Zohair%20Al%20Aseri.%20MD,%20FCEM%20(UK).%20FRCPC%20(EM

1
Pulmonary Emergencies
Zohair Al Aseri. MD, FCEM (UK). FRCPC
(EMCCM). Consultant, Departments of Emergency
Medicine Critical Care. Chairman, Department of
Emergency Medicine Director, Master Public
Health.King Saud University Hospitals. Riyadh,
KSA Email zalaseri_at_ksu.edu.sahttp//fac.ksu.edu
.sa/zalaseri
2
Pulmonary Emergencies

• Review and new update in
• Asthma exacerbation
• COPD exacerbation
• Pulmonary Embolism
• Update in Pneumonia
• Review Pleural Diseases

3
Management of acute asthma
Item Yes Not Sure No
Severity Scoring system
Chest X ray
ABG
100 Oxygen
Titrated Oxygen
Antibiotic
IV B2 Agonist
MG
Steroid
NIPV
IV NS
4
Management of acute asthma
Clinical features of asthma

• symptoms are
• worse at night and in the early morning
• present in response to exercise, allergen
  exposure and cold air
• present after taking aspirin or beta blockers

• More than one of the following
• Wheeze
• Breathlessness
• chest tightness
• cough

5
Management of acute asthma

• Clinical features influence asthma diagnosis
• History of atopic disorder
• Family history of asthma and/or atopic disorder
• Widespread wheeze
• Unexplained low FEv1 or PEF
• Unexplained peripheral blood eosinophilia

6
Management of acute asthma
Lessons from asthma deaths

• Most patients
• Chronically severe asthma.
• Inadequate treatment with steroid.
• Inappropriate prescription of ß-blockers and
  NSAIDs
• Behavioral and adverse psychosocial

7
Management of acute asthma

• Prediction of a severe asthma attack
• Most develop relatively slowly over 6 hs or more.
  
• In one study, over 80 developed over more than
  48 hours.

8
Management of acute asthma
Patients at risk of developing near-fatal or
fatal asthma

• Previous ventilation or respiratory acidosis
• Previous admission in the last year
• Requiring three or more asthma medications
• Heavy use of ß2 agonist
• Repeated ED visits in the last year

9
Management of acute asthma

• Levels of severity

10
Management of acute asthma

• PEF or FEv1
• PEF expressed as a percentage of the patients
  previous best value.
• PEF as a percentage of predicted gives a rough
  guide in the absence of a known previous best
  value.
• Different peak flow meters give different
  readings.
• Where possible the same or similar type of peak
  flow meter should be used.

11
Management of acute asthma

• Pulse Oximetry
• To determine the adequacy of oxygen therapy
• Aim is to maintain SpO2 9498.

12
Management of acute asthma

• Blood gases not alwayse
• SpO2 lt92 is associated with a risk of
  hypercapnia.

13
Gas Exchange
Severe Astma.
lactate production by the respiratory muscles
exceeding clearance mechanisms
muscle fatigue and inability to maintain adequate
alveolar ventilation
Metabolic Acidosis
Hypercapnia
Common ABG Mild-to-moderate hypoxemia
hypocapnia respiratory alkalosis.
14
Management of acute asthma

• Chest X-ray
• Only if

- ??pneumomediastinum - ??pneumothorax -
??consolidation - life-threatening asthma -
No response to treatment - Need for
ventilation.
15
Management of acute asthma

• Systolic paradox
• Inadequate indicator of the severity and should
  not be used

16
Management of acute asthma

• Admission Criteria
• any feature of a life-threatening or near-fatal
  asthma attack.
• any feature of a severe asthma attack persisting
  after initial treatment.

17
Management of acute asthma
Discharged from ED if peak flow is greater than
75 unless
Significant symptoms
Poor adherence Living alone/socially isolated
Psychological problems
Disability or learning difficulties
Previous near-fatal asthma attack
Attack despite steroid pre-pres
Pregnancy
18
Management of acute asthma
Treatment of acute asthma in adults
Oxygen

• Give all hypoxaemic patients to maintain an SpO2
  level of 9498.
• Lack of pulse oximetry should not prevent the use
  of oxygen.

19
Management of acute asthma
Oxygen
Ptco2 4 mm Hg at 60 min was significantly higher
in the high concentration oxygen group 44 vs
19 plt0.006
Perrin K, Wijesinghe M, Healy B, et al.
Randomised controlled trial of high concentration
versus titrated oxygen therapy in severe
exacerbations of asthma. Thorax 201166937-41.
20
Management of acute asthma
Treatment of acute asthma in adults

• ß2 agonist bronchodilators
• High doses act quickly
• Nebulised adrenaline (epinephrine), a
  non-selective ß2 agonist, does not have
  significant benefit over ß2
• Use pMDI in patients without life-threatening
  features

• All ß2, same efficacy

21
Management of acute asthma
Treatment of acute asthma in adults

• ß2 agonist bronchodilators
• Use Oxygen-driven nebulisers because risk of
  oxygen desaturation while using air-driven
  compressors.
• A flow rate of 6 l/min is required to drive most
  nebulisers.
• IF oxygen cylinders are used, a high flow
  regulator must be fitted.
• Absence of supplemental oxygen should not prevent
  nebulised therapy.

22
Management of acute asthma
Treatment of acute asthma in adults

• ß2 agonist bronchodilators
• In severe asthma consider continuous nebulisation

23
Management of acute asthma
INTRAVENOUS BETA(2)-AGONISTS
Travers AH, Milan SJ, Jones AP, Camargo CA, Jr.,
Rowe BH. Addition of intravenous beta(2)-agonists
to inhaled beta(2)-agonists for acute asthma.
Cochrane Database Syst Rev 201212CD010179.
Syst Rev
no significant benefits for adults with severe
acute asthma
24
Management of acute asthma
Treatment of acute asthma in adults

• Steroid therapy
• Reduce mortality relapses.
• Earlier related to better outcome
• Prednisolone 4050 mg daily or parenteral
  hydrocortisone 400 mg daily (100 mg six-hourly)
  are as effective as higher doses.
• No tapering
• Inhaled corticosteroids should be started or
  continued as soon as possible

25
Management of acute asthma
INHALED CORTICOSTEROIDS
Edmonds ML, Milan SJ, Camargo CA, Jr., Pollack
CV, Rowe BH. Early use of inhaled corticosteroids
in the emergency department treatment of acute
asthma. Cochrane Database Syst Rev
201212CD002308.

• 20 trials (7 adult)
• Reduction from 32 to 17 hospital admissions per
  100 patients treated with ICS in comparison with
  placebo.

26
Management of acute asthma
Edmonds ML, Milan SJ, Brenner BE, Camargo CA,
Jr., Rowe BH. Inhaled steroids for acute asthma
following emergency department discharge.
Cochrane Database Syst Rev 201212CD002316.
12 trials There was no demonstrated benefit of
ICS therapy following ED when used in addition to
oral corticosteroid therapy in the trials.
27
Management of acute asthma
Steroid therapy
CFC chlorofluorocarbon propellant DPI dry
powder inhaler HFA hydrofluoroalkane
propellant. Beclometasone dipropionate
CFC is included for comparison with older
literature.
28
Management of acute asthma
Treatment of acute asthma in adults

• Ipratropium Bromide
• nebulised (0.5 mg 46 hourly) for severe or
  life-threatening asthma or those with a poor
  initial response to ß2 agonist therapy

29
Management of acute asthma
Treatment of acute asthma in adults

• Magnesium Sulphate
• Weak evidence
• Consider giving a single dose of IV for acute
  severe asthma without good initial response to
  inhaled bronchodilator therapy.
• 1.22 g Iv infusion over 20 minutes.

30
Management of acute asthma
Goodacre S, Intravenous or nebulised magnesium
sulphate versus standard therapy for severe acute
asthma (3Mg trial) a double-blind, randomised
controlled trial. Lancet Respir Med
20131293-300.
Magnesium Sulphate
31
Management of acute asthma
Goodacre S, Intravenous or nebulised magnesium
sulphate versus standard therapy for severe acute
asthma (3Mg trial) a double-blind, randomised
controlled trial. Lancet Respir Med
20131293-300.
Magnesium Sulphate
Length of stay after initial hospital attendance
32
Management of acute asthma
Magnesium Sulphate
Powell C, Dwan K, Milan SJ, et al. Inhaled
magnesium sulfate in the treatment of acute
asthma. Cochrane. Database Syst Rev
201212CD003898.
Sixteen trials No overall clear evidence
33
Management of acute asthma
Treatment of acute asthma in adults

• Antibiotics
• Routine prescription is not indicated.

34
Management of acute asthma
NON-INVASIVE POSITIVE PRESSURE VENTILATION
Lim WJ, Mohammed Akram R, Carson KV, et al.
Non-invasive positive pressure ventilation for
treatment of respiratory failure due to severe
acute exacerbations of asthma. Cochrane Database
Syst Rev 201212CD004360.
Limited data that exist to support the use of
NPPV in patients in status asthmaticus.
35
Management of acute asthma
Treatment of acute asthma in adults

• Intravenous fluids
• Correct hypokalemia

36
Management of acute asthma
In Pregnancy

• Give drug therapy for acute asthma as for
  non-pregnant patients
• Deliver high flow oxygen
• Should be treated vigorously in hospital.
• Continuous fetal monitoring

37
Management of acute asthma
Item Yes Not Sure No
Severity Scoring system
Chest X ray
ABG
100 Oxygen
Titrated Oxygen
Antibiotic
IV B2 Agonist
MG
Steroid
NIPV
IV NS
38
Pulmonary Embolism
Risk Factors

• 30 of pt has no provoking factors can be detected

White RH.The epidemiology of venous thrombo
embolism. Circulation 2003 107(23Suppl1)I4I8.
39
Pulmonary Embolism
Item yes Not sure no
Risk factors
Low, inermidat and high
A-a gradient
D dimer for high
D dimer for low
C xray for all
Thrombolytic for stable
½ thrombolytic
Ttt for sub segmental
IV NS for shock
New oral anticoagulants
40
Pulmonarym Embolism
Clinical Characteristics
PollackCV. Clinical characteristics, management,
and outcomes of patients diagnosed with a cute PE
in the ED initial report of EMPEROR(Multi-Center
Emergency Medicine Pulmonary Embolism in the
Real World Registry). Jam Coll Cardiol
201157(6)700706.
41
Pulmonary Embolism
Blood Work

• 40 of the patients have normal arterial oxygen
  saturation
• 20 a normal alveolar-arterial oxygen gradient

Rodger MA, Diagnostic Value of Arterial Blood Gas
Measurement in Suspected Pulmonary Embolism.
AmJRespirCritCareMed 2000162(6)21052108.
Stein PD, Arterial blood gas analysis in the
assessment of suspected acute pulmonary embolism.
Chest 1996109(1)7881.
42
Pulmonary Embolism
Chest X-ray

• Frequently abnormal
• Usually nonspeci?c
• Useful for excluding other causes of dyspnoea or
  chest pain.

43
Pulmonary Embolism

• ECG
• RV strain in more severe cases of PE
• T waves inversion in leadsV1V4
• a QR pattern in V1
• S1Q3T3 pattern
• Incomplete or complete RBBB
• Sinus tachycardia
• 40 of patients.
• Atrial ?brillation may be associated with acute
  PE

Geibe lA. Prognostic value of the ECG on
admission in patients with acute major pulmonary
embolism. EurRespirJ 200525(5)843848
44
Pulmonary Embolism
Clinical prediction rules for PE
45
Pulmonary Embolism
Clinical prediction rules for PE
46
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47
Pulmonary Embolism

• MDCT
• multi-detector computed tomographic
  angiography
• Adequate for excluding PE in a non high clinical
  probability.
• Further investigation for negative CT and a high
  clinical probability is controversial.
• CT segmental or more proximal level is adequate
  proof of PE in patients with a non-low clinical
  probability.

Carrier M, Subsegmental pulmonary embolism
diagnosed by computed tomography incidence and
clinical implications. A systematic review and
meta-analysis of the management outcome studies.
JThrombHaemost 20108(8)17161722.
48
Pulmonary Embolism
MDCT multi-detector computed tomographic
angiography

• Isolated subsegmental PE on CT angiography
• Clinical signi?cance is questionable.
• In 4.7(2.57.6) of patients with PE imaged by
  single detector CT angiography and 9.4
  (5.514.2) of those submitted to MDCT.

Carrier M, Subsegmental pulmonary embolism
diagnosed by computed tomography incidence and
clinical implications. A systematic review and
meta-analysis of the management outcome studies.
JThrombHaemost 20108(8)17161722.
49
Pulmonary Embolism

• MDCT
• multi-detector computed tomographic angiography
• ? role for CUS to exclude DVT
• If no proximal DVT, decision to treat should be
  made on an individual basis, taking into account
  bleeding risk.

Isolated subsegmental PE on CT angiography
Stein PD, Diagnosis and management of isolated
subsegmental pulmonary embolism review and
assessment of the options. Clin Appl Thromb
Hemost 201218(1)2026.
50
Pulmonary Embolism
Ventilationperfusion scintigraphy (V/Qscan)

• for low clinical probability and a normal chest
  X-ray in
• young (particularly female) patients
• pregnancy
• history of contrast medium-induced anaphylaxis
  and strong allergic history
• severe renal failure
• myeloma and paraproteinaemia

Reid J H, Is the lung scan alive and well? Facts
and controversies in de?ning the role of lung
scintigraphy for the diagnosis of pulmonary
embolism in the era of MDCT. EurJNuclMedMol
Imaging 200936(3)505521.
51
Pulmonary Embolism
Compression venous ultrasonography CUS

• DVT was found in 70 of patients with proven PE.
• CUS replaced venography for diagnosing DVT.
• Sensitivity 90 and a Speci?city of approximately
  95 for symptomatic DVT

52
Pulmonary Embolism
53
Pulmonary Embolism
54
Pulmonary Embolism
Management Haemodynamic and respiratory support

• Modest 500mL
• Vasopressors is often necessary
• Norepinephrine

55
PE MANAGEMENT
PE
RV afterload
Hemodynamic Effects
RV dilate
LV prerload
COP
Septal shift
RV O2 Consumption
RV work
RV ischemia
56
Pulmonary Embolism
Management

• Hypoxaemia
• Usually reversed with oxygen.
• If mechanical ventilation is required
• be carful not to increase intrathorcic
  pressure
• PEEP should be applied with caution.
• Low tidal volumes to keep the end-inspiratory
  plateau pressure 30cmH2O.

57
Pulmonary Embolism
Management Anticoagulation

• Parenteral anticoagulation
• Unfractionatedheparin (UFH)
• LMWH
• or fondaparinux
• Over the ?rst 510 days.

58
PE MANAGEMENT
Anticoagulation
Why earlier is better?
Recurrence rate
23
anticoagulated in the first day
4-6,
Hull RD, Raskob GE, Brant RF, et al. Relation
between the time to achieve the lower limit of
apt therapeutic range and recurrent venous
thromboembolism during heparin treatment for deep
venous thrombosis. Arch Intern Med. 2568-157
25621997
59
Pulmonary Embolism
Management Anticoagulation
Low-molecular-weight heparins and
Pentasaccharide (fondaparinux) approved for the
treatment of PE
60
Pulmonary Embolism
Management Anticoagulation

• Heparin should overlap with vitamin K antagonist
• can be followed by one of the new oral
  anticoagulants dabigatran or edoxaban.
  Ifrivaroxaban or apixaban,
• Oral treatment with one of these agents should
  be started directly or after a12 day of UFH,
  LMWH or fondaparinux.

61
Pulmonary Embolism
Vitamin K antagonists

• Warfarin can be started at a dose of 10 mg in
  younger (e.g. ,60 years of age) healthy
• 5mg in older patients and in those who are
  hospitalized.
• Daily dose is adjusted according to the INR over
  the next 57 days, aiming for an INR level of
  2.03.0

62
Pulmonary Embolism
Management Anticoagulation

• LMWH or fondaparinux are preferred over UFH for
  lower risk of major bleeding and HIT
• UFH is recommended if
• Primary reperfusion is considered
• Serious renal impairment (CR clearance ,30mL/min)
• Severe obesity.

63
Pulmonary Embolism
Management Anticoagulation

• LMWH
• No routine monitoring
• periodic measurement of antifactor Xa activity
  (anti-Xa levels) may be considered during
  pregnancy.
• Peak values of antifactor Xa activity should be
  measured 4 hours after the last injection and
  trough values just before the next dose of LMWH
  Would be due
• Target range is
• 0.61.0IU/ mL for twice daily
• 1.02.0IU/Ml for once daily administration.

64
Pulmonary Embolism
Management Anticoagulation

• Fondaparinux
• Selective factor Xa inhibitor
• Daily SQ injection at weight adjusted doses,
• No monitoring.
• Not to be given with thrombolytic
• No proven cases of HIT.
• Contraindicated in patients with
• severe renal insuf?ciency (Cr clearance
  ,30mL/min)
• If (Cr clearance 3050mL/min) dose should be
  reduced by 50 in these patients.

65
Pulmonary Embolism
New oral anticoagulants

• Summary of results of the trials using NOACs in
  the treatment of VTE indicate that
• these agents are noninferior (in terms of
  efficacy)
• possibly safer (particularly in terms of major
  bleeding) than the standard heparin/VKA regimen

Experience with NOACs is still limited but
continues to accumulate.
66
Pulmonary Embolism
Phase III clinical trials with non-vitaminK-depend
ent new oral anticoagulants (NOACs) for the
acute-phase treatment and standard duration of
anticoagulation after VTE
67
Pulmonary Embolism
68
Pulmonary Embolism
69
Pulmonary Embolism
70
Pulmonary Embolism
71
Fibrinolysis for Patients with Intermediate-Risk
PE. nejm.org April 10, 2014
Pulmonary Embolism

• Tenecteplase plus heparin with placebo plus
  heparin
• in normotensive patients with intermediate-risk
  PE.
• Eligible patients had RV dysfunction on echo or
  CT, as well as myocardial injury as indicated by
  a positive test troponin I or T.

72
Pulmonary Embolism
Fibrinolysis for Patients with Intermediate-Risk
PE. nejm.org April 10, 2014
73
Fibrinolysis for Patients with Intermediate-Risk
PE. nejm.org April 10, 2014
Pulmonary Embolism
74
Pulmonary Embolism
Fibrinolysis for Patients with Intermediate-Risk
PE. nejm.org April 10, 2014
75
Fibrinolysis for Patients with Intermediate-Risk
PE. nejm.org April 10, 2014
Pulmonary Embolism
Conclusions In patients with intermediate-risk
pulmonary embolism, fibrinolytic therapy
increased the risk of major hemorrhage and stroke.
76
Fibrinolysis for Patients with Intermediate-Risk
Pulmonary Embolism

• Therefore, great caution is warranted when
  considering fibrinolytic therapy for
  hemodynamically stable patients with pulmonary
  embolism, right ventricular dysfunction, and a
  positive cardiac troponin test.

77
Pulmonary Embolism
1/2 thrombolysis in patients who are
hemodynamically stable but had moderate PE
evidenced on CTA
Single-center, randomized, unblinded
non-placebo-controlled study N121 patients with
moderate PE identified by CT criteria Randomizatio
n to either low-dose thrombolysis (n61) or
control (n60) Mean follow-up 28 months Primary
Outcome Pulmonary hypertension Secondary
Composite Outcome pulmonary hypertension or
recurrent PE
78
Pulmonary Embolism
The study was unblinded and only performed at a
single center and the primary outcome of
pulmonary hypertension reduction may not have a
patient centered effect.
Randomization to Half Dose Thrombolysis tPA
0.5 mg/kg (max 50 mg), given as 10 mg bolus
followed by remainder over 2 hours Warfarin
started on admission Enoxaparin 1mg/kg
subcutaneous twice daily or Heparin at 70U/kg
bolus with dosing to keep PTT at 1.5-2x
baseline Control same but no tPA
79
Pulmonary Embolism

• Venous ?lters
• Usually Infrarenal portion of the inferior vena
  cava (IVC).
• Suprarenal If thrombus is identi?ed in the renal
  veins.
• Indicated in
• acute PE with absolute contraindications to anti
  coagulant drugs
• In patients with recurrent PE despite adequate
  anticoagulation treatment

80
Pulmonary Embolism
81
Pulmonary Embolism
PE in pregnancy
82
Pulmonary Embolism
PE in pregnancy

• Estimated radiation (adapted from Bajc etal.
  (2009) and Chunilal etal. (2009)

83
Pulmonary Embolism
PE in pregnancy
Epidural analgesia cannot be used unless LMWH
has been discontinued at least 12 hs Treatment
can be resumed 1224 hs after removal of the
epidural catheter. After delivery, heparin
treatment may be replaced by anticoagulation with
VKA.
84
Pulmonary Embolism
Item yes Not sure no
Risk factors
Low, inermidat and high
A-a gradient
D dimer for high
D dimer for low
C xray for all
Thrombolytic for stable
½ thrombolytic
Ttt for sub segmental
IV NS for shock
New oral anticoagulants
85
COPD

• Working definition of COPD
• Characterised by airflow obstruction that is not
  fully reversible.
• Predominantly caused by smoking.
• Other factors, ie occupational exposures

86
Management of COPD
Item Yes Not Sure No
ETCO2
Chest X ray
100 Oxygen
Titrated Oxygen
Antibiotic
IV B2 Agonist
2 Weeks Steroid
NIPV
Permissive hypercapnia
87
COPD

• Definition
• Airflow obstruction is defined as a reduced
  FEV1/FVC ratio (where FEV1 is forced expired
  volume in 1 second and FVC is forced vital
  capacity), such that FEV1/FVC is less than 0.7.

88
COPD

• Diagnosis
• There is no single diagnostic test
• based on a combination of history, physical
  examination and confirmation of the presence of
  airflow obstruction using spirometry.

89
COPD
Clinical features differentiating COPD and asthma
90
COPD Exacerbations

• Definition
• Sustained worsening of the patient's symptoms
  from their usual stable state
• Beyond normal day-to-day variations.
• Acute in onset.

91
COPD Exacerbations

• Definition
• Commonly reported symptoms are
• Worsening breathlessness
• Cough
• Increased sputum production
• Change in sputum colour.
• The change in these symptoms often necessitates a
  change in medication

92
The accuracy of mainstream end-tidal carbon
dioxide levels to predict the severity of COPD
exacerbations presented to the ED. American
Journal of Emergency Medicine 32 (2014) 408
COPD Exacerbations
End-tidal carbon dioxide levels

• To analyze the alteration of the ETCO2 levels and
  its role in the decision making process
• 102 patients
• Strong correlation between the ETCO2 and PCO2
• ETCO2 levels were observed to be higher in
  admitted patients.
• Concordant with pCO2 levels in ABG.

93
COPD Exacerbations
ETCO2
The accuracy of mainstream end-tidal carbon
dioxide levels to predict the severity of COPD
exacerbations presented to the ED. American
Journal of Emergency Medicine 32 (2014) 408
94
COPD Exacerbations
GOLD Classifcation of Severity of COPD
95
COPD acute management bundle
96
COPD acute management bundle
97
COPD Exacerbations

• If a patient is hypercapnic or acidotic the
  nebuliser should be driven by compressed air, not
  oxygen (to avoid worsening hypercapnia).
• Provide oxygen to target a pulse o2 Sat of 88 to
  92
• Venturi mask can be useful for titrating FiO2

98
COPD Exacerbations

• High FiO2 usually not needed and can contribute
  to hypercapnia
• High FiO2 requirement should prompt consideration
  of alternative diagnosis eg, PE)

99
COPD acute management bundle
How much Oxygen
100
COPD acute management bundle
Effect of high flow oxygen on mortality in COPD
patients in prehospital setting randomised
controlled trial. BMJ 2010341
Objectives To compare standard high flow oxygen
treatment with titrated oxygen treatment for
patients with an acute exacerbation of COPD in
the prehospital setting. Design Randomised
controlled parallel group trial. Participants 405
patients
How much Oxygen
101
COPD acute management bundle
How much Oxygen
102
COPD acute management bundle
How much Oxygen
103
Short-term vs Conventional Glucocorticoid Therapy
in Acute Exacerbations of COPD JAMA, June 5,
2013Vol 309, No. 21
314 randomized patients a 5-day glucocorticoid
treatment course was non inferior to a 14-day
104
COPD acute management bundle

• ANTIBIOTICS If associated with pneumonia
• No Pseudomonas risk factor(s) Ceftriaxone 1 to 2
  grams IV, OR levofloxacin 750 mg IV or orally, OR
  moxifloxacin 400 mg IV or orally
• Pseudomonas risk factor(s) Levofloxacin 750 mg
  IV or orally, OR piperacillin-tazobactam 4.5
  grams IV, OR cefepime 1 to 2 grams IV, OR
  ceftazidime 1 to 2 grams IV

105
COPD acute management bundle

• NIVS
• can be highly effective in
• avoiding intubation
• increasing pH
• reducing Pco2 and dyspnea in the frst 4 hs
• reducing mortality rates
• decrease work of breathin
• Optimizes preoxygenation if intubation needed

106
COPD acute management bundle
NIVS Can be delivered by either nasal or
full-face mask. Patients with COPD and
respiratory distress have signifcant iPEEP,
CPAP BiPAP counteract iPEEP and decrease the
work of breathing.
107
COPD acute management bundle
NIVS Nasal CPAP is a simple technique, and 5 to
10 cm H2O pressure is required.

• Initial settings for bilevel NPPV
• 8 cm H2O inspiratory pressure (may increase up to
  15 cm H2O if needed to aid ventilation)
• 3 cm H2O expiratory pressure

108
COPD acute management
Non-invasive positive pressure ventilation for
treatment of respiratory failure due to
exacerbations of chronic obstructive pulmonary
disease. Ram FS Cochrane Database Syst Rev.
2004 Randomised controlled trials comparing
NPPV plus usual medical care versus no NPPV. 14
studies were included in the review.
CONCLUSIONS Data show benefit of NPPV as
first line intervention NPPV should be
considered early in the course of respiratory
failure
109
COPD acute management bundle
Mechanical Ventilation
Initial ventilator settings oxygen (Fio2) of
100 tidal volume in the 6- to 8-mL/kg RR of 8
to 10 breaths/min Assist-control mode with an
inspiratory fow rate of 80 to 100 L/min.
Neuromuscular blockade is not routinely
required and should be avoided when possible .
Follow capnography or ABGs
110
COPD acute management bundle
Mechanical Ventilation

• Permissive hypercapnia
• Essential
• Normalization of pH and Pco2 should be gradual
  over many hours.
• Low volume and rate settings will result in
  hypercapnia and respiratory acidosis.
• This approach helps prevent associated barotrauma

111
COPD acute management bundle
Mechanical Ventilation

• Permissive hypercapnia
• Hyperventilation alkalosis must be avoided,
  particularly because patients may have
  preexisting chronic metabolic alkalosis.
• Alkalosis can result in seizures and
  dysrhythmias, especially with coexisting
  hypokalemia.

112
COPD acute management bundle

Criteria for ICU admission include
High-risk comorbidities (pneumonia, arrhythmia, heart failure, HTN, renal failure, liver failure)
Continued need for NPPV or invasive ventilation
Hemodynamic instability
Need for frequent nebulizer treatments or monitoring
113
Management of COPD
Item Yes Not Sure No
ETCO2
Chest X ray
100 Oxygen
Titrated Oxygen
Antibiotic
IV B2 Agonist
2 Weeks Steroid
NIPV
Permissive hypercapnia
114
Pneumonia

• Diagnosis of pneumonia is based on symptoms and
  signs of an acute lower respiratory tract
  infection
• can be confirmed by a chest X-ray showing new
  shadowing
• R/O other DD

115
Pneumonia
116
Pneumonia
117
Pneumonia
118
Pneumonia
119
Community-Acquired Pneumonia in Older Children
and Adults Outpatient Treatment
CLINICAL SETTING ANTIBIOTIC REGIMEN COMMENTS
Previously healthy, no antimicrobials in last 3 mo   Doxycycline 100 mg PO bid level III evidence Preferred for adolescent/young adult when likelihood of mycoplasma is high variable activity vs. S. pneumoniae.
Previously healthy, no antimicrobials in last 3 mo   Azithromycin level I evidence) For typical bacterial and atypical. Variety of dosing regimens 500 mg once then 250 mg od for 4 500 mg PO daily for 3 days 2g extended release suspen. once. Can substitute clarithromycin.
120
Community-Acquired Pneumonia in Older Children
and Adults Outpatient Treatment
CLINICAL SETTING ANTIBIOTIC REGIMEN COMMENTS
Comorbidities, or antimicrobials in last 3 mo Levofloxacin 750 mg PO daily for 5 days Can substitute moxifloxacin or gemifloxacin.
    Treats common typical and atypical bacterial pathogens active vs. DRSP. Use if recently received ß-lactam or macrolide.
  Cefpodoxime 200 mg PO bid azithromycin 500 mg PO daily Use if recently received fluoroquinolones. Can substitute cefdinir, cefprozil, or amoxicillin/clavulanate for cefpodoxime. Variable activity against DRSP.
level I
level 1
121
Community-Acquired Pneumonia in Older Children
and Adults Inpatient Antimicrobial Treatment
CLINICAL SETTING ANTIBIOTIC REGIMEN COMMENTS
Community-acquired, nonimmunocompromised Ceftriaxone 1 g q24h azithromycin 500 mg q24h IV or PO Could substitute cefotaxime, ampicillin-sulbactam, or ertapenem for ceftriaxone.
  Respiratory fluoroquinolone (levofloxacin 750 mg IV q24h or moxifloxacin 400 mg IV q24h) Treats most common bacterial and atypical pathogens. Active vs. DRSP.
level I
122
Community-Acquired Pneumonia in Older Children
and Adults Inpatient Antimicrobial Treatment
CLINICAL SETTING ANTIBIOTIC REGIMEN COMMENTS
Severe pneumonia (ICU) Ceftriaxone 1 g IV q24h levofloxacin 750 mg IV q24h vancomycin 1 g IV q12h Can substitute cefotaxime, cefepime, ertapenem, or ß-lactam/ß-lactamase inhibitor for ceftriaxone. Can substitute moxifloxacin for levofloxacin. Can substitute linezolid for vancomycin.
Health careassociated pneumonia or severe pneumonia with neutropenia, bronchiectasis (risk for Pseudomonas) Cefepime 2 g IV q12h ciprofloxacin 500 mg IV q12h vancomycin 1 g IV q12h Can substitute other antipseudomonal ß-lactam, such as piperacillin-tazobactam, imipenem, or meropenem, for cefepime. Can substitute aminoglycoside plus macrolide for ciprofloxacin.
123
Community-Acquired Pneumonia in Older Children
and Adults Inpatient Antimicrobial Treatment
CLINICAL SETTING ANTIBIOTIC REGIMEN COMMENTS
Presumed PCP Trimethoprim-sulfamethoxazole 240/1200 mg IV q6h Add ceftriaxone to TMP/SMX if severe, until PCP confirmed. Alternatives for sulfa allergy include pentamidine third-generation cephalosporin clindamycin primaquine or atovaquone ceftriaxone.
124
Infectious Diseases Society of America/American
Thoracic Society Consensus Guidelines on the
Management of Community-Acquired Pneumonia in
Adults

• CURB-65 Pneumonia Severity Index (PSI), can be
  used to identify patients with CAP who may be
  candidates for outpatient treatment.
• (Strong recommendation level I evidence.)

CURB-65(confusion, uremia, respiratory rate, low
blood pressure, age 65 years or greater),
125
Pneumonia
Criteria for severe community-acquired pneumonia.

• RR 30 breaths/min
• PaO2/FiO2 ratio 250
• Multilobar infiltrates
• Confusion/disorientation
• Uremia (BUN level, 20 mg/dL)
• Leukopeniac (WBC lt4000 cells/mm3)

• platelet count, lt100,000 cells/mm3)
• Hypothermia (lt36C)
• Hypotension
• Invasive mechanical ventilation
• Septic shock with the need for vasopressors

126
Infectious Diseases Society of America/American
Thoracic Society Consensus Guidelines on the
Management of Community-Acquired Pneumonia in
Adults

• Early treatment (within 48 h of the onset of
  symptoms) with oseltamivir or zanamivir is
  recommended for influenza A.
• (Strong recommendation level I evidence.)

127
Infectious Diseases Society of America/American
Thoracic Society Consensus Guidelines on the
Management of Community-Acquired Pneumonia in
Adults

• Use of oseltamivir and zanamivir is not
  recommended for patients with uncomplicated
  influenza (level I evidence),
• These drugs may be used to reduce viral shedding
  in hospitalized patients or for influenza
  pneumonia.
• (Moderate recommendation level III evidence.)

128
Management of acute asthma
Summary
Item Yes Not Sure No
Severity Scoring system
Chest X ray
ABG
100 Oxygen
Titrated Oxygen
Antibiotic
IV B2 Agonist
MG
Steroid
NIPV
IV NS
129
Pulmonary Embolism
Summary
Item yes Not sure no
Risk factors
Low, inermidat and high
A-a gradient
D dimer for high
D dimer for low
C xray for all
Thrombolytic for stable
½ thrombolytic
Ttt for sub segmental
IV NS for shock
New oral anticoagulants
130
Management of COPD
Summary
Item Yes Not Sure No
ETCO2
Chest X ray
100 Oxygen
Titrated Oxygen
Antibiotic
IV B2 Agonist
2 Weeks Steroid
NIPV
Permissive hypercapnia
131
Pulmonary Emergencies

• Thank You
• Q?

132
Pleural Disease

• The two most common nontraumatic pleural
  problems
• spontaneous pneumothorax
• pleural infammation with effusion.

133
Spontaneous Pneumothorax

• Occurs in the absence of any external
  precipitating factor, either traumatic or
  iatrogenic.
• Primary spontaneous pneumothorax occurs in
  individuals without clinically apparent lung
  disease.
• Secondary spontaneous pneumothorax arises in the
  context of an underlying pulmonary disease
  process.

134
Spontaneous Pneumothorax

• Primary
• Typically occurs in healthy young men of taller
  than average height.
• Associated factors include
• cigarette smoking
• changes in ambient atmospheric pressure
• Mitral valve prolapse and Marfan syndrome

135
Spontaneous Pneumothorax

• Secondary
• Most commonly associated with COPD, nearly 70
  of cases.

136
Spontaneous Pneumothorax

• Secondary
• Malignancy is another common cause
• TB and lung abscess in developing countries

137
Spontaneous Pneumothorax

• Secondary
• Catamenial pneumothorax
• rare condition
• recurrent spontaneous pneumothorax occurs in
  association with menses (typically within 72
  hours of onset).

138
Spontaneous Pneumothorax

• Expiratory films
• Occasionally helpful in identifying a small
  apical pneumothorax
• Routine use does not improve diagnostic yield.
• In critically supine ill patients
• deep sulcus (i.e., a deep lateral costophrenic
  angle) can suggest the presence of pneumothorax
  on that side.

139
Spontaneous Pneumothorax

• Xray COPD
• pneumothorax more difficult to detect.
• giant bullae may simulate the radiographic
  appearance of pneumothorax.

140
Spontaneous Pneumothorax

• Xray COPD
• Pneumothorax vs Giant bulla
• A clue to differentiating
• Pneumothorax tends to run parallel to the chest
  wall.
• Giant bulla tends to have a more concave
  appearance.
• CT can differentiate

141
Pneumothorax Size ???
142
Spontaneous Pneumothorax

• Management
• Tension pneumothorax
• Decompressed.

143
Spontaneous Pneumothorax

• Management
• Reabsorption rate ranges from 1 to 2 per day,
  accelerated by a factor of 4 with the
  administration of 100 oxygen.

Healthy young patients small primary spontaneous
pneumothorax (i.e., lt20) minimal symptoms
Observation alone
144
Spontaneous Pneumothorax
Management

• 20
• Aspiration with an intravenous catheter may be
  attempted.
• If 6 hours after aspiration the xray shows no
  reaccumulation, the catheter is removed and the
  patient can be discharged home

145
Spontaneous Pneumothorax
Management
Type of Pneumothorax Tube size
primary spontaneous pneumothoraces 7-14F
secondary spontaneous pneumothorax 20-28F
If with pleural fluid or an anticipated need for mechanical ventilation 28F
146
Spontaneous Pneumothorax

• Common complications of chest tube
• incorrect placement
• pleural infection
• prolonged pain
• Reexpansion pulmonary edema
• reexpansion hypotension (rare) occurrences after
  rapid evacuation of large pneumothoraces.

147
PLEURAL INFLAMMATION AND EFFUSION

• Pleural effusion
• Large amount of fluid in the pleural space.
• Relatively common.
• The most common cause is CHF, followed by
  malignancy, bacterial pneumonia, and PE.

148
PLEURAL INFLAMMATION AND EFFUSION
Pleural effusion

• Other conditions
• --Viral infections --Uremia
• --Myxedema --Cirrhosis
• --Nephrotic syndrome
• --Ovarian hyperstimulation syndrome
• --Collagen vascular diseases (e.g., SLE,RA)
• --Intra-abdominal processes

In developing countries, TB is the leading cause
149
PLEURAL INFLAMMATION AND EFFUSION

• Pleuritis
• also referred to as pleurisy
• inflammation of the pleura.

150
PLEURAL INFLAMMATION AND EFFUSION

• Pleuritis
• Cause by wide range of diseases
• Viral syndromes
• Pneumonia
• PE
• SLE and other connective tissue diseases.

151
PLEURAL INFLAMMATION AND EFFUSION

• Parapneumonic effusion
• A pleural effusion associated with bacterial
  pneumonia, bronchiectasis,
• or lung abscess.
• Complicated parapneumonic effusion
  parapneumonic effusions that require tube
  thoracostomy.

152
PLEURAL INFLAMMATION AND EFFUSION

• Loculated effusion
• Fluid anatomically confined and not freely
  flowing in the pleural space.

153
PLEURAL INFLAMMATION AND EFFUSION
Pleural effusion

• Transudates
• Exudates
• May have characteristics of both like PE

154
PLEURAL INFLAMMATION AND EFFUSION

• Massive effusions (gt1.5-2 L)
• Mainly with malignancy
• Can arise in the setting of CHF, cirrhosis

155
PLEURAL INFLAMMATION AND EFFUSION

• The classic radiographic appearance
• volume of 250 to 500 mL of pleural fluid is
  required before radiographic demonstration is
  possible
• Other findings on the supine radiograph may
  include apical capping

156
PLEURAL INFLAMMATION AND EFFUSION

• Subpulmonic effusions
• fluid collections between the lung base and the
  diaphragm
• can be difficult to diagnose
• often simulating an elevated hemidiaphragm.

157
PLEURAL INFLAMMATION AND EFFUSION
Pleural effusion

• Lights criteria transudates vs exudates.

158
PLEURAL INFLAMMATION AND EFFUSION

• Pleural fluid
• pH of less than 7.3 is associated with
  parapneumonic effusions, malignancies, rheumatoid
  effusions, TB, and systemic acidosis.
• pH of less than 7.0 strongly suggests empyema (or
  esophageal rupture).
• pH of less than 7.0 and glucose less than 50
  mg/dL are indications for tube thoracostomy

159
PLEURAL INFLAMMATION AND EFFUSION

• Pleural fluid
• predominance of neutrophils suggests an acute
  process, such as pneumonia, pulmonary embolus, or
  acute tuberculous pleuritis.
• predominance of monocytes or lymphocytes suggests
  a more chronic process, such as malignancy or
  established tuberculosis.

160
PLEURAL INFLAMMATION AND EFFUSION
Pleural fluid

• In the absence of a traumatic tap, bloody fluid
  suggests trauma, neoplasm, or pulmonary
  infarction.
• If the hematocrit more than 50 that of the
  peripheral blood, the effusion is, by definition,
  a hemothorax

161
PLEURAL INFLAMMATION AND EFFUSION
Pleural Effusion, Management

• Drain if
• 1--Large effusions,
• urgent therapeutic thoracentesis may stabilize
  respiratory or circulatory status.
• 2--Empyema
• necessitates insertion of a chest tube to drain
  the pleural space adequately and prevent the
  development of loculations.
• 3--Hemothorax
• If bleeding exceeds 200 mL/hr, thoracotomy should
  be considered.

162
PLEURAL INFLAMMATION AND EFFUSION
Pleural Effusion, Management

• After thoracentesis do xray to r/o
• Iatrogenic pneumothorax
• Reexpansion pulmonary edema

163
Pulmonary Emergencies

• Refernces
• Rosen Emergency Medicine Text Book

164
Pulmonary Emergencies

• Thank You

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Hypoxemia

• Low O2 content of inspired gas
• High altitude
• V/Q mismatch
• Alveolar filling or airway obstruction or
  vascular anomalies
• Shunt
• Pulmonary (AVM, lobar / lung collapse) or
  extra-pulmonary (PFO)
• Hypoventilation
• Central, neuromuscular, myopathic, obesity,
  chronic lung disease
• Low DLCO
• Interstitial lung disease, Pulm HTN
• Low Mixed Venous O2 sat
• Shock / low output state

203
Basic Lung Physiology
204
Basic Lung Physiology
205
Basic Lung Physiology
Timed vital capacity volume of gas that can be
expired from the lungs with maximum effort in a
given time (usually 1 second "one-second forced
expired volume", FEV1) 1) usually expressed as
a fraction of the total volume expired in a
maximum effort, the Forced Vital Capacity
(FVC) 2) normal value of FEV1 / FVC ³ 80
3) because FEV1 / FVC incorporates both volume
and flow, it can distinguish between obstruction
and small or stiff lungs