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Monsoon Illnesses affecting Lungs (Part 1 of 2)

Manjit Tendolkar
Manjit Tendolkar
Manjit TendolkarResident, Pulmonary Medicine at Seth G. S. Medical College and K. E. M. Hospital

This continuing ;art includes the management of monsoon Illnesses with respect to pulmonary involvement.

Monsoon Illnesses affecting Lungs (Part 1 of 2)

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Monsoon Illnesses 
affecting Lungs (Part 2 
of 2) 
Dr. Manjit S. Tendolkar 
Department of Chest Medicine, 
Seth G. S. Medical College & K. E. M. Hospital.
Leptospirosis 
Management
Introduction 
Leptospirosis is a treatable disease, and hence 
early diagnosis and prompt treatment are 
important for the improvement of prognosis 
Although, efforts to reach a definitive diagnosis 
should always be undertaken, prompt institution 
of pertinent therapy should take precedence, as 
patients with leptospirosis are known to 
demonstrate a rapid deterioration in their clinical 
course
Suspecting Leptospirosis 
The most characteristic clinical signs for early 
diagnosis are acute febrile illness of sudden onset, 
severe general malaise, lumbago, muscular pains 
and conjunctival suffusion 
Proteinuria, raised erythrocyte sedimentation rate, 
and leucocytosis with neutrophilia are the most 
indicative clinical laboratory findings for early 
diagnosis 
Serum aspartate aminotransferase (AST/SGOT), 
alanine aminotransferase (ALT/SGPT) and lactic 
dehydrogenase (LDH) levels are slightly elevated 
even in severe patients with jaundice. These findings 
are very important in differentiating between 
leptospirosis and viral hepatitis
Treating Leptospirosis 
If the disease is not treated appropriately within 
the first 2-3 days, it may progress in severity 
In the olden days, immune horse serum or 
specific immunoglobulin were used, and proved 
to be effective when given early 
Effective antimicrobial therapy should also be 
initiated before the fifth day after the onset of 
illness 1
General Management and 
Supportive Therapy 
General management of leptospirosis includes 
providing symptomatic and supportive therapy, 
as indicated by the nature and severity of the 
symptoms and signs. Bed rest is required for 1-2 
weeks in the mild forms, and for 2-4 weeks in the 
severe forms. Return to work should be gradual. 
The progress is monitored with routine 
measurement of temperature, pulse rate and 
blood pressure, monitoring of the urinary output 
and fluid balance, and review of tests such as 
complete blood count, erythrocyte sedimentation 
rate, liver function tests, urinalysis, blood urea 
nitrogen (BUN), creatinine and electrolyte 
analysis

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Monsoon Illnesses affecting Lungs (Part 1 of 2)

  • 1. Monsoon Illnesses affecting Lungs (Part 2 of 2) Dr. Manjit S. Tendolkar Department of Chest Medicine, Seth G. S. Medical College & K. E. M. Hospital.
  • 3. Introduction Leptospirosis is a treatable disease, and hence early diagnosis and prompt treatment are important for the improvement of prognosis Although, efforts to reach a definitive diagnosis should always be undertaken, prompt institution of pertinent therapy should take precedence, as patients with leptospirosis are known to demonstrate a rapid deterioration in their clinical course
  • 4. Suspecting Leptospirosis The most characteristic clinical signs for early diagnosis are acute febrile illness of sudden onset, severe general malaise, lumbago, muscular pains and conjunctival suffusion Proteinuria, raised erythrocyte sedimentation rate, and leucocytosis with neutrophilia are the most indicative clinical laboratory findings for early diagnosis Serum aspartate aminotransferase (AST/SGOT), alanine aminotransferase (ALT/SGPT) and lactic dehydrogenase (LDH) levels are slightly elevated even in severe patients with jaundice. These findings are very important in differentiating between leptospirosis and viral hepatitis
  • 5. Treating Leptospirosis If the disease is not treated appropriately within the first 2-3 days, it may progress in severity In the olden days, immune horse serum or specific immunoglobulin were used, and proved to be effective when given early Effective antimicrobial therapy should also be initiated before the fifth day after the onset of illness 1
  • 6. General Management and Supportive Therapy General management of leptospirosis includes providing symptomatic and supportive therapy, as indicated by the nature and severity of the symptoms and signs. Bed rest is required for 1-2 weeks in the mild forms, and for 2-4 weeks in the severe forms. Return to work should be gradual. The progress is monitored with routine measurement of temperature, pulse rate and blood pressure, monitoring of the urinary output and fluid balance, and review of tests such as complete blood count, erythrocyte sedimentation rate, liver function tests, urinalysis, blood urea nitrogen (BUN), creatinine and electrolyte analysis
  • 7. Chest radiograph, electrocardiogram, determination of bleeding, clotting and prothrombin time, and analysis of cerebrospinal fluid are also important and are done to determine the severity of illness and for detection of complications.
  • 8. Renal Involvement -- Restriction of fluid intake and provision of a high carbohydrate, low protein diet Headache and muscular pains are treated with analgesic agents, and fever is managed with antipyretic agents Intravenous injection of diazepam is very effective in controlling convulsions
  • 9. Role of appropriate fluid management strategy titrated to clinical manifestations, state of illness and presence or otherwise of renal involvement cannot be over-emphasized. Oliguria due to dehydration or hypotension should be corrected and urine output maintained through fluid supplementation and restitution of blood pressure. After hydration and correction of blood pressure, furosemide (with doses up to 1000 mg/day) may be used to ensure adequate diuresis
  • 10. Severe and worsening renal failure is treated with dialysis. It is advisable to institute dialysis early, as soon as BUN level reaches 200 mg/dl. Peritoneal dialysis is preferred to haemodialysis, as it is technically simpler. Plasmapheresis with dialysis may be effective for serious case with disturbance of consciousness
  • 11. Management of bleeding and thrombocytopenia may require packed cell transfusion, or platelet transfusion, respectively Some authorities believe in prudent use of steroids in subjects with severe manifestations. However, association of remarkable haemorrhage, and macroscopic and histological changes with steroid therapy in experimentally infected guinea pigs cast doubts over its use 2
  • 12. Chemotherapy Penicillin kills leptospires in the logarithmic growth phase, but not in the stationary phase (also Erythromycin) Streptomycin has been shown to kill leptospires in both the logarithmic growth phase and the stationary phase High concentrations of tetracycline were associated with a leptospirocidal effect, which could not be attained with low concentrations of the drug
  • 13. Streptomycin was more effective than others in completely removing leptospires from all tissues Although, penicillin, cephems, tetracyclines and macrolides were also effective in experimental leptospirosis, small numbers of leptospires sometimes remained in the liver and kidney Truccolo et al. evaluated the susceptibility of leptospies to selected antimicrobial agents (ampicillin, doxycycline and ofloxacin) in a hamster model.[48] Their results demonstrated the ability of ampicillin at a high dose to clear leptospires from the host, except from kidneys and heart, where leptospires remained at day 6. Ofloxacin was unable to clear leptospires from blood or kidneys. With doxycycline, the clearance of leptospires occurred in 2 days in all the target organs studied, with the exception of liver, which required 3 days
  • 14. Prognosis Fatal outcome is mainly related to renal failure although other features such as hyperkalaemia, thrombocytopenia, cardiovascular failure with hypotension and arrhythmia, and respiratory failure with massive haemoptysis are known to contribute to the mortality rate. Most deaths occur between the 10th and 15th days of illness, although death can occur as early as the fifth day of illness in fulminant severe cases
  • 15. If the patient is not treated for the severe form within 2-3 days after the onset of illness, it may progress in severity and sometimes be fatal
  • 16. Ventillatory Management of ARDS3 Ventillatory Setup Calculate predicted body weight (PBW) Males = 50 + 2.3 [height (inches) - 60] Females = 45.5 + 2.3 [height (inches) -60] Select any ventilator mode Set ventilator settings to achieve initial VT = 8 ml/kg PBW Reduce VT by 1 ml/kg at intervals ≤ 2 hours until VT = 6ml/kg PBW. Set initial rate to approximate baseline minute ventilation (not > 35 bpm). Adjust VT and RR to achieve pH and plateau pressure goals below.
  • 17. Oxygenation Goal: PaO2 55-80 mmHg or SpO2 88- 95% Use a minimum PEEP of 5 cm H2O. Consider use of incremental FiO2/PEEP combinations
  • 18. Plateau Pressure Goal: ≤ 30 cm H2O Check Pplat (0.5 second inspiratory pause), at least q4h and after each change in PEEP or VT. If Pplat > 30 cm H2O: decrease VT by 1ml/kg steps (minimum = 4 ml/kg). If Pplat < 25 cm H2O and VT< 6 ml/kg, increase VT by 1 ml/kg until Pplat > 25 cm H2O or VT = 6 ml/kg. If Pplat < 30 and breath stacking or dys-synchrony occurs: may increase VT in 1ml/kg increments to 7 or 8 ml/kg if Pplat remains < 30 cm H2O.
  • 19. pH Goal: 7.30-7.45 Acidosis Management: (pH < 7.30) If pH 7.15-7.30: Increase RR until pH > 7.30 or PaCO2 < 25 (Maximum set RR = 35). If pH < 7.15: Increase RR to 35. If pH remains < 7.15, VTmay be increased in 1 ml/kg steps until pH > 7.15 (Pplat target of 30 may be exceeded). May give NaHCO3 Alkalosis Management: (pH > 7.45) Decrease vent rate if possible.
  • 20. I: E RATIO GOAL Recommend that duration of inspiration be < duration of expiration.
  • 21. Weaning Conduct a SPONTANEOUS BREATHING TRIAL daily when: FiO2 ≤ 0.40 and PEEP ≤ 8. PEEP and FiO2 ≤ values of previous day. Patient has acceptable spontaneous breathing efforts. (May decrease vent rate by 50% for 5 minutes to detect effort.) Systolic BP ≥ 90 mmHg without vasopressor support. No neuromuscular blocking agents or blockade.
  • 22. SPONTANEOUS BREATHING TRIAL (SBT): If all above criteria are met and subject has been in the study for at least 12 hours, initiate a trial of UPTO 120 minutes of spontaneous breathing with FiO2 < 0.5 and PEEP < 5: • 1. Place on T-piece, trach collar, or CPAP ≤ 5 cm H2O with PS < 5 • 2. Assess for tolerance as below for up to two hours. a. SpO2 ≥ 90% and/or PaO2 ≥ 60 mmHg b. Spontaneous VT ≥ 4 ml/kg PBW c. RR ≤ 35/min d. pH ≥ 7.3 e. No respiratory distress (distress= 2 or more) HR > 120% of baseline Marked accessory muscle use Abdominal paradox Diaphoresis Marked dyspnea • 3. If tolerated for at least 30 minutes, consider extubation. • 4. If not tolerated resume pre-weaning settings.
  • 23. Refrences 1. Kobayashi Y. Clinical observation and treatment of leptospirosis. J Infect Chemother 2001;7:59- 68. 2. Aso M. The effects of antihistamic drug, rutin and cortisone on hemorrhage of leptospirosis icterohaemorrhagica (In Japanese). Fukuoka Med Acta 1955;46:188-201. 3. http://www.ardsnet.org/system/files/Ventilator%2 0Protocol%20Card.pdf