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ACC > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What Organisms most commonly cause CAP in >5yrs?

A

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

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2
Q

What are the atypical organisms for CAP?

A

Mycoplasma
Legionella
Chlamydia

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3
Q

Symptoms of pneumonia?

A 
Cough (productive - rust colour = pneumococcus)
Fever
SOB
Pleuritic chest pain
Confusion in elderly
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4
Q

Signs of pneumonia?

A

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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5
Q

Organisms that commonly cause HAP?

A

Gram -ve enterobacter
S aureus
Klebsiella
pseudomonas

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6
Q

What is the curb 65 score?

A

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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7
Q

Management of pneumonia?

A

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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8
Q

Abx treatment for mild/moderate CAP?

A

Amoxicillin/clarithromycin or doxycycline (5 days)

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9
Q

Abx treatment for severe CAP?

A

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

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10
Q

Abx treatment for HAP?

A

Metronidazole + cefotaxime

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11
Q

What organisms commonly cause exacerbations of COPD?

A

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

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12
Q

Signs/symptoms of COPD exacerbation?

A 
Increased cough and dyspnoea
increase in purulent sputum (green/grey)
Confusion
Reduced exercise tolerance
Crackles +/- wheeze
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13
Q

Response for acute exacerbation of COPD?

A

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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14
Q

When should you consider BIPAP in a COPD patient?

A

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

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15
Q

When is BIPAP contraindicated?

A

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

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16
Q

How does an ABG guide treatment in acute COPD management?

A

Normal - continue O2 and nebs
Hypoxia - increase FiO2 and repeat ABG
Hypercapnic - BIPAP, ITU, Aminophylline

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17
Q

Causes of non-cardiogenic pulmonary oedema?

A 
altered aveloar-capillary permeability:
Drugs and alcohol
Status epilepticus, head injury etc
hypoalbuminaemia (liver failure, sepsis)
ARDS, PE
18
Q

Symptoms of cardiogenic pulmonary oedema?

A

Gradual/chronic dyspnoea (worse in morning, orthopnea–>PND)
cough - pink frothy sputum
fatigue
muscle wasting

19
Q

Signs of cardiogenic pulmonary oedema?

A

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

20
Q

Investigations for cardiogenic pulmonary oedema?

A 
CXR 
ECG - IHD, arrythmias
ABG - can lead to type II RF
Bloods - FBC, LFT, U+E, glucose
Doppler echo (confirms LVF)
21
Q

What should you look for in a CXR for a patient with suspected pulmonary oedema?

A 
A - alveolar oedma (bat wings)
B - kerley B lines
C - cardiomegaly
D - dilated pulmonary vessels
E - effusion
22
Q

Management of acute pulmonary oedema?

A

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

23
Q

Management after stabilisation of acute pulmonary oedema?

A 
Ace-i: ramipril 
B-blocker: bisoprolol
sprinolactone 
?digoxin
restrict soidum and fluid intake
24
Q

Risk factors for pneumothorax?

A 
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
25
Q

Features of pneumothorax?

A

Sudden onset of dyspnoea
Pleuritic chest pain
Unilateral reduced chest expansion, tactile fremitus, breath sounds
Unilateral hyper resonance on percussion

26
Q

Features of tension pneumothorax?

A 
Same as pneumothorax 
\+
Tachycardia, hypotension
Deviated trachea (away from affected side)
Distended neck veins
Respiratory distress
27
Q

Definition of large pneumothorax?

A

> 50% of lung (>2 cm from lung margin on CXR)

28
Q

Management of secondary pneumothorax 1-2cm?

A

If not breathless admit with high flow oxygen and observe for 24 hours

If breathless or >2cm - aspiration 2nd intercostal space mid clavicular line

29
Q

Management of tension pneumothorax?

A

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

30
Q

Risk factors for pulmonary embolism?

A 
Malignancy
Post surgery, immobilisation
OCP, pregnancy
Previous DVT/PE
Increasing age, obesity, smoking
Infection
Dehydration
Inherited thrombophilias
Right heart failure/pulmonary hypertension
31
Q

Features of PE?

A

Sudden onset of dyspnoea and pleuritic chest pain
Haemoptysis
Syncope/CVS collapse (tachycardia, hypotension)
Raised JVP
Hypoxia

Massive PE –> cardiac arrest and shock, cyanosis

32
Q

Investigation pathway for PE?

A

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

33
Q

What is the WELLS score?

A

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

34
Q

What might you see on an ECG from a patient with a massive PE?

A

S1Q3T3
Deep S wave in lead I
Pathological Q wave in lead III
Inverted T wave in Lead III

35
Q

What is the PERC criteria?

A

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
36
Q

Immediate management of PE?

A

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

37
Q

Management of PE after stabilization/confirmation?

A

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

38
Q

What would indicate a severe acute attack of asthma?

A

PEFR 35-50%
RR >25
HR >110
Inability to speak sentence in one breath

39
Q

What would indicate life threatening asthma?

A 
PEFR <33%
SPO2 <92%
PaO2 <8KPa
Normal PaCO2 (4.6-6)
Silent chest
cyanosis
Poor respiratory effort
Arrhythmia 
Exhaustion, altered conscious level
Hypotension
40
Q

What would indicate near-fatal asthma?

A 
Raised PaCO2 (>6KPa)
Requiring mechanical ventilaton
41
Q

Initial management of acute severe asthma?

A 
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+

42
Q

if there is no improvement from initial management of acute asthma what should be done next?

A

Contact ICU

IV Mg sulphate 2g IV over 25 minutes
Consider aminophylline IV
Consider salbutamol IV

ACC (5 decks)

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