Common Confounding Consults In Pulmonary & Critical Care - - PDF document

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Common Confounding Consults In Pulmonary & Critical Care - - PDF document

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10/17/2018 Common Confounding Consults In Pulmonary & Critical Care Lekshmi Santhosh, M.D. Assistant Professor, Pulm/Critical Care & Hosp Med Management of the Hospitalized Patient 10.20.2018 Disclosures None. 1 10/17/2018 Roadmap

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10/17/2018 1

Common Confounding Consults In Pulmonary & Critical Care

Lekshmi Santhosh, M.D. Assistant Professor, Pulm/Critical Care & Hosp Med

Management of the Hospitalized Patient 10.20.2018

Disclosures

None.

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Roadmap for the Hour

Help, Doc! My:

  • 1. Asthma/COPD is Still Wheezing
  • 2. BP Is Still Low
  • 3. Fluid Is Still Recurring
  • 4. Mind Is Still Fuzzy

Common Confounding Consults in Pulm/ICU

Roadmap for the Hour

Objectives:

Management of obstructive lung dz Management of severe hypotension Management of pleural effusions Management of post-ICU syndrome

Common Confounding Consults in Pulm/ICU

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Help, Doc! My Asthma/COPD Is Still Wheezing.

Case #1:Obstructive Lung Dz Mngmt

A 55 year old man who has a history of COPD, OSA, CAD, CKD, jaundice, & childhood asthma admitted for dyspnea. He is still wheezing & hypoxemic despite 5 d steroids &

  • antibiotics. What do you do next?
  • a. Order Th2 genotype testing
  • b. Treat empirically for PE
  • c. Order inpatient PFTs
  • d. Order Chest CT to rule-out other causes
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Not All OLD Are Equal, But . . .

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❏ When to just start empiric tx of asthma

  • r COPD?

❏ “Classic cases”

❏ For everyone else, PFTs are very helpful

❏ Spirometry - FEV1, FVC, FEV1/FVC ratio - with bronchodilator response ❏ Full PFT - Includes TLC & DLCO

PFTs: Low-Risk and High-Yield!

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Key Point

Don’t let the bronchodilator reversibility

  • verly sway you. COPD pts can have

some BD responsiveness, and asthma pts can show no responsiveness.

Key Point

All that wheezes is not asthma...nor COPD! Keep your ddx very broad and think outside the [lung] box.

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Common Asthma & COPD Mimics - Can Delay Dx

❏ Vocal cord dysfunction ❏ Allergic bronchopulmonary aspergillosis ❏ Vasculitides such as Eosinophilic Granulomatosis with Polyangiitis ❏ Infections such as Strongyloides ❏ Pulmonary embolism ❏ Decompensated CHF ❏ Obesity ❏ Bronchiectasis ❏ Occupational/environment al lung diseases ❏ Malignancy (lung or mets) ❏ Interstitial lung diseases

What about Reactive Airways Disease?

Different from Reactive Airways Dysfunction Syndrome - Acute wheezing in response to inhaled irritant

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Diagnostically, When to Refer? Anytime if:

❏ Basic diagnostics are not helpful (PFTs, Chest CT) ❏ You need advanced testing (e.g. methacholine/bronchoprovocation testing, exercise testing, bronchoscopy, etc.) ❏ You suspect an asthma/COPD mimic ❏ You just need extra diagnostic help!

Therapeutically, When to Refer? Anytime if:

❏ Severe asthma requiring ICU stay ❏ Uncontrolled asthma despite step-up therapy ❏ You are considering omalizumab or other IgE-mediated tx ❏ You suspect an asthma mimic

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Key Point

ICU Admission for asthma and intubation are strong predictors for fatal or near-fatal asthma. These patients can die before they reach the hospital.

Key Point

Don’t forget non-pharm management: smoking cessation, pulmonary rehab, trigger avoidance, exercise, flu vaccine & Pneumovax.

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Case #1:Obstructive Lung Dz Mngmt

A 55 year old man who has a history of COPD, OSA, CAD, CKD, jaundice, & childhood asthma admitted for dyspnea. He is still wheezing & hypoxemic despite 5 d steroids &

  • antibiotics. What do you do next?
  • a. Order Th2 genotype testing
  • b. Treat empirically for PE
  • c. Order inpatient PFTs
  • d. Order Chest CT to rule-out other causes
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Roadmap for the Hour

Help, Doc! My:

  • 1. Asthma/COPD is Still Wheezing
  • 2. BP Is Still Low
  • 3. Fluid Is Still Recurring
  • 4. Mind is Still Fuzzy

Common Confounding Consults in Pulm/ICU

Help, Doc! My BP Is Still Low.

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Case #2: Management of Severe Hypotension

A 45 year old man with a history of alcohol use disorder, GERD, and personality disorder NOS admitted with hypotension, found to be be be worsening despite 3 L boluses. You:

  • a. Start a central line & vasopressors
  • b. Start stress-dose steroids
  • c. Start Vitamin C cocktail
  • d. Start Angiotensin II

Case #2: Management of Severe Hypotension

At your hospital, providers are using the following for hypotension:

  • a. Vitamin C cocktail
  • b. Angiotensin II
  • c. Stress-dose steroids
  • d. None of the above - just pressors
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Steroids in Septic Shock: The Swinging Pendulum

❏ Current guidelines: Use hydrocort in septic shock if adequate fluid resuscitation & vasopressors haven’t restored HD stability...but weak rec based on low evidence ❏ 10 years ago, CORTICUS Trial of NEJM 2008 - now ADRENAL in NEJM 2018 ❏ Second line of the editorial: ❏ “Glucocorticoids have been used as an adjuvant therapy for septic shock for more than 40 years.”

What Do the 2018 Steroid Data Tell Us?

❏ ADRENAL randomized 3685 pts w/ septic shock to continuous IV infusion of hydrocortisone (200mg/24 hrs)

  • vs. placebo

❏ NO difference in 90-day mortality (~28% in both groups) ❏ Lower # of days on pressors (3 vs. 4)

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What Do the 2018 Steroid Data Tell Us?

❏ APROCCHSS randomized 1241 pts w/ septic shock to hydrocort + fludricort vs. Xigris (drotrecogin alpha) vs. all 3 vs. placebo ❏ Lower 90-day mortality w/ hydrocort + fludricort (43% vs 49%) ❏ Lower # of days on pressors (17 vs. 15)

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Has This Change Intensivists’ Practice?

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What’s the Deal with Vitamin C?

❏ CHEST 2017 controversial Marik paper ❏ Retrospective before & after clinical trial ❏ Cocktail of thiamine, steroids, Vit C ❏ C 1500q6 + Hydrocort 50q6 + B1 200q12 ❏ 47 pts, 47 (retrospective) controls - 40%

  • vs. 8.5% hospital mortality

What’s the Deal with Vitamin C?

❏ VICTAS Trial currently enrolling ❏ Double-blind placebo-controlled trial ❏ Expected completion in 2019-2020 CHEST Abstract this year on POC glucose measurements being inaccurate in patients with CKD

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What About Angiotensin II?

❏ New IV vasopressor - expedited FDA approval this year based on ATHOS-3 trial of 321 pts refractory to norepi or epinephrine ❏ At 3 hours, 70% reached target BP vs. 23% w/ usual care ❏ Side effects: Arterial & venous thromboses, esp DVTs ❏ 13% vs. 5%

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Case #2: Management of Severe Hypotension

A 45 year old man with a history of alcohol use disorder, GERD, and personality disorder NOS admitted with hypotension, found to be be be worsening despite 3 L boluses. You:

  • a. Start a central line & vasopressors
  • b. Start stress-dose steroids
  • c. Start Vitamin C cocktail
  • d. Start Angiotensin II
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Roadmap for the Hour

Help, Doc! My:

  • 1. Asthma/COPD is Still Wheezing
  • 2. BP Is Still Low
  • 3. Fluid Is Still Recurring
  • 4. Mind is Still Fuzzy

Common Confounding Consults in Pulm/ICU

Help, Doc! My Fluid is Still Recurring.

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Case #3: Management of Recurrent Pleural Effusions

A 65 year old woman is readmitted for pleural effusion of unknown etiology. Last thoracentesis had negative cytology & cx. You:

  • a. Repeat the thoracentesis
  • b. Refer for pleurodesis
  • c. Refer for pleural biopsy
  • d. Place a PleurX catheter

Dig Deep to Find an Etiology, Since Diff Mngmt

❏ Never place a chest tube to drain hepatohydrothorax. ❏ Consider serial drainage + diuretics for recurrent transudates ❏ If drainage slows but effusion persists: ❏ Consider reimaging: loculation? tube position? ❏ Consider TPA and DNAase ❏ If chest pain with chest tube beyond expected: ❏ Consider: tube dysfunction/malpositioning? ❏ Consider complications like infxn, lung lac, diaphragm injury, reexpansion pulm edema

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2018 ATS Guidelines on Malignant Pleural Effusions

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Case #3: Management of Recurrent Pleural Effusions

A 65 year old woman is readmitted for pleural effusion of unknown etiology. Last thoracentesis had negative cytology & cx. You:

  • a. Repeat the thoracentesis
  • b. Refer for pleurodesis
  • c. Refer for pleural biopsy
  • d. Place a PleurX catheter
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Roadmap for the Hour

Help, Doc! My:

  • 1. Asthma/COPD is Still Wheezing
  • 2. BP Is Still Low
  • 3. Fluid Is Still Recurring
  • 4. Mind is Still Fuzzy

Common Confounding Consults in Pulm/ICU

Help, Doc! My Mind is Still Fuzzy.

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Case 4: Post-ICU Sd Do you have a post-ICU Clinic after discharge?

  • A. Yes
  • B. No
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SCCM THRIVE Collaborative for Post-ICU Syndrome

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Thank You! Questions?

Lekshmi.Santhosh@ucsf.edu @LekshmiMD