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(3) 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 does this mean?

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 dyspnea?

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 are some causes of the following breath sounds:

  • Bronchial breathing
  • Diminished breath sounds
  • 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
Q

What are the signs and symptoms of anaphylaxis?

A
  • Pruitis
  • Urticaria
  • Angiooedema
  • Hoarseness progressing to stridor and bronchial obstruction
  • Wheeze and chest tightness from bronchospasm
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26
Q

When can someone be discharged after an anaphylactic reaction?

A

Need referral to allergy clinic and an interim adrenaline auto injector before discharge

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27
Q

What is the emergency management for anaphylaxis?

A
  • 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
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28
Q

How do you rate the severity of an asthma attack?

A
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29
Q

What is the emergency management for acute asthma?

A
  • 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
Q

What are some signs of a COPD exacebation?

A
  • Increasing cough
  • Breathlessness
  • Wheeze

Change in sputum volume/colour

  • Fever
  • Raised WCC/CRP
31
Q

What are some investigations to do when a patient is having an acute exacerbation of COPD?

A
  • 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
Q

What is the emergency management for an acute COPD exacerbation after sitting the patient upright?

A
  • 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
Q

What are some contraindications to NIV? (BIPAP)

A
  • Reduced GCS
  • Facial injury
  • Increased secretions
  • Vomiting
34
Q

How is acute pneumonia managed?

A
  • Oxygenation
  • If features of sepsis treat with sepsis pathway
  • Otherwise treat with abx as per CURB-65
35
Q

What is the CURB65 criteria?

A

Risk stratifies death in pneumonia

0-1: Low

2: Intermediate

3-5: High

36
Q

What is classified as a massive haemoptysis?

A

>240mls in 24 hours

>100mls/day over consecutive days

37
Q

How is a massive haemoptysis managed?

A
  • ABCDE

- 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
Q

What are some signs of a tension pneumothorax?

A
  • Hypotension
  • Tachycardia
  • Deviation of trachea away from side of pneumothorax
  • Mediastinal shift away from pneumothorax
  • Reduced expansion
  • Hyperresonance to percussion
  • Diminished breath sounds
39
Q

What is the emergency treatment of a tension pneumothorax?

A

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
Q

How do you manage a pneumothorax that is not a tension pneumothorax?

A
  • CXR
  • Needle aspiration
  • Chest drain into 5th ICS axillary line (safe triangle) or thoracotomy
41
Q

What are some major risk factors for a PE?

42
Q

What are some signs and symptoms of a PE?

A
  • Acute dyspnea
  • Pleuritic chest pain
  • Haemoptysis
  • Low cardiac output if huge
  • Low grade fever
43
Q

What is the acute management of a PE?

A

- 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
Q

What are some contraindications for treating a massive PE with thrombolysis?

45
Q

What are some complications of thrombolysis used to treat a massive PE?

46
Q

What are the borders of the safety triangle used for chest drain insertion?

A
  • Anterior border of lat dorsi
  • Lateral border of pec major
  • 5th ICS in line with base of axilla
48
Q

What are some common asthma triggers?

49
Q

When do you consider a tension pneumonthorax?

A
  • SOB with hyperresonance and absent breath sounds

- Hypotension and tachycardia as haemodynamic instability from crushing great vessels

- Mediastinal shift

50
Q

What are the BTS guidelines for the management of a sponataneous pneumothorax?

A
  • High flow oxgyen
  • Re-CXR after intervention to see if resolution
51
Q

How should you initially manage this patient?

A

Vitamin D deficiency can hinder immune response to TB

52
Q

What is the importance of recent travel in a respiratory history?

A
  • Infectious disease
  • VTE due to immobility
53
Q

When should we use high flow oxygen?

A
  • Cardiac arrest
  • Severe respiratory failure (Sats<85%) -Anyone acutely unwell

OTHERWISE USE CONTROLLED OXYGEN THERAPY

54
Q

What is the 5 step approach to ABG interpretation?

A
  • How is the patient
  • Are they hypoxaemic?
  • What is the pH?
  • Determine the respiratory component
  • Determine the metabolic component
55
Q

What is the target sats in COPD patients?

A
  • If no sign of type 2 respiratory failure or CO2 retention on ABG then normal 94-98%
56
Q

What is the difference between lobar and broncho-pneumonia on chest x-ray?

A
  • Lobar is solid consolidation. Usually Strep.Pneumoniae
  • Broncho is patchy consolidation. Usually H.Influenzae, Pseudomonas, Moraxella
57
Q

What happens to chest expansion, percussion, vocal resonance, breath sounds in the following cases:

  • Pleural effusion
  • Consolidation
  • Pneumothorax
  • Tension pneumothorax
  • Fibrosis
58
Q

How does aspergillus affect the lungs?

A
  • Asthma
  • Allergic bronchopulmonary aspergillosis (ILD)
  • Aspergilloma
  • Invasive aspergillosis
  • Extrinsic allergic alveolitis
59
Q

What are some of the causes of acute respiratory distress syndrome?

A
  • Pneumonia
  • Inhalation
  • Shock
  • Multiple transfusions
  • Pancreatitis
  • Head injury
  • Malaria
  • Drugs e.g aspirin, heroin
60
Q

What is ARDS?

A

Acute lung injury causing lung damage and release of inflammatory mediators so increased capillary permeability and pulmonary oedema often followed by multiorgan failure

61
Q

What are some features of ARDS and what investigations should you do for this?

A

Symptoms: cyanosis, tachypnea, tachycardia, bilateral fine inspiratory crackles

Investigations: FBC, U+Es, amylase, clotting, CRP, blood cultures, ABG, CXR

62
Q

What does a CXR show in ARDS?

A

Bilateral pulmonary infiltrates

63
Q

What is the diagnostic criteria for ARDS?

A
  • Acute onset
  • CXR showing bilateral infiltrates
  • Lack of clinical congestive heart failure
  • Refractory hypoxaemia
64
Q

How is ARDS managed?

A

Admit to ICU for respiratory support and circulatory support

Treat the underlying cause

65
Q

What is type I and type II respiratory failure?

A

Type I: PaO2 <8kPa and normal or low PaCO2

Type II: PaO2 <8kPa and PaCO2 >6kPa

66
Q

What are some causes of type I and type II respiratory failure?

A

Type I: pneumonia, PE, pulmonary oedema, pulmonary fibrosis

Type II: COPD, OSA, sedative drugs, neuromuscular diease e.g GBS, myasthenia gravis

67
Q

How do you manage type I and II respiratory failure?

68
Q

What is Cor Pulmonale and what are some causes of this?

A

Right heart failure due to pulmonary hypertension

69
Q

What are the clinical features of Cor Pulmonale?

A
  • Dyspnea
  • Fatigue
  • Tachycardia
  • Raised JBP
  • RV heave
  • Hepatomegaly
  • Oedema
70
Q

How is Cor Pulmonale investigated?

A

FBC: polycythemia

ABG: hypoxia with or without hypercapnia

CXR: enlarged right ventricle and prominent pulmonary arteries

ECG: right axis deviation

71
Q

How is Cor Pulmonale treated?

A
  • 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

(3) Medicine (24 decks)

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