Pulmonary

22.1 Aspirated Foreign Body

Ann Surg 1972;175:720

Cause: Usually accidental, may be anything that can be inhaled, such as small pieces of toys, coins, candy, and peanuts.

Epidem: Common in infants.

Pathophys: Inhalation of object in mouth or nose with lodging in larynx or bronchopulmonary tree.

Sx: Dyspnea; stridor; hemoptysis.

Si: Wheezing; tachypnea; decreased lung sounds in one lobe.

Crs: Benign if not obstructing entire airway/lung, and able to be retrieved with a bronchoscope.

Cmplc: Asphyxia; pneumothorax; pneumonia; pulmonary edema (Ped Emerg Care 1986;2:235).

Diff Dx: Asthma, croup, pneumonia.

Lab: X-Ray—CXR with expiratory film if radiolucent foreign body to look for area that does not symmetrically compress. If unable to locate foreign body, do lateral neck x-ray and abdominal x-ray to locate the foreign body (Radiol Clin N Am 1998;36:175).

Emergency Management:

O₂ if hypoxic, keep pt calm.
Iv access.
ENT or pulmonary consult immediately if in trachea, mainstem bronchus or beyond (Endoscopy 1977;9:216).
If severe respiratory distress or impending respiratory failure, consider rapid sequence intubation. Look for FB in larynx, remove with Magill forceps, and intubate. If cannot locate the FB, intubate and try to push object down one mainstem to oxygenate and ventilate the contralateral lung.

22.2 Asthma

Ann IM 2000;132:219; Nejm 2001;344:350

Cause: Innumerable allergens, with genetic susceptibility— Chromosome 5—, and is also found more often in those with atopy susceptibility.

Epidem: Approximately 5% of U.S. population and increasing; seen more in low income groups; common in those with first and second hand smoke.

Pathophys: Airway inflammation with decreased airway lumen size, bronchial edema, and increased mucus production. Inflammatory airway secretions with eosinophils, but neutrophils predominate (Am J Respir Crit Care Med 2000;161:1185), and mast cell infiltration of airway smooth muscle (Nejm 2002;346:1699). Also, hypothesized that the effect of glucocorticoids mediated by a glucorticoid receptor and the C/EBPα binding protein in bronchial smooth muscles—those with glucocorticoid resistant disease may lack C/EBPα (Nejm 2004;351:560). Multiple types including allergic; exercise-induced; infectious—approximately 25% of those with bronchiolitis go on to asthma, bronchiectasis, chronic bronchitis, and eventually some form of COPD; and emotional stress.

Morning wheezing due to circadian decrease in epinephrine and steroids. ASA sensitivity is a direct action on kinin receptors by acetyl groups, may be genetic as well. Food sulfites may precipitate an exacerbation, as may exposure to cigarette smoke.

Sx: Dyspnea; wheezing; exercise or cold induction of symptoms; opiate or ASA exacerbation induction.

Si: Wheezing, check with exertion or cough, if lung exam is normal at rest; dyspnea; nasal polyps correlates with atopic type; cyanosis, papilledema, pulsus paradoxus are three late signs.

Crs: Overall mortality has not increased.

Cmplc: Status asthmaticus—respiratory arrest with respiratory acidosis as most common mode of death (not arrhythmia); multifocal atrial tachycardia (Chest 1990;98:672) associated with hypoxia, theophylline, and catechol treatment; allergic asthma in mother associated with premature labor and respiratory distress syndrome of the newborn. Minor complication of mild hypokalemia in those with β-agonist therapy (Ped Pulmonol 1999;27:27).

Diff Dx: Aspirated FB in the young and elderly; croup; CHF in the elderly and peds with heart disease; vocal cord dysfunction; conversion reaction; pulmonary emboli, rarely.

Lab: If toxic or severe case—CBC with diff; ABG; blood cultures and sputum sample.

Peak flows poor predictor of severity in the ER (Am J Respir Crit Care Med 1996;154:889), length of speaking time just as useful (Am J Emerg Med 1998;16:572).

X-ray: Chest film if severe, febrile, or not following classic asthma pathway.

Emergency Management:

Med Lett Drugs Ther 2000;42:19

O₂, if hypoxic.
Control airway, rapid sequence intubation if pt losing consciousness or in 1 word or less dyspnea and not responding— safer to do earlier rather than later, ie, do not wait for pt to have cardiopulmonary arrest (Crit Care Med 1993;21:1727). When intubated, permissive hypercapnia (underventilating) is safe and appropriate (Chest 1994;105:891).
β-agonists—nebulized albuterol at 0.1-0.15 mg/kg up to 5 mg/dose if > 40 lbs, may select as continuous at 10 mg/hr, all suspended in NS; terbutaline (Brethine) 1 cc in 2 cc of NS; or bitolterol (Tornalate)—all probably equally effective. Inhaler with spacer as effective as nebulizers, if able to use effectively (J Peds 2000;136:497) and 5 puffs every 20 min in adult (Chest 2002;121:1036)—10 puffs equivalent to unit dose of albuterol nebulizer.
Ipratropium (Atrovent) is not approved for long-term maintenance (Nejm 1992;327:1413) but the literature supports acute use to decrease hospitalization in children with asthma (Nejm 1998;339:1030); consider dosing with albuterol at 0.5 cc in nebulized solution (Duoneb) for those with severe exacerbations or not responding to β-agonists, definitely not a chronic rx choice (Plotnick, L. H. and F. M. Ducharme (2000). “Combined inhaled anticholinergic agents and beta-2-agonists for initial treatment of acute asthma in children.” Cochrane Database Syst Rev 2).
Steroids—Hydrocortisone (100-300 mg every 6 hr), dexamethasone (4-8 mg every 8 hr), methylprednisolone (1-1.5 mg/kg iv every 12 hr) and prednisone (1-2 mg/kg qd) all equal at appropriate doses and give in ER; route of administration does not matter as far as onset of action or efficacy (6-8 hr or longer for onset of action). Outpatient rx should include a short course of steroids which may be extended depending on patient history (Rowe, B. H., C. H. Spooner, et al. (2000). “Corticosteroids for preventing relapse following acute exacerbations of asthma.” Cochrane Database Syst Rev 2). Consider inhaled steroids such as triamcinolone or budesonide, and perhaps some benefit in combining oral and inhaled steroids (Jama 1999;281:2119).
MgSO₄ 2 gm iv or nebulized (2.5-3 cc isotonic) (Am J Med 2000;108:193) may help in severe cases (Rowe, B. H., J. A. Bretzlaff, et al. (2000). “Magnesium sulfate for treating exacerbations of acute asthma in the emergency department.” Cochrane Database Syst Rev 2), but not suggested for routine use in any pts, especially peds (Ann EM 2000;36:572).
Aminophylline may be considered in severe cases, load at 5.6 mg/kg over 20-30 min, then 0.5 mg/kg/hr; decrease dose in those with CHF, liver disease, pneumonia, or h/o cardiac dysrhythmia.
Consider Heliox (60-80% helium), probably better in sick pts (Chest 1999;116:296) vs (Am J Emerg Med 2000;18:495). Albuterol nebulized with Heliox 80:20 had better spirometry after 3 treatments when compared with albuterol nebulized with air (Am J Respir Crit Care Med 2002;165:1317).
IVF important in severe cases, will need NaCl and KCl to reverse chloride depletion, be wary of pulmonary edema—ie, avoid fluid overload!
Antibiotics if bacterial focus or severe: Consider TMP/SMX DS 1 pill bid or see options under CAP (p425)—caution with those on theophylline.
May consider NaHCO₃ for severe acidosis if intubated, but do not overcorrect.
Internal medicine/primary care ER consult for those needing admission, outpatient follow-up with steroid taper for those with good response to rx—peak flows ideally > 80% predicted. As well, intervention in pediatric pts with home intervention on allergens and tobacco smoke will decrease morbidity (Nejm 2004;351:1068).
Salmeterol (Serevent), montelukast (Singulair), zafirlukast (Accolate), zileuton (Zyflo), cromolyn (Intal), nedocromil (Tilade) and the decision for outpatient theophylline (Slo-bid, Theodur) should be part of the outpatient physician’s realm or perhaps to help get pt off of ventilator.
Heparin is anti-inflammatory, its exact role in asthma has not been elucidated (Ann Pharmacother 2001;35:1161).
The role of 40 mg of nebulized furosemide to be determined, and one study claims a modest success (J Asthma 1998;35:89).

22.3 Community-Acquired Pneumonia (CAP)

Nejm 2002;346:429; Ped Infect Dis J 2000;19:251; Allergy Asthma Proc 2000;21:33; J Am Ger Soc 2000;48:82

Cause: (By age)

Ped Infect Dis J 2000;19:293

0-28 d: E. coli, group B streptococcus; less commonly Staphylococcus aureus, RSV, Enterobacter spp.

28 d to 5 yr: RSV, rhinovirus, Streptococcal Pneumoniae, parainfluenza virus, adenovirus; less commonly Chlamydia.

5 to 15 yr: Streptococcal pneumoniae, Influenza A, adenovirus; less commonly Mycoplasma.

Adults: Streptococcal pneumoniae, Haemophilus influenzae (more common in smokers), Atypicals (more common in young adults), including Mycoplasma and Chlamydia; less commonly aspiration (unless good history for such), S. aureus, Gram negatives, and Legionella.

Epidem: Much more common in immunosuppressed individuals who constitute 60% of hospital admissions for pneumonia; worse prognosis in the elderly if elevated BUN, hypotensive or respiratory rate > 30 breaths per min; incidence of 1.62:1000 population with males > females (Eur Respir J 2000;15:757). Acinetobacter in foundry workers (Ann IM 1981;95:688). Increased risk of acquiring CAP for those on gastric acid suppressing medications, and this is a dose-dependent phenomenon for those on PPI’s (but not H₂-blockers) (Jama 2004;292:1955).

Pathophys: Most likely either inoculation from airborne respiratory droplets, or part of systemic problem with hematogenous spread, or aspiration (look to the hx).

Sx: Cough, fever, dyspnea, sputum production, pleurisy, altered mental status in the elderly.

Si: Fever > 101°F, rales (80%), consolidation changes (30%), dullness, increased tactile fremitus, whispered pectoriloquoy, “E” to “A” changes (egophony), vesicles on tympanic membrane (bullous myringitis).

Crs: Poor prognostic factors (see Table 22.1) include age > 65 yr, T < 37°C, mental confusion, tachypnea, elevated BUN, hyponatremia, pleural effusion (Thorax 2000;55:219); or if nursing home-acquired (Chest 2000;117:1378).

Table 22.1 Patient Outcomes Research Team Score

The patient’s age (subtract 10 if female)
Nursing home resident		_______________	(+10)
Coexisting		_______________
	Neoplastic Disease		(+30)
	Liver Disease	_______________	(+20)
	CHF	_______________	(+10)
	CVA	_______________	(+10)
	Renal Disease	_______________	(+10)
Physical exam findings		_______________
	Altered mental status		(+20)
	Resp rate > 30 breaths/min	_______________	(+20)
	Systolic BP < 90 mm Hg	_______________	(+20)
	T < 35 or ≥ 40°C	_______________	(+15)
	Pulse ≥ 125 bpm	_______________	(+10)
		_______________
Laboratory
	Arterial pH < 7.35	_______________	(+30)
	BUN > 30	_______________	(+20)
	Na < 130	_______________	(+20)
	Blood glucose > 250	_______________	(+10)
	Hct < 30%		(+10)
	PaO₂ < 60 mm Hg	_______________	(+10)
	Pleural effusion	_______________	(+10)
Total (calculate the sum and find the appropriate class):		_______________
Class I: Mortality < 0.1%
	Age < 50 years; No significant co-morbid disease; Vital signs normal or nearly normal; Normal mental status
Class II: Mortality approximately 0.6%
	PORT Score of 70 points or less
Class III: Mortality approximately 2.8%
	PORT Score of 71-90 points
Class IV: Mortality approximately 8.2%
	PORT Score of 91-130 points
Class V: Mortality approximately 29.2%
	PORT Score of > 130 points
(Nejm 1997;336:243)

Cmplc: Lung abscess; sepsis; atypical types may go onto hemolytic anemia with cold agglutinins, myocarditis, or Guillain-Barré syndrome.

Diff Dx: Bronchitis—sputum does not differentiate bronchitis and pneumonia or automatically necessitate antibiotic use in the healthy population (J Gen Intern Med 1999;14:151; Lancet 2002;359:1648); sinusitis; influenza—prophylaxis best, rapid testing will not exclude diagnosis (Med Lett Drugs Ther 1999;41:121), and antibiotic drug therapy not useful in most.

Persistent coughs may be seen in those with TB, pertussis, aspirated FB, undiagnosed chronic lung disease, pulmonary neoplasm, PE, and postnasal drip.

Pleural effusion may be seen in CHF, cancer or other infections (TB); right-sided effusions may be sympathetic and due to gallbladder or liver disease (eg, sub-phrenic abscess, cholecystitis, amebiasis).

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