1. 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%

2. 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.
Stop for breath about 100 yards or a few minutes
Too breathless to leave house or dress.

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

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

5. 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%

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

7. COPD Antibiotic Selection
INDICATION: Increase Dyspnea Increase Sputum 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)

8. 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

9. 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= PAO Pa O2
alveolar O arterial O2
Normal = 5-10 (it increases 1 point for every 10 decade of life)
Thus 40 year old= = 14
High As gradiant means high effort to maintain normal oxygenation.
Oxygen dissolve in blood ….. 1.5% PaO2
Oxygen bound to Hgb……… % 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

10. 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.

11. 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

12. HCAP definition

13. Blood Gases

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

15. Base Excess

16. Carrico Index PaO2– Arterial Oxygen
FiO2= Fraction of inspired air- natural air is 20.9% oxygen.. Which is equivalent
To FiO2= 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.