Respiratory Flashcards

Question

Management / treatment of patients with acute exacerbation asthma ? hospital admittance

Answer 1

ADMIT ALL WITH LIFE THREATENING ASTHMA TO HOSPITAL . IF HYPOXIC - Give supplementary oxygen using face mask . (maintain oxygen sat at 94-98%) IF ADMITTED TO HOSPITAL life threatening 1ST LINE ``` 0 Nebulized salbutamol (SABA) 5mg - over 5 years 2.5mg - 2-5 years ( * oxygen driven nebuliser - 1st (air driven nebuliser - 2nd - risk of oxygen desaturation - be careful )) ``` Pressurised metered dose inhaler with large volume spacer SALBUTAMOL. ( used if nebulised salbutamol not possible or moderate severity) 2ND LINE SALBUTAMOL + NEBULIZED IPRATROPIUM BROMIDE (SAMA) * Consider quadrupling dose of ICS : prednislone (consider IM methypred or IV hydrocortisone if not able to swallow)

Answer 2

SABA (salbutamol) via large volume spacer. * Consider quadrupling dose of ICS - before doing this consider adherence (pl who are highly adherent may experience the ceiling effect & gain no additional benefit from increasing ICS. ceiling effect - drug reaches it's maximum effect. after symptoms subsided return to original dose. & monitor symptoms & PEFR. Follow up patient with 48 hrs. - Review symptoms, Lifestyle advise (pollutants avoidance etc. ), make sure patient has received self - management education and a personalised asthma action plan.

Answer 3

Normal : 94 -98% COPD / Risk of hypercapnia respiratory failure/ risk of c02 retention (morbid obesity , cystic fibrosis , chest wall deformities or spinal disease ( kyphosis-sclerosis), neuromuscular disorders , bronchchietasis): 88 - 92% reason - both C02 / 02 Can bind haemoglobin (so competing with each other - if there is a lot of 02 less C02 will bind to haemoglobin Haldene effect - 02 affecting decreases the affinity of Hb for C02/ H+----------> less C02 binds -------->reduces body capacity to remove C02 from tissues. etc. * Note - Bohr effect - C02 / h + (causes low PH) affecting the affintiny of Hb for 02. = reduces hb affinity for 02 * also in COPD as well as targets sat - keep Pa02 levels < 10Kpa

Answer 4

critically ill Commence 15l/min oxygen via reservoir mask(non -rebreathe or bag valve mask ) oxygen sat target is 88% - 92 % on alert card change to : 24 % or 28 % oxygen or 1-2l/min nasal oxygen (nasal cannula) + obtain aterial blood gas results * if target sat on alert card is 88 -92% but Pc02 = 6.0 kpa (this is the normal ) - change target to 94 -98% 1. if in respiratory acidosis - seek senior review & consider NIV or IV ---------------------------------------------------------> TREAT WITH 24 - 28 % Venturi mask to maintain target o2 sat. 2. if hypercapnia ( i.e. no low PH) --------------------------------> Treat with 24 -28 % Venturi or 1 -2 l/min nasal o2. -------------------------------> repeat blood gas at 30 -60 mins -----------------------> (if gone into respiratory acidosis - senior review , consider NIV or IV . ) / Consider reducing P02 if . 8.0Kpa

Answer 5

Venturi mask 0 Delivers 24-60% oxygen 0 Different colours deliver different rates Flow rate: Varies with colour. The correct flow rate to use with each colour it is shown on mask, along with the percentage of oxygen delivered. Types: - BLUE = 2-4L/min = 24% O2 - WHITE = 4-6L/min = 28% O2 - YELLOW = 8-10L/min = 35% O2 - RED = 10-12L/min = 40% O2 - GREEN = 12-15L/min = 60% O2 Venturi masks are often used in COPD, where it is important not to over-oxygenate the patient.

Answer 6

Initially give nasal cannula 2-6 l / min ( best ) or simple face mask (5 - 10l / min ) - target sat 94 -98 % once (If this not reach change to reservoir - 15l/min) if oxygen sat below 85 % and no risk of C02 retention : ``` Reservior mask (15l/min) (if oximetry not available give this oxygen and wait for arterial blood gas) can change back to nasal can or simple face mask once stabilised. ```

Answer 7

Nasal cannula or simple face mask (if nasal not tolerate / not possible )

Answer 8

All age groups normally desaturate to 90.4 % during the night.

Answer 9

Air gets inside & accumulates in the pleural space ( btw visceral & parietal pleura ) TENSION PNEUMOTHORAX - MEDICAL EMERGENCY ------> Pneumothorax leads to shift of medistinal structures. CLASSIFICATIONS /TYPES SPONTANEOUS - no trauma or preceeding event (this divided into primary & secondary) - Primary - no known respiratoty illness brought it on. - Secondary - occurs in patients with pre-existing pulmonary illnesses e.g . COPD , asthma , catamenial pnuemothorax etc. * In practice a patient with only mild respiratory illness e.g. intermittent asthma with no exacerbation of symptoms. at presentation may be treated as a primary sponatenous pneumothorax. NON SPONTANEOUS - caused by trauma or accentidenal (iatrogenic) : 0 Traumatic pneumo - caused penetrating or blunt injury to chest 0 Iatrogenic pneumo - medical prodcedures e.g. aspiration , thoracentesis , Central venous catheter placement , barotrauma ] * Barotrauma - means damage to body because of changes in barometric pressure * Barotauma ( to do with lungs ) - due to mechanical ventilation ( causes build up of transaveloar pressure causing rupture of air sacks-------> air leaks into surroudning extra alveolar space. ) OTHER TYPES Pneumothorax ex vaco , Catameinal pneuo SIGNS/ SYMPTOMS - Chest pain (typically pleuritic ) * Primary spontaneous pneumothorax (PSP) may experience shoulder tip pain instead. ) - Dyspnoea (more prominent in SSP) e.g. secondary SP - Ipsilateral reduced breath sounds (may indicate tension Pneumothorx but can happen with non - tension) - Ipisilateral hyperinflation of hemitorax (one side of lungs ) with hyper-resonance on percussion !!!! (NOT PRESENT IN PNEUMOTHORAX EX VACUO - TRAPPED LUNG) - hypoxia - generally late sign (more common in tension & SSP) If there is cardiopulonary deterioration indicates tension pneumo : ``` 0 Hypotension (suggest imminent cardiac arrest) 0 Tachycardia 0 Respiratory distress 0 Low oxygen sats 0 Shock 0 Loss of conciousness ``` other signs of tension pnuemo (tracheal deviation - shifted to contralateral side. ) , Sweating RISK FACTORS 0 Smoking - most common (important) - risk 22x for men , 9 x - women ``` 0 Fx of Pneumothorax 0 Tall slender body build 0 Structural abdnomalities - marfans syndrome - Ehlers - Danlos syndrome ) ``` 0 Male 0 Young age (though SSP more common > 55 yrs) ``` 0 Presence of underlying lung disease - COPD - Severe asthma - TB - Pneumocystis - Cystic Fibrosis - bronchiectasis - fibrotic lung disease (especially acute presentation e.g bullous COPD , asthma ) ``` ``` 0 lung disease 0 recent invasive procedures 0 trauma 0 Ventilated patients , NIV( barotrauma) 0 Hyperbaric oxygen treatment ``` 0 * Mensturation ( risk of catamenial pneumothorax) suspect if history of recurrent pneumothorax , endometrosis )

Answer 10

Pneumothorax ex vaco (Complication of lung collaspe)- precipated by lobar collaspe / aceletasis --------------------> elevated negative pressure in intrapleural spce the pleural cavity (btw visceral & parietal ) *( COLLASPE CAN BE CAUSED BRONCHIAL OBSTRUCTION FROM MUCOUS PLUGS , ASPIRATED FOREIGN BODIES OR MALPOSITIONED ENDOTRACHEAL TUBES) - important for treatment as pneumothorax can be relieved by relieveing obstruction rather than chest drain etc. ``` Negative pressure (in this case ) - means air pressure in pleural cavity is lower than that around it . ( * air flows from high pressure to low pressure (into pleural cavity , so accumulation of air -----> puemothorax ) ``` CATAMENIAL PNEUMOTHORAX -VERY RARE Affects women Have recurrent episodes of pneumothorax 72 hours before & after menstration . - CAUSE UNKNOWN however possible causes : 0 Endometrosis - endometrial tissue migrates from areas over than the uterus to diaprgam & pleural space (lungs )for example---------------------------> enometrosis can cause small holes in diapragm allowing air into & fluid to pass into pleural space. ( Thoracic endometrosis - endometrial tissue in the lungs ) Hormonal cause - Ovulation has elevated levels of prostogaldin F2 --------------------> causes constriction of bronchicles ---------------------> rapture of alveoli ----------------------------------> air leaks into pleural space. Anatomical cause - absence of normal mucous plug in menstration allows air to move from Genital tract through fenestrations in the diapragm. - MAJORITY OF CASES RIGHT LUNG AFFECTED. Treatment ( thoracic surgery statergies + hormonal manipulation ex - plaicng patches over fenestrations in diaphragm - electrocoagulation of endrometrosis depsoits & pleurodosis - Gonadotropin relasing hormone analagoues ( risk of amennhroea but less risk of reocurrance )

Answer 11

0 CXR - main one ( Tension p - not really imaged bcc emergency and treatment urgently) Order a Posterior - anterior CXR (an (AP) - anterior posterior not really used to assess things like cardiomegaly etc - bcc natural enlargement of mediastinal structures from the front) findings : - absent lung markings btw lung margin & chest wall - visible rim btw lungs & chest wall - surgical / subcatenous emphysema ( air in subcanteous soft tissue (tissue just under skin ) - felt as swelling in affected area & crepitus) Blood test - 0FBC 0 Clotting screen need to check INR > /=1.5 or platelets = 50 x 10^9 before you can insert a chest drain. CONSIDER Chest ultrasound - becoming increasingly used - especially immbolised patients following trauma when erect PA cannot be obtained. 0 CT scan - if CXR uncertain & patient still symptomatic. 0 ABG - if o2 sats <92 %

Answer 12

> 2cm between lung margin & chest wall (LARGE ) <2cm - small

Answer 13

Immediate decompression (with large bore cannula ) - unless Tension pneumothorax secondary to trauma. PLUS - high flw O2 + chest drain + hospital admission. (PUT OUT IMMEDIATE CARDIAC ARREST CALL. ( & dont wait for imaging to confirm)

Answer 14

If Bilateral or patient haemodymacally unstable ---------------------> 1ST LINE - Chest drain First thing - need decide whether primary or secondary spontaneous P (secondary often tolerated less well ) If secondary : & : > 2cm or breathless --------------------------> small bore (8 -14 F) chest drain 1-2 cm --------------------------------> aspirate 2.5 L with 16g -18 g cannula -------------> 1. if successful (below 1cm ) -----------------> Admit , HFO , Observe 24 if not successful ( Chest drain) <1cm -----------------------> admit , high flow oxygen ( unless 02 sensitive ) & observe 24hrs (admit , HFO , observe 24 )

Answer 15

If Bilateral or patient haemodymacally unstable ---------------------> 1ST LINE - Chest drain First thing - need decide whether primary or secondary spontaneous P (secondary often tolerated less well ) If Primary & : - > 2cm or breathless aspiate 2.5 L with 16 -18 G cannula -----------------> if sucessful ( less than 2cm with improved breathing )-----------------------------> Consider discharge , review in OPD (OUTPATIENTS ) in 2-4 weeks (IF NOT >2CM or breathless --------> discharge, review in OPD in 2-4 w) if not successful ---------------> small bore (8 -14 F)Chest drain -

Answer 16

iatrogenic - must resolve spontaneously (so onservation) -----------------------------------> if not - simple aspiration (needle?) Traumatic - high flow oxygen + observation + refer to thoracic surgeon

Answer 17

depends on size of Pneumothorax. NA should not be repeated if there are technical diffuclties -----------------------------------> if failed use Small bore (<14F ) chest drain.

Answer 18

Progressive - Build up of scar tissue in the lungs making it difficult to breathe as oxygen transport in blood is impaired. (Common type of interstitial lung disease - affects lungs & intersitium (support network of tissue the alveoli ) Sub types Idiopathic PF - no known cause (most common ) SIGNS / SYMPTOMS 0 Dyspnoea on excretion (most common) 0 Crackles - end expiratory crackles basilar crackles (typcially dry & velcro quality ) 0 Cough - typically (non -productive ) - weight loss - fatigue - malasie - clubbing * also may be pulmonary hypertension ( as pulmonary arterioles constrict to shuttle blood away from damaged areas -----> if there is widespread damage then widespread vasoconstriction ----------------> pulmonary hypertension--------------> right ventricular hypertrophy ( Cor pulmonale)aru. RISK FACTORS - advanced age ( most above 60 yrs) - Male sex - Fx of interstitual lung disease or FPF (familial pulmonary fibrosis) - cigarette smoking - 60 x more likely . Less common - organic & inorganic dust exposure GORD ( pre - dispose patients due acid aspiration) - infection - Diabetes

Answer 19

CXR - Opacities 0 High resolution CT ( HRCT) - ordered in all suspected patients. ``` 0 Anti -nuclear antibodies 0 Rheumatoid factor 0 anti - CCP 0 myositis panel (if elevated these 2 may indicate collagen vascular disease - link to Connective tissue disease (auto immune - attacking collagen - can cause Interstitial lung disease)) ``` CONSIDER 0 PFTs - restrictive - reduced VC , TLC , 0 surgical lung biopsy - used in pl who history , HCT , clincial evaluation do not support clear diagnosis of PF. - should see fibrosis of varying ages etc. 0 bronchoalveolar lavage (BAL) 0 CRP 0 ESR

Answer 20

1ST LINE Antifibrotic therapy e.g. pirfenidone or ninetanib + smoking cessation + pulmonaey rehab + 02 ADJUNCT - PPI if GORD 2ND LINE - Lung transplantation ACUTE EXACERBATION 1ST LINE - admission to hospital + high dose corticosteriod. (sometimes a cytoxic agent is added. )

Respiratory Flashcards

(44 cards)