Shortness of Breath Flashcards
What are the important aspects of history in an acute asthma attack?
- Baseline severity
- Exacerbation history
- Previous ICU admissions
- Normal PEFR
- Inhaler technique
- Home oxygen/nebs
What investigations should be done for a suspected asthma attack?
- Peak flow
- ABG
- CXR to exclude pneumothorax
- Bloods - regular potassium monitoring
What will an acute asthma attack abg show?
Will show hyperventilation
If it shows hypoxia/hypercapnia then patient is tiring
What are the features of a life-threatening asthma attack?
33, 92, CHEST PEFR <33% predicted <92% saturations Cyanosis Hypotension Exhaustion Silent chest Tachycardia
What are the features of severe, moderate and mild asthma attacks?
- Severe <50% predicted PEFR, cannot complete full sentences, resp rate >25, HR >110
- Moderate <75% PEFR
- Mild >75% PEFR
What is the management for an acute asthma exacerbation?
O SHIT ME
Oxygen - oxygen driven nebs
Salbutamol 2.5-5mg nebulised - back to back initially
Hydrocortisone 100mg IV
Ipratropium - 500mcg NEB
Theophyline - amniophylline infusion - usually in ICU
Magnesium sulphate 2g IV over 20 mins - one off dose
Escalate care - intubation and ventilation
What is the management for an acute exacerbation of COPD?
O SHIT Oxygen - venturi controlled 88-92% Salbutamol 5mg NEB Hydrocortisone 100mg IV Ipratropium 500mcg NEB Theophylline - usually in ICU
Antibiotics should be prescribed if signs of infection
Chest physio
Consider BiPAP if can’t maintain oxygenation without depressing respiratory drive
What are the intensive care indications for Acute asthma/COPD?
If they require ventilator support
Worsening hypoxia/hypercapnia/acidosis
Exhaustion
Drowsiness/confusion
What are the investigations for suspected pulmonary embolism?
To confirm/exclude diagnosis: -D-Dimer if low PE wells score -CTPA To investigate severity: -ECG may show RV strain (T-wave inversion in inferior leads), S1Q3T3 -CXR may show wedge infarcts, effusion -ECHO - for right heart strain/overload Look for cause e.g. anti-phospholipid, malignancy, thrombophilia
How do you manage a PE?
Calculate the PE wells score
If high risk or D-dimer positive - Start treatment dose LMWH 1.5mg/kg OD for 5 days
Most patients are then started on DOACs or Warfarin for 6 months anticoagulation
In patients with massive PE (SBP <90) then throbolyse with alteplase
In patients with sub-massive PE (e.g. saddle PE) - unfractionated heparin infusion for 72 hours so thrombolysis can be considered
What investigations should you do for acute pulmonary oedema?
Bloods - ABG, FBC, LFT, U+E, BNP, Trops if ACS suspected
CXR
ECG
echo
serial weights with catheter for accurate UO
What is the immediate managament for acute pulmonary oedema?
PODMAN Position - sit up Oxygen - high flow Diuretics - IV furosemide Morphine - causes venodilation and reduces preload Anti-emetic - metoclopramide 10mg IV Nitrates - in severe pulmonary oedema CPAP if still hypoxic
What is the long term management of heart failure?
Treat cause where possible -ACE inhibitor -Beta blocker -Diuretic - if pulmonary/peripheral oedema can add aldosterone antagonists e.g. spironolactone Non-pharmocological: -Cardiac resync deice -Implantable cardioverter defibrillator
When in the day are asthma symptoms usually worst?
Usually at night or early in the morning
Cold can make them worse
How is asthma diagnosed?
In high likelihood of asthma: Asked to keep a peak flow diary, diurnal variation will be greater than 20% and will improve with treatment
In intermediate likelihood of asthma: reversibility testing with spirometry
What 3 questions should be asked at an annual asthma review?
Has your asthma affected your sleeping?
Have you had your asthma symptoms during the day?
Has your asthma affected your daily activities?
What are the steps of treating asthma in the community?
1) SABA e.g. salbutamol
2) Add steroid e.g. beclomethasone, this is indicated by using SABA more than 3 times a week or having night symptoms
3) LABA e.g. salmeterol added
4) refer at this point, can add leukotriene receptor antagonists e.g. montelukast
Alternatively xanthine derivative such as theophylline
What are the two main patterns of wheezing in children?
There is Trasient acute wheezing (viral induced wheeze) and usually resolves by age 5
Chronic recurrent wheezing is usually due to asthma
How does asthma management in the community differ in children?
1) SABA
2) Leukotriene receptor antagonists
3) add inhaled steroid
4) increase steroid dose and consider theophyline
What should prompt hospital admission in chest infections in the community?
CURB-65 score >1 or SpO2 <94%
What are the components of the CURB-65 score? What scores equate to what severity?
Confusion Urea >7 Resp rate >30 Systolic BP <90 Age >65 Score >2 moderate, >3 severe, >4 ITU
What is the commonest causative organism for community aquired pneumonia?
Strep pneumoniae followed by haemophilus influenzae
What antibiotics should be used to treat CAP?
In community give amoxicillin 500mg TDS for 5 days
In moderate CAP give oral amoxicillin 500mg TDS and clarithromycin 500mg BD for 7-10 days
If severe then IV 1.2g Co-amoxiclav TDS and IV 500mg BD clarithromycin changing to oral when there is improvement, 7-10 days in total
What is the definition of HAP?
Must develop >48 hours after hospital admission
What are the common causative organisms for HAP?
Commonly staph aureus and pseudomonas
What investigations should be requested for a pneumonia?
Gain IV access Take bloods FBC shows raised WCC U and E and LFT for baseline and curb65 LFT can be raised in legionella ESR/CRP may be elevated ABG in patients with o2 <94% Blood cultures Sputum cultures Urine antigen testing for pneumococcal and legionella CXR ECG to rule out other causes
What are some potential causes of acute heart failure?
ACS
Acute mechanical disruption e.g. septal rupture or valve regurge
Arrhythmia
Acute outflow obstruction e.g. massive PE, tension pneumothorax, tamponade
How can pulmonary oedema be sub divided?
Cardiac and non cardiac Non cardiac: -ARDS -Hypoalbuminaemia -Iatrogenic fluid overload -Smoke inhalation
What are the signs a patient will present with in acute pulmonary oedema?
SOB Pink frothy sputum Widespread crackles Raised JVP Decreased sats gallop rhythm
What is the acute management of a patient with acute heart failure and severe pulmonary oedema?
A-E
Sit patient up and start high flow oxygen if decreased sats
Take ABG
Attach to cardiac monitor, blood pressure and spO2 monitoring
Get IV access
Give diamorphine 2.5-5mg IV slowly and metoclopramide 10mg IV
Give furosemide 20-40mg by slow IV injection
If SBP >90 give GTN spray
What investigations should be done for acute heart failure?
ABG if breathless FBC for anaemia U and E, troponins, INR, BNP ECG - look for ACS CXR to look for oedema echo for structual defects
What is the management fo acute heart failure after the initial stage?
Daily weights - aim for reduction of 0.5kg/day, regular obs
Repeat cxr
Switch IV furosemide to oral
If on large doses of loop diuretics consider thiazide in addition e.g. bendoflumethiazide
ACE i should be added if LVEF <40%
Consider beta blocker
Consider K+ sparing spironolactone if hypokalaemic
Consider if patient suitable for biventricular pacing
What are the 3 different types of AF?
- Paroxysmal AF is self-terminating within 7 days, this can be recurrent
- Persistent AF lasts >7 days and is not self-terminating, termination can be with cardioversion to sinus rhythm. This can degenerate into permanent AF
- Permanent AF lasts >1 year and has not been terminated by cardioversion
What is the first line treatment for atrial flutter?
Catheter ablation
If this fails can be rate controlled with beta blockers (Bisoprolol) or calcium channel blockers (verapamil)
What are the causes of SVT?
AVNRT - commonest
AVRT
atrial tachycardia
Which group of patients is adenosine contraindicated in?
Asthmatics as it causes bronchospasm
What us wolff-parkinson-white?
This is an accessory pathway from the atria to ventricles that causes an antegrade AVRT
This must be treated promptly as it can degenerate into VF as all electrical activity is bypassing the AV node
What are the ECG findings of WPW?
Short PR interval
Wide QRS with a slurred upstroke (delta wave)
What are the two conditions that make up COPD?
Chronic bronchitis is clinical and is a chronic productive cough for three months of the year for the last 2 years
Emphysema is permanent enlargement of the airways distal to the terminal bronchioles
What are the symptoms suggestive of COPD?
Exertional dyspnoea, chronic cough, regular sputum production, frequent chest infections, and wheeze
There should be exclusion of red flag symptoms such as weight loss, haemoptysis, ankle swelling, and PND
How can dyspnoea be quantified in COPD?
The mrc dyspnoea scale
1
Not troubled by breathlessness except on strenuous exercise
2
Short of breath when hurrying or walking up a slight incline
3
Walk slowly on flat because of breathlessness
4
Stops for breath after a few minutes/100m on flat
5
Too breathless to leave the house/ breathless on dressing and undressing
What are the signs of COPD?
Cachexia, hyper-inflated chest, pursed lip breathing, use of accessory muscles, paradoxical movement of lower ribs, reduced cricosternal distance
Wheeze, prolonged expiratory phase
What are the spirometry results in COPD?
FEV1/FVC is less than 0.7 and FEV1 <80% predicted
What are the main types of non small cell lung cancers?
Squamous cell carcinomas, generally more centrel, obstructive, local spread and show keratin formation
Adenocarcinomas are more peripheral, common in non smokers and invade the pleura and mediastinal nodes
Large cell carcinomas
Carcinoid tumours
What are the parts that make up the TNM staging of lung cancers?
T involves the size and location of the tumour
N involves which nodes are infiltrated
M is whether there is metastatsis or not
What are small cell lung cancers, how do they present?
These are derived from APUD endocrine cells and lead to undifferentiated, highly malignant tumours
Present with haemopysis, persistent cough, weight loss, dyspnoea etc.
What is the treatment of lung cancer?
Can have surgery which is typically lobectomy
Radical radiotherapy can be used when surgery not possible
Will have hilar and mediastinal lymph node sampling for staging
Chemotherapy can be used in conjunction with surgery
In NSCLC usually gemcitabine
In SCLC usually cisplatin or carboplatin
If NSCLC have EGFR mutation then can use biological agents such as gefitanib
What is the difference between adjuvant and neoadjuvant chemo?
Adjuvant is aiming to cure
neo adjuvant is aiming to shrink the tumour prior to survery or other curative options
What kind of spirometry defect will interstitial lung disease show?
It causes loss of elasticity so causes a restrictive defect
What medications can be used to slow the progression of idiopathic pulmonary fibrosis?
Acetylcysteine can be used
How can most idiopathic interstitial pneumonias be treated?
With corticosteroids
What sort of pneumonia is associated with target lesions (erythema multiforme)?
Mycoplasma pneumonia
