Respiratory Flashcards
Moderate Asthma features
PEFR 50 – 75% predicted
Increasing symptoms
No features of severe asthma
Severe Asthma features
PEFR 33-50% predicted
Resp rate >25 (>12 year olds) ,30 if between 5 and 12, 40 if between 2-5)
Heart rate >110(>12 year olds)
Unable to complete sentences in one breath
Spo2 equal or <92
Use of accessory muscles
Life-threatening asthma features
33,92,CHEST
<33%PEFR
<92%Sats
Cyanosis
Hypotension (Haemodynamic instability (i.e. shock))
Exhaustion, altered consciousness/confusion/coma
Silent chest- No wheeze. This occurs when the airways are so tight that there is no air entry at all.
Tachyarrhythmias
paOQ <8
Normal CO2
Investigations for asthma
Spirometry for obstructive evidence FEV1/FVC <0.7
Evidence of reversibility by spirometry and giving inhaled bronchodilator- level of reversibility that is supportive of asthma is 200 mls and 12% improvement of FEV1
Exhaled breath nitric oxide FeNO ( goes up if you have airway eosinophilic inflammation, >40ppb in adults or >35 ppb in children)
Blood eosinophilia ( 4% or more in FBC is suggestive)
Look for evidence of atopy by skin prick test or blood test,
Can look for variability over time by either peak flow diary (variability >20%)
Direct bronchial challenge test with histamine or methacholine
BTS asthma guidlines
- low dose ICS + SABA
- Regular preventer
- Add inhaled LABA to low dose ICS (fixed dose or MART)
- Consider increasing ICS to medium dose OR adding LTRA
If no response to LABA consider stopping LABA
BTS paediatric guidlines
- Very lose dose ICS + SABA
- Children >5 - ICS
Children <5 add LTRA - Children >5add inhaled LABA or LTRA
- Increase ICS to low dose OR children >5 add LTRA or LABA. if no reponse to LABA consider stopping
Acute asthma attack treatment
sit patient up
high flow o2
Salbutamol neb 5mg
Ipatropium bromide 0.5mg
Prednisolone 40mg po or hydrocortisone iV 100mg
Magnesium sulphate 2g IV
Aminophylline
CURB-65
Confusion (abbreviated mental test score <= 8/10)
Urea >7
Respiratory rate >= 30/min
Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg
Aged >= 65 years
Treatment of COPD
Symptoms/ airflow obstruction → bronchodilators SABA/SAMA , LAMA + LABA,for people with asthma/eosinophilic features also add ICS..
Exercise capacity/physical activity
Comorbidities optimisation
BMI → Underweight with COPD increases risk of dying, so need to maintain healthy weight, or even a bit above
Smoking→ cessation is priority, only thing proven to reduce mortality from COPD
Exacerbations→ Prevention by inhaled bronchodilators and also inhaled steroids for the right patients
pneumococcal and influenza vaccinations
COPD home o2 considered if
ABG on 2 occasions 3 weeks apart show
<7.3 or
7.3-8 + peripheral oedema, polycythaemia, pulm. HTN
Wells score
Clinical features DVT — +3
HR> 100 — +1.5
Immobilization for >3d or surgery in the prev 4w— +1.5
Prev DVT/PE — +1.5
Haemoptysis — +1
Cancer (receiving tx, treated in the last 6m, or palliative) — +1
An alternative diagnosis is less likely than PE — +3
Tx PE
DOAC/LWH/Warfarin
Thrombolysis if hypotensive
If recurrent, ivc filter
HAS BLED Score
H – Hypertension
A – Abnormal renal and liver function
S – Stroke
B – Bleeding
L – Labile INRs (whilst on warfarin)
E – Elderly
D – Drugs or alcohol
ORBIT tool for assessing a patient’s risk of major bleeding whilst on anticoagulation.
Low haemoglobin or haematocrit
Age (75 or above)
Previous bleeding (gastrointestinal or intracranial)
Renal function (GFR less than 60)
Antiplatelet medications
Causes of exudative pleural effusion
high protein count (>3g/dL or 30g/L)
inflammation results in protein leaking out of the tissues into the pleural space
eg lung cancer, PE, pneumonia, pancreatitis, RA
Causes of transudative pleural effusion
relatively lower protein count (<3g/dL or 30g/L)
relate to fluid moving across into the pleural space
eg Congestive cardiac failure , Constrictive, pericarditis , Hypoalbuminaemia, Hypothroidism, Meig’s syndrome, cirrhosis,Nephrotic syndrome
Lights criteria
. If the protein level is between 25-35g/L you use Light’s criteria to establish the type of effusion.
Exudative if >=1 of the following criteria are met:
Pleural fluid protein/ serum protein >0.5
Pleural fluid/serum LDH >0.6
Pleural fluid LDH >2/3 upper limit of normal serum LDH
Transudative if none of the above levels are met.
Indicators of empyema
Pleural aspiration shows pus
acidic pH (pH < 7.2)
low glucose <2.2 mmol/L
high LDH
Antiphospholipid syndrome
features
Clots - Usually VTE(dvt/pe), but arterial embolism (eg. MI or stroke) can also occur.
Livedo reticularis - A mottled, purple lace-like appearance of the skin on the lower limbs.
Obstetric loss - Recurrent miscarriages, pre-eclampsia and premature births can occur
Thrombocytopenia
ophthalmic vaso-occlusive pathologies
Diagnosis antiphospholipid syndrome time frame
One or more of the positive blood tests are needed on 2 occasions, 12-weeks apart
antiphospholipid antibodies
Lupus anticoagulant (frequently causes the aPTT to be prolonged)
Anticardiolipin antibodies
Anti-beta-2 glycoprotein I antibodies
tension pneumothorax treatment
Insert a large bore 16 G cannula into the second intercostal space in the midclavicular line on the affected side.
pneumothorax management : observation
primary pneumothorax no SOB and there is a < 2cm rim of air on the chest xray
If secondary, can observe if no SOB and <1cm
pneumothorax management: aspiration
Secondary : 1-2cm even if no SOB
Primary: If SOB and/or there is a > 2cm rim of air on the chest xray
Pneumothorax management: chest drain
If aspiration fails twice it will require a chest drain. Secondary pneumothorax greater than 2 goes straight to chest drain
Unstable patients or bilateral or secondary pneumothoraces generally require a chest drain.
Chest drain triangle of safety borders
5th intercostal space (inf nipple line)
Mid axillary line/lateral edge latissimus doors
Ant axillary line/lateral edge pectorals major
Addiotional pneumothorax education
Life long ban on sea diving, air travel restrictions until confirmed pneumothorax resolution, smoking cessation
Management ILD
Supportive care, home O2, patient support groups, specialist nurse, breathlessness management
Antifibroitc drugs: Pirfenidones, nintedanib
Lung transplant for younger patients
Drugs causing pulmonary fibrosis
Cyclophosphamide
Amiodarone
Bleomycin
Nitrofurantoin
Methotrexate
