UNSOM ITE Review: Pulmonary

ITI ReviewThoracic / Respiratory

Emergencies

ITI ReviewThoracic / Respiratory

Emergencies

J.D. McCourt, MD, FACEPAssociate Professor Department of Emergency MedicineUniversity of Nevada School of MedicineED Medical Director, University Medical Center So. Nevada

Practice Question: 1

Thoracic / Respiratory

A 10 year old present to ED with SOB and central cyanosis. Which of the following would be the most likely cause?A. Sicle cell anemia B. PolycythemiaC. MethemoglobinemiaD. L to R Congenital heart defect

ITE Review



A 10 year old present to ED with fatigue and central cyanosis. Which of the following would be the most likely cause?A. Sicle cell anemia B. PolycythemiaC. MethemoglobinemiaD. L to R Congenital heart defect

ITE Review

Cyanosis

Thoracic / RespiratoryITE Review

Central cyanosis• Impaired Ventilation

– Neurologic– Pulmonary– Cardiac

• Congenital heart disease (R to L shunt)

• Hemoglobin abnormalities– Methemaglobin

Causes

Cyanosis


• Central cyanosis only clinically apparent with >5g/dL desaturated Hb

• Cannot be anemic and cyanotic– cyanosis requires an absolute amount of

desaturated Hb – Getting >5g/dl desat with a total Hb of 8 is

clinically impossible

• Cyanosis more likely if also polycythemic (e.g. the blue bloater) – easy to have >5g/dl of hemoglobin desaturated with a total Hb of 18

Causes

+ Anemia

Pulse Oximetry


Fundamentals

• Anemia– Pulse ox does not consider Hgb level

• Supplemental O2

– Can mask severe pulmonary process (i.e. when there is an ↑ A-a gradient)

• Carboxyhemoglobinemia (CO)– Looks like 100% oxyhemoglobin

(e.g. false sat of 100%)

• Methemoglobinemia– Looks like 85% oxyhemoglobin

(e.g. false sat of 85%)



After 2 hrs of treatment Which asthma patient needs immediate attention

A. 7.40-40-95, wheezes, room air, no accessory muscle use

B. 7.45-35-85, wheezes, 100% fio2, moderate accessory muscle use

C. 7.40-40-85, wheezes, 100% fio2, moderate accessory muscle use

D. 7.5-30-85, wheezes, 100% fio2, moderate accessory muscle use

ITE Review

Asthma


• Mortality greater in:– African American and Latinos– Females– Adults

• Factors associated with asthma prevalence– Developed nations– Urban areas

• Factors associated with mortality/morbidity:– Poverty / lack of access– Overuse of OTC inhalers / episodic treatment– Under use of early steroids

ITE Review

Epidemiology

Pathophysiology

Clinical Evaluation

Death Risk Factors

Treatment

Asthma


Epidemiology

Pathophysiology

Clinical Evaluation

Death Risk Factors

Treatment

• Asthma is a chronic inflammatory disease

• Reduced airway diameter 2º to:

Bronchial constriction

Bronchial edema

Mucous plugging

Increased goblet cells

Bronchial muscle hypertrophy

Airway remodelling

Rev

ersi

bilit

y

Asthma


Epidemiology

Pathophysiology

Clinical Evaluation

Death Risk Factors

Treatment

Asthma


Epidemiology

Pathophysiology

Clinical Evaluation

Death Risk Factors

Treatment

Precipitants– URI (#1)– Allergy– Respiratory irritants

(smoke, chemicals)– Cold– Exercise– GERD– Beta blockers (even

eye drops)– Methacholine– ASA, NSAIDs (triad

with nasal polyps)– Menstruation– Psychological

Asthma


Epidemiology

Pathophysiology

Clinical Evaluation

Death Risk Factors

Treatment

Clinical Features–Decreased expiratory flow–Air trapping & barotrauma

PneumothoraxPneumomediastinum

–Decreased venous returnHypotensionPulsus paradoxus

–Hypercarbiahypoxemia–Muscle fatigue

Respiratory failure

Asthma


Epidemiology

Pathophysiology

Clinical Evaluation

Death Risk Factors

Treatment

• Bedside spirometry (PEFR, FEV1)– Measures large airway obstruction– Measures severity and response to

therapy– Predicts need for admission

• Pulse oximetry– Does not aid in predicting clinical

outcome– O2 saturation may paradoxically drop in

improving patient due to transient VQ mismatch

Asthma


Epidemiology

Pathophysiology

Clinical Evaluation

Death Risk Factors

Treatment

• Arterial Blood Gases (ABGs)– Not generally indicated– Should not be used to

determine therapy

• Chest X-ray– Not generally indicated– Obtain if:

• Complications suspected

(pneumothorax or pneumonia)

• Not improving• Requiring admission

Asthma


Epidemiology

Pathophysiology

Clinical Evaluation

Death Risk Factors

Treatment

Asthma


Epidemiology

Pathophysiology

Clinical Evaluation

Death Risk Factors

Treatment

• Hx of sudden severe exacerbations• Prior intubation• Prior ICU admit• >1 admission or >2 ED visits in past year• ED visit in past month• >2 adrenergic MDIs per month• Current/recent systemic steroid use• “Poor perceivers”• Concomitant disease – cardiopulmonary or

psychosocial• Illicit drug use

Asthma


Epidemiology

Pathophysiology

Clinical Evaluation

Death Risk Factors

Treatment

• 1st line therapy• Bronchodilators (via adenyl cyclase)• Selective β2 agonists have less unwanted

β1 effects (tachydysrhythmias)

• Evidence– Inhaled superior to oral and parenteral

routes, fewer side effects– Intermittent equal to continuous

administration– MDIs equal to nebulizers– Racemic equal to “R” enantiomer

preparations (levalbuterol)

Aerosolized β2 agonists

Asthma


Epidemiology

Pathophysiology

Clinical Evaluation

Death Risk Factors

Treatment

Steroids • Dual Action

– Delayed (hours)• Principal Mechanism

– Immunomodulatory– Up-regulate β-receptors

– Immediate (minutes)• Vasoconstriction (“Blanching Effect”)

• Evidence– Oral equal to IV administration– Systemic (PO and IV) superior to inhaled

route

Asthma


Epidemiology

Pathophysiology

Clinical Evaluation

Death Risk Factors

Treatment

Aerosolized Anticholinergics– Ipratropium bromide

(Atrovent)– Block tone in bronchial

smooth muscle– Modest effect when added

to β-agonists

Magnesium– IV infusion (2-3g IV over 10

minutes)– Smooth muscle relaxant– Incremental benefit in most

severe presentations

Asthma


Epidemiology

Pathophysiology

Clinical Evaluation

Death Risk Factors

Treatment

Not Indicated for Acute Treatment • Theophylline

– No benefit over β2 agonists– Narrow therapeutic index

• Long-Acting β2 agonists (Salmeterol)– Long term treatment only

• Leukotriene modifying agents (Montelukast) and mast cell stabilizers– Long term preventive treatment only

• Heliox– Balance of studies find no benefit– More convincing role in upper airway

obstruction

Asthma


Epidemiology

Pathophysiology

Clinical Evaluation

Death Risk Factors

Treatment

• Mechanical Ventilation– Does not treat obstruction (e.g. the

1° problem!)– Barotrauma is big concern– Low rate/ Low TV (8cc/kg)

IV Ketamine–Sedation and bronchodilation–Increases secretions

Anesthetic gases/ECMO–Transfer to the OR!

Critical Care

Asthma


Epidemiology

Pathophysiology

Clinical Evaluation

Death Risk Factors

Treatment

Preventing and Managing Barotrauma

• May use paralytics initially to facilitate ventilation

• Continue aggressive in-line nebulizer therapy

• Increase time for expiratory phase(e.g. ↑ inspiratory flow rate, ↓ respiratory rate, ↓ I:E ratio)

• Permissive hypercapnia (allow pCO2 to rise), pOx>88%

• Diligent pulmonary toilet, may need bronchoscopy

• External chest compression

Critical Care

Asthma


Epidemiology

Pathophysiology

Clinical Evaluation

Death Risk Factors

Treatment

Critical Care

Asthma Arrest1 Disconnect ventilator 2 Compress chest3 Bilateral chest tubes 4 Fluid bolus



A 60 year old Man with COPD presents with severe shortness of breath. Which of the following would indicate respiratory failure?A. Pulse ox 88%B. Severe anxietyC. Perioral cyanosisD. ABG: 7.28-55-60 (RA)E. ABG: 7.38-65-60 (RA)

COPD


Pathophysiology

Exacerbation

Treatment

• Definition– Chronic, inflammatory disease– Airflow limitation that is not fully

reversible and is progressive

• Pathophysiology– Different inflammatory markers

from asthma (e.g. neutrophils, not eosinophils)

– Proteases and oxidants result in tissue destruction

COPD


Pathophysiology

Exacerbation

Treatment

• Natural History– Hypoxemia and hypercapnia– Destruction of pulmonary

vascular bed and thickened vessel walls

– Pulmonary hypertension– Polycythemia– Right sided heart failure

(cor pulmonale)

COPD


Pathophysiology

Exacerbation

Treatment

Blue Bloater Pink Puffer

Clinical Phenotypes

COPD


Pathophysiology

Exacerbation

Treatment

• Definition– ↑ Dyspnea– ↑ Sputum volume– ↑ Sputum

purulence• Causes

– Viruses– Role of bacteria

controversial– Environmental

Consider Mimics– Progressive onset• Pneumonia• CHF

– Sudden onset • Pneumothorax• PE• Lobar atelectasis

COPD


Pathophysiology

Exacerbation

Treatment

Aerosolized β-agonists and anticholinergics– First line therapy

Steroids– Systemic steroids (IV in ED followed by

PO course) reduce rates of relapse and improve dyspnea following ED visit

Antibiotics– Indicated in cases with ↑sputum

volume and purulence

Non-Invasive ventilation– Improves acidosis, decreases respiratory distress– Effective at avoiding intubation if initiated early– Not appropriate in patients with respiratory arrest

or hemodynamic instability

COPD


Pathophysiology

Exacerbation

Treatment

Disease Altering Interventions– Only 2 interventions proven to reduce

mortality:• Smoking cessation• Home oxygen

(for PaO2 < 55 or signs of cor pulmonale)

Pneumococcal Vaccination

Long Term Interventions



3 y/o brought in by mom for persistent cough. Exam finds wheezing in right lung field. Which is the most appropriate?A. CXRB. Bronchoscopy C. Inspiratory Xray + Neb TXD. Amoxicillin and F/U with pediatritian

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3 y/o brought in by mom for persistent cough. Exam finds wheezing in right lung field. Which is the most appropriate?A. CXRB. Bronchoscopy C. Inspiratory Xray + Neb TXD. Amoxicillin and F/U with pediatrician

ITE Review

FB Aspiration


Basics

Children– Foreign body aspiration should be

considered when diagnosing:AsthmaPneumonia

Adults– At risk for foreign body aspiration:

Drug and alcohol abuseMental retardation / illnessNeuromuscular disorderEdentulousness / dental prosthetics

Why we miss the diagnosis• “sudden onset” of symptoms• Improvement with antibiotics and/or bronchodilators• “Pneumonia” seen on the x-ray• Negative chest x-ray• Over-reliance on imaging – ultimately need to pursue

bronchoscopy

FB Aspiration


Basics

Most cases in Children• Young children both lungs• Older > R• Dx: History/suspicion

• Coughing S/p choking• Recurrent pneumonia• Unilateral wheezing

FB Aspiration


Basics

Imaging

Foreign Body AspirationCASE STUDY: 7 MONTH OLD CHILD

COUGHING FOR 1 HR AFTER CHOKING EPISODE

FB Aspiration


Basics

Imaging

Lateral neck Expiratory film

FB Aspiration


Basics

Imaging

Failure of right lung to deflate on lateral decubitus film indicates a foreign body in the right main-stem bronchus

ARDS


BASICS

• Definition– Acute Lung Injury (ALI) and ARDS are

clinical diagnoses along a spectrum

• Pathogenesis – Noncardiogenic pulmonary edema due

to leaky alveolar capillary membranes • Diagnostic criteria

1 Hypoxia• PaO2 < 60 mm Hg

with FiO2 > 0.5

2 Normal ventricular function• PCWP < 18 mm Hg

3 Diffuse alveolar infiltrates• With normal heart size

ARDS


BASICS

Causes

• Sepsis (most common)• Trauma• Near-drowning• Aspiration• Toxicologic (ASA, opiates,

hydrocarbons)• Pancreatitis• Environmental (high-altitude)• Fat or amniotic fluid embolus• CNS catastrophe (e.g. SAH)

ARDS


BASICS

Causes

Treatment

• Supportive– Maintain O2 sat >85% while

minimizing FiO2 and airway pressures

– PEEP or CPAP– Pressure controlled or high

frequency ventilation • Recent Literature

– Lower mortality with low tidal volume ventilation (6mL/kg)

– Prone position improves oxygenation

Aspiration Pneumonia




• Risk factors– Seizure, alcoholic, obtunded,

depressed gag reflex

• Severity of syndrome depend on:– pH of aspirate (lower is worse – less

than 2.5)– Volume of aspirate (>25 mL)– Presence of particles such as food

(bad)– Bacterial contamination (usually

anaerobes)



• Clinical features– Immediate respiratory difficulty due

to chemical burn– Hypoxemia and respiratory alkalosis– Wheezes, rales, hypotension– CXR often negative initially– Localization related to dependent

lung

• Treatment– Supportive– Hold antibiotics until febrile to avoid

selecting out resistant organisms



A nurse from 35 year old nurse from 5S is sent down to the ED because her mandatory PPD test measured 11mm. What is the most appropriate next step?A. Move the patient to isolation immediatelyB. Order cxr and if normal start on INH, D/c C. Order cxr if Ca++ nodule admit to hospital for

active TB, notify health departmentD. No Tx necessary because TB result is negative

for this patient.

ITE Review

Tuberculosis


Natural History

Tuberculosis


Natural History

CXR

Reactivation TuberculosisCavitary Lesion RUL

Tuberculosis


Natural History

CXR

Miliary Tuberculosis (Hematogenous)

Tuberculosis


Natural History

CXR

• 50-80% of patients with pulmonary TB will have positive smears

• Sensitivity ~ 60%

• AFB NEGATIVENot helpful in suspicious cases

Diagnosis

Tuberculosis


Natural History

CXR

Diagnosis

TX: Side effects

• Hepatitis– Isoniazid (INH), Rifampin (RIF) and Pyrazinamide

(PZA)• Peripheral Neuropathy

– Isoniazid (INH)• Optic neuritis

– Ethambutol (EMB)• Gout

– Pyrazinamide (PZA)

• Ototoxicity and renal toxicity– Streptomycin and other aminoglycosides

• Discolored body fluids– Rifampin (reddish-orange urine, feces, saliva,

sweat, tears)

Tuberculosis


Natural History

CXR

Diagnosis

TX: Side effects

TB Skin Test

Pneumonia


Mimics

• Cancer• Tuberculosis• Pulmonary embolus• Toxicologic / environmental

– Chlorine gas, Farmer’s lung (allergic reaction to inhalation of moldy crops – hay, grain, tobacco)

• ARDS– e.g. from chronic ASA toxicity or other treatable cause

• Atelectasis• Right-sided endocarditis

– Septic emboli

• Diffuse alveolar hemorrhage– Low hemoglobin, immune disease

Pneumonia


Mimics

Typical/ Atypical

Bacterial Pneumonias

Pneumonia


Mimics

LLL Pneumonia (Pneumococcus)

RUL Pneumonia (Klebsiella) with bulging fissure and abscess formation

Typical/ Atypical

Pneumonia


MimicsPneumonia• Strep. pneumo, H. flu,

Staph. Aureus• TB

Non-Infectious Effusions• PE• Abdominal process

e.g. pancreatitis

•Aortic dissection• Boerhaave’s syndrome

(esophageal rupture)

Effusions

Typical/ Atypical

Lateral Decubitus: Best for small effusions

Pneumonia


Mimics

• Infection, Malignancy, Inflammatory process

• High Protein• High LDH

PH of Pleural effusion < 7.1 Empyema

Effusions Transudate VS. Exudate

• Hydrostatic /Oncotic shift

• CHF / Cirrhosis• Low Protein• Low LDH

Typical/ Atypical

Pneumonia


Mimics

Cavities• Staph• Pseudomonas• TB

Typical/ Atypical

Pneumonia


Mimics

Atypical Pneumonias

Typical/ Atypical

Pneumonia


Mimics

Interstitial infiltrates• Mycoplasma• Chlamydia• Viral Typical/ Atypical

Pneumonia


Mimics

Patchy perihilar infiltrate L>R

Mycoplasma Pneumonia

Typical/ Atypical

• Most common cause PNA < 40

• Extra pulmonary Bullous TM Rash to Steven John Heart blocks to

Myocarditis/pericarditis

Guillain-barr Aseptic meningitis Transvers myelitis

Pneumonia


Mimics

Legionella Pneumonia

X-ray in Legionella is not “atypical”

Typical/ Atypical

Pneumonia


Mimics

Mechanism

Type ( Mechanism) PNA Mortality• CAP 10%• HAP 19%

– (> 48hr Admission)• VAP 29%

– (> 48hr ETT)• HCAP

20%– NH/LTC facility– > 2 day in hospital (W/I 90 days)– Infusion/wound care/Dialysis

Typical/ Atypical



Which of the following is not a factor to consider for ICU admission of a patient with pneumonia?A. TemperatureB. Multipolar involvementC. Systolic B/PD. Albumin level

ITE Review

Pneumonia


Mimics

Mechanism

SMART COP• Systolic blood pressure (2 points),• Multilobar CXR involvement (1 point) • Albumin level low (1 point) • Respiratory rate high (1 point)• Tachycardia (1 point), • Confusion (1 point), Oxygenation (2

points),pH (2 points)

Typical/ Atypical

ICU Predictors



A previously healthy 60 y/o male with severe pneumonia and this CXR is being admitted to the ICU which is the most appropriate antibiotic regimen to start in the ED?A. Ampicillin-sulbactum and VancomycinB. Azithromycin and Levofloxin and DoxyC. Ceftriaxone and levofloxin D. Ceftriaxone and levofloxin and Vancomycin

ITE Review

Pneumonia


Mimics

Typical/ Atypical

Mechanism

ICU Predictors

Treatment

• Macrolide • Doxycycline

• β-lactam (Ceftriaxone) + Macrolide

• Respiratory Flouroquinolone

Typical/Atypical

Typical/AtypicalDRSP

Typical/AtypicalDRSPGram Neg

Community-Acquired Pneumonia TX

• β-lactam (Ceftriaxone) + Respiratory Flouroquinolone

• Vancomycin if MRSA – Vancomycin if MRSA

Pneumonia

Community-Acquired Pneumonia


Mimics

Typical/ Atypical

Mechanism

ICU Predictors

Treatment

Community-Acquired Pneumonia

Pneumonia


Mimics

Typical/ Atypical

Mechanism

ICU Predictors

Treatment

• antipseudomonal β-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem)

+• aminoglycoside or fluoroquinolone

+• vancomycin or linezolid for MRSA.

HCAP,HAP, VAP Pneumonia TX

Practice Question:8


A 3 week old is admitted to the hospital for pneumonia. What is the most appropriate abx treatment to begin in ED. A. VancomycinB. ErythromycinC. AmoxicillinD. Ceftriaxone

ITE Review



A 3 week old is admitted to the hospital for pneumonia. What is the most appropriate abx treatment to begin in ED. A. VancomycinB. ErythromycinC. AmoxicillinD. Ceftriaxone

ITE Review

Pneumonia


Mimics

Typical/ Atypical

Mechanism

ICU Predictors

Treatment

Children

Pneumonia in Children

Pneumonia


Mimics

Typical/ Atypical

Mechanism

ICU Predictors

Treatment

Children

• Hantavirus pulmonary syndrome– Southwest US, aerosolized rodent excreta– No Human to human spread– HPS (most common US): Flu sx then Pulmonary edema, hpox,

hypotension– Haemorrhagic fever + renal failure(Asia, Europe)

– Supportive therapy only

• Plague (Yersinia pestis)– Spread by fleas on rodents (bubonic), bioterrorism (pulmonary)– Very contagious person-to-person, strict respiratory isolation– Bilateral, multilobar pneumonia– Rx: doxycycline, fluoroquinolones, aminoglycosides

• Anthrax (Bacillus anthracis) – Inhaled (bioterror Class A agent)– No person-to-person transmission– Hemorrhagic mediastinitis (prominent mediastinum on x-

ray)– Rx: penicillin, doxycycline or fluoroquinolone

Rare

Pneumonia


Mimics

Typical/ Atypical

Mechanism

ICU Predictors

Treatment

Children

SARS

Severe Acute Respiratory Syndrome

– Coronavirus– Person-to-person spread– Originated from civet cat in Asia

(aerosolized fecal material)

Rare

Pneumonia


Mimics

Typical/ Atypical

Mechanism

ICU Predictors

Treatment

Children

• Infectious CD4Bacterial: >200 Most common

Same pathogens as non-AIDS

< 200Mycobacterial: TB, Mycobacterium avium

complex (MAC)Parasitic: ToxoplasmosisViruses: CMV, HSVFungal: PCP

Often disseminated

• Malignant– Kaposi's sarcoma– Non-hodgkin's lymphoma

Cryptococcosis, histoplasmosis,aspergillosis, candidiasis

HIV / AIDS

Rare

Pneumonia


Mimics

Typical/ Atypical

Mechanism

ICU Predictors

Treatment

Children

Rare

HIV / AIDS



20 year old presents to ED with double vision and difficulty swallowing that seems to be worse in evening. CXR. What is the next most appropriate action?A. Administer zithromax and d/cB. Notify health department of potential

Botulinum toxicicityC. Order a CT Brain, admit and

neurosurgery consultD. Admit, start pyridostigmine, Thoracic

surgery consult

ITE Review

Mediastinal Masses


• Mediastinum divided into anterior, middle, posterior compartments

• Anterior: from sternum to anterior pericardium

• Mass in anterior mediastinum: five “T”s – Thymoma (consider myasthenia gravis)– Thyroid (retrosternal)– Teratoma (teeth, hair, etc.)– T cell lymphoma– "Terrible“ (carcinoma)

Mediastinal Masses




A 60 year old Man with hx/o lung cancer presents to ED coughing up large amounts of blood every 3-5 minutes Patient is in moderate to severe extremis. Which of the following would be the most helpful information at this time? A. Where is your lung cancer?B. Are you a Jehovah's witness?C. Do you have a oncologist?D. Do you have TB?

ITE Review

Hemoptysis


• Causes– Most common is acute bronchitis– Other infections

• pneumonia, bronchiectasis– Neoplastic– TB– Vasculitis– Mycetoma (fungal balls)– Cardiovascular

• Minor versus Massive– Massive: >600mL in 24 hrs or 50mL in

single cough

– Death by asphyxiation not hemorrhage

Hematemesis: Minimal/no cough + Acidotic

Massive Hemoptysis


Supplemental O2

Rapid sequence intubationLarge bore ETT (>7.5)

Keep the bleeding side downAggressive pulmonary toiletSelective mainstem intubation

Correct coagulopathyFluid and/or blood resuscitation

A

B

C

Keep the bleeding side down

Selective mainstem intubation

Bronchial artery embolization will often be required.

Open surgery may also be necessary.

END

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UNSOM ITE Review: Pulmonary

Health & Medicine

Transcript of UNSOM ITE Review: Pulmonary