Lungs

Question 1

if one set of nebulisers don’t work to relieve asthma, what is the next prescription?

Answer 1

repeat 5 mg salbutamol nebs every 15-30 mins

or 10 mg/hr continuous nebulized salbutamol as needed

monitor ECG for arrhythmia

consider magnesium sulphate 1.2-2 g IV over 20 mins

Question 2

nebs and steroids…

what’s next for COPD exacerbation (settling)?

Answer 2

chest physio, mucolytics

antibiotics (amoxicillin, clarithromycin or doxycycline)

liaising with GP - vaccinations (pneumovax and flu), steroid step down, home oxygen requirements, smoking cessation

Question 3

common causative organisms for pneumonia

Answer 3

• strep pneumo* (60-75% of cases)
• influzena, parainfluenza, RSV* (15%)
• Haemophilus influenzae*
• mycoplasma pneumoniae*
• staph aureus (ITU patients)*
• klebsiella*
• pseudomonas areugenosa* & other gram -ve (immunocompromise, HAP, ICU)
• legionella spp. & chlamydia psittaci*
• mycobacterium tuberculosis*

Question 4

when do you call a surgical opinion for pneumothorax?

(5)

Answer 4

bilateral pneumothoracies

lung fails to expand withing 48 hours of chest drain insertion

>1 previous pneumothorax on that side

any pneumothorax on the other side

continous air leak

Question 5

how do you interpret CURB-65 score?

Answer 5

1 = home treatment if possible

2 = admit to hospital

3 = severe, consider ITU referral

Question 6

what is the treatment of a tension pneumothorax?

Answer 6

call med reg, ask for their presence at the bedside

>14 G cannula insertion above the rib in the 2nd IC space, mid clavicular line

syringe full of saline to watch bubbles coming through

then…

request CXR and place chest drain.

Question 7

what underlying pathology should be ruled out in the setting of VTE?

Answer 7

SLE

thrombophilia/polycythaemia/myeloproliferative disorder

underlying malignancy (?CT-abdo/pelvis and mammogram)

Question 8

initial COPD exacerbation and initial acute asthma attack nebulisers. Are they the same route/dose?

Answer 8

yes

5 mg salbutamol nebs

500 mcg/6 hours ipratropium nebs

Question 9

what are the ECG findings suggestive of PE?

Answer 9

right ventricular strain (V1-V3 dominant R waves, ST depression, T inversion)

new onset RBBB

new onset AF

S1Q3T3 - prominant S in I, pathological Q waves and inverted T waves in III

Question 10

management algorithm for pneumothoracies

Answer 10

primary, <2 cm - conservative management

primary >2 cm - aspiration. if unsuccessful, place chest drain

secondary, <2 cm - aspiration, then admit for 24 hours for observation

secondary, >2 cm - chest drain and admit. send to chest team

Question 11

how do you measure a pneumothorax?

Answer 11

distrance from chest wall to outer lung markings on CXR at the level of the hilum

Question 12

Unable to complete sentences in one breath.

Respiratory rate ≥ 25/min.

Pulse rate ≥110 beats/min.

pef 33–50% of predicted or best

what degree of asthma attack?

Answer 12

severe

Question 13

PEFR <33%

silent chest, cyanosis, very poor respiratory effort

arrhythmia or hypotension

exhaustion, confusion or coma

PaCO2 > 4.6 kPa, PaO2 < 8 kPa, SpO2 < 92%

what severity of asthma?

Answer 13

life-threatening

Question 14

steroids for COPD

drug route dose duration

Answer 14

hydrocortisone 200 mg IV

prednisolone 30-40 mg daily PO for 7-14 days

Question 15

what is the step down care from an acute asthma attack?

Answer 15

continue nebs every 15-30 mins PRN, if ipratropium was given initially then add subsequently

aim SpO2 94-98% OA

prednisolone 30-40 mg PO OD for 5-7 days

Question 16

what will ITU/anaesthetics do for an acute asthma attack beyond ward based care?

Answer 16

(mechanical) ventilatory support

IV salbutamol

IV aminophylline infusion

Question 17

what is the immediate treatment of all acute asthma attacks?

Answer 17

SpO2 aim 94-98 %

5 mg nebs salbutamol on 15 L oxygen

0.5 mg ipratropium nebs over 6 hours

steroids - hydrocortisone 100 mg IV, prednisolone 30-40 mg PO

monitor ECG for arrhythmia 2ary to salbutamol

Question 18

antibiotics for different pneumonias

CURB-65 = 1, 2 & >3

atypicals suspected

HAP

aspiration

Answer 18

• CURB-65
  
  • 1 = amox/clari/doxy PO (for 5 days)
  • 2 = amox + clari/doxy PO (for 7 days)
  • >3 = co-amox/cefuroxime + clari IV (for 7 days)
• atypicals
  
  • legionella = fluroquinolone + clari/rif
  • chlamydophilia = tetracycline
  • PCP = co-trimoxazole high dose
• HAP
  
  • probably gram -ve, pseudomonal or anaerobic = 3rd gen cephalosporin, anti-pseudomonal (tazocin) and aminoglycoside
• aspiration
  
  • strep pneumo or anaerobe = cephalosporin and metro

Question 19

nebs and steroids…

what’s next for COPD exacerbation (worsening)?

Answer 19

IV aminophylline (ITU/resp)

if RR >30/pH <7.35 = NIV (BiPAP)

if not available/not an option - respiratory stimulant drugs (e.g. doxapram)… call respiratory!

eventually, intubation and ventilation but significantly worsens outcomes

Question 20

how do we discharge asthmatic patients?

Answer 20

if PEFR >75% wihtin 1 hour of treatment initation then patient can be discharged immediately with outpatient follow up

if not…

• stable on discharge medication for at least 24 hours
• inhaler technique check/education
• PEFR >75%, with less than 25% variability in 24 hours
• PO and nebs steroids, bronchodilator nebs
• written management plan
• GP follow up within 2 days
• respiratory clinic in 4 weeks

Question 21

what defines a secondary pneumothorax?

Answer 21

underlying lung condition

smoker >50 years old

Question 22

oxygen therapy for COPD exacerbation?

what are the ABG values?

Answer 22

start with FiO2 24-28% aiming for sats 88-92%

aim for PaO2 > 8 kPa keeping PaCO2 < 15 kPa

Question 23

what are the anticoagulation durations for PE?

Answer 23

if a known cause that can be treated = 3 months

unknown cause = 3-6 months

untreatable cause = long-term

Question 24

complications of pneumonia

Answer 24

lung abscess, MI, septic shock, parapneumonic effusion, empyema, respiratory failure, pericarditis, myocarditis, AKI, jaundice