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Medicine > Respiratory Long Case (UKM) > Flashcards

Respiratory Long Case (UKM) Flashcards

1
Q

State the risk factor of pulmonary embolism

A
  • Recent surgery
  • Conditions that render immobilization
  • Underlying malignancy
  • Underlying connective tissue disease like SLE
  • Estrogen-based OCP
  • Family history of thrombophilic disorder
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2
Q

What are some possible differentials for pulmonary embolism?

A
  • ACS
  • Aortic dissection
  • Pneumothorax
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3
Q

State the complications of pulmonary embolism that can be viewed during physical examination

A
  • Pulmonary infarction -> reduced breath sound at the affected side
  • Pleural effusion
  • Right-sided heart failure -> peripheral edema
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4
Q

List the lethal complications of massive pulmonary embolism

A
  • Cardiac arrest -> PEA, asystole
  • Circulatory collapse
  • Cardiogenic shock
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5
Q

What are the signs of unstable hemodynamic status in a patient with pulmonary embolism?

A
  • Cardiac arrest
  • SBP <90 mmHg or requires vasopressor to achieve SBP >90 mmHg
  • End-organ hypoperfusion: altered mental status, cold clammy skin, oliguria/anuria, raised serum lactate
  • Persistent hypotension: SBP <90mmHg or drops >40mmHg longer than 15 minutes

Presence of hemodynamic instability = HIGH RISK PE

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6
Q

How would you treat a hemodynamic unstable pulmonary embolism patient?

A

Supportive treatment
- Oxygen if SpO2 <90% via high flow nasal prong, consider NIV if hypoxic
- CVP monitoring may be necessary
- Fluid challenge if hypotensive: <500mL NS over 15 - 20 minutes
- Vasopressor: Noradrenaline 0.2 - 1.2 microgram/kg/min
- Extracorporeal membrane oxygenation (ECMO): if circulatory collapse occurs

Immediate BEDSIDE ECHO to look for RV DYSFUNCTION
- RV:LV diameter ratio >1.0
- If RV dysfunction presents, confirm diagnosis via CTPA if available. Otherwise, treat as high risk PE
- If RV dysfunction not present in echo, consider other cause

Anticoagulation -> IV unfractionated heparin

Definitive treatment for high-risk PE: REPERFUSION TREATMENT
- 1st lined treatment: SYSTEMIC THROMBOLYSIS
- Agent used: IV rtPA 100mg over 2 hours
- Other reperfusion methods:
1. Percutaneous catheter-directed thrombolysis
2. Surgical embolectomy

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7
Q

How would you treat a hemodynamic stable pulmonary embolism patient?

A

Subsequent steps depend on clinical probability:
- High clinical probability: confirm diagnosis via CTPA
- Low or intermediate clinical probability: measure serum D-dimer
1. D-dimer positive: confirm diagnosis via CTPA
2. D-dimer negative: PE rule out
Give anticoagulation (SC LMWH)
When diagnosis is confirmed via CTPA, treat as low or intermediate-risk PE

Treatment for low or intermediate-risk PE
- Only anticoagulation, no reperfusion required

Treatment of intermediate risk PE:
- Measure serum TROPONIN
- If troponin +ve and RV dysfunction present: INTERMEDIATE HIGH-RISK -> need close monitoring, may require rescue thrombolysis
- If troponin -ve: INTERMEDIATE LOW RISK -> need admission for monitoring

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8
Q

How to distinguish between low or intermediate risk PE?

A

Look for
- Evidence of RV dysfunction in echo/CTPA
- Clinical signs using PESI (pulmonary embolism severity index)

If any one of the above is presents, it is regarded as intermediate risk PE

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9
Q

What is the treatment plan of PE in the ward?

A
  • Anticoagulation: either with heparin, fondaparinux
  • Start long-term warfarin
  • Investigate for underlying cause in patients with unprovoked DVT/PE: malignancy and thrombophilic disorder should be investigated
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10
Q

What is the long term treatment plan of DVT?

A

Anticoagulation
- For all patients: minimum of 3 months
- Patients with recurrent DVT/PE or antiphospholipid syndrome: lifelong anticoagulation with warfarin
- Patients with CA: SC LMWH for 6 months

IVC filter
- Indication: recurrent PE despite anticoagulation or when anticoagulation is contraindicated

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11
Q

State the components of the Well’s score and its grading classification

A

Well’s score -> To evaluate the clinical probability of PE

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12
Q

What is the role of D-dimer in managing PE?

A
  • D-dimer has a very good negative predictive value -> If negative results, we can confidently exclude the diagnosis
  • D-dimer is a FIBRIN-DEGRADATION PRODUCT that is formed when a thrombus is dissolved
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13
Q

List (5) complications of pulmonary embolism

A
  • Right ventricular ischemia, infarction and failure
  • Cardiac arrest
  • Atelectasis
  • Pulmonary infarction +/- complicated with pneumonia
  • Pleural effusion
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14
Q

What are the possible findings of CXR to look for in a case of pulmonary embolism?

A
  • Enlarged pulmonary artery
  • HAMPTON HUMP (wedge-shaped infarct at the periphery with its apex points to the hilum)
  • Atelectasis
  • Pleural effusion
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15
Q

What are the features that indicate severe exacerbation of COPD?

A
  • Altered mental status: confused, agitated
  • Speaks in words
  • Use of accessory muscles to breath
  • Very rapid breathing/Poor breathing effort (exhaustion)
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16
Q

State the possible cause of AECOPD

A
  • Respiratory infection
  • Non-compliance to inhaler
  • Poor inhaler technique
  • Non-compliance to smoking cessation
  • Exposure to allergen
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17
Q

What other life-threatening cause of SOB should be ruled out in a COPD patient?

A
  • Pneumothorax
  • Pulmonary embolism
  • Severe pneumonia
  • Heart failure
  • Cardiac arrhythmias
18
Q

State the complications of ICS

A
  • Oral/esophageal candidiasis
  • Recurrent pneumonia
19
Q

What are the possible examination findings of cor pulmonale?

A
  • Raised JVP
  • Right displacement of apex beat
  • Parasternal heave
  • Loud P2
  • Peripheral edema, hepatomegaly
20
Q

What are the possible findings on a RS examination for a COPD patient?

A
  • Reduced chest expansion
  • Reduced breath sounds, prolong expiratory phase, fine inspiratory crackles, wheezing/rhonchi
  • Hyperinflated lungs (Loss of cardiac dullness, downward displacement of liver)
21
Q

State the differences between a wheeze and a rhonchi

A
22
Q

List the initial investigations you would order to a patient coming with COPD (Based on patient’s condition as well)

A

Chest radiograph
- Evidence of COPD = hyperinflated lungs, hyper lucent lung fields
- Evidence of infection = CONSOLIDATION
- Cardiomegaly

ABG -> Respiratory acidosis
ECG -> to look for any comorbidity
FBC -> leucocytosis, polycythemia
BUSE
Sputum C&S if sputum is purulent
Blood C&S if pyrexia
Serum theophylline level in patient who takes theophylline

23
Q

What is the most important investigation to diagnose COPD?

A

SPIROMETRY

Done in 2 modes:
1. No bronchodilator
2. After taking bronchodilator
- 400mcg SABA -> repeat spirometry after 10-15 minutes
- 160mcg LABA -> repeat spirometry after 30-45 minutes

Following parameters to measure:
- FVC -> volume of air upon forceful expiration after maximal inspiration
- FEV1 -> volume of air exhaled in one second during forceful expiration
- FEV1/FVC calculated

24
Q

What results of the spirometry suggestive of COPD?

A
  • FEV1/FVC ratio <0.70 indicates presence of airflow limitation
  • Persistent FEV1/FVC ratio <0.70 after bronchodilator
25
Q

How do we classify COPD?

A

First, assess the severity of airflow limitation
- The value of FEV1 is poorly related to severity of symptoms
- Assessment based on symptoms is necessary using
1. mMRC
2. CAT

26
Q

List the initial management of COPD patient

A

Supplemental oxygen
- Either nasal cannula 1-2L/min or 24-48% venturi mask
- Maintain SpO2 88-90%

Pharmacological treatment
- Bronchodilator
- Corticosteroid (systemic corticosteroid for 5-7 days)
- Antibiotics (but, not all patients with AECOPD requires)

Review clinical response to treatment
Consider non-invasive ventilation in
- Patient with acute respiratory failure
- Failure to respond to initial treatment

27
Q

What are the indications for antibiotic treatment in COPD patient?

A

2 out of 3 of the following
- Increased dyspnea
- Increased sputum volume
- Increased sputum purulence

28
Q

List the risk of Pseudomonas colonization in COPD patient

A
  • Culture positive for Pseudomonas in the past year
  • Hospitalization/antibiotic use in past 3 months
  • Concomitant bronchiectasis
  • Use of systemic steroid
  • Advanced COPD

Cover pseudomonas with IV TAZOCIN or CEFEPIME

29
Q

State the indication for admission into ICU for a COPD patient

A
  • Severe dyspnea responds poorly to treatment
  • Change in mental status
  • Persistent or worsening hypoxemia, indicated by PaO2<40mmHg, or pH<7.25 despite O2 and NIV
  • Need for intubation
  • Hemodynamically unstable
30
Q

Describe the management of a stable COPD patient

A

Pharmacological
- Bronchodilator
- ICS
- PDE4-inhibitor (Phosphodiesterase-4 inhibitor) -> Consider in patient with severe to very severe COPD with history of exacerbation

Non-pharmacological
- Smoking cessation (most important)
- Vaccination (against Pseudomonas and influenza)
- Nutritional supplementation for malnourished patient
- Long term oxygen therapy (LTOT)

31
Q

List the pre-requisites for LTOT (Long term oxygen therapy)

A
  • PaO2<55mmHg or SpO2<88% with/without hypercapnia confirmed twice over a three-week period
  • PaO2 between 55-60mmHg or SpO2 of 88% if there is evidence of:
    1. Pulmonary hypertension
    2. Peripheral edema (suggesting CCF)
    3. Polycythemia with hematocrit >55%
32
Q

What are the conditions that require surgical intervention in COPD and state the surgical intervention done for each condition

A
  • Upper lobe emphysema -> Consider lung volume reduction surgery
  • Large bullae -> Surgical bullectomy
  • Advanced emphysema -> Therapeutic bronchoscopy to reduce end-expiratory lung volume
  • Very severe COPD -> consider lung transplantation
33
Q

List the differences between emphysema and chronic bronchitis

A
34
Q

List (5) contraindication for non-invasive ventilation

A
  • Upper airway obstruction
  • Untreated pneumothorax
  • Hemodynamically unstable
  • Basal skull fracture
  • Persistent vomiting
  • Patient’s refusal
35
Q

Define cor pulmonale

A

It is defined as altered structure or impaired function of the right ventricle caused by pulmonary hypertension due to primary disorder of respiratory or pulmonary artery system

36
Q

Why there is a higher incidence of pneumothorax in patients with COPD?

A

Due to rupture of SUBPLEURAL BULLAE

37
Q

How to check chest tube functioning?

A

Chest draining system consists of 3 compartments:
- Fluid collection
- Water seal
- Suction control

Detect air leak
- One will see intermittent bubbling in the water seal compartment (but this is normal in case of pneumothorax)
- Check for any disconnection, dislodgement of loose connection from away from patient to towards the patient

Extra information
- In case of pneumothorax, rise and fall of water level in the water seal compartment is NORMAL (indicates the system is working normally)
- Cessation of rise and fall of water level means either pneumothorax has resolved or blockage of the tube

38
Q

List the complications of bronchial asthma based on the bio-psycho-social model

A
39
Q

Differentiate between asthma and COPD

A
40
Q
A

Medicine (8 decks)

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