Respiratory Long Case (UKM) Flashcards
State the risk factor of pulmonary embolism
- Recent surgery
- Conditions that render immobilization
- Underlying malignancy
- Underlying connective tissue disease like SLE
- Estrogen-based OCP
- Family history of thrombophilic disorder
What are some possible differentials for pulmonary embolism?
- ACS
- Aortic dissection
- Pneumothorax
State the complications of pulmonary embolism that can be viewed during physical examination
- Pulmonary infarction -> reduced breath sound at the affected side
- Pleural effusion
- Right-sided heart failure -> peripheral edema
List the lethal complications of massive pulmonary embolism
- Cardiac arrest -> PEA, asystole
- Circulatory collapse
- Cardiogenic shock
What are the signs of unstable hemodynamic status in a patient with pulmonary embolism?
- 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
How would you treat a hemodynamic unstable pulmonary embolism patient?
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
How would you treat a hemodynamic stable pulmonary embolism patient?
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
How to distinguish between low or intermediate risk PE?
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
What is the treatment plan of PE in the ward?
- 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
What is the long term treatment plan of DVT?
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
State the components of the Well’s score and its grading classification
Well’s score -> To evaluate the clinical probability of PE
What is the role of D-dimer in managing PE?
- 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
List (5) complications of pulmonary embolism
- Right ventricular ischemia, infarction and failure
- Cardiac arrest
- Atelectasis
- Pulmonary infarction +/- complicated with pneumonia
- Pleural effusion
What are the possible findings of CXR to look for in a case of pulmonary embolism?
- Enlarged pulmonary artery
- HAMPTON HUMP (wedge-shaped infarct at the periphery with its apex points to the hilum)
- Atelectasis
- Pleural effusion
What are the features that indicate severe exacerbation of COPD?
- Altered mental status: confused, agitated
- Speaks in words
- Use of accessory muscles to breath
- Very rapid breathing/Poor breathing effort (exhaustion)
State the possible cause of AECOPD
- Respiratory infection
- Non-compliance to inhaler
- Poor inhaler technique
- Non-compliance to smoking cessation
- Exposure to allergen
What other life-threatening cause of SOB should be ruled out in a COPD patient?
- Pneumothorax
- Pulmonary embolism
- Severe pneumonia
- Heart failure
- Cardiac arrhythmias
State the complications of ICS
- Oral/esophageal candidiasis
- Recurrent pneumonia
What are the possible examination findings of cor pulmonale?
- Raised JVP
- Right displacement of apex beat
- Parasternal heave
- Loud P2
- Peripheral edema, hepatomegaly
What are the possible findings on a RS examination for a COPD patient?
- Reduced chest expansion
- Reduced breath sounds, prolong expiratory phase, fine inspiratory crackles, wheezing/rhonchi
- Hyperinflated lungs (Loss of cardiac dullness, downward displacement of liver)
State the differences between a wheeze and a rhonchi
List the initial investigations you would order to a patient coming with COPD (Based on patient’s condition as well)
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
What is the most important investigation to diagnose COPD?
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
What results of the spirometry suggestive of COPD?
- FEV1/FVC ratio <0.70 indicates presence of airflow limitation
- Persistent FEV1/FVC ratio <0.70 after bronchodilator
