6. Acute Respiratory Flashcards

1
Q

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

A

Pulmonary Embolism

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2
Q
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
A

CTPA

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3
Q

Pulmonary Embolism Definition and pathophysiology

A

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

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4
Q

RF for PE

A

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
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5
Q

Symptoms/signs of PE

A

SUDDEN ONSET
SOB, pleuritic chest pain
+/- haemoptysis
+/- haemodynamic compromise

  • Tachypnoea, tachycardia
  • Lower limb swelling
  • Cyanosis
  • May have signs of shock
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6
Q

Well’s Score

A
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
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7
Q

Core Investigations for PE

A

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

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8
Q

Additional Investigations for PE

A

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

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9
Q

Management of PE

A
  • 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
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10
Q

Pneumothorax definition and classification

A

Definition: Accumulation of air in the pleural space

Primary Spontaneous Pneumothorax: no underlying respiratory illness

Secondary Spontaneous Pneumothorax: associated with underlying lung pathology

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11
Q

Signs and symptoms of pneumothorax

A

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
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12
Q

RF for pneumothorax

A
  • Underlying lung disease
  • Connective tissue disorders (e.g. Marfans)
  • Smoking
  • Trauma
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13
Q

Investigations for pneumothorax

A

CXR - look for lung markings to differentiate between bullae and pneumothorax. Important to determine SIZE of pneumothorax

CT - will also differentiate between emphysematous bullae

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14
Q

Pneumothorax Tx

A

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

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15
Q

What is a Tension Pneumothorax

A

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

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16
Q

Tension Pneumothorax signs

A

Reduced breath sounds, tachycardia, tachypneoa
Deviation of trachea
Distended neck veins
Displaced apex beat

17
Q

Tension Pneumothorax mx

A

Immediate needle decompression - 2nd intercostal space, mid clavicular line + O2

18
Q

Tension Pneumothorax mx

A

Immediate needle decompression - 2nd intercostal space, mid clavicular line + O2

19
Q
  1. PA vs AP CXR
A

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
20
Q
  1. Demographics of the patient
A
  • Full patient name, DOB, Hospital number
  • Date and time of X-ray
  • Presenting complaint if known
21
Q
  1. Quality of the film
A

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”

22
Q
  1. ABCDE approach
A
  • 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)
23
Q

Tension pneumothorax vs pneumothorax CXR

A

TP:

  • Deviated trachea
  • Lung markings absent

P:

  • Central trachea
  • Lung markings absent, visible lung margin
24
Q

List some signs on a CXR

A

Fluffy alveolar (cotton wool) opacification = pneumonia

  • Fluid or pus
  • Air bronchograms

Reticulonodular (lines and dots)
- Fibrosis of interstitium

Completely opaque

  • Pleural effusion
  • Lung collapse
25
Q

One-sided pleural effusion CXR

A
  • Clear meniscal line
  • Complete opacity in mid/lower zones unilaterally
  • Loss of costophrenic angle unilaterally
26
Q

Heart failure CXR

A
A – alveolar shadowing 
B – Kerley B lines
C – cardiomegaly 
D – upper lobe diversion
E – pleural effusion (often bilateral)