Pulmonary

  • Asthma Exacerbation
  • Pleural Effusion
  • Pneumonia (Bacterial)
  • Pneumothorax
  • Pulmonary Embolism

Asthma Exacerbation

  • Background
    • Diffuse airway inflammation characterized by bronchial hyperresponsiveness and reversible airflow obstruction.
    • Acute exacerbations can be caused by viral infections, allergens, tobacco, or emotional factors
  • Signs/Symptoms
    • Dyspnea, cough, chest tightness. May present in respiratory failure.
    • (+) expiratory wheezing, (+) tripod positioning
  • Diagnosis
    • Clinical diagnosis in emergency setting
    • Formal diagnosis made with spirometry
  • Treatment
    • Nebulizers (albuterol/ipratropium), steroids, +/- magnesium, +/- epinephrine.
    • May require NIPPV or intubation
Video Credit: Osmosis

*Deep Dive: Asthma (First 10 EM)



Pleural Effusion

  • Background
    • Accumulation of excess fluid between the pleural space outside of the lungs.
    • May be transudative (due to fluid shifts) or exudative (due to infection, malignancy, etc.)
  • Signs/Symptoms
    • Dyspnea, pain with inspiration
    • (+) decreased breath sounds, (+) decreased tactile fremitus, (+) dullness to percussion
  • Diagnosis
    • CXR (shows blunting of costophrenic angle). Chest CT/US can also be used.
    • Thoracentesis is the gold standard. Light criteria used to differentiate transudative vs exudative effusion.
  • Treatment
    • Thoracentesis or tube thoracostomy (depending on size and etiology)
    • Diuresis helpful if due to CHF 
Video Credit: Pleural Effusion

*Deep Dive: ED evaluation and management of pleural effusion: One size doesn’t fit all (emDOCs)



Pneumonia (Bacterial)

  • Background
    • Acute inflammation of the lungs caused by bacterial infection (typically S. pneumonia)
  • Signs/Symptoms
    • Symptoms: Fever/chills, cough, dyspnea, rigors, pleuritic chest pain
    • Signs: Rust-colored sputum, tachycardia, rales/rhonchi
  • Diagnosis
    • Clinical findings, (+/-) CXR
  • Treatment
    • Antibiotics
      • Outpatient (doxycycline or azithromycin)
      • Inpatient (Ceftriaxone + azithromycin or fluoroquinolone)
Video Credit: Strong Medicine

*Deep Dive: Pneumonia (SAEM)



Pneumothorax

  • Background
    • Accumulation of free air in the pleural space, causing partial or complete collapse of the lung.
    • Can be spontaneous (blebs, COPD, TB), iatrogenic (central line, thoracentesis), or traumatic (blunt/penetrating trauma)
  • Signs/Symptoms
    • Symptoms: dyspnea, ipsilateral chest pain
    • Signs: (+) hyperresonance, (+) diminished breath sounds, (+) decreased tactile fremitus
  • Diagnosis
    • CXR (absent lung markings along periphery)
  • Treatment
    • Small pneumothorax (<15%) can be observed
    • Large pneumothorax (>15%) require thoracostomy
Video Credit: Osmosis

*Deep Dive: Pneumothorax (emDOCs)



Pulmonary Embolism

  • Background
    • Occlusion of pulmonary arteries by thrombi that typically originate from the lower extremities or pelvis
  • Signs/Symptoms
    • Symptoms: Dyspnea (most common), pleuritic chest pain, syncope
    • Signs: (+) tachypnea, (+) tachycardia, (+) hypotension
  • Diagnosis
    • CT PE is the gold standard
    • CXR may show “westermark sign” or “Hampton hump”
  • Treatment
    • O2, anticoagulation (heparin, LMWH), hemodynamic support (fluids, pressors)
    • Thrombolytics for unstable patients. 
Video Credit: Strong Medicine

*Deep Dive: Pulmonary Embolism (EM Cases)


Brandon Simpson, PA-C
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