Week 1 - Acute Breathlessness Flashcards
1
Q
Which systems of the body can be direct causes of chest pain and breathlessness?
A
- respiratory
- cardiovascular
- haematological
- nervous
- skeletal
- muscular
- digestive
- endocrine
- renal
- psychological
2
Q
How can the haematological system cause breathlessness?
A
Anaemia reduces ability to carry oxygen due to a lack of RBCs and haemoglobin which can result in breathlessness
3
Q
How can the nervous system cause breathlessness?
A
Damage to brain/spinal cord (e.g MS and Guillan-Barre) can result in breathlessness
4
Q
How can the skeletal system cause breathlessness?
A
- thoracic trauma e.g rib fracture
- spinal disorders e.g kyphosis, scoliosis can reduce lung expansion
5
Q
How can the muscular system cause breathlessness?
A
Weakened respiratory muscles due to trauma/neurological etc can cause SOB
6
Q
How can the digestive system cause breathlessness?
A
- acute GI bleed can lead to severe anaemia and cause breathlessness
- GORD leasing to aspiration can cause SOB
7
Q
How can the psychological system cause breathlessness?
A
Anxiety
8
Q
How can the endocrine system cause breathlessness?
A
- thyrotoxicosis (increased metabolic rate) can cause SOB
- hypothyroidism if left untreated/severe can cause respiratory muscle weakness = SOB and
9
Q
How can the renal system cause breathlessness?
A
Metabolic acidosis/alkalosis can cause breathlessness
10
Q
What does haemoptysis mean ?
A
Coughing up blood
11
Q
What are a list of differential diagnoses for acute breathlessness and chest pain?
A
- PE
- pneumothorax
- pleurisy
- musculoskeletal chest pain
12
Q
What are the most common presenting symptoms of lung cancer?
A
Haemoptysis
Chest pain on breathing and/or coughing
Persistent breathlessness
Persistent cough >3 weeks
Persistent tiredness/low energy
13
Q
Why is COPD an unlikely diagnosis for acute breathlessness ?
A
COPD presents as increasing breathlessness over years not hours
14
Q
Where is the chest pain felt in Acute Coronary Syndrome (ACS) ?
A
Sharp
On the left side of the chest
15
Q
What is pleurisy ?
A
Inflammation of the pleura
16
Q
What does the chest pain of an MI feel like?
A
Central and crushing
Radiating to left arm/shoulder/neck
17
Q
What causes musculoskeletal pain?
A
Injury to the muscles/bones in the area detected
Usually occurring after some exertion or injury
Exacerbated by movement
Pain can be severe and make patient feel breathless
18
Q
What is the pain of pleurisy described as?
A
Sharp
19
Q
What causes the pain of pleurisy?
A
The pleura gets inflamed to the 2 pleural layers start to rub against each other like sand paper with each breath
20
Q
What causes pleurisy?
A
- Viral infection (most common)
- Bacterial infection
21
Q
What are symptoms of pleurisy?
A
- pleuritic sharp chest pain
- cough
- runny nose or fever
22
Q
Is pleurisy associated with haemoptysis ?
A
No
23
Q
What kind of chest pain does a pneumothorax cause?
A
Sudden, sharp chest pain
24
Q
What are the risk factors of a pneumothorax?
A
- male
- smoking
- underlying lung disease (if secondary spontaneous)
25
What are the types of pneumothorax?
- simple (trauma)
- tension (trauma)
- spontaneous (primary and secondary)
26
What is the difference between a primary and secondary pneumothorax ?
Primary = no apparent cause/no underlying lung disease
Secondary = associated with an underlying lung disease
27
What symptoms can a PE cause?
- Breathlessness
- Pleuritic chest pain
- Haemoptysis (sometimes)
- Calf swelling
28
What is a PE?
An abnormal thrombus causing a blockage in the pulmonary arteries
29
What is the most common cause of chest pain in primary care?
Musculoskeletal chest pain
30
What is usually sufficient to treat musculoskeletal chest pain?
NSAIDs
31
What is a key diagnostic tool for differentiating if chest pain is musculoskeletal ?
Recreating the patients pain by:
- palpation
- movement
32
What other conditions must be considered before a diagnosis of Pleurisy is reached?
- PE
- MI
- pneumothorax
- pericarditis
- pneumonia
33
What are some viral infections that are associated with causing Pleurisy?
- Corona
- influenza
- parainfluenza
- mumps
- cytomegalovirus
- adenovirus
- Epstein-Barr
*there are others but their names are v complicated!*
34
What are some examples of underlying lung pathologies associated with secondary spontaneous pneumothorax?
- asthma
- COPD
- lung carcinoma
- interstitial lung disease
- CF
*etc*
35
What is the classic presentation of a primary spontaneous pneumothorax?
- sudden onset pleuritic pain
- dyspnoea at rest
36
Are symptoms more severe in:
A) primary spontaneous pneumothorax?
B) secondary spontaneous pneumothorax?
Why?
More severe in **secondary** spontaneous pneumothorax
Because **lung function may already be compromised** due to an underlying pathology.
37
What is the primary symptomatic complaint from patients suffering a secondary spontaneous pneumothorax?
**Breathlessness** that’s out of proportion to the size of the pneumothorax radiologically
38
Is alveolar pressure higher or lower than atmospheric pressure during inspiration ?
Inspiration = alveolar < atmospheric
to draw air in
39
Is alveolar pressure higher or lower than atmospheric pressure during expiration ?
Expiration = alveolar > atmospheric
to draw air out
40
What causes a simple pneumothorax?
**Trauma/puncture** of chest wall and/or lung
41
What type of pneumothorax demands a chest drain ?
A **simple** pneumothorax
42
How does a chest drain work?
Acts as a one-way valve to **release air from the pleural space during expiration**, re-inflating the lung
43
What is the result of a tension pneumothorax ?
On inspiration: air drawn into pleural space
On expiration: air is trapped and compressed
**this shifts the contents of the mediastinum over to the unaffected side**
44
What type of pneumothorax demands needle aspiration ?
Tension pneumothorax
45
What is seen characteristically on an X-ray depicting a tension pneumothorax?
- **mediastinal/tracheal shift** (towards unaffected side)
- **diaphragmatic depression** (on affected side)
- **rib cage expansion**
46
What is the most common source of pulmonary emboli ?
DVTs
47
What are the major risk factors for PE?
- DVT
- history of previous DVT or PE
- active cancer
- recent surgery
- lower limb trauma
- long term immobility
- pregnancy (primarily 6 weeks postpartum)
- combined oral contraceptives
- HRT
- long haul flights
- obesity
- increasing age (60+)
48
What is a complication that sometimes follows treatment of a PE?
chronic thromboembolic pulmonary hypertension
49
When should PE be considered as a diagnosis?
Suspected in people with one or more of:
- breathlessness (dyspnoea)
- pleuritic chest pain
- cough
- haemoptysis
- features of DVT (unilateral leg swelling, redness, venous distension, lower ab pain, raised temp)
- cyanosis
- dizziness and syncope
- tachycardia
- hypoxia
- pyrexia
- gallop rhythm
- pleural rub on auscultation
- hypotension
- shock
50
Are PEs more commonly associated with thrombi above or below the knee?
Above the knee
51
What investigation is done in patients with a **low** probability of having had a PE ?
D-Dimer assay (blood test)
52
What investigations are done in patients with a **high** probability of having had a PE ?
- CTPA scan !!
- ECHO
- Troponin
- ABGs
- Chest X-Ray
- ECG
- PESI score (high risk >80)
53
What is the immediate management of a PE?
- high flow oxygen + IV fluids + analgesics for pleurisy
- Enoxaparin (1.5mg/kg OD whilst being investigated)
- if severe: thrombolysis (tPA)
54
What is the long term management after a PE?
- DOAC (Apixaban, Rivaeoxaban, edoxaban)
- Warfarin
- inferior vena cava filter (rare, for recurrent VTE despite anticoagulation)
55
What physiological problems can a PE cause?
- Infarction of the lung
- Hypoxaemia
- Acute right-side heart failure
- Hypotension
- Syncope
- Circulatory shock
- Death
56
What’s the most common ECG abnormality ?
Sinus tachycardia
57
What features of a primary spontaneous pneumothorax constitutes a pleural aspiration ?
Pneumothorax >2cm and/or breathlessness
58
What features of a secondary spontaneous pneumothorax constitutes a chest drain ?
Pneumothorax >2cm or breathless
59
What features of a secondary spontaneous pneumothorax constitutes a pleural aspiration ?
Pneumothorax 1-2 cm
60
How long after a pneumothorax do most airlines make you wait before flying again?
6 weeks
61
What are the reasons a chest drain would stop bubbling ?
- the pneumothorax has resolved
- the drain is blocked
- the drain has been pulled out
62
What does it mean if the chest drain has stopped bubbling and it is swinging?
The pneumothorax has resolved
63
What does it mean if the chest drain has stopped bubbling and is not swinging?
The drain has either been pulled out or blocked
64
What should you do if the chest drain has stopped bubbling and is not swinging?
- check the site
- request an X-ray
*If tube not in pleural cavity:* reposition the chest drain
*If tube still in pleural cavity:* flush tube with aseptic technique with 10ml saline to unblock it
65
Anticoagulant therapy can be a cause of haemoptysis, would it also be associated with pleuritic chest pain and breathlessness?
**No** anticoagulant therapy is not associated with chest pain and breathlessness
66
When is a lactate test indicated?
When there is suspicion of **sepsis**
67
What is the definitive investigation to diagnose a PE?
CTPA
68
What investigations would you do to confirm a PE if the Wells score is suggesting high risk?
- CTPA
- chest X-Ray
- ECG
- ABGs
- routine blood tests (renal, liver function
*if pneumonia is also in differentials then perform a CRP*
69
What features may be present on the X-Ray of a PE patient?
- **normal** is most common
- small pleural effusions
70
When do you perform a D-Dimer ?
If the patient’s Wells score is suggesting low risk of having had a PE
71
What is the initial treatment for a potential PE patient, prior to performing a confirmatory CTPA?
- analgesia
- treatment dose LMWH
72
How do clots present on a CTPA?
As **grey abnormalities** surrounded by white contrast
73
What is anaphylaxis?
A life threatening **type 1 hypersensitivity** reaction causing mass release of histamine into blood stream
74
How do we differentiate an anaphylactic reaction from an allergic reaction?
Anaphylaxis reactions include:
- **airway problems** *and/or*
- **breathing problems** *and/or*
- **circulation problems**
75
What is an airway problem found during anaphylaxis?
Stridor = laryngeal oedema
*Caused by leaky capillaries in response to histamine*
76
What is a breathing problem found during anaphylaxis?
Wheeze = bronchospasm
*Caused by histamine binding to H1 receptors in the lungs*
77
What is a circulatory problem found during anaphylaxis?
(Pre)syncope = hypotension
*Caused by leaky capillaries in response to histamine*
78
How do we initially manage anaphylaxis ?
- **assess using ABCDE**
- **call for help** from resus team
- **remove the trigger**
- lie patient **flat/recovery position**
- **IM adrenaline** (1mg/ml; give 500mcg=0.5ml of 1:1000)
- give **oxygen**
- **IV fluids bolus** (500-1000ml)
79
When do you not perform a CTPA?
- where renal function is significantly impaired
- pregnant women
- known contrast allergy
80
What would you do instead of a CTPA if it is contraindicated ?
- a Doppler ultrasound of the legs to look for VTE
- ventilation/perfusion scan
81
What does a flattened inter-ventricular septum suggest in a PE patient?
Right heart strain
82
What is considered a very low risk PESI score?
65 or less
83
What is considered a low risk PESI score?
66-85
84
What is considered an intermediate risk PESI score?
86-105
85
What is considered a high risk PESI score?
106-125
86
What is considered a very high risk PESI score?
>125
87
When should a PE clinic follow up be conducted ?
After 3 months
88
What are the most common reactions to anticoagulation therapies?
Bleeding
Bruising
Nausea
Anaemia
89
What are the first line anticoagulants for patients with confirmed PE?
Apixaban
Rivaroxaban
90
What anticoagulants do you prescribe if first line treatments aren’t suitable ?
- LMWH for at least 5 days, followed by dabigatran or edoxaban
Or
- LMWH concurrently with Warfarin (VKA) until therapeutic anticoagulation is achieved
91
What are the contraindications of rivaroxaban ?
- Pregnancy
- Cirrhosis with coagulopathy
92
What sound on auscultation is suggestive of a PE ?
**Pleural rub**
Because a PE irritates the pleura, inflaming it and leading to pleural rub sounds
93
What do patients with Marfan syndrome have an increased risk of developing?
Pneumothorax
94
What are some features of Marfan Syndrome?
- tall, slender build
- disproportionately long arms/legs/fingers
- protruding or inverted breast bone
- crowded teeth
- heart murmurs
- extreme near sightedness
- abnormally curved spine
- flat feet
