SOB Flashcards
An ambulance arrives to your Emergency Department with a 60-year-old woman who reports she is having difficulty breathing.
Her vital signs en route were:
BP 190/100, HR 118, RR 34, and SpO2 87% on RA.
As they move her off the stretcher, you notice that she’s breathing fast, she isn’t talking, and her shoulders and abdomen move with each breath.
PE: Bibasilar crackles, b/l pitting edema, JVD
Hx: Ran out of anti-HTN and diuretics
Interval hx: Symptomatic improvement with BIPAP
What is your most likely diagnosis and what other orders would you make?
-what is BIPAP doesnt work -> intubate
-lasix takes 6 hours to work
-GIVE NITRATES- decrease afterload
dyspnea
-Feeling of difficult, labored, or uncomfortable breathing (subjective)
-Often cardiac or pulmonary in nature, although anxiety is also a common cause
-!!Respiratory distress is when a patient has subjective feelings of dyspnea PLUS signs of difficulty breathing
-In these cases, treatment/stabilization can precede getting a final dx
-upper airway- foreign body, swelling, blood, vomit
-lungs- PNA, PTX, PE, Asthma/COPD
-heart- ACS, CHF, pericardial effusion or tamponade, valvular insufficiency
-metabolic- sepsis, DKA drugs, liver or renal failure, CO poisoning, pregnancy, drugs
causes of dyspnea
-MC:
-Obstructive airway disease (Asthma, COPD)
Decompensated heart failure/cardiogenic pulmonary edema
Ischemic heart disease
Pneumonia
Psychogenic
-immediately life threatening causes:
Upper airway obstruction!!: foreign body, angioedema, anaphylaxis, hemorrhage
Tension pneumothorax
Pulmonary embolism
Neuromuscular weakness: myasthenia gravis, Guillain-Barré syndrome, botulism
Fat embolism
Tamponade
-uncommon causes of dyspnea:
-Valvular heart disease
Porphyria
Cardiomyopathy
Mechanical interference (pregnancy, ascites, obesity, hiatal hernia)
Ruptured diaphragm
Thyrotoxicosis
Guillain-Barre syndrome
Tick paralysis
MS
ALS
Polymyositis
initial eval of respiratory distress
-vitals- place on monitor, SPO2 %, peak flow
-if COPD is low prob dont need O2
-everyone else O2 to 97
-oxygen: Nasal cannula, NRB, BIPAP, Bag valve mask, if not breathing
Intubation
-IV access + Blood tests:
-POC glucose
-CBC/CMP- anemia, metabolic, WBC
-VBG/ABG!!!
-BNP
-Dimer?
-Troponin? - false elevation- renal failure, myocarditis
-imaging
-CXR, POCUS, CT chest, soft tissue neck (if upper airway)
-cardiac
-ECG
-ECHO
initial approach
-speaking = patent
clinical features of respiratory distress
-Tachypnea
-Tachycardia
-Accessory muscle use
-SCM, intercostals use, nasal flaring
-Inability to speak full sentences
-Depressed consciousness in hypercapnia
-Agitation or confusion in hypoxemia
-Paradoxical abdominal movements in diaphragmatic fatigue
-look at the pics
physical exam
-stridor- high pitched sound indicating obstruction in upper airway
-wheezing- indicative of bronchospasms
-diminished breath sounds- lack of airflow, think consolidation, effusion, pneumothorax, asthma
-crackles or rales- indicates intra-alveolar fluid, pneumonia or pulmonary edema
pitfalls of the pulse ox
-false high:
-anemia (HGB <10)
-carboxyhemoglobin
-methemoglobinemia
-supplemntal O2 masking
-false low:
-deeply pigmented skin
-high venous pressure (tourniquet, BP cuff, venous obstruction, CHF
-poor no reading:
-poor perfusion
-ambient light
-motion artifact
normal lung POCUS
-US love fluid and hate air
-black parts are ribs, the line is the pleura
abnormal lung POCUS
-B-lines in pulmonary edema
-looks underwater
A 55 year old man was found unconscious in the bathroom by his family. He has a GCS of 7.
His vital signs: HR 130, BP 90/55, RR 28, and an oxygen saturation 89% on room air.
He is lying flat on the resuscitation stretcher and making some sonorous breath sounds.
The eager PA student grabs a laryngoscope and says, “ABCs… let’s get this guy intubated”… after elevating the head of the bed to 30 degrees, inserting a nasopharyngeal airway, and applying a jaw thrust, he is breathing quietly at 23 breaths a minutes, and his oxygen saturation has climbed to 92% with facemask oxygen. Is it time for intubation?
PERI-INTBUATION period is a HIGH RISK time!
5 risk factors for cardiovascular collapse:
Hypoxemia
Hypotension
Severe metabolic acidosis
RV failure
Severe bronchospasm
KNOW YOUR EQUIPMENT
SOAPME
Suction, oxygen, airway equipment, pharm, monitors, ETCO2
Reference: https://emcrit.org/wp-content/uploads/2016/06/Checkboxed-Checklist-2016-05-03.pdf
RSI meds:
Induction: Etomidate, ketamine, propofol
Paralytics: Succinylcholine, rocuronium
Reference: https://first10em.com/airway-medications/
bag valve mask (BVM)
-USE THIS TO DELIVER MANUAL BREATHS TO PATIENT
-High flow oxygen (15L/min) is attached to system
-Place over nose+mouth
-TIGHT seal (two handed technique with assistant is better than 1-handed C-E technique)
-Slow, small squeezes
-!!Hyperventilation does not treat hypoxia!
BVM complications
- Easy to hyperventilate
-Poor seal is common (esp if one-handed CE grip is used) (facial trauma, beards)
-Gastric distension
-Aspiration
-Exhaled secretions and moisture can result in exhalation valve dysfunction and increased resistance to expiration
-Risk of barotrauma
-Equipment failure (e.g. due to incorrect assembly)
-Edentulous patients
intubation
-After you optimized the patient, got your equipment, you are ready for intubation!
-Consider ANATOMY
-Place in good position
-Avoid oxygen desat
-Push the RSI meds and wait!
-Move the laryngoscope blade along the tongue until you see the epiglottis, seat the tip of the blade in the vallecula, “superman” the blade to lift the head, insert the endotracheal tube, secure the tube
-How do we confirm placement?
-Direct visualization of the tube going through the vocal cords!
-End-tidal capnography
-Colorimeter
-EQUAL chest rise
-Bilateral breath sounds
-CXR
asthma stats
-Asthma Cost USA >$50 billion every year
-Prevalence 1.7 million ED visits in 2016
-Asthma exacerbation visits in the ED cost 5x more than office-based visits
-Higher among income below poverty level
-Highest in Northeast & Midwest regions
-Mortality greater in: AA and Latinos, females, adults
-Factors associated with asthma prevalence: Developed nations, urban areas
-Factors associated with mortality/morbidity: poverty with lack of access, overuse of OTC inhalers, underuse of preventive therapies
asthma
-Bronchoconstriction due to reversible causes (airway edema, bronchoconstriction, smooth muscle hypertrophy, mucous production)
-Decreased expiratory flow -> air trapping
-Decreased ventilation, oxygenation
-can cause permanent bronchial damage
asthma mucous plug
asthma triggers
-Environmental allergens: Pollen, dust mites, molds, animal dander, cockroaches
-Other triggers
-URI (most common)
-Aspirin-exacerbated respiratory disease (AERD)
-Various non-steroidal anti–inflammatory drugs
-!!Cold environments
-Exercise
-GERD
-Emotional stress
-Hormonal fluxes: Pregnancy, menstrual cycle
-!!Beta blockers (even eye drops)
-Samters triad:
-Nasal polyps,
-asthma,
-ASA/NSAID sensitivity
presentation of asthma exacerbation
-Shortness of breath
-Cough
-Audible wheezing
-Chest tightness
-Increased use of inhalers
-No relief with home steroids
-An underlying diagnosis of asthma is suggested by:
-1+ of respiratory sx (wheeze, chest tightness, cough, and dyspnea)
-episodes over time
-symptoms that are often worse at night
-precipitated by a trigger
-commencement of symptoms in childhood
-a family history of asthma
-a personal history of allergic rhinitis or eczema
asthma PE
-Assess vitals, pulse ox, LOC, work of breathing, breath sounds
-Signs of severe exacerbation include:
-Inability to speak in phrases
-Tripod
-Chest wall retractions
-AMS/Agitation
-Tachypnea (RR>40 in adults)
-Tachycardia (HR>120 in adults)
-Accessory muscle use
-SpO2<90%
-Peak flow < 40-50% of prediucted
-Poor air movement
-SILENT CHEST ≠ Reassurance
asthma worsening clinical features
-decreased expiratory flow
-air trapping and barotrauma- PTX, pneumomediastinum
-decreased venous return- hypotension, pulsus paradoxus
-keep inhaling and not exhaling -> lung pops
-causes hypotension
asthma critical differentials
-Acute decompensated heart failure
-Anaphylaxis
-Angioedema
-Foreign body aspiration
-Pneumonia
-Pneumothorax
-PE
asthma dx tests
-Routine radiographic, laboratory testing, ECG is generally NOT required
-Mild exacerbation -> NO IV/Cardiac monitoring
-Moderate-Severe -> cardiac monitoring and continuous pulse oximetry
-If possible, either peak flow or FEV1 should be obtained prior to tx
-Calculator: MdCalc
asthma tx
-ABCs
-Maintain oxygen ≥ 92%
-Most patients will have transient V/Q mismatch
-Avoid hypotension
-Normal saline 1-2 liters can prevent obstructive shock and combat insensible water loss
-albuterol causes variable shifts during tx -> dont be worried
asthma 1st line tx: nebulizers
-Inhaled SABA: Albuterol (Ventolin)
-Bronchodilator of the small airways
-MDI, MDI with spacer, or nebulizer treatment
-MDI is 4-6 puffs q20-40 minutes
-Nebulizer: 5mg q20 min x 3 doses
-There is no max dose of albuterol inhaler
-SE: TACHYCARDIA, Tremors, anxiety, Very high dose ↓ K
-Anticholinergics: Ipratropium bromide (Atrovent)
-Adjunct for moderate-severe asthma -> never give by itself
-Action = Bronchodilation by blocking bronchial smooth muscle
-MDI or nebs
-Administer WITH the beta agonists (never use solo)
-spacer for kids
asthma 2nd line tx: systemic steroids
-Systemic Corticosteroids
-Give in all but the mildest cases of acute asthma exacerbation
-Main defense against relapse
-Delayed action onset: gradual 1-2 hours, peaks 4 hours
-Upregulate beta receptors
-Side effects: ____________________________
-Oral is just as effective as parenteral
-Oral Prednisone 40-60mg daily for 5 days
-Children: 1-2mg/kg for 3-5 days
-Oral Dexamethasone 16mg daily for 1-2 days
-Methylprednisolone 125mg IV or IM (1mg/kg peds)
-oral = IM = IV
-dont need to know which steroids
treatment adjuncts: asthma
-Magnesium sulfate (3rd line):
-Smooth muscle relaxer
-Indicated in those with impending respiratory failure / severe asthma after 1 hour intensive therapy
-Onset of action as early as 2 minutes, lasting 1-2 hours
-Single dose of 2g IV in 100NS over 15-30 minutes (25-75mg/kg up to 2 g in children)
-Adverse effects: Flushing/hot feeling, bradycardia, muscle weakness, hypotension
-Epinephrine SUBQ/IM:
Epinephrine 0.1-0.3 mg SC (1:1,000)
-Give in cases of allergic reaction usually (not recommended for routine asthma treatment)
-Both a bronchodilator and a vasopressor
-Heliox
-A mix of helium-oxygen (80:20) can be used in severe exacerbations. Helium is less dense than oxygen, it can travel through smaller airways, increasing oxygen or inhaled medical delivery.
-Non-invasive ventilation
-Requires a cooperative patient, spontaneous breathing
-Bronchodilates -> recruits small airways, better beta-agonist facilitation
-Decreases WOB, fatigue, oxygenation -> rest for diaphragm
-Ketamine
-IV bolus and infusion
-Sedates the patient and relaxes them, but also increases secretions
-recommended induction agent of choice in asthmatic patients requiring intubation
astham: no indications
Antibiotics (unless pneumonia)
Aggressive hydration
Mucolytics
Sedation
Anti-tussives
Decongestants
asthma intubation
-The decision to intubate a patient with severe asthma should NOT be taken lightly
-Intubation -> laryngospasm, bronchospasm, hypotension, more hyperinflation, peri-intubation arrest
-Difficult to manage on ventilator
-Permissive hypercapnia (dont know this):
-Once intubated, the airway is secure, no need to rush and excessively ventilate
-Allow pCO2 to be elevated (eg 60-80mmHg, with SaO288-92%) acidosis to help oxygen dissociate better.
-Increase expiratory phase (↓ RR, ↑ inspiratory flow, ↓ tidal volume, This relaxes the bronchi. )
discharging an asthmatic home
-Discharge criteria
-No (or minimal) wheezing
-Feels better!
-Ambulates without hypoxia
-FEV1 ≥70% predicted or personal best after bronchodilator
-Prescription for albuterol MDI +/- steroids
-Albuterol MDI 4 puffs q4h PRN ± spacer ± age-appropriate face mask
-Prednisone 50mg daily x 5 days (if oral was used)
-Consider adding inhaled corticosteroids (ICS) such as fluticasone / budesonide / mometsaone / blecomethasone if the patient is not already on them
-Education:
-!!Important: teach concept of “controller” vs. “Rescue meds”
-!!Important: teach how to use an inhaler
-Emphasize need for continual and regular primary care follow up
-1 week follow up with PCP
-Avoid triggers
-asthma action plan
-pericardium
-pneumomediastinum
-asthma complication
-subcutaneous emphysema on the neck can cause
asthma key concepts
-Clinical signs and symptoms of asthma are…wheezing, chest tightness, cough
-History, symptoms, and signs of severe asthma are…recent cold? any meds, hospitialzation
-Step-wise treatment for asthma is….albuterol +- ipatropium, steroids, magnesium
-The side effects of treatment are…
-Diagnostic testing [is not] required for the majority of patients with asthma exacerbations….
-Remember that ASTHMA is COMMON, and it can KILL
A 54-year-old patient with a long-standing history of smoking, and hypertension, presents with shortness of breath, increased frequency of cough, and change in the baseline color of sputum over several days. On examination, the patient is in mild distress and has a respiratory rate of 28 breaths/minute, with a pulse oximetry reading of 86% on room air. The patient has mild accessory muscle use, and decreased breath sounds are observed bilaterally with faint end-expiratory wheezing. Temperature is 99.9F by mouth.
She denied any chest pain or fever. She has been smoking 1 pack a day for 40 years. She reports catching a small cold one day ago defined by nasal congestion and mildly productive cough.
On further eval – you note normal heart sounds, no JVD, no abdominal distension, no leg edema or tenderness.
What were your differentials?
-pneumonia
-TB
-bronchitis- should not have this low of O2
-lung cancer
-COPD
approach to critical pt: COPD excaerbation
-Supplemental oxygen goal 88-92% (100% is too high for COPD)
-Start BiPAP to reduce work of breathing
-Intubate if BiPAP if contraindicated
-Avoid aggressive bag-valve-mask ventilation
-Pre-oxygenate only if intubating
-Administer !!!bronchodilators, steroids, antibiotics!!!
-circulation:
-IV access and cardiopulmonary monitoring
-Generally tachycardic and hypertensive due to adrenergic drive
-Consider auto-PEEP and pneumothorax in hypotensive patients
-disability:
-depressed LOC -> maybe hypercapnia
COPD
-Chronic lung disease: Dyspnea, chronic cough, sputum production
-Most common symptom: Exertional dyspnea
-Most common cause is SMOKING
vicious cycle of flash AECOPD
focused history (if possible from pt or caregiver)
-Ask about current attack
-Onset
-Symptoms (wheezing, productive cough, SOB/DOE, exercise intolerance, sputum change)
-Increased use of inhalers, or new requirement of sleeping upright in chair
-Ask about baseline function
-Exercise tolerance
-Home oxygen use
-Ask about previous attacks
-Frequency of exacerbations
-Last exacerbation and normal course of illness (# days admitted, ICU, intubation)
-Ask about features that may point to alternative diagnosis
-Sudden onset -> PTX / PE?
-Fevers -> Pneumonia
-CP -> ACS or CHF?
-Remember that COPD is a chronic illness with exacerbations, so question WHY TODAY?
-Most common: Viral or bacterial infection
-Chest problem: Infection (PNA), PE, PTX, Atelectasis, CHF
-Meds: Non-compliance, underdosing, b-blockers, sedatives
-GI: Uncontrolled GERD
-Environmental: Smoking, pollution, weather
acute exacerbation of COPD (AECOPD)
Cough
Wheezing
Chest congestion
SOB
↑ Dyspnea
↑ Sputum volume
↑ Sputum purulence
Tachycardia
Pursed lip breathing
Accessory muscle use
Hyperresonant chest
Barrel chest
Wheezing or prolonged expiration
COPD investigations
-order these to RO other things
-Standard orders
-CBC, CMP
-VBG
-CXR
-!!!!ECG – tachycardia, MAT, cardiac mimics (STEMI)
-tachy, irregular, p-waves are diff - multifocal atrial tachy
-Additional orders if applicable (exclude alternate diagnosis)
-Troponin
-BNP
-D-Dimer ± CT angiogram chest
-Viral panel
-Sputum culture
-POCUS
diseases that mimic COPD
CHF
PE
PTX
Lung cancer
PNA
Ischemic heart disease
Brain natriuretic protein can be significantly elevated in cases of right heart strain, which occurs commonly in patients with COPD; this may be misinterpreted as a sign of left ventricular failure.
Indiscriminate use of D-dimer leads to false positive results and subsequent inappropriate (and potentially harmful) imaging. D-dimer should be obtained judiciously in cases where there is some clinical likelihood of venous thromboembolism.
COPD findings: flattened diaphragm, vertical heart, ↑ AP diameter, large focal lucencies indicating bullae
Alternative diagnosis: PNA, PE, PTX
-11 and 12 posterior rib
-COPD with right bullae
COPD VBG
7.3- acidic
-63 CO2- high
-bicarb - 29 -> chronically compensating
COPD management
-The decision to initiate one of these adjunctive therapies can be purely clinical. It can be based on overall assessment of work of breathing, or via direct measurement of arterial blood gases.
-Mild exacerbation
-Nasal cannula or venturi mask
-Target O2 sat: 88-92%
-Moderate-severe
-NIPPV e.g. BiPAP* or CPAP
-Contraindications: ________________________
-Rapid sequence intubation (RSI)
-Severe exacerbation, respiratory arrest, mental status changes
-Worsening oxygen, or worsening acidosis, despite BiPAP
-NIPPV advantages:
↓ Work of breathing
↓ Intubation rates
↓ Mortality
↓ Hospital LOS
↓ Days in ICU
-stay on bipap for at least 72 hrs no matter what
COPD sequence of tx
-O2
-beta agonist
-corticosteroids (MAINSTAY) -but doesnt work fast
-antibiotics- ceftriaxone in hospital, azithro at home (never really happens)
disposition COPD
-discharge home (uncommon)
-Mild-moderate symptoms
-Responded well to therapy
-Normal O2 on rest and EXERTION
-Discharge with: steroids, bronchodilators, antibiotics
-Follow up 1 week outpatient
-admit:
-Medical floors:
-Low O2 with exertion/ambulation
-ICU:
-HD unstable
-Intubated or biPAP
-Severe acid base disturbance
review COPD
-trigger- smoking
-acute COPD tx- O2, albuterol +- ipa, steroids, antibiotics
-non-invasive strat for work of breathing- nasal cannula and step up
-88-92%
52-year-old man with a history of smoking presents with fever, cough, dyspnea for 2 days. Exam is notable for tachypnea and mild rhonchi.
80-year-old male from a nursing home presents with confusion and generalized weakness
right lower lobe consolidation
-silhouette sign
approach to critical pneumonia
-airway/breathing:
-supplemental O2 as needed
-suction for aspiration
-NIPPV or intubate for hypoxemia +- respiratory distress
-circulation:
-IV access and cardiopulmonary monitoring
-crystalloid boluses for septic shock as needed
-vasopressors for septic shock (nor -epi, vasopresin, epi)
-tx: empiric antibiotics:
-Regimen 1 = Azithromycin, Cefepime, Vancomycin OR
-Regimen 2 = Cefepime, doxycycline, vancomycin OR
-Regimen 3 = Azithromycin, Zosyn, vancomycin
pneumonia (PNA)
-inflammation of the lung parenchyma
-Alveolar airspaces are filled w/ exudate and inflammatory cells
-Caused by infection (aspiration, inhalation, seeding) or chemical exposure
-RFs: chronic lung dz, smoking, older age, immunocompromise
-Classification based on pt and setting
-MCC is strep pneumonia (no matter what)
-Pneumonia is MCC of sepsis and septic shock!!
-Cough (80-90%)
-Fatigue / Malaise (90%)
-Fever, chills (75%)
-Sputum (60-65%)
-Tachypnea (45-70%)
-Pleuritic chest pain (39-49%
-Dyspnea (67-75%)
-ELDERLY often present ATYPICALLY
-Confusion, AMS, Delirium (>50%)
-Weakness
-Lethargy
-35% present w/o fever
-Common physical exam findings
-Tachycardia
-Abnormal lung sounds (rhonchi, crackles, wheezing, decreased lung sounds)
-Tactile fremitus
-Egophony
-Dullness to percussion
classification of pneumonia
-type of infection: bacterial (typical or atypical), viral, fungal
-pt health: health or unhealthy (co-morbid)
-setting: CAP or HAP/VAP
atypical pneumonia
-does not show up on gram stain
-more likely diffuse rather than lobar
-bullous myringitis
-red throat
-productive cough
HIV risk for pneumonia
-PCP
-histoplasmosis
-TB
bacterial pneumonias
-MRSA- recent flu that developed into bacterial
pneumonia dx (pic is right lower lobe- spine sign+)
-If pt HEALTHY and MINIMALLY ILL -> no labs indicated!! -> clinical dx
-Lab options include:
-Viral swab testing
-Respiratory cultures -If ICU admission, hx of MDRO, hx of MRSA/Pseuodomnas, recent parenteral antibiotics
-CBC, CMP, VBG (↑ WBC with left shift)- if teetering on sepsis
-Lactate- If signs of sepsis
-Urinary s. pneumonia or legionella (GI symptoms and hyponatremic) antigen- Only in severe and if indicated
-!A negative CXR does NOT rule out CAP
-!A negative WBC does NOT rule out CAP
-CXR in any pt with respiratory symptoms PLUS one or more:
-≥ 65 years old
-Abnormal vital signs
-Abnormal lung sounds
-CXR findings
-LOBAR INFILTRATES: Air bronchograms, Bulging fissure sign
-INTERSTITIAL PNEUMONIA- Diffuse ground glass opacities
-CAVITATIONS (rare)
-SILHOUETTE SIGN
-RETROCARDIAC INFILTRATE
-SMALL PLEURAL EFFUSIONS
-Or.. nothing!- early on, dehydration, immunocompromised (no compensation)
-other:
-ECG
-POCUS
-CT chest- if concerned
-pic shows left upper lobe- loss of cardiac sillohuette
A 60yom , HX of alcohol abuse, BIBEMS after being found intoxicated on the sidewalk. On arrival, he vomits while lying flat and appears to aspirate. His O2 sat decreases after this event but improves with suctioning and 2 L oxygen by nasal cannula. A CXR obtained shortly thereafter shows diffuse infiltrates.
diffuse
80yoF h/o stroke and dysphagia is sent to the ED from her NH with increased work of breathing. She appears frail and fatigued and is tachypneic. CXR shows infiltrates in the lower portions of the superior lobes bilaterally.
-aspiration
-upper lobes (usually would be lower)
Fevers and cough in 55yoF. They also have nausea and diarrhea, they were recently on a cruise. Labs notably hyponatremic.
legionella
20yoM fever, night sweats, hemoptysis
TB miliary
40 year old immunocompromised male fever, cough, right sided chest pain
A side note on cavitations:
- Anaerobes can cause abscesses, especially if there is an air fluid level
Staph aureus (IVDA)
Pseudomonas
Tuberculosis
-dont send home
-drain
-can evade a vessel and cause bleeding
CURB-65
-65 year old with pneumonia- should you send them home? -> idk? use this tool!
-Confusion = 1 pt
-Uremia (BUN >20) = 1 pt
-RR > 30 breath/min = 1 pt
-BP (SBP <90 or DBP <60 mmHg) = 1 pt
-Age > 65 = 1 pt
PORT score (PSI)
-Demographics
-Co-morbidities
-Presentation
-Labs & Imaging
CAP OUTPATIENT tx
-NO CO-MORBIDITIES (CHOOSE ONE):
-1. Amoxicillin1 g oral every 8 hours.
-2. Azithromycin500 mg oral (day 1), followed by 250 mg oral every 24 hours (days 2-5)only if local pneumococcal macrolide resistance is <25%.
-3. Clarithromycin1,000 mg oral every 24 hoursonly if local pneumococcal macrolide resistance is <25%.
-4. Doxycycline100 mg oral every 12 hours
-CO-MORBIDITIES (CHOOSE ONE):
-1a. Amoxicillin-clavulanate875 mg/125 mg oral every 12 hours AND
-1b. Azithromycin500 mg oral (day 1), then 250 mg oral every 24 hours (days 2-5). Or Doxycycline100 mg oral every 12 hours.
-2a. Cefpodoximeproxetil 200 mg oral every 12 hours or Cefuroxime axetil500 mg oral every 12 hours AND
-2b. Azithromycinor Doxycycline
-3. Levofloxacin 750mg oral every 24 hours -> Monotherapy fluoroquinolone not first line recommendation!!!!
non-severe INPATIENT CAP
-Combination therapy with beta-lactam:
-Ceftriaxone 1-2g IV QD OR Ampicillin + sulbactam 1.5-3g IV q6h (Unasyn) OR cefotaxime 1-2g IV q8h
-PLUS Azithromycin 500mg QD (doxycycline can replace macrolide if allergy)
OR…
-Monotherapy with respiratory fluoroquinolone:
-Levofloxacin 750mg IV/PO QD
severe CAP
-In non-severe CAP, even those with recent hospitalization, can defer treatment for these until positive test, or if high pre-test probability.
-In severe CAP, give these
-MRSA- Vancomycin or linezolid covers MRSA
-Pseudomonas- Pip-tazo or meropenem or cefepime
-PCP pneumonia- TMP/SMX
pneumonia mimics
-PE* fever and dyspnea
-ACS
-CHF
-Pulmonary abscess/emypema
-Atelectasis
-ARDS E.g. chronic toxicity from ASA
-Cancer
-Diffuse alveolar hemorrhage
-Right sided endocarditis with septic emboli (IVDA)
-Toxilogic or environmental
-Tuberculosis
-Low risk mimics:
-Bronchitis, URI, minor asthma exacerbations
pneumonia summary
-Most CAP is caused by?
-What can cause false negative CXR in PNA?
-Who does NOT need a CXR? outpt, healthy
-Risk factors for MRSA? recent hospitalization, intubation, recent flu
-Pseudomonas? recent hospitalization
-Tx for healthy outpatient CAP? betalactam - amox
25 year old male comes into ER for acute onset right sided chest pain
It was sudden onset, sharp, severe, pleuritic and associated with shortness of breath
Initial vitals:
BP 135/80 mm Hg , RR 22, HR 99, O2 88% on RA
Mild distress, slightly tachypneic
Decreased breath sounds on the right
A SUDDEN CHANGE
BP 65/32 mmHg
RR 35
HR 150
O2 not reading
-PE:
-trachea deviation
-JVD
-decreased breath sounds
-1st step -> emergent 14-16g needle decompression in the 2nd intercostal space midclavicular line
-stabilize with chest tube in 5th intercostal space anterior axillary line
spontaneous vs traumatic vs tension pneumothorax
-SPONTANEOUS:
-Primary- no underlying disease -> Think tall, thin, male smokers, Marfans, w/ blebs
-Secondary- pts WITH underlying ds -> COPD, asthma, rarely TB, PCP
-TRAUMATIC:
-Iatrogenic- Bx, thoracocentesis, nerve blocks, central lines
-Penetrating injury- Rib fractures, open wounds
-Blunt chest injury
-More likely to develop tension PTX due to 1-way valve
-TENSION:
-Any PTX can turn into a tension PTX
-Shifting of mediastinal structures
-DANGEROUS
pneumothorax
-Sudden onset
-Ipsilateral pleuritic chest pain
-Dyspnea
-Unilateral decreased breath sounds
-↑ RR and HR
-Lung collapse on CXR
-Small: <20% or apical <1-2 cm from chest wall!!!!!
-Minor symptoms
-Observation with nasal oxygen
-6-hour repeat CXR
-No definitive treatment
-Discharged home with close outpatient follow up.
-Expiratory films preferred in PTX
-no lung markings in the top left apical
need patient to stand upright for pneumo
-left deep sulcus sign- so big -> air is pushing down on diaphragm
pneumothorax: POCUS
-obtain view of lung slide to assess
-pleural side “ants on a log” = good
-no pleural slide = BAD
-M-MODE “seashore” is normal = good
-M-MODE “barcode” is indicative of pneumo = BAD
management of pneumothorax
-Small (simple) PTX
-Observe + supplemental 100% O2 + repeat CXR 6 hours
-Symptomatic or large (simple) PTX
-Chest tube
-TENSION, bilateral, expanding, or >20% lung
-1st step is needle decompression 2nd ICS MCL
-THEN definitive chest tube in 5th ICS Anterior axillary line
-CT surgery consultation
Which of the following is NOT correct regarding tension pneumothorax?
-Should be diagnosed by CXR!!!!!!!!!!
-Trachea deviation to the contralateral side
-Patients will have severe dyspnea
-Patients will be hypotensive
-Decreased breath sounds on affected side
A 61-year-old woman presents to the ED with shortness of breath.
O2 85% RA , BP is 185/90 mm Hg and pulse rate 110, RR 32.
On exam she has rales halfway up both of her lung fields , JVD, and lower extremity pitting edema.
What would you do?
approach to critical acute heart failure
-set up:
-IV access, vitals, monitor,
-ECG- new arrythmia, sepsis
-CXR
-POCUS
-airway/breathing:
-airway usually intact unless altered
-tachypnea, bibasilar dullness to percussion, hypoxic <90%, crackles +- wheezing are common
-100% O2 by NRB -> NIPPV! -> intubate
-circulation:
-appear diaphoretic (skin is cold, clammy)
-ECG to assess for new arrythmia
-assess for new murmurs, S3 gallop, JVD, mucus membrane, peripheral edema, hepatomegaly
-if HTN- consider nitroglycerin for preload and afterload reduction
-If overloaded: Consider IV furosemide (not every pt with pulmonary edema is volume overloaded)
-If hypotensive: Consider pressors. Think about causes of shock (MI, valvulopathy)
acute heart failure
-Leading cause of hospitalization
-Costs up to 50 billion a year
-80% admission rate
-Average LOS = 5 days
-Mortality rate 10% per year
-Heart cannot pump adequate blood
-HFrEF (Systolic dysfunction)
-Impaired contractility
-Low EF <45%
-Low cardiac output
-HFpEF (Diastolic dysfunction)
-Impaired relaxation of the heart leads to ↓ left ventricular filling and pulmonary congestion
-LVEFF >50%
-Can lead to systolic dysfunction
precipitating factors of acute HF
-Infection (e.g. pneumonia, sepsis)
-!!Myocardial infarction or ischemia
-Arrythmias
-Uncontrolled hypertension
-Excessive fluids, ↑ salt intake, renal failure
-High output states (wide pulse pressure):
-Profound anemia
-Hyperthyroidism
-Valvular disorders(severe aortic stenosis), dissection, PE, myocarditis/endocarditis
-Fluid retaining medications (NSAIDs, oral hypoglycemic pioglitazone)
-Medication non-compliance
acute HF sx
-Dyspnea = MC
-Orthopnea
-Fatigue/Weakness
-Leg swelling
-Weight gain
-Meds?
-Diet?
-Fevers?
-PND?
-Chest pain or RUQ pain?
-Respiratory distress
-Cool, clammy, diaphoretic
-Tachycardia
-Hypoxia
-Low pulse pressure (<40mmHg difference)
-Rales or crackles
-S3
-JVD
-Hepatojugular reflux
-Ascites
-Edema
-New murmur (requires stat echo)
acute heart failure dx labs
-ABG/VBG (pH, lactate)
-B-type natriuretic peptide (BNP) is secreted by the ventricles in response to wall stress (↑ in CHF or PE)
-Values <100 pg/mL has a negative predictive value of 98%
-BNP>500pg/dL or NT-proBNP>1000pg/dL suggests acute heart failure syndrome
-Troponin to evaluate for AMI
-CBC
-Anemia can cause high-output heart failure
-Leukocytosis might indicate infection
-CMP +Magnesium
-Liver and renal function- BUN/creatinine > 20 = pre-renal failure (poor prognosis), Liver abnormalities from congestion (↑ bili, ↓ albumin)
-Electrolyte abnormalities- Low K in chronic diuretics (thiazides, loop diuretics), Low Na in overload (poor prognosis)
-Thyroid panel
-VBG (pH, lactate)
acute heart failure imaging
-CXR can show cardiomegaly, pulmonary edema, pleural effusion, Kerley B lines, “batwing” congestion. R/o pneumonia, ptx
-ECG with left axis deviation (hypertrophy). R/O ischemia, arrythmia
-Ultrasound to look for 3 or more B-lines in one lung view, assess heart EF, wall motion, IVC
-CXR- ABCDE
-Alveolar edema (batwing)
-Kerley B lines
-Cardiomegaly
-Dilated upper lobe vessels
-Pleural effusion
-echo:
-checks for EF
-see how hard the heart is pumping
-B-lines in lungs represent increased fluid in the area
-DDX: Pulmonary edema in CHF, pneumonia, pulmonary contusion
acute heart failure
bag lining??- hilar infiltrates»_space;
-pulmonary edema
management of acute heart failure (no shock)
-Monitor, IV, pulse oximeter, sit up
-!Oxygen if needed (start with NRB 100%)
-!NIPPV (BiPAP) helps pulmonary edema
-!Nitroglycerin = 1st line in pts without cardiogenic shock!
-Can’t unload the LV if high afterload (HTN). Nitroglycerin reduces pre-load and afterload in hypertensive patients while redistributing fluid.
-Start with 30mcg/min IV nitro
-!IV diuretics (Furosemide (LASIX)) = in pts with fluid overload*
-Total body volume overload: medication non-compliance, fluid restriction non-compliance with pedal edema, JVD, bibasilar crackles, plump IVC!
-Removal of excess fluid can improve perfusion of heart and kidneys
-Not all acute HF has total body overload (just fluid backed up in pulmonary system)
-IV furosemide dose: double their total daily home dose as an IV bolus (often 40mg IVP)
-*EXCEPTION: Flash pulmonary edema can occur in the setting of MI. This will NOT have fluid overload and does NOT require diuretics.
management of acute heart failure if they are in cardiogenic shock
-Optimize oxygenation with NIPPV!
-Optimize BP with vasopressors!
-Norepinephrine!
-Goal MAP 65-80
-Optimize contractility! with inotropes!
-Dobutamine! can increase force of contraction and ↑ BP
-Can sometimes exacerbate the hypotension, be prepared to start vasopressors such as dopamine or nor-epinephrine
-Optimize volume status! (give IV crystalloid if intravascularly volume depleted, or, diuresis if overloaded)
-Assess end-organ perfusion: mental status, UOP, skin mottling/temp, elevated lactate levels
A 46 year old woman with a PMH of alcohol use disorder presents to the ER with increasing shortness of breath, abdominal pain, and vomiting. She is short of breath at rest and has not been able to keep anything down for 2 days. She was diagnosed with the flu 6 days ago.
BP 104/76, HR 118bpm, RR 24, O2 sat 88%.
Cardiac exam is unremarkable. Pulmonary exam reveals bilateral inspiratory crackling. Abdominal exam is distended with hypoactive bowel sounds, generalized pain with palpation that is worse in the epigastric area. There is no rebound tenderness.
Chest Xray reveals bibasilar interstitial edema. US of the abdomen is pending. Which of the following is the most likely diagnosis?
-Asthma
-Bacterial pneumonia
-Cholelithiasis
-Acute respiratory distress syndrome
ARDS
-pancreatitis
-aspiration
acute respiratory distress syndrome
-ARDS/Non-cardiogenic pulmonary edema= Acute, diffuse, inflammatory lung injury
-Poor lung oxygen exchange due to fluid in lung
-Some of the sickest! pts we see in the ED!
-ARDS is a not a primary disorder -> SECONDARY to other illnesses:
-Sepsis MC!
-INDIRECT: Pancreatitis, drug overuse, transfusion related injury, DIC
-DIRECT: Inhalation or burn injuries, pneumonia, toxin inhalation, lung contusions, drowning
-Hypoxemia!, tachycardia, dyspnea, diffuse crackles on exam
-PaO2/FiO2 ratio < 300!!!! (the worse the ratio, the more severe)
-CXR = diffuse pulmonary edema!!! bilaterally that is NOT explained by cardiac failure
-must r/o heart causes
-Immediate tx: High flow oxygen, IV fluids, PEEP!!, tx of underlying cause
-Supportive care, no direct therapy for reversal of ARDS
-Admit to the ICU!!!
anaphylaxis
-Typically, sudden onset
-Wheezing
-Hives (80%)
-Vomiting / diarrhea are common
-Hypotension
-Oropharyngeal edema
-angioedema
-urticaria
-erythema
-derm 90%
-tx:
-!Epinephrine saves lives
-0.3 - 0.5 mg of 1:1,000 IM q5m x 3
-(Peds is 0.01 mg/kg)
-Anterolateral thigh better than deltoid
-IM > subq
-Blue to sky, orange to thigh
-Other medications to give
-!Antihistamine (Benadryl) – blocks further antihistamine release
-!H2 blocker (famotidine)– blocks bradykinin
-!Steroids (dexamethasone) – block rebound anaphylaxis
-IV fluids – improve hypotension
-Glucagon – beta blockers can prevent effect of epinephrine, give to patients on BB
45 year old male presents with dyspnea and facial swelling
-urticaria
-edema of aryepiglottic folds
ANGIOEDEMA
-Histamine or bradykinin mediated
-Transient localized, non pitting swelling
-Hereditary, acquired, ACE-I, TPA
55 year old male “rush back” patient for shortness of breath
lung cancer
A previously healthy 7-year-old boy was referred by his primary care provider to our ED with a chief concern of cough for 1 week and difficulty breathing while running and playing at school for the last 2 days.
According to the primary care provider’s report, the boy had no nasal congestion, fever, drooling, dysphagia, wheezing, or stridor.
His symptoms had not been alleviated by over-the-counter cough remedies nor inhaled β-agonists prescribed by his primary care provider.
Temp 36.8°C (98.2F)
RR 20 breaths per minute
HR 90 beats per minute
BP 108/70 mm Hg
Oxygen saturation, 98% on room air.
Physical examination revealed a comfortable child in no apparent distress, but with significantly decreased air entry in the left lung field with no adventitious breath sounds.
Upon questioning, the patient reported that he had been chewing on the plastic end of a mechanical pencil 1 week before presentation and had choked on a small piece, which he thought he had swallowed
Otolaryngology was consulted
Elective rigid bronchoscopy for possible FBA.
A small plastic object surrounded by granulation tissue and mucopurulent secretions was found at the left secondary bronchus and was removed.
His postoperative course was uncomplicated, and he was discharged home after few hours of observation.
60 yr old female w/ a pmh significant for asthma and hypothyroidism who presents today with SOB, presents with dyspnea and near syncope.
BP 129/85 (Patient Position: Sitting) | Pulse (!) 121 | Temp 97.5 °F (36.4 °C) (Tympanic) | Resp 20 | Wt 110 kg (242 lb) | SpO2 96%
Constitutional: She appears well-developed and well-nourished. No distress.
Cardiovascular: Regular rhythm, S1 normal, S2 normal and normal heart sounds. Tachycardia present. Exam reveals no gallop, no distant heart sounds and no friction rub.
No murmur heard.
Pulmonary/Chest: Breath sounds normal. Accessory muscle usage present.
Abdominal: Soft. Normal appearance and bowel sounds are normal. She exhibits no distension. There is no tenderness.
Musculoskeletal: TTP of the L leg, some swelling noted on the L leg.
Nursing note and vitals reviewed.
POCUS in acute PE
RV wall hypokinesis,
RV dilation,
RA dilation,
paradoxical septal systolic motion and
dilated IVC with lack of respiratory collapse
“D” sign
-EKG
Sinus tach
RBBB
Poor R wave progression
TWI in precordial leads
CXR - normal
CBC (WBC 10)
CMP (Cr 1.2)
COAGS, T&S
TROPONIN (neg)
BNP (221)
VBG (pH 7.38, PCO2 48, Lactate 1.4)
-RV becomes bigger than LV due to massive PE blockage -> LV changes shape (D) bc its pushed -> D sign
-giant black spot is the PE
post intubation deterioration (DOPE)
-displaced ETT
-obstruction along circuit
-pneumothorax
-equipment failure
