Respiratory medicine

Question 1

O2 therapy + BiPAP + ventilator

Answer 1

O2 therapy

• O2 __L through nc/ mask
• O2 0-___L prn, aim SaO2 >=___%
• COPD: 88-92%

BiPAP (usu no alarm)
 - Decreased SaO2
 >>>> disconnect: reconnect
 >>>> sputum plug: suction
 >>>> PTX: stop BiPAP + chest drain
 - ABG
 - CXR
 - Increase FiO2
 - Sputum suction prn
 - Chest physio

Ventilator
 - Decreased SaO2
 >>>> disconnect: reconnect
 >>>> sputum plug: suction
 >>>> PTX: stop ventilator + chest drain
 >>>> fight ventilator: dormicum
 - ABG
 - CXR
 - Increase FiO2 (Max <60%)
 - Increase PEEP (recruit more alv, less dead space)
 - Increase CO2
 - Increase RR
 - Increase tidal vol (wash out CO2_
 - Sedation by IV dormicum 100mg in 100mL NS, 1ml/H infusion

 - High pressure
 >>>> sputum plug: suction
 >>>> PTX: stop ventilator + chest drian
 >>>> fight ventilator: dormicum
 - ABG
 - CXR

• Low pressure
  &raquo_space;» air leak: check
  &raquo_space;» low BP: check PTX

 - Small TV
 >>>> cuff leak
 >>>> tube kink/ biting
 >>>> cough
 >>>> peak pressure

• Disconnect
  &raquo_space;» reconnect
• Apnea
  &raquo_space;» change to CMV mode

Question 2

Asthma

Answer 2

Admission

• DAT (NPO if severe SOB)
• O2 supplement
• Pulse oximeter
• PEFR BD
• Obs q4H, q1H if unstable
• Bld x CBC LRFT bone clotting RG
• ABG
• Sputum x C/S
• NPA
• Ventolin 4puff q4H
• Atrovent 4puff q4H
• +- steroid (hydrocortisone/ prednisolone)
• Book lung function test
• +- intubate/ ICU if severe (tachycardia, tachypnea, acidosis)

Question 3

CAP/ aspiration PnA

Answer 3

HPI

• SOB
• cough, sputum
• fever
• RN
• chest pain
• LL edema
• loose stool, abd pain, ovomiting
• TOCC

Admission
 - DAT (NPO until ST assessment)
 - Obs q4H
 - O2 supplement, keep SpO2 >=94%
 - Sputum suction prn
 - Chest physio
 - Bld x CBC LRFT bone clotting RG
 - +- ABG if severe SOB/ high flow O2
 - +- C/S if fever >38
 - NPS x viruses
 - Sputum x C/S, AFBx3
 - Urine x multistix, C/S, (legionella & pneumococcal Ag)
 - CXR
 - ECG
 - Resume usual meds
 - PO panadol 500mg q4H prn
 - Antibiotics
 >>>> IV augmentin 1.2g q8H, PO clarithromycin 500mg daily
 >>>> IV tazocin 4.5g q8H if severe CAP, previously hospitalized, previous C/S P aeruginosa

• Consult ICU if young male 3-4L O2

Question 4

COPD

Answer 4

Admission
 - DAT (NPO if severe SOB + IVF)
 - O2 supplement keep SaO2 88-92%
 - Obs q1H x4 then q4H if stable
 -  Chest physio
 - Sputum suction prn
 - Bld x CBC LRFT bone clotting RG ABG
 - C/S if fever >38
 - TropI, CK q6H x3
 - Sputum x C/S, (AFB)
 - Urine x multistix
 - CXR
 - ECG
 - Resume usual meds
 >>>> Ventolin 4puff q4H
 >>>> Atrovent 4puff q4H
 >>>> Steroid (prednisolone 30mg daily/ hydrocortisone 100mg q8H)
 >>>> IV augmentin 1.2g q8H/ PO augmentin 1g BD if fever/ WCC/ purulent sputum)
 - BiPAP standby if severe hypercapnia/ SOB

Question 5

Cough

Answer 5

Ward complain

• Septic workup if fever, purulent sputum
• PO Actufed Co (codeiune + triprolidine + pseudoephedrine) 10mL TDS
• PO MES 10mL TDS prn (expectorant)
• PO Phlocodine 10mL TDS prn (suppressant)
• PO Phensedyl 10mL TDS prn (suppressant, cause AROU)
• PO Promethazine 10mL TDS prn
• PO Cocillana 10mL QID prn
• PO Elixir benadryl 10mL QID prn
• PO codeine 30mg TDS

Question 6

Mantoux

Answer 6

• 0.1mL 2U PPD, read result 48-72H later

Question 7

Hemoptysis

Answer 7

Admission

• NPO
• Hemoptysis chart
• +- chart I/O
• Suction prn
• +- lie latera
• O2 supplement
• Obs q1H
• Bld x CBC LRFT bone RG
• Sputum x C/S, AFBx3
• Urine x multistix
• CXR
• ECG
• Resume usual meds
• • IV transmin 500mg q6-8H
• W/H anticoagulant
• Transfusion if indicated
• +- early CT thorax with contrast
• Consult resp x bronchoscopy
• +- U bronchoscopy/ BAE if failed stop bleeding

Ward complain

• think TB, tumor
• Air borne precaution
• NPO
• IVF
• O2
• Hemoptysis chart
• Bld x CBC LRFT clotting
• +- Bld x ABG, TnI, TxS
• Sputum x C/S, cytology x3
• w/h aspirin or anticoagulant
• • IV transamine 500mg q8H (RO previous significant thrombosis)
• Call MO if severe (intubation, ICU)
• Further Ix (CT thorax, embolism, bronchoscopy, CTS surgery, R/O for RT)

Question 8

SOB

Answer 8

Ward complain
- SaO2
&raquo_space;» if desat, think abt causes (CAP, COPD, PTX, pleural effusion)
- Subjective SOB, check VBG for acidosis (e.g. DKA, renal acidosis)
- Think MI (chest pain), asthma (wheeze), anemia (pallor)

Question 9

Sore throat

Answer 9

Ward complain
 - check for candidiasis
 >>>> PO nystatin 1mL QID/ PO fluconazole 50mg daily x2/52
 - NPS x resp virus
 - PO Dequadin 500mcg QID prn
 - PO cepacol 1tab QID prn
 - PO strepsil 1tab QID prn
 - PO Difflam lozenge 1tab TDS/QID

• +- mouth wash preparation
• 0.2% chlorherxidine MW 10mL LA TDS
• Thymol gargle MW 10mL LA TDS
• PO Difflam MW 10mL Q3H during daytime
• PO neuzym 30mg/60mg TDS
• +- cough med
• +- piriton

Question 10

Sputum

Answer 10

Ward complain

• Septic workup if fever, purulent
• PO fluimicil A 200mg TDS
• PO bisolvon 8mg TDS
• SC buscopan 20mg q4H prn

Question 11

Pleural effusion

Answer 11

Admission

• DAT
• Obs q4H
• O2 supplement
• Bld x CBC LRFT bone clotting CRP/ESR INR RG CK TnT
• CEA if suspect CA
• Sputum x AFB x3, cytology x3, C/S
• CXR (erect, decub)
• ECG
• Resume usual meds
• W/H anticoagulant if pleural tap planned
• Pleural tap mane

Question 12

PTX

Answer 12

Admission

• DAT
• Obs q4H
• O2 3-4L
• Bld x CBC LRFT bone clotting INR RG
• CXR
• ECG
• Analgesics (PO Panadol 500mg q4H prn/ PO tramadol 50mg q6H prn)
• Chest drain if indicated
• Resume usual meds
• Consult CTS if recurrent PTX/ secondary PTX

Question 13

TB

Answer 13

Mx
- check HIV

AntiTB drugs
 - check LFT, VA, BW
 - warn about SE
 - normal case 6mo, DM/pleural effusion 9mo, CNS 12mo
 >>>> Rifampicin 450mg if <50kg; 600mg if >50kg
 >>>> Isoniazid 300mg
 >>>> Pyrazinamide 1.5g
 >>>> Ethambutol 800mg (VA)
 >>>> VitB6 (pyridoxine) 10mg QD

• W/H TB meds if hepatitis
• after LFT normalized, + PO levofloxacin 500mg daily
• Resume ethambutol
• Later attempt resume isoniazid + rifampicin

Dexamethasone
- If TB meningitis, laryngitis