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