Following up with last week’s Paucis Verbis card on Ventilator Settings for Acute Lung Injury and ARDS, here is the card on Ventilator Settings for Obstructive Lung Disease. This is for patients who present with acute asthma or COPD exacerbation who require endotracheal intubation.

What initial ventilator settings should you set for these patients?

Go to ALiEM (PV) Cards for more resources.

Thanks to Dr. Jenny Wilson for the card and Dr. Scott Weingart for the original stellar podcast from which this card was derived.

A patient presents with severe multilobar pneumonia and refractory hypoxia requiring endotracheal intubation. The respiratory therapist connects your patient to the ventilator.

“What settings would you like your patient on?”

Back in 2010, Dr. Scott Weingart posted a great podcast on “Dominating the Vent“. It’s such a fantastic distillation of the practical aspect of ventilator setting management of all intubated patients except those with an acute asthma or COPD exacerbation, Dr. Jenny Wilson and I thought this would be a great Paucis Verbis card to have in your peripheral brain.

Note: The tidal volume should be calculated based on Predicted Body Weight (PBW), which is based on patient gender and height. The calculation is at the bottom of the card. Using a patient’s actual weight might yield a tidal volume that is way too high. The initial vent settings in the example box are for a patient with a PBW of 70 kg. That’s basically a 5’9″ man or 5’11” woman.

PV Card: Ventilator Settings for Lung Protection

Adapted from [1]
See ALiEM (PV) cards.

Thanks to Dr. Jenny Wilson for the idea and writing this card, and Dr. Scott Weingart for a great podcast as always.

Reference

1. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-1308. [PubMed]

Did you know that there was an unexplained spike in Legionnaire’s disease (pneumonia caused by Legionella pneumophila) during the 2009 H1N1 flu pandemic?

Since the flu season is rapidly approaching, I thought I would review what Legionnaire’s disease looks like. Yes, they will have a fever, cough, and pneumonia on CXR. These patients are generally pretty sick and almost always need hospitalization. What makes it unique? The trick is to look for extrapulmonary findings, which help to distinguish it from other atypical pneumonias. Relative bradycardia is a sure tip.

Why do we want to differentiate it from other pneumonias? Legionnaire’s disease requires reporting to your state’s health department to help track for outbreaks.

PV Card: Legionella and Legionnaire’s Disease

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

More information on Legionella from the CDC website.

Reference

1. Cunha B. Legionnaires’ disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin North Am. 2010;24(1):73-105. [PubMed]

“Should I get a D-Dimer test or CT chest angiogram on my patient with atypical chest pain to rule-out a pulmonary embolism?” This is a common question asked by emergency physicians on a routine basis.

Here are 3 clinical prediction rules: PERC, Wells, and Simplified Geneva Score. Personally, I’ve never used the Geneva Score, but it’s worth looking at.

A WORD of CAUTION

These rules should be used with caution, because none of these scoring protocols are perfect. For instance, in a recent publication in the Journal of Thrombosis and Haemostasis, the authors found that the PERC rule does not actually safely exclude PEs.¹ Big bummer for us clinicians.

PV Card: Pulmonary Embolism Clinical Prediction Rules

Go to ALiEM (PV) Cards for more resources.

Thanks to Dr. Kit Tainter (Mount Sinai PGY-4 EM resident) for coming up with the idea for this card!

Reference

1. Hugli O, Righini M, Le G, et al. The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism. J Thromb Haemost. 2011;9(2):300-304. [PubMed]

Emergency physicians have the opportunity to educate patients and prescribe chronic inhaled corticosteroids to patients who should be on these medications chronically. Patients may be more receptive to education and advice given immediately after an asthma exacerbation, managed in the ED.  Using the National Institute of Health/ National Asthma Education and Prevention Program classification system, physicians can quickly determine if the patient is a candidate for inhaled corticosteroids and initiate therapy accordingly.

PV Card: Asthma Classification system

In short, patients can be classified into one of 4 classes: intermittent, mild persistent, moderate persistent, and severe persistent asthma. Patients in these classes should receive either Step 1, 2, 3, or 4/5 medications, respectively. I remember that patient using daily short-acting beta agonists (SABA) belong to the moderate persistent asthma category.

Go to ALiEM (PV) Cards for more resources.

Pneumonia is a common cause for ED visits. How do you decide on whether the patient can be managed as an outpatient or inpatient? To supplement your clinical judgment, many clinicians use the Pneumonia Severity Index (PSI) score.

Have you heard of CURB-65, supported by the British Thoracic Society? What about SMART-COP, which is meant to help you predict if your patient will need Intensive Respiratory or Vasopressor Support (IRVS)?

PV Card: Risk Stratification Scoring Tools in Pneumonia

Go to the ALiEM Cards for more resources.