Therapeutics Pulmonary Arnoldi Flashcard

Etiology of Acute Bronchitis

  • More common in winter months
  • Cold, damp climates
  • Air pollution
  • Cigarette smoke
  • Most commonly caused by respiratory viruses
  • Secondary bacterial infections

Common Bacterial Pathogens of Acute Bronchitis

  • M. pneumoniae
  • C. pneumoniae
  • B. pertussis

Other Possible Pathogens

  • Streptococcus
  • Staphylococcus
  • Haemophilus

Pathogenesis of Acute Bronchitis

  • Infection of trachea and bronchi
  • Edematous mucus membranes
  • Increased bronchial secretions
  • Destruction of respiratory epithelium
  • Impaired mucociliary activity

Acute Bronchitis: Signs/Symptoms

  • Cough persisting > 5 days to weeks
  • Coryza
  • Sore throat
  • Malaise
  • Headache
  • Fever rarely > 39 C

Acute Bronchitis: Physical Exam and Chest X-Ray Findings

  • Rhonchi or coarse, moist, bilateral rales
  • Purulent sputum in ~50% of patients
  • Chest X-Ray — Normal

Acute Bronchitis: Pharmacological Treatment

1.  Mild Analgesic/Anti-Pyretic Therapy

  • Acetaminophen
  • Ibuprofen

2.  Dextromethorphan

  • For persistent, mild cough that is bothersome
  • In general, avoid OTC products as they can dehydrate bronchial secretions and aggravate/prolong recovery

3.  Codeine

  • Antitussive for severe coughs
  • Avoid codeine in productive coughs

4.  Antibiotics

  • Empiric therapy against suspected bacterial pathogens
  • Avoid routine use

5.  Antivirals

  • In case of viral epidemics, consider amantadine, rimantadine, zanamavir, or oseltamivir

COPD Exacerbation: Pathophysiology

  • Increased neutrophils and eosinophils in sputum
  • Poor gas exchange
  • Increased muscle fatigue

COPD Exacerbation: Common Causes

  • Bacterial/Viral Infection
  • Indoor/Outdoor Air Pollution
  • Smoking

COPD Exacerbation: Common Bacterial Pathogens

  • S. pneumoniae
  • H. influenzae
  • M. catarrhalis

COPD Exacerbation: Signs/Symptoms

3 Cardinal Symptoms

  • INCREASED SOB
  • INCREASED SPUTUM VOLUME
  • INCREASED SPUTUM PURULENCE
  • Wheezing and chest tightness
  • Increased cough
  • Fever
  • Changes in mental status
  • Decreased exercise tolerance
  • Increased use of rapid-acting bronchodilators
  • Nasal flaring
  • Use of accessory muscles for respiration

Nonspecific:

  • Tachycardia, tachypnea, fatigue, insomnia

COPD Exacerbation: Acute Change in ABG from Baseline

Decrease PaO2 of 10-15 mmHg

+

SaO2 < 90%

+

PaO2 < 60 mmHg

 

AND

 

Increased PaCO2 that decreases serum pH < 7.3

COPD Exacerbation: Diagnostic Tests

Chest Radiography

  • New infiltrates
  • Limited value
  • Useful for finding alternative diagnosis

Sputum Cultures

  • Gram stain
  • Cells (Neutrophils > 25, Epithelial < 10)
  • Speciation and sensitivities
  • Colonization?

COPD Exacerbation: Differential Diagnosis

  • Pneumonia
  • CHF
  • AMI
  • PE
  • Pneumothorax
  • Pleural Effusion
  • Cardiac Arrhythmia

COPD Exacerbation: Stages of Severity

Mild

 

1 cardinal symptoms plus one of the following:

URTI within 5 days

Fever

Increased Wheezing

Cough

Tachypnea or Tachycardia

 

Moderate

 

2 Cardinal Symptoms

 

Severe

 

3 Cardinal Symptoms

 

 

COPD Exacerbation: Home Management

Bronchodilator Therapy

 

Increase dose/frequency of home Beta agonists and/or anticholinergics

 

Glucocorticoids

 

Systemic, NOT inhaled

Prednisone 30-40 mg PO QD x 7-10 days


COPD Exacerbation In-Hospital Management: Oxygen Therapy

  • CORNERSTONE of therapy

Goal Parameters:

SaO2 > 90%

+

PaO2 > 60 mmHg

 

 

COPD Exacerbation In-Hospital Management: Bronchodilator Therapy

SABA

  • Albuterol = 1st line agent
  • Albuterol 0.5% Sol’n Nebulizer, Albuterol MDI

Anticholinergic Agent

  • Ipratropium
  • Used concurrently or alternating with SABA
  • Ipratropium 0.02% Sol’n Nebulizer, Ipratropium MDI

Combination SABA/Anticholinergic

  • Albuterol/Ipratropium Nebulizer or MDI

 

COPD Exacerbation In-Hospital Management: Glucocorticoid Therapy

 

  • For moderate to severe exacerbations
  • Especially advantageous in patients who are wheezing
  • Oral or IV –> as addition to other therapies
  • Inhaled corticosteroids should NOT be used for treatment of acute exacerbation
  • Methylprednisolone, Prednisone

COPD Exacerbation In-Hospital Management: Antibiotic Therapy

Used in the following situations:

  • 3 cardinal symptoms present
  • 2 of 3 cardinal symptoms if increased purulence of sputum is one of the 2 symptoms
  • Mechanical ventilation is needed

Should be empiric based therapy

Duration usually 7-10 days

If concerned for other respiratory pathogens (MRSA), cover those pathogens (Vanco, Linezolid)

De-escalation of therapy if pathogen identified

TMP/SMX, amoxicillin, 1st Gen Ceph, and Erythromycin should not be used due to resistance

COPD Exacerbation In-Hospital Antibiotic Management: Uncomplicated Exacerbations

 

Patient characteristics, Likely Pathogens, and Treatment

Patient Characteristics

  • < 4 exacerbations/yr
  • No comorbid illnesses
  • FEV1 > 50% predicted

Likely Pathogens

  • S. pneumoniae
  • H. influenzae
  • M. catarrhalis
  • H. parainfluenza

Treatment

  • Macrolide
  • 2nd or 3rd Gen Ceph
  • Beta Lactam/Beta-Lactamase Inhibitor

COPD Exacerbation In-Hospital Antibiotic Management: Complicated Exacerbations

 

Patient characteristics, Likely Pathogens, and Treatment

Patient Characteristics

  • Age > 65 yr
  • > 4 exacerbations/yr
  • FEV1 < 50% but > 35% predicted

Likely Pathogens

  • S. pneumoniae
  • H. influenzae
  • M. catarrhalis
  • H. parainfluenza
  • Drug resistant Pneumococci
  • Beta-Lactamase producing H. influenzae, M. catarrhalis
  • Some enteric G-

Treatment

  • 2nd or 3rd Gen Ceph
  • Beta Lactam/Beta-Lactamase Inhibitor
  • Respiratory Fluoroquinolone

COPD Exacerbation In-Hospital Antibiotic Management: Complicated Exacerbations w/ Risk of Pseudomonas

 

Patient characteristics, Likely Pathogens, and Treatment

Patient Characteristics

  • > 4 exacerbations/yr
  • Chronic bronchial sepsis
  • Chronic corticosteroid therapy
  • Nursing home resident
  • FEV < 35% predicted

Likely Pathogens

  • S. pneumoniae
  • H. influenzae
  • M. catarrhalis
  • H. parainfluenza
  • Drug resistant Pneumococci
  • Beta-Lactamase producing H. influenzae, M. catarrhalis
  • Some enteric G-
  • Pseudomonas

Treatment

  • 3rd or 4th Gen Ceph w/ Pseudomonas activity
  • Beta Lactam/Beta-Lactamase Inhibitor
  • Fluoroquinolone

COPD Exacerbation: Non-Invasive Ventilatory Support

Indications, Relative Contraindications

  • Positive pressure ventilation provided via face mask or nasal mask
  • Common types — BiPAP and CPAP
  • FIRST LINE therapy — improves resp. acidosis and decreases resp. rate, severity of breathlessness, length of hospital stay, and intubation rate

Indications for NIV:

  • Moderate to severe dyspnea w/ use of accessory muscles and/or paradoxical abdominal motion
  • Moderate to severe acidosis (pH < 7.35)
  • Moderate to severe hypercapnea (PaCO2 > 45 mmHg)
  • Resp. rate > 25 breaths/min

Relative CI:

  • Respiratory arrest
  • Cardiovascular instability
  • Changes in mental status
  • High aspiration risk
  • Craniofacial trauma or recent craniofacial surgery

COPD Exacerbation: Invasive Ventilatory Support

Indications, Complications

Indications:

  • Unable to tolerate NIV or NIV failure
  • Severe dyspnea w/ use of accessory muscles and paradoxical abdominal motion
  • Resp. rate > 35 breaths/min
  • Life-threatening hypoxemia
  • Severe acidosis (pH < 7.25) and/or hypercapnea (PaCO2 > 60 mmHg)
  • Respiratory arrest
  • Worsening mental status despite optimal therapy
  • Cardiovascular complications (hypotension, shock)

Complications:

  • Ventilator-Associated Pneumonia
  • Barotrauma
  • Failure to extubate from invasive ventilation

COPD Exacerbation: Strategies for preventing future exacerbations

  • Smoking Cessation
  • Current vaccinations — influenza and pneumococcal
  • Patient education on current therapies
  • Proper inhalation/nebulizer technique
  • Education on recognizing symptoms of exacerbation

COPD Exacerbation: Appropriate Discharge Criteria

  • Clinically stable for 12-24 hrs
  • Arterial blood gas stable for 12-24 hrs
  • Inhaled SABA needed < q 4 hrs
  • Patient able to walk across room if ambulatory pre-hospitalization
  • Patient able to eat and sleep w/o frequent interruption by dyspnea
  • Patient/caregiver understands proper use of medications
  • Follow-up and home care arrangements completed

COPD Exacerbation: Monitoring

  • Assessment at 4-6 week F/U
  • FEV1 measurements
  • Reassessment of inhaler technique
  • Understanding of current treatment regimens
  • Need for long-term oxygen therapy and/or home nebulizer

COPD Exacerbation: Predictors of Poor Survival

  • Baseline Dyspnea
  • Lower BMI
  • Older age
  • CHF
  • Development of extra-pulmonary organ failures
  • Serum albumin levels
  • Cor pulmonale
  • Ventilation > 72 hrs

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