Resp Key Flashcards
Criteria “features” for Life-threatening Asthma:
PEF < 33% predicted or best.
• SpO2 < 92%.
• PaO2 < 8 kPa.
• PaCO2 is normal (4.6-6 k
Criteria “features” for Life-threatening Asthma
• Altered mental status with drowsiness.
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• Silent Chest (Absent chest sounds)
• Poor respiratory effort.
• Exhaustion.
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• Cyanosis.
• Arrhythmia.
• Hypotension.
Which of the following will indicate life threatening asthma?
A patient recently diagnosed of asthma which has been well controlled, now
presents with increase respiratory rate, temp 36.7, auscultation reveals
absent breath sound
absent breath sound.
A 3yr old boy with asthma presents to the A&E with acute attack of wheeze.
He is cyanotic and has RR of 45. His HR is 180bpm, he has intercostal recession
and widespread wheeze. What is the most significant feature that shows
impending respiratory failure?
Cyanosis
A 3yr old boy with asthma presents to the A&E with acute attack of wheeze.
He is cyanotic and has RR of 45. His HR is 180bpm, he has intercostal recession
and widespread wheeze. What is the most significant feature that shows
impending respiratory failure?
Cyanosis
A 3yr old boy with asthma presents to the A&E with acute attack of wheeze.
He is drowsy and has cold periphery. His HR is 180bpm, he has intercostal
recession and widespread wheeze. What is the most significant feature that
shows impending respiratory failure?
Drowsiness
A patient recently diagnosed of asthma which has been well controlled, now
presents with increase respiratory rate, temp 36.7, auscultation reveals
absent breath sound.
Which of the following will indicate life threatening asthma?
Absent breath sound
Question 1)
• Hx of being a worker “e.g., builder, a shipyard worker” (exposed to
asbestos) [+]
• Shortness of breath ▐ Chest pain ▐ Weight loss [±]
• Clubbing, Recurrent Pleural Effusion
◙ Suspect → Mesothelioma (Malignant tumour of mesothelial cells).
→ Bronchial carcinoma
◙ To confirm the Dx → Pleural Biopsy (not cytology).
◙ Malignant pleural effusion due to mesothelioma may require
→ Long-term indwelling pleural drain.
◙ Mesothelioma is seen in people exposed to asbestos such as:
√ Blue-collar Workers → Firefighters, construction workers (builders), power
plant workers, shipyard workers and others in blue-collar occupations.
√ Veterans → Primarily military personnel who served in the U.S. Navy, but also
those who served in the Army, Marine Corps, Air Force and Coast Guard, signet
ring sign and finger in glove sign.
So, it is considered an industrial disease, leading to “unnatural death”.
Therefore, deaths of mesothelioma should be reported to and consulted with
→ a coroner as compensation is often available. “important”
A 57 YO man is admitted to ICU after having MI. He has a Hx of
mesothelioma. A few days later he had cardiac arrest and died. Pick the
correct answer:
Refer to a coroner before issuing a death certificate.
A 60 YO retired builder has been having shortness of breath and chest pain
for the past 6 months.
He is a smoker. His chest x-ray shows mediastinal
lymphadenopathy and right-sided pleural effusion. CT scan shows irregular
pleural thickening.
√ The likely Dx → Mesothelioma.
√ The likely cause → Asbestos. “80% of mesothelioma are due to asbestos”.
√ If he dies → refer to a coroner.
Atelectasis is a common postoperative complication in which basal alveolar
collapse can lead to respiratory difficulty. It is caused when airways become
obstructed by bronchial secretions.
Features
It should be suspected in the presentation of dyspnoea, tachycardia ± ↑ Temp.
and hypoxaemia within 72 hours postoperatively
Management → chest physiotherapy
Pneumothorax
Pneumo = Air
♦ Acute respiratory distress “Tachypnea, Desaturation”.
♦ ↑ Jugular venous pressure (Distended neck veins).
♦ On percussion over the affected side → Hyperresonance “air”.
♦ ↓ BP (Hypotension) “not always”
.
♦ ↓ Air entry – no or diminished breath sounds – on the affected side.
♦ Trachea/ Mediastinum deviation to the “OPPOSITE” side (commonly in
Tension pneumothorax). “This feature is not always present”.
√ [Note that, distended neck veins and shifted trachea are seen more in
“Tension” pneumothorax than in “Simple” pneumothorax].
√ Note that “Tension” pneumothorax may occur after thoracic trauma.
√ One of the most common causes of tension pneumothorax is mechanical
ventilation in patients with pleural injury.
One should suspect it if a patient on
mechanical ventilation suddenly deteriorates and develops low O2 saturation
and hypotension. Imp √
Management of Tension Pneumothorax:
Do not wait for Chest X ray if the patient is severely distressed or the clinical
diagnosis is certain. Give √ initially and begin with:
1) → Needle Decompression (Needle Thoracocentesis):
High O2 (Insert a large-bore cannula into the 5th intercostal space midaxillary line on the
affected side.
You can hear a hiss sound due to air escaping, which confirms the
diagnosis and relieves the patient. The previous method was to insert the
cannula into the 2nd intercostal space in the mid-clavicular line on the “affected
side”.
However, the new ATLS guidelines now uses 5th intercostal space).
Then “after air has been aspirated and the patient has become less distressed”
2) → Insert a in 5th intercostal space anterior to mid-axillary line.
chest drain So, needle thoracocentesis is used first as a rapid treatment to buy time until a
more definitive treatment (chest drain) is put in place.
If the patient is stable with good O2 saturation, the 1st investigation would be
→ Chest X ray.
Do not confuse it with Cardiac Tamponade:
Cardiac Tamponade → Beck’s Triad →
Hypotension, Muffled Heart Sounds, High JVP (Distended neck veins).
N.B. Chest X-ray that shows enlarged globular heart
either Pericardial effusion (OR) Cardiac Tamponade.
• Dx: Echo is diagnostic
• Tx: Urgent pericardiocentesis.
Primary Spontaneous Pneumothorax:
→ Occurs spontaneously without a previous lung disease.
→ Mostly affects Tall Then Young Males (hints) with no apparent reason.
◙ “Please, consider primary spontaneous pneumothorax in any tall, thin, male
who presents with increasing dyspnea, chest pain”
◙ Sometimes, acute severe asthma may have an underlying pneumothorax.
◙ For initial Diagnosis → Erect Chest X-ray “if the patient is not severely
distressed” Otherwise, we proceed immediately to needle decompression.
Secondary Spontaneous Pneumothorax:
→ Occurs spontaneously in the presence of an underlying lung disease
Such as asthma or Chronic Obstructive Pulmonary Disease (e.g. Hx of Chronic
Smoking).
the initial management in the presence of underlying lung disease e.g.,
asthma, COPD:
◙ if the pneumothorax is (≤ 2 cm air rim i.e. ≤ 50%) → Aspirate “insert Cannula”
◙ if the pneumothorax is large (> 2 cm air rim i.e. > 50%) → “Insert Chest Drain
Traumatic Pneumothorax
Examples, post- car accident, after receiving a stab on the back, post-
interventional radiology into chest -e.g. CT guided biopsy to a mass in chest)
→ usually tension pneumothorax
→ insert cannula (large-bore) to the second intercostal space at the
midclavicular line on the affected side (Needle decompression).
♣ Sometimes, a stem would give a case of desaturating patient and Hx of
smoking or COPD but instead of giving you the other features (such as shifted
trachea), it would give you an apparent Chest X-ray:
