TABLE 661 Indications for Hospital Admission

The patient's vital signs, particularly the respiratory rate, should be assessed immediately, along with pulse oximetry and physical examination for the presence of cyanosis, diaphoresis, use of accessory muscles, signs of congestive heart failure, and adequacy of peripheral perfusion. Supplemental oxygen should be applied, intravenous access obtained, and the patient placed on a cardiac monitor. A chest radiograph should be obtained to identify infiltrates or pneumothorax and arterial blood gases may also have to be tested. b2 Agonists, anticholinergics, and antibiotics should be given as indicated.

Although the perioperative use of corticosteroids was formerly considered to be a contraindication to transplantation, this is changing somewhat. A maintenance dose of 0.2 to 0.3 mg/kg/day of prednisone is acceptable to most centers. If it is felt that a patient requires a corticosteroid burst or an increase in the maintenance dose to treat an acute exacerbation, the transplant coordinator should be contacted. A dose of prednisone greater than 20 mg/day may result in the patient being suspended from the transplant list until such time that the dose can safely be tapered down to 20 mg/day or less. In primary pulmonary hypertension (PPH) and Eisenmenger complex, consideration should be given to therapies that may help to decrease pulmonary vascular resistance, such as morphine sulfate, nitrates, and furosemide. For patients with respiratory failure, noninvasive ventilation or endotracheal intubation with mechanical ventilation may be required, increasing the risk of barotrauma. Ventilator dependence has generally been regarded as a relative contraindication to lung transplantation. Successes have been reported, but ventilator-dependent patients have a much higher mortality after transplantation.

Idiopathic pulmonary fibrosis (IPF) is a common indication for lung transplantation and carries with it the most dismal prognosis. Patients presenting with exacerbations of their disease in the pretransplant phase generally have a worse prognosis. Treatment with high-dose steroids is rarely successful at achieving a remission, and supportive therapy is the mainstay of acute management. The transplant team may recommend cytotoxic drugs such as cyclophosphamide and azathioprine for their steroid-sparing effect.

Chronic infection, especially common in patients with cystic fibrosis (CF), is a major issue with regard to eligibility for transplantation. CF patients tend to be infected with multiple organisms by the time transplantation is considered. The most common organisms include Pseudomonas sp., Burkholderia cepacia, Aspergillus, and nontuberculous mycobacteria. Aspergillus and mycobacterial infections have not been associated with worse outcomes in posttransplant patients. However, infection with B. cepacia and panresistant Pseudomonas sp. has been associated with poor outcomes and is considered a contraindication to transplantation in some centers. Therefore, emergency physicians need to pay particular attention to infection-control measures and antibiotic selection in pretransplant CF patients. Generally, those patients requiring antibiotics for acute infections require admission for broad spectrum, multiple-drug regimens to prevent the development of panresistant strains.

In patients with PPH, survival correlates with New York Heart Association (NYHA) classification. Recently, prostacyclin was approved for treatment of NYHA class III or IV patients, in whom it has been shown to improve hemodynamics, exercise tolerance and survival. Calcium-channel blockers have been the mainstay of treatment for NYHA class I and II patients for some time. Those patients who fail medical therapy are subsequently listed for transplant. In the acute setting, treatment with agents that may reduce pulmonary vascular resistance—including morphine, nitrates, and furosemide—may help provide stabilization in addition to other supportive measures and identification of precipitating factors.

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