Breathing Flashcards
describe the features of a
- moderate asthma attack
- acute severe asthma attack
- life-threatening asthma attack
- Moderate: PEFR 50-75% of best/ predicted. SpO2≥92%.
- Acute severe: PEFR 33-50% of best/ predicted. SpO2≥92%. RR ≥25, HR≥110. Cannot complete sentences in one breath.
- Life-threatening: PEFR <33% of best/ predicted. SpO2<92%. Silent chest, cyanosis, poor respiratory effort. Arrhythmia, hypotension. Exhaustion, altered LOC.
initial management of
- moderate
- acute severe
- life-threatening
asthma attacks
- Beta2-bronchodilator via spacer (one puff at a time; according to response give another puff every 60 seconds up to a max of 10 puffs)
- Beta2-bronchodilator (salbutamol 5mg) by oxygen driven nebuliser
- Obtain senior help. Give oxygen to maintain Sp02 94-98%. Salbutamol 5mg and ipatropium 0.5mg via oxygen driven nebuliser. Prednisolone 40-50mg PO/ Hydrocortisone 100mg IV.
if patient had asthma attack with PEFR <50% on presentation, what additional med should they be prescribed until recovery?
prednisolon 40-50mg/ day until (min 5 days)
- what scoring system is used to stratify risk of patient having a PE?
- state some of the components of this?
- geneva score
- clinical symptoms (tenderness and unilateral oedema), haemoptysis, active malignancy, aged ≥65, surgery/ # in past 4 wk, previous DVT/ PTE, unilateral lower limb pain, HR
NB: 0-3 = low risk, 4-10 = intermediate, ≥11 = high
what investigation is required if the risk is low?
d-dimer assay (if negative, seek alternative diagnosis)
if pt is intermediate/ high risk after geneva score (or low risk with +ve d-dimer) what Ix is the gold standard for PTE?
CTPA = gold standard
V/Q is equally useful in e.g. pregnancy
NB: patients must be scanned within 48hr
what is PESI scoring used for in pulmonary embolism management?
assessing suitability of using outpatient investigations (not valid in pregnancy)
T/F: d-dimer test is not valid in pregnant women
true
consider doppler leg first is signs are present
If DVT is suspected & confirmed on ultrasound – there is no need for VQ or CTPA
treatment of PE?
- rivaroxiban for at least 3 months
- appropriate lifestyle and bleeding advice
cardiac arrest caused by PE
treatment of underlying cause?
alteplase 50mg IV bolus
absoulte contraindications to thrombolysis?
- Major surgery or trauma in past 2 weeks
- Aortic Dissection
- Active internal bleeding
- Known cerebral tumour (not excised)
- History of cerebral haemorrhage or AVM
- Prolonged, traumatic CPR (more than 10 mins continuous compressions)
- Known/documented allergy to thrombolytic agent
- CVA with haemorrhage in last 12 months
- Pregnancy
alternative management of PTE for patients who are unsuitable for thrombolysis?
Mechanical disruption of PTE
what is CURB65 used for
assessing severity of CAP
components of CAP?
- Confusion, new
- Urea > 7mmol/l
- RR ≥30
- BP <90s or ≤60d
- ≥65
score 1 for each
acute exacerbation of COPD - initial Ix?
- ABG
- CXR
- U&Es, FBC, CRP
- ECG
- Blood cultures if patients meets Sepsis 6 criteria
- For acute COPD, titrate oxygen therapy to maintain SaO2 of __% in first instance
- Then carry out which investigation?
- 88-92
- ABG: to determine whether pt at risk of CO2 retention (type 1 = titrate to 94-98%, type 2 = titrate to 88-92%)
Treatment of acute COPD
- ensure appropriate O2 prescribing
- T/F: continue inhalers
- Salbutamol: ___ puffs MDI multi-dosed through spacer; or 2.5mg nebulised if unable to co-ordinate multi-dosing
- Continue _____ as single therapy if patient can coordinate the device, otherwise ipratropium 500 mcg nebulised QDS
- _____ 30mg od for 5 days
- Treat congestive cardiac failure with ____
- Antibiotics if 2 of: increased sputum volume, purulence and dyspnoea (First line ___ ; 2nd line ___)
- i.e. 88-92% for T1 resp failure and 94-98% for T2 resp failure
- Continue LABA/LAMA/ICS and LABA/LAMA combination inhalers
- 10
- LAMA
- Prednisolone
- diuretics
- amoxicillin, doxycycline
when treating acute COPD, should also consider and treat other causes of exacerbation such as..?
- Infection
- Sedatives
- Anxiety and hyperventilation
- Pneumothorax
- PE
- MI
in patients with acute COPD, IV ____ can be administered in patients with persisting bronchospasm despite core treatment
aminophylline
what procedure can be used for hypercapnic respiratory acidosis in acute COPD
Non-Invasive Ventilation (NIV)
what is non-invasive ventilation?
a process where a patient can be provided with a degree of respiratory support (e.g. CPAP) without the need to intubate them and transfer them to ICU.
how does non-invasive ventilation work?
Most commonly provided by tight-fitting mask or, occasionally, an inflatable hood and works by increasing recruitment of lung tissue to improve ventilation.
indications for NIV?
- acute/ acute on chronic T2 resp failure
- in particular, consider for acute COPD exacerbations with persistent acidosis despite maximum medical therapy
- Other likely indications: chest wall deformity, neuromuscular disease
absoute contraindications of NIV?
- Facial injuries including burns
- Airway obstruction
- Vomiting
where should NIV be carried out?
ICU, HDU or the respiratory ward
T/F: patient with infectious respiratory TB must be isolated in hospital whilst they are still infectious
True - if need be, they can be held against their will due to the infection risk they present to others.
Refer them to Infectious Diseases ward
T/F: all cases of TB must be reported to public health only when diagnosis is confirmed
false
TB is a notifiable disease.
Any case must be reported to Health Protection Scotland on suspicion of tuberculosis (NOT on diagnosis).
Ix if respiratory TB suspected?
- order a PA chest x-ray
- followed by at least 3 sputum samples (including 1 early morning sample) sent for TB culture and microscopy
TB treatment?
- RIPE (2 months)
- RE (further 4 months)
How long should patient with active respiratory TB be detaind in hospital for?
until their sputum is negative, at which point their treatment can continue in the community
where is the ‘triangle of safety’ (when inserting a chest drain)
Mid-axillary line, 5th intercostal space
- anterior border latissimus dorsi
- bordered by: anterior border latissimus dorsi, lateral border pectoralis major, a line superior to horizontal level of nipple, and an apex below the axilla
what Ix is required after inserting a chest drain?
CXR
tension pneumo treatment?
needle decompression using a 16- or 14-gauge needle (grey or orange cannula), inserted into the 2nd intercostal space in the mid-clavicular line. Remove the cap from the end of the cannula to allow the air to flow from the intercostal space.
Then insert a chest drain
NB: clinical diagnosis - do not order CXR to confirm
what is Haemopneumothorax (haemothorax)
presence of blood in the pleural space.
almost invariably associated with massive trauma.
treatment of haemothorax?
- Follow ABC guidelines.
- If significant haemothorax, insert a chest drain
- may need transfusion if bleeding continues
- senior help
what respiratory signs are associated with these non-resp problems?
- Metabolic acidosis (e.g. DKA)
- Panic attacks
- Raised intracranial pressure
- Opioid/sedative overdose
- Acute coronary syndromes
- Airway obstruction
- Neuromuscular diseases (e.g. myasthenia gravis)
- Congenital heart abnormality
- Anaemia
- Hyperventilation (Kussmaul breathing)
- Hyperventilation
- Hyperventilation
- Hypoventilation
- Breathlessness (especially in the elderly)
- See-saw breathing
- CO2 retention, use of accessory muscles of respiration
- Cyanosis
- Breathlessness
why must you beware pulse oximetry in
- carbon monoxide poisoning?
- anaemia
- The patient who is hypoventilating, and being given oxygen
- gives a falsely high SpO2 (oximeter cannot differentiate). If CO poisoning suspected, perform an ABG
- the saturation may be ok but oxygen carriage will not be
- Their saturation may be high, but the CO2 may also be high
Arterial blood gases are the best way to clinically meausure what?
a patient’s gas exchange and acid/base balance
Interpret and provide a differential for
- pH: low
- pCO2: high
- HCO3: normal
Uncompensated respiratory acidosis
Acute Type 2 Respiratory Failure (e.g. severe acute asthma)
Interpret and provide a differential for
- pH: low
- pCO2: normal
- HCO3: low
uncompensated metablic acidosis
DKA, poisoning, sepsis
Interpret and provide a differential for
- pH: high
- pCO2: low
- HCO3: normal
uncompensated respiratory alkalosis
hyperventilation
Interpret and provide a differential for
- pH: high
- pCO2: normal
- HCO3: high
uncompensated metabolic acidosis
Uncommon- can be due to vomiting, severe hypokalaemia
Is a patient with CO2 retention and an increased bicarbonate more likely to be chronically or acutely retaining CO2?
chronically
metabolic compensation is slow, taking several days to take effect
T/F: unlike metabolic compensation, respiratory compensation is quick, taking effect within minutes
True
As such, a patient in DKA will swiftly begin to hyperventilate and their CO2 will fall quite quickly.
what is the anion gap?
a way of calculating the concentration of unmeasured acidic ions in the blood
calculated as (Na+ + K+) – (HCO3– + Cl–)
Should be ≤12, if raised can indicate metabolic disturbance
Causes of High Anion Gap
- Alcohol
- Methanol poisoning
- Uraemia
- DKA
- Paraquat poisoning (highly toxic herbicide; no known antidote)
- Infection
- Lactic Acid
- Ethylene glycol poisoning
- Salicylates (e.g. aspirin overdose)
- target O2 concentration
- recommended inhaled O2
- device
used for majority of stable patients?
- 94-98%
- 4-6L/min
- nasal cannula/ simple face mask
- target O2 concentration
- recommended inhaled O2
- device
used for majority of stable patients?
- 88-92%
- 24 or 28%
- blue or white venturi mask
- recommended inhaled O2
- device
used for majority of stable patients?
- 100%
- resevoir mask (trauma mask) at 15L/min
