Respiratory Core Conditions Flashcards
What are the different types of pneumothoraces?
Tension: Life threatening
Open: Defect in chest wall
Primary/Spont: No underlying pathology.
Secondary: Trauma/underlying lung disease (COPD)
Who most commonly has a primary spontaneous pneumothorax?
Tall, thin young men due to ruptured pleural bleb
What are the clinical features of a tension pneumothorax
Pleuritic chest pain Breathlessness Reduced breath sounds Hyper-resonant percussion Tracheal deviation
What are the features of a tension pneumothorax on a CXR?
Tracheal deviation AWAY from the pneumothorax
Obvious lung collapse
How is a tension pneumothorax life-threatening?
Continuing increase in volume
Due to formation of one way valve allowing air into pleural space on inspiration but not out on expiration
Causes rapid increase in intra-thoracic pressure
Reduces venous return & dec CO leading to cardiac arrest
How is a pneumothorax investigated?
Tension should be diagnosed on clinical findings NOT CXR!!
CXR
CT if uncertainty
How is a pneumothorax treated?
Small: <2cm resolves with conservative treatment, no strenuous exercise, reassess 2weekly until air reabsorbed
Primary: SOB & >2cm on CXR, attempt aspiration, can be repeated
Secondary: SOB & >2cm on CXR, chest pain
How is a tension pneumothorax treated?
Large bore needle decompression 2nd intercostal space midclavicular
Chest drain: 5th intercostal space midaxillary
If at 48hours PT still remains or recurrence: Pleurectomy
What are the RFs of a pneumothorax?
Smoking Marfan's Homocystinuria FHx Lung disease: COPD, acute s. asthma, TB, CF
What are the different types of emboli?
Blood
Fat
Air
Amniotic fluid
What is the pathophysiology of a PE?
Usually complication of VTE from another source (Calf, pelvis) that becomes dislodged and flows via the bloodstream through the R side of the heart and lodges in the pulmonary circulation
What are the signs & symptoms of a PE?
Pyrexia Cyanosis Tachypnoea & SOB RR >16 Tachycardia HypoT Raised JVP Pleural rub Pleural effusion Previous DVT signs Pleuritic chest pain Cough (+/- haemoptysis)
How is a PE investigated?
PERC score Well's score D-Dimer: -ve can rule out but +ve not necessarily due to PE CXR: Exclude other causes ECG: Mostly normal, can be sinus tachy, sometimes T-wave inversion (lead 3) CTPA ABG: Metabolic acidosis ECHO: R heart strain
What does a PERC Score contain?
Rule out PE in low risk All factors must be -ve for a -ve PERC score. +ve factor = work up (Well's Score) Age >50 HR >100 O2 sats on room air <95% Unilateral leg swelling Haemoptysis Rx surgery/trauma Prev PE/DVT Exogenous OE
What does the Well’s Score contain?
Stratify pts as low or high risk High risk = imaging Low risk = D-dimer Clinically suspect DVT PE most likely diagnosis Tachycardia >100 Immobilisation >3days OR surgery last 4weeks Malignancy Haemoptysis Hx of DVT/PE in past
How is a PE treated?
LMWH: Dalteparin & Warfarin 10mg Stop LMWH when INR >2 but continue Warfarin Vena Cava filter Thrombolysis: Alteplase
What 3 factors make up Virchows triad?
Venostasis (Immobility, paralysis, AF, congestive HF)
Hypercoagulability (Malignancy, pregnancy, protein C&S deficiency, antithrombin deficiency)
Vessel wall inflammation (trauma, surgery, indwelling catheter)
What is the pathophysiology of pulmonary oedema?
Fluid leaks from pulmonary capillaries into lung interstitium & alveoli
Filtration of fluid exceeds capacity of lymphatics to clear the fluid
What are the 2 types of pulmonary oedema?
Cardiogenic/hydrostatic: Elevated pulmonary capillary pressure from LVHF
Non-cardiogenic: Minimal elevation of pulmonary pressure caused by altered membrane permeability- ARDS
What are the causes of pulmonary oedema?
Raised pressure: CHD, ACS, valvular, PE, tamponade, dissection
Renal: AKI, CKD, RA stenosis
Iatrogenic fluid overload
High output HF: anaemia, sepsis, thyrotoxic crisis
Acute/chronic URT obstruction
Inc pulmonary capillary permeability: ARDS, altitude, radiation, emboli
What are the signs & symptoms of pulmonary oedema?
Severe SOB PND/orthopnoea Cyanosis Congested neck veins Raised JVP Basal/widespread rales/fine crackles O2 sats <90% room air Cardiogenic shock: HypoT, Low CO, Oliguria
How is pulmonary oedema investigated?
Bloods: LFTs, clotting, U&Es, Cardiac enzymes, brain natriuretic peptides
ABG
CXR
How is pulmonary oedema managed?
O2 Nitrates/ GTN infusion Furosemide 20-40mg IV Opiates: Diamorphine 2.5-5g IV CPAP, ET tubing Ultrafiltration
Arrhythmia related: DC cardioversion
Acute HF: Furosemide, High-flow O2, VTE prophylaxis, opiates, inotropes, vasodilators
What components make up croup?
Harsh barking cough
Hoarse voice
Acute inspiratory stridor
What is the cause of croup?
PARAINFLUENZA Adenovirus RSV Measles Coxsackie Rhinovirus Echovirus Reovirus Influenza A&B
How is croup investigated?
Clinical diagnosis
ABG & CXR helpful in assessing severity
How is croup managed?
O2 if sats <92% on room air
Corticosteroids: Oral Dexamethasone
Severe/life-threatening: Nebulised Adrenaline 1:1000
What are the clinical features of croup?
Seal-like barking cough Worse at night Hoarse voice Inspiratory stridor Severe: Tracheal tug, struggling to breathe, drinking <50% than normal, dry nappies
Which cells are implicated in airway inflammation?
Eosinophils Mast cells Leukotrienes Prostaglandins T-Lymphocytes Macrophages Adhesion molecules
How can an asthma attack cause a cardiac arrest?
- Mucous plugging causing asphyxia COMMONEST
- Prolonged hypoxia = arrhythmia = cardiac arrest
- BronchoC inc airway pressures leading to breath stacking causing inc intrathoracic pressure = pneumothorax or dec venous return = circulatory collapse
What clinical features make asthma more likely in adults?
- > 1: Wheeze, cough, tightness, difficulty breathing
- Worse at night/early morning
- Triggered by Aspirin/Beta-blockers
- Occur in absence of a cold
- FHx including atopy
- Widespread wheeze on auscultation
- Unexplained low FEV1/PEFR
- Unexplained peripheral blood eosinophilia
How is asthma investigated?
Clinical
Spirometry: FEV1/FVC <0.7
Reversibility trial: 400ml improvement in FEV1
How is acute asthma treated?
Oxygen: Sats <94%
Salbutamol: 2.5-5mg Nebs back to back, takes 15-30mins for effect
Hydrocortisone/Pred: 100mg IV when PEFR <50% of best
Ipratropium: 500mcg Nebs, max 4hourly
Theophylline/ aminophylline infusion: 1g/1L saline usually in ICU (daily U&Es, cardiac monitor)
Magnesium Sulphate: 2g in 100mls saline IV/20mins one off dose
Escalate Care
What are the side effects of:
Salbutamol
Ipratropium
S: Tremor, Tachycardia
I: Dry mouth & eyes, blurred vision, tachycardia, flushing, confusion, urinary retention
What monitoring should be done for a patient having an asthma attack in A&E?
OBS PEFT: 15-30mins after Tx Stable: Reassess 1-2hourly O2 sats: Goal 94-98% Bloods: U&E (for K+) ABG: <1hour of Tx
When can a patient having an asthma attack be discharged? Not discharged?
Yes: PEFR >75% 1hour post-Tx
NO: Pregnant, Night presentation, Prev ICU admission, lives alone, learning disability, psych, exacerbation despite steroid tablets
How is the severity of an asthma attack established?
Mild/Mod: PEFR 50-75%
Severe: PEFR 33-50% RR >25, HR>110
Life-threatening: PEFR <33%, SpO2 <92%
How is an exacerbation of COPD treated?
Oxygen Salbutamol 2.5-5mg news Hydrocortisone 100mg IV Prednisolone 30mg 7-14days Ipratropium 500mcg news Theophylline 1g/1L saline Abx: Doxycycline 100mg Chest physic Consider within 60mins of admission with persistent acidosis if Tx is unsuccessful (BiPAP)
How is an exacerbation of COPD investigated?
ABG 15mins after oxygen administered
CXR: Underlying pathology
Bloods: U&E, FBC, WCC
How are asthma & COPD differentiated by different factors
(ex)Smoker: COPD nearly all, asthma possible
<35: COPD rare, Asthma often
Chronic productive cough: COPD common, asthma uncommon
SOB: COPD persistent & progressive, asthma variable
Night waking w/SOB: COPD uncommon, asthma common
Diurnal variation: COPD uncommon, asthma common
What is Cor Pulmonale?
Right sided HF
Result of pulmonary hypertension
Signs: Cyanosis, fluid retention, severe SOB, may have a diastolic murmur
How is HAP defined?
Pneumonia developing 48hours after admission
Usually gram -ve bacilli, Staph Aureus
What are the most common causes of CAP?
Strep Pneumoniae
H.Influenzae
Anaerobes (rare)
How is CAP diagnosed?
CXR Bloods: FBC, WCC, ESR, CRP Pleural fluid aspiration CURB 65: Confusion <8 Urea >7 RR >30 BP <90s/ <60d >65 >3= severe >2=Hospitalisation
How is pneumonia treated?
Rest
Fluids
Abx: Amoxicillin/Clarithromycin 500mg PO TDS 1week
Severe: Co-Amoxiclav 1.2g & Clarithromycin 500mg 7-10days
