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Shortness of Breath (Dyspnea) in the Emergency Department

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  • Assess severity of dyspnea, including need for intubation/airway management based on physical examination
  • Emergent intubation indicated regardless of cause if severe respiratory distress/arrest
  • Consider Critical diagnoses → may be able to cure patient and avert intubation if the underlying cause is corrected (i.e. chest tube insertion, foreign body removal…)
  • Then think of emergent diagnoses and begin specific treatment
Shortness of Breath Algorithm
Shortness of Breath Algorithm

ABCS: Emergent Rapid Sequence Intubation

Indication

  • No absolute set criteria → decision to intubate based on physician assessment and comfort
  • General Indications:
    • Failure of Noninvasive Positive Pressure Ventilation (NPPV)
    • Hemodynamic instability
    • Patient fatigue
    • Acute/progressive respiratory acidosis
    • Hypoxia not responsive to supplemental oxygen
    • Rapid decline in level of consciousness

RSI Steps

  • Preparation
    • Difficult airway?
      • Use LEMON law, have back-up devices (LMA, bougie, cricothyrotomy kit) handy, check equipment, have drugs drawn up
      • Failed airway algorithm: Difficult to intubate? Oxygenate and ventilate? Obtain a surgical airway?
      • First pass success is goal, complication rate of 47% with second pass
    • ET tube size:
      • Adult →usually 7.5 ETT
      • Peds →[Age (years)/4] + 4
    • Blade:
      • Adult→usually Mac 4 (varies depending on comfort)
Lemon Law
Lemon Law

  • Pre-oxygenation
    • Goal: establish O2 reservoir in lungs to prevent desaturation
      • 100% O2 for 5 minutes or 8 Vital Capacity breaths
  • Pretreatment
    • Goal: administer drugs to treat adverse effects associated with intubation, generally not used
      • Lidocaine (1.5mg/kg IV) →for ↑ICP or reactive airway disease (controversial)
      • Fentanyl (3mcg/kg IV) → for ↑HR or ↑BP in ICP, CAD, Aortic dissection, AAA
      • Atropine (0.02mg/kg IV, minimum 0.1 mg) → Have at bedside or consider pretreatment in peds <1yr (controversial)
  • Paralysis with Induction
    • Induction:
      • Etomidate 0.3mg/kg IV
      • Onset→20-30sec; Duration→ 7-14min
      • Adverse effects: N/V, myoclonic activity, pain at injection site, adrenal insufficiency (controversial)
    • Paralysis
      • Types: Noncompetitive depolarizing (succinylcholine) vs Competitive nondepolarizing (Rocuronium) neuromuscular blockers
      • Succinylcholine
        • i. Type: Noncompetitive Depolarizing
        • ii. Dose: 1.5-2mg/kg IV
        • iii.Onset → 45-60 sec; Duration →3-5min
        • iv. Contraindications: Hyperkalemia, Hx malignant hyperthermia, Burn>24h,
        • Crush/denervation > 7days, Neuromuscular disease
      • Rocuronium,
        • i. Dose: high dose 1mg/kg; Onset→60sec; Duration→40-60min
      • Vecuronium
        • i. Dose: 0.1 mg/kg vs high dose 0.3mg/kg: Onset →0-90sec; Duration → 100min
  • Peds Memorize
    Peds Memorize
  • Paralytic Agents
  • Induction Agents

  • Protection and Positioning
    • Avoid BVM (unless hypoxic)
    • Sniffing position (unless contraindicated →C-spine)
    • External laryngeal manipulation to improve view of epiglottis/cords
  • Placement and Proof
    • EtCO2, Bilateral breath sounds, pulse oximetry, no gastric sounds, fog in ETT, US?
  • Post-intubation management:
    • Secure tube, sedation, Vent management, CXR, ABG

Critical Diagnoses

1. Airway Obstruction

Assessment

  • Partial: Stridor, wheeze, SOB →assess cause and prepare for airway management
  • Complete: chest movement without air movement → emergent intubation
  • Clear obstruction immediately (complete obstruction)
    • Heimlich maneuver (for complete foreign body obstruction)
    • Forceps
    • Bronchoscopy

2. Anaphylaxis

General

  • Acute systemic allergic or hypersensitivity reaction that is rapid and may cause death
  • Airway compromise:
    • Upper airway → laryngeal edema
    • Lower airway → bronchospasm
  • Most commonly: Skin manifestations
  • Other manifestations: Diarrhea (may be only presenting symptom)
  • Cause: Unknown (40%), food (shellfish, peanuts), medication, blood products, latex

Presentation

  • Skin: Flushing, urticaria, angioedema
  • Eyes: Lacrimation, injection, edema
  • Respiratory: Rhinorrhea, stridor, cough, wheeze
  • CV: Tachycardia, hypotension, cardiac arrest
  • GI: N/V, diarrhea
  • CNS: Dizzy, syncope

Diagnosis

  • Criteria 1: Acute skin/mucosa illness (hives, pruritis, flushing) + 1 of the following:
    • Respiratory compromise (dyspnea, wheeze, bronchospasm, stridor, hypoxia)
    • Reduced BP (SBP < 90 or end organ dysfunction → syncope, shock)
  • Criteria 2: Exposure to LIKELY allergen + 2 or more:
    • Skin-mucosa involvement
    • Respiratory compromise
    • Reduced BP
    • Persistent GI symptoms (Intestinal anaphylaxis → vomiting, crampy abdominal pain)
  • Criteria 3: Reduced BP after exposure to KNOWN allergen for patient

Treatment:

Read Also : Use of Epinephrine in Anaphylaxis

  • General
    • Speed of symptom progression determines severity of reaction
    • Stop inciting agent (antibiotic, remove venom sac…)
  • Epinephrine
    • First line/Primary treatment for life threatening anaphylaxis!
    • Indication:
      • Laryngeal edema, severe bronchospasm, respiratory arrest, shock.
      • NO absolute contraindications to Epi in Anaphylaxis
      • Use with caution in CV disease, antidepressants (slow epi metab), recent surgery
    • IM Dosing:
      • Adult: 0.3-0.5ml of 1:1000 IM
      • Peds: 0.01mg/kg of 1:1000 IM
      • IM is route of choice: IM has shown better absorption and ↑plasma levels vs SC
    • IV Dose:
      • 0.1 mg IV = 100 mcg IV = 1ml of 1:10,000 (need to dilute to 10 or 100ml→ see below!)
      • Dilution options:
        • Option #1: add 1 ml of 1:10,000 epinephrine solution to 9ml NS →10 ml of 1:100,000 dilution (10mcg/ml) over 5-10 min →10-20mcg/min
        • Option #2: add 1ml of 1:10,000 (crash cart epi) to 100ml NS (1mcg/ml) and run over 5-10min
        • Pediatrics: 0.1 mcg/kg/min (diluted to 1:100,000 solution) and titrate to response
    • Epinephrine gtt
      • Same dilution as option #2 → (1mcg/ml), to run at 1-4 ml/min (1-4 mcg/min)
      • Caution in elderly and cardiac disease

  • Oxygen: 100% O2
  • IV Fluids:
    • May need large volume if persistently hypotensive
  • Antihistamines:
    • H1 blocker: Diphenhydramine 25-100 mg IV/SC/PO
    • H2 blocker: Famotidine 20mg IV; Ranitidine 50mg IV or 150 mg po
  • Steroids: Solumedrol 125 mg IV (2mg/kg)
  • Special Case: Patient taking Beta-blockers?
    • Glucagon 1- 3mg IV q 5min
  • Special Case: Cardiac arrest
    • Aggressive fluid resuscitation (4-8L)
    • High-dose epinephrine (1mg → 3mg → 5mg)
    • Usual care: Antihistamines IV, Steroids IV
    • Prolonged CPR (anaphylaxis may resolve)

Disposition

  • Minor allergic reaction (no hypotension/resp sx)
    • Diphenhydramine, Prednisone 40-60mg x 5-7days, H2 blocker
    • Consider observation x 4h?
    • Be certain to discharge home with EpiPen x 2
  • Severe Anaphylaxis: → ICU
  • Anaphylaxis that resolves?
    • Biphasic Reaction?
      • Previously, incidence in literature between 3-20% ((Journal of Emergency Medicine 2005;28:381)
      • Grunau et al, (Ann Emerg Med. 2014;63:736)
        • Biphasic reaction only occurred in 0.18% of patients
        • Bouncebacks are possible though (5.25% in 7 days)
      • Conclusion:
        • Biphasic reactions are rare and most anaphylaxis that resolves will unlikely need routine monitoring
        • Consider admission for severe anaphylaxis, even if patient improves
    • Consider admission vs observation, depending on severity
    • D/C Plan:
      • Reliable pt?
      • H1/H2, Steroids
      • EpiPen x 2
      • Allergist/Immunologist f/u

3. Angioedema

General

  • Incidence ~ 0.5%
  • Almost always secondary to ACE Inhibitors.
  • Not related to dose or frequency, can happen any time (even months to years after starting medication)
  • Mechanism is bradykinin release (ACE-I inhibits bradykinin breakdown)
  • Most commonly seen in African American

Treatment

  • No proven benefit with Epi, H1/H2 blockers, or steroids
  • Severe Angioedema
    • Consider early intubation in patient with tongue involvement
    • Prepare for nasotracheal intubation
    • Fiberoptic laryngoscopic intubation (ENT vs anesthesia)
    • Sedation: Ketamine
    • Anticipate surgical airway
    • Consider FFP (C1 esterase deficiency)
      • 2-3 Units ASAP
      • Case reports of effectiveness
  • Minor lip edema
    • Course is unpredictable; observe for 4-6 hours at least, consider admission

4. Tension Pneumothorax

Clinical Signs

  • Unilateral absent breath sounds
  • Beck’s triad (JVD, hypotension, deviated trachea)
  • Trauma vs Spontaneous PTX?

Diagnosis

  • US-look for sliding lung, comet tail
  • CXR

Treatment-depends on severity and primary vs secondary

  • Immediate needle decompression vs
  • Chest tube vs
  • Observation (O2, repeat CXR)

Emergent Diagnoses

1. Asthma

Assess severity of exacerbation

  • Mild:
    • Clinical: Dyspnea only with activity
    • FEV1 or PEF >70% predicted
  • Moderate:
    • Clinical: Dyspnea interferes/limits activity
    • FEV1 or PEF 40-69% predicted
  • Severe:
    • Clinical: Dyspnea at rest, interferes with conversation, accessory muscle use, chest retraction
    • FEV1 or PEF <40% predicted
  • Life threatening
    • Clinical: Too dyspneic to speak, diaphoretic, no air movement, impending intubation
    • PEF < 25% predicted

Medication

  • β-agonists
    • Mechanism of Action:
      • Potent bronchodilators that act on β-receptors → relax bronchial smooth muscle
    • Dosing
      • Depending on patient severity, can be given as MDI, intermittent nebulizer or continuous nebulizer
      • Albuterol 2.5-5mg nebulizer q 20min x3 in 1st hour or can use MDI
    • Journal club
      • Cochrane review: (Cochrane Database Syst Rev 2009:CD001115)
        • Continuous nebs better than intermittent nebs for preventing hospital admission (NNT =10)
  • Anticholinergics
    • Mechanism of Action:
      • Decrease vagally mediated smooth muscle contraction in the airways → bronchodilation
      • Works synergistically with β-agonists
    • Dose:
      • Ipatropium 0.5mg q 20min x 3 in 1st hour or MDI
      • Usually given concomitant with Albuterol
    • Journal Club:
      • Cochrane review: (Cochrane Database Syst Rev 2008:CD000060)
        • i. Anticholinergics decreased hospital admission by 25%
        • ii. NNT = 12 to prevent hospital admission
  • Steroids
    • Indication:
      • Moderate or severe asthma
      • β-agonists do not fully correct the decline in pulmonary function
    • Dosing
      • PO:
        • i. Prednisone 40-60 mg po (1-2 mg/kg)
        • ii. PO preferred and equivalent to IV, if patient is able to tolerate
        • iii. Continue steroids x 5-7 days if d/c
      • IV:
        • i. Indication: Moderate/severe asthma or not tolerating po
        • ii. Dose: Methylprednisolone 40-125mg IV
      • IM: IM steroids just as effective as IV (Chest 2004;126(2):362)
    • Journal club
      • Cochrane review: (Cochrane Database Syst Rev 2001;1:CD002178)
        • i. Decreased hospital admission if steroids given within 1 hour of ED presentation
        • ii. Absolute risk reduction 12.5% (NNT = 8)
  • Magnesium sulfate
    • Mechanism of Action:
      • Inhibits the influx of calcium into smooth muscle cells → causing bronchodilation
    • Dosing: MgSO4 2g IV over 15 min
    • Indication
      • Life-threatening exacerbations or
      • If the exacerbation remains severe (PEF <40%) after 1 hour of conventional therapy
    • Journal club
      • Cochrane review: (Cochrane Data- base Syst Rev 2009:CD001490)
        • MgSO4 significantly improved pulmonary function and ↓admission rates for severe asthma
      • Meta-analysis (Ann Emerg Med 2000;36(3):18)
        • i. Improvements seen only in severe asthma exacerbation subgroups
        • ii. Severe asthma: ↓Admission rates and improved pulmonary function (PEFR and FEV1)

Treatment (aggressiveness depends on severity)

Crashing Asthmatic
Crashing Asthmatic

  • Mild (Tune up and go home?)
    • O2 for hypoxia, all patients
    • β-agonists
      • Albuterol (2.5-5mg nebulizer q 20min x3 in 1st hour) or MDI
    • Anticholinergics
      • Ipatropium 0.5mg q 20min x3 in 1st hour) or MDI
    • Steroids
      • Prednisone 1-2mg/kg po (Solumedrol if not tolerate PO), continue x 5-7days
  • Moderate (“They look kinda bad”)
    • Albuterol/Ipatropium continuous nebulizer
    • Steroids: Solumedrol 2mg/kg (125mg) IV q6
    • Magnesium sulfate 2g IV over 15 min
  • Severe (Status Asthmaticus)
    • General: impending intubation, need maximal therapy to prevent intubation because of ↑risk of lung injury with ventilation
    • Moderate therapies +
    • Epinephrine
      • IM: 0.3mg IM or
      • Terbutaline 0.25mg SC q 20min x 2
      • Caution in elderly, cardiac disease
    • Epinephrine gtt:
      • 2.5 mls of 1:10,000 epi in 250mlNS (1mcg/ml) and run over 25 min (10mcg/min)
    • Epinephrine IV:
      • 0.25ml of 1:10,000 and flush (25mcg)
    • Heliox:
      • 80:20 or 70:30 helium to oxygen ratio used
      • Questionable efficacy, worth trying
    • BiPAP:
      • Reduces work of breathing and need for intubation
      • Start low and titrate up: IPAP 7-15, EPAP 3-5
  • Ketamine – consider sub dissociative dose 0.1-0.5 mg/kg
  • Intubation (goal is to prevent intubation)
    • RSI: ketamine vs etomidate? awake-nasal vs oral intubation
    • Most experienced practitioner, patients desaturate rapidly
    • Pretreatment with lidocaine to reduce bronchospasm is not proven therapy
  • Ventilator strategies:
    • General
      • Prolong expiratory time, avoid barotrauma
      • Do not hyperventilate →breath stacking, barotrauma, ptx, ↓venous return, cardiac arrest
    • Settings:
      • PRVC, RR: 6-8, Vt: 5-7ml/kg; Insp flow: 100l/min; PEEP : 5; I:E ratio: 1:3- 4
      • Keep Pplat <35 and auto-peep <15
    • Sedation (ketamine, lorazepam) and paralysis (Vecuronium, but try not to re-paralyze)
    • Complications
      • Barotrauma, PTX, Cardiovascular collapse
      • Hypotension/Arrest →disconnect from vent & push on chest →forced expiration, IVF bolus, bilateral chest tubes?

2. COPD Exacerbation

General

  • Definition: Acute worsening of symptoms including cough, wheeze, SOB, sputum production and fever
  • “Characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication” (GOLD 2014)

Cause

  • Infection (bacterial, viral, both)
  • Airway inflammation from non-infectious source (air pollution, occupational)
  • Alternative pathology (PTX, PE, CHF, mucus plug, anxiety/depression, cold)
  • Unknown in 1/3 of cases
Signs of Severe COPD
Signs of Severe COPD

Diagnosis

  • COPD diagnosis:
    • Clinical Sx: chronic cough, chronic sputum production, dyspnea at rest or with exertion
    • Physical exam: Cyanosis, barrel chest, pursed lip breathing, wheezing, right heart failure
    • History of COPD risk factors (exposure to tobacco smoke, occupational dust, and chemicals)
  • Acute exacerbation of COPD
    • Increasing dyspnea, worsening exercise tolerance, worsening sputum purulence, and
    • increased sputum production in a patient with known or likely COPD

Work-up

  • ABG
    • Guidelines recommend ABG for mod/severe exacerbation, SaO2 < 92% follow pH, PO2 and PCO2 before and after NPPV/intubation (GOLD 2014)
    • Caution with ABGs: painful, associated with complications and often not necessary
  • EKG: Rule out ischemia/arrhythmia and evaluate for right heart strain/hypertrophy
  • CXR:
    • Evaluate for cause, alternative diagnosis and complication (ie PTX) of COPD

Treatment

  • Similar to asthma exacerbation (see above)
  • Oxygen
    • Judicious use to keep SaO2 88-92%
    • ↑O2 causes CO2 retention and respiratory acidosis → cardiac depression (arrhythmias) and neurologic depression (AMS)
    • Increased mortality with high flow O2 in COPD patients (BMJ. 2010 Oct 18;341:c5462)
      • Mortality 9% (high flow O2) vs 4% (O2 titrated to SaO2 88-92%)
  • Bronchodilators
    • ß-agonist (Albuterol)
      • First line therapy (used for the reversible component of COPD)
      • MDI and nebulizer equivalent efficacy
    • Anticholinergics (Ipatropium)
      • Combination with ß-agonist shown superior to either alone
  • Steroids
    • Improves PaO2, FEV1, dyspnea improvement and ↓relapse
    • Journal club (Cochrane Data- base Syst Rev 2009;1:CD001288)
      • Cochrane review: Steroid use resulted in decreased treatment failures, shorter hospitalization and improved pulmonary function
      • NNT = 10 to avoid treatment failure
  • Antibiotics
    • ↑resolution of symptoms
    • Indication: (GOLD 2014)
      • COPD exacerbation with 3 cardinal symptoms (↑dyspnea, ↑sputum volume, ↑purulence)
      • Only 2 cardinal symptoms if one of them is ↑purulence
      • Mechanical ventilation (NPPV/Invasive)
    • Antibiotic choice (empiric)
      • Mild exacerbation: β-lactam, Tetracycline or TMP/SMX
      • Moderate: β-lactam/ β-lactamase inhibitor
      • Severe: Fluoroquinolone
    • Journal club
      • Cochrane review (Cochrane Database Syst Rev. 2012;12:CD010257)
      • Antibiotics reduced treatment failure in severe exacerbations/ICU patients

  • Magnesium sulfate (MgSO4)
    • Improves pulmonary function in severe exacerbations
  • NPPV
    • Benefit: better outcome, ↓intubation rates, ↓mortality rates, ↓hospital stay
    • Indications: mod/severe dyspnea, respiratory acidosis, ↓oxygenation,
    • Contraindications: respiratory arrest, medically unstable, unable to protect airway, ALOC, ↑secretions, improper fit of mask
    • Journal club Cochrane review (Cochrane Database Syst Rev 2004;3)
      • NPPV resulted in ↓mortality (NNT = 10)
      • Decreased need for intubation (NNT = 4)
      • Reduction in treatment failure (NNT = 5)
  • Mechanical ventilation
    • Indications:
      • Failed/not tolerate NPPV
      • Hypoxia
      • Resp failure (PCO2 > 60; pH < 7.25; RR > 35; )
      • Respiratory arrest
      • Somnolence, AMS
      • Other complications (Shock, sepsis, pneumonia, metabolic abnormalities)
    • Technique
      • Pre-oxygenate to 100%
        • Pt can desaturate quickly
        • Use NPPV with increased settings
      • Delayed sequence intubation?
        • Use in pt with AMS/combative and unable to pre-oxygenate
        • Consider Ketamine for sedation prior to intubation to assist in oxygenation?
      • Nasal canula with ↑O2 flow before and during intubation
      • IVF: NS bolus to avoid peri-intubation hypotension
    • Ventilator strategy
      • Avoid DHI (Dynamic hyperinflation)
        • COPD pts require prolonged expiratory time to exhale all air
        • If next breath given too soon before lungs fully evacuated → breath stacking → DHI
        • DHI causes ↑intra-thoracic pressure → hypotension → obstructive shock → PEA arrest
        • DHI can also cause barotrauma (PTX, pneumomediastinum, etc.)
      • Ventilator settings
        • PRVC, RR: 6-8, Vt: 5-7ml/kg; Insp flow: 100l/min; PEEP:5; I:E ratio: 1:3-4
      • Permissive hypercapnea
        • Vent settings lead to ↓ventilation → ↑CO2 → Acidosis
        • Can allow pH to go down to 7.15
        • May need to give supplemental HCO3 (controversial)
        • Need adequate sedation to avoid barotrauma and over breathing ventilator
      • Measure DHI
        • Auto-PEEP:
          • i. Elevated alveolar pressure at end of expiration
        • Plateau pressure
          • i. Airway pressure during inspiratory pause
          • ii. DHI = Plateau pressure > 30 cm
      • DHI Treatment (emergent)
        • Bronchodilators, sedation, ↓RR, ↓TV
        • Disconnect from ventilator and manually squeeze chest to decompress
        • Check for tension PTX

3. Congestive Heart Failure

General

  • Causes (acute exacerbation): Arrhythmia, MI, medication non-compliance, PE, pneumonia, pleural effusion, acute valvular emergency

Presentation

  • History/Physical
    • History: Orthopnea, PND, dyspnea
    • Physical: Rales, S3, JVD, increased body weight, pitting edema, wheezing (cardiac asthma), tachycardia, hypotension, new onset murmur (valvular emergency)
  • CXR
    • Findings
      • ✓ Pulmonary edema, cardiomegaly, Kerley B lines
      • ✓ Cephalization, interstitial edema, alveolar edema (highly specific findings)
    • Normal CXR does not exclude acute CHF (Ann Emerg Med. 2006;47:13)
      • ✓ Almost 20% of patients in one series had CHF with a negative CXR (sensitivity 81%)
    • Rule out other conditions: Pneumonia, pneumothorax etc.
  • EKG
    • R/O ischemia, infarction, arrhythmia (e.g. atrial fibrillation), and LVH
  • Labs
    • Troponin elevated from acute injury/ischemia or increased LV pressures causing demand ischemia
  • BNP (Circulation 2002;105:2328)
    • BNP < 100 pg/ml essentially rules out CHF
    • BNP > 400 pg/ml rules in CHF

Special Case: “Flash” pulmonary edema

  • Define: Rapid increase in fluid in pulmonary alveola or interstitium
  • Cause: Acute ischemia, hypertensive crisis, acute severe MR, stress induced (takotsubo) cardiomyopathy, bilateral renal artery stenosis (Pickering syndrome)
  • Treatment: Similar to Acute CHF, except must treated quicker

Treatment

  • Oxygen:
    • Correct hypoxia
  • Nitrates
    • 1st line therapy→↓preload, ↓afterload, ↑CO
    • Use: only in hypertensive/normotensive patients
    • Nitroglycerin dose:
      • Mild: PO, SL→ 400 mcg
      • Moderate: 1-2 inches trans-dermal
      • Severe: IV gtt→ start at 10mcg/min and titrate up quickly to 200-250 mcg/min
    • Caution in preload dependent states: RV infarct, PDE-5 inhibitors (Sildenafil)
    • Adverse effects: hypotension, headache, tolerance
  • Diuretics:
    • Dose:
      • Furosemide (20-100 mg IV, equal to or greater than maintenance dose up to 2x maintenance)
    • Mechanism of Action: Decrease preload → diuretic effect
      • However pulm edema pts have ↓renal blood flow → leads to delayed effect (30-120min)
      • Fluid restriction on arrival if hyponatremic (<130 meq/L)
    • Caution: severe hypotension, shock

  • Morphine:
    • Use: decrease preload (histamine effect)?, anxiolysis
    • Do not use to treat CHF (little evidence, may increase morbidity/mortality)
  • Positive Inotropes
    • Use: avoid if possible (JAMA. 2002;287(12):1541)
      • Use only for cardiogenic shock or severe hypotension
      • Bridge therapy until cath lab
    • Increases incidence of arrhythmias, hypotension, and VT
  • NPPV (CPAP, BiPAP)
    • Mechanism of Action: ↓preload (increases intrathoracic pressure), ↓Work of breathing (WOB), improves gas exchange, ↓afterload
    • Decreases need for intubation, ↓Length of stay (LOS)
    • Journal Club: 3CPO Trial (N Engl J Med 2008;359:142)
      • No mortality difference between O2 and NPPV
      • NPPV associated with improvement (at 1h) in dyspnea, HR, acidosis, and hypercapnea
  • ACE-Inhibitors
    • Mechanism of Action: Downregulate RAA system, ↓adrenergic tone, improve LV relaxation→ ↓preload and afterload
    • Use: Early initiation on ACE-I in CHF not recommended, avoid in hypotension
    • No good comparisons to nitrates
    • Dose: Captopril 25mg SL (12.5mg if SBP<110) or Enalaprilat 0.625-1.25mg IV Intubation/Vent
    • Indication: Hypoxia SaO2 <90%, unable to tolerate NPPV
  • Cardiogenic Shock
    • SBP ≈ 90 → Dobutamine 2-3 mcg/kg/min
    • SBP < 70 → Dopamine (5mcg/kg/min and ), if fails→Intra-aortic balloon pump, ultrafiltration, NE gtt
  • Treatment algorithm
    • NTG→ 1st line agent (IV NTG excellent single agent)
    • NPPV→ 1st line agent for severe CHF (use early and often)
    • Furosemide → 2nd line agent (AFTER preload and afterload reduction)
    • ACE-I → 2nd line agent
    • Do not use: β-blockers, morphine, Nesiritide

4. Pneumonia

Classical Presentation

  • Typical pneumonia
    • Most common organism: S. pneumoniae (60%)
    • Presentation: High fever, rigors, cough with rust-colored sputum, leukocytosis
    • CXR: lobar consolidation
  • Atypical pneumonia
    • Organisms: Mycoplasma, Legionella, and Chlamydophila
    • Presentation: more gradual onset, dry cough, well appearing, ambulatory
    • CXR: interstitial pattern

Classification

  • Community Acquired Pneumonia (CAP)
    • Definition:
      • Acute infection of pulmonary parenchyma, occurring outside the hospital, with clinical symptoms accompanied by the presence of an infiltrate on CXR
      • Patient has not been hospitalized or in a nursing home in the previous 14 days
    • Organisms
      • Streptococcus pneumoniae, Mycoplasma pneumoniae, Hemophilus influenzae, Clamydophilia sp, and viruses
  • Hospital Acquired Pneumonia (HAP)
    • Define
      • New respiratory infection that presents > 48 hours after hospital admission
    • Organisms
      • Pseudomonas, MRSA, Legionella, Klebsiella, H influenzae, Moraxella catarrhalis
  • Ventilator Associated Pneumonia (VAP)
    • Define
      • Pneumonia diagnosed > 48 hours after a patient has been intubated on ventilator in the ICU
    • Organisms
      • Pseudomonas, MRSA, Legionella, Klebsiella, H influenzae, Moraxella catarrhalis, Acinetobacter
  • Health-Care Associated Pneumonia (HCAP)
    • Define:
      • Pneumonia in patients hospitalized for 2 or more days in the previous 90 days
      • Includes dialysis, chemotherapy, chronic wound care, home IV antibiotics, immunocompromised and patients from nursing home facilities
    • Organisms
      • Pseudomonas, MRSA, Legionella, Klebsiella, H influenzae, Moraxella catarrhalis

Work-up

  • Labs (CBC, BMP, lactate etc.)
  • Blood Cultures
    • Studies show consistent low sensitivity and results do not alter management
    • ACEP Guidelines: “Do not routinely obtain blood cultures in patients admitted with CAP”
    • IDSA/ATS recommend blood cultures in the following:
      • Admission to the intensive care unit
      • Cavitary infiltrates
      • Leukopenia
      • Chronic severe liver disease
      • Asplenia
      • Pleural effusion
      • A positive pneumococcal urinary antigen test
      • Active alcohol abuse
  • Sputum culture (Clinical Infectious Diseases 2007; 44:S27–72)
    • Recommended in:
      • ICU admission;
      • Failure of outpatient antibiotic management
      • Cavitary infiltrates
      • Active alcohol abuse
      • Severe obstructive or structural lung disease
      • Positive Legionella urinary antigen test (UAT)
      • Positive pneumococcal UAT
      • Pleural effusion
  • CXR
    • Standard used to make diagnosis of pneumonia and r/o other pathology

Antibiotics

  • Empiric antibiotics based on pneumonia classification, severity of illness and most likely organisms
  • Outpatient
    • Healthy, no risk factors:
      • Macrolide or
      • ✓ Doxycycline
    • Comorbidity:
      • Respiratory fluoroquinolone or
      • β-lactam plus macrolide
  • Inpatient Ward
    • Respiratory fluoroquinolone or
    • β-lactam plus macrolide
  • Inpatient ICU
    • Minimum treatment:
      • β-lactam plus macrolide
    • Antipseudomonal coverage:
      • Antipseudomonal β-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either
        • i. Ciprofloxacin or levofloxacin (750-mg dose) or
        • ii. Aminoglycoside and azithromycin or
        • iii. Aminoglycoside and a respiratory fluoroquinolone
    • CA-MRSA coverage (consider)
      • Add vancomycin or linezolid

5. Pulmonary Embolism

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