European Respiratory Society
Pulmonary Emergencies

This Monograph, written by well recognised experts in the field, provides a comprehensive overview of pulmonary emergencies. A broad range of different respiratory emergencies is covered, from pneumothorax, pulmonary embolism, right heart failure and haematothorax to acute exacerbations of diseases such as asthma and chronic obstructive pulmonary disease. Recent developments in treatment strategies for acute pulmonary problems are also discussed in detail, with chapters on topics such as high-flow nasal cannula oxygen therapy, extracorporeal carbon dioxide removal and noninvasive ventilation.

  • ERS Monograph
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    1. Page 1
      Nick Maskell, Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, BS10 5ND, UK. E-mail:

      Pneumothorax is a heterogeneous condition whose presentation and disease course are influenced by individual phenotypes, risk factors and underlying pathophysiology. The management of pneumothoraces should be personalised, taking into account the presenting patient with their symptoms and accompanying chest imaging, as well as their risk of developing a subsequent pneumothorax. Further understanding of risk stratification, newer treatment options such as ambulatory devices and further research into the role of conservative management are likely to influence future management pathways.

    2. Page 15
      Stavros V. Konstantinides, Center for Thrombosis and Hemostasis, University Medical Center Mainz, Langenbeckstrasse 1, Building 403, 55131 Mainz, Germany. E-mail:

      Pulmonary embolism (PE) is a significant contributor to global disease burden. The presence and severity of right ventricle (RV) dysfunction is a key determinant of the patient's prognosis in the acute phase. Accordingly, risk-adapted treatment strategies have been developed and continue to evolve, tailoring initial management to the clinical presentation and the functional status of the RV. Beyond pharmacological and, if necessary, mechanical circulatory support, systemic thrombolysis remains the mainstay of treatment for haemodynamically unstable patients; in contrast, it is not routinely recommended for intermediate-risk PE. Catheter-directed pharmacomechanical reperfusion treatment represents a promising option for minimising bleeding risk; for reduced-dose intravenous thrombolysis, the data are still preliminary. New, non-vitamin-K-dependent oral anticoagulants, directly inhibiting factor Xa (rivaroxaban, apixaban, edoxaban) or thrombin (dabigatran), have simplified initial and long-term anticoagulation for PE, while reducing major bleeding risk. Use of vena cava filters should be restricted to selected patients with absolute contraindications to anticoagulation, or with PE recurrence despite adequately dosed anticoagulants.

    3. Page 32
      Laurent Savale, Université Paris-Sud, Centre de Référence de l'Hypertension Pulmonaire Sévère, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 78 Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France. E-mail:

      Pulmonary arterial hypertension (PAH) remains a progressive and fatal disease despite the development of specific therapies over the past decades. Right ventricular function of these patients is sustained by a delicate balance between progressively increasing pulmonary vascular resistance and adaptation to right ventricular afterload. The development of acute right heart failure (RHF), which can be precipitated by a trigger factor or the natural worsening of the disease, is associated with a very poor prognosis. Management of RHF in PAH suffers from a lack of clear recommendations and specific clinical trials. It is mainly based on trigger factor identification, fluid volume optimisation and pharmacological support to improve right ventricular function and perfusion pressure. At the same time, specific management of PAH according to the aetiology must be considered to reduce right ventricular afterload. The development of extracorporeal life support and the optimisation of graft allocation rules contribute to improve the outcome of patients with refractory RHF despite optimal medical management.

    4. Page 48
      Alexander John Mackay, Dept of Respiratory Medicine, The Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK. E-mail:

      Exacerbations of COPD cause considerable morbidity and mortality, and are among the commonest causes of medical admissions to hospital. Exacerbations of COPD are triggered predominantly by infection, resulting in increased airway inflammation in association with a deterioration in symptoms and lung function. Current management remains dependent on short-acting bronchodilators, oral corticosteroids and antibiotics, despite limited and often contradictory results of clinical trials for these therapies. Careful oxygen administration is appropriate in the context of hypoxia. Ventilatory support, both noninvasive and invasive, is extremely effective during COPD exacerbations and should be considered and initiated early. Where appropriate, palliative care is also an integral part of management, and rapid initiation of supportive and end-of-life care in such circumstances is essential. Future research is required to identify novel additional treatments in the acute setting, in particular targeting the excess inflammation seen at exacerbation.

    5. Page 66
      Stephen C. Lazarus, University of California San Francisco, 505 Parnassus Ave, San Francisco, CA 94143-0111, USA. E-mail:

      Acute severe asthma exacerbations are a significant cause of morbidity and mortality. A high proportion of severe exacerbations and deaths result from undertreatment. Risk factors for fatal asthma have been identified and should guide treatment. The time course for recovery from an exacerbation mirrors that for onset of signs and symptoms. Thus, early intervention is critical. Patients must be taught to adjust maintenance treatment to prevent an exacerbation, as well as how and when to initiate treatment. Home treatment consists of aerosolised short-acting β2-agonists, and systemic corticosteroids. If symptoms persist after ∼1 h, the patient should seek urgent medical attention, where the emphasis should be on briefly confirming the diagnosis and severity, while initiating therapy with inhaled bronchodilators and systemic corticosteroids and oxygen, titrated to SpO2 93–95%. The decision to admit or discharge should be made within 1–3 h. For patients who progress to respiratory failure, there are unique management issues related to noninvasive positive-pressure ventilation, intubation, ventilator settings and medications.

    6. Page 86
      Patrick B. Murphy, Lane Fox Respiratory Unit, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH, UK. E-mail:

      This chapter discusses the pathophysiology of hypercapnic respiratory failure in conditions other than COPD. First, the development of alveolar hypoventilation is explained, and the load–capacity–drive model of hypercapnic respiratory failure is described. An increase in respiratory load or a decrease in respiratory muscle capacity or neural drive will lead to alveolar hypoventilation. This model is used to explain the pathophysiology of hypercapnic failure in acute and chronic neuromuscular diseases and obesity hypoventilation syndrome. It is outside the scope of this chapter to comprehensively discuss the management of these conditions; however, key concepts related to the management of acute deteriorations and hypoventilation are outlined. Other causes of alveolar hypoventilation, such as cystic fibrosis and chest wall disorders, are discussed briefly.

    7. Page 101
      Adamantia Liapikou, Sotiria Chest Diseases Hospital, Mesogion 152, 11527, Athens, Greece. E-mail:

      Severe community-acquired pneumonia (sCAP) is the most frequent infectious cause of admission to the ICU and is associated with a high mortality rate that can reach 30–50%. Severity assessment is a main point of sCAP management to ensure the appropriate site of care and antibiotic therapy. The microbial aetiology of sCAP has changed over time; Streptococcus pneumoniae (pneumococcus) is the most frequent pathogen, and the proportion of sCAP caused by respiratory viruses and with a polymicrobial aetiology has increased, mainly due to better detection with new molecular techniques. Antibiotic therapy is a key factor in the management of sCAP, and several studies have shown that early empirical antibiotic administration improves patient outcomes. In general, the management of sCAP includes microbiological diagnosis, severity assessment and early empirical antibiotic treatment. The main challenge is the high prevalence of multidrug-resistant pathogens worldwide. This chapter focuses on the current state of knowledge on the management of sCAP.

    8. Page 117
      Jan C. Grutters, ILD Center of Excellence, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands. E-mail:

      Interstitial lung diseases (ILDs), or diffuse parenchymal lung disorders, constitute a group of more than 150 different disorders characterised by inflammation of the lung parenchyma or interstitium, sometimes followed by the occurrence of pulmonary fibrosis. In the most frequently occurring interstitial disorders, such as sarcoidosis, idiopathic pulmonary fibrosis (IPF), idiopathic nonspecific interstitial pneumonia, hypersensitivity pneumonitis and collagen vascular disease-related interstitial pneumonias, acute worsening of pulmonary symptoms can occur that can be defined as an acute exacerbation. There are important differences in presentation, aetiology and prognosis of acute exacerbations between these different ILDs. In sarcoidosis, an acute exacerbation is defined as an increase of pulmonary symptoms caused by new or worsening granulomatous inflammation. In acute exacerbations of IPF, for example, an acute worsening has to be present with new ground-glass abnormalities on CT and can be provoked by multiple triggers, such as infection, mechanical ventilation, drug toxicity and aspiration. When an acute exacerbation occurs in sarcoidosis, starting or increasing the dose of prednisolone is often successful. Steroids are also often used in treating an acute exacerbation of IPF, although unfortunately with a much lower chance of success. In acute exacerbations of non-IPF pulmonary fibrosis there might be an even more logical rationale for increasing the amount of immune suppression. However, in line with IPF, strong evidence is also lacking, indicating the need for future studies addressing this issue. Best supportive care during acute exacerbations, such as mechanical ventilation, is challenging and should be discussed case by case.

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      Muriel Fartoukh, AP-HP, Hôpital Tenon, 4 rue de la Chine, 75020 Paris, France. E-mail:

      Haemoptysis may be life threatening, with a mortality rate >50% in the absence of early and adequate management. Evaluation of the severity of haemoptysis is crucial to determine the most appropriate treatment in a timely fashion. The therapeutic management of severe haemoptysis has improved considerably with the advances in vascular interventional radiology, with thoracic surgery being reserved for failure of endovascular treatment or focal lesions at high risk of bleeding recurrence in selected patients. Evaluation of therapeutic strategies targeted on the risk of adverse outcomes and mortality is necessary to refine the management of severe haemoptysis and improve its prognosis.

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      Jan-Philipp Stromps, Dept of Plastic Surgery, Hand Surgery, Burn Center, Cologne-Merheim Medical Center, Ostmerheimer Str. 200, Cologne, 51109, Germany. E-mail:

      Foreign body aspiration is seen predominantly in children and elderly patients. Depending on the size, type and location of the foreign object, occlusion of the central airway can occur, resulting in life-threatening situations. Bronchoscopy is the cornerstone in the diagnosis and treatment of foreign body aspiration. Rigid bronchoscopy is preferred due to its larger lumen, allowing the use of more robust and larger tools and providing a secure airway during the procedure. In extreme cases, ECMO can be life-saving in children. The sooner the foreign body is removed, the less local inflammatory reaction occurs. The vast majority of foreign bodies can be retrieved by bronchoscopy. When unsuccessful, a thoracotomy may be needed. Inhalation injuries caused by smoke or chemical products of combustion are often associated with long-standing pulmonary dysfunction and significant morbidity and mortality. These traumas are often associated with skin burns, which increase the overall morbidity. Factors such as systemic inflammation, sepsis, ventilator-induced lung injury and post-traumatic development of pneumonia may also negatively affect the injured respiratory system. There is still no common consensus about the diagnostic strategy, and relatively few novel therapeutic options are available; therefore, treatments are for the most part supportive.

    11. Page 161
      Erich Stoelben, Lung Clinic/Thoracic Surgery, Cologne Hospital, Witten/Herdecke University, 51109 Cologne, Germany. E-mail:

      Haematothorax (or haemothorax) is defined as an accumulation of blood in the pleural cavity. Spontaneous haematothorax is a rare complication of various intrathoracic diseases, especially pneumothorax or benign and malignant neoplasms. In contrast, haematothorax has to be faced regularly after thoracic interventions due to the high number of interventional procedures in the thorax, especially thoracentesis or thoracic drainage. Diagnosis has to be made by means of the clinical picture, sonography and CT scan of the chest. Spontaneous or post-interventional haematothorax might turn out to be an emergency situation requiring immediate interdisciplinary treatment. Depending on the underlying cause, conservative and surgical treatment might be appropriate. However, early video-assisted thoracic surgery is an effective and safe treatment for the management of haematothorax irrespective of the underlying disease.

    1. Page 171
      Arnaud W. Thille, Service de Réanimation Médicale, CHU de Poitiers, 2 rue la Milétrie, 86021 Poitiers Cedex, France. E-mail:

      High-flow nasal cannula (HFNC) oxygen therapy is a recent technique enabling delivery of a high flow rate of gas heated and humidified as under physiological conditions. The main clinical effects include a significant decrease in respiratory rate, work of breathing, and patient discomfort and breathlessness as compared with standard oxygen. These effects are mainly due to the high flow rate of gas that effectively matches the high ventilatory demand in patients, and provides high FIO2, PEEP and continuous washing of dead space, thereby flushing carbon dioxide out of the upper airways. Several RCTs have compared HFNC oxygen versus standard oxygen or NIV. In keeping with this literature, the use of HFNC oxygen could be the first-line strategy of oxygenation in patients admitted to the ICU with acute hypoxaemic respiratory failure, during the post-extubation period or after cardiac surgery.

    2. Page 186
      Paolo Navalesi, Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale “Amedeo Avogadro”, Via Solaroli 17, 28100 Novara, Italy. E-mail:

      The use of NIV for acute respiratory failure (ARF) has progressively increased in the last two decades. In patients with ARF secondary to exacerbation of COPD, NIV largely decreases the need for intubation and invasive ventilation. Meta-analyses indicate that NIV reduces the risk of death in these patients. While strong evidence supports the use of noninvasive CPAP in patients with episodes of cardiogenic pulmonary oedema, fewer and less robust data are available on NIV for other forms of hypoxaemia, both in immunosuppressed and immunocompetent patients. NIV has been successfully applied to prevent re-intubation in post-operative patients, as a weaning strategy after early extubation and as a means to prevent post-extubation respiratory failure in at-risk patients.

    3. Page 200
      Christian Karagiannidis, Dept of Pneumology and Critical Care Medicine, ARDS and ECMO Centre, Cologne-Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, 51109 Cologne, Germany. E-mail:

      Extracorporeal carbon dioxide removal (ECCO2R) is an emerging technology in ICU medicine aimed at compensating for severe respiratory acidosis. Thereby, ECCO2R aims at immediately saving lives or reducing complications related to intubation and subsequent invasive mechanical ventilation by either avoiding intubation or allowing protective ventilation or early extubation following initial intubation. ECCO2R can be applied by pumpless arteriovenous (av-ECCO2R) and pump-driven venovenous (vv-ECCO2R) systems. Both systems require the cannulation of large vessels and are associated with technique-specific complications, most importantly bleeding, ischaemia and clotting. Therefore, the potential benefits of ECCO2R must be balanced against the possible complications in each individual. However, scientific evidence for ECCO2R is limited, and restricted to only a few experimental and clinical trials. Despite this, ECCO2R has been suggested to be live saving in selected patients when adequately considering the potential complications. Furthermore, technical developments have allowed ECCO2R to become widespread and larger RCTs are now in progress. Thus, ECCO2R is suggested to become an established treatment option in the near future in ICU medicine.

    4. Page 209
      Raffaele Scala, Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Via Nenni 20, 52100 Arezzo, Italy. E-mail:

      Acute bronchoscopy has a pivotal role in the bronchoscopy unit and intensive care settings. In the bronchoscopy unit, flexible bronchoscopy (FBO) is helpful for the diagnosis of intrathoracic tumours, interstitial lung diseases and suspected pneumonia, while rigid bronchoscopy with/without FBO is useful to manage central airway obstruction, haemoptysis and removal of inhaled foreign bodies. In intensive care settings, FBO is used to facilitate intubation in difficult airways scenarios, guide percutaneous dilatational tracheostomy and resolve lobar/lung atelectasis. “Bronchoscopic” sampling should be considered in suspected ventilator-associated pneumonia only if “noninvasive” techniques are inconclusive, as well as in nonventilated immunosuppressed patients. Despite the variable quality of evidence that exists in favour of the combined use of NIV and bronchoscopy in different scenarios, the best evidence supports prophylactic NIV to prevent intubation in nonventilated patients. The role of high-flow nasal cannula oxygen in “assisting” FBO needs to be further investigated. Benefits of acute bronchoscopy should be weighed against the risk of cardiopulmonary complications, bleeding and pneumothorax.

    5. Page 229
      Nabeel Ali, Dept of Respiratory Medicine, King's Mill Hospital, Mansfield Road, Sutton in Ashfield, NG17 4JL, UK. E-mail:

      Chest tube placement into the pleural cavity is performed to drain abnormal collections of air or fluid, or as a means to instil medications to perform pleurodesis. The choice of chest tube and insertion site depends on the indication for placement and the nature of the fluid/air to be drained. Small drains should be used for pneumothorax, free-flowing pleural effusions and pleural infection, and analgesia should be considered as a pre-medication. It is strongly recommended that all chest tubes for fluid should be inserted under image guidance. The tube should be inserted using full aseptic technique, and substantial force should never be used. Blunt dissection should be employed in cases of trauma or insertion of large-bore drains. Chest tubes should be managed on wards familiar with their management, and checked daily for fluid drainage volumes and any signs of wound infection, and documented for swinging and/or bubbling. The chest tube should be removed once pneumothorax has resolved and fluid drainage has decreased to <200 mL per day.