Misc Resp Flashcards
Chest drain sizes:
8- up to 14F = ‘small bore’ / intercostal catheter
16- 40F = ‘large bore’/ chest tube
SMALL BORE:
Neonate/ infant (8-12F)
Pneumothorax, effusion (10-14F)
Empyema (24F, or small bore with flushes)
LARGE BORE:
Haemothorax, major trauma (32+)
‘Triangle of safety’
Insertion of ICC:
At what French chest drain do you change from Seldinger, to blunt dissection?
Blunt dissection from 24F
Pneumomediastinum:
Causes:
Air from lungs, trachea/ bronchi, oesophagus, or penetration
BAROTRAUMA
- Forceful cough/ val salva (incl. labour)
- PPV
- Diving
PULMONARY
- Pneumothorax
- Asthma/ COPD
- Fibrosis
- Mass
TRAUMATIC
- Penetrating injury
- Oesophageal rupture
IATROGENIC
- ETT
- Bougie
- PPV
- Endoscopy
_____________________
PRESENTATION
Chest/ neck pain
Dyspnoea
Stridor
Voice change
Swallowing Sx
Subcut emphysema - face, neck, chest
Hamman’s Crunch
MANAGEMENT
Treat cause
Supportive (will resorb)
If tensioned, urgent mediastinotomy (CTx)
‘Coin lesion’ DDx:
Infection
- Pneumonia (partic kids, ‘round pneumonia’)
- TB (Gohn focus)
- Abscess
- Hydatid
Malignancy
- Primary
- Met
Benign
- Haematoma
- AVM
- Rheumatoid nodule
- Cyst (bronchogenic)
- Granuloma: (eg. polyangiitis)
Non-pulmonary
- Artefact: nipple, ECG dot
- Bony callous
- Costal cartilage calcification
- Skin lesion
‘Cavitating lung lesion’ DDx:
INFECTION
- Abscess
- Cavitating pneumonia
- TB
- Cryptococcus
NEOPLASM
GRANULOMA
- Rheumatoid
- Polyangiitis
INFARCT
Pseudo-cavity:
- Bronchogenic cyst
- Congenital airway malformation
Describe the physical examination in acute respiratory distress:
Pathophysiology of ARDS:
Stages:
1- Injury
2- Exudative
3- Infiltrative (Inflamm cells)
4- Fibrotic
5- Resolution
Insult/ injury occurs
Increased capillary permeability —> exudate ++ —> heavy, wet lungs with reduced alveolar air space
Ongoing inflammation +
=
Hypoxia
Surfactant dysfunction
Reduced compliance +++
Pulmonary HTN
Mortality and recovery time in ARDS:
Mortality 35-40%
Recover largely in 2 weeks
6-12mo pulmonary recovery (or, restrictive lung disease)
Management of ARDS:
Lung-protective ventilation
—> Functionally ‘baby lungs’
—> as per ARDSnet ARMA study
Other options:
- Proning
- Inhaled nitriC oxide (pulm HTN)
- Steroids
- Surfactant replacement
ARDS causes:
DIRECT
- Infection
- Near drowning
- Smoke
- Chemical inhalation
- Aspiration
- Reperfusion (ROSC, lysis)
- Fat/ amniotic fluid embolism
INDIRECT
- Blood transfusion (TRALI)
- Multiple trauma
- Sepsis
- DIC
- Pancreatitis
CXR in ARDS:
Diffuse, bilateral, opacities- patchy or coalescent. With air bronchograms
Main DDx APO. But:
- Not peri hilar
- No effusions (rare)
- No Cardiomegaly
- Air bronchs don’t occur in APO
Respiratory effects of obesity:
Airway soft tissue, prone to obstruction
Decreased compliance
—> harder to bag/ ventilate
—> Large abdo/ IAP contributes
Dependent atelectasis
—> Hypoventilation hypocarbia
Increased pulmonary arterial pressures
—> Cor pulmonale
Reduced FRC (and TLC, VC)
—> Less to Preoxygenate
—> Shorter safe apnoea time
Higher metabolic demand
—> shorter safe apnoea time
Aspiration
Gastric contents are sterile
May aspirate contaminated nasopharyngeal, or particulate matter
Most CXR will be normal
If CXR abnormal (pneumonitis) at presentation, high risk
ARDS within 5-6 hours
Routine antibiotics controversial. Use. If:
- contaminated contents (eg. Bowel obstruction)
- failed conservative Max
- abnormal
CXR
- Unwell
Amoxy/ benpen + metronidazole
Most can be observed
If elderly: inpatient.
