Asthma vs COPD Asthma COPD -FEV1 improves by 12% or more with Beta2 agonist -Cough is Non-Productive -Cough worse at night & early AM -triggered by allergies/environment -Asthma is reversible - NORMAL VALUES -FEV1= normal is >= 80% FVC=Empty 80% lungs in < 6 seconds FEV1/FVC-75-85% COPD - Cough all the time -Assoc with smoking -Not reversible -FEV1/FVC < 70%

MMRC Dyspneic Scale (Modified Medical Research Council) 0 --- only gets breathless with Strenuous Exercise 1--- SOA when hurrying on level ground or hill 2--- Walk slower than people your age. 3--- Stop for breath about 100 yards or a few minutes 4--- Too breathless to leave house or dress.

CAT-SCORES (COPD) Never cough ------------------------ 0 thru 5 Cough all the time Never have phlegm (mucous) ---0 thru 5 Chest completely full of mucous Chest is not tight ----------------- 0 thru 5 Chest feels very tight Stairs/hill-not breathless --------- 0 thru 5 hill/stairs- very breathless Not limited with home activities 0 thru 5 Very limited Confident leaving home ----------- 0 thru 5 Not confident leaving home Sleep soundly -------------------------0 thru 5 Don’t sleep soundly Lost of energy ------------------------ 0 thru 5 No energy at all COPD guidelines= CAT <10 or >=10 A < 10 B >=10 C < 10 D >=10 (COPD Categories A,B,C,D)

COPD GOLD GUIDELINES 4 types EXAC/YR FEV1 MMRC/CAT TREATMENT A SABA PRN B <= 1/YR FEV1 50-80% >=2 C < 10 LABA & SABA PRN OR LA anticholinergic C >= 2/YR FEV1 30-50% 0-1 C<10 ICS + LABA or LA anticholinergic D >=2/YR FEV1 <30% >=2 C>=10 ICS + LABA and/or anticholinergic

Asthma Severity Control 4 types Frequency Nite-time FEV1/FVC FEV1 Intermittent SABA PRN <=2x/wk < 2x/month Normal >80% Mild Persistant Low dose ICS alt: singulair or cromolyn >2x/week (but not daily) 3-4 x/month Mod Persist Low dose ICS & LABA or theophy/steroi Daily > 1x/week Not nightly 5% 60-80% Severe Persist Oral steroids/ics/+ LTM or theo May add spiriva Throughout The day 7 nits/week >5% < 60%

Curb-65 score Confusion BUN > 19 RR > 30 BP < 90/60 Age > 65 Curb score risk death 30 d location 0 0.7% outpt 2.1% out/in pt 9.2% inpt 14.5% inpt 40% inpt 57% inpt Curb = 1 .. Tx outpt Curb >1 .. Inpt Curb 4-5 . ICU

COPD Antibiotic Selection INDICATION: 1.0 Increase Dyspnea 2.0 Increase Sputum 3.0 Sputum Purulence BACTERIA IS USUALLY Moraxella Catarrhalic Haemophilus Influenza Strept Pneumo (pt >3 exacerb/yr _ FEV1 <50%.. Suspect pseudomonas AB selection: 2nd line med eg: zithromycin, doxy DURATION: 5 days (use to be 10-14)

CAP (outpt) Cap= no more than 2 days hospitalized in past 90 days, not a NH-resident, no iv ab, no chemo, no wound cure, EMPIRIC ---- Macrolid or Doxycycline With CoMorbidities (COPD, DM, CRF, CHF, CA,, --- levaquin 750mg or ---- amoxil 1gm tid or augmentin 2gm id PLUS Azithromycin or doxycycline

Aa Gradient Aa Gradient= PAO2 - Pa O2 alveolar O2 - arterial O2 Useful in determining if source of hypoxia is within the lungs or outside. (source of hypoxia) Aa Gradient= PAO2 - Pa O2 alveolar O2 - arterial O2 Normal = 5-10 (it increases 1 point for every 10 decade of life) Thus 40 year old= 10 + 4= 14 High As gradiant means high effort to maintain normal oxygenation. Oxygen dissolve in blood ….. 1.5% PaO2 Oxygen bound to Hgb……….. 98.5% SpO2 (pulse ox Hypoxia --- All or part of body cannot use or receive oxygen—anemic, Hypoxemia- Reduction in the concentration of oxygen in the arterial blood

CAP (Inpatient) EMPIRIC - Levaquin 750mg - Ampicillin, rocephin PLUS macrolide or doxycycline ICU unasyn PLUS Quinolone or Azithromycin rocephin PLUS Quinolone or Azithromycin Cefotaxime Plus Quinolone or azithromycin TREATMENT – AT LEAST 5 DAYS, MUST BE FEBRILE X 48 HOURS.

HCAP (Inpt) HCAP – IV-abx within past 5 days, hosp of 5 days or more, hosp 2 days or more in past 90 days, home infusion, HD in 30 days, home wound care, family member w MDR, immunosuppresant Hospital Stay < 5 days - 3rd generation cephalosporin - Quinolone - Unasyn - Ertapenem Hospital Stay > 5 days (need 2 drugs to cover pseudomonas) -- Ceftazidime or cefepime PLUS QUINOLONE OR AMINOGLYCOSIDE --Carbapenem PLUS QUINOLONE OR AMINOGLYCOSIDE --Zosyn PLUS QUINOLONE OR AMINOGLYCOSIDE --add van or linezolid if suspect mrsa

HCAP definition

Blood Gases

Blood Gases Look at pH and determine if it is acidotic (<7.35), normal (7.35 - 7.45), or alkalotic (> 7.45).

Base Excess

Carrico Index PaO2– Arterial Oxygen FiO2= Fraction of inspired air- natural air is 20.9% oxygen.. Which is equivalent To FiO2= 0.209 Oxygen delivered via cannula or mask increases oxygen by 4% for every Liter… Therefore 2 Liters O2 FiO2= 20.9% + 8% = 28.9% or FiO2= 0.289 Always keep FiO2 < 0.5 to avoid oxygen toxicity. PaO2/FiO2 = measures the ability to extract arterial oxygen from the alveoli If it is < 250… we say they have severe pneumonia.