IM Hemoptysis

Normal

• Normal ABG:
  • pH: 7.35-7.45
    
  • PaO2: 80-100 mmHg
    
  • PaCO2: 35-45 mmHg
    
  • HCO3: 22-26 mEq/L
    
  • O2: 94-100
• PF RATIO:
  • PaO2 / FiO2 (%) x 100
• PF ratio interpretation based on value:
  • Over 400 = normal
    
  • 300-400 = onset of lung injury
    
  • 200-300 = acute lung injury or mild ARDS
    
  • Under 200 = ARDS

Hemoptysis

• Etiology:
  • -100-600ml blood loss in 24hr
    
  • -MC is bronchial artery (high pressure)
    
  • -mortality and morbidity from impaired alveolar gas exchange
    
  • -MC causes: bronchiectasis, TB, cancer, CF, AVM, post-procedural , anticoagulation
    
  • -peds: infection, congenital heart, CF, trach bleed
• Important features on Hx:
  • – age and smoking
    
  • – duration and frequency
    
  • – blood vs. blood + phlegm
    
  • – infection Sx
    
  • – B Sx
    
  • – risks for lung cancer
    
  • – upper airway/GI Sx
    
  • – rheumatology conditions
    
  • – risks for PE
    
  • – cardiac disease
• Risks:
  • – >50
    
  • – male
    
  • – >40 pack year smoking
    
  • – > 1 week of slow hemoptysis
• Physical Exam:
  • – vitals
    
  • – focal/diffuse resp findings
    
  • – telangiectasia
    
  • – skin rash and inflammed joints
    
  • – splinter hemorrhages
    
  • – clubbing
    
  • – heart murmur
    
  • – DVT signs
• DDX (BATTLE CAMP):
  • Bronchiectasis/Bronchitis
    
  • Aspergillus/Autoimmune
    
  • TB
    
  • Tumor
    
  • Lung Abscess
    
  • Embolism
    
  • CF/Coagulopathy
    
  • AVM/DAH
    
  • Mitral Valve, Pneumonia
• DDX:
  • Airway Disease
    • -bronchitis
    • -bronchiectasis
    • -neoplasm
    • -trauma
    • -foreign body
  • Parenchymal disease
    • -TB
    • -lung abscess
    • -fungal infection
    • -neoplasm
  • Vascular
    • -PE
    • -AVM
    • -vasculitis
    • -pulm htn
    • -Aortic aneurysm
  • Hematologic
    • -DIC
    • -coagulopathy
    • -thrombocytopenia
  • Cardiac
    • -congenital
    • -valvular
    • -endocarditis
  • Infectious:
    • -TB
      
    • -staph aureus
      
    • -E coli
      
    • -strep pneumo
      
    • -klebsiella
      
    • -hantavirus
      
    • -Nocardia
      
    • -aspergillosis
      
    • -Strongyloides
  • other
    • -cocaine
    • -tracheal arterial fistula
• Work-Up:
  • CXR
    
  • Labs
    
    • – CBC/Hct
      
    • – creat/urine
      
    • – plts, INR, PTT, T + S
      
    • – ANA, ANCA, anti-GBM
      
    • – BNP
      
  • Bronchoscopy and CT (further)
• Intubation strategies for hemoptysis:
  • -intubate in rev trendelenberg/sitting up
    
  • -large ETT (8.0), try to put into ‘good lung’ if known
    
  • -position bleeding lung down
    
  • -double-lumen ETT by anesthesia
    
  • -correct coagulopathy
    
  • -IV fluid resuscitation
    
  • -CXR –> CT –> bronchoscopy –> bronchial artery embolization are all options
• Tracheo-innominate artery fistula:
  • -often seen 3-4 weeks post trach
    
  • -overinflate trach balloon
    
  • -if that doesn’t work, digital pressure at the site of bleeding inside trach
    
  • -will need to be intubated orally

Massive Hemoptysis

• Etiology: 
  • Def’n
    
    • – >100 – 600 mL in 24 h
      
• DDX:
  
  • – cancer
    
  • – vasculitis
    
  • – pulmonary AVM
    
  • – bronchiectasis
    
  • – TB
    
  • – mycetoma
  • Rule out non-pulmonary sources of bleeding 
    
    • -mouth, nose, GI tract
• Diagnosis:
  • -H&H 
  • -PT/INR
  • -PTT
  • -CBC &Diff
  • -UA/ creatinine
  • -CXR
  • -CT: abnormal CXR findings OR persistent hemoptysis despite a normal CXR
• Management:
  • Dependent positioning if side of bleeding can be identified
    • (e.g., position the patient in right-side down decubitus position if the right lung is bleeding)
      
  • Secure airway (intubation)
    
    • low threshold for intubation 
    • bleeding side down
      
    • can use a double lumen tube to ventilate one lung
  • Stabilize cardiovascular function (IV fluids/transfusion)
    
  • Stop bleeding
    • (correct coagulopathy, flexible bronchoscopy with balloon tamponade, arteriography with embolization if other measures fail)
  • Urgent surgical intervention 
    
    • -thoracotomy

Lungs Sounds

• Hyper-resonant percussion
  • Louder and hollower than normal
    
  • Sign of increased air inside the thoracic cavity: emphysema, bronchial asthma, pneumothorax
• Vesicular breathing
  • Soft and low pitched, through inspiration and part of expiration
    
  • Heard over both lungs
• Bronchovesicular breathing
  • Normal breath sound that is moderate pitch and amplitude that is heard EQUALLY during inspiration and expiration.
  • Location is over Major Bronchi where fewer alveoli are located such as posterior between the scapula; anterior around the upper sternum in first and second intercostal spaces
• Bronchial breathing
  • Expiratory sound is higher-pitched and louder than vesicular.
  • NORMAL over Trachea and Larynx.
  • ABNORMAL if heard over peripheral part of lungs.
• Tracheal breathing
  • very loud, high pitched
    
  • inspiration = expiration
    
  • harsh
    
  • extrathoracic trachea
• Fine crackles
  • short high pitched sounds during inspiration
    
  • Ex:
    • Asbestosis
      
    • Sarcoidosis
• Coarse crackles
  • Long duration, low-pitched, evident on inspiration. (sounds like blowing through a straw under water)
    
  • Ex:
    • Asthma
      
    • Bronchitis
• Wheezes
  • continuous high-pitched whistling sounds produced during breathing
    
  • Ex:
    • Asthma
      
    • Bronchitis
       
• Ronchi
  • loud rumbling sounds heard on auscultation of bronchi obstructed by sputum
• Stridor
  • Harsh or high-pitched respiratory sound, caused by an obstruction of the air passages
    
  • Inspiration:
    
    • Narrowing of the extrathoracic airway
    • Ex:
      • epiglottitis
      • pseudo croup
      • foreign body aspiration
      • bilateral vocal cord palsy
        
  • Expiration:
    
    • Obstruction of the intrathoracic airways
    • Ex:
      • bronchial asthma
      • COPD
• Pleural friction rub
  • the continuous, dry grating sound caused by inflammation of pleural surfaces and loss of lubricating pleural fluid
    
  • Ex:
    • Pleurisy
• Muffled or absent breath sounds
  • suggest the presence of air or fluid between the lung and the chest wall
    
  • Ex:
    • Pleural effusion
      
    • Pneumothorax
• Bronchophony
  • Increased transmission of voice sounds
    
  • Ask the patient to say “ninety-nine” in a normal voice while auscultating.
    
  • An asymmetric increase in voice transmission suggests a collapsed lung or atelectasis.
• Egophony
  • Ask the patient to say “ee” while auscultating.
    
  • If it sounds like “A” rather than “E”, this is called egophony and suggests lobar pneumonia.
• Whispered pectoriloquy
  • Ask the patient to whisper “ninety-nine” while auscultating.
    
  • Normally this is barely audible.
    
  • Clearly audible in the presence of consolidation
• Consolidation
  • lung tissue that has become more solid in nature due to the collapse of alveoli or infectious process (pneumonia)

Bronchiectasis

• Presentation:
  • copious purulent sputum 
    
• Diagnostic: 
  • elevated WBC
  • CXR – bronchiectasis shows dilated and thickened airways with irregular mucopurulent plugs
  • Chest CT – shows dilated airways

Tuberculosis

• Etiology:
  • Most common cause of hemoptysis in developing countries
• Reactivation TB Presentation:
  • fever
    
  • cough
    
  • night sweats
    
  • weight loss
    
  • hemoptysis
    
  • elevated WBC
• Diagnostic:
  • CXR – apical infiltrates with cavitary lesions & hilar lymphadenopathy

Aspergilloma

• Etiology:
  • A fungal mass in a pre-existing cavity that mainly affects the lungs and is visible on a chest X-ray as a “fungus ball” that moves on the repositioning of the patient. It is a form of chronic pulmonary aspergillosis.

Atelectasis

• Presentation:
  • Main symptom: Pain may be present
    
  • Movement of the chest wall: Asymmetrical
    
  • Tactile fremitus: Decreased
    
  • Percussion: Dull
    
  • Bronchophony: Decreased
    
  • Breath sounds: Decreased

Bronchial Asthma

• Presentation:
  • Main symptom: Paroxysmal attacks of dyspnoea and wheezing
  • Movement of the chest wall: Symmetrical
  • Tactile fremitus:
    • Depends on the severity
    • Normal or an overinflated (emphysematous) lung; occasionally pneumonia as well
  • Percussion: Hyper-resonant
  • Bronchophony:
    • Depends on the severity
    • Normal or an overinflated (emphysematous) lung; occasionally pneumonia as well
  • Breath sounds: Wheeze, a prolonged expiratory phase with decreased breath sounds

Chronic Exertional Dyspnea

• Presentation:
  • A condition characterized by shortness of breath and difficulty breathing when engaged in light to moderate physical activities.
  • Can be caused by a broad range of cardiac, pulmonary, and inflammatory conditions (e.g., CHF, asthma, COPD, sarcoidosis).
    
  • Suggests cardiac failure

COPD

• Etiology:
  • Persistent respiratory symptoms and airflow limitation that is due to airway or alveolar abnormalities
    
  • Usually caused by significant exposure to noxious particles or gases
• Path:
  • 1. Smoking, pollutants, host factors
    
  • 2. Impaired lung growth, accelerated decline, lung injury, lung, and systemic inflammation
    
  • 3. Small airway disorder or abnormalities, emphysema
    
  • 4. Persistent airflow limitation
    
  • 5. Clinical manifestations —> symptom, exacerbation, co-morbidities
• Chronic bronchitis
  • – persistent cough
    
  • – sputum production
    
  • – for most days of three months in a year, for at least 2 consecutive years
    
  • – may occur before or after the development of airflow limitation
• Emphysema
  • – abnormal permanent enlargement of the airspaces distal to terminal bronchioles
    
  • – destruction of their walls
    
  • – permanent fibrosis
• COPD Risk Factors:
  • – tobacco
    
  • – indoor and outdoor air pollution
    
  • – occupational exposures
    
  • – genetic
    
  • – age and sex
    
  • – lung growth and development
    
  • – socioeconomic status
    
  • – asthma and airway hyperreactivity
    
  • – chronic bronchitis
    
  • – infections (history of severe childhood respiratory infection OR recurrent lower respiratory tract infection)
• Presentation:
  • Main symptom: Chronic cough, SOB, Sputum
    
  • Movement of the chest wall: Symmetrical
    
  • Tactile fremitus: Depends on severity
    
  • Percussion: Possibly hyper-resonant
    
  • Bronchophony: Depends on severity
    
  • Breath sounds:
    • Wheeze, a prolonged expiratory phase when the disease is obstructive
      
    • Decreased breath sounds in emphysema
  • Dyspnea in COPD:
    • – progressive
      
    • – characteristically worse with exercise
      
    • – persistent
  • Chronic cough in COPD:
    • – intermittent
      
    • – unproductive
      
    • – recurrent wheeze
      
    • – seldom nocturnal only
• Diagnosis:
  • —> spirometry
    
  • – FEV/FVC < 0.7 confirms the presence of persistent airflow limitation
• Classification of COPD:
  • – Airflow limitation
    
    • GOLD 1: FEV >/= 80%
      
    • GOLD 2: FEV 50-79%
      
    • GOLD 3: FEV 30-49%
      
    • GOLD 4: FEV <30%
  • – Exacerbation history
    
  • – Assessment of symptoms
    • 1. mMRC Breathlessness Scale
      
      • – in a scale of 0 (least symptoms) to 4 (too breathless to leave house)
        
      • – 0-1: less symptoms
        
      • – 2-4: more symptoms
        
    • 2. COPD Assessment test (CAT)
      
      • – 0-40 —> higher score means more severe disease
        
      • – <10: less symptoms
        
      • – 10 and above: more symptoms, regular treatment needed
  • – Assessment risk of exacerbation
    • High risk
      
      • – 2 or more exacerbations in the past year
        
      • – 1 or more exacerbation leading to hospital admission
        
    • Low risk
      
      • – 0 or 1 exacerbation, not leading to hospital admission
• Classification of Groups:
  • A: less symptoms, Low risk
    
  • B: more symptoms, Low risk
    
  • C: less symptoms, high risk
    
  • C: more symptoms, high risk
• Goals of therapy:
  • Reduce symptoms
    
    • – relieve symptoms
      
    • – improve health status
      
    • – improve exercise tolerance
      
  • Reduce risk of exacerbations
    
    • – prevent disease progression
      
    • – prevent and treat exacerbation
      
    • – reduce mortality
• Management:
  • Group A:
    • A bronchodilator
      
      • – can be short term or Long term
  • Group B:
    • 1. LAMA or LABA
      
      • – if persistent breathlessness on monotherapy, move to 2 bronchodilators
    • 2. LAMA and LABA
      
      • – if adding the second bronchodilator does not improve symptoms
      • – May step down to monotherapy
      • – likely to have co-morbidities that add to their symptoms
      • – should be investigated and treated
  • Group C:
    • 1. LAMA
      
      • – better for exacerbation prevention
        
    • 2. LAMA and LABA (recommended) OR LABA and ICS
      
      • – as ICS may increase risk of developing pneumonia in some patients
  • Group D:
    • 1. LAMA
    • 2. LAMA and LABA (recommended) OR LABA and ICS
      
      • – two agents better than single agents
      • – LAMA/LABA better at preventing exacerbations and patient-reported outcomes
      • – ICS — risk of developing pneumonia
      • – LABA and ICS — first choice for asthma and COPD overlap
    • 3. LAMA/LABA/ICS (recommended)
      
      • – can add roflumilast if FEV <50%, chronic bronchitis and have 1 or more exacerbation
      • – can add macrolide in former smokers
• Benefits of LABA and LAMA:
  • – improve lung function, dyspnea, health status, exacerbation rates
  • – LAMA have a greater effect on exacerbation reduction than LABA
  • – combination of LABA and LAMA reduce symptoms more than monotherapy
  • Tiotropium —> a LAMA can improve the effectiveness of pulmonary rehabilitation in increasing exercise performance
• Inhaled corticosteroids in COPD:
  • – ICS/LAMA/LABA therapy can improve lung function, symptoms, and health status and reduce exacerbation
    
  • – regular treatment with ICS can increase the risk of pneumonia especially in those with severe disease
    
  • – side effects: oral thrush, cough, hoarse voice
• Antibiotics in COPD:
  • – reduce exacerbations over one year
    
  • – increased incidence of bacterial resistance and hearing test impairments
• Theophylline in COPD:
  • – less effective and less well tolerated
    
  • – not recommended if LABA is avail
    
  • – Low dose theophylline reduce exacerbation but does not improve post-bronchodilator function
    
  • – theophylline + salmeterol —> increase in FEV1 and a decrease in breathlessness more than salmeterol
• Non-pharmacological therapy:
  • – education and self-management
    
  • – physical activity
    
  • – pulmonary rehabilitation
    
  • – exercise training
    
  • – end of life palliative care
    
  • – nutritional support
    
  • – vaccination
    
  • – oxygen therapy
• Education and self-management:
  • Group A
    
    • – smoking cessation
      
    • – physical activity
      
    • – flu/ pneumococcal vaccination
      
  • Group B to D
    
    • – smoking cessation
      
    • – pulmonary rehabilitation
      
    • – physical activity
      
    • – flu/ pneumococcal vaccination
• Vaccination:
  • – influenza vaccination can reduce serious illness —> lower respiratory tract infection causing hospitalization
    
  • – pneumococcal vaccinations PCV13 and PPSV23 are recommended for all patients >65 years old
    
  • – PCV13 is more immunogenic
• Oxygen therapy:
  • Long term oxygen therapy is indicated for stable patients who have:
    
    • 1. PO2 less than 55mmHg and SaO2 at or below 88%, without hypercapnia confirmed twice over a three week period
    • 2. PaO2 between 55-60mmHg or SaO2 88%
      
      • – If there is evidence of pulmonary hypertension, peripheral edema
      • – suggesting congestive cardiac failure or polycythemia
• Monitoring and follow up focus on:
  • – dosage of prescribed medications
    
  • – adherence to the regimen
    
  • – inhaler techniques
    
  • – effectiveness of the current regime
    
  • – side effects

COPD Exacerbation

• Etiology:
  • Acute event characterised by a worsening of the patient’s respiratory symptoms that is beyond normal day to day variation and leads to a change in medication
• MC Causes:
  • – viral upper respiratory tract infections
    
  • – infection of the tracheobronchial tree
• Assessment:
  • – history
    
  • – clinical presentations
    
  • – physical examination
• History:
  • – time course of worsening of symptoms
    
  • – identify the potential course
    
  • – current treatment regimen
• Presentation:
  • – increased sputum volume or purulence
    
  • – worsening dyspnea
    
  • – fatigue
    
  • – drowsiness
    
  • – decreased exercise tolerance
    
  • – worsening cough
• Physical Examination:
  • – fever
    
  • – wheezing, decreased breath sounds
    
  • – use of accessory muscles
    
  • – cyanosis
    
  • – signs of right-sided heart failure
• Goal of treatment for exacerbation:
  • – minimize the impact of current exacerbation
    
  • – prevent the development of subsequent exacerbations
• Classification of severity:
  • Mild
    
    • – treat with short-acting bronchodilators only
      
  • Moderate
    
    • – treat with short-acting bronchodilators + antibiotics +/or oral corticosteroids
      
  • Severe
    
    • – hospitalization
      
    • – associated with acute respiratory failure
• No respiratory failure:
  • RR: 20-30 breath per min
    
  • Do not use accessory muscles
    
  • No change in mental status
    
  • Hypoxemia improved with supplemental oxygen (venturi 28-35% mask)
    
  • No hypercarbia
• Acute respiratory failure (not life-threatening):
  • RR: >30 breath per minutes
    
  • Use accessory muscles
    
  • No change in mental status
    
  • Hypoxemia improved with supplemental oxygen (Venturi mask 25-30%)
    
  • Hypercarbia present elevated 50-60mmHg
• Acute respiratory failure (life-threatening):
  • RR: >30 breath per minute
    
  • Use of accessory muscles
    
  • Change in mental status
    
  • Hypoxemia does not improve with supplemental O2 supply
    
  • Hypercarbia present elevated >60mmHg, acidosis pH < 7.25
• Oxygen therapy for exacerbation:
  • – maintain O2 > 60mmHg
    
  • – SaO2 88-92%
• Bronchodilator for exacerbation:
  • SABA
    
    • – MDI+spacer
      
    • – symptomatic relief
      
    • – reduced functional half-life
      
    • – initially every 1-2h
      
  • SAMA
    
    • – in combination with SABA
      
    • – for patients who do not have an adequate response to SABA alone
• Corticosteroids (systemic) for exacerbations:
  • —> for all patients with acute exacerbations
    
  • – improved lung function
    
  • – shorten the length of hospital stay
    
  • – decreased relapse stay
    
  • Prednisolone 30-40mg OM for 5-7 days
• Theophylline for exacerbations:
  • – 3rd or 4th line
    
  • – if not a response to the other bronchodilator
• Antibiotics requirements for exacerbation:
  • – controversy: viral infections is as common as bacterial infections and patients can be colonized with bacteria but not causing infections, overuse of antibiotics: results in the spread of resistant organisms
  • – has to have 3 cardinal symptoms: worsening dyspnea, increased sputum purulence, increased sputum volume
    —> can be just 2 cardinal symptoms with increased sputum purulence is one of them
  • – other indicators of infection: fever, increased WBC, change in chest X-ray
• Antibiotics options for exacerbation:
  • – augmentin —> amoxicillin/ clavulanate
    
  • – macrolides —> clarithromycin, azithromycin
    
  • – cefuroxime
    
  • – fluoroquinolones —> levofloxacin, moxifloxacin
    
  • —> For 5-7 days
    
  • Methyxanthines are not recommended
• Discharge criteria:
  • – off the parental drug for 12-24 hours
  • – inhaled bronchodilators no more than once every 4h
  • – maintenance therapy with Long-acting bronchodilators should be initiated as soon as possible before hospital discharge
  • – stable for 12-24 hours
  • – able to walk short distances
  • – understand the correct use of medication + inhaler technique
  • – follow up appointments
• Intervention that can reduce the frequency of exacerbation:
  • – bronchodilator
    
    • LABA, LAMA, LABA/LAMa
      
  • – corticosteroid
    
    • LABA/ICS, LAMA/LABA/ICS
      
  • – NSAIDs
    
    • roflumilast
      
  • – Anti-infective
    
    • vaccines
      
    • Long term macrolides

Emphysema

• Presentation:
  • Main symptom: Chronic dyspnoea
    
  • Movement of chest wall: Symmetrical but decreased
    
  • Tactile fremitus: Decreased
    
  • Percussion: Hyper-resonant
    
  • Bronchophony: Decreased
    
  • Breath sounds: Decreased

Lung Fibrosis

• Presentation:
  • Main symptom: Cachexia and weakness with dyspnoea
    
  • Movement of the chest wall: Symmetrical
    
  • Tactile fremitus: Normal or partially increased
    
  • Percussion: Dull
    
  • Bronchophony: Normal or partially increased
    
  • Breath sounds: Basal inspiratory crackles

Paroxysmal Nocturnal Dyspnea

• Presentation:
  • A symptom characterized by nocturnal bouts of coughing and acute shortness of breath resulting from the effect of lying in a supine position, which increases pulmonary venous congestion as well as reabsorption and redistribution of edema.
    
  • Suggests cardiac failure

Pleural Effusion

• Presentation:
  • Main symptom: Dyspnoea
    
  • Movement of the chest wall: Asymmetric
    
  • Tactile fremitus: Decreased
    
  • Percussion: Dull
    
  • Bronchophony: Decreased
    
  • Breath sounds: Decreased

Pneumothorax

• Risks:
  • – tall
    
  • – thin
    
  • – young
    
  • – male
    
  • – smoker
    
• Recurrence
  
  • – 30-40% after first
    
  • – 50% after the second
• Presentation:
  
  • Main symptom:
    • Acute dyspnea
      
    • pleuritic, acute chest pain
      
  • Movement of the chest wall: Asymmetrical
    
  • Tactile fremitus: Decreased or absent
    
  • Percussion: Hyper-resonant
    
  • Bronchophony: Absent or decreased
    
  • Breath sounds: Decreased or absent
• Types:
  • Primary
    
    • – no underlying lung disease
      
  • Secondary
    
    • – underlying COPD, IPF (higher mortality)
      
  • Iatrogenic
    
    • – wire insertion/acupuncture
      
  • Traumatic
    
    • – broken ribs
      
  • Tension
    
    • – result of any of the above causes
    • – MC on mechanical ventilation!
    • Mechanism
      • – pleural pressure exceeds atm pressure
        
      • – needs a one-way valve
        
    • Consequences
      
      • – decreases venous return => low CO and low BP
        
      • – obstructive shock
• Physical Exam:
  • – tachycardia/tachypnea
    
  • – hypoxia
    
  • – low BP (tension)
    
  • – tracheal shift (+/-)
    
  • – hyper-resonance on percussion
    
  • – tactile fremitus decreased
    
  • – decreased breath sounds
• Diagnosis:
  • – clinical suspect
    
  • – CXR
    
    • – hyperlucent area
      
    • – reflection of visceral pleura
      
    • – small effusion (+/-)
  • – may use CT in occult
• Goals:
  • 1. stability
    
    • – ABCs
      
    • – O2
      
  • 2. management of air in space
    
  • 3. prevent a recurrence
•  Management:
  • When to Treat:
    • – primary = Sx and large (>2-3 cm)
      
    • – tension
      
    • – secondary PTX
      
    • – ventilated patient
      
    • – pleural disease
      
    • – dyspnea
  • Options for managing pleural air:
    • – observation
      
    • – supplemental O2
      
    • – aspiration
      
    • – chest tube
      
      • – one-way valve hooked up to a water seal
        
      • – air bubbling
        
      • – fluctuations in a water seal container
      • When:
        • – no dyspnea
          
        • – PTX <2 cm
          
      • Mgmt – discharged, outpatient F/U
    • – needle decompression
  • Decompress tension pneumothorax:
    • – large-bore needle in 2nd intercostal space, mid-clavicular line
  • Options for preventing recurrence:
    • lower risk factors (smoking)
      
    • pleurodesis
      
      • – sclerosing talc
        
      • – VATS pleural abrasion
        
    • bullectomy (for the small blebs)

Pneumonia

• Types:
  • – community-acquired pneumonia (CAP)
    
  • – hospital-acquired pneumonia (HAP)*
    
  • – ventilator-associated pneumonia (VAP)*
    
  • – aspiration pneumonia
    
  • *48h after hospitalization/ventilation
• CAP:
  • Typical
    
    • – Strep pneumonia
      
    • – Haemophilus influenzae
      
    • – Moraxella catarrhalis
      
    • – Staph aureus
      
    • – Klebsiella pneumonia
      
  • Atypical
    
    • – Mycoplasma pneumonia
      
    • – Chlamydophila pneumonia
      
    • – Legionella pneumonia
  • Viruses
    
    • – Influenza (A + B)
      
    • – Respiratory syncytial virus
      
    • – Parainfluenza virus
      
    • – Adenovirus
      
    • – Humaon matapneumocirus
      
  • Fungi
    
    • – Histoplasma
      
    • – Coccidiosis
      
    • – Blastomyces
• HAP:
  • – S. aureus
    
  • – pseudo aeruginosa
    
  • – E. coli and friends
    
  • – acinetobacter
• Aspiration Pneumonia:
  • – Strep pneumo
    
  • – H. influenzae
    
  • – Staph aureus
    
  • – Kleb pneumo
    
  • – Oral flora
    
  • Mechanism: chemical pneumonitis that resolves => then turns into a pneumonia due to off-balance conditions
• Presentation:
  • Main symptom: Fever and dyspnoea
    
  • Movement of the chest wall:
    
    • Asymmetrical
      
    • In case of bilateral pneumonia, the movement can also be symmetric.
      
  • Tactile fremitus: Increased
    
  • Percussion: Dull
    
  • Bronchophony: Increased
    
  • Breath sounds: Coarse crackles
• Work-Up:
  • Microbial Testing:
    • – hospitalized
      
    • – failing therapy
      
    • – atypical presentation/findings
      
    • – relevant PMHx (lung disease, immunocompromised, etc.)
      
    • – NOT in CAP
  • Culture:
    • – sputum
      
    • – bronchial washing
      
    • – bronchoalveolar lavage
      
    • – pleural fluid tap
      
    • – lung tissue
      
    • – blood
  • Fungal culture
    
  • Molecular/PCR (mycoplasma, pneumocystis, legionella, virus)
    
  • Serology (mycoplasma, Histoplasma, coccidiosis)
    
  • Antigen testing (s. pneumonia, legionella, aspergillus)
• Management:
  • Community-acquired hospitalized pneumonia:
    • Fluoroquinolone
      
    • Possible macrolide plus 3rd gen ceph (Ceftriaxone)
  • Community-acquired ICU pneumonia:
    • Fluoroquinolone + beta-lactam (ampicillin or Ceftriaxone
      
    • Consider fluoroquinolone + clindamycin )
  • Community-acquired outpatient pneumonia:
    • If previously healthy and no abx use within 3 months
      
      • Amoxicillin
        
      • Doxycycline
        
      • Macrolide
    • Recent use of abx
      
      • Macrolide + beta lacy am (Augmentin or Cefuroxime)
        
      • Fluoroquinolone
  • Health care inpatient pneumonia:
    • Low drug resistance
      
    • Fluoroquinolone
      
    • Possibly Ceftriaxone or Unasyn (Amp/Sulba)
      
    • High drug resistance
      
    • Cefepime or Zosyn (Piper/Tazo)
      
    • PLUS
      
    • Levofloxacin
      
    • PLUS
      
    • Vancomycin or Linezolid
  • Health care outpatient pneumonia:
    • Fluoroquinolone
      
    • Possible macrolide + Augmentin
  • Aspiration Pneumonia:
    • Clindamycin
      
    • Possibly Augmentin or Impenem

Pulmonary Edema

• Presentation:
  • Main symptom: Severe dyspnoea
    
  • Movement of the chest wall: Symmetrical
    
  • Tactile fremitus: Possibly increased
    
  • Percussion: Dull
    
  • Bronchophony: May be present
    
  • Breath sounds: Fine or coarse crackles

Pulmonary Embolism

• Presentation:
  • Main symptom:
    
    • Acute dyspnoea
      
    • Pleuritic chest pain and tachypnoea
      
  • Movement of chest wall: Symmetrical
    
  • Tactile fremitus: Normal
    
  • Percussion: Normal
    
  • Bronchophony: Normal
    
  • Breath sounds: Normal

Tumour

• Presentation:
  • Main symptom:
    
    • Hemoptysis
      
    • Constitutional symptoms (weight loss, fever, night sweats)
      
  • Movement of the chest wall: Possibly asymmetrical
    
  • Tactile fremitus: Possibly decreased
    
  • Percussion: Possibly dull
    
  • Bronchophony: Possibly decreased
    
  • Breath sounds: Possibly decreased