Respiratory 3 Flashcards
What are the key respiratory related symptoms?
Dyspnoea, Cough, Wheeze, Pleuritic Chest Pain, Sputum Production, Haemoptysis, Systemic Symptoms (Fever, Weight Loss, Fatigue)
The 4 common presenting symptoms associated with a Deep Vein Thrombosis (DVT)
Leg (commonly calf) pain, Swelling, Warm to touch, Erythema
Common presenting symptoms of a Pulmonary Embolism (PE)
Pleuritic Chest Pain, Sudden Onset SOB, Cough +/- Haemoptysis, Dizziness/Syncope, Tachycardia
What are the three elements of Virchows Triad?
Vessel Wall Injury, Stasis of Blood Flow (Immobility), Hypercoagulability
What is the Well’s Score?
Criteria scoring system when suspecting a Pulmonary Embolism or a DVT. Score 4 or more = PE Likely. Score 2 or more = DVT likely
What (7) elements does the Well’s PE Score consist of?
(1) Clinical Signs of a DVT (3 points)
(2) PE #1 diagnosis, alternative diagnosis unlikely (3 points)
(3) Tachycardia (1.5 points)
(4) Immobilisation of 3 days/surgery in previous 4 weeks (1.5 points)
(5) History of DVT or PE (1.5 points)
(6) Haemoptysis (1 point)
(7) Malignancy (treatment <6 months ago or palliative) (1 point)
What is the CURB-65 score?
CAP severity score used in predicting mortality and assessing the need for hospital admission.
What is the MOA of Unfractionated Heparin?
Found naturally in the body, activates Antithrombin III which inhibits Factor Xa and Thrombin. Giving more enhances this effect.
How is Unfractionated Heparin administered?
IV Infusion or S/C Injection
Apart from Haemorrhage, what are the two other side effects of Unfractionated Heparin/LMWH?
Hyperkalemia
Thrombocytopenia
What is the name of the blood test used to monitor Unfractionated Heparin?
Activated Partial Thromboplastin Time (aPTT)
What is the MOA of Low Molecular Weight Heparin (LMWH)?
Similar mode of action to unfractionated heparin but preferentially inhibits factor Xa.
What are the main advantages of using Low Molecular Weight Heparin (LMWH) instead of Unfractionated Heparin (UFH)?
Low Molecular Weight Heparin (LMWH) has a more predictable response and greater duration of action - this means that it is administered less frequently (OD or BD) and does not require monitoring.
What is the MOA of Warfarin?
Vitamin K Antagonist. Inhibits vitamin K epoxide reductase (enzyme), thereby preventing activation of Vit K and synthesis of factors.
What is the normal INR value and what INR target would be expected in a patient who is taking Warfarin?
Normal INR = 1. Target for Warfarin pts = 2-3
Unless PE/DVT at this target, then 3-4
Name some of the main disadvantages of using Warfarin
Many food and drug interactions
Teratogenic
Low therapeutic index and unpredictable, hence requiring INR blood test monitoring
Takes 48-72 hours to work
What is the MOA of NOACs and DOACs? What are the drug names?
DOAC = Dabigatran, which is a direct thrombin inhibitor.
NOACs = Rivaroxaban, Apixaban, Edoxaban, which directly inhibit factor Xa.
In the event of the treatment of a PE/DVT, how long can the patient expect to be taking anticoagulants?
Minimum of 3 months
When treating a DVT/PE what (4) main practical considerations should you consider?
- Hemodynamically unstable or stable?
- Body weight
- Active Cancer?
- Renal function
A patient has a confirmed PE/DVT, they have a blood pressure of 90/50. What interventions should be done or considered?
Continuous IV infusion of Unfractionated Heparin, consider thrombolytic intervention.
What is the most common LMWH name?
Enoxaparin (Clexane)
A patient has a confirmed PE/DVT. They are hemodynamically stable and have no comorbidities. What is the first line medication should they be given?
Apixaban or Rivaroxaban (NOACs)
A patient has a confirmed PE/DVT. They have severe renal impairment (CrCl <15ml/min). What is the first line medications should they be given?
LMWH/UFH + Warfarin for at least 5 days until INR 2 on two consecutive readings, then Warfarin alone.
A patient has a confirmed PE/DVT. They have active cancer. What medication should they be given?
Dibigatran (DOAC). If not appropriate, LMWH + Warfarin for at least 5 days until INR 2 on two consecutive readings, then Warfarin alone.
A patient has a confirmed PE/DVT. They have Antiphospholipid syndrome. What medication should they be given?
LMWH + Warfarin for at least 5 days until INR 2 on two consecutive readings, then Warfarin alone.
What does the CURB-65 score comprise?
C - Confusion U - Urea >7 mmol/L R - Respiratory Rate > 30 B - Blood Pressure (<90 systolic or <60 diastolic) Over 65
An 85 year old man develops shortness of breath and sharp pleuritic chest pain. He recently underwent surgery for a dynamic hip screw, however, he has had poor mobility post-op. He has had 2 episodes of haemoptysis since the onset of symptoms. What is the most likely diagnosis?
Pulmonary Embolism
The name of another anticoagulant medication that is chemically related to LMWH, and is an indirect inhibitor of factor Xa, but it does not inhibit thrombin at all.
Fondaparinux
Define: Primary/Spontaneous Pneumothorax
Abnormal collection of air within the pleural space. Occurs without cause. Usually occurs in the absence of significant lung disease.
Define: Tension pneumothorax
Abnormal/Large collection of air within the pleural space. Occurs when a large amount of air is present within the lung causing the lung to deflate. One way air entry, air can collect on each inspiration, but cannot escape.
Define: Traumatic pneumothorax
Abnormal collection of air within the pleural space. Occurs as a result of trauma, e.g. knife wound, blunt trauma
What is the most common bacteria associated in community acquired pneumonia (CAP) in an otherwise healthy individual who is over 60 with consolidation changes on chest x-ray?
Streptococcus Pneumoniae still remains the common cause of CAP in over 60s.
What (3) atypical bacteria can be responsible for community acquired pneumonia (CAP)
Mycoplasma pneumoniae, Haemophilus influenzae, Legionella pneumophila
What are the 3 main viruses causing viral pneumonia?
Influenza A, B, C, Respiratory syncytial virus (RSV), SARS-CoV-2 (COVID-19)
In treating a pneumothorax, what is the criteria for conservative management/no treatment?
If no SOB and < 2cm rim of air on the chest x-ray then
no treatment required.
In treating a pneumothorax, what is the criteria for treating with needle aspiration?
If SOB and/or > 2cm rim of air on the chest x-ray = aspiration.
In treating a pneumothorax, how is needle aspiration performed?
Wide bore cannula, 2nd intercostal space, midclavicular line to decompress/aspirate.
In treating a pneumothorax, in what (3) circumstances/pathologies require a chest drain?
Unstable patients, bilateral or secondary pneumothoraces require a chest drain.
What are the two main classes of lung cancer? Which type is the most common.
Small cell lung cancer (SMLC) and Non small cell lung cancer (NSCLC). NSCLC are the most common, accounting for 85% of cases.
What are some of the risk factors for developing lung cancer?
Smoking, PMH or family history, occupational exposure (asbestos, silica), existing lung disease, radiation of non-lung cancer treatment
