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Pulmonary Pearls

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Review of common pulmonary medical problems …

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

Published in: Health & Medicine

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  • There are 3 reasones why one should obtain a blood gas:
  • This is a typical printout from a blood gas report:
  • Recall altitiude Recall RS Allows to assess properly if the lungs are transferring loxygen appropriately into the blood
  • Transcript

    • 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 rd Generation Cephalosporin+macrolide
      • 3 rd Generation 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
      • Oxacillin Resistant
      • Fluoroquinolone Intermediate
      • Macrolide Resistant
      • Cephalosporin Resistant
      • Vancomycin Sensitive
      • Clindamycin Sensitive
      • Linezolid Sensitive
      • Septra Sensitive
    • 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 Management Non-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 H2O with 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 alveolar CO2
          • 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 Gas Report( 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 2 saturation: calc. >90%
    • 29. Changes in PO 2 and PCO 2 as 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 2 calculated from Alveolar Air Equation
        • PaO 2 derived from a blood gas report
    • 31. ANALYSIS OF OXYGENATION
      • Alveolar Gas Equation
        • PAO 2 = FIO 2 (P B - 47) - 1.2(PaCO 2 )
        • PAO 2 defines upper limit of PaO 2
        • FIO 2 is 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 2 and PAO 2 with age
    • 34. Arterial Oxygen Values
      • Age L.L. PaO2 U.L. A-aDo2
      • 20 84 17
      • 30 81 21
      • 40 78 24
      • 50 75 27
      • 60 72 31
      • Max A-aDo2 = 2.5 + Age/5
      • Hypoxemia PaO2 < 70 (relative)
    • 35. Changes in P(A-a)O 2 with FIO 2
    • 36. Causes of a low PaO 2
      • P(B): Altitude
      • Alveolar Hypoventilation(Nl A-a Do2)
      • V/Q mismatch
      • Shunt
      • Diffusion Impairment
      • Decreased mixed / central venous O 2 content
    • 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 2 reduced?
    • 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
      • Binding sites for O 2 are heme groups
      • OXYGEN SATURATION
        • % of all heme sites saturated with O2
      • Measures the difference in the light absorbance characeteristics between Oxy Hb and Deoxy Hb
      • SpO2 = Oxy Hb x 100
      • Oxy Hb + Deoxy Hb
      • ABG SaO2 is a calculated value from PaO2
    • 40. Pulse Oximetry Whole Blood PaO2 SaO2 SpO2: Pulse Oximetry ABG
    • 41. Problem
      • 28 yo pt with fevers,chills, SOB,cough
        • Taking Dapsone for PCP prophylaxis
        • ABG: PaO2 90, PaCO2 35.2, pH 7.43, SaO2 100%
        • Pulse oximeter 89%
        • PCP Pneumonia, started on Septra, Clinda, and Prednisone
        • ABG: PaO2 378, PaCO2 of 35, pH 7.42, SaO2 100%
        • Pulse Oximeter 83%
        • Whats Happening?
    • 42. Methemoglobin
      • Oxidation of Fe++ to Fe+++ state
      • Met-Hb depresses the SpO2 reading
      • Dapsone is an oxidant
      • Met-Hb depresses the SpO2 to 80’s
        • Further increases in Met-Hb do not depress SpO2
      • Methylene Blue administration is Rx
    • 43.  
    • 44. Co-oximetry
      • SpO2 = Oxy-Hb
      • Oxy-Hb+Deoxy-Hb+CO-Hb+Met-Hb
    • 45. Oximetry
      • 54 yo WM with headaches, dyspnea and a Kerosene heater at home
        • ABG: PaO2 = 89, PaCO2 = 38, pH = 7.43
        • SaO2 from ABG= 98%
        • Pulse Oximetry = 98%
        • Whats the problem?
    • 46. Oximetry
      • Carboxyhemoglobin: Hb +CO
        • Does not affect PaO2 or pulse oximetry
        • P.O. reads CO as oxyhemoglobin
        • Need co-oximetry if suspected
      • Follow Up:
        • PaO2 = 79, PaCO2 = 31, SpO2 = 53%, pH =7.36
        • CO-Hb46%
    • 47.