Case 1: Acute Breathlessness Flashcards
How could the muscular system cause AB?
Weakness or loss of function of your respiratory muscles through any cause including trauma can result in pain and breathlessness.
How could the Haematological System cause AB?
Anaemia if severe enough reduces your ability to carry oxygen as you due to the reduction in red cells and as a consequence haemoglobin too can result in breathlessness.
How could the nervous System cause AB?
Damage to the brain or the spinal cord, such as multiple sclerosis and Guillain-Barre syndrome, can result in breathlessness.
How could the digestive System cause AB?
Acute GI bleed can lead to severe anaemia and cause breathlessness. Severe Gastrointestinal Reflux Disease (GORD) leading to aspiration can result in breathlessness.
How could the endocrine System cause AB?
For example, both thyrotoxicosis (increases metabolic rate) and hypothyroidism (severe and untreated leads to respiratory muscle weakness) can cause breathlessness.
How could the skeletal System cause AB?
Trauma, if you fracture your ribs for instance, can cause breathlessness and chest pain, and spinal disorders that reduce the ability to expand your lungs (kyphosis, scoliosis) can lead to breathlessness.
pleuritic chest pain
sharp stabbing pain on one side that is worse during inspiration or with certain movement of the chest wall
pneumothorax and AB
Pneumothorax is the presence of abnormal air between the two pleural linings (visceral and pleura) called the pleural space. Normally the pleural space contains very small amounts of pleural fluid. This air leak builds up, thus stretching the pleural lining and presses on the lung to cause it to collapse. As a result, a pneumothorax causes sudden sharp chest pain and breathlessness. Being male, having underlying lung disease and smoking are risk factors for pneumothorax. Pneumothorax can by spontaneous or caused by trauma. If spontaneous it can be primary (no underlying lung disease) or secondary to underlying disease e.g COPD .
pulmonary embolism
PE is an abnormal clot formation (thrombus) in the pulmonary circulation to the lung that results in a reduced blood flow to the region of the lung that the pulmonary artery supplies. This can cause infarction of the lung and leads to breathlessness and pleuritic chest pain. It is sometimes associated with haemoptysis. There may also be calf swelling and other risk factors.
pleurisy
an inflammation of the pleura that produces sharp chest pain with each breath
Viral infection is one of the most common causes of pleurisy. Viruses that have been linked as causative agents include influenza, parainfluenza, coxsackieviruses, respiratory syncytial virus, mumps, cytomegalovirus, adenovirus, Epstein-Barr and now of course corona virus.
primary spontaneous pneumothorax
The classic presentation is that of sudden onset of pleuritic chest pain and dyspnoea at rest. The symptoms do not correlate closely with the size of the pneumothorax [12]. In many cases the symptoms are mild and approximately half of patients will present after more than 2 days of symptoms.
secondary spontaneous pneumothorax
The symptoms are often more severe than those associated with a primary pneumothorax because lung function may already have been compromised by the underlying pathological process. The symptoms will vary depending on the cause e.g. fever, weight loss, night sweats but the primary complaint is that of breathlessness which is often out of proportion to the size of the pneumothorax radiologically.
Unlike symptoms, the examination findings in primary spontaneous pneumothoraces are affected by the size of the pneumothorax. A small pneumothorax can be impossible to identify on clinical examination.
pneumothroax
air in the pleural cavity
traumatic pneumothorax
iatrogenic, baro trauma. non iatrogenic: fall, trauma,
cause of primary PnTx
air leak from apical and subpleural blebs and bullae
bullae
Large blisters
cause of secondary PnTx
lung disease, ^ alveolar pressure, defects in connective tissue
risk factors for pneumothorax
- Smoking
- Pulmonary disease
- Age (20-40)
- Tall, thin, male
- Family hx
- trauma
risk factors for secondary pneumothorax
associated with asthma, cystic fibrosis, pulmonary fibrosis, tuberculosis, acute resp distress, and other lung diseases
Birt Hogg Dube syndrome
Marfans
smoking, cannabis
Homocystinuria
Cystathione synthase deficiency
Lens subluxation, thrombosis, marfanoid, intellectual disabiliity
Tx: pyridoxine
Birt-Hogg-Dube syndrome
Thin-walled oval-shaped lung cysts (looks like LAM)
Bilateral renal oncocytomas, chromophobe RCC
signs of pneumothorax
sudden chest pain with dyspnea, decreased lung sounds/affected side
SOB more severe in 2ndary
hyperinflation
reduced expansions
hyperesonant breath
quiet breath sounds
tachy
subcut empyshema
signs of pneumothorax on x ray
deep sulcus sign
ABGS for pneumothorax
Hypoxia
severity depends on width of the rim of lung in PnTx xray
Small <2cm > large
never clamp a drain for
pntx chest drain
chemical pleurodesis
a chemical is placed into the pleural space to cause inflammation and thereby reduce the effusion of the area
surgical pleurectomy
open thoracotomy
or VATS
causes inflation
tension pneumothorax
a type of pneumothorax in which air that enters the chest cavity is prevented from escaping
signs of tension pneumothorax
progressive shortness of breath, increasing alerted level of consciousness, neck vein distention, tracheal deviation
tension pneumothorax aspiration
14G cannula
2nd IC space, MCline
hiss - protect with gauze, leave it and prepare chest drain
Pneumothorax Pathophysiology
Air in the intrapleural space
- Complete or partial collapse of lung
pleural pressure equals atmospheric presure
- no force to counter elastic recoil
lung collapses
Normal lung expansion cannot take plane
the lung will stay collapsed until puncture sealed
tension Pneumothorax Pathophysiology
injury creates one way valve
air drawn into pleural space
on expiration the air in the pleural space is trapped and c ompressed. this pleural pressure exceeds central venous pressure
causes of PE
DVT.
Previous DVT or PE.
Active cancer.
Recent surgery.
Lower limb trauma.
Significant immobility, for example, due to hospitalisation.
Pregnancy and, in particular, for 6 weeks’ postpartum.
what percentage of leg thrombi will embolise
20%
rare forms of emboli
fat, N bubbles, atherosclerotic debris (cholesterol emboli), tumor fragments, bone marrow, foreign bodies
acute: thromboembolism PE
massive
Chronic thromboembolic PE
repeated small eboli - occlusion
symptoms of PE
sudden-onset dyspnea, chest pain, tachypnea & tachycardia
signs of PE
Sxs: pleuritic CP, hemoptysis, SOB, Decr pO2, tachycardia.
pleural rub
loud/split P2
JVP raised
DVT signs
Random signs: R heart strain on EKG, sinus tachy, decr vascular markings on CXR, wedge infarct, ABG w/ low CO2 and O2.
Westermark Sign on CXR - focus of oligemia (leading to collapse of vessel) seen distal to a pulmonary embolism (PE)
wells score
test used to assess an individual’s risk for DVT
< 4 - low (PE unlikely) pretest probability
4.5-6 moderate pretest probability
>6 high pretest probability
D-dimer test
is a global marker of coagulation activation and measures fibrin degradation products produced from fibrinolysis (clot breakdown). The test is used for the diagnosis of DVT when the patient has few clinical signs and stratifies patients into a high-risk category for reoccurrence. Useful as an adjunct to noninvasive testing, a negative D-dimer test can exclude a DVT without an ultrasound.
should not be performed in those who have a likely PE
imaging for PE
CT pulmonary angiography + Echo
venitalation perfusion - for pregnant patients
hemodynamic collapse in PE
massive PE, drop in CO, collapse, hypotension cyanosis, tachypnoea
TPA
tissue plasminogen activator
a thrombolytic that is administered to some patients having a heart attack or stroke
name some DOACs
Dabigatran
Rivaroxaban
Apixaban
Edoxaban
DOAC MOA
Factor Xa inhibitor
Warfarin MOA
Coumadin (brand name)
Vitamin K antagonist
IVC filter
Clot filter (lower abdomen)
PESI Score.
Pulmonary Embolism Severity Index
PE should be suspected in people with
Dyspnoea, chest pain, cough, haemoptysis, features of DVT (including leg pain and swelling [usually unilateral], lower abdominal pain, redness, increased temperature, and venous distension), dizziness, and syncope.
Tachypnoea or tachycardia, hypoxia, pyrexia, elevated jugular venous pressure, gallop rhythm, pleural rub, hypotension, and shock.
in embolised areas of the lung
lung tissue is ventilated but not perfused
large PE
causes high pulmonary resistance and acute right sided heart failure > hypertension + syncope
NEWS score
National Early Warning Score
systematic approach to chest x rays
Rotation: Is there equal space between the clavicles and spinous processes?Inspiration: Are there greater than 7 anterior and 9 posterior ribs>=?Picture: Can you see everything you want to see?Exposure: Can you see the vertebral bodies behind the heart
Airway: Is trachea central?
Breathing: Compare both sides of the lungs, look at hilar.
Circulation: Is the heart in correct position and correct size?
Diaphragm: Can you see costophrenic angle? If not why?
Everything else or extra tubes: Look at bones. Look for fractures. Look for lines, pacemakers, etc.
first line treatment for spontaneous pneumothorax
pleural aspirate
As per British Thoracic Society Guidelines as the size of the pneumothorax is greater than 2cm, and the patient is symptomatic with hypoxia the first treatment strategy is pleural aspiration
chest drain stops bubbling
If a drain stops bubbling this is because the drain has either blocked, been pulled out or the pneumothorax has resolved. The first step is therefore to check whether the drain is swinging. If the drain is swinging then you can be confident that the drain remains in the pleural cavity and it has stopped bubbling as the pneumothorax has resolved. You would therefore request a chest xray to confirm the lung has fully expanded and remove the chest drain.
If the drain is not swinging you should examine the drain site to see if it has fallen out and then request a chest xray to assess the position of the tube. If the tube remains in the pleural space on the chest xray you should flush the chest drain with aspetic technique with 10ml saline to try and unblock it.
chest drain review
When a patient has a chest drain - there are important aspects that need checking on a regular basis. The nurses perform this observation during their observation ward rounds and document this on a chest drain chart. However, doctors should also perform these checks on their ward rounds. To assess whether the drain is situated within the chest wall you should look for the water level within the chest drain bottle. The water in the sealed chamber will rise and fall during respiration due to the changes in the thoracic pressures. For a pneumothorax the drain should also be bubbling. This will stop once the pneumothorax has resolved and would be a sign to request a chest drain, assess if the lung has fully expanded and consider chest drain removal. For pleural effusions you should also document the amount of fluid drained on every observation ward round.
the presence of a short history of pleuritic chest pain, breathlessness and haemoptyis.
most likely PE
level 2 wells score
immbolisation > 3 dys or durgery within 4 weeks
an alternative diagnosis is less likely than PE
Malignancy within 6 months or palliative
Signs of DVT
HR> 100
Previous DVT/PE
Haemoptysis
C-reactive protein
A nonspecific protein, produced in the liver, that becomes elevated during episodes of acute inflammation or infection.
Sputum MCS
Sputum microscopy, culture and sensitivity for pneumonia
Lactate
a 3-carbon compound produced from pyruvate during anaerobic metabolism
Liver function tests
tests for the presence of enzymes and bilirubin in blood
CTPA
computed tomography pulmonary angiography
U&Es
urea and electrolytes test which checks kidney function
Arterial Blood Gases
clinical test on arterial blood to identify the levels of oxygen and carbon dioxide
V/Q scan
ventilation-perfusion scan - radioactive test of lung ventilation and blood perfusion throughout the lung capillaries (lung scan)
Full blood count
FBC
provides characteristics and numbers of cells in the blood: red blood cells, white blood cells and platelets.
Troponin
A protein of muscle that together with tropomyosin forms a regulatory protein complex controlling the interaction of actin and myosin and that when combined with calcium ions permits muscular contraction
Sinus Tachycardia
> 100bpm
ECG PE signs
Evidence of right heart strain with Right axis deviation, Right bundle branch block, T inversion in right sided leads V5 V6 or S wave in lead 1 Q wave and T inversion in lead 3 (S1 Q3 T3). (See example below.)
CXR for PE signs
small pleural Effusion
Normal - most common
If wells score high for PE investigation then first line investigation is
CTPA
PE on CTPA
his is a contrast enhanced scan so the blood vessels should be white due to contrast in them. However when the pulmonary arteries have clot in them you see a grey abnormality surrounded by white contrast which is a clot within the vessel - these are pulmonary emboli.
saddle embolus
embolus lodged at division of pulmonary artery -> sudden death due to right heart strain
Anaphylaxis
Severe allergic reaction
Type 1 hypersensitivity
IgE mediated hypersensitivity
Ex: Allergies. immediate
sensitized mast cells, antigen = mast cell degranulation and massive histamine release
common allergens
peanuts, eggs, milk, soy, wheat, shellfish
when would you not perform a CTPA?
Intravenous contrast is excreted by the kidneys and a rare side effect is renal damage. If the renal function is significantly impaired then IV contrast is contraindicated.
If there is a history of contrast allergy.
In pregnant women the radiation exposure to the breasts is very high as lactating breasts are very radiosensitive and this would increase your long term risk of breast cancer.
In these circumstances you would look for venous thromboembolism in the lower limbs by performing a Doppler ultrasound of the legs and/or perform a ventilation/perfusion scan which has less radiation exposure.
Drugs allergens
antibiotics, co amoxiclav, neuromuscular blockers
stridor
strained, high-pitched sound heard on inspiration caused by obstruction in the pharynx or larynx
Anaplylaxis first presentation
stridor, wheeze, presyncope
histamine causes
vasodilation and increased capillary permeability
how do we manage anaplylaxis
Call for help
remove trigger.
semi recombant position
give intrasmuscular adrenaline - middle third of thigh
0.5ml 1:1000
Establish ariway, high flow oxygen
ECG, pulse oximetry
If no response - repeat IM adrenaline after 5 mins and IV fliud bolus
500-1000ml crystalloid
drug treatment for confirmed PE
warfarin and apixaban
CTPA outcomes for PE
The CTPA will tell you the clot burden for example central or peripheral clots or unilateral or bilateral. The CTPA will also show features of right heart strain such as Interventricular septal flattening. If you have a large central clot or features suggestive of right heart strain with flattening of the interventricular septum then you would not discharge the patient but instead keep the patient in for observation. On the other hand if the pulmonary emboli are small subsegmental pulmonary emboli with no features of pulmonary hypertension then these could be considered for ambulatory management.
most important sign for ambulatory status in PE management
This is the single most important factor that will help you decide regarding ambulatory outpatient management of a PE and this is explained more below with respect to calculation of the PESI score.
PESI
he Pulmonary Embolism Severity Index (PESI) is a risk stratification tool that has been externally validated to determine the mortality and outcome of patients with newly diagnosed pulmonary embolism (PE).
If the patient is considered very low (≤ 65) or low risk (66-85) by the PESI score.Patient has an overall low risk of mortality or severe morbidity.Consider outpatient management of PE if clinically appropriate and social factors allow for it.
If the patient is considered intermediate (86-105), high risk (106-125) or very high risk (>125) by the PESI.Patient has an overall high risk of mortality and severe morbidity.Consider higher levels of care (e.g., ICU) for those with higher scores.
atrial fibrillation
rapid, random, ineffective contractions of the atrium
PE follow up clinic
Patients with pulmonary embolism should be followed up in a dedicated PE clinic at 3 months to ensure symptom resolution and assess any side effects with anticoagulation therapy. Some patients will have ongoing respiratory symptoms post PE and will require further investigations to exclude complications such as chronic thromboembolic pulmonary hypertension.
Pharma for PE
Offer apixaban or rivaroxaban first line
If these are not suitable, heparin (LMWH) for at least 5 days followed by dabigatran or edoxaban, or LMWH concurrently with a VKA (warfarin) till therapeutic anticoagulation is achieved
Take into account comorbidities, contraindications and the person’s preferences when choosing anticoagulation treatment
contraindications rivaroxaban
cirrhosis with coagulopathy and pregnancy
Apixaban contraindications
Hypersensitivity, active bleeding
treatment of secondary pneumothorax
This is a secondary pneumothorax of greater than 2cm and the BTS guidelines suggest chest drain as first line treatment.
A 59 year old woman has right sided sharp chest pain and breathlessness of recent sudden onset. Her temperature is 37.4º C, pulse rate 110 bpm, BP 132/82 mmHg, respiratory rate 14 breaths per minute and oxygen saturation 93% breathing air. Which additional feature would be most suggestive of pulmonary embolism?
Pleural Rub. Rationale: Pulmonary embolisms often cause a sudden onset of sharp, pleuritic chest pain because they irritate the pleura. This irritation and inflammation will also lead to a pleural rub when auscultating lung sounds. The patient also suffers from dyspnea due to the dead space and VP mismatch.
PE risk factors
Risk factors for Pulmonary Embolism include age above 60, Obesity, a history of previous venous thromboembolism, prolonged travel, immobility, pregnancy, hormone replacement therapy or oral contraceptive pill, surgery, malignancy or acute illness.
A 19 year old man presents with sharp right sided chest pain and breathlessness. His temperature is 36.9ºC, pulse rate 90 bpm, BP 115/65 mmHg, respiratory rate 14 breaths per minute and oxygen saturation 96% breathing air. He is 6foot 2 with a wide arm span. His chest xray confirms a right sided pneumothorax. Which of the following is the patient at increased risk of developing?
The clinical suspicion is that this gentleman has Marfan syndrome. Patients with Marfan are at increased risk of developing pneumothorax. Marfan syndrome is an inherited disorder that affects connective tissue. Marfan syndrome features may include:
- Tall and slender build- Disproportionately long arms, legs and fingers- A breastbone that protrudes outward or dips inward- A high, arched palate and crowded teeth- Heart murmurs- Extreme nearsightedness- An abnormally curved spine- Flat feet
