upper&lowerrespiratory&...

UPPER & LOWER RESPIRATORY & PLEURAL DISEASE

AHD Sept 13, 2012 DR J KOZAR CCFP(EM)

CASE

• 59 yr old male with 3 days – Cough with yellow sputum – Fever, rigors – Right pleuriQc chest pain – SOB on exerQon – Past med hx

• HTN • DM II • Smoker

– Exam • T38.2, HR 128, BP 146/90, RR 24, O2 sat 91% room air • Crackles right upper chest • Glucoscan 15 mmoL/L

QuesQons

• Clinical diagnosis? – Xray? – CT? – Blood cultures?

• DisposiQon – Admit?

– ICU? • AnQbioQcs?

Clinical Diagnosis

• Baseline prevalence of CAP in unselected pts with suspicion of CAP = 5%

• Review ArQcles (1997, 2003) – Typical symptoms disQnguish poorly between CAP and other respiratory illnesses

– Clinical signs limited value in ruling in or out CAP • Auscultory findings absent in 25% with CAP • Significant interobserver variability

– NO evidence to support use of History and Physical exam ALONE to include or exclude the diagnosis of CAP

• CXR required

Evidence Based Emergency Medicine, 1st ed, p 101-‐2.

CXR

• Long considered Gold Standard for CAP diagnosis

• Flaws – Interobserver variability

• Rates of agreement among radiologists: 80%

• EP Overdiagnosis – 2 studies showed 20% and 18.9% of EP diagnosed pneumonia read as Normal by radiologist

• EP underdiagnosis – 2 studies showed 0.35% and 3.1% of missed posiQve CXRs

Evidence Based Emergency Medicine, 1st Ed, p 102

CXR

• Comparison of CXR vs CT – One small study showed 30.8% of pneumonias seen on CT were missed on CXR

• ?should proceed to CT if high index of suspicion and normal or equivocal CXR – ?treat empirically for pneumonia – ?repeat CXR in 24-‐48 hrs

Evidence Based Emergency Medicine, 1st Ed, p 102

Should this paQent be admijed?

• Joint commijee to develop unified document for CAP – CAP & influenza: 7th leading cause of death in US – Directed at Primary care, EPs, Hospitalists in US & Canada

Admission Decision

Admission Decision

• PredicQon rule derived from database of >14,000 pts • Validated on database of > 38,000 pts and an observaQonal prospecQve cohort of >2000 pts • Risk straQfies into 5 mortality classes • Its ability to predict mortality has been confirmed in mulQple subsequent studies

PORT SCORE

Class I & II – outpaQent Class III – observaQon unit or short hospitalizaQon Class IV & V – inpaQent IDSA/ATS consensus guidelines

Algorithm incorporaQng PSI

Halm. Management of CAP. NEJM 2002: 347: 2039-‐2045

PSI criQcisms

• Complex with 20 variables • Emphasis on age

• Neglect of social aspects • May underesQmate severity of disease in younger pts without comorbidiQes

• BriQsh Thoracic Society – “CURB-‐65” • Combined 3 prospecQve studies from UK, NZ and Netherlands

• DerivaQon cohort 718 pts • ValidaQon cohort 214 pts

CURB CriQcisms

• Fails to take in account co-‐morbidiQes that may be destabilized with even mild CAP

Comparing PSI & CURB-‐65

• Unclear which is superior because no RCTs • When compared in same populaQon, PSI classified slightly more paQents with CAP in low-‐risk categories – May be bejer at avoiding unnecessary hospitalizaQon

• PSI less pracQcal as uses 20 variables • CURB easier to remember but not as extensively studied

• Commijee preferred CURB-‐65 – Ease of use – Designed to measure illness severity more than likelihood of mortality

Comparing PSI & CURB-‐65

• RetrospecQve chart review – PSI, CURB-‐65 & modified CRB-‐65 performed equally well for predicQng 30 d mortality in paQents > 65 yrs old with CAP

Ochoa-Gondar et al. Int J Clin Prac 2011; 65: 1165-1172.

Caveat

ICU Admission

3 minor

ICU admission

• These are proposed criteria that need prospecQve validaQon

DiagnosQc TesQng

• Clinical features – Cough – Fever – Sputum – PleuriQc chest pain

• CXR infiltrate – Physical exam less sensiQve and specific than CXR – Elderly

• Clinical features and physical exam findings may be lacking or altered

DiagnosQc TesQng for EQology

Blood Cultures

• Vast majority of studies have cast doubt on the clinical value of blood cultures – Significant +ve results

• 1.4-‐2.1% outpts • 5-‐14% inpts • >60% +ve for S. pneumonia

– No systemaQc reviews – No RCT assessing clinical impact of BC’s – Rosen’s: “RouQne blood cultures are of essenQally no value in nonimmunocompromised adults”

Sputum Gram Stain and Culture

• Yield variable and influenced by – Specimen collecQon

– Rapidity of transport and processing – Skill in interpretaQon – Absence of prior anQbioQc therapy

• Rosen’s: “Sputum Gram's stain rarely results in a change in therapy or outcome”

EQologic Agents

EQologic Agents

• ID of specific pathogen rarely possible within ED Qmeframe – Oven not idenQfied with inpt evaluaQon & Rx – Empiric Abx on basis of most likely pathogens

Treatment OutpaQent

Amoxicillin 1g Qd Clavulin 2g bid Cefuroxime 500 mg bid Cefpodoxime Cevriaxone

NB. European &Australasian Guidelines recommend B-‐Lactams (usually Amoxil) recognizing that: -‐macrolide resistance rising -‐atypicals usually mild in outpt -‐intermediate resistance S. Pneumoniae can be treated With B-‐lactams

Treatment OutpaQent

• Cochrane Review 2009 – Currently available evidence from RCTs is insufficient to make evidence-‐based recommendaQons for the choice of anQbioQc to be used for the treatment of CAP in ambulatory paQents

Treatment InpaQent

Cefotaxime Cevriaxone Ampicillin Ertapenem

Treatment ICU

Treatment –Other ConsideraQons

First Dose Abx

DuraQon Abx’s OutpaQent

• 7-‐10 days or longer tradiQonal • Few well-‐controlled studies • Levofloxacin

– 750 mg X 5d vs 500mg X7-‐10d – Equally succcessful and resulted in more afebrile paQents by day 3

Influenza

Pandemic H1N1 Rx Guidelines

(Tamiflu)

Pneumonia and HIV

• HAART and PCP prophylaxis reduce risk of opportunisQc infecQons – S pneumonia more common than PCP

• Most common cause bacterial pneumonia • 7-‐10 X higher incidence than non HIV • Bacterial infecQons more common with CD4 >800

– M tuberculosis • More common with CD4: 250-‐500 cells/mm3

– PneumocysQs jirovecii(carinii) • CD4 <200

PCP

• Clinical – Subacute onset of

• NonproducQve cough • Fever • SOB, hypoxia • Wt loss

• Tachypnea • Tachycardia • Increased LDH (compared with non PCP pneumonia)

Classic findings: -‐bilateral intersQQal Infiltrates begin perihilar Other: -‐normal -‐lobar infiltrates -‐pleural effusions -‐hilar adenopathy -‐parenchymal nodules -‐cavitary disease -‐pneumothoraces

HIV pneumonia

• Treatment – Cover for PneumocysQs and bacterial pathogens

• TMP-‐SMX, 20mg/kg TMP divided qid X 21d • Prednisone for PaO2<70 mmHg

– 40mg bid

– Consider TB in all HIV+ • Resp isolaQon unQl ruled out

TB

• About 1/3 of world’s populaQon infected – Worldwide 8 million develop acQve TB, 2 million die per year

• AcQve TB develops – Within 2 yrs of infecQon in 5% – Another 5% reacQvaQon disease later

• Risk increased with impaired cell mediated immunity – DM, CRF, malnutriQon, immunosuppressive Rx – HIV+ with +skin test

» 8% risk/yr – MulQdrug resistance increasing

• Clinical – Cough, non producQve or producQve – Fever avernoon, night sweats – Wt loss, faQgue, malaise, headache – Hemoptyis about 30%

• Non specific so index of suspicion dependent on symptoms, risk factors

• Risk factors – Close contacts with known case – HIV+ – From Asia, Africa, LaQn america – Medically underserviced, homeless – Elderly – LTC residents – IVDU – OccupaQonal exposure

xray

• Classic: upper lobe infiltrate or consolidaQon +/-‐cavitary lesions

• Normal CXR has high NPV for acQve TB – 1% false neg in immunocompetent

– Up to 40% false neg in HIV+ for acQve TB

Low Risk Criteria for TB

• Non-‐immigrant • No weight loss • No posiQve Mantoux or Hx TB

• Not homeless

• Not recently incarcerated • CXR: No cavitary or apical infiltrate • Absence of all above-‐ NPV of 99.7%

– CI (99.1-‐99.9%)

ReacQvaQon TB (Post-‐Primary)

CavitaQng lesion RLL

Primary TB

• Primary TB – Pneumonic infiltrate any lobe

• Like any bacterial pneumonia

– Enlarged hilar or mediasQnal nodes

– Pleural effusion – Miliary TB

Primary TB in young child

Primary TB

Extensive right paratracheal adenopathy and poorly defined rul consolidaQon in primary TB

TB suspected?

• Respiratory isolaQon – Surgical mask on paQent – NegaQve airflow room – Coughing, sneezing, talking produce infecQous droplets which dry rapidly

– InfecQve parQcle circulate airborne for prolonged periods • 1-‐5 um and travel to distal alveoli • N95 masks

• Respirology Consult

Case

• 87 yr old female from LTC – Choked while eaQng breakfast this morning

– Cough for several hours but seems to be improving

– RR 20, O2 sat 93%, T 37.5, BP 145/85 – Chest mild wheezing – PMHx

• Stroke, demenQa

– ?AnQbioQcs

AspiraQon PneumoniQs

• Inflammatory chemical injury of the tracheobronchial tree and pulmonary parenchyma caused by inhalaQon of regurgitated sterile gastric contents

• Risk Factors – Impaired swallowing, protecQve airway reflexes – Decreased LOC – CriQcally ill


• Pathophysiology – Dependent on volume and pH of aspirate – Direct causQc effect – Inflammatory response that peaks in 4-‐6hrs

• Clinical – NonproducQve cough – Tachypnea – Fever – PleuriQc CP – Bronchospasm – Respiratory distress or failure – Xray infiltrates


• Treatment – SucQon upper airway – Consider ET tube placement and sucQoning – Bronchodilators for bronchospasm – NO AnQbioQcs

• Not beneficial and may select for resistant organisms

– NO steroids • MAY lead to AspiraQon Pneumonia due to breakdown of pulmonary defenses

AspiraQon Pneumonia

• Alveolar space infecQon resulQng from the inhalaQon of pathogenic material from the oropharynx

• Risk Factors: – Oropharyneal colonizaQon with pathogenic bacteria – Impaired swallowing or gag reflex – Elderly/LTC residents – May have clinically obvious episodes of aspiraQon or silent aspiraQon

AspiraQon Pneumonia

• Microbiology – Strep pneumoniae – Staph aureus – Haemophilus influenza – Enterobacteriaceae – Hospital acquired

• Pseudomonas • Gram negaQve

– anaerobes – Peptostreptococcus, Bacteroides, Fusobacterium, and Prevotella spp

AspiraQon Pneumonia

Loca%on Recumbent paQents

• Posterior segments of upper lobes

• Superior segments of lower lobes

Upright paQents • Basal segments of lower lobes

AspiraQon Pneumonia

AspiraQon Pneumonia

• Delayed onset 24-‐48hrs aver aspiraQon • Fever • ProducQve cough • Dyspnea • Ill appearance, change in mental status

• Increased HR, RR • Lethargy ,nausea, vomiQng

• Expanding infiltrate on CXR

AspiraQon

• Who to treat with anQbioQcs? – Previously healthy adults whose symptoms of aspiraQon pneumoniQs fail to resolve in 24-‐48 hrs

– Signs of bacterial aspiraQon pneumonia

AspiraQon

• Chronically ill, LTC resident with episode of aspiraQon

• Stable and symptoms resolve: – Observe ?12-‐24hrs & discharge back to LTC

• SymptomaQc : conQnued observaQon, ?admission – PneumoniQs < 48 hrs

– AnQbioQcs discouraged because of lack of evidence of benefit and concern about selecQng for resistant organisms

• Worsening symptoms: anQbioQcs +/-‐ admission

Acute Respiratory Distress Syndrome

• ARDS – NonCardiogenic pulmonary edema

– Nonspecific response of lung to variety of insults – DefiniQon

• Acute onset • Bilateral infiltrates on CXR • PaO2/FiO2 < 200 • PAWP <18 mmHg (ie No cardiogenic pulmonary edema)

• > 1 predisposing condiQon

Rosen’s 7th ed

ARDS

• Pathophysiology – Results from damage to region of alveolar-‐capillary gas exchange

– Increased permeability to plasma fluid and protein

– Mediated by proteases, oxygen radicals, interleukins, cytokines, TNF, complement factors

– Usually develops in pts who are already seriously ill in hospital

ARDS CXR

Bilateral, diffuse, patchy or homogeneous infiltrates

ARDS Treatment

• SupporQve primarily – High inspiratory pressures and PEEP required to maintain oxygenaQon hence risk of barotrauma

• Reduced Qdal volumes (6ml/kg), permissive hypercapnia • Avoid oxygen toxicity-‐ sats 85-‐90%, FiO2 <65 • Inverse raQo venQlaQon with prolonged inspiratory Qme

• hi-‐frequency oscillator venQlaQon • Prone posiQoning • Inhaled nitric oxide, NAC, Prostaglandin E, Ketoconazole, NSAIDS, corQcosteroids

– NO evidence of benefit

Case

• 33 yr old male with 2 weeks – Cough, mildly producQve

– Feverish iniQally, resolved – Can’t sleep at night because of cough – Very mildly SOB

– HR 78, BP 135/75, RR 16, O2 sat 98% – Chest: clear – Wants anQbioQcs

Acute BronchiQs

• Acute respiratory infecQon – Cough +/-‐ sputum

– Other URTI symptoms – Not caused by pneumonia or chronic bronchiQs – Usually 1-‐3 weeks but can be longer

• 20% up to 2 months

– Typically late fall to early spring

– Self limited inflammaQon of large airways secondary to infecQon of bronchial epithelium • May involve small airways too

– Transient bronchial hyperresponsiveness appears to be mechanism for cough

Acute BronchiQs

• Clinical Diagnosis – Cough < 2weeks – No prior lung disease – No findings to suggest pneumonia

• T> 38C • HR>100 • RR>24 • Focal chest pain • Ausculatory abnormaliQes

Acute BronchiQs DiagnosQc TesQng

• CXR NOT required in previously healthy, non-‐elderly

• Unless cough> 3weeks • Evidence of pneumonia

• Spirometry • If wheezing heard or pt describes • 40% have reduced FEV1

• Sputum C&S – NO • Pro-‐Calcitonin to r/o bacterial cause ??

Acute BronchiQs Microbiology

• Resp Viruses Majority – Influenza A – Influenza B – Parainfluenza – RSV – Coronavirus – Adenovirus – Rhinovirus – coxsackievirus

• Atypicals 5-‐25% – Bordetella Pertussis – Mycoplasma pneumonia

– Chlamydia pneumonia – Legionella

Acute BronchiQs Treatment

• AnQbioQcs – Cochrane Review, Dec 2007

• Modest beneficial effect – Cough decreased

» RR 0.64 (CI 0.49-‐0.85) » NNT 6

– Night Cough » RR 0.67 (CI 0.54-‐ 0.83) » NNT 7

– ReducQon days feeling ill » 0.64 days(CI 0.13-‐1.16)

– ReducQon days with limited acQvity » 0.49 days (CI 0.04-‐0.94)

• Data on subsets who benefit lacking


• Need to consider – Side effects – MedicalizaQon of self-‐limiQng condiQon – Increased anQbioQc resistance – $

• Not recommended because although staQsQcal significance, not clinically significant – 0.6 day reducQon in cough


• Bronchodilators – Cochrane reviews, updated 2005

• Limited evidence: 2 trials in adults with inhaled beta 2 agonists showing mixed results

• May reduce symptoms, including cough in paQents with evidence of airflow obstrucQon

– Not well supported by data


• Inhaled Steroids – Brief (7day) trial of inhaled or oral corQcosteroids may be reasonable for troublesome cough (> 20 days) • No clinical data to support this

Wenzel et al. Acute BronchiQs. NEJM 2006, 355; 2125-‐30


• Cough Suppressants – Cochrane reviews, 2007

• No good evidence for or against OTC cough meds in URTI

• Insufficient evidence to draw any conclusions on OTC cough meds as adjuncQve treatment for pneumonia

Case

• 25 yr old male • Onset right pleuriQc chest pain and SOB yesterday while having shower

• RR 18, HR 94, BP 110/65, O2 Sat 95%

Case pneumothorax

Pneumothorax size

hjp://www.chestx-‐ray.com/calculator/PTX.html

Light Index Collin’s Method

Pneumothorax Size

American Guidelines

• Small pneumo – < 3cm apex of lung to cupola

• Large pneumo – > 3cm

Bri%sh Guidelines

• Small pneumo – <2 cm rim visible between

lung margin and chest wall • 2cm = 49% pneumo

• Large pneumo – > 2 cm

CalculaQon methods cumbersome and usually used for research purposes, not clinically

Types of Pneumothoraces

Pneumothorax

Spontaneous Pneumothorax

Traumatic Pneumothorax

Iatrogenic Pneumothorax

Primary Spontaneous

Pneumothorax

Secondary Spontaneous

Pneumothorax


• Secondary Spontaneous Pneumothorax – No precipitaQng external factor – But do have underlying lung disease

• COPD – 70% • Asthma • Malignancy

• PCP pneumonia

• CysQc Fibrosis – Typically > 40 yrs old – Oven more symptomaQc than primary SP’s because of poor pulmonary reserve


• Primary Spontaneous Pneumothorax – Individuals with no clinically apparent lung disease – But 90% have subpleural bulla (bleb) on CT, typically at apex: emphysema-‐like changes

– Incidence (1) • 15/100,000/year in men • 5/100,000/year in women

– Mortality • 0.09% men • 0.06% women

1. Rosen’s Emergency Medicine 6th Ed, 2006; 1143 -‐1145.


– Risk factors for Primary SP’s • Male

• Tall • Smoking

• Familial

• Mitral valve prolapse

• Marfan’s

• Not related to physical exerQon – Typical paQent – healthy male, 20-‐40 yrs. old, of taller than average height, smoker

– Risk of recurrence aver first SP = 1/3 (1)

Treatment Strategies

• ObservaQonal studies demonstrate extensive pracQce variaQon (2)

• American College of Chest Physicians (ACCP) commissioned development of pracQce guidelines in 2001 (3) – Commijee consisted of 32 members, 12 of which were thoracic surgeons, 4 EP’s

– Recognized there is insufficient data from RCT’s to develop evidence-‐based document

– ACCP recommendaQons would largely derive from expert opinion


– BriQsh Thoracic Society (BTS) developed guidelines (2003) by commijee • substanQally different from ACCP (4)

2. Baumann MH, Strange C. The clinician’s perspecQve on pneumothorax management. Chest 1997; 112; 822-‐828. 3. Baumann MH et al. Management of Spontaneous Pneumothorax: An American College of Chest Physicians Delphi Consensus Statement. Chest 2001; 119; 590-‐602. 4. Henry M et al. BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003: 58 (Suppl II); ii39-‐52.


• Observe • AspiraQon • Small bore chest drainage

– pigtail • Large bore chest drainage

– Chest tube • InpaQent vs OutpaQent

Secondary Spontaneous Pneumothorax

• Admit all • Small, stable

– Observe or tube thoracostomy or aspirate (BTS)

• Large or symptomaQc – Tube thoracostomy

Primary Spontaneous Pneumothorax Treatment Strategy:

ObservaQon • Pleural air is reabsorbed at about 1.25%-‐2% of involved hemithorax/day – If paQent suffers a 25% pneumothorax, will take 13-‐20 days to resolve (with no further leak)

– Supplemental O2 will increase resoluQon rate by 3-‐4 fold

• ACCP: Clinically stable paQents with small pneumothorax (<3cm apex to cupola) can be discharged home aver 3-‐6 hrs of observaQon and a repeat CXR which excludes progression, with follow-‐up in 12hrs to 2 days

Treatment Strategy: ObservaQon

• BTS: paQents with small (<2cm lung to chest wall) SP and without SOB can be discharged with early follow-‐up – no recommendaQon for observaQon in ED, repeat CXR

• CriQcisms: – Some SP’s are trivial in size but cause a lot of symptoms which only

resolve with evacuaQon of air – Very small risk of tension pneumothorax – Some observed paQents eventually need tube drainage because of

ongoing leak (5)

5. Baumann MH and Strange C. Treatment of spontaneous pneumothorax: a more aggressive approach? Chest 1997; 112; 789-‐804.

• ACCP: recommend for stable paQents with large SP (>3cm apex to cupola) should have small bore catheter (<14F) eg. pigtail catheter or 16F-‐22F chest tube and be hospitalized – “Reliable paQents who are unwilling to undergo hospitalizaQon may be discharged home from ED with small bore catheter ajached to Heimlich valve if the lung has reexpanded aver the removal of pleural air.

Follow-‐up should be arranged within 2 days (good consensus)”

Primary Spontaneous Pneumothorax Treatment Strategy

Primary Spontaneous Pneumothorax Treatment Strategy

• BTS: For paQents with SOB and/or large SP (>2cm air lung to chest wall) recommend small chest tube (10-‐14F) only if aspiraQon and reaspiraQon unsuccessful

Treatment Strategy: AspiraQon

• ACCP: AspiraQon not recommended – “rarely appropriate in any clinical circumstance”


• ProspecQve, randomized, pilot study of aspiraQon (16G IV needle) vs. chest tube in primary SP (6)

– 16/27 (59.3%) immediate success with aspiraQon, repeat aspiraQon in 6/11 but 0% successful.

• 9/11 had chest tubes-‐ all successful • 2/11 had immediate thoracoscopy • Report a 1 week intenQon to treat success rate of 25/27 (93%) of aspiraQon plus

chest tube – 21/33 (63.6%) ”immediate success” with chest tube (16-‐20F) which meant

tube out by 72 hrs • 1 week success rate 28/33 (85%)

– “StaQsQcal power insufficient to confirm therapeuQc equality”

6. Noppen M et al. Manual AspiraQon versus Chest Tube Drainage in First Episodes of Primary Spontaneous Pneumothorax. Am J Respir Crit Care Med 2002; 165; 1240-‐1244.


• RetrospecQve analysis from Hong Kong of 91 consecuQve primary SP’s who underwent aspiraQon (16G cannula) – Overall success rate 50.5% (7)

• Pneumo > 40% 15.4% success • Pneumo 21-‐39% 61.8% success • Pneumo <20% 68% success

7. Chan S, Lam P. Simple aspiraQons as iniQal treatment for primary spontaneous pneumothorax: results of 91 consecuQve cases. J Emerg Med. 2005; 28; 133-‐138.


• RetrospecQve review of SP (primary and secondary) in Singapore (8)

– N=159 – 75 (47.2%) treated with chest tube (?size) with complete reexpansion

in 65.3% – 28 (17.6%) had needle aspiraQon

• complete reexpansion in only 5/28 (17.9%) • 50% requiring either reaspiraQon or subsequent chest tube (42.9%) • all were admijed for monitoring

– 56 (35.2%) were admijed and observed

8. Ong M et al. Spontaneous Pneumothorax Outcome Study: a 2 year review. European J of Emergency Medicine 2004; 11; 89-‐94.


• SystemaQc review in 2004 looked at 3 RCTs comparing simple aspiraQon and chest tube 12 – Evidence limited; sample size too small to make any firm conclusion – Couldn’t combine success rates because of differences in outcome

definiQons – Couldn’t pool pain scores – AspiraQon resulted in shorter hospitalizaQon, but hospitalizaQon

mandated with chest tube – Doesn’t address use of small bore (8-‐14F) catheters or outpaQent

treatment

12. Devanand et al. Simple aspiraQon versus chest-‐tube inserQon in the management of PSP: a systemaQc review. Respiratory Medicine 2004; 98; 579-‐590.


• 2006 RCT from Kuwait of aspiraQon vs chest tube drainage in PSP (N=137) 13 – AspiraQon

• immediate success 40/65 (62%) • 1 week success 58/65 (89%) intenQon to treat • 3 month recurrence 15% • ComplicaQons 1 (2%)

– Chest tube (20F) • immediate success 49/72 (68%) • 1 week success 63/72 (88%) • 3 month recurrence 8%: not significant • ComplicaQons 5 (7%)

13. Ayed et al. AspiraQon versus tube drainage in PSP: a randomized study. European Respiratory Journal 2006; 27; 477-‐482.

CriQcal appraisal

• 3 RCT’s, fair quality • No significant difference between needle aspiraQon and tube thoracostomy – Immediate failure, 1 week failure – ComplicaQons – 1 yr recurrence

• Needle aspiraQon – Lower rates of hospitalizaQon and length of stay

• Conclusion – Needle aspiraQon at least as safe and effecQve – Benefit of fewer hospital admissions and shorter stay

Zehtabchi , Rios. Management of Emergency Department PaQents with Primary Spontaneous Pneumothorax: Needle AspiraQon or Tube Thoracostomy? Annals of Emerg Med 2008: 51: 91-‐100

Consensus?

• Small (<3cm apex to cupola) and AsymptomaQc first episode of PSP should be observed for several hours and discharged if stable

• A large (> 3cm) or symptomaQc first PSP should be treated with air evacuaQon: – Small catheter manual aspiraQon-‐once only OR – Small (14F) percutaneous catheter with Heimlich valve-‐ outpaQent OR water seal device –inpaQent 14

14. Baumann and Noppen. Pneumothorax. Respirology 2004. 9; 157-‐164

Consensus?

• Blurring of disQncQon between aspiraQon and chest catheter is making the debate moot: 15,16 – BTS guidelines also advocated in centres with experQse the use of

small bore catheter aspiraQon kits (8F seldinger) lev in place unQl re-‐expansion confirmed

– IV cannula (16 gauge) in inexperienced hands: • Frequently kinks • Difficult to keep sealed and in place while a f/u CXR is done • Doesn’t effecQvely exclude a persistent air leak • 40-‐50% require a second procedure ie tube thoracostomy

– If small bore catheter used as iniQal strategies, comes down to Qming of removal and choice of catheter

15. Baumann. Management of SP. Clinics in Chest Medicine 2006; 27; 369-‐381 16. Henry. Simple sequenQal treatment for PSP: one step closer. European Respiratory Journal 2006; 27; 448-‐450.

Consensus?

• Pilot study 2006: “One system, Serial-‐steps approach” to PSP 17 – 41 paQents, 8.5F pigtail catheter via seldinger, anterior route, connected to Heimlich and all admijed

• 24 hr success rate 61% (tube out and home) • 1 week success rate 85% • Analgesic use

– 8/41 required none – 2/41 required narcoQcs during sucQon, – Rest needed only non-‐narcoQc analgesics

• Next step: outpaQent management algorithm

17. Marqueje et al. Simplified stepwise management of PSP: a pilot study. European Respiratory Journal; 27; 470-‐476.

Treatment Strategy: OutpaQent Management

• Present TOH management is shiving from admission of paQents with SP treated with 14F pigtail catheter to selected outpt care

• OutpaQent management has been described several Qmes in the literature daQng back to mid 70’s in the thoracic surgery literature

Treatment ComplicaQons

• Failure to expand • Tension pneumothorax • Persistent air leak • InfecQon • Neurovascular bundle injury • Re-‐Expansion pulmonary edema

– Younger (20-‐39) – Larger pneumothorax – Present >72 hrs & rapidly re-‐expanded with sucQon – Rx is supporQve

Post Pneumothorax

• No flying unQl resolved • No scuba –ever • Discourage smoking

• DefiniQve treatment advised aver second recurrence – VATS: Video assisted thoracoscopic surgery

What’s this?

Beware of COPD pts: -‐Paucity of lung markings make pneumothorax difficult to detect -‐Giant bullae may simulate pneumothorax

Tension Pneumothorax

• Clinical diagnosis – Tachycardia (HR>120) – Hypoxia – JVD

• May be difficult to detect

– Hypotension • Late & ominous

– Tracheal displacement • Rare & preterminal

– Treatment?

Case

• 75 yr old woman with 3 weeks of – Progressive SOB on exerQon – Orthopnea – Mild cough, non producQve – No fever – No Chest pain

• HR 85, RR 20, O2 sat 93%, BP 165/95 • Decreased breath sounds right with a few crackles

• How would you manage with the following CXR?

CXR # 1 CXR # 2

Pleural Effusions

• Pleural fluid – Secreted by parietal pleura (systemic capillaries)

– Absorbed by visceral pleura (pulmonary capillaries)

– Increased producQon or decreased absorpQon will result in accumulaQon

Pleural Effusions Types

• Exudates – Results from pleural disease

– InflammaQon, neoplasia results in acQve fluid secreQon or leakage

– High protein content

• Transudates – Results from imbalance in hydrostaQc or oncoQc pressure

– Ultrafiltrate with low protein content

Pleural Effusions Examples

• Exudates – Cancer – Bacterial pneumonia with

parapneumonic effusion – Viral,fungal, mycobacterial

or parasiQc infecQon – PE – Rheumatologic condiQons – Uremia – PancreaQQs – Post cardiac surgery or

radiaQon

• Transudates – CHF (90%) – Cirrhosis with ascites – Peritoneal dialysis – NephroQc syndrome – PE

Light’s Criteria

The fluid is considered an exudate if any of the following apply:

Pleural fluid protein : serum protein > 0.5

Pleural fluid LDH : serum LDH > 0.6

Pleural fluid LDH > 2/3 of the upper limit of normal serum LDH

Pleural Effusions Clinical Features

• AsymptomaQc • SOB • PleuriQc chest pain

– Pleurisy= inflammaQon of pleura • With or without significant exudaQon of fluid • Viral pleuriQs usually preceded by viral prodrome

Pleural Effusions

• CXR – 250-‐500 ml fluid required to

visualize on PA or AP CXR

– Lesser amount visible on lateral view

Ultrasound

Pleural Effusions

• PE is most commonly overlooked disorder in workup of pleural effusions

• PE is most common cause of pleuriQc CP and pleural effusion in pt<40

Rosen’s 6th ediQon, p 1151

Pleural Effusions Management

• ED management – Underlying disease process

• Eg. If CHF (most common cause) suspected – Diurese first – Thoracentesis if

» not resolving » grossly unequal in size

– Analgesia for pleuriQs • NSAIDs • opioids


• RelaQvely asymptomaQc effusions of clear eQology may not require any further ajenQon

• Generally, unexplained effusions require invesQgaQon

• Thoracentesis – DiagnosQc or therapeuQc – Usually not done in ED, unless paQent unstable


• DiagnosQc Thoracentesis – For analysis in cases without a clear diagnosis

• Classify as transudaQve vs exudaQve – TransudaQve=treat underlying process – ExudaQve=more extensive diagnosQc workup

» Check pleural fluid pH » pH < 7.0 suggests empyema » pH < 7.3 suggests parapneumonic effusion, malignancy, TB, rheumatoid effusion,


• DiagnosQc Thoracentesis • Detect pleural space infecQon

– PaQents with pneumonia and significant pleural effusion (parapneumonic effusion)

» >5cm on lateral upright CXR (2007 guidelines)

– Gram stain, C&S, pH, cell count – If empyema, tube thoracostomy required

» Empyema = pus + bacteria on gram staining


• TherapeuQc Thoracentesis – For dyspnea at rest with large amounts of fluid

– Empyema

• At TOH, mandated to be done with US guidance

Case

• 69 yr old male – Cough for 3 weeks – 2 days of coughing up bright red blood, filling about 5 kleenexes a day

– No chest pain, fever, SOB – Smoker

What’s your approach to this paQent?

Hemoptysis

• Numerous causes • Lung has dual lung supply

– Bronchial • Systemic circulatory pressure • Supply supporQng structures of lung

– Pulmonary • Low pressure • Supply alveoli

Hemoptysis Clinical

• Categorized – Mild: < 20 ml in 24 hrs – Moderate: 20-‐600 ml in 24 hrs – Severe: >600 ml in 24 hrs – Not helpful in ED

• ED CategorizaQon – Scant/blood streaked sputum – Frank hemoptysis – Massive hemoptysis interfering with respiraQon

Hemoptysis Clinical

• Hx and Px only moderate roles in idenQfying source

• Try to r/o nasopharyngeal or GI source • Associated symptoms may help

– Cough, sputum, fever, dyspnea, chest pain, night sweats, wt loss

Hemoptysis InvesQgaQons

• CXR – 15-‐30% normal

• Most nonspecific bronchiQs

– 80-‐90% with neoplasm will have abnormal CXR

• Other invesQgaQons – CT – Bronchoscopy

Case

• 45 yo F • 3 day history of sore throat and associated fever • Today, significantly worse +++ pain • Hoarse voice • Can’t eat or drink • Not SOB • OE:

– Looks unwell, voice muffled – T 40°C, P100, BP 120/60, SaO2 95% RA – Oral cavity/oropharynx: mild erythema – Neck: normal ROM, No lymphadenopathy – Resp: good BS, no stridor, no tracheal tug

Supraglo�Qs

Supraglo�Qs

• Epiglo�Qs: InflammaQon of the epiglo�s • Supraglo�Qs: InflammaQon of supraglo�s (whole or part)

– Epiglo�s – Aryepiglo�c folds – Arytenoids – False Cords – Pharyngeal walls

• EQology: – InfecQon – Trauma (mechanical, thermal, causQc ingesQon)

• TradiQonally considered a pediatric condiQon caused by Haemophilus influenza B but now more likely to be seen in adults

H. Influenza Vaccine

• Hib vaccine – IntroducQon has resulted in a dramaQc decrease in the incidence of invasive H. influenza infecQons (meningiQs, epiglo�Qs)

• Health Canada ImmunizaQon Monitoring Program, AcQve (IMPACT) documented 99% fewer invasive Hib infecQons in 2000 vs 1985 (1)

Epidemiology

• Mayo-‐Smith et al(2):

– 18 year retrospecQve review (1975-‐1992) – 407 cases: 134 children, 273 adults – Incidence in children declined from 6.1/100,000 (1975-‐78) to

0.3/100,000 (1989-‐92) – Incidence in adults increased (0.78/100,000 to 2.9/100,000) – Adults comprised 31% of cases in first 3 years and ; 97% of cases in last

3 years, with no pediatric cases in the last 2 yrs

• Similar data published in Australia documenQng shiv from a pediatric to adult disease in the post Hib vaccine era (11)

Epidemiology

• Current incidence (3) – adults 2-‐3/100,000 – peds 0.3-‐0.6/100,000

• For adults: (4) – peak incidence: 35-‐39 yr age group – Male:female is 2.5:1 – Mortality rate: 1.2%-‐7.1% – Smoking is a risk factor

Microbiology

• PosiQve blood cultures reported in 12-‐26% adults (3) • Bacteremia less common in adults than children • Variety of pathogens in adults:

– H. influenza – Group A beta-‐hemolyQc Streptococcus – Non-‐group A beta-‐hemolyQc Streptococcus – Staphylococcus aureus – Streptococcus pneumonia – Candida albicans – Viral

Signs & Symptoms

Adapted from (2)

Diagnosis—Sov Tissue Lateral Neck Xray

• Thickening of the epiglo�s present on 73%-‐86% of films (3)

• Thumb sign: rounded shape of the epiglo�s due to swelling • Vallecula sign: complete or parQal obliteraQon of the vallecula

– Be wary of enlarged lingual tonsils • SensiQvity: 75% • ALL PATIENTS SHOULD BE ACCOMPANIED TO XRAY

DEPARTMENT WITH EQUIPMENT FOR AND PERSONNEL TRAINED IN AIRWAY MANAGEMENT

Epiglo�s – Sov Qssue xrays

Epiglo�Qs – Sov Qssue xrays

Diagnosis in Adults

• Laryngoscopy in adults does not precipitate acute airway obstrucQon (2,3)

• FibreopQc laryngoscopy is the gold standard(3,4) • Cherry red epiglo�s is the classic finding; most paQents also have supraglo�c inflammaQon as well

• No complicaQon of nasal flexible laryngoscopy in small case series of adults from Australia (5)

Epiglo�Qs

Epiglo�Qs/Supraglo�Qs

Treatment: Adults

• No consensus on airway management of adult epiglo�Qs. • Up to approximately 20% require airway intervenQon; hence

all require admission and close monitoring with airway support rapidly available (2,6)

• Risk factors that predicted need for aggressive airway management: – DYSPNEA (6, 12)

• For intubaQon: ppv=62%, npv=100% (6)

– Stridor (12, 13) – Muffled voice (12, 13)

– Diabetes (12, 13) – Rapid clinical course (ie presented < 12hrs aver symptom onset) (13)

Treatment: Adults

• Admit to ICU • ENT consult • Consent done for possible tracheostomy • Anesthesia made aware • High dose steroid (Dexamethasone 10mg IV q6h)

• AnQbioQcs

Treatment: Children

• Airway should be secured regardless of degree of apparent respiratory distress (7,8)

• PaQent should not be moved, reposiQoned or have airway examined with tongue depressor or laryngoscope

• DefiniQve airway management: – Intubated in the OR with ENT present, tracheostomy set open and

consent signed

• Dexamethasone • AnQbioQcs • Swabs done at intubaQon

Treatment: AnQbioQc Choice (9,10)

• AnQbioQcs: 2nd or 3rd generaQon cephalosporin with acQvity against beta-‐lactamase producing H. flu – Cefuroxime

• Adults: 0.75-‐1.5 gm IV q8h • Peds: 50 mg/kg IV q8h

– Cefotaxime • Adults: 2-‐3 gm IV q6-‐8h • Peds: 50mg/kg IV q8h

– Cevriaxone • Adults: 1-‐2 gm IV daily • Peds: 50 mg/kg IV daily

• AlternaQves – Ampicillin/Sulbactam

• Adults: 1.5-‐3 g IV q6h – Ticarcillin/Clavulanate

• Adults: 3.1 g IV q4-‐6h – Piperacillin/Tazobactam

• Adults: 3.375g IV q4-‐6h – Levofloxacin

• Adults: 500mg IV daily

– GaQfloxacin • Adults: 400mg IV daily

– Trimethoprim/Sulfamethoxazole

• Which American president is suspected to have died of epiglo�Qs despite vigourous bleeding by his physicians?

George Washington

Case

• 25 yr old male – Sore throat for 3 days, no cough – Normal vitals, afebrile – Tonsillar swelling, erythema and exudate – Tender submandibular nodes

– Normal voice, no trismus – Should he get anQbioQcs? Steroids?

PharyngiQs Clinical

• Clinical differenQaQon of eQologic organisms virtually impossible

• Hx – Associated symptoms

• Exam – Airway assessment – Voice changes – Pharyngeal erythema, exudate – Trismus – Adenopathy – Splenomegaly

PharyngiQs DiagnosQc Strategies

• GABHS – Culture – Rapid DiagnosQc Test – Clinical PredicQon Rule

• Centor score (1981) • Modified Centor (McIsaac 1998) • Simplified Walsh rule (McGinn 2003)

• Mono – Monospot – VCA

PharyngiQs Clinical PredicQon Rule-‐ Modified

Centor

MacIsaac et al. A Clinical Score to Reduce Unnecessary AnQbioQc Use in PaQents with Sore Throat. CMAJ 1998; 158: 75-‐83.

Modified Centor

Points % with strep infec%on (+/-‐ SD)

LR Post test probability of GABHS assuming prevalence of 15%

-‐1 or 0 1 +/-‐ 0.8 0.05 1 %

1 10 +/-‐ 3 0.52 8 %

2 17 +/-‐ 4 0.95 14 %

3 35 +/-‐ 5 2.5 31 %

4 or 5 51 +/-‐ 6 4.9 46 %

From Evidence Based Emergency Medicine. 1st ediQon 2009. p525

PharyngiQs Clinical PredicQon Rule – Modified

Centor

Simplified Walsh

McGinn et al. ValidaQon and ModificaQon of Streptococcal PharyngiQs Clinical PredicQon Rule. Mayo Clin Proc 2003; 78: 289-‐293

Simplified Walsh

Clinical PredicQon Rules

• “In Summary, there are a variety of clinical scoring systems available, and all provide modest to good posiQve and negaQve likelihood raQos for the diagnosis of strep pharyngiQs, and are thus useful guides to management”

Evidence Based Emergency Medicine 1st ed 2009, p 526

Rapid Strep Tests

• No meta-‐analyses • 10 clinical trials • 7 guidelines • Insufficient sensiQvity to be used alone

• Swab technique may limit accuracy

• EP’s should be cauQous in their use of rapid strep tests and use in conjuncQon with clinical scores to increase diagnosQc accuracy


• ProspecQve cohort study – Primary care walk in clinic, Geneva – How best to use Centor score, RSAT and culture – PharyngiQs with Centor >2, age > 15 – 5 strategies

• SymptomaQc Rx • SystemaQc RSAT • SelecQve RSAT Centor = 2 or 3, empirical Abx Centor=4 • Empirical Abx if Centor = 3 or 4 • SystemaQc Culture

Humair et al. Management of Acute PharyngiQs in Adults. Arch Intern Med 2006; 166: 640-‐644


• Overall prevalence of GAS – 37.6%

• Centor 2 23.6% • Centor 3 41% • Centor 4 60.3%

• Compared with C&S, RSAT had – SensiQvity 91.4% – Specificity 95.3% – PPV 92% – NPV 95%


Humair et al. Management of Acute PharyngiQs in Adults. Arch Intern Med 2006; 166: 640-‐644.

OpQmal Abx use Most expensive Wait for C&S results Nearly opQmal Abx use

Cheapest Immediate decision Best Strategy

Some Abx overuse 2nd best strategy

High anQbioQc overuse Some underuse


• Problems – Not an emerg populaQon but probably not that different from our pharyngiQs paQents

– Need a prospecQve trial looking at • Symptoms • ComplicaQons

• Our health care se�ng

– RSAT NOT available at TOH – Is available at some community hospitals (Dr Toye)

I D S A

PharyngiQs Treatment

• GABHS – Penicillin V 600mg po bid-‐Qd X 10d – AlternaQve for pen allergy

• Erythromycin, azithromycin • Clindamycin • Cephalosporin

• SymptomaQc treatment – AnQpyreQcs, analgesics – Gargling with warm saltwater? – Drinking warm liquids?

– CorQcosteroids ?

CorQcosteroids

• SystemaQc Review and Meta-‐analysis – 8 RCT’s comparing corQcosteroids vs placebo

• Children and adults • OutpaQent se�ngs • Steroids

– Dexamethasone up to 10 mg, prednisone 60 mg, betamethasone

– 6 trials used single doses • All paQents also received anQbioQcs • Excluded mono • High methodological quality

Hayward et al. CorQcosteroids for pain relief in sore throat: systemaQc review and meta-‐analysis. BMJ 2009; 339: b2976

CorQcosteroids Meta-‐analysis Primary outcomes

NNT = 3.7

NNT = 3.3

CorQcosteroids Meta-‐analysis Primary outcomes

CorQcosteroids

• Data suggest no effect in mild sore throat so use only with severe or exudaQve sore throat

• All trials include anQbioQcs, so effect of steroids alone unknown

• Effects most apparent in iniQal 24 hrs, implies single dose sufficient

• Route and dose not fully assessed but oral likely as effecQve as IM

Cochrane Review AnQbioQcs for Sore Throat

• 27 studies, updated 2006 • Symptoms

– Pain and fever reduced by about ½ by anQbioQcs – To prevent one sore throat at day 3, NNT=6 – To prevent one sore throat at day 7, NNT=21 – Subgroup analysis showed, anQbioQcs more effecQve at day 3, if C&S + for strep • RR 0.58 (CI 0.48-‐ 0.71) if + • RR 0.78 (CI 0.63-‐0.97) if -‐


• Non-‐suppuraQve complicaQons – RheumaQc fever

• AnQbioQcs reduced by >2/3 – RR 0.22 (CI 0.02-‐2.08)

– GlomerulonephriQs • Trend to benefit but insufficient cases to be sure

• (classically taught that Abx not effecQve)


• SuppuraQve ComplicaQons – AnQbioQcs reduced risk of

• AOM – RR 0.30 (CI 0.15-‐0.58)

• SinusiQs – RR 0.48 (CI 0.08-‐2.76)

• Peritonsillar abscess – RR 0.15 (CI 0.05-‐0.47)


• Abx confer benefit • But absolute benefits modest

– Shorten duraQon of symptoms by 16 hrs • In Western society, many will need to be treated with Abx to benefit few for suppuraQve and non-‐suppuraQve complicaQons

• Adverse effects – Diarrhea – Rash – resistance

GABHS PharyngiQs SuppuraQve ComplicaQons

• Peritonsillar abscess – Quinsy

• Retropharyngeal abscess • Other Deep space neck abscesses • SuppuraQve cervical lymphadeniQs • OQQs media • SinusiQs • MastoidiQs • Lemierre’s

– Jugular venous thromboplebiQs

PeritonsilliQs

• Peritonsillar celluliQs and peritonsillar abscess – Clinical conQnuum – Most common deep infecQon of H&N in adults – CollecQon of pus between tonsillar capsule and superior constrictor and palatopharyngeus muscles

• History – PharyngiQs symptoms followed in 2-‐5 days

• Increased odynophagia, dysphagia • drooling

Peritonsillar Abscess

• Displacement of tonsil medial and inferior

• Contralateral uvula deviaQon

• Trismus • Hot potato voice • Rancid breath

Peritonsillar Abscess Treatment

• Drainage – Needle aspiraQon

– Easier than I&D with simlar outcome – ?ultrasound guided

– I&D • CaroQd artery at risk • At TOH, done by ENT

• AnQbioQcs – Penicillin – Macrolides – Clindamycin – Clavulin

• Fluids if dehydrated • Analgesia

Mono

• Epstein Barr Virus (human herpesvirus4 ) • Spread by close contact • 1-‐2 month incubaQon period • Classic infecQous mononucleosis

– Fever, malaise – ExudaQve pharyngiQs/tonsilliQs – Lymphadenopathy – Splenomegaly – Atypical lymphocytosis – TransaminiQs

• In older adults hepatomegaly and jaundice

Mono

• ComplicaQons – Splenic rupture 0.1-‐ 0.5% – Autoimmune hemolyQc anemia – Thrombocytopenia – Neuro rare

• EncephaliQs, meningiQs, CN palsies, GBS

Mono

• Monospot (Heterophil anQbodies) – May be false negaQve in the 1st week of illness – Variability with age in paQents with mono

• Adults 95% • Children >5 90% • Age 2-‐4 75% • Age 0-‐20 mo. 30%

– IgM anQbodies to EBV capsid (VCA) • SensiQve 100% • Specific • Persist 4-‐8wks • IgG persist life long • Sent to CHEO (EBV Serology) , 2-‐5 day turnaround

– AnQbodies to EBV nuclear anQgen develop at 4-‐6 weeks and persist for life • Peripheral blood smears

– Atypical mononuclear cells in 75% pts – 2nd or 3rd week of illness

Ebell, EBV InfecQous Mononucleosis. American Family Physician 2004; 7: 1279-‐87

Mono

• Treatment – Mainly supporQve – CorQcosteroids – classic indicaQons

– Tonsillar hypertrophy that threatens airway patency – Severe thrombocytopenia – HemolyQc anemia

• Prednisone 1-‐2mg/kg/d • Evidence is contradictory • Not recommended for “rouQne” IM

– Avoid contact sports • Splenic rupture

Thompson. InfecQous Mononucleosis and CorQcosteroids. Archives of Otolaryngology-‐ Head and Neck Surgery 2005; 131: 900-‐4.

Deep Space InfecQons Neck & Face

• Spaces – Peritonsillar – Submandibular – Parapharyngeal – Retropharyngeal – Danger – prevertebral

SomeQmes referred to collecQvely as retropharyngeal


• Incidence decreased dramaQcally – Improved dental hygiene – AnQbioQcs

• Risk of airway compromise – Airway distorQon – Trismus

• IntubaQon – Awake technique preferable – FibreopQc best – RSI risky

• May be unable to intubate and venQlate • Only if double set up ready to proceed to surgical airway


• Submandibular – Sublingual & Submaxillary spaces

Ludwig’s Angina

• Ludwig’s angina – CelluliQs of the connecQve Qssues of the floor of the mouth and neck that begins in the submandibular space

– Polymicrobial • Mixed oral aerobic-‐anaerobic

• Strep, staph, bacteroides, H flu, pseudomonas, klebsiella, candida

Ludwig’s Angina

• Causes – Dental disease most common

– # mandible – LaceraQon floor of mouth, tongue piercing – Iatrogenic

• TraumaQc intubaQon • Bronchoscopy

– Spread from local infecQon

Ludwig’s Angina

• Symptoms – Dysphagia, odynophagia – Neck swelling and pain – Dysphonia, hot potato voice – Fever

• Signs – Bilateral submandibular swelling – ElevaQon and woody consistency floor of mouth – Tongue elevaQon – Bull neck: induraQon and edema above hyoid – Tenderness +/-‐ subcut emphysema

Ludwig’s Angina

Ludwig’s Angina

• Mainly clinical diagnosis • US useful for abscess • CT and MRI for complicaQons

– Spread to other deep spaces neck – MediasQniQs, empyema, pericardiQs – Internal jugular vein thrombosis (Lemierre’s) – CaroQd artery infecQon, erosion – NecroQzing fasciiQs – others

Ludwig’s Angina

• Management – Airway compromise can be rapid – FibreopQc intubaQon preferred – If surgical airway required, may need trach as cricthyroidotomy may not be possible

– AnQbioQcs • Penicillin 24MU q 4h + metronidazole 1g then 500mg q6h • CefoxiQn • Clindamycin • Pip-‐tazo

– Surgical drainage if not responding or abscess


• Parapharyngeal – CaroQd artery &jugular vein

– CN IX, X, XI, XII – Cervical sympatheQc chain

Parapharyngeal Abscess

• InfecQon spread from – Odontogenic – Pharyngotonsillar – Others: other deep space neck infecQons, paroQQs, sinusiQs, infected neck tumors, local lymphadeniQs, iatrogenic from nerve block, tonsillectomy

• polymicrobial


• Clinical – Neck pain & swelling,

torQcollis – Odynophagia – Fever – Medial tonsil displacement – Posterolateral pharyngeal

wall bulge – Trismus

– Tender & swelling angle of mandible


• Xray sov Qssue neck – usually not helpful

• US, CT, MRI


• ENT referral for surgical drainage • IV Abx

– Same as ludwig’s

• ComplicaQons – innumerable


• Retropharyngeal – Base of skull to superior mediasQnum (T2) – InfecQon has easy access to mediasQnum – Abscesses tend to occur lateral to midline

• Superior constrictor muscle adheres to prevertebral fascia

• Danger – Extends from base of skull to diaphragm – InfecQon has easy access to mediasQnum

• Prevertebral – Extends from base of skull to coccyx – InfecQon has easy access to mediasQnum

Retropharyngeal InfecQons

• All 3 above spaces • Children < 6yrs

– Prominent retropharyngeal nodes that can get infected and spread

• Adults – Spread from nasopharyngiQs, OM, paroQQs, tonsilliQs, quinsy, dental infecQons, ludwig’s, parapharyneal

– ComplicaQon of upper airway instrumentaQon – FB eg fish bones – Hematologic spread – OsteomyeliQs, disciQs


• Usually polymicrobial – Aerobes & anaerobes – TB rare

• Clinical – Sore throat – Dysphagia – Odynophagia – Neck sQffness, pain – Fever – Lump in throat


• Clinical – May appear quite ill – Dysphonia

• Cri du canard – Neck extended – Prefer supine – Erythema, edema, mass of post pharynx – Tender cervical adenopathy – Neck swelling, torQcollis – Trismus – Pain on rocking larynx /trachea


• Diagnosis – Xray sov Qssue neck

• > 7mm at inferior aspect 2nd vertebral body • At inferior aspect 6th vertebral body

– >22mm adults

– >14 mm children

– CT – MRI

Sov Qssue xray

CT Neck

Retropharyngeal abscesses


• Treatment – Referral to ENT for drainage – IV ABX

• Same as ludwig’s

Case

• 42 yr old male – Onset typical URTI 10 days ago – Was resolving but last 2 days

• Fever of 38C • Pain over lev zygoma • Purulent rhinorrhea

– Wants levaquin like last Qme he had sinusiQs – Xray? – AnQbioQcs? Which one? – AdjuncQve Rx

Sinus Anatomy

Frontal sinus

Maxillary sinus

Ethmoid Sinuses

Sphenoid Sinus

Sphenoid Sinus -‐paired -‐opQc nerve & CaroQd artery Occupy lateral walls

Ethmoid Sinuses -‐2 to 8 anterior air cells -‐1 to 8 posterior air cells -‐blood supply connects With ophthalmic vessels &Cavernous sinus -‐Risk of spread to CNS or orbit

Sinus Anatomy

CT Coronal views

OsQomeatal complex: area where the maxillary, anterior ethmoid, frontal sinuses drain, Between middle & inferior turbinate -‐the focal point for sinus disease -‐healthy sinus depends on patent meatus allowing air exchange and mucus drainage

Pathophysiology

• Most common causes of osQal obstrucQon – Viral URTI – Allergic RhiniQs

• Increased mucus viscosity and ciliary dysfuncQon

• Bacteria can be introduced through cough and nose blowing

Pathophysiology

• Viral URTIs – 90% have element of viral sinusiQs – “rhinosinusiQs” – O.5% -‐2% viral sinusiQs complicated by bacterial superinfecQon: acute bacterial sinusiQs

• S. pneumonia • H. influenza • M. catarrhalis

– Chronic sinusiQs • Anaerobic • Strep species • S .aureus • Fungi

Clinical

• Symptoms – Nasal congesQon – Mucopurulent discharge – Nasal obstrucQon – Post nasal drip – Fever – Pain/pressure/headache

• Maxillary: zygoma, teeth, periorbital • Ethmoid: medial canthal, periorbital , temporal • Sphenoid: vague headaches and focal points anywhere in head

• Symptoms – Typically 7-‐10 days – IniQal 5-‐7 days difficult to differenQate viral from bacterial

– Worsening aver 5 days or persistent aver 10 days • Suggests bacterial • “double sickening”

– Pt improves iniQally & then worsens

Independent Predictors of SinusiQs

Likelihood Ra%o (95% CI) LR (95% CI)

PosiQve NegaQve

Maxillary toothache 2.5 (1.2-‐5.0) 0.9 (0.8-‐1.0)

Purulent SecreQons 2.1 (1.5-‐3.0) 0.7 (0.5-‐0.8)

Poor response to decongestants

2.1 (1.4-‐3.1) 0.7 (0.6-‐0.9)

Abnormal transilluminaQon 1.6 (1.3-‐2.0) 0.5 (0.4-‐0.7)

History of coloured nasal discharge

1.5 (1.2-‐1.9) 0.5 (0.4-‐0.8)

Evidence Based Emergency Medicine, 1st ed, p536

Likelihood of Acute SinusiQs

Number of Signs & Symptoms Likelihood Ra%o

4 6.4

3 2.6

2 1.1

1 0.5

0 0.1

Evidence Based Emergency Medicine, 1st ed, p536

Authors suggested -‐no xray for score of 0, 1, 4 -‐xray for score of 2,3

InvesQgaQons

• Xray – Poor for ethmoid or sphenoid sinusiQs – PosiQve findings

• Sinus opacificaQon • Air fluid level • Mucosal thickening > 6 mm

– Common in asymptomaQc paQents

– NOT rouQnely – Limit to

• quesQonable diagnosis • Unresponsive to treatment

• CT – NOT rouQnely – For complicaQons

• Cultures of nasopharynx – NOT unless toxic or immunocompromised

• Gold standard: sinus aspiraQon – Rarely done

Right maxillary sinus opacificaQon Lev maxillary sinus air/fluid level

Coronal CT showing right maxillary And ethmoid opacificaQon, lev Maxillary sinus air-‐fluid level

Management

• Large proporQon resolve spontaneously • AnQbioQcs:

– Cochrane Review for cure • Penicillin vs Placebo RR 1.72 (95%CI 1.00-‐2.96) • NNT 7

– Not improving aver 7 days – Moderate to severe symptoms of any duraQon

• 1st line – Cochrane Review:

• No difference between – Newer non penicillins vs penicillins (RR 1.01, 95%CI 0.97-‐1.04) – Newer non penicillins vs clavulin ( RR 0.98, 95%CI 0.95-‐1.01)

– Amoxicillin • 10 days advised by IDSA guidelines • Evidence to suggest shorter (5-‐7days) equivalent to longer Rx

– TMP/Sulfa

• 2nd line – Clavulin – Cefuroxime axeQl – Clindamycin +/-‐ cipro, septra, macrolide

Management

• Decongestants – Cochrane review: insufficient data – Topical maximum 3-‐5days to avoid rebound – ?oral decongestants – Oral anQhistamines for allergic rhinosinusiQs only

• Inhaled steroids – Cochrane review for resoluQon or marked improvement of

symptoms with various doses • RRR 1.11 (95%CI: 1.04-‐1.18) • NNT=7

• Sphenoid or Frontal sinusiQs with air/fluid levels may require hospitalizaQon

ComplicaQons

• Spread to bones and sov Qssue face and orbit – Facial and periorbital celluliQs – Periorbital abscess – OpQc neuriQs – Orbital abscess

• Intracranial – MeningiQs – Cavernous sinus thrombosis – Empyema and brain abscess

Summary

• Pneumonia – IDSA/ATS 2007 guidelines – DisposiQon tools – Recommended AnQbioQcs

• AspiraQon pneumoniQs vs pneumonia

• Pneumothorax – Types & Size esQmaQon – ACCP vs BTS guidelines

• Acute BronchiQs • Pleural Effusions

– ExudaQve vs TransudaQve • Hemoptysis approach

• Supraglo�Qs – Change from peds to adults – Diagnosis and Treatment

• PharyngiQs – Clinical predicQon rules – Rapid strep tests – Quinsy, mono

• Deep Space Neck InfecQons – Submandibular – Parapharyngeal – Retropharyngeal

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upper&lowerrespiratory&...

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