysis in patients with AKI) | Absolute indications | Relative indications | |------------------------------------------------------------|------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------| | A - Acidosis | Refractory hyperkalemia (K+ > 6 mEq/L) Refractory acidemia (metabolic or mixed acidosis with pH <7.15) Signs and symptoms of uremia (bleeding, pericarditis, encephalopathy) Refractory volume overload with organ edema Toxicity or overdose of easily dialyzable medications or drugs | Oliguria/anuria (UO < 200 mL/24 hours) Azotemia; BUN > 100 mg/dL Hypermagnesemia in an anuric patient with loss of tendon reflexes (>8 mEq/L) Anticipating worsening electrolyte problems with AKI (tumor lysis syndrome, rhabdomyolysis) | | E - Electrolytes | | | | I - Intoxications | | | | O - Overload | | | | U - Uremia | | | ## Prognosis * Patients with acute kidney injury are more likely to develop chronic kidney disease in the future. They are also at higher risk of end-stage renal disease and premature death. * Patients who have an episode of acute kidney injury should be monitored for the development or worsening of chronic kidney disease. ## Patient-Specific Risk Factors for Acute Kidney Injury * Age * Gender * Chronic kidney disease * Proteinuria * DM * Sepsis * Congestive heart failure * Volume depletion * Chronic liver disease * Hyperuricemia ## Risk factors for chronic kidney disease after acute kidney injury * Age * Baseline GFR * Congestive heart failure * Hypertension * Recurrent AKI * Severity of AKI (AKI STAGE, REQUIREMENT FOR DIALYSIS) * GFR at hospital discharge ## Thank you

Chest Diseases & COPD + Acute Kidney Injury PDF

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