Pulmos Flashcards
COPD Exacerbation
** Taken from GOLD Recommendations 2017
HPI]
- *3 Cardinal signs**
1. Increased dyspnea (cough, wheeze)
2. Increased sputum volume
3. Increased sputum purulence
If 1 of 3 then NO Abx only bronchodilators
and symptomatic therapy.
If 2 of 3 then COPDE:
Uncomplicated COPDE
ID]
Age < 65
HPI]
FEV1 >50% of predicted
PMHx]
- *No frequent exacerbations , <2 per year**
- *No cardiac disease**
RECIPERE]
P/Infect]
Clarithromycin {Biaxin} 500mg PO q12h
Doxycycline 100mg PO BID
Complicated COPDE
One or more RISK factors:
ID]
Age > 65
HPI]
FEV1 <50% of predicted
PMHx]
- *Frequent exacerbations,** >or= 2 per year
- *Cardiac disease**
RECIPERE]
P/Infect]
Amox-Clav {Clavulin} 500mg PO TID
Levofloxacin {Levaquin} 750mg PO/IV OD
Moxifloxacin 400mg PO/IV OD
If suspecting Pseudomonas RISK factors include:
1. Recent hospitalization 2 or more days in the
last 90days.
2. Frequent administration of Antbiotics,
four or more courses in the last year.
3. Pseudomonas identified in a previous
hospitalization.
4. Severe COPD, FEV1<50% of predicted.
Also, from nursing home or ICU, prolonged
steroid use, structural lung disease.
RECIPERE]
P/Infect]
Ciprofloxacin 750mg PO q12h
Ceftazidime 500mg-1g IV q8h
Pip/Tazo 4.5g IV q6-8h (renal dosing)
Cefepime 2g IV q8h
Less effective Fluoroquinolones:
Levofloxacin {Levaquin} 750mg PO/IV q24h
Moxifloxacin 400mg PO/IV q24h
O/E] RR,SpO2mod/severe SpO2 <92%
General – pursed lip breathing, accessory respiratory muscle use (sternocleidomastoids, scalenes) intercostal retractions, paradoxal chest wall movements, cyanosis
Pulmos – decreased A/E, wheeze, barrel chest
No respiratory failure:
RR 20-30
No use of accessory respiratory muscles.
No changes in mental status.
Hypoxemia improved with supplemental oxygen
given via Venturi mask 28-35% inspired oxygen (FiO2).
No increase in PaCO2 (or PvCO2 for comparison).
Acute respiratory failure — non-life-threatening
RR > 30
Using accessory respiratory muscles.
No change in mental status.
Hypoxemia improved with supplemental oxygen
via Venturi mask 35-40% FiO2.
Hypercarbia i.e., PaCO2 (or using PvCO2 as correlation) increased compared
with baseline or elevated 50-60 mmHg.
Acute respiratory failure — life-threatening
RR > 30
Using accessory respiratory muscles.
ALOC.
Hypoxemia not improved with supplemental
oxygen via Venturi mask or requiring FiO2 > 40%.
Hypercarbia i.e., PaCO2 (or using PvCO2 as comparison) increased compared with
baseline or elevated > 60 mmHg or the presence
of acidosis (pH < 7.25).
POCUS]
lung sliding
A Lines
no B Lines
INVESTIGATIO]
L(H)/Haim] CBC, VBG, ABG (if NIV or intubation)
ABG used to establish a baseline for pH, pO2,
PCO2 before and after NPPV or intubation.
Note: VBG (in combination with SpO2) has excellent
correlation with arterial blood gas values for pH,
PCO2.O2 sat > 90% correlated with PaO2 greater
than 60mmHg about 95% of the time.
I]
CXR, ECG
RECIPERE]
NP/A,B] SpO2 88-92%, Venturi mask, NIV
NP/C] PIV
NP/Mon] SpO2
Note: Indications for NIV.
PaCO2>45mmHg OR pH(art)<7.35
(or use VBG values PvCO2 and pH)
Severe dyspnea with signs of respiratory
fatigue such as increased WOB, accessory
muscle use, paradoxal motion of abdomen or
intercostal retractions
Persistent hypoxemia despite supplemental O2
Note: Normal respiratory drive uses CO2
receptors, but in conditions of high CO2
levels a hypoxic drive occurs that uses O2
receptors instead. When there is an increase
in O2 the body will decrease the RR. BUT it
has been shown that in COPD the hypoxic
drive does not occur. HOWEVER on high O2
they may retain CO2 due to Haldane effect
and VQ mismatch. Haldane effect is the result
of oxygenation of blood in the lungs displaces
carbon dioxide from hemoglobin which increases
the removal of carbon dioxide. Conversely,
oxygenated blood has a reduced affinity for
carbon dioxide.
P/Org(Pulmos)]
NEBS or MIDI (6 puffs) q20min x 3
Albuterol {Ventolin} 5mg
Ipratropium {Atrovent} 0.5mg
THEN Ventolin MIDI 1 puff qhour x 3
P/Infla]
Prednisone 50mg PO x 5days (REDUCE trial)
OR Methylprednisolone {Solumedrol} 125mg IV
MgSO4
P/Infect] Antibiotics see above
Clarithromycin {Biaxin} 500mg PO BID OR
Amox-Clav {Clavulin} 500mg PO TID
Antibiotic Coverage
Bugs
Pneumonia Types and Treatments
CAP - Community Acquired
Infection outside the hospital.
** Streptococcus pneumoniae (GP) (20-60%)
Hemophilus influenzea (GN)
Staphylococcus aureus (GP)
RECIPERE]
<65 and no co-morbid disease:
Macrolide
- *Clarithromycin {Biaxin} 500mg PO BID**
- *Doxycycline 100mg PO BID**
>65 with co-morbid disease such as,
COPD, DM, renal, heart, liver, lung, malignancy,
EtOH, immunosupression, asplenia OR
Abx in last 3 months:
Respiratory Fluoroquinalone OR
Beta-lactam PLUS Macrolide
Levofloxacin {Levaquin} 750mg PO/IV OD OR
Amoxicillin 1g PO q8h PLUS
Clarithromycin {Biaxin} 500mg PO BID
Atypicals
Mycoplasma pneumoniae
Chlamydia pneumoniae
RECIPERE]
Clarithromycin {Biaxin} 500mg PO BID
Levofloxacin {Levaquin} 750mg PO/IV OD
Legionella pneumophila (GN)
RECIPERE]
**Levofloxacin {Levaquin} 750mg PO/IV OD**
Alcoholics
Klebsiella pneumoniae (GN)
RECIPERE]
Levofloxacin {Levaquin} 750mg PO/IV OD
HAP - Hospital Acquired
Respiratory infection >48h after being admitted.
** Pseudomonas aeruginosa (GN)
RECIPERE]
Ciprofloxacin 400mg PO q8h
Less effective fluoroquinolones:
Levofloxacin {Levaquin} 750mg PO/IV OD
Moxifloxacin 400mg PO/IV q24h
(be careful with fluoroquinolone resistence)
Ceftazidime 500mg-1g IV q8h
Pip/Tazo 4.5g IV q6-8h (renal dosing)
(MRSA) Syaphlyococcus aureus (GP)
RECIPERE]
Vancomycin 10-15 mg/kg IV q8h
Escherichia coli (GN)
Klebsiella pneumoniae (GN)
RECIPERE]
**Levofloxacin {Levaquin} 750mg IV OD**
HCAP - Health Care Associated (same as above)
Patient hospitalized for >2days in last 90days.
** Pseudomonas aeruginosa (GN)
(MRSA) Syaphlyococcus aureus (GP)
Klebsiella pneumoniae (GN)
Escherichia coli (GN)
Aspiration Pneumonia
Anerobe Covergae
Ampicillin PLUS Metronidazole 500mg IV q8h
IP - Immunocompromised pneumonia
Patient has cancer, HIV etc.
Aspergillus (mold)
Pneumocystis Jiroveci (fungus)
Cytomegalovirus
PaO2 and PaCO2
PaO2 - 100
PaCO2 - 40
PvO2 - 40
PvCO2 - 45
CURB-65
and
MDR
(Multidrug Resistance Risk Factors)
CURB-65
5 point decision rule in oder to decide
patient can be managed as an outpatient.
ID]
Age > 65
O/E] SBP<90, RR>30
General – Confusion - not oriented to person, place, time
INVESTIGATIO]
L(H)/Org(Nephros)] BUN>7mmol/L
CURB-65 < 1 – manage as outpatient
CURB-65 >or= 2 – consider admission
Note: CURB-65 does not evaluate hypoxia
which should be considered in the evaluation
of the patient. The patient should be maintaining
their typical O2 saturation that they receive
at home, on supplementary O2.
MDR
Four point scale based on:
1. Poor functional status – significant debilitation with incontinence, inability to perform ADLs.
2. Hospitalized >2days in the past 90 days.
3. Any antibiotics in past 90 days.
4. Immunosupression – ANC<1000, asplenia, hematological malignancy, predisone equivalent to >10mg daily for 2 or more weeks, congenital immunodeficiency, HIV, other immunosupression therapy.
Score;
0-1 is low risk
>or= 2 is high risk
Antibiotic Coverage (EMRAP Dec 2016)
i) Discharge
CURB-65 <2 patient can probably go home unless there is critical hypoxia.
Levofloxacin 750mg PO OD x5days
ii) Admit
CURB 65 >or=2
Levofolxacin 750mg PO/IV OD
**The decision to start oral therapy in the ER is associated with positive outcomes. Aside from critical illness, there is no proven benefit IV therapy. Shorter times to treatment and shorter hospitalizations have been found with oral antibiotics. Most PO antibiotics have similar bioavailability to the IV formulations.
iii) MDR
MDR >or= 2
Cefepime 2g IV q8h x10days - Psuedomonas
Vancomycin 15-20mg/kg/dose q8h - MRSA
Clarithromycin {Biaxin} 500mg PO q12h - Atypicals
iv) Aspiration
Amox-Clav {Clavulin} – Oral flora and anaerobes
Azithromycin {Zithromax} – Typical and atypical
