PULMONARYEMERGENCIES

PNEUMONIA

What are some important things to know about bacterial pneumonia?

It accounts for about 10—15% of admissions; Streptococcus pneumoniae is the most common agent; Most common mechanism is aspiration

Name some other important bacterial agents in bacterial pneumonia.

Pseudomonas aeruginoso; Hemophilus influenza; Staphylococcus aureus; Escherichiu coil

Some predisposing factors that increases susceptibility to bacterial pneumonia.

Impaired immunity; Impaired gag reflex/mucociliary transport; latrogenic (i.e., endotracheal tube); Chest wall dysfunction

What are some clinical features of bacterial pneumonia?

Fever, chills, productive cough, purulent sputum, and Pleuritic chest pain

What are some common physical findings in a patient with bacterial pneumonia?

Wheezing, Crackles, Dullness to percussion, Egophony, and Tactile fremitus

Some diagnostic tests to consider in addition to the CXR?

Arterial blood gas (ABG); Sputum culture (typically for high-risk patients); Blood culture

Some complications of bacterial pneumonia?

Abscess formation (esp. S. aureus); Sepsis; Empyema

Neonates Group B streptococci, E. coli, and C. pneumoniae

Children (5 weeks to 18 years)

Respiratory syncytial virus (RSV),

Mycoplasma pneumoniae, C. pneumoniae, and S. pneumoniae

Adults (18—40 years) M. pneumoniae, C. pneumoniae, and S. pneumoniae

Adults (45 years and older)

S. pneumoniae, H. influenzae, anaerobes, and gram-negatives

MOST COMMON AGENTS IN THE FOLLOWING AGE GROUP

What are some commonly used antibiotics in uncomplicated pneumonia? Penicillin, Macrolides (Azithromycin and

erythromycin), Doxycycline

What are some commonly used antibiotics for those with comorbidities? Fluoroquinolones (cipro, levaquin)

Three common causes of atypical pneumonia?

1. M. pneumoniae2. C. pneumoniae3. L. pneumophilia

What are some clinical features of atypical pneumonia?

Headache, fever, Nonproductive cough, and myalgias

Some important things to know about mycoplasma pneumonia: Most common cause of atypical pneumonia 1—3 weeks incubation; Most common in ages 4—40 years; CXR often show a reticulo-nodular pattern

What are some complications of mycoplasma pneumonia? Splenomegaly; Aseptic meningitis; Encephalitis; Respiratory failure

What is the preferred antibiotic? Erythromycin; Tetracycline, or Doxycycline

NAME THE MOST LIKELY ORGANISM

Alcoholic who presents with fever, chills, and productive cough. Chest x-ray (CXR) shows lobar pneumonia

Kiebsiella pneumoniae

45-year-old male who has been in the ICU for 2 weeks on vent sup port develops fever and chills with productive green sputum

P. aeruginosa

63-year-old male with a history of chronic obstructive pulmonary disease (COPD), DM, and debilitation presents with Shortness of breath (SOB), fever, and a Chest x-ray (CXR) that shows patchy infiltrates

H. influenza

41-year-old male presents with SOB, dyspnea, and productive cough recalls onset of symptoms after returning from a spa

Legionella pneumophila

49-year-old patient with AIDS and a cell count of <200 cells/mm3 presents with fever, nonproductive cough, and dyspnea

Pneumocystis carinii

ASTHMA

It is a chronic condition characterized by reversible airway constriction typically initiated by a variety of stimuli

More common in children and adolescents;

Prevalence is increasing; Asthma-related morbidity is also

increasing

Common triggers of asthma. Allergens; Exercise; Medications; Cold exposure

What are some of the clinical features of asthma? Dyspnea, cough, and wheezing

What are some important diagnostic tests to consider in asthma? Pulmonary function tests (i.e., PEFR); ABG (if impending respiratory failure); CXR (more to rule out other conditions); ECG (if you suspect ischemia)

Key points in the management of asthma Ensure adequate oxygenation; Optimize lung function (i.e., medication); Identify the cause of exacerbation

Three classes of drugs that are the mainstay for the treatment of asthma exacerbation: Beta-adrenergic (albuterol) Anticholinergic (ipratropium) Corticosteroids (methyiprednisolone)

Findings of impending respiratory failure: Use of accessory muscles; Cyanosis; Altered mental status (typically from

hypercapma); No breath sounds (no or very little airflow)

What procedure should be considered in the setting of impending respiratory failure? Intubation

What are some other agents that can be considered when the mainstay treatment of asthma shows little improvement? Magnesium sulfate (bronchospasm); Heliox (helium to improve airflow); Terbutamine (intravenous terbutaline for

severe status asthmaticus that had not improved after administration of corticosteroids and inhaled ß2 agonists (albuterol))

What are some important elements to consider when deciding to admit the patient? Social supports; Recent hospitalizations and past

intubations; Compliance with medication; Severity of the exacerbation

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

What are the disease elements that make up chronic obstructive pulmonary disease (COPD)? Emphysema: Irreversible airway destruction Asthma: Hyperactive airway and inflammation Chronic bronchitis: Airway hypersecretion

What are some important risk factors for the development of COPD? Tobacco use (most common cause); Environmental pollution; Alpha1—antitrypsin deficiency; Cystic fibrosis

What are some clinical features of COPD? Dyspnea, cough, chest tighthess, and occasional hemoptysis

Common causes of COPD exacerbation: Infections; Pulmonary embolism (PE); Congestive heart failure (CHF) exacerbation; Tobacco use

What are some of the common clinical features of the following COPD variant:

Chronic bronchitis (blue bloaters): Tend to be heavy set; Normal chest diameter; Productive wet cough

Emphysema (pink puffer): Tend to be thin; increased AP chest diameter; Dyspneic

What are some possible findings on CXR? Increased AP diameter; Overinflation; Presence of bullae

What are some other diagnostic tests to consider in COPD? ABGs; EKG (for ischemia or dysrhythmias)

Multifocal atrial tachycardia Atrial fibrillation

What are some key points in the management of COPD? Oxygenation is the cornerstone; Beta-adrenergic agonist; Anticholinergics; Corticosteroids use; Abx if signs of infection— purulent

sputum

Anticholinergic bronchodilatorsIn response to irritants such as cigarette smoke, the body produces a chemical "messenger" called acetylcholine that induces the airways to constrict. Anticholinergics are the only medications that act by blocking acetylcholine, thereby relaxing the muscle tissue and keeping the airways open.[24] Anticholinergic medications work via part of the parasympathetic nervous system, which controls airway size.

Anticholinergic bronchodilators, as a class, are the number one prescribed bronchodilator used in the treatment of COPD.[26] Currently, the leading anticholinergic medication prescribed by physicians is ipratropium bromide. It is sold alone under the brand name ATROVENT, Inhalation Aerosol or in combination with albuterol sulfate under the brand name COMBIVENT, Inhalation Aerosol.

Beta2-agonistsBeta2-agonists work via part of the nervous system that controls muscle tissue around the airways. They work by stimulating receptors in the sympathetic nervous system, leading to dilation of air passages.[8] Two types of beta2-agonists are available: short-acting beta- agonists and long-acting beta-agonists.

Short-acting beta2-agonistsThese medications are recommended by the American Thoracic Society for patients with COPD who experience intermittent symptoms.[9] They are also used as a "rescue" medication to fend off an impending attack of shortness of breath. Short-acting beta2- agonists are typically prescribed along with anticholinergics to open up the airways of COPD patients with continuing symptoms.[9] The short-acting beta2-agonist most commonly prescribed by physicians is albuterol.[26] In clinical studies, the most common side effects of albuterol included tremor, nausea, tachycardia, palpitations and nervousness.[27]

Long-acting beta-agonistsThese bronchodilators are taken twice a day and, like short-acting beta-agonists, work via part of the nervous system that controls muscle tissue around the airways. They are recognized as a treatment for COPD by the Global Initiative for Chronic Obstructive Lung Disease.[19]

Long-acting beta-agonists are often prescribed for nighttime breathing problems because they provide up to 12 hours of relief.[19] Patients using long-acting beta-agonists need to be reminded to continue using their short-acting beta-agonist for "rescue" therapy, because long-acting beta-agonists do not work as quickly and are indicated for use only twice a day.[28] The most common side effects seen with use of long-acting beta-agonists by patients with COPD include headache, upper respiratory tract infection, nasopharyngitis and cough.[27]

TheophyllineAnother bronchodilator used in the treatment of COPD is theophylline, which is taken orally. Theophylline affects many parts of the body, including muscle tissue and the heart. It works by opening up the airways, increasing muscle endurance, and decreasing muscle fatigue. At one time, theophylline was the most widely prescribed COPD medication, but it has lost favor because of side effects. However, theophylline may have benefits that go beyond bronchodilation, and it is still an important part of COPD management.[9] Theophylline is taken orally once or twice a day, so it may be particularly valuable for noncompliant patients who cannot optimally use aerosol therapy. The dosage should be adjusted to reach a therapeutic serum level, so blood levels should be monitored.[9] However, some patients experience side effects even at low serum levels. The most common side effects seen are nausea, vomiting, headache and insomnia.[31]

CorticosteroidsCurrently, inhaled corticosteroids are not indicated for the treatment of COPD. They are the cornerstone of asthma therapy, but have a limited role in the maintenance of lung function in patients with COPD. Only about 10 percent of patients with COPD show a significant improvement in lung function when treated with corticosteroids.[32] The reason is that different mediators cause inflammation in asthma and COPD.[32] The mediators that cause inflammation in COPD have only limited responsiveness to corticosteroids, while those mediators responsible for inflammation in asthma are dramatically affected by inhaled corticosteroids.[32]

Surveys of clinicians' prescribing habits, however, have shown little difference in the use of inhaled corticosteroids for asthma patients and for COPD patients.[33],34] Guidelines for the treatment of COPD suggest that because inhaled corticosteroids play only a minor role in the maintenance treatment of COPD and may produce systemic side effects, they should be reserved for patients whose symptoms are not optimally controlled with bronchodilators. This subgroup of patients should receive inhaled or oral corticosteroids for a trial period. If a significant objective clinical response is not achieved, corticosteroids should be discontinued. When a benefit is observed with oral corticosteroids, the dose should be tapered to the lowest possible dose. At that point, a trial of an inhaled corticosteroid should be initiated.[19,21] The most common side effects of inhaled corticosteroids include upper respiratory infection, headache and pharyngitis.

AntibioticsAntibiotics may be given to patients with COPD for acute bacterial infections of the respiratory tract, including sinusitis, acute bronchitis and some types of pneumonia.[8] Antibiotics are also used to treat exacerbations when symptoms of infection are present, such as fever, increased cough and sputum changes.[9]