10/17/2018 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. 1
10/17/2018 Roadmap for Help, Doc! My: the Hour 1. Asthma/COPD is Still Wheezing 2. BP Is Still Low Common Confounding Consults 3. Fluid Is Still Recurring in Pulm/ICU 4. Mind Is Still Fuzzy Objectives: Roadmap for Management of obstructive lung dz the Hour Management of severe hypotension Common Confounding Consults Management of pleural effusions in Pulm/ICU Management of post-ICU syndrome 2
10/17/2018 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
10/17/2018 Not All OLD Are Equal, But . . . 4
10/17/2018 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
10/17/2018 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
10/17/2018 Common Asthma & COPD Mimics - Can Delay Dx ❏ Vocal cord dysfunction ❏ Pulmonary embolism ❏ Allergic bronchopulmonary ❏ Decompensated CHF ❏ Obesity aspergillosis ❏ Vasculitides such as ❏ Bronchiectasis ❏ Occupational/environment Eosinophilic Granulomatosis with al lung diseases ❏ Malignancy (lung or mets) Polyangiitis ❏ Infections such as ❏ Interstitial lung diseases Strongyloides What about Reactive Airways Disease? Different from Reactive Airways Dysfunction Syndrome - Acute wheezing in response to inhaled irritant 7
10/17/2018 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
10/17/2018 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
10/17/2018 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
10/17/2018 Roadmap for Help, Doc! My: the Hour 1. Asthma/COPD is Still Wheezing 2. BP Is Still Low Common Confounding Consults 3. Fluid Is Still Recurring in Pulm/ICU 4. Mind is Still Fuzzy Help, Doc! My BP Is Still Low. 11
10/17/2018 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
10/17/2018 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) 13
10/17/2018 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
10/17/2018 Has This Change Intensivists’ Practice? 15
10/17/2018 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 glucose measurements being inaccurate in patients with CKD 16
10/17/2018 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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10/17/2018 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
10/17/2018 Roadmap for Help, Doc! My: the Hour 1. Asthma/COPD is Still Wheezing 2. BP Is Still Low Common Confounding Consults 3. Fluid Is Still Recurring in Pulm/ICU 4. Mind is Still Fuzzy Help, Doc! My Fluid is Still Recurring. 20
10/17/2018 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
10/17/2018 2018 ATS Guidelines on Malignant Pleural Effusions 22
10/17/2018 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
10/17/2018 Roadmap for Help, Doc! My: the Hour 1. Asthma/COPD is Still Wheezing 2. BP Is Still Low Common Confounding Consults 3. Fluid Is Still Recurring in Pulm/ICU 4. Mind is Still Fuzzy Help, Doc! My Mind is Still Fuzzy. 24
10/17/2018 Case 4: Post-ICU Sd Do you have a post-ICU Clinic after discharge? A. Yes B. No 25
10/17/2018 SCCM THRIVE Collaborative for Post-ICU Syndrome 26
10/17/2018 Thank You! Questions? Lekshmi.Santhosh@ucsf.edu @LekshmiMD 27
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