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

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.

2. Leptospirosis
Management

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

24. Thank You.