Breathlessness Flashcards
Presentation of acute asthma, what are the worrying signs?
SOB, wheeze, tight chest pain, cyanosis, poor air entry
worrying signs: cyanosis, fatigue, silent chest, accessory muscle use at rest, agitation, LOC
Investigations (and expected results) for acute asthma
Obs- BP, HR, RR, O2 (salbutamol will increase HR)
Peak flow - to compare to baseline
if 75% of baseline - mild
if 50% - moderate
if 33% - severe
ABG - will expect respiratory alkalosis since hyperventilation. Worrying if in acidosis (since retaining Co2, aren’t breathing effectively to blow it off - fatigue
Bloods - FBC, U&E, CRP - look for infective cause
CXR
Management of acute asthma
A-E
O SHIT ME
Oxygen
Salbutamol - 5mg nebulised with o2
Hydrocortisone - IV or prednisolone orally
Ipratropium
Theophylline
Magnesium sulphate ( 20mg over 20 mins need cardiac monitoring)
Escalate
Presentation of acute exacerbation of COPD, what are the worrying signs?
SOB, cough, increased suptum production, wheeze, reduced exercise tolerance,
Worrying signs: fatigue, oedema, pursed lip breathing, tripoding, cyanosis, confusion
Causes of acute exacerbation of COPD
acute progression of disease, can be triggered by infection, viral or bacterial, pollutant exposure of change in temperature.
Investigations for acute exacerbation of COPD
Obs - RR, HR, BP, O2 (aim for 88-94)
ABG - chronic CO2 retainers will have a metabolic compensation present.
Bloods: FBC, U&Es, blood cultures
ECG
CXR
Sputum culture
Management of acute exacerbation of COPD
A-E
Oxygen - venturi NOT NRB. 24% venturi at 2L/min.
Salbutamol - nebulised with air (do not over oxygenate)
Systemic steroids - oral Pred or IV hydrocortisone
Abx (is signs of infection)
IV theophylline (bronchodilator)
NIV if still hypercapnic - CPAP or BiPAP
Why is it important not to over oxygenate COPD patients?
Oxygen is their respiratory driver, if they have over oxygenation they will become hypercapnic since will not breathe (since o2 will not fall causing the centre to stimulate breathing)
What are the colours of the 5 venturi valves, how much O2 do they deliver per min and at what concentration?
Blue 2L 24% White 4L 28% Yellow 6L 35% Red 8L 40% Green 12L 60%
Presentation of pneumonia
SOB, productive cough, fever, malaise, chest pain.
Tachycardic, tachypnoeic, dullness on percussion, reduced air entry
Causes of Pneumonia
CAP - S. pneumoniae, S. aureus, Mycoplasma pneumonia, H. influenza, Chlamydia pneumoniae
HAP - more common in ventilation and immunocompromised pts
- S. pneumonia, H. influenzea, Moraxella catarrhalis, S.aureus, Legionella
Investigations for pneumonia
Bloods: FBC, U&Es, CRP, LFTs, blood cultures
ABG - can look at urea on here
CXR
ECG
Sputum sample
CRUB 65 score
What is the system used to calculate pneumonia severity? how is it calculated?
CURB - 65
Confusion - AMST of <8
Urea - >7mmol
RR - <30
BP - systolic <90 or diastolic <60
age over 65
Admit to hospital if score above 2
Management of pneumonia
A-E approach
Oxygen if hypoxic
Fluids
Analgesia
Nebulised saline - reduces sputum expiration
Abx - local guidelines
mild - amoxicillin or clarithromycin for 5 days. add fluclox if s.aureus suspected.
severe - IV co-amox, amox or clathrithromycin
Presentation of pneumothorax
SOB, sudden onset chest pain, pleurisy, cyanosis, fatigue.
O/E: tachycardic, tachypnoeic, hypotensive, reduced air entry, hyper resonant percussion, pulsus paradoxical (weak pulse as patients breathe in)
signs of a tension pneumothorax, what does it cause?
raised JVP, tracheal deviation (away from side of collapse),
Causes increased intrathoracic pressure, which leads to cardiac arrests.
Causes of penumothorax
Spontaneous - male, tall, young
Secondary - bulla rupture in COPD, severe asthma
Trauma
can have catamenial (at the time of mensuration, due to holes in the diaphragm and air entry in cervical plug)
Investigations of pneumothorax
Obs
ABG - look for hypoxia
CXR - absent lung markings, shadow of collapsed lung
- if tension treat before CXR!
management of non-tension pneumothorax
Oxygen 15L
Chest drain for air-decompression
If high recurrence or risk of effusion, Pleurodesis (TALC between pleura to cause pleura to stick together)
Management of tension pneumothorax
A-E
15L Oxygen
Large bore cannula in the second intercostal space for urgent decompression.
Then chest drain insertion
Presentation of a PE
acute SOB, chest pain, cough, haemoptysis, dizziness, syncope
O/E: tachycardia, tachypnoea, hypoxia, confusion, pyrexia, elevated JVP, shock
Causesof PE
obstruction in arterial tree - emoli are thrombuses, Fat, amniotic fluid, or air.
Investigations for PE
Respiratory examination and inspection of the calves.
ABG
Bloods: FBC, U&Es, Clotting, D-dimer (if indicated by wells)
ECG - to exlude cardiac cause, most likely will se sinus tachy.
CXR - should look normal
Wells score to assess possibility
if <4 points - PE unlikely. Do a D-Dimer and then decode whether to do a CTPA.
If >4 points - PE likely. Do a CTPA
What are the features measured in the Wells score? (7 things)
Clinical suspicion of DVT Alternative diagnosis likelihood Tachycardia Immobilisation History of DVT or PE Haemoptysis Malignancy (in the preceding 6 m/o)
ECG findings in PE
sinus tachy
new RBB with/or Right axis Deviation
S1 Q3 T3
- S wave in lead 1, Q wave in lead 3 and T wave inversion in lead 3.
Management of PE
A-E approach
15L O2
IV access and fluids
Analgesia
Anticoagulation
5 days of apixaban or rivoxibam or LMWH. If massive PE or unstable pt then do thrombolysis with unfractionated heparin. If fails, then do surgical embolectomy.
Long term anticoagulants - rivaroxaban for 3 months
If unprovoked PE - cancer screen
Presentation of pulmonary oedema
SOB, N/V, pale, sweating, history of cardiac failure, productive cough with pink frothy sputum, cyanosis.
O/E: tachypnoeic, tachycardic, hypoxia, hypotensive, gallop rhythm (third heart sound)
Causes of pulmonary oedema
Cardiac: - causes by elevated pulmonary capillary pressure (hydrostatic)
- ACS, MI, heart failure, PE, tamponade, renal causes eg CKD, AKI, anaemia.
Non-cardiac: altered capillary permeability
- respiratory distress syndrome, liver failure, trauma, airway obstruction, overdose, lymphatic insufficiency.
Investigations for pulmonary oedema
Bloods: FBC, U&Es, LFTs, Clotting, Troponin, BNP, glucose
ABG - hypoxia
ECG -look for cardiac cause, arrhythmia, signs of ischaemia, signs of LVH
may need and ECHO
CXR - haziness and decreased lung markings.
Management of pulmonary oedema
Find and treat cause
A-E
Supportive management: aims at oxygenation and diuresis.
O2, sit patient up right
Fluid management with catheter to monitor output
Sublingual or buccal nitrates - vasodilator and diuresis effects
IV Furosemide- 20mg IV slowly
IV diamorphine - pain relive and ease of breathlessness
Inotropes if needed to treat shock
After stabilisation patients will need long term ACEi, B blocker, Spironolactone and digoxin.
