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Pulmonology

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• local: Critical Care Values, Infectious Disease (Legionnaire's Disease), Pressure Meds

Asthma/Bronchospasm

• ref: New Strategies ...  - July 1998 - AFP
• meds I use are in asthma therapeutics. Other very rarely used meds include:
  • epinephrine (1:1000) .01 ml/kg/dose q 20 min. max 3/24h
  • susphrine 0.005 ml/kg/dose s/q q6h
  • isuprel: 0.25-0.5 ml (0.02 ml/kg/dosin 2.5-3.0 ml NSS q 1-2 h
  • theophyllines: choledyl elixir (oxytriphylline): 5-7 mg/kg/dose q6h (MAX 800 mg) Theodur typically 400 - 600 mg daily.
• poor response to therapy, esp. steroids: reevaluate diagnosis, consider reflux and adding Prilosec

Leukotriene antagonists

• use if failing inhaled steroids, along with long acting beta agonist inhaler
• may substitute for inhaled steroids in mild to moderate asthma

Chronic Cough

• AFP Dec 1998

Causes

• 0 - 18 mo: cough-variant asthma or aberrant innominate artery. Foreign body.
• 18 mo - 6 y: cough-variant asthma and sinusitis
• 6 y - 16 y: cough-variant asthma and psychogenic
• adult: post-infectious, asthma, GERD, postnasal drip, ACE-inhibitor, Pertussis (esp. if < 6 weeks). Rare: Tb, Work, Infec, bronchiectasis, sarcoidosis, LVG, interstitial lung disease, breast CA met, primary lung CA, hyperthyroid, carcinoid, Hodgkin's, Zenker's divertic, foreign body.

Management

• non-ACE, normal CXR: Consider PFT + methacholine, PPD, sinus CT, EGD
• try: antihistamine-decongestant, nasal steroids/Atrovent for 2 weeks
• try: add bronchodilator/inhaled steroids for 2 weeks
• try: GERD therapy (prilosec) for 2 weeks

Procedures

Pleural Effusion And Thoracentesis

Procedure

typical target is in post. mediolat. area; 7-8th interspace.

TRAY contents (if not preset):CONSENT, vacuum bottles, anaerobic and aerobic culture media, #15 scalpel, gloves, valium or s/l ativan. Tubes: EDTA, blue, purple, and red tops, blood gas. Send for pH, LDH, protein, glucose, culture, gram stain, AFB, cytology, amylase, triglycerides, cell count and diff, gases (complement).

method 1:

• anesth. rib and periosteum. Change to #19, advance to pleura and anesth pleura liberally as withdraw.
• attach #18 to 50 ml syringe and wd 30 ml. Take fluid for blood gas. May use 3-way stopcock to take blood gas, 30 ml sample, and drain to vacuum bottle (vi).
• inject into purple top (cell count), red top (LDH, protein, amylase, glucose, triglycerideand clear (C&S, gm stain, acid fastubes. Either inject into anaerobic medium or save in sealed tube.
• remove remainder (up to 1 liteinto vacuum bottles for cell block/cytology. May switch to large bore (#14 needle).

method 2:

• similar to above but use #16 DESERET subclavian catheter and 3 way stopcock. Withdraw needle partly and leave catheter in place.

Evaluation:

• glucose: <40 mg/dl; empyema, RA and tb
• amylase: incr. in pancreatitis and esoph. rupture
• trigly: incr. in chylous effusion
• LDH and protein: diff transudate vs exudate
• ph: <7.3 in empyema, malignancy, CVD, esophageal rupture.

Differential Diagnosis

Always rule out PE and tb. Exudate: fluid/serum protein < 0.5, fluid LDH >200, fluid/serum LDS >0.6, fluid protein > 3.

Transudate (protein < 3mg/dl)

• CHF - atelectasis - cirrhosis
• nephrotic syndrome
• (Meig's syndrome of Rt sided effusion with ovarian malignancy)

Exudate (protein > 3mg/dl)

• pnemonia (40% have effusion)
• pulmonary infarct (bloody, fever <101)
• tb (lymphocytic, +AFB)
• malignancy: breast, lung, prostate, lymphoma, ovary, gastric, melanoma (esp. hemorrhagic)
• pancreatitis (hi amylase)
• post-splenectomy (hard diff. from subphrenic abscess)
• trauma
• pneumothorax
• RA (lo glu, pH; hi LDH, lo complement)
• SLE (glu = blood glu, may be transudate)
• MISC: lymphoproliferative disease, primary lymphedema, myxedema, peritoneal dialysis.

Chest Tube Sclerosis

Give demerol/phenergan 1/2h prior to proceedure.

Need 21 gauge needle, 7.5 gloves, betadine wipes, 2 chest tube clamps and blue pagd. Clamp distal to the tube connector and inject the xylocaine, then the sclerosing solution (slowlthen the saline. Wait 1/2 hour then UNCLAMP.

need sclerosing solutions plus:

• lidocaine 1% 20 ml in 50 ml NSS
• 30 to 50 ml NSS

sclerosing solutions (one or the other):

• tetracycline 2 gm in 50 ml NSS
• 150 mg atabrine and 15 ml 1% xylocaine and add NSS to total 50 ml

Sleep Apnea Diagnostic Criteria (ref. #1177)

1. home oximetry: >1% of time at O2 sat < 90% (screening)
2. > 15 episodes of O2 sat < 4% below baseline (specific)
3. indeterminant measures require further referral/sleep studies
4. If normal test no further testing needed. If positive (as above) do PSG.

Ventilators and Oxygenation

DATED MATERIAL. See also: Critical Care Values and Cardiology. This stuff is so old I should probably delete it, but it's a useful starting point for me.

Oxygen transport and consumption

Equations

• CaO2= Hg x 1.38 x SaO2
• O2 transported = C.O. x CaO2 x 10. Ex: 900 ml/min = 5.0 x 18 ml/dl x 10
• O2 remaining = C.O. x CvO2 x 10 Ex: VO2 = C.O. x Hg x 13.8 x (SaO2 - SvO2)
• O2 consumed = transported-remaining

The response to decreased O2 delivery to tissues is to increase cardiac output (300%), increase venous O2 extraction (dec. SvO2 to 30% from 70%). A healthy person can compensate for a Hg as low as 1.6 without developing lactic acidosis (in theory).

Ventilator Management

• Intubation criteria: pH <= 7.25; more respiratory muscle fatigue & paradoxical respiration.
• Extubation mechanics: Vc > 10-15 ml/kg; PIMAX < -25; shunt < 10-20%; [Vc * 30]/2 > Ve; PO2 >= 60 with FiO2 0.4-0.6.

Ventilator settings

(@2000 settings have changed to reduce ARDS incidence. See literature. These settings are 10 years old.)

• tidal volume: normal 12 ml/kg. COPD 8-10 ml/kg.
• rate: norm 10-12; I:E 1:2 or 1:1.5
• peak insp. flow: norm 40 L/min; tachyp 70-90; RDS 85-100; COPD 40-60 L/min.
• Modes: Usually start with SIMV or assist/control to start. (SIMV of 8 is about same as assist/control) PSV of 10 is equal to work of breathing through tube. Apply PSV gradually until RR 20 and TV 7ml/kg.
• PEEP: In RDS use if PaO2 <60 with FiO2 >90.
• FiO2: Rule of 7: To incr PaO2 by 1% need incr FiO2 by 7mm Hg.

Sedation

1. valium 5 mg and MS 4mg then Pavulon 4mg; may repeat same with Pavulon 8 mg.
2. IV Haldol (flush line with saline first)
   Wait 20 minutes between doses, double the dose q20m until effective (max 40 mg qh)
   • mild: 0.5-2.0 mg
   • moderate: 5.0-10.0 mg
   • severe: 10.0 mg plus.
3. Pavulon: load with 0.05 to 0.1 mg/kg then give 0.02 to 0.05 q4h.

RDS Managment

• PEEP
• high flow rates
• keep dry: use dopamine rather than fluids for BP support.
• If SWAN keep PCWP <=Must measure off PEEP during expiratory phase.