B: CHEST

lungs

In the ABCs we consider Airway and then Breathing. There are all sorts of lungs diseases, including sarcoid and ILD. But in the ER our focus is on a few main categories: lung collapse, hyperinflation from obstructive lung disease, or lungs filled with fluid, pus or tumour. Think of CHEST: Collapse (pneumothorax) Hyperinflate (asthma/COPD) Effusion/edema Sick (pneumonia) Tumour

Collapse: pneumothorax

ptx

  • can be traumatic, spontaneous primary, or spontaneous secondary to an underlying cause (COPD, malignancy, TB, cystic fibrosis)
  • sudden sob and unilateral chest pain, reduced air entry (if large); can have normal physical exam if small or hypoxia/shock if large
  • diagnose on CXR, ultrasound (loss lung slide) or CT
  • treatment depend on severity: needle decompression for tension, Heimlich valve for moderate/large, observe and repeat CXR for small

Hyperinflate: asthma, COPD

copd

  • chronic inflammatory conditions with recurrent exacerbations
  • asthma triggers: allergic, infectious, exercise, menstrual, medication (aspirin, NSAID); COPD trigger: viral, bacterial, pneumo, PE
  • for progressive treatment think ASTHMA: Albuterol/atrovent Steroids Treat underlying (eg pneumonia, pneumothorax) Hydrate Mg Airway

Edema/effusion:

cxr_pleural_effusion

  • effusion: traumatic hemothorax, transudate (CHF, cirrhosis, nephrotic, hypoalbumin, PE), exudate (infection, neoplasm, connective tissue)
  • edema: cardiogenic vs non-cardiogenic
  • oxygenate, treat underlying +/- drain effusion

Sick: pneumonia

pneumonia

  • etiology: typical (S. pneumo, H fly), atypical (Mycoplasma, Chlamydia, Legionella), viral, fungal, mycobacterial
  • specific treatment depends on likely etiology and severity of infection
  • antibiotics, fluids +/- pressors +/- ventilatory support

Tumour: primary lung ca or metastatic

lungca

  • can present with chest pain, sob, hemoptysis, or be an incidental finding

 

By considering these problems as a system, it reminds us that they can influence each other, and you can have more than one process at the same time so you should consider all of them when assessing the CHEST

eg a COPD exacerbation might be caused by pneumonia, cardiogenic pulmonary edema, or pneumothorax

eg. recurring pneumonia might be caused by an undiagnosed tumour, or complicated by a parapneumonic effusion

 

You can also use the CHEST mnemonic to work through your bedside ultrasound findings:

Collapse: is there lung sliding or not –> loss lung slide +/- lung point

edeptx

  • DDx for no lung sliding: severe COPD, right-mainsteam intubation, fused pleura from pleurodesis or chronic pneumonia

Hyperinflate: are the lungs clear –> A lines (eg in normal lungs, COPD, or PE)

alines

Edema: is there pulmonary edema –> B lines diffuse

blines

Sick: are there focal B lines +/- consolidation

pleural-effusion-and-pneumonia

Tumour: are there any masses

lungcaede

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