Pulmonology

Anaphylaxis

NS IV

H1 blockers

H2 blockers

β2 agonists → bronchodilation

Steroids

Dexamethasone

Asthma

Criteria to support Dx of asthma in pre-schoolers

Asthma control

Risk stratification

mild moderate severe
PEF
(% predicted or
% personal best) 80-100% 50-80% < 50% or
response lasts < 2 hrs

Risk factors for death

Past history of sudden severe exacerbations
Prior intubation for asthma
Prior admission for asthma to ICU
≥ 2 hospitalizations for asthma in the past year
≥ 3 emergency care visits for asthma in the past year
Hospitalization or emergency care visit for asthma within the past month
Use of > 2 canisters per month of inhaled short-acting β2-agonist
Current use or recent withdrawal from systemic corticosteroids

Emergency Tx

Aerosolized β2 agonist:
Salbutamol (Ventolin) by nebulizer e.g. q20min, then q1h, then q4h as pt improves (may be given continuously if needed).
≤ 10 kg: 1.25-2.5 mg in 3 mL normal saline
11-20 kg: 2.5 mg in 3 mL NS
> 20 kg: 5.0 mg in 3 mL normal saline

Prenisone 1mg/kg/day PO

Epinephrine SC
β2 → bronchodilation
α1 → ↑ peripheral vascular resistance

Ketamine
Acts on cortex and limbic system → bronchodilation

MgSO4
Smooth muscle relaxation → bronchodilation

COPD

Stage	PFTs	Rx
0 - At risk	Normal - chronic intermittent symptoms	Eliminate exposures (e.g. tobacco)
I - Mild	FEV1/FVC <70%, FEV1 >80%	Short-acting beta-2 agonist 2 puffs QID prn
II - Moderate	FEV1 50-80%	Add inhaled anticholinergic (e.g. ipratropium 2 inh. QID prn [max. 12 per 24 hrs]) (OR substitute w. Combivent 2 inh QID) Add long-acting beta-2 agonist OR Advair Add low-flow oxygen at night and with exertion
III - Severe	FEV1 30-50%	Add leukotriene receptor antagonist ? Add theophylline
IV - Very severe	FEV1 <30%	Add buspirone (anxiolysis) Add MS Contin 10 mg q12h (for dyspnea)

Home Oxygen
Indications:
Stable clinical status
If no end-organ dysfunction: PaO2 < 55 mmHg or O2 < 88%
If end-organ dysfunction: PaO2 < 60 mmHg or O2 < 90%

Acute exacerbation of COPD
Short-acting beta-2 agonist up to 6-8 puffs q1-2h
Ipratropium up to 6 to 8 puffs q3-4h

Prednisone 30-40 mg/day PO x 10 days, then tapered over 2 weeks
OR
Solu-Medrol 1-2 mg/kg q6-12 hours IV x 3 days, then Prednisone 60 mg qd x 7 days, then tapered over 2 weeks

ABx if ↑ dyspnea + ↑ sputum + purulent sputum
Orgs: H. influenzae, S. pneumoniae, M. catarrhalis, C. pneumoniae, M. pneumoniae

First-Line:
Bactrim DS one tablet PO bid
Doxycycline 100 mg PO bid
Amoxicillin 500 mg PO tid

Alternatives:
Augmentin 875 mg PO BID
Clarithromycin 500 mg PO BID
Azithromycin 500 mg day 1, then 250 mg PO x4 days
Levofloxacin x 7 days

CAP in adults

No co-morbid factors

Pulmonary embolism

D-dimer

Sensitive
Not specific (e.g. recent injury or surgery, cancer, inflammatory disease, healthy elderly)

Ventilation/Perfusion scan (V/Q scan)
There are 3 V/Q lung scan patterns:
1. A normal perfusion scan rules out PE.
2. Most patients with a high probability scan (defined as one or more, segmental or larger, perfusion defects with relatively preserved ventilation) have PE and they can generally be treated without further testing.
3. All other lung scan patterns (about 60%) are nondiagnostic.

Wells criteria for PE (Wells PS, et al. Ann Intern Med 2001;135:98)

Clinical S&S's of DVT
(leg swelling and pain with palpation) 3.0
No alternative diagnosis is more likely than PE 3.0
HR > 100 1.5
Immobilization > 3 days
or surgery in previous 4 weeks 1.5
Previous DVT/PE 1.5
Hemoptysis 1.0
Malignancy (treated within previous 6 mos or palliative) 1.0

Probability of PE:

High > 6
Moderate 2 - 6
Low < 2

Wells criteria for DVT:
(Possible score -2 to 9)

Active cancer (treatment within
last 6 months or palliative) 1
Calf swelling >3 cm compared to other calf
(measured 10 cm below tibial tuberosity) 1
Collateral superficial veins (non-varicose) 1
Pitting edema (confined to symptomatic leg) 1
Swelling of entire leg 1
Localized pain along distribution
of deep venous system 1
Paralysis, paresis, or recent cast
immobilization of lower extremities 1
Recently bedridden > 3 days, or major
surgery requiring regional or general
anesthetic in past 12 weeks 1
Previously documented DVT 1
Alternative diagnosis at least as likely -2

Interpretation:
Score ≥ 2: DVT likely. Consider US leg veins.
Score < 2: DVT unlikely. Consider d-dimer test to further rule out DVT.

Mgt:

	mild	moderate	severe
PEF (% predicted or % personal best)	80-100%	50-80%	< 50% or response lasts < 2 hrs

Clinical S&S's of DVT (leg swelling and pain with palpation)	3.0
No alternative diagnosis is more likely than PE	3.0
HR > 100	1.5
Immobilization > 3 days or surgery in previous 4 weeks	1.5
Previous DVT/PE	1.5
Hemoptysis	1.0
Malignancy (treated within previous 6 mos or palliative)	1.0

Active cancer (treatment within last 6 months or palliative)	1
Calf swelling >3 cm compared to other calf (measured 10 cm below tibial tuberosity)	1
Collateral superficial veins (non-varicose)	1
Pitting edema (confined to symptomatic leg)	1
Swelling of entire leg	1
Localized pain along distribution of deep venous system	1
Paralysis, paresis, or recent cast immobilization of lower extremities	1
Recently bedridden > 3 days, or major surgery requiring regional or general anesthetic in past 12 weeks	1
Previously documented DVT	1
Alternative diagnosis at least as likely	-2