Breathlessness Case Study PDF

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 (On has a much higher : diffusion capacity : recording ↳ pulmonaryrolism -wholearound ? # Watch recording X-Ray a nati o n CASE 10 Akshi Kumar A Case Of Breathlessness CASE 15 – A Case of Breathlessness TASK 1 TASK 2 TASK 3 Co-morbidities that Crash Course through How to make sense of an contribute to Chest X-Rays ABG breathlessness TASK 4 TASK 5 TASK 6 Compensation How to manage a COPD Explaining the patient. pathophysiology of ankle oedema.  Inflammation due to irritants hyperplasia & hypertrophy of Inflammation leads to increased causes activity of neutrophil Eee-reading Bronchial mucinous glands main bronchiGoblet cells bronchioles. elastase leading to increased compliance , due to leads to Air breakdown of elastin Leads to Air Hypersecretion of mucus trapping : Productive cough. trapping & for at least 3 months per I consecutive hyperinflation alveoli can now expand more years. Pollution or Genetics def. Destruction of alveolar walls & Mainly due to Smoking al-antrypsin pulmonary capillaries. · , Bronchial COPD is collection of persistent airway symptoms due to Chronic Bronchitis & Emphysema narrowing & Alveolar Hyperinflation. · a. infections & Peripheral Oedema FEV FEV1 0 70 Symptoms include Dyspnea exertion Cyanosis with JVP distention Right heart failure Chronic cough frequent chest on , , , :. Treatment first includes lifestyle modifications smoking cessation Physical activity Supportive + Vaccinations + care Inhaled corticosteroids anti-inflammatory immunosuppressive must be used with bronchodilators Long Acting Beta Agonist LABA Long Acting Muscarinic Antagonist : Lama : + or Acute Exacerbation of COPD AECOPD is the development of severe dyspnea intensity of cough volume of purulence of Sputum or over 14 days often accompanied by wheezing , , tachypnea Initial Tests include Atrial Blood Gas ABG analysis for Hypoxemia, Hypoxia Hypercapnia & acidosis and Chest X-Ray.. Pulmonary Causes : Pneumonia Pneumothorax collapsed lung due to air in pleural space; Trachea deviates towards contralateralside , Pulmonary Embolism , thrombus of pulmonary artery Pleural Effusion fluid in pleural cavity. , Cardiovascular Causes Heart failure Acute Coronary Syndrome,Cardiac arrhythmias : ,. RR : 24 breaths min, Use of Respiratory accessory muscles HypoxemiadorfiOz 40% Hypercapnia & Severe acidosis LIfE THREATENING ACUTE RESPIRATORY or means a FAILURE Care for O2 induced hypercapnia ·.. Treatment includes getting SpO2 88 92%, Bronchodilators : Systemic Glucocorticoids Prednisone more potent than cortisol , Antibiotics. , x CASE 15 Task 1 Whenever you see a patient with shortness of breath, you will have a list of differentials at the back of your mind. When you first met Mr Craven (from 3 years ago) last year, you thought about the causes of shortness of breath in terms of respiratory and non respiratory causes. However, patients often have many contributing factors to their symptoms. We diagnosed Mr Craven with COPD the last previous time we met him. However, you will need to be aware that COPD is associated with many comorbidities. CASE 15 | Task 1 What is this case all about? MENTI - Can you name AECOPD some co-morbidities COPD – An acute exacerbation associated with worse prognosis of COPD? What is this task all about? Co-morbidities & statistics CASE 15 | Task 1 CSI STATISTICS – EVERYTHING YOU NEED TO KNOW The conditions in the dashed circle are statistically significant (p < 0.05). + Depression The bigger the circle, the greater the prevalence. The closer the circle to ’death’, the more closely A hazard ratio is how related ‘x’ is to ‘y’. associated it is to MENTI – Which of the following are not associated death. If it is more than ‘1’, it is positively correlated/related. with a statistically significant increase in mortality for COPD? A As it is outside : the circle. Diabetes with Neuropathy, CAD, OSA & AF? If it is less than ‘1’, it is negatively correlated/related. CASE 15 | Task 1 CSI STATISTICS – EVERYTHING YOU NEED TO KNOW 1.9 QUESTION 1.8 1.7 A group of scientists wanted to investigate the 1.6 behaviours exhibited by dogs (3 breeds) when they (Hazard Ratio) were jealous. 1.5 1.4 1.3 They tested this by placing the dogs with their owners as well as introducing another dog and observed the 1.2 behaviours of the dogs after 5 minutes. 1.1 1.0 Their findings are illustrated in the bar graph on the right. V Which behavior is most significantly associated with MENTI – Type in your answer. jealousy in Stuffed Dogs? CASE 15 | Task 1 CSI STATISTICS – EVERYTHING YOU NEED TO KNOW 1.9 ANSWER 1.8 1.7 Pushing/Touching Object. 1.6 (Hazard Ratio) 1.5 Pushing/Touching Owner, is the most associated BUT it 1.4 is not statistically significant. 1.3 All of snapping, whining, getting between 1.2 owner/object, pushing/touching object are statistically 1.1 significant. 1.0 Out of these, Pushing/Touching object was most V associated (tallest bar). This is a very typical question from CSI Remember that anything with a p < 0.05 is significant, statistics! and the measure of association is determined by the hazard ratio. CASE 15 Task 2 Mr Craven seems to have an acute exacerbation of COPD, and a CXR may allow us to find contributing factors to his symptoms. A CXR is a crucial investigation to order when you see a patient who presents with any cause of shortness of breath. In this task, let’s see if there is anything conspicuous in Mr Craven’s CXR. CASE 15 | Task 2 Chest X Rays - PA TECHNIQUE: Chest PA FINDINGS: ? IMPRESSI0N: ? Mr Craven – CXR taken on 27/07/2017 Mr Craven – CXR taken on 27/07/2022  CASE 15 | Task 2 Chest X Rays - PA Top Tip(from a very nice consultant) TECHNIQUE: Chest PA ‘Compare each zone. For example, LU – RU & LM-RM FINDINGS: CONSOLIDATION & LL-RL’ Spot Diagnosis? Significant consolidation in the lower right and left zones lungs. Some minor consolidation in the right upper zone Pneumonia/Infection/ IMPRESSI0N: Tumour/Blood. Infective exacerbation of COPD Other approaches A- Airways B- Breathing (lung fields) C- Consolidation D- Diaphragm E- Everything else (including CARDIO) Mr Craven – CXR taken on 27/07/2017 NORMAL CHEST X-RAY Mr Craven – CXR taken on 27/07/2022 best I Cardiac Parallel lines from most lateral size is measured via drawing points if heart is 50% that of ray thorax # , it is cardiomegaly hypertrophy CTR ratio iTrachea should be central , to the · or slight right as it passes aorta.. NORMAL : Pleura are only visible when abnormal Pneumothorax lung markings not up to chest wall; Effusion- 1 Trachea. costophrenic angles &hemidiaphragms not well defined "Costophrenic angles should be · 2 Hilum 3 sharp.. Lungs. Posterior Loss of definition of these contours Aortic Knuckle Decending aorta LMB Diaphragm ↳. can , , rib indicate disease : Aortic consolidation. aneurysm or Lung. Heart 5. Aortic knuckle 6 Santerior ribs incomplete inspiration for false Anterior = care negative in COPD rib 5 2.. Ribs A ribs 7. are the curved 7 anterior ribs = Lunghyperinflation expansion. ones , lateral to mid-clavicular line Spine can be seen through heart adequate X-ray penetration means an. 8. Scapulae 32 8.. Breasts 10 Bowel 9 gas. ABNORMALITIES : Tracheal displacement : rotation ? Pushed or Pulled ? Shifted left of midline = (addfor Pneumothorax and effusion Thyroid enlargement. e. t. c... Lung Abnormalities Many : are bilateral White-density ; Alveoli fill with dense material Consolidation Pneumonia Pus ; Cancer ; = dead cells ; Haemorrhage blood; Oedema blood ; Opacity with dark cavity; Multiple nodules Metastases Meniscus a area = :. effusion sign Pleural Effusion ; COPD Pleural Disease : Pleura only visible when abnormal; Visible pleural edge Pneumothorax tracheal deviation not tension = no so underlying c-t-antitrypsin deficiency Lunghyperinflation Flattened diaphragms Blunting of Costrophrenicangles 7A ribs Vertical heart -. SYSTEMATIC APPROACH : 1. Trachea and bronchi 2. Hilar structures 3. Lung zones 4. Pleura 5. Lung lobes and fissures 6. Costophrenic angles 7. Diaphragm 8. Heart 9. Mediastinum 10. Soft tissues 11. Bones - mage Quality : Rotation : Spinous processes at midpoint of clavicles ? Inspiration : 5-7 anterior ribs intersecting diaphragm at mid-clavicular line ? Penetration : Spine behind heart ? Standard ; Higher quality Spinous process is · magecheckedforInclusion Projection Rotation is halfway between , , medial clavical ends · ABCDEFGH & : : Large pleural effusion AIRWAY: Trachea can deviate normally to the right due to aortic knob; Towards affected lung : Lobar collapse; Fibrosis or Away from affected Lungs Tension pneumothorax : BONEs &-Soft fractures ; check intercostal spaces for signs of hyperinflation TISSUE : Check for changes in density osteolytic lesions ,. Posterior ribs appear more horizontal than anterior ribs S defined contours Contralateral shift. Abnormal Aortic contour= CARDIOVASCULAR : Well a large pleural effusion or Tension Pneumothorax can cause a aneurysmal dilation. LV= Left border ; RA = right border & Poorly defined heart contours = Pleural Effusion, Pneumonia , Aortic aneurysm , Aortic dissection. DIAPHRAGM : Right hemidiaphragm is higher than left liver ; Diaphragmatic elevations seen in : Atelectasis, Phrenic nerve injury, Hepatomegaly & Diaphragmatic depressions seen in Tension Pneumothorax, Hyperinflation COPD. EDGEs & EffUSIONS Deep sulcus sign deepening darkening of costophrenic angle I Visible Visceral pleura : + Pneumothorax; Homogenous radiopaque area Meniscus sign Large pleural effusion with tracheal deviation away from affected Lung S FIELDS : Lung Volume Ganterior & 10posterior ribs;= hyperinflation in COPD : or Obesity Ascites Interstitial lung disease or = , ,. Lung Density Should be uniform; Radiolucency in Pneumothorax; Bilateral Nodular Linear opacities in Interstitial Lung disease; : Lung Hila 2 triangular : superior to cardiac silhouette Left higher than Right ; Lung Markings Easily visualised in hilar & lower lung are as : zones; markings in upper lung feature of Pneumothorax Pulmonary oedema, Pulmonary Hypertensionn; Reduced lung markings zones = are a. GASTRIC BUBBLE HARDWARE Gastric bubble frequently under left hemidiaphragm :. TENSION PNEUMOTHORAX PERICARDIAL EFFUSION : Enlarged heart & Mediastinum a CTR of 50% shifted to contralateral left side Righthemidiaphragm depressed Right ICSs are widened CASE 15 | Task 2 COPD Chest X-Ray Cheatsheet This is a typical COPD ✅ Hyperinflation (ideally about 6 anterior should be visible in a CXR. standard CXR) ✅ Bullae (larger)/Blebs How can you tell? (smaller) ✅ Flattened Diaphragm Other findings: -Decreased lung markings -Vertical heart - CASE 15 | Task 2 Menti - Chest X-Ray Spot Diagnosis Quiz Can you tell me what this Chest X-Ray shows? Can you tell me your diagnosis? CASE 15 | Task 2 Chest X-Ray Spot Diagnosis Quiz Can you tell me what this Chest X-Ray shows? Can you tell me your diagnosis? This is a typical Lung ✅ Massive opacity in the left middle zone Cancer CXR. Well defined borders How can you tell? ‘The case of the disappearing lung mass’ Very careful with young children: Round pneumonia can be confused for a tumor so it’s important to look at the clinical history. CASE 15 | Task 2 Menti - Chest X-Ray Spot Diagnosis Quiz Can you tell me what this Chest X-Ray shows? Can you tell me your diagnosis? S CASE 15 | Task 2 Chest X-Ray Spot Diagnosis Quiz Can you tell me what this Chest X-Ray shows? Can you tell me your diagnosis? This is a typical ✅ ‘Meniscus’ sign Pleural Effusion CXR. 🚨 VERY IMPORTANT CLINCAL SIGN! How can you tell? This is one of the most common lung findings that you will come across so make sure to remember it. Do you know any causes? · Hepatology = Cirrhosis, Renal = Nephrotic Syndrome, Cardiology = Heart Failure, Infectious Diseases = Infection, Oncology = Malignancy · CASE 15 | Task 2 Chest X-Ray Spot Diagnosis Quiz Can you tell me what this Chest X-Ray shows? Can you tell me your diagnosis? This is a typical ✅ ‘Meniscus’ sign Pleural Effusion CXR. 🚨 VERY IMPORTANT CLINCAL SIGN! How can you tell? This is one of the most common lung findings that you will come across so make sure to remember it. Do you know any causes? Hepatology = Cirrhosis, Renal = Nephrotic Syndrome, Cardiology = Heart Failure, Infectious Diseases = Infection, Oncology = Malignancy CASE 15 | Task 2 What have we looked at? How to read a Chest X-Ray (ABCDE) Features of a COPD Chest X-Ray Features of a COPD w/ acute exacerbation Chest X-Ray Features of a Lung Tumor Chest X-Ray Features of a Pleural Effusion Chest X-Ray Any questions? CASE 15 Task 3 We saw that Mr Craven’s doctor suspects an infective exacerbation of COPD and he’s ordered a number of tests including a CXR, bloods, ECG, sputum and an ABG. Being in year 2, you will know why the doctor ordered a CXR, bloods, ECG and sputum tests. In this task we will focus on the ABG. CASE 15 | Task 3 WHAT IS AN ABG? A sample of arterial blood normally used to check the levels of WHAT ARE THE gases in the blood IMPORTANT VALUES? normally in the context of respiratory abnormalities. (YOU DO NOT NEED TO REMEMBER THE REFERENCE RANGES) CASE 15 | Task 3 HOW TO TELL IF ACIDOSIS IS EASY WAYS TO READ AN ABG RESPIRATORY OR METABOLIC? 1. Read the pH An easy way to think about things is: CO2 = Acid 2. Check the CO2 HCO3 = Base 3. Check the HCO3- Therefore, if the pH is low, it must be because EITHER: 4. Check the O2 CO2 is high (RESPIRATORY)Increased production of Ht. HCO3 is low (METABOLIC Less absorption through Kidneys or increased secretion *same applies to alkalosis. Anion Gap CASE 15 Task 4 What is compensation? CASE 15 | Task 4 · compensationformetabolicdisordersrespiratorycompensatioan tion Hypercapnia g WHAT IS COMPENSATION YOUR BODY IS MAKING A SOLUTION If your body detects that your CO2 is really high, causing a respiratory acidosis, it will act Don’t overcomplicate this – it’s just like body making sure the pH of a to increase your pH. solution in a beaker is the same. If it can’t reduce the CO2, it will go to your It does this by playing around with a jar of acid (CO2 levels). other way of changing the pH – HCO3 (and vice versa). Or by playing around with a jar of base/alkali (HC03 levels) So if high CO2 is causing acidosis, the body must make your blood more basic using HCO3 – how? INCREASING THE HCO3 – Remember that sometimes the body won’t do this and so you · don’t have compensation. Othertimes, BOTH CARBON DIOXIDE HYDROGEN CO2 AND HCO3 cause acidosis – in which case it is mixed acidosis. Majority of Hos homeostasis is due to Kidneys (ACID) Reabsorptionof CARBONATE HCO3 in proximal tubules & secretion of It in (ALKALI) distal tubules mmmGap : SerumAnionGap : Nat Cl HCOs , Rf : 6 12 mEq ; Correction for hypoalbuminuria increases anion gap by 15. mEq for every Ig d reduction in serum albumin. · Nat Cl HCOs , RF : 10 Immol Urine Anion Gap : Urine Nat + Urinekt Urine Cl High Anion Lap : Lactate Ketones B-hydroxybutarate acetoacetate or organic acids with no compensatory increase increase in Cl. other : Can indicate aetiology of metabolic acidosis Accumulation of endogenous & exogenous acids. Diarrhea ,GIfistula,Carbonic Normal Anion Lap with metabolic acidosis : egative vrine anion gap Acidosis likely due to loss of Bicarbonate Anhydrase inhibitors Positive renal excretion of acid Addisons diseases, Renal tubular acidosis , : urine anion gap = Acidosis likely due to decreased Hypercholemia CASE 15 | Task 4 PRACTICE Q1 PaO2 7.0 (11-13 kPa) pH 7.29 (7.35 – 7.45) PaCO2 9.1 (4.7 – 6.0 kPa) HCO3– 26 (22 – 26 mEq/L) CASE 15 | Task 4 PRACTICE Q1 PaO2 7.0 = LOW (11-13 kPa) pH 7.29 = LOW (7.35 – 7.45) PaCO2 = ACID 9.1 = HIGH (4.7 – 6.0 kPa) HCO3– = BASE 26 = NORMAL (22 – 26 mEq/L) ANSWER: RESPIRATORY ACIDOSIS WITH NO COMPENSATION (HYPOXAEMIA) 1. pH is low – ACIDOSIS 2. CO2 is high – therefore, it is respiratory acidosis 3. HCO3- is normal – no compensation CASE 15 | Task 4 PRACTICE Q2 PaO2 14.6 (11-13 kPa) pH 7.32 (7.35 – 7.45) PaCO2 4.0 (4.7 – 6.0 kPa) HCO3– 13 (22 – 26 mEq/L) CASE 15 | Task 4 PRACTICE Q2 PaO2 14.6 (11-13 kPa) pH 7.32 = LOW (7.35 – 7.45) PaCO2 = ACID 4.0 = LOW (4.7 – 6.0 kPa) HCO3– = BASE 13 = LOW (22 – 26 mEq/L) ANSWER: METABOLIC ACIDOSIS WITH PARTIAL RESPIRATORY COMPENSATION 1. pH is low – ACIDOSIS 2. HCO3 is low – therefore, it is metabolic acidosis 3. CO2 is low – SOME respiratory compensation BUT the pH is still acidotic. CASE 15 | Task 4 MORE PRACTICE Qs https://geekymedics.com/abg-quiz/ CASE 15 | Task 4 GENERAL FLOWCHART OF READING AN ABG Is the pH an acid or alkali Acid Alkali Is HCO3 low? Is CO2 high? Is HCO3 high? Is CO2 low? Is CO2 normal? Is CO2 low? Is HCO3 high? Is HCO3 normal? Is CO2 high? Is CO2 normal? Is HCO3 low? Is HCO3 normal? Metabolic acidosis Metabolic acidosis Respiratory Metabolic Respiratory acidosis Metabolic alkalosis Respiratory alkalosis Respiratory with partial with no respiratory with partial basic acidosis with no with respiratory alkalosis with no with partial metabolic compensation with no compensation compensation compensation compensation compensation compensation compensation compensation REMEMBER THIS IS NOT EXCLUSIVE AND JUST SERVES AS A BASIC UNDERSTANDING. The HENDERSON-HASSELBALCH EQUATION allows pH calculation from HCO5 &PCO2. CASE 15 | Task 4 Respiratory Failure Easy: Type 1 – Low oxygen, normal carbon dioxide [Treated with CPAP] - Mainly caused by things that stop the flow of air properly like a pneumonia, aspiration, pleural effusion, asthma + pulmonary contusions. Type 2 - Low oxygen, high carbon dioxide [Treated with BiPAP] - Mainly caused by things that stop breathing such as stroke, neuromuscular disorders, lesions in the respiratory centers AND COPD! espiratory failure & HypoxemicPammHg) togethera can occur · Hypokalemia Respiratory Muscle Weakness : Hypoatremia CNS Depression : CASE 15 Task 5 We have established that the cause of Mr Craven's shortness of breath is an infective exacerbation of COPD. This is a common cause of shortness of breath and we are going to think about the initial management of his shortness of breath. Management for any condition can be broadly split into medical (or drugs] and non medical treatment. CASE 15 | Task 5 TREATMENT OF COPD Rescue Medication Non – Pharmacological (always done) Pharmacological Stop smoking (every patient must Step 1: Starting with a Short acting B2 agonist (SABA)/ short be advised to do this) acting muscarinic antagonist (SAMA). Nutritional support Step 2: Add a long acting B2 agonist (LABA) AND a long acting muscarinic antagonist (LAMA). Flu vaccinations Triple combination therapy only added with PerSISTANT Symptoms Step 3: IF daily symptoms affect their activities of daily living then Pulmonary rehabilitation a 3 month trial of LAMA + LABA + ICS should be considered. Exercise training ; Breathing techniques · Encourage activity Inhaled Corticosteroids to only be used WITH LABA LAMA after exarcebation.  Used for Obstructed Sleep Apnea OSA While CPAP delivers I I · CASE 15 | Task 5. pressure BiPAP delivers 2 : inhale & exhale pressure ; this , TREATMENT OF AECOPD g means it is easier to breathe OUT with BiPAP preferred in COPD , Broad Spectrum· then specific Infective exacerbations? · Target = 88-92%; Care for O2-induced-hypercapnia Only for infection confirmed INITIALLY GIVE OXYGEN ( ), ANTIBIOTICS*, 24% O2 via Venturi mask: SpO2 88-92% SABA Glucocorticoids STEROIDS & BRONCHODILATORS. SABA or SAMA. ·salbutamol with Bromide Ipratropium CPAP contineous not used +airway type pressure Bilevel Positive Airway Pressure of ventilation form of Non-Invasive Positive Pressure Ventilation IF they still are suffering, give NIV (BiPAP since COPD is type 2 respiratory failure) After BiPAP, Pulse 88-92% continuously monitor Oximetry target *HAEMOPHILUS INFLUENZAE (normally if signs of infection)  Ventilation Mechanical Normal Breathing : Negative pressure Air sucked into Lungs Positive pressure breathing occurs when air is pushed into lungs; exhalation occurs through passive elastic recoil; invasive endotracheal or trachestomy non-invasive BiPAP CPAP via mask or or & Recruitment of alveoli ; Risk of ventilator induced · Promotes gas exchange damage Pulmonary artery pressure Avascular resistance; RV afterload LV afterload Organ perfusion , , , Non-Invasive Positive Pressure Ventilators NIPPV Continuous Positive Pressure CPAP Airway : constant Airway pressure ; used in Hypoxemic Respiratory Failure e.gOSA · Positive End Expiratory Pressure maintained in alveoli physiological. User can Breathe spontaneously & Determine tidal Volume , Rate and Respiratory Inspiratory flow. Non-Invasive Positive Pressure Ventilators NIPPV BiPAP Bi level Positive Airway Pressure : · Biphasic alterations between 2 positive airway pressures. 2 alternating pressure levels; used in Hypercapnic Respiratory failure &-Hypoxemic Respiratory Failure. Lower Pressure Expiratory Positive Airway Pressure EPAP PEEP Higher Pressure Inspiratory Positive Airway Pressure IPAP EPAP added inspiratory Pressure Support + PS Alternation frequency is determined via Respiratory Rate. Breathe Patient can spontaneously thus determine can respiratory rate and tidal volume. iPAP: forces air into the lungs—thus less work is required from the respiratory muscles.. ePAP: This mode of breathing support only applies positive pressure when you are exhaling. This is thought to work due to a belief that airway collapse Positive end-expiratory pressure (PEEP) is the positive pressure that will remain in the airways at the end of the respiratory cycle. Extrinsic PEEP can be used to increase oxygenation. Pressure support ventilation (PS) is a mode of positive pressure mechanical ventilation in which the patient triggers every breath. Stops when inspiratary flow reaches an end CASE 15 | Task 5 QUESTION A patient has arrived at a local A&E – he has a history of COPD and is coughing up yellow and green sputum. He complains of shortness of breath and is concerned about his underlying COPD. What is the initial management of this patient? a) Oxygen b) Oxygen, Bronchodilators & BiPAP c) Oxygen, Steroids, Bronchodilators. d) Oxygen, Bronchodilators, BiPAP & Steroids. CASE 15 | Task 5 ANSWER A patient has arrived at a local A&E – he has a history of COPD and is coughing up yellow and green sputum. He complains of shortness of breath and is concerned about his underlying COPD. What is the next best initial management of this patient? a) Oxygen b) Oxygen, Bronchodilators & BiPAP c) Oxygen, Steroids, Bronchodilators. (Remember that you would rarely give NIV initially) d) Oxygen, Bronchodilators, BiPAP & Steroids. CASE 15 | Task 5 TREATMENT OF AECOPD WITH CO-MORBIDITIES Patients with depression Patients with CKD Beware of corticosteroids! They can cause adverse Set a ceiling of care or provide a DNAR with a lot of psychiatric effects. these co-morbidities if they go on ventilation. SSRIs are first line for COPD patients experiencing Ventilation is important to blow off the excess CO2 depression that they build up from COPD. KEY MESSAGE Patients with hypertension Treatments change with co-morbidities. Tend not to give prescription antihypertensives Be aware of any other long-term conditions patients when patients develop hypotension – make sure you have. monitor them so that their hypertension does not Make sure that you know the first-line drugs, do not return and cause problems, uncontrolled. worry about every single contra-indications. Recommend they stop smoking! CASE 15 Task 6 Mr Craven had a problem with his legs. Why then are his ankles swollen? CASE 15 | Task 6 COR PULMONALE = RIGHT SIDED HEART FAILURE Due to lung diseases eg Copp Quite easy. All it is, is a backup of blood into the venous system. Think of a traffic jam caused by one road being closed. A traffic jam builds up and cars move far more slowly Some drivers become angry and take shortcuts through parks, pavements and other roads etc. CASE 15 | Task 6 THINK OF A BUSINESS. Lungs direct IF ONE BRANCH IS LOSING MONEY, IT more blood towards WHY DOES GETS SHUT DOWN TO PROTECT THE highO2 areas. THIS HAPPEN? WHOLE BUSINESS AND KEEP PROFITS + EFFICIENCY HIGH. THE LUNGS DO THE SAME THING…! CASE 15 | Task 6 RIGHT VENTRICLE COLLECTS BLOOD PVR REDUCES LEFT ATRIAL VOLUME OEDEMA CASE 15 | Task 6 QUESTION During Right Ventricular Heart Failure, associated with COPD, what phenomenon directly causes the reduced bloodflow into the left atrium. a) Pulmonary Vascular Resistance b) Pulmonary Hypoxia c) Right Ventricular Afterload d) Peripheral Oedema CASE 15 | Task 6 RISING PULMONARY VASCULAR RESISTANCE CAUSED BY HYPOXIC ANSWER PULMONARY VASCOCONSTRICTON (JUST VESSELS GETTING During Right Ventricular Heart Failure, associated with COPD, NARROW) what phenomenon directly causes the reduced bloodflow into the left atrium? a) Pulmonary Vascular Resistance b) Pulmonary Hypoxia – doesn’t DIRECTLY cause PVR and the intended effect c) Right Ventricular Afterload – might affect the right atrium but not the left atrium RA LA d) Peripheral Oedema – this occurs after reduced blood flow. Has not impact on left atrium directly. RV LV CASE 15 – A Case of Breathlessness TASK 1 TASK 2 TASK 3 Co-morbidities that Crash Course through How to make sense of an contribute to Chest X-Rays ABG breathlessness TASK 4 TASK 5 TASK 6 Compensation How to manage a COPD Explaining the patient. pathophysiology of ankle oedema. CASE 15 | Task N/A CSI STATISTICS PRACTICE QUESTION/S These are statistic questions that mirror the style of CSI questions. They mirror both style and quality of what you will be given (based off last year’s questions.) Have a go and check out the feedback to see if you get why the right answer is right. If you have any questions, improvements or queries, please feel free to email me ([email protected] + 07721013873) or ask others in your year – best of luck! CASE 15 | Task N/A CSI STATISTICS PRACTICE QUESTIONS QUESTION ANSWER/S A group of scientists wanted to investigate the responses that 1. Runners who ate a meal beforehand have a significantly decreased people had when they ran a 100m race, in normal conditions and maximum Heart Rate. 2. Runners who ate a meal beforehand have a significantly decreased chance of after eating a 3-course meal, 15 minutes beforehand. Profusely Sweating. 3. Runners who ate a meal beforehand have a significantly increased chance of A table that shows their findings (the number who have completing the race. experienced the feature/the total number in each group) has 4. Runners who ate a meal beforehand have a significantly decreased been inserted here. Which of the following statements can be maximum systolic BP. used to describe the data accurately? 5. Runners should not eat a meal before a race to avoid abdominal pain. Features No meal beforehand (number of group) Meal beforehand (number of group) Odds Ratio (95% CI) P value Maximum HR > 150 bpm 95 79 1.57 (1.35 – 1.77) 0.05 Maximum Systolic BP > 150 31 57 3.55 (1.57 – 5.57) 0.03 Abdominal Pain 27 97 0.53 (1.51 - 1.57) 0.99 Time >35 seconds 53 15 1.54 (1.01 – 5.79) 0.75 Profusely sweating 79 63 0.33 (0.17 – 0.77) 0.0001 Completed Race 57 47 1.55 (1.11 – 1.99) 0.97 CASE 15 | Task N/A CSI STATISTICS PRACTICE QUESTIONS What is an Odds Ratio? WHAT IS GOING ON? It is a direct way of showing the relationship between two groups. What is a P value? I’ve annotated all the relevant info with the level If the odds ratio is more than 1: the first group is more likely to Very simple way of easily eliminating some have experienced the outcome/feature options completely! of knowledge you need for CSI. If the odds ratio is less than 1: the first group is less likely to have If the P value is greater than 0.05, it is NOT experienced the outcome/feature. STATISTICALLY SIGNIFICANT and cannot be used to talk about the data. This is number not percentage, so you cannot If it is less than 0.05, it is STATISTICALLY compare the two directly, as SIGNIFICANT and it can be used. you don’t know the overall numbers in the group Features No meal beforehand (number of group) Meal beforehand (number of group) Odds Ratio (95% CI) P value Maximum HR > 150 bpm 95 79 1.57 (1.35 – 1.77) 0.05 Maximum Systolic BP > 150 31 57 3.55 (1.57 – 5.57) 0.03 Abdominal Pain 27 97 0.53 (1.51 - 1.57) 0.99 Time >35 seconds 53 15 1.54 (1.01 – 5.79) 0.75 Profusely sweating 79 63 0.33 (0.17 – 0.77) 0.0001 Completed Race 57 47 1.55 (1.11 – 1.99) 0.97 Confidence Intervals just tell you how confident you can be about a value, in most cases the odds ratio. In CSI, they are rarely important but essentially, the closer the values to each other, the more confident you can be about the value. If the confidence intervals cross 1 (e.g. 0.77 – 1.15), the odds ratio cannot be taken – although you will never really use this in CSI. If you see them, in most cases, disregard them as supplementary information. CASE 15 | Task N/A CSI STATISTICS PRACTICE QUESTIONS Why? ANSWER/S So first, ALWAYS LOOK AT THE P VALUE! 1. Runners who ate a meal beforehand have a significantly decreased In this case it is 0.05 so it’s significant. maximum Heart Rate. Now the odds ratio – it is more than 1 so the first group (no meal beforehand) is more likely tobe So these are the steps in doing any stats question in CSI. associated with the feature (maximum HR > 150 bpm). Basically – No meal beforehand means you are more likely to have a higher maximum Heart 1. CHECK THE ‘P’ VALUE! Rate. 2. Check the odds ratio, is it more or less than 1? 3. Double check which group is first and what the statement says. Therefore, those who had a meal beforehand are more likely to have had a lower maximum heart rate. The statement is correct. Features No meal beforehand (number of group) Meal beforehand (number of group) Odds Ratio (95% CI) P value Maximum HR > 150 bpm 95 79 1.57 (1.35 – 1.77) 0.05 Maximum Systolic BP > 150 31 57 3.55 (1.57 – 5.57) 0.03 Abdominal Pain 27 97 0.53 (1.51 - 1.57) 0.99 Time >35 seconds 53 15 1.54 (1.01 – 5.79) 0.75 Profusely sweating 79 63 0.33 (0.17 – 0.77) 0.0001 Completed Race 57 47 1.55 (1.11 – 1.99) 0.97 CASE 15 | Task N/A CSI STATISTICS PRACTICE QUESTIONS Why? ANSWER/S So first, ALWAYS LOOK AT THE P VALUE! 2. Runners who ate a meal beforehand have a significantly decreased In this case it is less than 0.05 as it is 0.0001 so it’s significant. chance of Profusely Sweating. Now the odds ratio – it is LESS than 1 so the first group (no meal beforehand) is less likely to be So these are the steps in doing any stats question in CSI. associated with the feature (Profusely Sweating). Basically – No meal beforehand means you are less likely to start profusely sweating. 1. CHECK THE ‘P’ VALUE! 2. Check the odds ratio, is it more or less than 1? Therefore, those who had a meal beforehand are more likely to start profusely sweating. 3. Double check which group is first and what the statement says. The statement is incorrect. Features No meal beforehand (number of group) Meal beforehand (number of group) Odds Ratio (95% CI) P value Maximum HR > 150 bpm 95 79 1.57 (1.35 – 1.77) 0.05 Maximum Systolic BP > 150 31 57 3.55 (1.57 – 5.57) 0.03 Abdominal Pain 27 97 0.53 (1.51 - 1.57) 0.99 Time >35 seconds 53 15 1.54 (1.01 – 5.79) 0.75 Profusely sweating 79 63 0.33 (0.17 – 0.77) 0.0001 Completed Race 57 47 1.55 (1.11 – 1.99) 0.97  CASE 15 | Task N/A CSI STATISTICS PRACTICE QUESTIONS Why? ANSWER/S So first, ALWAYS LOOK AT THE P VALUE! 3. Runners who ate a meal beforehand have a significantly increased In this case it is more than 0.05 as it is 0.97 so it’s not significant. chance of completing the race. STOP HERE – you know that any conclusion using this data cannot be used! So these are the steps in doing any stats question in CSI. The statement is incorrect. 1. CHECK THE ‘P’ VALUE! 2. Check the odds ratio, is it more or less than 1? 3. Double check which group is first and what the statement says. Features No meal beforehand (number of group) Meal beforehand (number of group) Odds Ratio (95% CI) P value Maximum HR > 150 bpm 95 79 1.57 (1.35 – 1.77) 0.05 Maximum Systolic BP > 150 31 57 3.55 (1.57 – 5.57) 0.03 Abdominal Pain 27 97 0.53 (1.51 - 1.57) 0.99 Time >35 seconds 53 15 1.54 (1.01 – 5.79) 0.75 Profusely sweating 79 63 0.33 (0.17 – 0.77) 0.0001 Completed Race 57 47 1.55 (1.11 – 1.99) 0.97  CASE 15 | Task N/A CSI STATISTICS PRACTICE QUESTIONS Why? ANSWER/S So first, ALWAYS LOOK AT THE P VALUE! 4. Runners who ate a meal beforehand have a significantly decreased In this case it is less than 0.05 as it is 0.03 so it’s significant. maximum systolic BP. Now the odds ratio – it is more than 1 so the first group (no meal beforehand) is more likely tobe So these are the steps in doing any stats question in CSI. associated with the feature (Maximum Systolic BP >150). Basically – No meal beforehand means you are more likely to have a higher maximum Systolic 1. CHECK THE ‘P’ VALUE! BP. 2. Check the odds ratio, is it more or less than 1? 3. Double check which group is first and what the statement says. Therefore, those who had a meal beforehand are more likely to have had a lower maximum Systolic BP. The statement is correct. Features No meal beforehand (number of group) Meal beforehand (number of group) Odds Ratio (95% CI) P value Maximum HR > 150 bpm 95 79 1.57 (1.35 – 1.77) 0.05 Maximum Systolic BP > 150 31 57 3.55 (1.57 – 5.57) 0.03 Abdominal Pain 27 97 0.53 (1.51 - 1.57) 0.99 Time >35 seconds 53 15 1.54 (1.01 – 5.79) 0.75 Profusely sweating 79 63 0.33 (0.17 – 0.77) 0.0001 Completed Race 57 47 1.55 (1.11 – 1.99) 0.97  CASE 15 | Task N/A CSI STATISTICS PRACTICE QUESTIONS Why? For questions like this, you don’t need to look at the data! You might be thinking that since the p value is more than 0.05, it’s insignificant so it is wrong – ANSWER/S which is partially true! That, though, isn’t the reason why this is completely wrong. This statement is an ASSUMPTION. 5. Runners should not eat a meal before a race to avoid abdominal pain. It assumes that even if this was statistically significant, not eating a meal before a race is DIRECTLY causative of abdominal pain. So these are the steps in doing any stats question in CSI. We don’t know that! It could be a coincidence or, that those who ate a meal beforehand had less 1. CHECK THE ‘P’ VALUE! time to stretch and pulled a muscle. It could be that those who ate beforehand, had food poisoning from the food that the scientists provided and that was the cause of the abdominal 2. Check the odds ratio, is it more or less than 1? pain - therefore, eating before isn’t going to stop you from getting abdominal pain if you 3. Double check which group is first and what the statement says. properly cook the food you eat! If you come across a statement like this that doesn’t have ‘significant’ in it or sounds just vague and a bit assumptive, it is WRONG. These are easy ones to eliminate from the choices. This statement is incorrect. Features No meal beforehand (number of group) Meal beforehand (number of group) Odds Ratio (95% CI) P value Maximum HR > 150 bpm 95 79 1.57 (1.35 – 1.77) 0.05 Maximum Systolic BP > 150 31 57 3.55 (1.57 – 5.57) 0.03 Abdominal Pain 27 97 0.53 (1.51 - 1.57) 0.99 Time >35 seconds 53 15 1.54 (1.01 – 5.79) 0.75 Profusely sweating 79 63 0.33 (0.17 – 0.77) 0.0001 Completed Race 57 47 1.55 (1.11 – 1.99) 0.97 CASE 15 | Task N/A CSI STATISTICS PRACTICE QUESTIONS QUESTION Which of the statements below describe the data accurately? Asthma is another obstructive condition that can present in 1. Patients without asthma have significantly reduced levels of COPD-asthma overlap syndrome in some patients. readmission for COPD Asthmatics can have worse outcomes when they are admitted for flare-ups of their COPD. 2. Patients with asthma have significantly reduced levels of readmission for COPD The status of asthma has been studied in relation to hospital readmissions for individuals with COPD. 3. Patients with asthma have significantly reduced levels of readmission for other causes Some of this data is summarised in the table below. 4. Patients without asthma have significantly reduced levels of readmission for other causes Outcome COPD with asthma (%) COPD without asthma (%) Odd ratio (95% CI) P value COPD-related readmission 26 (47.3) 33 (37.5) 3.59 (1.65-7.82) 0.03 Other cause readmission 37 (67.3) 55 (62.5) 2.32 (1.10-4.92) 0.04 CASE 15 | Task N/A CSI STATISTICS PRACTICE QUESTIONS WHY? Which of the statements below describe the data accurately? It is significant (p < 0.05) 1. Patients without asthma have significantly reduced levels of Even though the % is higher, the odds ratio is the only way to readmission for COPD compare both groups. Since it is higher than 1, it means the first group (COPD + asthma) is more likely to have COPD-related admissions. Outcome COPD with asthma (%) COPD without asthma (%) Odd ratio (95% CI) P value COPD-related readmission 26 (47.3) 33 (37.5) 3.59 (1.65-7.82) 0.03 Other cause readmission 37 (67.3) 55 (62.5) 2.32 (1.10-4.92) 0.04 CASE 15 | Task N/A CSI STATISTICS PRACTICE QUESTIONS WHY? Which of the statements below describe the data accurately? It is significant (p < 0.05) 1. Patients without asthma have significantly reduced levels of Even though the % is lower, the odds ratio is the only way to readmission for COPD compare both groups. 2. Patients with asthma have significantly reduced levels of Since it is higher than 1, it means the first group (COPD + readmission for COPD asthma) is more likely to have COPD-related admissions. And it must be wrong if (option 1) is right. Outcome COPD with asthma (%) COPD without asthma (%) Odd ratio (95% CI) P value COPD-related readmission 26 (47.3) 33 (37.5) 3.59 (1.65-7.82) 0.03 Other cause readmission 37 (67.3) 55 (62.5) 2.32 (1.10-4.92) 0.04 CASE 15 | Task N/A CSI STATISTICS PRACTICE QUESTIONS WHY? Which of the statements below describe the data accurately? It is significant (p < 0.05) 1. Patients without asthma have significantly reduced levels of Even though the % is higher, the odds ratio is the only way to readmission for COPD compare both groups. 2. Patients with asthma have significantly reduced levels of Since it is higher than 1, it means the first group (COPD + readmission for COPD asthma) is more likely to have other related admissions. 3. Patients with asthma have significantly reduced levels of readmission for other causes It should say ‘have significantly increased’. Outcome COPD with asthma (%) COPD without asthma (%) Odd ratio (95% CI) P value COPD-related readmission 26 (47.3) 33 (37.5) 3.59 (1.65-7.82) 0.03 Other cause readmission 37 (67.3) 55 (62.5) 2.32 (1.10-4.92) 0.04 CASE 15 | Task N/A CSI STATISTICS PRACTICE QUESTIONS WHY? Which of the statements below describe the data accurately? It is significant (p < 0.05) 1. Patients without asthma have significantly reduced levels of Even though the % is higher, the odds ratio is the only way to readmission for COPD compare both groups. 2. Patients with asthma have significantly reduced levels of Since it is higher than 1, it means the first group (COPD + readmission for COPD asthma) is more likely to have other related admissions. 3. Patients with asthma have significantly reduced levels of readmission for other causes 4. Patients without asthma have significantly reduced levels of readmission for other causes Outcome COPD with asthma (%) COPD without asthma (%) Odd ratio (95% CI) P value COPD-related readmission 26 (47.3) 33 (37.5) 3.59 (1.65-7.82) 0.03 Other cause readmission 37 (67.3) 55 (62.5) 2.32 (1.10-4.92) 0.04 CASE 15 | Task N/A CSI STATISTICS PRACTICE QUESTIONS QUESTION Outcome COPD without COPD with treatment P value measure treatment A group of scientists wanted to investigate the outcomes that Shortness of patients with untreated COPD experienced vs the outcomes -10.5 -13.6 0.13 Breath that patients with treated COPD experienced. Chest Pain -6.6 -7.7 0.21 These patients were followed up over the course of 15 years and were seen if any outcomes were improved through treatment Quality of Life +0.1 +0.2 0.04 or not. Reduction in -4.1 -5.7 0.14 FVC How many outcomes measures are significantly improved to a greater extent by the treatment compared with no treatment? Illness worry -4.1 -4.6 0.50 Anxiety -0.8 -0.9 0.95 a. 1 b. 2 Depression -3.6 -7.6 0.01 c. 3 d. 7 CASE 15 | Task N/A CSI STATISTICS PRACTICE QUESTIONS ANSWER Outcome COPD without COPD with treatment P value measure treatment Two Shortness of -10.5 -13.6 0.13