Respiratory Emergencies

Acute Severe Asthma

1. Assess severity and warn ITU
2. Start treatment immedately before investigations: PEF, ABG, CXR (pneumothorax, infx), FBC, U+E O' SHIT (oxygen, salbutamol, hydrocortisone, ipratropium, theophylline)
3. Sit patient up and give 100% Oxygen via non-rebreathing bag
4. Salbutamol 5mg plus ipratropium bromide 0.5mg nebulized with Oxygen
5. Hydrocortisone 100mg IV
6. CXR to exclude pneumothorax
7. Further management :
8. If not improving in 15-30 mins: salbutamol nebs back to back, continue ipratropium
9. If still not improving:
   • Senior review, discuss with ITU
   • Magnesium sulphate
   • Consider theophylline
10. If still no improvement: consider ITU admission accompanied with doctor prepared to intubate

Severe

• Unable to complete sentences
• RR>25/min
• Pulse>110 beats
• PEF<50% of predicted or best

Life-threatening

• PEF<33% of predicted or best
• Silent chest, cyanosis, feeble respiratory effort
• Bradycardia or hypotension
• Exhaustion, confusion, coma
• ABGs: normal/high PaCO2 , PaO2 <8, low pH (NB: normal CO2 is a life-threatening feature)

Before discharge patient must:

• Inhaler technique checked
• PEF>75%
• Review of drugs
• Own a PEF, have a management plan
• GP appointment within 1 week

Acute exacerbation of COPD

1. Controlled Oxygen therapy with venturi mask (Start at 24%, vary according to ABG)
2. Nebulised bronchodilators: salbutamol 5mg/4h, ipratropium 0.5 mg/6h
3. Steroids: IV hydrocortisone 200mg
4. ABX: if evidence of infx (eg amoxicillin)
5. Ix: PEF, ABG, CXR, FBC, U+E, CRP, Cultures of blood and sputum, ECG
6. Physiotherapy to aid sputum expectoration
7. If no response: repeat nebulizers and consider IV aminophylline
8. If no response:
   • Consider nasal intermittent positive pressure ventilation (NIPPV)
   • Consider intubation and ventilation
   • Consider a respiratory stimulant eg doxapram

Pulmonary Embolism

Most deaths occur within the first hour, so if good story and signs start treatment

1. Oxygen 100%
2. Morphine 10mg with anti-emetic for pain
3. IV access and start heparin
4. Then consider systolic BP:

   less than 90mmHg

   1. Rapid colloid infusion, dobutamine.
   2. If BP still low consider noradrenaline.
   3. If BP still < 90mmHg after 30-60min consider thrombolysis

   over 90 mmHg

   Start warfarin

5. Ix: Bloods: U+E, FBC, clotting
   ECG: right axis deviation, RBBB, AF, S1Q3T3
   ABG
   CT pulmonary angiography or VQ scan
   D-dimer
   
6. Subsequent management: TED stockings, heparin 5d (until INR>2), warfarin 6m (unless post-op where it is only continued for 3m)

Occurs classically

10d post-op with collapse and sudden breathlessness while straining at stool.

RFs

Malignancy, surgery, immobility, The Pill, previous, thrombophilia

Prevention

Early post-op mobilization, TEDs, heparin, avoid CoC, anticoagulation, VC filters

Signs/Symptoms

Acute dyspnoea, pleuritic chest pain, haemoptysis, syncope hypotension, tachycardia, gallop rhythm, raised JVP, loud P2 , RV heave, pleural rub, tachypnoea, cyanosis

Pneumothorax

1. Aspirate with large bore needle in 2nd intercostal space (above the rib) midclavicular line
2. Chest drain: 4-6 intercostal mid-axillary line

Pneumonia

1. O ₂ to maintain PaO ₂ >8 (Caution if hx of COPD)
2. Treat hypotension and shock
3. Ix: CXR
   Sats, ABG
   Bloods: FBC, U+E, LFT, CRP, atypical serology
   Blood and sputum cultures
   Pleural fluid may be aspirated for culture
   Bronchoscopy and bronchoalveolar lavage if immunocompromise
   
4. Antibiotics:

   Community Acquired

   Depends on the CURB65 score: Confusion, Urea >7mmol/L, Repiratory rate >30, BP < 90 mmHg, Age > 65. 0-1: Home treatment, 2 hospital therapy, >2 indicates severe.

   • Mild: Amoxiciilin and erythromycin
   • Severe: Co-amoxiclav IV and erythromycin
   • Atypicals: Legionella (clarithromycin), Chlamydia (tetracycline), Pneumocystis (co-trimoxazole)

   Hospital Acquired

   Gram negatives: give aminoglycoside IV