Respiratory conditions Flashcards
Primary vs Secondary vs Tension pneumothorax
primary- occurs in pt w/o a known resp disease
secondary- occurs in pt w/ pre existing resp disease
tension- severe pneumothorax involving displacement of mediastinal structures and haemodynamic compromise
primary pneumothorax risk factors
smoking
tall and thin
male
young
secondary pneumothorax risk factors
pre existing lung disease eg COPD, lung cancer, CF, pneumonia, connective tissue disorders - Marfan’s, trauma, iatrogenic (subclavian central line insertion)
pneumothroax presentation
Sudden
Dyspnoea
Pleuritic chest pain - ipsilateral
cough
tachypnoea
tachycardia
pneumothorax signs
hyperresonance on percussion
reduced breath sounds
reduced lung expansion
reduced vocal resonance
tension pneumothorax additional findings
tracheal deviation away from it
cyanosis
raised JVP
Management of primary pneumothorax
if rim of air is small (<2cm) and pt isn’t short of breath, then consider discharge and review
If rim of air is >2cm or pt is SoB, attempt aspiration in the 2nd ICS in the MCL. If this fails insert a chest drain in triangle of safety- 5th ICS, mid axillary line, anterior axillary line. Needle’s inserted just above the rib to avoid the NV bundle.
Management of secondary pneumothorax
If pt is >50, and rim of air is >2cm and or pt is SoB, then a chest drain should be inserted.
Attempt aspiration if rim of air is bwt 1-2cm. If aspiration fails, a chest drain should be inserted.
If pneumothorax is less than 1cm, give oxygen and admit for 24 hrs.
Management of Tension pneumothorax
emergency decompression- insert large bore cannula into 2nd ICS along the midclavicular line (same spot as usual aspiration)
chest drain insertion immediately after emergency decompression.
PE symptoms
Sharp chest pain (typically peluritic)
Dyspnoea
Haemoptysis
Sudden onset
if v large- dizziness/syncope
PE investigations
If suspect PE, do 2 levels PE Wells Score:
Clinical signs and symptoms of DVT (leg swelling + pain w/ palpation of deep veins)- 3 points
alternative diagnosis is less liekly than PE - 3 points
heart rate > 100bpm - 1.5 points
immobilisation for over 3 days or surgery in last 4 weeks - 1.5 points
previous DVT/PE- 1.5 points
Haemoptysis - 1 point
Malignancy - 1point
PE likely = more than 4 points
If PE is likely what do you do
CTPA immediately- give DOAC in meantime. IV contaast reveals thrombi
If PE is unlikely what do you do
D dimer test- if positive arrange immediate CTPA, if negative consider alternative diagnosis
Contraindications for CTPA- ie to do V/Q scan
renal impairment, contrast allergy, pregnancy
ECG changes in PE
S1Q3T3- large S waves in lead 1, large Q wave in lead III and an inverted T wave in lead III
ABG findings in PE
Low PaO2 and normal/low PaCO2 a massive PE may also cause metabolic acidosis
PE management
DOAC first line- apixaban or rivaroxaban
If not sutiable then LMWH follwoed by dabigatran or edoxaban or LMWH followed by VKA ie warfarin
If renal impairment is severe then LMWH, unfractionated heparin or LMWH followed by a VKA.
If pt has antiphospholipid syndrome (specifically triple positive in the guidance) then LMWH followed by a VKA should be used.
If VTE was provoked- stop treatment after 3 months.
If VTE was unrpvoked then continue for up to 3 further months
ORBIT Score to assess risk of bleeding
PE w/ haemodynamic instability- Thrombolysis.
Asthma symptoms
Wheeze (bilateral expiratory widespread)
Cough
Breathlessness
Dry cough often nocturnal
Symptoms often worse at night bcos less cortisol (which is immunosuppressive) at night
Asthma signs on examination
Tachypnoea
Hyperinflated chest
Hyperresonance on percussion
decrease air entry (sign of severe illness: silent chest)
wheeze on auscultation
Asthma diagnosis in patients 5-16 year old
Spirometry w/ bronchodilator reversibility test: FEV1:FVC <70% is obstructive. Asthma if there’s obstruction and >12% improvement in FEV1 w/ bronchodilator. Request fractional exhaled nitric oxide if there’s normal spirometry or obstructive spirometry w/ a negative bronchodilator reversibility test. FeNO >= 35 ppb is considered positive in children.
Asthma diagnosis in over 17s
Ask if symptoms better away from work/holidays- refer for occupational asthma specialist if so.
All pts should have spirometry w/ bronchodilator reversibility test. Asthma if obstruction and >12% improvement in FEV1 and increase in volume of 200ml or more. All pts should have FeNO test- >40 ppb is positive in adults
Asthma management
- SABA
- SABA and low dose ICS
- SABA + low dose ICS + LTRA
- SABA + low dose ICS + LABA (+LTRA)
- SABA + MART (combined ICS and LABA) (+LTRA)
- SABA + medium MART (+LTRA)
- SABA + high MART OR LAMA OR theophyline (+LTRA)
Acute Asthma presentation
Worsening dyspnoea
Bilateral wheeze
Cough not responding to salbutamol
Possilbe chest tightness
maybe triggered by a resp tract infection
Use of accessory muscles
moderate acute asthma features
PEFR 50-75% best or predicted
normal speech
RR <25/min
Pulse <110bpm
Severe asthma features
one of these:
PEFR: 33-50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110bpm
Life threatening asthma features
any of these:
PEFR <33% best or predicted
Oxygen sats <92%
normal pCO2 indicates exhaustion and should be classed as life threatening
Mnemonic CHEST:
C- cyanosis
H- hypotension
E- exhaustion, confusion or coma
S- silent chest (airways so tight there’s no air entry)
T- tachycardia (pulse >110)
Acute Asthma management
O SHIT ME:
Oxygen- maintain sats 94-98%
S- Salbutamol
H- Hydrocortisone 100 mg IV or prednisolone 40mg daily which should be continued daily for at least 5 days from the attack
I- ipratropium bromide- SAMA
T- Theophylline. aminophylline infusion if deteriorating
M- Magnesium sulphate IV if severe/life threatening
E- escalate to ICU if severe/life threatening
