ESSENTIAL Management Flashcards
Chronic Asthma management
- SABA
- +Low Dose Inhaled Steroid (200ug 2/d, <12:100ug)
- +LABA
+Increase Inhaled Steroid -
+Leukotrience antagonist
OR Theophylines
+Increase Inhaled Steroid - Oral steroids (consider immunosuppressants?) (RESP physician)
Acute asthma attack management
1. Quick investigations
- PEF
- Oximetry
- SpO2 <92% or Life threatening ⇒ ABG
Moderate (likely GP)
- Oxygen high-flow (Sp94-98%, 6-8L or 40-60% flow rate)
-
SABA via large-volume spacer
- Adult 4 then 2 every 2m
- Child 2 then 2 every 2m
- Repeat every 15m depending on responce
- Prednisolone tablet 40mg (max 60mg) for 5d
- Follow up next day/ sooner + 1wk
- Worsening ⇒ Admit + Severe
Severe
- Oxygen high-flow (SpO2 94-98%, 6-8L or 40-60% flow rate)
- Salbutamol 5mg + Ipratropium 500ug via Oxygen-driven nebuliser 6-8L/min Oxygen
-
Prednisolone tablet 40mg (max 60mg)
OR Hydrocortisone (preferably Sodium Succinate) 100mg slow IV bolus
No improvement 15-30min
- Salbutamol Neb 5mg every 15-30min
- Ipratropium 500ug 4hrly
Still no improvement ⇒ Life threatening
Life-threatening
-
Magnesium Sulphate 2g
+ 50ml NaCL 0.9% IV infusion/ 20min- 2nd dose discuss with consultant respiratory physician
- Speak to Critical Care Unit (CCU) + transfer if continued deterioration
- Transfer to CCU: Doctor accompanying prepared to intubate (anaesthetist)
Further investigations
- Chest XR (if not responding; exclude pneumothorax/ consolidation)
- U+Es (green top for accurate K+)
- FBC
- Theophyllines - therapeutic levels 10-20mg/L
Subsequent
- Admit to respiratory ward
- Correct fluid & electrolytes (especially K+)
- Maintain Sp02 >94%
- Nebulised Salbutamol 2.5mg + Ipratropium 250ug 6hrly
-
Prenisolone daily dose
OR Hydrocortisone 6hrly - Continue regular inhaled/ oral Preventer Medications
Pre-Discharge
- Sort discharge medications
- Check inhaler technique
Discharge + Follow-up
- Discuss reason for exacerbation
- Send GP details (inc potential best PEF)
- GP Follow-up within 2d
- Oral Steroids for 5d or until improved
- Inhaled steroid added to regular meds
- Ensure PEF meter (prescribable) and advise to record morning + evening before inhalers
- Written Personal Asthma Action Plan
Chronic COPD management
COPPPD-abct
- Cessation smoking, exercise etc
- O2 LTOT [3]
- Pulmonary function tests
- *P**neumococcal polysacharide + annual influenza vaccine
- *P**ulmonary rehab
Drugs (abct)
- Antimuscarinic 1. SAMA (Ipratropium) OR
- *B2 agonist** 1. SABA (Salbutamol)
- 2. LAMA (Tiotropium) OR
- *2.** LABA (Salmeterol) (ONLY FEV1>50%)
- 3. Corticosteroid Inhaled + LABA OR
- *3. LAMA + LABA**
- 4. Theophylline
Mucolytics: Chronic productive cough
Cor pulmonale: Loop Diuretics, LTOT
Acute COPD exacerbating management
-
Oxygen SpO2 88-92%
CI >24% O2 must NOT be given unless ABG confirm no CO2 retention -
Doxycyline 200mg PO (d1) ⇒ 100mg/d thereafter
Cant swallow: Co-Amoxiclav 1.2g IV 8hryl
+Penicillin allergic: Clarithromycin 500mg IV by infusion into larger proximal vein 12hrly [CI with Simvastatin]
Bronchodilators
- Salbutamol 2.5mg or Terbutaline 5mg via air-driven nebuliser 4-6hrly
- ⇒ Ipratropium bromide 500ug via nebuliser 6hrly
- 4hr no improvement ⇒ Aminophylline infusion
Corticosteroids
- Prednisolone 30mg PO daily (or increase maintanence by 30mg)
- Hydrocortisone 100mg slow IV bolus 6hrly
Sputum ⇒ Physiotherapy
Monitoring
- PEF
- ABG
- Sputum volume + conversion to purulent to mucoid
- Subjective dyspnoea
- Objective exercise tolerance
Subsequent Management
- Admit to ward
- Improving after 48hr
- Continue ABx until sputum mucoid
- Prednisolone same dose 7-14d then return to normal
- PaO2 >7.3kPa or SpO2 >92% stop oxygen but monitor
- Review mediations, inhaler technique, smoking cessation
- Advise GP to arrange influenza vaccination
- Not improving
- Consider resistant organism
- Consider underlying disease
Respiratory Failure types + causes
Type 1 = Low PaO2, normal PaCO2
- Asthma, pneumonia, pneumothorax, PE, oedema, fibrosis
Type 2 = Low PaO2, low PaCO2
- COPD exacerbation, neruomuscular/ dystrophy, encephalitis, respiratory depressants
Resp Failure management
Type 1
-
Oxygen via nasal cannulae 2-6L/min (SpO2 94-98)
or Simple Face Mask 5-10L/min or 24-60% Venturi mask - SpO2 <85% Reservoir mask 10-15L/min
Type 2
- 24-28% Venturi mask (SpO2 88-92%)
Aim for lowest dose Venturi mast possible - pH <7.35 (resp acidosis) ⇒ NIV (senior help)
- pH <7.25 ⇒ IV
Treatment for specific conditions
VTW treatment
- LMWH/ Fondaparinux for 5d+ AND INR >2.0 for 24hr
2, within 24hr start WARFARIN
-Provoked 3month
-Unprovoked 6months
CANCER
- LMWH 6months + compression stocking 2yrs
Unprovoked = screen for cancer
-exam, CXR, FBC, Ca2+, LFTs, urinalysis
+/- >40yr CTCAP/ mammography
USS review in 1 week
VTW inestigation
Two level Wells score
2+ = USS <4hrs, negative do D-Dimer
Cant do USS <4hr, do D-Dimer + LMWH treatment
0 or 1 = D-Dimer, positive USS <4hrs
Cant do USS <4hr, LMWH/ treatment
Exacerbation of chronic bronchitis
C larithromycin
A moxicillin
T etracycline
Uncomplicated CAP
Amoxicillin
PENAL: Doxycycline or Clarithromycin
Staph suspected (post flu): Flucloxacillin
Pneumonia possibly Atypical
Clarithromycin
HAP
- Co-amoxiclav
- Cefuroxime
>5d
- Piperacillin with Tazobactam
- Cephalosporin broad (eg Ceftazidime)
- Quinilone (eg Ciprofloxacin)
Lower UTI
Trimethoprim
Nitrofurantoin
Alternative:
- Amoxicillin
- Cephalosporin
Acute pyelonephritis
- *Cephalosporin** broad
- *Quinolone**
H Pylori
7d
- PPI
- Amoxicillin 1mg
- Clarithromycin 500mg OR Metronidazole 400mg
