An Algorithm for the Diagnosis of Wheezing and Stridor
Stridor: Louder, constant-pitch sound over central airways
Wheezing: Musical sound produced primarily during expiration
Inspiratory Stridor (Supraglottic):
• Extraluminal Compression: Goiter, Retropharyngeal abscess
• Intraluminal Compression: Malignancy, Foreign body
• Inflammatory: Anaphylaxis, Angioedema, Epiglottitis
Biphasic Stridor (Glottic/Subglottic):
• Functional: Vocal fold paralysis, Paradoxical vocal fold motion
• Extraluminal Compression: Malignancy, Vascular ring, aneurysm
• Intraluminal Compression: Foreign body
• Stenosis: Iatrogenic, Endotracheal intubation
Expiratory (Tracheal) Stridor:
• Extraluminal Compression: Malignancy, Mediastinal mass, Vascular ring, aneurysm
• intraluminal Compression: Foreign body
• Stenosis
- Iatrogenic: Endotracheal intubation, Tracheostomy
- Structural weakness: Tracheomalacia, Connective tissue disorder, GERD
- Autoimmune: GPA
Lower Airway Wheezing (Intrathoracic):
• Bronchoconstriction: Asthma, COPD, Anaphylaxis, Carcinoid
• Compression: Extraluminal - Peribronchial pulmonary edema
• Infectious: Bronchitis, Bronchiolitis, Parasite
• Focal: Mass, Foreign body, Consolidation (Infection, Infarction)
#Wheezing #Stridor #Noisy #Breathing #differential #diagnosis #algorithm #pulmonary
Bronchiectasis - Summary
What?
• Bronchiectasis is derived from the Greek words bronckos meaning airway and ectasis meaning widening.
• Permanent irreversible dilatation of cartilage containing airways.
Why?
Due to:
• Recurrent infection or inflammation
• Impaired mucociliary clearance
• Chronic inflammation causes irreversible bronchial wall injury → mucous stasis → perpetuating airway obstruction and inflammation
Symptoms:
• Chronic cough
• Hypoxia
• Dyspnea
• Hemoptysis
• Coughing up yellow or green mucus daily
• Fatigue, feeling run-down or tired
• Fevers and/or chills
• Wheezing
• Clubbing of nails
• Loss of weight
• Chest pain/tightness
Most Common Causes:
• Cystic fibrosis
• Aspiration
• Immunodeficiencies
• Connective tissue diseases
• Airway obstruction
• COPD
• Congenital
• Mounier-Kuhn syndrome (congenital tracheobronchomegaly)
• Hypersensitivity: ABPA
• Infection: TB, NTM, PNA
• Primary ciliary dyskinesia
• Young syndrome (bronchiectasis, sinusitis, and obstructive azoospermia and no evidence of cystic fibrosis)
Physical Examination:
• Crackles, rhonchi, scattered wheezing, and inspiratory squeaks on auscultation
• Digital clubbing (2-3% of patients; more frequent in moderate-to-severe cases)
• Cyanosis and plethora with polycythemia from chronic hypoxia
• Wasting and weight loss
• Nasal polyps and signs of chronic sinusitis
• Physical stigmata of cor pulmonale, in advanced disease
Complications:
• Superimposed infection - increase in the peribronchial thickening, presence of air-fluid levels, centrilobular nodules, or consolidation in the adjacent lung parenchyma.
• Pulmonary artery hypertension
• Mosaic attenuation
• Volume loss of the affected lung parenchyma
Diagnosis:
• HRCT (high-resolution chest CT)
• Broncho-arterial ratio (BAR) - BAR >1.0 is abnormal in adults
• Blood tests and sputum cultures (sputum for bacteria and Acid fast)
• Pulmonary function tests: obstructive
• Bronchoscopy
Laboratory:
• ANA, RF, CCP, ANCA
• HIV, Immunoglobulins (Ig M, A, G, E)
• Sweat chloride test, α1-antitrypsin deficiency
Sputum cultures growing uncommon pathogens:
• Pseudomonas aeruginosa
• Aspergillus
• Nontuberculous mycobacteria
Treatment:
• Clearing the airway
• Treating infections
• Preventing exacerbations
#Bronchiectasis #pulmonary #differential #diagnosis
Uncommon Causes of Noncardiogenic Pulmonary Edema (NCPE) - Differential Diagnosis Framework
High Altitude Pulmonary Edema:
• Accumulation of plasma and some red blood cells in the lung due to an interruption in the pulmonary blood-gas barrier.
• High-altitude pulmonary edema (HAPE) generally occurs above 2,500 m (8,000 ft) and is uncommon below 3,000 m (10,000 ft)
• Symptoms:
- Nonproductive cough, shortness of breath with exertion, difficulty walking uphill
- Dyspnea at rest will become severe with any type of exertion
- Cough may be productive for pink, frothy sputum, as well as frank blood.
- Lethargic and severely hypoxemic.
• Other common assessment findings associated with HAPE are:
- Tachypnea,
- Low-grade fever (up to 100.4°F [38°C]),
- Tachycardia,
- Inspiratory crackles in the right middle lobe that become bilateral and diffuse
Neurogenic Pulmonary Edema:
• Traumatic brain injury, cerebral hemorrhage, and seizure activity, especially status epilepticus
• Pathophysiology: The shift of fluid from the capillaries to the pulmonary interstitium and alveoli thus increases the permeability of the pulmonary capillaries
• Criteria:
- Bilateral pulmonary opacities,
- Amount of oxygen dissolved in the PaO2/FiO2 ratio < 200 mm Hg,
- Presence of central nervous system injury (with associated increased intracranial pressure),
- Absence of other common causes of acute respiratory failure or ARDS (aspiration, massive blood transfusion, sepsis),
- No evidence of left atrial hypertension
TRALI:
• Sudden onset of hypoxemic respiratory insufficiency shortly after or during the administration of a blood product.
• Symptoms: Hypoxemic respiratory insufficiency, fever, chills, pruritus, urticaria, pulmonary infiltrates on chest radiography, pink frothy airway secretions, hypotension, hypovolemia, cyanosis, tachycardia, and tachypnea
Preeclampsia/Eclampsia Pulmonary Edema:
• Pathophysiology:
- Poor uteroplacental circulation caused by inadequate remodeling of the spiral arteries that happens between weeks 8 and 18 of pregnancy.
- The predominant pathophysiologic finding: maternal vasospasm.
• Signs/Symptoms: Tachycardia, hypertension, dyspnea, tachypnea, hypoxemia, scattered crackles, chest pain, cough
Opioid Overdose:
• Any opioid can cause noncardiogenic pulmonary edema, especially fentanyl mixed with heroin, and methadone overdose.
• Signs/Symptoms:
- Respiratory depression and/or agonal respirations.
- The classic signs of opioid intoxication include depressed mental status, decreased respiratory rate, decreased tidal volume, decreased bowel sounds, and miotic pupils
Pulmonary Embolism:
• Acute pulmonary edema can be caused by a massive PE, as well as multiple smaller emboli.
• Pathophysiology:
- PE can cause noncardiogenic pulmonary edema by decreasing the pulmonary and adjacent pleural systemic circulations, raising hydrostatic pressures in pulmonary and systemic veins, and also decreasing pleural pressure due to airway collapse.
- PE also reduces the exit rates of pleural fluid by rising the systemic venous pressure thus limiting lymphatic drainage. Increasing lymphatic filling can also occur with a PE by diminishing pleural pressure.
#Noncardiogenic #pulmonary #edema #causes #differential #diagnosis #NCPE
Authors: Mark M. Ramzy, DO, EMT-P (@MarkRamzyDO, EM Resident Physician, Drexel University, Department of Emergency Medicine) and Richard J. Hamilton, MD (EM Chair, Drexel University, Department of Emergency Medicine)// Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)
Case
A 39-year-old male presents to the emergency department with shortness of breath and chest pain. Patient states he was assaulted three days ago with a punch to the chest, he suffered no head trauma or loss of consciousness. He was evaluated at another hospital immediately following the assault where a chest x-ray was performed, he is unable to recall the results. He was subsequently discharged from that hospital. Today he describes his centrally located chest pain as non-radiating, sharp, and pleuritic. Pertinent positives on physical exam include the following: anxious-appearing African American male in mild distress. The breath sounds on the upper left chest are decreased. There is point tenderness over the left anterior and lateral chest wall. Vital signs: BP 118/75, HR 96, RR 24, SpO2 88% on room air.
This patient’s clinical presentation and history raise many questions. Several of the diagnoses that emergency physicians are concerned about can often be answered by a good history. Unfortunately, the above patient is not a very good historian, leaving us to rely on our physical exam findings and clinical judgement skills. This post will focus on both threatening and non-threatening pulmonary conditions that may arise from blunt trauma to the chest. Furthermore, it will provide pearls and pitfalls for each condition that will enhance your ability to evaluate a patient with blunt injury to the chest.
Rib Fractures
Rib fractures, though often minor, can be an indication of a potentially more serious internal injury with significant associated structural and vascular complications. When considering the diagnosis of rib fracture in a patient, think of the following pearls and pitfalls:
Pearls
50/50 Rule (part 1):50% of patients admitted to the hospital following chest trauma are diagnosed with rib fractures.
Due to their short length, a considerable amount of force is required to fracture the first and second ribs.1
If you’re having difficulty appreciating a lateral rib fracture on a chest x-ray (CXR), try rotating it 90° with the concerning side pointing upwards. Because this breaks up the usual chest radiograph pattern that your brain is accustomed to, your vision does a better job of “seeing” each rib as it is, rather than defaulting to a normal interpretation.
Case Continued
Following our exam, the patient was placed on 3 liters of oxygen via nasal cannula. His dyspnea continued, and his oxygen saturation only improved to 90% after 5 minutes. He was then switched to 10 liters of oxygen via non-rebreather. Given the shortness of breath and point tenderness over the left anterior and lateral chest wall, a chest x-ray was ordered and interpreted using some of the pearls above.
Pitfalls
50/50 Rule (part 2): Within the first few days following an injury, 50% of rib fractures are not seen on a CXR.2
With multiple lower rib fractures, particularly ribs 9-12, it is important to consider intra-abdominal bleeding often from a liver or spleen laceration.
Elderly patients with multiple rib fractures may have difficulty clearing secretions and should be closely monitored for airway compromise.
Pulmonary Contusion
Most commonly caused by significant blunt injury to the chest wall following high speed motor vehicle crashes, pulmonary contusions and their complications can be associated with severe mortality and morbidity.
#Radiology #CTChest #Lung #Pulmonary #Contusion
Mixed Urinary Incontinence: Pathogenesis and Clinical Findings
Urgency Urinary Incontinence (UUI) -> Urinary leakage preceded by a sudden, strong urge to void
-> Overflow Incontinence -> Overfilling of the bladder from obstruction; BOO (tumour, stone, BPH, urethral or bladder neck stricture)
-> Detrusor Overactivity -> OAB (idiopathic), CNS lesion (neurogenic), inflammation/ infection (cystitis, UTI), diabetes mellitus
-> Bladder Wall Compliance ->
Progressive increase in intravesicle pressure during bladder filling pushing urine from the bladder
Stress Urinary Incontinence (SUI) -> Episodic involuntary urinary leakage with sudden increase in intra-abdominal pressure -> Urethral hypermobility, intrinsic sphincter deficiency, or a poorly coapting urethra -> Decreased Pelvic floor muscle and ligament strength causing Decreased tone of vesicoureteral sphincter unit; Decreased urethral strength and associated striated and smooth muscle; iatrogenic
- Failure to Void - Weak Stream (+/- dribbling), Intermittent, Straining, Incr PVR if a complication of urinary retention; obstruction visible on cystoscopy
- Failure to Store - Frequency, Urgency, Nocturia, Dysuria if SUI or UUI not caused by obstruction
- Urodynamic Studies - SUI — Decr urethral closure pressure with incr IAP/Bladder Volume and urinary leakage. UUI— involuntary detrusor contraction and/or detrusor sphincter dyssynergia
#Urinary #Incontinence #Mixed #Pathophysiology #Signs #Symptoms #Urology #Diagnosis
Lung Infections in HIV - Differential Diagnosis Framework
Disease by CD4 Count:
Any CD4 Count:
• Mycobacterium tuberculosis, Bacterial pneumonia
• Seasonal influenza
CD4 <200:
• Pneumocystis jirovecii pneumonia (PJP), MAI, Cryptococcal pneumonia, Extrapulmonary tuberculosis, Blastomycosis
CD4 <50-100:
• Toxoplasmosis
• Histoplasmosis, Coccidioidomycosis, CMV, Mycobacterium avium, Mycobacterium kansasii, Invasive aspergillosis, Rhodococcus equi, Pseudomonas
FUNGAL PNEUMONIAS:
• Weight loss, lethargy, fever
• Disseminated
• Pleuritic CP
• Cough, dyspnea
• (Less common since cART)
Aspergillus Pneumonia:
• 3 syndromes: ABPA, Mycetoma, Invasive Aspergillosis
• High fever, cough, and dyspnea, wheezing
• Pleuritic chest pain may be present. Hemoptysis (occasionally massive) - angioinvasive disease.
• CT: Halo sign
Coccidioides Immitis Pneumonia:
• "Flu-like", Valley fever
• Fever, weight loss, Lymphadenopathy, Chest pain, cough
• Polymorphic skin lesions (papules, pustules, erythematous nodules, plaques)
Cryptococcus Neoformans Pneumonia:
• Cough and dyspnea
• Lobar consolidation or nodular infiltrates
PJP Pneumonia:
• Risk: Can produce significant depression of the phagocytic function of alveolar macrophages in HIV
• Lung Exam: Can be normal
• Fever (It's usually low if you have HIV), Chills, Dry cough or wheezing, Shortness of breath, Fatigue, Chest pain or tightness when you breathe, Weight loss
Histoplasma Capsulatum Pneumonia:
• (Fever, weight loss), Lymphadenopathy, dry cough or dyspnea, hepatomegaly,
• Oral mucosal ulcers, erythema nodosum or erythema multiforme,
• Multiple skin lesions (pustules, crusted papules),
• Cytopenias
VIRAL PNEUMONIAS:
Influenza:
• Rapid onset of a "flu-like syndrome" consisting of dry cough, myalgias, headache and high fever
CMV:
• 2-4 week subacute course
• Nonproductive cough, dyspnea, and fever
BACTERIAL PNEUMONIAS:
Most Common:
• Streptococcus pneumoniae - 20% of pneumonias
• Haemophilus influenzae - 10-15% of pneumonias
• Staphylococcus aureus
Nocardia Pneumonia:
• Chest pain, cough, bloody sputum, sweats, chills, weakness, lack of appetite, weight loss
• Imaging: Irregular nodules or infiltrates-necrotizing
• Lung most commonly infected
M. Tuberculosis Pneumonia:
• Upper lung zone infiltrates
• Cavities
• Fever, chills, night sweats, anorexia, productive cough, and occasional hemoptysis
• Lymphadenopathy, CNS involvement
MAI Pneumonia:
• Constitutional symptoms (fever, weight loss, anorexia) Hepatosplenomegaly, lymphadenopathy,
• Abdominal pain, chronic diarrhea, cytopenias
M. Kansasii
Legionella:
• Nausea, vomiting, and diarrhea
• Hyponatremia
• Elevated hepatic transaminases
• C-reactive protein levels >100 mg/L
• Rhabdomyolysis (rare)
Co-MRSA Pneumonia:
• PVL virulence factor
• May cause rapidly progressive necrotizing pneumonia
Rhodococcus Equi Pneumonia:
• Indolent course with fever, cough and cavitary infiltrates, mimicking TB
Chlamydia Pneumoniae:
• Focal pneumonia, pleural effusion, or bronchitis
Mycoplasma Pneumoniae:
• Cough (reported in 100% of cases), anemia, arthralgia, dyspnea, sore throat along with fever, rales, interstitial infiltrates or lobar pneumonia
Coxiella Burnetii:
• Fever, headache, non-productive cough, myalgia
• Lung nodules possible in HIV
PARASITIC PNEUMONIAS:
• Toxoplasma gondii - Fever, nonproductive cough, and dyspnea
• Strongyloides stercoralis - Worms in lungs
• Cryptosporidium, and Microsporidium
#Lung #Infections #HIV #AIDS #pulmonary #differential #diagnosis #infectiousdiseases
Lung Abscess - Diagnosis and Management Summary
Lung Abscess Etiology:
• Necrosis of lung parenchyma by a polymicrobial infection
• Most common cause: Aspiration pneumonia
• DM risk factor for Klebsiella pneumonia
• Chronic alcoholism
• Periodontal disease/poor dentition/gingival disease
• IV substance use
• Esophageal dysmotility
• Depressed consciousness
• Large volume feeding tubes
Lung Abscess Pathophysiology:
1. Inoculum
2. Pneumonitis
3. Tissue necrosis (7-14 days later)
4. Lung abscess
Lung Abscess - Clinical Presentation:
• 80% have fever ≥ 38 degrees
• Chills, night sweats, fatigue, unexplained weight loss
• Late disease: Pleuritic chest pain, hemoptysis, dyspnea, productive cough
• Putrid sputum/sour-tasting sputum
Lung Abscess - Physical Exam:
• Poor dentition
• Gingival crevice disease
• Diminished breath sounds
• Rales
Lung Abscess Diagnosis:
• CBC - Leukocytosis, anemia
• Sputum/Blood cultures
• CXR (non-diagnostic in early disease)
• CXR upright or lat decubitus - air fluid level seen
• Chest CT
Lung Abscess Management:
• Antibiotics:
- IV Ampicillin-sulbactam
- Piperacillin/Tazobactam - pseudomonas
- Carbapenems
- IV Clindamycin in case of PCN allergy
- Switch to oral antibiotics once stable
- 10-15% require lobectomy or pneumonectomy if fail antibiotics
• Consider Surgical Intervention:
- Fevers > 10 days
- Hemoptysis
- Cavitation > 6 cm
- Neoplasm, or hemorrhage
• Treatment duration:
- 3 weeks or continue antibiotic treatment until the chest radiograph shows a small, stable residual lesion or is clear. This generally requires several months of treatment
• Delayed response: Evaluate for foreign body, cancer, or bronchial stenosis
Lung Abscess Pathogens:
• Aerobic Bacteria:
- Staph. Aureus
- Legionella
- H. Influenza
- E. Coli
- P. Aeruginosa
- Strep. Pyogenes
- K. Pneumonia
• Anaerobic Bacteria:
- Bacteroides
- Fusobacterium
- Peptostreptococcus
- Prevotella
• Fungal:
- Aspergillosis
- Blastomyces
- Dermatitidis
- Cryptococcus
- Coccidioides
• Parasite:
- Entamoeba histolytica
- Paragonimus westermani
• Other: TB, M. avium, M. kansii
Lung Abscess Differential Diagnosis:
• Vasculitis (e.g., Granulomatosis with polyangiitis)
• Malignancy
• Aspirated foreign body
• Bronchostenosis
#Lung #Abscess #pulmonary #differential #causes #management #treatment #diagnosis
