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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
Q

what type of illness is influenza?

A

respiratory illness

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26
Q

what parts of the respiratory tract does influenza affect?

A

upper & lower respiratory tracts

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27
Q

what is influenza accompanied by?

A

systemic signs & symptoms -> <b>fever, malaise</b>

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28
Q

what is the hallmark of influenza?

A

that it’s <b>ABRUPT IN ONSET</b>

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29
Q

what season does influenza primarily occur in?

A

winter

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30
Q

how do influenza outbreaks typically begin?

A

ABRUPTLY

-acutely debilitating, self-limiting, will get better

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31
Q

what is the peak of influenza and how long does it last?

A

peak over 2-3 weeks & can lasts 2-3 months

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32
Q

what is the earliest indication of influenza among children?

A

increase in febrile illness

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33
Q

what is influenza associated with?

A

increased morbidity and mortality in certain high-risk populations

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34
Q

what groups are susceptible to complications when get influenza?

A
  • Pregnant women
  • Children
  • > 65 years
  • Comorbidities
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35
Q

what virus causes influenza?

A

Orthomyxoviridae family

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36
Q

how many types of influenza are there and what are they?

A

3 types

A, B, & C
-humans get A & B

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37
Q

what are the subtypes of influenza?

A

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
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38
Q

what is the clinical manifestation of influenza?

A
  • <b>ABRUPT onset</b>
  • Headache
  • Fever
  • Myalgia
  • Cough
  • Sore throat
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39
Q

dx tests for influenza

A
  • rapid influenza antigen tests
  • immunofluorescence (not often done)
  • RT-PCR (not done b/c takes too long)
  • viral culture
  • serologic testing (not used)
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40
Q

what does the rapid influenza antigen test tell you?

A
  • tells you type A vs. B
  • is a <b>nasopharyngeal swab</b>
  • variable sensitivity, but good specificity
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41
Q

what is immunofluorescence dx test for influenza?

A

Direct and indirect staining

  • Slightly lower specificity and sensitivity than viral culture
  • Depends on laboratory expertise (Have to have the lab read it)

<b>Respiratory swab</b>

<b>NOT OFTEN DONE</b>

42
Q

what is RT-PCR dx test for influenza?

A
  • Most sensitive and specific
  • 4-6 hours for results -> takes too long, <b>NOT DONE</b>
  • Differentiates types and subtypes
  • Can use any fluid -> nasal swabs, bronchial lavage, throat swabs
43
Q

what is viral culture dx for influenza?

A

<b>-Not used for initial clinical management</b>

-Have to grow it out -> <b>takes too long</b>

44
Q

who should be tested for influenza?

A

<b>-Immunocompetent outpatients at risk for influenza complications with acute febrile illness who present w/in 5 days of illness onset</b>

<b>-Immunocompromised outpatients</b> with acute febrile respiratory illness regardless of illness onset

<b>-Inpatients with acute febrile respiratory illness, including those with CAP</b>

  • 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 <b>(cruise ships)</b>
45
Q

Txt options for influenza

A
  • Neuraminidase inhibitors

- Adamantane agents

46
Q

Neuraminidase Inhibitors for txt of influenza

A

Zanaminvir (Relenza)

Oseltamivir (Tamiflu)

Peramivir (Rapivab)

47
Q

Zanaminvir (Relenza)

A

<b>Neuraminidase inhibitor agent for txt of influenza</b>

  • inhalation
  • 5 days for txt, 7 days for ppx
48
Q

Oseltamivir (Tamiflu)

A

<b>Neuraminidase inhibitor agent for txt of influenza</b>

-5 days for txt, 7 days for ppx
<b>-MOST COMONLY USED</b>

49
Q

what is the most commonly used medication for txt of influenza?

A

Oseltamivir (Tamiflu)

50
Q

Peramivir (Rapivab)

A

<b>Neuraminidase inhibitor agent for txt of influenza</b>

  • IV over 15-30 mins
  • used for someone who can’t take PO
51
Q

Adamantane agents

A

Used for txt of flu

Amantadine (Symmetrel) - no longer recommended for txt or ppx

Rimantadine (Flumadine) - not approved for txt or ppx

52
Q

Amantadine (Symmetrel)

A

<b>Adamantane agent used for txt of influenza</b>

-anti-parkinsons agent
<b>-no longer recommended for txt or ppx d/t increasing resistance</b>

53
Q

what influenza vaccine is recommended for >65 years?

A

<b>-high dose trivalent recommended</b>

Ie. Fluzone High Dose

<b>More at risk for complications from flu so get high dose</b>

54
Q

what vaccine is NOT recommended for 2017-2018 flu season?

A

Flumist

-is the only one that is a live virus, doesn’t seem to work

55
Q

what does the trivalent vaccine for the flu contain?

A

2 influenza A virus antigens and 1 influenza B virus antigen

56
Q

what does the quadrivalent vaccine for influenza contain?

A

2 influenza A antigens and 2 influenza B antigens

57
Q

what did tuberculosis used to be called?

A

consumption b/c of wasting

58
Q

where are the highest rates of Tb?

A

sub-Saharan Africa, India, and the islands of Southeast Asia and Micronesia

59
Q

how many cases of Tb occur in developing countries?

A

95%

60
Q

what contributed to the uptick of TB cases?

A

HIV

-1 in 9 cases are in HIV infected individuals

61
Q

what are the major contributors to resurgence of Tb?

A

Drug resistance
-Tx regimen is so tough and long thatmany people give up on tx, leading to resistance

Poverty

HIV

62
Q

what are the risk factors for TB?

A

-Substance abuse
-HIV
-Nutritional status (more malnourished you are, more at risk you are)
-Men > Women
-Household contact
<b>-Birth in Tb endemic area (sub-Saharan Africa, India, islands of SE asia and micronesia)</b>
-Community setting
-Low socioeconomic status
-Minority

63
Q

how is TB transmitted?

A

Person-to-person transmission occurs via inhalation of droplet nuclei
<b>-airborne particles</b>

64
Q

what factors are associated with risk of transmission of TB?

A

-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
Q

what are risky procedures where medical professionals are at risk of contracting TB?

A
  • Intubation
  • Bronchoscopy
  • Sputum induction
  • Chest PT
  • Administration of aerosolized drugs
  • Irrigation of Tb abscesses
  • Autopsy on cadaver

<b>Wear your m-95 mask to protect yourself</b>

66
Q

what are the classifications of TB?

A

<b>-Immediate clearance of the organism</b> (if you have a good immune system)

<b>-Primary disease</b> - immediate onset of active disease -> symptoms right away

<b>-Latent Infection</b> - no symptoms right away, not active (reactivates when immune system is low – not feeling well)

<b>-Reactivation disease</b> - onset of active disease many years following a period of latent infection

67
Q

when is the greatest risk for progression of latent TB to active TB?

A

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
Q

why do you treat latent TB?

A

to prevent you from getting active disease

69
Q

clinical manifestations of Primary disease TB

A

Primary disease = new infection or active disease in a naïve host

<b>-Fever – most common</b>

  • Fatigue
  • Athralgias
  • Cough (2 to 3 weeks)
  • Pharyngitis (sore throat)
70
Q

clinicals manifestations of latent disease TB

A

<b>-Asymptomatic</b>
-Mild symptoms

<b>Basically, have no symptoms, but test positive on PPD</b>

71
Q

clinical manifestations of reactivation disease TB?

A
  • Weight loss
  • Night sweats
  • Anorexia
  • Pleuritic or retrosternal chest pain

<b>These are usually the symptoms you think of, when you think of TB</b>

72
Q

what are the typical symptoms of TB?

A
  • Weight loss
  • Night sweats
  • Anorexia
  • Pleuritic or retrosternal chest pain
73
Q

how do you screen for TB?

A

Purified protein derivative (PPD) AKA Tuberculin skin test (TST)

74
Q

what does a positive PPD (aka TST) for TB indicate?

A

Positive test supports a diagnosis of TB, <b>but cannot be used to establish diagnosis</b>

75
Q

what do you need to have to dx TB?

A

CXR

76
Q

does a negative PPD (aka TST) rule out active disease TB?

A

NO!

77
Q

what may interfere with PPD (aka TST) results?

A

BCG (vaccine) - can produce false positive

-usually do a TB Gold Test for these pts

78
Q

who is considered to have a positive PPD test with ≥5mm induration?

A
  • 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
Q

who is considered to have a positive PPD with ≥10mm induration?

A
  • Recent arrivals to the U.S (< 5 years) from high-prevalence countries
  • Injection drug users
  • Residents and employees of <b>high-risk congregate settings</b>
  • Mycobacteriology laboratory personnel
  • Persons with <b>medical conditions</b> that place them at high risk
  • Children < 5 years of age
  • Infants, children, and adolescents exposed to adults in high-risk categories
80
Q

who is considered to have a positive PPD test with ≥15mm induration?

A

everyone else

81
Q

the higher risk the patient for TB, the smaller what for positive test?

A

the smaller amount of induration needed for a positive test

82
Q

Active disease TB dx

A

Sputum
Interferon gamma release assays (IGRAs)
CXR

83
Q

Sputum as dx test for active TB

A

either spontaneous or induced

-Aerosolized mist that makes you cough -> culture the sputum and can diagnose

<u>Culture techniques:</u>
<b>-Acid-fast bacilli (AFB) stain (gold standard)</b>
-Mycobacterial culture
-Nucleic acid amplification

84
Q

Interferon gamma release assays (IGRAs) dx test for TB

A

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
Q

what are the benefits of doing interferon gamma release assay (IGRAs) test for dx of TB?

A
  • 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
Q

what are the disadvantages of doing interferon gamma release assay (IGRAs) test for dx of TB?

A
  • EXPENSIVE
  • Not often done
  • Will only use as confirmatory if CXR doesn’t confirm, but pt. has a positive PPD
87
Q

what dx test for TB is preferred for pts with hx of BCG vaccine?

A

Interferon gamma release assays (IGRAs)

88
Q

what type of TB does interferon gamma release assays (IGRAs) most specific for?

A

> 95% specificity for diagnosis of LTBI (latent)

89
Q

who do you do a CXR on for TB?

A
  • Anyone with suspected active TB
  • Anyone with positive PPD
  • Positive IGRA
90
Q

Goals of treatment for TB?

A
  • Eradication
  • Prevention of transmission
  • Prevent relapse
  • Prevent development of drug resistance
91
Q

Active TB medications

A

Isoniazid, Rifampin, Pyrazinamide, Ethambutol

+/- Streptomycin
-Used if patient has allergies or if their liver can’t handle Ethambutol

<b>Administered simultaneously</b>

-Synchronize peak serum concentrations

<b>BE CAREFUL of the LIVER, meds are cleared by the liver</b>

92
Q

Intensive Phase TB Medications

A

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
Q

how long must medications for intensive phase TB be taken?

A

2 months

94
Q

how must the 4 medications for intensive phase TB be taken?

A

must be taken on empty stomach

95
Q

what must you check at baseline for medications for intensive phase TB?

A

LFTs

96
Q

what must be done at end of intensive phase txt of TB?

A

clinical reassessment:

  • Repeat CXR and AFB smear
  • Then CXR monthly after that to assess clinical response
97
Q

TB Medications for Continuation phase

A

Isoniazid and Rifampin

  • 4 additional months after intensive phase
  • continued until 2 consectutive negative cultures (not fully treated until they’re negative)
98
Q

what is direct observation therapy for TB?

A

<b>-Entire time of treatment is under direct observation -> have to come in and take meds</b>

-This is so they can ensure you are taking them prevents resistance and spreading the disease

99
Q

Latent Disease TB medications

A

Isoniazid QD x 9 months

<b>-OR-</b>

Rifampin QD x 4 months

-Interrupted therapy may be continued if less than 3 months interrupted
-need baseline LFTs
<b>-self-administered b/c not showing sx’s</b>

100
Q

2 phases of txt for Active TB?

A

Intensive Phase (4 meds - RIPE)

Continuation Phase (2 meds - Isoniazid & Rifampin)

101
Q

what is MDR-TB?

A

Multidrug-resistant Tb

  • Resistant to at least <b>Isoniazid and Rifampin</b>
  • Possibly resistant to other chemotherapeutic agents
102
Q

what is XDR-TB?

A

Extensively drug-resistant TB

Resistant to at least <b>Isoniazid, Rifampin, and at least one of three injectable second line drugs (Capreomycin, Kanamycin, Amikacin)</b>

Clinical Medicine II (10 decks)

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