Resp - Miscellaneous Flashcards
URTI antibiotics
- pharyngitis/tonsillitis/laryngitis
- acute otitis media
- pharyngitis/tonsillitis/laryngitis: phenoxymethylpenicillin or erythromycin (if the patient is penicillin allergic)
- acute otitis media: amoxicillin (macrolide if allergic)
Infectious mononucleosis
(glandular fever) (EBV, also known as human herpesvirus 4, HHV-4) in 90% of cases
Triad:
- sore throat
- pyrexia
- lymphadenopathy (anterior and posterior triangles of the neck, in contrast to tonsillitis typically only in the upper anterior cervical chain)
- malaise, anorexia, headache, palatal petechiae
- splenomegaly - occurs in around 50% of patients and may rarely predispose to splenic rupture
- hepatitis, transient rise in ALT
Infectious mononucleosis - Dx and treatment
Dx: heterophil antibody test (Monospot test) - NICE guidelines suggest FBC and Monospot in the 2nd week of the illness to confirm a diagnosis
FBC: atypical lymphocytes
Mx
- rest, drink plenty of fluid, avoid alcohol
- simple analgesia for any aches or pains
- avoid playing contact sports for 8 weeks after having glandular fever to reduce the risk of splenic rupture
Why not give Abx for glandular fever?
A maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis
ARDS - features
Caused by the increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli, i.e. non-cardiogenic pulmonary oedema. Clinical features include dyspnoea, elevated RR, bilateral lung crackles and low sats.
Causes
- infection: sepsis, pneumonia
- massive blood transfusion
- smoke inhalation
- acute pancreatitis
- cardio-pulmonary bypass (cardiac surgery)
- Long bone fracture or multiple fractures (through fat embolism)
- Head injury (causes sympathetic nervous stimulation which leads to acute pulmonary hypertension)
ARDS - investigations and criteria
A chest x-ray and arterial blood gases are the key investigations.
Criteria (American-European Consensus Conference)
- 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 (200 mmHg)
ARDS - treatment
- due to the severity of the condition patients are generally managed in ITU
- oxygenation/ventilation to treat the hypoxaemia*
- general organ support e.g. vasopressors as needed
- treatment of underlying cause e.g. abx for sepsis
- certain strategies such as prone positioning and muscle relaxation can help
*Occasionally patients can be managed with NIV, but the failure rate is high and the majority will require endotracheal intubation.
ARDS - other supportive therapy
Standard supportive care of critically ill patients includes prevention of VTE, blood glucose control, prophylaxis against stress-induced GI bleeding (PPI or ranitidine), hemodynamic support to maintain a MAP >60 mmHg, and transfusion of packed RBC in patients with hemoglobin <7 g/dL. Nutrition should be provided enterally where possible.
Atelectasis
Atelectasis is a common postoperative complication in which basal alveolar collapse can lead to respiratory difficulty. It is caused when airways become obstructed by bronchial secretions.
Features
it should be suspected in the presentation of dyspnoea and hypoxaemia around 72 hours postoperatively
Management
chest physiotherapy: deep-breathing exercises (incentive spirometry); Positioning your body so that your head is lower than your chest (postural drainage);
Tapping on your chest over the collapsed area to loosen mucus (percussion).
If surgery is needed, removal of airway obstructions may be done by suctioning mucus or bronchoscopy
OSA - main features
Predisposing factors
- obesity
- macroglossia: acromegaly, hypothyroidism, amyloidosis
- large tonsils
- Marfan’s syndrome
The partner often complains of excessive snoring and may report periods of apnoea.
Consequence
- daytime somnolence
- compensated respiratory acidosis
- hypertension
OSA - diagnosis
- Epworth Sleepiness Scale - questionnaire completed by patient +/- partner
- Multiple Sleep Latency Test (MSLT) - measures the time to fall asleep in a dark room (using EEG criteria)
Diagnostic tests
- sleep studies (polysomnography) - ranging from monitoring of pulse oximetry at night to full polysomnography (including EEG, respiratory airflow, thoraco-abdominal movement, snoring and pulse oximetry)
OSA - management
- weight loss
- continuous positive airway pressure (CPAP) is first line for moderate or severe OSA
- intra-oral devices (e.g. mandibular advancement) may be used if CPAP is not tolerated or for patients with mild OSA where there is no daytime sleepiness
- the DVLA should be informed if OSA is causing excessive daytime sleepiness
Pleural Effusion - exudative
Exudate (> 30g/L protein)
- infection: pneumonia (most common exudate cause), TB, subphrenic abscess
- neoplasia: lung cancer, mesothelioma, metastases
- connective tissue disease: RA, SLE
- pancreatitis
- pulmonary embolism
- Dressler’s syndrome
Pleural Effusion - transudative
Transudate (< 30g/L protein)
- heart failure (most common transudate cause)
- hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
- hypothyroidism
- Meigs’ syndrome (triad of benign ovarian fibroma with ascites and pleural effusion that resolves after resection of the tumor)
Pleural effusion - assessment
- dyspnoea, non-productive cough or chest pain are possible presenting symptoms
- classic examination findings include dullness to percussion (stony dull), reduced breath sounds and reduced chest expansion
Ix:
- posterioranterior (PA) chest x-rays should be performed in all patients
- other: US (better aspiration), CT (for aetiology)
