Johnson Samuel

Loculated Pneumothorax Due To A Rare Combination Resulting In An Interesting Chest Radiograph.

A 35 years old man presented with acute onset left sided pleuritic chest pain and shortness of breath. On evaluation, he was found to have an interesting chest radiograph which showed a loculated pneumothorax with collapse of the left upper lobe and lingula but fully expanded left lower lobe. He is a known asthmatic who had allergic broncho pulmonary aspergillosis (ABPA) previously with left upper lobe and lingular collapse secondary to mucous plugging. This resolved on treatment with steroids and itraconazole. An interesting combination of events is proposed to explain the current presentation. CT scan chest and blood tests confirmed this sequence of events. He was appropriately treated resulting in complete clinical and radiological recovery. The events leading to the presentation and the likely physiological background for this interesting chest radiograph are discussed.

Screening for obstructive sleep apnoea using the STOPBANG questionnaire and the Epworth sleepiness score in patients admitted on the unselected acute medical take in a UK hospital

Abstract Obstructive sleep apnoea (OSA), which is often overlooked in patients presenting to primary and secondary care, is an increasingly common comorbidity. The prevalence of OSA has not been studied in the unselected acute medical take. The aim of this study was to screen for the prevalence of undiagnosed OSA using the STOPBANG Questionnaire and the Epworth sleepiness scale (ESS) score in an unselected acute medical take. This was a cross-sectional study in a busy UK general hospital. Patient demographics, comorbidities, ESS and STOPBANG scores on unselected acute medical takes were reviewed and analysed to assess the prevalence of OSA. Of 93 patients screened, more than 50% were obese. The STOPBANG score was ≥3 in 73%. The ESS was significantly increased (≥11) in 20%. On multivariate analysis, ESS continued to remain independently associated with the STOPBANG score with a p-value of 0.04. The routine use of the STOPBANG questionnaire followed by an ESS score in those with a score of ≥3 may focus evaluation for undetected OSA in the acute medical care setting.

Conundrum in an asthma exacerbation

A 66-year-old man, an asthmatic, presented with symptoms suggestive of an acute exacerbation of asthma. His arterial blood gas revealed type 1 respiratory failure (PaO2 <8 kPa or 60 mm Hg with normal or low PaCO2) with a compensated lactic acidosis. He was treated for an asthma exacerbation and sepsis. Despite treatment, his respiratory rate remained elevated although his hypoxaemia improved. There was progressive worsening of the lactic acidosis. Treatment for sepsis was augmented. Peak flow measurements were not used to assess the severity of his exacerbation nor his response to treatment. An alternate diagnosis of acute coronary syndrome with acute pulmonary oedema was made and his asthma treatment was stopped. This coincided with a decline in his serum lactate. A diagnosis of salbutamol-induced lactic acidosis (SILA) was made. SILA is a relatively common complication of salbutamol therapy in moderate/severe asthma exacerbations. It is caused by a mechanism different from the lactataemia that is associated with septic shock and life-threatening asthma.