PULMONARY

COPD and Asthma Exacerbations

1. Admission Orders

a. CXR and ABG for COPD’ers if not done in the ER or clinic.

b. Albuterol and Atrovent nebulizers q2-4 hours dependent on severity.

c. Solumedrol 80 mg q8h (may increase to 125 mg dependent on severity).

d. Antibiotics dependent on clinical picture (fever, sputum production, infiltrates on CXR, etc.)

e. Oxygen to keep sats > 92% (may be lower depending on severity of COPD).

f. Have a peak flow meter brought to the bedside.

2. Hospital course

a. These patients typically stay 2-4 days – you will generally notice a significant improvement in their physical exam (less wheezing/rhonchi, improved air movement and peak flows).

b. Start to taper down their steroids as they improve – one way is to go from Solumedrol 80 q8h to 40 q8h to Prednisone 60 mg bid – each resident has a different way of tapering.

c. A set of pulmonary function tests may be necessary to monitor long-term progress.

d. Does the patient need home oxygen? Walk them around the hall on room air; if they desaturate below 88-90%, they qualify for home oxygen.

Cystic Fibrosis Exacerbations

Stuff to know

² University Hospital has seen increasing numbers of admissions for CF exacerbation. The Pulmonary department has a protocol for these patients and the nurse coordinator will generally give you a previous discharge summary an order set to put in, including antibiotics and dosages.

² Make sure that you wash up before and after examining a CF patient – this includes swabbing down your stethoscope with alcohol. This is especially necessary if a patient is known to have B. cepacia, a bug that is easy to spread between CF patients and hard to eliminate.

² It is important that you get a sputum culture on admission – order the “Cystic Fibrosis Culture” (found in the alphabetized lab orders section in PIN) – and get chest physical therapy on all patients (unless they have active hemoptysis).

² Get at least one set of PFTs during the admission (usually a day before discharge).

² Patients do not require daily labs, but they do need a fluid balance and a CBC drawn every 3-4 days. Many patients are on an aminoglycoside, so they must be monitored for nephrotoxicity.

² The average patient stay is 10-14 days.

Pleural Effusions

Laboratory Findings

1. Diagnostic criteria for an exudate (at least one of 3 must be present)

a. Pleural fluid protein/serum protein ratio > 0.5

b. Pleural fluid LDH/serum LDH ratio > 0.6

c. Pleural fluid LDH > 2/3 upper limits of normal of the serum LDH

2. Transudates are usually due to altered hydrostatic and oncotic forces – they usually have WBCs < 1000/mL, mononuclear predominance, glucose levels in pleural fluid equal to that of serum, normal pH). They suggest absence of local pleural disease and are usually due to CHF.

3. Exudates

a. Normal pleural fluid pH ~ 7.6; pleural fluid pH < 7.3 suggests empyema, cancer, SLE/RA effusion, tuberculosis, esophageal rupture, or parapneumonic effusion.

b. Low glucose levels (< 60 mg/dL or pleural fluid glucose/serum glucose ratio < 0.5) suggest cancer, empyema, tuberculosis, esophageal rupture, or connective tissue disease.

c. Cell counts > 10000/mL are seen in pneumonia, acute pancreatitis, and lupus pleuritis; chronic exudates (tuberculosis, malignancy) usually have cell counts < 5000/mL.

d. Amylase-rich pleural effusions suggest acute pancreatitis, chronic pancreatic pleural effusions, esophageal rupture, and malignancy.

e. Lymphocyte predominance (85-95%) and absence of mesothelial cells suggest tuberculosis (include lymphoma, sarcoidosis, chylothorax, and chronic rheumatoid pleurisy in the differential).