Pulmonary
Disclaimer: the clinical information on this site is only meant to serve as a reference. Please consult with your team for individual diagnostic and treatment decisions.
Aspiration Pneumonitis/Aspiration Pneumonia
- Aspiration pneumonitis is a chemical burn from oral/gastric secretions that often has a brief but sharply elevated fever and brief but strikingly CXR infiltrate with respiratory distress that goes away without antibiotics after several hours. Aspiration pneumonia is an infection with neutrophil exudates so the fever, respiratory distress, and CXR infiltrate appear more gradually. Not every aspiration needs antibiotics.
- Aerobic bacteria: Strep pneumoniae, Staph aureus, Haemophilus influenzae, Pseudomonas aeruginosa, Klebsiella
- Anaerobic bacteria: Bacteroides, Prevotella, Fusobacterium, Peptostreptococcus
- Consider getting a sputum culture and MRSA swab
- UPHS Antibiotic Stewardship Guidelines for Empiric Treatment/Sensitivities
- Triggers: indoor and outdoor allergens, cigarette smoke, viral respiratory infections, running out of or insufficient inhaler medications
- Diagnostic: consider CXR, respiratory viral panel (if applicable)
- Inpatient flare: albuterol/ipratropium nebulizer, steroids PO or IV, magnesium sulfate or racemic epinephrine (if severe), BiPAP/intubation
- Nebulizers: use albuterol/ipratropium up to every 15 minute x 3 in ED then no more than every 4 hours on med-surg floor, eventually space out to every 6 hours prior to discharge
- Steroids: prednisone PO (usually about 50mg since is highest single tablet produced as 60mg requires two 30mg tablets) and methylprednisolone IV (usually 125mg as STAT dose in the ED then can use 40-60mg daily or switch to prednisone PO) have roughly the same bioavailability/onset of action. Much of steroid treatment in asthma/COPD is stylistic. Asthma patients are more likely than not to get a rapid taper of steroids and taper may be longer if still shedding virus (ex: influenza). Inhaled steroids/LABAs (ex: Advair, Symbicort, Dulera, Breo Ellipta) can be continued as Advair (Penn formulary).
- Magnesium sulfate: 2 gram IV infusion (stabilizes spasming of airway muscles) if severe
- Racemic epinephrine: through nebulizer, especially if hear stridor in the neck, if severe
- Triggers: indoor and outdoor allergens, cigarette smoke, viral respiratory infections, running out of or insufficient inhaler medications
- Diagnostic: consider CXR, respiratory viral panel (if applicable)
- Inpatient flare: albuterol/ipratropium nebulizer, steroids PO or IV, azithromycin or doxycycline for anti-inflammation
- Nebulizers: use albuterol/ipratropium up to every 15 minute x 3 in ED then no more than every 4 hours on med-surg floor, eventually space out to every 6 hours prior to discharge
- Inhaled LAMA (long acting muscarinic antagonist): Spiriva (tiotropium) which would be a longer acting form of ipratropium can be started at the end of admission for long term control
- Steroids: prednisone PO (usually about 50mg since is highest single tablet produced as 60mg requires two 30mg tablets) and methylprednisolone IV (usually 125mg as STAT dose in the ED then can use 40-60mg daily or switch to prednisone PO) have roughly the same bioavailability/onset of action. Much of steroid treatment in asthma/COPD is stylistic. COPD patients are less likely to get a prednisone taper (more likely to get a 5 day burst) unless on chronic oxygen, frequent COPD flares, or still shedding a respiratory virus. Inhaled steroids/LABAs (ex: Advair, Symbicort, Dulera, Breo Ellipta) can be continued as Advair (Penn formulary).
- Anti-inflammatories: while azithromycin and doxycycline (used as an azithromycin replacement if QTc > 500) can treat a possible pneumonia, they are used for anti-inflammatory properties in COPD exacerbations
- First line: Mucinex (guaifenesin), Robitussin (guaifenesin-dextromethorphan)
- Second line: guaifenesin-codeine
- Consider in hypertensive emergency with CHF or renal failure
- Give diuretic (start with Lasix 40mg IV if diuretic naive, if on diuretics consider Lasix 80mg IV, if CKD/ESRD may need Lasix 120mg IV) but this will take time to work
- Give nitroglycerin sublingually (can give drip if needed) to vasodilate, lower BP, and reduce fluid returning to heart/lungs
- Give hydralazine IV to arteriodilate, deliver blood to kidneys, and suppress the RAAS activation
- Brief differential: 5P’s (pulmonary embolism, pneumothorax, pneumonia, pulmonary edema, pleural effusion) or 5A’s (asthma/COPD, anaphylaxis, atelectasis, aspiration, ARDS)
- Oxygen modalities: room air, 6L NC, Ventimask, nonrebreather, high flow nasal cannula, BiPAP, bag valve mask, intubation, FiO2/PEEP changes, paralysis, recruitment maneuvers, proning, ECMO (exact order depends on situation)
- Consider: stat CXR, ABG, listen to both lungs, suctioning/chest PT, diuresis, IV methylprednisolone 125mg, antibiotics, IM epinephrine, CT PE protocol, thoracentesis, Flolan (epoprostenol)
- Tamiflu (oseltamivir) can be used in the first 48 hours of symptoms to reduce influenza symptoms by one day
- Higher risk patients can be treated with Tamiflu even after 48 hours of symptomsDosing is different in transplant patients and CKD/ESRD patients
- UPHS Antibiotic Stewardship Guidelines for Empiric Treatment/Sensitivities
- Community-acquired pneumonia: UPHS Antibiotic Stewardship Guidelines for Empiric Treatment/Sensitivities
- Healthcare-associated or hospital-acquired pneumonia: consider getting a sputum culture if possible and MRSA nasal swab: UPHS Antibiotic Stewardship Guidelines for Empiric Treatment/Sensitivities
- Diuresis: If known home dose, double it and give 1-2 times daily with goal 1-2L net negative. 1.5L fluid restriction with a low sodium diet. Bad kidneys (CKD) mean you need to start at a higher dose to be effective but careful if the patient is diuretic-naive.
- Lasix (furosemide) PO to IV is 2:1. Bumex (bumetanide) PO to IV is 1:1. Torsemide has no IV option. Some patients need metolazone (thiazide diuretic) given 30 minutes before the loop diuretic (Lasix/Bumex/torsemide) to potentiate the loop diuretic usually metolazone 2.5-5mg daily or MWF but this can also cause significant hypokalemia.
- Diurese until pulmonary edema is gone, legs not swollen, JVP normalizes, serum bicarbonate (CO2) rises, and/or creatinine rises. Convert to PO diuretic usually less than the IV equivalent based on whether or not the home dose was sufficient. Advise patient to take an extra diuretic dose and call the office if gains 5 pounds in 2 days.
- If have PE, do four extremity dopplers so if clot forms in the future you know if you failed anticoagulation or if the clot was already there
- If concern for submassive/massive PE that might need a PE response team consult for catheter-directed thrombolysis or mechanical thrombectomy, check BP (<90/60), troponin, proBNP, echocardiogram, and persistence of severe symptoms even after therapeutic anticoagulation for several days
- First provoked DVT/PE: 3 months anticoagulation
- First unprovoked DVT/PE: 6 months anticoagulation
- Cancer DVT/PE: treat as long as cancer is still active (could be lifelong)
- Massive PE, second DVT/PE, autoimmune or hereditary clotting disorder, lifelong immobility, common femoral (very proximal) DVT: discuss possibility of lifelong anticoagulation