Acute chest syndrome: Difference between revisions
| Line 79: | Line 79: | ||
***Multi-lobar disease | ***Multi-lobar disease | ||
***Previous history of severe acute chest syndrome or cardiopulmonary disease | ***Previous history of severe acute chest syndrome or cardiopulmonary disease | ||
**Can prevent the need for intubation | |||
==See Also== | ==See Also== | ||
Revision as of 19:23, 14 August 2023
Background
- The leading cause of death in patients with HbSS in the United States
- Occurs most commonly in the 2-4yr old age group and then declines with age
- Due to pulmonary ischemia and infarction; complication of pneumonia
Causes
- Pulmonary infection
- Chlamydia pneumoniae and Mycoplasma pneumoniae are most common organisms
- May also be caused by S. aureus, H. influenzae, Klebsiella, and viruses
- Infection due to S. pneumoniae is now rare due to pneumococcal immunization and prophylactic penicillin therapy
- Fat emboli
- Can cause microvasculature occlusion in the pulmonary circulation, leading to bone marrow infarction
- Autopsies have shown bony slivers and marrow fat found in pulmonary vasculature of patients
- Rib infarction
- Overly aggressive IV hydration
- Vaso-occlusive pain crisis
- Asthma
- Iatrogenic
- Opioid analgesics can lead to hypoventilation
Clinical Features
- New infiltrate on chest x-ray PLUS one of the following signs or symptoms
- Fever >38.5°C (101.3°F)
- Cough
- Wheezing
- Tachypnea
- Chest pain
Complications
- Pulmonary Embolism (bone marrow, fat or thrombotic)
- Pneumonia
- CVA
- Sepsis
Differential Diagnosis
Sickle cell crisis
- Vaso-occlusive pain crisis
- Bony infarction
- Dactylitis
- Avascular necrosis of femoral head
- Acute chest syndrome
- Asthma
- Pulmonary hypertension
- Gallbladder disease
- Acute hepatic sequestration
- Infection
- Parvovirus B19
- Splenic sequestration
- CVA
- Cerebral aneurysm and ICH
- Priapism
- Papillary necrosis
Evaluation
Work-Up
Evaluation
- New infiltrate seen on chest x-ray
- Chest x-ray findings may lag behind clinical features
- Lung ultrasound to CXR or CT finding correlations[1]
- Consolidation seen as hyperechoic punctiform air bronchograms
- Ground-glass opacities seen as coalescent B lines
- Pleural effusion, defined as large if interpleural distance > 25 mm
Management
- O2
- Titrate to pulse oximetry >95%
- Hydration
- Oral hydration preferred
- IV hydration with hypotonic fluid if patient unable to tolerate PO
- Consider D5 + 1/2 Normal saline at 1-1.5x maintenance rate
- Analgesia
- Prevent oversedation and hypoventilation
- Incentive Spirometry
- Bronchodilators
- Antibiotics
- 3rd generation cephalosporin + macrolide
- Transfusion (leucocyte depleted)
- Consider transfusion to goal of hemoglobin 11 / hematocrit 30 for:
- O2 Sat <92% on room air
- hematocrit 10-20% below patient's usual hematocrit or dropping hematocrit
- Consider transfusion to goal of hemoglobin 11 / hematocrit 30 for:
- Exchange transfusion
- Consider for:
- Progression of acute chest syndrome despite simple transfusion
- Severe hypoxemia
- Multi-lobar disease
- Previous history of severe acute chest syndrome or cardiopulmonary disease
- Can prevent the need for intubation
- Consider for:
See Also
External Links
Video
{{#widget:YouTube|id=pKxAsqj4GOE}}
References
- ↑ Razazi et al. Bedside Lung Ultrasound During Acute Chest Syndrome in Sickle Cell Disease. Medicine (Baltimore). 2016 Feb; 95(7): e2553.