Disposition
• CAP: See PNA Severity Index Score & CURB-65 (below)
• HCAP: Generally requires admission for IV abx
• PCP: Inpt unless SpO2 >95% w/o desaturation on exertion
• TB: Inpt, reported to Dept of Health
Pearls
• At the time of this writing, JCAHO & CMS mandate that abx must be delivered in w/i 6 h of the Dx of PNA. Blood cultures should be drawn prior to abx if drawn in ED. Order cultures in all pts who may go to ICU w/i 24 h or w/ severe disease, cavitary lesions, or significant comorbidities (Ann Emerg Med 2009;54:704).
• Consider social factors if discharging pt w/ PNA (eg, ability to comply w/ regimen)
Acute Bronchitis
Etiology
• Most commonly viral: Parainfluenza, adenovirus, rhinovirus, influenza
• Atypical bacteria ∼5% of cases; pertussis often occurs in epidemics
History
• Cough (dry or wet), self-resolving fever, often URI sxs, myalgias, wheezing
• Posttussive emesis, whoop, duration >1 wk a/w pertussis (JAMA 2010;304(8):890)
• All-cause median duration of cough is 18 d; pertussis was once called “100-day cough”
Physical Exam
• Fever is uncommon (consider influenza or PNA); may have chest wall tenderness from muscle strain; lungs often clear but up to 40% have bronchospasm/wheeze
Evaluation
• CXR nl or bronchial wall thickening; mild leukocytosis
• CXR not routinely needed: Reserve for abnl VS, extremes of age, comorbidities
Treatment
• Supportive care, antipyretics; abx NOT routinely indicated
• Bronchodilator (albuterol MDI 2 puffs QID) esp if wheezing heard or h/o asthma
• Antitussive (codeine 30 mg q4h, hydrocodone 5 mg q6h; Tessalon Perles 100 mg TID)
• No good evidence for or against OTC expectorants, decongestants, or antihistamines (Cochrane Database Syst Rev 2012;8:CD001831)
• Abx not routinely indicated (Cochrane Database Syst Rev 2012;CD000245)
• Reserved for elderly, significant comorbidities, high suspicion for pertussis
• Azithromycin 250 mg × 5 d or doxycycline 100 mg BID × 7 d, to cover pertussis
• See PNA section for influenza tx guidelines
Disposition
• Discharge home w/ PCP f/u as needed; pts will likely recover in 2–3 wk
DYSPNEA (SHORTNESS OF BREATH)
Definition
• Common sign of pulmonary disease but may be the primary manifestation of myocardial ischemia or Dysfxn, metabolic acidosis, toxins or CNS pathology
• Always assess for respiratory distress: RR >24 or <8, tripoding, accessory muscle use, unable to speak in full sentences, altered mental status (AMS), abnl chest movement
Asthma
Definition
• Chronic recurrent inflammatory disorder w/ airway hyperresponsiveness, bronchospasm, & reversible airway obstruction
Clinical Features
• Wheezing, dyspnea, chest tightness, cough (esp nocturnal), usually progresses over at least 6 h to days
• Always assess sx frequency, severity, duration, home txs, required past txs, baseline peak flow, number of ED visits, hospitalizations, intubations
• Evaluate for triggers: Cold air, exercise, URI, stress, allergens, meds (NSAIDs, βBs), respiratory irritants (perfumes, smoke, detergents, dander, dust)
Physical Exam
• Tachypnea, tachycardia, inspiratory/expiratory wheezes, prolonged expiration, decreased or no air movement, use of accessory muscles, tripoding, cyanosis
Evaluation
• CXR: Avoid in routine exacerbations; order if concern for PNA, PTX
• PEFR: Compare to pt’s baseline if he/she is aware. Varies by age, gender, & height. Average adult female: 300–470; adult male: 400–660.
• ABGs are not routinely indicated to assess for severity, but normocarbia in severe asthma may be a sign of “tiring out,” impending respiratory failure.
Chronic Obstructive Pulmonary Disease (COPD)
Definition
• Progressive airflow obstruction that is not fully reversible, w/ impaired gas exchange, usually w/ smoking hx. Most have both chronic bronchitis & emphysema.
History
• Usually cough, increased sputum production, dyspnea
• Precipitants: Cold weather (increased incidence in winter months), infection (viral > bacterial), cardiopulmonary disease, medication changes
Physical Exam
• Chronic bronchitis (“Blue Bloater”): Cough w/ marked sputum production, cyanotic, plethoric, not in overt respiratory distress; scattered rhonchi & rales
• Emphysema (“Pink Puffer”): Thin, anxious, dyspneic, tachypneic, noncyanotic, using accessory muscles (tripod position), pursed-lip exhalation (for auto-PEEP), barrel chest w/ diminished breath sounds
Evaluation
• Pulse oximetry
• ECG for associated dysrhythmia (AF or MAT), cor pulmonale (P pulmonale: Big P in II)
• CXR for underlying infection, PTX, edema, effusion, malignancy
• Consider testing for influenza during epidemics
• ABG not routinely indicated, may be useful in severe exacerbations
• CBC, BMP not often helpful in acute ED management but useful in admitted pts
Treatment
• Supplemental O2 to maintain O2 saturation >90% (only long-term therapy proven to decrease mortality, but watch for decreased respiratory drive leading to CO2 retention/apnea)
• Albuterol (short-acting β-agonist): 2.5–5 mg nebulized q30min × 3 doses, then q4h OR continuous in severe exacerbation OR self-administered MDI w/ spacer, if stable
• Ipratropium bromide (anticholinergic): 0.5 mg nebulized q30min × 3 doses, then q4h (synergistic effect w/ albuterol, so give together)
• Steroids: Prednisone 30–40 mg PO daily for 10–14 d OR methylprednisolone 60–125 mg IV q6–8h (for severely ill pts)
• Abx: GOLD guidelines recommend for increased sputum purulence & either increased sputum volume or increased SOB, & all severe cases (Am J Respir Crit Care Med 2013;187(4):347)
• Choice based on RFs (age >65, FEV1 <50%, recent abx, heart dz); duration 5–10 d
• Outpt uncomplicated: Macrolide, cephalosporin, doxycycline, or TMP/SMX
• Outpt w/ RFs: Fluoroquinolone or amoxicillin/clavulanate
• Inpt: Fluoroquinolone or 3rd-generation cephalosporin; consider additional pseudomonal coverage if at risk
• Ventilation:
• Noninvasive (BiPAP): For respiratory acidosis, severe dyspnea, signs of fatigue. Early use may prevent intubation. Watch for PTX w/ positive pressure.
• Invasive: Intubate for failure to tolerate BiPAP, impending respiratory failure, cardiovascular instability, &/or altered mental status
Disposition
• Home: Mild sxs, O2 saturation >90%, ambulatory, requiring <q4h bronchodilators, adequate home support, outpt f/u
• Admission: Significant worsening of sxs from baseline, severe underlying disease, incomplete response to tx, serious comorbidities, frequent exacerbations, older age, inability to cope at home (Am J Respir Crit Care Med 2013;187(4):347)
Acute Respiratory Distress Syndrome (ARDS)
Definition
• Acute noncardiogenic pulmonary edema due to inflammatory mediators causing capillary leak & inflammation of the alveoli & lung parenchyma, PaO2: FiO2 <200
Pathophysiology
• Impaired gas exchange, poor compliance, intrapulmonary shunt
Etiology
• Direct lung injury: PNA, aspiration, near-drowning, hydrocarbons, inhalational injury, embolism (thrombotic, fat, air, amniotic)
• Systemic: Sepsis, shock, DIC, trauma, burns, transfusion, pancreatitis, meds
Clinical Features
• Develops over 6–72 h, rapid progression w/ dyspnea, cyanosis, crackles, & eventual respiratory failure
Evaluation
• Dx requires ABG (to calculate PaO2:FiO2) & CXR w/ bilateral pulmonary edema
• Often need TTE to eval for CHF, bronchoscopy to r/o diffuse alveolar hemorrhage
Treatment
• Supportive, focus on treating the underlying condition
• Mechanical ventilation: Poor compliance so to prevent barotrauma keep VTs low (VT <6 mg/kg, plateau pressures <30), but high PEEP to keep alveoli open. Avoid hyperoxia (FiO2 <60%) (ARDS Net protocol, NEJM 2000, also Ann Intern Med 2009;151(8):566).
See Chapter on “Mechanical Ventilation”
• Fluids: CVP goal 4–6 cm to avoid excessive hydrostatic pressure & more edema
• No consensus on role of steroids; most meta-analyses show no mortality benefit
Upper Airway Obstruction/Foreign Body (FB)
History
• Acute FB aspiration: May be witnessed but often hx is unclear in adults
• RFs: Age >75, neuro disorders, syncope, szs, alcohol or sedative abuse
• Consider angioedema, infectious etiology (eg, epiglottitis) in DDx
• Subacute (eg, malignancy, expanding goiter): Often a delayed Dx (eg, wheezing unresponsive to bronchodilators)
Physical Exam
• General appearance: May arrive cyanotic & in respiratory arrest if total obstruction
• In breathing pt, respiratory exam depends on degree & location of obstruction; air movement, stridor, wheezing. Do not underestimate pt distress.
Evaluation
• CXR, XR neck rarely shows FB. Diagnostic bronchoscopy is standard.
Treatment
• If still breathing: Airway equipment, including cricothyrotomy kit, at bedside. Prepare for transfer to OR to remove FB in a controlled environment (bronchoscopy or DL).
• If not breathing: Attempt direct laryngoscopic visualization & removal of FB w/ forceps. If unsuccessful, perform surgical airway.
• If FB has moved inferior to vocal cords but still occluding, attempt to push object further into 1 lung by pressure from Ambu bag or ETT. Once intubated, position ETT to ventilate contralateral lung.
Disposition
• If object is safely removed & pt stable, can discharge home
HEMOPTYSIS
Definition
• Expectoration of blood or blood-stained sputum from below the vocal cords
• Massive is >100 cc/d (1 cup) or disrupting ability to breathe. High mortality 2/2 asphyxiation.
• Recall that bronchial arteries are high pressure, pulmonary arteries are low pressure