Pulmonary Pearls

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Review of common pulmonary medical problems Edward Omron MD, MPH, FCCP Pulmonary Medicine Morgan Hill, CA 95037

Text of Pulmonary Pearls

  • 1. Pulmonary Pearls Edward Omron MD, MPH Pulmonary/Critical Care Medicine

2. History

  • 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
    • 35 pack year tobacco use
    • Assisted care facility
    • Recent hospital admission for complicated UTI treated with levofloxacin

3. Physical Exam

  • Respiratory distress
  • Temp 101.8 F
  • Heart Rate 110
  • Blood pressure 80/55 mm Hg
  • Dullness to percussion on right side with crackles

4. Initial Tests

  • ECG: Sinus Tachicardia with LVH
  • WBC: 18,600
  • Creatinine: 1.5,BUN 47
  • ABG
    • pH 7.32
    • PaCO2 = 47 mm Hg
    • PaO2 = 58 mm Hg on 4 L NC

5. ER Chest X-RAY 6. What is the most likely pathogen in this patient?

  • S pneumoniae
  • H influenzae
  • S aureus
  • P aeroginosa
  • K pneumoniae
  • M tuberculosis
  • Other

7. Initial Treatment in the ER

  • Right IJ central venous access
  • Fluid bolus 1 Liter 0.9% NS
  • Oxygen converted to 40% venturi mask
  • Bipap on the way
  • 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?

  • Beta Lactam
  • Respiratory quinolone
  • 3 rdGeneration Cephalosporin+macrolide
  • 3 rdGeneration Cephalosporin+ respirotory quinolone
  • Carbopenem+ aminoglycoside
  • Vancomycin+ respiratory quinolone
  • Vancomycin + extended spectrum penicillin + aminoglycoside
  • Zyvox, Zosyn, levafloxacin
  • Other

9. Initial antibiotics given in the ER

  • Ceftriaxone 2 gram and levafloxacin 750 mg
  • Rationale:
    • 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
  • Community Acquired MRSA

11. Community Acquired MRSA Sensitivity in this patient

  • OxacillinResistant
  • FluoroquinoloneIntermediate
  • MacrolideResistant
  • CephalosporinResistant
  • VancomycinSensitive
  • ClindamycinSensitive
  • LinezolidSensitive
  • SeptraSensitive

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
  • Superbug
    • 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

  • Empiric regimen
    • Vancomycin 1.5 gm IV
    • Zosyn 3.375-4.5 grams q6 or Fortaz 1.5 gm to 2 gm q8
    • Tobramycin 5 mg/kg once daily
    • Pharmacy to DOSE!
    • 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?
    • ICU
    • Monitored Bed
    • Floor
  • 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.

23.

  • Non-invasive ventilation
    • 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
    • Congestive Heart Failure
      • CPAP at 10 cm H2Owith FIO2 Bleed in to maintain sats at 90%, humidified

24. COPD Management

  • For Acute Exacerbations
    • 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

  • Oxygenation
  • Ventilation
  • Acid-Base Status
  • The most sensitive indicator of physiologic stress irrespective of etiology

28. Blood GasReport( Arterial )

  • pH (No Units)7.35-7.45
  • PaCO 2 (mm Hg)35-45
  • PaO 2(mm Hg)110 - 0.5(age)
  • HCO 3 -(mmol/L): calc.22-26
  • B.E. (mmol/L)-2 to 2
  • O 2saturation: calc.>90%

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

  • Alveolar Gas Equation
    • 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
    • PAO 2 = 102

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

  • AgeL.L. PaO2U.L. A-aDo2
  • 208417
  • 308121
  • 407824
  • 507527
  • 607231
  • Max A-aDo2 = 2.5 + Age/5
  • HypoxemiaPaO2 < 70 (relative)

35. Changes in P(A-a)O 2with FIO 2 36. Causes ofa low PaO 2

  • P(B): Altitude
  • Alveolar Hypoventilation(Nl A-a Do2)
  • V/Q mismatch
  • Shunt
  • Diffusion Impairment
  • Decreased mixed / centralvenous O 2content

37.

  • 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
  • PAO 2= 150-1.2 (75) = 60
  • A-a gradient = 60 42 = 18 Nl
  • PaO2 +PCO2 = 120

39. Pulse Oximetry