Pulmonary Disorders

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Asthma
1.Admit to:
2.Diagnosis: Exacerbation of asthma
3.Condition:
4.Vital Signs: q6h. Call physician if P >140; R >30,
<10; T >38.5 C; pulse oximeter <90%
5.Activity: Up as tolerated.
6.Nursing: Pulse oximeter, bedside peak flow rate
before and after bronchodilator treatments.
7.Diet: Regular, no caffeine.
8.IV Fluids: D5 ½ NS at 125 cc/h.
9.Special Medications:
-Oxygen 2 L/min by NC. Keep O
 sat >90%.
2
Beta-Agonists, Acute Treatment:
-Albuterol (Ventolin) 0.5 mg and ipratropium
(Atrovent) 0.5 mg in 2.5 mL NS q1-2h until peak
flow meter  200-250 L/min and sat  90%, then q4h
OR
-Levalbuterol (Xopenex) 0.63-1.25 mg by nebulization
q6-8h prn.
-Albuterol (Ventolin) MDI 3-8 puffs, then 2 puffs q3-6h
prn, or powder 200 mcg/capsule inhaled qid.
-Albuterol/Ipratropium (Combivent) 2-4 puffs qid.
Systemic Corticosteroids:
-Methylprednisolone (Solu-Medrol) 60-125 mg IV q6h;
then 30-60 mg PO qd. OR
-Prednisone 20-60 mg PO qAM.
Aminophylline and Theophylline (second-line
therapy):
-Aminophylline load dose: 5.6 mg/kg total body
weight in 100 mL D5W IV over 20 min. Main-
tenance of 0.5-0.6 mg/kg ideal body weight/h (500
mg in 250 mL D5W); reduce if elderly, heart/liver
failure (0.2-0.4 mg/kg/hr). Reduce load 50-75% if
taking theophylline (1 mg/kg of aminophylline will
raise levels 2 mcg/mL) OR
-Theophylline IV solution loading dose 4.5 mg/kg total
body weight, then 0.4-0.5 mg/kg ideal body
weight/hr.
-Theophylline (Theo-Dur) 100-400 mg PO bid (3
mg/kg q8h); 80% of total daily IV aminophylline in 2-
3 doses.
Maintenance Inhaled Corticosteroids (adjunct
therapy):
-Advair Diskus (fluticasone/salmeterol) one puff bid
[doses of 100/50 mcg, 250/50 mcg, and 500/50
mcg]. Not appropriate for acute attacks.
-Beclomethasone (Beclovent) MDI 4-8 puffs bid, with
spacer 5 min after bronchodilator, followed by
gargling with water.
-Triamcinolone (Azmacort) MDI 2 puffs tid-qid or 4
puffs bid.
-Flunisolide (AeroBid) MDI 2-4 puffs bid.
-Fluticasone (Flovent) 2-4 puffs bid (44 or 110
mcg/puff).
Maintenance Treatment:
-Salmeterol (Serevent) 2 puffs bid; not effective for
acute asthma because of delayed onset of action.
-Pirbuterol (Maxair) MDI 2 puffs q4-6h prn.
-Bitolterol (Tornalate) MDI 2-3 puffs q1-3min, then 2-3
puffs q4-8h prn.
-Fenoterol (Berotec) MDI 3 puffs, then 2 bid-qid.
-Ipratropium (Atrovent) MDI 2-3 puffs tid-qid.
Prevention and Prophylaxis:
-Cromolyn (Intal) 2-4 puffs tid-qid.
-Nedocromil (Tilade) 2-4 puffs bid-qid.
-Montelukast (Singulair) 10 mg PO qd.
-Zafirlukast (Accolate) 20 mg PO bid.
-Zileuton (Zyflo) 600 mg PO qid.
Acute Bronchitis
-Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h OR
-Cefuroxime (Zinacef) 750 mg IV q8h OR
-Cefuroxime axetil (Ceftin) 250-500 mg PO bid OR
-Trimethoprim/sulfamethoxazole (Bactrim DS), 1 tab
PO bid OR
-Levofloxacin (Levaquin) 500 mg PO/IV PO qd [250,
500 mg].
-Amoxicillin 875 mg/clavulanate 125 mg (Augmentin
875) 1 tab PO bid.
10. Symptomatic Medications:
-Docusate sodium (Colace) 100 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO q12h OR
-Lansoprazole (Prevacid) 30 mg qd.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: Portable CXR, ECG, pulmonary function
tests before and after bronchodilators; pulmonary
rehabilitation; impedance cardiography,
echocardiogram.
12. Labs: ABG, CBC with eosinophil count, SMA7, B-
type natriuretic peptide (BNP). Theophylline level stat
and after 24h of infusion. Sputum Gram stain, C&S.
Chronic Obstructive Pulmonary
Disease
1.Admit to:
2.Diagnosis: Exacerbation of COPD
3.Condition:
4.Vital Signs: q4h. Call physician if P >130; R >30,
<10; T >38.5 C; O
 saturation <90%.
2
5.Activity: Up as tolerated; bedside commode.
6.Nursing: Pulse oximeter. Measure peak flow with
portable peak flow meter bid and chart with vital signs.
No sedatives.
7.Diet: No added salt, no caffeine. Push fluids.
8.IV Fluids: D5 1/2 NS with 20 mEq KCL/L at 125 cc/h.
9.Special Medications:
-Oxygen 1-2 L/min by NC or 24-35% by Venturi mask,
keep O
 saturation 90-91%.
2
Beta-Agonists, Acute Treatment:
-Albuterol (Ventolin) 0.5 mg and ipratropium
(Atrovent) 0.5 mg in 2.5 mL NS q1-2h until peak
flow meter  200-250 L/min, then q4h prn OR
-Levalbuterol (Xopenex) 0.63-1.25 mg by
nebulization q6-8h prn.
-Albuterol (Ventolin) MDI 2-4 puffs q4-6h.
-Albuterol/Ipratropium (Combivent) 2-4 puffs qid.
Maintenance Corticosteroids and Anticholinergics:
-Methylprednisolone (Solu-Medrol) 60-125 mg IV q6h
or 30-60 mg PO qd. Followed by:
-Prednisone 20-60 mg PO qd.
-Triamcinolone (Azmacort) MDI 2 puffs qid or 4 puffs
bid.
-Beclomethasone (Beclovent) MDI 4-8 puffs bid with
spacer, followed by gargling with water OR
-Flunisolide (AeroBid) MDI 2-4 puffs bid OR
-Ipratropium (Atrovent) MDI 2 puffs tid-qid OR
-Fluticasone (Flovent) 2-4 puffs bid (44 or 110
mcg/puff).
Aminophylline and Theophylline (second line
therapy):
-Aminophylline loading dose, 5.6 mg/kg total body
weight over 20 min (if not already on theophylline);
then 0.5-0.6 mg/kg ideal body weight/hr (500 mg in
250 mL of D5W); reduce if elderly, or heart or liver
disease (0.2-0.4 mg/kg/hr). Reduce loading to 50-
75% if already taking theophylline (1 mg/kg of
aminophylline will raise levels by 2 mcg/mL) OR
-Theophylline IV solution loading dose, 4.5 mg/kg
total body weight, then 0.4-0.5 mg/kg ideal body
weight/hr.
-Theophylline long acting (Theo-Dur) 100-400 mg PO
bid-tid (3 mg/kg q8h); 80% of daily IV aminophylline
in 2-3 doses.
Acute Bronchitis
-Trimethoprim/sulfamethoxazole (Septra DS) 160/800
mg PO bid or 160/800 mg IV q12h (10-15 mL in 100
cc D5W tid) OR
-Cefuroxime (Zinacef) 750 mg IV q8h OR
-Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h OR
-Doxycycline (Vibra-tabs) 100 mg PO/IV bid OR
-Azithromycin (Zithromax) 500 mg x 1, then 250 mg
PO qd x 4 or 500 mg IV q24h OR
-Clarithromycin (Biaxin) 250-500 mg PO bid OR
-Levofloxacin (Levaquin) 500 mg PO/IV qd [250, 500
mg].
10. Symptomatic Medications:
-Docusate sodium (Colace) 100 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO bid OR
-Lansoprazole (Prevacid) 30 mg qd.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: Portable CXR, PFTs with bronchodilators,
ECG, impedance cardiography, echocardiogram.
12. Labs: ABG, CBC, SMA7, UA. Theophylline level stat
and after 12-24h of infusion. Sputum Gram stain and
C&S, alpha 1 antitrypsin level.
Hemoptysis
1.Admit to: Intensive care unit
2.Diagnosis: Hemoptysis
3.Condition:
4.Vital Signs: q1-6h. Orthostatic BP and pulse bid. Call
physician if BP >160/90, <90/60; P >130, <50; R>25,
 sat <90%.
<10; T >38.5 C; O
2
5.Activity: Bed rest with bedside commode. Keep pat-
ient in lateral decubitus, Trendelenburg’s position,
bleeding side down.
6.Nursing: Quantify all sputum and expectorated blood
suction prn. O
 at 100% by mask, pulse oximeter. Dis-
2
continue narcotics and sedatives. Have double lumen
endotracheal tube available for use. Foley to closed
drainage.
7.Diet: NPO
8.IV Fluids: 1 L of NS wide open ( 6 gauge), then
transfuse PRBC. Then infuse D5 1/2 NS at 125 cc/h.
9.Special Medications:
-Transfuse 2-4 U PRBC wide open.
-Promethazine/codeine (Phenergan with codeine) 5
cc PO q4-6h prn cough. Contraindicated in massive
hemoptysis.
-Initiate empiric antibiotics if bronchitis or infection is
present.
10. Extras: CXR PA, LAT, ECG, VQ scan, contrast CT,
bronchoscopy. PPD, pulmonary and thoracic surgery
consults.
11. Labs: Type and cross 2-4 U PRBC. ABG, CBC,
platelets, SMA7 and 12, ESR. Anti-glomerular
basement antibody, rheumatoid factor, complement,
anti-nuclear cytoplasmic antibody. Sputum Gram
stain, C&S, AFB, fungal culture, and cytology qAM for
3 days. UA, INR/PTT, von Willebrand Factor. Repeat
CBC q6h.
Anaphylaxis
1.Admit to:
2.Diagnosis: Anaphylaxis
3.Condition:
4.Vital Signs: q1-4h; call physician if BP systolic >160,
<90; diastolic >90, <60; P >120, <50; R>25, <10; T
>38.5 C
5.Activity: Bedrest
6.Nursing: O
 at 6 L/min by NC or mask. Keep patient
2
in Trendelenburg's position, No. 4 or 5 endotracheal
tube at bedside. Foley to closed drainage.
7.Diet: NPO
8.IV Fluids: 2 IV lines. Normal saline or LR 1 L over 1-
2h, then D5 ½ NS at 125 cc/h.
9.Special Medications:
Gastrointestinal Decontamination:
-Gastric lavage with normal saline until clear fluid if
indicated for recent oral ingestion.
-Activated charcoal 50-100 gm, followed by
magnesium citrate 6% solution 150-300 mL PO.
Bronchodilators:
-Epinephrine (1:1000) 0.3-0.5 mL SQ or IM q10min or
1-4 mcg/min IV OR in severe life-threatening
reactions, give 0.5 mg (5.0 mL of 1: 10,000
solution) IV q5-10min prn. Epinephrine, 0.3 mg of
1:1000 solution, may be injected SQ at site of
allergen injection OR
-Albuterol (Ventolin) 0.5%, 0.5 mL in 2.5 mL NS
q30min by nebulizer prn OR
-Aerosolized 2% racemic epinephrine, 0.5-0.75 mL in
2-3 mL saline nebulized q1-6h.
Corticosteroids:
-Methylprednisolone (Solu-Medrol) 250 mg IV x 1,
then 125 mg IV q6h OR
-Hydrocortisone sodium succinate 200 mg IV x 1,
then 100 mg q6h, followed by oral prednisone 60
mg PO qd, tapered over 5 days.
Antihistamines:
-Diphenhydramine (Benadryl) 25-50 mg PO/IV q4-6h
OR
-Hydroxyzine (Vistaril) 25-50 mg IM or PO q2-4h.
-Cetrizine (Zyrtec) 5-10 mg PO qd.
-Cimetadine (Tagamet) 300 mg PO/IV q6-8h.
Pressors and Other Agents:
-Norepinephrine (Levophed) 8-12 mcg/min IV, titrate
to systolic 100 mm Hg (8 mg in 500 mL D5W) OR
-Dopamine (Intropin) 5-20 mcg/kg/min IV.
10. Extras: Portable CXR, ECG, allergy consult.
11. Labs: CBC, SMA 7&12.
Pleural Effusion
1.Admit to:
2.Diagnosis: Pleural effusion
3.Condition:
4.Vital Signs: q shift. Call physician if BP >160/90,
<90/60; P>120, <50; R>25, <10; T >38.5 C
5.Activity:
6.Diet: Regular.
7.IV Fluids: D5W at TKO
8.Extras: CXR PA and LAT, repeat after thoracentesis;
left and right lateral decubitus x-rays, ECG, ul-
trasound, PPD; pulmonary consult.
9. Labs: CBC, SMA 7&12, protein, albumin, amylase,
ANA, ESR, INR/PTT, UA. Cryptococcal antigen,
histoplasma antigen, fungal culture.
Thoracentesis:
Tube 1: LDH, protein, amylase, triglyceride, glucose
(10 mL).
Tube 2: Gram stain, C&S, AFB, fungal C&S (20-60
mL, heparinized).
Tube 3: Cell count and differential (5-10 mL, EDTA).
Syringe: pH (2 mL collected anaerobically,
heparinized on ice).
Bag or Bottle: Cytology.