 wheeze/crackles, cyanosed/pursed- lip breathing, look for infection and pneumothorax Wh eeze crackles, look for signs of infection or pneumothorax CXR hyperexpanded, fl at diaphragms; exclude pneumonia and pneumothorax dPEFR; CXR; exclude pneumonia and pneumothorax Asthma iWCC/N \230/CRP, consolidation or blunted angles on CXR (b p582) dPaCO2 hypoxia on ABGs, iD-dimer, CXR often normal Cardiomegaly + fl uid overload on CXR (b p582), ECG may show isc haemia or previous MI Needle decompression of tension pneumothorax; CXR shows pleura separa ted from ribs Eff usion on CXR Pneumonia Productive cough, Febrile, asymmetrical air entry, crackles, bronchial breath sounds dpercussion iJVP, iHR (may be only sign); may have evidence of DVT; can be severely shocked iJVP, symmetrical fi ne crackles, pink frothy sputum, dependent oedema, cold peripheries green sputum, feels unwell pleuritic pain PE risk factors, leg pain, pleuritic chest pain and haemoptysis Known cardiac problems, orthopnoea, swollen legs Pulmonary embolism Pulmonary oedema Pneumo- thorax Sudden onset pleuritic chest pain trauma. Underlying lung disease and previous episodes o r tall, thin, male Gradual onset breathlessness, pleuritic chest pain Concurrent severe i llness Chest pain, palpitations, dizziness, tiredness Sudden onset, itching, swelling, urti carial rash, new drugs/food Unequal air entry and expansion, hyperresonant displaced trachea (late) Pleural eff usion Reduced expansion, stony dull base ARDS Hypoxic New bilateral infi ltrates on CXR Abnormal ECG (b p572), dHb, icardiac markers IM adrenalin e, IV steroids (b p470); acute and convalescent serum tryptase Anemia/ MI/ arrhythmias 3 Anaphylaxis Irregular or fast pulse, shocked, pale Stridor, wheeze, shock, swollen lips and eyes, blanching rash OHFP.indb 272 OHFP.indb 272 30/05/2014 16:18 30/05/2014 16:18 273 BREATHLESSNESS AND LOW SATS Asthma1 (OHAM3 b p178) Common, chronic infl ammatory airway disorder characterized by airwa y hypersensitivity resulting in episodic obstruction, wheeze and dyspnoea. Symptoms episodi c breathlessness, dyspnoea and wheeze, night or morning cough, excess sputum; triggers may include exercise, NSAIDs, B-blockers, allergens, cold; family or personal Hx of atopy (hayf ever, eczema, asthma). Signs wheeze, prolonged expiration, tachypnoea, hyperinfl ated chest . Investigations PEFR reduced in acute setting compared with best or pre- dicted based upon age/height,1 or diurnal variation on self-monitoring as out-patient; ABG normal or dPaO2 w ith a dPaCO2 due to hyperventilation 3beware normal/rising CO2 ?Pt tiring; CXR hyperexpande d, exclude pneumonia and pneumothorax; spirometry dFEV1, dFEV1:FVC ratio. Acute exacerbatio n sit up and give 15l/min O2. Salbutamol 5mg NEB ipratropium 500micrograms NEB and predni solone 40mg PO (or hydrocortisone 200mg IV). Drive the nebuliser mask from O2 supply, not a ir. Repeat salbutamol 2.5mg nebs every 10 \200\22315min and reassess PEFR and sats frequent ly. Antibiotics if evidence of infection. 3Severe 3Life- threatening Incomplete sentences, PEFR <50% of best, HR >110, RR >25 PEFR <33% of best, silent chest, s ats <92%, PaO2 <8kPa, normal PaCO2, poor respiratory eff ort, exhaustion, cyanosis, altered GCS, arrhythmia CO2 retention \200\223 call ICU 3Near-fatal Beware those with previous ICU admissions \200 No improvement Call for senior help. Consi der: ICU input/assessment \200 Aminophylline 5mg/kg IV bolus over 20min unless the patient is on oral aminophylline or theophylline \200 Mg2+ sulfate 2g (8mmol) IV over 20min Improving admit those in whom PEFR<75% predicted after 1h therapy; gradually reduce supplemental O2 and step from nebs back to inhalers over several days; always check inhaler technique and ensure follow-up plan in place before discharge. Chronic treatment (OHCM9 b p174) Stepwise management (see Table 8.2) aiming for minimum tre atment resulting in symptom control; monitor PEFR; always check inhaler technique before es calation; consider allergen testing; smoking cessation; oral steroids for exacerbations. Table 8.2 Simpli \201 ed stepwise management of asthma1 Oral steroids (cid:57) High-dose steroid inhaler Long-acting B-agonist Low-dose steroid inhaler (cid:57) (cid:57) (cid:57) (cid:57) (cid:57) (cid:57) (cid:57) (cid:57) Salbutamol/terbutaline (cid:57) (cid:57) Step 1 Step 2 Step 3* Step 4 Step 5 (cid:57) (cid:57) (cid:57) (cid:57) Either low-dose steroid inhaler and long-acting B-agonist or high-dose steroid inhaler. 1 B TS Asthma guidelines available at (cid:27)www.brit-thoracic.org.uk/guidelines/asthma-guidel ines. aspx These include tables to predict PEFR where not known. _OHFP.indb 273 _OHFP.indb 273 30/05/2014 16:18 30/05/2014 16:18 274 CHAPTER 8 Respiratory COPD1 (OHAM3 b p186) Relatively fi xed airfl ow obstruction due to loss of elastic recoil i n alveoli (emphysema) and narrowing of airways with excess secretions (bronchitis) Worrying signs dGCS, rising CO2. Symptoms breathlessness, cough, isputum, tight chest, confusion, d exercise tolerance. NB dindex of suspicion in (ex-)smoker. Signs wheeze, cyanosis, barrel-c hested, poor expansion, tachypnoea. Investigations ABG often deranged in COPD, compare with previous samples and pay close attention to FiO2; repeat after 30min in seriously ill pati ents; CXR hyperexpanded, fl at diaphragm (look for evidence of infection, pneumothorax or b ullae); spirometry (see b p586) dFEV1, dFEV1:FVC ratio (<70%). Acute exacerbation sit the p atient up and give the minimum amount of O2 to maintain sats \211 88% (aim for PaO2 78kPa) . Give salbutamol 5mg ipra- tropium 500micrograms nebs (drive by air, leaving nasal O2 ca nnulae on under mask if necessary) and prednisolone 30mg PO (or hydrocortisone 200mg IV). S putum for M,C+S. Get an ABG and CXR (portable if unwell). Use ABG results and clinical obse rvations to guide further management: \200 Normal ABG (for them) continue current O2 and give regular nebs \200 Worsening hypoxaemia iFiO2, repeat ABG <30min, watch for confusion which should prompt a repeat ABG sooner; consider NIV (see box) iCO2 retention or dGCS request senior help urgently; consider: ICU input/assessment \200 aminophylline 5mg/kg IV bolus over 20min unless the patient is on oral aminophylline or theophylline NIV (see box). Antibiotics consider prescribing antibiotics (eg doxycycline 200mg PO loading then 100mg/24 h PO or amoxicillin 500mg/8h PO) if the patient has increased SOB, fevers, worsening cough, purulent sputum, or focal changes on CXR. Chronic treatment (OHCM9 b p176) Smoking cessati on and graded exer- cise are vital. Stepwise therapy with inhalers (see Table 8.3) is based upon inhaled short-acting B-agonist or anti-cholinergic, then inhaled long-acting agents, then adding inhaled steroid before oral theophylline. If still breathless despite maximal i nhaler therapy give home nebulisers. If PaO2 consistently \211 7.3kPa (or \211 8kPa with additional risk factors) long-term O2 therapy aiming for a minimum of 15h/d confers surviva l advantage. Complications exacerbations, infection, cor pulmonale, pneumothorax, respirato ry failure, lung cancer (beware haemoptysis and weight loss). respiratory failure, lung can cer (beware haemoptysis and weight loss). Non-invasive ventilation (NIV) These are machines that assist ventilation through a tightly fi tting mask rather than tracheal intubation. Bi-level positive airway pressure (BiPAP) u sed in COPD patients with a pH \211 7.35 and CO2 \211 6.0kPa who have failed to respond t o initial medical therapy reduces mortality and length of admission. Patients who need NIV are usually allocated specialist beds on the respiratory ward or on HDU/ICU. Continuous pos itive airway pressure (CPAP) is not a type of NIV since it does not help with the mechanics of ventilation (b p282). 1 NICE guidelines available at (cid:27)guidance.nice.org.uk/CG101 OHFP.indb 274 OHFP.indb 274 30/05/2014 16:18 30/05/2014 16:18 275 BREATHLESSNESS AND LOW SATS Table 8.3 Common inhalers for COPD and asthma Type of drug Short-acting B-agonist Blue Blue Color Medication Trade Ventolin Bricanyl Qvar Pulmicort Flixotide Atrovent Salbutamol Terbutaline Inhaled steroids Brown Beclometasone Brown Budesonide Orange White + Short-acting green anticholinergic Short-acting B-agonist White + orange and anticholinergic Red Inhaled steroids with long-acting B-agonist Purple Long-acting B-agoni st Green Gray Long-acting anticholinergic Fluticasone Ipratropium Salbutamol and ipratropium Budesonide and formoterol Fluticasone and salmeterol \200\223 Symbicort Seretide Serevent Spiriva Salmeterol Tiotropium Pulmonary rehabilitation There is good evidence1 that patients with chronic lung disease wh o take part in a pulmonary rehabilitation program see increased exer- cise tolerance and im proved well-being. These programs do not reverse the pathological process or improve spirom etry measurements. Most hospitals and general practices have access to such programs, and patients generally t ake part in a structured program for 8 \200\22312wk. Exercise is encouraged which becomes p rogressively more strenuous. Diet and other lifestyle advice are also usually covered. Once discharged from the program, patients are encouraged to continue the exercises they ha ve learned, either as part of their daily lives at home or at leisure centers. The British Lung Foundation can be contacted to fi nd local programs; 03000 030 555. 1 Summarized at (cid:27)www.brit-thoracic.org.uk/guidelines-and-quality-standards/pulmonary - rehabilitation-guideline/ Online respiratory resources British Thoracic Society British Lung Foundation Thorax (journal)2 Cochrane library www.brit-thoracic.org.uk www.lunguk.org thorax.bmj.com www.thecochranelibrary.com 2 Subscription required, but many NHS organizations will grant access via ATHENS. _OHFP.indb 275 _OHFP.indb 275 30/05/2014 16:18 30/05/2014 16:18 276 CHAPTER 8 Respiratory Pneumonia1 (OHAM3 b p166) Worrying signs CURB-65 score \211 3 (b Severity, p276). Symptoms cough, increased sputum (colored), pleuritic chest pain, breathless, haemoptysis, fever, u nwell, confusion, anorexia. Signs itemp, iRR, iHR, dsats, unequal air entry, reduced expans ion, dull percussion, bronchial breathing. Severity the CURB-65 criteria (see Fig. 8.1) are a validated set of variables that support (but do not replace) clinical judgment in commun ity acquired pneumonia on whether to admit.2 In the out-patient setting, omit urea to get a CRB-65 score; patients scoring 0 (and possibly 1 \200\2232) are suitable for home treatmen t. Investigations blds iWCC, iN \230, iCRP; bld cultures if CURB-65 \211 2; sputum culture s if CURB-65 \211 3 (or CURB-65=2 and not had antibiotics); urine if CURB-65 \211 2 test for pneumococcal antigen; if CURB-65 \211 3 or clinical suspicion, test for legionella ant igen; ABG dPaO2 ( dPaCO2 due to hyperventilation but not if tiring or COPD); CXR on hospit al admission may show focal consolidation; repeat at 6wk if ongoing symptoms or high risk f or malignancy. Treatment sit up and give O2 as required. Give antibiotics according to loca l policy or see b p179 for empirical treatment. Look for dehydration and consider IV fl uid s. Most patients who require IV antibiotics can safely be switched to PO therapy by day 3;3 if symptoms not resolving by this time, repeat CRP and CXR to exclude pleural eff usion/em pyema. Complications empyema, respiratory failure, sepsis, confusion. Hospital acquired pne umonia Pneumonia developing \211 48h after admission and not felt to have been incubating at time of admission. Causative organ- isms will include Gram \200\223ve bacilli (eg Pseud omonas or Klebsiella species, E. coli.) as well as S. pneumoniae and S. aureus (including M RSA). Symptoms and signs can be severe, particularly in frail patients with other comorbidi ties, and lung necrosis and cavitation may develop. Empirical antibiotic selection should b e guided by local policy discussion with a microbiologist. Aspiration pneumonia Aspiratio n of gastric contents refl uxing up the esophagus and down the trachea may lead to a steril e chemical pneu- monitis. Alternatively, oropharyngeal bacteria may be aspirated causing a bacterial pneumonia. Risk factors include dGCS (eg sepsis, anesthesia, seizures), oesophage al pathology (eg strictures, neoplasia), neurological disability (eg dementia, MS, Parkinso n \200\231s disease) or iatrogenic interven- tions (eg NG tube, OGD, bronchoscopy). At-risk patients can be identi- fi ed by bedside swallow evaluation (b p352). Care is supportive, with O2 supplementation, suctioning of secretions and attention to preven- tion of further aspiration (involve SALT). Empirical antibiotics can be of benefi t if bacterial pneumonia suspected (eg persistent fever, purulent sputum) \200\223 eg co-amoxiclav 625mg/8h PO or 1 .2g/8h IV with metroni- dazole 400mg/8h PO or 500mg/8h IV. 1 British Thoracic Society guide lines for the management of community acquired pneumonia in adults available at: (cid:27)ww w.brit-thoracic.org.uk/guidelines-and-quality-standards/community- acquired-pneumonia-in-ad ults-guideline/ 2 Lim, W.S. et al. Thorax 2003 58:377 full-text available free at: (cid:27)www.ncbi.nlm.nih .gov/pmc/ articles/PMC1746657 3 Oosterheert, J.J. et al. BMJ 2006 333:1193 full-text available free at: (cid:27)www.ncbi. nlm.nih.gov/ pmc/articles/PMC1693658 OHFP.indb 276 OHFP.indb 276 30/05/2014 16:18 30/05/2014 16:18 277 BREATHLESSNESS AND LOW SATS CURB-65 severity score: 1 point for each feature present: Confusion \200 Urea >7mmol/l \200 Respiratory rate \211 30/min \200 Blood pressure ( SBP <90 or DBP \211 60mmHg) \200 Age \211 65 years 0 \200\2231 Low severity (risk of death <3%) 2 Moderate severity (risk of death 9%) 3 \200\2235 High severity (risk of death 15 \200\22340%) Other reasons for admission (unstable co-morbidity, social) Hospital Hospital Supportive care Supportive care Consider transfer to critical care unit (especially if CURB-65 = 4 or 5) Give antibiotics eg amoxicillin 500mg-1g/8h PO plus clarithromycin 500mg/12h Yes No Give antibiotics eg co- amoxiclav 1.2g/8h IV plus clarithromycin 500mg/12h IV Send sputum a nd blood for culture Send blood cultures Send sputum for culture if no recent antibiotics Send pleural fluid (if present) for culture and pneumococcal antigen testing Send urine for legionella and pneumococcal antigen testing Send pleural fluid (if present) for culture and pneumococcal antigen testing Send urine for pneumococcal antigen testing and consider legionella and mycoplasma testing Hospital Home Give antibiotics eg amoxicillin 500mg/8h PO Give antibiotics eg amoxicillin 500mg/8h PO Consider atypical and viral pathogen serology (baseline and follow-up samples) Fig. 8.1 Severity assessment and investigations in community acquired pneumonia. Adapted by permission from BMJ Publishing Group Limited. British Thoracic Society guidelines for the management of community acquired pneumonia in adults: update 2009, Lim, W.S. et al. Thorax 2009 64 (Suppl 3):iii1. _OHFP.indb 277 _OHFP.indb 277 30/05/2014 16:18 30/05/2014 16:18 278 CHAPTER 8 Respiratory Pulmonary embolism1 (OHAM3 b p120) Symptoms often none except breathlessness; may have pleu ritic chest pain, haemoptysis, dizziness, leg pain; consider risk factors in Table 8.4. Sig ns iJVP, iRR, iHR, dBP, RV heave, hypotension, pleural rub, pyrexia. Tachycardia and tach ypnoea may be the only clinical signs. Investigations D-dimer will be raised in many situat ions, whilst a normal D-dimer must be interpreted in the clinical context (see box); ECG iH R, RBBB, inverted T waves V1 \200\223V4 or S1Q3T3; ABG dCO2, dO2 (if large); CT-PA is th e defi nitive imaging modality, though V/Q scan may be used eg in those with renal failure. Acute treatment sit up (unless dBP) and give 15l/min O2. If life-threatening seek immediat e senior support, arrange an urgent CT-PA echo and consider thrombolysis. Otherwise paren teral anticoagulation (b p399) eg enoxaparin 1.5mg/kg/24h SC and pain relief; IV fl uids if dBP. Chronic treatment generally oral anticoagulation (b p406) eg war- farin (INR 2 \200 \2233) for at least 3mth.2 farin (INR 2 3) for at least 3mth. Clinical risk assessment for PE R PEs are common and potentially fatal, but associated with non-spe- cifi c clinical signs. T he CT-PA off ers excellent diagnostic accuracy but exposes your patient to 3.6 years of bac kground radiation, along with nephrotoxic IV contrast medium, whilst taking up signifi cant resources. So can D-dimer testing help? Remember, the negative predictive value of any tes t is determined by the prevalence of whatever disease you are testing for: The value of D-d imer testing lies in the excellent negative predictive value when the risk of a PE is low. In those at high risk, nega- tive D-dimer levels do not provide suffi cient reassurance. Th e Wells score for PE is a clinically reliable method of identifying the risk of PE, and hen ce deciding on further testing Table 8.4 Wells score for pulmonary embolism3 Clinical feature Points Signs/symptoms of DVT (leg swelling & pain on deep vein palpation) 3 3 PE most likely clini cal diagnosis 1.5 HR >100 1.5 >3d immobilization or surgery in past 4wk 1.5 Previous DVT/PE 1 Haemoptysis Malignancy (current treatment or treatment in past 6mth or palliative) 1 Those scoring \211 4 are low risk: Test for D-dimers.3 If elevated, proceed to CT-PA; if negative, then consider alternative diagnoses Those scoring >4 are high risk: Proceed to CT-PA testing (with LMWH if scan cannot be performed immediately) 3 In pregnancy D-dimer testing is uninterpretable. If clinical suspicion, then a Doppler U/ S of leg veins is the safest initial investigation \200\223treat if DVT seen. If this is negativ e, a half-dose V/Q scan provides an acceptable balance of diagnostic utility with radiation exposure. The risk of CT-PA is not to the fetus (which can be shielded) but to proliferati ng maternal breast tissue. 1 NICE guidelines available at (cid:27)guidance.nice.org.uk/CG144 2 3mth may suffi ce if lo w risk (eg 1st PE with identifi ed risk factor now removed); if higher risk (recurrent or unprovoked PEs, or thrombophilia) treatment may need to be long term. OHFP.indb 278 OHFP.indb 278 30/05/2014 16:18 30/05/2014 16:18 279 BREATHLESSNESS AND LOW SATS Spontaneous pneumothorax (OHAM3 b p204)1 May occur apparently spontaneously (primary) or in the presence of underlying lung disease or injury (secondary). Risk factors primary tall, thin, male; Marfan \200\231s; recent central line, pleural aspiration or chest drain; secon dary COPD, asthma, infection, trauma, mechanical ventilation. Symptoms breathlessness che st pain. Signs hyper-resonant and reduced air entry on aff ected side, tachypnoea, may have tracheal deviation or fractured ribs. Investigations CXR lung markings not extending to th e peripheries, line of pleura seen away from the periphery. Treatment sit up and give 15l/m in O2. Chest drain/aspiration as directed by BTS guidelines (b p280). In essence, primary p neumothoraces can poten- tially be discharged, whilst secondary pneumothoraces require admi ssion and either aspiration (b p538) or, more usually, drainage (b p540). 3Tension pneumothorax If air trapped in the pleural space is under positive pressure (eg fo llowing penetrating trauma or mechanical ventilation) then mediastinal shift may occur, com pressing the contralateral lung and reducing venous return. The patient may be hypotensive, tachycardic, tachypnoeic, with unilateral hyperresonance and reduced air entry; iJVP and m ay have tracheal deviation. This is an emergency, it will rapidly worsen if not treated. Si t up and give 15l/min O2. Treat prior to CXR. Insert a large cannula (orange/gray) into the 2nd intercostal space, midclavicular line. Listen for a hiss and leave it in situ; insert a chest drain on the same side. If there is no hiss, leave the cannula in situ and consider placing a 2nd cannula or consider alternative diagnoses; a chest drain is usually still re quired to prevent a tension pneumothorax accumulating. Pleural eff usion (OHAM3 b p216)1 Ex cessive fl uid within the pleural space refl ects an imbalance between hydrostatic and onco tic pressures within the pleural vasculature, and/or disruption to lymphatic drainage. Caus es may be divided into those causing transudates (where pleural fl uid protein <25g/l \200 \223 tend to be bilateral) pulmonary oedema, cirrhosis, nephrotic syndrome, hypothyroidism, intestinal malabsoprtion/failure and exudates (protein >35g/l \200\223 may be unilateral or bilateral) malig- nancy, infection, vasculitides, rheumatoid; if purulent and pH <7.2, t his is empyema refl ecting infection. Light \200\231s criteria help diff erentiate, especia lly when protein >25g/l but <35g/l. Consider the eff usion an exudate if pleural protein:se rum protein >0.5, pleural LDH:serum LDH >0.6 or pleural LDH >2/3 of upper limit of normal s erum value. Symptoms may be breathless with pleuritic chest pain. Signs stony dull to percu ssion with reduced air entry, tachypnoea. Investigations CXR loss of costophrenic angle wit h a meniscus, b p582. Treatment sit up and give 15l/min O2. Investigate the cause; if the e ff u- sion is large, pleural aspiration (see b p538) may relieve symptoms and aid diagnosis (draining >1.5l/24h may cause pulmonary oedema). 1 British Thoracic Society guidelines ava ilable at (cid:27)www.brit-thoracic.org.uk/guidelines-and-quality- standards/pleural-disease-guideline/ _OHFP.indb 279 _OHFP.indb 279 30/05/2014 16:18 30/05/2014 16:18 280 CHAPTER 8 Respiratory Algorithms for the treatment of spontaneous pneumothorax Spontaneous Pneumothorax If Bilateral/Haemodynamically unstable proceed to Chest drain Age >50 and significant smoking history Evidence of underlying lung disease on exam or CXR? YES see Fig 8.3 NO Primary Pneumothorax YES* Aspirate 16 \200\22318G cannula Aspirate <2.5I Size>2cm and/or Breathless NO Success (<2cm and breathing improved) YES NO Consider discharge review in OPD in 2 \200\2234 weeks Chest drain Size 8 \200\22314Fr Admit In some patients with a large pneumothorax but minimal symptoms conservative management may be appropriate Fig. 8.2 Treating spontaneous pneumothorax in patients over 50 with no signifi - cant smoki ng history or evidence of underlying lung disease. Adapted by permis- sion from BMJ Publish ing Group Ltd, Management of spontaneous pneumothorax: British Thoracic Society pleural dis ease guideline 2010, MacDuff , A. et al. Thorax 2010 65 (Suppl 2):ii18. OHFP.indb 280 OHFP.indb 280 30/05/2014 16:18 30/05/2014 16:18 281 BREATHLESSNESS AND LOW SATS Spontaneous Pneumothorax If Bilateral/Haemodynamically unstable proceed to Chest drain Age >50 and significant smoking history Evidence of underlying lung disease on exam or CXR? NO see Fig 8.2 YES Secondary Pneumothorax YES >2cm or Breathless NO YES Aspirate 16 \200\22318G cannula Aspirate <2.5I Size 1 \200\2232cm NO Success Size now<1cm NO YES Chest drain Size 8 \200\22314Fr Admit Admit High flow oxygen (unless suspected oxygen sensitive) Observe for 24 hours Fig. 8.3 Treating pneumothorax in patients over 50 with signifi cant smoking history or evi dence of underlying lung disease. Adapted by permission from BMJ Publishing Group Ltd, Mana gement of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010 , MacDuff , A. et al. Thorax 2010 65 (Suppl 2):ii18. _OHFP.indb 281 _OHFP.indb 281 30/05/2014 16:18 30/05/2014 16:18 282 CHAPTER 8 Respiratory Pulmonary oedema (OHAM3 b p87) Symptoms dyspnoea, orthopnea, paroxysmal nocturnal dyspnoea, frothy sputum; coexistent dependent oedema or previous heart disease. Signs iJVP, tachypno ea, fi ne inspiratory basal crackles, wheeze, pitting cold hands and feet; oedema (ankles a nd/or sacrum) suggests right heart failure. Investigations blds (look specifi cally for anemia, infection or MI): FBC, U+E, CRP, cardia c markers; BNP (normal levels unlikely in cardiac failure); ABG may show hypoxia; ECG exclu de arrhythmias and acute STEMI, may show old infarcts, LV hypertrophy or strain (b p572); C XR cardiomegaly (not if AP projection), signs of pulmonary oedema (b p582); echo poor LV fu nction/ejection fraction. Acute treatment sit up and give 15l/min O2. If the attack is life-threat- ening call an int ensivist early as CPAP and ICU may be required. Otherwise monitor HR, BP, RR, and O2 sats w hilst giving furosemide 40 \200\223120mg IV diamorphine (repeat every 5min up to 5mg max, watch RR) 1mg boluses IV (repeat up to 5mg, watch RR). If further treatment is required, b e guided by blood pressure: \200 Systolic >100 Give 2 sprays of sublingual GTN followed b y an IV nitrate infusion (eg GTN starting at 4mg/h and increasing by 2mg/h every 10min, aim ing to keep systolic >100; usual range 4 \200\22310mg/h; see b p201) \200 Systolic <100 T he patient is in shock, probably cardiogenic. Get senior help as inotropes are often requir ed. Do not give nitrates Wheezing Treat as for COPD alongside above treatment \200 No improvement Give furosemide up to 120mg total (more if chronic renal failure) and consider CPAP (see below). Insert a urinary catheter to monitor urine output, CVP monitoring. Request senior help. Consider HDU/ICU. Once stabilized, the patient will need daily weights fl uid restriction. Document LV func tion with an echo and optimize treatment of heart failure (b p267). Oral bumetanide may be preferred to oral furosemide for diuresis since absorption is said to be more predictable i n the pres- ence of bowel oedema, though evidence for this is lacking. Always monitor U+E d uring diuresis: The heart-sink patients are those with simultaneously failing hearts and ki dneys who seem fated to spend their last days alter- nating between fl uid overload and acu te renal failure \200\223 close liaison with the patient \200\231s GP is as essential as e ver here. Continuous positive airway pressure (CPAP) Application of positive airway pressure througho ut all phases of the respiratory cycle limits alveolar and small airway collapse, though th e patient must still initiate a breath and have suffi cient muscular power to inhale and ex hale. Pursed-lip breathing has a similar eff ect, and is often observed in patients with ch ronic lung disease. CPAP is often used in the acute treatment of pulmonary oedema or the ch ronic treatment of sleep apnoea (may use nasal CPAP). OHFP.indb 282 OHFP.indb 282 30/05/2014 16:18 30/05/2014 16:18 283 BREATHLESSNESS AND LOW SATS SVC obstruction (OHCM9 b p526) Symptoms breathlessness, orthopnoea, facial/arm swelling, he adache. Signs facial plethora (redness), facial oedema, engorged veins, stridor. Pemberton \200\231s test elevating the arms over the head for 1min results in increased fac ial plethora and iJVP. Investigations CXR/CT mediastinal mass, tracheal deviation; venogram venous congestion dist al to lesion; other sputum cytology for atypical cells. Treatment Seek senior input early. Sit up and give 15l/min O2. Dexamethasone 4mg/6h PO/IV. Consider diuretics to decrease venous return and relieve SVC pressure (eg furosemide 40mg/1 2h PO). Otherwise symptomatic treatment whilst arranging for tissue diagnosis. Acute respiratory distress syndrome (ARDS) (OHAM3 b p198) Acute onset respiratory failure d ue to diff use alveolar injury following a pulmonary insult (eg pneumonia, gastric aspirati on) or systemic insult (shock, pancreatitis, sepsis). Characterized by the acute developmen t of bilateral pulmonary infi ltrates and severe hypoxaemia in the absence of evidence for cardiogenic pulmonary oedema. Symptoms breathlessness, often multiorgan failure. Signs hypoxic, signs of respiratory distress and underlying condition. Investigations CXR bilateral infi ltrates. Treatment sit up and give 15l/min O2. Refer to HDU/ICU and treat underlying cause. Often re quires ventilation. _OHFP.indb 283 _OHFP.indb 283 30/05/2014 16:18 30/05/2014 16:18 284 CHAPTER 8 Respiratory Stridor in a conscious adult patient Acute stridor \200\223 CALL anesthetist AND ENT URGENTLY Airway Breathing If poor respiratory eff ort \200\223 CALL ARREST TEAM Circulation If no palpable pulse \200\223 CALL ARREST TEAM 3Call for senior anesthetics and ENT help immediately. \200 Do not attempt to look in the mouth/examine the neck \200 If choking, follow algorithm in Fig. 8.4 \200 Avoid distur bing/upsetting the patient in any way \200 Let the patient sit in whatever position they choose \200 Off er supplemental O2 to all patients \200 Fast bleep senior anesthetist \200 Fast bleep senior ENT \200 Adrenaline (epinephrine) nebs (5ml of 1:1000 with O2) \200 Monitor pulse oximeter defi brillator \200\231s ECG leads if unwell \200 Check te mp \200 Take brief history from relatives/ward staff or check notes \200 Look for swell ing, rashes, itching (?anaphylaxis) \200 Consider serious causes (below) \200 Await ane sthetic and ENT input \200 Request urgent portable CXR \200 Call for senior help \200 Reassess, starting with A, B, C \200 Life-threatening causes Infection (epiglottitis, abscess) \200 Tumor \200 Trauma Foreign body \200 Post-op \200 Anaphylaxis Assess severity Severe Airway obstruction (ineffective cough) Mild Airway obstruction (effective cough) Unconscious Start CPR Conscious 5 back blows 5 abdominal thrusts Encourage cough Continue to check for deterioration to ineffective cough or until obstructi on relieved Fig. 8.4 Adult choking treatment algorithm, 2010 guidelines. Reproduced with the kind permi ssion of the Resuscitation Council (UK). OHFP.indb 284 OHFP.indb 284 30/05/2014 16:18 30/05/2014 16:18 285 COUGH Coughg Causes of coughs URTI, post-viral, post-nasal drip (allergy), pneumonia, LVF, PE Acute Chronic Asthma, COPD, bronchitis, bronchiectasis, smoking, post-nasal drip, oesophageal refl ux, pneumonia, TB, parasites, interstitial lung disease, heart failu re, ACE inhibitors, lung cancer, sarcoid, sinusitis, cystic fi brosis, habitual Bloody Massive bronchiectasis, lung cancer, infection (including TB and aspergilloma), trauma, AV malformations; other bronchitis, PE, LVF, mitral stenosis, aortic aneurysm, vasculitides, parasites Usually, the cause of coughing is obvious. However, chronic, unexplained coughing with a no rmal CXR and the absence of infective features requires a considered approach. Is there diu rnal or seasonal variation in coughing (cough-variant asthma might be investigated with a P EFR diary, lung function testing, and a trial of inhaled steroids)? Is there a history sug- gestive of gastro-oesophageal refl ux (consider a trial of PPI)? Does the onset of a dry c ough follow the introduction of an ACE inhibitor (consider using an AT II receptor blocker) ? Or is there a sensation of mucus accu- mulation at the back of the throat (consider chron ic/allergic rhinitis and \200\230post-nasal drip \200\231 and a trial of nasal steroids or antihistamines)? Haemoptysis coughing up blood, \211 400ml is considered \200\230massive \200\231. Managem ent FBC, U+E, LFT, clotting, G+S, sputum C+S and cytology, ABG, ECG, CXR. Sit up, 15l/min O 2. Codeine 60mg PO (may dcough) if massive: good IV access ( \211 green), monitor HR and BP , immediate referral to respiratory team for bronchoscopy CT thorax. Bronchiectasis1 (OHC M9 b p166) Abnormal and permanent distortion of the medium sized airways caused by destruct ion of the elastic tissue of the bronchial walls. Causes cystic fi brosis, infection (pneum onia, TB, HIV), tumors, immuno- defi ciency, allergic bronchopulmonary aspergillosis, forei gn bodies, rheuma- toid arthritis, idiopathic. Symptoms chronic cough with purulent sputum haemoptysis, halitosis. Signs clubbing, coarse inspiratory crepitations wheeze. Investi gations FBC, immunoglobulins, aspergillus serology; blood or sweat test (for CF); sputum C+ S; CXR thickened bronchial outline (tramline and ring shadows) fi brotic changes; CT thor ax bronchial dilatation; bronchoscopy to exclude other diagnoses. Acute treatment O2 BiPA P as required, bronchodilators cortico- steroids. Typical recurrent infections include Pseudomonas (consult local antibiotic guidelines). Chest physiotherapy to mobilize secretio ns. Chronic treatment postural drainage (chest physio), inhaled/nebulised bronchodilators/c orticosteroids/antibiotics, surgery may be consid- ered; consider prophylactic, rotating an tibiotics. Complications recurrent pneumonia, pseudomonal infection, massive haemoptysis, c or pulmonale. 1 British Thoracic Society guidelines available at (cid:27)www.brit-thoracic.org.uk/guideli nes-and-quality- standards/bronchiectasis-guideline/ _OHFP.indb 285 _OHFP.indb 285 30/05/2014 16:18 30/05/2014 16:18 This page intentionally left blank Chapter 9 Gastroenterology 287 Abdominal pain emergency 288 Abdominal pain 289 GI bleeding emergency 298 Acute upper GI bl eeds 299 Acute lower GI bleeds 301 Nausea and vomiting 304 Diarrhea 306 Constipation 310 Li ver failure emergency 312 Liver failure 313 Jaundice 318 _OHFP.indb 287 _OHFP.indb 287 30/05/2014 16:18 30/05/2014 16:18 288 CHAPTER 9 Gastroenterology Abdominal pain emergency Check airway is patent; consider maneuvers/adjuncts If no respiratory eff ort \200\223 CAL L ARREST TEAM Airway Breathing Circulation If no palpable pulse \200\223 CALL ARREST TEAM 3Call for senior help early if patient deteriorating. \200 15l/min O2 if SOB or sats <94% \200 Monitor BP, pulse oximeter, defi brillator \200\231s ECG leads if unwell \200 Obt ain a full set of observations, are they haemodynamically stable? \200 Take brief history if possible/check notes/ask ward staff \200 Examine patient: condensed RS, CVS, abdo, wound exam \200 Consider serious causes (see box) and treat if present \200 Initiate fu rther treatment, see b p289 \200 Venous access, take bloods: FBC, U+E, LFT, amylase, CRP, clotting, X-match 4 units, bld cultures Give IV \202 uids if hypovolaemic or shocked (b p476) \200 Analgesia as appropriate \200 Arterial blood gas, but don \200\231t leave the patient alone \200 Erect CXR (porta ble if unwell) and consider plain AXR \200 ECG \200 Urine dipstick and B-hCG (all pre-m enopausal women), catheter \200 Keep patient NBM if likely to need theater \200 Call for senior help \200 Reassess, starting with A, B, C \200 Life-threatening causes and emergencies Perforation \200 Bowel infarction/ischaemia \200 Bowel obstruction \200 Acute pancrea titis \200 Acute cholangitis \200 Appendicitis Leaking abdominal aortic aneurysm (AAA) \200 Strangulated hernia \200 Testicular or ova rian torsion \200 Ruptured ectopic pregnancy \200 Referred pain (MI, aortic dissection) OHFP.indb 288 OHFP.indb 288 30/05/2014 16:18 30/05/2014 16:18 289 ABDOMINAL PAIN Abdominal pain Worrying features sudden onset, iHR, dBP, dGCS, massive distension, peritonism, expansile m ass, persistent vomiting, haematemesis, massive PR bleeding; if life-threatening, see b p28 8. Think about pain by anatomical structure, see Fig. 9.1; common gas- troenteritis, peptic ul cer, gastro-oesophageal refl ux disease (GORD), constipation, infl ammatory bowel disease ( IBD), irritable bowel syndrome (IBS), diverticular disease, adhesions, mesenteric adenitis, renal colic, UTI/ pyelonephritis, urinary retention, biliary colic/sepsis, pancreatitis, b leeding AAA, incarcerated hernia, ischaemic bowel; obs/gynae ectopic preg- nancy, ovarian c yst, ovarian torsion, PID, endometriosis, labor; other trauma, MI, pneumonia, sickle-cell c rises, DKA, psoas abscess, porphyria. See Table 9.1. Ask about nature of pain (constant, colicky, changes with eating/ vomiting/bowels), duratio n, onset, frequency, severity, radiation to the back, dysphagia, dyspepsia, abdominal swell ing, nausea and vomiting, stool color, change in bowel habit, urinary symptoms, weight loss , breathlessness, rashes, lumps, chest pain, recent surgery, last period; PMH DM, IBD, IHD, jaundice, gallstones, pancreatitis, previous abdo surgery; DH NSAIDs; SH alcohol. Obs temp, HR, BP, RR, sats, fi nger-prick glucose, urine output. Look for jaundice, sweating, pallor, pulse volume, clubbing, leuconychia (white nails), lym phadenopathy (Virchow \200\231s node), abdominal scars, dis- tension, ascites, visible peri stalsis, tenderness, peritonitis (tenderness with guarding, rebound or rigidity), loin tend erness, hepatomegaly, sple- nomegaly, masses (?expansile/pulsatile), check hernial orifi ce s, examine external genitalia (4: testicular vs. epididymal tenderness), femoral pulses, bo wel sounds, lung air entry; PR perianal skin tags, fi ssures, warts; tender- ness, masses, prostate hypertrophy, stool, check glove for blood, mucus, melaena and stool color. Investi gations urine dipstick, B-hCG in all pre-menopausal women of reproductive age, MSU; blds FB C, U+E, LFT, amylase, Ca2+, glucose, 9cardiac markers, venous lactate, clotting, bld cultur es if pyrexial; ABG if unwell; ECG to exclude MI; erect CXR to exclude perforation; plain A XR to exclude bowel obstruction or KUB for renal colic; USS espe- cially if hepatobiliary c ause suspected; CT abdo discuss with senior. Treatment Give all patients O2, analgesia antiemetics; insert a urinary catheter if unwel l. Keep NBM until urgent surgery is ruled out. \200 Shocked IV fl uids 3urgent senior rev iew \200 Peritonitic with IV fl uids, IV antibiotics 3urgent senior review \200 >50yr i n severe pain ?AAA, IV fl uids 3urgent senior review \200 Abdo pain and vomiting consider obstruction, IV fl uids, NG tube, AXR (b p588) 3urgent senior review GI bleed resuscitate with IV fl uids (b p298) 3urgent senior review. _OHFP.indb 289 _OHFP.indb 289 30/05/2014 16:18 30/05/2014 16:18 290 CHAPTER 9 Gastroenterology Table 9.1 Common causes of abdominal pain History Examination Peritonitis, 9 bowel sounds Distension, tenderness, tinkling bowel sounds Shock , generalized tenderness Investigations 3Perforation Rapid onset, severe abdominal pain Gas under diaphragm, acidotic Dilated loops of bowel on AXR Bowel obstruction Pain, distension, nausea, vomiting, constipation iWCC, ilactate/ acidotic, AF or previous MI on ECG iWCC, iCRP Bowel ischaemia/ infarction Sudden onset, severe pain, previous arterial disease, AF Appendicitis RIF pain (initially periumbilical), anorexia, nausea, vomiting Slight temp, RIF tenderness, peritonitic Strangulated hernia Sudden onset pain, Tender hernial mass Epigastric tenderness Needs urgent surgery Consider need for OGD previous hernia Dyspepsia, heartburn, anorexia, NSAIDs GORD/peptic ulcer itemp, epigastric tenderness, no peritonitis Tender mass peritonitis iWCC, iCRP Gastroenteritis Rapid onset, vomiting, diarrhea iWCC, iCRP, iplts, oedematous bowel on AXR, lesions on colonoscopy iWCC, iCRP, diverticulae on colonoscopy iiiamylase, iWCC, iCRP, iglucose, dCa2+ Infl ammatory bowel disease Weight loss, mouth ulcers, PR blood mucus, diarrhea Diverticular disease Pain, diarrhea, Tenderness, peritonitis constipation, PR bleeding Constant epigastric pain radiating to back, vomiting, anorexia, i alcohol or gallstones Abdominal and back pain, collapse, prev heart disease/iBP, age >50yr, 4 3Acute pancreatitis Shock, epigastric tenderness, dbowel sounds 3Abdominal aortic aneurysm (AAA) Expansile mass, unwell, often dBP, dleg pulses Urgent USS (bedside if possible); immediate surgery if leaking Renal colic