Acute Resp

Question 1

Well’s Criteria for PE

Answer 1

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)

Question 2

Primary pneumothorax AND patient < 50 years mx

Answer 2

<2cm
- oxygen and consider discharge
>2cm
- aspiration
- if unsuccessful, intercostal drain

Question 3

Secondary pneumothorax OR patient > 50 years mx

Answer 3

<1cm
- high flow oxygen
1-2cm
- aspiration
>2cm
- intercostal drain

Question 4

What’s the difference between type I and II resp. failure?

Answer 4

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

Question 5

Acute causes of type I resp failure

Answer 5

Acute asthma
Atalectasis
Pulmonary oedema
Pneumonia
Pneumothorax
PE
ARDS

Question 6

Acute causes of type II resp failure

Answer 6

Acute severe asthma
COPD
Upper airway obstruction
Neuropathies (GBS, MND)
Drugs (opiates)

Question 7

Classic presentation of a pneumothorax (incl. RFs)

Answer 7

Sudden onset
Dyspnoea
Unilateral, pleuritic chest pain

RFs: male, Marfanoid habitus, smoking, trauma

Question 8

What is and how do you treat a primary pneumothorax?

Answer 8

Young, healthy, due to pleural blebs/adhesions

Discharge => no SOB or <2cm
Needle aspiration + oxygen => >2cm/SOB
Chest drain => otherwise above unsuccessful

Question 9

What is and how do you treat a secondary pneumothorax?

Answer 9

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

Question 10

Why is a tension pneumothorax a medical emergency?

Answer 10

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

Question 11

Tx for tension pneumothorax

Answer 11

2nd ICD, MCL (just above 3rd rib) chest drain with orange/grey needle

Question 12

Risk factors for a PE

Answer 12

‘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

Question 13

How can you prevent VTEs?

Answer 13

Mechanical

• anti-embolic stockings
• prevent pooling (stasis)

Pharmacological

• low-molecular weight heparin (tinzparin)
• promote action of antithrombin III + inhibits Xa and thrombin

Question 14

How may PE present based on the type of PE?

Answer 14

Acute massive PE

• collapse
• central crushing pain
• severe dyspnoea

Acute small PE

• pleuritic chest pain
• haemoptysis
• dyspnoea

Chronic PE
- exertional dyspnoea

Question 15

Ix for PE

Answer 15

Based on Well’s Criteria for PE:
<4 (low-risk)
- D-dimer

> /=4 (high-risk)
- CTPA

Question 16

What other ix might indicate a PE?

Answer 16

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)

Question 17

Tx for PE

Answer 17

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

Question 18

Why does ARDS lead to type I failure?

Answer 18

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

Question 19

Which criteria is used for ARDS?

Answer 19

'Berlin' criteria, simplified to:
A lternative cause (cardiogenic PO)
R apid onset, <1 week
D yspnoea
S imilar on CXR to heart failure

Question 20

What causes ARDS?

Answer 20

Pneumonia
Sepsis
Transfusion reactions
Severe burns
Barotrauma
Nearly drowning
Drugs

Question 21

What ix are done for ARDS?

Answer 21

ABG (PF ratio)
Echocardiogram (rule out cardiogenic cause)
CXR/CT (similar findings to heart failure)

Question 22

What is ARDS?

Answer 22

Acute respiratory distress syndrome

• non-cardiogenic pulmonary oedema
• form of hypoxaemic acute lung injury

Question 23

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

Answer 23

d) Needle aspiration and give oxygen

Question 24

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

Answer 24

e) PE

Question 25

Which of the following most accurately describes ARDS?

a) Hyaline Membrane Disease
b) Type 2 Respiratory failure due to acute lung injury
c) Non-Cardiogenic Pulmonary Oedema
d) Respiratory distress secondary to severe sepsis
e) Long-term respiratory sequelae of childhood rheumatic fever

Answer 25

c) Non-cardiogenic pulmonary oedema

Question 26

Celia is a 35 year old female who underwent a recent salpingectomy for an ectopic pregnancy. Today she awoke breathless, with pleuritic chest pain and haemoptysis. She has been taking the OCP for 5 years. A pulmonary embolism was suspected. CTPA identified filling defects within the pulmonary vasculature with pulmonary emboli. Her recent observations are:
Temp: 37.4°C
HR: 122 bpm
BP: 105/78
RR: 22
SaO2: 93% on RA

How should Celia be managed?

a) Anticoagulation
b) Thrombolysis
c) Embolectomy
d) Respiratory support
e) TED stockings

Answer 26

a) Anticoagulation

Question 27

A gentleman presents with acute breathlessness and chest pain. O/E his RR is 25bpm with good air entry in all fields. His ECG shows right axis deviation. What is his most likely diagnosis?

a) Pneumothorax
b) Pneumonia
c) COPD
d) PE

Answer 27

d) PE

Question 28

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?

a) Chest X-Ray
b) CTPA
c) D-Dimer
d) ECG

Answer 28

b) CTPA

Question 29

A 23 year old student presents to A&E with SOB. He says it came on
suddenly. O/E his trachea is undisplaced with reduced breath sounds on
the left. A chest x-ray confirms a 1cm pneumothorax. What is the most
appropriate management?

a) Immediate chest decompression
b) Intercostal drain
c) Aspiration
d) High flow oxygen

Answer 29

d) High flow oxygen