Respiratory Flashcards by Ben Cain

What Organisms most commonly cause CAP in >5yrs?

S pneumoniae (40%)
H influenzae
Influenza A + B
S aureus

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What are the atypical organisms for CAP?

Mycoplasma
Legionella
Chlamydia

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Symptoms of pneumonia?

Cough (productive - rust colour = pneumococcus)
Fever
SOB
Pleuritic chest pain
Confusion in elderly

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Signs of pneumonia?

Increased HR and RR
Crackles
Reduced air entry and bronchial breathing
Reduced chest expansion, pleural rub
Increased tactile fremitus, dull percussion

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Organisms that commonly cause HAP?

Gram -ve enterobacter
S aureus
Klebsiella
pseudomonas

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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

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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

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Abx treatment for mild/moderate CAP?

Amoxicillin/clarithromycin or doxycycline (5 days)

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Abx treatment for severe CAP?

Co-amoxiclav TDS 1.2g + clarithromycin 500mg BD
or
Cefotaxime/cefuroxime + clarithromycin + gentamicin if gram -ve bacilli

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Abx treatment for HAP?

Metronidazole + cefotaxime

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What organisms commonly cause exacerbations of COPD?

Same as CAP = s pneumoniae, H influenza, morexella catarrhalis

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Signs/symptoms of COPD exacerbation?

Increased cough and dyspnoea
increase in purulent sputum (green/grey)
Confusion
Reduced exercise tolerance
Crackles +/- wheeze

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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

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When should you consider BIPAP in a COPD patient?

Respiratory acidosis pH<7.3
Hypercapnic >6KPa
Cardiogenic pulmonary oedema
Weaning from intubation

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When is BIPAP contraindicated?

Impaired consiousness
Severe hypoxaemia
Patients with copious respiratory secretions
Consider intubation in these patients

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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

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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