Respiratory Core Conditions Flashcards by Amy Spicer

What are the different types of pneumothoraces?

Tension: Life threatening
Open: Defect in chest wall
Primary/Spont: No underlying pathology.
Secondary: Trauma/underlying lung disease (COPD)

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Who most commonly has a primary spontaneous pneumothorax?

Tall, thin young men due to ruptured pleural bleb

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What are the clinical features of a tension pneumothorax

Pleuritic chest pain
Breathlessness
Reduced breath sounds
Hyper-resonant percussion
Tracheal deviation

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What are the features of a tension pneumothorax on a CXR?

Tracheal deviation AWAY from the pneumothorax

Obvious lung collapse

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How is a tension pneumothorax life-threatening?

Continuing increase in volume
Due to formation of one way valve allowing air into pleural space on inspiration but not out on expiration
Causes rapid increase in intra-thoracic pressure
Reduces venous return & dec CO leading to cardiac arrest

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How is a pneumothorax investigated?

Tension should be diagnosed on clinical findings NOT CXR!!
CXR
CT if uncertainty

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How is a pneumothorax treated?

Small: <2cm resolves with conservative treatment, no strenuous exercise, reassess 2weekly until air reabsorbed
Primary: SOB & >2cm on CXR, attempt aspiration, can be repeated
Secondary: SOB & >2cm on CXR, chest pain

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How is a tension pneumothorax treated?

Large bore needle decompression 2nd intercostal space midclavicular
Chest drain: 5th intercostal space midaxillary
If at 48hours PT still remains or recurrence: Pleurectomy

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What are the RFs of a pneumothorax?

Smoking
Marfan's
Homocystinuria
FHx
Lung disease: COPD, acute s. asthma, TB, CF

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What are the different types of emboli?

Blood
Fat
Air
Amniotic fluid

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What is the pathophysiology of a PE?

Usually complication of VTE from another source (Calf, pelvis) that becomes dislodged and flows via the bloodstream through the R side of the heart and lodges in the pulmonary circulation

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What are the signs & symptoms of a PE?

Pyrexia
Cyanosis
Tachypnoea &amp; SOB RR >16
Tachycardia
HypoT
Raised JVP
Pleural rub
Pleural effusion
Previous DVT signs 
Pleuritic chest pain
Cough (+/- haemoptysis)

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How is a PE investigated?

PERC score
Well's score
D-Dimer: -ve can rule out but +ve not necessarily due to PE
CXR: Exclude other causes
ECG: Mostly normal, can be sinus tachy, sometimes T-wave inversion (lead 3)
CTPA
ABG: Metabolic acidosis
ECHO: R heart strain

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What does a PERC Score contain?

Rule out PE in low risk
All factors must be -ve for a -ve PERC score. +ve factor = work up (Well's Score)
Age >50
HR >100
O2 sats on room air <95%
Unilateral leg swelling
Haemoptysis
Rx surgery/trauma
Prev PE/DVT
Exogenous OE

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What does the Well’s Score contain?

Stratify pts as low or high risk
High risk = imaging
Low risk = D-dimer
Clinically suspect DVT
PE most likely diagnosis
Tachycardia >100
Immobilisation >3days OR surgery last 4weeks
Malignancy
Haemoptysis
Hx of DVT/PE in past

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How is a PE treated?

LMWH: Dalteparin &amp;
Warfarin 10mg 
Stop LMWH when INR >2 but continue Warfarin
Vena Cava filter
Thrombolysis: Alteplase

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What 3 factors make up Virchows triad?

Venostasis (Immobility, paralysis, AF, congestive HF)
Hypercoagulability (Malignancy, pregnancy, protein C&S deficiency, antithrombin deficiency)
Vessel wall inflammation (trauma, surgery, indwelling catheter)

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What is the pathophysiology of pulmonary oedema?

Fluid leaks from pulmonary capillaries into lung interstitium & alveoli
Filtration of fluid exceeds capacity of lymphatics to clear the fluid

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What are the 2 types of pulmonary oedema?

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Cardiogenic/hydrostatic: Elevated pulmonary capillary pressure from LVHF
Non-cardiogenic: Minimal elevation of pulmonary pressure caused by altered membrane permeability- ARDS

What are the causes of pulmonary oedema?

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Raised pressure: CHD, ACS, valvular, PE, tamponade, dissection
Renal: AKI, CKD, RA stenosis
Iatrogenic fluid overload
High output HF: anaemia, sepsis, thyrotoxic crisis
Acute/chronic URT obstruction
Inc pulmonary capillary permeability: ARDS, altitude, radiation, emboli

What are the signs & symptoms of pulmonary oedema?

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Severe SOB
PND/orthopnoea
Cyanosis
Congested neck veins
Raised JVP
Basal/widespread rales/fine crackles 
O2 sats <90% room air
Cardiogenic shock: HypoT, Low CO, Oliguria

How is pulmonary oedema investigated?

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Bloods: LFTs, clotting, U&Es, Cardiac enzymes, brain natriuretic peptides
ABG
CXR

How is pulmonary oedema managed?

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O2
Nitrates/ GTN infusion
Furosemide 20-40mg IV
Opiates: Diamorphine 2.5-5g IV
CPAP, ET tubing
Ultrafiltration

Arrhythmia related: DC cardioversion
Acute HF: Furosemide, High-flow O2, VTE prophylaxis, opiates, inotropes, vasodilators

What components make up croup?

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Harsh barking cough
Hoarse voice
Acute inspiratory stridor

What is the cause of croup?

``` PARAINFLUENZA Adenovirus RSV Measles Coxsackie Rhinovirus Echovirus Reovirus Influenza A&B ```

How is croup investigated?

Clinical diagnosis | ABG & CXR helpful in assessing severity

How is croup managed?

O2 if sats <92% on room air Corticosteroids: Oral Dexamethasone Severe/life-threatening: Nebulised Adrenaline 1:1000

What are the clinical features of croup?

``` Seal-like barking cough Worse at night Hoarse voice Inspiratory stridor Severe: Tracheal tug, struggling to breathe, drinking <50% than normal, dry nappies ```

Which cells are implicated in airway inflammation?

``` Eosinophils Mast cells Leukotrienes Prostaglandins T-Lymphocytes Macrophages Adhesion molecules ```

How can an asthma attack cause a cardiac arrest?

- Mucous plugging causing asphyxia COMMONEST - Prolonged hypoxia = arrhythmia = cardiac arrest - BronchoC inc airway pressures leading to breath stacking causing inc intrathoracic pressure = pneumothorax or dec venous return = circulatory collapse

What clinical features make asthma more likely in adults?

- >1: Wheeze, cough, tightness, difficulty breathing - Worse at night/early morning - Triggered by Aspirin/Beta-blockers - Occur in absence of a cold - FHx including atopy - Widespread wheeze on auscultation - Unexplained low FEV1/PEFR - Unexplained peripheral blood eosinophilia

How is asthma investigated?

Clinical Spirometry: FEV1/FVC <0.7 Reversibility trial: 400ml improvement in FEV1

How is acute asthma treated?

Oxygen: Sats <94% Salbutamol: 2.5-5mg Nebs back to back, takes 15-30mins for effect Hydrocortisone/Pred: 100mg IV when PEFR <50% of best Ipratropium: 500mcg Nebs, max 4hourly Theophylline/ aminophylline infusion: 1g/1L saline usually in ICU (daily U&Es, cardiac monitor) Magnesium Sulphate: 2g in 100mls saline IV/20mins one off dose Escalate Care

What are the side effects of: Salbutamol Ipratropium

S: Tremor, Tachycardia I: Dry mouth & eyes, blurred vision, tachycardia, flushing, confusion, urinary retention

What monitoring should be done for a patient having an asthma attack in A&E?

``` OBS PEFT: 15-30mins after Tx Stable: Reassess 1-2hourly O2 sats: Goal 94-98% Bloods: U&E (for K+) ABG: <1hour of Tx ```

When can a patient having an asthma attack be discharged? Not discharged?

Yes: PEFR >75% 1hour post-Tx NO: Pregnant, Night presentation, Prev ICU admission, lives alone, learning disability, psych, exacerbation despite steroid tablets

How is the severity of an asthma attack established?

Mild/Mod: PEFR 50-75% Severe: PEFR 33-50% RR >25, HR>110 Life-threatening: PEFR <33%, SpO2 <92%

How is an exacerbation of COPD treated?

``` Oxygen Salbutamol 2.5-5mg news Hydrocortisone 100mg IV Prednisolone 30mg 7-14days Ipratropium 500mcg news Theophylline 1g/1L saline Abx: Doxycycline 100mg Chest physic Consider within 60mins of admission with persistent acidosis if Tx is unsuccessful (BiPAP) ```

How is an exacerbation of COPD investigated?

ABG 15mins after oxygen administered CXR: Underlying pathology Bloods: U&E, FBC, WCC

How are asthma & COPD differentiated by different factors

(ex)Smoker: COPD nearly all, asthma possible <35: COPD rare, Asthma often Chronic productive cough: COPD common, asthma uncommon SOB: COPD persistent & progressive, asthma variable Night waking w/SOB: COPD uncommon, asthma common Diurnal variation: COPD uncommon, asthma common

What is Cor Pulmonale?

Right sided HF Result of pulmonary hypertension Signs: Cyanosis, fluid retention, severe SOB, may have a diastolic murmur

How is HAP defined?

Pneumonia developing 48hours after admission | Usually gram -ve bacilli, Staph Aureus

What are the most common causes of CAP?

Strep Pneumoniae H.Influenzae Anaerobes (rare)

How is CAP diagnosed?

``` CXR Bloods: FBC, WCC, ESR, CRP Pleural fluid aspiration CURB 65: Confusion <8 Urea >7 RR >30 BP <90s/ <60d >65 >3= severe >2=Hospitalisation ```

How is pneumonia treated?

Rest Fluids Abx: Amoxicillin/Clarithromycin 500mg PO TDS 1week Severe: Co-Amoxiclav 1.2g & Clarithromycin 500mg 7-10days

Respiratory Core Conditions Flashcards

(45 cards)