Respirology

Question 1

Discuss the indications for intubation in the ER

Answer 1

• loss of gag/cough reflex
  
  • GCS <8
• airway obstruction
• Anticipated airway obstruction
  Mechanical Ventilation
• Failure to ventilate
  
  • PaCO2 >50
• failure to oxygenate
• impending failure to ventilate or oxygenate

Question 2

Discuss the presentation and management of asthma in the ED

Answer 2

Presentation
- previous ICU, intubation, hospital admission
- triggers
- SOB
- Chest tightness
- wheezing
- increased puffer use
Investigation
- FEV1 
- CXR
Managemnt
- supplemental O2 to target >92%
- SABA with 3 back-to-back treatments initially
      - mild-mod MDI 4-6 puffs Q20-40min
      - severe nebulizer 2.5-5mg Q20min
- SAAC (ipatropium bromide)
      - same as SABA
- Epinephrine IM if due to anaphylaxis
- if FEV1 <40% despite treatment then MgSO4 2g IV over 20 minutes
- Decrease inflammation with prednision 50mg, dexamethasone 16mg or hydrocortisone 100-200mg IV

Question 3

Discuss the disposition for asthma exacerbation

Answer 3

Home
- Oxygen sat >90%
- no respiratory distress and normal exam for >1hr
- >=75% expected FEV1 >2hrs since treatment
- discharge with Salbutamol, prednisone 50mg for 4 days and inhaled corticosteroid
Admitted to Ward
- FEV1 40-75%
- Mild to moderate symptoms
- Risk factors or near-fatal attack
Admit to ICU
- FEV1 <40%
- PaCO2 <60
- PaCO2 >42
- Altered mental status

Question 4

Discuss the modified Dyspnea scale for asthma exacerbation

Answer 4

Level of consciousness
- Severe have altered
Appearance
- Respiratory distress and cyanosis in severe
- some respiratory distress in moderate
Vital Signs
- Mild: tachypnea, normal BP and O2 sat
- Mod: Tachypnea, normal BP, decreased O2 sat
- Severe: severe tachypnea, low BP, very low O2 sat
Physical Exam
- Mild: wheezing with bilateral air entry
- Mod: Talking in 3-4words, indrawing, decreased air entry and wheezing
- Severe: talking in 1 word, paradoxical breathing, may have no wheezing
FEV1
- Mild: 50-70%
- Mod: 25-50%
- Severe: <25%

Question 5

Discuss the presentation and management of COPD in the ED

Answer 5

Presentation
- SOB
- Exercise intolerance
- chest tightness
- Wheezing
- Increased use of puffer
- Infectious if >=2: increased sputum production, increased sputum purulence, increased dyspnea
Investigation
- CBC, electrolytes, creatinine, BUN
- VBG or ABG (if not responding to therapy)
      - increased pCO2, decreased pO2
- CXR
       - hyperinflated lungs
Management
- O2 support to target of 88-92 as can be CO2 retainers
    - can move to BiPAP
- SABA and SAAC same as asthma
- Systemic steroids
- Antibiotics if infectious cause

Question 6

Discuss the severity of COPD exacerbation

Answer 6

Mild
- symptoms controlled with increase dose of regular medication
Moderate
- symptoms controlled with systemic corticosteroids and antibiotics
Severe
- require hospitilization

Question 7

Discuss disposition for COPD

Answer 7

Home

• if O2 sat >90% at rest and with exertion
• Salbutamol, Prednisone 50mg for 10-14d and inhaled corticosteroid

Question 8

Discuss when to switch from BiPAP to intubation in COPD

Answer 8

• worsening hypoxemia
• confusion or decreased LOC
• worsening acidosis
• worsening hypercapnia
• pH <7.36 and PaCO2 >45

Question 9

Discuss the presentation and management of CHF in the ED

Answer 9

Triggers
- ACS
- change in medication
- salt intake
Presentation
- Fatigue, poor exercise tolerance
- left sided HF: pulmonary edema, dyspnea, PND, orthopnea, pink frothy sputum
- right sided HF: peripheral edema
- decreased breath sounds, crackles
- increased JVP, hepatosplenomegaly, ascites, peripheral edema, S3/S4
Investigations
- CBC, electrolytes, creatinine, troponin
- ECG
- CXR
Management
- Oxygen to >90% through nasal prong, mask or CPAP/BiPAP
- Fluid balance
- cardiogenic shock require careful fluid resuscitation and vasopressor
- volume overload require diuresis with furosemide
- morphine and nitroglycerin for symptom relieve