Acute Respiratory- Adults Flashcards
acute bronchitis
- Acute bronchitis is a lower respiratory tract infection involving the large airways (bronchi), without evidence of pneumonia, that occurs in the absence of chronic obstructive pulmonary disease.
- Self-limited inflammation of the bronchial respiratory mucosa leading to productive or non-productive cough
acute bronchitis: s/s
o Cough persisting > 5 days
o Dry or Productive
o May last several weeks
o +/- wheezes, rhonchi (will clear with cough)
o Fever/systemic symptoms typically absent
o Chest wall tenderness from coughing is common
o Often preceded by URI symptoms
acute bronchitis: diagnostics
o Based on hx and PE
o Focus should be on ruling out more serious illness
o CXR indicated only when clinical features suggest pneumonia
acute bronchitis: differentials
o Pneumonia, COVID, Influenza, etc.
o Postnasal drip/upper airway cough syndrome
o GERD
o Asthma
o COPD
o ACEI use
o Heart Failure
o PE
o Lung Cancer
tx for symptomatic acute bronchitis
o Cough suppressants:
* Dextromethorphan
* Guaifenesin
* Honey
* Codeine
o Humidification
oAntihistamine/Decongestants/Analgesics – if associated URI symptoms or muscle pain from cough
o Inhaled beta-agonists: Albuterol
* If wheezing or underlying lung disease
o Antibiotics are generally NOT indicated
acute bronchitis: pt education
o A nagging cough can last for several weeks
o Antibiotics are not indicated for acute bronchitis
o **You should follow-up in the office if you develop:
* A fever higher than 100.4°F (38°C)
* Chest pain when you cough, trouble breathing, or coughing up blood
* New discolored mucus (getting progressively darker)
* A barking cough that makes it hard to talk
* A cough and weight loss that you cannot explain
- Pneumonia is unlikely if all of the following are absent:
- fever >/ 100.4
- tachypnea >/ 24
- tachycardia >/100
- evidence of consolidation on chest exam: rales, egophony, fremitus
pertussis “whooping cough”
highly contagious
pertussis presentation
o Stage 1: Catarrhal period 1-2 weeks
* Nonspecific malaise, rhinorrhea and mild cough
* Excessive lacrimation and conjunctival injection are usually present
o Stage 2: Paroxysmal coughing fits that can last 2-3 months
* Characteristic “whoop” or barking cough
* Post-tussive syncope or emesis often present
* Otherwise feel well
o Stage 3: Convalescent; less persistent cough lasts 1-2 weeks
pertussis clinical criteria for testing
o Cough lasting >/= 2 weeks, without a more likely diagnosis and at least 1 of the following:
* Paroxysms of coughing
* Inspiratory whoop
* Posttussive vomiting
diagnosis pertussis
choice of testing depends on duration of cough
* culture (nasal swab or aspiration): gold standard
* PCR (nasal swab or aspiration)
* serology
tx of pertussis
o 1st line: Macrolide antibiotics (azithro or clarithromycin)
o 2nd line: Bactrim
o Close contacts should also be treated regardless of immunization history
o Abx treatment does not necessarily improve cough symptoms but reduces transmission to others
complications of pertussis
o Super-Infection (Pneumonia)
o Mechanical r/t severe cough (abd hernia, subconjunctival hemorrhage, rib fractures)
o Morbidity and mortality most common in infants and young children
o Adults can experience significant time away from work/school, social isolation, sleep deprivation, anxiety
pertussis prevention–vaccination
- Tdap: tetanus booster + reduced dose of diphtheria and pertussis approved for age 11-64
1 dose between 11 and 18
1 booster dose between 19 and 64 - Adults > 64 who have not previously received Tdap should receive a single booster
- Pregnant women should receive a Tdap booster btwn 27 and 36 weeks during every pregnancy
pneumonia
- Infection of the lower respiratory tract classified by how it is acquired
pneumonia etiology
o Typical bacteria: Streptococcus pneumoniae (60-70%) (although incidence is decreasing), Haemophilus influenzae, and Moraxella catarrhalis
o Atypical bacteria: Legionella pneumophila, Mycoplasma pneumoniae, and Chlamydophila pneumoniae
o Viruses: Influenza, rhinovirus, adenovirus, COVID-19
pneumonia risk factors
o Older age (>65)
o Smoking
o Alcohol use >80 gm/d (> 5 drinks)
o Comorbidities (COPD/lung disease, CHF, DM, malnutrition, stroke, immunocompromise)
o Viral respiratory infection
o Crowded living conditions
presentation pneumonia
loof for fever, chills, rigors, cough, malaise
presentation pneumonia typical
- age <5 or >40
- onset: abrupt
- cough: productive
- sputum: rusty/purulent
- rigors: often present
- fevers > 39 C
consolidation: present
leukocytosis: 15+, shift
presentation pneumonia: atypical
- age: <40
- onset: gradual
- cough: paroxysmal, non-productive
- sputum: minimal, mucoid
- rigors: absent
- fevers <39 C
- consolidation: often absent
- leukocytosis: often absent
pneumonia diagnosis
o Physical Exam:
* Full HEENT, respiratory exam, cardiac exam
* Significant findings: rales (unilateral= bacterial; bilateral= atypical) that do not clear with cough, bronchial breath sounds, dullness to percussion, egophony (E to A changes)
* Imaging:
* CXR (A/P plus lateral): can be normal in early disease, may show infiltrative changes
pt teaching pneumonia
o Clear directions for antibiotic use
o Follow up in 24 to 48 hours by phone or in person
o Push fluids by mouth
o Use antipyretics prn fever & myalgias
o If constant non-productive cough, try codeine, esp. qhs
tx pneumonias
o IDSA guidelines: monotherapy with Amoxicillin, Doxycycline, or Macrolide if there are risk factors for MRSA, pseudomonas, or comorbidities
o Duration of Treatment
* Outpatient: generally 5 days
follow-up pneumonia
o Clinical follow-up 24-48 hours after initiation of treatment is appropriate
* Assess VS, mentation, appetite
referral to hospitalization: pneumonia
o CURB-65 Calculator– Confusion, Uremia >7, RR >/ 30, BP <90/<60, Age>/65
o Pneumonia Severity Index (PSI) Calculator
pneumonia prevention
o Smoking cessation
o Influenza vaccination
o Pneumococcal vaccination for at risk patients
o Ongoing infection control measures
pneumonia vaccination
PCV20 - Pneumococcal polysaccharide vaccine
* average risk adults >/ 65- one dose
PPSV23
* recommended for adults >/ 65 and persons 19-64 with DM, ETOH, liver disease, cigarette smoker, chronic heart disease
PCV7/13/15/20
* childhood series, adults >/65, adults with immunocompromise, asplenia, CSF leak, cochlear implant, advanced kidney disease
infiltrative changes: typical pneumonia
unilateral: only one side of the lobe is inflamed and will be seen on imaging
infiltrative changes: atypical pneumonia
bilateral– both lower lobes are severely inflammed and will see on imaging
COVID-19: s/s
o Cough
o Fever
o Myalgias
o Headache
o Dyspnea
o Sore throat
o Diarrhea
o N/V
o Chest pain
o Anosmia or other smell abnormalities
o Agnosia or other taste abnormalities
o Rhinorrhea and/or nasal congestion
o Confusion
testing for COVID-19
o Symptoms= test immediately
o Exposed to COVID-19 w/o sx, wait at least 5 full days before testing. Too early = false negative
o If you are in certain high-risk settings*, routine testing programs.
o Consider testing before contact with someone at high-risk for severe COVID-19, especially if you are in an area with a medium or high COVID-19 Community Level.
o **High-risk settings: congregate living, prisons, LTC, hospitals
diagnosis: COVID-19
gold standard: PCR, NAAT
risk for severe COVID-19
- age >/ 65 years
- asthma
- cancer
- heart conditions
- smoking
- diabetes
- chronic lung disease
- physical inactivity
- pregnancy or recent pregnancy
- substance use disorders
who to treat: COVID-19
acute illness and at least 1 of the following:
* > 64 yrs old
* immunosuppression
* risk factors for severe COVID-19
* >49 years old and unvaccinated
what to treat with: COVID-19
- Nirmatrelvir-ritonavir (Paxlovid)
- Molnupiravir
- Remdesivir
Nirmatrelvir-ritonavir (paxlovid)
- Protease inhibitor (not unlike those used for HIV treatment)
- Must be started by 5th day from start of symptoms
- Generally, very well tolerated
Nirmatrelvir-ritonavir (Paxlovid): contraindications/precautions
o Contraindicated:
* Anti-arrhythmics (flecainide, amiodarone)
* Anti-psychotics (clozapine, lurasidone)
* Anti-seizure (phenytoin, phenobarbital, carbamazepine)
o Hold or adjust:
* Statins (esp. lova- simva-)
Nirmatrelvir-ritonavir (Paxlovid): side effect
covid rebound
o Mild sx returning after completion of antiviral course (24-48hrs)
o Rare progression to severe symptoms
o If sx recur, recommend antigen retesting and extend isolation if positive.
pt teaching: COVID-19
- Clear directions for antiviral use
- Follow up in 24 to 48 hours
- Push fluids by mouth
- Use antipyretic to control fever & myalgias as needed
- OTC cough suppressants, codeine may be appropriate
- Isolation:
o Isolate 5 day from start of symptoms
o Continue to wear mask for additional 5 days.
o If “rebound” and antigen is positive, isolate for additional 2 days, then retest
o Repeat testing not generally recommended
long COVID s/s
- fatigue
- dyspnea
- chest discomfort
- cough
- anosmia (loss of smell)
covid-19 prevention
- 6 ft distance
- Wear masks
- Do not touch mouth, eyes, nose,
- Stay at home if you are sick
- Clean and disinfect surfaces
- Hand hygiene
COVID-19 vaccination
Who:
o Everyone older than 6 months
o Adults and children same frequency, different dosing
* Immunocompromised – different recommendations
Moving toward annual boosters
o Flu-COVID combos
upper respiratory infection (“common cold”)
A self-limited viral illness of the upper respiratory structures
URI: common pathogens
o Rhinovirus (most common)
o Coronavirus
o Parainfluenza, adenovirus, enterovirus, RSV (more common in kids), & influenza
URI: modes of transmission
o Hand contact
o Direct contact with an infected person or indirect contact with a contaminated environmental surface
o Small particle droplets: Airborne from sneezing or coughing
o Large particle droplets: Requires close contact with an infected person
o Cold-inducing viruses are viable on human skin and fomites for 2+ hours
URI: infectivitiy
o Peak viral shedding is on the second and third day of illness
o Low levels of viral shedding may persist for up to two weeks
o 24-72 hour incubation period
o Typical duration of illness is 3-10 days but can last up to two weeks
o Smokers are more likely to experience prolonged symptom duration
URI: risk factors
o Exposure to children in daycare, psychological stress, poor sleep
URI: risk for increased severity
o Smoking, chronic illness, immunodeficiency, malnutrition
s/s of URI
o Rhinitis
o Nasal congestion: Clear and/or purulent discharge
o Sore throat: Often described as “scratchy” or “dry”
o Cough: Often begins a day or 2 after nasal symptoms
o Malaise
o Fever uncommon in adults but may occur in children
o Don’t judge your mucus by its color!
diagnosis of URI
o PE is typically largely unremarkable
o No diagnostic tests are routinely indicated
physical exam findings: URI
o Eyes: possible conjunctival injection
o Nasal mucosal swelling; nasal congestion
o Pharyngeal erythema
o Adenopathy: usually absent, or minimal
o Lung exam: Usually clear unless secondary bronchospasm; e.g. wheezing
tx of URI
o Treatment is supportive/symptomatic!
o Remember: Typically, self-limiting
Rhinorrhea:
* Intranasal cromolyn sodium (OTC NasalCrom) or ipratropium
* Combination decongestants (pseudoephederine) and antihistamines (loratadine, fexofenadine, cetirizine, diphenhydramine)
o Combination treatment thought to be more effective than either agent alone; antihistamines not helpful alon
* Fever/Sore Throat/Headache/Malaise:
o Analgesics/Antipyretics: acetaminophen, ibuprofen
* Cough:
o Antitussives (dextromethorphan) and expectorants (guaifenesin) shown to have marginal benefit at best; for mild symptoms, would not use
pt education on URI
o Review expected course and duration
o Discuss symptomatic treatment and prevention of transmission (hand hygiene)
o Provide reassurance that antibiotics are not needed and may have side effects
o Follow-up in the office if they develop:
* Persistent fever >100.5
* Shortness of breath
* Persistent dark colored secretions
Acute Rhinosinusitis (ARS)
- Symptomatic inflammation of the nasal cavity and paranasal sinuses lasting less than four weeks
common pathogens of acute rhinosinusitis
o Most common pathogens: rhinovirus, influenza, parainfluenza
Tx for acute rhinosinusitis
- Patients with acute viral rhinosinusitis (AVRS) should be managed with supportive care. There are no treatments to shorten the clinical course of the disease.
s/s acute rhinosinusitis
o Nasal congestion/post-nasal drip
o Halitosis (bad breath)
o Headache
o Referred dental pain
o Fever
o Ear fullness/otalgia
o Hyposmia/anosmia (decreased sense of smell or no sense of smell at all)
o May have sore throat, cough, nausea (often associated w/ post-nasal drip)
physical exam: acute rhinosinusitis
o Assessment of vital signs, eyes, ears, pharynx, teeth, sinuses, lymph nodes, and chest
o After vitals, start with eyes
o Tenderness to palpation over the sinuses
o Anterior rhinoscopy: mucosal edema & erythema, inferior turbinate hypertrophy, and rhinorrhea or purulent discharge
o Post-nasal drip, cobblestoning (can see this in allergic conditions as well)
o Good to also look at teeth, esp. if pt reports tooth pain. Use a tongue depressor to tap the teeth.
o Role of Imaging: when indicated, CT without contrast
diagnosis: acute rhinosinusitis
o Generally based on H&P
o Do not rely on sinus palpation to assist w/ dx
o For chronic symptoms or treatment failure consider:
o CT scan w/o contrast (gold standard)
o ENT referral
o X-rays: low sensitivity/specificity
o MRI: Not usually advised (tend to “overread”)
tx of acute rhinosinusitis
first line: OTC analgesics and antipyretics, saline irrigation, intranasal glucocorticoids
acute bacterial rhinosinusitis: s/s
- Persistent symptoms of ABRS lasting >10 days
o Specifically fever, purulent discharge, facial/dental pain
o Symptoms of a typical viral upper respiratory infection that are slowly improving but then worsen again with more severe symptoms and signs (new-onset fever, headache, nasal discharge) after five to six days - ”double worsening” or “double sickening”
o Onset of severe symptoms (high fever->102°F, purulent nasal discharge or facial pain) for at least 3-4 consecutive days at the beginning of illness
Acute Bacterial Rhinosinusitis (ABRS): risk factors
o chronic nasal congestion,
o asthma,
o cigarette smoking/exposure,
o anatomical abnormalities (polyps, deviated septum)
Acute Bacterial Rhinosinusitis (ABRS): common pathogen
strep pneumoniae
Acute Bacterial Rhinosinusitis (ABRS): complications
o orbital/periorbital cellulitis,
o osteomyelitis,
o sinus thrombus,
o intracranial/epidural abscess
o meningitis
Acute Bacterial Rhinosinusitis (ABRS): tx
o Many patients with ABRS have self-limited disease that resolves without antibiotic therapy!
o Amox/clavulanate aka Augmentin
o Amoxicillin
* Due to antibiotic resistance you will often see Augmentin as 1st line, but Amoxicillin also used
* For PCN allergy, doxycycline or third generation cephalosporin with or without clindamycin (due to resistance)
* Duration of therapy: 5-7 days usually enough unless severe; more SE with 10 day treatment courses
risk factors for resistance
o Age >/= 65
o Hospitalization in the last 5 days
o Antibiotic use in the previous month
o Immunocompromise
o Multiple comorbidities
o Severe infection
o **1st line treatment in high risk patients: High dose Augmentin (2gm PO bid)
indications for urgent referral
o Persistent high fevers
o Abnormal vision/EOM
o Change in mental status
o Periorbital edema
o Cranial nerve palsies
o Meningeal signs
influenza
acute respiratory infectio, a self-limiting virus
infleunza A
Affects multiple species, including:
o Humans
o Swine
o Equine
o Birds
influenza A transmission/incubation
o Large droplet transmission:
* Inhalation of resp particles (cough, sneeze)
o Small particle transmission:
* Talking, exhalation
o Fomite
o Virus detectable & may shed in resp secretions up to 24 hours BEFORE sx onset
o Incubation:
* 24-48 hours
s/s influenza A
o Abrupt onset!
o Fever, chills, myalgias
o Malaise, anorexia
o Headache
o Cough (dry)
o Nasal congestion (clear)
o Sore throat
o Fever 100-104℉
o Convalescent phase: 1-2 weeks after acute febrile stage
* Cough, malaise, fatigue
o Some people can have mild illness like a cold
Children:
* Irritability, refusal to eat, rhinitis, GI sx like v/d
Older adults:
* Less likely to have those classic flus sx like younger individuals, may not have fever, anorexia, malaise, dizziness;
* Higher morbidity/mortality
influenza A: H & PE
o Diagnosis largely rests on history
o Focused PE:
* General survey, HEENT, cardiac, pulmonary
o Clinical findings that may be present:
* Fever likely
* Skin: Hot/moist, flushed face
* May have enlarged, tender cervical LN
* Lungs typically clear
diagnostics influenza
RT-PCR (most sensitive/specific) stick up the nose
* Yields rapid results
* Differentiates between influenza types/subtypes
Rapid flu tests:
* Distinguishes between A&B; <30 min results
* Lower sensitivity than RT-PCR
When should we test?
* If the result will influence management decisions
* However, testing should not delay initiation of treatment, if indicated
tx for influenza
supportive therapy
* analgesics
* cough suppressants
* decongestants
* antihistamines
* local anesthetics
Antivirals
* most commonly used: Oseltamivir (Tamiflu)
who should receive antiviral tx?
- persons who are hospitalized
- persons who have severe, complicated or progressive illness
- other persons who are at high risk includng:
- persons <2 and >65
- persons with chrominc pulmonary (including asthma), cardiovascular, renal, hepatic, hematological, metabolic, or neurologic
- persons with immunosuppression
- persons who are pregnant or postpartum
- persons aged younger than 19 years who are receiving long-term aspirin therapy
- native americans/alaskian natives
- persons who have a BMI >/ 40
- residents of nursing homes and other chronic care facilities
influenza prevention
All persons 6 months and older should be vaccinated annually, ideally by October
influenza vaccine
The first time a child between ages 6 months and 8 years receives the flu vaccine TWO doses are required at least 4 weeks apart (cdc.gov)
URI vs influenza
URI
* no fever
* no headache
* general aches and pains is sometimes, mild
* fatigue and weakness is sometimes, mild
* no extreme fatigue
* runny nose
* sore throat
* sneezing
* cough
* chest dicomfort is sometimes, mild
* onset gradudal
influenza
* fever
* headache
* general aches and pain
* fatigue and weakness
* extreme fatigue
* runny, stuffy nose
* sneezing
* chest discomfort
* sudden onset
* can lead to pneumonia and respiratory failure
chemoprophylaxis
- Long term care facility – outbreaks; 2 lab confirmed cases within 72 hours in residents on the same unit
- Chemoprophylaxis is recommended for all asymptomatic patients, and consider for certain staff, especially unvaccinated and recently vaccinated persons
