Pneumonia Spontaneous Pneumothorax Acute PE Acute Pulmonary edema

1. Chest Emergencies in
Elderly
SITI NUR JANNAH SHAARI
10-6-97

2. CLINICAL PRESENTATION
• Fever
• malaise
• cough (unproductive),
• delirium,
• reduced concious level,
• lethargy,
• anorexia,
• falls,
• immobility dizziness
MOST COMMON
PRESENTATION:
-acute confusion or
delirium
-malnutrition
(kwashiokor-like)
CURB 65
Confusion – score 1
Urea >7mmol/L –
score 1
Resp>=30 – score 1
SBP<90 or DBP< 60 -
score 1
Age >65yr – score 1

3. DIAGNOSIS
1.Clinical evaluation
2. Lab
• WBC may raised,normal
or low level
• CRP- normal in early, very
high suggest pneumonia
disease or severe sepsis
• ABG
3. Radio
• CXR: reveal minimal
infective infiltrate

4. CAP management
1. Empirical therapy according to guidelines till results of
culture is out
2. All pt should be treated for possibility of atypical infection
• Elderly patient ,diagnosed as pneumonia need to be admitted
to hosp (based on Curb65 2points by age and confusion)
• Treatment includes: levofloxacin 750mg daily or Amoxicillin-
clavulinic acid 2gm twice daily+ azithromycin.
• 3. If suspected MRSA, we should add Vancomycin

5. References
• 1.http://www.atsjournals.org/doi/abs/10.1164/ajrccm.163.7.at1010
#.VtRo65x97IU
• 2.http://www.atsjournals.org/doi/abs/10.1164/ajrccm.156.6.970200
5?src=recsys#.VtRo7px97IV
• 3. http://ageing.oxfordjournals.org/content/17/3/181.short
• 4.Pulmonary Medicine, Chest Department,Alexandria Uni.
• 5.Oxford handbook of geriatrics.
• 6.Harwood-Nuss' Clinical Practice of Emergency Medicine, edited by
Allan B. Wolfson, Gregory W. Hendey, Louis J. Ling, Carlo L. Rosen
• 7. Geriatric Emergency Medicine, edited by Joseph H. Kahn, Brendan
G. Magauran, Jr, Jonathan S. OlshakerGeriatric Emergency Medicine,
edited by Joseph H. Kahn, Brendan G. Magauran, Jr, Jonathan S.
Olshaker

6. Spontaneous Pneumothorax in
elderly
Prepared by :
Sharifah Nur Atiqah bt Sh Abdullah

7. Clinical Picture
– unilateral pleuritic chest pain and dyspnoea.
Usually, in older patient, spontaneous pneumothorax is
secondary with pre-existing chronic lung diseases (COPD or
TB) and may also occur with asthma, bronchial carcinoma,
infection, and esophageal rupture.
•Tachypnoea, tachycardia
•Normal/hyper-resonant percussion note with
decrease air entry on the affected side.
•Rarely, there may be a clicking sound at the
cardiac apex.
Classical
symptoms
•Inability to speak, gasping, low SpO2
•Tracheal deviation,
•Tachypnoea, tachycardia, and hypotension.
Severe
symptoms

8. Investigation
• Chest x-ray
• ABG analysis
• Thoracocentesis manometry
• CT scan

10. Siti Nurul Afiqah binti Johari (10-6-95)

11. Clinical picture

12. Investigations
i. Laboratory:
• ABG: might be normal, type 1 RF, severe hypoxemia,
mild hypocapnea
• D-dimer
ii. ECG: Sinus tachycardia, Rt BBB,
ST-T abnormalities
ii. Radiological:
• Chest X-ray
• CTPA
• V/Q lung scan

13. What to consider in geriatrics?
• Sensitivity to the anticoagulant effect of a given
dose increases with age
• Polypharmacy (include self med) increases risk of
drug interactions which alter oral anticoagulant
effect or which increase the risk of bleeding
• Increased prevalence of concurrent or
intercurrent illness
• Decreased compliance or decreased access to
monitoring

14. Prophylaxis
• Patients who undergone
surgery, 4-6 weeks of
LMWH or UFH
• Graduated compressive
stockings and pneumatic
compression devices
Treatment
• LMWH prevents clot formation
and extension given SC 1/2x a
day
• Long term anticoagulation
after discharge is warfarin
• Thrombolytic therapy with
massive PE who have
significant pulmonary HTN,
obstruction of multiple
segments of pulmonary
circulation, rt ventricular dysfx
or systemic hypotension
• IVC filter in special
circumstances

15. ACUTE PULMONARY EDEMA
SYARIFAH ANITH ATIQA SYED ROZHAN

16. DEFINITION
Sudden accumulation of excessive fluid in the lungs
caused by rapid rise of pulmonary capillary hydrostatic
pressure.
DIAGNOSIS
Extreme dyspnea, restlessness, and anxiety with a
sense of suffocation
Often preceded by productive cough (pink frothy
sputum)
Diffuse diaphoresis
Pallor, cyanosis
moist respirations (gurgling)

17. - By PE:
• Pulse rapid and low volume
• Elevated respiratory rate
• Inspiratory retraction of intercoastal spaces
• Diffuse rhonchi, wheezing , fine inspiratory rales
TREATMENT
 Treatment of cause
 100% O2 by nonrebreather mask; upright position
 IV diuretic (eg, furosemide 0.5 to 1.0 mg/kg)
 Nitrates
 IV inotropes
 Morphine
 Ventilatory assistance