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Acute respiratory problems Flashcards

1
Q

What is an exacerbation of COPD

A
  • acute worsening of symptoms such as cough, shortness of breath, sputum production and wheeze
  • usually triggered by a viral or bacterial infection.
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2
Q

What does an ABG look like on a patient with an acute exacerbation of COPD

A
  • Low pH (acidosis)
  • raised pCO2 suggests: acutely retaining more CO2
  • (raised bicarb indicates chronic retainer of CO2)
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3
Q

What investigations should you do in an acute exacerbation of COPD

A
  • Chest xray
  • ECG: arrhythmia or evidence of heart strain (heart failure)
  • FBC
  • U&E
  • Sputum culture if significant infection is present
  • Blood cultures if septic
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4
Q

Medical treatment for exacerbation of COPD at home

A
  • Prednisolone 30mg once daily for 7-14 days
  • Regular inhalers or home nebulisers
  • Antibiotics if there is evidence of infection
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5
Q

Medical treatment for exacerbation of COPD in hospital

A
  • Nebulised bronchodilators (e.g. salbutamol 5mg/4h and ipratropium 500mcg/6h)
  • Steroids (e.g. 200mg hydrocortisone or 30-40mg oral prednisolone)
  • Antibiotics if evidence of infection
  • Physiotherapy can help clear sputum
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6
Q

In severe cases of exacerbation of COPD, what further treatment can you give

A
  • IV aminophylline
  • Non-invasive ventilation (NIV)
  • Intubation and ventilation with admission to intensive care
  • Doxapram can be used as a respiratory stimulant where NIV or intubation is not appropriate
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7
Q

What is a pleural effusion

A
  • collection of fluid in the pleural cavity
  • exudative: high protein count (>3g/dL)
  • transudative: relatively lower protein count (<3g/dL).
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8
Q

What is an exudative pleural effusion

A
  • Causes are related to inflammation.

- Inflammation results in protein leaking out of the tissues in to the pleural space (ex- meaning moving out of).

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9
Q

What are the causes of exudative pleural effusion

A
  • Lung cancer
  • Pneumonia
  • Rheumatoid arthritis
  • Tuberculosis
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10
Q

What is a transudative pleural effusion

A

Transudative causes relate to fluid moving across into the pleural space (trans- meaning moving across)

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11
Q

What are the causes of a transudative pleural effusions

A
  • Congestive cardiac failure
  • Hypoalbuminaemia
  • Hypothroidism
  • Meig’s syndrome (right sided pleural effusion with ovarian malignancy)
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12
Q

What is the presentation of a pleural effusion

A

Shortness of breath
Dullness to percussion over the effusion
Reduced breath sounds
Tracheal deviation away from the effusion if it is massive

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13
Q

What would you see on CXR in a patient with a pleural effusion

A
  • Blunting of the costophrenic angle
  • Fluid in the lung fissures
  • Larger effusions will have a meniscus
  • Tracheal and mediastinal deviation if it is a massive effusion
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14
Q

What would you look for on pleural aspiration

A

protein count, cell count, pH, glucose, LDH and microbiology testing.

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15
Q

What is the management of a pleural effusion

A
  • Conservative: small effusions will resolve with treatment of the underlying cause
  • Pleural Aspiration: sticking a needle in and aspirating the fluid
  • Chest drain
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16
Q

What is the complication of pleural aspiration

A

temporarily relieve the pressure but the effusion may recur and repeated aspiration may be required.

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17
Q

What is an empyema

A
  • Infected pleural effusion

- Suspect an empyema in a patient who has an improving pneumonia but new or ongoing fever.

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18
Q

What would pleural aspiration show in empyema

A

pus, acidic pH (pH < 7.2), low glucose and high LDH.

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19
Q

What is the management of empyema

A
  • chest drain to remove the pus and antibiotics.
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20
Q

What is a pneumothorax

A
  • Occurs when air gets in to the plural space separating the lung from the chest wall
  • can occur spontaneously or secondary
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21
Q

What can lead to a secondary pneuothorax

A

trauma
medical interventions (“iatrogenic”)
lung pathology.

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22
Q

What investigations should you do if suspected a pneumothorax

A
  • erect chest Xray
  • Measure the size on x ray
  • CT can pick up smaller pneumothoracies
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23
Q

Where should you measure a pneumothorax from

A

measuring horizontally from the lung edge to the inside of the chest wall at the level of the hilum.

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24
Q

Management of small pneumothorax (<2cm)

A
  • And no SOB
  • No treatment required: will spontaneously resolve.
  • Follow up in 2-4 weeks is recommended.
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25
Q

Management of a large pneumothorax (>2cm)

A
  • +/- SOB
  • aspiration and reassessment.
  • If aspiration fails twice it will require a chest drain.
  • Unstable patients or bilateral or secondary pneumothoraces generally require a chest drain.
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26
Q

What is a tension pneumothorax

A
  • caused by trauma to chest wall that creates a one way valve that lets air in but not out of the pleural space
  • On inspiration air is drawn in, but air is not released on expiration
  • This increases pressure inside the chest which can push the mediastinum AWAY from the pneumothorax
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27
Q

Signs of a tension pneumothorax

A

Tracheal deviation away from side of pneumothorax
Reduced air entry to affected side.
Increased resonant to percussion on affected side.
Tachycardia.
Hypotension.

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28
Q

What is the management of tension pneumothorax

A
  • Insert a large bore cannula into the second intercostal space in the mid-clavicular line
  • Do NOT wait for investigations
  • Chest drain for definitive management
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29
Q

Where do you place a chest drain

A
  • In the triangle of safety
  • The 5th intercostal space (or the inferior nipple line)
  • mid axillary line (or the lateral edge of the latissimus dorsi)
  • anterior axillary line (or the lateral edge of the pectoris major)
  • Insert needle just above rib to miss neurovascular bundle
  • CXR to confirm position of the drain
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30
Q

What is an acute exacerbation of asthma

A

Rapid deterioration in symptoms

- could be triggered by any of the typical asthma triggers such as infection, exercise or cold weather.

31
Q

What is the presentation of an acute exacerbation of asthma

A

Progressively worsening shortness of breath
Use of accessory muscles
Fast respiratory rate (tachypnoea)
Symmetrical expiratory wheeze on auscultation
The chest can sound “tight” on auscultation with reduced air entry

32
Q

What is considered a moderate exacerbation of asthma

A

PEFR 50 – 75% predicted

33
Q

What is considered a severe exacerbation of asthma

A

PEFR 33-50% predicted
Resp rate >25
Heart rate >110
Unable to complete sentences

34
Q

What is considered a life threatening exacerbation of asthma

A 
PEFR <33%
Sats <92%
Becoming tired
No wheeze/ silent chest
Haemodynamic instability (i.e. shock)
35
Q

What is the management of a moderate exacerbation of asthma

A
  • Nebulised beta-2 agonists (i.e. salbutamol 5mg repeated as often as required)
  • Nebulised ipratropium bromide (up to 500 micrograms)
  • Steroids. Oral prednisolone or IV hydrocortisone for 5 days
  • Antibiotics if bacterial infection
36
Q

What additional treatments should you give in a severe exacerbation of asthma

A

Oxygen if required to maintain sats 94-98%
Aminophylline infusion
Consider IV salbutamol
- GET HELP

37
Q

What additional treatments should you give in a life threatening exacerbation of asthma

A
  • IV magnesium sulphate infusion
  • Admission to HDU / ICU
  • Intubation in worst cases – decision should be made early because it is very difficult to intubate with severe bronchoconstriction
38
Q

What would an initial ABG look like in a patient with an acute exacerbation of asthma

A
  • respiratory alkalosis as tachypnoea causes a drop in CO2
39
Q

What are worrying features of an ABG of an acute exacerbation of asthma

A
  • normal pCO2 or hypoxia is a concerning patient is tiring and indicates life threatening asthma
  • respiratory acidosis due to high CO2 is a very bad sign in asthma.
40
Q

How do you manage response to treatment in patients with an acute exacerbation of asthma

A 
Respiratory rate
Respiratory effort
Peak flow
Oxygen saturations
Chest auscultation
MONITOR FOR HYPOKALAEMIA
41
Q

What should you do for an asthmatic patient prior to discharge

A
  • optimise asthma medications
  • discharge with an asthma action plan
  • Consider prescribing a rescue pack of steroids
  • Referral to a respiratory specialist after 2 attacks in 12 months.
42
Q

What is pneumonia

A

an infection of the lung tissue. It causes inflammation of the lung tissue and sputum filling the airways and alveoli

43
Q

When is it considered a hospital acquired pneumonia

A

Develops more than 48h after hospital admission

44
Q

What is the presentation of penumonia

A

Shortness of breath
Cough productive of sputum
Fever
Haemoptysis (coughing up blood)
Pleuritic chest pain (sharp chest pain worse on inspiration)
Delirium (acute confusion associated with infection)
Sepsis

45
Q

What are the signs of pneumonia

A 
Tachypnoea (raised respiratory rate)
Tachycardia (raised heart rate)
Hypoxia (low oxygen)
Hypotension (shock)
Fever
Confusion
46
Q

What chest signs may you find in pneumonia

A
  • bronchial breathing
  • Focal coarse crackles
  • Dullness to percuss
47
Q

What is bronchial breathing

A

harsh breath sounds equally loud on inspiration and expiration. These are caused by consolidation of the lung tissue around the airway.

48
Q

How do you assess severity of pneumonia

A

C – Confusion (new disorientation in person, place or time)
U – Urea > 7
R – Respiratory rate ≥ 30
B – Blood pressure < 90 systolic or ≤ 60 diastolic.
65 – Age ≥ 65

49
Q

When does CURB65 need to be admitted to hospital

A

Score 0/1: Consider treatment at home
Score ≥ 2: Consider hospital admission
Score ≥ 3: Consider intensive care assessment

50
Q

What are common causes of pneumonia

A 
Streptococcus pneumoniae (50%)
Haemophilus influenzae (20%)
51
Q

Patients with CF or bronchiectasis are more likely to be affected by which bugs

A
  • Pseudomonas aeruginosa

- staphylococcus aurees

52
Q

Immunocompromised patients are more like to be affected by which bug

A

Moraxella catarrhalis

53
Q

What is an atypical pneumonia

A
  • pneumonia caused by an organism that cannot be cultured in the normal way or detected using a gram stain
  • Don’t respond to penicillans
  • Treated with:
    - Macrolides e.g. clarithomycin,
    - fluoroquines (e.g. levofloxacin)
    - tetracyclines (e.g. doxycycline).
54
Q

What is Legionella pneumophila (Legionnaires’ disease)

A
  • typically caused by infected water supplies or air conditioning units
  • can cause hyponatraemia by causing an SIADH.
  • Atypical pneumonia
55
Q

What is Mycoplasma pneumoniae.

A
  • milder atypical pneumonia
  • can cause erythema multiforme characterised by varying sized “target lesions” formed by pink rings with pale centres.
  • can also cause neurological symptoms in young patient in the exams.
56
Q

What is Chlamydophila pneumoniae

A
  • school aged child with a mild to moderate chronic pneumonia and wheeze
  • Be cautious though as this presentation is very common without chlamydophilia pneumoniae infection.
57
Q

What is Coxiella burnetii AKA “Q fever”.

A

This is linked to exposure to animals and their bodily fluids. The MCQ patient is a farmer with a flu like illness.

58
Q

What is Chlamydia psittaci.

A

typically contracted from contact with infected birds. The MCQ patient is a from parrot owner.

59
Q

What is Pneumocystis jiroveci (PCP)

A
  • ## fungal pneumonia occurs in patients that are immunocompromised (Poorly controlled HIV)
60
Q

Symptoms of Pneumocystis jiroveci (PCP)

A
  • presents subtly
  • dry cough without sputum
  • shortness of breath on exertion
  • night sweat
61
Q

treatment of Pneumocystis jiroveci (PCP)

A
  • Treatment is with co-trimoxazole/ Septrin (trimethoprim/sulfamethoxazole)
  • Patients with low CD4 counts are prescribed prophylactic oral co-trimoxazole to protect against PCP.
62
Q

What investigations to do in hospital if suspected pneumonia

A
  • Chest xray
  • FBC (raised white cells)
  • U&Es (for urea)
  • CRP (raised in inflammation and infection)
  • Sputum cultures
  • Blood cultures
  • Legionella and pneumococcal urinary antigens (send a urine sample for antigen testing)
63
Q

What is the management of a mild CAP

A

5 day course of oral antibiotics (amoxicillin or macrolide)

64
Q

What is the management of a moderate/severe CAP

A

7-10 day course of dual antibiotics (amoxicillin and macrolide)

65
Q

What are the complications of pneumonia

A 
Sepsis
Pleural effusion
Empyema
Lung abscess
Death
66
Q

What is the management of giving O2 in a patient with COPD

A
  • 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92% PRIOR to getting gas
  • If CO2 normal on gas aim sats 94-98
67
Q

Causes of hemithorax causing trachea to pull TOWARDS white out

A
  • Pneumonectomy
  • Complete lung collapse e.g. endobronchial intubation
  • Pulmonary hypoplasia
68
Q

Causes of hemithorax causing trachea to stay central in a white out

A
  • Consolidation
  • Pulmonary oedema (usually bilateral)
  • Mesothelioma
69
Q

Causes of hemithorax causing trachea to push AWAY from white out

A
  • Pleural effusion
  • Diaphragmatic hernia
  • Large thoracic mass
70
Q

`Common causes of white shadowing in the lungs

A
  • consolidation
  • pleural effusion
  • collapse
  • pneumonectomy
  • specific lesions e.g. tumours
  • fluid e.g. pulmonary oedema
71
Q

What does a high PCO2 on a gas suggest

A

PaCO2 > 6.0 kPa suggests a respiratory acidosis (or respiratory compensation for a metabolic alkalosis)

72
Q

What does a low PCO2 on a gas suggest

A

PaCO2 < 4.7 kPa suggests a respiratory alkalosis (or respiratory compensation for a metabolic acidosis)

73
Q

What does a decrease in bicarbonate on a gas suggest

A

bicarbonate < 22 mmol/l (or a base excess < - 2mmol/l) suggests a metabolic acidosis (or renal compensation for a respiratory alkalosis)

74
Q

What does an increase in bicarbonate on a gas suggest

A

bicarbonate > 26 mmol/l (or a base excess > + 2mmol/l) suggests a metabolic alkalosis (or renal compensation for a respiratory acidosis)

Respiratory (3 decks)

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