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Breathlessness Flashcards

1
Q

What signs show respiratory distress?

A 
Low and high RR 
Pursed lip breathing
Agitation
Drowsy
Mottled/blue colour
Sweaty
Intercostal/subcostal recession
Grunting
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2
Q

What are the target O2 sats for normal patients and patients with chronic lung disease?

A

Normal - 94-98%

Chronic lung disease - 88-92%

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3
Q

What are the features of acute severe asthma?

A

PEFR 33-50% of predicted
Pulse > 110bpm
RR > 25 breaths/min
Inability to complete full sentences

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4
Q

What are the features of life threatening asthma attack?

A 
PEFR < 33% of predicted
Sats < 92% on air
Silent chest 
Bradycardia
Hypotension
Exhaustion/poor respiratory effort
Altered level of consciousness
Arrhythmia
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5
Q

What are the features of a near fatal asthma attack?

A

Raised PaCO2

Requiring mechanical ventilation (once CO2 > 6kPa)

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6
Q

How do you treat a mild asthma attack?

A

Up to 10 puffs salbutamol inhaler

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7
Q

What is the management of a severe asthma attack?

A

ABCDE assessment
Sit patient up

Oxygen - high flow 15L/min via non-rebreathe reservoir mask
Salbutamol - 5mg NEB b2b over 15-20 min intervals
Hydrocortisone - 100mcg IV
Ipratropium bromide - 500mcg (0.5mg) NEB 4-6 hourly
If no improvement, escalate to senior
Magnesium sulphate - 1.2-2g IV over 20 mins
Consider aminophylline IV 5mg/kg over 20 mins (requires senior medical advice)

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8
Q

What factors are important to ask about to assess severity of COPD?

A

LTOT/home nebulisers
Exercise tolerance
Weight loss
Number of courses of antibiotics/steroids in last 2 months
Previous hospital admissions in past 12 months
DNACPR
Previous non-invasive ventilation

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9
Q

What is the staging of COPD?

A

Mild - FEV1 > 80%
Moderate - FEV1 50-80%
Severe - FEV1 30-50%
Very severe - FEV1 < 30%

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10
Q

What does an ABG show in a patient with COPD?

A

Hypoxia and hypercapnia = type 2 respiratory failure

High bicarbonate = metabolic compensation

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11
Q

What might an ECG show in COPD?

A

Right ventricular hypertrophy:

  • P-pulmonale pattern: increase in p wave amplitude in leads II, III, aVF
  • Right axis deviation: lead III positive, lead I negative
  • RBBB: broad QRS complex
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12
Q

What is the management of an acute COPD exacerbation?

A

CORSICAARRR

Controlled Oxygen - venturi mask work-up
Salbutamol - 5mg NEB
Ipratropium bromide - 0.5mg NEB
Corticosteroids - hydrocortisone 100-200mg IV/prednisolone 40mg PO
Antibiotics - treat as pneumonia
Aminophylline (consider) 
Radiography - CXR
Respiratory support - BiPAP if CO2 is raised and respiratory acidosis persists 1hr after starting treatment
Refer
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13
Q

How does pneumonia present?

A 
Breathlessness
Cough with purulent sputum (+/- haemoptysis) 
Pleuritic chest pain
Fever
Confusion (especially in elderly)
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14
Q

What signs can be found on examination of pneumonia?

A 
Tachypnoea
Tachycardia 
Hypotension
Dull percussion
Decreased air entry
Crepitations
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15
Q

When is an ABG indicated in ?pneumonia?

A

If sats < 94%

In known COPD

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16
Q

What must be calculated in patient with pneumonia?

A

CURB-65 score

Confusion - AMTS < 8
Urea > 7mmol/L
Resp rate > 30
Blood pressure < 90/60
>65 years age
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17
Q

What scores of CURB-65 indicate what?

A 
0-1 = home treatment
2 = hospital admission
>3 = consider ITU, increased risk of death
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18
Q

What are the main organisms that cause CAP?

A
  1. Streptococcus pneumoniae
  2. Haemophilus influenzae
  3. Moraxella catarrhalis
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19
Q

What are the main organisms that cause HAP?

A
  1. Gram negative bacillus
  2. Staphylococcus aureus
  3. Pseudomonas
  4. Klebsiella
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20
Q

What atypical organisms can cause CAP?

A

Mycoplasma pneumoniae
Staphylococcus aureus
Legionella
Chlamydia pneumoniae

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21
Q

What is HAP defined as?

A

Pneumonia after 48 hours of hospital admission

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22
Q

What does loss of right heart border show on CXR?

A

Right middle lobe pneumonia

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23
Q

What antibiotics are used to treat CAP depending on the causative organism?

A

Streptococcus pneumoniae - amoxicillin/macrolide
Haemophilus influenzae - cephalosporins
Moraxella catarrhalis - amoxicillin/macrolides
Mycoplasma pneumoniae - macrolides
Staphylococcus aureus - penicillin/cephalosporin
Legionella - quinolone + clarithromycin/rifampicin
Chlamydia pneumoniae - tetracycline

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24
Q

What antibiotics are used to treat HAP depending on the causative organism?

A
  1. Gram negative enterobacteria - aminoglycoside + penicillin/cephalosporin
  2. Staphylococcus aureus
  3. Pseudomonas - quinolone or IV gentamicin
  4. Klebsiella - often resistant
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25
Q

Why should you do a urine culture in pneumonia?

A

Pneumococcal and legionella antigen tests

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26
Q

How do you treat an aspiration pneumonia?

A

Cephalosporin + metronidazole

27
Q

Who is most at risk of a primary pneumothorax?

A

Tall thin young men

28
Q

What causes a primary pneumothorax?

A

Primary = spontaneous rupture of pulmonary blebs (subpleural bullae)

29
Q

What causes a secondary pneumothorax?

A

Underlying lung condition - asthma, COPD, TB, CF, pneumonia, lung carcinoma

Iatrogenic - mechanical ventilation, central line, pleural aspiration

30
Q

In women, what is a risk factor for pneumothorax?

A

Endometriosis - occurs during menstruation

31
Q

How does a pneumothorax present?

A

Sudden onset of unilateral pleuritic chest pain and progressively worsening breathlessness

32
Q

What signs can be found on examination of pneumothorax?

A
  • Tachypnoea, tachycardia
  • Reduced chest expansion on affected side
  • Hyper-resonant percussion note
  • Diminished breath sounds
  • Tachycardia
  • Pulsus paradoxicus - pulse slows on inspiration
33
Q

What signs are found on examination of tension pneumothorax?

A
  • Tracheal deviation away from affected side
  • Hypotension
  • Raised JVP
  • Tachycardia
  • Respiratory distress
  • Distended neck veins (mediastinum is pushed over and compressing the great veins)
34
Q

What defines a small/large pneumothorax?

A 
Small = <2cm
Large = >2cm
35
Q

What investigations can be done in suspected pneumothorax?

A

CXR - will show areas devoid of lung markings (remember to check apices)
ABG - respiratory alkalosis

Do NOT do investigations before treatment in suspected tension pneumothorax

36
Q

How do you manage a tension pneumothorax?

A

ABCDE assessment

Sit patient up
Oxygen - high flow 15L/min NRBM
Aspirate - 16/18G cannula in 2nd intercostal space mid-clavicular line
Then insert chest drain in 5th intercostal space mid-axillary line

37
Q

How do you manage a primary pneumothorax >2cm?

A

Aspirate - 16/18G cannula in 2nd intercostal space mid-clavicular line

38
Q

How do you manage a primary pneumothorax <2cm and patient is not breathless?

A

Consider discharge and review in 2-4 weeks

39
Q

How do you manage a secondary pneumothorax >2cm?

A

Chest drain in 5th intercostal space mid-axillary line

40
Q

What is an open pneumothorax?

A 
Large defect (>60% size of trachea) in chest wall
When chest expands, air goes in through defect rather than down trachea
No gas exchange in pleural space 
No tension
41
Q

What is the main cause of PE?

A

DVT - clots break off, pass through veins to right side of heart and lodge in pulmonary artery

42
Q

What are the main risk factors for PE?

A

THROMBOSIS

Travel
Hypercoagulable, HRT
Recreational drugs
Old (>60)
Malignancy
Birth control pill
Obesity, Obstetrics
Surgery, Smoking
Immobilisation
Sickness
43
Q

What types of emobli exist?

A 
Septic emboli from endocarditis - IVDU
Fat - long-bone fractures
Air - surgery, trauma
Neoplastic cells - prostate/breast cancers most commonly 
Parasites
Amniotic fluid embolism
Foreign bodies - IVDU, iatrogenic
44
Q

How does a PE present?

A

Sudden onset SOB
Pleuritic chest pain, worse on inspiration
Haemoptysis
Syncope

45
Q

What signs are found on examination of PE?

A 
Tachycardia
Tachypnoea
Hypotension
Raised JVP
Hypoxia
Signs of DVT
46
Q

What score is calculated for PE and what do the scores indicate?

A

Well’s Score for PE

  • Clinical signs of DVT
  • Pulse > 100 bpm
  • Recent surgery
  • Previous DVT
  • Haemoptysis
  • Cancer
  • Alternative diagnosis is less likely than PE

Score < 4 = low-risk -> do D-Dimer, if positive do CTPA, if negative discharge

Score >4 = high-risk -> do CTPA

47
Q

What is seen on ECG in PE?

A

Sinus tachycardia

Possibly can see:

  • Right axis deviation
  • T wave inversion
48
Q

What is the treatment for a non-massive PE?

A

LMWH for 5 days
Unfractioned heparin if renal impairment

Then start DOAC or warfarin for 3 months

If unprovoked PE, continue anticoagulation for longer than 3 months.
If caused by malignancy, continue for 6 months

49
Q

How does a massive PE present? How are they managed?

A

Hypotension
Cardiac arrest

Give thrombolytic treatment

50
Q

What score is used to determine the mortality and outcome of patients with newly diagnosed PE?

A

PESI Score (Pulmonary Embolism Severity Index)

51
Q

Other than CT what scan can be done in PE?

A

V/Q Scan

52
Q

Which patients are more appropriate for VQ scans than CTPA?

A

Pregnant women

Under 40 year olds

53
Q

Does D-Dimer have good/bad specificity/sensitivity?

A

Poor specificity - it measures clot break down (i.e. can be any clots in the body)

High sensitivity - useful to rule out PE

54
Q

What is the pathophysiology behind cardiogenic pulmonary oedema?

A

LVF leads to increased pulmonary capillary pressure so fluid collects in extravascular pulmonary tissues faster than lymphatics clear it

55
Q

What can cause LVF?

A

Acute complication of: MI, IHD

Excerbation of: hypertension, valve disease, arrhythmias

Others: cardiomyopathy, negatively ionotropic drugs (beta-blockers), pericardial disease

56
Q

What is the pathophysiology behind non-cardiogenic pulmonary oedema?

A
  • Increased capillary permeability
  • Decreased plasma oncotic pressure (osmotic pressure induced by albumin)
  • Increased lymphatic pressure
57
Q

What can cause non-cardiogenic pulmonary oedema?

A 
Hypoalbuminaemia
IV fluid overload
ARDS
Smoke inhalation
Near-drowning incident 
High altitude sickness
58
Q

How does pulmonary oedema affect breathing?

A 
Short of breath
Unable to complete full sentences
Reduced exercise tolerance
Orthopnoea
Paroxysmal nocturnal dysponoea
59
Q

What is the cough like in pulmonary oedema?

A

Pink frothy sputum

Nocturnal cough

60
Q

What signs are found on examination of pulmonary oedema?

A 
Patient is anxious, sweaty, cool, pale (evidence of decreased cardiac output) 
Tachycardia
Tachypnoea
Cyanosis
Raised JVP 
Dull percussion note in bases 
Fine basal inspiratory crackles
Gallop rhythm if due to LVF
61
Q

What test distinguishes heart failure from other causes of dyspnoea? What levels are high?

A

B-type natriuretic peptide (BNP)
It is released when the myocardium is stressed and is related to left ventricular pressure

· High: >2000 pg/ml – urgent ECHO (2 weeks)
· Raised: 400-2000 pg/ml – 6 weeks
Normal: <400 pg/ml – normal

62
Q

What signs of heart failure/pulmonary oedema are seen on a CXR?

A

ABCDEF

Alveolar oedema - Bat's wings
B - Kerley B lines = interstitial oedema
Cardiomegaly
D - upper lobe diversion
Effusions
Fluids in fissures
63
Q

What is the management of acute pulmonary oedema?

A

ABCDE assessment
Sit the patient up

Oxygen - high flow 15L/min via NRBM or cPAP
GTN 2 sprays (IV nitrate if unresponsive)
Beta-blocker + ACEi
Diuretic - IV Furosemide 50mg (add thiazide if needed)
Diamorphine - IV 2.5mg

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