1. J.D. McCourt, MD, FACEP
Associate Professor
Department of Emergency Medicine
University of Nevada School of Medicine
ED Medical Director, University Medical Center So. Nevada

2. ITE Review
Thoracic / Respiratory
A 10 year old present to ED with SOB and central
cyanosis. Which of the following would be the
most likely cause?
A. Sicle cell anemia
B. Polycythemia
C. Methemoglobinemia
D. L to R Congenital heart defect
Practice Question: 1

3. ITE Review
Thoracic / Respiratory
A 10 year old present to ED with fatigue and
central cyanosis. Which of the following would be
the most likely cause?
A. Sicle cell anemia
B. Polycythemia
C. Methemoglobinemia
D. L to R Congenital heart defect
Practice Question: 1

4. ITE Review
Thoracic / Respiratory
Central cyanosis
• Impaired Ventilation
– Neurologic
– Pulmonary
– Cardiac
• Congenital heart disease (R to L
shunt)
• Hemoglobin abnormalities
– Methemaglobin
Cyanosis
Causes

5. ITE Review
Thoracic / Respiratory
• Central cyanosis only clinically apparent
with >5g/dL desaturated Hb
• Cannot be anemic and cyanotic
– cyanosis requires an absolute amount of
desaturated Hb
– Getting >5g/dl desat with a total Hb of 8 is
clinically impossible
• Cyanosis more likely if also polycythemic
(e.g. the blue bloater) – easy to have
>5g/dl of hemoglobin desaturated with a
total Hb of 18
Cyanosis
Causes
+ Anemia

6. ITE Review
Thoracic / Respiratory
• Anemia
– Pulse ox does not consider Hgb level
• Supplemental O2
– Can mask severe pulmonary process (i.e.
when there is an ↑ A-a gradient)
• Carboxyhemoglobinemia (CO)
– Looks like 100% oxyhemoglobin
(e.g. false sat of 100%)
• Methemoglobinemia
– Looks like 85% oxyhemoglobin
(e.g. false sat of 85%)
Pulse Oximetry
Fundamentals

7. ITE Review
Thoracic / Respiratory
After 2 hrs of treatment Which asthma
patient needs immediate attention
A. 7.40-40-95, wheezes, room air, no
accessory muscle use
B. 7.45-35-85, wheezes, 100% fio2,
moderate accessory muscle use
C. 7.40-40-85, wheezes, 100% fio2,
moderate accessory muscle use
D. 7.5-30-85, wheezes, 100% fio2,
moderate accessory muscle use
Practice Question: 2

8. ITE Review
Thoracic / Respiratory
After 2 hrs of treatment Which asthma
patient needs immediate attention
A. 7.40-40-95, wheezes, room air, no
accessory muscle use
B. 7.45-35-85, wheezes, 100% fio2,
moderate accessory muscle use
C. 7.40-40-85, wheezes, 100% fio2,
moderate accessory muscle use
D. 7.5-30-85, wheezes, 100% fio2,
moderate accessory muscle use
Practice Question: 2

9. ITE Review
Thoracic / Respiratory
• Mortality greater in:
– African American and Latinos
– Females
– Adults
• Factors associated with asthma prevalence
– Developed nations
– Urban areas
• Factors associated with
mortality/morbidity:
– Poverty / lack of access
– Overuse of OTC inhalers / episodic treatment
– Under use of early steroids
Asthma
Epidemiology
Pathophysiology
Clinical Evaluation
Death Risk Factors
Treatment

10. ITE Review
Thoracic / Respiratory
• Asthma is a chronic inflammatory
disease
Asthma
Epidemiology
Reversibility
• Reduced airway diameter 2º to:
Bronchial constriction
Bronchial edema
Pathophysiology
Clinical Evaluation
Mucous plugging
Increased goblet cells
Bronchial muscle hypertrophy
Airway remodelling
Death Risk Factors
Treatment

11. ITE Review
Thoracic / Respiratory
Asthma
Epidemiology
Pathophysiology
Clinical Evaluation
Death Risk Factors
Treatment

12. ITE Review
Thoracic / Respiratory
Precipitants
– URI (#1)
– Allergy
– Respiratory irritants
(smoke, chemicals)
– Cold
– Exercise
– GERD
– Beta blockers (even
eye drops)
– Methacholine
– ASA, NSAIDs (triad
with nasal polyps)
– Menstruation
– Psychological
Asthma
Epidemiology
Pathophysiology
Clinical Evaluation
Death Risk Factors
Treatment

13. ITE Review
Thoracic / Respiratory
Clinical Features
– Decreased expiratory flow
– Air trapping & barotrauma
Pneumothorax
Pneumomediastinum
– Decreased venous return
Hypotension
Pulsus paradoxus
– Hypercarbiahypoxemia
– Muscle fatigue
Respiratory failure
Asthma
Epidemiology
Pathophysiology
Clinical Evaluation
Death Risk Factors
Treatment

14. ITE Review
Thoracic / Respiratory
• Bedside spirometry (PEFR, FEV1)
– Measures large airway obstruction
– Measures severity and response to
therapy
– Predicts need for admission
Asthma
Epidemiology
Pathophysiology
• Pulse oximetry
– Does not aid in predicting clinical
outcome
– O2 saturation may paradoxically drop in
improving patient due to transient VQ
mismatch
Clinical Evaluation
Death Risk Factors
Treatment

15. ITE Review
Thoracic / Respiratory
• Arterial Blood Gases
(ABGs)
– Not generally indicated
– Should not be used to
determine therapy
• Chest X-ray
– Not generally indicated
– Obtain if:
• Complications
suspected
(pneumothorax or
pneumonia)
• Not improving
• Requiring admission
Asthma
Epidemiology
Pathophysiology
Clinical Evaluation
Death Risk Factors
Treatment

16. ITE Review
Thoracic / Respiratory
Asthma
Epidemiology
Pathophysiology
Clinical Evaluation
Death Risk Factors
Treatment

17. ITE Review
Thoracic / Respiratory
Asthma
Epidemiology
Pathophysiology
Clinical Evaluation
Death Risk Factors
Treatment

18. ITE Review
Thoracic / Respiratory
• Hx of sudden severe exacerbations
• Prior intubation
• Prior ICU admit
• >1 admission or >2 ED visits in past year
• ED visit in past month
Asthma
Epidemiology
Pathophysiology
• >2 adrenergic MDIs per month
• Current/recent systemic steroid use
• “Poor perceivers”
• Concomitant disease – cardiopulmonary or
psychosocial
• Illicit drug use
Clinical Evaluation
Death Risk Factors
Treatment

19. ITE Review
Thoracic / Respiratory
Aerosolized β2 agonists
• 1st line therapy
• Bronchodilators (via adenyl cyclase)
• Selective β2 agonists have less unwanted
β1 effects (tachydysrhythmias)
Asthma
Epidemiology
Pathophysiology
• Evidence
– Inhaled superior to oral and parenteral
routes, fewer side effects
– Intermittent equal to continuous
administration
– MDIs equal to nebulizers
– Racemic equal to “R” enantiomer
preparations (levalbuterol)
Clinical Evaluation
Death Risk Factors
Treatment

20. ITE Review
Thoracic / Respiratory
Steroids
• Dual Action
– Delayed (hours)
• Principal Mechanism
– Immunomodulatory
– Up-regulate β-receptors
– Immediate (minutes)
• Vasoconstriction (“Blanching Effect”)
•
Evidence
– Oral equal to IV administration
– Systemic (PO and IV) superior to inhaled
route
Asthma
Epidemiology
Pathophysiology
Clinical Evaluation
Death Risk Factors
Treatment

21. ITE Review
Thoracic / Respiratory
Aerosolized Anticholinergics
– Ipratropium bromide
(Atrovent)
– Block tone in bronchial
smooth muscle
– Modest effect when added
to β-agonists
Asthma
Epidemiology
Pathophysiology
Clinical Evaluation
Magnesium
– IV infusion (2-3g IV over 10
minutes)
– Smooth muscle relaxant
– Incremental benefit in most
severe presentations
Death Risk Factors
Treatment

22. ITE Review
Thoracic / Respiratory
Not Indicated for Acute Treatment
• Theophylline
– No benefit over β2 agonists
– Narrow therapeutic index
Asthma
Epidemiology
• Long-Acting β2 agonists (Salmeterol)
– Long term treatment only
Pathophysiology
• Leukotriene modifying agents (Montelukast)
and mast cell stabilizers
– Long term preventive treatment only
• Heliox
– Balance of studies find no benefit
– More convincing role in upper airway
obstruction
Clinical Evaluation
Death Risk Factors
Treatment

23. ITE Review
Thoracic / Respiratory
Critical Care
• Mechanical Ventilation
– Does not treat obstruction (e.g. the
1° problem!)
– Barotrauma is big concern
– Low rate/ Low TV (8cc/kg)
IV Ketamine
–Sedation and bronchodilation
–Increases secretions
Anesthetic gases/ECMO
–Transfer to the OR!
Asthma
Epidemiology
Pathophysiology
Clinical Evaluation
Death Risk Factors
Treatment

24. ITE Review
Thoracic / Respiratory
Critical Care
Preventing and Managing Barotrauma
•
•
•
•
•
•
May use paralytics initially to facilitate
ventilation
Continue aggressive in-line nebulizer
therapy
Increase time for expiratory phase
(e.g. ↑ inspiratory flow rate, ↓ respiratory
rate, ↓ I:E ratio)
Permissive hypercapnia (allow pCO2 to
rise), pOx>88%
Diligent pulmonary toilet, may need
bronchoscopy
External chest compression
Asthma
Epidemiology
Pathophysiology
Clinical Evaluation
Death Risk Factors
Treatment

25. ITE Review
Thoracic / Respiratory
Critical Care
Asthma
Epidemiology
Asthma Arrest
1 Disconnect ventilator
3 Bilateral chest tubes
2 Compress chest
4 Fluid bolus
Pathophysiology
Clinical Evaluation
Death Risk Factors
Treatment

26. ITE Review
Thoracic / Respiratory
A 60 year old Man with COPD presents with
severe shortness of breath. Which of the
following would indicate respiratory failure?
A. Pulse ox 88%
B. Severe anxiety
C. Perioral cyanosis
D. ABG: 7.28-55-60 (RA)
E. ABG: 7.38-65-60 (RA)
Practice Question: 3

27. ITE Review
Thoracic / Respiratory
A 60 year old Man with COPD presents with
severe shortness of breath. Which of the
following would indicate respiratory failure?
A. Pulse ox 88%
B. Severe anxiety
C. Perioral cyanosis
D. ABG: 7.28-55-60 (RA)
E. ABG: 7.38-65-60 (RA)
Practice Question: 3

28. ITE Review
Thoracic / Respiratory
• Definition
– Chronic, inflammatory disease
– Airflow limitation that is not fully
reversible and is progressive
• Pathophysiology
– Different inflammatory markers
from asthma (e.g. neutrophils,
not eosinophils)
– Proteases and oxidants result in
tissue destruction
COPD
Pathophysiology
Exacerbation
Treatment

29. ITE Review
Thoracic / Respiratory
• Natural History
– Hypoxemia and hypercapnia
– Destruction of pulmonary
vascular bed and thickened
vessel walls
– Pulmonary hypertension
– Polycythemia
– Right sided heart failure
(cor pulmonale)
COPD
Pathophysiology
Exacerbation
Treatment

30. ITE Review
Thoracic / Respiratory
Clinical Phenotypes
COPD
Pathophysiology
Exacerbation
Treatment
Blue Bloater
Pink Puffer

31. ITE Review
Thoracic / Respiratory
Consider Mimics
• Definition
– Progressive onset
– ↑ Dyspnea
– ↑ Sputum volume • Pneumonia
• CHF
– ↑ Sputum
purulence
– Sudden onset
• Causes
• Pneumothorax
• PE
– Viruses
• Lobar atelectasis
– Role of bacteria
controversial
– Environmental
COPD
Pathophysiology
Exacerbation
Treatment

32. ITE Review
Thoracic / Respiratory
Aerosolized β-agonists and anticholinergics
– First line therapy
Steroids
– Systemic steroids (IV in ED followed by
PO course) reduce rates of relapse and
improve dyspnea following ED visit
COPD
Pathophysiology
Exacerbation
Antibiotics
– Indicated in cases with ↑sputum
volume and purulence
Non-Invasive ventilation
– Improves acidosis, decreases respiratory distress
– Effective at avoiding intubation if initiated early
– Not appropriate in patients with respiratory arrest
or hemodynamic instability
Treatment

33. ITE Review
Thoracic / Respiratory
Long Term Interventions
Disease Altering Interventions
– Only 2 interventions proven to reduce
mortality:
• Smoking cessation
• Home oxygen
(for PaO2 < 55 or signs of cor pulmonale)
Pneumococcal Vaccination
COPD
Pathophysiology
Exacerbation
Treatment

34. ITE Review
Thoracic / Respiratory
3 y/o brought in by mom for persistent
cough. Exam finds wheezing in right lung
field. Which is the most appropriate?
A. CXR
B. Bronchoscopy
C. Inspiratory Xray + Neb TX
D. Amoxicillin and F/U with pediatritian
Practice Question: 4

35. ITE Review
Thoracic / Respiratory
3 y/o brought in by mom for persistent
cough. Exam finds wheezing in right lung
field. Which is the most appropriate?
A. CXR
B. Bronchoscopy
C. Inspiratory Xray + Neb TX
D. Amoxicillin and F/U with pediatrician
Practice Question: 4

36. ITE Review
Thoracic / Respiratory
Children
– Foreign body aspiration should be
considered when diagnosing:
Asthma
Pneumonia
Adults
– At risk for foreign body aspiration:
Drug and alcohol abuse
Mental retardation / illness
Neuromuscular disorder
Edentulousness / dental prosthetics
Why we miss the diagnosis
• “sudden onset” of symptoms
• Improvement with antibiotics and/or bronchodilators
• “Pneumonia” seen on the x-ray
• Negative chest x-ray
• Over-reliance on imaging – ultimately need to pursue
bronchoscopy
FB Aspiration
Basics

37. ITE Review
Thoracic / Respiratory
Most cases in Children
• Young children both lungs
• Older > R
• Dx: History/suspicion
• Coughing S/p choking
• Recurrent pneumonia
• Unilateral wheezing
FB Aspiration
Basics

38. ITE Review
Thoracic / Respiratory
Foreign Body Aspiration
CASE STUDY: 7 MONTH OLD CHILD
COUGHING FOR 1 HR AFTER CHOKING EPISODE
FB Aspiration
Basics
Imaging

39. ITE Review
Thoracic / Respiratory
FB Aspiration
Basics
Imaging
Lateral neck
Expiratory film

40. ITE Review
Thoracic / Respiratory
FB Aspiration
Basics
Imaging
Failure of right lung to deflate on
lateral decubitus film indicates a
foreign body in the right main-stem
bronchus

41. ITE Review
Thoracic / Respiratory
• Definition
– Acute Lung Injury (ALI) and ARDS are
clinical diagnoses along a spectrum
• Pathogenesis
– Noncardiogenic pulmonary edema due
to leaky alveolar capillary membranes
• Diagnostic criteria
1
Hypoxia
• PaO2 < 60 mm Hg
with FiO2 > 0.5
2
Normal ventricular function
• PCWP < 18 mm Hg
3
Diffuse alveolar infiltrates
• With normal heart size
ARDS
BASICS

42. ITE Review
Thoracic / Respiratory
•
•
•
•
•
•
•
•
•
Sepsis (most common)
Trauma
Near-drowning
Aspiration
Toxicologic (ASA, opiates,
hydrocarbons)
Pancreatitis
Environmental (high-altitude)
Fat or amniotic fluid embolus
CNS catastrophe (e.g. SAH)
ARDS
BASICS
Causes

43. ITE Review
Thoracic / Respiratory
• Supportive
– Maintain O2 sat >85% while
minimizing FiO2 and airway
pressures
– PEEP or CPAP
– Pressure controlled or high
frequency ventilation
• Recent Literature
– Lower mortality with low tidal
volume ventilation (6mL/kg)
– Prone position improves
oxygenation
ARDS
BASICS
Causes
Treatment

44. ITE Review
Thoracic / Respiratory
Aspiration
Pneumonia

45. ITE Review
Thoracic / Respiratory
• Risk factors
– Seizure, alcoholic, obtunded,
depressed gag reflex
• Severity of syndrome depend on:
– pH of aspirate (lower is worse – less
than 2.5)
– Volume of aspirate (>25 mL)
– Presence of particles such as food
(bad)
– Bacterial contamination (usually
anaerobes)
Aspiration
Pneumonia

46. ITE Review
Thoracic / Respiratory
• Clinical features
– Immediate respiratory difficulty
due to chemical burn
– Hypoxemia and respiratory
alkalosis
– Wheezes, rales, hypotension
– CXR often negative initially
– Localization related to dependent
lung
• Treatment
– Supportive
– Hold antibiotics until febrile to
avoid selecting out resistant
organisms
Aspiration
Pneumonia

47. ITE Review
Thoracic / Respiratory
A nurse from 35 year old nurse from 5S is sent
down to the ED because her mandatory PPD test
measured 11mm. What is the most appropriate
next step?
A. Move the patient to isolation immediately
B. Order cxr and if normal start on INH, D/c
C. Order cxr if Ca++ nodule admit to hospital for
active TB, notify health department
D. No Tx necessary because TB result is negative
for this patient.
Practice Question: 5

48. ITE Review
Thoracic / Respiratory
A nurse from 35 year old nurse from 5S is sent
down to the ED because her mandatory PPD test
measured 11mm. What is the most appropriate
next step?
A. Move the patient to isolation immediately
B. Order cxr and if normal start on INH, D/c
C. Order cxr if Ca++ nodule admit to hospital for
active TB, notify health department
D. No Tx necessary because TB result is negative
for this patient.
Practice Question: 5

49. ITE Review
Thoracic / Respiratory
Tuberculosis
Natural History

50. ITE Review
Thoracic / Respiratory
Tuberculosis
Natural History
CXR
Reactivation Tuberculosis
Cavitary Lesion RUL

51. ITE Review
Thoracic / Respiratory
Tuberculosis
Natural History
CXR
Miliary Tuberculosis (Hematogenous)

52. ITE Review
Thoracic / Respiratory
• 50-80% of patients with
pulmonary TB will have positive
smears
• Sensitivity ~ 60%
Tuberculosis
Natural History
CXR
Diagnosis
• AFB NEGATIVE
Not helpful in suspicious cases

53. ITE Review
Thoracic / Respiratory
• Hepatitis
– Isoniazid (INH), Rifampin (RIF) and Pyrazinamide
(PZA)
• Peripheral Neuropathy
Tuberculosis
Natural History
– Isoniazid (INH)
• Optic neuritis
– Ethambutol (EMB)
• Gout
– Pyrazinamide (PZA)
• Ototoxicity and renal toxicity
– Streptomycin and other aminoglycosides
• Discolored body fluids
– Rifampin (reddish-orange urine, feces, saliva,
sweat, tears)
CXR
Diagnosis
TX: Side effects

54. ITE Review
Thoracic / Respiratory
Tuberculosis
Natural History
CXR
Diagnosis
TX: Side effects
TB Skin Test

55. ITE Review
Thoracic / Respiratory
•
•
•
•
Cancer
Tuberculosis
Pulmonary embolus
Toxicologic / environmental
– Chlorine gas, Farmer’s lung (allergic reaction to
inhalation of moldy crops – hay, grain, tobacco)
• ARDS
– e.g. from chronic ASA toxicity or other treatable
cause
• Atelectasis
• Right-sided endocarditis
– Septic emboli
• Diffuse alveolar hemorrhage
– Low hemoglobin, immune disease
Pneumonia
Mimics

56. ITE Review
Thoracic / Respiratory
Bacterial Pneumonias
Pneumonia
Mimics
Typical/ Atypical

57. ITE Review
Thoracic / Respiratory
Pneumonia
Mimics
Typical/ Atypical
LLL Pneumonia
(Pneumococcus)
RUL Pneumonia
(Klebsiella) with bulging
fissure and abscess
formation

58. ITE Review
Thoracic / Respiratory
Effusions
Lateral Decubitus: Best for small effusions
Pneumonia
• Strep. pneumo, H.
flu, Staph. Aureus
• TB
Non-Infectious Effusions
• PE
• Abdominal process
e.g. pancreatitis
•Aortic dissection
• Boerhaave’s syndrome
(esophageal rupture)
Pneumonia
Mimics
Typical/ Atypical

59. ITE Review
Thoracic / Respiratory
Transudate
Effusions
VS.
Exudate
• Hydrostatic
/Oncotic shift
• CHF / Cirrhosis
• Low Protein
• Low LDH
• Infection,
Malignancy,
Inflammatory
process
• High Protein
• High LDH
PH of Pleural effusion < 7.1 Empyema
Pneumonia
Mimics
Typical/ Atypical

60. ITE Review
Thoracic / Respiratory
•
•
•
Cavities
Staph
Pseudomonas
TB
Pneumonia
Mimics
Typical/ Atypical

61. ITE Review
Thoracic / Respiratory
Atypical Pneumonias
Pneumonia
Mimics
Typical/ Atypical

62. ITE Review
Thoracic / Respiratory
Interstitial
infiltrates
• Mycoplasma
• Chlamydia
• Viral
Pneumonia
Mimics
Typical/ Atypical

63. ITE Review
Thoracic / Respiratory
Mycoplasma Pneumonia
• Most common cause
PNA < 40
• Extra pulmonary
 Bullous TM
 Rash to Steven John
 Heart blocks to
Myocarditis/pericardi
tis
 Guillain-barr
 Aseptic meningitis
 Transvers myelitis
Patchy perihilar infiltrate L>R
Pneumonia
Mimics
Typical/ Atypical

64. ITE Review
Thoracic / Respiratory
Legionella Pneumonia
Pneumonia
Mimics
Typical/ Atypical
X-ray in Legionella is not “atypical”

65. ITE Review
Thoracic / Respiratory
Type ( Mechanism)
• CAP
• HAP
PNA Mortality
10%
19%
– (> 48hr Admission)
• VAP
– NH/LTC facility
– > 2 day in hospital (W/I 90 days)
– Infusion/wound care/Dialysis
Mimics
29%
Typical/ Atypical
20%
Mechanism
– (> 48hr ETT)
• HCAP
Pneumonia

66. ITE Review
Thoracic / Respiratory
Which of the following is not a factor to consider
for ICU admission of a patient with pneumonia?
A. Temperature
B. Multipolar involvement
C. Systolic B/P
D. Albumin level
Practice Question: 6

67. ITE Review
Thoracic / Respiratory
Which of the following is not a factor to consider
for ICU admission of a patient with pneumonia?
A. Temperature
B. Multipolar involvement
C. Systolic B/P
D. Albumin level
Practice Question: 6

68. ITE Review
Thoracic / Respiratory
SMART COP
• Systolic blood pressure (2 points),
• Multilobar CXR involvement (1 point)
• Albumin level low (1 point)
• Respiratory rate high (1 point)
• Tachycardia (1 point),
• Confusion (1 point), Oxygenation (2
points),pH (2 points)
Pneumonia
Mimics
Typical/ Atypical
Mechanism
ICU Predictors

69. ITE Review
Thoracic / Respiratory
A previously healthy 60 y/o male with severe
pneumonia and this CXR is being admitted to the
ICU which is the most appropriate antibiotic
regimen to start in the ED?
A. Ampicillin-sulbactum and Vancomycin
B. Azithromycin and Levofloxin and Doxy
C. Ceftriaxone and levofloxin
D. Ceftriaxone and levofloxin and Vancomycin
Practice Question: 7

70. ITE Review
Thoracic / Respiratory
A previously healthy 60 y/o male with severe
pneumonia and this CXR is being admitted to the
ICU which is the most appropriate antibiotic
regimen to start in the ED?
A. Ampicillin-sulbactum and Vancomycin
B. Azithromycin and Levofloxin and Doxy
C. Ceftriaxone and levofloxin
D. Ceftriaxone and levofloxin and Vancomycin
Practice Question: 7

71. ITE Review
Thoracic / Respiratory
Community-Acquired Pneumonia TX
• Macrolide
Typical/At
• Doxycycline
ypical
Mimics
• β-lactam (Ceftriaxone) + Macrolide
• Respiratory Flouroquinolone
Pneumonia
Typical/At
ypical
DRSP
Typical/ Atypical
Mechanism
Typical/At
• β-lactam (Ceftriaxone) + Respiratory
ypical
Flouroquinolone
DRSP
Gram Neg
• Vancomycin if MRSA
– Vancomycin if MRSA
ICU Predictors
Treatment

72. ITE Review
Thoracic / Respiratory
Community-Acquired Pneumonia
Pneumonia
Mimics
Community-Acquired
Pneumonia
Typical/ Atypical
Mechanism
ICU Predictors
Treatment

73. ITE Review
Thoracic / Respiratory
HCAP,HAP, VAP Pneumonia TX
• antipseudomonal β-lactam (piperacillintazobactam, cefepime, imipenem, or
meropenem)
Pneumonia
+
Typical/ Atypical
• aminoglycoside or fluoroquinolone
+
• vancomycin or linezolid for MRSA.
Mimics
Mechanism
ICU Predictors
Treatment

74. ITE Review
Thoracic / Respiratory
A 3 week old is admitted to the hospital for
pneumonia. What is the most appropriate abx
treatment to begin in ED.
A. Vancomycin
B. Erythromycin
C. Amoxicillin
D. Ceftriaxone
Practice Question:8

75. ITE Review
Thoracic / Respiratory
A 3 week old is admitted to the hospital for
pneumonia. What is the most appropriate abx
treatment to begin in ED.
A. Vancomycin
B. Erythromycin
C. Amoxicillin
D. Ceftriaxone
Practice Question: 8

76. ITE Review
Thoracic / Respiratory
Pneumonia in Children
Pneumonia
Mimics
Typical/ Atypical
Mechanism
ICU Predictors
Treatment
Children

77. ITE Review
Thoracic / Respiratory
• Hantavirus pulmonary syndrome
– Southwest US, aerosolized rodent excreta
– No Human to human spread
– HPS (most common US): Flu sx then Pulmonary edema, hpox,
hypotension
– Haemorrhagic fever + renal failure(Asia, Europe)
– Supportive therapy only
• Plague (Yersinia pestis)
–
–
–
–
Spread by fleas on rodents (bubonic), bioterrorism (pulmonary)
Very contagious person-to-person, strict respiratory isolation
Bilateral, multilobar pneumonia
Rx: doxycycline, fluoroquinolones, aminoglycosides
• Anthrax (Bacillus anthracis)
– Inhaled (bioterror Class A agent)
– No person-to-person transmission
– Hemorrhagic mediastinitis (prominent mediastinum on xray)
– Rx: penicillin, doxycycline or fluoroquinolone
Pneumonia
Mimics
Typical/ Atypical
Mechanism
ICU Predictors
Treatment
Children
Rare

78. ITE Review
Thoracic / Respiratory
SARS
Pneumonia
Severe Acute Respiratory Syndrome
Mimics
– Coronavirus
– Person-to-person spread
– Originated from civet cat in Asia
(aerosolized fecal material)
Typical/ Atypical
Mechanism
ICU Predictors
Treatment
Children
Rare

79. ITE Review
Thoracic / Respiratory
•
Infectious
Bacterial:
CD4
>200
Most common
Same pathogens as non-AIDS
< 200
Mycobacterial:
TB, Mycobacterium avium complex
(MAC)
Parasitic:
Toxoplasmosis
Viruses:
CMV, HSV
Fungal:
PCP
Often disseminated
Cryptococcosis,
histoplasmosis,aspergillosis, candidiasis
•
Malignant
– Kaposi's sarcoma
– Non-hodgkin's lymphoma
Pneumonia
Mimics
Typical/ Atypical
Mechanism
ICU Predictors
Treatment
Children
Rare
HIV / AIDS

80. ITE Review
Thoracic / Respiratory
Pneumonia
Mimics
Typical/ Atypical
Mechanism
ICU Predictors
Treatment
Children
Rare
HIV / AIDS

81. ITE Review
Thoracic / Respiratory
Pneumonia
Mimics
Typical/ Atypical
Mechanism
ICU Predictors
Treatment
Children
Rare
HIV / AIDS

82. ITE Review
Thoracic / Respiratory
20 year old presents to ED with double
vision and difficulty swallowing that seems
to be worse in evening. CXR. What is the
next most appropriate action?
A. Administer zithromax and d/c
B. Notify health department of potential
Botulinum toxicicity
C. Order a CT Brain, admit and
neurosurgery consult
D. Admit, start pyridostigmine, Thoracic
surgery consult
Practice Question: 9

83. ITE Review
Thoracic / Respiratory
20 year old presents to ED with double
vision and difficulty swallowing that seems
to be worse in evening. CXR. What is the
next most appropriate action?
A. Administer zithromax and d/c
B. Notify health department of potential
Botulinum toxicicity
C. Order a CT Brain, admit and
neurosurgery consult
D. Admit, start pyridostigmine, Thoracic
surgery consult
Practice Question: 9

84. ITE Review
Thoracic / Respiratory
• Mediastinum divided into anterior,
middle, posterior compartments
• Anterior: from sternum to anterior
pericardium
• Mass in anterior mediastinum: five
“T”s
– Thymoma (consider myasthenia
gravis)
– Thyroid (retrosternal)
– Teratoma (teeth, hair, etc.)
– T cell lymphoma
– "Terrible“ (carcinoma)
Mediastinal Masses

85. ITE Review
Thoracic / Respiratory
Mediastinal Masses

86. ITE Review
Thoracic / Respiratory
A 60 year old Man with hx/o lung cancer presents
to ED coughing up large amounts of blood every
3-5 minutes Patient is in moderate to severe
extremis. Which of the following would be the
most helpful information at this time?
A. Where is your lung cancer?
B. Are you a Jehovah's witness?
C. Do you have a oncologist?
D. Do you have TB?
Practice Question: 10

87. ITE Review
Thoracic / Respiratory
A 60 year old Man with hx/o lung cancer presents
to ED coughing up large amounts of blood every
3-5 minutes Patient is in moderate to severe
extremis. Which of the following would be the
most helpful information at this time?
A. Where is your lung cancer?
B. Are you a Jehovah's witness?
C. Do you have a oncologist?
D. Do you have TB?
Practice Question: 10

88. ITE Review
Thoracic / Respiratory
• Causes
– Most common is acute bronchitis
– Other infections
–
–
–
–
–
• pneumonia, bronchiectasis
Neoplastic
TB
Vasculitis
Mycetoma (fungal balls)
Cardiovascular
• Minor versus Massive
– Massive: >600mL in 24 hrs or 50mL in
single cough
– Death by asphyxiation not hemorrhage
Hematemesis: Minimal/no cough + Acidotic
Hemoptysis

89. ITE Review
Thoracic / Respiratory
A
Supplemental O2
Rapid sequence intubation
Large bore ETT (>7.5)
B
Keep the bleeding side down
Aggressive pulmonary toilet
Selective mainstem intubation
C
Keep the bleeding side
down
Massive Hemoptysis
Correct coagulopathy
Fluid and/or blood resuscitation
Bronchial artery embolization
will often be required.
Open surgery may also be
necessary.
Selective mainstem intubation

90. ITE Review
Thoracic / Respiratory
END
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