Breathlessness Flashcards

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1
Q

Presentation of acute asthma, what are the worrying signs?

A

SOB, wheeze, tight chest pain, cyanosis, poor air entry

worrying signs: cyanosis, fatigue, silent chest, accessory muscle use at rest, agitation, LOC

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2
Q

Investigations (and expected results) for acute asthma

A

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

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3
Q

Management of acute asthma

A

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

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4
Q

Presentation of acute exacerbation of COPD, what are the worrying signs?

A

SOB, cough, increased suptum production, wheeze, reduced exercise tolerance,

Worrying signs: fatigue, oedema, pursed lip breathing, tripoding, cyanosis, confusion

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5
Q

Causes of acute exacerbation of COPD

A

acute progression of disease, can be triggered by infection, viral or bacterial, pollutant exposure of change in temperature.

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6
Q

Investigations for acute exacerbation of COPD

A

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

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7
Q

Management of acute exacerbation of COPD

A

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

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8
Q

Why is it important not to over oxygenate COPD patients?

A

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)

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9
Q

What are the colours of the 5 venturi valves, how much O2 do they deliver per min and at what concentration?

A
Blue    2L  24%
White   4L  28%
Yellow  6L  35%
Red     8L  40%
Green   12L  60%
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10
Q

Presentation of pneumonia

A

SOB, productive cough, fever, malaise, chest pain.

Tachycardic, tachypnoeic, dullness on percussion, reduced air entry

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11
Q

Causes of Pneumonia

A

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

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12
Q

Investigations for pneumonia

A

Bloods: FBC, U&Es, CRP, LFTs, blood cultures

ABG - can look at urea on here

CXR
ECG
Sputum sample

CRUB 65 score

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13
Q

What is the system used to calculate pneumonia severity? how is it calculated?

A

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

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14
Q

Management of pneumonia

A

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

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15
Q

Presentation of pneumothorax

A

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)

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16
Q

signs of a tension pneumothorax, what does it cause?

A

raised JVP, tracheal deviation (away from side of collapse),

Causes increased intrathoracic pressure, which leads to cardiac arrests.

17
Q

Causes of penumothorax

A

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)

18
Q

Investigations of pneumothorax

A

Obs
ABG - look for hypoxia
CXR - absent lung markings, shadow of collapsed lung
- if tension treat before CXR!

19
Q

management of non-tension pneumothorax

A

Oxygen 15L
Chest drain for air-decompression

If high recurrence or risk of effusion, Pleurodesis (TALC between pleura to cause pleura to stick together)

20
Q

Management of tension pneumothorax

A

A-E
15L Oxygen
Large bore cannula in the second intercostal space for urgent decompression.
Then chest drain insertion

21
Q

Presentation of a PE

A

acute SOB, chest pain, cough, haemoptysis, dizziness, syncope

O/E: tachycardia, tachypnoea, hypoxia, confusion, pyrexia, elevated JVP, shock

22
Q

Causesof PE

A

obstruction in arterial tree - emoli are thrombuses, Fat, amniotic fluid, or air.

23
Q

Investigations for PE

A

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

24
Q

What are the features measured in the Wells score? (7 things)

A
Clinical suspicion of DVT
Alternative diagnosis likelihood
Tachycardia
Immobilisation
History of DVT or PE
Haemoptysis
Malignancy (in the preceding 6 m/o)
25
Q

ECG findings in PE

A

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.

26
Q

Management of PE

A

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

27
Q

Presentation of pulmonary oedema

A

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)

28
Q

Causes of pulmonary oedema

A

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.

29
Q

Investigations for pulmonary oedema

A

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.

30
Q

Management of pulmonary oedema

A

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.