Respiratory Flashcards
What Organisms most commonly cause CAP in >5yrs?
S pneumoniae (40%)
H influenzae
Influenza A + B
S aureus
What are the atypical organisms for CAP?
Mycoplasma
Legionella
Chlamydia
Symptoms of pneumonia?
Cough (productive - rust colour = pneumococcus) Fever SOB Pleuritic chest pain Confusion in elderly
Signs of pneumonia?
Increased HR and RR
Crackles
Reduced air entry and bronchial breathing
Reduced chest expansion, pleural rub
Increased tactile fremitus, dull percussion
Organisms that commonly cause HAP?
Gram -ve enterobacter
S aureus
Klebsiella
pseudomonas
What is the curb 65 score?
Determines whether patient should be in or outpatient
>3 = inpatient/ITU 2 = inpatient 0-1 = outpatient
C = confusion (<8 on AMTS) U = urea (>7mmol/L) R = RR > 30 B = BP (SBP<90, DBP = <60) 65 = > 65
Management of pneumonia?
ABCDE
Venous access - fluid challenge
O2 NRBM - if not corrected or hypercapnic –> ventilation
Analgesia
Start empirical Abx after blood cultures are taken (IV f high CURB score - usually 5-7 days, 10 in high risk patients
Abx treatment for mild/moderate CAP?
Amoxicillin/clarithromycin or doxycycline (5 days)
Abx treatment for severe CAP?
Co-amoxiclav TDS 1.2g + clarithromycin 500mg BD
or
Cefotaxime/cefuroxime + clarithromycin + gentamicin if gram -ve bacilli
Abx treatment for HAP?
Metronidazole + cefotaxime
What organisms commonly cause exacerbations of COPD?
Same as CAP = s pneumoniae, H influenza, morexella catarrhalis
Signs/symptoms of COPD exacerbation?
Increased cough and dyspnoea increase in purulent sputum (green/grey) Confusion Reduced exercise tolerance Crackles +/- wheeze
Response for acute exacerbation of COPD?
Sit up
Controlled O2 therapy (venturi - aim for 88-92%)
ABG
IV access - blood cultures, FBC, U+Es, glucose
Salbutamol 5mg and Ipatropium bromide 500mcg nebuliser driven by air
Steroids - hydrocrotisone 200mg IV or 30mg prednisilone
Abx - amoxicillin/co-amoxiclav or doxycycline (5 days)
ECG for evidence of cor pulmonale
Sputum culture and chest physio
When should you consider BIPAP in a COPD patient?
Respiratory acidosis pH<7.3
Hypercapnic >6KPa
Cardiogenic pulmonary oedema
Weaning from intubation
When is BIPAP contraindicated?
Impaired consiousness
Severe hypoxaemia
Patients with copious respiratory secretions
Consider intubation in these patients
How does an ABG guide treatment in acute COPD management?
Normal - continue O2 and nebs
Hypoxia - increase FiO2 and repeat ABG
Hypercapnic - BIPAP, ITU, Aminophylline
Causes of non-cardiogenic pulmonary oedema?
altered aveloar-capillary permeability: Drugs and alcohol Status epilepticus, head injury etc hypoalbuminaemia (liver failure, sepsis) ARDS, PE
Symptoms of cardiogenic pulmonary oedema?
Gradual/chronic dyspnoea (worse in morning, orthopnea–>PND)
cough - pink frothy sputum
fatigue
muscle wasting
Signs of cardiogenic pulmonary oedema?
Inspiratory crackles
Wheeze
Collapse/cardiac arrest
Shock
Signs of underlying disease - pale, sweaty, distressed, chest pain, palipitations, oliguria, increase JVP, triple gallop rhythm murmur, displaced apex beat
Investigations for cardiogenic pulmonary oedema?
CXR ECG - IHD, arrythmias ABG - can lead to type II RF Bloods - FBC, LFT, U+E, glucose Doppler echo (confirms LVF)
What should you look for in a CXR for a patient with suspected pulmonary oedema?
A - alveolar oedma (bat wings) B - kerley B lines C - cardiomegaly D - dilated pulmonary vessels E - effusion
Management of acute pulmonary oedema?
ABCDE
Sit patient up
O2 - may need NIV if still hypoxaemic
IV access + bloods: FBC, LFTs, U+Es, Glucose
Treat any arrhythmias Diamorphine 2.5-10mg Furosemide 40-120mg slowly - +thiazide if needed Metaclopramide 10mg IV Salbutamol if wheeze is prominent
If SBP <90 treat as cardiogenic shock
If SBP>90 give GTN 2 sprays and set up GTN infusion 50mg in 0.9% saline IV at 2ml/hr–>20ml/hr if SPB>110
Investigate cause - CXR, ECG, echo
Management after stabilisation of acute pulmonary oedema?
Ace-i: ramipril B-blocker: bisoprolol sprinolactone ?digoxin restrict soidum and fluid intake
Risk factors for pneumothorax?
Tall young men, smoker (primary) Chronic disease e.g. COPD/asthma exacerbations NIV and ventilation patients CPR Trauma Infection Blocked, clamped or displaced chest drains Hyperbaric O2 treatment Thoracic surgery
Features of pneumothorax?
Sudden onset of dyspnoea
Pleuritic chest pain
Unilateral reduced chest expansion, tactile fremitus, breath sounds
Unilateral hyper resonance on percussion
Features of tension pneumothorax?
Same as pneumothorax \+ Tachycardia, hypotension Deviated trachea (away from affected side) Distended neck veins Respiratory distress
Definition of large pneumothorax?
> 50% of lung (>2 cm from lung margin on CXR)
Management of secondary pneumothorax 1-2cm?
If not breathless admit with high flow oxygen and observe for 24 hours
If breathless or >2cm - aspiration 2nd intercostal space mid clavicular line
Management of tension pneumothorax?
ABCDE
O2 NRBM 15L
Needle decompression - 2nd IC space, mid-clavicular line with wide-bore needle filled with 0.9% saline
Then Chest drain mid axillary line, 5th IC space
Risk factors for pulmonary embolism?
Malignancy Post surgery, immobilisation OCP, pregnancy Previous DVT/PE Increasing age, obesity, smoking Infection Dehydration Inherited thrombophilias Right heart failure/pulmonary hypertension
Features of PE?
Sudden onset of dyspnoea and pleuritic chest pain
Haemoptysis
Syncope/CVS collapse (tachycardia, hypotension)
Raised JVP
Hypoxia
Massive PE –> cardiac arrest and shock, cyanosis
Investigation pathway for PE?
WELLS score:
>4 - PE likely - do CTPA
≤4 - PE unlikely - do D-dimer
D-Dimer:
+ve –> CTPA
-ve –> PE unlikely
CTPA (90% specific)
If -ve but high probability of PE –> VQ scan
ABG as part of ABCDE
ECG
Troponin - can be raised but will differentiate from MI
What is the WELLS score?
Calculates probability of PE:
Clinical signs and symptoms of DVT = 3 points
Alternative diagnosis less likely than PE = 3 points
HR >100 BPM = 1.5 points
Immobilisation for >3days or surgery in past 4 weeks = 1.5 points
Previous PE/DVT = 1.5 points
Haemoptysis = 1 point
Malignancy = 1 point
What might you see on an ECG from a patient with a massive PE?
S1Q3T3
Deep S wave in lead I
Pathological Q wave in lead III
Inverted T wave in Lead III
What is the PERC criteria?
A clinical tool for ruling out PE, if none of the below are present and WELLS is <3 then PE can be ruled out.
Think HAD CLOTS:
Hormone use
Age >50
DVT/PE previously
Coughing up blood uniLateral leg swelling Oxygen sats >95% Tachycardia Surgery or trauma
Immediate management of PE?
ABCDE
Sit patient up + O2 15L NRBM (Consider respiratory support)
ABG
IV access and bloods: FBC, U+Es, glucose
ECG
Treat hypotension - colloids 500ml
LMWH (tinzaparin) or UFH for 5 days - if very unstable consider immediate thrombolysis with 50mg lteplase
PO NSAIDS - avoid/caution opiates as will exacerbate hypotension
Management of PE after stabilization/confirmation?
Start warfarin - continue LMWH until INR of 2-3 is achieved
Can use IVC filter if confirmed DVT
If PE is unprovoked (no rosk factors) do CT for malignancy
What would indicate a severe acute attack of asthma?
PEFR 35-50%
RR >25
HR >110
Inability to speak sentence in one breath
What would indicate life threatening asthma?
PEFR <33% SPO2 <92% PaO2 <8KPa Normal PaCO2 (4.6-6) Silent chest cyanosis Poor respiratory effort Arrhythmia Exhaustion, altered conscious level Hypotension
What would indicate near-fatal asthma?
Raised PaCO2 (>6KPa) Requiring mechanical ventilaton
Initial management of acute severe asthma?
ABCDE Sit patient up O2 NRBM 15L ABG IV access and bloods: FBC, U+Es, glucose
Salbutamol 5 mg
Ipatroprium bromide 500mcg
Prednisilone (30-50mg) or hydrocortisone (200mg IV)
Monitor PEFR, ABG, K+
if there is no improvement from initial management of acute asthma what should be done next?
Contact ICU
IV Mg sulphate 2g IV over 25 minutes
Consider aminophylline IV
Consider salbutamol IV
