Handbook of Pulmonary Emergencies

This book is written for medical students and house officers working on the wards, in the intensive care unit, and in the emergency room. It is intended for use by all whose work involves the daily evaluation and management of medical emergencies. The material is a compilation of information gained from our personal experiences in clinical practice, from participation in professional meet­ ings and conferences, and from searching the medical literature. The introductory chapters in Part I form a foundation that is devel­ oped in the subsequent parts where specific topics are discussed. When possible, we have simplified complex approaches to diagnosis and man­ agement by formulating algorithms and handy reference tables. Since this is a handbook and not a textbook, we have limited our discussion of pathogenesis and pathophysiology in order to concentrate on practical aspects and specific details that are useful in the diagnosis and management of pulmonary emergencies. Our aim is to alert young physicians to common pulmonary emergencies and guide them through their initial management.

I. The Approach to Patient Evaluation.- 1 Clinical Assessment of the Patient with Pulmonary Disease.- Common Features in the Emergency Management of Pulmonary Diseases.- Immediate Steps.- Clinical Signs and Symptoms of Pulmonary Disease.- Cough.- Sputum Production.- Chest Pain.- Dyspnea.- Wheezing.- Hemoptysis.- Cyanosis.- Additional Clinical Information.- Other Symptoms.- Drug and/or Medication Use.- Toxic Chemical Exposure.- Physical Examination.- Initial Appearance.- Vital Signs.- Laboratory Assessment.- Chest X Ray.- Sputum Examination.- ABG.- Pulmonary Function Tests.- Special Laboratory Studies.- Indications for Hospitalization of the Patient with Pulmonary Disease.- 2 Interpretation of Arterial Blood Gases in the Emergency Patient.- Source of Blood for ABG Analysis.- Uses of ABG Measurements.- Oxygenation and the ABG.- Blood Oxygenation.- Tissue Oxygenation.- Lung Injury and the ABG.- Hypoxemia, Differential Diagnosis.- P(A-a)O2 Differentiation of Hypoxemic Diseases.- Hypoxemia due to Pulmonic Diseases.- Hypoxemia due to Extrapulmonic Diseases.- Acid-Base Balance and the ABG.- Sources of Acidemia.- Renal and Respiratory Compensation for Acid-Base Imbalance.- Finding the Origin of Acid-Base Imbalance with the ABG.- Identifying the Respiratory Component of Acid-Base Imbalance.- The Calculated pH for Source Identification.- The Calculated Base Deficit in the Treatment of Severe Acidosis.- Other Considerations in ABG Sampling and Interpretation.- Complications of Arterial Puncture.- Summary.- II. Normal Lungs with Acute Respiratory Decompensation.- 3 Extrapulmonic Ventilatory Failure.- Differential Diagnosis of Extrapulmonic Ventilatory Failure.- Category I: Decreased Ventilatory Drive.- Category II: Neural or Muscular Dysfunction.- Category III: Increased Impedance.- ABG in Diagnosis and Management of EPVF.- Importance of P(A-a)O2.- Computation of P(A-a)O2.- ABG Guidance in the Treatment of Acidosis.- Computation of Calculated pH.- Comment.- Emergency Evaluation of the Patient with EPVF.- History.- Physical Examination.- Laboratory Assessment.- Emergency Management of EPVF.- Indications for Mechanical Ventilation in EPVF.- Complications of EPVF.- Summary.- 4 Life-Threatening Pneumonia.- Recognizing Life-Threatening Pneumonia.- Identification of the Specific Pathogen.- Examination of Respiratory Tract Secretions.- Additional Helpful Diagnostic Studies.- Treatment of Life-Threatening Pneumonia.- General Measures.- Blood Pressure Support.- Supplemental Oxygen.- Hydration.- Mechanical Ventilation.- Specific Antimicrobial Therapy.- Empiric Antimicrobial Therapy.- General Guidelines for Empiric Therapy.- Other Therapeutic Modalities in Severe Pneumonia.- Antipyretics.- Analgesics.- Bronchodilators.- Antitussives.- Other Measures.- Specific Pneumonias.- Streptococcus pneumoniae.- Staphylococcal Pneumonia.- Klebsiella pneumoniae.- Hemophilus influenzae.- Other Gram-Negative Bacteria.- Legionella.- Anaerobic Bacteria.- Mycobacteria.- Pneumocystis.- 5 Acute Inhalation Lung Disease.- General Approach to Possible Acute Inhalation Lung Disease.- Nitrogen Dioxide.- Chlorine.- Ammonia.- Smoke Inhalation and Carbon Monoxide Poisoning.- Other Nonmetallic Gases.- Acetaldehyde.- Acrolein.- Hydrogen Chloride.- Hydrogen Fluoride.- Hydrogen Sulfide.- Phosgene.- Phosphine.- Sulfur Dioxide.- Inhalation of Metals and Metal Compounds.- Metal Fume Fever.- Cadmium Oxide.- Mercury Vapor.- Other Metals.- Polymer Fume Fever.- Paraquat Poisoning.- Insecticides.- Hydrocarbon Injury.- Acute Silicosis.- 6 Pulmonary Edema.- Definition.- Physiologic Classification.- Examples.- Differential Diagnosis of Pulmonary Edema.- History.- Physical Examination.- Routine Laboratory and X-Ray Studies.- Clinical Course as a Diagnostic Parameter.- Special Studies.- Treatment.- General.- Cardiogenic Pulmonary Edema.- ARDS.- 7 Near-Drowning.- Differential Diagnosis.- Problem Assessment.- Initial History.- Initial Physical Examination and Laboratory Tests.- Parameters to Be Followed.- Therapeutic Management.- Category I: Observation Only.- Category II: Abnormalities Are Present, but Not Severe.- Category III: Major Support Is, or May Be, Required.- Other Injuries or Medical Complications Associated with Drowning.- 8 Chest Trauma.- Emergency Evaluation and General Guidelines.- Chest Wall Contusions.- Clavicular Fractures.- Rib Fractures.- Symptoms and Signs.- Management.- Flail Chest.- Treatment.- Sternal Fractures.- Pulmonary Contusion.- Clinical Signs.- Treatment.- Pulmonary Hematoma.- Pulmonary Laceration.- Clinical Signs.- Treatment.- Pneumomediastinum.- Tracheobronchial Disruption.- Clinical Signs.- Treatment.- Cervical Tracheal Disruption.- Clinical Signs.- Treatment.- Esophageal Rupture.- Chylothorax.- Rupture of the Diaphragm.- Left Diaphragm.- Right Diaphragm.- 9 Upper-Airway Emergencies.- Clinical Signs and Symptoms.- Differential Diagnosis.- Investigating the Obstruction.- Immediate Assessment.- History.- Physical Examination.- Endoscopy.- Arterial Blood pH and Gases.- XRays.- Pulmonary Function.- Management.- Assess the Need for Intervention.- Assess the Location and Extent of the Obstruction.- Ensure a Patent Airway.- Determine the Etiology of the Obstructing Lesion.- Treatment.- III. Chronic Lung Disease with Acute Respiratory Decompensation.- 10 Acute Respiratory Failure in the Patient with Chronic Airflow Obstruction.- Precipitating Events and Pathophysiology.- Clinical Findings and Diagnosis.- Treatment.- Low-Flow Controlled Oxygen Therapy.- Masks (Venturi Type).- Nasal Cannula.- Notes about Oxygen Therapy.- Improving Lung V/Q.- Clearing Airway Secretions.- Relieving Bronchospasm and Reducing Inflammation.- Treating Infection and/or Bacterial Colonization of the Lower Airways.- Choice of Antimicrobial Agent(s).- Reducing Pulmonary Vascular Resistance.- Improving Cardiac Output.- Precipitating Factors.- Criteria for Intensive Care Admission.- Tracheal Intubation and Mechanical Ventilation.- Indications for Tracheal Intubation in the CAO Patient.- Mechanical Ventilation.- Weaning from the Ventilator.- 11 Asthma.- Diagnosis.- History.- Physical Examination.- Spirometry.- Chest X Ray.- Sputum Examination.- Judging the Severity of the Asthmatic Attack.- Spirometry.- Arterial Blood Gas.- Other Laboratory Factors.- Treatment.- Oxygen and Nonpharmacologic Measures.- Sympathomimetic Agents.- Theophylline Therapy.- Corticosteroid Therapy.- Treatment to Avoid.- Who to Hospitalize.- Signs of Impending Respiratory Failure.- Objective Measurements of Improvement.- Examples.- When to Intubate.- IV. Pulmonary Vascular Emergencies.- 12 Hemoptysis.- Differential Diagnosis.- Diagnostic Evaluation.- Initial Evaluation.- Assessing the Urgency of Therapeutic Intervention.- Bronchoscopy.- Other Techniques Used to Localize the Bleeding Site.- Therapy of Pulmonary Hemorrhage.- Goals.- General Measures.- When to Intubate.- Nonspecific Therapy.- Medical Management.- Surgical Management.- Other Forms of Therapy to Control Hemoptysis.- Endobronchial Tamponade.- Arterial Embolization Therapy.- Laser Photocoagulation.- Summary.- 13 Embolic Pulmonary Disease.- Venous Thrombosis.- Diagnosis of DVT.- DVT Prophylaxis.- Pulmonary Thromboembolism.- Clinical Presentation.- Laboratory Studies.- Arterial Blood Gas Analysis.- Therapy.- Complicated Pulmonary Emboli.- Nonthrombotic Pulmonary Embolism.- 14 Superior Vena Cava Syndrome.- Etiology.- Clinical Signs and Symptoms.- Diagnostic Approach.- Chest X Ray.- Computerized Tomography.- Radioisotope Scanning.- Venography.- Biopsy Procedures.- Therapy.- Empiric Radiation Therapy in Emergency Clinical Situations.- Fibrinolytic and Anticoagulant Therapy.- Radiation Therapy for Proven Malignancy.- Chemotherapy for Specific Malignancy.- Surgery.- Additional Comments about Management.- Venous Access Procedures.- V. Pleural Emergencies.- 15 Catastrophic Pleural Disease.- Causes of Catastrophic Pleural Disease.- Changes in Gas Exchange.- Hemodynamic Consequences of Positive Intrapleural Pressure.- Nature of Fluid.- Pneumothorax.- Spontaneous Pneumothorax.- Traumatic Pneumothorax of Iatrogenic Variety.- Noniatrogenic Posttraumatic Pneumothorax.- Clinical Signs and Symptoms of Pneumothorax.- Diagnosis.- Management of Spontaneous Pneumothorax.- Management of Traumatic Pneumothorax.- Tension Pneumothorax.- Clinical Signs and Symptoms of Tension Pneumothorax.- Management.- Tension Hydrothorax.- Clinical Signs and Symptoms of Tension Hydrothorax.- Differential Diagnosis.- Definitive Diagnosis.- Management.- Hemothorax.- Etiology.- Clinical Signs and Symptoms.- Differential Diagnosis.- Definitive Diagnosis.- Management.- Pleural Empyema.- Clinical Signs and Symptoms.- Definitive Diagnosis.- Management.- Closed Drainage.- Open Drainage.- Decortication.- VI. Ventilator Emergencies.- 16 Ventilatory Assistance and Its Complications.- Airway Access.- Principles of Mechanical Ventilation.- Choosing a Mechanical Ventilator.- Pressure-Cycled Ventilator.- Volume-Cycled Ventilator.- Time-Cycled Ventilator.- High-Frequency Ventilators.- Initiating Mechanical Ventilation.- Selecting Initial Ventilator Settings.- Adjusting the Initial Ventilator Settings.- Positive End-Expiratory Pressure.- Complications of Mechanical Ventilation.- Discontinuing Mechanical Ventilation.- Conclusion.- Appendix A Terms and Symbols Terms and Symbols.- Appendix B Normal Values Ventilation (BTPS).- Lung Volumes (BTPS).- Mechanics of Breathing.- Oxygenation.- Hemodynamic Parameters.- Miscellaneous.