Ch 9 Lower Respiratory Tract Flashcards
atypical pneumonia/walking pneumonia pathogens
Mycoplasma pneumoniae
Chlamydia pneumoniae
Atypical pneumonia (M pneumoniae, C pneumoniae) sx’s
less severe sx’s
dry cough
large cough transmitting close proximity (correctional facilities, dorms, long-term care facilities, small offices)
Legionella organism is contracted by
inhaling mist or aspirating liquid from contaminated water source
NO evidence for person to person spread
pathogens that cause Community-Acquired Pneumonia (CAP)
if no comorbidities: S pneumonia, M pneumoniae, C pneumonia
if co: S p, M.p., C. p. AND H influenzae, Legionella spp
legionella organismal major risk factors for contraction
older age, male, smoking, DM
CAP lab orders
order:
-CBC with diff (check for anemia and bacterial shift and immune sys responding)
-BUN/Cr (dehydration; poor renal fxn = lesser outcome)
-chest x ray (confirms)
how long for CAP therapy?
5 days of antibiotics
- afebrile for 2-3 days before stopping antibiotics (ave 5-7 days)
what antibiotics for CAP with no significant comorbidities? (COPD, DM, renal/heart failure, asplenia, alcohol use disorder)
AABCDE
oral: azithromycin, amoxicillin, Biaxin/clarithromycin, doxycycline, or erythromycin
check if >20% rate of resistance in my area
what antibiotics for CAP with significant comorbidities? (COPD, DM, renal/heart failure, asplenia, alcohol use disorder)
PO fluoroquinolone (moxi - , levfloxacin)
OR
doxy or azithromycin or clarithromycin PLUS amoxicillin-clavulanate, cefpodoxime, cefuroxime
physical examination of pneumonia
-fever (>100.4F)
-tachypnea (24 or more RR)
-crackles or rales (inspiratory, clicking, rattling) does not go away with a cough
-consolidation (dullness to percussion; increased tactile fremitus/tissue density)
-pleuritic friction rub (sharp, localized pain worse with deep breath/cough)
what is the most sensitive and specific finding for pneumonia, esp in children and elderly?
tachypnea
how do you determine if a pt needs inpatient care for pneumonia?
CURB 65
-Confusion of new onset (delirium, new-onset mental status change)
-blood Urea nitrogen > 19 (hydration status)
-RR 30 or more
-BP SBP < 90 or DBP < 60
-65 years or older
score of:
0-1: outpatient with oral antibiotics
2: consider short stay hospital or watch closely as outpatient, adequate home support. oral or IV antibiotics by severity, GI function, care setting
3-5: require hospitalization possible ICU; IV antib
pulse pressure
systolic BP - DBP
ex: 114/70 = 44
40-60 range is healthy
< 40 is bad cardiac output = heart failure
what condition do you assess along with signs of pneumonia?
signs of heart failure!
pneumonia dramatically increases right sided heart workload
how is bronchitis similar to pneumonia?
everyone with pneumonia will have infected bronchus and lung parenchyma
how long does the continued fatigue and SOB last after pneumonia tx last?
few weeks-months
when does the chest x-ray clear up from pneumonia?
takes 1-2 months for the lungs to clear up. so don’t need repeat chest x-ray once pneumonia diagnosed has been made
acute bronchitis
lower airway inflammation with cough, with or without sputum production
NO fever and tachypnea
lasting >5 days, usually after URI
-only in absence of asthma, COPD or other airway diseases
most likely causative organism for acute bronchitis
respiratory tract VIRUSES
acute bronchitis management
most resolve without treatment (>75%)
If have a protracted, problematic cough, can give:
-inhaled bronchodilator via MDI (SAMA: ipratropium bromide Atrovent)
or SABA (albuterol, Proventil)
or short course prednisone 40 mg PO QD x 3-5 days
in <5% pts with bacterial pathogens (M pneumonia, C pneumonia): RARE
- oral macrolide (azithromycin, clarithromycin, erythromycin, or doxycycline)
pneumonia vs bronchitis
Fever >100.4F?
tachypnea 24 or more?
consolidation, crackles on chest exam?
cough?
Fever >100.4F? pnuemonia
tachypnea 24 or more? pneumonia (difficult with O2 exchange bc of infection of parenchyma of lung)
consolidation, crackles on chest exam? pneumonia
cough? both
asthma defined
chronic airway inflammation
airway inflammation first, then bronchospasm follows after
asthma sx’s
wheeze, SOB, chest tightness and/or cough due to variable airflow obstruction and bronchial hyperresponsiveness due to airway inflammation
how to diagnose asthma?
spirometry needed to diagnose!
peak flow is used for monitoring (not dx)
goals of asthma therapy
good control of sx’s and maintain normal activity
-minimize risk of asthma related death, exacerbations
what are the rescue/reliever medications PRN?
- short acting beta 2 agonist (SABA’s)
albuterol (Proventil)
p[irbuterol (Maxair_
levalbuterol ( xopenex)
when to use SABA medications?
for acute bronchospasm
if use more than 2 days a week, need better control of airway inflammation
controller medications for asthma: ICS
inhaled corticosteroids (ICS) prevent airway inflammation
preferred controller therapy
used DAILY for control, PRN for reliever
mometasone
fluticasone
budesonide
beclomethasone
controller medications for asthma: ICS/LABA
ICS= airway inflammation
LABA= prevents bronchoconstriction
used DAILY for control, PRN for reliever
Budesonide + formoterol (Symbicort)
fluticasone + salmeterol (Advair)
Mometasone + formoterol (Dulera)
if asthma is NOT adequately controlled with ICS + LABA, what is an add on med and how to use?
add in long-acting muscarinic antagonist (LAMA)
Tiotropium bromide (Spirvia). It’s a bronchodilator via cholinergic/muscarinic receptor
NEED consistent daily use for optimal effect
during asthma flare, give
systemic corticosteroids = provides aggressive tx of inflammation
prednisone 40-60 mg PO x 3-10 days (taper not needed)
prednisolone
methylprednisolone
dexamethasone
when do you need steroid taper off?
2 weeks or more would cause adrenal suppression so that is when you’d need to taper off. 5-7 days of prednisone for asthma flare is not long enough needed for a taper off
controller medications for asthma: leukotriene modifiers (Montelukast/Singulair)
prevents the formation of airway inflammation
discourage as 1st line bc BOX WARNING: neuro psych events: anxiousness, depression, hallucinations, insomnia, and SI
what med to give if have asthma sx’s < 2 times a month?
low dose ICS/formoterol
-can be used as controller AND/OR reliever
what med to give if have sx’s 2 or more a month but NOT daily?
DAILY low-dose ICS or low-dose ICS/formoterol PRN
what med to give if have sx’s most days, or waking up with asthma 1 or more a week?
controller: low dose ICS/LABA
reliever: low dose ICS/formoterol PRN or SABA PRN
what questions do you want to ask to assess asthma control in 12 and older pt’s to assess?
in the past 4 weeks…
1. any daytime asthma sx’s more than 2x/week?
2. any night awakening due to asthma?
3. SABA reliever for sx’s >2x/week?
4. any activity limitation due to asthma?
if 0: well controlled, 1-2: partially, 3-4: uncontrolled
when to measure FEV1?
at time of diagnosis,
after 3-6 months of controller therapy,
then periodically for ongoing risk assessment
what potentially modifiable risk factors for asthma exacerbations
-meds: high SABA use, inadequate ICS, poor adherence, wrong inhaler technique
-other med conditions (obesity, chronic rhinosinusitis, GERD, confirmed food allergy, pregnancy)
-exposure (smoking, allergen, air pollution)
-poor lung function (FEV1 < 60%)
air trapping conditions and objective findings
COPD (exacerbations)
asthma (exacerbations)
-hyper resonance on percussion
-decreased tactile fremitus (excess air in lungs)
-wheeze (expiratory first, then inspiratory later)
-low diaphragms
-increased anteroposterior (AP) diameter = barrel chest in COPD or longstanding poorly controlled asthma
if a beta 2 agonist isn’t working too well, think
airway inflammation is present! since it is normally a potent bronchodilator
FEV1 measures
lower airway obstruction and can compare
what is COPD (chronic obstructive pulmonary disorder)?
includes chronic bronchitis AND emphysema
-irreverisble airflow limitation
-destruction/remodeling of airway and alveoli damage
-SMOKING
most common sx’s of COPD
chronic cough & sputum production
activity intolerance
dyspnea on exertion!! (worse with exercise)
most common COPD risk factors
exposure irritants (tobacco use, occupational exposure to irritants)
indoor/outdoor air pollution
family hx of COPD, advancing age
consider dx in any individual who has dyspnea, chronic cough, or sputum production and/or hx of exposure to risk factors
goals of COPD
relieve sx’s
relieve exacerbations and improve exercise tolerance and health status
exacerbations worsen and deconditions the health
COPD diagnosis
FEV/FVC < 0.70 AFTER/post bronchodilator use confirms persistent airflow limitation/COPD
spirometry is required for diagnosis
what are the questionaires to assess COPD sx’s?
COPD assessment test (CAT) or the clinical COPD questionnaire (CCQ)
COPD classification of airway limitation
GOLD 1: Mild: FEV 80%+
GOLD 2: Moderate: 50-80%
GOLD 3: Severe: 30-49%
GOLD 4: Very Severe: <30%
Gold 3 & 4 is mostly seen in office (1 & 2 hasn’t been diagnosed yet)
Meds used in COPD treatment
-SABA (albuterol), SAMA (iptratropium bromide) = PRN for relief of bronchopsasm
-inhaled LABA (salmeterol) = DAILY use for protracted duration bronchodilator
-inhaled LAMA = DAILY use for protracted duration bronchodilator and minimizes risk of COPD exacerbation
-ICS = DAILY use for anti-inflammatory, minimizes COPD exacerbation but modest increase in pneumonia risk
-oral theophylline = DAILY use for bronchodilator (NARROW TI and $$)
-oral PDE-4 inhibitor (roflumilast) = DAILY use to min exacerbation but mood destabilization
First-line stage for COPD treatment for GOLD 1 & GOLD 2
in pt’s with FEV1/FVC < 0.70 post bronchodilators:
GOLD 1 (FEV1>80%) & 2 (50-80%) (mild to moderate) with 1 or less exacerbation per year,
with less sx’s: give SAMA (ipratropium/Atrovent) or SABA (albuterol, proventil) prn
with more sx’s: give LAMA (tiotropium/Spiriva) or LABA (salmeterol /Servent)on set schedule
(LAMA better though)
LAMA vs LABA for COPD treatment
LAMA has added benefit of minimizing COPD exacerbation
**First-line stage for COPD treatment for GOLD 3 & GOLD 4
in pt’s with FEV1/FVC < 0.70 post bronchodilators:
GOLD 3 (FEV 30-50%) & 4 (<30%) with 2 or more exacerbations per year:
High exacerbation risk with less sx’s: give LAMA (tiotropium) on set schedule (NOT prn)
High exacerbation risk with more sx’s: give LAMA (tiotropium) or (LABA (salmeterol) + LAMA) or (ICS + LABA) on set schedule
causes of COPD exacerbations
change in baseline (dyspnea, cough, sputum) that needs change in management
-60% tobacco, air pollution, viral RTI
-40% bacterial (gram - H influ, moraxella catarrhalis) and gram + S. pneumoniae
COPD exacerbation treatment
-bronchodilators (SABA and/or SAMA prn)
add LABA or LAMA if pt not currently using
- prednisone x 5 days to shorten recovery time, and hypoxemia, and minimize relapse risk
-mixed evidence on antibiotics use (5-7 days)
which medication do you avoid with use with ace inhibitors/arbs, esp with CKD and/or dehydration due to hyperkalemia
TMP-SMX (bactrim)
which medication is vulnerable to destruction by beta-lactamase
penicillins (amoxicillin)
which medication has QT long elongation, esp in those with higher CVD risk?
macrolides (Azithromycin)
which medication is a/s with tendon rupture risk, esp when used with systemic corticosteroid?
fluoroquinolones (tendon rupture risk increases by 40% when sued with systemic corticosteroids Moxifloxacin
which meds have less than 1% cross risk of penicillin allergy?
-cephalosporins (cefpodoxime)
-can use cephalosporines in NONanaphylactic reactions
antimicrobial therapy in COPD exacerbation in outpatient setting
consider risk vs benefit ratio
-PUT on steroid! calms down swelling that produces phlegm
-antib usually not indicated
mild to moderate COPD exacerbation in antib therapy
-prednisone
IF prescribed, use 1 of these x 5 days:
-Amoxicillin (strep pneumo, Hflue, mcat)
-TMP-SMX (not for comorbities)
-Doxycycline (will take care of the strep pneumo, H flu, Mcat)
-Cephalosporin (cefdinir, cefpodoxime, etc)
more severe COPD exacerbation
antib debated.. if give, consider risk/benefit ratio
consider severity and comorbidities
give prednisone and..
1 of these for 5 days:
-Beta-lactam: amoxicillin-clavulanate (Augmentin; tough on stomach so don’t give), cephalosporin (easy on stomach; prob best antib choice out of all these), –Macrolides: azithromycin (prolong QT), clarithromycin,
-Fluroquinolones: moxi-, levofloxacin (consider tendon rupture; avoid bc they’re already on a steroid)
long term O2 therapy in COPD
using it >15 hrs a day (not PRN)
ensure adequate O2 delivery by keeping Sa o2 >90%
