Respiratory Medicine 🫁✅ Flashcards
Primary pneumothorax <2cm Mx
Discharge
Primary pneumothorax with >2cm marking. Mx
Aspirations (then chest drain if unsuccessful)
Secondary pneumothorax in >50 year old, with >2 cm marking, and/or patient is short of breath… Mx
Chest drain
Secondary pneumothorax with 1-2cm marking Mx
Aspiration (drain if fails)
Secondary pneumothorax with <1cm marking Mx
Give o2 and admit for 24hours
Signs of mild airway obstruction
Patient is able to speak and answer the question, cough, and breathe
Symptoms of severe airway obstruction
Patient is unable to speak they will only respond to you by nodding, they may be wheezy, unable to breathe, and attempt to cough are silent
How to manage a patient with mild airway obstruction
First ask if patient is choking, to know whether they can answer and that it is mild away obstruction. Then encourage patient to cough them self.
Management of patients with severe airway obstruction and his conscious
Give five back blows, five abdominal thrusts and continue until successful
Management of severe airway obstruction and unconscious
Call an ambulance and start CPR. 30 chest compressions then 2 mouth-to-mouth
The presence of warm flushed skin and bounding pulses is a sign of which type of acute respiratory failure 
Type II, because the high CO2 causes an acidosis
Two main investigations to do for a patient with acute respiratory failure
ABG to confirm the diagnosis and chest x-ray
Indications for ventilation in acute resp failure
O2 therapy doesn’t increase PaO2 to 60. Ph less that 7.25, resp muscle fatigue, apnoea, RR > 30, hemodynamically unstable.
Management for acute respiratory failure. Consider when to give O2. Recall considerations for ventilation
Prompt hospitalisation. ABCDE. Aim for oxygen of more than 90% saturation.
Discharge advice to patients following a pneumothorax
All patients should stop smoking, do not fly until two weeks after successful drainage (given you have seen a good x-ray). And completely avoid scuba-diving unless the patient has had surgical pleurectomy
Final option for patient if they have recurrent pneumothorax even after chest tube and drainage
Refer for video assisted thorascopic surgery to seal the pleura to the thorax
First thing to do in a patient with tension pneumothorax
Insert a large ball cannula in the second intercostal space in the mid clavicular line (do not wait for investigations)
Two features that score 3 on Wells criteria for PE
Signs of DVT and an alternative diagnosis being less likely and PE
Three features on the wells criteria that score 1.5
Heart rate above 100, previous DVT and immobilisation for more than three days or surgery in the past month
Two features that score one on Wells criteria
Hemoptysis and malignancy
Patient presents with PE like symptoms and scores more than four on Wells.
What is the initial investigation
CTPA, If there is a delay give therapeutic anticoagulation until performed
Following a patient with a Wells score above four and after a CTPA is done and is negative… what next?
Proximal leg ultrasound with Doppler to check for DVT
Patient presents with PE like symptoms with a wells score of four or less. First investigation
Do a D dimer test
If a patient had a Well’s score of four or less, and the d-dimers is positive what to do
Do a CTPA
If a patient has a renal impairment, do you do a CTPA or VQ
VQ To avoid contrast nephropathy
Most common finding on an ECG for PE
Sinus tachycardia, less commonly S1Q3T3
Role of x-ray in PE investigation
To exclude other pathology
First line management of PE
Direct oral anti-coagulant
Alternatives to DOAC in management of PE
Low molecular weight heparin and dabigatran or low molecular weight heparin and warfarin
If a patient’s DVT was provoked, how long should anticoagulation be done for
Three months
If the patient’s PE was unprovoked how long should anticoagulation be for
Six months
If a patient PE was due to malignancy How long should anticoagulation be for
Between six and three months
First line for massive PE or PE with circulatory failure
Thrombolysis
Main investigations for asthmatic suspicious patients. Children have two tests, adults can use another two also.
Spirometry and Bronco dilator reversibility test for both. FeNO and metacholine challenge can also be used
When is the fractional exhaled nitrogen oxide test done
It is a diagnostic test in adults only for asthma
When is the Metacholine: challenge test done for asthma
In adults only, if all of the tests were uncertain
What would be a significant value for bronchodilator reversibility test in an asthmatic
An increase in the FEV1 of more than or equal to 12%
Step 1 in asthma treatment
Newly diagnosed and not bad asthma. SABA ONLY
Step 2 in asthma treatment
For patients not managed on step 1, or with 3 or more symptoms a week, or night time waking. SABA and low dose ICS
3rd step in asthma management
SABA, ICS, LTRA
4 step in asthma management
SABA, low dose ICS, LABA (with or without the LTRA previously)
5th step in asthma management
SABA and MART (with or without LTRA)
6th step in asthma management
SABA, Medium dose MART (with or without LTRA)
7th step in asthma management
SABA, high dose ICS and trial of additional drug (theo or high dose ICS). With or without LTRA
Asthma Patient on SABA and ICS… not well controlled. Add what?
LTRA (not LABA). This is step 2 to 3
Moderate asthma exacerbation is defined
X-X% of PEFR
RR< x
Pulse < x
50-75% of PEFR
RR< 25
Pulse < 110
Severe asthma exacerbation is defined
X-X% of PEFR
RR > x
Pulse > x
33-50% of PEFR
RR > 25
Pulse > 110
Life threatening asthma exacerbation is defined As?
PEFR < 33%, O2 < 92%, silent chest, hemodynamic changes, confusion (AMS) = overrules anything else
Investigation for acute asthma exacerbation
ABG, not X-ray unless suspect pneumothorax or life threatening asthma
Who should be admitted to hospital (regarding acute asthma exacerbation)
Life threatening cases or severe cases who don’t respond to treatment
When to give oxygen in acute asthma exacerbation
If patient is hypoxemic, or if patient is acutely unwell. 15L of supplemental O2 via a non rebreathe mask
General treatment for all patients with acute asthma exacerbation.
High dose inhaler SABA (nebulise if life threatening exacerbation). Oral prednisolone (for at least 5 days). IV cortisone for patients unable to swallow.
Discharge requirements for patients with acute asthma exacerbation
PEGR > 75%, inhaler technique check, stable on med for 12-24 hours
When could you give ipratropium bromide in acute asthma exacerbation
If patient didn’t respond to SABA
Best investigation for COPD
Spirometry
Stage 1 COPD
FEV1 > 80% predicted
Stage 2 COPD
FEV1 50-79% predicted
Stage 3 COPD
FEV1 30-49% predicted
Stage 4 COPD
FEV1 < 30% predicted
Advise and Vx for patients with COPD
Stop smoking, annual influenza, one off pneumococcal, rehab if QoL impaired.
First treatment for COPD
SABA or SAMA
If SABA or SAMA doesn’t work for a patient with COPD. Assess what?
Steroid responsiveness/asthmatic features
What features suggest asthmatic features/steroid responsiveness in COPD.
History of asthma/atopy, raised eosinophils, diurnal variation in FEV1 and peak flow (more than 20%)
If a patient has COPD with asthmatic features and failed on SABA. Do what?
SABA or SAMA, and LABA and ICS
If patient is not steroid responsive, has COPD that failed with SABA. Do what
SABA, AND LABA AND LAMA
3rd step for COPD treatment (regardless of steroid responsiveness)
SABA. LABA, LAMA, ICS
When to give mucolytics in COPD
If patient has chronic productive cough
Patient had more than three COPD exacerbations. What should be given as prophylaxis?
Oral Azithromycin (azif my magic… no more exac)
Treatment for cor pulmonale
Loops and long term o2
2 things that improve COPD survival
Quit smoking and long term O2 therapy
Oxygen therapy in COPD. When do we give?
Give us O2 less then 7.3, or between 7.3-8 with polycythemia, edema, pulmonary hypertension
Cause of severe exacerbation of COPD
Haemophilus I. (Main one).
Streptococcus and moraxella second
