Download Asthma

PULMONARY
EMERGENCIES
Summer 2009
Topics
•Asthma
•COPD
•Pulmonary Embolism
•Pneumonia
•Pneumothorax
Asthma
Asthma is a chronic inflammatory
disorder characterized by
increased responsiveness of the
airways to multiple stimuli.
Asthma
Affects approximately 4 to 5 percent of the
population in the United States.
It is the most common chronic disease of
childhood.
About one-half of cases of asthma develop
before the age of 10 and another one-third
before the age of 40.
The 2:1 male to female preponderance of
asthma in childhood equalizes by age 30.
Asthma
Relevant History
• The possible cause of exacerbation
• Previous ICU admission for asthma
• Previous intubations
• Length of recent steroid use
• Frequency of asthma medications
Asthma
Clinical Presentation
Most common symptoms
• Dyspnea or chest tightness
• Wheezing
• Cough
Asthma
Clinical Presentation
Severe Asthma
• Tripod position and gasping for air
• Audible wheezes with prolonged
expiration
• Accessory muscle use
• Tachycardia
• Tachypnea
• Hypertension
• Hypoxia
Asthma
Clinical Presentation
Indication of severe bronchospasm
• Cyanosis and Diaphoresis
• Pulses paradoxus of >20mmHg or more
Indication of hypercapnia
Altered mental status
Tremor
Apnea
Asthma
Evaluation
Peak flow
Pulse ox for O2 saturation
ABG to assess for:
Hypercapnia
Respiratory acidosis
CXR
EKG
Asthma
Treatment
The goal of treatment of acute asthma
in the ED is to:
Reverse airflow obstruction rapidly
by repetitive or continuous administration
of inhaled b2 agonists
Ensure adequate oxygenation
Relieve inflammation
Asthma
Treatment
Oxygen
Albuterol nebulized
Atrovent nebulized
Systemic corticosteroids
Terbutaline sulfate
Epinephrine
Magnesium sulfate
Asthma
Treatment
Indications for mechanical ventilation
Hypoxia
Severe hypercapnia
Altered mental status
Exhaustion
Worsening acidosis
COPD
The American Thoracic Society
(ATS) defines COPD as a disease
state characterized by the
presence of airflow obstruction
due to
chronic bronchitis or emphysema
COPD
• In North America, COPD is rare in persons
younger than age 40
• Common among older individuals
– prevalence of approximately 10 percent in those
aged 55 to 85 years.
• In the United States, COPD is
– The fourth most common cause of death
– The third most common cause of hospitalization
– The only leading cause of death increasing in
prevalence.
Risk factors
• Cigarette smoking(80-90% )
 a1-antitrypsin deficiency
Treatment for
COPD Exacerbation
• The first goal in the treatment of
COPD is to correct or prevent
life-threatening hypoxemia.
COPD Exacerbation
Treatment
Oxygen
Nasal cannula if needed
Albuterol nebulized
Atrovent nebulized
Systemic corticosteroids
Not for mild or moderate
Antibiotic choices include:
Macrolides
Trimethoprim-sulfamethoxazole
Fluoroquinolones
COPD Exacerbation
Admission Criteria
Failure to improve adequately inspite of
therapy
Deterioration in condition in spite of therapy
H/o significant comorbid illnesses
Patients without an intact social support system
at home.
Pneumothorax
• Pneumothorax occurs when air enters
the potential space between the
visceral and parietal pleura.
• The cause may be:
– Spontaneous
– Penetrating trauma
• Iatrogenic pneumothorax
– Blunt trauma
Pneumothorax
Four causes of iatrogenic pneumothorax
• CVP line placement
• Thoracentesis
• Intercostal nerve block
• Mechanical ventilation
SPONTANEOUS PNEUMOTHORAX
• Primarily a disease of male smokers who
have larger height-to-weight ratios.
• Three peaks:
–among neonates
• (due to hyaline membrane disease or aspiration)
–among 20- to 40year-olds
• (such cases tend to be primary)
–among those older than age 40
• (typically secondary cases)
SPONTANEOUS PNEUMOTHORAX
• Secondary causes
– COPD
– Asthma Cystic fibrosis
– Interstitial lung disease
– Cancer
– Pneumocystis carinii pneumonia
Thoracocentesis at the 7th intercostal, midthoracic space
PNEUMOTHORAX
• Symptoms
– Pleuritic chest pain
– Dyspnea
• Signs
– Decreased breath sounds
– Tachypnea
PNEUMOTHORAX
Gold standard for diagnosis
•CXR (PA) expiratory
Treatment
Treatment goals are:
• the elimination of intrapleural air
• optimization of pleural healing
• prevention of recurrences.
Treatment
• O2
• Observation over 6hours if small and
asymptomatic ( < 20%)
• Thoracostomy
If tension
• Needle thoracostomy
• Then tube thoracostomy
Pneumonia
Pneumonia
• Community-acquired pneumonia is a
common medical problem, accounting for
about 4million cases and 1 million
hospitalizations per year in the U.S.
• Pneumonia is the 6th leading cause of death
in the U.S.
Pneumonia
• Pneumococcus is the most common
cause of bacterial pneumonia
• Some other causes of include: E. coli,
Pseudomonas aeruginosa, Klebsiella
pneumoniae, Staph aureus, H.
influenzae, and group strep A.
• Legionella species and anaerobes are less
frequent.
Pneumonia
• Mycoplasma, Chlamydia , and respiratory
are grouped into atypical pneumonia.
• Pneumocystis carinii pneumonia (PCP) is
a common complication of HIV infection.
• Aspiration pneumonia occurs more
frequently in alcoholics and patients with
seizures, stroke, or other neuromuscular
disorders.
Pathophysiology
• Pneumonia is an infection of the alveolar or
gas exchange portions of the lung. Some
forms of pneumonia produce an intense
inflammatory response within the alveoli
that leads to filling the air space with
organisms, exudates, and WBCs.
• Patients at most risk for pneumonia
include those with predisposition to
aspiration, impaired mucociliary clearance,
or risk of bacteremia.
Clinical features
• Bacterial pneumonia generally presents as
fever, dyspnea, cough, pleuritic ches pain,
and sputum production
• Pneumococcal pneumonia classically
presents abruptly with fever, rigors, and
rusty brown sputum.
• Pleural effusion occurs in 25% of patients.
Clinical features
• H. Influenzae is more common in smokers
and the elderly.
• Reveals rales and ronchi on examinmation
without signs of consolidation.
• Legionella is spread through aerolized
water droplets rather than by person-toperson contact.
• Presents with F/C malaise, dyspnea, and
nonproductive cough.
Clinical features
• Legionella commonly presents with GI
symptoms e.g. Anorexia, nausea, vomiting
and diarrhea. Mental status changes may
also be present.
• Begins with findings of patchy
bronchopneumonia and progresses to
signs of frank consolidation, other
common signs relative bradycardia and
confusion.
Clinical features
• Staph aureus frequently follows a viral
respiratory illness , especially influenzae
and the measles.
• Klebsiella exhibit signs of consolidation
including bronchial breath sounds,
egophony, increased tactile fremitus, and
dullness to percussion. A pleural friction
rub and cyanosis may be present.
Clinical features
• Mycoplasma, Chlamydia, and viral
pneumonias present w/ fever/chills,
malaise, dyspnea and nonproductive
cough.
• Mycoplasma , Chlamydia, and viral
pneumonia may exhibit fine rales, rhonchi,
or normal breath sounds.
• Bullous myringitis, when present is
pathognomonic for Mycoplasma
infection.
Clinical features
• Empyemas are most common w/ S. aureus,
Klebsiella, and anaerobic infections.
• Aspiration pneumonitis depends on the
volume and pH of the aspirate, the
presence of particulate matter in the
aspirate, and bacterial contamination.
• Acid aspiration results in rapid onset of
symptoms of tachypnea, tachycardia, and
cyanosis.
Clinical features
• Acid aspiration often progresses to frank
pulmonary failure, most other cases of
aspiration pneumonia progress more
insidiously.
• Physical signs develop over hours and
include rales, ronchi, wheezing, and
copious frothy or bloody sputum.
• RLL is most commonly involved.
Diagnosis and differential
• DDX: acute tracheobronchitis, pulmonary
embolus or infarction, COPD
exacerbation, pulmonary vasculitides,
including Good-pasture’s disease and
Wegener’s granulomatosis; bronchiolitis
obliterans; and endocarditis.
Diagnosis and differential
• The diagnosis is suspected based on a
constellation of symptoms and signs, but
individual symptoms and clinical findings
lack accuracy for precise diagnosis.
• CXR
• WBC w/diff, pulse ox, blood cx, pleural
fluid examination, ABG(ill-appearing
patients)
Diagnosis and differential
• Sputum gram’s stain rarely changes
therapy.
• LFTs, serum chemistry, serologic testing
for mycoplasma, urine antigen for
legionella species.
• Most patients do not require identification
of a specific organism.
Treatment
• The ED treatment and disposition depends
primarily on the severity of the clinical
presentation and X-ray findings.
• O2 prn
• Antibiotics treatment should be initiated.
Treatment
• Outpatient treatment is standard in
healthy patients who are nontoxic and
without comorbid disease. Antibx include
zithromax, biaxin, cefpodoxime,
augmentin, or doxycycline.
• Oral fluroroquinolones are highly effective
; however, the CDC recommends reserving
them for those who cannot tolerate or have
failed other agents.
Treatment
• For outpatient management of patients <60
years old or those w/comorbid diseases,
levaquin is a good choice as a single agent.
• Augmentin or biaxin in combination w/
either cefuroxime or augmenting are
excellent drug regimens.
• Close follow-up is necessary to monitor
response to therapy.
Treatment
• Hospital admission should be reserved for
patients at the extremes of life,
immunocompromised patients , pregnant
women, and those with clinical signs of
hypoxemia (respiratory rate
>30breaths/min, HR >125bpm, SBP <90mm
Hg, hypoxemia, altered mental status or
volume depletion)
Treatment
• Serious comorbid). condions (eg,
neoplastic disease, renal failure, diabetes,
cardiac disease, or debilitated state
• Patients requiring admission generally
receive empiric antibiotic therapy.
• Recommended treatment include
ceftriaxone, levaquin, cefotaxime,
ampicillin-sulbactum, piperacillintazobactam, or cefepime.
Treatment
• Patients at high risk for gram-negative
pneumonia or Legionella (eg, alcoholics,
diabetics, and institutionalized or
intubated patients)
• Should be treated w/levaquin as
monotherapy or w/ a combination of a
macrolide such as erythromycin and either
ampicillin-sulbactam or ceftriaxone.
Treatment
• If Pseudomonas is suspected double
coverage w/ antipseudomonal penicillin or
cephalosporin plus either an
antipseudomonal aminoglycoside or a
fluoroquinolone is recommended.
• Local antibiotic sensitivities and resistance
patterns, as well as local standards of care,
should help determine final antibx choice.
Treatment
• Aspiration pneumonitides require a
different approach.
• Witnessed aspirations should be tx’d
w/immediate tracheal suctioning, and pH
of aspirate ascertained
• Bronchoscopy is indicated for the removal
of large particles and further clearing of
airways.
Treatment
• Patients requiring intubation should also
receive positive end-expiratory pressure.
• O2 should be administered, but steroids
and prophylactic antibx are of no value
and should be withheld.
• For patients at risk for aspirtion and for
those that present w/ signs & symptoms of
infection, antibiotics are indicated.
Treatment
• Levaquin or rocephin are sufficient for
most cases of aspiration.
• In cases of severe periodontal dz., putrid
sputum, or alcoholism, consider
piperacillin-tazobactam or impenem or a
fluoroquinolone plus clindamycin.
Treatment
• Failure of outpatient therapy generally
requires hospital admission and broaderspectrum IV antibx.
• Patients w/hypoxemia despite O2 therapy
or those with impending respiratory
failure should be tx’d w/ endotracheal
intubation and mechanical ventilation.
DEFINITION
THROMBOEMBOLISM
A condition in which a blood
vessel is blocked by an embolus
carried in the bloodstream from
the site of formation of the clot,
usually from a peripheral vein.
.
DEFINITION
PULMONARY THROMBOEMBOLISM
The blockage of a pulmonary
artery by foreign matter such as
fat, air, tumor tissue or thrombus
that usually arises from a
peripheral vein.
–Mostly form in the deep vein of
the thigh.
PTE
• Thromboembolism
– Arise from right side of the heart.
– Arise from thrombus in venous circulation.
• Tumor emboli - arise from tumors that invade the
venous circulation.
• Other sources
–
–
–
–
Fat.
Air.
Bone marrow.
Foreign IV material.
Predisposing factors
Symptoms & signs
• Clinical findings in acute PTE depend on
– The size of the embolus.
– The patient’s preexisting cardiopulmonary
status.
• No single symptom or sign or
combination of clinical findings is
pathognomonic of PTE.
• Massive PE results in
– Acute Rt side ventricular failure.
– Systemic hypotension.
Symptoms
• Dyspnea.
• Pleuritic chest pain.
• Hemoptysis.
• Cough.
• Chest pain.
• Anxiety.
• Sweats.
• Syncope.
Classic triad
SIGNS
• Tachypnea.
• Tachycardia.
• Crackles.
• Accentuated pulmonary component
of second heart sound.
• Low grade fever.
• Cardiac arrhythmias.
– Atrial arrythmias.
• Cyanosis.
Symptoms & signs
Small embolism distally near the pleura.
– Dyspnea (most common symptom).
– Tachypnea (most frequent sign)
– Pleuritic pain.
– Cough, or hemoptysis.
– Syncope.
Massive PTE
– Dyspnea.
– Tachypnea
– Syncope.
– Hypotension.
– Cyanosis.
DDX
•
•
•
•
•
•
•
•
•
•
•
•
•
Pneumonia, bronchitis, COPD exacerbation.
Myocardial infarction, unstable angina.
Pneumothorax.
Rib fracture.
Congestive heart failure.
Asthma.
Pericarditis.
Primary pulmonary hypertension.
Costochondritis, ``musculoskeletal pain,''
Anxiety.
Cellulitis or lymphangitis.
Ruptured baker’s cyst.
Muscle strain or rupture.
Key tests
ABG
– Acute respiratory alkalosis due hyperventilation.
– Po2 <80 mm Hg.
– Pco2 due to tachypnea.
EKG is abnormal but non diagnostic.
– Tachycardia.
– Non-specific ST-T changes.
–S1Q3, T wave inversion in V1-3
– Rt. axis deviation.
– Rt. bundle branch block.
Imaging
• CXR
– Usually abnormal but no pathognomonic findings.
• Lung scan
• Lower extremity evaluation by ultrasound.
• Pulmonary arteriography (Gold standard)
• Echocardiography.
• D-Dimer
TREATMENT
•IV fluids
•Intravenous heparin.
•Warfarin beginning day one or day two of
– IV heparin for long term therapy
•Therapy for least three months.
– Warfarin dose adjusted to prolong prothrombin
time to an INR of 2.5 (range 2.0 to 3.0).