Breathlessness

Question 1

Describe a moderate asthma attack

Answer 1

PEFR 50-75% expected
mild chest discomfort/tightness
normal speech
no other features

Question 2

Describe a severe asthma attack

Answer 2

PEFR 33 - 50%
RR >25, Pulse >110
Cant talk in complete sentences
accessory muscle use
O2 Sats <92%

Question 3

Describe a life threatening asthma attack

Answer 3

PEFR <33%
Poor respiratory effort - exhaustion
altered consciousness
Hypotension, cardiac arrhythmias
Cyanosis
silent chest!

Question 4

SABA dosage in acute asthma

Answer 4

Salbutamol - 5mg, Neb

Repeat every 20 - 30 mins

Question 5

Dosage of Ipratropium bromide

Answer 5

0.5mg, Neb, every 4 hours

Question 6

What steroid treatment in acute asthma?

Answer 6

Prednisolone, 40-50mg, PO
OR
Hydrocortisone 100mg IV

Given in hospital, and a 7 day course post-discharge

Question 7

Options for intensifying treatment in acute asthma? if regular bronchodilators do not work

Answer 7

IV Magnesium sulphate - 1 - 1.2mg IV
IV Aminophylline
IV salbutamol

Question 8

Principals of management for exacerbation of COPD

Answer 8

Intensify bronchodilator therapy (^ dose/frequency)
Oral steroids - 30mg Prednisolone, 7-14 days
Abx if appropriate
O2 therapy

Question 9

Abx of choice for exacerbation of COPD?

Answer 9

Amoxicillin, 500mg TDS

Alternatives - Doxycycline, clarithromycin

Question 10

Explain the CURB 65 scoring system

Answer 10

C = confusion
U = urea >7mmol/L
R = RR >30
B = SBP <90
65 = age 65+

0-1 = manage in primary care, 2 = moderate mortality, hospital. 3+ = high mortality, hospital

Question 11

Abx of choice for each severity of pneumonia, as guided by CURB 65

Answer 11

0 - 1 = Amoxicillin (or Doxy, or Clarith)
2 = Amoxicillin + Clarithromycin
3+ = Co-Amoxiclav (or Cefuroxime + Clarith)

Question 12

Causative organisms of CAP

Answer 12

Most often - cause not found

Strep Pneumoniae
Staph A
Mycoplasma
H. Influenzae

Question 13

Treatment for Pneumocystis Jirovecii in immunocompromised patient

Answer 13

Co-trimoxazole

Question 14

Presenting features of pneumothorax

Answer 14

Sudden onset chest pain, SoB, tachycardia
Pulsus paradoxus
Hyperresonant chest, reduced breath sounds
Deviation of trachea away from collapse

Question 15

Describe purpose of Well’s score

Answer 15

Indicates likelihood and risk for DVT/PE

> 4 points, PE likely
<4 points, PE unlikely

Question 16

What is PERC - Pulmonary Embolism Rule Out criteria?

Answer 16

Checklist of 8 questions.

If all 8 are negative - no further testing required, however if 1 positive, test for PE

Question 17

Order of investigations for PE?

Answer 17

1st - CTPA - can have interim anticoagulation
- V/Q perfusion scan

Not much value to either D-dimer or Chest x-ray

Question 18

Management of PE?

Answer 18

Anticoagulation with LMWH / Heparin (if renal function impaired)

Aim for oral switch once INR stable at 2+

Question 19

Treatment and dosages for acute Pulmonary Oedema

Answer 19

L - Loop diuretics - Furosemide 40mg IV
M - morphine, 5-10mg IV
N - nitrates, 800mcg, 2 puffs
O - oxygen, high flow NRBM
P - positioning, sat upright

Question 20

Pneumonic for management of exacerbation of COPD

Answer 20

COSI CAR

CO - controlled Oxygen (venturi - titrate to sats of 88-92%)
S - salbutamol nebs - 5mg, B2B
I - ipratropium bromide - 500mcg neb
C - corticosteroids - 30mg Pred PO, or 200mg Hydrocortisone IV
A - Abx / Aminophylline
R - respiratory support - BiPAP

Question 21

Indications for CPAP vs BiPAP

Answer 21

CPAP - type I respiratory failure - forces O2 in

BiPAP - type II respiratory failure - forces O2 in, forces CO2 out

Question 22

Primary vs Secondary pneumothorax?

Answer 22

Primary = no underlying lung disease, <50yrs, no smoking history

Secondary = underlying lung disease, >50yrs, smoking history

Question 23

Management of primary pneumothorax

Answer 23

If <2cm, asymptomatic - observe/ discharge

If >2cm, or symptomatic - needle decompression

If this fails –> chest drain

Question 24

Management of secondary pneumothorax

Answer 24

If >50yrs, OR >2cm, or SoB - chest drain

If 1-2cm - aspiration

All patients should be admitted for 24hrs

If <1cm - give O2, observe

Avoid scuba diving permanently