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Respiratory > PE + Pleural Effusion + Resp Failure > Flashcards

PE + Pleural Effusion + Resp Failure Flashcards

1
Q

RF for PE

A
  • Oestrogen/Pregnancy
  • Acute and chronic medical illness (eg: CCF and COPD)
  • Postoperative
  • Travel of >4 hours
  • Cancer
  • Hereditary (present in 25-50% of patients with PE)
  • Obesity (BMI >30)
  • Metabolic syndrome
  • Smoking
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2
Q

What is the utility of troponin and BNP in PE?

A

Troponin and BNP - often elevated in submassive PE and massive PE
Could add weight to decision to treat with thrombolysis

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3
Q

Wells criteria in PE

A

Wells Criteria
- If Wells >4/high risk = straight to imaging

  • If negative (≤4), PERC next, if negative PE is excluded
  • If PERC positive, proceed to D dimer

PERC

  • Age < 50
  • Pulse >100
  • O2 >94%
  • No haemoptysis
  • No estrogen
  • No previous DVT/PE
  • No surgery/trauma within 4 months
  • Nil unilateral leg swelling
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4
Q

ECG for PE

A

sinus tachycardia
However, the “S1Q3T3” pattern of acute cor pulmonale is classic; this is termed the McGinn-White Sign. A large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain.

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5
Q

Indications for thrombolysis

A

Thrombolysis (systemic or catheter directed): in massive PE only if SBP < 90 or at high risk of developing hypotension

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6
Q

Contraindications to thrombolysis

A

Absolute contraindications include

  • any prior intracranial hemorrhage
  • known structural intracranial cerebrovascular disease (eg, arteriovenous malformation)
  • known malignant intracranial neoplasm
  • ischemic stroke within 3 months
  • suspected aortic dissection
  • active bleeding or bleeding diathesis
  • recent surgery encroaching on the spinal canal or brain, andrecent significant closed-head or facial trauma with radiographic evidence of bony fracture or brain injury
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7
Q

Indications for IVC filter

A
  • Recent surgery
  • Haemorrhagic CVA
  • Active bleeding
  • Massive PE where recurrent embolism would be fatal
  • Recurrent PE despite adequate anticoagulation
  • May need removal after 3 months
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8
Q

Duration of PE treatment

A

-Provoked PE
Transient risk factor: 3 months
Permanent risk factor: indefinite

  • Unprovoked PE: 3-6 months
  • Submassive PE: 6-12 months
  • Massive PE: indefinite
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9
Q

Complications for PE

A
  • Acute: sudden death, shock, arrhythmia

- Chronic: chronic thromboembolic pulmonary hypertension (CTEPH)

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10
Q

Non thrombotic causes of PE

A
  • Fat
  • Tumour
  • Air
  • Amniotic fluid
  • IV drug abuse - foreign particles or septic emboli
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11
Q

What could haemorrhagic pleural fluid indicate?

A

Malignancy

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12
Q

Lights criteria for pleural effusion

A

Exudative effusion if any of the following 3 is present

  • Pleural fluid protein/serum protein ratio > 0.5
  • Pleural fluid LDH/serum LDH ratio > 0.6
  • Pleural fluid LDH > 2/3 upper limit of normal serum level

Exudative Causes

  • Autoimmune
  • Esophageal rupture
  • Infection - parapneumonic, TB, fungal, empyema
  • Malignancy
  • Pancreatitis
  • Post CABG
  • PE

Transudative

  • Hypoalbuminaemia - cirrhosis, nephrotic syndrome
  • Heart failure
  • Constrictive pericarditis

Light’s criteria misclassifies up to 25% effusions as exudates

  • Eg: patients who have heart failure or liver failure who have been on diuretics
  • Rules to classify effusion as exudate (borderline cases)
  • Measure serum-pleural protein gradient (subtract)
  • ≤31g/L: consistent with exudate
  • If > 31g/L, consider measuring serum-pleural albumin gradient
  • ≤12g/L is consistent with exudate
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13
Q

What are features that suggest a complicated parapneumonic effusion?

A

pH < 7.2
glucose < 60mg/dL (3.3mol),
elevated LDH >3x the ULN for serum
CRP > 100mg/L

  • In these cases a therapeutic thoracocentesis. If the fluid cannot be drained with a therapeutic
    thoracocentesis, a chest tube should be inserted and consideration given to the intrapleural instillation of fibrinolytics and DNAse

If the loculated effusion persists, the patient should be referred for video-assisted thoracoscopic surgery, and if the lung cannot be expanded with this procedure, a full thoracotomy with decortication should be considered.

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14
Q

What could high ADA (adenosine deaminase) indicate?

A

TB Pleurisy

▪ Released as a result of cell mediated immune response provoked T lymphocyte enzyme ADA and pro-inflammatory cytokines IFN gamma
▪ ADA: 92% sensitivity, 90% specificity
▪ The most widely accepted cut-off value for pleural ADA is 40U/L.

  • Although 1/3 parapneumonic effusions and 70% of empyemas exhibit ADA levels above this threshold
  • An extremely high ADA activity in pleural fluid (>250U/L) should raise the suspicion of empyema or lymphoma rather than TB

TB Pleurisy
- TB High endemic fluid: pleural fluid ADA and lymphocyte: neutrophil ratio has 100% specificity and 89% sensitivity (not used in developed countries)

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15
Q

In which cancers is pleural cytology more likely to be positive in?

A
  • Cytology more likely to be positive in adenocarcinoma than squamous cell carcinoma or lymphoma
  • Pleural fluid provides a definitive diagnosis of mesothelioma in only 1/3 of cases and a suspected diagnosis in further 20% –> definitive diagnosis of mesothelioma needs VATS biopsy of pleura
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16
Q

Rapid score for parapneumonic effusion

A

RAPID score of Pleural Infection
Patient with pleural infection, defined by the presence of at least one of the following:
- Purulent fluid.
- Positive bacterial culture in fluid.
- Positive result for bacteria on Gram staining in fluid.
- Fluid pH <7.2, measured using a blood gas analyzer

RAPID score used in patients with confirmed pleural infection and used for risk stratification of patient with pleural infection

5-7: high risk, 3 month mortality of 30%

17
Q

Treatment for Parapneumonic effusion

A
  • Low-Moderate: IV benpen + metronidazole
  • High Severity: IV ceftriazone
  • Chest tube drainage (if pleural fluid is purulent, gram stain or culture positive, pH < 7.2)
  • VTE prophylaxis
  • Adequate nutrition
  • Consideration of intrapleural t-PA and Dnase (intrapleural fibrinolytic therapy) or VATs
    MIST 2 trial: intrapleural t-PA-Dnase therapy improved fluid drainage in patients with pleural infection and reduced the frequency of surgical referral and the duration of the hospital stay
    Would give 10mg tPA and 5mg DNAse BD for 3 days
  • Surgery:
    Small RCTs showed VATs can be definitive treatment for empyema in 91% of cases.
    When performed later in the course of disease, higher conversion rate to thoracotomy and more complications.
18
Q

Indications for BIPAP

A

Type 2 respiratory failure

COPD

19
Q

Indications for CPAP

A
  • Sleep apnoea
  • Cardiogenic shock/APO/pulmonary oedema to help splint the airways/alveoli
    Increase cardiac output and decrease congestion
  • Can occasionally be used for type 2 respiratory failure
20
Q

Ventilation vs Perfusion

A
  • Ventilation: refers to the flow of air into and out of the alveoli
  • Perfusion: refers to the flow of blood to alveolar capillaries
21
Q

Treatment for ARDS

A
  • Prone positioning
  • Mechanical ventilation with low tidal volumes and inspiratory pressures
  • High frequency oscillatory ventilation
  • Higher PEEP
22
Q 
Recognised methods for managing ARDS include 
	A. Use of high frequency oscillation 
	B. Low PEEP and high tidal volumes 
	C. High driving pressures 
	D. Prone ventilation 
        E. All of the above
A

D. Prone ventilation

23
Q

Long term O2 therapy for chronic obstructive airway disease

A
  • Improved dyspnoea
  • Improved exercise capacity
  • Health related QOL
  • Studies have shown it needs to be used 16 hours/day to reduce mortality
24
Q

Use of long term oxygen therapy in chronic respiratory failure
A. Definitively increases physical activity
B. Reduces overall mortality when given nocturnally
C. Definitively increases physical activity
D. Should be administered for at least 15 hours per day to be effective
E. All of the above

A

D. Should be administered for at least 15 hours per day to be effective

25
Q

Factors that predict NIV failure

A
  • Acidosis pH < 7.25
  • Marked new onset hypoxaemia
  • Respiratory distress signs
  • Non pulmonary organ failure
26
Q

Non-invasive ventilation in neuromuscular disease
A. Is most effective when commenced electively for incipent respiratory failure as opposed for critically ill presentations in respiratory failure
B. Is most effective in motor neurone disease when commenced in patients with normal or mildly impaired bulbar function
C. Is most effective in patients with chest wall deformities
D. a,b,c above
None of the above

A

D. a,b,c above

27
Q

Management of respiratory failure should include
A. Use of cough assist devices when sputum clearance is impaired
B. Use of extracorporeal support when PEEP is greater than 10 cm H2O
C. Routine use of oxygen to improve mobility in exercise induced hypoxaemia
D. Regular use of oxygen therapy for nocturnal episodic hypoxaemia
E. A and C above

A

E. A and C above

28
Q

CAP severity - CURB65

A 
Confusion 
Urea > 7
RR >30 
BP <90/60
Age >65

0-1 : home
2 : likely admit
3-5 : admit and treat as severe

  • Note: these scores tend to underestimate the severity of pneumonia in younger patients due to not scoring for certain comorbidities and age
  • Confusion is the strongest predictor of mortality, often a marker of frailty
29
Q

Red flags for pneumonia and admission

A 
· RR >25
	· O2 < 92% RA
	· Multilobar involvement on CXR 
	· SBP < 90mmHg
	· Acute onset confusion 
	· HR > 100
         · Lactate > 2

Respiratory (10 decks)

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