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Y3 Medicine > 5 - General Respiratory and Respiratory Emergencies > Flashcards

5 - General Respiratory and Respiratory Emergencies Flashcards

1
Q

What is the MRC dyspnea score?

A
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2
Q

What is the WHO performance status?

A
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3
Q

How do you take a respiratory history? (importance of occupation history)

A

- PC: dyspnea, chest pain, wheeze, cough, sputum, haemoptysis

- HPC: see image

- PMHx: asthma, COPD, DVT, previous lung infections, surgery, CVS illness, cancer, childhood infections

- DHx and allergies: inc adherance

- FHx: resp and cardo disease, cancer, CF

- SHx: smoking, alcohol, occupational history (birds), travel, immobility, pets, asbestos exposure, ADLs, performance status

- Systems review

- ICE

- Summarise

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4
Q

What are the 6 respiratory features to ask about in a respiratory history?

A
  • Dyspnea
  • Chest pain
  • Wheeze
  • Cough
  • Sputum
  • Haemoptysis

ALSO CHECK ABOUT FEVER AND WEIGHT LOSS

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5
Q

How do you perform a respiratory examination?

A
  • General inspection
  • Hands
  • Face
  • Neck
  • Chest inspection
  • Chest expansion
  • Chest percussion
  • Chest auscultation
  • Vocal resonance
  • Complete exam
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6
Q

What are some tests you should offer to do at the end of a respiratory exam?

A
  • Check oxygen saturations and temperature
  • Sputum sample
  • Peak flow assessment PEFR
  • Chest X-ray
  • ABG
  • CVS exam
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7
Q

What are some bedside and special tests in chest medicine?

A

Bedside:

  • Sputum sample
  • PEFR
  • Pulse oximetry
  • ABG
  • Spirometry

Special: lung function tests, CXR, CTPA, bronchoalveolar lavage, lung biopsy, rigid bronchoscopy

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8
Q

What is stridor and what are some causes?

A

Inspiratory sound due to partial obstruction of the upper aiways

Within lumen: foreign body, tumour

Within wall: oedema from anaphylaxis, tumour

Extrinsic: goitre, lymphadenopathy

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9
Q

What do each of the following coughs indicate?

  • Loud brassy cough
  • Bovine cough
  • Barking cough
  • Chronic cough
  • Dry chronic cough
A
  • Pressure on trachea e.g tumour
  • Laryngeal nerve palsy
  • Croup
  • Pertussis, TB, asthma
  • Acid irritation from GORD or ACEi
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10
Q

What are some causes of haemoptysis and how should you manage a patient in hospital with this?

A
  • IVI
  • CXR
  • Blood gases
  • FBC
  • INR/APTT
  • Cross match
  • IV morphine
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11
Q

What are some causes of dyspnoea?

A

- Lung disease e.g asthma

- Cardiac disease e.g heart failure

- Anatomical e.g diseases of chest wall, muscles, pleura

- Shock

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12
Q

What is the description and some causes of the following breath sounds:

  • Bronchial breathing
  • Diminished breath sounds
  • Silent chest
  • Wheeze
  • Crackles
  • Pleural rub
A
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13
Q

What are some signs of respiratory distress?

A
  • Tachypnea
  • Nasal flaring
  • Tracheal tug (pulling of thyroid cartilage to sternum on inspiration)
  • Use of accessory muscles
  • Intercostal and subcostal recession
  • Pulsus paradoxus
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14
Q

What are the causes of Kussmaul respiration and Cheyne-Stokes breathing?

A

Kussmaul: deep sighing breaths in severe metabolic acidosis to blow off CO2. DKA, Alcoholic ketoacidosis, renal impairment

Cheyne-Stokes: breathing gets deeper and deeper and then shallower in cycles. Due to brainstem lesions or compression (e.g strok)

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15
Q

What should you send a sputum sample for and what do the following sputum colours indicate?

  • Black specks
  • Yellow/green
  • Pink frothy
  • Red
  • Clear
A

Send for gram stain, culture, cytology

  • Smoking
  • Infection
  • Pulmonary oedema
  • Haemoptysis (TB, malignancy, PE)
  • Saliva
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16
Q

How do you report on a chest x-ray?

A
  • Name and Age of patient
  • Date and Time taken
  • Type of x-ray e.g erect or mobile, AP or PA
  • Quality of film (RIP)
  • ABCDE using zones and cardiothoracic ration

- Say what you see e.g blunting of costophrenic angle which could mean pleural effusions

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17
Q

What is vital capacity, forced vital capacity (FVC), and forced expiratory volume (FEV1)?

A

VC is not forced

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18
Q

How do FEV1 and FVC values change in obstrutive and restrictive lung disease?

A
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19
Q

What are the causes of hypoxia (low PaO2)?

A
  • Hypoventilation
  • Diffusion impairment
  • Shunt
  • V/Q mismatch
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20
Q

What happens to the pH, PaCO2 and HCO3- when there is metabolic acidosis/alkalosis and respiratory acidosis/alkalosis?

A
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21
Q

What are some causes of respiratory acidosis?

A
  • Alveolar hypoventilation e.g COPD
  • Hypoventilayion e.g neuromuscular disease
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22
Q

What is the A-a gradient and what can it be used for?

A

PAO2 - PaO2

where (arterial) PAO2 = PIO2 - PaCO2/0.8

Gradient should be <2kPa in the young and <4kPa in elderly.

If >4kPa this implies lung pathology

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23
Q

What is the AA gradient for this case and what is the conclusion from the gradient?

A
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24
Q

What is the AA gradient for this case and what is the conclusion?

A
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25
What are the signs and symptoms of anaphylaxis?
- Pruitis - Urticaria - Angiooedema - Hoarseness progressing to stridor and bronchial obstruction - Wheeze and chest tightness from bronchospasm
26
When can someone be discharged after an anaphylactic reaction?
Need referral to allergy clinic and an interim adrenaline auto injector before discharge
27
What is the emergency management for anaphylaxis?
- Remove trigger - Maintain airway and **100% O2** **- Lie flat** and fluid resuscitation **- IM 0.5mg adrenaline** **- IV chlorphenamine 10mg** - Measure serum tryptase - Treat bronchospasm with NEB salbutamol - Treat laryngeal oedema with NEB adrenaline
28
How do you rate the severity of an asthma attack?
29
What is the emergency management for acute asthma?
- Assess severity with ABCDE - Aim for O2 94-98%. Need ABG if \<92% ***- 5mg NEB salbutamol*** that can repeat in 15 minutes ***- 40mg oral prednisolone*** or ***100mg IV hydrocortisone*** ***- If severe 500ug ipratropium bromide NEB*** - If ***life threatening urgent ITU assessment, urgent portable CXR, IV aminophylline, consider IV salbutamol***
30
What are some signs of a COPD exacebation?
- Increasing cough - Breathlessness - Wheeze Change in sputum volume/colour - Fever - Raised WCC/CRP
31
What are some investigations to do when a patient is having an acute exacerbation of COPD?
- ABG - CXR to exclude pneumothorax and infection - FBC, U+E, CRP, Theophylline level if patient on therapy at home - ECG - Sputum culture - Blood culture if pyrexial
32
What is the emergency management for an acute COPD exacerbation after sitting the patient upright?
- ABCDE **- Oxygen therapy aiming for 88-92% sats** with serial ABGs **- Salbutamol and ipratropium bromide NEBS** **- 30mg PO prednisolone** and ccontinue for 7 days **- Antibiotics** if raised CRP/WCC or purulent sputum - CXR - Consider **IV aminophylline** - Consider **NIV (BIPAP)** if type 2 resp failure and pH 7.25-7/35 - If pH\<7.25 consider **ITU referral**
33
What are some contraindications to Non-invasive ventilation (NIV)? (BIPAP)
- Reduced GCS - Facial injury - Increased secretions - Vomiting
34
How is acute pneumonia managed?
- Oxygenation - If features of sepsis treat with sepsis pathway - Otherwise treat with abx as per CURB-65
35
What is the CURB65 criteria?
Risk stratifies death in pneumonia **0-1:** Low **2:** Intermediate **3-5:** High
36
What is classified as a massive haemoptysis?
\>240mls in 24 hours \>100mls/day over consecutive days
37
How is a massive haemoptysis managed?
- ABCDE high flow o2, request urgent cxr, bloods including group and save and abg **- Lie patient on suspected side of lesion** lateral decubitus **- Oral tranexamic acid** IV for 5 days **- Stop NSAIDs, aspirin, anticoagulants** - Abx if infection - Consider Vit K **- CT aortogram** that can do **bronchial artery embolisation**
38
What are some signs of a tension pneumothorax?
- Hypotension - Tachycardia - Deviation of trachea away from side of pneumothorax - Mediastinal shift away from pneumothorax - Reduced expansion - Hyperresonance to percussion - Diminished breath sounds
39
What is the emergency treatment of a tension pneumothorax?
Needs urgent treatment as mediastinal shift, compresses great vessels and cardiorespiratory arrest will occur. DO NOT WAIT FOR CXR **- Large bore intravenous cannula (14-16G) into 2nd ICS MCL** - If no cannula use needle with syringe and small amount of water attached - Chest drain into affected side once stable
40
How do you manage a pneumothorax that is not a tension pneumothorax?
- CXR - Needle aspiration - Chest drain into 5th ICS axillary line (safe triangle) or thoracotomy
41
What are some major risk factors for a PE?
42
What are some signs and symptoms of a PE?
- Acute dyspnea - Pleuritic chest pain - Haemoptysis - Low cardiac output if huge - Low grade fever
43
What is the acute management of a PE?
**- Oxygen** if hypoxic **- Fluid resus** if hypotensive **- Start DOAC** and continue long term - Reduce risk factors **- If haemodynamically unstable** or massive PE on ECHO or CT then consider **thrombolysis with IV alteplase** to prevent cardiac arrest
44
What are some contraindications for treating a massive PE with thrombolysis?
45
What are some complications of thrombolysis used to treat a massive PE?
46
What are the borders of the safety triangle used for chest drain insertion?
- Anterior border of lat dorsi - Lateral border of pec major - 5th ICS in line with base of axilla
47
What are some common asthma triggers?
48
When do you consider a tension pneumonthorax?
- SOB with hyperresonance and absent breath sounds **- Hypotension and tachycardia** as haemodynamic instability from crushing great vessels **- Mediastinal shift**
49
What are the BTS guidelines for the management of a sponataneous pneumothorax?
- High flow oxgyen - Re-CXR after intervention to see if resolution
50
How should you initially manage this patient?
Vitamin D deficiency can hinder immune response to TB
51
What is the importance of recent travel in a respiratory history?
- Infectious disease - VTE due to immobility
52
When should we use high flow oxygen?
- Cardiac arrest - Severe respiratory failure (Sats\<85%) -Anyone acutely unwell OTHERWISE USE CONTROLLED OXYGEN THERAPY
53
What is the 5 step approach to ABG interpretation?
- How is the patient - Are they hypoxaemic? - What is the pH? - Determine the respiratory component - Determine the metabolic component
54
What is the target sats in COPD patients?
- If no sign of type 2 respiratory failure or CO2 retention on ABG then normal 94-98%
55
What is the difference between lobar and broncho-pneumonia on chest x-ray?
- Lobar is solid consolidation. Usually Strep.Pneumoniae - Broncho is patchy consolidation. Usually H.Influenzae, Pseudomonas, Moraxella
56
What happens to chest expansion, percussion, vocal resonance, breath sounds in the following cases: - Pleural effusion - Consolidation - Pneumothorax - Tension pneumothorax - Fibrosis
57
How does aspergillus affect the lungs?
- Asthma - Allergic bronchopulmonary aspergillosis (ILD) - Aspergilloma - Invasive aspergillosis - Extrinsic allergic alveolitis
58
What are some of the causes of acute respiratory distress syndrome?
- Pneumonia - Inhalation - Shock - Multiple transfusions - Pancreatitis - Head injury - Malaria - Drugs e.g aspirin, heroin
59
What is ARDS?
Acute lung injury causing lung damage and release of inflammatory mediators so **increased capillary permeability** and **pulmonary oedema** often followed by **multiorgan failure**
60
What are some features of ARDS and what investigations should you do for this?
**Symptoms**: cyanosis, tachypnea, tachycardia, bilateral fine inspiratory crackles **Investigations:** FBC, U+Es, amylase, clotting, CRP, blood cultures, ABG, CXR
61
What does a CXR show in ARDS?
Bilateral pulmonary infiltrates
62
What is the diagnostic criteria for ARDS?
- Acute onset - CXR showing bilateral infiltrates - Lack of clinical congestive heart failure - Refractory hypoxaemia
63
How is ARDS managed?
Admit to ICU for respiratory support and circulatory support Treat the underlying cause
64
What is type I and type II respiratory failure?
**Type I:** PaO2 \<8kPa and normal or low PaCO2 **Type II**: PaO2 \<8kPa and PaCO2 \>6kPa
65
What are some causes of type I and type II respiratory failure?
**Type I:** pneumonia, PE, pulmonary oedema, pulmonary fibrosis **Type II:** COPD, OSA, sedative drugs, neuromuscular diease e.g GBS, myasthenia gravis
66
How do you manage type I and II respiratory failure?
67
What is Cor Pulmonale and what are some causes of this?
Right heart failure due to pulmonary hypertension
68
What are the clinical features of Cor Pulmonale?
- Dyspnea - Fatigue - Tachycardia - Raised JBP - RV heave - Hepatomegaly - Oedema
69
How is Cor Pulmonale investigated?
**FBC:** polycythemia **ABG:** hypoxia with or without hypercapnia **CXR:** enlarged right ventricle and prominent pulmonary arteries **ECG:** right axis deviation
70
How is Cor Pulmonale treated?
- Treat underlying cause **- Give 24% oxygen** for respiratory failure if PaO2 \<8. Consider LTOT for COPD - Treat cardiac failure with **furosemide** - Consider **venesection** if Hct\>55% - Consider **heart lung transplant** if young

Y3 Medicine (24 decks)

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