Pulmonary/Chest Cases

Question 1

Asthma in the ED

Answer 1

• Bilateral wheezing is the hallmark
• Dyspnea, cough, chest “tightness”
• Pronged expiratory phase, I:E ratio 1:3 or 4
• Tachypnea, tachycardia, hypoxia, hypercarbia
• Poor peak expiratory flow measurements (PEFR)
• Med non-compliance, viral illness most common reasons
• “All that wheezes isn’t asthma”
• New onset after 40yo is likely NOT asthma
• Correct the exacerbation: that is the goal

-You dont develop primary asthma after age 40

Question 2

Mild to moderate asthma exacerbations

Answer 2

• Hand held nebulizer – asap Albuterol 2.5mg in nebulizer:
  
  • Once, x3 q20min or 10ml/1 hr
• Oral Prednisone (60mg) PO (as good as IV initially)
• Peak flow (PEFR) after each neb tx, repeat VS, reassess
• Usually no need for labs, CXR, EKG, ABG, etc…unless…
  
  • Severe sx’s, fever, not improving, get worse or considering alternate Dx

-Albuterol nebulizer dosing: 2.5mg Albuterol (0.5ml of 0.5% diluted in 3ml normal saline)
-If shes a smoker or has COPD, you would consider Atrovent as well
-PREDNISONE IS KEY
-The HR will increase after the neb treatment – if the HR is now 160, THAT’S A PROBLEM
USUALLY NO NEED FOR LABS, CXR, ETC!!!
-If they have a fever, you need CXR

• Walk ‘em – while youre walking, you want to hear them speak. If they cant say a sentence without taking a breath, they cant go home!
• Most people do 60mg oral steroid
• B2 agonists can cause the lactic acid to rise
• If someone with asthma has ever been intubated,, that should scare you
• If they’ve ever had an exacerbation with a steroid burst, THEY CANNOT GO HOME!!

Question 3

When to discharge asthma exacerbations

Answer 3

• Walk ‘em, assure f/u, return precautions
• Rx’s: Oral steroid burst (60mg x5d or tapered dose Rx), inhaled steroid prescription
• Can’t go home if…
  
  • Not responding to treatment, worsening
  • Hypoxic - ambulatory pulse ox <94-95%
  • PEFR not improved to 65-70% predicted
  • ED visit in past 3 days for same
  • Exacerbation during steroid burst

Question 4

COPD in the ED

Answer 4

• Exacerbations common, but why?
  
  • Disease progression
  • Med non-compliance, out of home O2
  • Infection - viral, bronchitis, pneumonia
  • Cardiac - pump failure/impairment, arrhythmia
  • Metabolic acidosis, other illness on top
  • Exposure/environment
  • Sedation, drugs
• Treatment goals – reverse hypoxia, reverse hypercarbia, restore effective ventilation
• Is this COPD or something else??

On CXR:
-Hyperexpanded lung fields, narrow
cardiac silhouette, flat diaphragms,
blunted costophrenic angles

• New arrhythmia with COPD exacerbation is NOT GOOD!!
• MUDPILERS – metabolic acidosis

Question 5

COPD diagnosis and tx

Answer 5

• IV, monitor, CXR, EKG, lung/cardiac US, labs (cbc, cmp, Utox, +/- troponin)
• Continuous nebulizer treatments
  
  • Beta 2 agonists (10mg over 1h)
  • Inhaled anticholinergics
• Oral steroids, IV if admit
• Antibiotics if appropriate
• NIPPV: Bipap – Bi-level positive airway pressure
  
  • If no response to above tx
• Albuterol + Atrovent (Ipratropium) = DuoNeb– > 3mg Albuterol/0.5mg Ipratropium
• COPDers are often much older and sicker than asthmatics – don’t turn around as quickly as asthmatics
• IV O2 monitor
• Lung and cardiac US very important
• Beta 2 agonists, anticholinergics and steroids!
• Most of the time, people use doxy because these people often get weird pneumonias

-COPDers that fall asleep with RR of 40, THEY ARE HYPERCARBIC!!

Question 6

When should you NOT send home a COPD exacerbation

Answer 6

• Not responding, worsening symptoms/signs
• Mental status changes
• If require Bipap (usually)
• Hx recent severe exacerbations/intubation
• Older, co-morbidities
• New arrhythmia
• Uncertain of diagnosis
• Poor ambulatory pulse ox
• Poor home support

Question 7

pneumothorax

Answer 7

-IV, O2, monitor; EKG, tx pain

• CXR – search edges
  
  • +/-Expir film, lateral decub; deep sulcus sign if in bed
• Bedside ultrasound
  
  • Absence of “comet tailing”; the friction of pleural sliding
• Shock? Or stable now?
  
  • Can deteriorate quickly
• Primary or Secondary?
• Chest CT
• Surgery consult
• Tall young males who have spontaneous pneumothorax
• What made you think this? He had a sudden onset, decreased pulse ox, increased RR
• Not thinking PNA or MI because hes 19

Question 8

Treatment of pneumothorax

Answer 8

• Treatment depends on size
  
  • Pigtail catheter w/ Heimlich valve
  • Chest tube

-Majority are admitted to Surgery

• Small, primary pneumos (<15% total lung) in select cases, a stable patient can go home if:
  
  • Not a secondary pneumo
  • Stable vitals after 3-4hrs
  • Repeat CXR with no enlargement
  • Pt is reliably able to return in 12-24hrs for repeat CXR
  • If catheter re-expansion (Stable x6hrs)
  • Surgical consult agrees

Question 9

Tension pneumothorax

Answer 9

• Air into pleural space - one-way valve
• Rare, deadly: seconds count
• Clinical diagnosis - often post-trauma
  
  • Severe dyspnea, sudden change in VS/LOC
  • *Decreased breath sounds affected side
  • *Hypotension
  • *Distended neck veins
  • *Tracheal shift
• Needle thoracentesis: 2nd ICS at MCL
• Follow with chest tube immediately
• This is a CLINICAL diagnosis!! NOT AN XRAY DIAGNOSIS
• This person will die if you don’t treat it!!
• Usually a 16 gauge that you can find – 2nd intercostal space at the mid clavicular line

Question 10

Pulmonary effusion

Answer 10

• IV, O2, monitor, pain control, labs
• CXR; Lateral decubitus film – does it layer out?
• Bedside ultrasound - see fluid, guides tap – also check for pericardial effusion
• Chest CT - gold standard
  
  • Excellent for small effusions, other dx’s
  • CT guided thoracentesis if loculated – doesn’t layer out
• Effusions can be infectious, malignant, reactive, chronic, post-surgical, traumatic
• If you get a pleural effusion, you as the practitioner need to check for pericardial effusion!!

Question 11

pulmonary effusion treatment

Answer 11

• Sick? Is this shock? Fever?
• Triple scan US: fluid status, pericardial effusion
• US guided Thoracentesis
  
  • Diagnostic and therapeutic
  • Slow removal of fluid - ultrasound guided
  • No more than 1000 - 1500ml (To avoid re-expansion pulmonary edema)
  • CXR after to check for pneumothorax

-Pleural fluid analysis

Question 12

The flu red flags

Answer 12

• Who should you be worried about?
  
  • Young, old, immunocomp, recent surg/hosp, lung Dz

-Who gets a CXR

• Hypotension/tachy/tachy/fever, hypoxic, lung findings
  
  • **No viral syndrome sx’s, worsening, sx’s >2wks
• Who gets moved to the main ED?
  
  • Abnormal VS, chest pain, young/old, risks, look sick
• Which Hx/PE findings really make a difference?
  
  • ROS: SOB, DOE, hemoptysis, leg edema/pain, syncope
  • PMHx (cardiac, lung dz, DM, steroids), SH (etoh, home)
  • VS, diaphoresis, new wheezes, rales, edema, rash

-Who has the flu vs. who has pneumonia, other dx??

• Tachy tachy = tachycardic and tachypnic
• Bacteria, PNA are different – cough (sore throat), no n/v, no diarrhea
• If you don’t have viral sxs (runny nose, upset stomache, n/v, diarrhea, etc.)

Question 13

pneumonia

Answer 13

• Common: sick or not sick? Know Sx’s/Red Flags/Risks
• CXR for Dx
• If +/- sick, risks: lactic acid for sepsis; labs, CURB65
• Admit sick; D/C not sick w/ close f/u, return precautions
• Abx: Azithro, Levo?, Doxy
• If D/C: educate, sx relief
• 100 CXR’s…
• CURB65 – clinical decision score to determine 30 day mortality risk in patients with pneumonia.
• Points for confusion, BUN, respiratory rate, blood pressure, age >65
• Higher the score, greater risk for 30 day mortality. Indication for admission
• PNA is a big cause of sepsis so you need to recognize it!

Question 14

Hemoptysis

Answer 14

• Pulmonary or non-pulmonary?
• Amount in 24hrs? Small amounts common
• Hemodynamically stable?
• Common causes:
  
  • Pneumonia
  • Coumadin/thinners
  • Tuberculosis
  • Cancer
  • Pulmonary embolus
  • Hematemesis?
  • Nasal, dental, oral source?
  • Trauma
• ABC’s, vitals; IV(s), O2, monitor
• Hx: Onset? Chest pain? SOB? Weight loss? Fever? Trauma? Coumadin/thinners? CAM?
• PE: Usual suspects + look for non-pulmonary source
• CXR, EKG, Labs, lactic acid, PT/INR. Type and screen/cross?
• Chest CT if significant
• If very significant, ongoing: a big airway concern. Make a plan
• Pulmonary consult: bronchoscopy
• Admit: significant or bad dx
• Hemodynamically stable = appropriate BP and nomal HR
• If hemoptysis is significant, you need a chest CT to find out why

Question 15

HIV with infitrates

Answer 15

• IV, O2, monitor
• CXR, labs, lactic acid, LDH, cultures, HIV labs: CD4 count, viral load
  
  • CD4 >200 = immunocompetent
• Need isolation? Reverse Isolation? TB concern? Mask
• Tx common and special pathogens
  
  • Rapid initiation of IV Abx
• Monitor LOC, respiratory effort
• Admit all immunocompromised pt’s if febrile and/or hypoxic
• LDH is very important for AIDS pts
• Note their respiratory effort

Question 16

Tuberculosis clinical presentation

Answer 16

• Classic: Cough, fever, weight loss, fatigue, night sweats, pleuritic chest pain, dyspnea and hemoptysis.
• High index of suspicion
  
  • Classic sx’s, endemic area of origin - travel
  • Risks: immunocomp, incarcerated, known exposure, homeless, EtOH
• Lung exam variable
• Hx +PPD – reactivation TB
• Multi-drug resistance
• If respiratory distress - are very sick

Question 17

Tuberculosis ED diagnostics

Answer 17

• Mask, isolation precautions asap
• Chest Xray asap
  
  • Infiltrates/consolidation
  • Reactivation favors upper lobes
  • Pleural effusion
  • Cavitary lesions
  • Calcifications
  • Miliary pattern
• PPD?
• Sputum for AFB, culture
• Quantiferon Gold - an aid for detecting latent Mycobacterium tuberculosis infection. It measures a component of cell-mediated immune reactivity to M. tuberculosis. The test is based on the quantification of interferon-gamma (IFN-) released from sensitized lymphocytes in whole blood incubated overnight with purified protein derivative (PPD) from M. tuberculosis and control antigens.
• Result is not affected by prior BCG

Question 18

TB disposition in the ED

Answer 18

• Suspected TB in respiratory distress = admit
• High risk, classic symptoms, CXR with any infiltrate or effusion = you are done – admit
• Positive PPD hx, CXR neg, classic symptoms = admit
• Unknown PPD + risk + sx’s + neg CXR = place PPD, get Quantiferon Gold, admit if sick, close f/u if not sick
• Positive PPD, CXR neg, no sx’s = home, PCP or TB coordinator f/u to initiate treatment
• ED rarely initiates outpatient treatment
• Outpatient TB treatment is complicated. Must identify appropriate drug, requires monitoring (compliance and LFT’s). ED not suited for this level of follow-up.
• Classic sxs: cough, night sweats, weight loss, hemoptysis

Question 19

Differential Diagnosis for Breathlessness, chest tightness, pale, anxious, uncomfortable

Answer 19

• CHF
• AMI/ACS
• PE
• Pericardial effusion
• Infection
• Pleural effusion
• Renal failure
• Cancer
• Begin with: IV, O2, monitor, EKG, CXR, Triple scan ULS (then formal)
• CBC, CMP, lactic acid, troponin, UA, Tox screen
• Solid Hx & PE when more stable
• **BNP: $$, positive in PE/COPD too.
• Order when Dx unclear, no ULS available

Question 20

Cardiogenic pulmonary edema

Answer 20

-CHF is a simplified term for a more complex problem
-Structural or functional inability of ventricles to fill and pump blood effectively:
-Acute (less common, emergent) vs. Chronic (common, familiar, recurrent)
Acute: ”flash” pulmonary edema; L-sided – MI, HTN emergency, valve rupture, etc
-Chronic: HTN, valve Dz, CAD -> cardiomegaly, mitral regurg, aortic stenosis, etc

-Think: Left or Right-sided (or both) failure? Systolic or Diastolic failure?
-Low or High output failure?
Left sided: left ventricle fails to pump blood out effectively (Sx’s: DOE, cough, fatigue, orthopnea, PND, rales, S3 gallop.)
-Right sided: usually result of left sided failure (Sx’s: JVD, peripheral edema, hepatomegaly, anasarca)
-Systolic: ventricle can’t “squeeze” enough to empty contents. Low EF, common
-Diastolic: “Squeeze” ok but ventricle can’t “relax” to fill during diastole
-Low output: common, chronic CHF. Low EF
-High output: compensating for demand: thyroid storm, anemia, etc

• Symptoms mimic several entities – keep a broad DDx!!
• Flash pulmonary edema – result of sudden rise in left-sided filling pressures

Question 21

CHF tx

Answer 21

• Reduce preload, afterload with Vasodilators -> Nitroglycerin
• IV (100mics), sublingual (0.4mg = 400mics!) waiting for drip
• **No NTG if RV/inferior MI, Viagra, tamponade, aortic stenosis, hypovolemia
• Diuretics IF volume overload: Lasix is first choice (US the IVC)
• NIPPV is first line tx, if sick
• Oxygen, Positioning
• Admit all new CHF – search for cause – this is key!
• Admit moderate, severe, recurrent or unstable CHF

BNP is expensive (>$200 in our ED)

• Nitro contraindicated if RV infarct/inferior wall MI, Viagra, aortic stenosis, pericardial tamponade. May start lower than 100mics – often tx with 200mics or more
• Morphine is weak vasodilator and sometimes indicated/helpful

-Isolated diastolic dysfunction is not common and is complex and difficult to manage. Consult the intensivist/ICU team for recommendations

Question 22

Symptomatic Anemia

Answer 22

• Anemia is often chronic, well compensated:
• Increase cardiac output (HR) for O2 delivery to tissues when needed.
• When compensation fails = Sx’s: DOE, dizzy, weak, malaise, palpitations, chest pain, syncope
• Transfusion is treatment
  
  • Not benign! It’s not the numbers. It’s the sx’s, effects of low Hgb
  • Risks: transfusion Rx, infection, hyperkalemia
• Type/screen, type/cross for packed red blood cells (units)
• So…why is this patient anemic?? Melena? Menstrual? Cancer? Renal Failure? Iron? Macro- or Microcytic?

Question 23

Thoracic Aortic Dissection

Answer 23

• Marfan’s, Ehlers-Danlos, connective tissue dz, pregnancy, syphilis, family hx of sudden death at young age – all are risk factors
• Classic: sudden “tearing/ripping” w/ SOB, HTN. Jaw, neck, chest - pain evolves, changes. Rarely classic presentation….
• Migrating pain above and below the diaphragm; GI complaints – n/v/d
• Dizziness, near-syncope, neuro sx’s common
• If sx’s present, consider this Dx – it is elusive
  
  • Document risk factors - you thought of it
• CT chest w/ contrast, Transesophageal echo
• Young patients with SOB, chest discomfort can be sick too!
• Ehlers-Danlos syndrome: inherited connective tissue disease, 13 subtypes, incurable. Features: hypermobile joints; stretchy, “velvety”, fragile skin that bruises easily; vascular fragility/rupture
• Syphilis can cause this!!!
• Ripping in my chest -> SCAN IMMEDIATELY!!
• Radiation to the back -> think aorta!!

Question 24

Venous thromboembolism

Answer 24

• Deep Venous Thrombosis (DVT) & Pulmonary embolus (PE)
  
  • DVT: Unilateral leg pain, edema, warmth (leg most common)
  • PE: Clot has travelled to the pulmonary vasculature
• Risk: Virchow’s Triad (1856)
  
  • Venous Stasis: LE cast, hospital stay, bedridden, travel, paralysis
  • Hypercoagulability: previous DVT/PE (#1 risk), malignancy, increased estrogen, coagulation dz, inflammatory (Pregnancy; hormone BC; Factor V Leiden, Protein S, C or antithrombin III deficient, lupus, sickle cell, vasculitis)
  • Endothelial damage: recent surgery (<3mos), trauma, indwelling venous catheter, IVDU
• PE is a complication of DVT
• Risk factors for DVT same as for PE
• ER is the one that diagnoses this!
• Rare to have primary clot ONLY in your chest
• NUMBER ONE RISK IS PREVIOUS DVT OR PE

Question 25

Pulmonary embolism

Answer 25

- 650,000 diagnosed in US/year; 400,000 missed dx; 30% dx’d at autopsy - 3rd leading cause death in hospitalized pt’s - Ventilation-perfusion mismatch: no perfusion = no diffusion - Right heart outflow impeded -> reduction in left ventricular preload -> refractory hypotension -> shock -> death - Massive PE: dramatic presentation - Submassive/segmental PE: everyone else – this is our challenge

Question 26

When do you suspect a PE

Answer 26

- Consider PE in everyone w/ chest pain or...classic presentation: - Sudden/rapid, unexplained dyspnea - Pleuritic chest pain, resting tachycardia - Cough, usu non-productive, maybe hemoptysis - Lower extremity pain, swelling with above symptoms - Lung, cardiac, extremity exam is often normal - Resting, persistent tachycardia (>100)*** - Resting, persistent tachypnea (>20min)*** - Low grade temp maybe, but <102 - O2 saturation may be normal: normal O2 sat does not R/O PE - Chest wall +/- tender - reproduces pleuritic pain - Anxiety - 50% with PE have it. Hyperventilation???

Question 27

PE on the ddx

Answer 27

- Work up is tricky, extensive, radiation (chest CT w/ contrast) - Assess pt’s risk for PE: begin with Hx (Virchow’s Triad), PE, DDx - Determine a “pre-test probability” – your clinical gestalt plus a clinical prediction tool - “Pre-test probability”: Low, Moderate or High - Assign score prior to testing to help determine the probability & likelihood for Dz = “risk stratify” the pt - Problem: 20% of patients with a proven PE had NO risk factors - Lack of risk factors alone does not rule out a PE - Lack of risk factors affects your pre-test probability only - Chest CT w/ contrast PE protocol (contrast timed, thin cuts 0.3mm) is the Gold Standard test for PE

Question 28

Well's Criteria for PE

Answer 28

- Assign a score: - Signs/Sx’s DVT - 3pts - PE #1 Dx – 3pts - Heart rate >100 - 1.5pts - Immobilization 3 days or surgery <1mo - 1.5pts - Hx proven PE/DVT-1.5pts - Hemoptysis – 1pt - Active malignancy – 1pt - Three tier model: - Low prob = <2 pts (1.3%) - Moderate = 2-6 pts (16.2%) - High prob = >6 pts (37.5%) - Two tier model - “PE Unlikely” = 0-4 pts (12%) - “PE Likely” = >4 pts (37%)

Question 29

PERC score - the LOW RISK PATIENT

Answer 29

- PE rule-out criteria - MUST have LOW Risk and Pre-test Probability to even use this tool! - MUST answer YES to all questions: 1pt each - Score must be 8 or cannot “PERC ‘em out” - In “Low Risk” patient - <2% PE - if all true - Document PERC score - Age <50 - Pulse <100 - SaO2 >94% - No unilateral leg swelling - No hemoptysis - No recent trauma or surgery - No hx prior DVT or PE - No hormone use

Question 30

Can't use the PERC criteria?

Answer 30

- Low to Moderate risk pt (Well’s <4) that you can’t “PERC out” - You already have a Low to Moderate pre-test probability - The patient’s Well’s score for PE is 4 or less - PE is “unlikely” (two tier method) - Order a D-dimer - If the D-dimer is normal: 98% had no PE in this study - If the D-dimer is positive (>500): You now have to test for a PE - Chest CT w/ contrast, PE protocol - The Christopher Study

Question 31

ED work-up of PE

Answer 31

- Chest Xray - often non-specific - Hamptom’s hump, Westermark’s sign (both late findings) - EKG - often non-specific, sinus tach, S1Q3T3 in 15%  - Labs, lactic acid, PT/INR - D-Dimer – low-moderate risk and low pre-test probability patients only - Bedside ULS and/or formal doppler ULS for DVT; bedside echo for right heart strain, “D” sign - Treatment if PE present: - Low-molecular weight heparin* - Admit * Stool guaiac before treatment! * Heparin also acceptable. Some new anticoagulants being considered as first line treatment for PE Echo with Right Heart Strain: RA & RV enlargement; “bowing” of R ventricle – the “D” sign – highly suggestive

Question 32

PE summary - ED decision making

Answer 32

- Low risk and low PTP? PERC score 8? <2% have PE - Low Risk/PTP but can’t PERC ‘em out? - D-dimer - Lower extremity doppler ultrasound for DVT - If both negative – done – unlikely PE - “Practitioner gestalt” – valuable (but takes experience) - Moderate (Well’s >4) to High Risk and high PTP? - Must perform testing for PE - D-dimer not useful in these patients – do not order it! - Ultrasound bilat lower extremities for DVT, echo for RV strain, “D” sign - Chest CT with contrast, PE protocol – Gold Standard test - Consider VQ scan: if can’t CT, allergy to contrast, new ARF (creat >2) - MRI may be a possibility in some centers - PPT = pre-test probability - Practitioner gestalt is still more valuable than a D-dimer

Question 33

the big 6

Answer 33

- In every patient with chest pain, you must consider the “Big 6” – “cannot miss” diagnoses (2 A’s, 3 P’s, a B) - Your chart, presentation and DDx should address all of these in any patient with chest pain - AMI/ACS/USA - AMI/ACS/USA = Acute Myocardial Infarction/Acute Coronary Syndrome/Unstable Angina - Thoracic aortic dissection - Pericarditis/pericardial effusion - Pulmonary embolus - Pneumothorax - Boerhaave’s (espohageal rupture/pneumomediastinum)