The causes of bronchial breath sound are:

• 3Cs
  • Consolidation
  • Cavitation
  • Collapse with patent bronchus
• Fibrosis

* Pre-exam preparation for medicine, HN Sarker

The types of breath sound are:

• Vesicular
• Vesicular with prolonged expiration
• Bronchial.

* Pre-exam preparation for medicine, HN Sarker

The obstructive pulmonary diseases are:

• COPD
• Bronchial asthma.

* Pre-exam preparation for medicine, HN Sarker

The restrictive pulmonary diseases are:

• Interstitial lung disease
• Pulmonary fibrosis.

* Pre-exam preparation for medicine, HN Sarker

* Pre-exam preparation for medicine, HN Sarker

Asthma is a chronic inflammatory disorder of the airways, associated with airway hyper-responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing, particularly at night and in the early morning, usually associated with widespread but variable airflow obstruction within the lung that is often reversible, either spontaneously or with treatment.

*Based on– Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 666

Asthma is a chronic inflammatory condition of respiratory tract presenting with features of reversible airflow limitations.

* Step on to Paediatrics, Md Abid Hossain Mollah, 3rd Edition Page: 95

Asthma generally grouped into 3 types

1. Intermittent asthma
2. Persistent asthma
   • Mild persistent asthma
   • Moderater persistent asthma
   • Severe persistent asthma
3. Special variant asthma
   • Seasonal asthma
   • Exercise induced asthma
   • Drug induced asthma
   • Cough variant asthma
   • Occupational asthma

Any of these types may develop acute exacerbation.

* Step on to Paediatrics, Md Abid Hossain Mollah, 3rd Edition Page: 96

When asthma symptoms become cumbersome, following exposure to certain situations are called special variant asthma.

* Step on to Paediatrics, Md Abid Hossain Mollah, 3rd Edition Page: 96

As follows:

Intrinsic asthma (non atopic or late onset asthma):

• When no causative agent can be identified.
• It is not allergic, usually begins after the age of 30 years, tends to be more continuous and more severe.

Extrinsic asthma (atopic or early onset asthma):

• When a definite external cause is present.
• There is history of allergy to dust, mite, animal danders, pollens, fungi, etc.
• It occurs commonly in childhood and usually shows seasonal variations.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 64

It is defined as “severe acute persistent attack of asthma without any remission in between and not controlled by conventional bronchodilator”. Previously it was called status asthmaticus.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 64

There is no breath sound heard on auscultation. This is a sign of life-threatening asthma.

* Pre-exam preparation for medicine, HN Sarker

Three cardinal features:

• Airflow limitation – it is usually reversible spontaneously or with treatment
• Airway hyper-responsiveness – airway is hyper-responsive to a wide range of nonspecific stimuli like exercise, cold air
• Airway inflammation – there is inflammation of the bronchi with infiltration of eosinophils, T cells and mast cells. Also there is plasma exudation, edema, smooth muscle hypertrophy, matrix deposition, mucus plugging and epithelial damage

(In chronic asthma, inflammation may lead to irreversible airflow limitation due to airway wall remodeling, involving the large and small airways with mucus impaction.)

* Long Cases in Clinical Medicine, ABM Abdullah Page: 62

Pathophysiological events are

• Exaggerated spasm of bronchial smooth muscles
• Vasodilation with increased permeability and swelling of wall of airway
• Profuse mucous secretion
• Vagal stimulation

The net pathological consequences are – Recurrent airway

• Inflammation
• Airflow obstruction/narrowing

* Step on to Paediatrics, Md Abid Hossain Mollah, 3rd Edition Page: 95

Common triggering factors

Pollens, dust, smoke, aerosol spray, viral catarrh, NSAID, foods, house dust, mites, cockroach and many others.

* Step on to Paediatrics, Md Abid Hossain Mollah, 3rd Edition Page: 95

The common causes of occupational asthma are:

• Isocyanates
• Flour and grain dust
• Colophony and fluxes
• Latex
• Animals
• Aldehydes
• Wood dust.

* Pre-exam preparation for medicine, HN Sarker

Typical symptoms include recurrent episodes of

• wheeze,
• chest tightness (older children),
• breathlessness and
• cough

which display a diurnal pattern, with symptoms and lung function being worse in the early morning.

* Pre-exam preparation for medicine, HN Sarker; Step on to Paediatrics, Md Abid Hossain Mollah, 3rd Edition Page: 96

The features of acute severe asthma are:

• Respiratory rate is ≥ 25/min
• Heart rate is ≥ 110/min
• Inability to complete sentences in 1 breath
• PEF 33%–50% predicted (< 200 L/min).

* Pre-exam preparation for medicine, HN Sarker

Note:

Pulsus paradoxus may be found in up to 45% of acute severe asthma.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 64

As follows:

• Profound exhaustion
• Cyanosis
• Silent chest
• Feeble respiratory effort
• Bradycardia or arrhythmia
• Hypotension

Note:

On examination:

• PEFR < 33% of predicted (< 100 L/min)
• Blood gas analysis – SpO₂  < 92% or PaO₂  <8 kPa (60 mm Hg) even with O₂
• Normal or raised PaCO₂  (> 6 kPa) and low or falling blood pH.
• If a patient has raised PaCO₂ and/or requires mechanical ventilation with raised inflation pressure, it is called near fatal asthma.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 64; Step on to Paediatrics, Md Abid Hossain Mollah, 3rd Edition Page: 96; Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 671

See on dyspnea from presenting problems of respiratory system

As follows:

Stridor is a high pitched, loud sound produced by partial obstruction of major airways like larynx, trachea or large bronchi. It is heard both in inspiration and expiration. Causes are— foreign body in larynx or trachea, laryngeal edema (angioedema), laryngeal tumor, vocal cord palsy due to recurrent laryngeal nerve paralysis, tumor, infection (e.g. epiglottitis, acute laryngitis, diphtheria, whooping cough) or inflammation, paratracheal and subcarinal lymphadenopathy pressing over the main bronchi, laryngismus stridulus in tetany. This indicates an emergency condition.

Wheezes are a musical sound heard from a distance, due to small airways obstruction. High pitched wheezes are produced by obstruction in smaller bronchi and low pitched wheezes are produced in larger bronchi. It is present both during inspiration and expiration but prominent during expiration. Wheezes are caused by severe bronchial asthma, chronic bronchitis or COPD or airways obstruction by a foreign body or tumor.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 69

Key distinguishing feature is the reversibility test. Bronchial asthma is fully reversible with use of bronchodilator which leads to >15% and 200 mL increase in FEV1 (except in severe persistent asthma). COPD is not fully reversible and the increase in FEV1 after bronchodilator is < 15%. The differences between bronchial asthma and COPD are:

* Long Cases in Clinical Medicine, ABM Abdullah Page: 68

Examination of chest

• Inspection : Hyperinflation of chest, suprasternal, subcostal & intercostal recession
• Percussion : Hyper resonant
• Auscultation : Vesicular breath sound with prolonged expiration, rhonchi

* Step on to Paediatrics, Md Abid Hossain Mollah, 3rd Edition Page: 96

Peak expiratory flow rate is the bedside test of asthama.

* Pre-exam preparation for medicine, HN Sarker

Reversibility test is to see the reversibility of airflow obstruction in obstructive lung diseases.

* Pre-exam preparation for medicine, HN Sarker

Reversibility test is done by measuring forced expiratory volume in 1 second before and 20 minutes after administration of 200–400 μg of inhaled salbutamol or after 2 weeks of a trial of corticosteroids (e.g. 30 mg prednisolon daily for 2 weeks).

* Pre-exam preparation for medicine, HN Sarker

When FEV1 ≥ 15% (or 200 mL) increase following administration of a bronchodilator /trial of corticosteroids.

* Pre-exam preparation for medicine, HN Sarker

There is no single satisfactory diagnostic test for all patients with asthma.

1. Lung function tests
   • Peak expiratory flow rate (PEFR)
     • The diurnal variation in PEFR is a good measure of asthma activity.
     • It helps in the longer-term assessment of the patient’s disease and its response to treatment.
   • Spirometry
     • Asthma can be diagnosed by demonstrating a greater than 15% improvement in FEV1 or PEFR following the inhalation of a bronchodilator.
   • The carbon monoxide (CO) transfer test is normal in asthma.
2. Exercise tests
   • These have been widely used in the diagnosis of asthma in children.
3. Blood gas analysis
   • PaO₂ (reduced )and PaCO₂ (raised or normal).
4. CBC and sputum for eosinophil count
   • Patients with asthma sometimes have increased numbers of eosinophils in peripheral blood (>0.4 × 109/L) but sputum eosinophilia is a more specific diagnostic finding.
5. Chest X-ray
   • There are no diagnostic features of asthma on the chest X-ray, although overinflation is characteristic during an acute episode or in chronic severe disease.
   • A chest X-ray may be helpful in excluding a pneumothorax, which can occur as a complication, or in detecting the pulmonary infiltrates associated with allergic bronchopulmonary aspergillosis.
6. Histamine or methacholine bronchial provocation test
   • This test indicates the presence of AHR (airway hyperresponsiveness), a feature found in most asthmatics, and can be particularly useful in investigating those patients whose main symptom is cough.
   • The test should not be performed on individuals who have poor lung function (FEV1 <1.5 L) or a history of ‘brittle’ asthma. In children, it is often easier to carry out controlled exercise testing as a measure of bronchial hyper-responsiveness.
7. Trial of corticosteroids
   • A substantial improvement in FEV1 (>15%) confirms the presence of a reversible element and indicates that the administration of inhaled steroids will prove beneficial to the patient.
8. Exhaled nitric oxide
   • This test is a measure of airway inflammation and an index of corticosteroid response; it used to assess the efficacy of corticosteroids.
9. Skin-prick test
   • To help identify allergic trigger factors.
10. Allergen provocation tests
    • Required when investigating patients with suspected occupational asthma, but not in ordinary asthma.

* Kumar and Clark’s Clinical Medicine, 9th Edition; Long Cases in Clinical Medicine, ABM Abdullah Page: 61

How to make a diagnosis of asthma

Compatible clinical history plus either/or :

• FEV1 ≥ 15%¹ (and 200 mL) increase following administration of a bronchodilator/trial of corticosteroids
• > 20% diurnal variation on ≥ 3 days in a week for 2 weeks on PEF diary
• FEV1 ≥ 15% decrease after 6 mins of exercise

¹Global Initiative for Asthma (GINA) definition accepts an increase of 12%.

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 668

Acute exacerbation of COPD (Chronic obstructive pulmanary disease).

Patient is young adult, lifelong nonsmoker with positive family history of asthma, seasonal variation and morning dipping – all are againt the diagnosis of COPD.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 230

In chronic bronchitis, there is presence of cough with sputum production not attributable to other causes, on most of the days for at least 3 consecutive months in a year for at least 2 successive years.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 61

Cardiac asthma means left ventricular failure in which

• the patient usually presents with sudden severe dyspnea and cough with profuse mucoid expectoration.
• On examination, there are bilateral basal crepitations and no rhonchi or wheeze.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 61

* Long Cases in Clinical Medicine, ABM Abdullah Page: 64

* Long Cases in Clinical Medicine, ABM Abdullah Page: 69

We can manage acute severe asthma by the followings—

• Urgent hospitalization and send blood for ABG.
• Nebulized salbutamol
  • Adult: 5 mg 2–4 hourly
  • Children: 0.15–0.3 mg/kg/dose every 20 minutes for 3 times or continuously.
• Propped up position/ head up position
• Oxygen
  • High-flow/60%.
  • In children, 4–6 L/min (40–60%) through oxygen hood/ head box
• Prednisolone 40 mg orally (or hydrocortisone 200 mg IV if patient cannot swallow or vomit).
  • Child dose:
    • Inj. hydrocortisone 3–4 mg/kg/dose 4–6 hourly or,
    • Prednisolone 2 mg/kg/day for 3–5 days or as necessary.
• IV access, chest X-ray, send blood for urea and electrolytes, theophylline level.
• If condition does not improve, nebulized ipratropium bromide may be added
  • Administer repeat salbutamol 5mg + ipratropium bromide 0.5 mg nebulizer.
  • If failure to respond, continuous salbutamol nebulizer 5–10 mg/hr.
• If not respond, consider
  • IV magnesium sulfate 1.2–2 gm over 20 mins, or
  • Aminophylline 5 mg/kg loading dose over 20 mins followed by a continuous infusion at 1 mg/kg/hr.
• Correct fluid and electrolytes (esp. K⁺ ) (repeated use of salbutamol may cause hypokalemia).
• In refractory cases
  • Mechanical ventilation and for children, PICU support.

Figure: Immediate treatment of patients with acute severe asthma.

Note:

Arterial blood gases are measured. If PaCO₂ > 7 kPa, ventilation should be considered.

* Pre-exam preparation for medicine, HN Sarker; Step on to Paediatrics, Md Abid Hossain Mollah, 3rd Edition Page: 97; Long Cases in Clinical Medicine, ABM Abdullah Page: 65; Figure: Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 672; 

Nebulized salbutamol.

* Pre-exam preparation for medicine, HN Sarker

As follows:

• Repeated PEFR in every 15 to 30 min
• Pulse oxymetry (SaO₂ should be kept > 92%)
• Repeat arterial blood gas analysis
• X-ray chest to exclude pneumothorax.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 65

Note

• Sedative is contraindicated in acute severe asthma
• No role of chest physiotherapy, antihistamine, antitussive drugs in acute attack.

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 672; Long Cases in Clinical Medicine, ABM Abdullah Page: 65

As follows:

• Stable on discharge medication
• Without nebulisation for at least 24 hours
• PEFR 75% of predicted or personal best.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 66

Management of chronic asthma is stepwise to achieve optimum control.

General measures

• Patient education about disease process, compliance, inhaler technique, peak flow monitoring, and self management.
• Avoidance of known precipitants.
• Smoking cessation.
• Immunizations against influenza and pneumococcus.

Drug therapy

1. Step 1
   • Occasional use of inhaled short-acting β2- adrenoreceptor agonist bronchodilators: salbutamol or terbutaline.
2. Step 2
   • Inhaled β2-agonists as required (Step 1)+
   • Low dose inhaled corticosteroids (ICS) such as beclomethasone (200–800 μgm/day), budesonide or leukotriene modifier.
3. Step 3
   • Inhaled β2-agonists as required (Step 1)+
   • Medium or high dose ICS Or,
     • Low dose ICS +
       • long-acting β2-agonists Or,
       • leukotriene modifier. Or,
       • sustained release theophylline.
4. Step 4
   • Inhaled β2-agonists as required (Step 1)+
   • Medium or high dose ICS +
   • Long-acting β2-agonists +/–
     • Leukotriene modifier +/–
     • Sustained release theophylline
5. Step 5
   • Step 4 +
   • Oral steroid +/–
     • Anti-IgE treatment.

Step care management in children, age <5 years:

Step care management in children, age 6-12 years:

Figure: Stepwise approach to asthma therapy according to the severity of asthma and ability to control symptoms.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 231; Step on to Paediatrics, Md Abid Hossain Mollah, 3rd Edition Page: 98, 99; Figure: Harrison’s Principles of Internal Medicine, 19th Edition Page: 1679

If patient’s asthma is under control, then at every 3 months interval, reduce the dose of inhaled corticosteroids by 25 to 50%.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 66

As follows:

• Methotrexate
• Cyclosporine
• Intravenous immunoglobulin
• Etanercept
• Anti-IgE monoclonal antibody (omalizumab).

* Long Cases in Clinical Medicine, ABM Abdullah Page: 67

As follows:

• Omalizumab, a monoclonal antibody directed against IgE, can be given subcutaneously 2 to 4 weekly
• Bronchoplasty – a stent is applied to dilate constricted bronchi
• Bronchothermoplasty – hyperplastic bronchial smooth muscle is reduced by thermal coagulation.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 67

If the patient develops severe asthma or loss of control at any step during therapy, a short course of oral corticosteroid is given. This is called rescue therapy.

Tablet prednisolone 30 to 60 mg daily (1 to 2 mg/kg daily for children) is given in a single morning dose or two divided doses for 3 to 14 days. Tapering is not necessary, if it is not given for more than 3 weeks.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 67

Indications are:

• Morning symptoms persist till mid-day
• Onset or worsening of sleep disturbance by asthma
• Progressively diminishing response to inhaled bronchodilators
• Symptoms severe enough to require treatment with nebulized or injected bronchodilators
• Symptoms and PEF get progressively worse day by day
• PEFR falls below 60% of patient’s personal best recording.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 67

When it is given for more than 3 weeks.

* Pre-exam preparation for medicine, HN Sarker

The patient should follow the rule of 5:

• The patient should be sitting comfortably in up right position.
• Give 5 puffs of bronchodilator inhaler with a large volume spacer.
  • Initially 5 puffs (1 puff and 5 sucks) at 5 minutes interval through spacer up to 5 times (25 puffs) within 1 hour.
  • If no improvement, the patient should go to the nearby hospital.
• If spacer is not available, the patient should take the puffs in the above rule but hold breath for 5 seconds for each puff.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 67

Figure: How to use a metered-dose inhaler

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 670

It is a type of asthma in which there is chronic dry cough with or without sputum eosinophilia, but no abnormalities in airway function. It is also called eosinophilic bronchitis, common in young children. Cough is the only symptom, mostly at night. Examination during day may not reveal any abnormality. Cough may be increased with exercise, exposure to dust, strong fragrances or cold air. Methacholine challenge test is positive.

Clinical criteria for diagnosis:

• Dry cough persisting more than 6 to 8 weeks
• Presence of bronchial hyper-responsiveness
• Absence of dyspnea and wheeze.

Treatment : Should be according to the stepwise approach for long-term. Nedocromil sodium is effective. Also consider the following points:

• Allergic rhinitis should be treated, if present.
• Gastroesophageal reflux disease should be treated with proton pump inhibitor (e.g. omeprazole) and/or gastric prokinetic agent (e.g. domperidone).
• Any environmental factors like cold, dust, fume, etc. should be avoided.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 62

When exercise produces asthma, it is known as exercise-induced asthma. 10% or more reduction of FEV1 after exercise is diagnostic.

Cold dry air that enters into the lungs during exercise is the main trigger factor. Increased ventilation results in water loss from the pericellular lining fluid of the respiratory mucosa trigger mediator release. Heat loss from the respiratory mucosa is also involved.

Treatment:

• Single dose short acting β2 agonist, sodium chromoglycate or nedocromil sodium immediately before exercise should be used.
• Inhaled corticosteroid twice daily for 8 to 12 weeks reduces severity.
• If abnormal spirometry and persistent symptoms- inhaled corticosteroid with long acting β2
• Leukotriene receptor antagonist may be used.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 63

It may be defined as “asthma induced at work by exposure to occupation related agents, which are mainly inhaled at the workplace”. The most characteristic feature is symptoms that worsen on work days and improves on holidays.

Atopic individual and smoker are at increased risk. Commonly found in chemical workers, farmers, grain handlers, cigarette manufacturers, fabric, dye, press and printing workers, laboratory workers, poultry breeders, wood and bakery workers.

Measurement of 2 hourly peak at and away from work is helpful for diagnosis.

Treatment:

• Avoidance of further exposure
• Using mask at work
• If no response, step care asthma management plan.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 63

Symptoms of asthma that occurs after use of certain drugs such as aspirin, beta blocker, some nonsteroidal anti-inframmatory drugs (NSAIDs), etc. These drugs can cause bronchospasm.

Treatment:

Avoidance of triggering drugs. Safe NSAIDs are paracetamol, tramadol, also etoricoxib.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 63

Some patients with asthma have more troublesome disease reflected by:

• High medication requirements to maintain disease control or
• Persistent symptoms, asthma exacerbation, or airflow obstruction despite high medication use.
• This group is called refractory asthma.

Treatment:

• Home nebulization—continuous or as required
• Vaccination—influenza, measles, pneumococcal vaccine
• Anti-IgE (omalizumab), sublingual immunotherapy
• Disease modifying agent—methotrexate, cyclosporine, gold salt
• Patient’s education
• Identifying pitfalls of management.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 67

This is an unusual variant of asthma characterized by severe, life-threatening attacks that may occur within hours or even minutes without little or no warning symptoms. Patients are at risk of sudden death although their asthma may be well controlled in between attacks.

Management:

• The patient should be advised to keep emergency supplies of medications at home, in the car and at work.
• There should be oxygen and resuscitation equipments at home and at work.
• Nebulized b2 agonists should be available at home and at work. Inhaled long acting b2 agonists with a corticosteroid can be very effective.
• Self injectable epinephrine should be kept at home, at work and should be carried by the patent at all times.
• Prednisolone 60 mg.
• Medic Alert bracelet.

On developing wheeze, patient should attend the nearest hospital immediately. Direct admission to ICU may be required.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 68

It is a chronic specific systemic infectious disease caused by Mycobacterium tuberculosis complex.

* Pre-exam preparation for medicine, HN Sarker

According to site:

1. Pulmonary tuberculosis
   • Primary
   • Postprimary
     • Reactivation
     • Reinfection
2. Extrapulmonary tuberculosis
   • Outside the lung parenchyma (according to USA)
   • Outside the lung and pleura (according to UK).

According to bacteriological specimen

1. Smear positive
   • 2 sputum positive for AFB
   • 1 sputum positive with chest X-ray abnormality
   • 1 sputum positive with one culture positive.
2. Smear negative
   • Symptoms suggestive of tuberculosis with 3 negative sputum specimens
   • Persisting symptoms after a course of antibiotics
   • 3 negative sputum specimen or repeated X-ray negative

According to treatment category

1. Category 1
2. Category 2.

* Pre-exam preparation for medicine, HN Sarker

A combination of

• Ghon’s focus,
• hilar lymphadenopathy and
• lymphangitis.

* Pre-exam preparation for medicine, HN Sarker

The formation of a granuloma surrounding an area of caseation leads to the appearance of primary lesion in the lung is known as Ghon’s focus.

* Pre-exam preparation for medicine, HN Sarker

FDC means fixed dose combination, i.e. drugs are present in fixed amount in single tablet.

* Pre-exam preparation for medicine, HN Sarker

New case: A patient who has never taken anti TB or taken for less than 1 month.

Relapse: A patient who recently received treatment and was cured or treatment completed and now again developed smear positive pulmonary TB.

Treatment failure: A patient while on management remain smear positive or becomes smear positive at 5 months or more after start of management or a patient who was initially smear negative and is found smear positive at the end of 2nd month of treatment.

Treatment after default: A patient who completed at least 1 month of treatment and returned after at least 2 months after interruption of treatment.

Chronic: A patient who remained smear positive after completing directly observed retreatment regimen.

* Pre-exam preparation for medicine, HN Sarker

• Primary drug resistance: It occurs in those exposed to others infected with resistant organism.
• Secondary drug resistance: Occurs in patients who do not comply with the treatment regimen.
• Multidrug resistance: Resistance to INH + rifampicin with or without other drug resistance.
• XDRTB: Resistance to rifampicin +INH and any member of the quinolone and at least any of the injectable 2nd line drug.

* Pre-exam preparation for medicine, HN Sarker

Causes of giving BCG (bacille Calmette–Guérin) vaccine are:

• Protection against tubercular meningitis and military tuberculosis.
• To protect the babies from TB which may be transmitted from mother or other source.
• Lack of maternal antibody against TB. The earlier the age, the higher the protection.

* Pre-exam preparation for medicine, HN Sarker

Protections are:

• BCG gives protection upto 7 years
• Protect in young 0%–70%.

* Pre-exam preparation for medicine, HN Sarker

Prevention of TB:

• General health promotion
• Effective treatment of sputum positive case
• Specific protection
• Active immunization
• Chemoprophylaxis—INH 5 mg/kg/day for 9 months.

* Pre-exam preparation for medicine, HN Sarker

The organisms are:

• Mycobacterium tuberculosis
• Mycobacterium bovis
• Atypical mycobacteria, e.g.
  • M. kansasii ,
  • M. marinum, and
  • M. avium intracellulare complex .

* Pre-exam preparation for medicine, HN Sarker

Mycobacterium leprae causing leprosy.

* Pre-exam preparation for medicine, HN Sarker

Mycobacterium is called acid or alcohol fast because it resists decolorization with acid and alkali.

* Pre-exam preparation for medicine, HN Sarker

The sources of infection are:

• Human source
• Bovine source.

* Pre-exam preparation for medicine, HN Sarker

Routes of entry are:

• Nasal (most common)—droplet infection
• Oral
• Percutaneous
• Direct inoculation
• Transplacental.

* Pre-exam preparation for medicine, HN Sarker

The sites of primary tuberculosis are:

• Lungs
• Intestine
• Tonsil

* Pre-exam preparation for medicine, HN Sarker

The sites of pulmonary TB are:

• Primary pulmonary TB
  • Subpleural lesion.
• Postprimary TB
  • Apical lesion.

* Pre-exam preparation for medicine, HN Sarker

The sites of extrapulmonary TB are:

• Lymph node (20%–40%)—Cervical and supraclavicular are most common
• Serous membrane (like pleura 20%–25%, peritoneum)
• Meninges
• Intestine
• Genitourinary (5%–18%)
• Bones and joints
• Liver
• Adrenal gland.

* Pre-exam preparation for medicine, HN Sarker

The organs are

• Cardiac muscle
• Skeletal muscle
• Thyroid gland
• Pancreas

* Pre-exam preparation for medicine, HN Sarker

The clinical features of pulmonary tuberculosis are:

• Asymptomatic
• Symptomatic
  • Respiratory symptoms
    • Cough >3 weeks
    • Sputum production
    • Hemoptysis
    • Chest pain
    • Shortness of breath
    • Localized wheez.
  • General symptoms
    • Fever (low grade with evening rise of temperature and relieved at late night by sweating)
    • Weight loss
    • Anorexia
  • Signs
    • No physical signs in most of the cases
    • Signs of
      • Fibrosis
      • Collapse
      • Pleural effusion
      • Pneumothorax
      • Cavitary lesion may be found.

* Pre-exam preparation for medicine, HN Sarker

• Chronic cough, often with haemoptysis
• Pyrexia of unknown origin
• Unresolved pneumonia
• Exudative pleural effusion
• Asymptomatic (diagnosis on chest X-ray)
• Weight loss, general debility
• Spontaneous pneumothorax

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 691

The histological findings are:

• Caseating granuloma
• Epithelioid cell
• Multinucleated giant cell.

Figure: Tuberculous granuloma. Normal lung tissue is lost and replaced by a mass of fibrous tissue with granulomatous inflammation characterised by large numbers of macrophages and multinucleate giant cells (white arrow). The central area of this focus shows caseous degeneration (black arrow).

* Pre-exam preparation for medicine, HN Sarker; Figure: Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 689

The radiological presentations are:

• Soft patchy opacities
• Consolidation
• Collapse
• Cavitation
• Fibrosis
• Miliary shadowing
• Pleural effusion/empyema.

* Pre-exam preparation for medicine, HN Sarker

Soft patchy opacities.

* Pre-exam preparation for medicine, HN Sarker

After starting treatment with anti-TB drugs, sputum should be examined after 2, 3, and 5 months.

* Pre-exam preparation for medicine, HN Sarker

The aims are:

• To interrupt TB transmission by rendering patient noninfectious thus reducing mortality and morbidity.
• To prevent development of drug resistance.

* Pre-exam preparation for medicine, HN Sarker

• To prevent the emergence of resistance, e.g. INH acts on rapidly growing bacteria, pyrazinamide enters into the caseous material, refampicin acts on dormant bacilli.
• To prevent resistance due to spontaneous mutation.

* Pre-exam preparation for medicine, HN Sarker

Multidrug treatment is rational due to:

• Better patient compliance
• Prevent drug resistance.

* Pre-exam preparation for medicine, HN Sarker

The advantages of FDC are:

• Prescription errorless likely to occur due to straight-forward dose recommendations and easier patient weight to dose adjustment.
• Small number of tablet to be ingested.
• Decreased drug resistance

* Pre-exam preparation for medicine, HN Sarker

Long-term treatment is required because:

• Mycobacterium tuberculosis multiplies slowly.
• Intensive phase rapidly reduces bacterial population.
• Continuation phase destroys the remaining bacteria.

* Pre-exam preparation for medicine, HN Sarker

1. 1st line drugs
   • INH
   • Rifampicin
   • Pyrazinamide
   • Ethambutol
   • Streptomycin
   • Thiacetazone.
2. 2nd line drugs
   • Aminoglycosides : Kanamycin and amikacin
   • Thionamides: Ethionamide
   • Fluoroquinolone
   • Cycloserine
   • Para-aminosalicylic acid
   • Clofazimine and rifabutin.

* Pre-exam preparation for medicine, HN Sarker

Initial phase— 2 months.

Continuation phase—4 months.

* Pre-exam preparation for medicine, HN Sarker

• INH—Peripheral neuropathy
• Rifampicin — Hepatitis
• Pyrazinamide—Hepatitis/ Hyperuricemia (gouty arthritis)
• Ethambutol—Optic neuritis
• Streptomycin—Ototoxicity (8th cranial nerve palsy)
• Thiacetazone—Steven-Johnson’s syndrome.

* Pre-exam preparation for medicine, HN Sarker

Treatment response—

• By 2nd week—Sputum smear becomes negative
• After 4 weeks—Feeling well, weight gain, no fever, no cough and sputum
• By 2 months—80% culture negative
• By 3 months—100% culture negative
• Chest radiograph— Should have improved.

* Pre-exam preparation for medicine, HN Sarker

Management of patient—

• Anti-TB drugs should be stopped.
• Liver function tests are done.
• Viral serology are done to exclude viral hepatitis.
• Supportive measures should be taken, e.g. nutrition.
• Wait till jaundice disappears and liver function returns to normal.
• After that anti-TB drugs will be reintroduced slowly.

* Pre-exam preparation for medicine, HN Sarker

The accumulation of serous fluid within the pleural space is termed pleural effusion.

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 661

According to color, pleural effusion may be:

• Serous (hydrothorax)
• Purulent (empyema or pyothorax)
• Hemorrhagic (hemothorax)
• Straw
• Milky or chylous (chylothorax)

Note

Clinically, only pleural effusion should be mentioned. After drawing the fluid and according to its color, other diagnosis may be done. e.g. if pus, it is empyema.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 104

Light’s criteria is for distinguishing pleural transudate from exudate.

• Plural fluid is likely exudate if one or more of the following criteria are met:
  1. Pleural fluid protein : serum protein ratio > 0.5
  2. Pleural fluid LDH : serum LDH ratio > 0.6
  3. Pleural fluid LDH > two-thirds of the upper limit of normal serum LDH

(LDH = lactate dehydrogenase)

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 662

When pleural fluid protein is between 2.5 and 3.5 gm/dL.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 243

In empyema thoracis, fluid may come out subcutaneously in the chest wall. This is called empyema necessitans.

Characteristics of empyema fluid:

• Fluid is purulent
• Thick
• Biochemical—glucose low, < 3.3 mmol/L, protein exudative, LDH > 1000 U/L
• C/S—organism may be found
• Pleural biopsy may be done to exclude tuberculosis.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 106

When the pleural effusion is transudative, it is called hydrothorax. It is usually bilateral due to any cause causing transudative pleural effusion.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 106

Effusion between the lower surface of lung and upper surface of diaphragm.

• Confused with subphrenic abscess.
• Detected by chest X-ray in lateral decubitus position or USG or CT scan.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 107

It is the accumulation of fluid in interlobular fissure, usually found along the lateral chest wall.

• Chest X-ray shows rounded homogeneous opacity, misdiagnosed as a tumor.
• It is confirmed by USG (localized or encysted effusion) or CT scan.
• It disappears with resolution of effusion.
• It is commonly found in CCF.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 107

It is a congenital disorder characterized by:

1. Nails—yellow, thick, onycholysis
2. Lymphedema of legs
3. Pleural effusion or bronchiectasis.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 107

Note:

If the patient is young, common causes are

• Pulmonary tuberculosis
• Parapneumonic
• Others—Lymphoma and SLE in female (also pulmonary infarction).

If the patient is middle age or elderly, common causes are

• Pulmonary tuberculosis
• Parapneumonic
• Bronchial carcinoma.

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 661; Long Cases in Clinical Medicine, ABM Abdullah Page: 103

As follows:

Exudative (protein  >3 g%) :

• Pneumonia (para-pneumonic effusion)
• Pulmonary tuberculosis
• Pulmonary infarction
• Malignant disease, e.g. bronchial carcinoma, lymphoma
• Collagen disease (SLE, rheumatoid arthritis)
• Dressler’s syndrome (post-myocardial infarction syndrome characterised by pain, pyrexia, pericarditis, pleurisy and pneumonitis).
• Others—acute pancreatitis, subphrenic abscess, liver abscess, pleural mesothelioma, secondaries in the pleura, yellow nail syndrome, etc.

Transudative (protein  <3 g%):

• Congestive cardiac failure (CCF)
• Nephrotic syndrome
• Cirrhosis of liver
• Malnutrition
• Hypothyroidism
• Meig’s syndrome (ovarian fibroma, ascites and right sided pleural effusion)
• Chronic constrictive pericarditis
• Acute rheumatic fever.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 103; Short and Long Cases in Clinical Medicine, HN Sarker Page: 243

As follows:

Causes of right-sided pleural effusion

• Liver abscess
• Meig’s syndrome
• Dengue hemorrhagic fever.

Causes of left-sided pleural effusion

• Acute pancreatitis
• Rheumatoid arthritis
• Dressler’s syndrome (pleurisy, pericarditis, and pyrexia-3P)
• Esophageal rupture (Boerhaave’s syndrome)
• Dissecting aneurysm.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 103

As follows:

• All causes of transudative effusion (CCF, nephrotic syndrome, cirrhosis of liver, malabsorption or malnutrition or hypoproteinemia).
• Collagen diseases (rheumatoid arthritis and SLE).
• Lymphoma
• Bilateral extensive pulmonary TB.
• Pulmonary infarction.
• Malignancy (usually multiple metastases involving both lungs).

* Long Cases in Clinical Medicine, ABM Abdullah Page: 103

As follows:

• Chest injury or trauma
• Bronchial carcinoma
• Pulmonary infarction
• Pleural mesothelioma
• Others – SLE, lymphoma, acute pancreatitis.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 105

As follows:

• Bacterial pneumonia
• Lung abscess (bursting in pleural cavity)
• Bronchiectasis
• Tuberculosis
• Secondary infection after aspiration
• Rupture of subphrenic abscess or liver abscess
• Infected hemothorax.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 105

Injury or obstruction of thoracic duct due to any of the following causes:

• Traumatic (surgery and trauma to the thoracic duct)
• Neoplastic (bronchial carcinoma and metastasis)
• Infective (tuberculosis and filariasis)
• Lymphoma involving thoracic duct.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 106

In both cases, fluid may be cloudy. It is centrifuged and following is observed:

• If clear, empyema
• If persistent cloudy or milky, chylothorax.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 106

As follows:

• Bronchial carcinoma
• Pleural mesothelioma
• Lymphoma
• Collagen disease (SLE)
• All causes of transudate (CCF, nephrotic syndrome, cirrhosis of liver).

* Long Cases in Clinical Medicine, ABM Abdullah Page: 106

As follows:

• Pulmonary eosinophilia
• Polyarteritis nodosa
• Rarely lymphedema.

Note

• High eosinophil in the pleural fluid but not in the blood is likely due to pulmonary embolism.
• High eosinophil in pleural fluid is unlikely to be malignant.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 107

Excess pleural fluid accumulation occurs when pleural fluid formation exceeds absorption or normal pleural fluid formation with reduced absorption. Probable mechanisms are:

• Increased hydrostatic pressure (as in CCF)
• Reduced plasma colloidal osmotic pressure (as in hypoproteinemia)
• Involvement of pleura causing increased permeability (as in TB and tumor)
• Impaired lymphatic drainage of pleural space (as in obstruction of lymphatic system by tumor, TB and radiation)
• Transdiaphragmatic passage of fluid (in liver disease, ascites and acute pancreatitis).

* Long Cases in Clinical Medicine, ABM Abdullah Page: 107

Hypersensitivity to tuberculous protein in pleural space.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 108

Pleuritic chest pain is localized, sharp or lancinating in nature, worse on coughing, deep inspiration or movement.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 102

As follows:

• Pleural effusion (stony dullness)
• Thickened pleura
• Consolidation (woody dullness)
• Collapse of the lung
• Raised right hemidiaphragm (due to hepatomegaly or liver pushed up)
• Mass lesion.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 102

Stony dullness on percussion and reduced or absent breath sound (confirmed by aspiration).

* Long Cases in Clinical Medicine, ABM Abdullah Page: 102

• Inspection
  • Movement diminished on right side
• Palpation
  • Trachea and apex beat deviated to left
  • Expansibility reduced on right side
  • Vocal fremitus diminished on right side
• Percussion
  • Stony dull on right side
• Auscultation
  • Breath sound diminished or absent on right side
  • Vocal resonance diminished or absent on right side.

* Pre-exam preparation for medicine, HN Sarker

As follows:

1. X-ray chest P/A view
2. Hb%, TC, DC, ESR (high ESR in TB, leukocytosis in pneumonia)
3. Mantoux test (MT)
4. Aspiration of pleural fluid for analysis-
5. Physical appearance (straw colored, serous, hemorrhagic, chylous)
   • Gram-staining, cytology (routine) and exfoliative cytology (malignant cells)
   • Biochemistry (protein and sugar), also a simultaneous blood sugar, protein and lactate dehydrogenase (LDH) may be done
   • ADA (high in tuberculosis)
   • Culture and sensitivity (C/S)
   • AFB and mycobacterial C/S
6. Pleural biopsy by Abram’s or Cope’s needle
7. Other investigation of pleural fluid (according to suspicion of cause):
   • Cholesterol, LDH and rheumatoid factor (in rheumatoid arthritis)
   • Amylase (high in acute pancreatitis, esophageal rupture, malignancy)
   • Trigycerides (in chylothorax)
8. Sputum (if present) for Gram staining, C/S, AFB, mycobacterial C/S and malignant cells (exfoliative cytology)
9. If palpable lymph node: FNAC or biopsy (for lymphoma, metastasis)
10. Other investigations according to suspicion of causes include:
    • ANF, anti-ds DNA (SLE)
    • Liver function tests
    • Urine for protein and serum total protein (nephrotic syndrome)
    • Bronchoscopy and biopsy (if needed in bronchial carcinoma)
    • CT scan in some cases (it helps to clarify pleural abnormalities more readily than chest X-ray and ultrasonogram, and also helps to distinguish between benign and malignant diseases).

* Long Cases in Clinical Medicine, ABM Abdullah Page: 101

X-ray chest PA view showing:

• Dense homogenous opacity in left lower zone with a curvilinear upper border (concave upper margin).
• There is obliteration of left costophrenic angle.
• Trachea and heart (mediastinum) are shifted to the right.
• Rest of the lung field is normal and bony case and soft tissue shadows are normal.

Radiological diagnosis: Left-sided pleural effusion.

X-ray chest PA view showing dense homogenous opacity with curvilinear upper border in both lower zones obliterating both costophrenic angles.

Radiological diagnosis: Bilateral pleural effusion.

* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 536

By doing:

• X-ray in lateral decubitus position
• Ultrasonogram (USG) of lower part of the chest
• Occasionally, CT scan of chest may be needed.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 102

At least 500 mL clinically and 300 mL radiologically in PA film.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 243

1. Diagnostic purposes
   • To detect the cause.
2. Therapeutic purposes
   • To reduce breathlessness

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 243

At least 50 mL for diagnostic purpose and not more than 1.5 L on first occasion.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 243

As follows:

• Straw or amber color
• Exudative
• High lymphocyte in pleural fluid
• AFB is found in 20% cases
• Culture for AFB is found in one-third cases
• Pleural biopsy is positive in 80% cases.

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 662

As follows:

• Infection (empyema)
• Tuberculosis
• Advanced malignancy
• SLE
• Rheumatoid arthritis
• Esophageal rupture.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 108

• Pleural fluid amylase may be higher than serum amylase in acute pancreatitis, bacterial pneumonia, esophageal rupture and malignancy.
• It is high in adenocarcinoma of lung and may be useful in differentiating it from mesothelioma.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 108

Right sided pneumothorax.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 242

This is not right-sided pneumothorax as onset is insidious and percussion note is stony dull. In pneumothorax, there is hyper-resonance on percussion.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 243

This is more likely to be tubercular, because:

• In the history, there is low grade fever with evening rise and night sweating
• Marked weight loss
• Cough with slight mucoid sputum.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 100

Example:

The patient is young, bronchial carcinoma is less common (but he is a heavy smoker for 15 years, so carcinoma should be excluded.)

* Long Cases in Clinical Medicine, ABM Abdullah Page: 101

In this case, there is history of breathlessness, weight loss and fever which are not present in thickened pleura. Also, on examination, there is mediastinal shifting with stony dullness on the affected side. These are not found in thickened pleura.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 101

There is stony dullness and reduced breath sound and vocal resonance in the affected area along with mediastinal shifting. These are against consolidation (In consolidation, there is woody dullness, bronchial breath sound, increased vocal resonance and no shifting of the mediastinum).

* Long Cases in Clinical Medicine, ABM Abdullah Page: 101

In para-pneumonic effusion,

• Patient usually has high remittent fever with pleuriac chest pain of short duration.
• Patient is usually toxic.
• On auscultation there may be bronchial breath sound and crepitations though bronchial breath sound is a usual finding above pleural effusion.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 243

In case of collapse, the apex beat and trachea will be shifted to the same side. In addition, if there is collapse with patent bronchus, there will be bronchial breath sound and increased vocal resonance.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 101

As follows:

• Fluid may be thick (empyema)
• Thickened pleura
• Mass lesion.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 102

Note:

• Pleural fluid cholesterol level < 60 mg/dl indicates transudate. In all malignant effusion, pleural fluid cholesterol > 60 mg/dL. So, this test is useful to separate these two types of effusion.
• High pleural fluid ADA indicates tubercular pleural effusion.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 104

* Long Cases in Clinical Medicine, ABM Abdullah Page: 105

As follows:

From history:

• High fever, sometimes hectic, may be associated with chill, rigor and sweating. Fever is persistent or recurrent despite treatment with a suitable antibiotic.
• Malaise, weight loss.
• Pleuritic chest pain, breathlessness.
• Copious purulent sputum if empyema rubtures into a bronchus (bronchopleural fistula).

On examination:

• Toxic, emaciated.
• Tachypnea.
• Tachycardia.
• Features of pleural effusion.
• Clubbing.
• To be confirmed—aspiration which shows pus or purulent fluid.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 105

Clinically this can be diagnosed by:

• Presence of primary cause like CCF, nephrotic syndrome, cirrhosis of liver, etc.
• Associated edema which may be generalized, also ascites, pericardial effusion.
• No history of fever or acute infection.
• Aspiration of fluid shows transudative in nature (serous in color and protein < 3 g%).

* Long Cases in Clinical Medicine, ABM Abdullah Page: 106

As follows:

• Clincally—elderly emaciated or cachexic patient having clubbing with nicotine stain, palpable lymph node, radiation mark on the chest, etc.
• Pleural fluid is hemorrhagic and there is rapid accumulation after aspiration.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 107

Treatment should be according to cause. For example:

• If tuberculosis:
  • Full course antitubercular therapy.
  • Prednisolone 20 to 30 mg daily may be given for 4 to 6 weeks, especially in large effusion.
• If parapneumonic:
  • Aspiration of fluid, may be repeated (if necessary if patient becomes breathless)
  • Antibiotic should be given.
  • If complicated case, especially empyema, thoracostomy may be done.
  • Sometimes, if all fails, thoracotomy with decortication may be necessary.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 108

Usually up to 1500 mL.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 108

Not more than 1.5 L.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 243

Re-expansion pulmonary edema.

Mechanism

• Because of effusion, lung is compressed and there is ischemia to lung parenchyma and necrosis of pulmonary vessels.
• If more fluid is drawn, there is rapid expansion of the lung, as no regeneration of necrotic vessels.
• As a result, more leakage of fluid causing pulmonary edema.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 243; Long Cases in Clinical Medicine, ABM Abdullah Page: 108

• Steroid is mostly given in tubercular pleural effusion.
• Although its role is controversial, some evidences suggest that it promotes rapid absorption of pleural fluid and gives the patient quick symptomatic relief.
• It also prevents pleural fibrosis and adhesion.
• Steroid should be used along with antitubercular therapy.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 108

According to cause:

1. Non-tuberculus:
   • Drainage of pus with wide bore intercostal tube using water seal drainage.
   • Antibiotic for 2 to 6 weeks. IV Co-amoxiclav or cefuroxime plus metronidazole. May be given according to C/S.
   • Surgical intervention if pus is thick or loculated. Surgical decortication of the lung may be needed, if visceral pleura is grossly thickened.
2. Tuberculous empyema:
   • Antitubercular drug
   • Wide bore needle aspiration or intercostal tube drainage
   • Sometimes surgical ablation of pleura.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 106

Treatment of recurrent pleural effusion is done by pleurodesis in the following way:

• A plain rubber tube is introduced in the intercostal space, and fluid is removed as far as possible. Introduce the drug, tetracycline (500 mg) or kaolin or talc through the tube, clamp it and keep for 4 to 8 hours (may be overnight). In malignant pleural effusion, bleomycin 30 to 60 mg is introduced.
• Patients’ posture should be changed 2 hourly to allow the drug to spread in pleural space.
• After 4 to 8 hours, remove any remaining fluid and take out the drainage tube at the height of inspiration.
• The patient usually complains of severe chest pain after pleurodesis. In such case, analgesic should be given.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 107

• Pleural fluid normally present: 5 to 15 mL
• At least 500 mL of fluid is necessary to detect clinically
• At least 300 mL of fluid is necessary to detect radiologically in PA view
• At least 100 mL of fluid is necessary to detect radiologically in lateral decubitus position
• Less than 100 mL or small amount of fluid is detected by ultrasonography (even 20 to 25 mL fluid can be detected).

* Long Cases in Clinical Medicine, ABM Abdullah Page: 102

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease characterised by persistent airflow limitation that is usually progressive, and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases.

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 673

The components of COPD are:

• Chronic bronchitis
• Emphysema.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 235

Chronic bronchitis is defined as cough and sputum on most days for at least 3 consecutive months for at least 2 successive years.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 235

Emphysema is defined as abnormal permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 235

FEV1< 80% predicted and FEV1: FVC<70%.

• FEV1 = Forced expiratory volume,
• FVC = Forced vital capacity

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 235

Figure: Spirometric classification of COPD severity based on post-bronchodilator FEV1

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 675

When pulmonary gas exchange fails to maintain normal arterial oxygen and carbon dioxide levels is termed respiratory failure.

* Pre-exam preparation for medicine, HN Sarker

Type I and II relates to the absence or presence of hypercapnia (raised PaCO₂)

1. Type I respiratory failure (PaO₂<8 and PaCO₂<6.6)
2. Type II respiratory failure (PaO₂<8 and PaCO₂>6.6).

* Pre-exam preparation for medicine, HN Sarker

15% of smokers are susceptible to develop COPD.

* Pre-exam preparation for medicine, HN Sarker

As follows:

• Increased mucus production and reduced mucocilliary clearance
• Loss of elastic recoil
• Increased muscle tone
• Pulmonary hyperinflation.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 79

Airflow obstruction in emphysema is irreversible but in chronic bronchitis there is some degree of reversibility of airflow obstruction due to presence of inflammation.

* Pre-exam preparation for medicine, HN Sarker

• Environmental
  • Tobacco smoke accounts for 95% of cases in UK
  • Indoor air pollution; cooking with biomass fuels in confined areas in developing countries
  • Occupational exposures, such as coal dust, silica and cadmium
  • Low birth weight may reduce maximally attained lung function in young adult life
  • Lung growth: childhood infections or maternal smoking may affect growth of lung during childhood, resulting in a lower maximally attained lung function in adult life
  • Infections: recurrent infection may accelerate decline in FEV1; persistence of adenovirus in lung tissue may alter local inflammatory response, predisposing to lung damage; HIV infection is associated with emphysema
  • Low socioeconomic status
  • Cannabis smoking
• Host factors
  • Genetic factors: α1-antiproteinase deficiency; other COPD susceptibility genes are likely to be identified
  • Airway hyper-reactivity

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 674

At least 10 pack years (1 pack year = 20 cigarets/day/year).

* Pre-exam preparation for medicine, HN Sarker

• Common organisms: Haemophilus influenzae and Streptococcus pneumoniae.
• Other less common organisms are Moraxella catarrhalis, Chlamydia pneumoniae and Pseudomonas aeruginosa.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 80

Centriacinar, panacinar, and periacinar.

* Pre-exam preparation for medicine, HN Sarker

The causes of type I respiratory failure are:

• Acute asthma
• Emphysema
• Pulmonary edema
• Pneumonia
• Lung fibrosis.

* Pre-exam preparation for medicine, HN Sarker

The causes of type II respiratory failure are:

• Acute severe asthma
• COPD
• Ankylosing spondylitis
• Kyphoscoliosis.

* Pre-exam preparation for medicine, HN Sarker

Usually the patient is above 40 years, male and smoker. There is:

• Chronic cough and sputum production, which is progressively increasing
• Progressive breathlessness
• There may be hemoptysis, edema and morning headache (due to hypercapnia).

* Long Cases in Clinical Medicine, ABM Abdullah Page: 79

See more about dyspnoea at presenting problems of respiratory system

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 674

• Muscular weakness reflecting deconditioning and cellular changes in skeletal muscles
• Increased circulating inflammatory markers
• Impaired salt and water excretion leading to peripheral oedema
• Altered fat metabolism contributing to weight loss
• ↑ Prevalence of osteoporosis

Figure: The pulmonary and systemic features of COPD.

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 673

General examination

• Patient is dyspneic.
• Pursed-lip breathing.
• Cyanosis
• Respiratory rate is 30/min

Examination of the chest

• Inspection
  • The chest is barrel shaped.
  • Excavation of supraclavicular and suprasternal fossae.
  • Indrawing of costal marginson inspiration (due to low flat diaphragm), and intercostals spaces.
  • Prominent accessory muscles (e.g.sternomastoid and scalene muscles) of respiration.
• On palpation:
  • Trachea, central, tracheal tug is present (descent of trachea during inspiration).
  • Cricosternal distance (distance between suprastemal notch and cricoid cartilage) is reduced (normally three fingers or more).
  • Apex beat is not felt.
  • Chest expansion is reduced and chest movement is vertical.
  • Vocal fremitus is reduced on both sides.
• On percussion:
  • Increased resonance or hyperresonance in both lung fields.
  • Obliteration of liver and cardiac dullness (liver dullness may be lower down)
• On auscultation:
  • Breath sound, diminished; but vesicular with prolonged expiration.
  • Low or medium-pitched rhonchi may be present, if associated with chronic bronchitis.
  • Vocal resonance normal.

* Pre-exam preparation for medicine, HN Sarker; Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 157

We can predict acute infective exacerbation by—

• Increased breathless and cough
• Increased sputum volume and purulence
• Fever

* Pre-exam preparation for medicine, HN Sarker

• Blood
  • complete blood count (CBC),
  • erythrocywe sedimentation rate (ESR),
  • packed cell volume (PCV)
• X-ray chest posteroanterior (PA) view
• Electrocardiogram (ECG)
• Arterial blood gas (ABG)
• Sputum-microscopy (culture and sensitivity)
• Lung function test
• High-resolution computed tomography
• α-antitrypsin level.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 236

Emphysema

The radiological findings in COPD are:

• Hyperinflated lung field
• Low flat diaphragm
• Long tubular heart shadow
• Hyperlucent lung fields
• Horizontal ribs
• Widened intercostal spaces
• Roomy apex
• Emphysematous bullae

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 236; Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 158

The ECG findings in COPD are:

• Right ventricular hypertrophy +/– strain
• Right atrial hypertrophy (P pulmonale)
• Multifocal atrial tachycardia.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 236

• Type II respiratory failure (PaO₂ <8 and PaCO₂ >6.6) in chronic bronchitis.
• Type I respiratory failure (PaO₂ <8 and PaCO₂ <6.6) in emphysema.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 236

As follows:

• FEV1 < 80% predicted
• FEV1 : FVC < 70% predicted
• Bronchodilator reversibility test shows <15% increase in FEV1  after giving bronchodilator.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 79

• FEV1<80% predicted and FEV1: FVC<70% (airflow obstruction)
• ↑ Total leukocyte count (TLC), functional residual capacity (FRC) and residual volume
• ↓ Vital capacity(VC)
• ↓ TLCO (carbon monoxide transfer factor).

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 237

The patient is a heavy smoker, taking … cigarettes a day for … years, there is chronic cough with breathlessness, which is progressively increasing day by day.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 78

As follows:

• Chronic severe or persistent bronchial asthma
• Bronchiectasis
• Chronic bronchitis
• Congestive cardiac failure.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 78

Because chronic bronchitis is defined as the presence of cough with sputum, not attributable to other causes, on most of the days of at least 3 consecutive months for 2 successive years.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 78

Bronchial asthma is reversible, but COPD is not fully reversible and it is progressive.

See full difference at Bronchial asthma

* Long Cases in Clinical Medicine, ABM Abdullah Page: 78

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 236

By spirometry and reversibility test.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 94

General measures

• Stop smoking completely and permanently.
• Vaccination for influenza and pneumococcal pneumonia.

Drug therapy

1. Mild COPD
   • Short-acting bronchodilators, such as the β2-agonists salbutamol or the anticholinergic, ipratropium bromide, as needed.
2. Moderate COPD
   • Regular short-acting bronchodilators (alone/combination) +
   • Longer-acting bronchodilators, such as the β2- agonists salmeterol and formoterol, or the anticholinergic tiotropium bromide (alone/combination)
3. Severe COPD
   • Short-acting bronchodilators (alone/combination) +
   • Longer-acting bronchodilators, such as the b2- agonists salmeterol and formoterol, or the anticholinergic tiotropium bromide(alone/combination) +
   • Inhaled corticosteroids (ICS) if two or more exacerbations requiring antibiotics or oral steroids per year. +/–
   • Oral theophylline.

Figure: Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for treatment of COPD.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 237; Figure: Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 676

Oxygen O2 is given 2 to 4 L/min for 15 hours/day by nasal prongs. The aim is to increase the PaO2 to at least 8 kPa (60 mm Hg) at sea level during rest or SaO2 to at least 90% (greater benefit may be seen in patients who receive > 20 hours per day).

Note: Regarding air travel:

• Preflight assessment should be done by spirometry and hypoxic challenge test with 15% oxygen. If saturation is maintained >90%, the patient can be allowed to travel. If not, air travel should be avoided or undertaken only with inspired oxygen therapy.
• Sufficient supplementary oxygen should be given during flight to keep the PaO2 above 50 mm Hg, which is achieved by increasing the flow by 1 to 2 L/min.
• Patient who use to take continuous oxygen at home will require this supplementation.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 81

Inhaled steroid is recommended for symptomatic patient with moderate to severe COPD and for patients with frequent exacerbations, but not in mild COPD. It reduces the frequency and severity of exacerbation. There is small improvement of FEV1, but it does not alter the natural history of FEV1 decline.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 82

Bullectomy, lung volume reduction surgery (LVRS), and lung transplantation.

* Pre-exam preparation for medicine, HN Sarker

Home management: Mild to moderate exacerbation by the use of

• Increased bronchodilator therapy
• A short course of oral corticosteroids
• Antibiotics if appropriate.

Hospitalization

• Oxygen 24% or 28% (Continuous low concentration oxygen via Venturi mask)
• Bronchodilators: Nebulized short-acting β2-agonists combined with an anticholinergic agent (e.g. salbutamol with ipratropium).
• Corticosteroids: Oral prednisolone—30 mg daily for 10 days.
• Antibiotics: Amoxicillin or macrolide.
• Respiratory support: Noninvasive ventilation for severe hypercapneic respiratory failure (pH<7.35)
• Respiratory stimulant, i.e. doxapram if noninvasive ventilation is not available.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 237; Long Cases in Clinical Medicine, ABM Abdullah Page: 82

The indications for hospitalization are:

• Cyanosis
• Peripheral edema
• An alteration in consciousness
• Comorbidity
• Social isolation.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 237

The principles are:

• In type I, high concentration (i.e.>35%, usually 60%)/high flow (6–8 L/min)
• In type II, low concentration (24%–28%)/low flow(1–2L/min).

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 236

• A small percentage of patients with severe chronic COPD and type II respiratory failure develop abnormal tolerance to raised PaCO2.
• The patient may become dependent on hypoxic drive for respiration
• High flow oxygen blunts the chemoresponsiveness of the respiratory center in the medulla (part of the brainstem) and thus aggravates respiratory failure (Type 2 respiratory failure).
• To avoid this, in these patients, lower concentrations of oxygen 24%–28% by Venturi mask should be used to avoid precipitating worsening respiratory depression.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 236; Long Cases in Clinical Medicine, ABM Abdullah Page: 83

When the patient is clinically stable on his or her maintenance medication.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 237

• The prognosis is inversely related to age and directly related to the post-bronchodilator FEV1.
• A composite score comprising the body mass index (B), the degree of airflow obstruction (O), a measurement of dyspnoea (D) and exercise capacity (E) may assist in predicting death from respiratory and other causes.
• Respiratory failure, cardiac disease and lung cancer represent common modes of death.

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 677

The complications of COPD are:

• Pulmonary hypertension
• Cor pulmonale
• Respiratory failure
• Polycythemia
• Pneumothorax
• Secondary infection.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 237