Review of common pulmonary medical problems Edward Omron MD, MPH, FCCP Pulmonary Medicine Morgan Hill, CA 95037
- 1. Pulmonary Pearls Edward Omron MD, MPH Pulmonary/Critical Care Medicine
- 74 year-old woman presents with 4 days cough, chills, dyspnea and fever
- Hemoptysis with right sided pleuritic chest pain x2 days
- Unable to walk due to dyspnea
- Recent hospital admission for complicated UTI treated with levofloxacin
3. Physical Exam
- Blood pressure 80/55 mm Hg
- Dullness to percussion on right side with crackles
4. Initial Tests
- ECG: Sinus Tachicardia with LVH
- PaO2 = 58 mm Hg on 4 L NC
5. ER Chest X-RAY 6. What is the most likely pathogen in this patient?
7. Initial Treatment in the ER
- Right IJ central venous access
- Fluid bolus 1 Liter 0.9% NS
- Oxygen converted to 40% venturi mask
- Albuterol / Atrovent neb treatments
- Transduced CVP < 8 mm Hg after fluid bolus and second 1 L 0.9% NS given
8. What antibiotic regimen would you prescribe in the ER?
- 3 rdGeneration Cephalosporin+macrolide
- 3 rdGeneration Cephalosporin+ respirotory quinolone
- Carbopenem+ aminoglycoside
- Vancomycin+ respiratory quinolone
- Vancomycin + extended spectrum penicillin + aminoglycoside
- Zyvox, Zosyn, levafloxacin
9. Initial antibiotics given in the ER
- Ceftriaxone 2 gram and levafloxacin 750 mg
- Most likely diagnosis was thought to be CAP (Strep pneumo + H influ)
- Atypical pathogen coverage for legionella
10. Follow Up
- Urine legionella antigen negative
- Sputum: gram + cocci in clusters 4+ which later grew out MRSA
- Blood Cultures: MRSA, PVL+ or CA-MRSA
11. Community Acquired MRSA Sensitivity in this patient
12. CA-MRSA Pneumonia
- MRSA is an increasing threat in all forms of pneumonia
- CA-MRSA is the newest threat to hospitalized patients with pneumonia
- Enhanced antibiotic resistance
- Higher mortality than MSSA strains
- Expresses multiple virulence factors
13. CA-MRSA: 48 hours of destruction Admission 48 hours later 14. 15. 16. 17. 18. 19. Healthcare Acquired Pneumonia
- Zosyn 3.375-4.5 grams q6 or Fortaz 1.5 gm to 2 gm q8
- Tobramycin 5 mg/kg once daily
- ID or Pulmonary to de-escalate therapy next day.
20. 59 yo with dyspnea and increased work of breathing
- ABG: pH = 7.27, PCO2= 56, PaO2 = 60
- Pulse 125, RR = 32,BP= 120/80, Sat 90% RA
- WBC 17K, BUN = 30, Creat 1.2
- Conversational dyspnea but alert and oriented
- Where should this patient go?
- How should we manage the airway?
21. CXR 22. COPD ManagementNon-invasive ventilation
- Very useful in acute exacerbation especially with dynamic hyperinflation and muscle failure.
- Can be tried even in hypercapneic narcosis.
- Night time use for severe COPD with hypercapnia may be of benefit if tolerated.
- Hypercapneic failure PCO2> 45 mg Hg
- BIPAP: Initial 10 IPAP/ 5 EPAP cm H2O with FIO2 bleed in to maintain sats at 90%, humidified
- Hypoxic and Hypercapneic ventilatory Failure
- Bipap: Initial 10 IPAP /10 EPAP cm H2O with FiO2 Bleed in to maintain sats at 90%, humidified
- CPAP at 10 cm H2Owith FIO2 Bleed in to maintain sats at 90%, humidified
24. COPD Management
- Injudicious administration 02 in CO2 retaining pts may cause acute rise in PaCO2.
- Loss of alveolar hypoxemic vasoconstriction causes flooding of vasculature with alveolarCO2
- NOT LIKELY loss of hypoxemic drive.
- Appears as such because sudden rise in PaCO2 causes narcosis.
- Titrate to 90% at all times
- Avoid respiratory depressants
25. Severe COPD Normal 26. Severe COPD Normal 27. ABG INDICATION
- The most sensitive indicator of physiologic stress irrespective of etiology
28. Blood GasReport( Arterial )
- PaO 2(mm Hg)110 - 0.5(age)
- HCO 3 -(mmol/L): calc.22-26
29. Changes in PO 2and PCO 2as oxygen moves from atmosphere to arterial blood 30.
- Alveolar arterial O2 gradient
- The difference in oxygen pressure between alveolar air and arterial blood
- INCREASE in alveolar / arterial pressure gradient indicates either lung disease or a problem with oxygen transfer
- PAO 2calculated from Alveolar Air Equation
- PaO 2derived from a blood gas report
31. ANALYSIS OF OXYGENATION
- PAO 2= FIO 2 (P B- 47) - 1.2(PaCO 2 )
- PAO 2defines upper limit of PaO 2
- FIO 2is 21% at all altitudes
- Factor 1.2 determined by RQ
- Water vapor pressure = 47 mm Hg
- PAO 2 = 150 - 1.2(PaCO 2 ) at room air
32. Alveolar-Arterial Oxygen Difference
- A-aDo 2= PAO 2 -PaO 2 (from ABG)
- Insight in the patients state of gas exchange
- If elevated,defect in gas exchange
- Proper interpretation of the PaO 2
33. Changes in PaO 2and PAO 2with age 34. Arterial Oxygen Values
- HypoxemiaPaO2 < 70 (relative)
35. Changes in P(A-a)O 2with FIO 2 36. Causes ofa low PaO 2
- Alveolar Hypoventilation(Nl A-a Do2)
- Decreased mixed / centralvenous O 2content
- A 73 yo is brought to the emergency room comatose. The family states she had become confused and had swallowed an excess number of sleeping pills. ABG while breathing room air (FIO 2= 0.21) shows the PaO 2 , is 42 mm Hg, the PaCO 2 , is 75 mm Hg, and the pH is 7.10. Why is her PaO 2reduced?
38. Alveolar Hypoventilation
- No increase in P(A-a)O2 gradient
- A-a gradient = 60 42 = 18 Nl
39. Pulse Oximetry