Pulmonary Emergencies Flashcards
Initial actions and primary survey in patients with respiratory distress?
ABCs Full set of vitals O2 application via NC, non-rebreather, or BVM if patient requires assisted ventilations IV access Cardiac and pulse oximetry monitoring EKG
Indications for non-invasive PPV?
Moderate to severe dyspnea Accessory muscle use Paradoxical abdominal movement Fatigue RR>25 pH <7.35, pCO2>45
Contraindications for non-invasive PPV?
Respiratory arrest/absent respiratory drive Hemodynamic instability Aspiration risk Airway obstruction Unable to tolerate mask Mask does not fit Altered mental status
Important history to gather in a patient with respiratory distress?
Did the dyspnea begin suddenly? (If so, consider PE or spontaneous PT; if more gradual, consider COPD, pneumonia, or CHF) Chronic or recurrent? Positional or exertional? Precipitating events? Pertinent PMHx?
Important physical exam findings in a patient with respiratory distress?
Visible swelling in the upper airway (allergic reaction or angioedema)
Voice changes, stridor, drooling (ominous signs concerning for impending obstruction, can be related to infection, allergic reaction, or foreign body)
Focally absent or diminished breath sounds (consolidation, effusion, PT)
Wheezing (broncho-spasm)
Rales (pneumonia, PE, pleural effusions)
Unilateral leg swelling/tenderness
Signs of chest trauma (crepitus, bruising, tenderness)
Tripoding or use of accessory muscles
Additional tests in patients with respiratory distress?
EKG (ischemia, dysrhythmia, PE, pericarditis, pericardial effusion)
CXR (pneumonia, pleural effusions, pneumothorax, chest wall injuries)
Chest CTs (atypical infections, traumatic injuries, PE, aortic pathologies)
Bedside US (lungs, heart, lower extremities)
D-Dimer, BNP, serial enzymes
DDx for respiratory distress?
Acute CHF exacerbation ACS Anaphylaxis Asthma exacerbation Cardiac tamponade Non-cardiogenic pulmonary edema PE Pneumonia PT Upper airway obstruciton
Basic management for acute CHF exacerbation?
Nitrates
Diuretics
PPV
Basic management for ACS?
Aspirin
Antiplatelet/anticoagulant agents
Reperfusion
Basic management for anaphylaxis?
Epinephrine
Beta-agonists
Antihistamines
Steroids
Basic management for asthma exacerbation?
Beta-agonists
Steroids
Basic management for cardiac tamponade?
Pericardiocentesis
Basic management for non-cardiogenic pulmonary edema?
Supplemental O2
PPV
Diuretics
Basic management for PE?
Anticoagulation
Basic management for pneumonia?
ABX
Basic management for PT?
Needle decompression
Chest tube
Basic management for upper airway obstruction?
Early intubation for airway protection (cricothyrotomy as alternative), treat underlying cause
General definition of community acquired pneumonia?
Patient from the community or general population that do not have significant contact with the healthcare system
Typical and atypical pathogens seen in community acquired pneumonia?
Typical: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella cattarhalis
Atypical: Mycoplasma pneumonia, Chlamydophila pneumonia, Legionella, and respiratory viruses
Single most common cause of CAP?
S. pneumoniae (25-50% of all infections)
Compare typical vs. atypical pathogens in terms of whether or not they are seen on gram stain and what can be used to treat them?
Typical - seen on gram stain, can be inhibited or killed using beta-lactam ABX
Atypical - cannot be visualized on gram stain and require special culture methods, not killed or inhibited by beta-lactam ABX
HCAP criteria?
Hospitalization for 2+ days in the preceding 90 days (not incubating at the time of admission)
Residence in a nursing home/facility
In the past 30 days: attendance at a hospital or hemodialysis clinic, home or clinic IV therapy (ABX and chemo), home wound care
Subtype - VAP develops >48-72 hours after intubation
Common pathogens causing HCAP?
Pseudomonas aerugonosa, Escherichia coli, Klebsiella pneumonia, Acinetobacter, Staphylococcus aureus
Signs and symptoms of pneumonia?
Fever, chills, productive cough, pleuritic pain, chest pain, dyspnea, malaise
DDx of pneumonia?
Bronchitis, viral URIs, influenza, PE, TB, pleural effusions, other cardiopulmonary patholgoies
Initial actions and primary survey in suspected pneumonia?
ABCs
-Airway: evaluate for stridor, edema, upper airway obstruction (reposition patient, place on non-rebreather and/or NC, airway maneuvers/adjuncts (head tilt/chin lift, jaw thrust, nasal trumpet insertion)
Breathing: assess for adequate ventilation; look for tachypnea, increased WOB, signs of respiratory distress (supplemental O2, non-invasive ventilation, ET intubation)
Circulation: assess perfusion of vital organs and identify signs of CV compromise from pneumonia causing sepsis or septic shock (if concern for sepsis -> 2 large-bore peripheral IVs, saline bolus of 30 cc/kg, early broad-spectrum ABX, possible central line/vasopressors)
Disability: assess mental status
Vitals
Peripheral access, monitoring, O2
True or false - historical features are helpful in distinguishing typical from atypical CAP.
False
Classical presentation of typical vs. atypical CAP
Typical: sudden onset of fever or chills, productive cough, pleuritic chest pain
Atypical: more protracted course beginning with upper respiratory symptoms, slowly worsening cough, malaise, fatigue
Classic finding of pneumonia 2/2 S. pneumoniae
Bloody or rust colored sputum
Classic finding of pneumonia 2/2 H. influenzae
Fever, muscle pain, fatigue
Classic finding of pneumonia 2/2 Mycoplasma pneumonia
“Walking pneumonia” - upper respiratory symptoms, gradually worsening over weeks or even months
Classic finding of pneumonia 2/2 chlamydophilia pneumonia
Pharyngitis, laryngitis, sinusitis, associated with outbreaks in close-contact settings
Classic finding of pneumonia 2/2 legionella
Respiratory + GI symptoms
Risk factors for HAP with S. aureus?
Ventilator-dependence IVDU Immunocompromise Recent influenza infection Aspiration
Risk factors for HAP P. aeruginosa?
High-dose steroid use
Prolonged hospitalization or nursing home residence
Pre-existing lung disease
Distinguish aspiration pneumonia from aspiration pneumonitis.
Pneumonia: inhalation of oropharyngeal or gastric contents into the larynx or respiratory tract
Pneumonitis: chemical injury from inhalation of gastric contents due to regurgitation that can occur with drug OD, seizures, CVA, anesthesia
Risk factors for aspiration?
Dysphagia
Nursing home residents
Alcohol abuse
ABX for aspiration pneumonia?
Activity against GN -> 3rd generation cephalosporins, FQs, piperacillin
True or false - there are no individual or combination of clinical findings that rule in the diagnosis of pneumonia.
True
Dx pneumonia?
CXR
List # factors that predict pneumonia on CXR.
Temperature >37.8 C, tachycardia, absence of asthma, rales, locally decreased breath sounds on auscultation
Pathogens of typical of lobar vs. multi-lobar vs. patchy infiltrates
Lobar - S. pneumoniae, K. pneumoniae
Multi-lobar - S. aureus, P. aeruginosa
Patchy infiltrates - Mycoplasma pneumonia, chlamydophila, legionella
How might bedside US be used in the diagnosis of pneumonia?
Sensitivity of 86%, specificity of 89%, LR 7.8
Gold standard for diagnosing pneumonia?
CT Chest (only use if CXR is equivocal or when other etiologies are suspected)
In addition to CXR, what other diagnostic studies should be ordered in patients with suspected/confirmed pneumonia?
EKG, especially if tachycardic (patients with CHF, CT disease, severe sepsis/shock may develop cardiac ischemia and infarct 2/2 severe pnuemonia)
Blood Cx if requiring ICU admission or MV, septic patients, CAP + increased risk for bacteremia and resistant organisms
Risk factors for CAP patients at increased risk of bacteremia and resistant organisms?
Cavitary lesions Leukopenia Severe liver disease Asplenia Pleural effusions Alcohol abuse Severe CAP
ABX options for CAP?
Macrolides
FQs
Doxycycline
ABX options for HAP?
Antipseudomonal beta-lactam Pip-tazo Imipenem, meropenem Cefepime Ceftazidime Anti-MRSA agent Vancomycin Linezolid
ABX options for aspiration?
Amp/sulbactam
Pip/tazo
Clinda + AG
ABX for PCP?
Bactrim
What ABX should be avoided in suspected TB, as it can increase resistance?
FQs
ABX for chlamydophila?
Macrolides (first line)
Tetracyclines and FQs also effective
Who needs admission for pneumonia?
Unable to tolerate PO ABX
Hypoxia
Sepsis
Respiratory distress
Purpose of PSI (Pneumonia Severity Index)?
Validated risk stratification instrument for CAP; identify lower risk patients for outpatient treatment with PO ABX
PSI categories?
Sex (M vs. F)
Demographics (Age, nursing home resident?)
Comorbid illnesses (cancer, liver disease, heart failure, CVD, renal disease)
PE findings (AMS, RR, BP, Temp, Pulse)
Lab and radiographic findings (arterial pH, BUN, sodium, glucose, Hct, PP arterial O2, pleural effusion)
PSI scoring?
Sex - male (0) vs. female (-10)
Demographics - age (1 point for each year), nursing home (+10)
Comorbidities - neoplastic disease (+30), liver disease (+20), heart failure (+10), CVD (+10), renal disease (+10)
Exam findings - AMS (+20), RR 30+ (+20), systolic <90 (+20), temperature <35 or >40 (+15), Pulse 125+ (10)
Lab findings - arterial pH <7.35 (+30), BUN 30+ (+20), sodium <130 (+20), glucose 250+ (+10), Hct <30% (+10), PP O2 <60 or O2 saturation <90% (+10), pleural effusion (+10)
PSI score interpretation
Class I (0-50 points): 0.1% mortality Class II (51-70 points): 0.6% mortality Class III (71-90 points): 0.9% mortality Class IV (91-130 points): 9.3% Class V (131-395 points): 27.0%
CURB-65?
Confusion (+1) BUN 20+ (+1) RR 30+ (+1) Systolic <90 or diastolic 60 or less (+1) Age 65+ (+1)
0 or 1: mortality 0-2.6%
2 - possible OP management with close follow-up or short admission/observation
3: mortality 14%
4 or 5: mortality 27.8%
Classic presentation of acute asthma?
Progressive (hours, days, weeks) symptoms of SOB
Non-productive cough
Wheezing in all lung fields
Chest tightness due to a decrease in expiratory airflow
Most common trigger of acute asthma? Other triggers?
URTI; respiratory allergens, exercise, psychosocial stressors
Initial actions and primary survey in a patient with suspected acute asthma?
Decide whether there is an immediate need for definitive airway management -> rapid sequence induction and intubation for patients in severe respiratory distress AND one of the following:
- Albuterol or other medical therapies doo not reverse symptoms
- Significant hypoxia even with supplemental O2
- Too tired to continue breathing on their own
If not needed, do H&P while initiating treatment
Initial treatment in acute asthma?
O2 required regardless of severity of breathing
Concurrent aerosolized beta-2 adrenergic bronchodilator through handheld or facemask nebulizer (O2 to 6-8 L/min, albuterol is 0.5% solution mixed with 2 mL of saline)
Monitor with continuous pulse ox (goal SpO2 >92%)
pIV if moderate to severe
If severe exacerbation not improving with aerosolized albuterol, give IM epinephrine 0.3-0.5 mg Q20 min (adults) up to 3 doses or subQ epinephrine 0.2 mg or terbutaline 0.25 mg
Oral or IV steroids if no initial response to albuterol or moderate to severe exacerbation
Dx testing for acute asthma?
Not routinely indicated for acute exacerbation in known asthmatics
CBC if concern for underlying infection (limited usefulness because it can be elevated in acute asthma alone)
ABG only if hypoxic after initiation of supplemental O2
CXR if diagnosis is uncertain
EKG is not routinely helpful unless concern for other causes of symptoms
PFTs at bedside are the most useful objective test to aid in the treatment and disposition of a patient with acute asthma -> confirm cause of symptoms (obstructive lung disease), severity of exacerbation, monitor treatment response
Define mild vs. moderate vs. severe exacerbations based on FEV1/PFTs.
Mild: >70% predicted/personal best of PEFR
Moderate: 40-69%
Severe: <40%
Goals of Rx of acute asthma?
Correction of significant hypoxemia
Rapid reversal of airflow obstruction
Reduction of likelihood of relapse by intensifying therapy
First-line therapy for acute asthma?
Methods of delivery?
Onset of action/duration of action?
Beta-2 adrenergic agonists
MDI or aerosolized via nebulizer
5 minutes
6 hours
Administration of MDI vs. nebulizer?
MDI appropriate in mild to moderate exacerbations; as effective as neb
- Use spacer
- Albuterol two 90 mcg puffs into the spacer, repeat Q4-6 hours
Nebulizer
- 0.5-1.0 mL (2.5-5.0 mg) of solution in 3 mL of saline
- Q 20 minutes up to 3 doses
Side effects of albuterol?
Tremor
Tachycardia
Mild hypokalemia
How are anticholinergics used in acute asthma?
Ipratropium can be used in severe asthma or beta-blocker induced asthma
Evidence suggests that there is additional benefit when combined with albuterol (Duoneb or Combivent)
What is the role of steroids in acute asthma?
Reduce airway inflammation
IV and PO have equal efficacy
Indicated in moderate to severe and in those who fail to respond to albuterol
Onset in 4-6 hours, but may take up to 24 hours to exert a significant clinical effect
Inhaled are used only for prevention (during Rx of asthma), not indicated during exacerbation
Role of magnesium sulfate in acute asthma?
Beneficial in severe acute asthma
2 grams IV over 20 minutes
Role of theophylline in acute asthma?
No role; no benefit when combined with beta-agonists, side effects include tremors, nausea, anxiety, arrhythmia
What is Heliox and what is its role in acute asthma?
Helium-oxygen (80:20 or 70:30) mixture that may provide benefit with severe exacerbations
Helium is less dense than room air, allowing it to travel through narrow air passages in a more laminar fashion, increasing delivery of O2 or bronchodilators
What determines dispo in acute anxiety?
Response to treatment over time measured by PEFR or FEV1 (goal -> obtain >70% predicted or personal best FEV1 or PEFR)
Dispo for patients who require multiple nebs in the ED or who have a moderate to severe exacerbation that demonstrates a good response to ED Rx?
Discharge home with beta-2 agonists and steroids (short burst for 4-7 days or tapered dose over 10-14 days)
Dispo for patients who have an incomplete response to therapy (40-69% predicted)?
Continued ED treatment until improvement
Who gets admitted in acute asthma?
Poor response to treatment
Persistent severe symptoms
Persistent hypoxia (<90% sPO2) despite supplemental O2
PEFR or FEV1 <40%
Classic presentation of COPD exacerbation?
Wheezing Productive cough DOE Chest congestion Fatigue Hypoxia Tachycardia Increased use of inhalers Sputum change in color or quantity New requirement of an upright sleeping position Fever/chills
Causes of an acute decompensation of a COPD patient
Superimposed infection Continued smoking Non-compliance Lack of usual medications or O2 therapy Spontaneous PT
Exam findings in COPD exacerbation?
Pursed lip breathing Cyanosis Use of accessory muscles Intercostal retractions Barrel chest Hyper-resonant chest Wheezing/rhonchi/rales Prolonged expiratory phase Tachycardia Tachypnea Finger clubbing Diminished or absent breath sounds
Initial action and primary survey in a patient with COPD exacerbation?
ABCs
Vitals, monitor, continuous pulse ox, IV
Apply controlled O2 to all hypoxic patients (delivery system like Venturi mask or NC)
Avoid routine use of a non-rebreather mask with 15 L/min unless patient is not responding to lower flow rates -> in patients with chronic CO2 retention, high flow O2 may cause respiratory depression with rapid rise in O2 depressing the central ventilatory drive
Look for signs of respiratory distress/fatigue
Work-up for COPD exacerbation?
Good H&P
CXR
Consider EKG, BNP, ABG, cardiac markers, D-Dimer if suspicious for another cause
Consider bedside US to look for pericardial effusion or PT
Typical CXR findings in COPD?
Increased AP diameter
Flattening of the diaphragm
Decreased lung markings
Absence of another acute abnormality
Common EKG features of COPD?
Low voltage, R-axis deviation
P pulmonale - peaked P waves in II, III, aVF
R atrial hypertrophy
Tachycardia
Multifocal atrial tachycardia (rare but specific to COPD)
General treatment of COPD exacerbation?
Bronchodilators
Corticosteroids
ABX
After O2, what is the initial treatment of choice in COPD exacerbation?
Bronchodilators (inhaled albuterol); no role for LABAs
Anti-cholinergic bronchodilators such as ipatropium bromide are also first line; Q4 hours
Combination therapy has not been shown to be superior but is frequently used
Role of steroids in COPD exacerbation?
IV methylprednisolone or PO prednisone, typically 10-14 days with tapering doses (compared to 5 day pulse therapy in asthma exacerbation)
Complications of steroids?
Worsening HTN
Elevated blood sugars
Gastritis
Psychosis
Role of ABX in COPD exacerbation?
Used if signs of infection (fever, color change of sputum, increased volume of sputum) are present and in patients with moderate to severe exacerbations
Common options include macrolides, FQs, tetracyclines, and cephalosporins
Adjunctive therapy for decompensated patients?
Continued respiratory decompensation with worsening CO2 retention and hypoxia despite standard treatment -> NPPV or ET intubation
If rapid-sequence intubation is necessary, how should the ventilator be set?
TV 4-5 mL/kg of ideal body weight
Initial O2 flow: 50-100% depending on pulse ox and blood gas measurement
Initial mode - assist control with a fixed # ventilations
General ventilator guidelines?
Correct acidosis
Correct hypoxia
Avoid high peak and plateau airway pressures by ongoing use of bronchodilators
Aggressive suctions of secretions
If peak pressure increase due to stacking phenomenon, disconnect the ETT and start with a more prolonged expiratory phase or decreasing the MV
What happens in a pneumothorax and why can it be fatal?
Potential space between parietal and visceral pleura of the lung fills with air and collapses the lung; can be fatal if tension builds and pressure is placed on the vascular structures within the mediastinum
Causes of spontaneous pneumothorax?
Frequently caused by a ruptured bleb
Primary -> no underlying disease, common in thin, young men with a history of tobacco use
Secondary -> underlying disease such as COPD, CF, lung cancer, and Marfan’s
Classic presentation of spontaneous pneumothorax?
Sudden onset of sharp chest pain, often unilateral, with SOB that often increases over time, cough, pain more prominent in the back and shoulder, vitals may show tachycardia, tachypnea, hypoxia, and hypotension (depending on severity)
Presentation of iatrogenic and traumatic PT?
Similar to spontaneous but with close proximity to trauma (penetrating and blunt) or invasive procedure (central line, thoracentesis, pacemaker, tracheostomy, biopsy)
Other causes include CPR and PPV
Initial actions and primary survey
Consider, diagnose, and treat a tension pneumothorax
Classic findings -> hypotension, tracheal deviation away from side of injury, distended neck veins, respiratory distress/arrest, extreme difficulty bagging if intubated
If stable, ask about duration and onset of symptoms, hx of chronic diseases/prior presentation, recent procedures, traumas
Exam findings include unequal breath sounds, hyperresonance with percussion, decreased wall movement on affected side, palpate chest wall, note signs of trauma, vitals
CXR unless unstable/suspecting tension -> treatment
CXR findings in PT
CXR (upright) -> linear delineation of the edge of the collapsed lung with no further lung markings beyond this line, tension will show shifting of mediastinal structures away from PT, subQ air, deep sulcus sign (anterior PT)
Other Dx testing in PT?
CT scan - if stable, can be useful to quantify the size of PT and any underlying pathology or other injuries
US - very useful if upright CXR cannot be obtained
Rx of PT?
Depends on severity; all patients get O2 and monitor
Tension - needle decompression with 14-gauge angiocatheter into 2nd ICS at midclavicular line, followed by chest tube
Large (>20%) - chest tube
Small - needle aspiration, small pigtail catheter, or simple observation with repeat CXR to assess for spontaneous resolution
Dispo of PT?
Option of observing otherwise healthy patients with a small PT in the ED for 4 hours with repeat CXR
Majority will be admitted for further obs and management
