Respiratory emergencies

Question 1

What 4 pieces of advice would you give to a patient following management of spontaneous pneumothoraces?

Answer 1

1. Return to hospital if you become more breathless and call an ambulance if you develop sudden severe difficulty in breathing.
2. Avoid air travel until advised to do so by a chest physician, and full resolution of pneumothorax confirmed on radiological tests approx 6-8 weeks after.
3. Avoid SCUBA diving at all, unless bilateral plreurodectomy performed
4. Stop smoking, including cannabis.

Question 2

Can you list the 4 features of acute severe asthma according to the BTS asthma guidelines?

Answer 2

1. PEFR 33-50% best
2. RR>25
3. HR > 110
4. inability to complete sentences in 1 breath

Question 3

Can you list the 11 features of Life threatening asthma?

Answer 3

1. PEFR < 33% best
2. SPO2 < 92%
3. Pa02 < 8kpa
4. PaC02 normal
5. Poorly ( poor respiratory effort )
6. blue ( cyanosis )
7. silently ( silent chest )
8. exhausted
9. & confused ( altered mental state )
10. hypotension
11. arrythmia

You know an asthmatic patient’s life is at threat when they are :

“POORLY BLUE,SILENTLY EXHASUTED & CONFUSED”

Question 4

Name 5 indications for performing a CXR as part of the management of acute asthma.

Answer 4

1. suspected pneumothorax/pneumomediastinum
2. suspected consolidation
3. failure to respond to treatment adequately
4. Life threatening asthma
5. requiring ventilation

Question 5

What are the indications to refer a patient with asthma to ITU ?

Answer 5

REFER ANY PATIENT THAT:

A. REQUIRING VENTILATORY SUPPORT

B. WITH ACUTE SEVERE/LIFE THREATENING ASTHMA THAT HAS FAILURE TO RESPOND TO THERAPY AS EVIDENCED BY:

1. deteriorating PEFR
2. worsening hypoxia
3. hypercapnoea
4. exhaustion
5. confusion
6. respiratory arrest

Question 6

What is the BTS criteria for commencing NIV in patients with COPD?

Answer 6

copd exacerbation with the following persiting features (pH <7.35 and PaCO2 >6.5kpa and RR > 23) after bronchodilator and controlled oxygen therapy

Question 7

list 3 absolute contra-indications to NIV in COPD and 3 relative contra-indications

Answer 7

ABSOLUT:

• fixed upper airway onstruction
• facial burns
• severe facial deformity

RELATIVE:

• cognitive impairment
• confusion
• GCS<8
• PH < 7. 15

No INDICATION:

• pneumonia
• asthma

Question 8

What is the definition of hospital acquired pneumonia?

Answer 8

1. pneumonia that develops 48 hrs after hospital admission that was not incubating at the time of admission.
2. Or in readmitted patients up to 5 days post discharge

Question 9

what are the pathogens involved in hospital acquired pneumonia and what common antibiotic would you prescribe?

Answer 9

organisms: pseudomonas, MRSA, klebsiella

antibiotic options: 1.2 co-amoxiclav or 4.5g Tazocin & gentamycin 5mg/kg

Question 10

Which patients would you apply the PERC criteria to?

Answer 10

In a patient who is “low risk “according wells scoring. any patient that is moderate to high risk would not be suitable to have PERC rule applied.

Question 11

what is the pathophysiology of hereditary angioedema?

Answer 11

autosomal dominant disorder in which there is an abnormality of C1 esterase inhibitor.

Question 12

What 2 treatment options would you consider in a patient that presents with an acute attack of hereditary angioedema?

Answer 12

1. C1 esterase inhibitor replacement protein

2. FFP’s

Question 13

A patient with COPD has been on NIV for a few hours but you note 1 or more of the following:

PH< 7.25 on optimal NIV
RR > 25 persisiting
new onset confusion or patient distress.

What action would you take in the ED to improve these factors?

Answer 13

according to BTS_ICS guideline on page 9:

Check the following:

• synchronisation
• mask fit
• exhalation port

and try the following:

• bronchodilator
• anxiolytics
• physiotherapy

Question 14

what are the ECG features of pulmonary embolism?

Answer 14

ECG features of PE:

• sinus tachycardia
• atrial fibrillation
• RBBB
• right axis deviation
• S1Q3T3

Question 15

A 30 year old man works as a whirl pool & jacuzzi installer. he has a few and dry cough for a few days. today he is very breathless and has pleuritic chest pain and diahroea episodes.

1. what is the most likely diagnosis?
2. what is the causative organism
3. how would you treat him?

Answer 15

1. diagnosis:
   legionnaires disease
2. likely organism:
   Legionella pneumophillia - a gram negative bacterium
3. which antibiotics to treat:

macrolde - clarithromycin OR
quinolone- ciprofloxacin OR
tetracycline - doxycycline

Question 16

A 62 year old man has worsening shortness of breath, haemoptysis, arm and hand swelling and facial swelling and numerous diilated teleangiectasia on his chest wall. he is a smoker.

1. what is your diagnosis?
2. outline 4 important management points in the ED

Answer 16

1. superior vena cava syndrome
2. management steps in ED:

• elevate the head of the bed
• administer high-flow oxygen
• give high-dose steroids
• organise urgent CT scan of chest
• urgent referal to on call medical team

Question 17

WHat are the clinical features of superior vena cava syndrome/obstruction?

Answer 17

clinical features of SVCO:

• chest pain, breathlessness, cough
• face, neck , arm swelling
• facial flushing
• cyanosis
• neck, arm & chest wall dilated veins and teleangiectasia
• stridor ( due to laryngeal oedema
  *

Question 18

Can you name the parametres that comrpise the PERC rule?

Answer 18

1. <50 years of age,
2. with a pulse <100 bpm,
3. SaO2 ≥95%,
4. no hemoptysis,
5. no estrogen/hormone use,
6. no history of surgery/trauma within 4 weeks,
7. no prior PE/DVT and no present signs of DVT
8. no unilateral leg swelling

Only use in a patient that is deemed low risk. and if all the above criteria are met then the patient does not warrant any further testing.

In the setting of a low-risk patient who is not PERC negative, the physician should consider a d-dimer for further evaluation.

Question 19

a 35 year old works at a zoo in the aviary. she has fever, cough, shortness of breath, and headache. on examination she has reddish macular rash on face, marked bilateral lower lobe crackles and splenomegaly.

1. what is the diagnosis?
2. what is the rash on face?
3. what treatment would you give?

Answer 19

1. Psitacosis- a zoonotic infection caused by Chlamydia psittaci. most commonly occuring in domestic bird owners. . splenomegaly in 2/3 of patients.
2. Horder’s spots
3. treat with tetracycline= doxycline 100mg bd for 14 days

Question 20

A farmer presentes with flu like sympotms, high fevers, headaches and myalgia.now developed a dry cough, diahroea and abdominal pain. no chest signs ut enlarged liver on examination.

1. what is the likely diagnosis?
2. what would you expect to find on blood tests?

Answer 20

1. Q-fever caused by coxiella burnetti - a highly infectious zoonotic infection causing an atypical pneumonia.
2. raised wcc
   * raised ALP, ALT/AST
   * relative thrombocytosis

Question 21

a 35 year old with cough , several episodes of haemoptysis and dark urine. no previous history other than smoking.

1. what is the likely diagnosis?

Answer 21

diagnosis: goodpasteurs syndrome

confirm on renal biopsy - anti-GBM antibodies

Question 22

What are the indications to admit a patient with COPD exacerbation?

Answer 22

INDICATIONS TO ADMIT copd EXACERBATION@

Rapid onset of symptoms, Cyanosis, confusion, worsening peripheral oedema

Already on LTOT

Unable to cope at home

Reduction in daily activities

Significant co-morbidities,IHD and IDDM

Oxygen saturations < 90%, ph <7.35, po2<7kpa

Question 23

What is the mechanism of action of salbutamol and ipratropium bromide?

Answer 23

Bronchodilators-

Beta 2 agonists- act on b2 receptors causing smooth muscle relaxation and dilation of airways.

Ipratropium bromide is a muscarinic receptorantagonist.

Question 24

Explain the physiology of Heart failure secondary to COPD ?

Answer 24

COPD leads to pulmonary arterial hypertension. This is associated with right ventricular hypertrophy and cardiac failure. Also called Cor pulmonale.

Question 25

Describe the physiological changes from NIV that inmproves lung function?

Answer 25

NIPPV provides PEEP and ventilator support ·Recruit collapsed alveoli- this maintains gas exchange and intraalveolar forces against pulmonary oedema. ·Increased Tidal volume and functional residual capacity ·Improved lung compliance. The physiological effects causes decreased respiratory effort and improves oxygenation.

Question 26

In a patient with COPD that you are starting NIV, what IPAP and EPAP settings would you commence?

Answer 26

NIV settings: IPAP - 10-12cm H20 titrate upwards according to patient response. EPAP -4- 5 cm H20 titrate upwards according to patient response.

Question 27

What are the 2 treatments options when a patient is haemodynamically unstable with an acute pulmonary embolism?

Answer 27

For people who are haemodynamically unstable thrombolytic therapy or embolectomy may be offered Massive PE with circulatory collapse- Thrombolysis-If cardiac arrest is imminent- 50mg Bolus of Alteplase. Alteplase 10mg iv over 2 minutes, then infuse 90mg over 2 hours.

Question 28

what are the cxr features of pulmonary embolism?

Answer 28

Chest X-ray features - atelectasis, pleural effusion, or elevated hemidiaphragm.

Question 29

What are the echo findings of PE?

Answer 29

ECHO FINDINGS OF PE: 1. right ventricular wall hypokinesis 2. right ventricular dilatation 3. RV larger than LV in apical view 4. Mconnells sign 5. thrombus seen in the right heart

Question 30

Does supplemental high flow oxygen have a role in pneumothorax management ?

Answer 30

YES! Oxygen relieves hypoxia and use of high flow Oxygen has shown to result in a 4 fold increase in rate of pneumothorax resorption. Reference: http://bestpractice.bmj.com/best-practice/monograph/504/treatment.html

Question 31

Can you name 4 clinical situations where tension pneumothora may arise?

Answer 31

Tension pneumothorax commonly occurs in: 1. Ventilated patient 2. Trauma patient 3. After placement of central line. 4. CPR - resuscitation patient 5. Lung disease - acute asthma/COPD 6. Blocked/ displaced chest drain 7. patient on NIV

Question 32

according to BTS guidelines when would you insert a chest drain rather than aspiration of pneumothorax?

Answer 32

Place a chest drain if: 1. Bilateral pneumothoraces 2. Haemodynamically unstable pneumothorax 3. Secondary pneumothorax and patient is breathless or size> 2cm

Question 33

Give 2 Respiratory complications of Community acquired pneumonia.?

Answer 33

Complications of community-acquired pneumonia include: 1. Pleural effusion and empyema. 2. Lung abscess. 3. Septicaemia and metastatic infection such as meningitis, septic arthritis, endocarditis, and peritonitis.

Question 34

Name the antibiotics and dose used in a patient with severe pneumonia requiring hospitalisation.

Answer 34

An intravenous combination of: broad spectrum B-lactamase co-amoxiclav 1.2g iv and macrolide Clarithromycin 500mg iv.

Question 35

What is the differential diagnosis of a patient with unilateral upper limb swelling?

Answer 35

1. Necrotising Fascitis 2. Cellulitis 3. Superficial Thrombophlebitis 4. Muscle tear 5. Lymphoedema 6. Lymphangitis 7. Muscle haemorraghe

Question 36

What are the risk factors for an upper limb DVT?

Answer 36

RISK FACTORS FOR UPPER LIMB DVT: 1. Recent Central line placements- PICC 29%, IJV 29%, subclavian 12% , Hickman, tessio -30% 2. Thrombophilia 3. Infection 4. Active cancer/ Malignancy 5. Oral contraceptive pill 6. Pregnancy 7. Arm surgery or trauma 8. Immobilisation of arm POP/ Splints 9. Cardiac procedure- pacemaker wires 10. Recent trauma or fracture 11. Primary causes are rare - Thoracic outlet syndrome - Anatomical abnormality Compression of neurovascular bundle- brachial plexus, subclavian artery and vein as it exists thoracic inlet.

Question 37

What are the complications of an upper limb DVT?

Answer 37

1. Pulmonary Embolism 7-20% 2. Recurrent thrombosis 3. Post Thrombotic syndrome - valvular incompetence, discomfort or swelling. 4. Superior Venacaval syndrome 5. Compartment syndrome 6. Right ventricular failure 7. Phlegmasia caerulea dolens - arterial and venous compromise 8. Thoracic duct obstruction 9. Chylous pleural or pericardial effusion

Question 38

What are the CXR features of severe COPD?

Answer 38

·Hyperinflation: ·Flattened hemi-diaphragms: most reliable sign ·Irregular and increased radiolucency of lungs. ·Widely spaced ribs. ·Small heart.

Question 39

What are the complications of a pancoast tumour?

Answer 39

1. Horner’s syndrome 2. Recurrent laryngeal nerve palsy 3. Superior venacava syndrome 4. Reflex sympathetic dystrophy 5. Brachial plexus invasion.

Question 40

What are the main causes of cardiac arrest in Asthma?

Answer 40

1. Asphyxia due to severe bronchospasm and mucous plugging 2. cardiac arrythmias due to * hypoxia * electrolyte abnormalitis * stimulant drugs ( aminophylline and B - adrenergic ) 3. dynamic hyperinflation in mechanically ventilated patients causes gradual build up of pressure and reduces venous return and blood pressure