Acute chest syndrome - Revision history

Rossdonaldson1: /* Background */

2024-04-24T18:51:03Z

Background

← Older revision		Revision as of 18:51, 24 April 2024
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	==Background==		==Background==
	[[File:Lung and diaphragm.jpg\|thumb\|Lobes of the lung with related anatomy.]]		[[File:Lung and diaphragm.jpg\|thumb\|Lobes of the lung with related anatomy.]]
			[[File:Computed tomograph of pulmonary vessels.jpg\|thumb\|Pulmonary arterial tree anatomy.]]
	*The leading cause of death in patients with HbSS in the United States		*The leading cause of death in patients with HbSS in the United States
	**HbSS individuals are at higher risk than HbSC, but acute chest may occur in both genotypes		**HbSS individuals are at higher risk than HbSC, but acute chest may occur in both genotypes

Rossdonaldson1: /* Background */

2024-04-24T18:35:22Z

Background

← Older revision		Revision as of 18:35, 24 April 2024
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	==Background==		==Background==
			[[File:Lung and diaphragm.jpg\|thumb\|Lobes of the lung with related anatomy.]]
	*The leading cause of death in patients with HbSS in the United States		*The leading cause of death in patients with HbSS in the United States
	**HbSS individuals are at higher risk than HbSC, but acute chest may occur in both genotypes		**HbSS individuals are at higher risk than HbSC, but acute chest may occur in both genotypes

Rossdonaldson1: /* Video */

2024-04-17T20:12:40Z

Video

← Older revision		Revision as of 20:12, 17 April 2024
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	==External Links==		==External Links==
	*[https://emcrit.org/ibcc/sickle-chest/ IBCC Chapter on Acute Chest Syndrome]		*[https://emcrit.org/ibcc/sickle-chest/ IBCC Chapter on Acute Chest Syndrome]
	~~==Video==~~
	~~{{#widget:YouTube\|id=pKxAsqj4GOE}}~~

	==References==		==References==
	<references/>		<references/>
	[[Category:Heme/Onc]]		[[Category:Heme/Onc]]
	[[Category:Pulmonary]]		[[Category:Pulmonary]]

Patricklin at 18:55, 27 November 2023

2023-11-27T18:55:04Z

← Older revision		Revision as of 18:55, 27 November 2023
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	==Background==		==Background==
	*The leading cause of death in patients with HbSS in the United States		*The leading cause of death in patients with HbSS in the United States
			**HbSS individuals are at higher risk than HbSC, but acute chest may occur in both genotypes
	*Occurs most commonly in the 2-4yr old age group and then declines with age		*Occurs most commonly in the 2-4yr old age group and then declines with age
	*~~Due~~ to pulmonary ischemia and ~~infarction; complication of~~ [[~~pneumonia]~~]		*Pathophysiology is due to deoxygenation of Hb, leading to sickling in the pulmonary vasculature, causing vaso-occlusionm, ischemia, and endothelial injury<ref>Friend A, Settelmeyer TP, Girzadas D. Acute Chest Syndrome. [Updated 2023 Feb 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441872/</ref>
			**In pediatric population, ACS is more often triggered by asthma or viral/bacterial pulmonary infection, leading to local hypoxia
			**In adult population, ACS is commonly associated with vaso-occlusive pain, which may lead to hypoventilation or long bone fat/marrow emboli
			**However, a specific cause is not identified in a majority of cases

	===Causes===		===Causes===
	*Pulmonary infection		*Pulmonary infection
	**[[~~Chlamydia~~ pneumoniae]] and [[Mycoplasma pneumoniae]] are most common organisms		**[[Chlamydophila pneumoniae]] and [[Mycoplasma pneumoniae]] are most common organisms
	**May also be caused by [[S. aureus]], [[H. influenzae]], [[Klebsiella]], and viruses		**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		***Infection due to [[S. pneumoniae]] is now rare due to pneumococcal immunization and prophylactic penicillin therapy
	*[[Fat embolism\|Fat emboli]]		*[[Fat embolism\|Fat emboli]]
			**Suspect if symptoms start 2-3 days following acute pain crisis
	**Can cause microvasculature occlusion in the pulmonary circulation, leading to bone marrow infarction		**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		**Autopsies have shown bony slivers and marrow fat found in pulmonary vasculature of patients
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	**[[Tachypnea]]		**[[Tachypnea]]
	**[[Chest pain]]		**[[Chest pain]]
			**[[Hypoxemia]]

	==Complications==		==Complications==
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	*[[Blood culture]] /sputum cultures		*[[Blood culture]] /sputum cultures
	*[[CXR]]		*[[CXR]]
			*Type and screen/crossmatch

	===~~Evaluation~~===		===Imaging===
	*New infiltrate seen on chest x-ray		*New infiltrate seen on chest x-ray
	**Chest x-ray findings may lag behind clinical features		**Chest x-ray findings may lag behind clinical features
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	**Ground-glass opacities seen as coalescent B lines		**Ground-glass opacities seen as coalescent B lines
	**[[Pleural effusion]], defined as large if interpleural distance > 25 mm		**[[Pleural effusion]], defined as large if interpleural distance > 25 mm
			*Consider CTPE for persistent hypoxia with unclear cause

	==Management==		==Management==
	*[[O2]]		*[[O2]]
	**Titrate to pulse oximetry >95%		**Titrate to pulse oximetry >95%
			**NNoninvasive or invasive positive pressure ventilation may be required in severe cases
	*Hydration		*Hydration
	**[[oral rehydration therapy\|Oral hydration]] preferred		**[[oral rehydration therapy\|Oral hydration]] preferred
	**[[IV hydration]] with hypotonic fluid if patient unable to tolerate PO		**[[IV hydration]] with hypotonic fluid if patient unable to tolerate PO
	***Consider D5 + 1/2 Normal saline at 1-1.5x maintenance rate		***Consider D5 + 1/2 Normal saline at 1-1.5x maintenance rate
			**While dehydration can predispose sickling, overhydration can cause pulmonary edema that exacerbates sickling
	*[[Analgesia]]		*[[Analgesia]]
	**~~Prevent~~ oversedation and hypoventilation		**Opioids often required for adults and sometimes needed for pediatrics
			**However, attempt to prevent oversedation and hypoventilation, atelectasis
	*Incentive Spirometry		*Incentive Spirometry
	*[[Bronchodilators]]		*[[Bronchodilators]]
	*[[Antibiotics]]		*[[Antibiotics]]
	**3rd generation [[cephalosporin]] + [[macrolide]]		**3rd generation [[cephalosporin]] + [[macrolide]]
	*[[Transfusion]] (leucocyte depleted)		*Simple [[Transfusion]] (leucocyte depleted)
	**Consider [[pRBCs\|transfusion]] to goal of hemoglobin 11 / hematocrit 30 for:		**Consider [[pRBCs\|transfusion]] to goal of hemoglobin 11 / hematocrit 30 for:
	***O2 Sat <92% on room air		***O2 Sat <92% on room air
	***hematocrit 10-20% below patient's usual ~~hematocrit~~ or dropping hematocrit		***hematocrit/hemoglobin 10-20% below patient's usual values, or continuously dropping hematocrit/hemoglobin
	*[[Exchange transfusion]]		*[[Exchange transfusion]]
	**Consider for:		**Consider for:
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	***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		**Can prevent the need for intubation

			==Disposition==
			*Admission
			*Consider consultation to hematologist

	==See Also==		==See Also==

Rossdonaldson1: /* Evaluation */

2023-09-13T16:13:41Z

Evaluation

← Older revision		Revision as of 16:13, 13 September 2023
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	==Evaluation==		==Evaluation==
			[[File:Transfusion-related acute lung injury chest X-ray.gif\|thumb\|Chest X-ray of TRALI (left) compared to the same subject after resolution of symptoms (right).]]
	===Work-Up===		===Work-Up===
	*CBC		*CBC
	*Retic count		*Retic count
	*[[VBG]] / [[ABG]]		*[[VBG]] / [[ABG]]
	*Blood culture /sputum cultures		*[[Blood culture]] /sputum cultures
	*[[CXR]]		*[[CXR]]

Masoodrm: /* Management */

2023-08-14T19:23:47Z

Management

← Older revision		Revision as of 19:23, 14 August 2023
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	***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==

Masoodrm: /* Management */

2023-08-14T19:23:14Z

Management

← Older revision		Revision as of 19:23, 14 August 2023
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	==Management==		==Management==
	*[[O2]]		*[[O2]]
	**Titrate to pulse oximetry >92%		**Titrate to pulse oximetry >95%
	*Incentive Spirometer
	*Hydration		*Hydration
	**[[oral rehydration therapy\|Oral hydration]] preferred		**[[oral rehydration therapy\|Oral hydration]] preferred
	**[[IV hydration]] with hypotonic fluid if patient unable to tolerate PO		**[[IV hydration]] with hypotonic fluid if patient unable to tolerate PO
			***Consider D5 + 1/2 Normal saline at 1-1.5x maintenance rate
	*[[Analgesia]]		*[[Analgesia]]
	**~~Pulmonary toilet is important but avoid excessive sedation~~		**Prevent oversedation and hypoventilation
			*Incentive Spirometry
	*[[Bronchodilators]]		*[[Bronchodilators]]
	*[[Antibiotics]]		*[[Antibiotics]]

Masoodrm: /* Evaluation */

2023-08-14T19:20:27Z

Evaluation

← Older revision		Revision as of 19:20, 14 August 2023
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	===Evaluation===		===Evaluation===
	*New infiltrate on ~~[[CXR]] with at least one of the following:<ref>Novelli EM, Gladwin MT. Crises in Sickle Cell Disease. Chest. 2016; 149 (4): 1082~~-~~1093.</ref>~~		*New infiltrate seen on chest x-ray
	**[[Fever]] >38.5		**Chest x-ray findings may lag behind clinical features
	**[[Cough]]
	**~~[[Wheezing]]~~
	**[[Tachypnea]]
	**New [[hypoxemia]]
	**[[Chest ~~pain]]~~
	*Note: CXR findings may lag behind ~~the~~ clinical features
	*[[Lung ultrasound]] to CXR or CT finding correlations<ref>Razazi et al. Bedside Lung Ultrasound During Acute Chest Syndrome in Sickle Cell Disease. Medicine (Baltimore). 2016 Feb; 95(7): e2553.</ref>		*[[Lung ultrasound]] to CXR or CT finding correlations<ref>Razazi et al. Bedside Lung Ultrasound During Acute Chest Syndrome in Sickle Cell Disease. Medicine (Baltimore). 2016 Feb; 95(7): e2553.</ref>
	**Consolidation seen as hyperechoic punctiform air bronchograms		**Consolidation seen as hyperechoic punctiform air bronchograms

Masoodrm: /* Clinical Features */

2023-08-14T19:19:50Z

Clinical Features

← Older revision		Revision as of 19:19, 14 August 2023
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	*New infiltrate on chest x-ray PLUS one of the following signs or symptoms		*New infiltrate on chest x-ray PLUS one of the following signs or symptoms
	**[[Fever]] >38.5°C (101.3°F)		**[[Fever]] >38.5°C (101.3°F)
	*[[Cough]]		**[[Cough]]
	*[[Wheezing]]		**[[Wheezing]]
	*[[Tachypnea]]		**[[Tachypnea]]
	*[[Chest pain]]		**[[Chest pain]]

	==Complications==		==Complications==

Masoodrm: /* Clinical Features */

2023-08-14T19:19:18Z

Clinical Features

← Older revision		Revision as of 19:19, 14 August 2023
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	==Clinical Features==		==Clinical Features==
	*[[Fever]] >38.5		*New infiltrate on chest x-ray PLUS one of the following signs or symptoms
			**[[Fever]] >38.5°C (101.3°F)
	*[[Cough]]		*[[Cough]]
	*[[Wheezing]]		*[[Wheezing]]