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Y5 Respiratory System > List I - Act Core Conditions > Flashcards

List I - Act Core Conditions Flashcards

1
Q

What is acute asthma?

A
  • Usually always on a background of history of asthma
  • Clinical features include:
  • Worsening dyspnoea, wheeze and cough that is not responding to salbutamol
  • May be triggered by a respiratory tract infection
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2
Q

How is acute asthma stratified?

A
  • Moderate
  • Severe
  • Life-threatening

NB a patient having any one of these features should be treated as having a life threatening asthma attack

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3
Q

What are the features of moderate asthma?

Adults

A
  • PEFR 50-57% best or predicted
  • Speech normal
  • RR <25 / min
  • Pulse <110 bpm
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4
Q

What are the features of severe asthma?

Adults

A
  • PEFR 33-50% or predicted
  • Can’t complete sentences
  • RR >25 / min
  • Pulse > 110 bpm
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5
Q

What are the features of life-threatening asthma?

Adults

A
  • PEFR < 33% best or predicted
  • Oxygen sats < 92%
  • Silent chest, cyanosis or feeble respiratory effort
  • Bradycardia, dysrhythmia or hypotension
  • Exhaustion, confusion or coma
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6
Q

What does a normal pCO2 in acute asthma attack indicate?

A
  • Exhaustion - should therefore be classified as life threatening
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7
Q

What does a raised pCO2 and/or requiring mechanical ventilation with raised inflation pressures in acute asthma indicate?

A
  • Near fatal asthma
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8
Q

What is the initial assessment for a patient with acute asthma?

A
  • ABG for patients with sats <92%
  • Chest x-ray if:
  • Life threatening asthma
  • Suspected pneumothorax
  • Failure to respond to treatment
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9
Q

What is the admission criteria for patients with acute asthma?

A
  • All patients with life threatening asthma should be admitted in hospital
  • Patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment
  • Other admission criteria include a previous near fatal asthma attack. pregnancy, an attack occurring despite already using oral corticosteroid and presentation at night
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10
Q

What medications are required for the management of acute asthma?

A
  • OSHITME
  • Give the following all together:
  • Oxygen 15L via NRBM titrated to maintain a SpO2 94-98%
  • SABA (Salbutamol or Terbutaline) high dose 2.5mg - 5mg (NEB for life threatening or near fatal asthma)
  • Hydrocortisone 100mg IV or 40-50 mg of prednisolone orally (daily which should continue for at least 5 days or until the patient recovers from the attack) - continue normal medication during this time
  • Ipratropium bromide (0.5mg/6 hrs NEB) - in patients with severe or life threatening asthma or in patients who have not responded to beta agonist and corticosteroid treatment (NEB)
  • Theophylline - IV aminophylline may be considered following consultation with senior medical staff - 1g in 1L of saline 0.5ml/kg/hr
  • Magnesium sulphate 2g IV over 20 mins
  • Escalate care - patients who fail to respond to treatment require senior critical care support and should be treated in an appropriate ITU/HDU setting
  • Treatment options include:
  • Intubation and ventilation
  • Extracorporeal membrane oxygenation (ECMO)
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11
Q

What is the criteria for discharge following an acute asthma attack?

A
  • Patient must have been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12-24 hours
  • Steroid and bronchodilator medication prescribed
  • Inhaler technique checked and recorded
  • PEF >75% of best or predicted
  • GP appointment within 1 week
  • Respiratory clinic appointment in 4 weeks
  • F/U for at least 1 year with respiratory specialist
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12
Q

How is acute asthma recognised in younger children between 2 and 5 years?

A
  • Moderate
  • SpO2 > 92%
  • No clinical features of severe asthma
  • Severe
  • SpO2 < 92%
  • Too breathless to talk or feed
  • Heart rate > 140/min
  • Respiratory rate > 40/min
  • Use of accessory neck muscles
  • Life-threatening attack
  • SpO2 <92%
  • Silent chest
  • Poor respiratory effort
  • Agitation
  • Altered consciousness
  • Cyanosis
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13
Q

How should mild to moderate asthma be managed in children?

A
  • Give salbutamol via a spacer (for a child < 3 years use a close fitting mask)
  • Give 1 puff every 30-60 seconds up to a maximum of 10 puffs
  • If symptoms are not controlled repeat salbutamol inhaler and refer to hospital
  • Steroid therapy should be given to all children with an asthma exacerbation for 3-5 days
  • Dose as follows:
  • 2-5 years 20 mg od or 1-2 mg/kg od (max 40 mg)
    > 5 years 30-40 mg od or 1-2 mg/kg od (max 40 mg)
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14
Q

What is an acute exacerbation of COPD?

A
  • Sustained worsening of symptoms from usual stable state that is beyond normal day to day variations and is acute in onset
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15
Q

What are the clinical features of an acute exacerbation of COPD?

A
  • Increase in dyspnoea, cough, wheeze
  • There may be an increase in sputum suggestive of an infective cause
  • Patients may be hypoxic and in some cases have acute confusion
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16
Q

What are the most common bacterial organisms that cause infective exacerbations of COPD?

A
  • Haemophilus influenzae (most common)
  • Streptococcus pneumoniae
  • Moraxella catarrhalis
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17
Q

What level of COPD exacerbations are accounted for by viral causes?

A
  • 30% wit human rhinovirus being the most common
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18
Q

What are the appropriate investigations for a patient with an acute exacerbation of COPD?

A
  • FBC, U and E’s CRP, theophyline level (if already on it on admission), cultures if pyrexial
  • Chest x-ray - exclude pneumothorax/infection
  • PEF, ABG, sputum, ECG
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19
Q

What are the principles of management of acute COPD exacerbation?

A
  • A - maintain
  • B - 24-28% venturi mask controlled O2
  • Re-assess after 30 mins, aim for 88-92% sats
  • Salbutamol neb 2.5/5mg / 6hrs ad ipratropium bromide 500mcg/6h
  • Steroids - hydrocortisone 200mg IV plus prednisolone 30-40mg po continued for 7-14 days
  • No response to
  • Antibiotics if there is evidence of infection (amoxicillin 500mg/8h po or clarithromycin/doxycycline 100mg/12h
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20
Q

What are the indications for NIV in an acute exacerbation of COPD?

A
  • COPD with respiratory acidosis pH 7.25-7.35
  • Type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
  • Cardiogenic pulmonary oedema unresponsive to CPAP
  • Weaning from tracheal intubation
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21
Q

What are the recommended settings for bi-level pressure support in COPD?

A
  • Expiratory Positive Airway Pressure (EPAP): 4-5 cm H2O
  • Inspiratory Positive Airway Pressure (IPAP): RCP advocate 10 cm H20 whilst BTS suggest 12-15 cm H2O
  • Back up rate: 15 breaths/min
  • Back up inspiration:expiration ratio: 1:3
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22
Q

What is a hyperventilation?

A
  • Breathing occurring more deeply and/or more rapidly than normal - classification 1 or 2
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23
Q

What is classification 1 hyperventilation?

A
  • Psychogenic (inappropriate)
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24
Q

What is classification 2 hyperventilation?

A
  • Metabolic acidosis (DKA, uraemia, sepsis, hepatic failure) poisoning (aspirin, methanol, CO, cyanide, ethylene glycol) pain reduced O2, hypovolaemia, respiratory disorders (PE, asthma, pneumothorax)
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25
Q

What are the risk factors for 1 hyperventilation?

A
  • Female
  • Agitated
  • Distressed
  • PMH - panic attacks/hyperventilation
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26
Q

What is the pathophysiology of hyperventilation?

A
  • CO2 is ‘blown off’ leading to respiratory alkalosis
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27
Q

What are the symptoms of hyperventilation?

A
  • Dizziness, paraesthesia, chest pain, PMH panic attacks
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28
Q

What are the appropriate investigations for a person with hyperventilation?

A
  • BM
  • FBC
  • U and E’s
  • ABG if sats low
  • CXR if symptoms do not settle
  • ECG
  • pulse oximetry
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29
Q

What is the management of a person with hyperventilation?

A
  • Reassure
  • Breathing exercises in via nose count to 8 out via mouth, hold for count of 4 and repeat
  • Discharge once patient has settled, discharge and arrange GP follow up
  • If this fails re-assess and reconsider the diagnosis
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30
Q

What are the complications of hyperventilation?

A
  • Respiratory alkalosis
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31
Q

What is acute bronchitis?

A
  • Acute inflammation of the lung bronchi
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32
Q

What are the causes of acute bronchitis?

A
  • Viral - RSV, rhinovirus, influenza virus

* Bacterial - Streptococcus pneumoniae, haemophilus influenzae, staphylococcus aureus

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33
Q

What are the risk factors for acute bronchitis?

A
  • COPD, smoking, dusty environments
34
Q

What are the symptoms of acute bronchitis?

A
  • Predominent cough +/- sputum, pleuritic/retrosternal chest pain, wheeze, SOB
35
Q

What are the signs of acute bronchitis?

A
  • May have mild fever
  • May have course crackles, wheeze
  • Lack of systemic illness/focal chest signs
36
Q

What are the differential diagnoses for acute bronchitis?

A
  • UTRI
  • Chronic bronchitis
  • Pneumonia
37
Q

What are the management options for acute bronchitis?

A
  • Conservative - will often resolve without antibiotics
  • Medical - antibiotics (only if high suspicion of bacterial/severe)
  • If indicated give - amoxicillin 500mg/8h po for 5d (penicillin allergy: oxytetracycline 250-500 mg /6h po or doxycycline 200 mg po stat then 100 mg/24 h po
38
Q

What is the prognosis of acute bronchitis?

A
  • Cough - usually resolves <7 - 10 days (may last 3 weeks)

* Risk of chronic bronchitis (chronic productive sputum most days for 3 months in 2 consecutive years)

39
Q

What is the mechanism of a tension pneumothorax?

A
  • Progressive increase in air in the pleural space with each breath (air is drawn into space on inspiration but cannot exit on expiration - one way valve, no route of escape)
  • Leads to collapsing on the lung on affected side, tension - leading to mediastinal shift, compressing the venous system, reducing venous return to the heart - leading to cardiogenic shock
40
Q

What are the presenting clinical features of tension pneumothorax?

A
  • Medical emergency
  • Sudden onset of ipsilateral pleuritic chest pain, severe SOB
  • Increased HR, decreased BP, cyanosis, distended neck veins, tracheal deviation (away from lesion)
  • Reduced chest expansion, hyper-resonant percussion, reduced breath sounds, reduced vocal resonance, look for signs of respiratory distress
41
Q

What is the management of a tension pneumothorax?

A
  • Call for help
  • A - Maintain patency
  • B - 15L/min o2 - insert a large bore (14-16G) cannula into the 2nd ICS, MCL on affected side, remove the stylet and should hear a hiss, tape down securely while awaiting a chest drain (do not recover as it will recur), then insert an intercostal chest drain, request a chest x-ray
42
Q

What are the complications of a tension pneumothorax?

A
  • Cardiogenic shock

* Cardiorespiratory arrest

43
Q

What is the ongoing advice after a patient has been treated for a tension pneumothorax?

A
  • Avoid air travel for 6 weeks after normal chest x-ray

* Avoid diving forever

44
Q

What is a pulmonary embolism?

A
  • Usually refers to lodging of venous emboli in pulmonary arterial circulation (should ALWAYS be suspected in sudden collapse 1-2 weeks after surgery, often 10 days)
45
Q

What are the risk factors for a PE/VTE?

A
  • Major
  • Recent major surgery
  • Late pregnancy
  • Lower limb fracture/varicose veins, malignancy, previous proven DVT/PE, reduced mobility
  • Minor
  • Indwelling central line, oral oestrogens, long distance travel, obesity, thrombotic disorder
46
Q

How common is a PE?

A
  • 65/100,000/year
  • M>F
  • > 80% of patients will have 1 or more risk factors
  • 70% associated with emboli from DVT (usually clinically undetectable)
47
Q

What is the pathophysiology of a PE?

A
  • Small - pulmonary infarcts
  • Medium - cause a V/Q mismatch
  • Large - obstruction of major pulmonary artery (RVF leading to cardiogenic shock)
48
Q

What are the presenting features of a small PE?

A
  • Small - haemoptysis and pleuritic chest pain (60% pulmonary haemorrhage), cough
  • Medium - acute SOB, sometimes sudden collapse while straining
  • Large - circulatory collapse (some), syncope/dizziness, LOC, central chest pain
49
Q

What are the signs of a PE?

A
  • Increased HR, decreased BP, dyspnoea, tachpnoea, cyanosis, raised JVP, RV heave, loud P2, gallop rhythm, pleural rub, occasional evidence of DVT/AF +/- pyrexia
50
Q

What can be used for initial assessment of a patient who is deemed low risk - to determine if they have a PE or not?

A
  • PERC rule - used for when the diagnosis of a PE is being considered but the patient is deemed low risk
  • NICE define low risk as <15% (if clinician suspicion is greater than this then move straight to perform a 2 level Wells score (without doin the PERC score)
51
Q

What is the 2 level Wells score?

A
  • Clinical signs and symptoms of a PE - 3
  • Alternative diagnosis is less likely than a PE - 3
  • HR >100 bpm 1.5
  • Immobilisation for more than 3 days or surgery in the previous 4 weeks - 1.5
  • Previous DVT/PE - 1.5
  • Haemoptysis - 1
  • Malignancy (on treatment, treated in the last 6 months or palliative) - 1
52
Q

How is the Wells score interpretted?

A
  • PE likely - more than 4 points

* PE unlikley - 4 points or less

53
Q

What is the management for a Wells score >4 with likely PE?

A
  • Arrange an immediate CTPA
  • If there is delay then interim therapeutic anticoagulation should be given until the scan can be performed
  • NICE recommend if giving an anticoagulant that it can be continued if the result of the CTPA is positive therefore a DOAC such as apixaban or rivaroxaban is recommended
54
Q

What is the management for a Wells score <4 with unlikely PE?

A
  • Arrange a D-Dimer test
  • If positive arrange immediate CTPA
  • If there is delay then interim therapeutic anticoagulation should be given until the scan can be performed
  • If negative then PE is unlikely - consider an alternative diagnosis
55
Q

What other investigations can be done for a patient with suspected PE?

A
  • Chest x-ray
  • To exclude other pathology
  • Typically normal for a PE
  • Possible findings can be a wedge shaped opacification
  • ECG
  • Classical ECG changes seen in a PE are a large S wave in lead I, a large Q wave in lead III, and an inverted T wave in lead III - S1Q3T3 (seen in 20%)
  • RBBB and right axis deviation are also associated with PE
  • Sinus tachycardia is the most common
56
Q

What are the principles of management of patients with a PE?

A
  • DOACs are recommended first line by NICE
  • Outpatient treatment is recommended in low risk patients
  • Routine cancer screening is no longer recommended following a VTE diagnosis
57
Q

How is outpatient management determined in patients with PE?

A
  • NICE recommends using a risk stratification tool to determine the suitability of outpatient treatment
  • Pulmonary Embolism Severity Index score can be used
  • Key requirements would also include haemodynamic stability, lack of comorbidities and support at home
58
Q

Which anti-coagulant treatment is recommended for PE treatment?

A
  • DOAC’s - apixaban or rivaroxaban first line
  • If neither are suitable then either LMWH followed by dabigatran or edoxaban Or LMWH followed by vitamin K agonist i.e. warfarin
59
Q

Which patients are unable to have DOAC’s and require LMWH, unfractionated heparin or LMWH followed by a VKA?

A
  • Severe renal impairment e.g. <15/min

* Antiphospholipid syndrome (specifically triple positive)

60
Q

How long should patients be anti-coagulated for following PE?

A
  • At least 3 months
  • Dependent on whether the PE was provoked or unprovoked
  • Provoked e.g. immobilisation following major surgery
  • Typically stopped after 3 months
  • Unprovoked e.g. unknown factors
  • Continued for total of 6 months
61
Q

What is the management of patients with PE with haemodynamic instability?

A
  • Thrombolysis is now first line where there is circulatory failure e.g. hypotension
62
Q

What is the management for people with repeat PE’s despit adequate anticoagulation?

A
  • May be considered for an IVC filter

* Work by stopping clots formed in the deep veins of the leg from moving to the pulmonary arteries

63
Q

What is pneumonia?

A
  • Infection of the lung tissue in which the air sacs in the lungs become filled with micro-organisms, fluid and inflammatory cells, affecting the function of the lungs
64
Q

What is the difference between community acquired pneumonia and hospital acquired pneumonia?

A
  • CAP - pneumonia that is acquired outside the hospital or <48 hours after admission
  • HAP - pneumonia >48 hours after hospital admission and is not incubating at hospital admission
65
Q

What is thought to affect the prognosis of HAP?

A
  • Early onset (within 4 days of admission) HAP is usually caused by the same bacteria as CAP and has a good prognosis
  • Late onset (starting 5 days or more after admission) HAP has a worse prognosis because it is usually caused by the micro-organisms that are acquired from the hospital environment
  • Pseudomonas aeruginosa
  • MRSA
  • Other non-pseudomonal gram negative bacteria are the most common causes
66
Q

What are the main causes of CAP?

A
  • Mostly bacterial
  • Streptococcus pneumoniae (most common)
  • Haemophilus influenzae
  • Staphylococcus aureus
  • Group A streptococci
  • Moraxella catarrhalis
  • Atypicals - macrolide treatment (erythromycin/clarithromycin)
  • Mycoplasma pneumoniae - dry cough, haemolytic anaemia, erythema multiform
  • Chlamydia psittaci - birds
  • Legionella species - air conditioning, hyponatraemia
  • Klebsiella pneumoniae - seen in alcoholics/diabetics, red current jelly sputum
  • Pneumocystis jiroveci - seen in people with HIV
  • Viral causes
  • Influenza type A and B
  • Respiratory syncytial virus
  • Adenovirus
  • Coronaviruses
67
Q

How common is CAP in adults?

A
  • Annual incidence is 5-10/1000 adults

* Rate of hospital admission in people with CAP is 22-42%

68
Q

What is the prognosis of CAP?

A
  • Mortality rate of <1% for those managed in primary care
  • Ranges from 5-14% in people requiring admission to hospital and rises to more than 30% in people requiring intensive care
69
Q

What are the possible complications of CAP?

A
  • Pleural effusion
  • Empyema
  • Lung abscess
  • Acute respiratory distress syndrome
  • Septic shock
  • DIC
70
Q

How is pneumonia defined in the hospital setting?

A
  • Acute LRT illness with new radiographic shadowing
71
Q

What is bronchopneumonia?

A
  • Patchy shadowing of >1 lobe
72
Q

What is lobar pneumonia?

A
  • Uniform shadowing involving 1 lobe
73
Q

What are the symptoms of pneumonia?

A
  • Productive cough
  • SOB
  • Haemoptysis
  • Pleuritis chest pain
  • Fever
  • Rigors
  • Malaise
  • Anorexia
74
Q

What are the possible signs of pneumonia?

A
  • Fever >38c
  • Cyanosis
  • Confusion
  • Increased RR
  • Increased HR
  • Decreased BP
75
Q

How might the patient appear on examination?

A
  • Reduced unilateral chest expansion
  • Increased TVF
  • Dull percusion
  • Reduced air entry, diminished breath sounds, bronchial breathing
  • Pleural rub
  • Scattered crepitations
76
Q

What are the differential diagnoses to consider in a patient presenting with features suggestive of pneumonia?

A
  • PE
  • Pneumothorax
  • COPD
  • Pleural effusion
  • Lobar collapse
77
Q

What is the role of the CURB65 in the management of pnuemonia?

A
  • CURB65 identifies severity of pneumonia
  • 0 - Likely suitable for home treatment
  • 1-2 - Consider hospital referral
  • 3 or 4 - Urgent hospital admission
78
Q

How is the CURB65 scored?

A
  • Confusion - AMTS = or <8/10 or <3 (time, place, self)
  • Urea - > 7 mmol/l
  • RR - > or = 30
  • BP - SBP <90 or DBP < or = 60
  • Age > or = 65 years

1 point for each

79
Q

What are the suggested antibiotic treatments for low and moderate pneumonia (CURB65 0 or 1 or 2)?

Guided by microbiology when results are available

A
  • First line
  • Amoxicillin 500mg TDS
  • Alternatives
  • Doxycycline 200 mg day 1, then 100 mg once per day for 4 days (5 day course in total)
  • Clarithromycin 500 mg x 2 per day for 5 days
  • Erythromycin (in pregnancy) 500 mg x 4 per day for 5 days
80
Q

What are the suggested antibiotic treatments for high severity pneumonia (CURB65 3 or 4 or 5)

Guided by microbiology when results are available

A
  • First line
  • Co-amoxiclav 500/125 mg x 3 per day orally or 1.2 g x 3 per day IV for 5 days with
  • Clarithromycin 500 mg x 2 per day orally or IV for 5 days

or in pregnancy
* Erythromycin 500 mg x 4 per day orally for 5 days

  • Alternative
  • Levofloxacin 500 mg x 2 per day orally or IV for 5 days

Y5 Respiratory System (3 decks)

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