ACT Respiratory Flashcards
(37 cards)
Describe panic hyperventilation
Stress and anxiety causes a heightened awareness of breathing and hyperventilation. Hypocapnia causes a rise in blood pH, increasing the binding of Calcium to albumin. The reduction in ionised calcium causes the symptoms: numbness, tingling, tinnitus, muscle excitability.
If severe, LOC can be caused by hypocapnia induced vasoconstriction of cerebral vasculature
Assessment and investigation of hyperventilation
ABG if concerned - respiratory alkalosis
CXR - normal
Bloods - FBC ?anaemia, TFT ?hyperthyroid
Management of hyperventilation
Educate that symptoms of tingling/numbness are harmless
Breathing into a bag is no longer recommended
Placing palms (usually cold) to the cheeks can suppress breathing impulse (divers reflex)
If required – sedation with diazepam
What signs define a moderate asthma attack:
Peak flow >50% normal
Increasing symptoms but
No features of severe asthma
What signs define a severe asthma attack:
Peak Expiratory flow rate of 33-50% of predicted or best
RR 25 or more
HR 110 or more
Inability to complete sentences in one breath
What signs define a life threatening asthma attack
Peak Expiratory flow of < 33% of predicted or best 02 sats < 92% Silent chest, Cyanosis Hypotension, Arhythmia Exhaustion, Confusion, Coma ABG - p02 = < 8kPa - normal C02
What defines a near fatal asthma attack
PaCO2 > 6.0 kPa (Normal Range 4.5 – 6kPa)
Management of acute asthma attack
Oxygen - aim sats 94-98%
Salbutamol 5mg nebulised oxygen driven
Prednisolone 40mg for 5 days
Ipratropium bromide 500micrograms 4-6hrly
Senior help - consider ITU admission
Magnesium 1.2-2g IV infusion over 20mins
Check inhaler technique
Follow-up within 48 hours of presentation, if not admitted to hospital.
Follow-up all people admitted to hospital within 2 working days of discharge.
Follow up by Respiratory for at least 1 year if severe
Or for the rest of their life if near fatal attack
What are the indications for intensive care referral in acute asthma attack
Refer any patient:
1. Requiring ventilatory support
2. Acute severe or life-threatening asthma, who
is failing to respond to therapy, as evidenced by:
- deteriorating PEF
- persisting or worsening hypoxia
- hypercapnia
- ABG analysis showing acidosis
- exhaustion, feeble respiration
- drowsiness, confusion, altered conscious state
- respiratory arrest.
When should patients with acute asthma attacks be admitted
Admit all patients with any feature of a life-threatening or near-fatal asthma attack.
Admit patients with any feature of a severe asthma attack persisting after initial treatment.
Patients whose peak flow is greater than 75% best or predicted one hour after initial treatment may be discharged from ED, unless there are other reasons why admission may be appropriate.
What are the colours of venturi mask in order and what percentage oxygen to they deliver
Blue = 24% 2-4L White = 28% 4-6L Yellow = 35% 8-10L Red = 40% 10-12L Green = 60% 12-15L
Medical management of stable asthma
SABA for all - step up if used 3+ times a week
1st: low dose ICS
2nd: LABA + low dose ICS
3rd: stop or continue LABA depending on response and
- consider medium dose of ICS
- or trial of other therapy: TRA, S-R theophylline, LAMA
4th: Refer to specialist and consider
- High dose ICS
- or adding fourth drug
Non pharmacological management of asthma
Patient education Written personalised self management plan Avoidance of triggers Smoking cessation Weight loss if overweight Breathing exercise programs
Description of asthma
More than one of: ‘wheeze, breathlessness, chest tightness, cough’ with variable airflow obstruction.
Aetiology of asthma
Extrinsic - Dust mites, pollen, chemicals
Atopy - circulating IgE in the blood
Hygiene hypothesis
Description of Chronic Obstructive Pulmonary Disorder
Airflow obstruction that is not fully reversible and is both progressive and associated with inflammation in response to noxious particles or gasses.
Combines emphysema, where there is widening of distal airspaces and destruction of alveolar walls, and chronic bronchitis, where there is increased number of mucus secreting goblet cells and infiltration of bronchial walls with inflammatory cells.
This leads to scarring and thickening of the walls and poorer gas exchange.
Aetiology of COPD
Long term exposure to toxic particles
SMOKING - 20 per day = 30 x risk
Urban population
Age > 35
Management of stable COPD
Patient education
Personalised written self management plan
Smoking cessation - nicotine, varenicline or bupropion
Pneumococcal + annual influenza vaccine
Manage comorbidities
Pulmonary rehabilitation + Chest physiotherapy
Inhaled therapies - ensure good technique
All get SABA or SAMA when needed
Asthmatic features: 1st LABA + ICS. 2nd + LABA
No asthmatic: 1st LABA + LAMA
Consider spacer or nebulisers
Mucolytics for chronic productive cough
Oral theophylline - only after failed inhaled or can’t inhale
- requires monitoring, many interactions, caution elderly
Rescue pack for exacerbations
Management of acute exacerbation of COPD
Target sats depend on if CO2 retainer or not
Titrate Oxygen therapy - Blue or White Venturi to start
Salbutamol 5mg nebulised back to back if needed
Ipratropium bromide 500mcg nebulised 4-6hrly
Prednisolone 30mg for 7-14 day
ABx if purulent sputum or clinical signs of pneumonia
1st: Amoxicillin 500mg TDS for 5 days
or Clarithromycin 500mg BD for 5 days
or Doxycycline 200mg first day, 100mg OD till 5 days
2nd: Alternative first drug, if no improvement after 3 days
Consider NIV
Most common causative organisms of acute exacerbation of COPD?
Haemophilus influenzae (most common cause)
Streptococcus pneumoniae
Moraxella catarrhalis
Criteria for NIV and ITU in acute COPD exacerbation
Respiratory acidosis (pH <7.35 or pCO2 > 6 kPa) on controlled oxygen therapy and after usual medical treatment is an indication for Non Invasive Ventilation
ICU referral when pH < 7.25 or PaO2 < 7.3 for consideration of intubation
Management of acute bronchitis
Usually viral - influenza most common
Patient education on self care strategies:
- Keep hydrated, paracetamol, ibuprofen
- Expectation of 14 days
Smoking cessation
Abx not usually indicated, but are if:
- Systemically very unwell
- CRP > 100mg/L
- at risk of serious complications due to comorbidities
- 65+yo with two, or 80+yo with one of the following:
- Hospital admission in the previous year.
- Type 1 or type 2 diabetes mellitus.
- Known heart failure.
- Concurrent use of oral corticosteroids.
The three main causes of a metabolic acidosis
Ketoacidosis - Diabetics with high ketones
Renal acidosis - High Urea and Creatinine
Lactic acidosis - Tissue hypoxia eg. Shock
Treatment of tension pneumothorax
Sit up + Oxygen 15L
Needle thoracocentesis:
- 14/16G cannula attached to syringe with saline
- 2nd ICS, mid-clavicular line, just above rib
- aspirate quickly, then remove plunger
- Air should bubble through fluid
- LEAVE IN SITU
- No hiss/bubbling? Needle may be too short/blocked.
- Insert another cannula 5th ICS mid-auxiliary line
Insert a chest drain same side asap
