6. Acute Respiratory Flashcards
A gentleman presents with acute breathlessness and chest pain. O/E his respiratory rate is 25bpm with good air entry in all fields. His ECG shows right axis deviation. What is the most likely diagnosis?
Pneumothorax
Pneumonia
COPD
Pulmonary Embolism
Pulmonary Embolism
A 35 year old lady presents with acute onset SOB, chest pain and one episode of haemoptysis. She has recently noticed a swelling in the left leg. O/E her RR is 28 and HR is 105. You suspect a pulmonary embolism. What is the most appropriate investigation to perform? Chest X-Ray CTPA D-Dimer ECG
CTPA
Pulmonary Embolism Definition and pathophysiology
A condition in which one or more emboli lodge in the pulmonary circulation. Emboli most commonly originate from the deep venous system.Lung tissue is VENTILATED but not PERFUSED –> impaired gas exchange
RF for PE
Patient Factors
- Immobility > 1 week
- Previous PE/DVT
- FHx of PE/DVT
- Pregnancy
- Long distance travel
- Oestrogen
- Smoking
Disease Factors
- Malignancy
- Recent surgery
- Cardio-respiratory disease
- Hypoxaemia
Symptoms/signs of PE
SUDDEN ONSET
SOB, pleuritic chest pain
+/- haemoptysis
+/- haemodynamic compromise
- Tachypnoea, tachycardia
- Lower limb swelling
- Cyanosis
- May have signs of shock
Well’s Score
Signs and symptoms of PE: 3 Alternative diagnosis unlikely: 3 Immobile for 3 days/ surgery in past 4 weeks: 1.5 HR > 100: 1.5 Previous PE/DVT: 1.5 Haemoptysis: 1 Malignancy: 1
Core Investigations for PE
Based on Well’s Score
> 4 (PE likely): Admit to hospital and perform immediate CTPA
<4 (PE unlikely): Perform D-Dimer –> +ve: as above; -ve: consider alt. Dx
Additional Investigations for PE
NB these should NEVER delay management
ECG
sinus tachycardia, right axis deviation, RBBB, ‘S1 Q3 T3’ – very uncommon
CXR
pleural effusion, elevation of hemidiaphragm
Unprovoked PEs – screen for Ca, antiphospholipid, protein C/S
Management of PE
- Analgesia
- Oxygen – aim for sats >94%
- Fluids
If haemodynamically stable:
- LMWH or fondaparinux for at least 5 days or until INR > 2
- Start oral anticoagulation warfarin at the same time
If haemodynamically unstable:
- Thrombolysis e.g. Alteplase
- Embolectomy
Pneumothorax definition and classification
Definition: Accumulation of air in the pleural space
Primary Spontaneous Pneumothorax: no underlying respiratory illness
Secondary Spontaneous Pneumothorax: associated with underlying lung pathology
Signs and symptoms of pneumothorax
SUDDEN ONSET
- SOB (severity depends on size of pneumothorax)
- Chest pain (same side as pneumothorax)
- Reduced/absent breath sounds
- Reduced/absent vocal resonance
- Hyperresonant
- Reduced chest expansion
RF for pneumothorax
- Underlying lung disease
- Connective tissue disorders (e.g. Marfans)
- Smoking
- Trauma
Investigations for pneumothorax
CXR - look for lung markings to differentiate between bullae and pneumothorax. Important to determine SIZE of pneumothorax
CT - will also differentiate between emphysematous bullae
Pneumothorax Tx
Primary Pneumothorax AND patient < 50 years:
<2cm: O2 + consider discharge
>2cm: aspiration; if unsuccessful –> intercostal drain
Secondary Pneumothorax OR patient > 50 years
<1cm: high flow O2
1-2: aspiration –> if reduced to <1cm, follow above; if still >1cm, follow below
>2cm: Intercostal drain
What is a Tension Pneumothorax
MEDICAL EMERGENCY
Build up of air in the pleural space due to a one way valve
Air can get into the space during inspiration, but not out on expiration
Build up of pressure pushes the mediastinum across cavity
Reduces venous return to the heart
Tension Pneumothorax signs
Reduced breath sounds, tachycardia, tachypneoa
Deviation of trachea
Distended neck veins
Displaced apex beat
Tension Pneumothorax mx
Immediate needle decompression - 2nd intercostal space, mid clavicular line + O2
Tension Pneumothorax mx
Immediate needle decompression - 2nd intercostal space, mid clavicular line + O2
- PA vs AP CXR
PA (posterior-anterior) is the preferred CXR method
- Plate is in front of the patient and X-ray source is behind them
- Patient has to be STANDING UP
- If not mentioned, assume CXR is PA
- Demographics of the patient
- Full patient name, DOB, Hospital number
- Date and time of X-ray
- Presenting complaint if known
- Quality of the film
Rotation
- Look at the medial ends of the clavicles
- Are they equidistant from spinous processes?
Inspiration
- 6th anterior and 10th posterior ribs should be visible
- Any more and the lungs are hyperinflated e.g. COPD
Penetration
- Vertebral bodies should be just visible
- Over-penetrated when it is too black
“Regarding the quality of the film, there was no rotation, adequate inspiration and penetration”
- ABCDE approach
- Airway (trachea) – is it central/patent?
- Breathing (lung fields) – do the lung margins extend to the full width of the cavity? Are there any areas of opacification in the lung fields?
- Circulation (heart and great vessels) – how big is the heart? Can you see the cardiophrenic angles?
- Diaphragms (costophrenic angles) – is the diagphragm visible/flattened/air underneath? Can you see the costophrenic angles?
- Everything else (foreign bodies, bones, breasts)
Tension pneumothorax vs pneumothorax CXR
TP:
- Deviated trachea
- Lung markings absent
P:
- Central trachea
- Lung markings absent, visible lung margin
List some signs on a CXR
Fluffy alveolar (cotton wool) opacification = pneumonia
- Fluid or pus
- Air bronchograms
Reticulonodular (lines and dots)
- Fibrosis of interstitium
Completely opaque
- Pleural effusion
- Lung collapse
One-sided pleural effusion CXR
- Clear meniscal line
- Complete opacity in mid/lower zones unilaterally
- Loss of costophrenic angle unilaterally
Heart failure CXR
A – alveolar shadowing B – Kerley B lines C – cardiomegaly D – upper lobe diversion E – pleural effusion (often bilateral)
