Resp Flashcards
Classification of acute asthma,a
Moderate
- PEFR: 50-75%
Severe
- PEFR: 33-50%
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- RR > 25/min
- HR > 110 bpm
Life threatening
- PEFR< 33%
- So2 <92%
- silent chest, cyanosis, feeble resp effort
- bradycardia, dysrhythmia, hypotension
- Exhaustion, confusion or coma
- normal pCO2 (4-6kPa)
Near fatal
- raised pCO2
Acute asthma mx
ABG for SO2 <92%
Chest x ray if: life threatening, pneumothorax, failure to respond to tx
Mx
- Admission criteria: life threatening, severe not responding to tx, pmhx of life threatening, pregnancy, night px, using oral corticosteroid already
- O2 -> start of 15L and then titrate to maintain 94-98%
- nebulised SABA
- 40-50mg of prednisolone orally
- nebulised ipratropium bromide
- IV magnesium sulphate
- IV aminophylline - after consulting senior
- senior critical care support in ITU/HDU setting: intubation and ventilation, extracorporeal membrane oxygenation (ECMO)
discharge criteria
- stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours
- inhaler technique checked and recorded
- PEF >75% of best or predicted
Acute bronchitis tx
analgesia, good fluid intake
ABx therapy (doxycycline. CI in pregnancy/ children) : systemically v unwell, pre-existing co-morbidities, CRP high,
Acute exacerbation of COPD
- increase bronchodilator freq, consider nebuliser
- prednisolone 30 mg daily for 5 days
- Abx only if sputum is purulent or there are clinical signs of pneumonia (amoxicillin or clarithromycin or doxycycline)
Admit: severe SoB, confusion, cynosis, SO2<90, social reasons, significant comorbidity
Severe exacerbation
- O2 therapy: initially 28% Venturi mask at 4 l/min w target of 88-92% & do ABG. if ABG pCO2 normal -> adjust target to 94-98%
- Nebulised bronchodilator: SABA/ ipatropioum
- Steroid
- IV theophylline
- T2RF w pH 7.25-7.35: non-invasive ventilation
- If pH < 7.25, can still use BiPaP but HDU monitoring & lower threshold for intubation & ventilation
Acute respiratory distress syndrome (ARDS) criteria
acute onset (within 1 week of a known risk factor)
pulmonary oedema: bilateral infiltrates on chest x-ray (‘not fully explained by effusions, lobar/lung collapse or nodules)
non-cardiogenic (pulmonary artery wedge pressure needed if doubt)
pO2/FiO2 < 40kPa (300 mmHg)
( prone positioning and muscle relaxation helpful)
Allergic bronchopulmonary aspergillosis mx
oral glucocorticoids
itraconazole is sometimes introduced as a second-line agent
Asthma dx
Patients >= 17 years
- all pts: spirometry with a bronchodilator reversibility (BDR) test
- all pts: FeNO test
Children 5-16 years
- spirometry with a bronchodilator reversibility (BDR) test
- if negative BDR -> a FeNO test
Patients < 5 years
- clinical judgements
BDR +ve test criteria
- in adults: improvement in FEV1 of >= 12% & increase in volume of 200 ml or more
- only improvement in FEV1 of >= 12%
Asthma mx
Adults
1. SABA
2. SABA + low-dose ICS
3. SABA + low-dose ICS + LTRA
4. SABA + low-dose ICS + LABA +/- LTRA
5. SABA + low-dose MART +/- LTRA
6. SABA + medium-dose MART +/- LTRA OR #4 w medium-dose ICS
7. high dose ICS #4 OR ++ a long-acting muscarinic receptor antagonist OR ++ theophylline OR refer
- consider stepping down treatment every 3 months or so
- reducing the dose of inhaled steroids by 25-50% at a time.
safe triangle chest drain
mid axillary line of the 5th intercostal space. It is bordered by
Anterior edge latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and the apex below the axilla.
severity of COPD
FEV1 (of predicted):
>80% - stage 1- mild
50-79% - 2 - mod
30-49% - 3- sev
<30% - 4- v sev
LTOT COPD criteria
pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
peripheral oedema
pulmonary hypertension
COPD mx
> smoking cessation advice, annual influenza, one off pneumococcal, pulmonary rehab
- SABA OR SAMA
- asthmatic features: LABA + ICS + SAMA/SABA
- No asthmatic fx: LABA + LAMA + SABA
- LABA + LAMA + ICs + SABA
Prophylactic abx:
- azithromycin (ECG to look for QT prolongation)
Phosphodiesterase-4 (PDE-4) inhibitor, roflumilast, -> severe COPD(FEv1<50%) and a history of frequent COPD exacerbations (2 or more in last yr despite LAMA+LABA+ICS)
Lung ca referral criteria
2ww
have chest x-ray findings that suggest lung cancer
are aged 40 and over with unexplained haemoptysis
urgent chest x-ray in 2w
40 and over if they have 2 of below
smoker (/ex)
cough
fatigue
shortness of breath
chest pain
weight loss
appetite loss
lower vs upper coat fibrosis
upper zone fibrosis:
CHARTS
C - Coal worker’s pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
Lower
CADI
Connective tissue disorder (except ank spond)
Asbestosis
Dug: amiodarone, bleomycin, methotrexate
Idiopathic pulmonary fibrosis
oxygen dissociation cure shifts
shifts to Left = Lower oxygen delivery
HbF, methaemoglobin, carboxyhaemoglobin
Low [H+] (alkali)
Low pCO2
Low 2,3-DPG
Low temperature
Shifts to Right = Raised oxygen delivery
Raised above factors ^^^
