#Asthma
Rescue inhaler: albuterol-budesonide > albuterol alone (NEJM 2022, Papi et al)
#COPD Exacerbation: Patient with GOLD Stage ** COPD. Now with X cardinal symptoms of COPD exacerbation (increased dyspnea, sputum volume, purulence). Trigger likely ***. Patient with/without risk factors for pseudomonas (chronic colonization or prior infection with pseudomonas, very severe COPD with FEV1<30% predicted, bronchiectasis on imaging, Abx use in past 3 months, chronic steroid use); thus *no* need for pseudomonal coverage.
-Start Prednisone 40mg daily (for total 5-day course, IAW REDUCE trial)
-Start Moxifloxacin 400mg daily (for total 5-day course) or Levofloxacin 750mg (for total 7-day course)
-Amoxicillin 500-875 PO TID or Doxy 100mg PO BID for 10-14 days if can be treated as outpatient
-Supplemental O2 to maintain sat between 88-92%
-Continue home inhaler medications -
-Can d/c home meds and start Fluticasone/Duonebs or Stiolto
#Pulmonary embolus
Massive: SBP<90 or a drop in SBP >40 for at least 15 minutes or shock (hypoperfusion, hypoxia, AMS, oliguria, cool/clammy extremities)
Submassive: RV dysfunction/hypokinesis with any of the following: RV dysfunction on POCUS, RV dilation (>.9 RV:LV on POCUS, BNP >500, trop >0.04, new EKG changes (RBBB, anteroseptal ST elevation/depression, anterolateral T wave inversion)
POCUS: RV/LV end diastolic diameter >1 in apical 4 chamber view, RV end diastolic diameter >30mm, paradoxical septal systolic motion, McConnell sign (akinesia of RV free wall sparing the apex (spec 94%, sens 77%)
-for hypoxia: HFNC, BiPAP/CPAP
-avoid fluids
Levo is first line pressor; dobutamine and milrinone improve RV function, but can worsen hypotension
-inhaled nitric oxide decreases pulmonary vascular resistance without reducing systemic pressures and improves v/q mismatch
-per accp, aha, eha, acep: thrombolytics are first line for massive
- rt-PA 50mg over 2 hours
Pulm htn:
CHF (WHO 2): TTE
COPD: PFTs
Diffuse parenchyma lung disease (ILD)/OSA; need “high res” CT or sleep study (WHO 3)
CTEPH: Dx with v/q scan
Primary pulm HTN: work up ANA, RF, SSA SSB, HIV and hepatitis panel, RHC
#cough
Acute (<3 weeks), Subacute (3-8 weeks), Chronic (>8 weeks)
Recent viral infection?
ACE inhibitor? Smoking history?
Other symptoms such as fever, dyspnea, chest pain, or cardiopulmonary physical exam findings
CXR for HR>100, RR>24, temp>38, lung sounds, or AMS
Signs of rhinosinusitis or bronchitis?
Indication for flu/COVID testing?
Immunocompromise? If yes, increased risk of infection; consider fungi, cytomegalovirus, varicella, herpesvirus, and Pneumocystis jirovecii; risk of TB?
Hemoptysis? Acute bronchitis is a common cause of mild and self-limited hemoptysis; more serious causes include bronchiectasis, cancer, tuberculosis, pulmonary embolism, and left ventricular failure. Rare causes include anti–glomerular basement membrane antibody disease (Goodpasture syndrome) and granulomatosis with polyangiitis
Exclude epistaxis or hematemesis
Cxr; probably chest CT and/or bronchoscopy
Unexplained chronic cough needs multimodality speech pathology intervention, and a 6 month trial of gabapentin; also beneficial are dextromethorphan and benzonatate and guaifenesin
-side effects of gabapentin include dizziness, disequilibrium, somnolence, weight gain, peripheral edema, cognitive difficulties
For subacute cough, (after history, physical exam, cxr, cessation of ace inhibitor/tobacco), stepwise treatment = trial of empiric treatment for upper airway cough syndrome (intranasal glucocorticoid (fluticasone nasal spray), first gen antihistamine, and decongestant) -> spirometry for asthma (Cough-variant asthma is diagnosed if spirometry and/or bronchial hyperresponsiveness testing results are abnormal, and symptoms should improve with standard therapy for asthma, including inhaled glucocorticoids.) -> if fails asthma therapy, exclude nonasthmatic eosinophilic bronchitis (NAEB) with sputum analysis for eosinophils or exhaled nitric oxide testing. If test results are abnormal, therapy with inhaled glucocorticoids should be initiated -> if still no improvement, PPI trial -> if no improvement, ambulatory pH monitoring -> if normal, chest CT (as long as no red flag symptoms meriting earlier scan (unexplained weight loss, abnormal pulm exam, or cxr findings)
If post tussive emesis, consider bordatella
Important but less common causes include chronic bronchitis, lung neoplasm, bronchiectasis, and chronic aspiration
Consider further testing: barium esophagography, bronchoscopy, TTE, environmental assessment, endoscopic or videofluoroscopic swallow eval, high res CT, 24hr pH, sinus imaging
Lung cancer screening
The U.S. Preventive Services Task Force recommends lung cancer screening with an annual low-dose CT of the chest for persons aged 50 years to 80 years with at least a 20-pack-year smoking history who are still smoking or who quit within the past 15 years.
Screening alone cannot prevent most lung cancer–related deaths, and smoking cessation is essential.