Acute Resp Flashcards
Well’s Criteria for PE
Signs + sx of PE (3)
Alt. diagnosis unlikely (3)
Immobile 3 days/surgery past 4 weeks (1.5)
HR>100 (1.5)
Previous PE/DVT (1.5)
Haemoptysis (1)
Malignancy (1)
Primary pneumothorax AND patient < 50 years mx
<2cm
- oxygen and consider discharge
>2cm
- aspiration
- if unsuccessful, intercostal drain
Secondary pneumothorax OR patient > 50 years mx
<1cm
- high flow oxygen
1-2cm
- aspiration
>2cm
- intercostal drain
What’s the difference between type I and II resp. failure?
Type I
- hypoxia
- focal problem; V/Qmismatch
- can still breath off CO2
Type II
- hypoxia AND hypercapnia
- global problem; alveolar hypoventilation
- total failure of gaseous exchange
Hypoxia <8kPa/Hypercapnia >6.7kPa
Acute causes of type I resp failure
Acute asthma
Atalectasis
Pulmonary oedema
Pneumonia
Pneumothorax
PE
ARDS
Acute causes of type II resp failure
Acute severe asthma
COPD
Upper airway obstruction
Neuropathies (GBS, MND)
Drugs (opiates)
Classic presentation of a pneumothorax (incl. RFs)
Sudden onset
Dyspnoea
Unilateral, pleuritic chest pain
RFs: male, Marfanoid habitus, smoking, trauma
What is and how do you treat a primary pneumothorax?
Young, healthy, due to pleural blebs/adhesions
Discharge => no SOB or <2cm
Needle aspiration + oxygen => >2cm/SOB
Chest drain => otherwise above unsuccessful
What is and how do you treat a secondary pneumothorax?
Pre-existing lung pathology predisposing, i.e. COPD, CF, old smoker
Discharge => no SOB or <1cm
Needle aspiration + oxygen => 1-2cm
Chest drain => >2cm/SOB
Why is a tension pneumothorax a medical emergency?
Creates a one-way valve resulting in:
- Lung compression = severe dyspnoea, reduced expansion on lesioned side, tracheal deviation AWAY from lesion, hyperresonant chest
- Mediastinal shift = hypotension, tachycardia
Tx for tension pneumothorax
2nd ICD, MCL (just above 3rd rib) chest drain with orange/grey needle
Risk factors for a PE
‘CT, s’il vous plait’
C = cancer, chemo, COPD, cardiac failure, factor C def.
T = trauma, time (age), thrombocytosis
S = stasis, surgery, factor S def.
V = varicose veins, Virchow’s triad, factor V Leiden
P = pill (OCP), pregnancy, puerperium, prev. VTE, polycythaemia, paraprotein deposition
How can you prevent VTEs?
Mechanical
- anti-embolic stockings
- prevent pooling (stasis)
Pharmacological
- low-molecular weight heparin (tinzparin)
- promote action of antithrombin III + inhibits Xa and thrombin
How may PE present based on the type of PE?
Acute massive PE
- collapse
- central crushing pain
- severe dyspnoea
Acute small PE
- pleuritic chest pain
- haemoptysis
- dyspnoea
Chronic PE
- exertional dyspnoea
Ix for PE
Based on Well’s Criteria for PE:
<4 (low-risk)
- D-dimer
> /=4 (high-risk)
- CTPA
What other ix might indicate a PE?
ECG
- S1Q3T3 (prominent S-wave, Q+T inverted)
- RAD, RBBB, sinus tachycardia*
CXR
- Westermark’s sign (increased translucency of region due to focus of hypovolaemia distal to p. artery occluded by PE)
Tx for PE
Haemodynamically stable (subacute/chronic PE)
- resp support
- anticoagulation (fondaparinux/heparin for 5 days, warfarin for 3 months)
Not haemodynamically stable (massive PE)
- resp support
- 1st line = thrombolysis (alteplase, streptokinase, rt-PA)
- 2nd line = embolectomy
Why does ARDS lead to type I failure?
Body reacts with profound inflammatory response leading to increased vascular permeability
=>
Leads to fluid entering lungs which puts pressure on alveoli
=>
Causes alveoli to collapse so decrease rate of oxygen with capillary
=>
Type I resp failure
Which criteria is used for ARDS?
‘Berlin’ criteria, simplified to:
A lternative cause (cardiogenic PO)
R apid onset, <1 week
D yspnoea
S imilar on CXR to heart failure
What causes ARDS?
Pneumonia
Sepsis
Transfusion reactions
Severe burns
Barotrauma
Nearly drowning
Drugs
What ix are done for ARDS?
ABG (PF ratio)
Echocardiogram (rule out cardiogenic cause)
CXR/CT (similar findings to heart failure)
What is ARDS?
Acute respiratory distress syndrome
- non-cardiogenic pulmonary oedema
- form of hypoxaemic acute lung injury
Lanky Schmidt is a tall, 29 year old male. He has presented to A+E feeling short of breath. He has right sided pleuritic chest pain. He is a non-smoker and otherwise healthy.
A chest radiograph shows a right sided pneumothorax 8mm in diameter.
How should the medical team proceed?
a) Reassure and Discharge
b) Observe for 6 hours and give Oxygen
c) List for elective Surgical Pleurodesis
d) Needle Aspiration and give Oxygen
e) Immediate wide bore cannula insertion at 2nd intercostal space
d) Needle aspiration and give oxygen
Mr Waternoose is a 67 year old admitted with severe dyspnoea and left sided chest pain at rest. The pain is worse on inspiration. Last week he had one of his many hips replaced. Following discharge, he was on bed rest for 4 days due to pain. His leg is swollen and tender on examination. His recent observations are:
Temp: 38.1°C
HR: 116 bpm
BP: 96/64
RR: 20
SaO2: 91% on RA
What is the most likely diagnosis?
a) Pleural effusion
b) Pneumothorax
c) Pneumonia
d) Pericarditis
e) PE
e) PE
