respiratory Flashcards
A 16 year old male is referred by his GP to your emergency department with 1 month of nonproductive cough and dysphagia.
Describe the major abnormality evident on this chest X-ray.
anterior mediastinal mass
List three (3) differential diagnoses for this chest X-ray finding.
- malignant lymphoma (hodgkins/non-hodgkins) - most common
- teratoma
- thymoma (thyroid mass/goitre with retrosternal extension
Describe how you would elicit Pemberton’s sign
Ask the patient to raise both arms above their head for 1 minute.
list four clinical findings with Pemberton’s sign if positive
- Facial flushing or plethora
- Jugular vein distension (non-pulsatile)
- cyanosis
- inspiratory stridor/dyspnoea
- inability to swallow
list four (4) non-respiratory signs you would examine to assess for superior vena cava syndrome
- Neck/chest vein dilatation
- Presence of collateral veins in the neck/chest
- Visual disturbance
- Confusion/altered mental status
- Hypotension
- Inability to lie flat
What is the first step for a 45-year-old male presenting with sudden dyspnea and hypoxia (SpO2 85%)?
Administer high-flow oxygen via a non-rebreather mask at 15 L/min to rapidly improve oxygenation while assessing the underlying cause, such as pulmonary embolism, pneumothorax, or acute pulmonary edema.
What is the initial bronchodilator for a 60-year-old smoker with COPD presenting with severe dyspnea and wheeze?
Salbutamol 5 mg nebulized, delivered continuously or every 15-20 minutes, to relieve bronchospasm and improve airflow in this acute exacerbation.
What is the diagnosis for a 30-year-old with chest trauma and absent breath sounds on the left?
Pneumothorax, likely traumatic, caused by lung puncture from rib fracture or blunt force, leading to collapsed lung and reduced air entry.
What is the next step for a 25-year-old asthmatic with a silent chest and SpO2 88%?
Administer IV magnesium sulfate 2 g over 20 minutes to relax bronchial smooth muscle and improve ventilation in this severe, life-threatening asthma exacerbation.
What is the first-line antibiotic for a 70-year-old with fever and cough and consolidation on CXR?
Ceftriaxone 1 g IV plus azithromycin 500 mg IV, targeting common community-acquired pneumonia pathogens like Streptococcus pneumoniae and atypical organisms (e.g., Mycoplasma).
What is the likely cause for a 50-year-old with sudden chest pain and hypoxia with a widened mediastinum on CXR?
Aortic dissection, a life-threatening condition where a tear in the aortic wall may compress the pulmonary artery or cause pleural effusion, leading to respiratory distress.
What is the diagnosis for a 35-year-old diver presenting with dyspnea after a rapid ascent?
Pulmonary barotrauma, where rapid decompression causes alveolar rupture, leading to pneumothorax, pneumomediastinum, or arterial gas embolism.
What is the initial ventilatory support for a 65-year-old with COPD with a PaCO2 of 70 mmHg and drowsiness?
BiPAP with settings (e.g., IPAP 10-15 cmH2O, EPAP 4-5 cmH2O) to reduce work of breathing, improve CO2 clearance, and prevent intubation in this hypercapnic respiratory failure.
What is the treatment for a 40-year-old with a stab wound to the chest and tracheal deviation?
Needle decompression at the 2nd intercostal space, midclavicular line, to relieve tension pneumothorax, followed by chest tube insertion to prevent reaccumulation.
What is the next step for a 28-year-old with severe asthma who is tiring and has a peak flow of 25% predicted?
Prepare for rapid sequence intubation using ketamine 1-2 mg/kg IV and rocuronium 1 mg/kg IV, as exhaustion and poor air entry indicate imminent respiratory arrest.
What is the fluid bolus for a 55-year-old with pneumonia who develops septic shock?
30 mL/kg of crystalloid (e.g., normal saline or Hartmann’s) over 30-60 minutes to restore intravascular volume and improve perfusion, per Surviving Sepsis guidelines.
What is the management for a 22-year-old with sudden dyspnea and a small apical pneumothorax on CXR?
Observation with supplemental oxygen if asymptomatic and <3 cm from apex to pleural cupola, as spontaneous resolution is likely in stable primary spontaneous pneumothorax.
What is the initial treatment for a 68-year-old with heart failure presenting with pink frothy sputum?
CPAP at 5-10 cmH2O plus sublingual GTN 0.4 mg every 5 minutes to reduce preload and improve oxygenation in acute cardiogenic pulmonary edema.
What is the treatment for a 33-year-old with a cough and hemoptysis who has a massive PE on CTPA?
Alteplase 100 mg IV over 2 hours for thrombolysis, indicated in massive PE with hemodynamic instability, to dissolve the clot and restore pulmonary perfusion.
What is the next step for a 50-year-old smoker with COPD who has a pH of 7.25 and PaCO2 of 80 mmHg?
Initiate NIV (e.g., BiPAP with IPAP 12 cmH2O, EPAP 5 cmH2O) to offload respiratory muscles and correct hypercapnia in this acute-on-chronic respiratory failure.
What is the diagnosis for a 19-year-old with a rib fracture who has worsening dyspnea and hypoxia?
Hemothorax, where blood from the fractured rib accumulates in the pleural space, compressing the lung and impairing oxygenation.
What is the disposition for a 75-year-old with pneumonia who has a CURB-65 score of 4?
Admit to ICU for close monitoring and potential ventilatory support, given the high mortality risk indicated by severe pneumonia scoring.
What is the next bronchodilator for a 42-year-old with asthma who has no improvement after salbutamol?
Ipratropium bromide 500 mcg nebulized, added to salbutamol every 20 minutes, to enhance bronchodilation via anticholinergic effects in severe asthma.
What is the imaging for a 60-year-old with sudden dyspnea who has an S1Q3T3 pattern on ECG?
CT pulmonary angiogram (CTPA) to confirm pulmonary embolism, as the ECG suggests right heart strain from acute pulmonary artery obstruction.
What size chest tube is used for a 27-year-old with a tension pneumothorax who is deteriorating?
28-32 Fr inserted at the 5th ICS, anterior axillary line, to evacuate air and prevent further lung collapse in this unstable patient.
What is the next step for a 35-year-old with severe COPD exacerbation who is hypoxic despite NIV?
Intubate using RSI (e.g., ketamine 1-2 mg/kg IV) to secure the airway and provide mechanical ventilation due to failure of non-invasive support.
What is the next step for a 50-year-old with pneumonia and hypoxia who has a pleural effusion on CXR?
Perform thoracentesis to drain the effusion and send fluid for analysis (pH, glucose, LDH) to assess for complicated parapneumonic effusion or empyema.
What is the cause for a 23-year-old with chest pain after a fall who has a pneumothorax and subcutaneous emphysema?
Tracheobronchial injury, where a traumatic rupture allows air to escape into the mediastinum and subcutaneous tissues.
What is the oxygen target for a 65-year-old with COPD presenting with dyspnea and a PaO2 of 55 mmHg?
SpO2 88-92% using controlled oxygen (e.g., Venturi mask) to avoid suppressing hypoxic drive in chronic CO2 retainers.
What is the treatment for a 30-year-old with acute dyspnea who has bilateral wheeze and a rash?
IM adrenaline 0.5 mg (1:1000) stat, followed by antihistamines and steroids, for anaphylaxis causing bronchospasm and respiratory distress.
What is the ventilatory strategy for a 70-year-old with pneumonia who develops ARDS?
Low tidal volume ventilation (6 mL/kg ideal body weight) with PEEP 5-15 cmH2O to minimize barotrauma and optimize oxygenation in ARDS.
What is the diagnosis for a 45-year-old with a stab wound who has bubbling from the chest?
Open pneumothorax (sucking chest wound), where air enters the pleural space through a penetrating injury, collapsing the lung.
What is the dose of hydrocortisone for a 25-year-old asthmatic with SpO2 90% who is not responding to nebs?
100 mg IV stat to reduce airway inflammation, with effects starting within 1-2 hours in severe asthma exacerbation.
What is the next test for a 55-year-old with dyspnea who has a D-dimer of 2000 ng/mL?
CTPA to confirm pulmonary embolism, as elevated D-dimer and respiratory symptoms suggest a high pretest probability in this scenario.
What is the BiPAP setting for a 60-year-old with COPD who has a respiratory rate of 30 and pH 7.30?
IPAP 12 cmH2O, EPAP 5 cmH2O initially, titrated to reduce RR and improve CO2 clearance in this hypercapnic exacerbation.
What is the initial management for a 32-year-old with trauma who has a flail chest?
Administer oxygen via NRB and IV analgesia (e.g., fentanyl 100 mcg) to stabilize breathing and reduce pain from paradoxical chest wall motion.
What is the vasopressor for a 70-year-old with pneumonia who has a lactate of 5 mmol/L?
Noradrenaline 0.01-0.5 mcg/kg/min IV after fluid resuscitation to maintain MAP ≥65 mmHg in septic shock.
What is the oxygen flow for a 40-year-old with sudden dyspnea who has a small pneumothorax and is stable?
High-flow nasal cannula at 30-60 L/min to increase FiO2 and accelerate pneumothorax resorption in a stable patient.
What does a PaCO2 of 50 mmHg indicate for a 28-year-old with asthma?
Impending respiratory failure, as rising PaCO2 in asthma suggests fatigue and inadequate ventilation, requiring urgent escalation.
What is the treatment for a 65-year-old with COPD who presents with confusion and PaCO2 90 mmHg?
NIV (BiPAP, IPAP 15 cmH2O, EPAP 5 cmH2O) to reduce CO2, improve mentation, and avoid intubation in this acute hypercapnic failure.
What is the antibiotic timing for a 50-year-old with pneumonia who has a BP of 80/50?
Within 1 hour of recognition, as early broad-spectrum antibiotics (e.g., ceftriaxone 1 g IV) reduce mortality in septic shock.
What is the concern for a 22-year-old with chest trauma who has a widened pulse pressure?
Aortic injury, where traumatic aortic rupture causes hemodynamic changes, potentially leading to respiratory compromise from mediastinal hematoma.
What is the treatment for a 35-year-old with dyspnea after a flight who has RV strain on echo?
Heparin 80 units/kg IV bolus followed by 18 units/kg/h infusion to anticoagulate and prevent further clot propagation in pulmonary embolism.
What is the next step for a 60-year-old with COPD exacerbation who has a pH of 7.20?
Trial NIV (e.g., BiPAP IPAP 12-15 cmH2O, EPAP 5 cmH2O) for 1-2 hours to correct acidosis and hypercapnia, with reassessment for intubation if no improvement.
What is the needle decompression site for a 45-year-old with pneumonia who develops a tension pneumothorax?
2nd intercostal space, midclavicular line, using a 14-gauge needle to relieve pressure and restore hemodynamic stability.
What is the ventilator setting for a 25-year-old with severe asthma who is intubated?
Low rate (6-8 breaths/min), tidal volume 6-8 mL/kg, long expiratory time (I:E 1:4) to prevent air trapping and barotrauma.
What is the diagnosis for a 70-year-old with dyspnea who has bilateral crackles and JVD?
Cardiogenic pulmonary edema, where left heart failure causes fluid backup into the lungs, leading to respiratory distress.
What is the antibiotic for a 30-year-old with a cough who has lobar consolidation and Streptococcus pneumoniae?
Benzylpenicillin 1.2 g IV every 6 hours, targeting the most common CAP pathogen in a penicillin-sensitive strain.
What is the oxygen delivery for a 55-year-old with COPD who has a PaO2 of 50 mmHg on room air?
Controlled oxygen via Venturi mask at 24-28% FiO2 to maintain SpO2 88-92%, avoiding CO2 retention.
What is the initial treatment for a 40-year-old with trauma who has a sucking chest wound?
Apply a three-sided occlusive dressing to allow air exit but prevent entry, followed by chest tube insertion to manage the open pneumothorax.
What is the next drug for a 28-year-old with asthma who has a silent chest after nebs?
Magnesium sulfate 2 g IV over 20 minutes to relieve severe bronchospasm and improve airflow in this near-fatal asthma scenario.
What is the next imaging for a 65-year-old with pneumonia who has a pleural rub and hypoxia?
Chest CT to evaluate for complications like empyema, abscess, or underlying malignancy in this hypoxic patient.
What is the chest tube size for a 50-year-old with dyspnea who has a massive hemothorax?
36 Fr inserted at the 5th ICS, anterior axillary line, to drain large-volume blood and monitor ongoing bleeding.
What is the diagnosis for a 35-year-old with sudden dyspnea who has a normal CXR but high D-dimer?
Pulmonary embolism, where a normal CXR with hypoxia and elevated D-dimer strongly suggests a clot obstructing pulmonary arteries.
What is the intubation indication for a 60-year-old with COPD who is tiring on BiPAP?
Worsening hypercapnia (e.g., PaCO2 >80 mmHg) or acidosis (pH <7.20) despite optimized NIV, indicating respiratory muscle fatigue.
What is the steroid dose for a 25-year-old with asthma who has a respiratory rate of 40?
Prednisolone 50 mg PO or hydrocortisone 100 mg IV to reduce airway inflammation, with oral preferred if the patient can swallow.
What is the fluid type for a 70-year-old with pneumonia who has a BP of 90/60 and lactate 3 mmol/L?
Normal saline 30 mL/kg IV over 1 hour to address hypoperfusion in early septic shock, guided by lactate elevation.
What is the treatment for a 45-year-old with trauma who has a pneumothorax and hypotension?
Chest tube insertion (28-32 Fr) at the 5th ICS, anterior axillary line, to relieve pressure and stabilize hemodynamics.
What is the diagnosis for a 30-year-old with dyspnea who has bilateral infiltrates on CXR?
ARDS, where diffuse alveolar damage from trauma, sepsis, or aspiration causes non-cardiogenic pulmonary edema and hypoxia.
What is the management for a 55-year-old with COPD who has a PaCO2 of 60 mmHg and pH 7.35?
Salbutamol 5 mg and ipratropium 500 mcg nebulized every 20 minutes to reverse bronchospasm, as this is a compensated exacerbation.
What is the concern for a 40-year-old with a cough who has a cavitating lesion on CXR?
Tuberculosis or lung abscess, where cavitation suggests necrotizing infection requiring sputum AFB and possible drainage.
What is the management for a 55-year-old with COPD, PaCO2 of 60 mmHg, and pH 7.35?
Salbutamol 5 mg and ipratropium 500 mcg nebulized every 20 minutes to reverse bronchospasm, as this is a compensated exacerbation.
What is the concern for a 40-year-old with a cough and a cavitating lesion on CXR?
Tuberculosis or lung abscess, where cavitation suggests necrotizing infection requiring sputum AFB and possible drainage.
What is the ventilator mode for a 28-year-old with asthma who is hypoxic despite treatment?
Pressure control ventilation with low rate (8-10/min) and PEEP 5 cmH2O to manage bronchospasm and prevent barotrauma.
What is the next step for a 65-year-old with pneumonia and SpO2 of 88% on 15 L/min?
Intubate with RSI (e.g., ketamine 1-2 mg/kg IV) due to refractory hypoxia indicating respiratory failure in severe pneumonia.
What is the analgesia for a 50-year-old with trauma, flail chest, and hypoxia?
IV fentanyl 1-2 mcg/kg titrated to pain, reducing splinting and improving ventilation in this chest wall injury.
A 35-year-old with dyspnea has a Wells score of 6. What is the anticoagulant?
Heparin 80 units/kg IV bolus followed by 18 units/kg/h infusion to prevent clot progression in high-probability pulmonary embolism.
A 60-year-old with COPD has a pH of 7.15 after NIV. What is the next step?
Intubate with RSI (e.g., propofol 1-2 mg/kg IV) as persistent acidosis indicates failure of non-invasive ventilation.
A 25-year-old with asthma has a PaO2 of 60 mmHg. What is the oxygen delivery?
High-flow nasal cannula at 40-60 L/min and 100% FiO2 to correct hypoxemia while escalating bronchodilator therapy.
A 70-year-old with pneumonia has a CURB-65 of 3. What is the antibiotic?
Ceftriaxone 1 g IV daily plus azithromycin 500 mg IV daily to cover severe CAP with risk of ICU admission.
A 45-year-old with trauma has a tension pneumothorax. What is the chest tube site?
5th intercostal space, anterior axillary line, using a 28-32 Fr tube to fully evacuate air and prevent recurrence.
A 30-year-old with dyspnea has a tracheal tug and stridor. What is the diagnosis?
Upper airway obstruction, potentially from epiglottitis or foreign body, causing inspiratory distress and visible neck muscle use.
A 55-year-old with COPD has a respiratory rate of 35. What is the initial treatment?
Salbutamol 5 mg and ipratropium 500 mcg nebulized back-to-back to rapidly relieve bronchospasm and improve air entry.
A 40-year-old with pneumonia has a pleural effusion with pH <7.2. What is the treatment?
Chest tube drainage (e.g., 14-20 Fr) for empyema, followed by antibiotics (e.g., piperacillin-tazobactam 4.5 g IV).
A 28-year-old with asthma has no wheeze and SpO2 85%. What is the immediate action?
RSI with ketamine 1-2 mg/kg IV and rocuronium 1 mg/kg IV due to silent chest indicating critical airflow limitation.
A 65-year-old with dyspnea has bilateral infiltrates and fever. What is the ventilator setting?
PEEP 5-10 cmH2O, tidal volume 6 mL/kg IBW, FiO2 titrated to SpO2 >90% for ARDS management.
A 50-year-old with trauma has a hemopneumothorax. What is the initial management?
Insert a 32-36 Fr chest tube at the 5th ICS, anterior axillary line, to drain blood and air, monitoring output for surgical referral.
A 35-year-old with sudden dyspnea has a D-dimer of 1000 ng/mL. What is the next step?
CTPA to confirm pulmonary embolism, as elevated D-dimer with acute symptoms warrants definitive imaging in moderate-high risk.
A 60-year-old with COPD has a PaCO2 of 85 mmHg on BiPAP. What is the next ventilator setting?
Increase IPAP to 18-20 cmH2O while maintaining EPAP at 5 cmH2O to enhance CO2 elimination in worsening hypercapnia.
A 25-year-old with asthma has a peak flow of 30% after nebs. What is the next step?
IV salbutamol 250 mcg over 10 minutes as a bolus, followed by infusion if needed, to achieve systemic bronchodilation.
A 70-year-old with pneumonia has a SpO2 of 90% on 6 L/min. What is the disposition?
High-dependency unit (HDU) for close monitoring and potential escalation to NIV or intubation if hypoxia worsens.
A 45-year-old with trauma has a sucking chest wound and hypoxia. What is the dressing type?
Occlusive three-sided dressing taped on three sides to allow air escape during expiration, preventing tension pneumothorax.
A 30-year-old with dyspnea has a barking cough and stridor. What is the treatment?
Nebulized adrenaline 5 mL (1:1000) to reduce airway edema in croup, with dexamethasone 0.6 mg/kg IV for longer-term effect.
A 55-year-old with COPD has a pH of 7.28 and PaCO2 70 mmHg. What is the BiPAP adjustment?
Increase IPAP by 2-4 cmH2O (e.g., to 14-16 cmH2O) to improve ventilation and correct mild acidosis.
A 40-year-old with pneumonia has a BP of 85/50. What is the vasopressor dose?
Noradrenaline 0.01-0.5 mcg/kg/min IV titrated to MAP ≥65 mmHg after 30 mL/kg fluid bolus in septic shock.
A 28-year-old with asthma is intubated and has high peak pressures. What is the adjustment?
Decrease tidal volume to 6 mL/kg and rate to 6-8/min to reduce air trapping and prevent barotrauma in bronchospasm.
A 65-year-old with dyspnea has a massive PE and RV dysfunction. What is the thrombolytic?
Alteplase 100 mg IV over 2 hours to dissolve the clot, indicated for massive PE with RV strain and hemodynamic compromise.
A 50-year-old with trauma has a flail chest and RR 40. What is the ventilatory support?
Mechanical ventilation via intubation with volume control (6 mL/kg) to stabilize chest wall and support breathing.
A 35-year-old with dyspnea has a Wells score of 7. What is the thrombolytic indication?
Hemodynamic instability (e.g., SBP <90 mmHg) with confirmed PE, warranting alteplase 100 mg IV for massive embolism.
A 60-year-old with COPD has a PaCO2 of 75 mmHg and pH 7.25. What is the BiPAP setting?
IPAP 15 cmH2O, EPAP 5 cmH2O initially, titrated upward if CO2 persists, to improve ventilation in hypercapnic failure.
A 25-year-old with asthma has a peak flow of 20% predicted. What is the IV drug?
Magnesium sulfate 2 g IV over 20 minutes to relax bronchial smooth muscle and prevent progression to respiratory arrest.
A 70-year-old with pneumonia has a SpO2 of 85% on NRB. What is the next step?
Intubate with RSI (e.g., ketamine 1-2 mg/kg IV) due to refractory hypoxia requiring mechanical ventilation in severe pneumonia.
A 45-year-old with trauma has a flail chest and hypoxia. What is the analgesia dose?
Fentanyl 100 mcg IV stat, titrated every 5-10 minutes, to reduce pain and improve chest wall excursion without respiratory depression.
A 30-year-old with dyspnea has a barking cough and fever. What is the dose of adrenaline?
Nebulized adrenaline 5 mL of 1:1000 solution to reduce laryngeal edema in croup, repeated if needed every 20-30 minutes.
A 55-year-old with COPD has a pH of 7.22 and PaCO2 80 mmHg. What is the NIV adjustment?
Increase IPAP to 18 cmH2O from baseline to enhance CO2 clearance, monitoring for improvement within 1-2 hours.
A 40-year-old with pneumonia has a BP of 80/50 and lactate 5 mmol/L. What is the fluid type?
Hartmann’s solution 30 mL/kg IV over 1 hour, preferred for balanced electrolytes in septic shock resuscitation.
A 28-year-old with asthma is intubated and has hypotension. What is the cause?
Dynamic hyperinflation from air trapping, causing reduced venous return; treat by disconnecting ventilator briefly to allow exhalation.
A 65-year-old with dyspnea has a massive PE and hypotension. What is the thrombolytic dose?
Alteplase 100 mg IV over 2 hours, given as 10 mg bolus then 90 mg infusion, to lyse the clot in this unstable PE.
A 50-year-old with trauma has a hemothorax and SpO2 88%. What is the chest tube volume?
36 Fr tube; if >1500 mL blood drained initially or >200 mL/h ongoing, urgent thoracic surgery is indicated.
A 35-year-old with dyspnea has a D-dimer of 1500 ng/mL and tachycardia. What is the next test?
CTPA to definitively diagnose pulmonary embolism, as tachycardia and elevated D-dimer suggest moderate-high risk.
A 60-year-old with COPD has a PaCO2 of 70 mmHg and RR 32. What is the initial treatment?
BiPAP (IPAP 12-15 cmH2O, EPAP 5 cmH2O) with salbutamol 5 mg nebs to reduce work of breathing and CO2 retention.
A 25-year-old with asthma has a silent chest and SpO2 87%. What is the RSI induction?
Ketamine 1-2 mg/kg IV for its bronchodilatory and hemodynamic stability properties, ideal in severe asthma intubation.
A 70-year-old with pneumonia has a CURB-65 of 5. What is the antibiotic dose?
Ceftriaxone 1 g IV daily plus azithromycin 500 mg IV daily, escalated to ICU-level care for this critically ill patient.
A 45-year-old with trauma has a pneumothorax and BP 85/50. What is the chest tube size?
32 Fr at the 5th ICS, anterior axillary line, to rapidly evacuate air and restore hemodynamic stability in tension pneumothorax.
A 30-year-old with dyspnea has stridor and a recent URI. What is the diagnosis?
Croup (laryngotracheobronchitis), where viral infection causes subglottic edema, leading to stridor and respiratory distress.
A 55-year-old with COPD has a PaO2 of 55 mmHg on 4 L/min. What is the oxygen delivery?
Venturi mask at 28% FiO2 to maintain SpO2 88-92%, preventing hyperoxia and CO2 retention in this chronic retainer.
A 40-year-old with pneumonia has a pleural effusion and hypoxia. What is the next step?
Thoracentesis to drain effusion, sending fluid for pH, Gram stain, and culture to diagnose empyema or parapneumonic effusion.
A 28-year-old with asthma has a PaCO2 of 60 mmHg and RR 40. What is the ventilatory support?
Intubate with RSI (ketamine 1-2 mg/kg IV) as rising CO2 and tachypnea indicate exhaustion and need for mechanical ventilation.
A 65-year-old with dyspnea has bilateral infiltrates and SpO2 82%. What is the diagnosis?
ARDS, where bilateral infiltrates and severe hypoxia (PaO2/FiO2 <300) suggest acute lung injury from sepsis or trauma.
A 50-year-old with trauma has a flail chest and RR 38. What is the ventilatory support?
Mechanical ventilation via intubation with volume control (6 mL/kg IBW) to stabilize chest wall and ensure adequate oxygenation.
A 35-year-old with dyspnea has a Wells score of 5 and RV strain. What is the anticoagulant?
Heparin 80 units/kg IV bolus then 18 units/kg/h infusion to prevent further embolization in this confirmed pulmonary embolism.
A 60-year-old with COPD has a pH of 7.20 and PaCO2 85 mmHg. What is the next step?
Intubate with RSI (e.g., propofol 1-2 mg/kg IV) due to severe acidosis and hypercapnia unresponsive to NIV.
A 25-year-old with asthma has a peak flow of 25% and SpO2 90%. What is the IV steroid?
Hydrocortisone 100 mg IV stat to reduce airway inflammation, followed by oral prednisolone 50 mg daily for 5 days.
A 70-year-old with pneumonia has a SpO2 of 87% on 10 L/min. What is the disposition?
ICU admission for probable intubation and advanced respiratory support given persistent hypoxia in severe pneumonia.
A 45-year-old with trauma has a tension pneumothorax and hypoxia. What is the needle size?
14-gauge needle at the 2nd ICS, midclavicular line, to decompress tension and restore lung expansion urgently.
A 30-year-old with dyspnea has bilateral wheeze and angioedema. What is the treatment?
IM adrenaline 0.5 mg (1:1000) stat, followed by H1-blocker (e.g., cetirizine 10 mg) and hydrocortisone 200 mg IV for anaphylaxis.
A 55-year-old with COPD has a PaCO2 of 60 mmHg and pH 7.34. What is the treatment?
Salbutamol 5 mg and ipratropium 500 mcg nebulized every 20 minutes to reverse bronchospasm in this compensated exacerbation.
A 40-year-old with pneumonia has a BP of 90/60 and lactate 3 mmol/L. What is the fluid volume?
30 mL/kg crystalloid (e.g., normal saline) over 1 hour to improve perfusion in early septic shock, guided by lactate.
A 28-year-old with asthma is intubated and has hypotension. What is the ventilator adjustment?
Decrease rate to 6-8/min and extend expiratory time (I:E 1:4) to reduce auto-PEEP and improve venous return.
A 65-year-old with dyspnea has a massive PE and RV dysfunction. What is the thrombolytic?
Alteplase 100 mg IV over 2 hours (10 mg bolus, 90 mg infusion) to relieve RV strain and restore pulmonary flow in massive PE.
A 50-year-old with trauma has a hemopneumothorax and SpO2 85%. What is the chest tube site?
5th intercostal space, anterior axillary line, using a 32-36 Fr tube to drain both blood and air effectively.
A 35-year-old with dyspnea has a D-dimer of 1200 ng/mL and tachycardia. What is the imaging?
CTPA to confirm pulmonary embolism, as tachycardia and elevated D-dimer in a young patient suggest moderate-high risk.
A 60-year-old with COPD has a PaCO2 of 80 mmHg and pH 7.25. What is the BiPAP adjustment?
Increase IPAP to 16-18 cmH2O from baseline to enhance tidal volume and CO2 clearance in worsening hypercapnia.
A 25-year-old with asthma has a silent chest and RR 42. What is the next step?
RSI with ketamine 1-2 mg/kg IV and rocuronium 1 mg/kg IV due to critical airflow limitation and imminent arrest.
A 70-year-old with pneumonia has a CURB-65 of 3 and lactate 2 mmol/L. What is the antibiotic?
Ceftriaxone 1 g IV plus azithromycin 500 mg IV to cover severe CAP, with HDU monitoring for potential deterioration.
A 45-year-old with trauma has a flail chest and hypoxia. What is the analgesia?
Fentanyl 1-2 mcg/kg IV stat, repeated as needed, to control pain and improve ventilation without excessive sedation.
A 30-year-old with dyspnea has a barking cough and stridor. What is the steroid?
Dexamethasone 0.6 mg/kg IV (max 16 mg) to reduce laryngeal inflammation in croup, complementing nebulized adrenaline.
A 55-year-old with COPD has a PaO2 of 50 mmHg and PaCO2 65 mmHg. What is the oxygen delivery?
Venturi mask at 28-35% FiO2 to achieve SpO2 88-92%, balancing oxygenation and CO2 retention risk.
A 40-year-old with pneumonia has a pleural effusion with glucose <2 mmol/L. What is the treatment?
Chest tube drainage (14-20 Fr) for empyema, with antibiotics (e.g., piperacillin-tazobactam 4.5 g IV) targeting anaerobic infection.
A 28-year-old with asthma has a PaCO2 of 50 mmHg and SpO2 88%. What is the next step?
Trial NIV (IPAP 12 cmH2O, EPAP 5 cmH2O) for 1-2 hours to support ventilation, escalating to intubation if PaCO2 rises further.
A 65-year-old with dyspnea has bilateral infiltrates and SpO2 82%. What is the ventilator mode?
Volume control with tidal volume 6 mL/kg IBW, PEEP 8-12 cmH2O, FiO2 titrated to SpO2 >90% for ARDS.
A 50-year-old with trauma has a pneumothorax and RR 40. What is the chest tube size?
28-32 Fr at the 5th ICS, anterior axillary line, to evacuate air and stabilize breathing in this traumatic pneumothorax.
A 35-year-old with dyspnea has a Wells score of 6 and hypotension. What is the thrombolytic dose?
Alteplase 100 mg IV over 2 hours (10 mg bolus, 90 mg infusion) for massive PE with hemodynamic instability.
A 60-year-old with COPD has a pH of 7.22 and PaCO2 75 mmHg. What is the NIV setting?
IPAP 14 cmH2O, EPAP 6 cmH2O, adjusted upward if needed, to improve ventilation and correct acidosis.
A 25-year-old with asthma has a peak flow of 28% and SpO2 89%. What is the IV drug?
Magnesium sulfate 2 g IV over 20 minutes to relax bronchial smooth muscle and enhance bronchodilation in severe asthma.
A 70-year-old with pneumonia has a SpO2 of 86% on NRB. What is the next step?
Intubate with RSI (e.g., ketamine 1-2 mg/kg IV) due to persistent hypoxia indicating need for mechanical ventilation.
A 45-year-old with trauma has a sucking chest wound and RR 35. What is the dressing?
Three-sided occlusive dressing (e.g., petroleum gauze) to allow air exit, followed by chest tube to manage open pneumothorax.
A 30-year-old with dyspnea has stridor and a recent intubation. What is the treatment?
Urgent ENT consult for possible laryngoscopy or tracheostomy due to post-extubation subglottic stenosis causing obstruction.
A 55-year-old with COPD has a PaCO2 of 70 mmHg and pH 7.30. What is the treatment?
Salbutamol 5 mg and ipratropium 500 mcg nebulized every 20 minutes, with BiPAP if RR increases or pH drops.
A 40-year-old with pneumonia has a BP of 85/50 and lactate 4 mmol/L. What is the vasopressor?
Noradrenaline 0.01-0.5 mcg/kg/min IV after 30 mL/kg fluids to maintain MAP ≥65 mmHg in septic shock.
A 28-year-old with asthma is intubated and has hypotension. What is the ventilator adjustment?
Decrease rate to 6/min and extend I:E to 1:4 to reduce dynamic hyperinflation, improving cardiac output.
A 65-year-old with dyspnea has a massive PE and hypoxia. What is the anticoagulant dose?
Heparin 80 units/kg IV bolus followed by 18 units/kg/h infusion to prevent further clot growth in massive PE.
A 50-year-old with trauma has a hemothorax and SpO2 87%. What is the blood volume?
10 mL/kg packed red cells IV if >1500 mL drained initially, with surgical consult for ongoing bleeding.
A 35-year-old with dyspnea has a D-dimer of 900 ng/mL and RV strain. What is the next step?
CTPA to confirm pulmonary embolism, as RV strain on echo and elevated D-dimer indicate significant clot burden.
A 60-year-old with COPD has a PaCO2 of 80 mmHg and RR 30. What is the initial support?
BiPAP (IPAP 15 cmH2O, EPAP 5 cmH2O) with salbutamol nebs to reduce CO2 and support fatiguing respiratory muscles.
What is the initial management step for a patient with suspected tension pneumothorax in the ED?
Perform immediate needle decompression by inserting a 14-16 gauge cannula into the 2nd intercostal space, midclavicular line on the affected side. This relieves pressure from trapped pleural air compressing the lung and mediastinum, impairing venous return. A hiss of air confirms diagnosis. Follow with a chest tube (4th-5th intercostal space, anterior axillary line). Monitor for re-accumulation; consider trauma or barotrauma as causes.
What are the clinical signs of tension pneumothorax?
Hypotension, tracheal deviation to the opposite side, absent breath sounds on the affected side, and distended neck veins. Tachypnea and hypoxia are common due to lung collapse and mediastinal shift. Diagnose clinically in extremis; urgent decompression precedes imaging. Caused by a one-way valve mechanism (e.g., penetrating trauma).
What is the target SpO2 for a patient with an acute COPD exacerbation?
88-92%, per ACEM and BTS guidelines. Chronic hypercapnia in COPD patients relies on hypoxic drive; excess oxygen (>92%) risks CO2 retention via Haldane effect and V/Q mismatch. Use a Venturi mask (24-28%) and monitor ABG for PaCO2 rise. Escalate to NIV (BiPAP) if pH <7.35.
What is the most common cause of community-acquired pneumonia in NSW?
Streptococcus pneumoniae, a gram-positive diplococcus, accounts for 20-60% of CAP cases. Presents with lobar consolidation, rusty sputum, and fever. Diagnose with chest X-ray (infiltrates) and sputum culture; treat empirically with amoxicillin ± macrolide (CURB-65 for severity).
What is the treatment for severe asthma not responding to initial salbutamol?
Administer IV magnesium sulfate (2 g over 20 minutes) to relax bronchial smooth muscle. Use if no response to continuous nebulized salbutamol (5 mg) and ipratropium. Add IV hydrocortisone (200 mg) for inflammation. Monitor for silent chest or respiratory failure (ABG); consider ICU.
What are the diagnostic criteria for acute respiratory distress syndrome (ARDS)?
Per Berlin criteria: bilateral infiltrates on CXR/CT, PaO2/FiO2 ratio <300 mmHg (on PEEP ≥5 cmH2O), onset within 1 week of insult (e.g., sepsis), and not fully explained by cardiac failure. Reflects diffuse alveolar damage. Treat with lung-protective ventilation (TV 6 mL/kg).
What is the most common cause of spontaneous pneumothorax in young adults?
Rupture of subpleural blebs in tall, thin males (primary spontaneous). Presents with sudden chest pain and dyspnea. CXR shows a visceral pleural line. Small (<2 cm apex-to-cupola): observe with oxygen; large: chest tube. Recurrence risk ~30%.
What is the classic triad of pulmonary embolism?
Dyspnea, pleuritic chest pain, hemoptysis—though present in <20% of cases. Dyspnea reflects V/Q mismatch, pain from pleural infarction, hemoptysis from alveolar bleed. Tachycardia and hypoxemia are more common. Confirm with CTPA; risk stratify with Wells score.
What is the initial management of acute pulmonary edema in the ED?
Provide high-flow oxygen (target SpO2 >94%), nitrates (GTN 400-800 µg SL, then IV if BP allows), CPAP (5-10 cmH2O) to reduce preload/afterload, and furosemide (40-80 mg IV) for diuresis. Caused by LV failure (e.g., MI). Monitor for hypotension.
What is the most common cause of upper airway obstruction in children?
Croup (viral laryngotracheobronchitis, often parainfluenza) causes subglottic swelling, leading to stridor, barking cough, and hoarseness. Peak age 6 months-3 years. Treat with dexamethasone (0.6 mg/kg PO/IM) and nebulized adrenaline if severe.
What is the treatment for massive pulmonary embolism with hemodynamic instability?
Administer thrombolysis (alteplase 100 mg IV over 2 hours) to lyse the clot and relieve RV strain (SBP <90 mmHg, RV dilation on echo). Contraindications include recent surgery. Support with fluids, noradrenaline; consider ECMO if thrombolysis fails.
What ECG changes suggest pulmonary embolism?
S1Q3T3 pattern (S wave in I, Q wave in III, inverted T in III), though rare (<20%). More common: sinus tachycardia, RV strain (RBBB, T-wave inversion V1-V4). Reflects acute RV pressure overload. CTPA confirms diagnosis; ECG guides urgency.
What is the most common organism causing epiglottitis in adults?
Streptococcus pyogenes (Group A Strep) causes supraglottic inflammation, leading to stridor, dysphagia, and drooling. Less common since Hib vaccine in kids. Diagnose with lateral neck X-ray (thumb sign) or laryngoscopy; secure airway, give ceftriaxone + steroids.
What are the signs of a flail chest?
Paradoxical chest wall movement (segment moves inward on inspiration), dyspnea, and severe pain from ≥3 contiguous rib fractures. Hypoxia results from underlying contusion. Diagnose clinically/CXR; treat with analgesia (e.g., PCA), oxygen, consider ventilation.
What is the treatment for a severe COPD exacerbation with respiratory acidosis?
Initiate non-invasive ventilation (NIV) (BiPAP, e.g., IPAP 10-15, EPAP 4-5 cmH2O) if pH <7.35 despite oxygen and bronchodilators (salbutamol, ipratropium). Improves ventilation, reduces CO2. Monitor ABG; intubate if NIV fails or contraindicated (e.g., coma).
What is the most common cause of hemoptysis in Australia?
Bronchitis, often viral/bacterial, irritates airways, causing small vessel bleeding. Presents with blood-streaked sputum and cough. Differentiate from massive hemoptysis (e.g., TB, cancer) with CXR/history. Treat supportively; investigate if persistent.
What is the diagnostic test for suspected pulmonary embolism in pregnancy?
V/Q scan if chest X-ray normal (lower fetal radiation vs. CTPA). If X-ray abnormal or V/Q indeterminate, use CTPA. PE risk rises in pregnancy (hypercoagulability). Use modified Wells score; D-dimer less specific. Balance maternal/fetal safety.
What are the features of a severe asthma attack?
Inability to speak in sentences, respiratory rate >30/min, heart rate >120 bpm, SpO2 <92% on air, silent chest, indicating severe airflow obstruction. PEF <50% predicted if measurable. Treat as life-threatening; escalate to IV magnesium, ICU if unresponsive.
What is the management of a simple pneumothorax >2 cm in a stable patient?
Insert a chest tube (e.g., 12-16 Fr, 4th-5th intercostal space, anterior axillary line) connected to an underwater seal. Oxygen accelerates reabsorption. Monitor CXR post-insertion; remove when no air leak and lung re-expanded. Recurrence risk guides pleurodesis.
What is the most common cause of hospital-acquired pneumonia?
Pseudomonas aeruginosa, a gram-negative bacillus, common in ventilated or immunocompromised patients. Presents with fever, purulent sputum, new infiltrates. Treat with piperacillin-tazobactam or meropenem; culture guides therapy.
What is the treatment for anaphylaxis with respiratory compromise?
Give adrenaline (0.5 mg IM, 1:1000, repeat q5 min if needed) to reverse bronchospasm and hypotension. Add oxygen, IV fluids (1 L NS), antihistamines (e.g., cetirizine), and steroids (hydrocortisone 200 mg IV). Monitor airway; intubate if stridor persists.
What are the CXR findings in pulmonary edema?
Bilateral perihilar haziness, interstitial markings, Kerley B lines, pleural effusions. Reflects fluid in alveoli/interstitium from LV failure. Differentiate from pneumonia (focal consolidation). Treat with nitrates, CPAP; echo confirms cardiac cause.
What is the most common viral cause of pneumonia in children?
Respiratory syncytial virus (RSV) causes bronchiolitis/pneumonia in <2-year-olds, with wheezing, crackles, and hypoxia. Diagnose clinically; CXR shows hyperinflation, patchy infiltrates. Supportive care (oxygen, fluids); ribavirin rarely used.
What is the management of a patient with suspected foreign body aspiration?
Assess airway: if complete obstruction, perform Heimlich maneuver; if partial, urgent bronchoscopy (rigid preferred) to remove the object (e.g., peanut). CXR may show hyperinflation or collapse distal to blockage. Oxygen, stabilize pre-procedure.
What is the hallmark sign of pleural effusion on physical exam?
Dullness to percussion over the affected lung field, with reduced breath sounds and tactile fremitus. Large effusions cause dyspnea, tracheal shift (if massive). Confirm with CXR (blunted costophrenic angle); ultrasound guides thoracentesis.
What is the treatment for massive hemoptysis (>500 mL/24h)?
Secure airway (intubate if unstable), position bleeding lung down, resuscitate with blood/fluids. Urgent CT angiography identifies source (e.g., bronchiectasis); bronchial artery embolization or surgery if uncontrolled. Antibiotics if infection-driven.
What is the most common cause of secondary spontaneous pneumothorax?
Chronic obstructive pulmonary disease (COPD), from bullae rupture in emphysema. More severe than primary; presents with dyspnea, hypoxia. CXR confirms; treat with chest tube, oxygen. High recurrence risk; consider pleurodesis.
What are the diagnostic criteria for ventilator-associated pneumonia (VAP)?
New/progressive infiltrate on CXR after ≥48 hours of ventilation, plus ≥2 of: fever (>38°C), leukocytosis/leukopenia, purulent secretions, worsening oxygenation. Culture ETT aspirate; treat empirically (e.g., piperacillin-tazobactam) pending results.
What is the treatment for acute epiglottitis with airway compromise?
Secure airway (intubation in OR by ENT, avoid blind attempts), give IV ceftriaxone (1-2 g) for bacterial coverage (e.g., Strep pyogenes), and dexamethasone (10 mg IV) to reduce swelling. Stridor, drooling indicate urgency; lateral X-ray (thumb sign) confirms.
What is the most common cause of bronchiolitis in infants?
Respiratory syncytial virus (RSV), a paramyxovirus, causes small airway inflammation, wheezing, and crackles in <2-year-olds. Diagnose clinically; supportive care (oxygen, hydration) is mainstay. High-risk (e.g., prematurity) may get palivizumab prophylaxis.
What are the signs of respiratory distress in a neonate?
Tachypnea (>60/min), nasal flaring, grunting, intercostal retractions, cyanosis. Reflects immature lungs or pathology (e.g., RDS). Assess SpO2, CXR; treat with oxygen, CPAP, or surfactant if preterm (RDS). Urgent neonatal consult.
What is the management of a patient with suspected carbon monoxide poisoning affecting respiration?
Administer 100% oxygen via non-rebreather (reduces CO half-life from 4-6 hours to ~1 hour) or hyperbaric oxygen if severe (COHb >25%, neuro symptoms). CO binds Hb 200x stronger than O2, causing hypoxia. Monitor COHb, ECG, neuro status.
What is the most common cause of chronic cough in adults?
Postnasal drip (upper airway cough syndrome), often from rhinitis/sinusitis, causes persistent throat irritation. History of nasal congestion, mucus. Treat with antihistamines, nasal steroids (e.g., budesonide); CXR if atypical to exclude malignancy.
What is the treatment for a tension pneumothorax not responding to needle decompression?
Insert a chest tube immediately (e.g., 28-32 Fr, 4th-5th intercostal space, anterior axillary line) if needle decompression fails (persistent hypotension, hypoxia). Suspect cannula misplacement or large leak. Surgical consult if ongoing air leak.
What are the CXR findings in pneumothorax?
Visceral pleural line with absent lung markings beyond it, possible mediastinal shift if tension. Small pneumothoraces (<1 cm) may be subtle; expiratory films enhance visibility. Ultrasound (no lung sliding, barcode sign) is more sensitive.
What is the most common bacterial cause of pneumonia in alcoholics?
Klebsiella pneumoniae, a gram-negative bacillus, causes severe, necrotizing pneumonia with “currant jelly” sputum (hemoptysis). CXR shows cavitation. Treat with ceftriaxone + gentamicin; high mortality if delayed.
What is the management of a patient with suspected pertussis in the ED?
Isolate (droplet precautions), treat with azithromycin (500 mg day 1, 250 mg days 2-5) to reduce infectivity, support with oxygen if needed. Paroxysmal cough, whoop, post-tussive vomiting in unvaccinated. Diagnose with PCR; notify public health.
What are the signs of impending respiratory failure in asthma?
Silent chest, exhaustion, altered mental status, SpO2 <90% despite oxygen, PaCO2 >45 mmHg (normalizing from hypocapnia). Indicates severe obstruction/fatigue. Intubate urgently; use ketamine (bronchodilator) for induction.
What is the treatment for pulmonary contusion in trauma?
Provide oxygen to maintain SpO2 >94%, aggressive analgesia (e.g., intercostal block, PCA) to optimize breathing, and monitor for deterioration (CXR shows patchy infiltrates). Avoid overhydration; ventilate if ARDS develops.
What is the most common cause of stridor in adults?
Laryngeal edema from anaphylaxis or infection (e.g., epiglottitis). Presents with inspiratory stridor, dyspnea. Diagnose with laryngoscopy (if safe); treat with adrenaline (anaphylaxis) or antibiotics/steroids (infection). Secure airway if worsening.
What are the diagnostic features of a massive pleural effusion?
Tracheal deviation to the opposite side, stony dullness, absent breath sounds, dyspnea. CXR shows complete opacification with mediastinal shift. Thoracentesis (diagnostic/therapeutic) relieves pressure; analyze fluid (e.g., Light’s criteria).
What is the treatment for cyanide poisoning affecting respiration?
Administer hydroxocobalamin (5 g IV over 15 minutes) to bind cyanide into cyanocobalamin, plus 100% oxygen. Alternative: sodium thiosulfate (12.5 g IV). Rapid apnea from cytochrome oxidase inhibition (e.g., smoke inhalation). Monitor in ICU.
What is the most common cause of pneumonia in cystic fibrosis?
Pseudomonas aeruginosa, thrives in thick mucus, causing recurrent infections. Presents with increased sputum, fever, dyspnea. Treat with IV antipseudomonal (e.g., ceftazidime + tobramycin); bronchoscopy if severe. Chronic therapy includes azithromycin.
What is the management of a patient with suspected tracheobronchial injury?
Suspect in blunt/penetrating trauma with subcutaneous emphysema, pneumomediastinum, persistent pneumothorax. CT chest confirms; urgent bronchoscopy localizes tear. Secure airway (avoid over-pressurizing), surgical repair by thoracic team.
What are the signs of acute exacerbation of interstitial lung disease?
Worsening dyspnea, dry cough, new ground-glass opacities on CT, often triggered by infection or unknown cause. Hypoxia progresses rapidly. Treat with high-dose steroids (methylprednisolone 1 g/day IV x3), oxygen; prognosis poor if idiopathic.
What is the treatment for severe bronchiectasis exacerbation?
Give IV antibiotics (e.g., piperacillin-tazobactam) based on prior cultures (often Pseudomonas), chest physiotherapy to clear secretions, and oxygen if hypoxic. Chronic dilatation causes purulent sputum, hemoptysis. Admit; consider bronchoscopy if refractory.
What is the most common cause of lung abscess?
Aspiration of anaerobic oral flora (e.g., Peptostreptococcus) in alcoholics, seizure patients. Presents with foul sputum, fever, cavitation on CXR/CT. Treat with clindamycin or amoxicillin-clavulanate; drain if large (>6 cm).
What are the CXR findings in ARDS?
Diffuse bilateral infiltrates, often “whiteout” appearance, from alveolar flooding (e.g., sepsis, trauma). No cardiomegaly or pleural effusions (unlike CHF). PaO2/FiO2 <300 mmHg. Treat with low tidal volume ventilation (6 mL/kg), PEEP.
What is the management of a patient with suspected opioid-induced respiratory depression?
Administer naloxone (0.4-2 mg IV/IM, titrate q2-3 min) to reverse μ-receptor-mediated apnea. Onset 1-2 minutes; repeat or infuse (2/3 effective dose/hour) for long-acting opioids (e.g., methadone). Support ventilation first; monitor for withdrawal.
What is the most common cause of nosocomial pneumonia in ICU?
Pseudomonas aeruginosa, prevalent in ventilated patients due to biofilm formation. Fever, purulent sputum, new infiltrates after 48 hours. Treat empirically with meropenem or piperacillin-tazobactam; adjust per culture.
What are the signs of a pulmonary embolism with RV strain?
Hypotension, tachycardia, elevated JVP, RV heave, with echo showing RV dilation/hypokinesis. ECG may show RBBB, T-wave inversion V1-V4. Massive PE obstructs >30% pulmonary flow. Thrombolyse if unstable; heparin if stable.
What is the treatment for severe croup with stridor at rest?
Give nebulized adrenaline (5 mL of 1:1000) for rapid vasoconstriction, plus dexamethasone (0.6 mg/kg PO/IM) to reduce inflammation. Monitor airway; intubate if worsening (rare). Parainfluenza drives subglottic edema.
What is the most common cause of pneumonia in immunocompromised patients?
Pneumocystis jirovecii (PCP) in HIV (CD4 <200) or transplant patients. Diffuse interstitial infiltrates, hypoxia, dry cough. Diagnose with induced sputum (silver stain); treat with trimethoprim-sulfamethoxazole + steroids if PaO2 <70 mmHg.
What are the diagnostic features of empyema?
Pleural fluid pH <7.2, glucose <2.2 mmol/L, LDH >1000 IU/L, with loculations on ultrasound/CT. Complicates pneumonia (e.g., S. pneumoniae). Fever, pleuritic pain persist. Drain with chest tube + antibiotics (e.g., ceftriaxone).
What is the management of a patient with suspected smoke inhalation injury?
Assess for airway burns (soot, stridor—intubate early), give 100% oxygen for CO/cyanide, check COHb/lactate. Bronchoscopy confirms injury (edema, charring); steroids/antibiotics only if infected. Monitor for ARDS.
What is the most common cause of wheezing in adults?
Asthma, from reversible airway obstruction (allergens, infection). Wheeze, dyspnea, cough; PEF reduced. Treat with salbutamol (nebulized 5 mg), steroids (prednisolone 50 mg). Differentiate from COPD (irreversible, smoking history).
What are the signs of hypercapnic respiratory failure?
PaCO2 >50 mmHg, confusion, drowsiness, asterixis, from hypoventilation (e.g., COPD, neuromuscular disease). Tachypnea early, then bradypnea. Treat underlying cause; NIV (BiPAP) improves ventilation, avoiding intubation.
What is the treatment for acute exacerbation of pulmonary fibrosis?
High-dose methylprednisolone (1 g/day IV x3) for inflammation, oxygen to maintain SpO2 >90%, supportive care. Rapid dyspnea, ground-glass on CT. Poor prognosis; rule out infection/CHF. Lung transplant may be considered.
What is the most common cause of aspiration pneumonia?
Anaerobic bacteria (e.g., Bacteroides) from oral flora in patients with impaired consciousness (e.g., stroke, alcohol). Right lower lobe infiltrate, foul sputum. Treat with amoxicillin-clavulanate; CT if abscess suspected.
What are the CXR findings in pulmonary embolism?
Often normal; Westermark sign (oligemia distal to clot), Hampton’s hump (wedge-shaped opacity), or Fleischner sign (enlarged central artery) are rare. CTPA is diagnostic; CXR excludes mimics (e.g., pneumothorax).
What is the management of a patient with suspected allergic bronchopulmonary aspergillosis (ABPA)?
Treat with oral prednisone (0.5 mg/kg/day, taper over weeks) for inflammation, itraconazole (200 mg BD) for Aspergillus. Asthma, eosinophilia, IgE >1000 IU/mL, fleeting infiltrates. Monitor lung function, CXR.
What is the most common cause of pneumonia in neonates?
Group B Streptococcus (GBS) from maternal colonization, acquired perinatally. Tachypnea, grunting, infiltrates on CXR. Treat with ampicillin + gentamicin; urgent neonatal consult. Differentiate from RDS (preterm, surfactant-deficient).
What are the signs of a severe pulmonary hemorrhage?
Hemoptysis (>200 mL/24h), hypoxia, anemia, diffuse infiltrates on CXR, from alveolar bleeding (e.g., vasculitis, trauma). Shock if massive. Intubate, transfuse, urgent bronchoscopy/CT to localize; treat cause (e.g., steroids for Goodpasture’s).
What is the treatment for severe pertussis with respiratory distress?
Support with oxygen, azithromycin (500 mg day 1, 250 mg days 2-5) to reduce spread, isolate. Paroxysmal cough exhausts infants; apnea common. Admit high-risk (e.g., <6 months); ECMO rare but life-saving if hypoxic failure.
What is the most common cause of chylothorax?
Trauma (e.g., thoracic surgery, penetrating injury) disrupts thoracic duct, causing milky pleural fluid (triglycerides >110 mg/dL). Dyspnea, no fever. Diagnose with thoracentesis; treat with drainage, low-fat diet, octreotide if persistent.
What are the diagnostic features of acute bronchiolitis?
Wheezing, crackles, tachypnea in <2-year-olds, often RSV-driven. CXR shows hyperinflation, atelectasis. SpO2 <92% guides admission. Supportive care (oxygen, fluids); bronchodilators controversial (trial if severe).
What is the management of a patient with suspected laryngeal fracture?
Suspect in blunt neck trauma with hoarseness, stridor, subcutaneous emphysema. CT neck confirms; secure airway (intubation/tracheostomy by ENT), avoid manipulation. Steroids reduce edema; surgical repair if displaced.
What is the most common cause of pneumonia in HIV patients with CD4 <200?
Pneumocystis jirovecii (PCP), causing dry cough, hypoxia, interstitial infiltrates. LDH elevated; diagnose with sputum PCR. Treat with trimethoprim-sulfamethoxazole (15-20 mg/kg/day TMP) + prednisone if PaO2 <70 mmHg.
What are the signs of a bronchopleural fistula?
Persistent air leak post-chest tube, bubbling in underwater seal, failure of lung re-expansion. Common post-lung surgery/trauma. CT locates; treat with large-bore tube, suction, surgical closure if large (>5 mm).
What is the treatment for severe pneumonia with septic shock?
Broad-spectrum antibiotics (e.g., ceftriaxone 2 g IV + azithromycin) within 1 hour, fluids (30 mL/kg NS), noradrenaline if MAP <65 mmHg. Source control (e.g., empyema drainage). Monitor lactate, cultures guide de-escalation.
What is the most common cause of pulmonary hypertension in young adults?
Idiopathic pulmonary arterial hypertension (IPAH), a rare vasculopathy, causes dyspnea, fatigue, RV failure. Echo shows elevated PA pressure (>25 mmHg at rest); RHC confirms. Treat with vasodilators (e.g., sildenafil), oxygen.
What are the CXR findings in tension pneumothorax?
Hyperlucency on affected side, mediastinal shift to opposite side, flattened diaphragm, from air trapping under pressure. Tracheal deviation visible late. Immediate decompression critical; CXR delays treatment in extremis.
What is the management of a patient with suspected vocal cord dysfunction?
Suspect in paradoxical inspiratory stridor, normal SpO2, often anxiety-driven. Diagnose with laryngoscopy (adducted cords on inspiration). Calm patient, coach breathing (pursed lips); no role for bronchodilators. Mimics asthma.
What is the most common cause of pneumonia post-influenza?
Staphylococcus aureus (MSSA/MRSA), a secondary bacterial infection, causes necrotizing pneumonia with hemoptysis, cavitation. Treat with vancomycin or flucloxacillin; high mortality if delayed. CXR shows rapid progression.
What are the signs of acute respiratory alkalosis?
PaCO2 <35 mmHg, pH >7.45, dizziness, paresthesia, from hyperventilation (e.g., anxiety, PE). Tachypnea common; treat underlying cause (e.g., oxygen for hypoxia). Rebreathing into a bag rarely needed.
What is the treatment for severe pulmonary edema with hypotension?
CPAP (10 cmH2O) or BiPAP, inotropes (e.g., dobutamine 5-20 µg/kg/min) for cardiogenic shock, cautious fluids. Nitrates contraindicated if SBP <90 mmHg. Echo guides therapy; urgent PCI if MI-driven.
What is the most common cause of hemothorax in trauma?
Intercostal artery injury from rib fractures, causing >1500 mL blood in pleural space. Shock, dullness, absent breath sounds. CXR/ultrasound confirms; chest tube, transfusion, thoracotomy if bleeding >200 mL/hour.
What are the diagnostic features of tuberculous pleural effusion?
Exudative fluid (Light’s criteria), lymphocytic predominance, ADA >40 U/L, positive AFB smear/culture (low yield). Chronic cough, night sweats. Thoracentesis + pleural biopsy; treat with RIPE (rifampicin, isoniazid, pyrazinamide, ethambutol).
What is the management of a patient with suspected angioedema affecting the airway?
Adrenaline (0.5 mg IM) if allergic, C1 esterase inhibitor or FFP if hereditary, secure airway if stridor (intubation/tracheostomy). Swelling of tongue/larynx; steroids, antihistamines for allergic type. Monitor closely; CT if unclear cause.
What is the most common cause of pneumonia in nursing home residents?
Streptococcus pneumoniae, followed by gram-negatives (e.g., E. coli). Aspiration risk high; presents with altered mental status, infiltrates. Treat with ceftriaxone + azithromycin; adjust per cultures, frailty.
What are the signs of a severe COPD exacerbation?
Accessory muscle use, cyanosis, SpO2 <88% on air, confusion, indicating ventilatory failure (PaCO2 >50 mmHg). Silent chest rare. NIV if pH <7.35; bronchodilators (salbutamol, ipratropium), steroids (prednisolone 50 mg).
What is the treatment for acute asthma with pneumomediastinum?
Manage asthma (salbutamol 5 mg neb, hydrocortisone 200 mg IV), observe pneumomediastinum (CXR: air around mediastinum). Rare from alveolar rupture; resolves spontaneously unless tension (subcutaneous emphysema). Avoid positive pressure if possible.
What is the most common cause of pulmonary edema in renal failure?
Fluid overload from impaired excretion, raising pulmonary capillary pressure. Dyspnea, crackles, bilateral infiltrates. Treat with dialysis (urgent if refractory), cautious diuresis (furosemide), oxygen. Echo excludes cardiac cause.
What are the CXR findings in bronchiectasis?
Tram-track lines, ring shadows, cystic dilatation, from chronic airway damage (e.g., CF, infections). Sputum copious, purulent. CT confirms; physiotherapy, antibiotics (culture-guided) manage exacerbations.
What is the management of a patient with suspected airway burn?
Early intubation if signs of injury (soot in mouth, hoarse voice, stridor), oxygen, bronchoscopy to assess extent (edema, charring). Steroids controversial; monitor for ARDS, infection. High mortality if delayed.
What is the most common cause of atypical pneumonia?
Mycoplasma pneumoniae, causing walking pneumonia with dry cough, low-grade fever, patchy infiltrates. Diagnose with PCR/serology; treat with azithromycin (500 mg day 1, 250 mg days 2-5). Common in young adults.
What are the signs of a severe allergic reaction affecting respiration?
Bronchospasm (wheeze), laryngeal edema (stridor), hypoxia, from mast cell degranulation (e.g., peanuts). Hypotension may coexist. Adrenaline IM (0.5 mg), oxygen, fluids; intubate if airway swells.
What is the treatment for severe ARDS with refractory hypoxia?
Prone positioning (16-18 hours/day) improves V/Q matching, ECMO if PaO2/FiO2 <80 mmHg despite max ventilation (TV 6 mL/kg, PEEP). Paralytics (e.g., cisatracurium) reduce O2 demand. ICU; mortality high.
What is the most common cause of pneumonia in ventilated neonates?
Staphylococcus aureus (often MRSA), from invasive devices. Tachypnea, infiltrates post-48 hours. Treat with vancomycin; culture ETT aspirate. Differentiate from RDS (surfactant-deficient, preterm).
What are the diagnostic features of pulmonary infarction?
Pleuritic pain, hemoptysis, wedge-shaped opacity on CT (Hampton’s hump rare), from distal PE occlusion. Hypoxia moderate. CTPA confirms; treat with anticoagulation (e.g., heparin), oxygen.
What is the management of a patient with suspected pneumocystis pneumonia?
Trimethoprim-sulfamethoxazole (15-20 mg/kg/day TMP IV) for 21 days, prednisone (40 mg BD) if PaO2 <70 mmHg. Hypoxia, dry cough, interstitial infiltrates in HIV (CD4 <200). Sputum PCR; oxygen support critical.
What is the most common cause of respiratory failure in neuromuscular disease?
Diaphragmatic weakness (e.g., Guillain-Barré, myasthenia gravis) reduces tidal volume, causing hypercapnia. Fatigue, shallow breathing, PaCO2 >50 mmHg. NIV.
What is the treatment for hypoxia in HIV patients?
TMP IV for 21 days, prednisone (40 mg BD) if PaO2 <70 mmHg. Hypoxia, dry cough, interstitial infiltrates in HIV (CD4 <200). Sputum PCR; oxygen support critical.
What is the most common cause of respiratory failure in neuromuscular disease?
Diaphragmatic weakness (e.g., Guillain-Barré, myasthenia gravis) reduces tidal volume, causing hypercapnia. Fatigue, shallow breathing, PaCO2 >50 mmHg. NIV (BiPAP) supports; intubate if vital capacity <15 mL/kg.
What are the signs of a severe asthma exacerbation in a child?
Retractions, nasal flaring, SpO2 <92%, silent chest, inability to feed/speak. PEF <50% predicted if measurable. Salbutamol (2.5-5 mg neb), oxygen, steroids (prednisolone 1 mg/kg); ICU if deteriorating.
What is the treatment for severe pulmonary hypertension crisis?
Inhaled nitric oxide (20-40 ppm) reduces PA pressure, IV epoprostenol (2-10 ng/kg/min) vasodilates, oxygen to SpO2 >90%. RV failure (JVP, hypotension) drives hypoxia. Echo guides; ECMO bridge to transplant.
What is the most common cause of pneumonia in smokers?
Streptococcus pneumoniae, exacerbated by ciliary dysfunction, followed by Haemophilus influenzae. Cough, sputum, infiltrates. Treat with amoxicillin or ceftriaxone; smoking cessation critical. CXR confirms.
What are the CXR findings in pleural effusion?
Blunted costophrenic angle, meniscus sign, opacity layering on upright film. Large effusions shift mediastinum. Ultrasound quantifies; thoracentesis (e.g., transudate vs. exudate) guides cause (CHF, malignancy).
What is the management of a patient with suspected blast lung injury?
High-flow oxygen, monitor for pneumothorax/hemothorax (CXR), avoid overhydration (risks edema). Barotrauma causes alveolar rupture, dyspnea, hypoxia. Intubate if ARDS; chest tubes for pneumothorax.
What is the most common cause of acute respiratory failure in the elderly?
Pneumonia, often S. pneumoniae or gram-negatives, worsened by comorbidities (e.g., COPD). Confusion, hypoxia, infiltrates. Antibiotics (e.g., ceftriaxone), oxygen; NIV if hypercapnic. High mortality.
What are the signs of a severe tracheoesophageal fistula?
Coughing with feeds, recurrent pneumonia, air in stomach on CXR, from congenital or traumatic connection. Dyspnea, cyanosis in infants. Endoscopy confirms; surgical repair urgent. Support respiration pre-op.
What is the treatment for severe respiratory distress in anaphylaxis?
Adrenaline (0.5 mg IM, repeat q5 min), oxygen, IV fluids (1 L NS), secure airway if stridor (intubation). Bronchospasm, edema drive hypoxia. Antihistamines (cetirizine), steroids (hydrocortisone 200 mg IV) adjunctive; monitor closely.
