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CF Guidelines - Admissions with Chest Exacerbations
               
    Patient Admissions with Chest Exacerbations:
        Most admissions will have been co-ordinated by the CF team. If this is not the case the CF team - consultant or specialist nurse - must be informed at the first appropriate opportunity. If patients are unwell and there is any uncertainty about the appropriate management then the CF consultant should be contacted via the hospital switchboards - even if this is out of hours. Where ever possible, admissions should be made directly to side rooms on the appropriate paediatric or respiratory wards. If the patient has had Burkholderia cepecia admit them to a different ward.
               
        All admissions should have the following blood tests during their admission:
       
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FBC.
       
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U&E's, LFT's, bone profile and Mg2+.
       
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Clotting studies.
       
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Blood sugar.
       
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C-reative protein.
       
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BM measurements before and 2 hour after meals.
               
        Ideally T.I.V.A.D's - indwelling IV ports - should not be used to obtain blood sample - as there are concerns that this increases the risk of them blocking. However, if peripheral access is difficult - or informed patient prefers - they may be used. You must not access the T.I.V.A.D yourself, ask help from a nurse who has received the specific training.
               
        Additional things to consider with an admission include the following:
       
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Blood cultures - if pyrexial, especially if the patient has T.I.V.A.D device.
       
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Amylase.
       
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Glycosylated Hb - HbA1c.
       
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IgE and RAST to Aspergillus.
       
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Virology - if history suggestive of recent viral infection. Blood and nasal swabs/washings for culture and PCR using viral transport media.
       
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Theophylline or Itraconazole levels if on them long term.
       
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ABG's if the patient is significantly hypoaemic (SaO2 < 88% on air), or the patient is requiring more oxygen than normal or complaining of a headache.
               
    Sputum/Cough Swap:
        All admissions should be have a sputum sample or cough swabs sent MC&S (+ AFB if none in past 12 month or clinically indenticated) on arrival. A second sample should be sent for MC&S just prior to discharge. Additional samples do not routinely need to be sent during the admission.
               
    Radiology:
        Almost all admissions should have a CXR, which should be reviewed promptly for evidence of pneuomothorax - see specific guidelines. Most CF patients with chest pain do not require a CTPA - there are many more causes of pulmonary emboli in CF patients. However, remember that T.I.V.A.D's may cause thrombosis, or even fracture and embolise fragments.
               
    Drug treatment:
        Almost all CF patients, regardless of presenting complaint, will be treated with intravenous antibiotics. These should be given intravenously - hospital policies regarding switching to oral antibiotics do not apply. If the patient has cultured Pseudomonas aeruginosa in their sputum during the past 2 years, or is on a prophylactic antibiotic to treat Pseudomonas aeruginosa - nebulised Colomycin or nebulised TOBI - they must be given 2 antibiotics that are active against this pathogen.
               
        The commonest drug combinations are:
       
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IV Ceftazidime (2g - 3g) tds + IV Tobramycin (8mg - 10mg/kg) od.
       
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IV Meropenem (1g - 2g) tds + IV Tobramycin (8mg - 10mg/kg) od.
               
        The choice of antibiotics is principally determined by what has worked well previously and limitations caused by patient tolerances. Antibiotic regimes should not be changed based on laboratory sensitivities. - or apparent resistance - unless there is a lack of desired response. Refer to local authority guidelines for dosages and schedules, especially in paediatrics. Ensure normal saline flush - 10ml are written up on a drug chart and given after each dose of antibiotics. Also ensure that HepSal - 50 units/5ml - is also prescribed for use after each full dose of antibiotics.
        Prophylactic nebulised antibiotics may be stopped while on intravenous antibiotics. If patients are on nebulised DNAse, this should be continued. Ensure all other medications are written up on the patients drug chart. Patients with an exacerbation may benefit from nebulised salbutamol. Nebulised Iprotropium - Atrovent - is less useful and not routinely given. CF patients do not routinely need to be given oral prednisolone - sputum in airways causes wheezes - although some who do have asthma should receive it. Some patients derive significant benefit from IV Aminophylline given as an overnight infusion, for example if clinically dehydrated, if oral intake is poor or if their respiratory secretions have become drier or reduced in volume.
               
       
Check the medications with the patient - they often know what the usually take.
               
    Physiotherapy:
        Ensure the ward contact the CF physiotherapist - working hours - or on call respiratory physiotherapist so that patients receive chest treatment twice daily. If in doubt, contact the CF team.
               
        Dowloadable PDF File - PDF File    
           
Document approved - 2011
           
Document due for review - December 2013
               
        Acknowledgements: The Peninsula CF team acknowledges the use of guidelines produced by The CF Trust, Manchester, Papworth, Leeds and Brompton CF teams during development of these local Peninsula protocols and guidelines.
               
Disclaimer: While efforts have been made to ensure that all the information published on this web site is correct, the authors take no responsibility for the accuracy of information, or for harm arising as a consequence of errors contained within this web site. If you have concerns regarding treatment, drugs or doses then consult your local CF consultant.