Handbook of Pulmonary Emergencies

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.