Respiratory Flashcards
(36 cards)
CAP (I)
CRB-65 (severity assessment [in community]):
- C: Confusion (AMT 8 or less) – 1 point
- R: Respiratory rate 30 or more – 1 point
- B: Blood pressure <90/60 (either systolic or diastolic) – 1 point
- 65: Age 65 or more – 1 point
CAP (II)
CRB Categories
- Score 0: low risk of death – consider home care
- Score 1-2: intermediate risk of death – consider hospital assessment
- Score 3-4: high risk of death – consider hospital assessment (admit)
CAP (III)
CRB-65 of 0: Amoxicillin 500mg TDS 5 days (Doxycycline/Clarithromycin/Erythromycin if Penicillin allergy)
CRB-65 of 1-2: Amoxicillin 500mg TDS 5 days and (if atypical pathogens suspected) Clarithromycin or Erythromycin
CRB-65 of 3-4: Options may include: Co-amoxiclav + Clarithromycin or Erythromycin
Higher severity
(hospital)
General self-care management: e.g. rest, fluids, analgesia, (don’t recommend cough syrups)
Asthma diagnosis
Asthma diagnosis based of probability:
- Variable symptoms in history?
- Personal/family history of atopy?
- FeNO (fractional exhaled nitric oxide): Positive if 40 ppb (steroid-naïve adults), Positive if 35 ppb (age 5-16)
- Tests suggesting airflow:
Spirometry (over age 5, look for FEV1/FVC ratio ,70%)
Bronchodilator reversibility (do B-agonists/corticosteroids improve FEV1 by 12%?)
Peak flow variability (look for 20% variability – measure at least BD over 2-4 weeks)
- Direct bronchial challenge test: with histamine or methacholine (Needs specialist referral for this)
Asthma Management (non-acute, 17 and over)
Asthma Management (non-acute, 17 and over
1. Reliever therapy: SABA inhaler as needed
2. Low-dose inhaled ICS (Beclomethasone/Budesonide/Fluticasone): e.g. if uncontrolled: Asthma symptoms/inhaler used 3x a week or more OR woken at night by symptoms once a week
3. LTRA (Montelukast): In addition to a low dose ICS
4. Add LABA (Salmeterol/Formoterol): In combination with low dose ICS ((Beclomethasone/Budesonide/Fluticasone) +/- LTRA (Montelukast)
5. Offer MART regime:
Maintenance and Reliever therapy together (MART)
Combination of low dose ICS and fast acting LABA (e.g. fomoterol) in one inhaler (Symbicort, Fostair)
6. Increase steroid dose to - Moderate-dose steroid: Either with MART, or back as individual inhalers
7. Other options or Refer:
- Increase steroid dose to - High-dose steroid
- Additional medications, e.g. LAMA, theophylline
Ashma Management (non-acute, 5-16)
Ashma Management (non-acute, 5-16)
1. Reliever therapy: SABA inhaler as needed
2. Low-dose inhaled ICS (Beclomethasone/Budesonide/Fluticasone): e.g. if uncontrolled: Asthma symptoms/inhaler used 3x a week or more OR woken at night by symptoms once a week
3. LTRA (Montelukast): In addition to a low dose ICS (Beclomethasone/Budesonide/Fluticasone)
4. Add LABA (Salmeterol/Formoterol): In combination with low dose ICS ((Beclomethasone/Budesonide/Fluticasone) STOP LTRA (Montelukast)
5. Offer MART regime:
Maintenance and Reliever therapy together (MART)
Combination of low dose ICS and fast acting LABA (e.g. fomoterol) in one inhaler (Symbicort, Fostair)
6. Increase steroid dose to - Moderate-dose steroid: Either with MART, or back as individual inhalers
7. Refer:
- Increase steroid dose to - High-dose steroid
- Additional medications, e.g. LAMA, theophylline
Asthma Management (non-acute, under 5s)
- Reliever therapy: SABA inhaler as needed
-
Moderate-dose inhaled ICS trial:
**8-week trial ** and review (as a test)
Stop and monitor symptoms
If symptoms recur in 4 weeks, commence maintenance low-dose ICS
Consider LRTA ((Montelukast): In addition to low-dose ICS (Beclomethasone/Budesonide/Fluticasone)
4. Refer
Acute asthma Assessment
Moderate: PEFR 50-75% predicted (for that age)
Severe: PEFR 33-50% predicted (for that age)
Life-threatening: PEFR: <33% predicted (for that age): Also, may have
- Sats <92%
- Silent chest
- Exhaustion
- Altered conscious level
- Cyanosis
Acute Asthma - Community Management
Admit if severe/life-threatening asthma or if in doubt, but if not:
- Oxygen
- B-agonist: either inhaled or nebulised salbutamol
- Considered nebulised ipratropium 0.5mg (500mcg)
- Steroids: Prednisolone 40-50mg OD 5 days or IM methylprednisolone 160mg (adult)
COPD investigations/dx
Post-bronchodilator spirometry:
- Carry out 15-20 minutes after taking a bronchodilator
- Airflow obstruction: FEV1/FVC ratio <0.7 (less than 0.7)
- Imaging: e.g. CXR (rule out other conditions), CT chest
- FBC: check for polycythaemia (high RBC or high haematocrit or high Hb or high platelets or high WBC or low EPO), anaemia
- Serial peak flow: if asthma considered
- Serum alpha-1 antitrypsin: deficiency especially if young or FH
- Sputum culture
- Cardiac investigations: e.g. ECG, BNP, echo
- NO CLUBBING in COPD. (Note clubbing in mesothelioma)
COPD grading
Stage 1 Mild FEV1 >80% predicted
Stage 2 Moderate FEV1 50-79% predicted
Stage 3 Severe FEV1 30-49% predicted
Stage 4 Very Severe FEV1 <30% predicted
Smoking, RSV, Flu, Covid jab, Pulmonary rehab
COPD Management
Step 1: Short-acting bronchodilators (SABA or SAMA) – SABA (salbutamol, terbutaline), SAMA (ipratropium)
Step 2:
YES asthma features: LABA (salmeterol) + ICS (Beclomethasone/Budesonide/Fluticasone)
NO asthma features: LABA (salmeterol) + LAMA (tiotropium)
Step 3: LABA (salmeterol) + LAMA (tiotropium) + ICS (Beclomethasone/Budesonide/Fluticasone)
Add on therapies may include (with respiratory input):
- Regular oral steroids
- Oral theophylline
- Oral mucolytics, e.g. Carbocisteine
- Prophylactic antibiotics, e.g. Azithromycin (usually 250mg 3 times a week)
*Remember ICS not to be used alone in COPD
Flu jab annually + PPV (ONE OFF)
Reccurent infective exacerbations (further info)
Azithromycin 250 mg three times a week can be used (off-label licence) as antibiotic prophylaxis for patients with chronic obstructive pulmonary disease who are prone to exacerbations (usually four or more in a year), or prolonged productive exacerbations or those resulting in hospitalisations.
Acute COPD Exacerbation
Consider need for admission, e.g. how unwell, sats, past history etc.
Increase SABA – not beyond maximum recommended
Prednisolone: 30mg OD 5 days (? Osteoporosis prophylaxis) [lower dose pred than asthma]
(if multiple COPD exacerbations in the last year consider osteoporosis prophylaxis)
Antibiotics if purulent sputum (dependent on local guidance):
- Amoxicillin 500mg TDS for 5 days
- Doxycycline 200mg day 1, then 100mg OD for 5-day total course
- Clarithromycin 500mg BD for 5 days
In hospital may need nebs, O2, theophylline, NIV etc.
(Check steroid risk over over year)
LTOT in COPD
Consider LTOT in:
- Chronic hypoxemia oxygen saturation of <92% (measured on two occasions at least 3 weeks apart and at least 5–6 weeks after an exacerbation)
- Partial pressure of oxygen (PaO2) <7.3 kPa (8 kPa in patients with pulmonary hypertension, secondary polycythaemia, peripheral oedema from cor pulmonale)
Pulmonary Embolism (I)
- Multiple risk factors:
Previous history, age
Smoking, obesity, COCP, long flights, immobility
Acute infection, varicose veins, hospitalisation, pregnancy/postpartum, cancer, chemotherapy - Classic presentation:
Dyspnoea, pleuritic chest pain, cough, haemoptysis
Calf swelling/pain - Examination:
Tachycardia, high RR, hypoxia
Gallop rhythm, raised JVP, widely split 2nd heart sound
Pulmonary Embolism Management (I)
Admit if pregnant (or having given birth within the past 6 weeks) and PE suspect (don’t use Well’s score if pregnant)
2-level PE Well’s score:
- PE likely if score of more than 4 points
- PE unlikely if score of 4 or less
Well’s score
- Clinical features of DVT (minimum of leg swelling and pain with palpation of the deep veins) - minus 3 points
- An alternative diagnosis is less likely than PE - 3 points
- Heart rate greater than 100 beats per minute - 1.5 points
- Immobilization for more than 3 days or surgery in the previous 4 weeks - 1.5 points
- Previous DVT or PE - 1.5 points
- Haemoptysis - 1 point
- Cancer (receiving treatment, treated in the last 6 months, or palliative) - 1 point
Pulmonary Embolism Management (II)
If PE likely: Admit for CTPA (V/Q scan if contraindicated) immediately – if not possible, offer interim therapeutic anticoagulation
If PE unlikely: Check D dimer within result within 4 hours – if result not possible within 4 hours, offer therapeutic anticoagulation therapy while awaiting the result. If D dimer positive, admit to hospital for immediate CTPA
Other investigations (likely in secondary care), e.g. CXR, Bloods, ABG to rule out differentials
Interim anticoagulation & treatment/mgt. for confirmed PE
If interim anticoagulation is needed: First-line – Apixaban or Rivaroxaban (LMWH if not suitable)
If confirmed PE, management may include:
- Medications, e.g. LMWH / fondaparinux / ongoing oral anticoagulants (e.g. apixaban) / streptokinase
- Interventions, e.g. IVC filters
- Will need ongoing anticoagulation at least 3 months if proven PE
- Unprovoked PE: screen for cancers, thrombophilia screen
Pneumothorax
Different types:
- Simple vs tension
- Spontaneous (e.g. tall thin men) vs traumatic (e.g. biopsy/trauma)
Presentation:
- May be asymptomatic (particularly small ones)
- SOB, chest pain, deterioration of conditions, e.g. asthma/COPD
Examination:
- Tachycardia, high RR, pulsus paradoxus (pulse slows inspiration)
- Reduced air entry, reduced expansion, hyperresonance, trachea may be deviated away (typically if very large pneumothorax)
Pneumothorax Management
Non-tension:
- Conservative VS
- Active intervention (e.g. needle/chest drain/surgery) – depending
Tension (ATLS):
- Large-bore cannula
- Adult: 5th intercostal space, mid-axillary line of the affected side
- Child: 2nd intercostal space, mid-clavicular line of the affected side
Pleural effusion
Different types:
- Transudate – lower levels of protein - (protein less than <30g/L), e.g. due CCF, nephrotic syndrome – usually a problem outside of the lung
- Exudate – higher level of protein - (protein more than >30g/L), e.g. due to infection, malignancy – usually a problem inside of the lung (except Meigs syndrome)
Examination:
- Classic: stony dull percussion
- Reduced breath sounds, Displaced trachea, Reduced fremitus, Reduced tactile vocal resonance
Investigations:
- Include CXR, USS, pleural tap, pleural biopsy
Management: Conservative management (is possible if small), may need drainage (sometimes repeatedly), Pleurodesis, Surgery
Lung cancer referral
Appointment within 2 weeks (with lung cancer clinic):
- Have CXR findings that suggest lung cancer
- Over 40 with unexplained haemoptysis
Urgent CXR with 2 weeks
Urgent CXR within 2 weeks if Over 40 if:
EITHER (symptoms)
Have 2 or more of below unexplained symptoms OR if ever smoked and 1 symptom:
- Cough
- Fatigue
- SOB
- Chest pain
- Weight loss
- Appetite loss
OR (signs):
- Persistent or recurrent chest infection
- Finger clubbing
- Supraclavicular LN
- Persistent cervical LN
- Chest signs consistent with lung cancer
- Thrombocytosis (high platelets)
