Respiratory Flashcards
What are the biochemical features of exudate from effusion?
Purulent pleural fluid
* + gram stain / culture
* WCC > 50,000
* Pleural fluid glucose <3
* Pleural fluid pH <7.2
* Pleural fluid LDH >1000
What is the Lights criteria for exudate
Lights criteria (High protein and LDH = exudate), determines presence of exudate with protein and LDH levels
Pleural fluid protein to serum protein ratio >0.5
Pleural fluid LDH to serum LDH ratio >0.6
Pleural fluid level >2/3 of upper value for serum LDH
What are the US features of empyema?
Loculation
effusion
consolidation
What are the steps in management for empyema?
- Supportive - Oxygen, analgesia, fluids
- Medical - Iv abx eg tazocin or vanc if MRSA. 20fr chest drain
- Surgical - fibrinolytics via chest drain, VATS (video assisted thorascopic surgery). open thoracotomy
list two pathological processes linked to the Gas and explain it
Severe acute Resp acidosis - Raised Pco2 with low PH
Chronic resp acidosis with metabolic compensation - HCO3 is raised at 44 more than would be expected for a
purely acute process (expect about HCO3 of 34) ie raise of 1
mmol/L for every raise in 10mmHg of CO2
Raised A/a gradient - A-a gradient = PAO2 – PaO2
What is the A-a gradient
A-a gradient is calculated as PAO2 – PaO2
Normal is 5-10mmHG
It is a measure of the difference in oxygen concentration between alveolar and the arteries
Someone is failing BIPAP for severe COPD. What are the next steps in ED?
- Intubate
- hyperventilate to decrease Co2
- reduce Fi02
- IV abs
- IV fluid
What are the abnormalities?
Diagnosis?
- Left hilar mass - rounded opacity left hilum and patchy consolidation around this area
- Confluent consolidation RUL with air bronchograms
- Consolidation right middle lobe oscuring right hear border
Diagnosis
Multi lobe pneumonia with likely malignancy left hilum
multi lobe pneumonia with following obs
What are the treatment steps and end points?
- titrate o2 to over 92
- IV fluid boluses aiming for HR under 100 and systolic BP over 100
- IV cef and azi
abnormalities?
Differentials?
Investigations and justification
- RUL opacification
- cavitating lesion with air fluid level
- RUL collapse with trachel deviation
- small left effusion
Differentials
Neoplastic - Primary lung or secondary mets
Lung abscess - bacterial infection. TB
Vasculitis eg Wegners
chemo for melanoma
two positve and two negative findings
What are the possible infective causes?
non infective
Positive
* bilateral symmetrical infiltrates
* alveolar infiltrates with round lesions
Negative
* no effusions
* no pneumorax
* normal heart size
Infective causes:
Mycoplasma pneumonia
influenza/covid
Aspergillosis
TB
Non Infective
Pulmonary haemorrhage
ARDS
Pulmonary oedema
SOB
what are the significant findings?
What are the possible infective causes?
Non infective
Positive
left upper zone cavitating lesion with air fluid level
Air bronchograms
Negative
no effusion
no pneumothorax
Infective
S.pneumonae
S.aureus
Klebsiella
Non infective
malignancy
infarct
Vasculitis
pulmonary haemorrhage
What are the eight steps in inserting IJ line
- *Aseptic preparation
- Head down
- Local anaesthetic to site
- Use of USS guided technique where possible
- Insert needle to IJV
- Pass wire
- Dilate vein
- Insert central line
- Flush all lumens
- Secure to skin*
when assessing a patient with CP what features are important in the history?
- communication - how do they communicate and express pain
- Diet - PEG or oral feed
- any CP co-morbidities eg seizures
- previous ICU admissions
- Previous intubations
- advanced health care directive
What are the differences between aspiration pneumonia and aspiration pneumonitis?
someone with CP and sats 88% with fi01 0.21 (normal air) - what methods are there for oxygenation
Non Invasive
Hudson - if for ward based therapies, non able to blow of Co2, less invasive
Invasive
high flow nsal probs. BIPAP/CPAP
what features of a history would suggest poor asthma control
- daytime symptoms twice a week
- reliever needed twice a week
- limitations on activities
- symptoms overnight
- 3 or more presentations in a month
- prior ICU admissions
- poor health/social literacy
what do you need to ensure to safely discharge asthma patient?
- ASTHMA PLAN
- scripts
- preventer
- GP FU
- understand when to return
- handout in appropriate language
What are the advantages and disadvantages on NIV in asthma
Advantages
* PEEP aids with WOB
* IPAP increases tidal volume
* prevents intubation
* shorter inspiratory times increase tidal volumes
Disadvantages
* may delay intubation
* wrong settings may increase WOB
* increased risk pneumothorax
* difficult to clear secretions
asthma
what are the contraindications for NIV in COPD
- decreased GCS
- patient refusal
- vomiting
- haemoptysis
- not intiating own breathing
- facial abnormalities
- lack of nursing staff to supervise
how may you alter NIV settings if no improvement after an hour and why?
- Increase IPAP - increase TV and ventilation to remove CO2
- increse Fio2 or PEEP increase oxygenation
abnormalities
- Marked hyperinflation
- Moderate/Large left sided pneumothorax
- Mediastinal shift to the right – possible tension PTX
- Bilateral widespread pulmonary infiltrates
- Right midzone (basal segment of upper lobe) wedge shaped cavitating
lesion/consolidation - Right apical focal consolidation
- Interposed hepatic flexure under right hemidiaphragm (Chilaiditti
syndrome)
what are the causes of massive haemoptysis?
- bronchiectasis
- tuberculosis
- immune - good passtures
- malignancy - lung/bronchial
- AVM
- lung abscess
- necrotising bacterial infection
- iatorgenic - post procedure
- coagulopathy
what are the key interventions for massive haemoptysis?
- ABC
- fluid resus with fluid and blood
- massive transfusion protocol
- clear airway - may need intubation
- TXA
- reversal of anticoagulation
- urgent bronchoscopy
- NBM
- may need IR
- abx to cover infection
main abnormality
solitary lesion left upper zone
contains air/fluid
Cavitating lesion
what are the top three causes of pneumomediastinum linked to vomiting
- oesophageal perforation
- vasalva
- asthma
- chest trauma
- ideopathic
what is the management of someone shocked with pneumomediastinum
- abx to cover GI source eg taz
- fluid resus to 0.05ml/kg hr UO
- cardiothoracic referral
- analgesia
main pathology and why
large right pleural effusion
Reasons:
* homogenous opacification of right middle and lower lobe
* loss of right hemidiaphragm
* rim of opacity around rim consistent with fluid
what are the causes of large pleural effusions
- malignancy
- parapneumonic effusion
- PE
- hydrothorax from massive PE
investigations and justification for large PE
what are the causes of a pleural exudate
infection eg pneumonia
malignancy
inflammatory eg RA
PE
asbestos related
Pancreatitis
what are the indications for thoracocentesis of pleural effusion in ED?
- respiratory compromise
- haemodynamic instability
- mediastinal shift
- severe symptoms
what are the risk factors for re-expansion pulmonary oedema post thoracocentesis
under 30
pleursl effusion over 7 days
over 3 litres aspirated
suction used
rapid drainage of over 1.5l/hr
6 radiological abnormalities
- multiple opacities left lung
- loss volume right hemithorax
- right upper lobe consolidation
- air bronchograms
- pleural effusion right side
- hilar mass
positive and negative findings
Positive
right pneumothorax
significant tension
flattened right hemidiphragm
small pleural effusion
Negative
trachea midline
no lines
no consolidation
what are the immediate management steps of tension pneumothorax
- immediate chest decompression via needle thoracostomy - finger thoracostomy
- ensure improvement via clinical sgns
- chest drain with underwater seal
complications of needle thoracostomy for pneumothorax
- misplacement of ICC
- solid organ injury
- infection
- haemorrhage
- tube blockage/kinking
describe and interpret
left sided pneumothorax
what would point toward conservative management of pneumothrax
symptoms
patient choice
primary
size
in pre hospital setting what are advantages and disadvantages of using US to diagnose pneumothorax
Pros
* fast
* no radiation
* accurate with training
Cons
* need training
* patient access may be difficult
* subcut air may disrupt views
Write brief notes on the pros and cons of needle decompression vs finger
thoracostomy
signs and symptoms of tension pneumothorax
hypotension
tachycardia
hypoxia
tachypnoeia
increased WOB
SOB
what are the causes of a pneumthorax
- primary
- secondary - asthma
- trauma/rib fracture
- inhalation/IVDU
- collagen disease eg marfans
pneumothorax
why is this lung US a tension pneumothorax:
IVC is like lead pipe and not changing
what is happening here on lung US
IVC collapsing on inhalation so low intrathoracic pressure
pneumothorax on m mode
for a cavitating lung lesion
what are the symptoms of pulmonary hypertension?
Dyspnoea
Chest pain
Syncope
what are the ED investigations for ?pulmonary hypertension
Echo - Dilated RV
ECG - Right heart strain
- PAH - idiopathic or drug use eg cocaine
- **PVH **- systolic or diastolic dysfunction, MS, MR
- Chronic hypoxaemia - COPD, ILD
-
Thromboembolic - PE
5. Misc - sarcoidosis, vasculitis, SLE
abnormalities
left midzone opacities
right midzone opacificaiton
kerly b lines
small effusion
differentials and investigative finding
major acid base disturbance and evidence
- Respiratory acidosis – raised CO2 61, low pH
- High anion gap metabolic acidosis - Low HCO3, raised AG 17, low pH
Anion Gap
Delta Gap
A-A gradient
Formula/ Interpretation and clinical implication
COPD
two conclusions from this gas
Conclusion 1: There is acute on chronic respiratory failure with elevated CO2 and low pH, however
shift is less than predicted if all acute, and HCO3 elevated suggesting chronic compensation.
Conclusion 2: She has a large A-a gradient with PAlv O2 of 266 and gradient of approx. 170
(elevated) – indicative of shunt.
unwell post lung transplant
key findings
Differentials
- Bilateral areas of consolidation in RML, RLL & LLL
- Multiple clips bilaterally consistent with double lung transplant
- CTR within normal limits
- (No Pneumothorax or pleural effusions)
- (No free gas under diaphragm)
Differentials
Infection - Bacterial, viral or fungal
acute rejection
CCF
PE
On physical examination he has multiple petechiae around his eyes, and an intermittent
cough. He has mild indrawing of intercostal muscles and mild tracheal tug, but no stridor.
Post FB inhalation -explain symptoms
- cough - trachobrochial irritaiton
- petichae - raised venous pressure suggesting choking episode
- tracheal tug - intrathoracic airway obstruction
post choking episode
list significant findings
Diagnosis
mediastinal shift to right on expiratory film
increased lucency left lung on expiration
hyper expansion left lung on exspiration
Normal inspiratory film
Diagnosis:
Ingaled FB left main bronchus
management post choking episode and child becomes cyanosed and unresponsive
- attempt bag valve ventilation with anaesthetic circuit
- perform direct laryngoscopy with magills forceps to remove FB
- Intubate if unable to remove - either ETT or LMA
- needly cricothyroidotomy if unsuccessful and oxygen with occlusion of y connected 1 second on and 4 off
Good pastures - describe Xray
bilateral patchy infiltrates
widespread
Differentials
Pulmonary haemorrhage
CCF
ARDS
bilateral infection
malignancy
opportunistic infection eg PCP
Steps in intubation
- Fluid load – 0.9% saline 10ml/kg bolus, repeat to SBP >100mmHg
- Augmented induction agent – ie ketamine IV at reduced dose ie 0.5-1mg/kg, rocuronium 1.2mg/kg
- Co-administration of inotrope at induction – 1mcg/kg adrenaline with induction
- Optimised pre-oxygenation with ongoing NRBM at 15lpm PLUS NP O2 at 15lpm
- NP O2 at 15lpm throughout induction stage
- Mitigate hypoxia/acidosis by bagging through induction with BVM O2 at 15lpm
- Intubate at 30 degrees to minimise risk of hypoxia
what are the treatment options for asthma post burst and steroids?
- IV magnesium 2gm IV over 20 mins
- Salbutamol IVI 250mcg bolus followed by an infusion 5 -10 mcg/kg/hour
- BIPAP (IPAP 7 -15 cmH2O; EPAP 3 – 5 cm H2O)
- Adrenaline 0.3mg IM or IV infusion
- Aminophylline also acceptable if in discussion with ICU
how do you optimise asthma patient prior to intuabation
a) Keep upright until last moment
b) Preoxygenate (BiPaP or 15L NRBM)
c) High flow oxygen by nasal cannula (15L/min)
d) Continuous salbutamol nebulisation 10 – 15 mg/hr
e) Normal Saline 1L IV bolus
what are the steps for dealing with post intubation hypotension in asthmatic?
- Disconnect from ventilator & allow prolonged exhalation
- IV fluid bolus 10 – 20 ml/kg
- Rule out tension pneumothorax (clinical/ USS) or needle /finger thoracostomies
- Vasopressors eg metaraminol 0.5-1mg bolus / adrenaline 10mcg IV bolus
treatment for severe asthma in kids
- Oxygen via mask to keep sats >92%
- Salbutamol nebs 2.5 - 5mg continuous
- Ipratropium 250mcg times 3 nebs in first hour
- Steroid IV – methypred 1mg/kg or hydrocortisone 4mg/kg
- Salbutamol IV – 5-10mcg/kg bolus then infusion
- Also accept MgSO4 – 50mg/kg bolus then infusion
- Also accept aminophylline – 10mg/kg loading dose
intubation drugs for asthma in kids
Ketamine 1-2mg/kg
Sux 1-2mg/kg
what are the clinical manifestions of Wegners (granulomatosis with polyangitis)
- Renal failure
- pulmonary haemorrhage
- conjunctivits/episcleritis/scleritis
- myalgia/arthralgia
- pulmonary fibrosis, subglottic stenosis
- myo/pericarditis
what is the bloods test for wegners
ANCA
what diseases can cause renal failure and pulmonary haemorrhage
wegeners
malaria
leptospirosis
Influenza
Dengue
Hantavirus
What are some non infective causes of haemoptysis and haematuria
Goodpastures
Churg strauss
SLE
HSP
microscopic polyangitis
IGA nephropathy
Behcets
IV fluid bolus (N Saline 1-2L. Aim SBP 100
Central venous access and commence vasopressor if patient remains hypotensive (Noradrenaline infusion – Aim MAP 60-65)
Organise bed side echo – look for elevated RV pressure and/or deviation of interventricular septum suggestion increased RV pressure
Find further information of cerebral aneurysm – were there more thanone aneurysm/ what interventions done
Discuss with cardiothoracic surgery regarding suitability for surgicalembolectomy (preferred treatment option)
Discuss other treatment options with patient and family – thrombolysiswith tenecteplase (if RV pressure is high) / anticoagulation with heparin(if RV pressure normal)
If patient arrests – thrombolysis
post PEA
abnormalities
Sinus tachy
RBBB
RAD
S1Q3T3 - RV strain
St depression in V1 and V2 suggesting RV strain
What ECG changes may you get in P.E
Sinus tachy
RBBB
RAD
S1Q3T3 - RV strain
St depression in V1 and V2 suggesting RV strain
what may you fine on bedside US for PE
Dilated RV
Dilated IVC
Poorly contractile RV
Hyperdynamic LV
