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UWEC NRSG 811 > Acute Illness Respiratory: Part 1 > Flashcards

Acute Illness Respiratory: Part 1 Flashcards

1
Q

Acute Bronchitis

A
  • ACUTE BRONCHITIS = Inflammation of the tracheobronchial tree
  • COURSE: Self-limited in healthy individuals-Clinical course: 10-14 days
  • INCIDENCE: More common fall & winter; Men > women
  • CAUSE: Usually infectious but also from allergens & irritants
  • PATHOGENS:
  • *Viruses (primary cause):** Adenovirus, influenza, parainfluenza, respiratory syncytial virus
  • *Bacterial:** Bordetella pertussis (consider in adults with persistent cough), Mycobacterium tuberculosis, Corynebacterium diphtheriate, Mycoplasma pneumoniae
  • PREDISPOSING FACTORS: Viral infections, URIs, exposure to cigarette smoke or other irritants, allergens, GERD, immunocompromise & frailty
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2
Q

Chronic Bronchitis

A
  • CHRONIC BRONCHITIS = Excessive mucous secretion with chronic or recurrent productive cough occurring 3 successive months a year for 2 consecutive years
    -Patients have more mucus than normal because of either increased production or decreased clearance
    -Coughing is mechanism for clearing excess secretions
  • INCIDENCE:
    Uncertain-Lack of definitive diagnostic criteria & overlap with asthma;
    Increases with age;
    Highest in African American & Caucasian ethnicities
  • PATHOGENESIS:
    Bacteria: Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, & Moraxella catarrhalis
    Occupational exposure: Coal, cement, welding, fumes, organic dusts, engine exhausts, fire, smoke, & secondhand smoke
    PREDISPOSING FACTORS: Cigarette smoking, cold weather, acute viral infection, COPD, occupational exposure to other airborne irritants, chronic/recurrent aspiration or GERD, allergies, immunosuppression, & frailty
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3
Q

Pathogen Clinical Features

A

Clinical features and epidemiologic associations with specific pathogens:

Influenza virus=acute onset fever, chills, myalgias, and cough during influenza season or in patients with known exposure ofr recent travel

Bordetella pertussis=Cough lasting greater than 2 weeks without an apparent cause, with one of the following symptoms: paraxysms of coughing, inspiratory whoop, or post-tussive emesis, particularly during outbreaks or in patients with known exposures

Bordetella Bronchoseptica=Pertussive-like syndrome in patient with animal exposure, particularly if immunocompromised

Mycoplasma pnuemoniae= No distinguishing clinical features, although outbreaks reported across large geographic regions and among families or persons living in close quarters.

Chlamydia pneumoniae= No distinguishing clinical features, although outbreaks reported in persons living in close quarters

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4
Q

Acute Bronchitis-Other Signs and Symptoms

A
  • Sore throat
  • Rhinorrhea or nasal congestion
  • Rhonchi during respiration
  • Low-grade fever
  • Malaise
  • Retrosternal pain during deep breathing & coughing
  • Decreased/lack of appetite
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5
Q

ACUTE BRONCHITIS-CHIEF CONCERNS

A

Dry, hackling, or raspy-sounding cough (loosens & becomes productive)

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6
Q

Chronic Bronchitis-Chief Concerns

A
  • Worsening cough: Hacking, harsh, or raspy sounding
  • Changes in color (yellow, white, or greenish), amount, & viscosity of sputum
  • “Rattling” sound in chest
  • Dyspnea/breathlessness
  • Wheezing
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7
Q

Chronic Bronchitis-Other Signs and Symptoms

A
  • Pursed lip breathing
  • Use of accessory muscles
  • Tripod position
  • Barrel chest
  • Cyanosis (fingertips, tip of nose, lips)
  • Tachypnea
  • Tachycardia
  • Difficulty speaking or performing tasks
  • JVD
  • Abnormal, diminished, or absent lung sounds
  • Mental status changes
  • Anxiety & depression
  • Pulmonary hypertension
  • Cor pulmonale
  • Left-sided heart failure
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8
Q

Bronchitis-Physical Exam

A
  • VITALS: Temperature (absence of high fever), pulse, BP, respirations, pulse oximetry
  • INSPECT:
    General appearance & signs of respiratory distress: Non-toxic, LOC
    HEENT: Pharynx may be injected; Conjunctivitis suggests adenovirus
    Skin turgor & mucus membranes for dehydration
  • PALPATE:
    Maxillary & frontal sinuses
    Cervical lymph notes
    Advanced skills-Tactile fremitus
  • PERCUSS:
    Sinuses; Lungs for consolidation
  • AUSCULTATE:
    Lungs: Wheezing, crackles, rhonchi-Advanced skills
    Heart
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9
Q

Bronchitis-Diagnostic Tests

A
  • Chest X-ray: Consider to rule out pneumonia or other diseases/complications
  1. Severe respiratory symptoms
  2. Fever >100 / Tachycardia >100
  3. Abnormal lung sounds / percussion
  4. Cough > 2-3 weeks (exclude other causes)
  • LABS: Consider sputum cultures to identify bacteria-Otherwise labs necessary
  • Pulmonary Function Test (PFTs): Can be helpful evaluating asthma & may be required for those with COPD along with ECG
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10
Q

Bronchitis-Differential Assessment/Diagnoses

A
  • Bronchitis-Acute or chronic
  • URI
  • Asthma
  • Sinusitis
  • Cystic fibrosis
  • Aspiration
  • Respiratory tract anomalies
  • Foreign-body aspiration
  • Pneumonia
  • COPD & emphysema
  • Pertussis
  • Postnasal drip syndrome
  • GERD§Ace-inhibitor
  • Heart failure
  • PE
  • Lung CA
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11
Q

Acute Bronchitis-Plan/Management (Nonpharmacologic)

A
  • Increase fluids
  • Rest
  • Humidification
  • Smoking cessation
  • Remove irritants
  • Hot tea
  • Honey
  • Patient education
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12
Q

Acute Bronchitis-Plan/Management (Pharmacologic)

A
  • FEVER/MALAISE: Acetaminophen
  • COUGH: Expectorants (guaifenesin with dextromethorphan) or throat lozenges: Cough suppressants including opiates are rarely appropriate & include the risk of sedation in elderly
  • Benzonatate (Tessalon): Non-centrally acting anti-tussive (if dextromethorphan isn’t helping)
  • Ibuprofen, oral corticosteroids, or herbal remedies for cough have lack of efficacy or safety concerns
  • ANTIBIOTICS ARE NOT GENERALLY RECOMMENDED-MOST CASES VIRAL
  • If symptoms persist for 2 weeks with supportive treatment & suspect pertussis: Macrolides (azithromycin, erythromycin, clarithromycin)-Alternative agent Trimethoprim-sulfamethoxazole
    Augmentin, doxycycline-Sputum cultures prior to antibiotics help isolate causative pathogens
  • WHEEZING: Inhaled beta-agonists (Albuterol HFA): Reserve for wheezing & underlying pulmonary disease
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13
Q

Chronic Bronchitis-Plan/Management (Nonpharmacologic)

A
  • Rest, smoking cessation/stay away from secondhand smoke, exercise for patients with COPD
  • Patient’s goal: Improve symptoms and to decrease cough & production of sputum
  • Advance directives
  • Dietary management: Increase fluids if not contraindicated & eat nutritious food
  • Patient education
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14
Q

Chronic Bronchitis-Plan/Management (Pharmacologic)

A
  • BRONCHODILATORS-For bronchodilators for bronchospasm: Albuterol sulfate MDI
  • ANALGESICS & ANTIPYRETICS: Fevers, myalgias, & arthralgias
  • ORAL STEROIDS-Consider to decrease inflammation
  • INHALED CORTICOSTEROIDS (ICS)-May be effective: Beclomethasone (QVAR) MDI, Fluticasone (Flovent HFA, Flovent Diskus)
  • ANTIBIOTICS-2 of the following should be present to consider antibiotics: Dyspnea, increased cough, or purulent sputum
  • Augmentin, doxycycline, trimethoprim-sulfamethoxazole, levofloxacin (suspected pseudomonas coverage or 65 or older with cardiac disease)
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15
Q

Bronchitis Prevention

A
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16
Q

Difference between Pneumonia-CAP Versus HAP

A

COMMUNITY-ACQUIRED PNEUMONIA (CAP):

  • Acute infection of pulmonary parenchyma in a patient acquiring the infection in the community

HOSPITAL-AQUIRED (NOSOCOMIA) PNEUMONIA (HAP):

  • Acute infection of pulmonary parenchyma in a patient who acquiring the infection in the hospital
  • Common & potentially serious illness
  • Associated with considerable morbidity & mortality, particularly in older adults, very young, & those with major comorbidities
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17
Q

Bacterial Pneumonia

A
  • BACTERIAL PNEUMONIA: Inflammation & consolidation of lung tissue due to a bacterial pathogen
    Causative agent & anatomic location classify pneumoniaüNot uncommon to have acute viral bacterial pneumonia concurrently
    Other types of pneumonia & pulmonary inflammation occur secondary to smoking, exposure to chemicals or fungi, near drowning, & recurrent aspiration with GERD
  • HOSPITALIZATION: Recommended in severe cases of pneumonia
  • SOURCES OF INFECTION: Streptococcus pneumoniae (most common & resistance is a concern), Hib (second most common), Staphylococcus aureas, Legionella, Chlamydia trachomatis, Chlamydia pneumoniae, Mycoplasma pneumoniae, Pseudomonas, Klebsiella, & Pneumocystis jiroveci pneumonia (PCP) in patients with HIV
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18
Q

Viral Pneumonia

A
  • VIRAL PNEUMONIA = Inflammation & consolidation of lung tissue due to viral pathogens
  • Hospitalization recommended for patients who are significantly immunocompromised & frail elderly
  • INCIDENCE: Accounts for a small portion of pneumonia cases in adult pneumonia-Not uncommon to have concurrent viral & bacterial infections
    Elderly persons have highest rate of influenza-associated hospitalizations
  • PATHOGENESIS: Results from inflammation of alveolar space & may compromise air exchange-Caused by influenza viruses (most common), parainfluenza virus, adenovirus, & RSV
    Spread through cough or sneeze
  • PREDISPOSING FACTORS: Fever, cough, dyspnea, tachypnea, wheezing (more common in viral pneumonia)§§
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19
Q

Pneumonia-Incidence and Pathogenesis

A
  • INCIDENCE: Leading cause of death for patients older than 65 years
  • Bacterial pneumonia more prevalent in the very old & very young
  • Higher mortality rate occurs in persons with immunodeficiency, comorbid conditions, abnormal vital signs, and virulent pathogens
  • Incidence rate varies with pathogens
  • PATHOGENESIS: Results from inflammation of alveolar space-4 stages of pneumonia
20
Q

What are the 4 Stages of Pneumonia

A
  1. Vascular congestion and alveolar edema within first 24 hours
  2. Red hepatization (2-3 days) characterized by erythrocytes, neutrophils, & fibrin within alveoli
  3. Gray hepatization (2-3 days) characterized by a gray-brown to yellow color secondary to exudate
  4. Reabsorption & restoration of the pulmonary architecture-A rub may be auscultated due to fibrinous inflammation–
21
Q

Pneumonia Predisposing Factors

A
  • Advanced age
  • Impaired mentation
  • Smoking
  • COPD
  • Alcoholism
  • Aspiration
  • Heart failure
  • Diabetes
  • Heart disease
  • Crowded conditions (dorms, LTC centers)

§Immunodeficiency§Congenial anomalies§Abnormal mucus clearance§Lack of immunization§Measles§Indoor air pollutants from cooking or heating with wood§History of pneumonia§Lung CA

22
Q

Pneumonia Common Concerns

A
  • Fever
  • Shaking chills
  • Dyspnea
  • Rapid/labored breathing
  • Cough
  • Rust-colored sputum
23
Q

Pneumonia-Other Signs and Symptoms

A
  • Increased respiratory rate (tachypnea)
  • CP (localized)
  • URI (pharyngitis)
  • Headache
  • Nausea/vomiting

§Vague abdominal pain§Diarrhea§Myalgias§Arthralgias§Anorexia§Change in LOC (confusion)–

24
Q

Pneumonia-Physical Exam

A
  • VITALS: Temperature, BP (low BP in elderly may mean sepsis), pulse, respirations, pulse oximetry (O2 sat < 92% is indicator of severity & need for oxygen therapy), weight
  • INSPECT:
    General appearance: Ill-looking or toxic, LOC
    Observe breathing pattern, use of accessory muscles, grunting, retractions, & tachypnea
    Check for cyanosis (nail beds, lips)
    HEENT
    Skin turgor & mucous membranes for dehydration

§PALPATE:üMaxillary & frontal sinuses-Sinusitis can be sign of Mycoplasma infectionüCervical lymph notesüAdvanced skills-Tactile fremitus§PERCUSS: üSinuses; Lungs for areas of consolidation§AUSCULTATE:üLungs: Crackles (80%), wheezes, decreased breath sounds-Advanced skillsüHeart

25
Q

Pneumonia-Diagnostic Tests

A
  • CXR (posterior, anterior, & lateral): Infiltrates confirm diagnosis
  • LABS/TESTING:
    CBC with differential
    BUN & GFR
    CULTURES:
    •Blood cultures if critically ill, immunocompromised, or persistent symptoms
    •Sputum cultures reserved for very ill patients or unusual presentations
  • Consider rapid viral testing
  • Consider skin testing for TB for high-risk exposure risk
26
Q

Bacterial Pneumonia-Plan/Management (Nonpharmacologic)

A
  • Rest
  • Avoid smoking/secondhand smoke
  • Vaporizer to increase humidity
  • Good handwashing or use of hand sanitizer
  • Patient education
  • Dietary management-Nutritious food & increased fluid intake
27
Q

Viral Pneumonia-Plan/Management (Nonpharmacologic)

A
  • Rest
  • Avoid smoking/secondhand smoke
  • Require respiratory isolation: May use facial masks
  • Good handwashing or use of hand sanitizer
  • Patient education
  • Dietary management-Nutritious food & increased fluid intake
28
Q

Viral Pneumonia-Plan/Management (Pharmacologic)

A

§ANTIVIRALS-Limited support for efficacy-Most effective if started within 24-48 hours of onset of symptomsüZanamivir (Relenza) MDI, Oseltamivir (Tamiflu), Amantadine, RimantadineüCDC Flu Treatment: https://www.cdc.gov/flu/treatment/index.html §ANTIBIOTICS: Patients with viral pneumonia who are superimposed with bacterial organisms require antibiotic therapy§COUGH SUPPRESANTS: Avoid cough suppressants-Suppression of cough may interfere with airway clearance§FEVER: Acetaminophen§IMMUNIZATIONS: Pneumonia & influenza vaccinations for prevention

28
Q

Viral Pneumonia-Plan/Management (Pharmacologic)

A

§ANTIVIRALS-Limited support for efficacy-Most effective if started within 24-48 hours of onset of symptomsüZanamivir (Relenza) MDI, Oseltamivir (Tamiflu), Amantadine, RimantadineüCDC Flu Treatment: https://www.cdc.gov/flu/treatment/index.html §ANTIBIOTICS: Patients with viral pneumonia who are superimposed with bacterial organisms require antibiotic therapy§COUGH SUPPRESANTS: Avoid cough suppressants-Suppression of cough may interfere with airway clearance§FEVER: Acetaminophen§IMMUNIZATIONS: Pneumonia & influenza vaccinations for prevention

29
Q

Pnuemonia follow up

A

§Educate patients with signs of respiratory distress & seek medical attention§Follow-up by telephone in 24 hours (preferred)§If no improvement within 48 hours on antibiotics, patient should call back§Schedule return visit in 2 weeks for evaluation-If elderly or living alone, follow-up in person within a week§CXR:§Follow-up with CXR in 4-6 weeks for patients older than 60 years & who smoke to document resolution & exclude underlying disease§No follow-up CXR if less than 60 years, a nonsmoker, & feels well at 6-week follow-up

30
Q

Pneumonia-Emergent Issues/Instructions

A

§Patients demonstrating the following needs same-day ED evaluation:üRespiratory compromiseüNeurologic changes including CNS involvementüProfound dehydration or alterations in vital signs

31
Q

Pneumonia Prevention

A

§Vaccinations: Influenza, pneumonia, pertussis (TDAP)§https://www.cdc.gov/vaccines/hcp/vis/current-vis.html§Cover cough§Handwashing§

32
Q

RHINITIS

A

§RHINITIS is the presence of one or more of the following: Sneezing, rhinorrhea (anterior and/or posterior), nasal congestion (stuffiness), nasal itching§MOST COMMON FORMS OF RHINITIS:üAllergic rhinitisüNonallergic rhinitis (various forms)üRhinitis of pregnancyüOccupational rhinitisüExposures to irritant agents

33
Q

Allergic Rhinitis

A

§ALLERGIC RHINITIS: Chronic or recurrent condition characterized by nasal congestion, clear nasal discharge, sneezing, nasal itching, conjunctival itching, & periorbital edemaüUsually occurs seasonally after exposure to allergens (same time every year, associated with pollen count) or it may be perennial (year-round, related to indoor inhalants, animal dander, & moldü“Allergic” suggests a specific immunoglobulin E (IgE) antibody mediates the condition

§INCIDENCE: Prevalence varies according to geographical region: 10%-30% of adults have allergic rhinitis-80% of cases develop before age 20üAllergic rhinitis is risk factor for obstructive sleep apnea§PATHOGENESIS: IgE-mediated inflammatory disease involving nasal mucus; IgE antibodies bind to mast cells in the respiratory epithelium, and histamine is released which results in immediate local vasodilation, mucosal edema, & increased mucus production§PREDISPOSING FACTORS: Genetic predisposition to allergy; Exposure to allergic stimuli: Pollens, molds, animal dander dust mites, & indoor inhalants§

34
Q

Nonallergic Rhinitis

A

NONALLERGIC RHINITIS: Inflammation of nasal mucous membranes, usually accompanied by nasal discharge & mucosal edema-No correlation to specific allergen exposures

CLASSIFICATION: Vasomotor, perennial, atrophic, geriatric, drug-induced, gustatory, or hormonal

INCIDENCE: Chronic or recurrent nasal congestion occurs in about 10% to 40% of the population

PATHOGENESIS:
Vasomotor & perennial nonallergic rhinitis results from hyperactive nasal mucosa
Atrophic & geriatric rhinitis results from progressive degeneration & atrophy of the mucosa membranes & bones of the nose
Overuse of topical nasal decongestants can worsen symptoms & cause severe rebound congestion
Cocaine abuse cases nasal congestion & discharge
Rhinitis in pregnancy: Nasal membranes swell when a large amount of estrogen is in the body. Blood volume is another reason. Congestion abates with delivery

35
Q

NON-ALLERGIC RHINITIS PREDISPOSING FACTORS:

A

–PREDISPOSING FACTORS:–Adulthood–Abrupt changes in temperature, humidity. Odors, irritants, emotional stress, certain foods, medication SE

36
Q

Rhinitis-Presentation

A

COMMON CONCERNS:

§Nasal congestion§Sneezing§Clear rhinorrhea§Coughing from postnasal drip§Sore throat§Itchy, puffy eyes with tearing

OTHER SIGNS & SYMPTOMS:§Dry mouth from breathing, snoring§Sleep disturbance due to difficulty breathing, leading to malaise/fatigue§Itchy nose

37
Q

Rhinitis-Physical Exam

A

§VITALS: Temperature, BP, pulse, respirations§INSPECT: Face-Dennie-Morgan lines (above pic), allergic salute§ DM: fold or line in the skin below the lower eyelid§PALPATE: HEENT-Sinuses, cervical lymph nodes§PERCUSS: Sinuses, lungs§AUSCULTATE: Heart, lungs§

38
Q

Rhinitis-Diagnostic Tests

A

§None particularly helpful§Wright’s stain of nasal secretions: Presence of eosinophils confirms allergy, but may be normal§Skin testing for allergies§CBC with increased eosinophils (confirms allergy)

39
Q

Rhinitis-Differential Diagnoses

A

§Nonallergic rhinitis§Allergic rhinitis§URI§Intranasal foreign body§Sinusitis§Otitis media

–

§Deviated septum§Nasal polyps§Endocrine conditions (hypothyroidism & pregnancy)§Drug use: Oral contraceptives, aspirin, ACE inhibitors, NSAIDs, nasal decongestant overuse, cocaine

40
Q

Allergic Rhinitis-Plan/Management (Nonpharmacologic)

A

§Avoid allergens§Keep bedroom as allergen-free as possible

41
Q

Allergic Rhinitis-Plan/Management (Pharmacologic)

A

§Antihistamines-(H1 receptor antagonist second generation) Drug of choice-Switch occasionally to prevent tolerance:üAzelastine HCL (Astelin), Loratadine (Claritin), Fexofenadine HCL (Allegra), Cetirizine (Zyrtec)§Intranasal steroid spray:üFluticasone propionate (Flonase), Triamcinolone acetonide (Nasacort AQ), Mometasone furoate (Nasonex), Beclomethasone dipropionate (Beconase AQ), Budesonide (Rhinocort Aqua)§ü

§Topical decongestants-No longer than 3 days: Oxymetazoline hydrochloride (Afrin) spray or drops, phenylephrine (Neo-synephrine) spray or drops§Leukotrine antagonists-Block the chemical reaction that leads to the inflammatory process-Montelukast (Singulair)§First generation antihistamines-Benadryl (sedation risk)§Saline nasal spray§Petroleum jelly with Q-tip to inside mucosa of nares 3-4 times per day for lubrication & hold in moisture

42
Q

Nonallergic Rhinitis-Plan/Management (Nonpharmacologic)

A

§Avoid changes in temperature, odors, & emotional stress§Identify triggers for condition and avoid if possible§Patient education: Avoid smoking, smoke-filled rooms, wood-burning stoves/fireplaces, sprays, perfumes

43
Q

Nonallergic Rhinitis-Plan/Management (Pharmacologic)

A

§Depends on type§Physiologic saline nasal spray§Nasal antihistamines (Azelastine-ASTELIN, Olopatadine-PATANASE)§Intranasal corticosteroid sprays (Fluticasone-FLONASE)§Decongestants-Oral & nasal not recommended unless the use of antihistamines & glucocorticoids has failed (Pseudoephedrine or nasal oxymetazoline-AFRIN and phenylephrine-NEO-SYNEPHRINE)§

44
Q

Rhinitis Risk Factors/Prevention

A

RISK FACTORS:§Close quarters (daycare, schools, dorms, residential)üTransfer of virus via secretions on hands

PREVENTION:§Handwashing§Avoidance of exposure

UWEC NRSG 811 (11 decks)

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