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
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
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
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
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
6
Q
What does a normal pCO2 in acute asthma attack indicate?
A
- Exhaustion - should therefore be classified as life threatening
7
Q
What does a raised pCO2 and/or requiring mechanical ventilation with raised inflation pressures in acute asthma indicate?
A
- Near fatal asthma
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
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
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)
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
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
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)
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
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
16
Q
What are the most common bacterial organisms that cause infective exacerbations of COPD?
A
- Haemophilus influenzae (most common)
- Streptococcus pneumoniae
- Moraxella catarrhalis
17
Q
What level of COPD exacerbations are accounted for by viral causes?
A
- 30% wit human rhinovirus being the most common
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
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
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
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
22
Q
What is a hyperventilation?
A
- Breathing occurring more deeply and/or more rapidly than normal - classification 1 or 2
23
Q
What is classification 1 hyperventilation?
A
- Psychogenic (inappropriate)
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)
25
What are the risk factors for 1 hyperventilation?
* Female
* Agitated
* Distressed
* PMH - panic attacks/hyperventilation
26
What is the pathophysiology of hyperventilation?
* CO2 is 'blown off' leading to respiratory alkalosis
27
What are the symptoms of hyperventilation?
* Dizziness, paraesthesia, chest pain, PMH panic attacks
28
What are the appropriate investigations for a person with hyperventilation?
* BM
* FBC
* U and E's
* ABG if sats low
* CXR if symptoms do not settle
* ECG
* pulse oximetry
29
What is the management of a person with hyperventilation?
* 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
30
What are the complications of hyperventilation?
* Respiratory alkalosis
31
What is acute bronchitis?
* Acute inflammation of the lung bronchi
32
What are the causes of acute bronchitis?
* Viral - RSV, rhinovirus, influenza virus
| * Bacterial - Streptococcus pneumoniae, haemophilus influenzae, staphylococcus aureus
33
What are the risk factors for acute bronchitis?
* COPD, smoking, dusty environments
34
What are the symptoms of acute bronchitis?
* Predominent cough +/- sputum, pleuritic/retrosternal chest pain, wheeze, SOB
35
What are the signs of acute bronchitis?
* May have mild fever
* May have course crackles, wheeze
* Lack of systemic illness/focal chest signs
36
What are the differential diagnoses for acute bronchitis?
* UTRI
* Chronic bronchitis
* Pneumonia
37
What are the management options for acute bronchitis?
* 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
What is the prognosis of acute bronchitis?
* 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
What is the mechanism of a tension pneumothorax?
* 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
What are the presenting clinical features of tension pneumothorax?
* 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
What is the management of a tension pneumothorax?
* 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
What are the complications of a tension pneumothorax?
* Cardiogenic shock
| * Cardiorespiratory arrest
43
What is the ongoing advice after a patient has been treated for a tension pneumothorax?
* Avoid air travel for 6 weeks after normal chest x-ray
| * Avoid diving forever
44
What is a pulmonary embolism?
* 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
What are the risk factors for a PE/VTE?
* 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
How common is a PE?
* 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
What is the pathophysiology of a PE?
* Small - pulmonary infarcts
* Medium - cause a V/Q mismatch
* Large - obstruction of major pulmonary artery (RVF leading to cardiogenic shock)
48
What are the presenting features of a small PE?
* 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
What are the signs of a PE?
* Increased HR, decreased BP, dyspnoea, tachpnoea, cyanosis, raised JVP, RV heave, loud P2, gallop rhythm, pleural rub, occasional evidence of DVT/AF +/- pyrexia
50
What can be used for initial assessment of a patient who is deemed low risk - to determine if they have a PE or not?
* 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
What is the 2 level Wells score?
* 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
How is the Wells score interpretted?
* PE likely - more than 4 points
| * PE unlikley - 4 points or less
53
What is the management for a Wells score >4 with likely PE?
* 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
What is the management for a Wells score <4 with unlikely PE?
* 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
What other investigations can be done for a patient with suspected PE?
* 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
What are the principles of management of patients with a PE?
* 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
How is outpatient management determined in patients with PE?
* 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
Which anti-coagulant treatment is recommended for PE treatment?
* 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
Which patients are unable to have DOAC's and require LMWH, unfractionated heparin or LMWH followed by a VKA?
* Severe renal impairment e.g. <15/min
| * Antiphospholipid syndrome (specifically triple positive)
60
How long should patients be anti-coagulated for following PE?
* 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
What is the management of patients with PE with haemodynamic instability?
* Thrombolysis is now first line where there is circulatory failure e.g. hypotension
62
What is the management for people with repeat PE's despit adequate anticoagulation?
* 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
What is pneumonia?
* 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
What is the difference between community acquired pneumonia and hospital acquired pneumonia?
* 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
What is thought to affect the prognosis of HAP?
* 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
What are the main causes of CAP?
* 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
How common is CAP in adults?
* Annual incidence is 5-10/1000 adults
| * Rate of hospital admission in people with CAP is 22-42%
68
What is the prognosis of CAP?
* 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
What are the possible complications of CAP?
* Pleural effusion
* Empyema
* Lung abscess
* Acute respiratory distress syndrome
* Septic shock
* DIC
70
How is pneumonia defined in the hospital setting?
* Acute LRT illness with new radiographic shadowing
71
What is bronchopneumonia?
* Patchy shadowing of >1 lobe
72
What is lobar pneumonia?
* Uniform shadowing involving 1 lobe
73
What are the symptoms of pneumonia?
* Productive cough
* SOB
* Haemoptysis
* Pleuritis chest pain
* Fever
* Rigors
* Malaise
* Anorexia
74
What are the possible signs of pneumonia?
* Fever >38c
* Cyanosis
* Confusion
* Increased RR
* Increased HR
* Decreased BP
75
How might the patient appear on examination?
* Reduced unilateral chest expansion
* Increased TVF
* Dull percusion
* Reduced air entry, diminished breath sounds, bronchial breathing
* Pleural rub
* Scattered crepitations
76
What are the differential diagnoses to consider in a patient presenting with features suggestive of pneumonia?
* PE
* Pneumothorax
* COPD
* Pleural effusion
* Lobar collapse
77
What is the role of the CURB65 in the management of pnuemonia?
* CURB65 identifies severity of pneumonia
* 0 - Likely suitable for home treatment
* 1-2 - Consider hospital referral
* 3 or 4 - Urgent hospital admission
78
How is the CURB65 scored?
* 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
What are the suggested antibiotic treatments for low and moderate pneumonia (CURB65 0 or 1 or 2)?
Guided by microbiology when results are available
* 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
What are the suggested antibiotic treatments for high severity pneumonia (CURB65 3 or 4 or 5)
Guided by microbiology when results are available
* 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
