Breathlessness

Question 1

Presentation of acute asthma, what are the worrying signs?

Answer 1

SOB, wheeze, tight chest pain, cyanosis, poor air entry

worrying signs: cyanosis, fatigue, silent chest, accessory muscle use at rest, agitation, LOC

Question 2

Investigations (and expected results) for acute asthma

Answer 2

Obs- BP, HR, RR, O2 (salbutamol will increase HR)

Peak flow - to compare to baseline
if 75% of baseline - mild
if 50% - moderate
if 33% - severe

ABG - will expect respiratory alkalosis since hyperventilation. Worrying if in acidosis (since retaining Co2, aren’t breathing effectively to blow it off - fatigue

Bloods - FBC, U&E, CRP - look for infective cause

CXR

Question 3

Management of acute asthma

Answer 3

A-E
O SHIT ME

Oxygen
Salbutamol - 5mg nebulised with o2
Hydrocortisone - IV or prednisolone orally
Ipratropium
Theophylline
Magnesium sulphate ( 20mg over 20 mins need cardiac monitoring)
Escalate

Question 4

Presentation of acute exacerbation of COPD, what are the worrying signs?

Answer 4

SOB, cough, increased suptum production, wheeze, reduced exercise tolerance,

Worrying signs: fatigue, oedema, pursed lip breathing, tripoding, cyanosis, confusion

Question 5

Causes of acute exacerbation of COPD

Answer 5

acute progression of disease, can be triggered by infection, viral or bacterial, pollutant exposure of change in temperature.

Question 6

Investigations for acute exacerbation of COPD

Answer 6

Obs - RR, HR, BP, O2 (aim for 88-94)

ABG - chronic CO2 retainers will have a metabolic compensation present.

Bloods: FBC, U&Es, blood cultures

ECG
CXR
Sputum culture

Question 7

Management of acute exacerbation of COPD

Answer 7

A-E

Oxygen - venturi NOT NRB. 24% venturi at 2L/min.

Salbutamol - nebulised with air (do not over oxygenate)

Systemic steroids - oral Pred or IV hydrocortisone

Abx (is signs of infection)

IV theophylline (bronchodilator)

NIV if still hypercapnic - CPAP or BiPAP

Question 8

Why is it important not to over oxygenate COPD patients?

Answer 8

Oxygen is their respiratory driver, if they have over oxygenation they will become hypercapnic since will not breathe (since o2 will not fall causing the centre to stimulate breathing)

Question 9

What are the colours of the 5 venturi valves, how much O2 do they deliver per min and at what concentration?

Answer 9

Blue    2L  24%
White   4L  28%
Yellow  6L  35%
Red     8L  40%
Green   12L  60%

Question 10

Presentation of pneumonia

Answer 10

SOB, productive cough, fever, malaise, chest pain.

Tachycardic, tachypnoeic, dullness on percussion, reduced air entry

Question 11

Causes of Pneumonia

Answer 11

CAP - S. pneumoniae, S. aureus, Mycoplasma pneumonia, H. influenza, Chlamydia pneumoniae

HAP - more common in ventilation and immunocompromised pts
- S. pneumonia, H. influenzea, Moraxella catarrhalis, S.aureus, Legionella

Question 12

Investigations for pneumonia

Answer 12

Bloods: FBC, U&Es, CRP, LFTs, blood cultures

ABG - can look at urea on here

CXR
ECG
Sputum sample

CRUB 65 score

Question 13

What is the system used to calculate pneumonia severity? how is it calculated?

Answer 13

CURB - 65

Confusion - AMST of <8
Urea - >7mmol
RR - <30
BP - systolic <90 or diastolic <60

age over 65

Admit to hospital if score above 2

Question 14

Management of pneumonia

Answer 14

A-E approach

Oxygen if hypoxic
Fluids
Analgesia
Nebulised saline - reduces sputum expiration

Abx - local guidelines
mild - amoxicillin or clarithromycin for 5 days. add fluclox if s.aureus suspected.
severe - IV co-amox, amox or clathrithromycin

Question 15

Presentation of pneumothorax

Answer 15

SOB, sudden onset chest pain, pleurisy, cyanosis, fatigue.
O/E: tachycardic, tachypnoeic, hypotensive, reduced air entry, hyper resonant percussion, pulsus paradoxical (weak pulse as patients breathe in)

Question 16

signs of a tension pneumothorax, what does it cause?

Answer 16

raised JVP, tracheal deviation (away from side of collapse),

Causes increased intrathoracic pressure, which leads to cardiac arrests.

Question 17

Causes of penumothorax

Answer 17

Spontaneous - male, tall, young
Secondary - bulla rupture in COPD, severe asthma
Trauma

can have catamenial (at the time of mensuration, due to holes in the diaphragm and air entry in cervical plug)

Question 18

Investigations of pneumothorax

Answer 18

Obs
ABG - look for hypoxia
CXR - absent lung markings, shadow of collapsed lung
- if tension treat before CXR!

Question 19

management of non-tension pneumothorax

Answer 19

Oxygen 15L
Chest drain for air-decompression

If high recurrence or risk of effusion, Pleurodesis (TALC between pleura to cause pleura to stick together)

Question 20

Management of tension pneumothorax

Answer 20

A-E
15L Oxygen
Large bore cannula in the second intercostal space for urgent decompression.
Then chest drain insertion

Question 21

Presentation of a PE

Answer 21

acute SOB, chest pain, cough, haemoptysis, dizziness, syncope

O/E: tachycardia, tachypnoea, hypoxia, confusion, pyrexia, elevated JVP, shock

Question 22

Causesof PE

Answer 22

obstruction in arterial tree - emoli are thrombuses, Fat, amniotic fluid, or air.

Question 23

Investigations for PE

Answer 23

Respiratory examination and inspection of the calves.

ABG
Bloods: FBC, U&Es, Clotting, D-dimer (if indicated by wells)
ECG - to exlude cardiac cause, most likely will se sinus tachy.

CXR - should look normal

Wells score to assess possibility
if <4 points - PE unlikely. Do a D-Dimer and then decode whether to do a CTPA.
If >4 points - PE likely. Do a CTPA

Question 24

What are the features measured in the Wells score? (7 things)

Answer 24

Clinical suspicion of DVT
Alternative diagnosis likelihood
Tachycardia
Immobilisation
History of DVT or PE
Haemoptysis
Malignancy (in the preceding 6 m/o)

Question 25

ECG findings in PE

Answer 25

sinus tachy
new RBB with/or Right axis Deviation
S1 Q3 T3
- S wave in lead 1, Q wave in lead 3 and T wave inversion in lead 3.

Question 26

Management of PE

Answer 26

A-E approach
15L O2
IV access and fluids
Analgesia

Anticoagulation
5 days of apixaban or rivoxibam or LMWH. If massive PE or unstable pt then do thrombolysis with unfractionated heparin. If fails, then do surgical embolectomy.

Long term anticoagulants - rivaroxaban for 3 months

If unprovoked PE - cancer screen

Question 27

Presentation of pulmonary oedema

Answer 27

SOB, N/V, pale, sweating, history of cardiac failure, productive cough with pink frothy sputum, cyanosis.

O/E: tachypnoeic, tachycardic, hypoxia, hypotensive, gallop rhythm (third heart sound)

Question 28

Causes of pulmonary oedema

Answer 28

Cardiac: - causes by elevated pulmonary capillary pressure (hydrostatic)
- ACS, MI, heart failure, PE, tamponade, renal causes eg CKD, AKI, anaemia.

Non-cardiac: altered capillary permeability
- respiratory distress syndrome, liver failure, trauma, airway obstruction, overdose, lymphatic insufficiency.

Question 29

Investigations for pulmonary oedema

Answer 29

Bloods: FBC, U&Es, LFTs, Clotting, Troponin, BNP, glucose

ABG - hypoxia
ECG -look for cardiac cause, arrhythmia, signs of ischaemia, signs of LVH
may need and ECHO

CXR - haziness and decreased lung markings.

Question 30

Management of pulmonary oedema

Answer 30

Find and treat cause

A-E
Supportive management: aims at oxygenation and diuresis.
O2, sit patient up right
Fluid management with catheter to monitor output
Sublingual or buccal nitrates - vasodilator and diuresis effects
IV Furosemide- 20mg IV slowly
IV diamorphine - pain relive and ease of breathlessness
Inotropes if needed to treat shock

After stabilisation patients will need long term ACEi, B blocker, Spironolactone and digoxin.