Respiratory

Cor- Pulmonale

1. Treat the underlying cause.
2. Same as congestive heart failure (for details see section on CHF).

References

Cor Pulmonale. In: Harrison’s Principles of Internal Medicine. Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp 1355-1359.

Bronchiectasis

1. Cap Amoxycillin 50 mg/kg in 3 divided doses.
   Or
   Cap Amoxycillin + Clavulanic acid (625 mg 3) times a day.
   Or
   Cap Tetracycline 25-50 mg/kg/day in 3 divided doses.
   Or
   Tab. Cotrimoxazole 800 mg + 160 mg 2 times a day.
   The antibiotic choice is modified by gram stain and sputum culture and is given for 7-
   10 days.
   If Staph aureus suspected or isolated-
   Cap Ampicillin + Cloxacillin 1 g 4 time a day.
   Or
   Inj. Methicillin IV 4 times a day.
   If Pseudomonas isolated use atleast 2 effective antipseudomonal drugs
   Inj. Ceftazidime 1-2 g IV 8 hourly + Inj Gentamicin 3-5 mg/kg/day.
2. Salbutamol inhaler 200 mcg four times a day and SOS.
3. Tab. Etophylline + Theophylline 100-200 mg 3 times a day.
   Surgery is indicated in case of uncontrolled haemoptysis and if the disease is localized to one lobe/lobule.
   Observe for the improvement in amount and colour of sputum and constitutional symptoms. If no clinical response and sputum culture report is available, change the antibiotic accordingly. If bronchospasm is not relieved by metered dose inhaler, nebulization should be done.
   Hospitalization is required for severe bronchospasm, a very sick patient or significant haemoptysis.

Patient education

• Emphasise on stoping smoking, annual vaccination against pneumococcus, prompt treatment of upper respiratory tract infections, physiotherapy, early antibiotic treatment if change in colour of sputum.

References

Bronchiectasis. In: Harrison’s Principles of Internal Medicine. Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp 1485-1487.

Chronic Obstructive Airway Disease (COAD)

1. Oxygen inhalation (24-28%) with the venturi mask or through nasal prongs at flow rate of 1-2 litres/min.
2. Salbutamol solution 2.5 mg inhaled using nebulization 4 times a day and as and when required.
3. Inj. Aminophylline 250- 500 mg ( 5 mg/kg) dissolved in 20 ml of 5% dextrose given slowly over 20 minutes (not given if patient already receiving theophylline) followed by infusion at the rate of 0.5 mg/kg/h.
4. Inj. Ampicillin 1 g 6 hourly for 7-10 days.
   Refer the patient to hospital for further treatment/assisted ventilation if no response to above treatment, severe cyanosis and/or altered sensorium.

B. Maintenance treatment

1. Salbutamol inhalation 200 mcg 4 times a day and as and when required (use spacer if coordination is a problem for the patient).
   Or
   Terbutaline inhaler 250 mcg 4 times a day and as and when required.
2. If no complete response to the above Ipratropium bromide inhalation 200 mcg 2 times a day.
3. Tab. Choline theophyllinate 100-200 mg 3 times a day given after meals.
4. If patient is expectorating yellowish sputum Cap Amoxycillin 500 mg 3 times a day for 7 days.
   Steroids have a very limited role in selected patients only, should be administered by the specialist.
   Indication about home therapy of oxygen to be decided by the specialist and if indicated, should be taken for 15 hours a day.

Patient education

• Explain about importance of total cessation of smoking and its benefit not only during the acute stage but even about the long term recovery of lung functions.
• Patient should also be given 1 week dose of antibiotic and instructed to used if the symptoms start worsening with change in colour of sputum to yellow/green.

References

Chronic Bronchitis, Emphysema, and Airways Obstruction. In: Harrison’s Principles of Internal Medicine. Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp 1495-1499.

Bronchial Asthma

1. Salbutamol inhaler 200 mcg as and when required.
   (Use spacer device or rotahaler if coordination is a problem with the patient).
   Or
   Terbutaline inhaler 250-500 mcg as and when required.

B. Mild asthma (periodic symptoms, reacts to triggers, restricts activity 2-3 times a
week).

1. Salbutamol/terbutaline inhaler as in (A) 2-3 times a day on SOS basis.
2. Beclomethasone inhaler 100- 200 mcg 2 times a day.
   Or
   Sodium cromoglycate inhalation 400 mcg 2-4 times a day.
   (More effective in young females with allergic diathesis).

C. Moderate asthma (daily wheeze, no significant diurnal variation, mild limitation of activity)

1. Same as (B) – needs bronchodilators regularly and increase dose of inhaled steroid to 800 mcg per day, if needed.
2. If no relief, Salmeterol inhaler 200 mcg twice a day instead of SOS.
3. Ipratropium bromide inhaler 200 mcg 2 times a day (added if no complete response to above treatment).
4. Tab. Etophylline + Theophyllinate 100-200 mg 3 times a day (if patient is still symptomatic despite above treatment (1-3) or nocturnal symptoms).

D. Severe asthma (daily wheeze, severe nocturnal symptoms, poor quality of life, off work/school, repeated hospitalizations)

1. Same as above.
2. Tab. Prednisolone 0.75-1 mg/kg /day as single dose until symptoms are controlled. Taper it off by reducing the dose to half every 3-5 days and then maintain on inhaled Beclomethasone as above.

E. Severe acute asthma (severe wheeze, cannot complete sentences in one breath, may have mild cyanosis, RR > 25/min, HR > 110/min, peak expiratory flow rate (PEFR < 50% predicted)

1. Hospitalize the patient.
2. Oxygen inhalation 50-60% with venturi mask initially and continue till the patient is better and not dyspnoeic. Intubate and ventilate if the patient is unconscious.
3. Salbutamol or terbutaline inhalation 2.5 ml to be nebulised. Repeat dose at 15 min if required during the 1st hour; hourly for next few hours till bronchospasm is controlled. Continue with 2-4 hourly doses as required.
4. Inj. Hydrocortisone hemisuccinate 100 mg 6-8 hourly IV.
5. If patient not receiving theophylline earlier and there is not adequate response to nebulised Salbutamol) Inj. Aminophylline 250-500 mg IV stat (given slowly over 20 minutes) followed by Aminophylline infusion at the rate of 0.5 mg/kg/hour.

F. Status asthmaticus or severe acute attack (silent chest, cyanosis, feeble respiratory efforts, bradycardia, hypotension, exhaustion, altered sensorium, PEFR <33% predicted)-Refer immediately to a higher centre with ICU facility

1. Intubate the patient and give assisted ventilation
2. Start the treatment as in severe acute asthma
   NOTE: A confused, restless or tired patient indicates impending respiratory failure. Monitor blood gases – a normal or increased CO2 is a sign of respiratory failure and indicates need for close monitoring for intubation and ventilation. Chest X-ray must be done to ruleout pneumothorax.

Patient education

• Explain the chronic nature of the disease and need to continue the medication depending upon the severity of disease.
• Educate the patient regarding use of inhalers of different types, problems of misuse of systemic steroids on long term basis without a definite indication.
• Educate the patient about common triggers, advise regarding reporting to hospital if acute attack does not responds to inhaled drugs at home.
• Stress on abstinence from smoking and avoidance of aspirin.

References

1. Asthma. In: Harrison’s Principles of Internal Medicine. Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York , pp 1456-1463.
2. New Guidelines in asthma management. Editorial BMJ, 1997, 315-316.

Pneumonia

1. Same as (B).
2. Inj. Gentamicin 1-1.5 mg/kg IV 8 hourly.
   Or
   Inj. Amikacin 5 mg/kg IV 8-12 hourly.

D. Aspiration pneumonia

1. Inj. Penicillin G 1.0 million unit IV every 4-6 hourly.
   Or
   Cap Amoxicillin 500-750 mg 8 hourly.
   Or
   Same as (B), if aspiration occurs in the hospital.
2. Inj. or Tab. Metronidazole 400 mg 8 hourly. Duration of treatment is 7-14 days.

E. Non-specific treatment if high fever and body aches (see section on fever)
Follow Up
Continue same antibiotic if good clinical response for 7-10 days. Change of antibiotic required only if culture results show resistance to given antibiotic and there is no clinical improvement. Repeat chest X-ray at 4-5 days interval and follow up X-ray to be done after 3-4 weeks of completing treatment.

Patient education

• Explain the importance of chest percussion and gravity drainage of sputum.

References

1. Pneumonia, including Necrotising Pulmonary Infection (Lung abscess). In: Harrison’s Principles of Internal Medicine. Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp 1475-1485.
2. Guidelines for the Management of Adult with Community-acquired Pneumonia – American Thoracic Guidelines. Am J Resp & Critical Care Medicine Vol 16, 2001, pp 1730-1754.