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TRANSCRIPT
10/17/2018
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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 Wheezing2. BP Is Still Low3. Fluid Is Still Recurring4. 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 testingb. Treat empirically for PEc. Order inpatient PFTsd. 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 or 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 overly 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 testingb. Treat empirically for PEc. Order inpatient PFTsd. Order Chest CT to rule-out other causes
10/17/2018
11
Roadmap for the Hour
Help, Doc! My:
1. Asthma/COPD is Still Wheezing2. BP Is Still Low3. Fluid Is Still Recurring4. Mind is Still Fuzzy
Common Confounding Consults in Pulm/ICU
Help, Doc! My BP Is Still Low.
10/17/2018
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Case #2: Management of Severe HypotensionA 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 & vasopressorsb. Start stress-dose steroidsc. Start Vitamin C cocktaild. Start Angiotensin II
Case #2: Management of Severe Hypotension
At your hospital, providers are using the following for hypotension:
a. Vitamin C cocktailb. Angiotensin IIc. Stress-dose steroidsd. 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 glucosemeasurements 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 HypotensionA 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 & vasopressorsb. Start stress-dose steroidsc. Start Vitamin C cocktaild. Start Angiotensin II
10/17/2018
20
Roadmap for the Hour
Help, Doc! My:
1. Asthma/COPD is Still Wheezing2. BP Is Still Low3. Fluid Is Still Recurring4. Mind is Still Fuzzy
Common Confounding Consults in Pulm/ICU
Help, Doc! My Fluid is Still Recurring.
10/17/2018
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Case #3: Management of Recurrent Pleural EffusionsA 65 year old woman is readmitted for pleural effusion of unknown etiology. Last thoracentesis had negative cytology & cx. You:
a. Repeat the thoracentesisb. Refer for pleurodesisc. Refer for pleural biopsyd. 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 thoracentesisb. Refer for pleurodesisc. Refer for pleural biopsyd. Place a PleurX catheter
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Roadmap for the Hour
Help, Doc! My:
1. Asthma/COPD is Still Wheezing2. BP Is Still Low3. Fluid Is Still Recurring4. Mind is Still Fuzzy
Common Confounding Consults in Pulm/ICU
Help, Doc! My Mind is Still Fuzzy.
10/17/2018
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Case 4: Post-ICU Sd
Do you have a post-ICU Clinic after discharge?A. YesB. No
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SCCM THRIVE Collaborative for Post-ICU Syndrome
