Respiratory - Level 1 Flashcards
Pathology of asthma?
o Usually reversible either spontaneously or treatment
o 1. Airway narrowing
Smooth muscle contraction, thickening of airway wall by cellular infiltration and inflammation
Secretions within the airway
o 2. Inflammation
Mast cells, eosinophils, T cells, dendritic cells cause IgE production and release of histamine, prostaglandin D2, leukotriene C4
o 3. Remodelling
Hypertrophy and hyperplasia leading to more mucous secreting goblet cells
Epidemiology of asthma?
- 10-15% of people develop asthma in 2nd decade of life
- More common in developed world
- 15% of asthma induced at work
Risk factors of asthma?
- FHx of atopic disease
- Respiratory infections in infancy
- Tobacco smoke
- Low birth weight
- Social deprivation
- Inhaled particulates
Precipitating factors of asthma?
- House dust mite and its faeces
- Viral infections
- Cold air
- Exercise
- Irritant dust, vapours, fumes (cigarettes, perfume, exhaust)
- Emotion
- Drugs (Aspirin, beta-blockers)
Symptoms of asthma exacerbation?
o Acute SOB and wheeze
o May have chest tightness and cough
Assessment of asthma exacerbation?
o PEFR
o Symptoms and response to treatment
o HR and RR
o O2 sats
Severity assessment of asthma exacerbation - moderate?
PEFR 50-75% best or predicted
Increasing symptoms
No features of acute severe asthma
Severity assessment of asthma exacerbation - severe?
Any 1 of: • PEFR 33-50% best or predicted • Unable to complete sentences in 1 breath • RR ≥25 • HR ≥110
Severity assessment of asthma exacerbation - life-threatening?
Patient with severe asthma with any 1 of: • Altered consciousness • Cyanosis • Hypotension • Exhaustion, poor respiratory effort • Silent Chest • Threatening - SpO2<92% (PaO2<8kPa), PEFR <33% • Bradycardia • Normal pCO2 (4.6-6)
Severity assessment of asthma exacerbation - near-fatal asthma?
Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures
DDX of acute asthma exacerbation?
Exacerbation of COPD
Infection
Management of asthma exacerbations - initial assessment?
o Clinical features
o PEFR
o HR, RR, Pulse Oximetry
o Assess Severity
Management of asthma exacerbations - further investigations?
ABG (if O2 <92% or life-threatening)
CXR (if suspected pneumothorax, consolidation, life-threatening asthma)
Management of asthma exacerbations - moderate asthma attack?
o Treat at home or in surgery and assess response to treatment
o Salbutamol via spacer every 60 seconds up to 10 puffs
o If no improvement – via salbutamol 5mg nebuliser
o Prednisolone 40-50mg for 5 days
o Admit if features of severe, life-threatening asthma or recent nocturnal symptoms/hospital admission
Management of asthma exacerbations -acute severe or life-threatening - initial management?
Make sure patient is sitting up
15L/min Oxygen via NRB mask if hypoxic (aim 94-98%)
IV access (FBC, U&E, glucose, CRP, cultures (if septic))
ABG
Salbutamol 5mg (or terbutaline 10mg) nebulised with oxygen
• If does not respond – every 15 mins or continuous nebuliser
Ipratropium Bromide 500mcg (0.5mg) added to nebulisers if poor initial response
• 4-6 hourly
Hydrocortisone IV 100mg every 6 hours (or prednisolone PO 40-50mg for 5 days if can take orally)
Magnesium Sulphate 1.2g-2g IV over 20 mins
Management of asthma exacerbations -acute severe or life-threatening - further treatment?
o Senior review if not improving – consider ITU
IV aminophylline IVI 5mg/kg over 20 mins
IV salbutamol
Management of asthma exacerbations -acute severe or life-threatening - when to refer to ITU?
Drowsiness, confusion, exhaustion, coma, worsening hypoxia, normo/hypercapnoea, ABG showing decreased pH
Management of asthma exacerbations -acute severe or life-threatening - if symptoms improving?
Nebulised salbutamol every 4 hours
Prednisolone 40-50mg OD PO for 5-7 days
Aim for O2 at 94-98%
Monitoring of asthma exacerbations?
HR, RR, O2 sats, ECG
Discharge advice given after acute severe asthma attack?
PEFR >75% best or predicted 1 hour after treatment
Oral Prednisolone OD 40-50mg for 5 days
Review inhaler technique and PEFR by asthma liason nurse
Advise GP follow-up within 2 days
Respiratory clinic appointment within 4 weeks
Return to hospital if symptoms worsen/recur
Classes of COPD patient?
Type 1 Respiratory Failure (Pink puffers)
Low paO2, normal PaCO2
Emphysema predominantly, breathless not cyanosed
Type 2 Respiratory Failure (blue bloaters)
Low PaO2, High PaCO2
Chronic bronchitis – cyanosed develop cor pulmonale and rely on hypoxic drive
Symptoms of COPD?
o Exertional dyspnoea o Cough o Sputum o Wheeze o Ask about present treatment, past medical history, exercise tolerance, recent history
Signs of COPD?
o Dyspnoea, tachypnoea, accessory use muscles, lip pursing
o Hyperinflation (barrel chest)
o Wheeze/Coarse crackles
o Cyanosis, right heart failure (severe disease)
o Tremor, bounding pulse, peripheral vasodilatation, drowsiness
DDx of exacerbation of COPD?
- Asthma
- Pulmonary Oedema
- Pneumothorax
- PE
- URTI
Investigations to perform in COPD exacerbation?
- SpO2, RR, HR, BP, Temp, PEFR
- CXR
o Look for hyperinflation, pneumothorax, bullae, pneumonia - ECG
- ABG (documenting FiO2 and pCO2 to guide O2 therapy)
- Bloods – FBC, U&E, glucose, theophylline levels, blood cultures, CRP
- Sputum culture and microscopy
- Blood cultures if pyrexia
Management of exacerbation of COPD - initial management?
o Sit patient upright
o Oxygen
If hypoxic and before ABG result – give 15L/min via NRM
Aim for SpO2 88-92%, give O2 28% via Venturi mask and obtain ABG
Titrate up to minimum FiO2 to achieve 88-92%
o Investigations in breathing
ABG
CXR
o Salbutamol 5mg (or terbutaline 5-10mg) nebulised
o Ipratropium 0.5mg nebulised
If hypercapnoeic, acidotic COPD – use compressed air for nebulisers
o Hydrocortisone IV 200mg or Prednisolone PO 30mg (for 7-14 days)
o Investigations in circulation
IV access (FBC, U&E, glucose, blood cultures)
ECG
Management of exacerbation of COPD - antibiotic therapy?
Amoxicillin 500mg TDS PO for 5 days (Alt: Doxycycline)
If no improvement over 2-3 days:
• Use alternative
If unable to take oral antibiotics or severely unwell
• Amoxicillin 500mg TDS IV
• Co-amoxiclav 1.2g TDS IV
• Clarithromycin 500mg BDS IV
Management of exacerbation of COPD - further treatments?
o IV aminophylline or IV salbutamol if no response to nebulised bronchodilator
Management of exacerbation of COPD - if no response to initial management?
o Consider NIV - if RR >30 or pH<7.35 or paCO2 rising
CPAP or BiPAP
o If pH<7.26 and PaCO2 is rising despite NIPPV:
Consider intubation and ventilatory support
Management of exacerbation of COPD - discharge advice?
o Liaise with GP regarding steroid reduction
o Smoking cessation
o Flu and Pneumococcal Vaccine
Definition of acute bronchitis?
o Lower respiratory tract infection causing bronchial inflammation
Epidemiology of acute bronchitis?
- Prevalence = 4%
- Most during autumn or winter
Risk factors of acute bronchitis?
o Smoking
o Damp or dusty environment
Causes of acute bronchitis?
o Viral – rhinovirus, enterovirus, influenzas A and B, parainfluenza, coronavirus, RSV, adenovirus o Bacteria (1-10%) – Streptococcus pneumoniae, Haemophilus influenza, Moraxella catarrhalis o Rarely, atypicals – Mycoplasma pneumoniae, Chlamydophilia pneumoniae, Bordatella pertussis
Symptoms of acute bronchitis?
o Cough (clear/white) o +/- sputum, wheeze, breathlessness o Substernal or chest wall pain upon coughing o Sore throat o Fever
Signs of acute bronchitis?
o Absence of focal chest signs or systemic upset
Clinical diagnosis of acute bronchitis?
- Clinical Diagnosis (O2 sats) o CRP – if uncertain about antibiotic indications <20 – no antibiotics 20-100 – delayed antibiotics >100 – immediate antibiotics
Investigations in acute bronchitis?
- If wanting to rule out pneumonia:
o CXR
Management of acute bronchitis - general advice?
Adequate fluid intake
PRN paracetamol/ibuprofen
Other ideas – honey, OTC medications (honey, pelargonium)
Stop smoking
Seek medical help if symptoms worsen or do not improve after 3-4 weeks or become systemically unwell
Management of acute bronchitis - when to give immediate antibiotics?
• CVD, CKD, cirrhosis, immunosuppressed, CF
• >65 with 2 or more, >80 with one or more:
o Hospital admission in last year, DM, Hx of CHF, use of corticosteroids
• CRP >100 immediately (delayed 20-100 – if symptom worse rapidly or significantly)
Management of acute bronchitis - what immediate antibiotics to give - adults?
o Oral doxycycline 200mg 1st day then 100mg OD for 4 days (5-day total)
o Alternatives: Amoxicillin (pregnant women), clarithromycin, erythromycin
Management of acute bronchitis - what immediate antibiotics to give - children <17?
o Oral amoxicillin for 5 days
o Alternatives: clarithromycin, erythromycin, doxycycline
Management of acute bronchitis - follow up?
Not necessary
Seek medical help if symptoms worsen, do not improve after 3-4 weeks or very unwell
Prognosis of acute bronchitis?
o Usually self-limiting and cough lasts 3-4 weeks
¼ will have cough for >4 weeks and may persist for up to 6 months (post-bronchitis syndrome)
o Antibiotics do not make a difference to duration of symptoms and have side effects
Definition of tension pneumothorax?
- Life-threatening emergency and requires prompt treatment
- Gas progressively enters pleural space but unable to leave
- Increased pressure causes complete lung collapse on affected side and mediastinal shift
- Leads to kinking of great vessels therefore decreased venous return and cardiac output
- Cardiac arrest can occur within minutes
Causes of tension pneumothorax?
o Trauma
o Iatrogenically (insertion of central line, CPR)
o IPPV
o Lung disease (Asthma or COPD)
Symptoms of tension pneumothorax?
o SOB, dyspnoea, acute respiratory distress
o Chest pain
Signs of tension pneumothorax?
o Absent breath sounds on affected side
o Hyper-resonant over affected lung
o Tracheal deviation away from affected side
o Distended neck veins, tachycardia, hypotension, loss of consciousness
Management of tension pneumothorax - initial management?
o 15L/min O2 by NRB mask o Insert IV cannula (16G or larger) into 2nd intercostal space MC line just above third rib o Axillary chest-drain immediately o Remove cannula o Check patient okay and CXR
Management of tension pneumothorax - how to insert Chest drain?
Give IV opioid analgesia
Abduct arm fully
Clean skin and sterilise
Identify 5th ICS just anterior to MA line
Local anaesthetic (1% lidocaine + adrenaline) under skin and down to periosteum
28-32FG chest drain
Make 2-3cm incision in line of ribs
Use blunt dissection with artery forceps and insert gloved finger into pleural cavity to ensure no adhesions
Insert chest drain ensuring all drainage holes are in chest cavity
Connect drain to underwater seal and look for swinging
Suture drain securely in place and cover with adhesive dressing
Obtain CXR
Risk factors for PE?
o Surgery (pelvic/abdominal) o Thrombophilia o Leg fracture o Bed rest/Reduced mobility o Malignancy o Pregnancy o OCP/HRT
Causes of PE?
o Embolism of DVT o RV thrombosis (post-MI) o Right endocarditis o Fat, air or amniotic fluid o Neoplastic cells
Symptoms of PE?
o Acute dyspnoea o Pleuritic chest pain o Cough and Haemoptysis o Syncope o Symptoms of DVT
Signs of PE?
o Tachycardia o Tachypnoea o Hypotension o Pyrexia with lung infarction o Pleural rub o Cyanosis o Gallop rhythm o Increased JVP o RV heave
Assessment of PE? What is PE rule out criteria?
o ECG o CXR o Pulmonary Embolism Rule-Out Criteria Rule out PE if none of 8 criteria are present with low Wells Score (<2) • age < 50 years • pulse < 100 beats min • SaO2 ≥ 95% • No haemoptysis • No oestrogen use • No surgery/trauma requiring hospitalization within 4 weeks • No prior VTE • No unilateral leg swelling
Initial investigations of PE?
o Full history and examination of respiratory and CV systems
o Examine legs for signs of DVT
o CXR
Often normal – wedge shaped area of infarction, decreased vascular markings, small pleural effusion
Excludes pneumonia and pneumothorax
o PE Wells Score
What is the PE wells score?
Embolism History (DVT/PE) 1.5
Malignancy (on treatment, treated in the last 6 months, or palliative) 1
Bed for more than 3 days or surgery in the previous 4 weeks 1.5
Oral haemoptysis 1
Leg DVT signs and symptoms (minimum of leg swelling and pain with palpation of the deep veins) 3
Increased HR >100bpm 1.5
Most likely diagnosis is PE 3
Management of Well’s PE score of more than 4?
Immediate CTPA
o If CTPA cannot be carried out immediately – interim LMWH anticoagulation and hospital admission
o IF CTPA negative and DVT suspected – proximal leg US
o V/Q Scan - If allergy to contrast or renal impairment (eGFR<30) or pregnant or woman <40
Diagnosed PE with positive CTPA or V/Q scan
Consider alternative diagnosis if negative CTPA and no suspected DVT
Management of PE if Well’s score 4 or less?
• D-Dimer
o If positive, then CTPA
If CTPA cannot be carried out immediately – interim LMWH anticoagulation and hospital admission
V/Q Scan
• If allergy to contrast or renal impairment (eGFR<30) or pregnant or woman <40
o If negative D-dimer or positive D-dimer and negative CTPA, then excluded
Other tests to be performed in A-E of PE management?
Bloods
• FBC, U&Es, baseline clotting, D-Dimer (if Wells of <4 to exclude PE)
ABG (if hypoxic, SOB)
• Low PaO2, Low PaCO2, pH often raised
ECG (if tachycardic or chest pain)
• Commonly normal – can have sinus tachycardia, RBBB, RV strain pattern (S1Q3T3), RAD, AF
• S1Q3T3 – in up to 50% (sign of Cor Pumonale)
Diagnostic imaging in PE?
o CTPA
First-line
When Wells >4 or, elevated D-Dimer
o V/Q Scanning
Used in pregnancy or young people (women<40)
Usually need CTPA afterwards to confirm
Initial management of PE?
o If hypoxic – 15L/min Oxygen o Analgesia (Morphine) + Antiemetic – if in pain or very distressed
Management of massive PE?
o If massive PE/haemodynamically unstable (BP <90mmHg, hypoxic, tachycardia, tachypnoea):
Urgent ICU help
Rapid colloid infusion
If BP still <90mmHg – consider dobutamine then IV noradrenaline infusion
Alteplase 100mg over 2 hour or 0.6mg/kg over 15 mins
Management of diagnosed PE - pharmacological interventions? What if cannot have anticoagulation therapy? What if recurrent DVT?
LMWH (175U/kg Tinzaparin SC/24h) as soon as possible for at least 5 days or until INR >2 for at least 24 hours, whichever is longer
• For severe renal impairment (eGFR <30) – Unfractionated heparin (UFH)
• If PE and haemodynamically unstable – offer UFH and thrombolytic therapy
Warfarin offered within 24 hours of diagnosis and continue for 3 months provoked / 6 months unprovoked PE
• Alternatives: NOACs (Apixaban, dabigatran, rivaroxaban)
If cannot have anticoagulation therapy:
• Temporary inferior vena cava filter
If recurrent DVT:
• Inferior vena cava filter after alternatives (raise INR 3-4, switching to LMWH)
Management of diagnosed PE - thrombolytic therapy?
- Consider systemic thrombolytic therapy for patient with haemodynamic instability
- Alteplase 100mg over 2 hour or 0.6mg/kg over 15 mins
Management of diagnosed PE - Investigations to find cause?
Cancer investigations for unprovoked DVT:
• Examination
• CXR
• Bloods (FBC, serum Ca, LFTs)
• Urinalysis
• Consider abdomino-pelvic CT scan if >40 with 1st unprovoked DVT
Thrombophilia testing
• Antiphospholipid antibodies in patients with unprovoked DVT if it is planned to stop anticoagulation therapy
• Hereditary thrombophilia testing – unprovoked DVT with 1st degree relative with DVT/PE if planned to stop anticoagulation
When to test for thrombophilias after diagnosed PE?
- Antiphospholipid antibodies in patients with unprovoked DVT if it is planned to stop anticoagulation therapy
- Hereditary thrombophilia testing – unprovoked DVT with 1st degree relative with DVT/PE if planned to stop anticoagulation
What tests are performed to investigate cancer after diagnosed PE?
- Examination
- CXR
- Bloods (FBC, serum Ca, LFTs)
- Urinalysis
- Consider abdomino-pelvic CT scan if >40 with 1st unprovoked DVT
Definition of pneumonia?
- Pneumonia is an acute infection of the lung parenchyma
Classes of pneumonia?
o Lobar – one or more lobes
o Broncho- Affecting lobules and bronchi
Epidemiology of pneumonia?
- Major cause of death in over 70s
- Incidence 1%
- Mortality 20% in hospital
Aetiology of pneumonia?
o Cigarette smoking o Hospitalised o Alcohol o Bronchiectasis o Lung cancer o Immunosuppression/IVDU
Causative organisms of community acquired pneumonia?
Bacterial (80-90%) • Streptococcus pneumoniae • Haemophilus influenza • Mycoplasma pneumoniae • Legionella (Air conditioning) • Chlamydia psittaci (birds) • TB
Viral (10%)
• Influenza A&B, RSV
Causative organisms of hospital acquired pneumonia?
HAP (>48h after admission)
Gram-neg enterobacteria
S.Aureus
Pseudomonas
Kleibsiella
Causative organisms of aspiration pneumonia?
Oropharyngeal Anaerobes
Symptoms of pneumonia?
o Fever o Cough o Sputum – green o SOB o Pleuritic chest pain o Myalgia o Rigors o Haemotypsis
Signs of pneumonia?
o Fever o Cyanosis o Confusion o Tachycardia o Tachypnoea o Hypotension o Consolidation (diminished expansion, dull percussion, increased tactile vocal fremitus, bronchial breathing), pleural rub
Severity assessment of person with pneumonia in primary care?
o In primary care – CRB-65 score
0 – low risk – home management
1-2 intermediate risk – hospital admission
3-4 – high risk – urgent admission
Severity assessment of person with pneumonia in hospital?
o CURB-65 Score Confusion (AMTS≤8) Urea >7mmol/L RR ≥30/min BP <90/60mmHg Age≥65 • Score of 0 or 1 - managed at home • Score of 2 –inpatient treatment, oral Abx • Score of ≥3 – admit to ICU, IV Abx
Investigations to perform in hospital in pneumonia?
o RR, HR, BP, glucose, SpO2 (ABG <94% or known COPD)
If SEPSIS, start BUFALO and ABCDE SEPSIS management
o CXR - Patchy or lobar consolidation, mass lesions or air bronchogram
o Bloods
FBC, U&Es, LFT, CRP, atypical serology
o Blood Cultures
o Sputum cultures
o Consider pneumococcal and legionella urinary antigen tests
When to refer pneumonia to hospital?
o Cardiorespiratory failure
o Sepsis
o Symptoms not improving with antibiotics
o Unable to take oral medications
Management of pneumonia - general advice?
o Stop smoking
o Paracetamol for pleuritic pain
o Adequate fluid intake
Management of pneumonia - initial hospital management?
o Oxygen (if hypoxic)
o Simple Analgesia
o IV fluids if hypotensive
o Antibiotics (started within 4 hours of diagnosis (1 hour if sepsis))
Management of community acquired pneumonia - antibiotic therapy - CURB65 0/1?
- Oral Amoxicillin 500mg TDS for 5 days
* Alternatives – Doxycycline, clarithromycin, erythromycin (pregnancy)
Management of community acquired pneumonia - antibiotic therapy - CURB65 2?
- Oral Amoxicillin 500mg TDS + Clarithromycin 500mg BD – if atypical suspected for 5 days
- Alternatives – Doxycycline, Erythromycin (in pregnancy)
Management of community acquired pneumonia - antibiotic therapy - CURB65 3/4/5?
- IV Co-amoxiclav 1.2g TDS + Clarithromycin 500mg BD for 5 days
- Alternatives – Oral co-amoxiclav, erythromycin (pregnant), levofloxacin
Management of pneumonia - if no improvement?
Contact ICU and prepare for central line and urinary catheter insertion
Aim for CVP>8mmHg, MAP>65mmHg, Urine output >0.5mg/kg/hr
Management of hospital acquired pneumonia - antibiotic therapy - non-severe?
- Oral Co-amoxiclav 500/125mg TDS for 5 days then review
* Alternatives: Doxycycline, cefalexin, co-trimoxazole
Management of hospital acquired pneumonia - antibiotic therapy - severe?
- IV tazocin 4.5g TDS, 48h and then review
* Alternatives: Ceftazidime, ceftriaxone, cefuroxime, meropenem
When should you not discharge patient with pneumonia?
o Do not discharge if 2 or more of following:
Temperature >37.5, RR >24, HR>100, BP <90, O2 <90%ora, abnormal mental status, unable to eat or drink
Follow up advice for patient after pneumonia?
o CXR at 6 weeks if symptoms persisting despite treatment or high risk of underlying malignancy (smokers or people over 50)
Complications of pneumonia?
o Pleural effusion o Empyema o Lung Abscess o Respiratory failure o Sepsis o Pericarditis o AKI
Oxygen management - 1 - critically ill requiring O2?
15L/min via Non-rebreathe (Reservoir) mask
Once stable - reduce oxygen dose and aim 94-98%
COPD - same initial target sats - measure ABG and move to controlled oxygen if needed
Oxygen management - 2 - serious illness requiring moderate if patient hypoxic?
Initial O2 - 2-6L/min nasal cannula or 5-10L/min via facemask
If O2 <85% - 15L/min via non-rebreathe mask
Aim 94-98%
Oxygen management - 3 - COPD and other conditions requiring controlled oxygenation?
Use 28% Venturi aiming 88-92% until ABG available
If CO2 raised or Hx of IPPV/NIV then continue 88-92%, if not then aim 94-98%
If high O2 sats - reduce dose of O2
Recheck ABG within 60 minutes or earlier if deterioration - if pH<7.35, H >45, PCO2 >6.0 - senior for NIV or ventilation
Indications for NIV?
Respiratory acidosis - pH<7.35 or PCO2>6.0
In people with COPD, respiratory muscle weakness, chest wall deformity, obesity hypoventilation
Difference between CPAP and NIV/BiPAP?
CPAP - does not reduce CO2 - don’t use in T2RF
NIV/BiPAP - difference between IPAP and EPAP increases patients tidal volume and decreased arterial CO2
