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Respiratory
Published in Faye Hill, Sash Noor, Neel Sharma, Tiago Villanueva, Medical and Surgical Emergencies for Students and Junior Doctors, 2021
Faye Hill, Sash Noor, Neel Sharma
Patients with a suspected acute exacerbation of chronic obstructive pulmonary disease should undergo an arterial blood gas, chest X-ray and ECG. Blood investigations include a full blood count, urea and electrolytes, C-reactive protein and blood cultures. Sputum should also be sent for microscopy, culture and sensitivity. If the patient is on theophylline, a theophylline level should be taken at admission.
Practice Paper 3: Answers
Published in Anthony B. Starr, Hiruni Jayasena, David Capewell, Saran Shantikumar, Get ahead! Medicine, 2016
Anthony B. Starr, Hiruni Jayasena, David Capewell
This man has an acute exacerbation of chronic obstructive pulmonary disease (COPD), as evidenced by a decreasing exercise tolerance, increased sputum production and increased sputum purulence. COPD is a chronic progressive disorder characterized by airflow obstruction. The obstruction may be partially (but not completely) reversible with bronchodilators. COPD encompasses bronchitis and emphysema. Chronic bronchitis is defined as cough with sputum for most days of a 3-month period on two consecutive years. Emphysema is a pathological diagnosis of permanent destructive enlargement of the alveoli. Smoking is the main risk factor, and 15% of smokers develop COPD. The pathology includes hypertrophy of the goblet cells and decreased cilia with loss of alveoli elastic recoil. The persistent hypoxaemia seen in COPD results in pulmonary vascular hypertension, which leads to cor pulmonale. Features of COPD include a productive cough (worse in the mornings), recurrent respiratory tract infections, exertional dyspnoea, expiratory wheeze and bibasal crepitations. Examination may also reveal tracheal tug, intercostal in-drawing, a barrel chest (increased anterior–posterior diameter), pursed lips, central cyanosis, CO2 retention (flapping tremor, bounding pulse and warm peripheries) and right heart failure.
Screening for Methicillin resistant Staphylococcus aureus (MRSA) - a valuable antimicrobial stewardship tool?
Published in Expert Review of Anti-infective Therapy, 2021
Glenn S. Tillotson, Nick van Hise
The question of who should enforce and know the results of nares screening are important to those who have direct input to managing antibiotic use. With the advent of Antibiotic Stewardship Programs (ASP), the hospital clinical pharmacist is one of the ASP team leaders. An interesting study by Willis et al. [20] examined 300 patients in a retrospective, single-center, quasi-experimental, pre-post cohort study. A list of all patients who received IV vancomycin and had pneumonia or an acute exacerbation of chronic obstructive pulmonary disease (COPD) were assessed for study inclusion. Negative nasal swab PCR results were used to guide the de-escalation of vancomycin therapy. The primary outcomes were days of therapy of vancomycin, and secondary outcomes included length of hospital of stay, rate of vancomycin-associated acute kidney injury (AKI), and in-hospital mortality. Importantly, the post-protocol cohort had a reduced course of vancomycin, 2.1 days vs. 4.2 days (p < 0.0001). Concerning the secondary outcomes, fewer serum vancomycin assays were obtained in the post-protocol group versus pre-protocol group 1 vs. 2 (p < 0.0001). Due to the sample size, no significant between-group differences were noted with regard to patients reaching clinical stability, rate of AKI, and in-hospital mortality. In patients with suspected or confirmed hospital or ventilator-associated pneumonia or acute exacerbation of COPD, the ability of the pharmacist to order MRSA nares screening can lead to a reduction in IV vancomycin use without compromising clinical outcomes [20].
Pharmacotherapeutic management of bronchial infections in adults: non-cystic fibrosis bronchiectasis and chronic obstructive pulmonary disease
Published in Expert Opinion on Pharmacotherapy, 2020
Marta Di Pasquale, Stefano Aliberti, Marco Mantero, Andrea Gramegna, Francesco Blasi
Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) represent a key-moment in the progression of COPD and it is associated to a decline in health status and lung function [8,9]. The true incidence of AECOPD is quite difficult to assess because about 50% of exacerbations are not reported by patients [8]. Costs on health care systems increase with exacerbation frequency, severity, need of hospitalization, relapses and with the presence of comorbidities [8,9]. Reducing AECOPD treatment failure and relapse could contribute to reduce the burden of disease and ameliorate the management of COPD patients [10]. Recents studies showed that approximately 80% of patients admitted for AECOPD received antibiotic treatments, even if less than 25% had an evidence of bacterial infection [11]. Studies also suggest that the majority of bronchial infections are primarly viral, nevertheless antibiotic treatment is prolonged during hospitalization, representing inappropriate use [12].
Novel applications for serum procalcitonin testing in clinical practice
Published in Expert Review of Molecular Diagnostics, 2018
Justin J. Choi, Matthew W. McCarthy
Distinguishing between bacterial pneumonia and an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) can be difficult clinically given overlapping clinical features and disease presentations [101]. In both conditions, patients may develop shortness of breath, cough, lethargy, and purulent sputum. Unfortunately, many of the studies involving PCT including patients with respiratory illness and COPD did not include microbiologic assessment to ‘rule-in’ or ‘rule-out’ bacterial infection [102]. Notably, the common cutoff value of 0.25 ng/mL to ‘rule-out’ bacterial infection is based on recovery without antibiotics or with an abbreviated course as a surrogate marker for absence of infection rather than microbiologic data demonstrating absence of infection. The absence of microbiologic data has given many pause is using PCT as a ‘rule-out’ marker [103–105].