Asthma vs COPD

• Asthma• -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 Streneous Exercise1--- SOA when hurrying on level ground or hill2--- Walk slower than people your age.3--- Stop for breath about 100 yards or a few minutes4--- 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 GLD GUIDELINES

A … <=1 exac/yr FEV >=80% mmr=0-1 Cat <10- SABA PRNB <=1 exac/yr FEV1 50-80% MMR>=2 CAT<10- LABA & SABA PRN OR LA anticholinergicsC >=2 exac/yr FEV 30-50% MMR 0-1 CAT <10 ICS + LABA or LA anticholinergicD >=2 exac/yr FEV < 30% MMR >=2 CAT >=10 ICS + LABAQ and/or AnticholinergicFEV1 <50% use steroids If incr dyspnea = refluokost(DALIRESP)

Asthma Severity Control4 types Frequency Nite-time FEV1/FVC FEV1

IntermittentSABA PRN

<=2x/wk < 2x/month Normal >80%

Mild PersistantLow dose ICSalt: singulair or cromolyn

>2x/week (but not daily)

3-4 x/month Normal >80%

Mod PersistLow dose ICS & LABA or theophy/steroi

Daily > 1x/weekNot nightly

5% 60-80%

Severe PersistOral steroids/ics/+ LTM or theoMay add spiriva

Throughout The day

7 nits/week >5% < 60%

Curb-65 scoreConfusionBUN > 19RR > 30BP < 90/60Age > 65

Curb score risk death 30 d location0 0.7% outpt1 2.1% out/in pt2 9.2% inpt3 14.5% inpt4 40% inpt5 57% inpt

Curb = 1 .. Tx outptCurb >1 .. InptCurb 4-5 . ICU

Hypoxia --- All or part of body cannot use or receive oxygen—anemic,

Hypoxemia- Reduction in the concentration of oxygen in the arterial blood

• Oxygen dissolve in blood ….. 1.5% PaO2• Oxygen bound to Hgb……….. 98.5% SpO2 (pulse ox)• Aa gradient …. PAO2 – PaO2• Normal A-a-gradient = (age/4) + 4 … incr with age• PAo2= 150- (PaCo2/0.8)

COPD Antibiotic SelectionINDICATION: 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 pseudomonasAB 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

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

HCAP (Inpt)HCAP – ab 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, immunosuppresantHospital Stay < 5 days - 3rd generation cephalosporin - Quinolone - Unasyn - ErtapenemHospital 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