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Arterial-Alveolar Gradient
A-a
_
Measured PaO
Calculated PaO
=
2
2
Gradient
Quick A-a formula: 150 ? (PaCO2 x 1.2 + PaO2)
? Normal: 10-15mm Hg (increases with age)
MECHANISM
EXAMPLE PATHOLOGY
? Increased: Shunt ASD, AV Fistula
VQ Mismatch PE, COPD, Pneumonia
Diffusion Interstitial Disease
2
Some Fundamentals
Cyanosis
? Central cyanosis only clinical y
apparent with >5g/dL desaturated Hb
? Cannot be both anemic and cyanotic
because cyanosis requires >5g/dL of
Central cyanosis
(seen in the tongue)
desaturated Hb (e.g. having >5g/dl
desaturated Hb with a total Hb of 8 is
clinical y impossible)
? Cyanosis is more likely if also
polycythemic (e.g. the blue bloater) ?
(e.g. easy to have >5g/dl of
desaturated Hb with a total Hb of 18
3
The "blue bloater"
Some Fundamentals
Pitfalls of the Pulse Oximeter
? Anemia
?Pulse ox does not consider Hgb level
? Supplemental O2
?Can mask severe pulmonary process
(i.e. when there is an A-a gradient)
? Carboxyhemoglobinemia (CO)
?Looks like 100% oxyhemoglobin
(e.g. false sat of 100%)
? Methemoglobinemia
?Looks like 85% oxyhemoglobin
(e.g. false sat of 85%)
4
Asthma (1)
Epidemiology
? Mortality greater in:
?African American and Latinos
?Females
?Adults
? Factors associated with asthma prevalence
?Developed nations
?Urban areas
? Factors associated with mortality/morbidity:
?Poverty / lack of access
?Overuse of OTC inhalers / episodic treatment
?Under use of early steroids
5
Asthma (2)
Pathophysiology
? Asthma is a chronic
inflammatory disease
? Reduced airway diameter 2? to:
Bronchial constriction
Bronchial edema
bility
Mucous plugging
rsi
Increased goblet cells
eve
Bronchial muscle hypertrophy
R
Airway remodelling
6
Asthma (3)
Pathophysiology
Bronchial muscle hypertrophy
Bronchial constriction
Bronchial edema
Mucous plugging
NORMAL
ASTHMA
Airway remodel ing
7
Asthma (4)
Pathophysiology
A bronchial cast of inspissated mucus at autopsy 8
Asthma (5)
Precipitants
Clinical Features
?URI (#1)
?Decreased expiratory flow
?Allergy
?
?
Air trapping & barotrauma
Respiratory irritants
(smoke, chemicals)
?Pneumothorax
?Cold
?Pneumomediastinum
?Exercise
?
?
Decreased venous return
GERD
?Beta blockers (even
?Hypotension
eye drops)
?Pulsus paradoxus
?Methacholine
?
?
Hypercarbia!hypoxemia
ASA, NSAIDs (triad
with nasal polyps)
?Muscle fatigue
?Menstruation
?
?
Respiratory failure
Psychological
9
Asthma (6)
Diagnosis
? Bedside spirometry (PEFR,
FEV1)
?Measures large airway obstruction
?Measures severity and response
to therapy
?Predicts need for admission
? Pulse oximetry
?Does not aid in predicting clinical
outcome
?O2 saturation may paradoxical y
drop in improving patient due to
transient VQ mismatch
10
Asthma (7)
Diagnosis
? Arterial Blood Gases (ABGs)
?Not general y indicated
?Should not be used to determine
therapy
? Chest X-ray
?Not general y indicated
?Obtain if:
? Complications suspected
(pneumothorax or pneumonia)
? Not improving
? Requiring admission
11
Asthma (8)
Asthma Phases
Clinical Signs
12
Asthma (9)
Phases
Norma l Mild Moderate Severe
Arterial Blood
Gas Changes
13
Asthma (10)
Death Risk Factors
? Hx of sudden severe exacerbations
? Prior intubation
? Prior ICU admit
? >1 admission or >2 ED visits in past year
? ED visit in past month
? >2 adrenergic MDIs per month
? Current/recent systemic steroid use
? "Poor perceivers"
? Concomitant disease ? cardiopulmonary
or psychosocial
? Il icit drug use
14
Asthma Therapy (1)
Aerosolized 2 agonists
? 1st line therapy
? Bronchodilators (via adenyl cyclase)
? Selective 2 agonists have less
unwanted 1 effects (tachydysrhythmias)
? Evidence
?Inhaled superior to oral and
=
parenteral routes, fewer side effects
?Intermittent equal to continuous
administration
?MDIs equal to nebulizers
?Racemic equal to "R" enantiomer
preparations (levalbuterol)
15
Asthma Therapy (2)
Steroids
? Dual Action
?Delayed (hours)
?Principal Mechanism
?Immunomodulatory
?Up-regulate -receptors
=
?Immediate (minutes)
?Vasoconstriction ("Blanching Effect")
? Evidence
?Oral equal to IV administration
?Systemic (PO and IV) superior to
inhaled route
16
Asthma Therapy (3)
Indicated for Sev ere Exacerbations
?Aerosolized Anticholinergics
?Ipratropium bromide (Atrovent)
?Block tone in bronchial smooth muscle
?Modest effect when added to -agonists
?Magnesium
?IV infusion (2-3g IV over 10 minutes)
?Smooth muscle relaxant
?Incremental benefit in most severe
presentations
17
Asthma Therapy (4)
Not Indicated fo r Acute Treatment
? Theophylline
? No benefit over 2 agonists
? Narrow therapeutic index
? Long-Acting 2 agonists
(Salmeterol)
? Long term treatment only
? Leukotriene modifying agents
(Montelukast) and mast cell stabilizers
? Long term preventive treatment only
An asthmatic patient in Ghana
? Heliox
is successfully treated with O2
?
and theophylline IV
Balance of studies find no benefit
? More convincing role in upper
airway obstruction
18
Asthma Therapy (5)
Intubation and Beyond
? Mechanical Ventilation
?Does not treat obstruction (e.g.
the 1? problem!)
?Barotrauma is big concern
? IV Ketamine
?Sedation and bronchodilation
?Increases secretions
? Anesthetic gases/ECMO
?Transfer to the OR!
19
Asthma Therapy (6)
Intubation and Beyond
Preventing and Managing Barotrauma
? May use paralytics initially to facilitate ventilation
? Continue aggressive in-line nebulizer therapy
? Increase time for expiratory phase
(e.g. inspiratory flow rate, respiratory rate, I:E ratio)
? Permissive hypercapnia (allow pCO2 to rise), pOx>88%
? Diligent pulmonary toilet, may need bronchoscopy
? External chest compression
Asthma Arrest
1 Disconnect ventilator 2 Compress chest
3 Bilateral chest tubes 4 Fluid bolus
20
Bronchiolitis
? Presentation and Diagnosis
?Presents like URI-triggered asthma
exacerbation in smal children
(<2 years old, peak age=6 months)
?Clinical diagnosis
? Etiology
?Viral ? usual y respiratory syncytial
virus (RSV)
?Nasal swab for hospital epidemiology
? Treatment
?Supportive, symptomatic care
?Trial of beta-agonists
?Steroids ineffective
?Ribavirin for congenital y il children
21
COPD (1)
? Definition
?Chronic, inflammatory disease
?Airflow limitation that is not
ful y reversible and is
progressive
? Pathophysiology
?Different inflammatory markers
from asthma (e.g. neutrophils,
not eosinophils)
?Proteases and oxidants result
in tissue destruction
22
COPD (2)
? Natural History
?Hypoxemia and hypercapnia
?Destruction of pulmonary
vascular bed and thickened
vessel wal s
?Pulmonary hypertension
?Polycythemia
?Right sided heart failure (cor
pulmonale)
23
COPD (3)
Clinical Phenotypes
Blue Bloater
Pink Puffer
24
COPD (3)
Clinical Phenotypes
Blue Bloater
Pink Puffer
25
COPD (4)
Acute Exacerbations
?Definition
? Consider Mimics
? Dyspnea
?Progressive onset
? Sputum volume
?Pneumonia
? Sputum purulence
?CHF
?
?Sudden onset
Causes
?Pneumothorax
?Viruses
?PE
?Role of bacteria
controversial
?Lobar atelectasis
?Environmental
26
COPD (5)
Differential Diagnosis of Acute Exacerbation
Pneumothorax in a Supine Patient:
The Deep Sulcus Sign
27
COPD (6)
CT of Anterior Pneumothorax
28
COPD (7)
Bleb Mimicking a Pneumothorax in COPD
Initial Film
After Chest Tube (Oops!)
29
COPD (8)
Another Bleb in COPD Patient
30
COPD (9)
CT Confirmation of Bullous Disease
(Pneumothorax ruled out)
Septation
(wall of bleb)
Diffuse patchy destructive disease
31
COPD (10)
Lobar Atelectasis
? Sudden
decompensation
? Volume loss
distinguishes from
pneumonia
? May require emergent
bronchoscopy fol owing
intubation
Lobar collapse with volume loss
(diaphragm pulled up)
32
COPD (11)
Therapy for Acute Exacerbations
? Aerosolized -agonists and anticholinergics
? First line therapy
? Steroids
? Systemic steroids (IV in ED
fol owed by PO course) reduce
rates of relapse and improve
dyspnea fol owing ED visit
? Antibiotics
? Indicated in cases with sputum
volume and purulence
Non-Invasive Ventilation
? Non-Invasive ventilation
? Highly effective at avoiding intubation if initiated early
? Not appropriate in patients with respiratory arrest or
hemodynamic instability
33
COPD (12)
Long Term Interventions
? Disease Altering Interventions
?Only 2 interventions proven to
reduce mortality:
?Smoking cessation
?Home oxygen
(for PaO2 < 55 or signs of cor
pulmonale)
? Pneumococcal Vaccination Pneumococcal Vaccine
34
Acute Respiratory Distress Syndrome (1)
? Definition
?Acute Lung Injury (ALI) and
ARDS are clinical diagnoses
along a spectrum
? Pathogenesis
?Noncardiogenic pulmonary
edema due to leaky alveolar
capil ary membranes
? Diagnostic criteria
1 Hypoxia
? PaO2 < 60 mm Hg
with FiO2 > 0.5
2 Normal ventricular function
? PCWP < 18 mm Hg
3 Diffuse alveolar infiltrates
35
? With normal heart size
Acute Respiratory Distress Syndrome (2)
? Causes
?Sepsis (most common)
?Trauma
?Near-drowning
?Aspiration
?Toxicologic (ASA, opiates,
hydrocarbons)
?Pancreatitis
?Environmental (high-altitude)
?Fat or amniotic fluid embolus
?CNS catastrophe (e.g. SAH)
36
Acute Respiratory Distress Syndrome (3)
? Treatment
?Supportive
?Maintain O2 sat >85% while
minimizing FiO2 and airway
pressures
?PEEP or CPAP
?Pressure control ed or high
frequency ventilation
?Recent Literature
?Lower mortality with low tidal
volume ventilation (6mL/kg)
?Prone position improves
oxygenation
37
Pneumonia
Critical Mimics Not to Miss
? Cancer
? Tuberculosis
? Pulmonary embolus
? Toxicologic / environmental
? Chlorine gas, Farmer's lung (al ergic reaction to
inhalation of moldy crops ? hay, grain, tobacco)
? ARDS
? e.g. from chronic ASA toxicity or other treatable cause
? Atelectasis
? Right-sided endocarditis
? Septic emboli
? Diffuse alveolar hemorrhage
? Low hemoglobin, immune disease
38
Bacterial Pneumonias
ORGANISM
TYPICAL PATTERN
TYPICAL HOST
Everyone
Streptococcus
Lobar
Community-acquired
pneumoniae
(Rusty sputum,Single Rigor)
Most common overall
Haemophilus
Lobar or patchy
COPD
influenzae
Smokers
Staphylococcus
Pleural Effusion
Post-viral
Necrotizing (Abscesses,
aureus (including MRSA) Cavitation, Empyema)
IVDA
Klebsiella
Lobar (esp. RUL)
Alcoholics
Bulging minor fissure
pneumoniae
(Currant jelly sputum)
COPD, Diabetics
Patchy, multilobar,
Hospital acquired
Pseudomonas
necrotizing, fulminant Immunocompromised
and Enterobacter (sickly sweet odor)
Cystic fibrosis
Anaerobes
Patchy(esp. lower lobes) Alcoholics
(foul smelling sputum)
39
Poor dentition
Lobar Pneumonia
LLL Pneumonia (Pneumococcus)
RUL Pneumonia (Klebsiella)
with bulging fissure and
abscess formation
40
Pneumonia with Effusion
Pneumonia
? Strep. pneumo, H. flu,
Staph. aureus
? TB
Non-Infectious Effusions
? PE
? Abdominal process
e.g. pancreatitis
? Aortic dissection
? Boerhaave's syndrome
(esophageal rupture)
41
Lung Cavitation
Cavities
? Staph
? Pseudomonas
? TB
42
Atypical Pneumonias
ORGANISM
CLINICAL FEATURES
SPECIAL FEATURES
"Walking pneumonia"
Extrapulmonary findings
Mycoplasma
Young adults
Guillain-Barr?, encephalitis,
pneumoniae
hemolysis, cold agglutinins,
CXR: Patchy interstitial bullous myringitis, erythema
multiforme
Non-toxic appearing
Staccato cough
Chlamydia
Infants at 3-20 weeks
Conjunctivitis
pneumoniae
Outbreaks in young adults
(in infant group)
CXR: Patchy interstitial
Contaminated water
GI symptoms (N,V,D)
Legionella
sources, air conditioning
Low serum sodium
pneumophilia
Older, sickly men
Abnormal LFTs
Toxic patients, altered
No person-to-person
with relative bradycardia
transmission
CXR: Unilateral lobar
No organisms on
infiltrates
standard smear
43
Interstitial Infiltrates
Interstitial infiltrates
? Mycoplasma
? Chlamydia
? Viral
44
Mycoplasma Pneumonia
Patchy perihilar infiltrate L>R
45
Legionella Pneumonia
X-ray in Legionella is not "atypical"
46
Really Atypical Pneumonias
ORGANISM
RISK GROUPS
CLINICAL FEATURES
Southwest US
Fungi
Chest pain
(Coccidioidomycosis)
Erythema nodosum
Mississippi River Valley
(Histoplasmosis)
Southeast US
(Blastomycosis)
CXR: Hilar adenopathy
Diffuse patchy infiltrates
Vets, farmers
Hepatitis
Q fever
(Coxiel a burneti )
Sheep, goats, cattle
Endocarditis
CXR: Highly variable
Epistaxis
Psittacosis
Bird handlers
Relative bradycardia
(Chlamydia psittaci)
Sepsis and shock
CXR: Highly variable
47
Low WBC count
Fungal Pneumonia
Bilateral adenopathy with patchy infiltrates
48
Pneumonia: Gram's Stain
Gram's Stain
Organism
Gram positive diplococci
Streptococcus pneumoniae
Gram positive cocci in chains
Group A streptococcus
Gram positive cocci in clusters
Staph. aureus
Gram positive rods
Bacil us anthracis (anthrax)
Smal Gram neg rods
H. Influenza
Short, fat Gram neg paired rods
Klebsiel a pneumonia
Gram neg rods
Pseudomonas, Enterobacter
Yersinia pestis (plague)
Intracel ular, Gram negative
Chlamydia
No bacteria, large PMNs only
Legionella
No bacteria, mononuclear cel s
Mycoplasma
49
Strep Pneumoniae Sputum Gram Stain
Gram Positive Diplococci
50
Med-Challenger ? EM
Pneumonia Treatment
Organisms
Antibiotics
Macrolide
Outpatient
Strep. pneumoniae
or
Atypicals
<60 years old
Doxycycline
Outpatient
Strep. pneumoniae Macrolide + Cephalosporin
or
H. flu
>60 years old
Fluoroquinolone
Gram negatives
Inpatient, Ward Same as above
Same as above
Add:
Inpatient, ICU
Antipseudomonal
1 Pseudomonas
or
cephalosporin
2 Drug resistant Strep.
Health Care Associated
or aminoglycoside
pneumo
+ Vancomycin
3 MRSA coverage
51
Pneumonia in Children
Organisms
Antibiotics
Birth-
Group B strep
Ampicillin + gentamicin
or
E. coli
3 weeks
Cefotaxime
Listeria monocytogenes
Strep. Pneumoniae
3 weeks-
Chlamydia trachomatis
Erythromycin
3 months
or
Bordetel a pertussis
Cefotaxime
RSV / Parainfluenza virus 3
Viruses
4 months-
Strep. pneumoniae
Erythromycin
4 years
or
Mycoplasma pneumoniae
Cefotaxime
Mycoplasma pneumoniae
5 years-
Erythromycin/Doxycycline (>8y)
Strep. pneumoniae
or
15 years
Cefotaxime (sicker)
Staph. aureus
All ages (sick)
Vancomycin
52
Uncommon but Deadly
? Hantavirus pulmonary syndrome
? In Southwest US, from aerosolized rodent excreta
? Pulmonary edema with cardiac and renal failure
? Supportive therapy only
? Plague (Yersinia pestis)
? Spread by fleas on rodents (bubonic), bioterrorism
(pulmonary)
? Very contagious person-to-person, strict respiratory
isolation
? Bilateral, multilobar pneumonia
? Rx: doxycycline, fluoroquinolones, aminoglycosides
? Anthrax (Bacil us anthracis)
? Inhaled (bioterror Class A agent)
? No person-to-person transmission
? Hemorrhagic mediastinitis (prominent mediastinum
on x-ray)
? Rx: penicil in, doxycycline or fluoroquinolone
53
Uncommon but Deadly (2)
SARS/MERS
Severe Acute Respiratory Syndrome
?Coronavirus
?Person-to-person spread
?Originated from civet cat in Asia
(aerosolized fecal material)
54
AIDS: Pulmonary Manifestations (1)
? Infectious
Bacterial:
Most common
Same pathogens as non-AIDS
Mycobacterial:
TB, Mycobacterium avium complex (MAC)
Parasitic:
Toxoplasmosis
Viruses:
CMV, HSV
Fungal:
PCP
Often disseminated
Cryptococcosis, histoplasmosis,
aspergil osis, candidiasis
? Malignant
?Kaposi's sarcoma
?Non-hodgkin's lymphoma
55
AIDS: Pulmonary Manifestations (2)
CD4 COUNT
PATHOGENS
NOTES
Community acquired
Atypical CXR appearances
200+
pneumonia (CAP) with bacterial pathogens
e.g. H. flu, S. pneumo
TB ? may have minimal
Tuberculosis (TB)
CXR findings
CAP, TB
PCP
Pneumocystis carinii
<200
Subacute presentation
pneumoniae (PCP)
Bilateral interstitial
(Lymphs usually <1000)
infiltrates (may be lobar)
Hypoxemia
LDH
CAP, TB, PCP
CMV, fungi and other
pathogens in end stage
<50
Cytomegalovirus (CMV)
disease often disseminated
Mycobacterium avium
complex (MAC)
Malignancy (Kaposi's
Fungi (Cryptoccocus , etc.)
sarcoma) may mimic
pneumonia
56
PCP Pneumonia in AIDS
? Diagnosis
? Myriad presentations
? Fatigue, dyspnea on exertion, "not wel "
? LDH is very sensitive but non-specific
? Clinical Diagnosis
? Definitive diagnosis may require broncho-
alveolar lavage
PCP on special silver stain
? Treatment
? TMP/SMX (1st line)
? High incidence of al ergy in HIV
? Pentamidine
? IV (watch for hypoglycemia, hypotension)
? Inhaled (watch for pneumothorax)
? Dapsone
? Methemaglobinemia
Steroids
Classic "bat-wing" infiltrate
? if pO
57
2 < 70 mm Hg or A-a gradient > 35
Foreign Body Aspiration
? Children
? Foreign body aspiration should be
considered when diagnosing:
? Asthma
?
?
Bronchiolitis
Pneumonia
? Croup
? Adults
? At risk for foreign body aspiration:
? Drug and alcohol abuse
? Mental retardation / il ness
? Neuromuscular disorder
? Edentulousness / dental prosthetics
Why we miss the diagnosis
? No clear "sudden onset" of symptoms
? Improvement of symptoms with antibiotics and/or bronchodilators
? "Pneumonia" seen on the x-ray
? Negative chest x-ray
? Over-reliance on imaging ? ultimately need to pursue bronchoscopy 58
Foreign Body Aspiration
CASE STUDY: 7 MONTH OLD CHILD
COUGHING FOR 1 HR AFTER CHOKING EPISODE
59
Further films
Lateral neck
Expiratory film
60
Further films
Failure of right lung to deflate on lateral decubitus film
indicates a foreign body in the right mainstem bronchus
61
Aspiration Pneumonia (1)
? Risk factors
?Seizure, alcoholic, obtunded, depressed gag
reflex
? Severity of syndrome depend on:
?pH of aspirate (lower is worse ? less than 2.5)
?Volume of aspirate (>25 mL)
?Presence of particles such as food (bad)
?Bacterial contamination (usual y anaerobes)
62
Aspiration Pneumonia (2)
? Clinical features
?Immediate respiratory difficulty due to chemical
burn
?Hypoxemia and respiratory alkalosis
?Wheezes, rales, hypotension
?CXR often negative initial y
?Localization related to dependent lung
? Treatment
?Supportive
?Hold antibiotics until febrile to avoid selecting out
resistant organisms
63
Tuberculosis (1)
Natural History
64
Reactivation Tuberculosis
Cavitary Lesion RUL
65
Miliary Tuberculosis (Hematogenous)
66
Tuberculosis (2)
ED Diagnosis
? 50-80% of patients
with pulmonary TB
wil have positive
smears
? Sensitivity ~ 60%
? AFB NEGATIVE
Not helpful in
suspicious cases
67
Tuberculosis (3)
Treatment Side Effects
? Hepatitis
? Isoniazid (INH), Rifampin (RIF) and Pyrazinamide (PZA)
? Peripheral Neuropathy
? Isoniazid (INH)
? Optic neuritis
? Ethambutol (EMB)
? Gout
? Pyrazinamide (PZA)
? Ototoxicity and renal toxicity
? Streptomycin and other aminoglycosides
? Discolored body fluids
? Rifampin (reddish-orange urine, feces, saliva, sweat, tears)
68
Tuberculosis (4)
TB Skin Testing
69
Sarcoidosis
? Non-infectious, non-caseating
multi-system granulomatous
disease
? Most prevalent in African-
American adult women
? Bilateral hilar adenopathy,
pulmonary infiltrates, ocular and
skin lesions
Bilateral hilar adenopathy
? Asymptomatic through cough,
SOB, eye pain, fever, night
sweats
Sarcoid
skin
? Anemia Ca 2+ ALP
lesions
? Treat cardiac, CNS, ocular
complications with steroids
70
Mediastinal Masses
? Mediastinum divided into anterior, middle,
posterior compartments
? Anterior: from sternum to anterior pericardium
? Mass in anterior mediastinum: five "T"s
?Thymoma (consider myasthenia gravis)
?Thyroid (retrosternal)
?Teratoma (teeth, hair, etc.)
?T cel lymphoma
?"Terrible" (carcinoma)
Bronchogenic CA most common mediastinal mass
71
Anterior Mediastinum Mass (Thymoma)
72
Med-Challenger ? EM
Superior Vena Cava Syndrome
? Definition
?Obstruction of SVC with resultant
engorgement and edema of face
and arms
? Presentation
?Headache (increased intracranial
pressure), plethoric facies, visual
changes, syncope, dyspnea
? Treatment
?SVC stenting (interventional rads)
?Radiation / chemotherapy therapy
for malignant causes
73
Spontaneous Pneumothorax
? Causes
? Primary (tal , thin men)
? Valsalva or Mul er maneuver (drug smokers)
? Asthma, COPD
? Neoplasm
? Marfan's, Ehlers-Danlos
? Cystic fibrosis
? Pneumonia
? Catamenial: associated with menstruation (endometriosis-related)
? Treatment Options
? Observation, high flow O2
? Mini-catheter aspiration
? Heimlich flutter valve
? Formal chest tube
? Patient on ventilator requires chest tube
74
Pneumothorax
Upright PA View
Visceral pleural line
No vessels past line
Density equal
to other lung
75
Pneumothorax
Inspiratory
Expiratory
76
Tension Pneumothorax
? Pathophysiology
? Pleural defect creates one-way
valve, leading to positive
pressure in pleural space
? Mediastinal shift pressure on
SVC hypotension arrest
? Diagnosis
? Clinical - do not wait for CXR
? Treatment
? Needle thoracostomy in 2nd ICS
at MCL
? Fol ow up with chest tube
77
Hemoptysis
? Causes
?Most common is acute bronchitis
?Other infections
? pneumonia, bronchiectasis
?Neoplastic
?TB
?Vasculitis
?Mycetoma (fungal bal s)
?
Sputum is bright, red, frothy
Cardiovascular
and alkaline compared with
hematemesis
? Minor versus Massive
?Massive: >600mL in 24 hrs or 50mL
in single cough
?Death by asphyxiation not
hemorrhage
78
Bronchopulmonary tree
Massive Hemoptysis
Treatment
? Supplemental O2
A ? Rapid sequence intubation
? Large bore ETT (>7.5)
? Keep the bleeding side down
B ? Aggressive pulmonary toilet
Keep the bleeding side down
? Selective mainstem intubation
? Correct coagulopathy
C ? Fluid and/or blood resuscitation
Bronchial artery embolization
wil often be required.
Open surgery may also be
necessary.
79
Selective mainstem intubation
Pneumomediastinum
?Often benign
In Trauma
Consider tracheobronchial injury
In Non-trauma
Consider Boerhaave's syndrome
?Hamman's crunch (sound heard
synchronous with heart beat)
?Tension pneumomediastinum
?Rare
?Presents as hypotension
?Sternal notch blunt
dissection to relieve tension
80
Stripe of air on CXR
Mediastinal air on
lateral neck film
81
Pleural Effusion
Transudative vs. Exudative
Transudate
Exudate
hydrostatic pressure or
Neoplastic
Pathophysiology oncotic pressure
Inflammatory
Infectious
CHF
Common Causes
Lung cancer
Cirrhosis
Lupus (SLE), RA
Nephrotic syndrome
Pneumonia, TB, abscess
Total protein <3 mg/dL
Total protein >3 mg/dL
Pleural Fluid
Pleural/serum protein <0.5
Pleural/serum protein >0.5
Analysis
LDH <200 IU/mL
LDH>200 IU/mL
Directed at underlying cause
Management
May need further work-up (exudates)
Therapeutic thoracentesis or tube if resp. distress
82
Pulmonary Embolus (1)
Risks
? Virchow's triad
?Stasis
? Immobilization, catheters
? CHF, COPD
?Endothelial damage
? Trauma, postoperative
? Smoking
?Hypercoagulable states
? Cancer
? Hormonal (pregnancy, OCP,
estrogen therapy)
? SLE (lupus anticoagulant)
? HIV, nephrotic syndrome
(antithrombin III deficiency)
83
Pulmonary Embolus (2)
Clinical Presentation
? Symptoms
?Dyspnea
?Pleuritic chest pain
?Syncope
? Signs
?Tachypnea
?Tachycardia
?DVT
?Wheezing or rales
?Fever (pulmonary infarction)
?Shock
84
Pulmonary Embolus (3)
Diagnosis ? The Role of Pretest Probability
Well's Criteria for PE
Clinical Signs and Symptoms of
?
Yes
Diagnostic workup involves
DVT?
+3
Bayesian approach
PE Is #1 Diagnosis, or Equally
Yes
? Definition: incorporation of
Likely
+3
pre-test probability to guide
Heart Rate > 100?
Yes
+1.5
aggressiveness of workup
Immobilization at least 3 days, or
Yes
Surgery in the Previous 4 weeks
+1.5 ? Pretest probability can be:
Previous, objectively diagnosed PE Yes
or DVT?
+1.5
? estimated by MD
Hemoptysis?
Yes
+1
- or -
Malignancy w/ Rx within 6 mo, or
Yes
? calculated using a scoring
palliative?
+1
system (e.g. Wel s criteria)
SCORE
85
Pulmonary Embolus (4)
Diagnosis ? Sample Algorithm
Suspicion of PE
Low or Moderate Pretest Probability
High Pretest Probability
D?dimer normal
D?dimer elevated
CTPA
(<500 ng/mL)
(>500 ng/mL)
CTPA
Negative
Positive
Negative
Positive
Further testing
No PE
PE
86
Pulmonary Embolus (5)
Diagnosis ? Basic Tests
ABG
? Most commonly abnormal but non-specific
? Hypoxemia, A-a gradient
? As A-a gradient , PE more likely (but up to 25% have
PaO2>80)
EKG
? Most commonly abnormal but non-specific
? e.g. non-specific ST/T changes
? May see signs of acute right heart strain:
? Inverted T waves V1-V4
? P pulmonale
? S1Q3T3
? Right axis deviation
? RBBB
? Tachycardia
CXR
? Most commonly abnormal but non-specific
? e.g. elevated hemidiaphragm
? Less common but more specific signs:
? Hampton's hump (pleural based wedge infarction)
? Westermark's sign (oligemia distal to infarct)
87
Pulmonary Embolus (6)
Radiologic Signs of a Large PE
Hampton's Hump
Westermark Sign
Wedge-shaped pulmonary
Marked decrease vascularity
infarction broadest at the pleural
distal to a large PE
edge
88
Pulmonary Embolus (7)
Radiologic Signs of a Large PE
Westermark sign
(oligemia distal to PE)
Hampton's hump
(pleural based wedge infarction)
89
Pulmonary Embolus (8)
EKG Findings of right heart strain
RBBB
P pulmonale
Pattern
S1Q3T3
(Rightward
axis)
Tachycardia
Inverted T waves V1-V4
90
Pulmonary Embolus (9)
Diagnosis ? Basic Tests
D dimer
Type of assay matters
ELISA superior to latex agglutination
Quantitative superior to qualitative
Sensitive but not sensitive enough
Must stil proceed with imaging on high-risk patients
Not specific
Must proceed with imaging even when positive
A Bedside Qualitative
CAUSES OF FALSE POSITIVE D-DIMER TEST
D-dimer test
Trauma
Stroke/MI
Pregnancy
Infection
Recent surgery
New indwel ing catheter
Inflammatory disease (e.g. SLE)
91
Pulmonary Embolus (10)
Diagnosis ? Imaging
CTPA
Offers specific alternative diagnoses
When negative, not sufficiently
sensitive to rule out PE in high risk
patients
Filling defect on CTPA
VQ Scanning
When negative (normal), sufficiently
sensitive to rule out PE in high risk
patients
Large VQ mismatch on 92
VQ scan
Pulmonary Embolus (11)
Treatment
? Heparin
? Sufficient doses are important
? 80u/kg bolus, fol owed by 18u/hour infusion
? May use enoxaparin 1mg/kg q12hours
? IVC Filter (Greenfield)
? Can be used when anticoagulation is contraindicated
? Fibrinolytics (tPA)
? Now indicated only for PE causing shock
? Echocardiogram showing RV enlargement may help
identify candidates
? Surgical embolectomy
? Rarely indicated but may be life saving
? Involves using bypass (and hence heparin)
93
THE 7 P's OF RSI
t ? 10 minutes
Preparation
Preoxygenation
Pretreatment
Paralysis With Induction
TIME ZERO
Protection And Positioning
Placement And Proof
Post-intubation Management
t + 90 seconds
94
The Difficult Airway (1)
? Predicting a crisis in RSI
? Always ask:
? CAN I BAG THIS PATIENT
? CAN I TUBE THIS PATIENT
? CAN I CRIC THIS PATIENT
Hard to Tube (ETT)
Hard to Bag (BVM)
Hard to Cric
95 95
The Difficult Airway (2)
CAN I TUBE THIS PATIENT?
The 3-3-2 Rule
L ook at general anatomy
?Mouth opening = 3 fingers
E valuate the 3-3-2 rule
?Hyoid-chin distance = 3
fingers
M allampati score
?Thyroid cartilage-mouth
floor distance = 2 fingers
O bstruction
N eck mobility
Mallampati score
Patients who fail the 3-3-2 Rule 96
The Difficult Airway (3)
Scenarios
? Anterior airway
? Attempt using adjunct
? Adjuncts: gum elastic bougie, lighted stylet,
intubating laryngeal mask airway (LMA)
? Angioedema
? Swel ing is anterior
? Attempt awake nasopharyngeal intubation
? Penetrating neck trauma
? Paralysis may cause airway col apse
? Attempt awake intubation
? Consider ketamine for sedation
97
Tracheostomies
Approach to Respiratory Distress
ASSUME AIRWAY OBSTRUCTION FIRST
Remove inner cannula
Suction
1 Irrigate with saline
if patient not better
Removing inner cannula
Remove (+/- replace) entire tracheostomy
(over a catheter if there is a concern of losing site)
2
if patient not better
Find another cause for the respiratory distress
3
98
Tracheostomy Bleeding
Tracheoinnominate Fistula
In cases of life-
threatening bleeding,
hyperinflation of the
bal oon and levering
of the tracheal tube
may be attempted.
A desperation
maneuver.
The innominate artery lies
adjacent to the tracheostomy
Patient is intubated
site.
from above and a
finger is inserted
With new or ill-fitting tubes,
through the trachea
life-threatening bleeding may
hole for direct
ensue.
pressure on the
artery.
Any significant bleeding
must be taken seriously.
99
PULMONARY QUESTIONS
100
A 75 year old smoker presents with
pleuritic chest pain and shortness of
breath. He just returned from an 8 hour
car trip. Which of the following is the
most appropriate next step?
A. ABG
B. D-dimer
C. Lower extremity venography
D. CT Pulmonary angiogram
E. Ventilation scan
PU 1
A patient presents with a sudden onset of
SOB. Last menses: Current. PMHx:
Endometriosis. Breath sounds are
diminished, on the right. HR: 123; RR: 28;
BP: 84/50; Pox: 88%. What should you
do?
A. Request a pulmonary consult
B. Do a needle decompression
C. Do a stat CT scan of the chest
D. Initiate thrombolytic therapy
E. Order a D-dimer
PU 2
A 65 y/o male presents with a COPD
Exacerbation. His ECG reveals a SVT at 130
bpm. The PR intervals are variable and the
P-wave morphologies are variable. He is
hemodynamically stable. What is the most
effective treatment for this dysrhythmia?
A. 0.5 mg Digoxin IVP
B. Lopressor 5 ?10 mg slow IVP
C. Esmolol
D. Verapamil 2.5 mg IVP
E. Initiate supplemental oxygenation and
nebulized albuterol
PU 3
A 64 y/o patient presents with a 3 day
history of productive cough, fever and
chills. He has a history of COPD and DM.
He was given Azithromycin 500 mg PO at
his Dr's office. What additional antibiotic
would be most appropriate?
A. Ampicil in
B. Gentamicin
C. Clindamycin
D. Vancomycin
E. Ceftriaxone
PU 4
An AIDS patient presents with a cough
and fever. His CD4 count is 100. BP:
102/55; RR: 24; HR: 110; POx: 91%. CXR
= bilateral interstitial infiltrates, what is the
most appropriate treatment?
A. Bactrim
B. Zithromax
C. Bactrim and steroids
D. Pentamidine
E. Ceftriaxone and Gentamicin
PU 5
Characteristics of PCP pneumonia in
AIDS patients include which of the
following features?
A. Maculopapular rash
B. Normal blood gases
C. Increased LDH
D. Classic RUL infiltrate with bulging fissure
E. CD4 > 200
PU 6
A 78 y/o female presents with a cough for
4 hours after a choking episode at the
nursing home. L.S.: mild wheezing and
scattered rhonchi. Her chest radiograph
is normal. POx: 85% on RA. The most
appropriate statement is:
A. The patient's presentation is consistent with
PE
B. The patient has an aspiration pneumonia
C. The patient can be discharged, as her x-ray is
normal
D. Antibiotics are indicated immediately
E. The patient should have a PEG tube placed
PU 7
A 45 y/o male presents in January with a
cough, rust colored sputum, pleuritic
chest pain, fever and rigors. Which
statement is true?
A. The etiologic agent is the most common for
community acquired pneumonia
B. Excel ent prognosis despite non-treatment
C. This presentation is most consistent with
Legionel a pneumophilia
D. GS = PMNs and Gram negative diplococci
E. Meningitis is not associated with this pathogen
PU 8
A 35 y/o HIV positive patient with a CD4
count of 600 has a cough, night sweats
and weight loss. His PPD converted 12
months ago. Which CXR finding is most
consistent with his diagnosis?
A. Diffuse interstitial changes
B. Left pleural effusion
C. Left upper lobe/apical opacity with cavitation
D. Right lower lobe opacity with hilar
adenopathy
E. Reticulonodular pattern
PU 9
A 52 y/o patient presents with fever and a
cough productive of "currant jelly" sputum.
The patient has a history of alcoholism.
Regarding the most likely etiology, which of
the following is true?
A. More common in alcoholics and diabetics
B. Can be treated as an outpatient
C. Is not associated with empyema
D. Organism = Gram positive rod
E. Is only community acquired
PU 10
Regarding pulmonary embolism,
which of the following statements is
correct?
A. A negative doppler ultrasound of the lower
extremities excludes the diagnosis
B. Lower extremity DVT is not considered a major
cause of pulmonary emboli
C. A negative CT cannot rule out segmental or
sub-segmental PE
D. Lower extremity ultrasound is the study of
choice in pregnancy
E. A normal ABG excludes PE
PU 11
Which of these findings is typical for
the diagnosis of legionella
pneumonia in a 70 year old man?
A. GI symptoms
B. Hypernatremia
C. During the Winter
D. Pathogen seen on sputum Gram stain
E. A wel -appearing patient
PU 12
A 6-month-old presents with significant
new-onset wheezing in association with
fever and rhinorrhea. CXR =
Hyperinflation. Which of the following is
true?
A. The likely cause is respiratory syncytial virus
B. Steroid therapy is an essential component of
care
C. Chest x-rays are usual y very abnormal
D. Antiviral therapy is routinely indicated
E. Albuterol is never beneficial
PU 13
Treatment for Anthrax would
include any of the following
except...?
A. Penicil in
B. Levofloxacin
C. Pentamidine
D. Doxycycline
E. Ciprofloxacin
PU 14
Which of the following most
appropriately describes Psittacosis?
A. Seen primarily in the southwestern United
States
B. Hilar adenopathy is typical on the chest
radiograph
C. Associated with hepatitis
D. Also known as Coxiel a burneti
E. Associated with bird handlers
PU 15
A 21 y/o asthmatic presents in severe
respiratory distress. The patient is
intubated. Which of the following is true,
regarding permissive hypercapnea?
A. It is intended to reduce barotrauma
B. Respiratory acidosis is not tolerated wel by
mechanical y ventilated patients
C. Achieved by reducing the expiratory time of
the ventilatory cycle
D. Rapid normalization of the PCO2 is critical
E. Pulse oximeter readings should remain
100%
PU 16
Which type of patient is more likely to
demonstrate cyanosis?
A. A patient with sickle cel anemia
B. A patient with COPD
C. A patient with chronic renal failure
D. A pregnant patient
E. A patient with CO poisoning
PU 17
A 3 y/o presents with an acute onset of
coughing. He has mild bronchospasm
unresponsive to albuterol. He has no URI
symptoms. CXR = Hyperinflation on the right
side and volume loss on the left. Which of
the following is the most likely cause of his
cough?
A. The patient has a foreign body on the left
B. The patient has laryngotracheobronchitis
C. The patient has an atypical pneumonia
D. The patient has a left sided pneumothorax
E. The patient has a foreign body on the right
PU 18
A 78 y/o patient presents with a new
pleural effusion. A diagnostic and
therapeutic thoracentesis is performed.
Which of the following is consistent with
an exudative effusion?
A. Total protein < 3 g/dl
B. Pleural protein/Serum protein < 0.5
C. WBC < 100/hpf
D. LDH > 200 IU/ml
E. Pleural glucose > 100 mg/dl
PU 19
The superior vena cava syndrome is
most often:
A. a manifestation of non-Hodgkin's
lymphoma in the chest
B. associated with ptosis and anhydrosis on the
affected side
C. associated with increased intracranial
pressure
D. a result of hypertensive crises
E. a self-limiting disease process
PU 20
Pulmonary Answer Key
1. D
11.C
2. B
12.A
3. E
13.A
4. E
14.C
5. C
15.E
6. C
16.A
7. B
17.B
8. A
18.E
9. C
19.D
10.A
20.C
This post was last modified on 24 July 2021