II: PULMONARY



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)




Figure 2.1 Treatment algorithm. From NHBLI Expert Panel Report 3, 2007. NIH Pub no. 08–4051.


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



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Sep 6, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on II: PULMONARY

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