1 Pulmonary Flashcards by Susan Johnston

Common etiologies of cough

Asthma
GERD
Infxn
ACE inhibitors
Chronicbronchitis- smokers
Lung cancer- 2%.  Smokers

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Acute cough vs chronic cough

Acute less than 3wks

Sub acute 3-8
>=8 wks chronic

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Acute bronchitos tx

And etiology

Treat synptoms only!!!! Dont give abx

98% are virus

Upper and lower airway sxs

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50 yo pt with sxs acute bronchitis.

If has fever, the standard of care is to:

Get a chest Xray- AP and Lat

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When acute cough present, these factors warrant a chest Xray:

Fever >38C or100.4 F
Abn vitals: increased RR or HR ( w/o fever in elderly),
>= 75 yrs with cough

Elderly: pneumonia presents as tachypnea, decreased O2 sat, or change in MS behavior

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Acute bronchitis: how long will cough last?

Pharm mngt: what helps?

Can last up to 3 wks! Last thing to go…

Nothing helps cough- but could give them antitussive or nsaid

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Clinical sxs of pneumonia- CAP

Cough
Sputum production
Fever
Chills
SOB. >=24 RR
Chest pain 
Increased RR and HR-
Leukocytosis 15-30,000/mm

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Gold standard for CAP Dx:

Chest xray PA and LAT

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85% CAP is bacterial. What r they?

Strep pneumo- most common cause of death**. Rust colored sputum
Atypical organisms:
- M.pneumoniae
- Chlamydophila pneumoniae
* use macrolide (azithro or clarithromycin) or doxycycline

If pt with comorbitities or Abxs in last 90d:

Then you MUST suspect drug resistant strep pneumo!!! DRSP. Use resp quinalone (gemifloxacin, moxifloxacin, or levofloxacin)

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CAP: If pt with comorbitities or Abxs in last 90d:

What abxs to use??

Then you MUST suspect drug resistant strep pneumo!!! DRSP. Use resp quinalone (gemifloxacin, moxifloxacin, or levofloxacin

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Risk factors for DRSP:

Abxs in last 90 d- pcn, cephalosporin, macrolide, quinolone

Alcoholism, liver or renal disease

Co-morbitities

Immunosuppression

Exposure to child in day care

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DRSP abxs

First and if allergy

Resp quinolone: gemifloxacin. Levofloxacin (levoquin) moxifloxacin

OR
If allergy

Beta lactam (Pcn or Ceph) plus macrolide (‘thromyacin)

Beta lactam plus doxycycline

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Beta lactam abx

PCN or Cephalosporin

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Resp quinolone: first line for DRSP

gemifloxacin. Levofloxacin (levoquin) moxifloxacin

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Macrolide

Thromycin

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Summary of tx for CAP

Most pts
If DRSP suspected

Most pts. Macrolide (thromycin) or doxy

If DRSP suspected.

Resp quinolone(floxacin) or

Beta lactam(pcn or ceph) plus macrolide or doxy

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How long to treat CAP?

With Azithromycin (Macrolide)?

Usually 10 days
Give abxs 3 more d after clinically stable

Azithro has long half life so <5 d om

When is Follow up chest Xray needed after pneumonia?

If >40 years or a smoker, consider xray in 7-12 weeks after Tx

To exclude underlying disease like malignancy

When does pneumonia need hospitalization?

*mneumonic

CRB-65

C-confusion
R-RR>=30/min
B-BP=
65

Score of 0 or 1, then outpatient tx

Septic shock- hypotension, tachycardia the organ failure. That is why they push IV fluids

Pneumococcal vaccine. PPSV23

Who gets?
What bacteria does it protect against?

For Strep pneumo- most lethal!

*All adults >=65
*give one time only- NO boosters. Can give same time as flu shot
A second dose is recommended for people 65 years and older who got their first dose when they were younger than 65 and it has been 5 or more years since the first dose.

*Adults 19-64 years with increased risks/comorbids. Smokers asthma and chronic disease. Can give age 2-64 pta high risk

New vaccine- PPSV13 (give it along with normal vaccine PPSV23) only for aslenia, immunocomprimising conditions, CDF leaks, cochlear implants, adv CKD

COPD

2 types?

How much of population has?

Pack year calculation?

COPD= chronic bronchitis and emphysema

Affects 10% of pop. >40yrs
smokers!!!! Amt and duration contributes to severity

#packs of cigs/day X # of years
Ex. Smoked 2ppd for 15 yrs= 30 pack yr hx

COPD

Chronic Bronchitis

Production of sputum for at least 3 m annually for 2 yrs with cough.
Chronic mucous production results from hyperplasia of the mucous membranes lining the bronchial walls

COPD

Emphysema

Lung disease with permanent enlargement of the aveolar ducts and air spaces distal to the terminal bronchioles.
Results in air trapping and loss of elastic recoil of lungs

What is common early sx of COPD

*Exertional dyspnea. DOE

Get SOB on way to mailbox!

Consider COPD in any pt who presents with: Differential of COPD:

Chronic cough Sputum produx Dyspnea Inhalation exposure tob smoke dust chemicals Differential: ``` CHF Asthma Bronchiectasis TB Constrictive bronchiolitis ```

COPD is ranked in how many stages? And What meds for each stage? Anticholinergic s.e.

IV I. Mild COPD. SABA prn II. Mod COPD. SABA prn. And LABA regularly III Severe COPD SABA and LABA and steroids (inh glucocorticoids- sign sxs, acute exacerbations, ..) IV Very severe COPD SABA and LABA and steroids (inh glucocorticoids- sign sxs, acute exacerbations, ..) and long term Oxygen therapy if resp failure. Consider surgical tx * this list doesnt include Anticholinergics, (Ipatropium- Atrovent... "Tropium"). Which r used often and great in combo w bronchodilators Anticholinergics w LOTS Of s.e. Constipation, inc IOP, dry mouth, urinary retention, blurred vision, glaucoma, "I cant see I cant pee I cant spit I cant shit

MEMORIZE!!! Defing characteristic of COPD no matter what stage: And ALL COPD pts need this (safety issue)

FEV1/FVC <70 percent Forced expiratory volume in 1 sec, forced vital capacity If u dont hv this something else is making u sick... ----------- Must have a SABA- like Albuterol Short acting beta agonist (stimulates beta cells- beta 1 -heart. Beta 2-lungs)

What study can screen for lung cancer secondary to cigarette smoking? Who needs it?

Chest CT. Annual Low dose CT Screen ALL smokers 55-79 yrs w/ 30 ppd who currently smoke or quit w/in past 15 yrs Annually!!! Lung CA is leading cause of CA related death in men and women 20% redux in mortality w screening

Supraclavicular nodes have high rate of: right: Left:

Malignancy!!! Right: lungs Mediastinum Esophagus Left: abdominal malignancy (Stomach liver pancreas ovaris prostate)

Anticholinergics for COPD

Ipatropium- Atrovent... "Tropium" Which r used often and great in combo w bronchodilators ``` Anticholinergics w LOTS Of s.e. Constipation, inc IOP, dry mouth, urinary retention, blurred vision, glaucoma, "I cant see I cant pee I cant spit I cant shit ```

4 grps meds used for COPD

1. Beta agonists. - SABAs. Albuterol. Rescue med - LABAs. Salmeterol (serovent) not rescue (takes 10-20 min to work but lasts 12hrs) 2. Inh Anticholinergics "Tropium". Ipatropium-Atrovent Grt combo w bronchodilators Lots s.e.!! 3. Inh steroids "One" or "ide" Fluticasone. Mometasone... Grt combo w bronchodilators 4. Steroid plus bronchodilators Fluticasone plus salmeterol (Advair), budesonide plus formeterol(Symbicort) -No generics. Very $$$$$$!!!!

Exam: Stage 3 COPD using albuterol. What should u add next? (Hx of glaucoma)

Add a LABA next! *Salmeterol BID Not inh steroid and bronchodilator (steroid only for exacerbations or SEVERE COPD, not just sxs w exertion) No Tiotropium- bc antocholinergic bad w Hx glaucoma

Manage COPD exacerbations (inc cough/sputum produx, SOB) From virus, pollution, PE, MI, HF....

1. SABA 2. Glucocorticoid- nebulize 3. Antbx prn 4 other

Diference between COPD and asthma

COPD is progressive, not reversible. Asthma is reversible airway obstruction inflammation and airway hyper responsiveness 75% diagnosed by age 7

Health promotion COPD

**Smoking cessation single most effective** Regular exercise PPSV vaccine (anyone w comorbids one time, otherwise one shot at 65 yrs) Influenza annually Know names and use of meds

Combo inhaler for copd and asthma- u dont have to know what meds r in them just what it means

Usually aLABA and a steroid

**see quiz questions at end of Resp packet** An ACE cough

Can get ry away or later, but dry and will occurs with all ACE if get with one

COPD pt w rapid HR after taking breathing med: ``` What is least likely culprit: Steroid Albuterol Ipatropium Salmeterol ```

Steroid least likely All 3 could cause inc HR: albuterol, ipatropium (atrovent an anticholinergic) and salmeterol a LABA

A stage III COPD has SOB at rest. What contraindicated Ipatropium use? Dyssrythmia Cataracts Osteoporosis Glaucoma

Glaucoma bc anticholinergic inc IOP

63 yo has asthma and got pneumococcal vaccine 10 yrs ago. When should he get again.

Get again at 65 yrs

55yo has asthma and 102 temp, wheezes and pure lent sputum how should she be managed.

Levofloxacin (bc DRSP likely) and nebulized albuterol q4-6hrs Not w steroids!!!

What are possible s.e. of chronic inh steroid use ?

Osteoporosis Cataracts Glaucoma