Category: Thoracic and Respiratory

Asthma and COPD

5 core treatments and 5 MORE treatments

5 Core Treatments

  • Albuterol
    • Beta agonist
      • Bronchodilator
    • Core treatment for asthma
  • Ipratropium
    • Anti-muscarinic
      • Relax muscles around the airways
    • Works synergistically with albuterol
  • Steroids
    • Decrease inflammation in the airways
    • Prednisone (PO)
    • Methylprednisone (IV)
  • BiPAP (COPD)
    • Decreases work of breathing
    • Decreases rates of intubation
    • Decreases mortality
  • Antibiotics (COPD)
    • Infection common cause of inflammation

5 More Treatments

  • Magnesium sulfate
  • Ketamine
  • Epinephrine (systemic beta agonist)
  • Heliox
  • LAST RESORT – Intubation
    • Decrease rate and volume
    • Increase expiratory time and inspiratory flow

Additional Reading

Pulmonary Embolism

Introduction

Pulmonary embolism (PE) is caused when a deep venous thrombosis from somewhere else in the body “embolizes” and becomes lodged in the pulmonary arteries

Can cause pulmonary infarction (which mimics pneumonia on chest x-ray)

Basic Approach to the Diagnosis of PE

  • Step 1: Consider PE in any patient with signs or symptoms consistent with the disease
    • Common signs/symptoms
      • Shortness of breath
      • Chest pain
      • Syncope
      • Tachycardia
      • Hypoxemia
      • Hypotension
  • Step 2: Do not do additional testing for PE in patients with a CLEAR alternative diagnosis
    • Common alternative diagnoses
      • COPD exacerbation
      • Acute coronary syndrome
      • Pneumonia
    • Keep in mind that these diagnoses are also the most frequent misdiagnoses in cases of missed PE!!! Be careful.
  • Step 3: Calculate Wells Score and PERC criteria
  • Step 4: Get a D-Dimer
    • IF…
    • Low risk Wells but fails PERC criteria
    • Medium risk Wells score
  • Step 5: Get a CTA
    • IF…
    • Wells score is high
    • Elevated d-dimer
      • (Update: it is now established that you can safely use AGE ADJUSTED D-DIMER)
        • ACEP’s clinical policy supporting this can be found HERE

Final Thoughts

  • Bilateral lower extremity ultrasounds not sensitive enough to rule out PE
  • The classic EKG finding is S1Q3T3

Additional Reading

Hemoptysis

There are 3 main “categories” of hemoptysis…

Mild, “Streaky” Hemoptysis

  • Most common diagnosis
    • Bronchitis
  • Testing plan
    • Chest xray
      • Rules out alternative causes of hemoptysis
        • Pneumonia
        • Cancer
        • Pulmonary Embolism
        • Vasculitis

Scary but Stable Hemoptysis

  • Patient is coughing up frank blood
  • Testing plan
    • CTA of the chest
    • CBC
    • PTT/PT/INR
    • Electrolytes
      • Need renal function if giving IV contrast

Oh-My-God-That’s-A-Lot-Of-Blood!!!

  • Intubate the patient
  • Consult cardiothoracic surgery/interventional radiology

Additional Reading

Shortness of Breath

You need an organized, anatomical approach.

Step 1: Consider Differential Diagnosis

  • Upper airway
    • Angioedema
    • Foreign body
    • Abscess
  • Lower airway
    • COPD
    • Asthma
  • Alveoli
    • Pneumonia
    • Pulmonary edema
  • Blood
    • Anemia
    • Acidosis
      • DKA
      • Sepsis (lactic acid)
      • Toxins (salicylic acid)
  • Blood vessels
    • Pulmonary embolism
    • Aortic dissection
  • Heart
    • Myocardial infarction
    • Acute heart failure
    • Cardiac tamponade

Step 2: Examine Anatomically

  • Upper airway
    • Stridor
    • Voice changes
  • Lower airway
    • Wheezing
  • Alveoli
    • Crackles
  • Blood
    • Pallor
  • Heart
    • Dysrhythmia
    • Jugular vein distension (JVD)
    • Edema

Step 3: Testing Plan

  • Common tests
    • Chest x-ray
    • EKG
    • CBC
    • Electrolytes
  • Less common tests
    • Blood gas
    • Troponin
    • BNP
    • D-Dimer

Step 4: Calculate Wells Score and PERC

Additional Reading

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