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CAP: severity and empirical Tx | CAP: specific Tx

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AcuteAsthmaPathway2008.ppt

CAP: Severity | Empirical Treatment

Src: BTS 2004 Update

CURB

Mort/ICU

Admiss

empirical PO

empirical IV

- 0=0.7% Home 1=AmoxPO
[2=ClariPO]
-
Confus 1=3.2% ?Home
Urea>7 2=13% ?SSW 1=AmoxPO
+Claribd
[2=LevoflPO|
MoxiflPO]
1={AmoxIV|
B-PenIV}
+ClariIV
[2=LevoflIV]
RR≥30 3=17% Hosp
=
severe
CAP
[from IV:
Cef:CoamoxPO;
B-Pen:AmoxPO]
1={CoamoxIV|
CefuroxIV|
CefotaxIV|
CeftriaxIV}
+ClariIV
[2=B-PenIV
+LevoflIV/PO]
BP<90/≤60 4=41.5%
65≥age 5=57%

Amox=PO/IV0.5-1tds; AmpiIV=0.5qds; B-PenIV=1.2qds; Coamox=PO0.625/IV1.2tds
ClariPO=0.5bd; Levo=PO/IV0.5bd; MoxiflPO=0.4od
CefuroxIV=1.5tds; CefotaxIV=1tds; CeftriaxIV=2od;

Discharge: Instability: T°>37.8°C; NBM/confus; HR>100; RR>24; SBP<90; SO2<90%

Pneumonia: Pathogen-specific treatment

Pathogen Preferred Alternative
S.pneumoniae Amox 0.5-1POtds | B'Pen1.2IVqds Ery 0.5POqds | Clarith 0.5PObd | Cefurox 0.75-1.5IV tds | Cefotax 1-2IVtds | Ceftriax 2gIVod
M.pneumoniae Ery 0.5PO/IVqds | Clari 0.5PO/IVbd Tetrac 0.25-0.5POqds | Quinol PO/IV
C.psittaci | C.burnetti Tetrac 0.25-0.5POqds/0.5IVbd Ery 0.5POqds | Clari 0.5IVbd
Legionella spp. Clarith 0.5PO/IVbd | Rifampicin 0.6PO/IVod/bd Quinol PO/IV
H.influenzae Non-beta-lact: Amox 0.5POtds | Ampic 0.5IV qds;
Beta-lact: Co-amox 0.625POtds/1.2IVtds
Cefurox 0.75-1.5IV tds | Cefotax 1-2IVtds | Ceftriax 2gIVod | Quinol PO/IV
Gram-neg enteric bacilli Cefurox 1.5IV tds | Cefotax 1-2IVtds | Ceftriax 2gIVod Quinol IV | Imipenem 0.5IVqds | Meropenem 0.5-1IVtds
P.aeruginosa Ceftaz 2IVtds + Gent|Tobra Cipro 0.4IVbd | Piperac 4IVtds+Gent|Tobra
S.aureus Non-MRSA: Fluclox 1-2IVqds ± Rifam 0.6PO/IVod/bd;
MRSA: Vanc 1IVbd (monitor dose)
Non-MRSA: Teicopl 0.4IVbd ± Rifam 0.6PO/IVod/bd;
MRSA: Linezolid 0.6IV/PObd

Pulmonary Embolism (Teaching Jan 2008 Dr Ian Webster)

  • D-dimer (preferably ELISA): for low clinical probability situations
  • in pregnancy: [D-dimer: only if negative?]; always do USS legs, only if -ve: either eg perfusion scan (lowest risk to fetus and maternal breast), CTPA lowest fetal irradiation but icr in breast cancer risk, VQ highest irradiation risk; guidelines: Obstetrics 2006(?) vs Radiology 2007 (?)

Respiratory Quiz (Teaching Jan 2008 Dr Kevin Jones)

  • Asthma vs COPD: if complete normalization of FEV1 to treatment
  • Tissue O2 delivery = Hb x SO2 x 1.34mLO2(?)/L x CardiacOutput = 120g/L x 0.92 x 1.34mL/L x 4L/min: best increased with icr in CardiacOutput to 5L/min (vs icr Hb to 15 vs icr SO2 to 0.99)
  • p(a)O2 + p(a)CO2 <=25kPa on air
  • COPD Tx (as per BTS guidelines): aim p(a)O2>=6.7 while no worsening of acidosis
  • healthy pO2 ~ FiO2 - 10kPa (or 2/3 x FiO2); eg pO2~30kPa on 40% O2
  • p(Alv)O2=p(I)O2 - p(Alv)CO2/R; with p(I)O2=(atmospheric pressure - water pressure pH2O) x FiO2= (100kPa - 6kPa) x 0.21; p(Alv)CO2 ~ p(a)CO2 b/o excellent diffusion; R=respiratory exchange ratio(?)=0.8; therefore: if pCO2=5: p(Alv)O2=94 x 0.21 - 5/0.8 = 20 - 6 = 14; if pO2=8, alveolar-arterial gradient=14-8=6 (healthy is ~2); therefore eg ?PE
  • 2L/min via nasal prongs ~ 24-30% FiO2

Bolton Asthma (NOT COPD) Care Pathway Nov 2007 Ages 16-70

A) Life-Threatening Asthma?

Assessment (ANY of the following?):

  • PEFR<33% best/predicted
  • SaO2<92%
  • paCO2>4.6kPa / pH<7.35
  • paO2<8kPa / cyanosis
  • Silent chest
  • poor resp effort / RR<10
  • arrhythmia / HR<50bpm
  • hypotension
  • exhaustion, coma, confusion

Treatment:

  • Call anaesthetist
  • Give High-flow O2 (>60%)
  • Salbutamol 5mg + Ipatropium 500mcg via O2 driven nebuliser
  • IV Hydrocortisone 100mg stat
  • Give Salbutamol 5mg via O2 driven nebuliser repeatedly
  • Consider IV Mg 2g, IV Aminophylline 250mg IV or IV Salbutamol 250mcg
  • Admit HDU/ITU

Investigations:

  • ABG, CXR (exclude pneumothorax!), U&E, FBC

B) Moderate / Severe asthma?

Criteria:

  • PEFR 33-75% best/predicted; severe if:
  • PEFR<50% best/predicted
  • RR>=20/min
  • HR>=110bpm
  • can't finish sentences

Treatment:

  • Give Salbutamol 5mg via O2 driven nebuliser
  • Prednisolone 40mg od

Investigations:

  • ABG, CXR if severe (exclude pneumothorax)

30 min review:

  • if PEFR still<50% or life-threatening features: treat as life-threatening
  • if PEFR 50-75%: repeat Salbutamol 5mg via O2-driven nebuliser

60 min review:

  • if deteriorating: treat as life-threatening
  • if clinically stable, consider discharge

Discharge:

  • not if previous near-fatal asthma, psychological issues, poor compliance
  • on discharge: give acute asthma pack, and inform asthma nurse (24h Tel: 5278 for review within 7/7)
  • discharge on Prednisolone 40mg od until review, double regular steroid inhaler, or start Qvar 50mcg 2p bd

C) Mild asthma

  • PEFR>75% best/predicted
  • Give usual bronchodilator or Salbutamol 200mcg