Breathlessness Flashcards
What signs show respiratory distress?
Low and high RR Pursed lip breathing Agitation Drowsy Mottled/blue colour Sweaty Intercostal/subcostal recession Grunting
What are the target O2 sats for normal patients and patients with chronic lung disease?
Normal - 94-98%
Chronic lung disease - 88-92%
What are the features of acute severe asthma?
PEFR 33-50% of predicted
Pulse > 110bpm
RR > 25 breaths/min
Inability to complete full sentences
What are the features of life threatening asthma attack?
PEFR < 33% of predicted Sats < 92% on air Silent chest Bradycardia Hypotension Exhaustion/poor respiratory effort Altered level of consciousness Arrhythmia
What are the features of a near fatal asthma attack?
Raised PaCO2
Requiring mechanical ventilation (once CO2 > 6kPa)
How do you treat a mild asthma attack?
Up to 10 puffs salbutamol inhaler
What is the management of a severe asthma attack?
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)
What factors are important to ask about to assess severity of COPD?
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
What is the staging of COPD?
Mild - FEV1 > 80%
Moderate - FEV1 50-80%
Severe - FEV1 30-50%
Very severe - FEV1 < 30%
What does an ABG show in a patient with COPD?
Hypoxia and hypercapnia = type 2 respiratory failure
High bicarbonate = metabolic compensation
What might an ECG show in COPD?
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
What is the management of an acute COPD exacerbation?
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
How does pneumonia present?
Breathlessness Cough with purulent sputum (+/- haemoptysis) Pleuritic chest pain Fever Confusion (especially in elderly)
What signs can be found on examination of pneumonia?
Tachypnoea Tachycardia Hypotension Dull percussion Decreased air entry Crepitations
When is an ABG indicated in ?pneumonia?
If sats < 94%
In known COPD
What must be calculated in patient with pneumonia?
CURB-65 score
Confusion - AMTS < 8 Urea > 7mmol/L Resp rate > 30 Blood pressure < 90/60 >65 years age
What scores of CURB-65 indicate what?
0-1 = home treatment 2 = hospital admission >3 = consider ITU, increased risk of death
What are the main organisms that cause CAP?
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
What are the main organisms that cause HAP?
- Gram negative bacillus
- Staphylococcus aureus
- Pseudomonas
- Klebsiella
What atypical organisms can cause CAP?
Mycoplasma pneumoniae
Staphylococcus aureus
Legionella
Chlamydia pneumoniae
What is HAP defined as?
Pneumonia after 48 hours of hospital admission
What does loss of right heart border show on CXR?
Right middle lobe pneumonia
What antibiotics are used to treat CAP depending on the causative organism?
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
What antibiotics are used to treat HAP depending on the causative organism?
- Gram negative enterobacteria - aminoglycoside + penicillin/cephalosporin
- Staphylococcus aureus
- Pseudomonas - quinolone or IV gentamicin
- Klebsiella - often resistant
Why should you do a urine culture in pneumonia?
Pneumococcal and legionella antigen tests
How do you treat an aspiration pneumonia?
Cephalosporin + metronidazole
Who is most at risk of a primary pneumothorax?
Tall thin young men
What causes a primary pneumothorax?
Primary = spontaneous rupture of pulmonary blebs (subpleural bullae)
What causes a secondary pneumothorax?
Underlying lung condition - asthma, COPD, TB, CF, pneumonia, lung carcinoma
Iatrogenic - mechanical ventilation, central line, pleural aspiration
In women, what is a risk factor for pneumothorax?
Endometriosis - occurs during menstruation
How does a pneumothorax present?
Sudden onset of unilateral pleuritic chest pain and progressively worsening breathlessness
What signs can be found on examination of pneumothorax?
- Tachypnoea, tachycardia
- Reduced chest expansion on affected side
- Hyper-resonant percussion note
- Diminished breath sounds
- Tachycardia
- Pulsus paradoxicus - pulse slows on inspiration
What signs are found on examination of tension pneumothorax?
- Tracheal deviation away from affected side
- Hypotension
- Raised JVP
- Tachycardia
- Respiratory distress
- Distended neck veins (mediastinum is pushed over and compressing the great veins)
What defines a small/large pneumothorax?
Small = <2cm Large = >2cm
What investigations can be done in suspected pneumothorax?
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
How do you manage a tension pneumothorax?
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
How do you manage a primary pneumothorax >2cm?
Aspirate - 16/18G cannula in 2nd intercostal space mid-clavicular line
How do you manage a primary pneumothorax <2cm and patient is not breathless?
Consider discharge and review in 2-4 weeks
How do you manage a secondary pneumothorax >2cm?
Chest drain in 5th intercostal space mid-axillary line
What is an open pneumothorax?
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
What is the main cause of PE?
DVT - clots break off, pass through veins to right side of heart and lodge in pulmonary artery
What are the main risk factors for PE?
THROMBOSIS
Travel Hypercoagulable, HRT Recreational drugs Old (>60) Malignancy Birth control pill Obesity, Obstetrics Surgery, Smoking Immobilisation Sickness
What types of emobli exist?
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
How does a PE present?
Sudden onset SOB
Pleuritic chest pain, worse on inspiration
Haemoptysis
Syncope
What signs are found on examination of PE?
Tachycardia Tachypnoea Hypotension Raised JVP Hypoxia Signs of DVT
What score is calculated for PE and what do the scores indicate?
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
What is seen on ECG in PE?
Sinus tachycardia
Possibly can see:
- Right axis deviation
- T wave inversion
What is the treatment for a non-massive PE?
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
How does a massive PE present? How are they managed?
Hypotension
Cardiac arrest
Give thrombolytic treatment
What score is used to determine the mortality and outcome of patients with newly diagnosed PE?
PESI Score (Pulmonary Embolism Severity Index)
Other than CT what scan can be done in PE?
V/Q Scan
Which patients are more appropriate for VQ scans than CTPA?
Pregnant women
Under 40 year olds
Does D-Dimer have good/bad specificity/sensitivity?
Poor specificity - it measures clot break down (i.e. can be any clots in the body)
High sensitivity - useful to rule out PE
What is the pathophysiology behind cardiogenic pulmonary oedema?
LVF leads to increased pulmonary capillary pressure so fluid collects in extravascular pulmonary tissues faster than lymphatics clear it
What can cause LVF?
Acute complication of: MI, IHD
Excerbation of: hypertension, valve disease, arrhythmias
Others: cardiomyopathy, negatively ionotropic drugs (beta-blockers), pericardial disease
What is the pathophysiology behind non-cardiogenic pulmonary oedema?
- Increased capillary permeability
- Decreased plasma oncotic pressure (osmotic pressure induced by albumin)
- Increased lymphatic pressure
What can cause non-cardiogenic pulmonary oedema?
Hypoalbuminaemia IV fluid overload ARDS Smoke inhalation Near-drowning incident High altitude sickness
How does pulmonary oedema affect breathing?
Short of breath Unable to complete full sentences Reduced exercise tolerance Orthopnoea Paroxysmal nocturnal dysponoea
What is the cough like in pulmonary oedema?
Pink frothy sputum
Nocturnal cough
What signs are found on examination of pulmonary oedema?
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
What test distinguishes heart failure from other causes of dyspnoea? What levels are high?
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
What signs of heart failure/pulmonary oedema are seen on a CXR?
ABCDEF
Alveolar oedema - Bat's wings B - Kerley B lines = interstitial oedema Cardiomegaly D - upper lobe diversion Effusions Fluids in fissures
What is the management of acute pulmonary oedema?
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
