All that wheezes... - Approach to management of Asthma and COPD in the ED

Objectives: identify similarities and differences in asthma and COPD presentations as well as their causes, relevant history and physical exam findings, diagnosis and complications, treatment, and disposition.

 

Asthma: reversible bronchoconstriction of the upper airways. Type 1 hypersensitivity response with immediate and late (“delayed”) phase.

Common precipitants: environmental (most common cause- worsened by poor compliance and includes cold temperature, pollution, airborne allergens, exercise), infection less common.

Presentation: acute dyspnea over hours to days with wheezing and/or poor air movement on exam.

Assessment: ABC’s as always. Are they protecting their airway? How alert are they? Are they in respiratory distress or able to speak in clear, complete sentences? Are they using accessory muscles to breathe? What is heard on their lung exam? Relevant history: ever intubated? How many exacerbations and hospitalizations per year? ICU admission?

From these questions you must decide what type of asthmatic you are dealing with and from here on out we detail these separately in either column: stable vs unstable (see pdf).

 Always the wrong answer on tests and in real life: theophylline, Heliox. We do not give these medications in the ED as they are no longer indicated (as for Theo.), or they are often controversial with limited data (Heliox).

-Leukotriene modifiers/antagonists, LABAs, and Omalizumab should never be given.

                                                                                                                                               

Bonus time: NIPPV à BiPAP and CPAP             

NIPPV is a form of noninvasive respiratory support delivered via face mask that has a tight seal. Oxygen, inhaled medications, and other gases can be given with higher airway pressures. NIPPV helps “stent” airways open and allow for better oxygenation, ventilation, and relief from obstructive lung disease.

-BiPAP: 2 pressure settings, inspiratory (IPAP) and expiratory (EPAP). Bigger the IPAP = bigger the “push” of air coming in. EPAP is essentially PEEP.

-CPAP: same thing as PEEP à positive end expiratory pressure. This mode keeps a steady stream of pressurized air in the airways throughout the respiratory cycle, allowing for alveoli to remain open and be recruited.

                                                                                                                                                                                   

Last resort: Intubation

-Endotracheal intubation does NOT help fix the underlying problem in asthma and COPD. It should only be used if the patient can no longer tolerate the work of breathing and ventilation/airway protection are the concern.

-Delayed sequence intubation:

-Once intubatedà continue efforts to maximize airway obstruction (Albuterol through ETT, Mag, steroids, etc.)

-Vent settings: “permissive hypercapnia”. We want to avoid barotrauma which includes pneumothorax, so we do the following… low tidal volumes, low minute ventilation (6-8 breaths/min), <5 PEEP, Oxygen >88% is fine, and pH does not need full normalization. I:E ratio 1:4.

-In a critical scenario when the patient appears to be arresting or the ventilator states there is high peak pressure, disconnect the vent and compressing the chest to release trapped air. Also, these patients should be heavily sedated and consider short term paralysis so that the patient does not interfere with the ventilator.

                                                                                                                                                                                   

COPD

Overview: COPD is just a name. It is divided into emphysema and chronic bronchitis, but for ED purposes these patients receive the same therapy. The good news is the algorithm for COPD workup is almost the same as asthma, except for 2 critical differences: 1) COPD is a destructive pathology of the lung, 2) COPD patients are generally older, have more medical problems, and therefore need a more established workup.

Assessment: same as asthma patients (see above!). In addition, Gold Criteria is used for COPD patients.

Gold Criteria for COPD exacerbation: increased cough, increased sputum production/change in color, increased dyspnea

Causes: unlike asthma, the most common cause of COPD exacerbation is infection (70%). Greatest predictor of COPD exacerbations is prior exacerbations (duh). >2 exacerbations/year or >1 hospitalization/year = high risk COPD patient! (see pdf for stable vs unstable).

*Fluoroquinolones should be used with caution or avoided altogether in many older patients (>65) as they have been shown to cause multiple concerning side effects (neuropathy, delirium, QT prolongation, tendinopathy and arthropathy, hepatic toxicity).

Other quick facts from studies (not for the test but good to know!):

MDI equals Nebulizer delivery for efficacy, however nebulizer preferred in acute setting due to patient tolerance and reliable delivery.

PO equals IV steroids for efficacy and time of onset but it’s the same story as above. We want to optimize patient breathing and tolerance. No swallowing pills.

Steroids can be considered the most important part of treatment so these need to be given as early as possible if able: multiple studies have shown decreased hospital stay, improved lung function and symptoms, reduced treatment failure risk by 50%, and even reduced relapse risk at 1 month.

Nearly all patients should be discharged home with steroids unless contraindicated or if they were recently given a course and are still on that prior course.

Critically, the 5 day “burst” course of 50-60mg daily prednisone found to be the same as tapered prednisone. Burst preferred due to easier dosing and less complications from patient’s mis-dosing.

Not just gas: appendicitis in adults in kids

Introduction

Inflammation of the vermiform appendix is one of the most common causes of acute abdomen worldwide. It occurs most commonly in ages 10-30. In children <5 years old, appendicitis is <5% incidence.

Forget what you learned in medical school. This condition can be very difficult to diagnose in patients without CT imaging. The presentation is extremely variable, especially children.

This guide will discuss clinical features, presentation, and diagnosis of appendicitis in adults and kids

Pathology

Initial inflammation (due to obstruction from fecalith, calculi, lymphoid hyperplasia, infection, tumors) -> Increase in intraluminal pressure along with bacterial overgrowth  —> necrosis and perforation

20% of patients have perforation in <24 hours of initial symptoms. 65% had perforation after 48 hours of symptoms.

 Presentation in adults

RLQ abdominal pain with anorexia. The case of periumbilical pain that migrates to the RLQ only occurs about 50-60% of the time.

The location of the appendiceal tip is also important. The tip can be located anterior, retrocecal, or even RUQ (pregnancy). Atypical abdominal pain is not uncommon.

Fever is often late in presentation. A strong differential of other causes of fever should be present.

McBurney’s Sign: point tenderness 2 inches from the ASIS on a straight line to the umbilicus. Sens and Spec range considerably (50-94%; 75-85% respectively).

Rovsing’s Sign: tenderness with palpation of LLQ which can reflect peritoneal irritation. Once again, Sens and Spec vary (20-70%; 60-96% respectively).

Psoas Sign: RLQ pain with passive right hip extension. The sensitivity <40% is quite awful, the specificity is 80-97% when done correctly.

Obturator Sign: flexion of the patient’s right hip and knee along with internal rotation of the right hip causes RLQ pain. Sens is 8% (not a typo), and Spec is 94%.

Diagnosis

Labs are not very helpful. Typically, CBC, CMP, pregnancy test and urine studies are ordered.

80% of patients have leukocytosis, but leukocytosis is nonspecific in most cases of disease as well. Sens and Spec of leukocytosis: 80 and 55% respectively.

Its presence does not necessarily suggest appendicitis, but its absence might help.

Best diagnostic test: CT abdomen and pelvis with contrast. It is most accurate than the other modalities and the fastest to acquire. Findings that suggest appendicitis:

-enlarged >6mm diameter with occluded lumen

-wall thickening >2 mm

-fat stranding along periappendix or wall enhancement

-Appendicolith (~25% of patients)

One of the biggest concerns is nonvisualization of the appendix (10-20% of cases). This decreases the likelihood of appendicitis but does not eliminate it. Overall, Sens and Spec 95% and 96%, respectively.

US: preferred in children and pregnancy. Most accurate finding: appendiceal diameter >6 mm

Advantages: no radiation, no contrast. Unfortunately, the test is strongly dependent on patient body habitus, and operator experience. Overall, Sens 85% and Spec 90%.

This test effectively rules in/out appendicitis if the appendix is visualized.

MRI: most often used in pregnancy. Not well tolerated by patients as they are often in pain and have to lie on the table for >10 minutes for testing.

Plain radiographs have no role in diagnosis.

 

Modified Alvarado Score: Used to identify patients with low likelihood of appendicitis.

-Migratory RLQ pain (1 pt)      -Anorexia (1 pt)

-Nausea or vomiting (1 pt)       -RLQ tenderness (1 pt)

-Fever >99.5 (1 pt)                      -Rebound tenderness in RLQ (1 pt)

-Leukocytosis (2 pts)

Physician gestalt has been found in multiple studies to be equal in performance to the Alvarado score.

Analgesia: there is often concern that analgesia will limit the surgeon’s physical exam findings. Although there are no studies on the impact of analgesia on diagnosis, pain control has not been found to negatively impact overall care. Multiple studies where patients received IV morphine in the ED. Morphine was not associated with increased risk of perforation, negative appendectomy, or missed appendicitis.

 

What about the kids?!

Children have some of the same clinical features as noted above, however at much different rates. The absence of classic clinical features as noted above in the adult section is not sensitive or specific for excluding appendicitis.

-Lack of migration to RLQ (50%of patients), Absence of anorexia in 40%, no rebound tenderness in 50%. Wow, got to make it difficult don’t you, pediatrics? 

Neonates: appendicitis is rare. High mortality at 30%. Abdominal distention, vomiting, sepsis, anorexia. Huge overlap with necrotizing enterocolitis. These children typically look sick.

Children <5: uncommon. RLQ <50% of patients. Diffuse pain, fever, irritability, vomiting, grunting respirations, refusal to ambulate are all more common.

Children 5-12: frequent. Anorexia, vomiting, fever. RLQ pain and migration from periumbilical region is common. In most children they lie still, with one or both hips flexed. Not too uncomfortable unless they are disturbed. Abdominal pain can be elicited if child is asked to hop on one foot.

Children >12: mirrors adult findings as noted above.

CBC, CMP, urine studies, pregnancy test (in appropriate age and setting).

Leukocytosis: 96% of patients have it but has Sens and Spec of 70% and 80%, respectively.

Urine studies: pyuria can be seen up to 25% of patients. Its presence or absence alone should never be used to diagnose appendicitis.

Ultimately, patients with a clear alternative diagnosis present (pneumonia, UTI, pharyngitis) should undergo treatment for that condition first. For those whom it is difficult to exclude appendicitis, we divide patients into low, moderate, high risk groups.

Low risk: few clinical features, negative lab studies, no RLQ pain or RLQ pain but none with walking/jumping. Discharge with generous return precautions. If RLQ pain is present and distressing, reeval by PCP in 24 hours is warranted.

Moderate risk: decent exam findings and some symptoms, often leukocytosis. US evaluation +/- surgery eval. +/- admission with repeat abdominal exams.

High risk: strong exam findings, +/- concern for perforation, leukocytosis. Call surgery.

Many clinical scoring systems have been developed, all are beyond the scope of this handout and all have limited ability to identify patients. No studies have evaluated their ability to improve diagnosis compared to gestalt. We do not routinely use them.

Management with antibiotics?

There is a lot of ongoing talk about using a nonoperative approach to appendicitis with antibiotic therapy and close follow up. Its all the rage in Europe apparently. This discussion is outside the scope of the review, and to date there are 6 trials have been published.

Its definitely worth investigating further, but in general this decision will be made in concert with a surgeon’s evaluation. Surgery should always be called on cases of suspected or confirmed appendicitis.

Saddle up: All about Pulmonary Emboli

Sometimes in the ED you just need to saddle up and face adversity... John Wayne said something once to the effect of “Saddling up requires one to always think of PE”. We cannot find the reference but read it on Buzzfeed so it must be true. PE always seems to be on the differential. Its ever-elusive, dropping people dead at will, and we’re left rolling the dice with D-dimer. Let's review PE, its classic presentations, how to diagnose, treat, and disposition.

Airway Superiority: ED RSI

Wish to be an Airway ace? King of the glottis? This guide defines RSI, why we do it in the ED, when to do it/not do it, and a step by step overview with paralytics and induction agent details. ALL IN 2 PAGES. NO BS. It’s time to rule the airway.