Pt w/ SOB Flashcards
Acute asthma attack presentation?
What are precipitants of asthma attack?
Acute asthma attack
- Acute SOB
- Wheeze
- Cough
- Cyanosis (if extreme)
PRECIPITANTS in hx: cold, exercise, allergens, smoke, infection
***the patient might not know they have asthma or they might come in with a dx and having tried to manage their own asthma at home and failed
**for the patient who does not know wheeze is an important sign
Grading of severity for acute asthma (moderate, severe, life threatening) -think about the nemonics
At what point would you think this is near FATAL?
MODERATE = PEFR 50-75% with none of below features
SEVERE = 50STaR
- 33%-50% PEFR
- Sentences-Inability to complete full sentences
- Tachycardia >110/min
- RR >25/mi
LIFE-THREATENING = 33 92, NO CHEST
- <33% PEFR
- 92% Sats
- Normal CO2 (4.6-6kPa)
- Oxygen (<8kPa)
- Cyanosis
- Hypotensive
- Exhaustion/confusion
- Silent chest
- Tachycardia (can get arrhythmia)
Near FATAL: ↑PaCO2> 6kpa ± requiring mechanical intervention
Investigations in acute asthma
Bedside
- O2 sats
- Resp rate
- ECG (look for arrhythmias)
- Peak flow (PEFR)
Bloods
- ABG (increased Co2 concerning, high bicarbonate suggests poorly controlled asthma over several days)
- FBC (infection)
- CRP
- Us and Es
Imaging
-CXR
How many puffs of inhaler is maximum before going to hospital?
Management of acute asthma in hospital?
GO TO A AND E IF NO IMPROVEMENT AFTER 10 PUFFS
Management of acute asthma:
• ABCDE
• Oxygen -15L/min via non-rebreathe mask(maintain sats of 94-98%)
• Salbutamol 5mg NEB with oxygen (back to back-THREE IN A ROW)
• If severe or life threatening (PEFR<50%) add ipatropium bromide 0.5mg NEB
• Early treatment with Oral Pred (40mg) or IV hydrocortisone 100mg if can’t tolerate
Reassess every 15 mins
• If still <75% repeat salbutamol nebs every 15-30 mins
CALL SENIOR - Magnesium sulphate (with cardiac monitoring), theophylline, or IV salbutamol
(in reality you would just get nurses to mix ipratropium bromide and salbutamol for nebs-takes longer to run through but its good to get both going)
Monitoring response to treatment
What is an important side effect of treatment used in acute asthma?
When should you refer to ICU?
Monitoring response to treatment
- PEFRs regularly
- Repeat ABGs 1-2hrly (consider arterial line)
Side effect
-Monitor serum K+ (hypokalaemia as a result of β2-agonists) (also cardiac monitoring for mag sulphate)
***if poor response or life threatening (33% PEFR) arrange admission to ICU
Acute COPD presentation
COPD
- SOB
- Wheeze
- Cough (productive, infective if infective exacerbation)
- Fever
- Tachypnoeic
- Accessory muscle use
Acute COPD examination findings
Examination
- hyperinflation
- hyper-resonant
- wheeze
- cyanosis
- right sided heart failure (cor pulmonale)
- signs of hypercapnia (flap, bounding pulse, vasodilatoin)
Causes of acute COPD
Can either be infective or non-infective
INFECTIVE = H. influenzas or S. pneumonia
Hx factors will help determine (productive sputum, fever, malaise, anorexia)
Investigations for acute COPD, what would they show?
Continuous observation
Bloods FBC, U+E, CRP, ESR, gas
CXR (hyperinflation, flattened diagphrams,?consolidation)
ECG
• AF
• RVH increase in p wave amplitude
• Right axis deviation
• RBBB
ABG (type 2 resp failure, high bicarb-met compensation)
Septic screen (blood cultures, CXR, sputum culture)
Initial management of acute COPD
Initial COPD management- COSICARRR
- Controlled Oxygen 88-92% targets
- Salbutamol (5mg) NEB
- Ipatropium bromide (0.5mg) NEB
- Corticosteroid- oral prednisolone 30mg or IV hydrocortisone
- Antibiotics if infective (amoxicillin/clarithromycin/ doxycycline)
- Aminophylline if SEVER
- Radiography - CXR
- Respiratory support - BiPAP
- Refer
Criteria for NIV in acute COPD
CPAP or BiPAP
- Persisting respiratory acidosis after 1hr of medical management: (O2, salbutamol, ipratropium, prednisolone, and abx when indicated)
- Bipap is for T2RF
Pneumonia presentation (symptoms and on examination)
PNEUMONIA
• Shortness of breath
• Cough
- Productive in adults - purulent sputum
- Often dry in infants/elderly or atypical pneumonia
- Sometimes haemoptysis
• Pleuritic chest pain - most painful on inspiration
• Fever, rigors, sweats
• Nausea
O/E
Tachycardia, tachypnoea, crackles, hypotensive, febrile, confused
What are the most common organisms to cause a CAP?
name some atypical causes?
CAP
- Streptococcus pneumoniae 50%
- Haemophilus influenzae (COPD)
- Moraxella catarrhalis
Atypical
- Mycoplasma pneumoniae
- Legionella
- Chlamydia pneumoniae
- Define HAP
- What are the common organisms?
HAP
-Pneumonia 48 hours after admission (or 5+ days depending on trust) OR 4-6 WEEKS post admission
- different profile of organism
1. Gram negative enterobacteria
2. Staphylococcus aureus
3. Pseudomonas
4. Klebsiella pneumoniae
Investigations for pneumonia
BEDSIDE
- regular observations (HR, RR, BP, temp,ECG)
- sputum culture if not improving or atypical suspicion
- urinalysis (pneumococcal and legionella antigen)
BLOODS
- ABG
- Cultures
- FBC
- CRP
- Glucose
- Us and Es (urea prognostic)
- LFTS (can affect liver + also side effect of antibacterials)
IMAGING
-CXR
SPECIAL
-CURB 65 score
Score for CAP severity? Explain it
Whats the managment for each score?
CURB-65 should be worked out for all
- Confusion - present as symptom (AMTS ≤ 8)
- Urea >7mmol/L
- Resp rate ≥ 30
- Blood pressure Systolic < 90 mmHg or Diastolic ≤ 60
- 65yo +
***influences anti-microbial management
Initial management of pneumonia
O2 - 15L NRBM aim for sats 94-98% (less for COPD patients)
IV fluids
Obtain blood cultures and sputum cultures
VTE prophylaxis
IV abx
Anitmicrobial management for CAP (depending on CURB65 score)
Antimicrobial treatment for HAP?
CAP
- Mild (score 0-1) = amoxicillin OR clarithromycin
- HOME MONITORING
- Moderate (score 2) = amoxicillin AND clarithromycin (or tetracycline)
- ADMIT or CLOSE OUTPATIENT MONITORING
- Severe (score 3+) IV antibiotics (e.g. co-amoxiclav)
- DEFFO ADMIT (switch to oral when improving 5-7 days)
HAP
- IV aminoglycoside e.g. gentamicin (gram neg cover) and IV piperacillin Tazocin
Explain the pathophysiology of pulmonary oedema (caused by cardiac)
Give examples of what may cause this
Explain the pathophysiology of pulmonary oedema (caused by non cardiac)
Give examples of what may cause this
CARDIOGENIC
-LVF leads to increased pulmonary capillary pressure so fluid collects in extravascular pulmonary tissues faster than lymphatics clear it
E.g. arrhythmias, failure of prosthetic valve, VSD, cardiomyopathy, negative inotropic drugs (beta blockers), hypertension/acute complication of MI/IHD/myocarditis
NON CARDIOGENIC
-increased capillary permeability, decreased plasma oncotic pressure (so water leaves vessels), increased lymphatic pressure
-E.g.
•ARDS
• IV fluid overload
• Smoke inhalation
• Near drowning incident (water drawn out of vessels into interstitium)
Symptoms of acute pulmonary oedema presentation
SEVERE DYSPNOEA (main sx)
- Coughing up frothy pink sputum, unable to talk
- Orthopnea- sitting up and tripod helps breathlessness
- Breathlessness wakes at night (PND)
- Reduced exercise tolerance
- Sweaty, peripherally cool (incr CRT) and clammy (these all point towards a cardiogenic cause)
Examination findings in acute pulmonary oedema
Examination findings acute pulmonary oedema B -tachypnoea -cyanosis -wheeze -fine basal inspiratory crackles -dull percussion in bases -accessory muscle use -raised JVP C -tachycardia -3rd and 4th hearts sounds - gallop (if due to LVF) -evidence of decreased C/O (sweaty, cool, pale)
Investigations for acute pulmonary oedema
INVESTIGATIONS OF ACUTE PULMONARY ODEMA Bedside -Attach continuous cardiac monitoring -Regular observations -ECG (look for arrhythmias)
Bloods -B-type natriuretic peptide (BNP) • High: >2000 pg/ml - urgent ECHO (2 weeks) • Raised: 400-2000 pg/ml - 6 weeks • Normal: <400 pg/ml - normal -FBC, B U+Es, LFTs, troponin -ABG
Imaging
- Echo
- CXR
Initial management of acute pulmonary oedema
ACUTE PULMONARY ODEMA
- ABCDEF assessment, monitor fluid balance (catheter)
- Sit patient upright
- Give O2 15L via NRBM or cPAP!!!!!!
- IV Diamorphine (improve dyspnoea, careful if COPD)
- IV furosemide (loop diuretic-intense diuresis)
- GTN spray SL 2 puffs (don’t give if systolic BP <90)
- If systolic >100 start nitrate infusion e.g. isosorbide dinitrate
if systolic BP <100 treat as cariogenic shock>ICU
X-Ray signs of pulmonary oedema?
Pulmonary oedema Xray signs (ABCDEF) Alveolar oedema - Bat's wings B - Kerley B lines = interstitial oedema Cardiomegaly Dilated vessels in upper lobe Effusionsat costophrenic angle Fluids in fissures
What criteria might make you consider admission in someone having an acute exacerbation of asthma?
<18yo Poor treatment adherence Living alone Psychogical problems Physical or learning disability Previous asthma attack Exacerbation despite adequate dose of oral corticosteroids before presentation Presentation in afternoon or night Recent nocturnal symptoms Recent hospital admission Pregnancy
Summarise the treatment algorithm for an acute exacerbation of asthma
FOR EVERYONE
O2 if hypoxic
Nebulised salbutamol 5mg- can repeat every 20-30mins or give continuously
40-50mg Prednisolone or 200mg IV hydrocortisone
IF SEVERE (<50%) Nebulised Ipratropium Bromide (500micrograms) - do not repeat within 4 hours
If unresponsive consider theophylline, and MgSO4
What score estimates the in hospital mortality for COPD patients?
DECAF score
- Dyspnea
- Eosinipenia
- Consolidation
- Acidosis (respiratory)
- AF
Questions you would ask to determine the severity of someone COPD?
- how far can you walk?
- home oxygen? home nebulisers?
- admitted to hospital in last 12 months?
- how many chest infections have you had
- how many AB and steroids have you taken in last 2 months
- previous non invasive ventilation?
- lost any weight?
- DNACPP?
Managment of pleural effusion
- ultrasound guided thoracocentesis
- measure pleural pH (if <7.2 indicates empyema-chest drain)
Complications of pneumonia
- effusion/empyema
- lung basess (more common with staph arues, klebsiella and pseudomonas)
- cavitation
- sepsis and multi organ failure
Inhalation injury overview
usually of cleaning chemicals such as ammonia and chloride or SMOKE from fire
Dissolve in mucosal layer of alveoli and cause inflammatory response causing response symptoms
When can you discharge a patient who has had an acute asthma attack?
What drugs would you discharge them with?
What should you arrange for discharge?
Can DISCHARGE if PEF > 75% and off nebs
Discharge:
- Prescribe oral prednisilone for 5-7 days
- Prescribe salbutamol weaning 6 puffs QDS>4 puffs QDS
-Arrange follow up with GP WITHIN 2 DAYS (asthma action plan (inhaler review and technique)
What is the management of acute asthma attack in children?
How do you follow up with kids?
ACUTE ASTHMA IN CHILDREN
- NEB SALBUTAMOL FIRST LINE IN KIDS 2.5-5mg
- HIGH FLOW OXYGEN (aim for sats above 94%)
- NEB IPRATROPIUM BROMIDE (250-500mg) NEB Repeat bronchodilators every 20-30 mins if persist
- NEB MAGNESIUM SULPHATE with each reapeat NEB if symptoms are severe and sats are <92%
- STEROIDS: oral prednisolone or IV hydrocortisone if severe
- IV SALBUTAMOL
- IV AMINOPHYLLINE 500-700mcg/kg/hr can be considered if severe or life-threatening
- IV MAGNESIUM SUPFATE
GP appointment 2 days and peads appointment at 2 months
AB of choice for HAP? (early vs late)
Within 5 days of admission: co-amoxiclav or cefuroxime
More than 5 days after admission: piperacillin with tazobactam OR a broad-spectrum cephalosporin (e.g. ceftazidime) OR a quinolone (e.g. ciprofloxacin)
What is common pathogen causing pneumonia following influenza?
AB of choice ?
- Staph aureus commonly causes pneumonia after flu
- Add Flucoxacillin
What is common pathogen causing pneumonia following aspiration?
Aspiration pneumonia-poor swallow (anaerobic organisms), klebsiella common in alcoholics
What would loss of right heart border show?
Right middle lobe pneumonia
What would loss of right hemidiaphragm show?
Right lower lobe pneumonia
What would loss of left heart boarder show?
Left upper lobe pneumonia
What would loss of left hemidiaphragm show?
Left lower lobe pneumonia
Acutely unwell patient (low BP, high HR, low O2) with COPD. What oxygen should you do?
Oxygen therapy in unwell COPD patient
- start with 15L NBR (hypoxia will kill first)
- then start on 28% (white 4L) and titrate
what flow rate do nebs need?
What do you do if this oxygen flow s too high for COPD patients?
- Nebulisers need flow rate of 6-8L
- If this is too high for COPD patient then just drive it through air and stop oxygen
- after its gone through start oxygen at their controlled rate (start 28% and titrate)
What antibiotics in infective exacerbation of COPD?
Infective exacerbation of COPD
-amoxicillin (can do IV) /clarithromycin (can do IV)/ doxycycline
What is ARDS?
- Lung damage > release of inflammatory mediators> increased capillary permeability> non cariogenic pulmonary odema
- Often also have multi organ failure
What are the 2 main categories of ARDS causes?
ARDS is either caused by direct lung injury or secondary to severe systemic illness
Pneumonia and sp
What are some specific causes of ARDS?
Direct lung injury
- Pneumonia (most common)
- Aspiration
- Inhalation injury
- Trauma
Systemic illness
- Sepsis (most common)
- Systemic trauma
- Shock
- DIC
- Fat embolism
- Pregnancy
- Other organs: pancreatitis/acute liver failure/head injury/raised ICP
- Drugs/toxins
What are the symptoms of ARDS?
SIGNS AND SYMPTOMS
- ACUTE ONSET
- Cyanosis
- SOB (confirmed hypoxia on ABG)
What are the signs of ARDS?
Signs
- Tachycardic
- Tachypnoeic
- Refactroy hypoxaemia
- Peripheral vasodilation
- Bilateral fine inspiratory crackles (confirmed on X-ray-bilateral infiltrates)
What Pulmonary Capilary Wedge Pressure (PCWP) would make you think of ARDS?
PCWP<19 (or lack of clinical congestive heart failure) would make you think of ARDS
What is the treatment for ARDS?
TREAT SEPSIS (dont use nephrotoxic AB)
- Respiratory support
- 40-60% O2 on CPAP
- Mechanical ventilation if ABG O2 is <8.3 despite oxygen (most patients will require that) - Circulatory support
- Arterial line monitoring
- Conservative fluid managment
- Ionotropes to maintain CO (dobutamine)
- Consider pulmonary vasodilator-because they will probs have pulmonary HTN (nitric oxide)
What can be a side effect of ventilation in ARDS?
How do you minimise this risk?
- ARDS patients on ventilation may get a pneumothorax
- Because patients with ARDS have reduced lung compliance
-To overcome: use low tidal volumes use lower PEEP
What is mortality for ARDS?
Mortality is 50-70%
more if infectuion, less if trauma
