Respiratory Flashcards

Question

What is the management of exacerbation of COPD?

Answer 1

ncrease the frequency of bronchodilator use and consider giving via a nebuliser give prednisolone 30 mg daily for 5 days it is common practice for all patients with an exacerbation of COPD to receive antibiotics. NICE do not support this approach. They recommend giving oral antibiotics 'if sputum is purulent or there are clinical signs of pneumonia' the BNF recommends one of the following oral antibiotics first-line: amoxicillin or clarithromycin or doxycycline.

Answer 2

severe breathlessness acute confusion or impaired consciousness cyanosis oxygen saturation less than 90% on pulse oximetry. social reasons e.g. inability to cope at home (or living alone) significant comorbidity (such as cardiac disease or insulin-dependent diabetes)

Answer 3

Oxygen therapy COPD patients are at risk of hypercapnia - therefore an initial oxygen saturation target of 88-92% should be used prior to the availability of blood gases, use a 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92% for patients with risk factors for hypercapnia but no prior history of respiratory acidosis adjust target range to 94-98% if the pCO2 is normal Nebulised bronchodilator beta adrenergic agonist: e.g. salbutamol muscarinic antagonists: e.g. ipratropium Steroid therapy as above IV hydrocortisone may sometimes be considered instead of oral prednisolone IV theophylline may be considered for patients not responding to nebulised bronchodilators Patients with COPD are prone to develop type 2 respiratory failure. If this develops then non-invasive ventilation may be used typically used for COPD with respiratory acidosis pH 7.25-7.35 the BTS guidelines state that NIV can be used in patients who are more acidotic (i.e. pH < 7.25) but that a greater degree of monitoring is required (e.g. HDU) and a lower threshold for intubation and ventilation should be used bilevel positive airway pressure (BiPaP) is typically used with initial settings: Expiratory Positive Airway Pressure (EPAP): 4-5 cm H2O Inspiratory Positive Airway Pressure (IPAP): RCP advocate 10 cm H20 whilst BTS suggest 12-15 cm H2O

Answer 4

NICE recommends that patients should initially be assessed in primary care using the CRB65 criteria: Criterion Marker C Confusion (abbreviated mental test score <= 8/10) R Respiration rate >= 30/min B Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg 65 Aged >= 65 years Patients are stratified for risk of death as follows: 0: low risk (less than 1% mortality risk) NICE recommend that treatment at home should be considered (alongside clinical judgement) 1 or 2: intermediate risk (1-10% mortality risk) NICE recommend that ' hospital assessment should be considered (particularly for people with a score of 2)' 3 or 4: high risk (more than 10% mortality risk) NICE recommend urgent admission to hospital

Answer 5

This is currently not widely available but they make the following recommendation with reference to the use of antibiotic therapy: CRP < 20 mg/L - do not routinely offer antibiotic therapy CRP 20 - 100 mg/L - consider a delayed antibiotic prescription CRP > 100 mg/L - offer antibiotic therapy

Answer 6

Criterion Marker C Confusion (abbreviated mental test score <= 8/10) U urea > 7 mmol/L R Respiration rate >= 30/min B Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg 65 Aged >= 65 years NICE recommend, in conjunction with clinical judgement: consider home-based care for patients with a CURB65 score of 0 or 1 - low risk (less than 3% mortality risk) consider hospital-based care for patients with a CURB65 score of 2 or more - intermediate risk (3-15% mortality risk) consider intensive care assessment for patients with a CURB65 score of 3 or more - high risk (more than 15% mortality risk)

Answer 7

chest x-ray in intermediate or high-risk patients NICE recommend blood and sputum cultures, pneumococcal and legionella urinary antigen tests CRP monitoring is recommend for admitted patients to help determine response to treatment

Answer 8

amoxicillin is first-line if penicillin allergic then use a macrolide e.g Clarithromycin or tetracycline eg doxycycline NICE now recommend a 5 day course of antibiotics for patients with low severity community acquired pneumonia

Answer 9

dual antibiotic therapy is recommended with amoxicillin and a macrolide a 7-10 day course is recommended NICE recommend considering a beta-lactamase stable penicillin such as co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide in high-severity community acquired pneumonia

Answer 10

NICE recommend that patients are not routinely discharged if in the past 24 hours they have had 2 or more of the following findings: temperature higher than 37.5°C respiratory rate 24 breaths per minute or more heart rate over 100 beats per minute systolic blood pressure 90 mmHg or less oxygen saturation under 90% on room air abnormal mental status inability to eat without assistance. They also recommend delaying discharge if the temperature is higher than 37.5°C.

Answer 11

NICE recommend that the following information is given to patients with pneumonia in terms of how quickly their symptoms should symptoms should resolve: Time Progress 1 week Fever should have resolved 4 weeks Chest pain and sputum production should have substantially reduced 6 weeks Cough and breathlessness should have substantially reduced 3 months Most symptoms should have resolved but fatigue may still be present 6 months Most people will feel back to normal.

Answer 12

6 weeks after clinical resolution to ensure that the consolidation has resolved and there is no underlying secondary abnormalities (e.g. a lung tumour).

Answer 13

Heerfordt's syndrome (uveoparotid fever), which includes parotid enlargement, uveitis, and facial nerve palsy.

Answer 14

Raised platelets

Answer 15

First-line investigations NICE measure the eosinophil count OR fractional nitric oxide (FeNO) diagnose asthma, without further investigations, if: eosinophil is above the reference range FeNO is ≥ 50 ppb If asthma is not confirmed by the eosinophil count or FeNO measure bronchodilator reversibility (BDR) with spirometry diagnose asthma if: the FEV1 increase is ≥ 12% and 200 ml or more from the pre-bronchodilator measurement, or the FEV1 increase is ≥ 10% of the predicted normal FEV1 if spirometry is not available or it is delayed, measure peak expiratory flow (PEF) twice daily for 2 weeks diagnose asthma if: PEF variability (expressed as amplitude percentage mean) is ≥ 20% If asthma is not confirmed by eosinophil count, FeNO, BDR or PEF variability but still suspected on clinical grounds: refer for consideration of a bronchial challenge test diagnose asthma if bronchial hyper-responsiveness is present

Answer 16

First-line investigation NICE measure the fractional nitric oxide (FeNO) diagnose asthma if: FeNO is ≥ 35 ppb If the FeNO level is not raised, or if FeNO testing is not available: measure bronchodilator reversibility (BDR) with spirometry diagnose asthma if: the FEV1 increase is ≥ 12% from the pre-bronchodilator measurement, or the FEV1 increase is ≥ 10% of the predicted normal FEV1 if spirometry is not available or it is delayed, measure peak expiratory flow (PEF) twice daily for 2 weeks diagnose asthma if: PEF variability (expressed as amplitude percentage mean) is ≥ 20% If asthma is not confirmed by FeNO, BDR or PEF variability but still suspected on clinical grounds: perform skin prick testing to house dust mite OR measure total IgE level and blood eosinophil count exclude asthma if there is no evidence of sensitisation to house dust mite on skin prick testing OR if the total serum IgE is not raised diagnose asthma if there is evidence of sensitisation OR a raised total IgE level and the eosinophil count is > 0.5 x 109/L If there is still doubt about the diagnosis refer to a paediatric specialist for a second opinion, including consideration of a bronchial challenge test

Answer 17

The guidelines acknowledge the difficulty of performing tests in such young children. They suggest: NICE treating with inhaled corticosteroids as per the management guidelines with regular review if they still have symptoms at age 5 then attempt objective tests refer to a specialist respiratory paediatrician any preschool child with an admission to hospital, or 2 or more admissions to an emergency department, with wheeze in a 12-month period.

Answer 18

NIV should be considered in all patients with an acute exacerbation of COPD in whom a respiratory acidosis (PaCO2>6kPa, pH <7.35 ≥7.26) persists despite immediate maximum standard medical treatment COPD with respiratory acidosis pH 7.25-7.35 the BTS guidelines state that NIV can be used in patients who are more acidotic (i.e. pH < 7.25) but that a greater degree of monitoring is required (e.g. HDU) and a lower threshold for intubation and ventilation should be used type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea cardiogenic pulmonary oedema unresponsive to CPAP weaning from tracheal intubation

Answer 19

Expiratory Positive Airway Pressure (EPAP): 4-5 cm H2O Inspiratory Positive Airway Pressure (IPAP): RCP advocate 10 cm H20 whilst BTS suggest 12-15 cm H2O back up rate: 15 breaths/min back up inspiration:expiration ratio: 1:3

Answer 20

Serial measurements of peak expiratory flow are recommended at work and away from work. Referral should be made to a respiratory specialist for patients with suspected occupational asthma.

Answer 21

isocyanates - the most common cause example occupations include spray painting and foam moulding using adhesives platinum salts soldering flux resin glutaraldehyde flour epoxy resins proteolytic enzymes

Answer 22

usually central arise from APUD* cells associated with ectopic ADH, ACTH secretion ADH → hyponatraemia ACTH → Cushing's syndrome ACTH secretion can cause bilateral adrenal hyperplasia, the high levels of cortisol can lead to hypokalaemic alkalosis Lambert-Eaton syndrome: antibodies to voltage gated calcium channels causing myasthenic like syndrome

Answer 23

Poor dental hygiene Swallowing difficulties Prolonged hospitalization or surgical procedures Impaired consciousness Impaired mucociliary clearance

Answer 24

The right middle and lower lung lobes are the most common sites affected, due to the larger calibre and more vertical orientation of the right main bronchus.

Answer 25

Streptococcus pneumoniae Staphylococcus aureus Haemophilus influenzae Pseudomonas aeruginosa Klebsiella: often seen in aspiration lobar pneumonia in alcoholics

Answer 26

Bacteroides Prevotella Fusobacterium Peptostreptococcus

Answer 27

The first step is assessing whether the patient is symptomatic the BTS define minimal symptoms as 'no significant pain or breathlessness and no physiological compromise' no or minimal symptoms → conservative care, regardless of pneumothorax size symptomatic → assess for high-risk characteristics If a pneumothorax is symptomatic, the next step is assessment for high-risk characteristics high-risk characteristics are defined as follows: haemodynamic compromise (suggesting a tension pneumothorax) significant hypoxia bilateral pneumothorax underlying lung disease ≥ 50 years of age with significant smoking history haemothorax if no high-risk characteristics are present, and it is safe to intervene, then there is a choice of intervention: conservative care ambulatory device needle aspiration if high-risk characteristics are present, and it is safe to intervene → chest drain How is safety or intervention determined? before a needle aspiration/chest drain insertion, the safety of intervention should be assessed this depends on the clinical context, but is usually: 2cm laterally or apically on chest x-ray, or any size on CT scan which can be safely accessed with radiological support Management options Conservative care patients with a primary spontaneous pneumothorax that is managed conservatively should be reviewed every 2-4 days as an outpatient patients with a secondary spontaneous pneumothorax that is managed conservatively should be monitored as an inpatient if stable, follow-up in the outpatients department in 2-4 weeks Needle aspiration a chest drain should be inserted if needle aspiration of a pneumothorax is unsuccessful if resolved, discharge and follow-up in the outpatients department in 2-4 weeks Chest drain insertion daily review as an inpatient remove drain when resolved discharge and follow-up in the outpatients department in 2-4 weeks

Answer 28

If a patient has a persistent air leak or insufficient lung reexpansion despite chest drain insertion, or the patient has recurrent pneumothoraces, then video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy.

Answer 29

Smoking patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men Fitness to fly absolute contraindication, the CAA suggest patients may travel 2 weeks after successful drainage if there is no residual air. The British Thoracic Society used to recommend not travelling by air for a period of 6 weeks but this has now been changed to 1 week post check x-ray Scuba diving the BTS guidelines state: 'Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.'

Answer 30

Azithromycin prophylaxis

Answer 31

patients should not smoke, have optimised standard treatments and continue to have exacerbations other prerequisites include a CT thorax (to exclude bronchiectasis) and sputum culture (to exclude atypical infections and tuberculosis) LFTs and an ECG to exclude QT prolongation should also be done as azithromycin can prolong the QT interval

Answer 32

General management >smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion annual influenza vaccination one-off pneumococcal vaccination pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above) Bronchodilator therapy a short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA) is first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators the next step is determined by whether the patient has 'asthmatic features/features suggesting steroid responsiveness' There are a number of criteria NICE suggest to determine whether a patient has asthmatic/steroid responsive features: any previous, secure diagnosis of asthma or of atopy a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up substantial variation in FEV1 over time (at least 400 ml) substantial diurnal variation in peak expiratory flow (at least 20%) No asthmatic features/features suggesting steroid responsiveness add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA) if already taking a SAMA, discontinue and switch to a SABA Asthmatic features/features suggesting steroid responsiveness LABA + inhaled corticosteroid (ICS) if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS if already taking a SAMA, discontinue and switch to a SABA NICE recommend the use of combined inhalers where possible Oral theophylline NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy the dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed

Answer 33

have had an exacerbation within the last year understand how to take the medication, and are aware of associated risks and benefits know to when to seek help and when to ask for replacements once medication has been used

Answer 34

smoking cessation - the single most important intervention in patients who are still smoking long term oxygen therapy in patients who fit criteria lung volume reduction surgery in selected patients

Answer 35

features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, loud P2 use a loop diuretic for oedema, consider long-term oxygen therapy ACE-inhibitors, calcium channel blockers and alpha blockers are not recommended by NICE

Answer 36

oral PDE-4 inhibitors such as roflumilast reduce the risk of COPD exacerbations in patients with severe COPD and a history of frequent COPD exacerbations NICE recommend if: the disease is severe, defined as a forced expiratory volume in 1 second (FEV1) after a bronchodilator of less than 50% of predicted normal, and the person has had 2 or more exacerbations in the previous 12 months despite triple inhaled therapy with a long-acting muscarinic antagonist, a long-acting beta-2 agonist and an inhaled corticosteroid

Answer 37

should be 'considered' in patients with a chronic productive cough and continued if symptoms improve

Answer 38

asthma pulmonary haemorrhage (e.g. granulomatosis with polyangiitis, Goodpasture's) left-to-right cardiac shunts polycythaemia hyperkinetic states male gender, exercise More blood, more hemoglobin, more surface area = higher TLCO

Answer 39

pulmonary fibrosis pneumonia pulmonary emboli pulmonary oedema emphysema anaemia low cardiac output

Answer 40

Quick way to remember: KCO = gas transfer efficiency per lung volume. TLCO = total gas transfer across all lungs. 📈 High KCO can happen when: Lungs are smaller but functioning very well (e.g., lung collapse, lobectomy) — "what lung is left is working overtime." Pulmonary hemorrhage (lots of hemoglobin around, even if lung size is normal) 📉 Low KCO can happen when: Lung tissue is damaged (e.g., emphysema — destroyed alveoli and capillaries) Severe pulmonary fibrosis Sometimes the TLCO might be low just because the lung size is small (e.g., after lung surgery or collapse), not because the lung tissue itself is bad. KCO helps separate whether the issue is small lung size or poor gas exchange. pneumonectomy/lobectomy scoliosis/kyphosis neuromuscular weakness ankylosis of costovertebral joints e.g. ankylosing spondylitis

Answer 41

obstructive

Answer 42

no smoking supportive: bronchodilators, physiotherapy intravenous alpha1-antitrypsin protein concentrates surgery: lung volume reduction surgery, lung transplantation

Answer 43

patients who manifest disease usually have PiZZ genotype lungs: panacinar emphysema, most marked in lower lobes liver: cirrhosis and hepatocellular carcinoma in adults, cholestasis in children

Answer 44

FEV1 - significantly reduced FVC - reduced or normal FEV1% (FEV1/FVC) - reduced Asthma COPD Bronchiectasis Bronchiolitis obliterans

Answer 45

FEV1 - reduced FVC - significantly reduced FEV1% (FEV1/FVC) - normal or increased Pulmonary fibrosis Asbestosis Sarcoidosis Acute respiratory distress syndrome Infant respiratory distress syndrome Kyphoscoliosis e.g. ankylosing spondylitis Neuromuscular disorders Severe obesity

Answer 46

Management admission all patients with life-threatening should be admitted in hospital patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment. other admission criteria include a previous near-fatal asthma attack, pregnancy, an attack occurring despite already using oral corticosteroid and presentation at night oxygen if patients are hypoxaemic, it is important to start them on supplemental oxygen therapy if patients are acutely unwell they should be started on 15L of supplemental via a non-rebreathe mask, which can then be titrated down to a flow rate where they are able to maintain a SpO‚‚ 94-98%. bronchodilation with short-acting beta‚‚-agonists (SABA) high-dose inhaled SABA e.g. salbutamol, terbutaline in patients without features of life-threatening or near-fatal asthma, this can be given by a standard pressurised metered-dose inhaler (pMDI) or by an oxygen-driven nebulizer in patients with features of a life-threatening exacerbation of asthma, nebulised SABA is recommended corticosteroid all patients should be given 40-50mg of prednisolone orally (PO) daily, which should be continued for at least five days or until the patient recovers from the attack during this time, patients should continue their normal medication routine including inhaled corticosteroids. ipratropium bromide: in patients with severe or life-threatening asthma, or in patients who have not responded to beta‚‚-agonist and corticosteroid treatment, nebulised ipratropium bromide, a short-acting muscarinic antagonist IV magnesium sulphate the BTS notes that the evidence base is mixed for this treatment that is now commonly given for severe/life-threatening asthma IV aminophylline may be considered following consultation with senior medical staff patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Treatment options include: intubation and ventilation extracorporeal membrane oxygenation (ECMO)

Answer 47

been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12-24 hours inhaler technique checked and recorded PEF >75% of best or predicted

Answer 48

Streptococcus pneumoniae (pneumococcus)

Answer 49

Staphylococcus aureus

Answer 50

Mycoplasma pneumoniae

Answer 51

Legionella pneumophilia

Answer 52

Klebsiella pneumoniae

Answer 53

Pneumocystis jiroveci

Answer 54

is a group of non-infective causes of pneumonia. Examples include cryptogenic organizing pneumonia which describes a form of bronchiolitis that may develop as a complication of rheumatoid arthritis or amiodarone therapy.

Answer 55

Allergic bronchopulmonary aspergillosis results from an allergy to Aspergillus spores. In the exam questions often give a history of bronchiectasis and eosinophilia.

Answer 56

eosinophilia flitting CXR changes positive radioallergosorbent (RAST) test to Aspergillus positive IgG precipitins (not as positive as in aspergilloma) raised IgE

Answer 57

oral glucocorticoids itraconazole is sometimes introduced as a second-line agent

Answer 58

bronchoconstriction: wheeze, cough, dyspnoea. Patients may have a previous label of asthma bronchiectasis (proximal)

Answer 59

Whilst mesothelioma is in some ways synonymous with asbestos, lung cancer is actually the most common form of cancer associated with asbestos exposure.

Answer 60

Eosinophilic Granulomatosis with Polyangiitis (EGPA)—formerly called Churg-Strauss syndrome—is a rare form of ANCA-associated vasculitis that affects small- to medium-sized blood vessels, with eosinophilic infiltration and granuloma formation.

Answer 61

Key Characteristics Triad: Asthma Eosinophilia Systemic vasculitis It classically progresses in three phases: Allergic phase – asthma, allergic rhinitis, sinusitis. Eosinophilic phase – marked peripheral eosinophilia, eosinophilic infiltration of lungs and GI tract. Vasculitic phase – systemic necrotizing vasculitis affecting multiple organs (esp. nerves, skin, kidneys). Features asthma blood eosinophilia (e.g. > 10%) paranasal sinusitis mononeuritis multiplex renal involvement occurs in around 20% pANCA positive in 60%

Answer 62

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)

Answer 63

Leukotriene receptor antagonists may precipitate the disease.

Answer 64

more common in alcoholic and diabetics may occur following aspiration 'red-currant jelly' sputum often affects upper lobes Prognosis commonly causes lung abscess formation and empyema mortality is 30-50% A chest X-ray is carried out which shows bilateral cavitating opacities in the upper lobe.

Answer 65

Pseudomonas aeruginosa is a common pathogen in bronchiectasis and cystic fibrosis. It is a common cause of hospital-acquired pneumonia, especially in those patients in the ITU on a ventilator. It doesn't cause the X-ray changes seen in this scenario. Instead, 'ground-glass' attenuation can often be noticed on a CT scan.

Answer 66

Mycoplasma pneumoniae causes flu-like symptoms such as a headache, arthralgia and myalgia followed by a dry cough which are not seen in this case. Chest X-ray often shows patchy consolidation of one lower lobe.

Answer 67

Legionella pneumophilia also causes flu-like symptoms such as fever, myalgia. It can also cause extra-pulmonary symptoms such as hepatitis, diarrhea and vomiting. Bi-basal consolidation can be seen on chest X-ray.

Answer 68

Staphylococcus aureus is often seen in intravenous drug users (IVDU), young, elderly or people with an underlying disease such as leukemia or cystic fibrosis. The patient's history of alcoholism points more towards Klebsiella

Answer 69

Renal cell carcinoma can metastasise to the lungs, causing 'cannonball metastases' although they can also be seen with other malignancies such as choriocarcinoma or endometrial cancer.

Answer 70

NICE guidelines suggest a prescription of 250mg azithromycin three times per week if: The patient no longer smokes. Has optimised non-pharmacological management & inhaled therapies. Referred to pulmonary rehab (if appropriate). 4 acute exacerbations in the last year (producing sputum), requiring hospital admission at least once.

Answer 71

Nasogastric tubes are safe to use if pH <5.5 on aspirate If aspirate >5.5, request a chest x-ray to confirm the position of the NG tube. If no aspirate can be obtained, the following manoeuvres can be used: Turn the patient on to their left side Inject 10-20ml air Offer a drink (if safe swallow) or mouth care (if nil by mouth) and re-check aspirate in 15-20 minutes Advance or withdraw the NG tube by 10-20 cm If an aspirate can still not be obtained, request a chest x-ray to confirm the position of the NG tube.

Answer 72

Steroids are only indicated in patients with stage 2/3 disease who are symptomatic, have hypercalcaemia, or who have heart, eye, or neuro involvement. As this patient has none of these features, treatment is not indicated.

Answer 73

A chest x-ray may show the following changes in sarcoidosis: stage 0 = normal stage 1 = bilateral hilar lymphadenopathy (BHL) stage 2 = BHL + interstitial infiltrates stage 3 = diffuse interstitial infiltrates only stage 4 = diffuse fibrosis

Answer 74

Bupropion should not be used in a patient with epilepsy as it reduces seizure threshold

Answer 75

INR > 1.3 Platelet count < 75 Pulmonary bullae Pleural adhesions Please note, all of the above represent only relative contraindications, addressing respiratory compromise in an emergency situation should always be on an individual case basis.

Answer 76

Failure of insertion - the drain may be abutting the apical pleura, in which case it should be pulled back, or may be subcutaneous or in rare cases could enter the abdominal cavity. In both latter cases, the drain should be removed and re-sited. Bleeding - around the site of the drain or into the pleural space Infection Penetration of the lung Re-expansion pulmonary oedema Re-expansion pulmonary oedema may be preceded by the onset of a cough and/or shortness of breath. In the event of concerns regarding re-expansion pulmonary oedema, the chest drain should be clamped and an urgent chest x-ray should be obtained. To avoid re-expansion pulmonary oedema, it is recommended that the drain tubing should be clamped regularly in the event of rapid fluid output i.e. drain output should not exceed 1L of fluid over a short period of time (less than 6 hours).

Answer 77

In cases of fluid drainage from the pleural cavity, the drain should be removed when there has been no output for > 24 hours and imaging shows resolution of the fluid collection. In cases of pneumothorax, the drain should be removed when it is no longer bubbling spontaneously or when the patient coughs and ideally when imaging shows resolution of the pneumothorax. Drains inserted in cases of penetrating chest injury should be reviewed by the specialist to confirm an appropriate time for removal.

Respiratory Flashcards

(101 cards)