Resp OSCE Flashcards
ARDS Definition
Berlin Criteria- Acute Onset < 1 week- PF ratio < 300 (40) - Bilateral opacities on imaging not attributable to LVF- Patient ventilated with a PEEP >/= 5
Lung Protective ventilation
ARDSnet trial- TV 6-8mls/kg of IBW- Pplat < 30- PEEP titrated to FiO2- Permissive hypercapnia
ARDS Management Strategies
Proning at least 16 hrs/day - PROSEVA (2013)NMB - ACURASYS (2010)ECMO - CESAR (2009) showed reduced mortality - EOLIA (2018) showed no change in mortality but a high crossover rate
Emerg Trache Mx
O2 to mouth - waters circuit to tracheCheck capnography - is patient breathing?HELPAttempt ventilation via tracheRemove inner tube - try to pass suction catheter - Can I?Deflate cuff - ?breathingRemove trache and reassess the stoma and mouth - ?breathingCover stomaBag/mask ventilate orally?Insert supraglottic airway and gently ventilatePlan for oral ETT intubation - likely to be difficult - pass beyond stomaCan attempt stoma intubation with small ETT if above difficult
CAP
CURB65 - Confusion, Urea > 7, RR > 30, BP <90 or <60, Age > 65Comm - Strep, Haemophilus, Atypicals (mycoplasma, legionella) - Amox, clarithromycinHosp - Gram -ve, MRSA - TazABCDE, surviving sepsis, Abx
Capnography
Phase 1 - insp baseline Phase 2 - exp upstrokePhase 3 - alveolar gas plateau - ETCO2 = highest point on plateauPhase 0 - Insp downstrokeAsthma - flattening of upstroke and loss of plateauLoss of trace = decreased CO/cardiac arrest, large V/Q mismatch, pulm oedema, equipment issue, loss of ETTCO2 vol trace - gives vent/perfusion info, dead space measurement, CO2 elimination
Spontaneous Breathing Trial
Traditionally attach patient to t-piece and allow top breathing unassisted Generally now use ‘minimal’ ventilator settings (PEEP 5 and PS 7-8) for 30 - 120 mins.
Failure:Objective -1 - RR > 352 - Sats < 90%3 - HR >140 or change 20%4 - BP > 180 or <90Subjective - 1 - Agitation2 - Anxiety or increased WOB
Readiness to wean
Predicting successful weaning1 - RR < 352 - TV > 5mls/kg3 - RSBI < 100 (likely success if < 65)4 - Max insp pressure < 20cmH2OHaemodynamically stable, FiO2 < 50%Co-operative, good cough, no excessive secretions
Failure to wean
Resp1 - inappropriate ventilator settings2 - thick/copious secretions 3 - Effusions, pulm oedema, diaphragm splinting4 - Met acidosis, shockCVS1 - IHD, valvular HD, CCFNeuro/Musc1 - Decreased central drive - sedation, brain stem pathology2 - Neuromuscular pathology - GBS, CIPN, electrolyte disturbance3 - Neuropsychological - anxiety, delirium NutritionAnaemia, malnutrition, obesity
Pleural effusion
Approach:Any resp compromise? - if so drainUnilateral or suspicious? - if so tapTap shows empyema - then drain (pH < 7.2) - normal pH = 7.62Lights criteriaPleural to serum prot > 0.5Pleural to serum LDH > 0.6Pleural LDH >2/3 upper normal limit
Proning
Improved V/Q matching by ventilating previously dependent areasRedistribution of oedemaMediastinal weight moved to sternum rather than lungIncreased FRCReduced atelectasis Improved diaphragm function
ECMO
Complications- bleeding - haemolysis- equipment failure- clot formation- air embolism
Pneumonia
Strep pHaemophilusMoraxella CURB65 0-1 (home), 2 moderate, 3+ severeurea > 7, RR > or = 30, SBP < 90 or DBP <60Abx: amox and clarithromycinAtypicals: Mycoplasma and chlamydia - don’t have accessible cell walls for penicillins
Influenza
Flu vaccination:Age > 65, children 2-10, pregnant, chronic respiratory/CVS/DM/renal, immunosuppressed, obesity, RH/NH, frontline healthcare workers, care home staffActs against 3-4 viruses that are most likely to cause an epidemic in up coming season - 60-80% protection - inactivated or live attenuated (nasal in kids)Flu A - subtypes, cause pandemics, hosted in birdsFlu B - two types, contribute to seasonal epidemics but never caused a pandemic, humans main reservoir Present:Fever, malaise, URT, headaches, arthralgia, viral pneumonitis (ARDS)
Complications:Resp: secondary pneumonia, ARDSCVS: myocarditisNeuro; GBS, encephalitis, meningitis Musc: myosotis, rhabdoRenal: AKIMeds:Neuroamindase inhibitors- Oseltamivir (oral, SE - N&V, headache, diarrhoea, psych), zanamivir (inhaled, SE - bronchospasm)M2 inhibitors- amantidine (hallucinations, movement disorders)Post-exposure prophylactics
Pregnant patient with flu:High-risk for severe flu, spontaneous abortion, pre-term labourInvolve obstetriciansO2, resp support Early antiviralsAntipyretics
APRV
P high - around 30cmH2OP low - always 0T high - around 4-6 secsT low - around 0.5 secs - aim to achieve 50% exp flow timeAdvantages- Lung recruitment - Less lung trauma - Spontaneous breathing- reduced LV intramural pressure Disadvantages - can not be used in hypovol patients - worsen RV failureContraindicationsProfound CVS instability - recent pulm surg- severe bronchospasm - pulm HTN
