Disposition

•  CAP: See PNA Severity Index Score & CURB-65 (below)

•  HCAP: Generally requires admission for IV abx

•  PCP: Inpt unless SpO₂ >95% w/o desaturation on exertion

•  TB: Inpt, reported to Dept of Health

Pearls

•  At the time of this writing, JCAHO & CMS mandate that abx must be delivered in w/i 6 h of the Dx of PNA. Blood cultures should be drawn prior to abx if drawn in ED. Order cultures in all pts who may go to ICU w/i 24 h or w/ severe disease, cavitary lesions, or significant comorbidities (Ann Emerg Med 2009;54:704).

•  Consider social factors if discharging pt w/ PNA (eg, ability to comply w/ regimen)

Acute Bronchitis

Etiology

•  Most commonly viral: Parainfluenza, adenovirus, rhinovirus, influenza

•  Atypical bacteria ∼5% of cases; pertussis often occurs in epidemics

History

•  Cough (dry or wet), self-resolving fever, often URI sxs, myalgias, wheezing

•  Posttussive emesis, whoop, duration >1 wk a/w pertussis (JAMA 2010;304(8):890)

•  All-cause median duration of cough is 18 d; pertussis was once called “100-day cough”

Physical Exam

•  Fever is uncommon (consider influenza or PNA); may have chest wall tenderness from muscle strain; lungs often clear but up to 40% have bronchospasm/wheeze

Evaluation

•  CXR nl or bronchial wall thickening; mild leukocytosis

•  CXR not routinely needed: Reserve for abnl VS, extremes of age, comorbidities

Treatment

•  Supportive care, antipyretics; abx NOT routinely indicated

•  Bronchodilator (albuterol MDI 2 puffs QID) esp if wheezing heard or h/o asthma

•  Antitussive (codeine 30 mg q4h, hydrocodone 5 mg q6h; Tessalon Perles 100 mg TID)

•  No good evidence for or against OTC expectorants, decongestants, or antihistamines (Cochrane Database Syst Rev 2012;8:CD001831)

•  Abx not routinely indicated (Cochrane Database Syst Rev 2012;CD000245)

• Reserved for elderly, significant comorbidities, high suspicion for pertussis

• Azithromycin 250 mg × 5 d or doxycycline 100 mg BID × 7 d, to cover pertussis

• See PNA section for influenza tx guidelines

Disposition

•  Discharge home w/ PCP f/u as needed; pts will likely recover in 2–3 wk

DYSPNEA (SHORTNESS OF BREATH)

Definition

•  Common sign of pulmonary disease but may be the primary manifestation of myocardial ischemia or Dysfxn, metabolic acidosis, toxins or CNS pathology

•  Always assess for respiratory distress: RR >24 or <8, tripoding, accessory muscle use, unable to speak in full sentences, altered mental status (AMS), abnl chest movement

Asthma

Definition

•  Chronic recurrent inflammatory disorder w/ airway hyperresponsiveness, bronchospasm, & reversible airway obstruction

Clinical Features

•  Wheezing, dyspnea, chest tightness, cough (esp nocturnal), usually progresses over at least 6 h to days

•  Always assess sx frequency, severity, duration, home txs, required past txs, baseline peak flow, number of ED visits, hospitalizations, intubations

•  Evaluate for triggers: Cold air, exercise, URI, stress, allergens, meds (NSAIDs, βBs), respiratory irritants (perfumes, smoke, detergents, dander, dust)

Physical Exam

•  Tachypnea, tachycardia, inspiratory/expiratory wheezes, prolonged expiration, decreased or no air movement, use of accessory muscles, tripoding, cyanosis

Evaluation

•  CXR: Avoid in routine exacerbations; order if concern for PNA, PTX

•  PEFR: Compare to pt’s baseline if he/she is aware. Varies by age, gender, & height. Average adult female: 300–470; adult male: 400–660.

•  ABGs are not routinely indicated to assess for severity, but normocarbia in severe asthma may be a sign of “tiring out,” impending respiratory failure.

Chronic Obstructive Pulmonary Disease (COPD)

Definition

•  Progressive airflow obstruction that is not fully reversible, w/ impaired gas exchange, usually w/ smoking hx. Most have both chronic bronchitis & emphysema.

History

•  Usually cough, increased sputum production, dyspnea

•  Precipitants: Cold weather (increased incidence in winter months), infection (viral > bacterial), cardiopulmonary disease, medication changes

Physical Exam

•  Chronic bronchitis (“Blue Bloater”): Cough w/ marked sputum production, cyanotic, plethoric, not in overt respiratory distress; scattered rhonchi & rales

•  Emphysema (“Pink Puffer”): Thin, anxious, dyspneic, tachypneic, noncyanotic, using accessory muscles (tripod position), pursed-lip exhalation (for auto-PEEP), barrel chest w/ diminished breath sounds

Evaluation

•  Pulse oximetry

•  ECG for associated dysrhythmia (AF or MAT), cor pulmonale (P pulmonale: Big P in II)

•  CXR for underlying infection, PTX, edema, effusion, malignancy

•  Consider testing for influenza during epidemics

•  ABG not routinely indicated, may be useful in severe exacerbations

•  CBC, BMP not often helpful in acute ED management but useful in admitted pts

Treatment

•  Supplemental O₂ to maintain O₂ saturation >90% (only long-term therapy proven to decrease mortality, but watch for decreased respiratory drive leading to CO₂ retention/apnea)

•  Albuterol (short-acting β-agonist): 2.5–5 mg nebulized q30min × 3 doses, then q4h OR continuous in severe exacerbation OR self-administered MDI w/ spacer, if stable

•  Ipratropium bromide (anticholinergic): 0.5 mg nebulized q30min × 3 doses, then q4h (synergistic effect w/ albuterol, so give together)

•  Steroids: Prednisone 30–40 mg PO daily for 10–14 d OR methylprednisolone 60–125 mg IV q6–8h (for severely ill pts)

•  Abx: GOLD guidelines recommend for increased sputum purulence & either increased sputum volume or increased SOB, & all severe cases (Am J Respir Crit Care Med 2013;187(4):347)

• Choice based on RFs (age >65, FEV1 <50%, recent abx, heart dz); duration 5–10 d

• Outpt uncomplicated: Macrolide, cephalosporin, doxycycline, or TMP/SMX

• Outpt w/ RFs: Fluoroquinolone or amoxicillin/clavulanate

• Inpt: Fluoroquinolone or 3rd-generation cephalosporin; consider additional pseudomonal coverage if at risk

•  Ventilation:

• Noninvasive (BiPAP): For respiratory acidosis, severe dyspnea, signs of fatigue. Early use may prevent intubation. Watch for PTX w/ positive pressure.

• Invasive: Intubate for failure to tolerate BiPAP, impending respiratory failure, cardiovascular instability, &/or altered mental status

Disposition

•  Home: Mild sxs, O₂ saturation >90%, ambulatory, requiring <q4h bronchodilators, adequate home support, outpt f/u

•  Admission: Significant worsening of sxs from baseline, severe underlying disease, incomplete response to tx, serious comorbidities, frequent exacerbations, older age, inability to cope at home (Am J Respir Crit Care Med 2013;187(4):347)

Acute Respiratory Distress Syndrome (ARDS)

Definition

•  Acute noncardiogenic pulmonary edema due to inflammatory mediators causing capillary leak & inflammation of the alveoli & lung parenchyma, PaO₂: FiO₂ <200

Pathophysiology

•  Impaired gas exchange, poor compliance, intrapulmonary shunt

Etiology

•  Direct lung injury: PNA, aspiration, near-drowning, hydrocarbons, inhalational injury, embolism (thrombotic, fat, air, amniotic)

•  Systemic: Sepsis, shock, DIC, trauma, burns, transfusion, pancreatitis, meds

Clinical Features

•  Develops over 6–72 h, rapid progression w/ dyspnea, cyanosis, crackles, & eventual respiratory failure

Evaluation

•  Dx requires ABG (to calculate PaO₂:FiO₂) & CXR w/ bilateral pulmonary edema

•  Often need TTE to eval for CHF, bronchoscopy to r/o diffuse alveolar hemorrhage

Treatment

•  Supportive, focus on treating the underlying condition

•  Mechanical ventilation: Poor compliance so to prevent barotrauma keep VTs low (VT <6 mg/kg, plateau pressures <30), but high PEEP to keep alveoli open. Avoid hyperoxia (FiO₂ <60%) (ARDS Net protocol, NEJM 2000, also Ann Intern Med 2009;151(8):566).

See Chapter on “Mechanical Ventilation”

•  Fluids: CVP goal 4–6 cm to avoid excessive hydrostatic pressure & more edema

•  No consensus on role of steroids; most meta-analyses show no mortality benefit

Upper Airway Obstruction/Foreign Body (FB)

History

•  Acute FB aspiration: May be witnessed but often hx is unclear in adults

• RFs: Age >75, neuro disorders, syncope, szs, alcohol or sedative abuse

• Consider angioedema, infectious etiology (eg, epiglottitis) in DDx

•  Subacute (eg, malignancy, expanding goiter): Often a delayed Dx (eg, wheezing unresponsive to bronchodilators)

Physical Exam

•  General appearance: May arrive cyanotic & in respiratory arrest if total obstruction

•  In breathing pt, respiratory exam depends on degree & location of obstruction; air movement, stridor, wheezing. Do not underestimate pt distress.

Evaluation

•  CXR, XR neck rarely shows FB. Diagnostic bronchoscopy is standard.

Treatment

•  If still breathing: Airway equipment, including cricothyrotomy kit, at bedside. Prepare for transfer to OR to remove FB in a controlled environment (bronchoscopy or DL).

•  If not breathing: Attempt direct laryngoscopic visualization & removal of FB w/ forceps. If unsuccessful, perform surgical airway.

•  If FB has moved inferior to vocal cords but still occluding, attempt to push object further into 1 lung by pressure from Ambu bag or ETT. Once intubated, position ETT to ventilate contralateral lung.

Disposition

•  If object is safely removed & pt stable, can discharge home

HEMOPTYSIS

Definition

•  Expectoration of blood or blood-stained sputum from below the vocal cords

•  Massive is >100 cc/d (1 cup) or disrupting ability to breathe. High mortality 2/2 asphyxiation.

•  Recall that bronchial arteries are high pressure, pulmonary arteries are low pressure

Related posts:

VIII: DERMATOLOGY XVII: AIRWAY MANAGEMENT XII: MUSCULOSKELETAL & RHEUMOTELOGICAL X: ENVIRONMENTAL XVI: TOXICOLOGY XVIII: TRAUMA