Pt w/ SOB Flashcards
Acute asthma attack presentation
Acute SOB, wheeze, cough and 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 = PEFR 50-75% with none of below features
ACUTE SEVERE = 30-50% PEFR, RR >25, Tachycardia >100/min, Inability to complete a sentence
LIFE-THREATENING = 33 92, CHEST (33% PEFR, 92% Sats, Cyanosis, hypotension, exhaustion, silent chest, tachycardia)
NEAR FATAL = Raised PaCO2 or immediate requirement for ventilation
Investigations in acute asthma
ABG (increased Co2 concerning, high bicarbonate suggests poorly controlled asthma over several days) Sats CXR BLOODS: FBC (infection), U&E, CRP ECG PEFR
Immediate management for acute asthma
Oxygen therapy Salbutamol nebulisers 5mg or terbutaline 10mg (up to every 15mins, space as appropriate) Add ipratropium o.5mg 6-4hrly IV ACCESS IV hydrocortisone 200mg Abx if evidence of infection Hydration (IV fluid) CALL SENIOR - theophylline, MgSO4 or IV salbutamol
Monitoring response to treatment - acute asthma
PEFRs regularly
Repeat ABGs 1-2hrly (consider arterial line or topical anaesthetic cream)
Monitor serum K+
***if poor response arrange admission to ICU
Acute COPD presentation
SOB, Wheeze, tachypnoea, accessory muscle use, cough (productive of infective sputum if infective exacerbation)
Acute COPD examination findings
Hyperinflation, hyper resonance, wheeze, cyanosis, right sided heart failure, hypercapnia symptoms (CO2 flap, trembling, bounding pulse, vasodilation)
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
FBC, U&E, CRP, ESR Continuous observation CXR ECG ABG Septic screen (blood cultures, CXR, sputum culture)
Initial management of acute COPD
Oxygen to aim for sats 88-92% (ventures can be useful for this to make sure you’re not giving too much. Consider 28% venturi)
Salbutamol nebs 5mg
Ipratropium bromide
Oral steroid PRED 30-40mg PO or IV hydrocortisone 200mg
Abx if infective exacerbation suspected AMOXicillin 500mg-1g TDS or follow local protocols
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)
Pneumonia presentation
Symptoms of infection: temperature, malaise, anorexia, sweats, nausea
Resp symptoms: SOB, dyspnoea, cough (productive of purulent sputum), haemoptysis, pleuritic pain
Examination findings in pneumonia
Tachycardia, tachypnoea, crackles, hypotensive, febrile, confused
Causes of pneumonia
CAP - agents usually haemophilia influenzae or strep pneumonia (also mycoplasma, staph a)
HAP - classified as pneumonia >48hrs post admission - different profile of organism
Investigations for pneumonia
CXR
ABG
FBC, U&E CRP, ESR, glucose
Regular observations
Scoring pneumonia severity
CURB-65 should be worked out for all Confusion - present as symptom Urea >7mmol/L Resp rate >30 Blood pressure <90/<60 (either) >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 of pneumonia
CAP
- Mild = amoxicillin or clarithromycin
- Moderate / severe = Co-amoxiclav + clarithromycin
HAP
- Tazocin
Acute pulmonary oedema presentation
SEVERE DYSPNOEA (main sx)
- coughing up frothy pink sputum, unable to talk
- breathlessness is positional - sitting up helps as does tripoding
- Sweaty, peripherally cool (incr CRT) and clammy (these all point towards a cardiogenic cause)
Examination findings in acute pulmonary oedema
Unable to talk (breathless), tachypnoea, tachycardia, accessory muscle use
Wheeze
Fine inspiratory crepitations
3rd and 4th hearts sounds - gallop
Causes of acute pulmonary oedema
Either cardiogenic or not
CARDIOGENIC (due to increase pulmonary blood pressure)
- arrhythmias, failure of prosthetic valve, VSD, cardiomyopathy, negative inotropic drugs, acute myocarditis
NON-CARDIOGENIC
ARDS
Decreased plasma oncotic pressure
Increased lymphatic pressure
Investigations for acute pulmonary oedema
Attach continuous cardiac monitoring Regular observations ECG Echo CXR FBC, U&E, LFTs, troponin ABG
Initial management of acute pulmonary oedema
Sit patient upright, give O2 (15L NRBM) Consider SL GTN 2x puffs IV furosemide 50mg Can manage pain with opioid Urinary catheter to monitor fluid output NIV
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
PE
See chest pain pack
Pneumothorax
See chest pain pack
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 (to life-threatening or severe) - can repeat every 20-30mins or give continuously
40-50mg Prednisolone or 200mg IV hydrocortisone if severe
FOR LIFE-THREATENING OR SEVERE
Nebulised Ipratropium Bromide (500micrograms) - do not repeat within 4 hours
If unresponsive consider theophylline, and MgSO4
