pulmonary pneumonia treatment :: Article CreatorCombined Valve Implantation Improves Severe Emphysema Outcomes
Photo Credit: Mohammed Haneefa Nizamudeen
Combining Zephyr and Spiration valve therapy benefited patients with COPD and advanced pulmonary emphysema while imparting a manageable risk profile.
Endoscopic lung volume reduction using valves represents a minimally invasive approach for managing severe pulmonary emphysema. Among the available options, the Zephyr and Spiration valves are two distinct systems that can be implanted concurrently within the same procedure.
In a study published in Respiratory Medicine, A. Susanne Dittrich, MD, and colleagues aimed to evaluate the impact of combined valve therapy on lung function, exercise capacity, and patient-reported outcomes for people with severe emphysema undergoing endoscopic lung volume reduction.
"Previous studies focused on the outcome of either Zephyr or Spiration valve treatment, but little is known about a combined implantation of Zephyr and Spiration valves during the same bronchoscopic procedure," Dr. Dittrich and colleagues explained.
The researchers performed a retrospective analysis of 108 patients with chronic obstructive pulmonary disease (COPD) who underwent simultaneous implantation of Zephyr and Spiration valves. Clinicians tailored the selection and number of valves implanted to each patient's anatomical requirements. The study authors assessed the effects of the combined treatment on lung function, exercise capacity, and atelectasis formation, along with any associated complications, at 90 and 180 days post-treatment.
At the 90-day follow-up (n=90), the mean change in forced expiratory volume in 1 second (FEV1) was 86.7 ±183.7 mL, and residual volume (RV) showed a mean reduction of -645.3 ±1276.5 mL, with responder rates of 39.8% and 46.5%, respectively. The researchers observed complete atelectasis in 16.7% of patients, while partial atelectasis occurred in 25.5%.
Patients' 6-minute walk tests increased by an average of 27.0 meters (range, -1.5-68.5). The incidence of pneumothorax at 6 months was 10.2%, aligning with rates reported in randomized controlled trials. However, due to the inclusion of high-risk patients in this cohort, there was a notably higher incidence of severe COPD exacerbations (21.3%) and pneumonia (12.0%) compared with other studies.
The researchers concluded that the simultaneous implantation of Zephyr and Spiration valves yielded significant clinical and functional outcomes improvements, with a manageable risk profile.
"The current data show that simultaneous, combined implantation of Zephyr and Spiration valves can be an effective and safe treatment strategy for endoscopic lung volume reduction in patients with severe emphysema and complete interlobar fissures, especially if the anatomy requires it," Dr. Dittrich and colleagues concluded.
Doctors Confirm Recent Cases Of Atypical Pneumonia In Oklahoma
THIS BEHAVES AND WHO NEEDS TO PAY ATTENTION TO IT. A TYPICAL PATIENTS HAVE MUCH MILDER SYMPTOMS. THEY MAY NOT EVEN HAVE A SIGNIFICANT TEMPERATURE. DOCTOR WHITSON SAYS ATYPICAL PNEUMONIA IS A LITTLE HARDER TO FIGURE OUT THAN A USUAL CASE. MORE PROMINENT SYMPTOM IS A COUGH THAT JUST LINGERS, WON'T GO AWAY. IT'S ALSO CALLED WALKING PNEUMONIA AND IS CONSIDERED TO BE CONTAGIOUS, BUT SYMPTOMS TAKE LONGER TO PRESENT THEMSELVES, SO SOME OF THE AGENTS THAT CAUSE ATYPICAL PNEUMONIA, A LOT OF THOSE ARE VIRUSES FOR INSTANCE, COVID COULD BE CONSIDERED AN ATYPICAL PNEUMONIA. YEAH, VIRUSES ARE PRETTY CONTAGIOUS. SO I WOULD SAY YES, MORE THAN A CLASSIC BACTERIAL PNEUMONIA. THE DOCTOR TOLD ME OLDER POPULATIONS ARE THE ONES THAT NEED TO BE MOST AWARE OF THIS, ESPECIALLY PEOPLE WITH CONDITIONS LIKE COPD, CHRONIC ASTHMA OR INTERSTITIAL LUNG DISEASE. A LOT OF CONDITIONS THAT MAKE KIDS MILDLY ILL CAN REALLY MAKE THEM ILL, ESPECIALLY GRANDPARENTS. PEOPLE THAT ARE OLDER MAY HAVE SOME IMMUNE PROBLEMS. IF YOUR CHILD COMES DOWN WITH ATYPICAL PNEUMONIA, DON'T PANIC. ANTIBIOTICS ARE THE BEST FORM OF TREATMENT TO KICK IT TO THE CURB AND KEEP THEM FROM SPREADING THE SICKNESS. I THINK PEOPLE GET MORE CONCERNED WHEN THEY HEAR THE DIAGNOSIS OF PNEUMONIA. ALTHOUGH THESE CASES NECESSARILY
Doctors confirm recent cases of atypical pneumonia in Oklahoma
Pediatrics have confirmed recent cases of atypical pneumonia in Oklahoma, an illness that doesn't always present obvious symptoms.
Updated: 10:19 PM CDT Oct 10, 2024
Pediatrics have confirmed recent cases of atypical pneumonia in Oklahoma, an illness that doesn't always present obvious symptoms.Get the latest news stories of interest by clicking here.KOCO 5 spoke with a doctor at Norman Regional Hospital about the illness and who needs to pay attention to it."Atypical patients have much milder symptoms and may not even have a significant temperature," said Dr. Brian Whitson, a pulmonologist with Norman Regional Hospital.Whitson said atypical pneumonia, also known commonly as walking pneumonia, is a little harder to figure out than a usual case."The more prominent symptom is probably a cough; it just lingers, it won't go away," Whitson said.>> Download the KOCO 5 AppAtypical pneumonia is considered to be contagious, but symptoms take longer to present themselves."Some of the agents that cause atypical pneumonia, a lot of those are viruses. For instance, COVID, could be considered an atypical pneumonia. Yes, viruses are pretty contagious, so I would say yes, more than a classic bacterial pneumonia," Whitson said.Whitson said older populations are the ones that need to be most aware of the illness, especially people with chronic obstructive pulmonary disease, chronic asthma or interstitial lung disease."A lot of conditions that make kids mildly ill can really make them ill, especially grandparents, people that are older — that may have some immune problems," Whitson said. But if your child comes down with atypical pneumonia, don't panic. Antibiotics are the best form of treatment to kick it to the curb and keep it from spreading the illness."I think people get more concerned when they hear the diagnosis of pneumonia, although these cases aren't necessarily critical," Whitson said.Top HeadlinesSUV badly damaged, wedged under dump truck after crash in north Oklahoma CityHurricane Milton: Videos show impacts to FloridaAt least 10 dead as Milton knocks out power to millions and spawns 150 tornadoes across FloridaFormer Oklahoma Congressman outlines how dangerous suspects are tracked downWATCH: Doorbell camera and other videos show storm surge, flooding from Hurricane Milton
OKLAHOMA CITY —
Pediatrics have confirmed recent cases of atypical pneumonia in Oklahoma, an illness that doesn't always present obvious symptoms.
Get the latest news stories of interest by clicking here.
KOCO 5 spoke with a doctor at Norman Regional Hospital about the illness and who needs to pay attention to it.
"Atypical patients have much milder symptoms and may not even have a significant temperature," said Dr. Brian Whitson, a pulmonologist with Norman Regional Hospital.
Whitson said atypical pneumonia, also known commonly as walking pneumonia, is a little harder to figure out than a usual case.
"The more prominent symptom is probably a cough; it just lingers, it won't go away," Whitson said.
>> Download the KOCO 5 App
Atypical pneumonia is considered to be contagious, but symptoms take longer to present themselves.
"Some of the agents that cause atypical pneumonia, a lot of those are viruses. For instance, COVID, could be considered an atypical pneumonia. Yes, viruses are pretty contagious, so I would say yes, more than a classic bacterial pneumonia," Whitson said.
Whitson said older populations are the ones that need to be most aware of the illness, especially people with chronic obstructive pulmonary disease, chronic asthma or interstitial lung disease.
"A lot of conditions that make kids mildly ill can really make them ill, especially grandparents, people that are older — that may have some immune problems," Whitson said.
But if your child comes down with atypical pneumonia, don't panic. Antibiotics are the best form of treatment to kick it to the curb and keep it from spreading the illness.
"I think people get more concerned when they hear the diagnosis of pneumonia, although these cases aren't necessarily critical," Whitson said.
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Management Of Respiratory Failure In The Emergency Department
History of Present Illness
A 65-year-old White man is brought in by emergency medical services (EMS) for worsening shortness of breath over the previous 2 days, cough producing purulent sputum, and fever of 103°F. On EMS arrival at the residence, the patient's oxygen saturation readings were 75% on room air. Bilateral breath sounds revealed expiratory wheezing to all lobes anteriorly and posteriorly, with diminished breath sounds to bases posteriorly. Breath sounds were noted to be very "tight." EMS administered an albuterol sulfate/ipratropium bromide inhalation treatment, began supplemental oxygen at 2 to 4 liters per minute per nasal cannula, and transported the patient to the hospital.
The patient has a history of hypertension, hyperlipidemia, gout, and smoking, and previously underwent appendectomy, cholecystectomy, and repair of a gunshot wound to the chest. Although the patient quit smoking 10 years ago, he had a 30-pack per-year history. On arrival at the emergency department (ED), he is in moderate respiratory distress. Acute bronchospasms persist, and the patient's oxygen saturation levels fail to improve above 86% on 4 liters of supplemental oxygen or on high-flow oxygen therapy through a nasal cannula. Noninvasive positive pressure ventilation (NIPPV) is initiated using the bilevel positive airway pressure (BiPAP) mode.
Vital Signs and Physical Examination
Heart tones reveal a regular rhythm, but the patient's heart rate remains slightly tachycardic at 110 (sinus tachycardia). His blood pressure is 166/108 mmHg and his respiratory rate is 30 breaths per minute. He is using his accessory muscles to breathe.
The table shows the results of the laboratory workup. Arterial blood gas (ABG) analysis is indicative of acute respiratory acidosis with hypoxemia. The B-type natriuretic peptide (BNP) level is less than 100, which is considered within normal limits. Rapid influenza diagnostic testing (RIDT) for Influenza types A and B, and rapid testing for COVID-19 were all negative. Clinicians may consider obtaining a respiratory polymerase chain reaction (PCR) panel.
Table. Laboratory Test Results Tests Value Basic metabolic panel Sodium, mEq/L 138 Potassium, mEq/L 3.6 Chloride, mEq/L 105 CO2, mEq/L 35 BUN, mg/dL 24 Creatinine, mg/dL 1.6 Complete blood count WBC, cells/mcL 18,000 Hemoglobin, g/dL 18 Hematocrit, % 56 Differential Leftward shift Arterial blood gases pH 7.32 PaCO2, mmHg 60 PaO2, mmHg 48 HCO3, mEq/L 28 B-type natriuretic peptide <100 BUN, blood urea nitrogen; PaCO2,partial pressure of carbon dioxide in arterial blood; PaO2, partial pressure of oxygen in arterial blood; HCO3,bicarbonate
A chest radiograph reveals diffuse, patchy infiltrates in the right upper lobe, right middle lobe, and right lower lobe. No infiltrates are seen in the left lung, and no pneumothorax or effusions are noted. The heart size is within normal limits.
Figure. Radiograph of the chest taken in the emergency department. Image courtesy of Stephanie P. Arceneaux, DNP, MSN, APRN, ANP-C. Making the Diagnosis
The patient is diagnosed with combined acute hypoxemic (type I) and acute hypercapnic (type II) respiratory failure along with community-acquired pneumonia (CAP).
For a diagnosis of pneumonia to be confirmed, patients must have 3 of the following 5 criteria: elevated white blood cell count (WBC), fever, infiltrates on chest radiograph, cough, and mucopurulent sputum production.¹
Discussion
In cases where there is no suspicion for methicillin-resistant staphylococcus aureus (MRSA) or Pseudomonas organisms,2 treatment of pneumonia in the inpatient setting includes ceftriaxone and azithromycin administered via intravenous piggyback (IVPB). The general course of treatment is 5 to 7 days, with a transition to oral antibiotics after approximately 3 days if there is clinical improvement. Monotherapy with a respiratory fluoroquinolone (levofloxacin 750 mg IV or orally daily, moxifloxacin 400 mg IV or orally daily, or gemifloxacin 320 mg orally daily) is an appropriate alternative for patients who cannot receive a beta-lactam plus a macrolide.
Resolution of infiltrates on imaging lags behind clinical improvement. Therefore, the goal is to demonstrate clinical improvement. If pneumonia does not clear fully, patients can develop an empyema, which would require surgical intervention and an extended period of IV antibiotics.
"
Although there was no previous formal diagnosis of COPD before his hospital stay, because of hypercapnia and long history of cigarette smoking, there was a high suspicion of COPD.
Because the patient was in respiratory failure, NIPPV was employed. Guideline-recommended indications for NIPPV include chronic obstructive pulmonary disease (COPD) exacerbation and cardiogenic pulmonary edema.3 The most common mode used in the ED for acute respiratory failure is BiPAP. NIPPV typically is administered with a nasal/oral mask, and a good seal must be maintained during treatment. By employing inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP) settings, the BiPAP mode most closely mimics the normal respiratory breathing cycle and is instrumental in decreasing the work of breathing (WOB), improving ventilation (blowing off PaCO2), and improving oxygenation.
Contraindications to NIPPV include a patient's inability to protect their airway and profuse secretions. Studies have demonstrated NIPPV's efficacy in lowering PaCO2, increasing PaO2, and decreasing the WOB. NIPPV has been proven to be beneficial because it decreases rates of intubation, hospital lengths of stay, and complications from mechanical ventilation, such as ventilator-associated pneumonia.4
Management of CAP and Respiratory Failure
Since MRSA or Pseudomonas are not suspected, and the patient has no known allergies, he is initiated on a beta-lactam and a macrolide. A regimen of ceftriaxone (1 g IVPB daily) and azithromycin (500 mg IVPB daily) is started. Considering the patient's significant bronchospasms and respiratory failure, methylprednisolone sodium succinate also is started at a dose of 80 mg IVP every 8 hours. NIPPV, with settings of IPAP 12 and EPAP of 6, is continued. Oxygen titration to achieve the lowest fraction of inspired oxygen to keep the oxygen saturation level greater than or equal to 92% is to be maintained. Respiratory therapy orders indicate that the patient should be weaned from NIPPV as tolerated. Cardiac monitoring and continuous pulse oximetry are ordered. Renal and red blood cell indices are indicative of mild volume depletion, so isotonic crystalloids-normal saline is started at 75 mL/h, albuterol sulfate/ipratropium bromide treatments are ordered every 6 hours, and a respiratory polymerase chain reaction panel is collected.
The patient will need to be transitioned from the IV steroid to oral steroids (Prednisone), complete a prednisone taper, and finish the course of oral antibiotics after discharge. He also will need to follow up with his primary care provider 1 to 2 weeks after discharge and obtain a 2-view chest x-ray at 4 to 6 weeks to document the clearing of infiltrates. Since there was a high suspicion of underlying COPD in this patient, an order for full pulmonary function testing will be given to the patient to be completed at an outpatient facility.
Case Lessons
Acute respiratory failure is a common occurrence in the ED, and providers must be skilled in providing evidence-based treatments to stabilize patients quickly and efficiently. The patient in this case had a combination of type I and type II respiratory failure, with an underlying etiology of CAP. Although there was no previous formal diagnosis of COPD before his hospital stay, because of his hypercapnia and long history of cigarette smoking, there was a high suspicion of COPD.
Systemic corticosteroids are not routinely used in the treatment of CAP, but because the patient had significant bronchospasms, corticosteroids were warranted. In addition, providers should not hesitate to use NIPPV in the ED for hypercapnic and hypoxemic respiratory failure. Numerous complications associated with mechanical ventilation can be avoided by the judicious use of NIPPV. If the patient can protect their airway and does not have copious respiratory secretions, they should be given a trial of NIPPV.
Indications for NIPPV include respiratory acidosis (typically with a pH<7.30, respiratory rate >25, PaCO2>45, and increased WOB).5 Studies have found NIPPV to be beneficial in cases of COPD exacerbation and cardiogenic pulmonary edema.6 Patients undergoing NIPPV must be monitored very closely for decompensation, and ABGs should be repeated 1 hour after the treatment is initiated. Realistically, it may require up to 2 hours of treatment before there is near full resolution of acid-base balance and decreased WOB.
Stephanie Arceneaux, DNP, MSN, APRN, ANP-C, is a board-certified Adult Nurse Practitioner and continues to maintain active practice as a part-time Hospitalist Nurse Practitioner at Ochsner Lafayette General Medical Center in Lafayette, Louisiana. She is an Assistant Professor of Nursing at the University of Louisiana at Lafayette, College of Nursing and Health Sciences, and teaches in the graduate Nursing programs (MSN-NP and DNP).
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