Week 1 - Acute Breathlessness Flashcards
Which systems of the body can be direct causes of chest pain and breathlessness?
- respiratory
- cardiovascular
- haematological
- nervous
- skeletal
- muscular
- digestive
- endocrine
- renal
- psychological
How can the haematological system cause breathlessness?
Anaemia reduces ability to carry oxygen due to a lack of RBCs and haemoglobin which can result in breathlessness
How can the nervous system cause breathlessness?
Damage to brain/spinal cord (e.g MS and Guillan-Barre) can result in breathlessness
How can the skeletal system cause breathlessness?
- thoracic trauma e.g rib fracture
- spinal disorders e.g kyphosis, scoliosis can reduce lung expansion
How can the muscular system cause breathlessness?
Weakened respiratory muscles due to trauma/neurological etc can cause SOB
How can the digestive system cause breathlessness?
- acute GI bleed can lead to severe anaemia and cause breathlessness
- GORD leasing to aspiration can cause SOB
How can the psychological system cause breathlessness?
Anxiety
How can the endocrine system cause breathlessness?
- thyrotoxicosis (increased metabolic rate) can cause SOB
- hypothyroidism if left untreated/severe can cause respiratory muscle weakness = SOB and
How can the renal system cause breathlessness?
Metabolic acidosis/alkalosis can cause breathlessness
What does haemoptysis mean ?
Coughing up blood
What are a list of differential diagnoses for acute breathlessness and chest pain?
- PE
- pneumothorax
- pleurisy
- musculoskeletal chest pain
What are the most common presenting symptoms of lung cancer?
Haemoptysis
Chest pain on breathing and/or coughing
Persistent breathlessness
Persistent cough >3 weeks
Persistent tiredness/low energy
Why is COPD an unlikely diagnosis for acute breathlessness ?
COPD presents as increasing breathlessness over years not hours
Where is the chest pain felt in Acute Coronary Syndrome (ACS) ?
Sharp
On the left side of the chest
What is pleurisy ?
Inflammation of the pleura
What does the chest pain of an MI feel like?
Central and crushing
Radiating to left arm/shoulder/neck
What causes musculoskeletal pain?
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
What is the pain of pleurisy described as?
Sharp
What causes the pain of pleurisy?
The pleura gets inflamed to the 2 pleural layers start to rub against each other like sand paper with each breath
What causes pleurisy?
- Viral infection (most common)
- Bacterial infection
What are symptoms of pleurisy?
- pleuritic sharp chest pain
- cough
- runny nose or fever
Is pleurisy associated with haemoptysis ?
No
What kind of chest pain does a pneumothorax cause?
Sudden, sharp chest pain
What are the risk factors of a pneumothorax?
- male
- smoking
- underlying lung disease (if secondary spontaneous)
What are the types of pneumothorax?
- simple (trauma)
- tension (trauma)
- spontaneous (primary and secondary)
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
What symptoms can a PE cause?
- Breathlessness
- Pleuritic chest pain
- Haemoptysis (sometimes)
- Calf swelling
What is a PE?
An abnormal thrombus causing a blockage in the pulmonary arteries
What is the most common cause of chest pain in primary care?
Musculoskeletal chest pain
What is usually sufficient to treat musculoskeletal chest pain?
NSAIDs
What is a key diagnostic tool for differentiating if chest pain is musculoskeletal ?
Recreating the patients pain by:
- palpation
- movement
What other conditions must be considered before a diagnosis of Pleurisy is reached?
- PE
- MI
- pneumothorax
- pericarditis
- pneumonia
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!
What are some examples of underlying lung pathologies associated with secondary spontaneous pneumothorax?
- asthma
- COPD
- lung carcinoma
- interstitial lung disease
- CF
etc
What is the classic presentation of a primary spontaneous pneumothorax?
- sudden onset pleuritic pain
- dyspnoea at rest
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.
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
Is alveolar pressure higher or lower than atmospheric pressure during inspiration ?
Inspiration = alveolar < atmospheric
to draw air in
Is alveolar pressure higher or lower than atmospheric pressure during expiration ?
Expiration = alveolar > atmospheric
to draw air out
What causes a simple pneumothorax?
Trauma/puncture of chest wall and/or lung
What type of pneumothorax demands a chest drain ?
A simple pneumothorax
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
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
What type of pneumothorax demands needle aspiration ?
Tension pneumothorax
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
What is the most common source of pulmonary emboli ?
DVTs
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+)
What is a complication that sometimes follows treatment of a PE?
chronic thromboembolic pulmonary hypertension
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
Are PEs more commonly associated with thrombi above or below the knee?
Above the knee
What investigation is done in patients with a low probability of having had a PE ?
D-Dimer assay (blood test)
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)
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)
What is the long term management after a PE?
- DOAC (Apixaban, Rivaeoxaban, edoxaban)
- Warfarin
- inferior vena cava filter (rare, for recurrent VTE despite anticoagulation)
What physiological problems can a PE cause?
- Infarction of the lung
- Hypoxaemia
- Acute right-side heart failure
- Hypotension
- Syncope
- Circulatory shock
- Death
What’s the most common ECG abnormality ?
Sinus tachycardia
What features of a primary spontaneous pneumothorax constitutes a pleural aspiration ?
Pneumothorax >2cm and/or breathlessness
What features of a secondary spontaneous pneumothorax constitutes a chest drain ?
Pneumothorax >2cm or breathless
What features of a secondary spontaneous pneumothorax constitutes a pleural aspiration ?
Pneumothorax 1-2 cm
How long after a pneumothorax do most airlines make you wait before flying again?
6 weeks
What are the reasons a chest drain would stop bubbling ?
- the pneumothorax has resolved
- the drain is blocked
- the drain has been pulled out
What does it mean if the chest drain has stopped bubbling and it is swinging?
The pneumothorax has resolved
What does it mean if the chest drain has stopped bubbling and is not swinging?
The drain has either been pulled out or blocked
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
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
When is a lactate test indicated?
When there is suspicion of sepsis
What is the definitive investigation to diagnose a PE?
CTPA
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
What features may be present on the X-Ray of a PE patient?
- normal is most common
- small pleural effusions
When do you perform a D-Dimer ?
If the patient’s Wells score is suggesting low risk of having had a PE
What is the initial treatment for a potential PE patient, prior to performing a confirmatory CTPA?
- analgesia
- treatment dose LMWH
How do clots present on a CTPA?
As grey abnormalities surrounded by white contrast
What is anaphylaxis?
A life threatening type 1 hypersensitivity reaction causing mass release of histamine into blood stream
How do we differentiate an anaphylactic reaction from an allergic reaction?
Anaphylaxis reactions include:
- airway problems and/or
- breathing problems and/or
- circulation problems
What is an airway problem found during anaphylaxis?
Stridor = laryngeal oedema
Caused by leaky capillaries in response to histamine
What is a breathing problem found during anaphylaxis?
Wheeze = bronchospasm
Caused by histamine binding to H1 receptors in the lungs
What is a circulatory problem found during anaphylaxis?
(Pre)syncope = hypotension
Caused by leaky capillaries in response to histamine
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)
When do you not perform a CTPA?
- where renal function is significantly impaired
- pregnant women
- known contrast allergy
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
What does a flattened inter-ventricular septum suggest in a PE patient?
Right heart strain
What is considered a very low risk PESI score?
65 or less
What is considered a low risk PESI score?
66-85
What is considered an intermediate risk PESI score?
86-105
What is considered a high risk PESI score?
106-125
What is considered a very high risk PESI score?
> 125
When should a PE clinic follow up be conducted ?
After 3 months
What are the most common reactions to anticoagulation therapies?
Bleeding
Bruising
Nausea
Anaemia
What are the first line anticoagulants for patients with confirmed PE?
Apixaban
Rivaroxaban
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
What are the contraindications of rivaroxaban ?
- Pregnancy
- Cirrhosis with coagulopathy
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
What do patients with Marfan syndrome have an increased risk of developing?
Pneumothorax
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
