Respiratory Flashcards
Acute Asthma Attack
- and follow up after acute attack
Oxygen - 15L via non-rebreathe mask
Salbutamol nebs 5mg back to back
Ipratropium nebs 0.5mg
Orla pred 50mg/ Hydrocortisone 100mg IV if unable to take orally
- at this point if no improvement may need to think about escalation to critical care
mg sulphate 2g IV over 20mins
Aminophylline/IPPV
follow up treatment
- salbutamol/ipratropium nebs 4hrly until discharge
- chart PEF after each neb
- prednisolone 50mg 5 days
- check inhaler technique prior to discharge and make sure GP follow up in 2 weeks.
Long term management of asthma
1) SABA
2)SABA + ICS
3)SABA + ICS + LTRA
if no improvement with LTRA then scrap, if improvement then keep
need to be seeing specialist at this point.
4) SABA + ICS + (LTRA) + LABA
5) + MART = maintenance and reliever therapy = Seretide
6) increase ICS dose to moderate
7) increase ICS dose to high and consider theophylline/LAMA
COPD long term management
Education is important and to be able to recognise an exacerbation early and have an action plan. Have rescue medications if frequent exacerbations. Lifestyle modification is also paramount.
SABA or SAMA
FEV more than 50
- LABA –> LABA + ICS –> LABA + LAMA + ICS
OR
- LAMA –> LABA + LAMA + ICS
FEV less than 50
- LABA + ICS –> LABA + LAMA + ICS
OR
- LAMA –> LABA + LAMA + ICS
Consider oral aminophylline if triple therapy doesn’t work
Specialist treatment for COPD?
Pulmonary rehabilitation - 3 sessions a week for 6 weeks. Involves educational, physical and behavioural training
Mucolytics if productive cough
Nutritional support if low BMI e.g. pink puffer
LTOT - if FEV is 30% of predicted, cor pulmonale, nocturnal hypoxia, cyanosis, secondary polycythaemia, sats are below 92% at best.
15 hours a day increases survival
Surgery
- pleurectomy
- bullectomy
- lung volume reduction surgery
Acute Exacerbation of COPD
Admit if
- severely breathless
- rapid onset
- acute confusion
- cyanosis
- low oxygen sats
- worsening pulmonary oedema
Outpatient Rx
- increase dose/frequency of SABA, use spacer if not already doing so
- prescribe prednisolone 30mg/7-14days (if more than 3 courses a year then make sure to prescribe bisphosphonates)
- Oral abx for when purulent sputum or clinical signs of pneumonia
- safety net and review in 6 weeks
Bronchiectasis
First assess for any rare but treatable causes - RA, CF, TB
Education and lifestyle measures - stop smoking
Physiotherapy - inspiratory muscle training
Postural drainage
Mucolytics
Rescue antibiotics for exacerbations
Immunisations - pneumococcal and yearly flu vaccine minimum
Bronchodilators can sometimes be useful
CF
Resp treat as per bronchiectasis w/ two antibiotics to decrease chance of resistance developing - one abx to cover pseudomonas. Lung transplant if resp failure develops.
GI - pancreatic enzyme replacement - creon
Fat soluble vitamin supplementation - ADEK
Liver transplant for advanced cirrhosis
treatment of diabetes
fertility counselling
genetic counselling
Treatment of CAP
CURB 0/1 - oral amoxicillin/doxycycline if allergic - outpatient
CURB 2 - oral amoxicillin and clarithromycin, doxycycline if allergic. usually admit.
CURB >2 - IV clarithromycin plus co-amoxiclav, admit to HDU
if allergic/MRSA suspected then treat with levofloxacin and vancomycin
If aspirated then add metronidazole (like in ARDS)
Treat for at least 10 days.
Follow up CXR in 6 weeks, to ensure resolution of consolidation and assess for persistent possibility of endobrachial obstruciton
Treatment of HAP
First check for any MRSA risk factors - indwelling lines, catheters, infected cannula, skin breaks.
Mild HAP - treated with oral doxycycline
Severe HAP - treated with co-trimoxazole
Follow up CXR in 6 weeks, to ensure resolution of consolidation and assess for persistent possibility of endobrachial obstruciton
Tuberculosis
Admit if patient is severely unwell - put in negative pressure side room with droplet precautions.
If admission is not necessary then arrange referral to specialist TB service in 2 weeks.
Assess for risk factors for MDR TB - immunocompromised, previous TB treatment, contact with people with MDR TB.
Usually treat with 6m of Isoniazid (w/ pyroxidine to prevent encephalopathy and peripheral neuropathy) and Rifampicin. Supplement with ethambutol and pyrazinamide.
All household members to be traced for latent TB.
MDR TB treated with 6 antibiotics that they are sensitive too. Rifampicin = the marker for MDR TB
If neuro involvement then I+R for 12m
Tension Pneumothorax
100% oxygen
Large bore cannula, 2nd ICS mid-clavicular line
CXR
Chest drain - triangle of safety
Spontaneous Pneumothorax
If rim of air <2cm and patient not short of breath:
- discharge, advise to avoid strenuous exercise. CXR every 2 weeks until resolution. Advise to quit smoking
If rim of air >2cm or acutely short of breath
- attempt aspiration and admit for at least 24 hours if there is a secondary cause (copd, cf, tb, bronchiectasis, marfans/E-D).
- if aspiration is successful and primary cause then consider discharging and repeat CXR in 24 hours.
- if aspiration fails then insert chest drain
Pleural Effusion
If aspirated fluid is purulent/turbid or has a pH of <7.2, then insert a chest drain and consider IV abx.
Drainage should tae place if symptomatic, either with aspiration as per the diagnostic tap, or using intercostal drain.
Manage underlying cause of effusion.
Non-small cell carcinoma of the lung
Surgical excision if peripheral enough and no lymph node involvement of metastatic spread. Must be >2cm from the carina.
Curative radiotherapy can be an alternative if poor respiratory reserve, with adjuvant radiotherapy
Chemo-radiotherapy for more advanced disease
Palliation
radiotherapy for obstructive symptoms (SVC/bronchial) or bone pain
SVC stenting
Pleural drainage/pleurodesis for symptomatic effusion
