Week 3: Respiratory medicine (1) (medication, acute respiratory presentationsand history taking) Flashcards
name some sympathomimetics
short acting: salbutamol, terbutaline
SABA
long acting: foremeterol, salmeterol
LABA
main indication for sympathomimetics (salbutamol, formeterol)
bronchospasm
action of sympathomimetics
B2-selective adrenergic agonistst
- increases cAMP in SMC resulting in relaxation and thus bronchodliation
side effects of symphathomimetics
tremor, headache, GI upset, palpitations, tachycardia, hypokalaemia
name some xanthines
aminophylline and theophylline
xanthines indication
asthma and COPD
action of xanthines
block phosphodiesterase resulting in decreased cAMP breakdown causing bronchodilation
common side effects of xanthines
headache, GI upset, reflux, palpitations, dizziness
name some antimuscarinics used in resp medicine
short acting: Ipratropium bromide(SAMA)
long acting: tiotropium bromide (LAMA)
action of antimuscarinics
muscarinic antagonist
- decreases cGMP which affects intracellular calcium resulting in decreased SMC contractility
common side effects of antimuscarinics
dry mouth, constipation, cough, headache
name some inhaled steroids (glucocorticoids) used in resp medicine)
beclomethasone, budesonide, fluticasone
when are inhaled steroids indicated
asthma, COPD
action of inhaled steroids
increased airway calibre by decreasing bronchial inflammation +- modifying allergic reactions
common side effects of inhaled steroids
cough, oral thrust, unpleasant taste, hoarseness
name some corticosteroids
Inhaled
beclomethasone, budesonide
Oral
prednisolone (PO), hydrocortione (IV/IM), dexamethasone (PO/IV), triamclinolone (IM)
main indication of corticosteroids
suppress inflammation, allergy and immune responses
action of corticosteroids
alter gene transcription
side effects of coritcosteroids
adrenal suppression , hyperglycaemia, psychosis, insomnia, indigestion, mood swings, diabetes, cushinggoids appearance
general approach to acute resp presentation
call for help early + ABCDE
oxygen
- It’s a drug
- Needs prescribing
- Aim for target sats
- General principle – do ABG if sats <92%
types of oxygen masks
nasal cannula
venturi masks
when is high flow O2 used
- Cardiac arrest
- Severe resp failure
- 76% or less with pneumonia
- <85% with new resp failure
controlled oxygen
- Avoiding over-oxygenation
- Minimum oxygen conc to achieve correct target sat
- Evidence that over oxygenation can cause harm
Case 1
give differentials and some further tests
- Acute asthma
- Acute bronchitis
- Less like- pneumonia, foreign body, cardiac disease, PE
Further tests
- PEFR (and predicted)
- Blood pressure
- RR
- HR
- O2 sats
- ABG
- CXR
classify this asthma
- Severe
- 50% decrease PEFR
- RR 28
- Heart rate 115
- Not talking in full sentences
- Only need one of these to be classified as severe
Peak expiratory flow rate measurement
classification of asthma
mild/moderate
severe
life threateninf
Near fatal asthma- raise PaCO2- immediate requirement for ventilation
Management if acute severe asthma
- Controlled oxygen
- Nebulised B2- agonist
- Use O2 driven neb
- Salbutamol 2.5-5mg
- Every 15-30 mins depending on responds
- Nebulised ipratropium bromide (give 0.5mg with salbutamol)
- Steroids
- PO prednisolone 40mg OD
- IV hydrocortisone 200 mg ( if patient cant swallow)
Further management of acute severe
- IV aminophylline
- Patient on oral aminophylline/theophylline should never be given the loading dose
- Other options e.g. IV salbutamol
- IV magnesium sulphate
management of anaphylaxis and angioedema
DO NOT DELAY AND GET HELP
- remove trigger, maintain airway, controlled oxygen (ABCDE)
- IM adrenaline 0.5mg (repeat every 5 mins)
- Adult IM dose 0.5 mg IM (= 500 micrograms = 0.5 mL of 1:1000) adrenaline (epinephrine).
- IV hydrocortisone 200mg (corticosteroid)
- IV chlorpheniramine 10mg (antihistamine)
- if hypotensive: lie flat and fluid resus
- treat bronchospasm: neb salbutamol
- laryngeal oedema: neb adrenaline
symptoms of anaphylaxis
occurs in minutes
pruritus, urticaria and angioedema
hoarseness, progressing to stridor and bronchial obstruction
wheeze and chest tightness from bronchospasm
investigations for COPD exacerbation
CXR
ABG
blood tests: FBC, U and E, LFTs, blood culture
sputum culture
management of acute COPD exacerbation
- Sit the patient up
- ABCDE approach
- Controlled O2
- Aim for 88-92% in COPD
- If no evidence of Type 2 respiratory failure then aim for 94-98%
- Nebulised bronchodilators (salbutamol and ipratropium)
- Steroids
- Prednisolone (PO)
- Antibiotics – give if purulent sputum
- If not improving
- Consider IV aminophylline
- Consider non invasive ventilation
- Consider ITU if pH <7.25
- Non invasive
diagnose
pneumonia / lung cancer
summarise pneumonia management
CURB-65
diagnose
tension pneumo- haemodynamically unstable
→ X-ray should not have happened→ should be discovered before
causes of haemoptysis
common: ifnection, brocnhiectasis, TB, lung abscess, aspergilloma, malignancy
rare: PE, systemic vasculitis, A-V malformation, arterial fistulae, cardiac causes (mistral stenosis)
management of haemoptysis
- maintain a patent airway, ABCDE
- oxyegnation
- place pt slightly head down in the lateral decubitus positon, lying on the side of the suspected lesion
- determien cause, site and severity of bleeding
- tranexamic acid
- definitive therapy will depend on eact aetiology
key PE risk factors
- Surgery
- obstetric: late pregnancy, caesarian section
- lower limb: fracture, varicose veins
- malignancy: abdominal/ pelvic, advanced/ metastatic
- reduced mobility
- previous proven VTE
- unprovoked
management of PE if haemodynamically stable
- anticoagulation (assuming no contraindications) whilst waiting for CTPA
- initial recommended treatment is apixaban or rivaroxaban (DOAC)
- Low molecular weight heparin (LMWH) is an alternative where these are not suitable, or in antiphospholipid syndrome. It should be started immediately before confirming the diagnosis in patients where DVT or PE is suspected and there is a delay in getting the scan. Examples are enoxaparin and dalteparin.
- ambulatory care
- consider causes in cases f unprovoked PE
management of PE if haemodynamically unstable
- ABCDE approach 0 resus measures if eneded
- thrombolysis should be cosnidered if a ‘massive PE’-→ consider without imaging if there is substantial clinical suspicion and hypotension +/- cardiac arrest imminent)
- subsequent anticoagulation when stable
classification of PE
- Massive (high risk)
- Submassive
- Acute (stable/low risk)
- Chronic
presenting complaints resp
- Dyspnoea
- Chest Pain
- Wheeze
- Cough
- Sputum
- Haemoptysis
HPC dyspnoea
- MRC score, Exercise Tolerance, triggers, relieving factors, diurnal variation, orthopnoea, PND
- how many pillows?
- do you wake up in the night gasping for air?
HPC chest pain
- Chest Pain – site, severity, radiation, triggers, relieving factors, associated symptoms
- cardiac or non-cardiac
HOC wheeze
- triggers, relieving factors, diurnal
- variation, associated cough
HPC Cough – dry or productive, triggers, relieving factors, diurnal variation, association with eating or dyspepsia, positional, nasal secretions, associated fever
dry or productive, triggers, relieving factors, diurnal variation, association with eating or dyspepsia, positional, nasal secretions, associated fever
HPC sputum
how much over 24 hours, colour, consistency
HPC haemoptysis
quantity and frequency, fever / night sweats, appetite, weight loss
MRC dyspnoea score
PMH resp
Past Medical and Surgical History (PMH)
- All relevant
- Asthma (previous hospitalisation / ITU)
- COPD
- DVT / PE
- Nasal Polyps
- Previous lung infections, including TB
- Childhood lung infections
- Surgery
- Cardiovascular illness
- Cancer
DH resp
- What drug
- Dose
- Frequency
- Route
- Patient Adherence
- Also ask about over the counter drugs / herbal medicines
Allergies history resp
- If allergic to something – when and what reaction
- Distinguish between allergy and side effects
FH resp
- Respiratory Disease
- Cardiac disease
- Cancer
- Thrombophilia (if DVT / PE)
- Cystic Fibrosis (if young and chest infections)
Social History (SH) resp
- Smoking – current (pack years), ex (pack years, when stopped), never or passive; also vaping
- Occupational History – specifically asbestos
- Pets – specifically cats, birds (budgies, parrots, pigeons) – also friends / neighbours
- Recent Foreign Travel
- Immobility – flights / long car or bus journeys Activities of daily living – self care, cooking, cleaning, shopping, type of accommodation, helpers / carers
- Alcohol
- Performance Status (Cancer)
systems review
- Bowels ok? Appetite / weight loss
- Any problems with your water works?
- Joint pains? Rashes?
- Neuro / Cardio
