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Zohair Al Aseri. MD, FCEM (UK). FRCPC (EM&CCM).

Pulmonary Emergencies. Zohair Al Aseri. MD, FCEM (UK). FRCPC (EM&CCM). Consultant, Departments of Emergency Medicine & Critical Care. Chairman, Department of Emergency Medicine Director, Master Public Health. King Saud University Hospitals. Riyadh, KSA

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Zohair Al Aseri. MD, FCEM (UK). FRCPC (EM&CCM).

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  1. Pulmonary Emergencies Zohair Al Aseri. MD, FCEM (UK). FRCPC (EM&CCM). Consultant, Departments of Emergency Medicine & Critical Care. Chairman, Department of Emergency Medicine Director, Master Public Health.King Saud University Hospitals. Riyadh, KSA Email: zalaseri@ksu.edu.sahttp://fac.ksu.edu.sa/zalaseri Zohair Al Aseri FRCP EM & CCM

  2. Pulmonary Emergencies • Review and new update in • Asthma exacerbation • COPD exacerbation • Pulmonary Embolism • Update in Pneumonia • Review Pleural Diseases Zohair Al Aseri. FRCP EM & CCM

  3. Management of acute asthma

  4. Management of acute asthma Clinical features of asthma • symptoms are • worse at night and in the early morning • present in response to exercise, allergen exposure and cold air • present after taking aspirin or beta blockers • More than one of the following • Wheeze • Breathlessness • chest tightness • cough Zohair Al Aseri. FRCP EM & CCM

  5. Management of acute asthma Clinical features influence asthma diagnosis • History of atopic disorder • Family history of asthma and/or atopic disorder • Widespread wheeze • Unexplained low FEv1 or PEF • Unexplained peripheral blood eosinophilia Zohair Al Aseri. FRCP EM & CCM

  6. Management of acute asthma Lessons from asthma deaths: Most patients • Chronically severe asthma. • Inadequate treatment with steroid. • Inappropriate prescription of β-blockers and NSAIDs • Behavioral and adverse psychosocial Zohair Al Aseri. FRCP EM & CCM

  7. Management of acute asthma Prediction of a severe asthma attack: • Most develop relatively slowly over 6 hs or more. • In one study, over 80% developed over more than 48 hours. Zohair Al Aseri. FRCP EM & CCM

  8. Management of acute asthma Patients at risk of developing near-fatal or fatal asthma: • Previous ventilation or respiratory acidosis • Previous admission in the last year • Requiring three or more asthma medications • Heavy use of β2 agonist • Repeated ED visits in the last year Zohair Al Aseri. FRCP EM & CCM

  9. Management of acute asthma Levels of severity Zohair Al Aseri. FRCP EM & CCM

  10. Management of acute asthma PEF or FEv1 • PEF expressed as a percentage of the patient’s previous best value. • PEF as a percentage of predicted gives a rough guide in the absence of a known previous best value. • Different peak flow meters give different readings. • Where possible the same or similar type of peak flow meter should be used. Zohair Al Aseri. FRCP EM & CCM

  11. Management of acute asthma Pulse Oximetry • To determine the adequacy of oxygen therapy • Aim is to maintain SpO2 94–98%. Zohair Al Aseri. FRCP EM & CCM

  12. Management of acute asthma Blood gases not alwayse • SpO2 <92% is associated with a risk of hypercapnia. Zohair Al Aseri. FRCP EM & CCM

  13. Gas Exchange Severe Astma. lactate production by the respiratory muscles exceeding clearance mechanisms muscle fatigue and inability to maintain adequate alveolar ventilation Metabolic Acidosis Hypercapnia Common ABG: Mild-to-moderate hypoxemia + hypocapnia + respiratory alkalosis. Zohair Al Aseri. FRCP EM & CCM

  14. Management of acute asthma Chest X-ray Only if : - ??pneumomediastinum - ??pneumothorax - ??consolidation - life-threatening asthma - No response to treatment - Need for ventilation. Zohair Al Aseri. FRCP EM & CCM

  15. Management of acute asthma Systolic paradox Inadequate indicator of the severity and should not be used Zohair Al Aseri. FRCP EM & CCM

  16. Management of acute asthma • Admission Criteria • any feature of a life-threatening or near-fatal asthma attack. • any feature of a severe asthma attack persisting after initial treatment. Zohair Al Aseri. FRCP EM & CCM

  17. Management of acute asthma Discharged from ED if peak flow is greater than 75% unless: Zohair Al Aseri. FRCP EM & CCM

  18. Management of acute asthma Treatment of acute asthma in adults • Give all hypoxaemic patients to maintain an SpO2 level of 94–98%. • Lack of pulse oximetry should not prevent the use of oxygen. Oxygen Zohair Al Aseri. FRCP EM & CCM

  19. Management of acute asthma Oxygen Ptco2 ≥4 mm Hg at 60 min was significantly higher in the high concentration oxygen group 44% vs 19% p<0.006 Perrin K, Wijesinghe M, Healy B, et al. Randomised controlled trial of high concentration versus titrated oxygen therapy in severe exacerbations of asthma. Thorax 2011;66:937-41. Zohair Al Aseri. FRCP EM & CCM

  20. Management of acute asthma Treatment of acute asthma in adults β2 agonist bronchodilators • High doses act quickly • Nebulised adrenaline (epinephrine), a non-selective β2 agonist, does not have significant benefit over β2 • Use pMDI in patients without life-threatening features • All β2, same efficacy Zohair Al Aseri. FRCP EM & CCM

  21. Management of acute asthma Treatment of acute asthma in adults β2 agonist bronchodilators • Use Oxygen-driven nebulisers because risk of oxygen desaturation while using air-driven compressors. • A flow rate of 6 l/min is required to drive most nebulisers. • IF oxygen cylinders are used, a high flow regulator must be fitted. • Absence of supplemental oxygen should not prevent nebulised therapy. Zohair Al Aseri. FRCP EM & CCM

  22. Management of acute asthma Treatment of acute asthma in adults β2 agonist bronchodilators • In severe asthma consider continuous nebulisation Zohair Al Aseri. FRCP EM & CCM

  23. Management of acute asthma INTRAVENOUS BETA(2)-AGONISTS Travers AH, Milan SJ, Jones AP, Camargo CA, Jr., Rowe BH. Addition of intravenous beta(2)-agonists to inhaled beta(2)-agonists for acute asthma. Cochrane Database Syst Rev 2012;12:CD010179. Syst Rev no significant benefits for adults with severe acute asthma Zohair Al Aseri. FRCP EM & CCM

  24. Management of acute asthma Treatment of acute asthma in adults Steroid therapy • Reduce mortality & relapses. • Earlier related to better outcome • Prednisolone 40–50 mg daily or parenteral hydrocortisone 400 mg daily (100 mg six-hourly) are as effective as higher doses. • No tapering • Inhaled corticosteroids should be started or continued as soon as possible Zohair Al Aseri. FRCP EM & CCM

  25. Management of acute asthma INHALED CORTICOSTEROIDS Edmonds ML, Milan SJ, Camargo CA, Jr., Pollack CV, Rowe BH. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database Syst Rev 2012;12:CD002308. • 20 trials (7 adult) • Reduction from 32 to 17 hospital admissions per 100 patients treated with ICS in comparison with placebo. Zohair Al Aseri. FRCP EM & CCM

  26. Management of acute asthma Edmonds ML, Milan SJ, Brenner BE, Camargo CA, Jr., Rowe BH. Inhaled steroids for acute asthma following emergency department discharge. Cochrane Database Syst Rev 2012;12:CD002316. 12 trials There was no demonstrated benefit of ICS therapy following ED when used in addition to oral corticosteroid therapy in the trials. Zohair Al Aseri. FRCP EM & CCM

  27. Management of acute asthma Steroid therapy CFC: chlorofluorocarbon propellant; DPI: dry powder inhaler; HFA: hydrofluoroalkane propellant. *Beclometasone dipropionate CFC is included for comparison with older literature. Zohair Al Aseri. FRCP EM & CCM

  28. Management of acute asthma Treatment of acute asthma in adults Ipratropium Bromide • nebulised (0.5 mg 4–6 hourly) for severe or life-threatening asthma or those with a poor initial response to β2 agonist therapy Zohair Al Aseri. FRCP EM & CCM

  29. Management of acute asthma Treatment of acute asthma in adults Magnesium Sulphate • Weak evidence • Consider giving a single dose of IV for acute severe asthma without good initial response to inhaled bronchodilator therapy. • 1.2–2 g Iv infusion over 20 minutes. Zohair Al Aseri. FRCP EM & CCM

  30. Management of acute asthma Goodacre S, Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. Lancet Respir Med 2013;1:293-300. Magnesium Sulphate Zohair Al Aseri. FRCP EM & CCM

  31. Management of acute asthma Goodacre S, Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. Lancet Respir Med 2013;1:293-300. Magnesium Sulphate Length of stay after initial hospital attendance Zohair Al Aseri. FRCP EM & CCM

  32. Management of acute asthma Magnesium Sulphate Powell C, Dwan K, Milan SJ, et al. Inhaled magnesium sulfate in the treatment of acute asthma. Cochrane. Database Syst Rev 2012;12:CD003898. Sixteen trials No overall clear evidence Zohair Al Aseri. FRCP EM & CCM

  33. Management of acute asthma Treatment of acute asthma in adults Antibiotics • Routine prescription is not indicated. Zohair Al Aseri. FRCP EM & CCM

  34. Management of acute asthma NON-INVASIVE POSITIVE PRESSURE VENTILATION Lim WJ, Mohammed Akram R, Carson KV, et al. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev 2012;12:CD004360. Limited data that exist to support the use of NPPV in patients in status asthmaticus. Zohair Al Aseri. FRCP EM & CCM

  35. Management of acute asthma Treatment of acute asthma in adults • Intravenous fluids • Correct hypokalemia Zohair Al Aseri. FRCP EM & CCM

  36. Management of acute asthma In Pregnancy • Give drug therapy for acute asthma as for non-pregnant patients • Deliver high flow oxygen • Should be treated vigorously in hospital. • Continuous fetal monitoring Zohair Al Aseri. FRCP EM & CCM

  37. Management of acute asthma

  38. Pulmonary Embolism Risk Factors • 30% of pt has no provoking factors can be detected White RH.The epidemiology of venous thrombo embolism. Circulation 2003; 107(23Suppl1):I4–I8. Zohair Al Aseri. FRCP EM & CCM

  39. Pulmonary Embolism Zohair Al Aseri. FRCP EM & CCM

  40. Pulmonarym Embolism Clinical Characteristics PollackCV. Clinical characteristics, management, and outcomes of patients diagnosed with a cute PE in the ED: initial report of EMPEROR(Multi-Center Emergency Medicine Pulmonary Embolism in the Real World Registry). Jam CollCardiol 2011;57(6):700–706. Zohair Al Aseri. FRCP EM & CCM

  41. Pulmonary Embolism Blood Work • 40% of the patients have normal arterial oxygen saturation • 20% a normal alveolar-arterial oxygen gradient Rodger MA, Diagnostic Value of Arterial Blood Gas Measurement in Suspected Pulmonary Embolism. AmJRespirCritCareMed 2000;162(6):2105–2108. Stein PD, Arterial blood gas analysis in the assessment of suspected acute pulmonary embolism. Chest 1996;109(1):78–81. Zohair Al Aseri. FRCP EM & CCM

  42. Pulmonary Embolism Chest X-ray • Frequently abnormal • Usually nonspecific • Useful for excluding other causes of dyspnoea or chest pain. Zohair Al Aseri. FRCP EM & CCM

  43. Pulmonary Embolism ECG RV strain: in more severe cases of PE • T waves inversion in leadsV1–V4 • a QR pattern in V1 • S1Q3T3 pattern • Incomplete or complete RBBB Sinus tachycardia • 40% of patients. Atrial fibrillation may be associated with acute PE GeibelA. Prognostic value of the ECG on admission in patients with acute major pulmonary embolism. EurRespirJ 2005;25(5):843–848 Zohair Al Aseri. FRCP EM & CCM

  44. Pulmonary Embolism Clinical prediction rules for PE Zohair Al Aseri FRCP EM & CCM

  45. Pulmonary Embolism Clinical prediction rules for PE Zohair Al Aseri FRCP EM & CCM

  46. Zohair Al Aseri FRCP EM & CCM

  47. Pulmonary Embolism MDCT {multi-detector computed tomographic angiography} • Adequate for excluding PE in a non high clinical probability. • Further investigation for negative CT and a high clinical probability is controversial. • CT segmental or more proximal level is adequate proof of PE in patients with a non-low clinical probability. Carrier M, Subsegmental pulmonary embolism diagnosed by computed tomography: incidence and clinical implications. A systematic review and meta-analysis of the management outcome studies. JThrombHaemost 2010;8(8):1716–1722. Zohair Al Aseri. FRCP EM & CCM

  48. Pulmonary Embolism MDCT {multi-detector computed tomographic angiography} Isolated subsegmental PE on CT angiography • Clinical significance is questionable. • In 4.7%(2.5–7.6%) of patients with PE imaged by single detector CT angiography and 9.4% (5.5–14.2%) of those submitted to MDCT. Carrier M, Subsegmental pulmonary embolism diagnosed by computed tomography: incidence and clinical implications. A systematic review and meta-analysis of the management outcome studies. JThrombHaemost 2010;8(8):1716–1722. Zohair Al Aseri. FRCP EM & CCM

  49. Pulmonary Embolism MDCT {multi-detector computed tomographic angiography} • ? role for CUS to exclude DVT • If no proximal DVT, decision to treat should be made on an individual basis, taking into account bleeding risk. Isolated subsegmental PE on CT angiography Stein PD, Diagnosis and management of isolated subsegmental pulmonary embolism: review and assessment of the options. ClinApplThrombHemost 2012;18(1):20–26. Zohair Al Aseri. FRCP EM & CCM

  50. Pulmonary Embolism Ventilation–perfusion scintigraphy (V/Qscan) for low clinical probability and a normal chest X-ray in: • young (particularly female) patients • pregnancy • history of contrast medium-induced anaphylaxis and strong allergic history • severe renal failure • myeloma and paraproteinaemia Reid J H, Is the lung scan alive and well? Facts and controversies in defining the role of lung scintigraphy for the diagnosis of pulmonary embolism in the era of MDCT. EurJNuclMedMol Imaging 2009;36(3):505–521. Zohair Al Aseri. FRCP EM & CCM

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