Houseman handbook

Question 1

Massive hemoptysis

Answer 1

100-200mL over 24H
Complication of asphyxia, localize and stop bleeding, underlying cause

Lateral position (to bleeding side)
Obs (vitals, O2 supp, IV)
Avoid 1. Sedation 2. Cough suppressant 3. Anticoagulant
Correct possible cause of bleeding: antibiotic for infection
Flexible bronchoscopy
U CT throax/ bronchial arteriogram x Bronchial artery embolization
Consult ICU/HDU x airway protection
Consult anes x intubation (suction/ ventilation)
Consult surgery x emergency lung resection

Question 2

Spontaneous PTX

Answer 2

Visible rim btw lung margin and chest wall
Small <2cm; Large >=2cm
Primary no lung patho; Secondary underlying lung

Tension PTX: cyanosis, sweating, tachypnea, tachycardia, hypotension

Mx
Chest drain if bil PTX/ HD unstable
Primary Small: obs + O2 therapy
Primary Large: chest drain (<14F) / needle aspiration
Secondary Small: obs + O2 therapy
Secondary Large: chest drain (<14F or >=20F)
Surgical pleurodesis (open thoracotomy/VATS) if
1. Second ipsi
2. First contra
3. Synchronous
4. Hemothorax
5. Persistent air leak
6. Profession at risk (pilots, diver)
7. Pregnancy
Medical pleurodesis (Talc, minocycline) if unfit for surg

Question 3

Pleural effusion

Answer 3

Diagnostic tapping
- Not for transudate (bil) unless refractory to Tx/ atypical
Pleural fluid x
Appearance
Biochem (light criteria exudate if: protein >0.5, LDH >0.6, LDH >2/3 ULN): protein, LDH
Microbiological: smear C/ST, AFB smear C/ST, TB PCR, ADA, fungal C/ST
Cytology
Thoracoscopy if inconclusive pleural tap

Therapeutic tapping
CXR: loculation/ CT throax: pleural thickening
Frank pus
Complicated parapneumonic effusion: pH <7.2, glc <2.2
Gram stain, C/ST +
Large (>40% hemithorax)

Supportive
Consult resp if difficult
Tube drainage and chemical pleurodesis: Talc up to 5g in 100mL NS / minocycline 300mg in 50-100mL NS
Clamp drain 1-2H post-sclerosant, then release
Unclamp till drainage daily output <150mL/D x 2/7 + CXR reexpansion
Surgical pleurodesis
LT ambulatory indwelling pleural catheter drainage

Question 4

O2 supplementation

Answer 4

Nasal cannula: 0-6L, FiO2 20% + 4x O2 litre flow per min
Simple face mask: 6-10L, FiO2 50%
Non-rebreathing mask: 10-15L, FiO2 60-100%
Venturi: 3-15L, FiO2 adjustable 24% to 50%

LT O2 in COPD aim 89-93%: start only when stable 3-4/52 if:
1. Resting PaO2 <=7.3kPA/ SaO2 <=88%
2. Resting PaO2 7.4 – 7.9 / SaO2 >=89% +
 Depd edema suggestive of cor pulmonale
 P pulmonale on ECG (P >3mm in II III aVF)
 Erthrocythemia (Hct >56%)