Respiratory emergency for resident · pneumothorax • Subpleural blebs and bullae are found at the...

Respiratory emergency for

resident

Pichaya Petborom M.D.

Division of Respiratory Disease and Critical care, Department of Medicine, Faculty of Medicine, HRH princess Maha Chakri Sirindhorn Medical Center

Hospital Srinakharinwirot University

Objectives

• Approach to common problems

• Diagnosis and proper investigations

• Emergency management

Symptoms

• Dyspnea

• Cough

• Chest pain

• Hemoptysis

• Upper airway obstruction

• Respiratory arrest

Laboratory

• Hypoxemia

• Hypercarbia

Respiratory Emergency

Hypoxemia Hypercarbia

•กระสบกระสาย

•หมดสต

•ปวดศรษะ

•เขยวคล า(cyanosis)

•ความดนเลอดต า

•หวใจเตนเรว

•ระยะหลงจะชาลง

•การท างานหวใจซกขวาลมเหลว

•ชกกระตก

•งวงซม, หมดสต

•เหงอออก

•มนศรษะ

•ผวกายรอนวบวาบ

•มอเทากระพอ(asterixis)

•ความดนเลอดสง

•หวใจเตนผดจงหวะ

•Papilledema

Case 1

ผปวยชายไทย ค อาย 60 ป

อส. เจบหนาอกดานขวา 2 ชวโมง กอนมา ร.พ.

ปป. 2 ชวโมงกอนมาโรงพยาบาล ขณะก าลงท าสวน มอาการเจบหนาอกดานขวาทนท เจบแปลบๆ ขณะหายใจเขาจะเจบมาก รสกแนนหนาอก และเหนอยขน จงมาโรงพยาบาล

ปอ. เคยเปนวณโรคปอดเมอ 20 ปกอน, รกษาครบ

ปส. ไมสบบหร, ไมดมสรา

Case 1: ตรวจรางกาย

VS : T 37.0o C P 120/min R 26/min BP 120/80 mmHg

GA : Good consciousness, not pale, no jaundice, tachypnea, no

cyanosis

RS : Trachea in midline,

Decreased chest movement Rt.

Decreased breath sound and vocal resonance Rt.

Hyperresonance on percussion Rt.

CVS : PMI at 5th ICS, MCL

Normal S1 S2, no murmur

Others: Unremarkable

ค าถาม

1. จงใหการวนจฉย และมแนวทางสบคนเพมเตมอยางไร

Case 1

ค ำถำม

2. ทำนจะมแนวทำงในกำรดแลรกษำ

อยำงไรตอไป

Case 1

Pneumothorax

• Spontaneous

– Primary

– Secondary

• Traumatic

• Iatrogenic

Primary spontaneous

pneumothorax• Subpleural blebs and bullae are found at the lung apices

at thoracoscopy and on CT scanning in up to 90% of

cases of PSP

• Smoking has been implicated in etiological pathway, the

smoking habit being associated with a 12% risk of

developing pneumothorax in healthy smoking men

compared with 0.1% in non-smokers

• Patients tend to be taller than control patient

• Younger than SSP

• The gradient of negative pleural pressure increased from

the lung base to the apex, so that alveoli at the lung

apex in tall individuals are subject to significantly greater

distending pressure than those at eh base of lung and

predispose to the development of apical subpleural blebs

• The risk of recurrence of PSP is as high as 54% within

the first 4 years, with isolated risk factors including

smoking, height and age > 60 years

Etiology of secondary spontaneous

pneumothorax

• Obstructive lung disease

• Interstitial lung disease

• Infection

• Malignancy

• Connective tissue disease

• Other

Sahn SA. Pleural disease. ACCP Pulmonary Broad Review Course Syllabus 2008. Illinois, IL: American College of Chest Physicians; 2008.

Etiology

of SSP

• SSP is associated with a higher morbidity and mortality than PSP.

• Pneumothorax is not usually associated with physical exertion

• Risk factors for recurrence of SSP include age, pulmonary fibrosis and emphysema

• Strong emphasis should be placed on smoking cessation, to minimise the risk of recurrence

(in PSP and SSP)

Clinical Evaluation

• Symptoms in PSP may be minimal or absent

• In contrast, symptoms are greater in SSP,

even if the pneumothorax is relatively small in

size

• The presence of breathlessness influences

the management strategy

• Severe symptoms and signs of respiratory

distress suggest the presence of tension

pneumothorax

Clinical features

• Asymptomatic

• Dyspnea

• Pleuritic chest pain

• Cough

• Hypoxemia

• Hemodynamic instability

• P.E.

– Decreased breath sound and vocal resonance

– Hyperresonance on percussion

ImagingInitial Diagnosis

• Standard erect chest radiographs in inspiration

are recommended for the initial diagnosis of

pneumothorax, rather than expiratory films

• Radiographic appearance:

– Separation of visceral and parietal pleura

(visible of visceral pleura)

– Avascular zone

– Depend on position

• Upright: apex

• Supine: ventral surface

Deep sulcus sign

Skin fold, not pneumothrorax

Size of pneumothorax

• Apex to cupola

distance

• Interpleural distance

at hilar level

• Cut off point = 2 cm.

– > 2 cm. “large”

– ≤ 2 cm. “small

Rate of resolution/reabsorption

of spontaneous pneumothorax

~ 1.25-2.2% of the volume of

hemithorax every 24 hr

Size of pneumothorax

• %PNX = (1 - lung3 ) × 100

hemithorax3

• Average distance = (A + B + C)/3

– 1 = 15%

– 2 = 20%

– 3 = 30%

– 4 = 40%

– 5 = 50%

A

B

C

Treatment options

• Observe

• Simple aspiration

• Tube thoracostomy

• Surgery

•Small or large size•Symptomatic or asymptomatic

•Primary or secondary

Primary spontaneous pneumothorax

Size > 2 cm. and/or

breathlessness

Observation and

O2 supplement

Simple aspiration16-18 G cannulaAspirate < 2.5 L

If not successTube thoracostomy

8-14 F, admit

No Yes

Failure

BTS guideline for pleural disease 2010

Secondary spontaneous pneumothorax

• Admit

• High flow O2 supplement (increase rate of

absorption 4 times)

• Drainage

– Simple aspiration (if < 2 cm and no

breathlessness)

– Tube thoracostomy (if > 2 cm or

breathlessness or fail simple aspiration)

• Pleurodesis (medical or surgical)

Case 1

แพทยไดใส intercostal chest (ICD) Rt. พบวำมลมปด

ออกมำ

ค ำถำม

3. ทำนจะตอสำย ICD อยำงไร

4. ทำนจะ apply negative pressure หรอไม, บอกเหตผล

1 bottle system 2 bottle system

3 bottle system 4 bottle system

Thoracic suction

• Should not be routinely employed

• Consider in persistent air leak and

incomplete expansion

• May precipitate re-expansion pulmonary

edema

• Optimal pressure -10 to -20 cmH2O

Case 1

• แพทยไดตอสำย ICD ดงภำพ

• 24 ชวโมง ตอมำ แพทยไดสงตรวจภำพรงสทรวงอก พบวำ

ปอดยงไมขยำยตว

ค ำถำม

5. ทำนคดวำมสำเหตใดบำงทท ำใหปอดยงไมขยำย

6. ทำนมวธกำรใดบำงทจะท ำใหทรำบถงสำเหตน

Causes of failure to expansion

Causes Methods

•Malfunction of ICD tube •Fluctuation

•Persistent air leak •Air leakage during cough

•Endobronchial obstruction •Bronchoscopy

Case 1

แพทยไดใหผปวยไอ พบวำระดบน ำในทอม

fluctuation ดและมลมปดออกมำขณะไอทกคร ง

ค ำถำม

7. ทำนจะใหกำรรกษำอยำงไรตอไป

Case 1

• แพทยไดตอ negative pressure 10

20 ซม.น ำ ดงภำพ

• หลงตอ negative pressure 5 วน

กำรตรวจภำพรงสทรวงอก พบวำปอดขยำยตว

เกอบเตมท แตยงคงมลมปดเมอใหผปวยไอ

ค ำถำม

8. ทำนจะปฏบตอยำงไรตอไป

Indication for surgery

• Second ipsilateral pneumothorax

• First contralateral pneumothorax

• Synchronous bilateral spontaneous pneumothorax

• Persistent air leak (5-7 days) or failure of expansion

• Spontaneous hemothorax

• Professions at risk (pilot, diver)

• Pregnancy

Recurrence of pneumothorax

• 30-50% during next 5 yr, esp. 1st yr

• High recurrence in

» Secondary spontaneous pneumothorax

» Already had at least one recurrence

» Large numbers of blebs or large blebs

Tension pneumothorax

• Medical emergency

• Situation at risks

– Ventilated patients

– CPR

– Trauma

– Lung disease

– Blocked, clamped or displaced chest drain

• One-way valve system

Tension pneumothorax• Clinical diagnosis

– Severe dyspnea, tachypnea, cyanosis

– Hypotension, hypoxemia

– Tracheal deviation

– Unilateral chest hyperinflation

– Subcutaneous emphysema

• Management

– High O2 concentration

– Emergency needle decompression

– ICD insertion

Case 2

• ผปวยหญง อำย 30 ป

• มอำกำรหอบเหนอย 1 ชวโมงกอนมำโรงพยำบำล

• T 37.0oC P 120/min R 30/min BP 120/80 mmHg

• Lungs: wheezing, BL

ค ำถำม

1. ทำนมกำรวนจฉยแยกโรคอะไรบำง

2. ทำนจะซกประวตและตรวจรำงกำยอะไรเพมเตม

Causes of bronchospasm

• Obstructive airway disease

– Asthma

– COPD

– Bronchiectasis

• Upper airway obstruction

• Foreign body

• Congestive heart failure

• Anaphylaxis

Case 2 ประวตและตรวจรางกายเพมเตม

• เปนโรคหดมำต งแตเดก

• มอำกำรหอบกลำงดก

• มไขต ำๆ น ำมกใส ไอเสมหะใส มำ 3 วน

• นอนรำบได ปฏเสธ PND

• ปฏเสธประวตส ำลก

• JVP ปกต

• วด PEF ดวย mini Wright Peak flow = 100 L/min

Case 2

3. ทำนจะปฏบตรกษำตอไปนหรอไม อยำงไร❑ Oxygen

❑ Bronchodilators

❑ Corticosteroids

❑ Antibiotics

❑ Cough suppressants

Case 2: แพทยใหการรกษาดงกลาว

• 1 ชม. ตอมำ อำกำรยงไมดขน• P 120/min, R 28/min, PEF 100 L/min

ค ำถำม

4. ทำนจะปฏบตรกษำอยำงไรตอไป

Asthma

• Chronic inflammatory disorder of airway

• Reversible airflow obstruction

• Associated with airway hyperresponsiveness

• Recurrent episodes

– Wheezing

– Breathlessness

– Coughing

– Chest tightness

– Particularly at night or early morning

GINA 2018

GINA 2018

Global Strategy for Diagnosis, Management and Prevention of COPD

Differential Diagnosis: COPD and Asthma

COPD

• Onset in mid-life

• Symptoms slowly progressive

• Long smoking history

• PFT: not fully reversible airflow

limitation

• Steroid – limited role

ASTHMA

• Onset early in life (often childhood)

• Symptoms vary from day to day

• Symptoms worse at night/early morning

• Allergy, rhinitis, and/or eczema also present

• Family history of asthma

• PFT: reversible airflow limitation

• Steroid – mainstay therapy

© 2013 Global Initiative for Chronic Obstructive Lung Disease

Definition of asthma exacerbations

GINA 2018

Acute asthma(exacerbation of

asthma, asthma attack)• Episodes of progressive increase in shortness of breath, cough, wheezing,

or chest tightness, or some combination of these symptoms

• A flare-up or exacerbation is an acute or sub-acute worsening

of symptoms and lung function compared with the patient’s usual status

(GINA 2016)

• The aims of treatment are to relieve airflow obstruction and hypoxemia as

quickly as possible, and to plan the prevention of future relapses.

Severity of exacerbation

Mild Moderate Severe Respiratory arrest

imminent

Breathless Walking Talking At rest

Talks in Sentences Phrases Words

Alertness May be agitated Usually agitated Usually agitated Drowsy or confused

Respiratory rate Increased Increased Often > 30/min

Accessory muscle Usually not Usually Usually Abdominal paradox

Wheezing Moderate Moderate Loud Absent wheeze

Pulse rate < 100 100-120 > 120 Bradycardia

Pulsus paradoxus Absent May be present Often present

PEF > 80% 60-80% < 60%

PaO2 and/or

PaCO2

Normal

< 45 mmHg

> 60 mmHg

> 45 mmHg

< 60 mmHg

> 45 mmHg

SpO2 > 95% 91-95% < 90%

Management of acute

asthma• O2 supplement (goal SpO2 93-95%)

• Rapid acting 2-agonist

– Salbutamol: 0.5-1 ml (2.5-5 mg)

– Ipratopium bromide/fenoterol

• Systemic corticosteroids (30-40 mg/d prednisolone at least

5-7 days)

• Avoid sedation

• Antibiotics if indicated

• Refractory case: aminophylline, MgSO4 (2 g iv in 20 min)

Rapid-acting 2 agonist

Nebulizer MDI with spacer

ฃ

GINA 2018

GINA 2018

Evaluation of acute asthma • Re-assess within 1-2 hour

• Discharge when

– Improvement of symptoms

– PEF > 60% predicted/personal best or >250 L/min

• Consider admission or respiratory support

– Not improved

– PEF < 60% predicted/personal best or <250 LPM

– Alteration of consciousness

– Persistent hypoxemia or hypercarbia

ฃ

ขอบงชในกำรรบผปวยไวรกษำในโรงพยำบำลในผปวยโรคหด

ก ำเรบเฉยบพลน (thai guideline 2555)

• 1. ไมตอบสนองตอการรกษาตามแนวทางการรกษาขางตน ภายใน 1-2 ช วโมง หรอ

มการอดก นของหลอดลมเพมขนหลงการรกษา เชน มคา PEF ลดลงนอยกวา

50% ของคามาตรฐาน หรอนอยกวา 200 ลตร/นาท

• 2. มประวตเดมของอาการหอบหดรนแรง หรอเคยไดรบการรกษาใน ไอซย เนองจาก

โรคหดก าเรบมากอน

• 3. มปจจยเสยงตอการเสยชวตจากโรคหด เชน มประวต near fatal asthma หรอ

เคยไดรบการรกษาอาการหอบหดรนแรงในโรงพยาบาล ในระยะหนงปทผานมา ลลล

• 4. มอาการซม หรอสบสน

• 5. มอาการหอบตอเนองมานาน กอนทจะมาพบแพทยทหองฉกเฉน

• 6. สภาพแวดลอมและการดแลทบานไมเหมาะสม

• 7. ไมสะดวกในการเดนทางจากบานมาโรงพยาบาลในเวลารวดเรว

Global Strategy for Diagnosis, Management and Prevention of COPD

Manage Exacerbations

• COPD exacerbations defined as an acute worsening of

respiratory symptoms that result in additional therapy

h2018 Global Initiative for Cronic Obstructive Lung Disease

▪ The most common causes are viral upper respiratory tract infections and infection of the tracheobronchial tree.

▪ The goal of treatment is to minimize the impact of the current exacerbation and to prevent the development of subsequent exacerbations

Global Strategy for Diagnosis, Management and Prevention of COPD

Manage Exacerbations: Key Points

© 2014 Global Initiative for Chronic Obstructive Lung Disease

COPD exacerbation• Change in baseline dyspnea, increased sputum

purulence and volume, increased cough and wheeze

• Beyond normal day-to-day variation

• Acute onset

• Infection – most common cause (other→air pollution)

• Assessment

– Clinical

– CXR

– Pulse oximetry

– Arterial blood gas

Assessment of COPD exacerbations

▪ Short-acting inhaled beta2-agonists with or without short-acting anticholinergics are usually the preferred bronchodilators for treatment of an exacerbation

▪ Systemic corticosteroids and antibiotics can shorten recovery time, improve lung function (FEV1) and arterial hypoxemia (PaO2),and reduce the risk of early relapse, treatment failure, and length of hospital stay

▪ COPD exacerbations can often be prevented

Global Strategy for Diagnosis, Management and Prevention of COPD

Manage Exacerbations: Key Points

© 2014 Global Initiative for Chronic Obstructive Lung Disease

Impact on

symptoms

and lung

function

Negative

impact on

quality of life

Consequences Of COPD Exacerbations

Increased

economic

costs

Accelerated

lung function

decline

Increased

Mortality

EXACERBATIONS

Oxygen: titrate to improve the patient’s hypoxemia with a

target saturation of 88-92%.

Bronchodilators:Short-acting inhaled beta2-agonists with or

without short-acting anticholinergics are preferred.

Systemic Corticosteroids: Shorten recovery time, improve

lung function (FEV1) and arterial hypoxemia (PaO2), and

reduce the risk of early relapse, treatment failure, and length

of hospital stay. A dose of 40 mg prednisone per day for 5

days is recommended .

Global Strategy for Diagnosis, Management and Prevention of COPD

Manage Exacerbations:Treatment Options

Antibiotics should be given to patients with:

▪ Three cardinal symptoms: increase in dyspnea, sputum volume, and sputum purulence (have 2 of 3 if increased purulence of sputum is one of the two symptoms)

▪ Who require mechanical ventilation.

Global Strategy for Diagnosis, Management and Prevention of COPD

Manage Exacerbations:Treatment Options

© 2014 Global Initiative for Chronic Obstructive Lung DiseaseGOLD 2018

Noninvasive ventilation (NIV) for patients

hospitalized for acute exacerbations of COPD:

▪ Improves acute respiratory acidosis,

decreases respiratory rate, severity of

dyspnea, work of breathing, severity of

breathlessness, complications(VAP) and

length of hospital stay

▪ Decreases mortality and needs for intubation.

Global Strategy for Diagnosis, Management and Prevention of COPD

ManageExacerbations: TreatmentOptions

GOLD 2018

Indication for hospitalization assessment

GOLD 2018

GOLD

2018

GOL

D

2018

Case 3

• ผปวยชำยไทย อำย 30 ป มำดวยไอออกเลอด 2 ชวโมง กอนมำ รพ.

• ปป. 2 ชวโมง กอนมำ รพ. ขณะนงท ำงำนมอำกำรไอออกเปนเลอดสด

ปรมำณ 1 แกวน ำ ท งหมด 3 คร ง รสกเจบหนำอกดำนขวำ มอำกำร

เหนอยมำกขน

• ปอ. เคยเปนวณโรคปอดเมอ 5 ปกอน รกษำครบ

• Physical examination

V/S: T 37Oc, BP 100/60 mmHg, P 100/min, RR 24/min

GA: alert, not pale, mild tachypnea, no clubbing of finger

CVS: normal S1S2, no murmur

RS: equal breath sound, crackles at Rt.lung, no rhonchi

Case 3

ค ำถำม

1. จงใหกำรวนจฉย

2. จงบอกแนวทำงกำรดแลรกษำ

Hemoptysis

• Massive hemoptysis

– > 150-200 ml in 1 episodes

– > 600 ml/24 hours

• Life threatening hemoptysis

– Hemodynamic instability

– Respiratory failure

– Inadequate respiratory reserve

Hemoptysis vs HematemesisHemoptysis

• Frothy blood expectorated

• Bright red

• Alkaline pH

• Hemosiderin-laden

macrophage

• History of cough

Hematemesis

• Blood is vomited

• Dark or coffee ground

• Acid pH

• Food particles

• History of gastric

complaint

Causes of massive hemoptysisCommon

• Tuberculosis

• Bronchiectasis

• Lung abscess

• Mycetoma

Uncommon

• Iatrogenic

• Lung cancer

• Alveolar hemorrhage

• Cardiovascular disease

• Bronchial adenoma

• Metastatic CA

• Broncholithiasis

• FB aspiration

• Lung contusion

• Dissecting aneurysm

Management of hemoptysis

• ABCD

• NPO

• Hemodynamic stabilization

– Large bore iv

– Cross match blood

– Work up for coagulopathy

• Oxygen supplement

• Airway protection and prevent asphyxiation (bad lung down)

• Localization of bleeding

• Antibiotics/bronchodilators (if indicated)

• Cough suppressant

• Avoid sedation

• Notify radiologist, cardiothoracic surgeon

Diagnostic approach for

localization

• Hemoptysis or GI tract or sinus or

epistaxis

• PE: crackles, wheezes

• 55% non-localizing examination

• CXR : helpful in 60%

• Bronchoscopy: best single test

Endobronchial tamponade

• Selective one lung ventilation

• Double lumen endotracheal intubation

• Balloon tamponade

Bronchial embolization

• Useful in controlling majority but only

temporary in some patients

• 10% recurred in first few days

• Higher recurrence in aspergilloma,

bronchiectasis, lung cancer

• Complication: anterior spinal artery

occlusion

Surgery(lobectomy,

pneumonectomy)• Failure to medical treatment

• Mortality rate 15-30%

• Contraindication

– Severe underlying lung disease

– Diffuse lung disease

– Unresectable carcinoma

– Inability to localized bleeding

Case 4

• ชำยอำย 60 ป

• อส. เหนอย 1 ชวโมง กอนมำ รพ.

• ปป. 5 วน กอนมำ รพ. ขำขวำบวมปวด ไมมไข ไมมประวตไดรบบำดเจบ

เพงเดนทำงกลบจำกอเมรกำ

1 ชม. กอนมำ รพ. เหนอยทนททนใด ไมไอ ไมเจบหนำอก ไมม

หำยใจเสยงดงวด

• BP 80/50 mmHg, P 120/min, RR 28/min

• CVS & RS: within normal limit

• Swelling at Rt.calf, warm, not tender

• SpO2 83% (room air) → 90% (O2 10 LPM)

Case 4

ค ำถำม

1. จงใหกำรวนจฉย

2. จงใหกำรรกษำ

Acute pulmonary embolism

• Obstruct pulmonary vasculature by

– Thromboembolism

– Air

– Fat

– Amniotic

– Tumor

• Major source of VTE – lower extremity

Clinical presentation

• Sudden onset of dyspnea

• Hypoxemia – not well response to oxygen

therapy

• Chest pain

• Hemoptysis

• Shock or cardiac arrest

PE

2014 ESC Guidelines on the diagnosis andmanagement of acute pulmonary embolism

Investigation

• Chest X-ray: non-specific

• ECG

– Sinus tachycardia (most common)

– S1Q3T3

• Echocardiography

• D-dimer

• CT pulmonary angiography

Westermark’s sign: focal oligemia

Hampton’s hump sign: wedge shape infarction in PE

2014 ESC Guidelines on the diagnosis andmanagement of acute pulmonary embolism

2014 ESC Guidelines on the diagnosis andmanagement of acute pulmonary embolism

Proposed diagnostic algorithm for patients with suspected

high-risk PE, i.e. presenting with shock or hypotension.

ESC

2014

Proposed diagnostic algorithm for patients with

suspected not high-risk pulmonary embolism

ESC 2014

PE severity index(PESI)

Management

Management of acute PE

• Hemodynamic resuscitation

• Oxygen supplement

• Anticoagulation

• Thrombolytic therapy

• Surgical embolectomy Massive PE

NEJM: 359;26, 2008

NEJM: 359;26, 2008

Thank you