Respiratory Diseases and Treatments

COPD

• Chronic Obstructive Pulmonary Disease (COPD) is a chronic lung disease that causes obstruction of airflow from the lungs
• COPD includes chronic bronchitis and emphysema
• Chronic bronchitis involves inflammation of the airways causing swelling and mucus buildup
• Emphysema affects the small air sacs (alveoli) in the lungs, causing them to collapse
• COPD often involves damage to both airways and alveoli

Pulmonary Fibrosis

• Pulmonary fibrosis is scarring and thickening of the tissues surrounding the alveoli
• This makes it difficult for oxygen to pass into the bloodstream

Mechanical Ventilation

• Mechanical ventilators help patients breathe, especially when oxygen levels are low (pneumonia) or carbon dioxide levels are high (COPD)
• Intermittent Mandatory Ventilation (IMV) delivers a set number of breaths at a fixed volume, but allows patients to trigger spontaneous breaths
• Continuous Positive Airway Pressure (CPAP) uses mild air pressure to keep airways open during sleep, treating sleep disorders like apnea

Extracorporeal Membrane Oxygenation (ECMO)

• ECMO is a life support system for patients with severe heart or lung failure
• It acts as an artificial heart and lung, oxygenating the blood and removing carbon dioxide
• Types of ECMO include veno-venous (V-V), veno-pulmonary (V-P), and veno-venoarterial (V-VA)

Pulmonary Edema Treatment

• Treatment includes disorder-specific and symptomatic approaches
• Disorder-specific treatment targets the underlying cause, like arrhythmias, myocardial infarction, hypertensive crisis, or stroke
• Symptomatic treatment includes:
  • Nitroglycerine (vasodilator) to relax blood vessels
  • Diuretics to lower blood pressure, increase urine output, and reduce pressure on the heart
  • Oxygen therapy

Spontaneous Pneumothorax

• A sudden onset of chest pain, often unilateral (one-sided)
• Emphysema can be a common underlying condition
• Symptoms can include:
  • Absent breathing sounds on one side
  • Hyperresonant percussion (may be absent when the air space is narrow)
  • Absence of lung sliding on ultrasound

Tension Pneumothorax

• An increasing pressure within the chest cavity, compressing the heart, major blood vessels, and lungs
• Symptoms include:
  • Chest pain
  • Difficulty breathing
  • Shock
  • Neck vein distention
  • Cyanosis
• Treatment:
  • Needle aspiration in the 2nd intercostal space, midclavicular line, or 4-5th intercostal space, midaxillary line (midaxillary is safer)
  • Finger thoracostomy

Acute Asthma Exacerbation

• Treatment involves:
  • Beta mimetics for inhalation (salbutamol)
  • Hydrocortisone intravenously (prednisolone)
  • Magnesium sulfate
  • Theophylline (infuse slowly, risk of blood pressure drop)

Asthma & COPD Guidelines: Cardiac Arrest Prevention

• Airway:
  • Ensure a patent (open) airway
  • Treat life-threatening hypoxia with high-flow oxygen
  • Titrate oxygen therapy with pulse oximetry (SpO2 94-98% for asthma; 88-92% for COPD)
• Breathing:
  • Assess respiratory rate, accessory muscle use, ability to speak, pulse oximetry, percussion, and breath sounds
  • Request chest X-ray
  • Provide nebulized bronchodilators (oxygen-driven for asthma, consider air-driven for COPD)
  • Administer steroids (Prednisolone or hydrocortisone)
  • Consider IV magnesium sulfate for asthma
• Circulation:
  • Assess heart rate and blood pressure
  • Attach an ECG
  • Obtain vascular access
  • Consider IV fluids
  • Treat arrhythmias

Tachycardias

• Broad Complex Tachycardia

  • Irregular rhythm: Magnesium 2g over 10 minutes
  • Regular rhythm:
    1. Vagal maneuvers
    2. Adenosine 6mg rapid IV (if unsuccessful, +12mg, if unsuccessful, +18mg) If ineffective:
       • Procainamide 10-15mg/kg over 20 minutes
       • Amiodarone 300mg IV over 10-60 minutes
  • If ineffective: Synchronized shock (up to 3 attempts)

• Narrow Complex Tachycardia

  • Irregular rhythm (probable atrial fibrillation):
    1. Control heart rate with beta-blockers or calcium channel blockers (diltiazem)
    2. Consider digoxin or amiodarone if heart failure
    3. Anticoagulant if duration >48 hours
  • Regular rhythm:
    1. Vagal maneuvers
    2. Adenosine 6mg rapid IV (if unsuccessful, +12mg, if unsuccessful, +18mg)
  • If ineffective:
    • Verapamil, calcium channel blockers (diltiazem), or beta-blockers
  • If ineffective: Synchronized shock (up to 3 attempts)

Bradycardia

• Approach:
  • Provide oxygen if SpO2 <90%
  • Exclude pseudohyperkalemia (false high potassium levels)
  • Treat hyperkalemia if suspected
• Hyperkalemia:
  • Mild (K+ 5.5-5.9 mmol/l) and severe (K+ >6.5 mmol/l): Monitor serum potassium and blood glucose, assess underlying cause, and prevent recurrence
  • Moderate (K+ 6.0-6.4 mmol/l):
    • If ECG changes (peaked T waves, flat/absent P waves, broad QRS, bradycardia, or VT)
      • 10ml 10% calcium chloride IV or 30ml 10% calcium gluconate IV
    • If ECG changes persist: Same treatment as below
    • If no ECG changes:
      • Insulin-glucose IV infusion (25g glucose with 10 units insulin over 15-30 minutes IV)
      • If pretreatment blood glucose <7.0 mmol/l: 10% glucose infusion at 50ml/hour

Respiratory Failure

• Cardiac arrest due to acute pulmonary embolism is the most serious consequence of venous thromboembolism, often originating from a deep vein thrombosis (DVT)
• Diagnosis of "confirmed pulmonary embolism" involves considering the probability of PE and the need for specific treatment
• Key steps for diagnosis:
  • Clinical history and assessment
  • Information on past medical history, predisposing factors, and medication that may support a diagnosis of PE