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EXAMINATION
INSPECTION
 General look of the patient
i.
Cyanosed
ii.
Breathless
iii.
Air hunger
iv.
Pursed lip breathing (COPD)
v.
Pink puffer (Emphysema)
vi.
Blue Bloaters (chronic Bronchitis)
 Inspection of Chest
 Respiratory rate
 Shape of the chest (Elliptical- Normal, Barrel, Funnel, Ricketic, Pigeon shape)
 Movement of chest
 Symmetry of Chest (Symmetrical, Asymmetrical)
 Types of Respiration (Abdomino-thoracic or Thoraco-abdominal)
 Visible Apex Beat
 In drawing of Ribs
 Tracheal Tug
 Supraclavicular Fossae
 Prominent Veins, Scar, Pigmentation
PALPATION
 Trachea
(Normally it is centrally placed) if not then
 Pull
(Fibrosis, Collapse)
 Push
(Pleural Effusion, Pneumothorax, Malignancy)
 Trail Sign is +ve in COPD
 Chest Expansion
(Normal expansion is 3-5 cm)
 Decreased in
(Fibrosis, Collapse, Pleural effusion, Pneumothorax, Consolidation)
 Vocal Fremitus (Tactile Fremitus)
 Increased in
(Consolidation, Cavitation, Collapse with Patent Bronchus)
 Decreased in
(Pleural Effusion, Pneumothorax, Fibrosis, Collapse with Obs:
Bronchus)
 Apex Beat
 Displaced in
(Collapse, Pleural Effusion, Pneumothorax, Fibrosis)
 Tenderness
 Hypertrophic Pulmonary Osteoarthropathy
(Bronchogenic Carcinoma)
 Teitz Syndrome
(Costo-chondritis)
 Fracture of Rib
PERCUSSION
 Normal percussion note is RESONANT
 Hyper-Resonant
(Emphysema, Pneumothorax)
 Dull
(Consolidation, Fibrosis, Collapse)
 Stony Dull
(Pleural effusion)
 We do Tidal Percussion for the movement of Diaphragm
AUSCULTATION
 Normal Breathing is “Vesicular Breathing”
 Inspiration is longer than Expiration
 Inspiration is harsher than Expiration
 No gap b/w Inspiration & Expiration
 Bronchial Breathing
(Consolidation, Fibrosis, Collapse)
 Expiration is longer than Inspiration
1






 Marked gap b/w Inspiration & Expiration
Plural Rub
(Pleuritis)
Pericardial Rub
(Pericarditis)
Pleuro-Pericarditis
Crepitations
(Fine in Pulmonary edema, Coarse in TB & Pneumonia)
Wheeze
(Asthma, COPD)
Vocal Resonance
 Increased in
(Consolidation, Cavitation, Collapse with Patent Bronchus)
 Decreased in
(Pleural Effusion, Pneumothorax, Fibrosis, Collapse with Obs:
Bronchus)
PNEUMONIA
Def: Acute inflammatory consolidation of lung parenchyma.
CLASSIFICATION OF PNEUMONIA
ANATOMICAL
 Lobar Pneumonia
 Segmental / Lobular Pneumonia
 Broncho pneumonia
HISTOLOGICAL
 Typical Pneumonia
 Atypical Pneumonia
PATHOLOGICAL (Causative Organism)
 Bacterial Pneumonia
i.
Streptococcal Pneumonia
ii.
H-influenza
iii.
Staphylococcal Aureus
iv.
Klebsella
v.
Moraxella Catarrhalis
vi.
Pseudomonas
vii.
E-coli
viii. Anaerobes
ix.
Mycoplasma
x.
Coxiella Burnetti
xi.
Rickettsia
xii.
Legionella
 Viral Pneumonia
i.
Adeno virus
ii.
Coxsackie Virus
iii.
Influenza virus A, B etc….
 Parasites (Loeffler’s Pneumonia)
i.
Ascaris Lumbricoides
ii.
Toxicora
iii.
Paragonimus Westermeni
 Fungal Pneumonia
i.
Aspergilloma
 Lipid Pneumonia
(Bronchogenic Carcinoma)
CLINICAL CLASSIFICATION
 Community Acquired Pneumonia (Pneumonia which occur in previously healthy or
within 48 hours of hospitalization)
 Hospital Acquired Pneumonia
(After 48 hours of hospitalization)
(E-Coli, Klebsella, Pseudomonas, Staphylococcus Aureus)
C/F
 Fever (high grade) with Chills
 Cough initially dry then productive (initially Mucoid then Purulent)
 Dysponea, Chest pain
2
EXAMINATION
Inspection
 Increased Respiratory Rate
 Decreased Chest Movement on the affected side
Palpation
 Chest expansion reduced
 Increased Vocal Fremitus
 Trachea may be deviated to opposite side if pleural effusion
Percussion
 Note is DULL
Auscultation
 Bronchial Breathing
 Some times Crepitations
INVESTIGATION
1.
Chest X-ray:
 Consolidation (Opacity) in Lobar / Segmental
 Patchy infiltration
in Bilateral Bronchopneumonia
 Para pneumonic Effusion
2.
Blood CP:
 Increased WBC
 Raised ESR
3.
Sputum for Microscopy
4.
Sputum for Culture
5.
Serology
 Ab
(against Mycoplasma, Rickettsia, Chlamydia, Legionella etc…)
 Immunoflouresence Ab
 Coombs Test
ATYPICAL PNEUMONIA
In this case extra pulmonary are more common.
i.
Low grade fever
ii.
Head ache
iii.
Nausea
iv.
Vomiting
v.
Diarrhea
vi.
Myalgia
vii.
Arthralgia
viii. Dry Cough
TREATMENT OF PNEUMONIA
Empirical therapy (out patient treatment) for 14 days
 Amoxycillin + Clavilumic Acid (Augmentin 625mg 1+0+1)
OR
 Cefaclor
(Ceclor 500mg)
OR
 Cefuraxime axetil
(Zinacef 250mg 1 x OD)
OR
 Clarithromycin
(Klaricid)
OR
 Ofloxacin
(Oflobid)
OR
 Levofloxacin
(Xeflox, Novidate).
CRITERIA FOR HOSPITALIZATION
 Extreme of Age
(>65 years or <05 years)
 Co morbidity
(IHD, DM, CLD, COPD, AIDS, Renal Failure etc…)
 Seriously ill patients
 Not responding to empirical therapy
 Leucopoenia
 If we found these signs
o Tachycardia
>140 beats/ min
3
o Tachypenia
o PaO2
>30 breaths/ min
<60cm of H2O
TREATMENT
 Bed Rest
 Proper Nutrition
 Anti Pyretic
 O2 inhalation if require
 Empirical Therapy (out patient treatment) but all in the form of injections.
COMPLICATIONS OF PNEUMONIA








Pulmonary Complications
Lung Abscess
Bronchiectasis
Cavitation
Collapse
Respiratory Failure
Pleural effusion
Empyema
Pleuritis
Extra Pulmonary Complication
Sinusitis
Meningitis
Otitis Media
Endocarditis
Precipitate Cardiac Failure
Precipitate Atrial Fibrillation
ATN
Septicemia
COPD
Chronic Bronchitis
Emphysema
Chronic Bronchitis: Chronic persistent productive cough for more than 3 months in consecutive 2
years is called chronic Bronchitis.
Emphysema:
Permanent dilation of Respiratory Unit (below the level of terminal
bronchiole) because of destruction of wall of it.
Risk factors:
Active
 Smoking
>10pack year (20 cigarettes per day till 10 years)
Passive
 Pollution
 Free Radicals
 Alpha 1 Anti trypsin deficiency (Pi ZZ) genotype
Symptoms
 Persistent Cough, some times turbid, productive usually in morning time.
 Dysponea
Signs (on inspection)
 Barrel shaped chest
 Pink puffer / Blue bloaters
 Pursed Lip Breathing
 Accessory muscle use during respiration
 In drawing of ribs
 Prominent Supra Clavicular Fossa
 Tracheal tug may be seen
 RR may be increased
On Palpation
 Tracheal tug (trail sign)
4
 Apex beat may be displaced
On Percussion
 Hyper resonant
On Auscultation
 NVB with may be prolong expiration
 There may be Wheeze
 There may be Crepitations
INVESTIGATION
1.
Chest x-ray
 Hyper translucent Lung folds
 Widening of intercostal spaces
 Flattening of diaphragm
 Tubular Heart
 Emphysematous Bullae
2.
Pulmonary Function Test (Spirometry)
 FEV1
=
<80%
 FEV1 / FVC
=
<70%
3.
Blood CP
 Polycythemia
 ESR (may be raised)
 C-reactive Protein Raised
4.
ECG
5.
6.
 P- Pulmonale
Sputum DR & Culture
 Infections
ABGS
 For Severity
 Alpha 1 Anti trypsin deficiency
 Alpha 1 Anti trypsin Level
MANAGEMENT
 Cessation of smoking
 First Ask then Advice then Assess then Augment then Assist
 5 years complete cessation is equal to non-smokers.
 To reduce Dysponea
 Theophylline
 Ipratropium bromide
 B2 Agonist (sos short term)
 Anti inflammatory
 Corticosteroids
 If infection then give antibiotics
 L.T.O.T: (Severely ill)
 O2 for 15 hrs in 24 hrs
COMPLICATIONS
 Pneumothorax
 Fibrosis
 Collapse
5
 Pulmonary HTN
 Cor- Pulmonale
 Type II Respiratory Failure (hypoxemia + hypercapnia)
TUBERCULOSIS
Def: Chronic grnulomatous inflammation with caseous necrosis caused by Acid Fast Bacilli.
CAUSATIVE ORGANISM (Obligate Aerobes)
1. Mycobacterium tuberculosis
Typical
2. Mycobacterium Bovis
3. Mycobacterium Avium Intercellularis
4. Mycobacterium Cheloni
5. Mycobacterium fortuitum
Atypical
6. Mycobacterium Marinum
7. Mycobacterium Gastrae
SITE:
Primary sites:
i.
Lung
ii.
Intestine
iii.
Lymph nodes
iv.
Tonsils
v.
Skin
Secondaries
i. TB Meningitis
ii.
iv. Genito urinary TB v.
vii. Lupus Vulgaris (skin)
Tuberculoma (Brain)
TB Osteomyelitis
etc…
iii.
vi.
TB Serositis
TB Adrenal Glands
PRIMARY TUBERCULOSIS
 In non immune person who is not previous infected
 It can lead to Miliary TB
 Usually A symptomatic
 Calcification cause buried of Mycobacterium
 We see GHON FOCUS (sub plural parenchyma around interlobar fissure)
 We also see GHON COMPLEX (ghon focus + hillar Lymph node involvement)
SECONDARY TUBERCULOSIS
 Because of re-infection OR re-activation of previous lesion.
 Symptomatic
 Usually lung apex involve
 Cavitation
SYMPTOMS
 Low grade fever
 Night sweats
 Anorexia
 Wt: loss
 Lethargic
 Chronic cough with sputum
 If long standing TB then Hemoptysis
 If TB complicated then Pleuritis, Pleural effusion, Pneumothorax, and Chest pain.
6
W.H.O CATEGORIZATION OF TB
Category I:
 New cases smear +ve with pulmonary parenchymal involvement
 Smear –ve with severely parenchymal disease
 Severe extra pulmonary TB (eg. TB Meningitis)
Category II:
 Defaulters
 Re RX
 Relapse
Category III:
 Extra pulmonary TB
Category IV:
 Drug resistant
 MDR
 Chronic cases
Some important definitions
 New Cases: Patients who never taken ATT before OR if taken then less then 4 weeks.

Smear Positive: Consecutive 3 samples of sputum for AFB. Out of them 2 are positive OR if
one is positive + chest X-ray shows active lesion.

Smear Negative: Only chest X-ray shows active pulmonary lesion.

Relapse: patient has completed ATT course and declared as a cure patient but now again he
come with active lesion.

Drug Resistant: Patient has taken regular ATT for 5 months but still he is smear positive.

Multiple Drug Resistant: Patient is resistant for RIFAMPICIN + ISONIAZID.

Chronic Cases: Complete 8 months therapy but not declared as a cure.
INVESTIGATION
1.
Chest X-ray:
 Consolidation
2.
Sputum for AFB
 Total 03 samples, 01 sample every morning for 03 days before breakfast.
3.
Sputum Culture Sensitivity
4.
PCR
5.
Biopsy
6.
Tuberculin Skin Test {PPD} (Montoux Test)
 > 15 mm suggestive of TB
 10-15 mm doubtful
Sensitivity & Specifity is low
 05-10 mm unlikely
7
TREATMENT
Category I
Initial Regimen
Give initial regimen for 02 months, which include
(Rifampicin + Isoniazid + Ethambutol + Pyrizinamide)
Then go for Sputum AFB
If Sputum –ve
if Sputum +ve
Then continue initial regime for 1 month more
Then start maintenance therapy
then start maintenance therapy
Maintenance Regimen (continuation phase)
Rifampicin + Ethambutol (for 6 months)
OR
Rifampicin + Isoniazid (for 4 months)
Total regimen duration for ATT in Category I
{08 months if continuation with Rifampicin + Ethambutol}
OR
{06 months if continuation with Rifampicin + Isoniazid}
Category II
Initial Regimen
Give initial regimen for 02 months with 05 drugs
(Rifampicin + Isoniazid + Ethambutol + Pyrizinamide + Streptomycin)
Then go for Sputum AFB
If Sputum –ve
Then give 4 drugs for 01 month
{R H E Z}
if Sputum +ve
then continue initial regime for 1 month more
{R H E Z + S}
Now again go for sputum AFB
Then start maintenance therapy
Maintenance Regimen (continuation phase)
then start maintenance therapy
Rifampicin + Ethambutol + Isoniazid (for 5 months)
In category II go for Sputum AFB
 At the end of 02 months
 At the end of 03 months
 At the end of 05 months
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Category III
Initial Regimen
Give initial regimen for 02 months, which include
(Rifampicin + Isoniazid + Ethambutol + Pyrizinamide)
Then go for Sputum AFB
If Sputum –ve
if Sputum +ve
Then continue initial regime for 1 month more
Then start maintenance therapy
then start maintenance therapy
Maintenance Regimen (continuation phase)
Rifampicin + Ethambutol (for 6 months)
OR
Rifampicin + Isoniazid (for 4 months)
Category IV
In this case we treat with one of the following drug or combination of 2 or 3 drugs
1. Ofloxacin
2. Amakacin
3. Kanamycin
4. Cycloserine
5. Ethionamide
6. Rifabutin
7. 5 Amino salicylic Acid
8. Capreomycin
9. Levofloxacin
INDICATION OF STEROIDS IN T.B
1.
2.
3.
4.
5.
6.
(Market name: - Oflobid)
(Market name: - Gracil, Amakin)
(Market name: - Novidat, xeflox, leflox)
Disseminated T.B (Miliary)
Extensive Pulmonary parenchymal lesion
If Rashes Developed
Drug Resistant
TB Meningitis
Genito urinary TB
T.B IN PREGNANCY
In case of T.B in pregnancy we can give all the drugs except “STREPTOMYCIN” because it cross
the placental barrier & can Cause
 Vestibular Damage
 VIII cranial nerve lesion
 Renal failure both Mother & Baby (Fetus)
 Abortion
 Still Death
9
DESCRIPTION OF INDIVIDUAL DRUGS
ISONIAZID
Mechanism of Action: - It inhibit Mycotic Acid present in the wall of Mycobacteria, so it is
BACTERICIDAL
Indications:

Treatment of T.B

Prophylaxis of T.B
Side Effects:

Hepatotoxicity (Jaundice)

Peripheral Neuropathy

Hypersensitivity Reaction
Dose:
5 mg /kg /day
Max: 300 mg / day before breakfast
RIFAMPICIN
Mechanism of Action: - Inhibits DNA dependent RNA polymerase
Indications:

Treatment of T.B

Prophylaxis of T.B
Side Effects:

Hepatotoxicity (Jaundice)

Skin Rashes

Hypersensitivity Reaction

Flu Syndrome (fever, Rhino rhea, Cough)

Abdominal Pain, Diarrhea

Discoloration of Urine

Cause Enzyme Induction
Dose:
10 mg /kg /day before breakfast
ETHAMBUTOL
Mechanism of Action: - Unclear
Indications:

Treatment of T.B

Prophylaxis of T.B
Side Effects:

Retinobulbar Neuritis (Should not given to Children)

Colour Blindness

Hepatitis

Hypersensitivity Reaction
Dose:
15-25 mg /kg /day before breakfast
10
PYRIZINAMIDE
Side Effects:



Hyperurecemia
Gont
Hepatitis
Dose:
15-30 mg /kg /day before breakfast
STREPTOMYCIN
Dose:
15 mg /kg /day I/M injection
DOT THERAPY (Directly Observed Therapy)
This is the observing therapy, which is for checking the patients that he is taken medicine properly or
not & see the improvement in the patient’s health after taking medicine and it is done by
1. Close Family Member
2. Patient himself come to nearby health facility unit
3. Any respectable member of society.
COMPLICATIONS OF T.B








Pulmonary Complications
Consolidation
Bronchiectasis
Fibrosis
Collapse
Cavitation
Pleural effusion
Pneumothorax
Respiratory Failure
Extra Pulmonary Complication
T.B Meningitis
Fluctynular Conjunctivitis
Lupus Vulgaris (skin)
T.B Pericarditis
T.B Lymph Nodes
Pott’s Disease
TB Osteomyelitis
Infertility
ASTHMA
Def: Chronic inflammatory reversible process of Airway in which there is episodic attacks of
breathlessness, cough, and wheeze & chest tightness.
1.
2.
3.
4.
Cardiac Asthma
Central chest pain radiating to shoulder
Neck & arm etc…
No attacks when exposed to dust
Occurs usually at night & during exertion
At daytime.
Because of Pulmonary edema Bilateral
Crepitations.
Bronchial Asthma
not radiate to shoulder, neck, arm etc…
H/o of attack when exposed to dust, pollen, cold
Usually attacks in Morning & Evening
Wheeze with NVB with prolong expiration
11
TYPES OF ASTHMA:
1. Extrinsic Asthma (Atopic)
Patient is hypersensitive to exogenous Allergens.
(Ag - Ab reaction) Type-I Allergy
2. Intrinsic Asthma
Hyper responsive Airway to endogenous substance
(Viral Fever, Emotions)
3. Chronic Asthma
Chronic persistent Asthma, which is episodic for 6 months
4. Occupational Asthma
CLINICAL CLASSIFICATION
1. Mild Asthma
 Dysponea on activity
 Patient can complete sentence during attack
 On auscultation wheeze during end of expiration
2. Moderate Asthma
 Dysponea on talking
 Can complete phrase
 On auscultation wheeze during whole expiration
3. Severe Asthma
 Dysponea on rest
 Speak only single word with difficulty
 On auscultation wheeze during all phase of respiration
Status Asthmaticus
Severe Asthma + Tachycardia > 120/ min + pulsus Paradoxus + RR >30 /min +Use of
Accessory Muscle +Cyanosed
INVESTIGATION
1.
Pulmonary Function Test (gold standard)
 FEV1
=
<80 %
this shows Obstructive pattern.
 FEV1 / FVC =
<70%
Now give Beta 2 Agonist inhalation (inhaler, nebulizer)
So if FEV1 & FEV1 / FEC ratio becomes normal after giving Beta 2 Agonist so Asthma
is Confirmed
Means Reversibility Test is +ve
2.
Chest X-ray
 Usually Normal
3.
Blood CP
 Esinophilia
4.
Ig E Level
 Increased in Atopic Asthma
5.
Other Lab Investigations
 Curshman’s Spirals Present in Sputum OR Exfoliated Pseudostatified Epithelium
 Charcot Laden Crystals: - These are the protein liberated from esinophils & mast cells
6.
If a patient is in Acute Severe Asthma & is Cyanosed then send ABGS.
12
TREATMENT
 STEP UP THERAPY: - Previous Concept that start Anti Asthmatic RX with low dose
 STEP DOWN THERAPY: - New concept start RX according to the level of severity.
STEP I:
STEP II:
STEP III:
STEP IV:
STEP V:
Occasional Use of Broncho dilators (Beta 2 Agonist)
Regular Inhaled Corticosteroids (15 – 30 mg / day) with Beta 2 Agonist
High Dose Inhaled Steroids ( 1 mg /kg of body wt / day)
High Dose Inhaled Steroids with Regular Bronchodilator
High Dose Inhaled Steroids with Regular Bronchodilator & Oral steroid
TREATMENT OF MILD ASTHMA


Intermittent -------------Persistent --------------
Step I
Step II
TREATMENT OF MODERATE ASTHMA

Step III & Step IV Therapy
TREATMENT OF SEVERE ASTHMA

1.
Step V Therapy
Short Term Relievers
Beta 2 agonist
Methyl xanthenes derivates
Ipratropium bromide
Short Acting Steroids

BETA 2 AGONIST
i.
Albuterol
ii. Procaterol
iii. Terbuterol
iv.
Salbutamol
v.
Salmeterol
vi.
Formetrol
MEDICATIONS
2.
LONG TERM CONTROLLERS
Long Acting Steroids (see Above)
Mast Cell Stabilizing Agents
(Cromolyn Sodium, Nedocromil)
Leukotrine Inhibitors
(Montelukast, Zafirlukast, Zileuton)
Long Acting B2 Agonist
Desensitization
Short Acting
Long Acting
Mechanism of Action: - These Drugs act on B2 receptors that causes Bronchial dilation
SIDE EFFECTS: - Tremors, Tachycardia, Hyperglycemia, Insomnia, Wild goose chase
13

METHYL XANTHENES DERIVATES
i.
Theophylline
Mechanism of Action: - 5’ diestrase Enzymes Inhibitions so therefore CAMP level
increased, which cause relaxation of Bronchiole Smooth
Muscle.
SIDE EFFECTS: - Hyperkalemia, Cardiac Arrhythmias

IPRATROPIUM BROMIDE
It is Anticholinergic drug
SIDE EFFECTS: - Constipation, Anorexia, Urinary Retention, Dry mouth

GLUCO – CORTICOSTEROIDS
i.
Hydro cortisone
ii.
Prednisolone
iii. Dexamethasone
iv.
Beclomethasone
v.
Fludrocortisone
Mechanism of Action: - Anti inflammatory & it inhibits the gene for cycloxgenase pathway.
SIDE EFFECTS: Truncal Obesity, HTN, Paper Money Skin, Lemon on Stick
Abdominal Striae, Brittle Hair, Osteoporosis, Cataract, Glaucoma
Pseudo tumor cerebri, Hyperglycemia, Secondary Diabetes etc…
COMPLICATIONS
 Hypoxemia (type I Respiratory Failure)
 Pulmonary HTN
 Cor Pulmonale
 Airway Infection
 Acute Severe Asthma
Late Cyanosis
Exhaustion of Respiratory Muscle
Respiratory Arrest
Death
BRONCHOGENIC CARCINOMA
Risk Factors
1. Smoking
2. News paper worker
3. Mine Worker
4. Pollution
5. Uv Rays / Radiotherapy
6. Asbestosis
7. H/o Head & Neck Tumors
8. Fibrosis
14
TYPES
 Central: Small cell Carcinoma & Squamous Cell Carcinoma
 Peripheral: Adeno Carcinoma, Large Cell Carcinoma & Broncho alveolar Ca
C/F
 Clinical feature of tumor itself
 Clinical feature because of Pressure symptoms
 Clinical feature because of paraneoplastic Syndrome
 Clinical feature because of Metastasis
Clinical feature of tumor itself
 Chronic cough, Hemoptysis
 Purulent sputum
 Weight loss
 Anorexia
 Cachexia (generalized muscle wasting)
 Dysponea (if pleural effusion)
 Chest Pain (if Pneumothorax)
Clinical feature because of Pressure symptoms
 Dysphagia (pressure on esophagus)
 Hoarseness of voice (compression over recurrent laryngeal nerve)
 Superior Vena Cava Syndrome (dusky face & prominent Neck Vein)
 Vagus Nerve Involvement (Tachy arrhythmias)
 Pan coast Syndrome (if tumor is of Apical part of lung then medial & lateral cord of Brachial
plexus are compressed so Medial part of upper limb with upper lateral
part of the limb with shoulder pain)
 Horner’s Syndrome (if sympathetic trunk is involved which is present in the carotid sheath so
leading to Partial Ptosis, Anhydrosis on the affected side, Miosis
enophthalmous)
 Ribs Fracture (Rib Osteoporosis)
Paraneoplastic Syndrome
Def: - Symptoms complex apart from Cachexia related to certain substance, which are released
from tumor cells.
Squamous Cell Carcinoma
1. PTH Gamma Peptide (Hyperparathyroidism)
C/f: - Depression, Behavioral Changes, Constipation, Peptic Ulcer, Kidney stone,
Polyuria, Pancreatitis etc…
2. Ectopic ACTH released
Cushing Syndrome with Pigmentation
3. Lambert Eaton Myasthenic Syndrome
I
II
III
Myasthenia Gravis
Autoimmune Disease
As the day passes weakness of Muscle
Progresses
EMG shows “Decremental Waves”
Lambert Eaton Myasthenic Syndrome
Paraneoplastic Syndrome
As the Activity is performed Weakness
reduced
EMG shows “Incremental Waves”
15
4. Trousseaus’ Sign
Hypercogulability because of formation of clotting factors like substance
Small Cell Carcinoma
 ACTH (Cushing Syndrome)
 ADH (Syndrome of inappropriate ADH secretion)
 Decreased Urination
 Volume overload
 Dilutional electrolyte Imbalance
Clinical feature because of Metastasis
SITES

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Lymph Nodes
Brain
Adrenal gland
Liver
Bone
Lymph Nodes: - Large palpable, hard, fixed to skin & underlying structure, Non- mobile, May be
Ulcerated, May compress adjacent Viscera etc…
Brain: -
Fits---> Seizure-----> Coma -----> Death
Adrenal gland: -
Addison’s disease
Liver: - Jaundice, Carcinomatous Cirrhosis, Liver Failure, Hepatic Encephalopathy, Coma, and
Death
Bone: -
Decreased density if bone, Bone Fracture etc…
INVESTIGATION
1. Biopsy (Trans bronchial)
2. Chest X-ray

Consolidation

Fibrosis

Mediasternal widening

Trachea shifted

Collapse

Rib Erosions

Bronchogram Pattern
3. Sputum Cytology
4. CT Scan (Chest, Brain, Abdomen)

To know the extent of tumor & Metastasis
5. Other Lab Investigations

Blood CP (Polycythemia, Increased ESR >100)
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
LFTS (may be deranged, PT & APTT may be prolonged)
TREATMENT
Small Cell Carcinoma
Squamous Cell Carcinoma
Large Cell Carcinoma
Adeno Carcinoma
Chemotherapy
Radiotherapy followed by Chemotherapy
Very Resistant to treatment
Chemotherapy
STAGING
Stage 0
Stage I
Stage II
Ca in situ
Only Tissue Involvement
Tissue Involved + 1 Lymph Node involve
A (more than 3 tissue involvement & 2 Lymph nodes)
Stage III
B (> 3 tissue involvement & 3 Lymph Nodes)
Stage IV
Metastasis
RX According to Stage
If Stage I & Stage II
Stage III A
Stage III B & Stage IV
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Surgery followed by specific treatment of particular Ca.
may be benefited from Surgery
Chemotherapy & Radiotherapy & Palliative treatment.
PLEURAL EFFUSION
Def:
Abnormal collection of fluid in the pleural cavity is called Pleural effusion.
Normally 15 ml is present in the pleural space.
Types of Fluid:
 Transudates
 Exudates s
 Chylous
 Hemorrhagic
TRANSUDATIVE CAUSE
 Liver Cirrhosis
 Protein losing Enteropathy
 Nephrotic Syndrome
 Malnutrition
 CCF
 Constrictive Pericarditis
 Cardiac Temponade
 Peritoneal Dialysis
 Myxedema
HypoAlbuminemia
Cardiac Causes
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EXUDATIVE CAUSES (Inflammation)
 Para pneumonic Effusion (Empyema)
 T.B
 Malignancy
 Connective tissue disorder
 Pulmonary Embolism
 Rickettsia, Chlamydia Infection
 Meig’s Syndrome
(Ovarian Fibroma + Rt Sided Pleural Effusion)
 Viral Infections
 Fungal infections
 Parasitic infections
 Dressler’s syndrome (shoulder pain, fever, pleuropericardial effusion)
CHYLOUS EFFUSION: (Milky white lymph accumulation)
 Lymph Node enlargement & compression over lymphatic draining the pleural cavity
 T.B
 Malignancy
 Sarcoidosis
 Milroy’s disease
HEMORRHAGIC EFFUSION
 Trauma
 Tumor
 Esophageal rupture
 Acute Pancreatitis
C/F
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Exertional Dysponea
Cough
Restlessness
Chest pain
Wt: loss
Wasting
May be fever etc…
INVESTIGATIONS
1. Clinical Examination
 Chest movement reduced
 Trachea may be shifted
 Vocal Fremitus decreased
 Percussion note is Stony Dull
 Breath Sounds Diminished
2. Chest X-ray
 Loss of Costopherinic angle (initially)
 Loss of Lung Field (Massive Effusion)
3. Chest U /s (for loculated effusion)
4. Diagnostic Thoracentesis
 Aspirate pleural fluid for the diagnosis of cause of effusion.
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LIGHT’S CRITERIA (modified) for Exudates
 Pleural fluid LDH > 200 units
 Pleural fluid proteins / serum proteins ratio > 0.5
 Pleural fluid LDH / serum LDH ratio >0.6
 Serum effusion Albumin gradient <1.2
5. Biopsy (pleural) for Malignancy
6. Sputum for AFB / Culture for T.B
Other things which help in Diagnosis
1. Pleural fluid Glucose Reduced
 Para pneumonic Effusion
 T.B
 Malignancy
2. Decreased PH < 7.3 (pleural Fluid)
 Para pneumonic Effusion
 T.B
 Malignancy
 Acute Pancreatitis
 Esophageal Rupture
TREATMENT
LIGHT’S CRITERIA
Transudative Effusion
Exudative Effusion
Give RX of Cause
 Frusimide
 ACE inhibitor
 O2
Aspirate (not more then 1 liter)
Observe for 03 days
If No relief
Then Aspirate
then Give RX of Cause
If T.B then ATT
If Pneumonia then Antibiotic
Etc…
If no relief then go for Chest U/s
For Loculated Effusion
then we inject Streprokinase
If Recurrent Effusion then do
Pleurodesis (Complete Adhesion
of Perital & Visceral Pleura by
Tetracycline, Talk)
WHEN DO INTUBATION
 If frank pus in Pleural Aspirate
 Pleural Fluid PH < 7.1 – 7.2
 If Pleural LDH > 1000 units
 If Pleural Glucose <60 mg/ dl
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RESTRICTIVE LUNG DISEASES
Obstructive Lung Disease
Restrictive Lung Disease
1.
Chronic Bronchitis + Emphysema
Asbestosis, Sarcoidosis, Pneumoconiosis,
ARDS, Pulmonary HTN etc…
2.
Pathology id Airway Obstruction
Pathology shows Interestial Hypertrophy &
Hyperplasia so Airway dimension is reduced
3.
FEV1 Reduced
FEV1 Usually Normal
4.
FVC usually Normal
FVC Reduced
5.
FEV1 / FVC ratio Decreased
FEV1 / FVC ratio Increased
SARCOIDOSIS
Def: Autoimmune disease involving multisystem & is non-Caseating grnulomatous inflammation
and is associated with other autoimmune disease.
i.e. Scleroderma, Sjogram Syndrome, Hashimoto Thyroidosis etc…
C/F




Exertional Dysponea
May be Cough
Fatigability
Lethargic
Initially it involves Lung
 Hillar Lymphadenopathy
 Montoux Test –ve
 Pulmonary Nodules
 Pulmonary Fibrosis
& Then Multi system involvement EYES, BLOOD VESSEL, SKIN etc…
DIAGNOSIS

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Calcium Increased
Kidney Stone
Pulmonary Nodule
Increased ACE enzyme level in blood
Erythema Nodosum on skin (usually at Shin)
TREATMENT
Immunosuppresin ( usually we give Corticosteroids)
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PNEUMOCONIOSIS
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C/F

Asbestosis
Silicosis
Coal Worker Pneumoconiosis
Baggasosis
Bissinosis
Dysponea ---- Cough ------ Sputum------ Resp: Distress ------ Inc: Chances of Malignancy
Cor Pulmonale
DIAGNOSIS
1. First of all take Occupational history
2. Chest X-ray
 ASBESTOSIS: - Pleural thickening, Pleural Plaque / Calcification, Lung fibrosis
 SILICOSIS: - Nodules usually in upper lobe, egg shape Calcification
 Coal worker pneumoconiosis: - fibrosis, may lead to Esophageal carcinoma
CAPLAN SYNDROME:
Rheumatoid Arthritis
+ Pneumoconiosis
TREATMENT
 O2
 No specific treatment
BRONCHIECTASIS
Def: - Permanent dilation of bronchi & Bronchioles above the level of terminal Bronchioles
Congenital
Immotile Sillia Syndrome
Kartegner’s Syndrome
(Dextrocardia, infertile sinusitis & Bronchiectasis)
C/F
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Acquired
Lung Abscess
Severe Pneumonia
T.B
Malignancy
Fungal infection
Cystic Fibrosis
Cough
Copious Sputum
Rusty Smelling
Recurrent infection of Airway
Wheeze & Crackles
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INVESTIGATIONS
It is not a disease. It is just a Complication of Disease
 Chest X-ray
 CT Scan
 Bronchogram
TREATMENT
 Postural Drainage
 Steam Inhalation
 If fever give Antibiotic
 If Secretion Obstructs Airway then Bronchodilator
 Symptomatic relief by Expectorants
LUNG ABSCESS
Def: - Pus containing cavity is called Abscess.
CAUSES
 Streptococci
 Staphylococci
 Klebsella
 Pseudomonas
 H- influenza
 E- coli
 Bacteroides
C/F
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Fever, cough with sputum
Sputum of foul smelling
Poor Dentition
Wt: loss
DIAGNOSIS

Chest X-ray
Thicken walled solitary cavity surround by consolidation & an air fluid level is presenting
the cavity.
TREATMENT
Medical: -
Antibiotics (I/v)
If not response to max: dose of antibiotic then do
U/S guided Drainage
OR
CT guided Drainage
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SLEEP APNEA
Def: Cessation of Air flow > 10 sec at least 10- 15 times/ hrs during sleep
Types
Obstructive
Central
Usually in very obese
ON DINE Curse
Pickwickian Syndrome
Even with proper ventilatory drive
in this central ventriculatory
drive is inadequate
DIAGNOSIS
 Sleep Study (Polysomnography)
TREATMENT
 Continuous +ve Airway Pressure
 Uvulopalatopharyngoplasty (UPPP)
 Nasal septoplasty
ATELACTESIS
Collapse of lung
TYPES
1. COMPRESSION ATELACTESIS
 Pneumothorax
 Pleural effusion
 Malignancy
2. RESORPTION ATELACTESIS
 Foreign body
 Operational hematoma
 Tumor
 Mucous Plug
3. MICRO ATELACTESIS (Absent Surfactant)
 ARDS
 Acute Pancreatitis
 Heavy Smoke
4. BASAL ATELACTESIS
 Diaphragm move inadequately
C/F



Dysponea
Fever
Tachycardia / palpitation
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SIGNS
 Trachea deviated
 Collapse with patent bronchus then vocal Fremitus increased
 Breath sounds decreased
DIAGNOSIS
 Chest X-ray
TREATMENT
Treat the cause
If mucous plug / hematoma then do BRONCHOSCOPY
If compression Atelactesis then treat the pleural effusion & Pneumothorax
If Micro Atelactesis then give SURFACTANT
PULMONARY HTN
Def: Pulmonary Arterial pressure is more than 30 mmHg
TYPES
 Primary pulmonary HTN
 Secondary pulmonary HTN
C/F
 Dysponea
 Orthopnea
 Chest pain
SIGNS
 P2 Loud
 Systolic ejection click
 Raised JVP
 Peripheral Cyanosis
 Bat Wing X-ray Appearance
INVESTIGATIONS
 Chest X-ray
 Echo
 ECG
 Pulmonary Function Test
TREATMENT
Once pulmonary HTN develops then HEART LUNG TRANSPLANTATION
Or we can give vasodilator (Ca++ blocker, Nitroglycerine, Hydralizine etc…)
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