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Clinical Medicine II > Acute Bronchitis, Influenza, & TB > Flashcards

Acute Bronchitis, Influenza, & TB Flashcards

1
Q

where in the respiratory system does bronchitis occur?

A

in the lower respiratory system (below the trachea)

99% is viral

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2
Q

what is acute bronchitis?

A

inflammation of the large airways of the lungs

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3
Q

is acute bronchitis self-limited?

A

YES! lasts about 1-3 weeks

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4
Q

what is the most common cause of acute bronchitis?

A

usually viral -> DON’T NEED ANTIBIOTICS!!!

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5
Q

what seasons does acute bronchitis present in?

A

fall and winter

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6
Q

what viruses cause acute bronchitis?

A
  • Influenza A & B
  • Parainfluenza
  • RSV
  • Coronavirus
  • Rhinovirus
  • Adenovirus
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7
Q

what is the pathology of acute bronchitis?

A
  • season (fall & winter)
  • outbreak (i.e. flu outbreak)
  • vaccination status
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8
Q

what are the clinical manifestations of acute bronchitis?

A

<b>-Persistent cough 1-3 weeks (with or without sputum)</b>

<b>-Low grade fever</b> (most commonly do not have fever, if do it is low grade (99-100 degrees))

-Wheezing, mild dyspnea

<b>-Rhonchi that clears with cough</b> (hear wet type cough and then have them cough and breathe again and it’s clear)

  • Indistinguishable from URI (e.g. sore throat) first few days of illness
  • Chest pain
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9
Q

what are the most common symptoms of acute bronchitis?

A

Cough (+/- sputum) that lasts 1-3 weeks (HALLMARK)

Low grade fever

Rhonchi that clears with cough

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10
Q

when is acute bronchitis suspected?

A

Suspected in a patient with a cough for at least 5 days

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11
Q

what will patients with acute bronchitis not have?

A

No clinical findings suggestive of pneumonia or COPD - Ie. High fever

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12
Q

what imaging is done to dx acute bronchitis?

A

CXR

-unlikely to change your management

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13
Q

what is the primary reason to do a CXR in pts with suspected acute bronchitis?

A

to rule out pneumonia

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14
Q

what are the indications to do a CXR for acute bronchitis?

A
  • Tachycardia
  • Tachypnea
  • Fever
  • Hypoxia (under 90% O2)
  • Dementia
  • Rales, egophony, tactile fremitus
  • Mental status changes in patients >75 yrs

<b>Good idea to do one if they have other co-morbidities or if they’re a smoker</b>

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15
Q

is sputum test helpful for dx of acute bronchitis?

A

no, unlikely to be helpful, unless suspicion for Tb

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16
Q

what is the procalcitonin test for dx of acute bronchitis?

A
  • Emerging biomarker for diagnosis of bacterial infection
  • Will be below the level of detection in healthy individuals
  • Rises in response to pro-inflammatory stimulus (especially of bacterial origin -> assume bacterial infection if elevated)
  • Can be indicator for sepsis or pneumonia caused by bacteria
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17
Q

what are the lab values for procalcitonin test?

A

<0.10 mcg/L strongly discourage abx use

<0.25 mcg/L discourage

> 0.25 mcg/L encourage

> 0.50 mcg/L strongly encourage

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18
Q

what do you educate pts about for acute bronchitis?

A

that abx are not needed b/c cause is viral

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19
Q

txts for acute bronchitis

A

Antitussives
-Bronchodilators (+/-) - albuterol
<b>-no use for steroids</b>

<b>-OTC cough medications (dextromethorphan & guaifenesin)
-Rx cough medications (robitussin AC & Tessalon Pearles - bnzonatate)</b>

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20
Q

OTC cough medications for acute bronchitis

A

Dextromethorphan (DM) & Guaifenesin

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21
Q

Dextromethorpham (DM) - what is it? names? metabolite?

A

OTC cough med for acute bronchitis

  • <b>Cough suppressant</b> -> Nyquil, Mucinex, Robitussin
  • Metabolite is dextrophan (in high doses produces similar effects to Ketamine and PCP)
  • Dissociative hallucinogen
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22
Q

Guaifenesin

A

OTC cough medication for acute bronchitis

  • <b>Expectorant</b> (used for wet cough) -> Dayquil, Mucinex, Robitussin, Guiatuss
  • Usually used in conjunction with codeine, dextromethorphan, pseudoephedrine, acetaminophen
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23
Q

Rx cough medications for acute bronchitis

A

Robitussin AC (comes in combo w/codeine) & Tessalon Pearles (benzonatate)

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24
Q

Tessalon Pearles - what is it? chemically related to? why don’t bite it?

A

Rx cough medication for acute bronchitis

<b>benzonatate
-numbs cough</b>

  • Chemically related to ester local anesthetics - ie. Procaine and tetracaine
  • Don’t bite the pearls, just swallow them -> will numb mouth, <b>supposed to numb cough</b>
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25
what type of illness is influenza?
respiratory illness
26
what parts of the respiratory tract does influenza affect?
upper & lower respiratory tracts
27
what is influenza accompanied by?
systemic signs & symptoms -> fever, malaise
28
what is the hallmark of influenza?
that it's ABRUPT IN ONSET
29
what season does influenza primarily occur in?
winter
30
how do influenza outbreaks typically begin?
ABRUPTLY -acutely debilitating, self-limiting, will get better
31
what is the peak of influenza and how long does it last?
peak over 2-3 weeks & can lasts 2-3 months
32
what is the earliest indication of influenza among children?
increase in febrile illness
33
what is influenza associated with?
increased morbidity and mortality in certain high-risk populations
34
what groups are susceptible to complications when get influenza?
- Pregnant women - Children - >65 years - Comorbidities
35
what virus causes influenza?
Orthomyxoviridae family
36
how many types of influenza are there and what are they?
3 types A, B, & C -humans get A & B
37
what are the subtypes of influenza?
Subtyped by surface hemagglutinin (H) and neuraminidase (N) antigens -3 major subtypes that affect humans H1, H2, H3, and N1, N2 - Avian flu (2003) = H5N1 - Swine flu (2009) = H1N1 - Spanish flu (1918) = H1N1
38
what is the clinical manifestation of influenza?
- *ABRUPT onset* - Headache - Fever - Myalgia - Cough - Sore throat
39
dx tests for influenza
- rapid influenza antigen tests - immunofluorescence (not often done) - RT-PCR (not done b/c takes too long) - viral culture - serologic testing (not used)
40
what does the rapid influenza antigen test tell you?
- tells you type A vs. B - is a nasopharyngeal swab - variable sensitivity, but good specificity
41
what is immunofluorescence dx test for influenza?
Direct and indirect staining - Slightly lower specificity and sensitivity than viral culture - Depends on laboratory expertise (Have to have the lab read it) Respiratory swab NOT OFTEN DONE
42
what is RT-PCR dx test for influenza?
- Most sensitive and specific - 4-6 hours for results -> takes too long, NOT DONE - Differentiates types and subtypes - Can use any fluid -> nasal swabs, bronchial lavage, throat swabs
43
what is viral culture dx for influenza?
-Not used for initial clinical management | -Have to grow it out -> takes too long
44
who should be tested for influenza?
-Immunocompetent outpatients at risk for influenza complications with acute febrile illness who present w/in 5 days of illness onset -Immunocompromised outpatients with acute febrile respiratory illness regardless of illness onset -Inpatients with acute febrile respiratory illness, including those with CAP - Individuals who develop acute respiratory illness after admission - Local surveillance - Healthcare workers, residents or vistors to an institution experiencing an outbreak - Individuals linked to an influenza outbreak (cruise ships)
45
Txt options for influenza
- Neuraminidase inhibitors | - Adamantane agents
46
Neuraminidase Inhibitors for txt of influenza
Zanaminvir (Relenza) Oseltamivir (Tamiflu) Peramivir (Rapivab)
47
Zanaminvir (Relenza)
Neuraminidase inhibitor agent for txt of influenza - inhalation - 5 days for txt, 7 days for ppx
48
Oseltamivir (Tamiflu)
Neuraminidase inhibitor agent for txt of influenza -5 days for txt, 7 days for ppx -MOST COMONLY USED
49
what is the most commonly used medication for txt of influenza?
Oseltamivir (Tamiflu)
50
Peramivir (Rapivab)
Neuraminidase inhibitor agent for txt of influenza - IV over 15-30 mins - used for someone who can't take PO
51
Adamantane agents
Used for txt of flu Amantadine (Symmetrel) - no longer recommended for txt or ppx Rimantadine (Flumadine) - not approved for txt or ppx
52
Amantadine (Symmetrel)
Adamantane agent used for txt of influenza -anti-parkinsons agent -no longer recommended for txt or ppx d/t increasing resistance
53
what influenza vaccine is recommended for >65 years?
-high dose trivalent recommended Ie. Fluzone High Dose More at risk for complications from flu so get high dose
54
what vaccine is NOT recommended for 2017-2018 flu season?
Flumist | -is the only one that is a live virus, doesn't seem to work
55
what does the trivalent vaccine for the flu contain?
2 influenza A virus antigens and 1 influenza B virus antigen
56
what does the quadrivalent vaccine for influenza contain?
2 influenza A antigens and 2 influenza B antigens
57
what did tuberculosis used to be called?
consumption b/c of wasting
58
where are the highest rates of Tb?
sub-Saharan Africa, India, and the islands of Southeast Asia and Micronesia
59
how many cases of Tb occur in developing countries?
95%
60
what contributed to the uptick of TB cases?
HIV | -1 in 9 cases are in HIV infected individuals
61
what are the major contributors to resurgence of Tb?
Drug resistance -Tx regimen is so tough and long thatmany people give up on tx, leading to resistance Poverty HIV
62
what are the risk factors for TB?
-Substance abuse -HIV -Nutritional status (more malnourished you are, more at risk you are) -Men > Women -Household contact -Birth in Tb endemic area (sub-Saharan Africa, India, islands of SE asia and micronesia) -Community setting -Low socioeconomic status -Minority
63
how is TB transmitted?
Person-to-person transmission occurs via inhalation of droplet nuclei -airborne particles
64
what factors are associated with risk of transmission of TB?
-Presence of active untreated pulmonary or laryngeal disease -Presence of cavitary disease -Presence of sputum positive for M. Tuberculosis -> acid-fast bacilli (if smear is positive for acid-fast bacilli, can assume its Tb)
65
what are risky procedures where medical professionals are at risk of contracting TB?
- Intubation - Bronchoscopy - Sputum induction - Chest PT - Administration of aerosolized drugs - Irrigation of Tb abscesses - Autopsy on cadaver **Wear your m-95 mask to protect yourself**
66
what are the classifications of TB?
-Immediate clearance of the organism (if you have a good immune system) -Primary disease - immediate onset of active disease -> symptoms right away -Latent Infection - no symptoms right away, not active (reactivates when immune system is low – not feeling well) -Reactivation disease - onset of active disease many years following a period of latent infection
67
when is the greatest risk for progression of latent TB to active TB?
Greatest risk for progression to active disease happens in first 2 years after infection - After which, lifetime risk is 5-10% of getting active disease - 5% of individuals progress to TB disease
68
why do you treat latent TB?
to prevent you from getting active disease
69
clinical manifestations of Primary disease TB
Primary disease = new infection or active disease in a naïve host -Fever – most common - Fatigue - Athralgias - Cough (2 to 3 weeks) - Pharyngitis (sore throat)
70
clinicals manifestations of latent disease TB
-Asymptomatic -Mild symptoms Basically, have no symptoms, but test positive on PPD
71
clinical manifestations of reactivation disease TB?
- Weight loss - Night sweats - Anorexia - Pleuritic or retrosternal chest pain **These are usually the symptoms you think of, when you think of TB**
72
what are the typical symptoms of TB?
- Weight loss - Night sweats - Anorexia - Pleuritic or retrosternal chest pain
73
how do you screen for TB?
Purified protein derivative (PPD) AKA Tuberculin skin test (TST)
74
what does a positive PPD (aka TST) for TB indicate?
Positive test supports a diagnosis of TB, but cannot be used to establish diagnosis
75
what do you need to have to dx TB?
CXR
76
does a negative PPD (aka TST) rule out active disease TB?
NO!
77
what may interfere with PPD (aka TST) results?
BCG (vaccine) - can produce false positive | -usually do a TB Gold Test for these pts
78
who is considered to have a positive PPD test with ≥5mm induration?
- HIV infected persons - Recent contacts of TB case - Persons with fibrotic changes on chest radiograph consistent with old healed TB - Patients with organ transplants and other immunosuppressed patients (receiving the equivalent of ≥ 15 mg/day of prednisone for ≥ 1 month)
79
who is considered to have a positive PPD with ≥10mm induration?
- Recent arrivals to the U.S (< 5 years) from high-prevalence countries - Injection drug users - Residents and employees of high-risk congregate settings - Mycobacteriology laboratory personnel - Persons with medical conditions that place them at high risk - Children < 5 years of age - Infants, children, and adolescents exposed to adults in high-risk categories
80
who is considered to have a positive PPD test with ≥15mm induration?
everyone else
81
the higher risk the patient for TB, the smaller what for positive test?
the smaller amount of induration needed for a positive test
82
Active disease TB dx
Sputum Interferon gamma release assays (IGRAs) CXR
83
Sputum as dx test for active TB
either spontaneous or induced -Aerosolized mist that makes you cough -> culture the sputum and can diagnose Culture techniques: -Acid-fast bacilli (AFB) stain (gold standard) -Mycobacterial culture -Nucleic acid amplification
84
Interferon gamma release assays (IGRAs) dx test for TB
2 major types available: QuantiFeron-TB Gold (QFT-GIT) and T-SPOT TB - Blood tests for immune response to M. Tuberculosis - >95% specificity for diagnosis of LTBI (latent) -Preferred for patients with Hx of BCG vaccine
85
what are the benefits of doing interferon gamma release assay (IGRAs) test for dx of TB?
- Great for diagnosis because no room for human error like with PPD readings - Can also diagnose BCG patients, which you can’t with PPD
86
what are the disadvantages of doing interferon gamma release assay (IGRAs) test for dx of TB?
- EXPENSIVE - Not often done - Will only use as confirmatory if CXR doesn’t confirm, but pt. has a positive PPD
87
what dx test for TB is preferred for pts with hx of BCG vaccine?
Interferon gamma release assays (IGRAs)
88
what type of TB does interferon gamma release assays (IGRAs) most specific for?
>95% specificity for diagnosis of LTBI (latent)
89
who do you do a CXR on for TB?
- Anyone with suspected active TB - Anyone with positive PPD - Positive IGRA
90
Goals of treatment for TB?
- Eradication - Prevention of transmission - Prevent relapse - Prevent development of drug resistance
91
Active TB medications
Isoniazid, Rifampin, Pyrazinamide, Ethambutol +/- Streptomycin -Used if patient has allergies or if their liver can’t handle Ethambutol Administered simultaneously -Synchronize peak serum concentrations **BE CAREFUL of the LIVER, meds are cleared by the liver**
92
Intensive Phase TB Medications
Isoniazid, Rifampin, Pyrazinamide, Ethambutol - Taken for 2 months - Must be taken on empty stomach - Check baseline LFTs Clinical reassessment at end of intensive phase: - Repeat CXR and AFB smear - Then CXR monthly after that to assess clinical response
93
how long must medications for intensive phase TB be taken?
2 months
94
how must the 4 medications for intensive phase TB be taken?
must be taken on empty stomach
95
what must you check at baseline for medications for intensive phase TB?
LFTs
96
what must be done at end of intensive phase txt of TB?
clinical reassessment: - Repeat CXR and AFB smear - Then CXR monthly after that to assess clinical response
97
TB Medications for Continuation phase
Isoniazid and Rifampin - 4 additional months after intensive phase - continued until 2 consectutive negative cultures (not fully treated until they're negative)
98
what is direct observation therapy for TB?
-Entire time of treatment is under direct observation -> have to come in and take meds -This is so they can ensure you are taking them prevents resistance and spreading the disease
99
Latent Disease TB medications
Isoniazid QD x 9 months -OR- Rifampin QD x 4 months -Interrupted therapy may be continued if less than 3 months interrupted -need baseline LFTs -self-administered b/c not showing sx's
100
2 phases of txt for Active TB?
Intensive Phase (4 meds - RIPE) Continuation Phase (2 meds - Isoniazid & Rifampin)
101
what is MDR-TB?
Multidrug-resistant Tb - Resistant to at least Isoniazid and Rifampin - Possibly resistant to other chemotherapeutic agents
102
what is XDR-TB?
Extensively drug-resistant TB Resistant to at least Isoniazid, Rifampin, and at least one of three injectable second line drugs (Capreomycin, Kanamycin, Amikacin)

Clinical Medicine II (10 decks)

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