Pulmonary Clinical Suitev2.0

Start NIV therapy; patient has chronic respiratory failure secondary to COPD requiring a non-invasive ventilator. BiPAP has been tried and failed as it does not adequately ventilate the patient nor does it adequately reduce patient\'s CO2 level nor does it offer high flow oxygen therapy which is pertinent to the patient staying out of the hospital. Patient\'s mortality is severely at risk if they do not receive NIV.

Start LUISA device; patient has chronic respiratory failure secondary to COPD requiring a non-invasive ventilator. NIPPV and BiPAP has been tried and failed during inpatient stay and was found that it does not adequately ventilate the patient nor does it adequately reduce patient\'s CO2 level nor does it offer high flow oxygen therapy which is pertinent to the patient staying out of the hospital. PCO2 remains high on BIPAP. Patient\'s mortality is severely at risk if they do not continue using the LUISA device.

Patient has chronic obstructive pulmonary disease and chronic respiratory failure as a result of COPD. CPAP and BIPAP have been considered and ruled out due to the need for auto backup rate specific to ventilations. I am prescribing patient a noninvasive ventilator for chronic respiratory failure and severe chronic obstructive pulmonary disease. Patient requires this to decrease work of breathing, improve pulmonary status and prevent interruption of respiratory support, which could lead to additional hospital readmissions and serious harm to the patient.

Start vest therapy; manual chest physiotherapy has been insufficient to clear secretions, flutter device has been ineffective due to insufficient expiratory force, patient has had productive daily cough x 6+ months, and 3+ exacerbations in the last one year requiring multiple courses of antibiotic therapy with very little response.

Patient has severe chronic respiratory impairment secondary to COPD/Chronic Bronchitis with documented trial of optimal inhaled anticholinergic/bronchodilator therapy. Qualifies for home oxygen therapy under Medicare Group II criteria (SpO2 89% with pulmonary hypertension / cor pulmonale / congestive heart failure). Prescribe nocturnal oxygen concentrator at 2 LPM via nasal cannula to maintain SpO2 >= 90%.

Start BiPAP 22/17 cm H2O; patient has severe obstructive sleep apnea and hypoxemia and has failed CPAP therapy. Requires BiPAP as a medical necessity due to persistent nocturnal desaturations and severe obstructive airway collapse.

Patient has severe mobility limitations due to COPD, chronic respiratory failure with exertional hypoxemia, and interstitial pulmonary fibrosis that significantly impairs patient's ability to participate in mobility-related activities of daily living (MRADLs) at home. Patient's mobility limitations cannot be sufficiently resolved by use of an appropriately fitted cane or walker. Use of a manual wheelchair will significantly improve patient's ability to participate in activities of daily living and patient will use it on a regular basis at home. Patient has a caregiver who is available, willing, and able to provide assistance with wheelchair operations.

Preoperative risk stratification for bariatric surgery: Based on Arozullah index, patient is Class II (1.8% risk of post-op respiratory failure). Based on Canet index, patient is intermediate risk (13.3% risk of postoperative pulmonary complications such as atelectasis or pneumonia). Recommend use of 6 mL/kg ideal body weight tidal volume intraoperatively to minimize atelectasis (Futier et al. NEJM 2013, PMID 23902482). Recommend extubation to noninvasive positive pressure ventilation (NIPPV/BiPAP), DuoNeb nebulizer QID, early post-op ambulation, and incentive spirometry. Obesity Class III: Tolerating reasonably well; candidate for surgical intervention.

Low risk for respiratory failure with planned procedure. Arozullah Class I (0.5% risk of respiratory failure); Canet Index Low Risk (1.6% complication rate). Plan: Inhaled DuoNeb QID, extubate to room air or NIPPV as needed, early post-op ambulation, incentive spirometry, and intraoperative lung-protective ventilation (6-8 mL/kg PBW).

Recommend spinal or regional anesthesia for all surgical procedures requiring anesthetics, as patient is HIGH risk for acute post-operative respiratory failure and prolonged mechanical ventilation under general endotracheal anesthesia. If general anesthesia unavoidable, maintain intraoperative lung protection (6 mL/kg IBW) and extubate directly to continuous positive airway pressure / BiPAP in PACU.

Prednisone 10 mg tablets (#30): Take 40 mg (4 tabs) PO daily in morning x 3 days, then 30 mg (3 tabs) PO daily x 3 days, then 20 mg (2 tabs) PO daily x 3 days, then 10 mg (1 tab) PO daily x 3 days, then discontinue. Discussed steroid risks (hyperglycemia, insomnia, fluid retention, gastritis).

Prednisone 10 mg tablets (#10): Take 10 mg PO daily in morning x 7 days, then take 10 mg every other day x 7 days (take day 8, skip day 9, take day 10, skip day 11...), then discontinue.

Compounded Magic Mouthwash: Maalox 200 mL + Lidocaine 2% Viscous 100 mL + Diphenhydramine (Benadryl) 12.5 mg/5 mL elixir 200 mL (Total volume 500 mL). Sig: Shake well. Swish and spit (or swish and swallow) 15–30 mL PO every 4 hours as needed for oral mucositis/aphthous ulcers. #1 bottle.

MRSA Decolonization Protocol: (1) Bleach baths: Add 1/4 to 1/2 cup household bleach to a full standard bathtub (~40 gallons) of warm water; soak for 5–10 minutes twice weekly. (2) Mupirocin 2% nasal ointment: Apply small amount inside both anterior nares BID x 10 days. (3) Bactrim DS 1 tab PO BID x 7-10 days if systemic coverage indicated.

Alpha-1 Antitrypsin deficiency counseling: Discussed strict avoidance of respiratory irritants, especially all tobacco smoke and toxic fumes. Counseled on testing for first-degree relatives and spouse. Emphasized complete avoidance of heavy alcohol use. Completed full baseline PFTs with DLCO and ordered baseline non-contrast CT Chest. Patient informed that expected survival is favorable with proactive lifestyle and adherence.

Coccidioidomycosis: Initiating Fluconazole 200 mg PO BID (400 mg/day). Repeat Coccidioides complement fixation (CF) titer and liver enzymes in 1 month. Follow-up non-contrast CT Chest in 3 months to assess for infiltrate resolution.

Begin guideline-directed 3-drug MAC regimen for minimum 18 months: Azithromycin 500 mg PO 3x/week (M/W/F), Ethambutol 1200 mg PO 3x/week, and Rifampin 600 mg PO 3x/week. Baseline visual acuity & color vision testing (Ishihara) ordered. Sputum AFB cultures and liver function panel monthly.