Smart Phrases And Workups – Pulm Crit

ARDS		

ASTHMA 

#Mild Asthma
Triggers: exercise, cold air, irritants, allergins, infection (URI/bronchitis/sinusitis), drugs (ASA, NSAIDs, beta-blockers, opioids)
FEV1/FVC <0.7, reverses with bronchodilator, worsens with methacholine
Peak expiratory flow <80 personal best = poor control
*** CXR:
- supplemental O2 prn | goal SpO2 92-96%
- SABA q4-6 hours
- lower rates severe exacerbation with quadrupling inhaled steroids at symptom onset (NEJM 2018;378:902)
- consider ABG | anticipate respiratory alkalosis (normal pH >> impending respiratory failure)
- consider prednisone 40 mg x5 days
- if severe consider Mg 2g IV over 20 mins (JAMA 1989;262:1210)
- vaccines: flu, PCV13, PPSV23

Adult onset: consider allergic bronchopulmonary aspergillosis, EGPA, eosinophilic esophagitis, systemic mastocytosis

#Severe Asthma
Triggers: exercise, cold air, irritants, allergins, infection (URI/bronchitis/sinusitis), drugs (ASA, NSAIDs, beta-blockers, opioids)
FEV1/FVC <0.7, reverses with bronchodilator, worsens with methacholine
Peak expiratory flow <80 personal best = poor control
*** CXR:
- f/u ABG | anticipate respiratory alkalosis (normal pH >> impending respiratory failure)
- supplemental O2 prn | goal SpO2 92-96% | consider intubation with high rate (80-100 l?min), low Vt 6 cc/kg, low RR (10-14), permissive hypercapnea
- continuous albuterol nebs
- lower rates severe exacerbation with quadrupling inhaled steroids at symptom onset (NEJM 2018;378:902)
- methylprednisone 125 mg IV q6h (Archives 1983;143::1324)
- Mg 2g IV over 20 mins (JAMA 1989;262:1210)
- consider Heliox
- admit to ICU
COPD	
COPD
Risk factors: smoking, air polution, A1AT deficiency
FEV1/FVC <0.7
Severity: mMRC breathlessness, CAT health impairment, Gold Staging Spirometry, Frequency of exacerbations
***CXR
***EKG
- f/u CBC, BMP, VBG, NT-proBNP, D-dimer, procalcitonin
- supplemental O2 prn | goal SpO2 88-92% (BMJ 2010;341:c5462)
- albuterol q4h + q2h prn, ipratropium q4h standing (duoneb = albuterol + ipratropium)
- hold home ICS, LABA, LAMA
- prednisone 40 mg x4 days (Cochrane 2018;3:CD006897)
- consider azithromycin vs levofloxacin if increased sputum | antibiotics decrease mortality and readmission

Outpatient maintenance
- LAMA + LABA: increase FEV1, decrease symptoms and exacerbations (Cochrane 2015;(10):CD008989)
- PDE-4 inhibitors (roflumilast): increase lung function, decrease exacerbations severe COPD (Lancet 2015;385:857)

- on discharge counsel on smoking cessation, risk factor reductions, pulmonary rehab
- vaccines: influenza, PCV13, PPSV23
- annual low-dose CT lung cancer screening (age 55-80 with 20 pack-year hx and active use or quit <15 years ago)
- home O2 if SpO2 <88%

COVID	
#COVID Pneumonia
Risk factors: age, obesity, cancer, CKD, COPD, immunocompromised, SCD, tobacco use, DM
*** symptom onset
*** COVID swab +
CXR ***
- f/u COVID severity labs
- f/u strep pneumo, legionella
- contact and droplet precautions
- supplemental O2 prn; goal SpO2 90-96%; wean as tolerated
- encourage patient to prone position to recruit atelectic lung tissue in dependent lung basis | ideally 12-18 h/day
- supportive care with IS, combivent q4h, benzonatate prn, guanifenesin prn
- Daily zinc supplementation (PMID 33094446) for known antioxidant, anti inflammatory, immunomodulatory and antiviral activity.
- Daily vitamin D supplementation (PMID 33142828)-- can dc if pending vitamin D level >20.
- Remdesivir x5 days given not intubated and GFR >30
- dexamethasone 6 mg x10 days or off O2; whichever comes first
- home O2 eval pending anticipated discharge date
- counseled on the importance of vaccination

HEMOPTYSIS	

#Hemoptysis
Etiology: bronchitis, bronchiectasis, malignancy, trauma, infection (PNA, abscess, TB, aspergilloma), GPA, SLE/cryo/HSP, Goodpasture, drug-induced vasculitis (cocaine, PTU), coagulopathy, endometriosis, inhalation injury, sarcoid, PE, CHF, mitral regurg, AVM
***CXR:
- f/u CBC, coags, UA (vasculitis),
- sputum Cx
- CT chest if stable
- consider BNP, ESR/CRP, C3/C4, ANA, ANCA, anti-GBM, anti-cardiolipin, beta2 glycoprotein, lupus antibody, AFB or interferon gamma, d-dimer

- massive hemoptysis >500 cc's >> interventional pulm for bronch

ILD Workup	

#Interstitial Lung Disease
Etiology: UIP, sarcoid, amyloid, ANCA vasculitis, scleroderma, polymyositis, dermatomyositis, rheumatoid arthritis, systemic lupus erythmatosis, inhalation exposure (mold, bird, silica, aspestos), drugs (amiodarone, nitrofurantoin, MTX, nivolumab, pembrolizumab, ipilimumab, radiation
- CBC, CMP, ESR, CRP, CPK, aldolase, C3/C4, ANA, anti-RNP, anti-Ro/La, Scl-70, RF, anti-CCP, ANCA, hypersensitivity panel, myositis panel, anti-Jo1
- f/u CXR, CT Chest, PFTs
- pirfenidone (antifibrotic) or nintedanib (TKI - reduces FVC decline, no survival benefit) (NEJM 2014;370:2083 and NEJM 2014;370:2071)

pHTN	

#Pulmonary Hypertension
Mean PA pressure >/= 25 mmHg at rest
Symptoms: DOE (early), syncope (late)
Classification: Group 1 (idiopathic, intoxication, infectious, inflammatory), Group 2 (L heart disease), Group 3 (lung disease), Group 4 (thromboembolic), Group 5 (SCD, MPN)
*** EKG
*** CXR
- f/u LFTs, ANA, RF, CCP, ANCA, Scl-70, Ro/La, BNP, HIV
- f/u TTE
- outpatient PFTs, 6 min walk test before discharge
- RHC in outpatient setting

Treatment
Group 1: endothelin R antagonist (bosentan, ambrisentan, macitentan - decrease mortality NEJM 2013;369:809), PDE5 inhibitors (sildenafil, tadalafil - increase exercise capacity NEJM 2005;353:2148), sGC stimulator (riociguat), R agonist (selexipag (decrease hospitalization NEJM 2015;373:2522)
Group 2: treat underlying cause
Group 3: PDE5 inhibitors (sildenafil, tadalafil - improves hemodynamics - NEHM 2013;369:330)
Group 4: sCG stimulator (riociguat - NEJM 2013;369:330)

RES DISTRESS	

#Respiratory Distress
Tachypnea (RR>20), cyanosis (SpO2 <80%), increased wob (nostril flaring, retractions, grunting, tripod-ing, diaphoretic), obstruction (wheezing, stridor)
- f/u ABG | MICU eval if pH <7.25, PaCO2 > 45 mmHg (poor ventilation), PaO2 < 60 mmHg (poor oxygenation
- f/u CBC, BMP, lactate, trop, BNP
- f/u EKG, CXR
- supplemental O2 prn | goal SpO2 92-96%
- NIPPV (BIPAP for COPD; CPAP for CHF): RR >25-30, accessory muscle use, pH < 7.35, PaCO2 >45mmHg

Sepsis	

#Septic Shock
Admission Vitals: ***
Admission Labs: ***
CXR ***
- f/u BCx x2, sputum Cx
- IVF bolus 30 cc/kg with LR (lower mortality and AKI NEJM 2018;378:829)
- antibiotics (NEJM 2017;376:2235) x7-10 days
- may use procal to discontinue antibiotics or shorten course (Lancet Inf Dis 2016;16:819)

- if immunocompromised, recent pseudomonas: anti-pseudomonal beta-lactam + aminoglycoside or fluoroquinolone (Crit Care med 2010;38:1773)
- if toxic shock syndrome, add clindamycin

- later may consider straight leg raise or IVC US for fluid responsiveness
VTE	
DVT/PE
Major risk factors: hip/pelvis/femur fracture, major trauma, abdominal/pelvic surgery, recent spinal cord injury
Wells Criteria:
- f/u DVT US
- f/u CTPE
- LMWH preferred (Chest 2008;133:381) due to decreased bleeding over heparin TID (Chest 2007;131:507) or apixaban (NEJM 2011;365:2167)

Wells Criteria
- signs/symptoms DVT (3 pts)
- PE #1 dx (3 pts)
- HR >100 (1.5 pts)
- immobilized x3 days OR surgery in last 4 weeks (1.5 pts)
- prior DVT/PE (1.5 pts)
- hemoptysis (1 pt)
- malignancy dx or tx in last 6 months (1 month)

0-1 pts: low (1.3%) risk >> d-dimer or PERC
2-6 pts: intermediate (16.2%) risk >> d-dimer
>6 pts: high (38%) risk >> CTPE
Adjust vent settings
Ventilation determines CO2 | decrease PaCO2 by increasing minute ventilation (RR and/or VT)
Adjust RR first | avoid if RR >30-35 due to auto-PEEP
Adjust VT | Pplat < 30 to minimize lung injury
Oxygenation determines PaO2 | increase PaO2 by increasing PEEP and/or FiO2
FiO2: beware of oxygen toxicity if >0.6 for prolonged period
PEEP: increase alveolar recruitment, decrease afterload and preload
P:F Ratio	P:F Ratio = quick surrogate for A-a gradient
PaO2/FiO2
P:F <300 = mild ARDS
P:F <200 = moderate ARDS
P:F <100 = severe ARDS	
CPAP vs BIPAP	
CPAP provides PEEP | CHF >> decreased intubation and mortality (Eur Respir J 2017;50:1602426)
BiPAP provides IPAP and PEEP | COPD >> decreased mortality, intubation, length of stay (Ann Intern Med 2003;138:861 and Cochrane 2017;7:CD004104)
(
ARDS

ASTHMA

#Mild Asthma
Triggers: exercise, cold air, irritants, allergins, infection (URI/bronchitis/sinusitis), drugs (ASA, NSAIDs, beta-blockers, opioids)
FEV1/FVC <0.7, reverses with bronchodilator, worsens with methacholine
Peak expiratory flow <80 personal best = poor control
*** CXR:
- supplemental O2 prn | goal SpO2 92-96%
- SABA q4-6 hours
- lower rates severe exacerbation with quadrupling inhaled steroids at symptom onset (NEJM 2018;378:902)
- consider ABG | anticipate respiratory alkalosis (normal pH >> impending respiratory failure)
- consider prednisone 40 mg x5 days
- if severe consider Mg 2g IV over 20 mins (JAMA 1989;262:1210)
- vaccines: flu, PCV13, PPSV23

Adult onset: consider allergic bronchopulmonary aspergillosis, EGPA, eosinophilic esophagitis, systemic mastocytosis

#Severe Asthma
Triggers: exercise, cold air, irritants, allergins, infection (URI/bronchitis/sinusitis), drugs (ASA, NSAIDs, beta-blockers, opioids)
FEV1/FVC <0.7, reverses with bronchodilator, worsens with methacholine
Peak expiratory flow <80 personal best = poor control
*** CXR:
- f/u ABG | anticipate respiratory alkalosis (normal pH >> impending respiratory failure)
- supplemental O2 prn | goal SpO2 92-96% | consider intubation with high rate (80-100 l?min), low Vt 6 cc/kg, low RR (10-14), permissive hypercapnea
- continuous albuterol nebs
- lower rates severe exacerbation with quadrupling inhaled steroids at symptom onset (NEJM 2018;378:902)
- methylprednisone 125 mg IV q6h (Archives 1983;143::1324)
- Mg 2g IV over 20 mins (JAMA 1989;262:1210)
- consider Heliox
- admit to ICU
COPD
COPD
Risk factors: smoking, air polution, A1AT deficiency
FEV1/FVC <0.7
Severity: mMRC breathlessness, CAT health impairment, Gold Staging Spirometry, Frequency of exacerbations
***CXR
***EKG
- f/u CBC, BMP, VBG, NT-proBNP, D-dimer, procalcitonin
- supplemental O2 prn | goal SpO2 88-92% (BMJ 2010;341:c5462)
- albuterol q4h + q2h prn, ipratropium q4h standing (duoneb = albuterol + ipratropium)
- hold home ICS, LABA, LAMA
- prednisone 40 mg x4 days (Cochrane 2018;3:CD006897)
- consider azithromycin vs levofloxacin if increased sputum | antibiotics decrease mortality and readmission

Outpatient maintenance
- LAMA + LABA: increase FEV1, decrease symptoms and exacerbations (Cochrane 2015;(10):CD008989)
- PDE-4 inhibitors (roflumilast): increase lung function, decrease exacerbations severe COPD (Lancet 2015;385:857)

- on discharge counsel on smoking cessation, risk factor reductions, pulmonary rehab
- vaccines: influenza, PCV13, PPSV23
- annual low-dose CT lung cancer screening (age 55-80 with 20 pack-year hx and active use or quit <15 years ago)
- home O2 if SpO2 <88%

COVID
#COVID Pneumonia
Risk factors: age, obesity, cancer, CKD, COPD, immunocompromised, SCD, tobacco use, DM
*** symptom onset
*** COVID swab +
CXR ***
- f/u COVID severity labs
- f/u strep pneumo, legionella
- contact and droplet precautions
- supplemental O2 prn; goal SpO2 90-96%; wean as tolerated
- encourage patient to prone position to recruit atelectic lung tissue in dependent lung basis | ideally 12-18 h/day
- supportive care with IS, combivent q4h, benzonatate prn, guanifenesin prn
- Daily zinc supplementation (PMID 33094446) for known antioxidant, anti inflammatory, immunomodulatory and antiviral activity.
- Daily vitamin D supplementation (PMID 33142828)-- can dc if pending vitamin D level >20.
- Remdesivir x5 days given not intubated and GFR >30
- dexamethasone 6 mg x10 days or off O2; whichever comes first
- home O2 eval pending anticipated discharge date
- counseled on the importance of vaccination

HEMOPTYSIS

#Hemoptysis
Etiology: bronchitis, bronchiectasis, malignancy, trauma, infection (PNA, abscess, TB, aspergilloma), GPA, SLE/cryo/HSP, Goodpasture, drug-induced vasculitis (cocaine, PTU), coagulopathy, endometriosis, inhalation injury, sarcoid, PE, CHF, mitral regurg, AVM
***CXR:
- f/u CBC, coags, UA (vasculitis),
- sputum Cx
- CT chest if stable
- consider BNP, ESR/CRP, C3/C4, ANA, ANCA, anti-GBM, anti-cardiolipin, beta2 glycoprotein, lupus antibody, AFB or interferon gamma, d-dimer

- massive hemoptysis >500 cc's >> interventional pulm for bronch

ILD Workup

#Interstitial Lung Disease
Etiology: UIP, sarcoid, amyloid, ANCA vasculitis, scleroderma, polymyositis, dermatomyositis, rheumatoid arthritis, systemic lupus erythmatosis, inhalation exposure (mold, bird, silica, aspestos), drugs (amiodarone, nitrofurantoin, MTX, nivolumab, pembrolizumab, ipilimumab, radiation
- CBC, CMP, ESR, CRP, CPK, aldolase, C3/C4, ANA, anti-RNP, anti-Ro/La, Scl-70, RF, anti-CCP, ANCA, hypersensitivity panel, myositis panel, anti-Jo1
- f/u CXR, CT Chest, PFTs
- pirfenidone (antifibrotic) or nintedanib (TKI - reduces FVC decline, no survival benefit) (NEJM 2014;370:2083 and NEJM 2014;370:2071)

pHTN

#Pulmonary Hypertension
Mean PA pressure >/= 25 mmHg at rest
Symptoms: DOE (early), syncope (late)
Classification: Group 1 (idiopathic, intoxication, infectious, inflammatory), Group 2 (L heart disease), Group 3 (lung disease), Group 4 (thromboembolic), Group 5 (SCD, MPN)
*** EKG
*** CXR
- f/u LFTs, ANA, RF, CCP, ANCA, Scl-70, Ro/La, BNP, HIV
- f/u TTE
- outpatient PFTs, 6 min walk test before discharge
- RHC in outpatient setting

Treatment
Group 1: endothelin R antagonist (bosentan, ambrisentan, macitentan - decrease mortality NEJM 2013;369:809), PDE5 inhibitors (sildenafil, tadalafil - increase exercise capacity NEJM 2005;353:2148), sGC stimulator (riociguat), R agonist (selexipag (decrease hospitalization NEJM 2015;373:2522)
Group 2: treat underlying cause
Group 3: PDE5 inhibitors (sildenafil, tadalafil - improves hemodynamics - NEHM 2013;369:330)
Group 4: sCG stimulator (riociguat - NEJM 2013;369:330)

RES DISTRESS

#Respiratory Distress
Tachypnea (RR>20), cyanosis (SpO2 <80%), increased wob (nostril flaring, retractions, grunting, tripod-ing, diaphoretic), obstruction (wheezing, stridor)
- f/u ABG | MICU eval if pH <7.25, PaCO2 > 45 mmHg (poor ventilation), PaO2 < 60 mmHg (poor oxygenation
- f/u CBC, BMP, lactate, trop, BNP
- f/u EKG, CXR
- supplemental O2 prn | goal SpO2 92-96%
- NIPPV (BIPAP for COPD; CPAP for CHF): RR >25-30, accessory muscle use, pH < 7.35, PaCO2 >45mmHg

Sepsis

#Septic Shock
Admission Vitals: ***
Admission Labs: ***
CXR ***
- f/u BCx x2, sputum Cx
- IVF bolus 30 cc/kg with LR (lower mortality and AKI NEJM 2018;378:829)
- antibiotics (NEJM 2017;376:2235) x7-10 days
- may use procal to discontinue antibiotics or shorten course (Lancet Inf Dis 2016;16:819)

- if immunocompromised, recent pseudomonas: anti-pseudomonal beta-lactam + aminoglycoside or fluoroquinolone (Crit Care med 2010;38:1773)
- if toxic shock syndrome, add clindamycin

- later may consider straight leg raise or IVC US for fluid responsiveness
VTE
DVT/PE
Major risk factors: hip/pelvis/femur fracture, major trauma, abdominal/pelvic surgery, recent spinal cord injury
Wells Criteria:
- f/u DVT US
- f/u CTPE
- LMWH preferred (Chest 2008;133:381) due to decreased bleeding over heparin TID (Chest 2007;131:507) or apixaban (NEJM 2011;365:2167)

Wells Criteria
- signs/symptoms DVT (3 pts)
- PE #1 dx (3 pts)
- HR >100 (1.5 pts)
- immobilized x3 days OR surgery in last 4 weeks (1.5 pts)
- prior DVT/PE (1.5 pts)
- hemoptysis (1 pt)
- malignancy dx or tx in last 6 months (1 month)

0-1 pts: low (1.3%) risk >> d-dimer or PERC
2-6 pts: intermediate (16.2%) risk >> d-dimer
>6 pts: high (38%) risk >> CTPE
Adjust vent settings
Ventilation determines CO2 | decrease PaCO2 by increasing minute ventilation (RR and/or VT)
Adjust RR first | avoid if RR >30-35 due to auto-PEEP
Adjust VT | Pplat < 30 to minimize lung injury
Oxygenation determines PaO2 | increase PaO2 by increasing PEEP and/or FiO2
FiO2: beware of oxygen toxicity if >0.6 for prolonged period
PEEP: increase alveolar recruitment, decrease afterload and preload
P:F Ratio P:F Ratio = quick surrogate for A-a gradient
PaO2/FiO2
P:F <300 = mild ARDS
P:F <200 = moderate ARDS
P:F <100 = severe ARDS
CPAP vs BIPAP
CPAP provides PEEP | CHF >> decreased intubation and mortality (Eur Respir J 2017;50:1602426)
BiPAP provides IPAP and PEEP | COPD >> decreased mortality, intubation, length of stay (Ann Intern Med 2003;138:861 and Cochrane 2017;7:CD004104)
(

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