Common Confounding Consults In Pulmonary & Critical Care

Transcription

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

2 Roadmap for the Hour Common Confounding Consults in Pulm/ICU Help, Doc! My: 1. Asthma/COPD is Still Wheezing 2. BP Is Still Low 3. Fluid Is Still Recurring 4. Mind Is Still Fuzzy Roadmap for the Hour Common Confounding Consults in Pulm/ICU Objectives: Management of obstructive lung dz Management of severe hypotension Management of pleural effusions Management of post-icu syndrome 2

3 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 3

4 Not All OLD Are Equal, But... 4

5 PFTs: Low-Risk and High-Yield! 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 5

6 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. 6

7 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 7

8 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 8

9 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. 9

10 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 10

11 Roadmap for the Hour Common Confounding Consults in Pulm/ICU Help, Doc! My: 1. Asthma/COPD is Still Wheezing 2. BP Is Still Low 3. Fluid Is Still Recurring 4. Mind is Still Fuzzy Help, Doc! My BP Is Still Low. 11

12 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 12

13 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 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) 13

14 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) 14

15 Has This Change Intensivists Practice? 15

16 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 CHEST Abstract this year on POC glucose measurements being inaccurate in patients with CKD 16

17 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% 17

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19 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 19

20 Roadmap for the Hour Common Confounding Consults in Pulm/ICU Help, Doc! My: 1. Asthma/COPD is Still Wheezing 2. BP Is Still Low 3. Fluid Is Still Recurring 4. Mind is Still Fuzzy Help, Doc! My Fluid is Still Recurring. 20

21 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 21

22 2018 ATS Guidelines on Malignant Pleural Effusions 22

23 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 23

24 Roadmap for the Hour Common Confounding Consults in Pulm/ICU Help, Doc! My: 1. Asthma/COPD is Still Wheezing 2. BP Is Still Low 3. Fluid Is Still Recurring 4. Mind is Still Fuzzy Help, Doc! My Mind is Still Fuzzy. 24

25 Case 4: Post-ICU Sd Do you have a post-icu Clinic after discharge? A. Yes B. No 25

26 SCCM THRIVE Collaborative for Post-ICU Syndrome 26

27 Thank You! 27