“It Hurts When I Sing”

1. “It Hurts When I Sing” Sachin B. Patel, M.D. Pulmonary Boot Camp WakeMed August 18, 2015

2. Case Presentation 69 yo F presents with several days of… Yellow productive cough Low-grade fevers Myalgias Dizziness

3. Case Presentation Past Medical Hx • Allergic Rhinitis • HTN Meds • HCTZ • Flonase

4. Case Presentation Social History • Single • + second-hand smoke • -IVDU • ++alcohol • Occasional THC (for medical purposes) • Exposures • +tattoos • Extensive world travel • -known mold exposure • Family History • - pulmonary dz

5. Physical Examination VS: 38.4 87/60  90 rr 31 Pulse ox: 91% on RA 46kg GEN: fatigued, a bit confused (thinks we are in Vegas)HEENT: NCAT -LADCV: mild tachy, -m/r/gPulm: Inspiratory crackles at right base. - wheezesGI: S/NT/NDExt: -edemaSkin: -clubbing, cyanosis, or rashes

6. Labs 12 131 98 21 94 253 12 4.0 21 0.56 43 90% Seg 6% Bands LFTs wnl

7. Imaging

8. “I wanna go home! I have to be on a plane to LA” • Discharge home with Doxycycline? • Admit to floor and Rx Ceftriaxone/Azithro? • Admit to ICU and Rx with Levaquin?

9. “But Why? I’m a Rock Star”

10. Pneumonia

11. Objectives 1. Classification of PNAs 2. Bugs 3. Respiratory Physiology 4. Risk Stratification 5. Drugs

12. History of Pneumonia way before 400 BCE Greek Physicians "Peripneumonia, and pleuritic affections, are to be thus observed:  If the fever be acute, and if there be pains on either side, or in both, and if expiration be if cough be present, and the sputa expectorated be of a blond or livid color, or likewise thin, frothy, and florid, or having any other character different from the common.

13. Infuenza Pandemic 1918 1918

14. Development Penicillin WWII 1945

15. Epidemiology • 7th Leading cause of death • Leading cause of death from infx • More than 5.6 million cases of CAP/yr • 1.1 million hospitalizations per year • Greater than 100,000 deaths per year • Mean mortality rate equals 12% • Cost: $21 billion Bartlett at all: Clinical infectious disease. 26:811–838, 1998

16. “Pneumonia” Lobar Interstitial Infectious Inflammatory Infectious Inflammatory Bugs • AIP • DIP • AEP • LIP • etc Bugs OP

17. Classification of Infectious Pneumonias • Community-acquired pneumonia • Healthcare associated pneumonia • Hospital-acquired pneumonia • Ventilator associated pneumonia • Bacterial pneumonia superinfection

18. “Who’s Hosting?” Heart Disease Alcoholism Asthma (ICS, PPI) Institutionalization Immunocompromised Age > 70

19. Investigate Sick contacts Travel Hx Insect bites Endobronchial Obstruction Noxious gasses Bats, Cats, Birds, Rabbits, oh my Mold exposure Genital Lesions? IVDA Medications 4 corners or Middle East “Do you have an immune system?” China Homeless? Tooth pain? SNF A fifth or two a night? Flu Boils, rashes, cuts

20. Community Acquired Pneumonia Typical Atypical Source: Reimer and Caroll: Clinical infectious diseases 26:742–748, 108.

21. Respiratory Physiology in PNA

22. Respiratory Physiology in PNA

23. Respiratory Physiology in PNA Shunt Pa02/FIO2

24. Risk Stratification Outpatient Inpatient CURB-65

25. Risk Stratification: CURB-65 Confusion 0-1 Low Risk BUN >7mmol/L RR ≥ 30/min 2-5 High Risk SBP <90 or DBP ≤ 60 mmhg Age >65

26. Risk Stratification Outpatient Inpatient Floor ICU CURB-65 IDSA/ATS Severe CAP Guidelines

27. Risk Stratification: IDSA/ATS Severe CAP Guidelines ≥3 minor criteria Lim et al : Thorax 2003; 58: 377-382

28. Drugs: Outpatient CAP macrolide or doxycycline “Average Joe” No chronic medical conditions and no antibiotics within the last 3 months Chronic Illnesses: heart, lung, liver, renal, diabetes, alcoholism, cancer, immunosuppression, antibiotic exposure, asplenia Respiratory quinolone or beta-lactam plus macrolide or Doxy

29. Drugs: Inpatient CAP Respiratory quinolone or beta-lactam plus macrolide or Doxy Non-ICU patients

30. Drugs: ICU CAP No Pseudomonal risk Yes Pseudomonal risk beta-lactam plus azithromycin or respiratory quinolone or respiratory quinolone plus aztreonam Anti-pneumococcal/ anti-pseudomonal beta lactam plus ciprofloxacin or levofloxacin or the above beta-lactam plus an aminoglycoside and azithromycin or the above beta-lactam plus an aminoglycoside and an antipseudomonal quinolone Just add Vanc or Linezolid!

31. Hospital Acquired vs. HCAP vs. VAP • Hospitalized in the preceding 90 days >48 hours after hospital admission • Nursing home/extended care facility residence • Home infusion therapy including antibiotics • Chronic dialysis • Home wound care • Family member with MDR pathogen

32. Hospital Acquired vs. HCAP vs. VAP • Purulent sputum • Fever or hypothermia • Leukocytosis ± left shift • Expanding infiltrate • Positive culture

33. Drugs: HCAP

34. Risk Stratification Outpatient Inpatient CURB-65

35. Case Review VS: 38.4 87/60  90 rr31 Pulse ox: 90% on RA 46kg GEN: fatigued, a bit confused (thought we were in Vegas)HEENT: NCAT-LADCV: mild tachy, -m/r/gPulm: Inspiratory crackles at right base. - wheezesGI: S/NT/NDExt: -edemaSkin: -clubbing, cyanosis, or rashes

36. Labs 12 131 98 21 94 253 12 4.0 21 0.56 43 90% Seg 6% Bands LFTs wnl

37. Imaging

38. Risk Stratification: CURB-65 Confusion 0-1 Low Risk BUN >7mmol/L RR ≥ 30/min 2-5 High Risk SBP <90 or DBP ≤ 60 mmhg CURB-65=5 Age >65

39. Risk Stratification Outpatient Inpatient Floor ICU CURB-65 IDSA/ATS Severe CAP Guidelines

40. Risk Stratification: IDSA/ATS Severe CAP Guidelines ≥3 minor criteria Lim et al : Thorax 2003; 58: 377-382

41. Take Home Points • Appreciate physiologic respiratory changes in PNA • Recognize risk factors and classification of PNAs • Understand triage and mindful antibiotic choices