Neurology - Level 3 Flashcards
1
Q
Classes of brain tumours?
A
o High-grade – grows rapidly and is aggressive
o Low-grade – grows slowly but which may/may not be successfully treated
2
Q
Epidemiology of brain tumours?
A
- 2% of all tumours
- Lifetime risk is 1 in 77
- Common 50-70
3
Q
Risk factors of brain tumours?
A
o Ionising radiation o Vinyl chloride o Immunosuppression o Oil refining, embalming, textiles o Neurofibromatosis, VHL disease, TSC, Li-Fraumeni syndrome, Cowden’s disease
4
Q
Types of brain tumours - malignant?
A
o Metastases most commonly from other sites 10x
Lung, breast, stomach, prostate, thyroid, colorectal, melanoma, kidney
5
Q
Types of brain tumours - high grade?
A
Gliomas, glioblastoma multiforme
Primary cerebral lymphomas
Medulloblastoma
6
Q
Types of brain tumours - low grade?
A
Meningioma Acoustic neuroma Neurofibromas Pituitary tumours Pineal tumours Craniopharyngioma
7
Q
Symptoms of brain tumours?
A
o Headache Worst in mornings, coughing o Nausea and vomiting o Seizures o Progressive focal neurological deficits Diplopia, visual field defect, upper/lower limbs o Behavioural changes o Papilledema
8
Q
Symptoms related to location of mass of brain tumours - temporal?
A
dysphasia, contralateral homonymous hemianopia, amnesia, odd phenomenon
9
Q
Symptoms related to location of mass of brain tumours - frontal?
A
hemiparesis, personality change (indecent, indolent, facetious), Broca’s dysphasia, unilateral anosmia, concrete thinking, perseveration, executive dysfunction
10
Q
Symptoms related to location of mass of brain tumours - parietal?
A
hemisensory loss, sensory inattention, dysphasia
11
Q
Symptoms related to location of mass of brain tumours - occipital?
A
contralateral visual field defects, seeing multiple images
12
Q
Symptoms related to location of mass of brain tumours - cerebellum?
A
DASHING (dysdiadochokinesia, ataxia, slurred speech, hypotonia, intention tremor, nystagmus, gait abnormalities)
13
Q
Investigations in brain tumours?
A
• Urgent direct access MRI scan of brain (CT if MRI CI)
Progressive, sub-acute loss of central neurological function
• Urgent referral appointment for children within 48 hours
• Others: Technetium brain scan, Magnetic resonance angiography, PET
- Stereotactic biopsy via skull burr-hole
14
Q
Investigations in gliomas?
A
MRI
MDT team
MR perfusion/spectroscopy
Molecular markers (IDH1&2, ATRX, 1p/19q, H3.3K27M, BRAF, MGMT, TERT)
15
Q
Management of glioma - low grade?
A
- 5-ALA-guided resection (within 6 months)
• If not appropriate: Biopsy to attain histology and molecular diagnosis - If very low grade – active monitoring – then resection if progressing
- Post-surgical Radiotherapy followed by 6 cycles of PCV chemotherapy
• If 1p/19q, IDH-low grade glioma and >40 or residual tumour
16
Q
Management of glioma - Grade 3?
A
5-ALA-guided resection (within 6 months)
- Post-surgical radiotherapy followed by PCV chemotherapy
• If newly diagnosed grade 3 glioma with 1p/19q codeletion
17
Q
Management of glioma - Grade 4?
A
- Radiotherapy with temozolomide chemotherapy
• If newly diagnosed glioma
18
Q
Management of glioma - Recurrent grade 3 or 4?
A
- PCV or lomustine chemotherapy
19
Q
Investigations in meningioma?
A
MRI (CT if assessing bones)
20
Q
Management of meningioma?
A
5-ALA-guided resection (within 6 months)
Radiotherapy
21
Q
Investigations in brain metastases?
A
MRI (CT if assessing bones)
22
Q
Management of brain metastases - single?
A
- Systemic anti-cancer therapy if likely to respond (germ cell, small-cell lung)
- Surgical excision
- Stereotactic radiosurgery or radiotherapy
23
Q
Management of brain metastases - multiple?
A
- Adjuvant stereotactic radiosurgery/radiotherapy if 1-3 metastases
24
Q
Follow up in brain tumours?
A
- MRI scans and clinical assessment
25
Other medications used in management of brain tumours?
* Analgesics – codeine
* Anticonvulsants – phenytoin
* Corticosteroids – dexamethasone, mannitol for raised ICP
26
Complications of brain tumours?
- Acute haemorrhage
- Hydrocephalus
- Increases in ICP
27
Definition of encephalitis?
- Inflammation of brain parenchyma, often caused by viral infections
28
Risk factors of encephalitis?
* <1 or >65
* Immunodeficiency
* Viral infection
* Animal/Insect bites
29
Viral types of encephalitis?
- Acute (caused by direct viral infection)
| - Post-infectious (autoimmune process)
30
Viral causes of encephalitis?
- Herpes Simplex 1&2
- CMV
- EBV
- VZV
- Measles
- Mumps
- Adenovirus
- Influenza
- Polio
- Rubella
- Rabies
- HIV – toxoplasmic meningoencephalitis
31
Bacterial causes of encephalitis?
Any cause of bacterial meningitis
32
Fungal causes of encephalitis?
Cryptococcosis, histoplasmosis, candidiasis
33
Parasitic causes of encephalitis?
Trypanosomiasis, toxoplasmosis, schistosomiasis
34
Symptoms of encephalitis?
- Triad:
• Fever, headache, altered mental status
- May have confusion, seizures, focal neurological signs
- Symptoms of raised ICP – headache, vertigo, nausea, convulsions
35
Investigations of encephalitis?
```
- Bloods
• FBC and film
• U&E
• LFTs
• CRP/ESR
• Viral PCR
• Malaria film
```
- Blood Cultures
- Throat swab
- CT Scan
• Focal bilateral temporal lobe involvement – HSV
• Before LP
- Lumbar Puncture
• Send for cells, protein, glucose, lactate and PCR
• Viral – lymphocytosis, normal glucose ratio
- EEG
• Diffuse slowing with periodic discharges
36
What to send for in LP of encephalitis?
* Send for cells, protein, glucose, lactate and PCR
| * Viral – lymphocytosis, normal glucose ratio
37
Management of encephalitis - initial management?
- Assess using ABCDE and check glucose
- Immediate LP
• If contraindications for LP then urgent CT scan
• Send for opening pressure, CSF and serum glucose, CSF protein, 2x M, C &S, virology PCR, lactate
38
Management of encephalitis - if CSF findings do not suggest encephalitis?
• Repeat LP in 24 hours
39
Management of encephalitis - if CSF findings suggest encephalitis?
• IV Aciclovir (within 30 mins of arrival)
10mg/kg/8h
- Neonate 20mg/kg
- 3 months – 12 years – 500mg/m2
14 days if >12 years
21 days if immunosuppressed or <12 years old
Adjust dose according to eGFR every 12/24h
* MRI within 24-48 hours if not already performed
* ICU or HDU if severe
40
Management of encephalitis - symptomatic treatment?
* Intubation and ventilation
* Phenytoin for seizures
* Sedatives
41
Management of encephalitis - if elevated ICP?
* Elevate head of bed to 45 degrees
* Hyperventilation
* Corticosteroids
* Mannitol
42
Management of encephalitis - specific treatments to CMV, Syphilis, Rocky Mountain fever?
* CMV – ganciclovir + foscarnet
* Syphilis – Benzylpenicillin
* Rocky Mountain spotted Fever – Doxycycline
43
Clinical contraindications to LP?
* GCS <13 or fall or 3 or more
* Focal neurological signs (unequal, poorly dilating or responsive pupils)
* Abnormal posture
* Papilloedema
* After seizures until stabilised
* Relative bradycardia and hypertension
* Abnormal doll eyes movements
* Immunocompromise
* Systemic shock
* Coagulopathies – platelets <100, anticoagulation therapy
* Local infection at puncture site
* Respiratory insufficiency
* Suspected meningococcal septicaemia
44
Pathology of fibromyalgia?
- Chronic pain disorder
o Aberrant peripheral and central pain processing
o Allodynia and hyperaesthesia
45
Epidemiology of fibromyalgia?
- Women 10x
| - Aged 20-50
46
Risk factors of fibromyalgia?
```
o Female
o Middle Aged
o Low income
o Divorced
o Low educational status
o Psychosocial:
Sickness behaviours, social withdrawal, emotional problems, problems at work
```
47
Associations of fibromyalgia?
o Chronic fatigue syndrome, IBS, chronic headaches, RA/SLE
48
Symptoms of fibromyalgia?
o Chronic widespread pain
Multiple sites, low back pain
Worse in cold and stress
o Morning stiffness
o Fatigue
o Poor concentration
o Low mood
o Sleep disturbances
o Numbness, tingling, cold/heat insensitivity, TMJ dysfunction
49
Investigations to perform in fibromyalgia?
o Normal – FBC, TFTs, CRP/ESR, RF, Anti-CCP, ANA
| o Other tests all normal
50
Diagnosis made of fibromyalgia when?
o >3 months
o Widespread (left and right sides, above and below waist and axial skeleton) with no inflammation
o Pain on palpation (4kg/cm2)of at least 11/18 tender points (left and right):
Suboccipital muscle insertion
Anterior aspect of inter-transverse spaces at C5-7
Midpoint of upper border of trapezius
Origin of supraspinatus near medial border of scapular spine
Costochondral junction of 2nd rib
2cm distal from lateral humeral epicondyle
Upper outer quadrant of gluteal
Posterior to greater trochanter
Knee, at medial fat pad proximal to joint line
51
Management of fibromyalgia - general points?
o Explain diagnosis and reassure no serious underlying pathology/joint damage
o MDT approach – GP, rheumatologists, psychologist, psychiatrists, physios
52
Management of fibromyalgia - non-pharmacological?
o CBT
| o Graded-exercise programmes
53
Management of fibromyalgia - drug therapy?
```
o Paracetamol/Tramadol
o Low-dose amitriptyline or pregabalin
o Venlafaxine
o SNRIs (duloxetine)
```
54
Diagnostic criteria of chronic fatigue syndrome?
- Persistent disabling fatigue lasting >4 months, affecting mental and physical function, present in >50% of time with 4 or more of:
```
o Myalgia
o Polyarthralgia
o Poor memory
o Unrefreshing sleep, insomnia, hypersomnia
o Fatigue after exertion >24h
o Persistent sore throat
o Tender lymph nodes
```
55
Investigations of chronic fatigue syndrome?
o Urinalysis
| o Bloods – FBC, LFT, U&E, TFT, ESR, CRP, glucose, coeliac, Ca, CK, ferritin
56
Management of chronic fatigue syndrome - symptoms control?
Nausea – eating little and often, sipping fluids, anti-emetic if severe
Pain – paracetamol
Sleep - Sleep hygiene advice, rest periods during day, relaxation techniques
57
Management of chronic fatigue syndrome - when to refer?
```
o Refer to specialist within 6 months if mild, 4 months if moderatre and immediately if severe
Graded-exercise programme and,
CBT
Activity Management
Amitriptyline if poor sleep or pain
```
58
Definition of hydrocephalus?
o Increase in volume of CSF occupying cerebral ventricles
Usually due to reduced absorption or excessive secretion
o Ventricle dilatation and CSF permeates through ependymal lining in periventricular white matter – white matter damage and gliotic scarring
59
Classification of hydrocephalus?
o Non-communicating – flow of CSF is obstructed within ventricles or between ventricles and subarachnoid space
o Communicating – communication between ventricles and subarachnoid space and problem lies outside of ventricular system (reduced absorption or blockage of venous drainage)
60
CSF physiology of production and flow?
o Produced at rate of 500ml per day in adults, by choroid plexus of lateral, third and fourth ventricles
o Flow is caudal through ventricles and into subarachnoid space through the foramina of Luschka and Magendie
o Passes through tentorial hiatus and over hemispheric convexity where it is absorbed into venous system through arachnoid granulations
61
Risk factors for congenital hydrocephalus?
o Pre-Eclampsia
o Hypertension during pregnancy
o Alcohol use during pregnancy
62
Causes of hydrocephalus - non communicating?
Congenital (aqueduct stenosis, atresia of outflow foramina (Dandy-Walker), Chiari malformation)
Posterior fossa neoplasm
Intraventricular haemorrhage
63
Causes of hydrocephalus -communicating?
SAH
Meningitis
Choroid plexus papilloma
64
Causes of hydrocephalus - others in adults?
Idiopathic (1/3)
| Normal pressure hydrocephalus
65
Symptoms of hydrocephalus - in infants?
o Rapid increase in head circumference
o Dysjunction of sutures, dilated scalp veins and tense fontanelle
o Setting-sun sign (fixed downward gaze, upper lids retracted and sclera visible above iris)
o Macewen’s sign (cracked pot soung on percussion of head)
o Increased limb tone
66
Symptoms of hydrocephalus - in adults - acute?
Headache
Nausea and Vomiting
Papilloedema or impaired upward gaze
67
Symptoms of hydrocephalus - in adults - gradual onset?
```
Unsteady gait
Large head
Blurred/double vision
Cognitive decline
Incontinence
```
68
Investigations in hydrocephalus - antenatally?
US scan
69
Investigations in hydrocephalus - infants?
USS +/- CT
70
Investigations in hydrocephalus - adults?
CT
o If dilated lateral + 3rd ventricle:
With normal 4th ventricle – aqueduct stenosis
With abnormal 4th ventricle – posterior fossa mass
71
Management of hydrocephalus - if acute deterioration and communicating hydrocephalus?
Lumbar puncture
72
Management of hydrocephalus - medical management?
```
o Furosemide (inhibits CSF secretion)
o Isosorbide (promotes reabsorption)
```
73
Management of hydrocephalus - surgical management?
o External ventricular drain (temporary)
o Insertion of shunt (majority of cases, ventricular catheter drains CSF through reservoir down to right atrium of heart (ventriculoatrial shunt) or peritoneal cavity (ventriculoperitoneal shunt))
o Other – Choroid plexectomy, endoscopic cerebral aqueductoplasty
74
Complications of hydrocephalus?
- Often fatal if untreated
- Epilepsy
- Learning difficulties
- Of shunt surgery – infection, subdural haematoma, shunt obstruction
75
Definition of normal pressure hydrocephalus?
- Form of communicating hydrocephalus with ventricular dilatation in absence of raised CSF pressure on LP
- Characterised by triad of gait abnormality, urinary incontinence and dementia
76
Aetiology of normal pressure hydrocephalus?
```
o 50% idiopathic
o SAH
o Meningitis
o Head injury
o CNS tumour
```
77
Symptoms of normal pressure hydrocephalus?
o Gait disturbance (distortion of corona radiata by dilated ventricles)
Slow, broad-based and shuffling gait OR gluing-to-floor on attempting to walk
Gait apraxia
o Sphincter Disturbance (sacral nerve supply)
Urinary incontinence (+/- bowel incontinence)
```
o Dementia (distortion of periventricular system)
Memory loss, inattention, inertia, bradyphrenia
```
78
Signs of normal pressure hydrocephalus?
o Pyramidal tract signs
o Reflexes brisk
o NO PAPILLOEDEMA
79
Investigations of normal pressure hydrocephalus - initial?
o MRI/CT Scan – ventricular enlargement
| o Lumbar Puncture (5-18mmHg) – CSF pressure normal or mildly elevated
80
Investigations of normal pressure hydrocephalus - if PArkinson's suspected?
o Levodopa Challenge – if suspected Parkinsons’ disease – if no response then NPH possible
81
Investigations of normal pressure hydrocephalus - further testing?
o Intraventricular pressure monitoring
| o Lumbar infusion test (Intrathecal infusion test) – abnormal sustained rise in CSF suggest NPH
82
Diagnosis of normal pressure hydrocephalus made when?
o Clinical triad
o No papilloedema
o No evidence of raised ICP
83
Management of normal pressure hydrocephalus - general measures?
o Control blood pressure
o Smoking cessation
o Statin
84
Management of normal pressure hydrocephalus - surgical management?
- Surgery (1st line)
| o CSF shunt – to RA or peritoneum
85
Management of normal pressure hydrocephalus - medical management?
- Medical (if surgery unsuitable)
o Acetazolamide (carbonic anhydrase inhibitors)
o Repeated lumbar punctures
86
Definition of myasthenia gravis?
* IgG antibody-mediated autoimmune disease to nicotinic acetylcholine receptors, interfering with neuromuscular transmission via depletion of post-synaptic receptor sites
* Patient present with muscle weakness, worsens with continued activity and improves on rest
87
Physiology of normal neuromuscular junction?
• When action potential arrives at pre-synaptic terminal, depolarisation opens voltage-gated Ca channel (In Lambert-Eaton – this is disrupted)
• Influx of Ca through VGCCs triggers fusion of synaptic vesicles with pre-synaptic membrane (botulinum interferes with this), and neurotransmitter released into cleft
• Transmitters cross by diffusion and bind to receptors on post-synaptic membranes causing depolarisation
• Triggers onward transmission of action potential or muscle contraction at NMJ
In myasthenia gravis, antibodies block post-synaptic Ach receptors, preventing end-plate potential from becoming large enough
• Termination occurs by acetylcholinesterase degradation, uptake into pre-synaptic membrane or glial cell, or diffusion away
• Anticholinesterase treatments (pyridostigmine) reduce rate of degradation of Ach increasing chance of end-plate potential
88
Epidemiology of myasthenia gravis?
| Most common in people under and over 50?
- Peak incidence in 30s women, 60s men
- <50 – commoner in women
• Associated with thymic hyperplasia
- >50 – commoner in men
• Association with thymic atrophy/tumour, RA, SLE
89
Aetiology of myasthenia gravis?
• IgG1-dominant antibodies to Ach receptors cause weakness of skeletal muscles
90
Symptoms of myasthenia gravis?
• Increasing muscular fatigue
Order of muscle groups – extra-ocular, bulbar (swallowing, chewing), face, neck, limb girdle, trunk
Worsened by pregnancy, low K, infection, over-treatment, change of climate, emotions, exercise, drugs (opiates, gentamicin, tetracyclines, quinine, B-blockers)
• Slurred speech
• Eating/chewing problems
• Difficulty walking/sitting
91
Signs of myasthenia gravis?
* Diplopia
* Ptosis
* Myasthenic snarl (smile)
* Peek sign
* On counting to 50 – voice fades
92
Examination of myasthenia gravis?
* No muscle wasting/fasciculations
* Tone, sensation and tendon reflexes normal
* Upward gaze – starts to lower after a while
93
Classification criteria of myasthenia gravis?
• Class 1 – any eye muscle weakness, ptosis, all other muscle strength normal
• Class 2 – Mild weakness of other muscles, +/- eye muscle weakness
A – predominantly limb or axial muscles or both
B – predominantly oropharyngeal/respiratory muscles
• Class 3 – moderate weakness of other muscles, +/- eye muscle weakness
A – predominantly limb or axial muscles or both
B – predominantly oropharyngeal/respiratory muscles
• Class 4 – severe weakness, +/- eye muscle weakness
A – predominantly limb or axial muscles or both
B – predominantly oropharyngeal/respiratory muscles
• Class 5 – Intubation needed to maintain airway
94
Investigations to perform in myasthenia gravis - bloods?
* Anti Ach-R antibodies
* If seronegative – look for anti-MUSK & anti-LRP4 antibodies
* TFTs
95
Investigations to perform in myasthenia gravis - neurophysiology?
* Decremental muscle response to repetitive nerve stimulation
* If negative – single-fibre electromyography
96
Investigations to perform in myasthenia gravis - imaging?
* CT thymus
| * MRI brain – if seronegative and negative electrophysiology but compatible symptoms
97
Investigations to perform in myasthenia gravis - others?
- Used less now, Edrophonium (Tensilon test)
• IV short-acting acetylcholinesterase inhibitor and watch improvement of muscle strength
• Rarely done as can results in bradycardia
98
Management of myasthenia gravis - symptoms control?
Anticholinesterase inhibitor (Pyridostigmine 30-120mg PO up to 6x daily, max 1.2g/day)
99
Management of myasthenia gravis - immunosuppression?
Prednisolone
Regimens:
- 10mg on alternate days, increase by 10mg/week up to 1-1.5mg/kg on treatment day
- 5mg daily, increased in steps of 5mg daily, maintenance 60-80mg (0.75-1mg/kg)
- Lower dose (10-40mg) if ocular myasthenia only
Give bisphosphonate prophylaxis
Azathioprine
Methotrexate
100
Management of myasthenia gravis - surgical?
• Thymectomy (if <50 or thymomas on CT)
101
Complications of myasthenia gravis?
Aspiration pneumonia
| Myasthenic crisis
102
Definition and triggers of myasthenic crisis?
• Definition
Emergency where worsening muscle weakness results in respiratory failure
• Triggers
Infection, post-surgery, medications (antibiotics, beta blockers, quinidine, verapamil, atracurium, vecuronium, lithium, opiates, phenytoin, statins, steroids)
103
Investigations and management of myasthnic crisis?
• Investigations
Monitor arterial O2 sats & force vital capacity
• Management
Intubation & Ventilation
Immunoglobulins, steroids or Plasmaphoresis
104
Definition of motor neurone disease?
- Cluster of major degenerative diseases characterised by selective loss of neurons in motor cortex, cranial nerve nuclei and anterior horn cells
- Upper and lower motor neurones affected
105
How to distinguish MND from other neurological conditions?
* MS as never affected sensory nerves
| * Myasthenia as never affects eye movements
106
Epidemiology of motor neurone disease?
- 50% ALS
- Women more
- Mean onset 60 years
- Often fatal in 2-4 years
107
Risk factors of motor neurone disease?
• ALS-FTD locus on 9p21
108
When to suspect MND?
- Think MND in over 40, stumbling spastic gait, foot drop and proximal myopathy, weak grip
109
Types of motor neurone disease - Amyotrophic lateral sclerosis?
- Loss of motor neurons in motor cortex and anterior horn of cord
- Weakness and UMN signs (upgoing plantars)
- LMN wasting and fasciculations
- Thenar wasting
110
Types of motor neurone disease - Progressive bulbar palsy?
- Only affects cranial nerves 9-12
| - LMN lesion of tongue and muscles of talking/swallowing, flaccid, fasciculating tongue
111
Types of motor neurone disease - progressive muscular atrophy?
- Anterior horn cells only thus no UMN signs
| - Distal muscle groups before proximal
112
Types of motor neurone disease - primary lateral sclerosis?
- Loss of Betz cells in motor cortex thus mainly UMN signs and marked spastic leg weakness
113
Signs in motor neurone disease?
UMN Signs
- Spasticity, brisk reflexes, increased plantars
LMN Signs
- Wasting, weakness, fasciculations, speech and swallowing affected
114
Diagnostic criteria of motor neurone disease?
El Escorial Diagnostic Criteria for ALS
- Definite
• LMN and UMN signs in 3 regions
- Probable
• LMN and UMN signs in 2 regions
- Probably with lab support
• LMN and UMN signs in 1 region and EMG shows acute denervation in >2 limbs
- Possible
• LMN and UMN signs in 1 region
- Suspected
• LMN OR UMN signs only in 1 or more region
115
Imaging performed in motor neurone disease?
- Brain/Cord MRI
- LP
- Neurophysiology
116
How to manage motor neurone disease?
- Referral to neurologist
| - MDT approach – doctor, palliative nurse, hospice, physio, OT, SALT, dietician
117
Management of motor neurone disease - drug therapy?
• Antiglutaminergic (riluzole) – prolongs life by 3 months in ALS
118
Management of motor neurone disease - symptoms control - muscle problems?
Exercise programme
Quinine for muscle cramps/stiffness/spasticity
Baclofen, dantrolene, gabapentin alternatives
119
Management of motor neurone disease - symptoms control - nutrition?
Assess early and refer appropriately if needed
| Gastrostomy
120
Management of motor neurone disease - symptoms control - psychological support?
• Psychological support with counselling and psychological assessment
121
Management of motor neurone disease - symptoms control - saliva problems?
Propantheline/amitriptyline – stops drooling
122
Management of motor neurone disease - symptoms control - Speech and communication?
Provide alternative communication equipment a patient needs (alphabet, word or picture board and PC/tablet based voice output aids)
123
Management of motor neurone disease - symptoms control - respiratory symptoms - assessment and lung function tests?
Assessment of function
- Symptoms – SOB, orthopnoea, recurrent infections, disturbed sleep, nightmares, daytime sleepiness, poor concentration, morning headaches, fatigue
- Signs – increased RR, shallow breathing, weak cough/sniff, use of accessory muscles
Baseline Lung function tests and repeat every 2-3 months
- SpO2
- Forced vital capacity
- ABG/CBG if SpO2 <92% with lung disease or <94% without lung disease
124
Management of motor neurone disease - symptoms control - respiratory symptoms - cough, SOB and ventilation?
If sleep related symptoms – refer to respiratory ventilation service for nocturnal oximetry
Ineffective Cough
- Manual assisted cough or unassisted breath stacking
Breathlessness
- Opioids
- Benzodiazepines if anxiety related
Non-Invasive Ventilation
- When respiratory impairment if likely to benefit
- Need risk assessment and care plan
- Perform during day at start then regular treatment during night and build up hours
125
Management of motor neurone disease - general advice?
* End of life care
* Advanced decisions
* LPAs
