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Mod A > Resp > Flashcards

Resp Flashcards

1
Q

Asthma Definition + Cause

A

recurrent episodes of dyspnoea, cough, wheeze due to reversible airway obstruction

stimuli triggers bronchial constriction, mucosal inflammation and swelling, increased mucous production

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2
Q

Asthma S+S

A

dyspnoea, cough (nocturnal), wheeze, sputum

hyperinflated chest, hyper-resonant percussion, dec air entry, widespread polyphonic wheeze

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3
Q

Severe Asthma S+S

A

Inability to complete sentences
HR >110bpm
RR >25/min
PEF 33-50% predicted

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4
Q

Life threatening asthma S+S

A 
Silent chest
Confusion
Exhaustion
Cyanosis: PaO2<8kPa, PaCo2 4.6-6.0, SpO2<92%
Bradycardia
PEF<33% predicted

If inc PaCO2 = near fatal

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5
Q

Increased probability of asthma

A
  • wheeze, chest tightness, dyspnoea
  • diurnal variation
  • responds to triggers: exercise, cold air, allergens
  • onset after aspirin or beta blockers
  • history of atopy
  • FH of atopy/asthma
  • widespread wheeze heard on auscultation
  • unexplained low FEV1/PEF
  • unexplained peripheral blood eosinophilia
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6
Q

Asthma precipitants

A

Cold air, exercise, emotion, allergens, infection, smoking, pollution, NSAIDs, beta-blockers

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7
Q

Asthma Hx factors

A

precipitants, diurnal variation, exercise tolerance, difficulty sleeping, acid reflux, atopic disease, home: pets, carpet, feather pillows/duvets. occupation, days off

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8
Q

Asthma Ix - Adults

A

Low prob = Ix or treat other cause, consider referral, if no response to Rx, further Ix or referral

Medium prob = FEV1/FVC ><0.7

High prob = trial of asthma Rx, if successful continue minimum effective dose, if unsuccessful check compliance/technique, if no improvement, refer

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9
Q

Asthma Rx

A

Conservative = stop smoking, avoid precipitants, lose weight, check technique, monitor PEF 2x/day, self adjust rx, breathing techniques

Pharm =

  • move up if uncontrolled, down if control for >3m
  • rescue prednisolone
    1. occasional short acting beta-2-agonist –> if use >1/day or nighttime
    2. standard dose inhaled steroid: beclometasone
    3. long acting beta-2-agonist
    4. higher dose steroid, modified release oral theophylline, modified release oral b-2-agonist tablets, oral leukotriene receptor antagonist
    5. regular oral prednisolone
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10
Q

Bronchiectasis About

A

= chronic inflammation of bronchi and bronchioles causing permanent dilatation and thinning
= mainly H influenzae, Strep pneumoniae, Staph aureus, Pseudomonas aeruginosa

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11
Q

Bronchiectasis Causes

A

Congenital: cystic fibrosis, Young’s syndrome, primary ciliary dyskinesia, Kartagener’s syndrome

Post-infection: measles, pertussis, bronchiolitis, pneumonia, TB, HIV

Other: bronchial obstruction (tumour, foreign body), allergic bronchopulmonary aspergillosis, hypogammaglobulinaemia, rheumatoid arthritis, ulcerative colitis, idiopathic

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12
Q

Bronchiectasis S+S

A

Persistent cough, copious purulent sputum, intermittent haemoptysis

Clubbing, coarse inspiratory crepitations, wheeze (asthma, ABPA)

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13
Q

Bronchiectasis Ix

A

Sputum culture
CXR: cystic shadows, thickened bronchial walls (tramline and ring shadows)
HRCT chest: assess extent and distribution of disease
Spirometry: obstructive pattern
Bronchoscopy: locate site of haemoptysis, exclude obstruction and obtain samples for culture
Serum immunoglobulins, CF sweat test, Aspergillus precipitins or skin-prick test RAST and total IgE

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14
Q

Chronic Asthma Ix

A

PEF monitoring
Diurnal variation of >20% on >3d a week for 2wks
Spirometry: obstructive defect = dec FEV1/FVC and inc RV
Usually 15% improvement in FEV1 after beta-2-agonists or steroids
CXR: hyperinflation
Skin prick test for allergens
Histamine or methacholine challenge
Aspergillus serology

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15
Q

Bronchiectasis Rx

A

Airway clearance techniques and mucolytics
○ Chest physiotherapy and flutter valve may aid sputum expectoration and mucus drainage

Antibiotics

  • Pseudomonas requires oral ciprofloxacin or IV antibiotics
  • If >3 exacerbations/yr consider long term antibiotics

Bronchodilators

  • Nebulised salbutamol
  • In those with asthma, COPD, CF, ABPA

Corticosteroids
- Prednisolone + itraconazole for ABPA

Surgery for localised disease or for severe haemoptysis

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16
Q

COPD

A

progressive obstructive airway with little/no reversibility
= chronic bronchitis and emphysema

  • if >35yrs
  • smoking/pollution related
  • chronic dyspnoea
  • sputum production
  • minimal diurnal variation
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17
Q

Chronic bronchitis definition

A

cough and sputum production on most days for 3m of 2 successive years

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18
Q

Emphysema definition

A

enlarged alveoli and destruction of alveoli wall

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19
Q

Pink puffers

A
  • Inc alveolar ventilation
  • Near normal PaO2 and a normal or low PaCO2
  • Breathless but not cyanosed
  • May progress to type 1 respiratory failure
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20
Q

Blue bloaters

A
  • Dec alveolar ventilation
  • Low PaO2 and high PaCO2
  • Cyanosed but not breathless
  • May go on to develop cor pulmonale
  • Respiratory centres are relatively insensitive to CO2 and they rely on hypoxic drive to maintain respiratory effort
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21
Q

COPD S+S

A
  • Cough
  • Sputum
  • Dyspnoea
  • Wheeze
  • Tachypnoea, use of accessory muscles of respiration
  • Hyperinflation, dec cricosternal distance (<3cm), dec expansion
  • Resonant or hyperresonant percussion note
  • Quiet breath sounds, wheeze
  • Cyanosis
  • Cor pulmonale
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22
Q

COPD Ix

A
  • FBC: inc PCV
  • CXR: hyperinflation, flat hemidiaphragms, large central pulmonary arteries, dec peripheral vascular markings, bullae
  • CT: bronchial wall thickening, scaring, air space enlargement
  • ECG: right atrial and ventricular hypertrophy (cor pulmonale)
  • ABG: dec PaO2 +/- hypercapnia
  • Spirometry: obstructive and air trapping
    (FEV1<80% of predicted, FEV1:FVC ratio <70%, inc TLC, inc RV, dec DLCO in emphysema)
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23
Q

COPD Rx

A
  1. SABA/SAMA - FEV1><50%
  2. LABA or LAMA or LABA+ICS inhaler
  3. LAMA + LABA/ICS inhaler
  • LTOT if PaO2<7.3kPa
  • NIV if hypercapnic on LTOT

Smoking cessation advice
Encourage exercise and diet advice with supplements
Mucolytics: productive cough
Disabilities may cause serious depression: screen for this
Respiratory failure
Oedema: diuretics
Flu and pneumococcal vaccinations
BODE (BMI, airflow Obstruction, Dyspnoea, Exercise capacity) index helps predict outcome and number and severity of exacerbations

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24
Q

COPD Acute Rx

A
  1. nebulised bronchodilators: salbutamol + ipratropium
  2. O2 start 24-28%
  3. steroids: IV hydrocortisone 200mg + oral prednisolone 30mg OD
  4. Abx if evidence of infection: amoxicillin 500mg/8h PO
  5. physiotherapy to aid sputum expectoration

if no response to nebulisers and steroids: IV aminophylline
if no response,
- NIPPV if RR>30, acidotic, PaCO2 rising
- resp stimulating drug: doxapram 1.5-4mg/min IV in those who can’t have mechanical ventilation
if pH<7.26 = consider intubation

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25
Q

Causes of rib fractures

A
  • Mostly blunt trauma to chest wall
  • Common in polytrauma as chest injuries present in 25% of major trauma
  • Spontaneous rib fractures rarely after coughing/sneezing
    ○ PMH of osteoporosis, steroid use, COPD
  • Pathological from cancer met
    ○ Prostate in M, Breast in F
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26
Q

Rib Fracture S+S

A
  • Severe, sharp chest wall pain
    ○ Pain often more with deep breaths or coughing
  • Chest wall tenderness over site of fracture, bruising
  • Crackles
  • Reduced breath sounds
  • Reduced ventilation, dropped O2 sats
  • Pneumothorax: complication = reduced expansion, reduced breath sounds, hyper-resonant percussion
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27
Q

Flail Chest

A
  • Multiple rib fractures occurring after trauma
  • > 2 fractures along >3 consecutive ribs, usually anterior
  • Flail segment moves paradoxically during respiration and impairs ventilation of lung on side of injury
  • Segment can cause contusional injury to underlying lung
  • Rx: invasive ventilation, surgical fixation
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28
Q

Rib Fracture Rx

A
  • Most are conservatively managed with analgesia to ensure breathing not affected by pain
  • Fixation can be considered to manage pain or if fractures failed to heal after 12wks conservative management
  • Flail chest segments need urgent Rx
  • Complications (pneumothorax, haemothorax) managed
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29
Q

ILD S+S

A

= conditions that affect lung parenchyma diffusely

  • Dyspnoea on exertion
  • Non-productive paroxysmal cough
  • Abnormal breath sounds
  • Abnormal CXR or high res CT
  • Restrictive pulmonary spirometry with dec DLCO
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30
Q

ILD Causes

A

With known cause

- Occupational/environmental ex.) asbestosis, berylliosis, silicosis, cotton worker's lung (byssinosis)
- Drugs ex.) nitrofurantoin, bleomycin, amiodarone, sulfasalazine, busulfan
- Hypersensitivity reactions: hypersensitivity pneumonitis
- Infections ex.) TB, fungi, viral
- Gastro-oesophageal reflux

Associated with systemic disorders

- Sarcoidosis
- Rheumatoid arthritis
- SLE, systemic sclerosis, mixed connective tissue disease, Sjogren's syndrome
- Ulcerative colitis, renal tubular acidosis, autoimmune thyroid disease

Idiopathic

- Idiopathic pulmonary fibrosis
- Cryptogenic organising pneumonia
- Non-specific interstitial pneumonitis
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31
Q

Extrinsic Allergic Alveolitis

A

= repetitive inhalation of allergens (fungal spores or avian proteins) provokes hypersensitivity reaction

Acute phase = alveoli infiltrated with acute inflammatory cells

Chronic exposure = granuloma formation, obliterative bronchiolitis occurs

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32
Q

EAA Cause

A
  • Bird fancier’s and pigeon fancier’s lungs (proteins in bird droppings)
  • Farmer’s and mushroom worker’s lung (Micropolyspora faeni, Thermoactinomyces vulgaris)
  • Malt worker’s lung (Aspergillus clavatus)
  • Bagassosis or sugar worker’s lung (Thermoactinomyces sacchari)
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33
Q

EAA S+S

A

4-6hr post-exposure
- Fever, rigors, myalgia, dry cough, dyspnoea, fine bibasal crackles

Chronic
- Finger clubbing, increasing dyspnoea, weight loss, exertional dyspnoea, type I resp failure, cor pulmonale

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34
Q

EAA Ix

A

Acute

- Blood: FBC - neutrophilia, inc ESR, ABGs, serum antibodies (may indicate exposure/previous sensitisation)
- CXR: upper zone mottling/consolidation, hilar lymphadenopathy (rare)
- Lung fn: reversible restrictive defect, reduced gas transfer during acute attacks

Chronic

- Bloods: serum antibodies
- CXR: upper zone fibrosis, honeycomb lung
- CT chest: nodules, ground glass appearance, extensive fibrosis
- Lung fn: restrictive defect
- Bronchoalveolar lavage: inc lymphocytes and inc mast cells
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35
Q

EAA Rx

A

Acute
- Remove allergen
- Give O2 (35-60%)
- PO prednisolone (40mg/24h PO) reduces course
Chronic
- Allergen avoidance
- Wear facemask or positive pressure helmet
- Long term steroids often achieve CXR and physiological improvement
- Compensation may be payable

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36
Q

Idiopathic Pulmonary Fibrosis

A
  • A type of idiopathic interstitial pneumonia
  • Inflammatory cell infiltrate and pulmonary fibrosis of unknown cause
  • Commonest cause of ILD
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37
Q

IPF S+S

A
  • Dry cough
  • Exertional dyspnoea
  • Malaise
  • Dec weight
  • Arthralgia
  • Cyanosis
  • Finger clubbing
  • Fine end-inspiratory crepitations
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38
Q

IPF Ix

A
  • Blood: ABG (dec PaO2, if severe inc PaCO2), inc CRP, inc immunoglobulins, ANA (30% +ve), rheumatoid factor (10% positive)
  • Imaging: dec lung volume, bilateral lower zone reticulo-nodular shadows, honeycomb lung (advanced)
  • CT: shows similar changes to CXR but is more sensitive and is an essential for diagnosis
  • Spirometry: restrictive, dec transfer factor
  • BAL: may indicate activity of alveolitis: inc lymphocytes (good response/prognosis) or inc neutrophils and inc eosinophils (poor response/prognosis
  • TC-DTPA scan: disease activity
  • Lung biopsy: may be needed for diagnosis, histological changes = usual interstitial pneumonia
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39
Q

IPF Rx

A
  • Supportive care: O2, pulmonary rehabilitation, opiates, palliative care input
  • All should be considered for clinical trials or transplantation
  • Strongly recommended that high dose steroids are not used except where diagnosis is in doubt
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40
Q

CAP organisms

A

Streptococcus pneumoniae = commonest
- Haemophilus influenzae, Moraxella catarrhalis

Atypicals: Mycoplasma pneumoniae, Staphylococcus aureus, Legionella species, Chlamydia

Rare: gram negative bacilli, Coxiella burnetii, anaerobes

- Viruses 15%
- Flu can be complicated by CAP MRSA
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41
Q

HAP organisms

A
  • > 48hr after hospital admission
  • Most common = gram negative enterobacteria or Staph aureus
    • Pseudomonas, Klebsiella, Bacteroides, Clostridia
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42
Q

Aspiration pneumonia causes

A

bulbar palsy, stroke, myasthenia gravis, dec consciousness, oesophageal disease, poor dental hygeine

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43
Q

Immunocompromised pneumonia organisms

A

Strep pneumoniae, H influenzae, Staph aureus, M catarrhalis, M pneumoniae, Gram -ve bacilli, Pneumocystis jirovecii
- Other fungi, viruses (CMV, HSV), mycobacteria

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44
Q

Pneumonia S+S

A

Fever, rigors, malaise, anorexia, dyspnoea, cough, purulent sputum, haemoptysis, pleuritic pain

- Pyrexia, cyanosis, confusion, tachypnoea, tachycardia, hypotension, signs of consolidation (reduced expansion, dull percussion, inc tactile vocal fremitus/vocal resonance, bronchial breathing), pleural rub
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45
Q

Pneumonia Ix

A
  • Assess oxygenation: O2 sat, ABGs if SaO2 <92% or severe pneumonia, BP
  • Blood tests: FBC, U&E, LFT, CRP
  • CXR: lobar or multilobar infiltrates, cavitation, pleural effusion
  • Sputum MC&S
  • Urine: Legionella/Pneumococcal urinary antigens
  • Atypical organism/viral serology = PCR sputum/BAL, complement fixation tests acutely, paired serology
  • Pleural fluid aspiration for culture
  • Bronchoscopy and bronchoalveolar lavage if immunocompromised or on ITU
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46
Q

CURB-65

A
  • Confusion (abbreviated mental test <8)
  • Urea >7mmol/L
  • Respiratory rate >30/min
  • BP <90 systolic and/or 60mmHg diastolic
  • Age>65

0-1 = PO antibiotic/home treatment
2 = hospital therapy
>3 = severe pneumonia indicates mortality 15-40%, consider ITU
Features inc risk of death: comorbidity, bilateral/multilobar, PaO2<8kPa

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47
Q

Pneumonia Rx

A

Local hospital antibiotic:
- Non severe and not vomiting = PO antibiotic
- Severe = IV
- O2: keep PaO2>8 and or saturation>94%
- IV fluids (anorexia, dehydration, shock) and VTE prophylaxis
- Analgesia if pleurisy
- Consider ITU if shock, hypercapnia, or remains hypoxic
Follow up: 6wks with CXR

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48
Q

Pneumonia complications

A

Pleural effusion, empyema, lung abscess, respiratory failure, hypotension, septicaemia, brain abscess, pericarditis, myocarditis, cholestatic jaundice

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49
Q

Pneumococcal Pneumonia

A
  • Affects all ages, commoner in elderly, alcoholics, post-splenectomy, immunosuppressed, patients with chronic heart failure or pre-existing lung disease
  • Fever, pleurisy, herpes labialis
  • CXR: lobar consolidation
  • If mod/severe check for urinary antigen
  • Rx: amoxicillin, benzylpenicillin, cephalosporin
  • Vaccine given to >65, DM, chronic organ condition, immunosuppression
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50
Q

Staphylococcal Pneumonia

A
  • May complicate influenza infection or in young, elderly, IVDU, patients with underlying disease (leukaemia, lymphoma, cystic fibrosis)
  • Bilateral cavitating bronchopneumonia
  • Rx: flucloxacillin and rifampicin
  • MRSA: consider vancomycin
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51
Q

Klebsiella Pneumonia

A
  • Rare
  • Occurs in elderly, diabetics, alcoholics
  • Cavitating pneumonia, particularly of upper lobes, often drug resistant
  • Rx: cefotaxime, imipenem
52
Q

Pseudomonas Pneumonia

A
  • Common pathogen in bronchiectasis and CF
  • Causes hospital acquired infections, particularly on ITU or after surgery
  • Rx: anti-pseudomonal penicillin, ceftazidime, meropenem, ciprofloxacin + aminoglycoside
    Dual therapy to minimise resistance
53
Q

Mycoplasma Pneumonia

A
  • In epidemics every 4yrs
  • Insidious presentation with flu like symptoms: headache, myalgia, arthralgia, then dry cough
  • CXR: reticular-nodular shadowing or patchy consolidation often of one lower lobe, worse than signs suggest
  • Diagnosis: PCR sputum/serology, cold agglutinins may cause autoimmune haemolytic anaemia
  • Complications: skin rash (erythema multiforme), Stevens-Johnson syndrome, meningoencephalitis or myelitis, G-B syndrome
  • Rx: Clarithromycin or doxycycline, or fluoroquinolone (ciprofloxacin, norfloxacin)
54
Q

Legionella Pneumonia

A
  • Colonises water tanks - hotel air conditioning and hot water systems
  • Flu like symptoms (fever, malaise, myalgia) precede dry cough and dyspnoea
  • Extra-pulmonary features: anorexia, D&V, hepatitis, renal failure, confusion, coma
  • CXR: bi-basal consolidation
  • Blood tests: lymphopenia, hyponatraemia, deranged LFTs
  • Urinalysis: haematuria
  • Diagnosis: urine antigen/culture
  • Rx: fluoroquinolone for 2-3wks or clarithromycin
55
Q

Chlamydia Pneumonia

A
  • Commonest chlamydia infection
  • Person to person spread, biphasic illness: pharyngitis, hoarseness, otitis, followed by pneumonia
  • Diagnosis: Chlamydophila complement fixation test, PCR invasive samples
  • Rx: doxycycline, clarithromycin
56
Q

Chlamydophila psittaci pneumonia

A
  • Causes psittacosis = ornithosis acquired from infected birds (parrots)
  • Symptoms: headache, fever, dry cough, lethargy, arthralgia, anorexia, D&V
  • Extra-pulmonary: meningo-encephalitis, infective endocarditis, hepatitis, nephritis, rash, splenomegaly - all rare
  • CXR: patchy consolidation
  • Diagnosis: Chlamydophila serology
  • Rx: doxycycline, clarithromycin
57
Q

Pneumocystis pneumonia

A
  • In immunosuppressed
  • Dry cough, exertional dyspnoea, dec PaO2, bilateral crepitations
  • CXR: normal or bilateral perihilar interstitial shadowing
  • Diagnosis: visualisation of organism in sputum, bronchoalveolar lavage, lung biopsy specimen
  • Rx: high dose co-trimoxazole or pentamidine by slow IVI for 2-3wks, steroids beneficial if severe hypoxaemia
  • Prophylaxis indicated if CD4 count <200x106/L or after 1st attack
58
Q

Viral pneumonia

A
  • Influenza commonest but swine flu (H1N1) considered seasonal and covered by flu vaccine
    Other: measles, CMV, VZV
59
Q

Lung cancer RFs

A
  • Cigarette smoking
  • Passive smoking
  • Asbestos
  • Chromium
  • Arsenic
  • Iron oxides
  • Radiation - radon gas
60
Q

Lung cancer S+S

A
  • Cough, haemoptysis, dyspnoea, chest pain, recurrent or slow resolving pneumonia, lethargy, anorexia, weight loss, cachexia, anaemia, clubbing, HPOA wrist pain
  • Supraclavicular or axillary nodes
  • Chest: consolidation, collapse, pleural effusion
  • Mets: bone tenderness, hepatomegaly, confusion, fits, focal CNS signs, cerebellar syndrome, proximal myopathy, peripheral neuropathy
61
Q

Paraneoplastic Syndrome

A

Endocrine = ectopic secretion of ACTH, ADH, PTH, HCG = Cushing’s, SIADH, hypercalcaemia, gynaecomastia

Neuro = cerebellar degeneration, myopathy, polyneuropathy, myaesthenic syndrome

Vascular = thrombophlebitis migrans, anaemia, DIC

Cutaneous = dermatomyositis, herpes zoster, acanthosis nigricans

Skeletal = clubbing, HPOA

62
Q

Lung Cancer Complications

A
  • Recurrent laryngeal nerve palsy
  • Phrenic nerve palsy
  • SVC obstruction
    ○ Impairs venous backflow into right atrium, causing congestion in head, neck and upper extremities
    ○ Headache, dyspnoea, oedema of upper extremities and face, worse in morning and leaning forward/lying down
    ○ Venous pattern on face, chest, upper extremities
  • Horner’s syndrome (Pancoast’s tumour)
  • Rib erosion
  • Pericarditis
  • AF
63
Q

Lung Cancer Ix

A
  • CXR: peripheral nodules, hilar enlargement, consolidation, lung collapse, pleural effusion, bony secondaries
  • Cytology: sputum and pleural fluid (20mL)
  • FNA or biopsy (peripheral lesions/lymph nodes)
  • CT to stage tumour and guide bronchoscopy
  • Bronchoscopy: give histology and assess operability + Endobronchial US for assessment and biopsy
  • F-deoxyglucose PET or PET/CT EBUS scan to help staging
  • Radionuclide bone scan if suspect mets
  • Lung function tests: assess suitability for lobectomy
64
Q

NSCLC Rx

A
  • Lobectomy (open or thorascopic)
    ○ If medically fit, curative intent
    ○ Parenchymal sparing op for patients with borderline fitness and smaller tumours (T1a-b, N0, M0)
  • Radical radiotherapy
    ○ I, II, III NSCLC
  • Chemotherapy and radiotherapy
    ○ More advanced disease
    ○ Regimens may be platinum based ex.) with monoclonal Abs targeting epidermal growth factor receptor = Cetuximab
65
Q

SCLC Rx

A
  • Surgery with limited stage disease
  • Chemo and radio if well enough
  • Palliation
    ○ Radiotherapy: bronchial obstruction, SVC obstruction, haemoptysis, bone pain, cerebral mets
    ○ SVC obstruction: stent and radiotherapy and dexamethasone
    ○ Endobronchial therapy: tracheal stenting, cryotherapy, laser, brachytherapy
    ○ Pleural drainage/pleurodesis for symptomatic pleural effusions
    ○ Drugs: steroids, antiemetics, cough linctus, bronchodilators, antidepressants
66
Q

Mesothelioma S+S`

A
  • Chest pain
  • Dyspnoea
  • Weight loss
  • Finger clubbing
  • Recurrent pleural effusion
  • Signs of mets: lymphadenopathy, hepatomegaly, bone pain/tenderness, abdo pain/obstruction (peritoneal malignant mesothelioma)
67
Q

Mesothelioma Ix

A
  • CXR/CT
  • Pleural thickening/effusion
  • Bloody pleural fluid
  • biopsy
  • thorascopy
68
Q

Mesothelioma Rx

A
  • Pemetrexed and Cisplatin chemo can improve survival
  • Surgery hard to evaluate
  • Radiotherapy controversial
  • Pleurodesis and indwelling intra-pleural drain may help
69
Q

Pleural effusion transudate causes

A
  • Inc venous pressure (cardiac failure, constrictive pericarditis, fluid overload)
  • Hypoproteinaemia (cirrhosis, nephrotic syndrome, malabsorption)
  • Hypothyroidism
  • Meigs’ syndrome = R pleural effusion and ovarian fibroma
70
Q

Pleural effusion exudate causes

A
  • Inc leakiness of pleural capillaries secondary to infection, inflammation, malignancy
  • pneumonia, TB
  • pulmonary infarction
  • rheumatoid arthritis, SLE
  • bronchogenic carcinoma, malignant mets, lymphoma, mesothelioma, lymphangitis carcinomatosis
71
Q

Pleural effusion S+S

A
  • Asymptomatic
  • Dyspnoea
  • Chest pain
  • Dec expansion
  • Stony dull percussion note
  • Diminished breath sounds on affected side
  • Dec tactile vocal fremitus and vocal resonance
  • Bronchial breathing above effusion where lung is compressed
  • Tracheal deviation away, with large effusions
  • Aspiration marks, signs of ass. disease:
    ○ malignancy, stigmata of chronic liver disease, cardiac failure, hypothyroidism, rheumatoid arthritis, butterfly rash of SLE
72
Q

Pleural effusion Ix

A
  • CXR: small effusions blunt costophrenic angles, larger ones are seen as water dense shadows with concave upper borders
    ○ Pneumothorax = flat horizontal upper border
  • US: identify presence of pleural fluid, guide diagnostic or therapeutic aspiration
  • Diagnostic aspiration:
    ○ Percuss upper border of pleural effusion
    ○ 1/2 intercostal spaces below
    ○ Infiltrate down to pleura with lidocaine
    ○ Insert needle w. syringe just above upper border of appropriate rib
    ○ Draw pleural fluid, sent to lab: protein, glucose, pH, LDH, amylase, MCS, auramine stain, TB culture, cytology, immunology (rheumatoid factor, ANA, complement)
  • Pleural biopsy
    ○ If pleural fluid analysis inconclusive
    ○ Thoracoscopic or CT guided pleural biopsy inc diagnostic yield
73
Q

Pleural effusion Rx

A
  • underlying cause
  • Drainage = if symptomatic, drain slowly - aspirated as diagnostic tap or using intercostal drain
  • Pleurodesis = w/ talc for recurrent effusions
    ○ Thorascopic mechanical pleurodesis most effective for malignant effusions
    ○ Empyemas drained using chest drain, using US/CT
  • Intra-pleural alteplase and dornase alfa = empyema
  • Surgery - persistent or inc pleural thickness
74
Q

Haemothorax

A
  • from laceration of lung, intercostal vessel or internal mammary artery
  • if large enough to appear on CXR treat with large bore chest drain
  • Surgical exploration if>1500ml blood drained immediately
75
Q

Pneumothorax causes

A
  • Spontaneous (esp young thin men) rupture of subpleural bulla
  • Chronic lung disease: asthma, COPD, cystic fibrosis, lung fibrosis, sarcoidosis
  • Infection: TB, pneumonia, lung abscess
  • Traumatic: iatrogenic (CVP line insertion, pleural aspiration or biopsy, percutaneous liver biopsy, positive pressure ventilation)
  • Carcinoma
  • Connective tissue disorders: Marfan’s syndrome, Ehlers-Danos syndrome
76
Q

Pneumothorax S+S

A
  • Can be asymptomatic or sudden onset of dyspnoea and pleuritic chest pain
  • Asthma/COPD patients = sudden deterioration
  • Mechanically ventilated patients = develop hypoxia or inc in ventilation pressures
  • Reduced expansion, hyper-resonance to percussion, diminished breath sounds on affected side
  • Tension pneumothorax: trachea deviated away from affected side
77
Q

Pneumothorax Ix

A
  • no CXR if tension pneumothorax is suspected
  • Expiratory film = areas devoid of lung markings, peripheral to edge of collapsed lung
  • Ensure it is not large emphysematous bulla
  • ABG in dyspnoeic, hypoxic, chronic lung disease
78
Q

Pneumothorax Rx

A
  • Depends on primary or secondary (underlying lung disease or smoker >50yrs), size, symptoms

1: SOB and/or rim of air >2cm on CXR pp
- if yes, aspirate then chest drain
- if no, review in 2-4wks
2: if SOB or rim of air >1cm then aspirate, if >2cm chest drain
- if no, admit for obs and O2 for 24h

  • Size = measured from visible lung margin to chest wall at level of hilum
  • Aspiration then chest drain
  • Pneumothorax due to trauma or mechanical ventilation requires chest drain
    ○ Tubes removed 24hr after lung has re-expanded and air leak has stopped
    ○ Done during expiration or Valsalva manoeuvre
  • Surgical: if bilateral pneumothoraces, lung fails to expand within 48h of drain insertion, persistent air leak, 2 or more previous pneumothorax on same side, history of pneumothorax on opposite side
79
Q

Tension pneumothorax

A
  • Air drawn into pleural space with each inspiration has no route of escape
  • Mediastinum pushed over into CL hemithorax, kinking, compressing great veins
  • Cardiorespiratory arrest can occur
80
Q

Tension pneumothorax S+S

A
  • Respiratory distress tachycardia, hypotension, distended neck veins, trachea deviated from side of pneumothorax
  • Increased percussion note, reduced air entry/breath sounds on affected side
81
Q

Tension pneumothorax Rx

A
  • Insert large bore needle with syringe, partially filled with saline into 2nd intercostal space in midclavicular line
  • Remove plunger to allow trapped air to bubble through syringe until chest tube can be placed
  • Or large bore Venflon in same location
  • BEFORE CXR
  • Then insert chest drain
82
Q

Cor pulmonale

A

= right heart failure from chronic pulmonary arterial hypertension

83
Q

Cor pulmonale causes

A

Chronic lung disease
- COPD, bronchiectasis, pulmonary fibrosis, chronic severe asthma, lung resection

Pulmonary vascular disorders
- PE, vasculitis, primary pulmonary hypertension, ARDS, sickle cell, parasite

Neuromuscular and skeletal diseases
- kyphosis, scoliosis, thoracoplasty, myaesthenia gravis, poliomyelitis, MND

Hypoventilation

  • sleep apnoea
  • enlarged adenoids in children

Cerebrovascular disease

84
Q

Cor pulmonale S+S

A
  • Dyspnoea
  • Fatigue
  • Syncope
  • Cyanosis
  • Tachycardia
  • Raised JVP with prominent a and v waves
  • RV heave
  • Loud P2
  • Pansystolic murmur (tricuspid regurgitation)
  • Early diastolic Graham Steell murmur
  • Hepatomegaly
  • Oedema
85
Q

Cor pulmonale Ix

A
  • FBC: Inc Hb and haematocrit (secondary polycythaemia)
  • ABG: hypoxia, +/- hypercapnia
  • CXR: enlarged RA and RV, prominent pulmonary arteries
  • ECG: P pulmonale, RAD, RVH/strain
86
Q

Cor pulmonale Rx

A
  • Treat cause
  • Treat respiratory failure: start acutely 24% O2 if PaO2<8kPa, inc O2 conc if PaCO2 stable
    ○ In COPD, LTOT increases survival
  • Treat cardiac failure: furosemide 40-160mg/24h PO
    ○ Monitor U&E
    ○ Amiloride or K supplements
    ○ Alternative: spironolactone
  • Consider venesection if haematocrit >55%
  • Consider heart lung transplantation in young patients
87
Q

Shunt Perfusion V/Q

A

= alveoli perfused but not ventilated, low V/Q

= pneumonia, pulmonary oedema, tissue trauma, atelectasis, mucus plugging, pulmonary AV fistulas

88
Q

Deadspace Ventilation

A

= alveoli ventilated but perfused, high V/Q

= cardiovascular shock, emphysema, PE

89
Q

Type 1 respiratory failure

A

= PaO2 <8kPa, normal or low PaCO2

= 
V/Q mismatch
	§ Pneumonia
	§ Pulmonary oedema
	§ PE
	§ Asthma
	§ Emphysema
	§ Pulmonary fibrosis
	§ ARDS
○ Hypoventilation
○ Abnormal diffusion
○ R to L cardiac shunts
90
Q

Type 2 respiratory failure

A

= PaO2 <8kPa, PaCO2>6kPa

=
○ Alveolar hypoventilation, +/- VQ mismatch
○ Pulmonary disease = asthma, COPD, pneumonia, end stage pulmonary fibrosis, obstructive sleep apnoea
○ Reduced respiratory drive = sedative drugs, CNS tumour or trauma
○ Neuromuscular disease = cervical cord lesion, diaphragmatic paralysis, poliomyelitis, myasthenia gravis, G-B syndrome
○ Thoracic wall disease = flail chest, kyphoscoliosis

91
Q

Respiratory failure S+S

A

Hypoxia

  • Dyspnoea, restlessness, agitation, confusion, central cyanosis
  • Long-standing; polycythaemia, pulmonary hypertension, cor pulmonale

Hypercapnia

  • Headache, papilloedema, confusion, drowsiness, coma
  • Peripheral vasodilation, tachycardia, bounding pulse, tremor/flap
92
Q

Respiratory failure Rx

A

Type 1

- Underlying cause
- O2 (24-60%) facemask
- Assisted ventilation if PaO2<8kPa despite 60% O2

Type 2

- May be insensitive to CO2 and respiration could be driven by hypoxia
- Underlying cause
- Controlled O2 24%, given with care
- Recheck ABG after 20min, if PaCO2 steady or lower, increase O2 conc to 28%, if PaCO2 has risen >1.5kPa and still hypoxic, consider assisted ventilation: NIPPV
- If fail, consider intubation and ventilation
93
Q

Sarcoidosis

A

= multisystem granulomatous disorder

  • Unknown cause
  • 20-40yrs
  • More in F, African-Caribbeans esp. extra-thoracic disease
  • Associated with HLA-DRB1 and DQB1 alleles
94
Q

Sarcoidosis Ix

A
  • Bloods: inc ESR, lymphopenia, inc LFT, inc serum ACE, inc Ca, inc immunoglobulins
  • 24h urine: inc Ca
  • CXR
  • ECG: arrhythmias, BBB
  • Lung fn: normal or reduced lung volumes, impaired gas transfer, restrictive ventilatory defect
  • Transbronchial biopsy: diagnostic = non-caseating granulomata
  • Bronchoalveolar lavage: inc lymphocytes in active disease, in neutrophils with pulmonary fibrosis
  • US: nephrocalcinosis, hepatosplenomegaly
  • Bone x-ray: punched out lesions in terminal phalanges
  • CT/MRI: assess severity of pulmonary disease or diagnosing neurosarcoidsosis
  • Ophthalmology assessment
95
Q

Sarcoidosis CXR Staging

A

○ 0 - normal
○ 1 - BHL
○ 2 - BHL + peripheral pulmonary infiltrates
○ 3 - peripheral pulmonary infiltrates alone
○ 4 - progressive pulmonary fibrosis, bulla formation (honeycombing), pleural involvement

96
Q

Sarcoidosis Rx

A
  • Patients with BHL alone don’t need Rx
  • Acute sarcoidosis: bed rest, NSAIDs
  • Indications for corticosteroids
    ○ Parenchymal lung disease: symptomatic, static or progressive
    ○ Uveitis
    ○ Hypercalcaemia
    ○ Neurological or cardiac involvement
  • Prednisolone (40mg/24h) PO for 4-6wks
  • Severe: IV methylprednisolone or immunosuppressants (methotrexate, hydroxychloroquine, ciclosporin, cyclophosphamide)
  • Anti-TFN-alpha therapy in refractory cases or lung transplant
97
Q

Acute sarcoidosis S+S

A

○ Fever
○ Erythema nodosum
○ Polyarthralgia
○ Bilateral hilar lymphadenopathy (Lofgren syndrome) resolves spontaneously

98
Q

Sarcoidosis pulmonary S+S

A 
○ Abnormal CXR with BHL, pulmonary infiltrates or fibrosis
○ Dry cough
○ Progressive dyspnoea
○ Dec exercise tolerance
○ Chest pain
99
Q

Causes of BHL

A

Sarcoidosis
Infection: TB, mycoplasma
Malignancy: lymphoma, carcinoma, mediastinal tumours
Organic dust disease: silicosis, berylliosis
Hypersensitivity pneumonitis
Histocytosis X

100
Q

Obstructive sleep apnoea syndrome

A

= intermittent closure/collapse of pharyngeal airway causing apnoeic episodes during sleep, terminated by partial arousal

101
Q

Obstructive sleep apnoea S+S

A
  • Obese, middle aged man, presents with snoring or daytime somnolence
  • (partner describes apnoeic episodes during sleep)
  • Loud snoring
  • Daytime somnolence
  • Poor sleep quality
  • Morning headache
  • Decreased libido
  • Nocturia
  • Dec cognitive performance

Complications

- Pulmonary hypertension, type II resp failure
- Sleep apnoea is independent risk factor for hypertension
102
Q

Obstructive sleep apnoea Ix

A
  • Pulse oximetry, video recordings
  • Polysomnography = monitors O2 saturation, airflow at nose and mouth, ECG, EMG chest, abdominal wall movement during sleep = diagnostic
  • Occurrence of >15 episodes of apnoea or hypopnoea during 1h of sleep indicates significant
103
Q

Obstructive sleep apnoea Rx

A
  • Weight reduction
  • Avoiding tobacco and alcohol
  • Mandibular advancement device
  • CPAP via nasal mask for mod to severe
  • Surgery = tonsillectomy, polypectomy
104
Q

RF for TB reactivation

A

new infection (<2yr), HIV, organ transplantation, immunosuppression (corticosteroids), silicosis, drugs, malnutrition, high risk settings (homeless shelter, prison), low socio-economic status, haemodialysis

105
Q

Primary TB

A
  • Ghon focus = small lung lesion = tubercle-laden macrophages
  • Ghon complex = ghon focus and hilar lymph nodes
  • Immunocompetent people –> lesion heals by fibrosis
  • Immunocompromised –> may have disseminated disease (miliary tuberculosis)
106
Q

Secondary TB

A
  • Initial infection reactivated
  • Generally in apex of lungs, may spread locally or to most distant sites
  • Immunocompromised: steroids, HIV, malnutrition
107
Q

RF for active TB

A
  • Silicosis
  • Chronic renal failure
  • HIV +ve
  • Solid organ transplantation with immunosuppressants
  • IV drug use
  • Haematological malignancy
  • Anti-TNF treatment
  • Previous gastrectomy
108
Q

TB Systemic S+S

A
  • Low grade fever
  • Anorexia
  • Weight loss
  • Malaise
  • Night sweats
  • Clubbing (bronchiectasis)
  • Erythema nodosum
109
Q

TB Pulmonary S+S

A
  • Cough (>2-3 wks, dry then productive)
  • Pleurisy
  • Haemoptysis (uncommon, seen with bronchiectasis)
  • Pleural effusion
  • Aspergilloma/mycetoma may form in cavities
  • Presentation varies, may be silent or atypical, especially with immunosuppression
110
Q

Latent TB Ix

A

testing of close contacts of those with pulmonary/laryngeal TB, with immune dysfunction, healthcare workers, high risk populations

  • Tuberculin skin testing (TST) <6, 6-15, >15
  • Interferon-gamma release assays (IGRAS)
111
Q

Active TB Ix

A
  • CXR = Fibronodular/linear opacities in upper lobe (typical), middle or lower lobes (atypical), cavitation, calcification, miliary disease, effusion, lymphadenopathy
  • Sputum smear
    ○ 2 specimens needed inc. early morning sample
    ○ Ziehl-Neelsen stain
    ○ Stained for presence of acid-fast bacili
    ○ If AFB seen, treatment commenced and patient isolated
  • Sputum culture
    ○ More sensitive than smear
    ○ Takes 1-3 wks (liquid media) or 4-8 wks (solid media)
    ○ Can assess drug sensitivity
  • Nucleic acid amplification test (NAAT)
    ○ Direct detection of M. tuberculosis in sputum by DNA or RNA amplification
    ○ Rapid diagnosis <8hrs
    ○ Can also detect drug resistance

HIV test for all

112
Q

Latent TB Rx

A
  • Balance risk of active disease with side effects of treatment
  • Consider treatment in all at inc. risk of active disease
  • Offer HIV, hepatitis B and C testing prior to treatment
    = 3 months of isoniazid w/ pyridoxine and rifampicin OR 6 months isoniazid w/ pyridoxine
113
Q

Active TB Rx

A

= Rifampicin, Isoniazid, Pyrazinamide, Ethambutol

○ Active CNS disease inc. spinal cord –> continuation phase of treatment extended from 4-10 months
- CNS and pericardial disease –> use adjunctive high dose steroids

114
Q

Drug resistant TB Rx

A
  • NAAT for drug resistance
  • single agent/multi drug/ extensively drug resistant
  • > 6 agents that are sensitive
115
Q

BCG Vaccine

A
  • Live attenuated Mycobacterium bovis
- First have tuberculin skin test
	○ Except children <6yrs who have had no contact
- Given intradermally, normally lateral L upper arm
- Limited protection against TB
- CI
	- Previous BCG vaccination
	- Past history of TB
	- HIV
	- Pregnancy
	- Positive tuberculin test
	- Not given to anyone >35
116
Q

Who gets BCG

A
  • UK: given to high risk infants
    ○ All infants (0-12 months) living in high annual incidence areas
    ○ All infants with parent or grandparents who was born in country where annual incidence is high
    (same with older children but if >6y/o they need tuberculin skin test first)
  • Previously unvaccinated tuberculin-negative contacts of cases of respiratory TB
  • Unvaccinated, tuberculin negative <16yrs who were born in or who have lived for prolonged period (>3m) in country with high annual incidence
  • Healthcare workers
  • Prison staff
  • Care home staff
  • Work with homeless people
117
Q

Cystic fibrosis

A

= autosomal recessive condition caused by mutations in CF transmembrane conductance regulator (CFTR) gene on Ch7 (Cl channel)

  • defective Cl secretion and inc Na absorption across airway epithelium
  • changes composition of airway surface liquid –> predispose lung to chronic pulmonary infections and bronchiectasis
  • 1:25 carry copy of faulty gene
  • Caucasians
  • Babies in UK screened at birth
118
Q

Cystic fibrosis S+S

A

Neonate = failure to thrive, meconium ileus, rectal prolapse

  • Cough, wheeze, recurrent infections, bronchiectasis, pneumothorax, haemoptysis, respiratory failure, cor pulmonale
  • Pancreatic insufficiency (DM, steatorrhoea), distal intestinal obstruction syndrome, gallstones, cirrhosis
  • Male infertility
  • Osteoporosis, arthritis
  • Vasculitis
  • Nasal polyps, sinusitis
  • Hypertrophic pulmonary osteoarthropathy
  • Cyanosis, finger clubbing, BL coarse crackles
119
Q

Cystic fibrosis Ix

A
  • Sweat test = sweat Na and Cl >60mmol/L (Cl > Na)
  • Genetic screening
  • Faecal elastase = screen for exocrine pancreatic dysfunction
  • Blood: FBC, U&E, LFT, clotting, vitamin A, D, E, annual OGTT
  • Bacteriology: cough swab, sputum culture
  • CXR: hyperinflation, bronchiectasis
  • Abdo US: fatty liver, cirrhosis, chronic pancreatitis
  • Spirometry: obstructive defect
  • Aspergillus serology/skin test (ABPA)
  • Faecal fat analysis
120
Q

Cystic fibrosis Rx

A
  • Physician, GP, physiotherapist, specialist nurse, dietician
  • Chest physiotherapy (postural drainage, airway clearance techniques)
  • Abx for acute infective exacerbations and prophylactically
  • Chronic pseudomonas infection is important predictor of survival
  • Mucolytics can be useful (Dnas [Dornase alfa] 2.5mg daily nebulised or nebulised hypertonic saline)
  • Bronchodilators
  • Annual CXR monitoring
  • Oxygen, diuretics (cor pulmonale), NIV, lung or heart/lung transplant

GI

  • Rx malabsorption, GORD, distal obstruction syndrome
  • Pancreatic enzyme replacement
  • Fat soluble vitamin supplements (A, D, E, K)
  • Ursodeoxycholic acid for impaired liver function
  • Cirrhosis may require liver transplantation
  • Treatment of CF-related diabetes (screen annually with OGTT from 12yrs)
  • Screen/Rx of osteoporosis (DEXA), arthritis, sinusitis, vasculitis
  • Fertility and genetic counselling
121
Q

ARDS

A

= acute lung injury, either by direct lung injury or secondary to severe systemic illness

  • Release of inflammatory mediators cause inc capillary permeability and non-cardiogenic pulmonary oedema
  • Often with multi-organ failure
122
Q

ARDS Causes

A
  • Pneumonia
  • Gastric aspiration
  • Inhalation
  • Injury
  • Vasculitis
  • Contusion
  • Other: shock, septicaemia, haemorrhage, multiple transfusions, DIC, pancreatitis, acute liver failure, trauma, head injury, malaria, fat embolism, burns, eclampsia, drugs/toxins (aspirin, heroin, paraquat)
123
Q

ARDS S+S

A
  • Cyanosis
  • Tachypnoea
  • Tachycardia
  • Peripheral vasodilation
  • BL fine inspiratory crackles
124
Q

ARDS Diagnosis

A
  1. Acute onset
  2. CXR: BL infiltrates
  3. PCWP <19mmHg or lack of clinical congestive heart failure
  4. Refractory hypoxaemia with PaO2: FiO2<200
    • Also total thoracic compliance <30mL/cmH2O
125
Q

ARDS Supportive Measures

A
  • Early ARDS: CPAP with 40-60% O2
  • Most patients need mechanical ventilation
  • Indications for ventilation
    ○ PaO2<8.3kPa despite 60% O2
    ○ PaCO2 >6kPa
    ○ Large TV (10-15mL/kg) produced by conventional ventilation plus reduced lung compliance in ARDS may lead to high peak airway pressures and pneumothorax
    ○ Low TV, pressure-limited approach: low or moderate high positive end-expiratory pressure (PEEP)
  • Invasive haemodynamic monitoring with arterial line and Swan-Ganz catheter (PCWP and cardiac output)
  • Conservative fluid management
  • Maintain CO and O2 delivery with inotropes (dobutamine 2.5-10mcg/kg/min IVI), vasodilators, blood transfusion
  • Consider treating pulmonary hypertension with low dose nitric oxide
  • Haemofiltration may be needed in renal failure and to achieve negative fluid balance

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