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MBBS VI - Medicine Final Summary > Respiratory handbook > Flashcards

Respiratory handbook Flashcards

1
Q

What is management of primary spontaneous pneumothorax based on size?

A
  1. Size <1cm and minimal symptoms
    Observation and oxygen therapy
  2. Size 1-2cm and minimal symptoms: chest drain insertion (small bore) or consider needle aspiration if skills and expertise available.
  3. Size >2cm or symptomatic
    Chest drain insertion (e.g. small bore <14F); or large bore >20 if suspect large leak
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2
Q

What are the indications for surgical pleurodesis (open thoracotomy/VATS)?

A
  • Second ipsilateral pneumothorax
  • First contralateral pneumothorax
  • Synchronous bilateral spontaneous pneumothorax - Spontaneous haemothorax
  • Persistent air leak
  • Professions at risks (eg. pilots, divers)
  • Pregnancy.
    Medical pleurodesis (e.g. Talc, minocycline) may be considered for patients who refuse or are considered unfit for surgery.
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3
Q

How is the dx of pleural effusion done?

A
  1. Pleural tapping should not be performed for bilateral pleural effusions in clinical setting strongly suggestive of a transudate unless presence of atypical features or failure to respond to therapy
  2. Diagnostic tapping with bedside USG guidance improves success rate and reduces complications
  3. Differentiate the nature of pleural fluid by the followings:
    - Appearance (e.g. Pusempyema; Milkyconsider chylothorax)
    - Light’s criteria: (can be “Exudative” if any one of followings met)
    Fluid protein/serum protein >0.5
    Fluid LDH/serum LDH >0.6
    Fluid LDH > 2/3 of the upper limit of the normal range of serum LDH
    - Microbiological workup
    Bacterial: gram stain, culture (using blood culture bottle) TB: AFB smear/culture, MTB-PCR, ADA, (closed pleural biopsy)
    Fungal: fungal culture
    - Send fluid for cytology if malignant effusion is suspected
  4. In case of parapneumonic effusion, it is “complicated” if pH<7.2
    (measured by proper ABG method) or glucose <2.2mmol/L.
  5. Thoracoscopy (Medical or Surgical with VATS) is the next investigation of choice in exudative pleural effusions with inconclusive diagnostic pleural tap. Close pleural biopsy can be considered if there is a high pretest probability of TB.
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4
Q

What is the assessment for asthma control?

A

GINA assessment of asthma control
1. Symptom control over past 4 weeks
- Daytime asthma symptoms > 2/week
- Nocturnal symptoms/awakening
- Reliever needed for symptoms > 2/week - Activity limitation due to asthma
Well controlled: None
Partly controlled: 1–2 features Uncontrolled: >3–4 features

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5
Q

What is the treatment for acute exacerbation of COPD?

A
  1. Ensure patient has no pneumothorax
  2. Supplemental O2 (start with 24% Venturi mask or 1–2L/min by
    nasal prongs) to maintain SpO2 88–92%.
  3. Short acting inhaled (with spacer) B2 agonist (ventolin +/- ipratropium bromide
  4. Corticosteroids (hydrocortisone 100mg IV Q6-8H or oral prednisolone 30-40mg daily)
  5. Antibiotic in patients requires invasive or non invasive ventilation (NIV) and/or at least 2 cardinal symptoms (one being increased sputum purulence)
    Increased dyspnea, sputum volume, purulent sputum
  6. NIV to relieve dyspnoea by decreasing work of breathing, improve respiratoary acidosis
  7. Invasive mechanical ventilation for patients who are unable to tolerate or failed NIV
    Severe haemodynamic instability without reponse to fluid and vasopressor
    Severe ventricular arrhythmia, respiratory or cardiac arrest
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6
Q

What is the dx and severity assessment of OSA?

A

Dx of OSA: polysomnography
Severity of OSA is classified by apnoea-hypopnea index (AHI)
Mild: 5-15/hr, moderate: 15-30/hr, severe: >30/hr

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7
Q

Define massive haemoptysis?
What are the management objectives?

A

Definition: arbitrary, expectorated blood ranging from >100-200ml.24 hours. Bleeding rate and underlying function are important factors for management. Increased bleeding volume confers higher mortality risk due to asyphyxia instead of compromising haemodynamics

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8
Q

What is the management of massive haemoptysis?

A
  • Airway protection is most important in massive haemoptysis, close observation in ICU/HDU is desirbale
  • Lie lateral on bleeding side
  • Closely monitor vital signs, O2 supplement and establish IV access
  • Avoid sedation and cough suppressant
  • Correct possible causes of bleeding: antibiotic for infection, stop anticoagulant
  • Intubation for suction and ventilation if depressed consious state with risk of asyphxia: single lumen ET if urgent; double lumen ET by anaesthetist is better for isolation of bleeding side.
  • Flexible bronchoscopy may help to localzie bleeding site + therapy
  • Urgent contrast CT thorax/bronchial arteriogram for bronchial arterial embolization (BAE) if expertise is available
  • Consult surgeon for emergency lung resection if bleeding fail to be controlled
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9
Q

What are factors that guide management of spontaneous pneumothorax?
What signs will lead to suspicion of tension pneumothorax?

A

Factors affecting management
* Size: visible rim between lung margin and chest wall at level of hilum. Small <2cm, large >2cm
* Symptomatic (requires chest drain insertion) or asymptomatic
* If recurrent pneumothorax –> indication for pleurodesis to prevent recurrence

Primary spontaneous pneumothorax: no underlying lung disease
Secondary spontaneous pneumothorax: underlying lung disease

Suspect tension pneumothorax if associated with cyanosis, sweating, severe tachypnoea, tachycardia and hypotension

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10
Q

What are the indications for pleural fluid drainage in pleural effusion?

A
  • Frank pus or turbid/cloudy pleural fluid on diagnostic tapping
  • Loculation on CXR/USG or pleural thickening with contrast enhancement on CT thorax
  • Positive gram stain +positive culture of pleural fluid
  • Pleural fluid biochemistry: pH <7.2 or glucose <2.2mol/L
  • Large non purulent effusions (>40% of hemithorax)

Consider intrapleural therapies (tPA with DNAase. If this fails proceed to VATS (but rarely needed) to facilitate the drainge of multiloculated pleural collections in patients not fit for surgical decortication.

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11
Q

What is the management of persistent/recurrent malignant pleural effusion?

A
  1. Supportive care
  2. Consult respiratory physician for difficult cases
  3. Tube drainage and chemical pleurodesis. Agent: Talc up to 5g in 100ml NS (or minocycline 300mg in 50-100ml NS). Must be performed under adequate analgesia and sedation.
    * Clamp drain for 1-2 hours post sclerosant applicaiton, than release clamp
  4. Surgical pleurodesis (can be considered in patietns with good performance status)
  5. Long term ambulatory indwelling pleural catheter drainage

Other indications for chest drain insertion (in pleural effusion)
Haemothorax (surgical consultation usually indicated)

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12
Q

What are devices with variable FiO2 for oxygen delivery methods?

A

Actual FiO2 delivered is variable: depends on many factors such as O2 flow, patients tidal volume/respiratory rate and volume of reservoir that stores oxygen. The FiO2 delivery can be increased by increasing the volume of reservoir and O2 flow rate
1. Standard dual prong nasal cannula (reservoir: nasopharynx): FiO2 0.23-0.4 if O2 flow rate set at 1 to 6L/min. >6L/min is waste of O2 and dryness of nasal mucosa.
2. Simple face mask with no reservoir bag (reservoir: nasopharynx and volume of face mask): FiO2 up to 0.5 if O2 flow rate set at 6-10L/min. O2 flow rate set below <5L/min may cause Co2 rebreathing
3. Rebreathing mask with reservoir bag (reservoir: nasopharynx/reservoir bag): FiO2 0.7 if O2 flow rate set at 6-10L/min. O2 flow must be >6L/min to keep reservoir bag inflated thoroughout inspiration and expiration. No one way valve between reservoir bag and mask
4. Non rebreathing mask with reservoir (reservoir: nasopharynx/reservoir bag): FiO2 0.6-1 if O2 flow rate set at 10-15L/min. Equipped with one way valve to prevent exhalation into reservoir bag and inhalation through mask exhalation ports (usually only 1 of the 2 valves on the mask exhalation ports is installed for safety reason)

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13
Q

What are devices with fixed FiO2 for oxygen delivery methods?

A

Delivery of oxygen at a fixed and pre-set concentration regardless of patients clinical status (RR, tidal volume)
1. Venturi mask: accurate FiO2 adjustable from 0.24 to 0.5 if O2 flow rate set at 3-15L/min (O2 required to drive can be read off from the Venturi device)
2. Humidified high flow nasal cannula e.g. Optiflow, Airvo systems. Delivers humidifed O2 at fixed FiO2 at high flow (up to 60L/min) better patients tolerance to high flow O2 and the O2 is humidified. Provide a PEEP effect that enhances oxygenation.

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14
Q

Apart from variable and fixed o2 delivery methods what are other common oxygen delivery methods?

A
  • T piece to endotracheal or tracheostomy tube: O2 delivered through the shorter end, open window by 1/3 if pCO2 is high
  • Thermovent to endotracheal or tracheostomy tube. Avoid using if copious sputum. Requires daily exchange
  • Tracheostomy mask: consider using humidification in non infectious situation (e.g. heated humidifier)
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15
Q

What are the indications for long term O2 therapy in COPD?

A

Start only when clinically stable for 3-4 weeks and after optimization of other therapy
Continous opxygen for at least 15 hours/day (proved to improve survival in the following situations)
* Resting pO2 <7.3kPa or SaO2 <88%: to maintian PaO2 >8kPa (SaO2 >90%)
* Resting pO2 7.4-7.9kPa or SaO2 >89% in the presence of any of the following
Dependent edema suggestive of cor pulmonale
P pulmonale on ECG (P wave >3mm in standard leads II, III or aVF)
Erythrocythemia (haematocrit >56%)

There is no survival benefit in moderate resting desaturation (SaO2 89-93%) or moderate excercise induced desaturation.

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16
Q

Define asthma exacerbation

A

Episodes characterized by a progressive increase in symptoms of shortness of breath, cough, wheezing or chest tightness AND progressive decrease in lung function.
The decrease in expiratory airflow by PEF or FEV1 is more reliable indicators of severity of the exacerbation than symptoms

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17
Q

What is the assessment of adult acute asthma?
SS for mild/moderate/severe exacerbation

A
18
Q

What is the monitoring for adult acute exacerbation of asthma?
What is management?

A
19
Q

What is the reassessment done for adult acute exacerbation of asthma?
What is management after initial treatment if satisfactory/unsatisfactory treatment?

A

Clinical status and response treatment done in all patients 1 hour after initial treatment. Preferably with lung function measurement (PEF/FEV1)
If satisfactory response
* Controlled O2 aiming 93-95%, gradual weaning
* Prednisolone up to 50mg/d (or hydrocortisone 200mg/d in divided doses) for 5-7 days, adequate for most patients
* Continue inhaled B2 agonist q4h
If unsatisfactory response
* Inhaled B2 agonist 6-10 puffs up to q15min
* Inhaled ipratropium bromide 3-4 puffs than q6-8h

20
Q

When to consider ICU admission for adult acute exacerbation of asthma?

A
  • Life threatening features present
  • Deterioration in PEF/FEV1
  • Worsening or persistent hypoxia or hypercapnia
  • Respiratory failure requiring PPV
  • Respiratory or cardiorespiratory arrest
21
Q

After improvement in adult acute exacerbation what is done?

A
  • Stabilize in ward
  • Discharge may be considered when symptoms have cleared, lung function PEF/FEV1 >60% predicted/best
    Actions recommended on discharge include
  • Identify and avoid triggering factors that precipitated attack
  • Prednisolone tablets (up to 50mg daily for 5-7 days)
  • Early outpatient follow up and review of long term treatment plan especially inhalational steroids and reivewing technique on use of inhaler and peak flow meter
22
Q

What therapies are not recommended in adult acute exacerbation of asthma?

A
  • Sedatives (avoid strictly)
  • Cough suppressant (avoid as far as possible)
  • Mucolytic drug (may worsen cough)
  • Chest PT (increase chest discomfort)
  • Antibiotics (unless strong evidence of lung infection)
  • Hydration with large volumes of fluid
23
Q

What is general long term management of asthma?

A
24
Q

What are the 5 steps of long term management of asthma?

A

Step 1: as needed reliever medication
* For untreated patients with occasional symptoms of short duration alon and normal lung function. Short acting bronchodilator (inhaled B2 agonist prn). Alternative: regular low dose ICS +prn SABA, to reduce the risk of exacerbations
Step 2: low dose controller medication + as needed reliever medication
* Preferred: low dose ICS
* Alternatives: leukotriene receptor antagonists
* Not recommended: cromoglycate or nedocroil or theophylline SR
Step 3: 1/2 controllers + as needed reliever medication
* Preferred: low dose ICS + long acting B2 agonist (LABA) or combination of low dose ICS/formoterol as both maintenance and reliever treatment.
* Alternatives: medium dose ICS/low dose ICS + LTRA/low dose ICS +theophylline SR. LTRA for aspirin sensitivity or excercise induced asthma
Step 4: 2 or more controllers + as needed reliever medication
* Preferred: medium/high dose ICS + LABA, combination of low dose ICS/formoterol as both maintenance and reliever treatment
* Add on therapies: tiotropium (LAMA) by mist inhaler as add on therapy for those with history of exacerbations. Sublingual allergen immunotherapy in those with allergic rhinitis and sensitization to house dust mite with exacerbations despite ICS if FEV1>70% predicted
* Alternatives: high dose ICS + LABA, medium/high dose ICS +theophylline SR/LTRA
Step 5: higher level care and/or add on treatment
* Step 4 + specialist referral for Ix and consideration of add on treatment
* Add on tiotropium (LAMA)
* Anti IgE treatment
* Add on anti IL5 or anti IL5 receptor
* Sputum guided treatment (sputum eosinophilia)
* Bronchial thermoplasty
* Low dose oral corticosteroid

Step down: review treatment every 3-6 months. If control sustained for >3 months, consider a gradual stepwise reduction. Aim at finding patients lowest treatment that controls both symptoms and exacerbations
Step up: if control not achieved, consider stepping up after reviewing patients inhaler technique, compliance, environmental control (avoidance of allergens/trigger factors), comorbidities and alternative dx

25
Q

What are the ICS dosage for asthma (low, medium, high)?

A
26
Q

What is the GOLD grade for asessment of COPD?

A

FEV1% predicted
GOLD1: >80%
GOLD2: 50-79%
GOLD3: 30-49%
GOLD4: <30%
All patients should have smoking cessation, encouraged physical activity and vaccination +rehabilitation

27
Q

What is the follow up pharmacological management of COPD?

A
28
Q

When should patients be evaluated for OSA?

A
  1. OSA symptoms: snoring, choking at night/witnessed apnea, excessive daytimme sleepiness unexplained by other factors, non refreshing sleep sleep maintenance insomnia, morning headache, impaired concentration/memory loss
  2. As comprehensive evaluation of patients at high irsk of OSA
    * Obesity, preop assessment for bariatric surgery
    * Congestive heart failure, AFib, young hypertension/refractory hypertension, stroke
    * Unexplained pulmonary hypertension
    * High risk occupation e.g. occupational drivers
29
Q

What is the treatment of OSA?
When should early initiation of CPAP be arranged?

A
  1. Lifestyle modification: weight control, sleep hygiene, avoidance of alcohol and sedatives before bedtime
  2. CPAP: all patients with moderate to severe OSA. Midl OSA with symptoms/risk factors
  3. Alternative therapy: positional therapy (sleep in lateral position), dental appliance, surgery

Early initiation of CPAP therapy should be arranged in
* OSA with obesity hypoventilation syndrome (OHS< daytime hypercapnia ), pulmonary hypertension or cor pulmonale
* Significant cardiovascular (malignant arrhythmia) or resp comorbidities
* Excessive daytime sleepiness that may impose risk t to the patient and/or others e.g. occupational drivers

30
Q

What is the periop management of patients with OSA?

A
  1. High risk factors: major surgery that involves GA, need of post op opioids, severe OSA, OSA with concomitant hypoventilation (COPD, OHS, neuromuscular disease), cardiovascular comorbidities
  2. Patients with known OSA on treatment: reinstitute thereapy (e.g. PAP or dental appliance) post op
  3. Patients with unknown or untreated OSA
    * Emergency surgery: proceed as indicated
    * Elective surgery: proceed with close monitoring for low risk procedure; for high risk procedure; consider optimization before surgery in patients with significant comorbidiies, hypoventilation syndrome/ hypoxemia/ severe pulmonary hypertension
  4. Close monitoring for development of resp failure during recovery period in all OSA patients
  5. Benefit of perioperative PAP in patients with untreated OSA is uncertain.
31
Q

What is the preop evaluation of pulmonary function for resection of lung cancer?

A
32
Q

What are the indications for mechanical ventilation?
What is the criteria (or clinical assessment suggesting the need of mechanical ventilation)?

A

Indications
* Resp failure (defined as insufficient oxygenation, insufficient alveolar ventilation or both) not adequately corrected by other means
* Failure to protect the airway (GCS <8)
* Cardiac and/or respiratory arrest

33
Q

What are the suggested initial ventilator settings for mechanical ventilation?

A
34
Q

What to monitor during mechanical ventilation?

A
35
Q

What is the checklist for troublshooting when there is patient ventilatory asynchrony?

A
36
Q

What conditions is the efficacy of non invasive ventilation?
When is NIV less efficacious or even harmful?

A

Efficacy in
1. COPD complicated by hypercapnic acidosis (PaCO2 >6 kPa or pH <7.3)
2. Hypercapnic respiratory failure secondary to chest wall deformity or neuromuscular disease
3. Cardiogenic pulmonary oedema
4. Weaning from tracheal intubation (esp COPD)
5. Acute respiratory failure in immunosuppressed states
6. Post-operative hypoxaemia (except in upper GI surgery)
7. Patients decided not for intubation

Less efficacious or even harmful in
1. Acute severe asthma
2. Acute lung injury (ALI) or Acute respiratory distress syndrome (ARDS)
3. Pneumonia, esp if copious secretions
4. Treatment of established post-extubation respiratory failure

37
Q

What are the contraindications to NIV (non invasive ventilation)?

A
  • respiratory arrest
  • medical instability
  • inability to protect airway
  • severely impaired consciousness
  • excessive secretions
  • uncooperative or agitated status
  • high aspiration risk
  • unfitting mask, and recent upper airway or gastrointestinal surgery, facial surgery / trauma / deformity
38
Q

What are the practical aspects of NIV (non invasive ventilation)?

A
39
Q

What are the factors associated with success and failure of non invasive ventilation?

A

Factors associated with success
* less sick (lower APACHE II score)
* higher pH
* lower respiratory rate (RR)
* lower PaCO2
* subjective improvement within one hour of start

Factors associated with failure
* edentulous, pneumonia
* excess secretions
* mouth leaks
* poor coordination
* ARDS
* PaO2/FiO2 ≤146
* sicker patient [Simplified Acute Physiology Score (SAPS II) ≥35].

40
Q

What is the common setting for NIV (non invasive ventilation)?

A
41
Q

What are important considerations to ensure proper NIV in patient?

A

MBBS VI - Medicine Final Summary (20 decks)

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