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AGPCNP Board Prep > Ch10: Lower Respiratory > Flashcards

Ch10: Lower Respiratory Flashcards

1
Q

pneumonia is infection of the….

A

lungs and bronchi

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2
Q

everyone with pneumonia also has….

A

bronchitis

but not everyone with bronchitis has pneumonia

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3
Q

most-likely causative pathogens in pneumonia depends on whether they have underlying conditions, including: (6)

A
  • COPD
  • diabetes
  • heart failure
  • liver disease
  • CKD
  • asplenia
  • alcoholism
  • malignancy
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4
Q

Most likely causative pathogens in someone with CAP without significant comorbidities (6)

A

BACTERIAL

  • Strep pneumoniae (most common)
  • M. pneumoniae (atypical)
  • C. pneumoniae (atypical)
  • Staph aureus

VIRAL

  • influenza A or B
  • respiratory synctial virus (RSV)
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5
Q

Most likely causative pathogens in someone with CAP and with significant comorbidities (6)

A

same as before, PLUS Haemophilus pneumoniae and legionella

  • S. pneumoniae
  • H. influenzae
  • M. pneumoniae
  • C. pneumoniae
  • Staph aureus
  • Legionella
  • respiratory viruses (influenza A/B, RSV)
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6
Q

who is likely to have M. pneumoniae or C. pneumoniae pneumonia

A

atypical

largely cough-transmitted

often seen in groups of people who have recently spent extended time in close proximity (e.g., correctional facilities, college dormitories, long-term care facilities, small offices)

index patient 1 –> 3 weeks later, the rest of the group is sick with it

will cause a bilateral pneumonia

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7
Q

typical presentation of CAP caused by M. pneumoniae or C. pneumoniae

A

atypical
“walking pneumonia”

(most commonly from M. pneumoniae)

usually dry cough with less severe signs or symptoms

usually bacterial

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8
Q

how is legionella pneumonia transmitted

A

usually contracted by inhaling mist or aspirating liquid that comes from a water source contaminated with Legionella

No evidence for person-to-person spread

outbreaks occur when common source of contaminated water or air conditioning systems

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9
Q

major risk factors for severe legionella pneumonia disease

A
  • older age
  • male
  • smoking
  • diabetes

with these risk factors, may get very very ill and need ICU

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10
Q

who gets Staph Aureus pneumonia?

A

largely limited to post-influenza pneumonia

folks who were recently sick with flu

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11
Q

only see this pneumonia occurring after an influenza infection

A

staph aureus pneumonia

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12
Q

diagnostic evaluation for pneumonia

A
  • CBC with diff
  • BUN/Cre
  • additional testing based on patient presentation and comorbidity
  • chest xray
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13
Q

why do a CBC with diff in someone with pneumonia?

A
  • see if WBCs are responding to infection

- those with anemia do worse than those without

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14
Q

why get BUN/Cre in someone with pneumonia?

A
  • hydration status (BUN)

- those with kidney disease do worse than those without

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15
Q

recommended length of antibiotics for CAP

A
  • minimum of 5 days
  • needs to demonstrate evidence of increasing stability
  • must be afebrile for 48-72 hrs before discontinuation
  • average length = 5-7 days
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16
Q

Empiric antibiotic options for CAP WITHOUT comorbidities (3)

A
  • doxycycline (best choice per Fitzgerald)
  • macrolide (azithromycin, clarithromycin, erythromycin) if local resistance rates are low
  • amoxicillin (high dose)
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17
Q

how to determine if azithromycin or other macrolide (e.g., clarithromycin, erythromycin) is a good prescription for someone with CAP?

A

take into consideration local Strep Pneumoniae macrolide resistance rates

if rate >20%, do not use

can be determined from local antibiogram, from public health department

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18
Q

best choice antibiotic for CAP without comorbidities

A

doxycycline (per Fitzgerald)

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19
Q

Empiric antibiotic options for CAP WITH comorbidities (3)

A
  • respiratory fluoroquinolone (levofloxacin, moxifloxacin)
  • doxycycline OR macrolide (azithromycin, clarithromycin) PLUS a beta-lactam such as amoxicillin-clavulanate, cefpodoxime, or cefuroxime
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20
Q

best choice antibiotic for CAP with comorbidities

A

respiratory fluoroquinolone

levofloxacin, moxifloxacin, gemifloxicin

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21
Q

what are the (3) respiratory fluoroquinolones

A

levofloxacin, moxifloxacin, gemifloxicin

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22
Q

significance of tachypnea in CAP

A

one of the most sensitive and specific findings for pneumonia, especially in children and the elderly

this may be a better sign in elderly than a fever (don’t always develop fever)

s/t impaired gas exchange, possibly due to fever

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23
Q

significance of crackles or rales on respiratory exam in CAP

A

occurs with sudden opening of distal fluid-filled airways

often demonstrate partial (not full) resolution with a cough

noted in pneumonia and heart failure, among others

crackling, clicking, rattling sound on inspiration

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24
Q

evidence of consolidation in CAP

A
  • dullness to percussions (dense tissue when percussed sounds dull)
  • increased tactile fremitus (increases with increased tissue density)
  • cough does not alter the sound
  • may have bronchial or tubular breath sounds, often with late inspiratory crackles, that do not clear with cough
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25
Q

pneumonia with consolidation findings is most commonly associated with what etiology…

A

bacterial pneumonia

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26
Q

most likely to encounter pleuritic friction rub in pneumonia when there is….

A

pleural inflammation (pleurisy)

will hear this on inspiration and expiration

sounds similar to a pericardial friction rub

would be an uncommon and late sign of a PE

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27
Q

pleuritic chest pain

A

localized area of sharp pain worse with deep breath, movement, or cough

may have audible pleural friction rub from movement of inflamed pleural layers

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28
Q

most likely pneumonia types to give you pleural friction rub (2)

A
  • strep pneumoniae

- legionella

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29
Q

Score to help you determine whether CAP can be treated outpatient vs inpatient

A

CURB 65

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30
Q

CURB 65 scoring

A 
C - confusion (new onset)
U - urea (BUN >19)
R - respiratory rate >30
B - blood pressure <90/<60
65 - age 65yo or older

each characteristic is worth 1 point

0-1 points can treat as an outpatient with oral antibiotics

2 points, consider short stay in hospital or watching closely as outpatient with adequate home support

3-5 requires hospitalization, possibly ICU

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31
Q

CURB65 score where ok to treat CAP at home

A

0 or 1

2 may consider it with really close monitoring

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32
Q

CURB65 score where need to hospitalize for CAP

A

3 or higher

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33
Q

always look out for ______ in elderly adults with pneumonia

A

heart failure

up to 20% of older adults with pneumonia will develop CHF

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34
Q

tactile fremitus [increases vs. decreases] over areas of consolidation

A

increases

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35
Q

pt follow-up after pneumonia treatment - expected findings?

A

you want them to come back in the next few days, ensure that they are starting to feel better and at least are not feeling worse

would not be surprised if they were still tired but should be starting to feel better

would not be surprised if the chest exam remains abnormal for the next 4-6weeks as long as they are symptomatically continuing to feel better

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36
Q

what is the most common pathogen implicated in acute bronchitis

A

respiratory viruses!!!!!

VIRAL

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37
Q

% of acute bronchitis infections that will resolve without treatment within _____ weeks

A

> 75% resolve within 2 weeks

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38
Q

how do you diagnose acute bronchitis

A

clinical!

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39
Q

what is acute bronchitis

A

lower airway inflammation

usually presents with cough (with or without sputum) but WITHOUT fever or tachypnea, lasts >5 days, and typically follows a URI

diagnosed only in the ABSENCE of asthma, COPD, or other airway disease (e.g., otherwise is a flare of their asthma or COPD exacerbation)

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40
Q

acute bronchitis is notably different than pneumonia because presents WITHOUT these (2) symptoms

A

tachypnea
fever

if present, think pneumonia rather than acute bronchitis

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41
Q

% of acute bronchitis that is caused by VIRUS

A

> 95%

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42
Q

treatment for acute bronchitis

A
  • > 75% will resolve on its own without treatment
  • for protracted, problematic cough can use an inhaled bronchodilator via MDI such as a short-acting muscarinic antagonist (SAMA; ipatropium bromide [Atrovent]) or a short-acting beta agonist (SABA; albuterol [Proventil, Ventolin])
  • can also consider short course of oral corticosteroid for severe cough (prednisone 40mg PO QD x3-5 days)
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43
Q

regimen for a short-course steroid burst

A

prednisone 40mg PO QD x3-5 days

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44
Q

(3) medication classes helpful for acute bronchitis

A
  • SAMA = short acting muscarinic antagonist …. e.g., ipatropium bromide
  • SABA = short acting beta agonist… e.g., albuterol (Proventil, Ventolin)
  • oral steroids …. e.g., prednisone 40mg PO QD x3-5 days
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45
Q

<5% of acute bronchitis is caused by bacteria. which are the (3) most common causative bacterial agents

A
  • M. pneumoniae
  • C. pneumoniae
  • B. pertussis
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46
Q

in the rare case that you suspect an acute bronchitis is bacterial in origin, what antibiotics would be options? (2)

A
  • oral doxycycline

- oral macrolide (azithromycin, clarithromycin, erythromycin)

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47
Q

pneumonia-like symptoms in a patient who presents with hemoptysis and chest xray which demonstrates RUL infiltrate. you suspect….

A

tuberculosis

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48
Q

pneumonia with infiltrates…. where?

A

bilateral or lower lobes

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49
Q

TB with infiltrates… where?

A

upper lobe

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50
Q

risk factors for TB infection

A
  • HIV
  • h/o positive PPD skin test result
  • h/o prior TB treatment
  • known or suspected active TB exposure
  • travel to or emigration from an area where TB is endemic
  • homelessness, shelter-dwelling, or incarcerated
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51
Q

clinical presentation of TB

A
  • congested
  • productive cough with white/yellow or blood-streaked sputum
  • hemoptysis
  • chest pain
  • fever
  • unexplained weight loss
  • anorexia
  • night sweats
  • fatigue
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52
Q

diagnostic testing for TB

A

DIAGNOSTIC

  • chest xray or thoracic CT
  • acid-fact bacilli smear or culture from sputum sample
  • enzyme-linked immunospot assay for mycobacterial ribosomal RNA

SCREENING

  • mantoux tuberculin skin test or QuantiFERON-TB Gold
  • HIV testing if status is unknown
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53
Q

a common chronic disorder that is complex and characterized by underlying airway inflammation that leads to variable airflow obstruction and bronchial hyperresponsiveness

A

asthma

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54
Q

which comes first in asthma: airway inflammation or bronchospasm?

A

airway inflammation

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55
Q

symptoms of asthma

A
  • recurrent cough, wheeze, shortness of breath and/or chest tightness d/t variable airflow obstruction and bronchial hyperresponsiveness
  • triggered by underlying airway inflammation
  • symptoms are worse at night and/or with exercise, viral URI, aeroallergens, or pulmonary irritants (e.g., smoke)
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56
Q

most common reason for an asthma flare

A

viral URI

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57
Q

in order to diagnose asthma, the airflow obstruction needs to be at least partially….

A

reversible (demonstrated via spirometry)

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58
Q

diagnosis of asthma is based on an increase in _____ by at least _____ from baseline after using a SABA (e.g., albuterol)

A

FEV1

>12% improvement

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59
Q

_____ is needed for the diagnosis of asthma, versus _____ is used for monitoring (not diagnosing)

A

spirometry = diagnosis

peak flow meter = monitoring

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60
Q

medication class: mometasone (Asmanex)

A

inhaled corticosteroid

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61
Q

medication class: fluticasone (Flovent)

A

inhaled corticosteroid

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62
Q

medication class: budesonide (Pulmicort)

A

inhaled corticosteroid

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63
Q

medication class: beclomethasone (Qvar)

A

inhaled corticosteroid

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64
Q

medication class: ciclesonide (Alvesco)

A

inhaled corticosteroid

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65
Q

what is the role of inhaled corticosteroids in the management of asthma

A

prevents the formation of airway inflammation

in order to have this effect, requires consistent, daily use

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66
Q

medication class: budesonide + formoterol (Symbicort)

A

combined inhaled corticosteroid (ICS) + long acting beta agonist (LABA)

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67
Q

medication class: fluticasone + salmeterol (Advair)

A

combined inhaled corticosteroid (ICS) + long acting beta agonist (LABA)

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68
Q

medication class: mometasone + formoterol (Dulera)

A

combined inhaled corticosteroid (ICS) + long acting beta agonist (LABA)

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69
Q

medication class: formoterol

A

long acting beta agonist (LABA)

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70
Q

medication class: salmeterol

A

long acting beta agonist (LABA)

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71
Q

role of combined ICS + LABA in the management of asthma

A

ICS = prevents the formation of airway inflammation

LABA = prevents bronchoconstriction

again, this requires consistent, daily use for optimal effect

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72
Q

medication class: montelukast (Singulair)

A

leukotriene modifier

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73
Q

role of leukotriene modifiers in the management of asthma

A

blocksthe action of a single inflammatory mediator, leukotriene

thus, is only 50% as potent as an ICS in preventing the formation of airway inflammation

thus, seldom first line therapy as ICS is preferred

also requires consistent, daily use for optimal effect

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74
Q

medication class: tiotropium bromide (Spiriva)

A

long acting muscarinic antagonist (LAMA)

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75
Q

role of a LAMA in asthma management

A

LAMAs act as a bronchodilator via the blockage of muscarinic receptors, minimizing the risk of asthma exacerbation

requires consistent, daily use for optimal effect

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76
Q

role of theophylline in asthma management

A

asthma controller drug even though it doesn’t control inflammation

prevents bronchoconstrictor

mild-to-moderate bronchodilator

requires consistent, daily use for optimal effect

rarely used today because it is a fussy drug - needs monitoring of therapeutic levels, lots of interactions, chemically-related to caffeine, so has similar adverse effects as being overcaffeinated

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77
Q

(5) medication classes that are options for use in asthma CONTROLLER therapy

A
  • inhaled corticosteroids (FIRST LINE!)
  • long-acting beta2 agonists (LABAs – often combined with ICS)
  • leukotriene modifiers
  • long-acting muscarinic antagonist (LAMA)
  • theophylline
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78
Q

all of the asthma CONTROLLER medications require _____ to be effective

A

consistent, daily use

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79
Q

rescue medications in asthma are used to relieve what?

A

acute bronchospasm

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80
Q

all asthma rescue inhalers are this medication class

A

short-acting beta2 agonist (SABA)

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81
Q

SABA options for asthma rescue therapy

A
  • albuterol (Proventil)
  • pirbuterol (Maxair)
  • levalbuterol (Xopenex)
82
Q

use of asthma rescue inhaler >____days/week suggests a need for better control of airway inflammation (except pre-treating before exercise)

A

> 2days/week

83
Q

medication recommendation for preventing exercise-induced bronchospasm

A

use SABA (rescue inhaler) 15-30 minutes before activity

84
Q

medication class: prednisone

A

systemic corticosteroid

85
Q

medication class: prednisolone

A

systemic corticosteroid

86
Q

medication class: methylprednisone

A

systemic corticosteroid

87
Q

medication class: dexamethasone

A

systemic corticosteroid

88
Q

generally, adults need ____ days of prednisone to recover from asthma flare

A

5-7 days

89
Q

(2) reasons to taper a steroid

A
  • you think you suppressed the adrenal glands (only worrisome with >14 days of use)
  • you worry the reason they were on the steroid is going to come back (not worried about this with viral URI since those clear up in 5-7 days usually)

aka….. she thinks there is no reason to ever prescribe a tapering Medrol dose pack

90
Q

almost all asthma flares are triggered by…..

A

viral URI

91
Q

specific prescription for systemic corticosteroids for asthma flare in adult

A

prednisone 40-60mg PO QD x3-10 days (typically 5-7)

92
Q

when to use systemic corticosteroids in asthma management

A

all asthma flares

93
Q

majority of adults with asthma seen in primary care will have this diagnosis of severity

A

moderate persistent

94
Q

normal FEV1/FVC ratio for 20-39yo

A

80%

95
Q

normal FEV1/FVC ratio for 40-59yo

A

75%

96
Q

normal FEV1/FVC ratio for 60-80yo

A

70%

97
Q

normal chest percussion should be

A

resonant

98
Q

with air trapping (COPD and asthma exacerbation), chest percussion will be….

A

hyperresonant

99
Q

objective physical exam findings to expect in an asthma exacerbation or COPD (5)

A
  • hyperresonance of the chest on percussion
  • decreased tactile fremitus
  • wheeze (starts with expiratory wheeze, inspiratory wheeze is a later sign)
  • low diaphragm
  • increased AP diameter (“barrel chest”)
100
Q

dropping SaO2 is an [early vs. late] sign in asthma flare

A

LATE

once they cannot bring air in

101
Q

dropping FEV1 or peak flow is an [early vs. late] sign in asthma flare

A

EARLY

first, they cannot get air out

102
Q

characterize asthma severity:

  • symptoms cough/wheeze <2 days/week
  • nighttime sxs <2x/month
  • SABA use <2 days/week
  • no interference with usual activities
  • normal FEV1 between exacerbations
  • FEV1 >80% predicted
  • FEV1/FVC ratio is normal
  • 0-1 exacerbations per year requiring oral steroids
A

intermittent asthma

103
Q

STEPWISE step for someone with intermittent asthma severity

A

step 1

104
Q

characterize asthma severity:

  • symptoms cough/wheeze >2 days/week but less than daily
  • nighttime sxs 3-4x/month
  • SABA use >2 days/week but less than daily
  • minor interference with usual activities
  • FEV1 >80% predicted
  • FEV1/FVC ratio is normal
  • 0-1 exacerbations per year requiring oral steroids
A

mild persistent

105
Q

STEPWISE step for someone with mild persistent asthma severity

A

step 2

106
Q

characterize asthma severity:

  • symptoms of cough/wheeze daily
  • nighttime sxs >1x per week, but less than every night
  • SABA use daily
  • some interference with usual activities
  • FEV1 >60% predicted, but <80%
  • FEV1/FVC ratio is reduced by 5%
  • 2 or more exacerbations per year requiring oral steroids
A

moderate persistent

107
Q

characterize asthma severity:

  • symptoms of cough/wheeze daily, throughout the day
  • nighttime sxs every night
  • SABA use several times daily
  • extreme interference with usual activities
  • FEV1 <60% predicted
  • FEV1/FVC ratio is reduced by >5%
  • 2 or more exacerbations per year requiring oral steroids
A

severe persistent

108
Q

STEPWISE step for someone with moderate persistent asthma severity

A

step 3 + short course of oral systemic corticosteroids to relieve the inflammation already present

109
Q

STEPWISE step for someone with moderate persistent asthma severity

A

step 4 + short course of oral systemic corticosteroids to relieve the inflammation already present

110
Q

STEPWISE Approach for Managing Asthma: STEP 1

A

SABA PRN

111
Q

STEPWISE Approach for Managing Asthma: STEP 2

A

SABA PRN
+
Inhaled Corticosteroids (ICS), low dose

112
Q

STEPWISE Approach for Managing Asthma: STEP 3

A

SABA PRN
+
Inhaled Corticosteroids (ICS), medium dose

OR

(less common for insurance to cover this)
SABA PRN
+
Inhaled Corticosteroids (ICS), low dose
+
Long-Acting Beta2 Agonist (LABA), low dose

113
Q

STEPWISE Approach for Managing Asthma: STEP 4

A

SABA PRN
+
Inhaled Corticosteroids (ICS), medium dose
+
Long-Acting Beta2 Agonist (LABA), medium dose

114
Q

STEPWISE Approach for Managing Asthma: STEP 5

A 
SABA PRN
\+
Inhaled Corticosteroids (ICS), high dose
\+
Long-Acting Beta2 Agonist (LABA), high dose
115
Q

STEPWISE Approach for Managing Asthma: STEP 6

A 
SABA PRN
\+
Inhaled Corticosteroids (ICS), high dose
\+
Long-Acting Beta2 Agonist (LABA), high dose
\+
Oral corticosteroids
116
Q

general rule for when to step UP to next Step in STEPWISE Approach for Managing Asthma

A

use of SABA rescue >2x per week (excluding prevention of EIB)

117
Q

consider adding this medication for folks with asthma who have allergies in Steps 2-4

A

subcutaneous allergen immunotherapy with omalizumab

118
Q

Characterize well-controlled (therapeutic goal) for asthma symptoms

A
  • symptoms <2days/week
  • nighttime sxs <2x/month
  • SABA use <2days/week
  • FEV1 or peak flow >80% predicted or personal best
  • 0-1 exacerbations per year requiring oral corticosteroids
119
Q

general rule for when to step DOWN to below Step in STEPWISE Approach for Managing Asthma

A

consider stepping down if they have been well-controlled (at therapeutic goal) for at least 3 months

120
Q

general rule for when to have patient RTC for FUP with well-controlled asthma

A

Q1-6 months to maintain control and monitoring

121
Q

general rule for when to have patient RTC for FUP with not well-controlled asthma

A
  • consider short course of oral steroids
  • step up on stepwise approach
  • RTC for re-evaluation in 2-6 weeks depending on severity
122
Q

(3) validated questionnaires for monitoring control of asthma symptoms

A

ACT (asthma control test)
ACQ (asthma control questionnaire)
ATAQ (asthma therapy assessment questionnaire)

123
Q

guidelines name for managing COPD

A

Gold Guidelines

124
Q

(4) preventive measures always recommended with COPD

A
  • smoking cessation
  • physical activity
  • pulmonary rehab
  • flu and pneumonia vaccines
125
Q

common, preventable and treatable disease characterized by persistent respiratory symptoms and airflow limitation that is NOT fully reversible. exacerbations and comorbidities contribute to the overall severity

A

COPD

126
Q

COPD symptoms

A
  • chronic cough
  • chronic sputum production
  • activity intolerance
  • progressive symptoms over time
127
Q

most common COPD risk factors

A
  • TOBACCO (#1)
  • occupational exposure to irritants
  • air pollution
  • family h/o COPD
  • advancing age
128
Q

how do you diagnose COPD on spirometry

A

FEV1/FVC ratio <0.70 (<70%) post-bronchodilator which confirms persistent airflow limitation of COPD (as opposed to asthma)

129
Q

(2) standardized questionnaires for determining severity of COPD

A
  • CAT (COPD Assessment Test)

- CCQ (clinical COPD questionnaire)

130
Q

who should receive screening for alpha-1 antitrypsin deficiency (AATD)

A

ALL patients with a COPD diagnosis, particularly in….

  • areas with high AATD prevalence
  • COPD <45yo
  • European ancestry
  • strong family history of early-onset COPD
  • panniculitis (inflammation under the skin, looks like spider varicosities)
131
Q

% of patients with COPD who have alpha-1 antitrypsin deficiency (AATD)

A

3%

132
Q

Spirometry results for GOLD 1 stage COPD severity

A

Mild

FEV1/FVC ratio <0.70

FEV1 >80% predicted

133
Q

Spirometry results for GOLD2 stage COPD severity

A

Moderate

FEV1/FVC ratio <0.70

FEV1 <80% but >50% predicted

134
Q

Spirometry results for GOLD3 stage COPD severity

A

Severe

FEV1/FVC ratio <0.70

FEV1 <50% but >30% predicted

135
Q

Spirometry results for GOLD4 stage COPD severity

A

Very severe

FEV1/FVC ratio <0.70

FEV1 <30% predicted

136
Q

FEV1/FVC ratio required for diagnosis of COPD

A

<0.70

not reversible with use of bronchodilator

137
Q

PRN medication options in COPD (2)

A

SABA inhaler (e.g., albuterol)

or

short-acting muscarinic antagonist (SAMA) e.g., ipatropium

138
Q

Controller medication options in COPD (5)

A
  • inhaled long-acting beta agonists (LABA, e.g., salmeterol)
  • long-acting muscarinic antagonist (LAMA, e.g., tiotropium bromide)
  • inhaled corticosteroids (ICS, e.g., fluticasone)
  • oral theophylline
  • oral PDE-4 inhibitor
139
Q

role of SABAs or SAMAs in COPD

A

relief of a bronchospasm

140
Q

role of LABA in COPD

A

protracted duration bronchodilation

141
Q

role of LAMA in COPD

A
  • protracted duration bronchodilation

- minimizes risk of COPD

142
Q

role of ICS in COPD

A
  • antiinflammatory
  • minimizes risk of COPD exacerbation

use limited by modest increase in risk of pneumonia

143
Q

Use of inhaled corticosteroids as controller therapy for COPD comes with increased risk of which other respiratory condition

A

pnuemonia

144
Q

role of oral theophylline in COPD

A

bronchodilator

not commonly used

145
Q

role of oral PDE-4 inhibitor in COPD

A

minimizes the risk of COPD exacerbation

146
Q

medication class: roflumilast

A

oral PDE-4 inhibitor for COPD controller therapy

not super effective and got a BBW for psychosis

only one of its class on the market

147
Q

GOLD 1st line recommendations for pharmacologic therapy: GOLD 1 / MILD

low exacerbation risk, less symptoms

A

SAMA or SABA PRN

148
Q

medication class: ipatropium bromide

A

short-acting muscarinic antagonist (SAMA)

149
Q

GOLD 1st line recommendations for pharmacologic therapy: GOLD 2 / MODERATE

low exacerbation risk/ more symptoms

A

SAMA or SABA PRN
+
scheduled LAMA or LABA for controller therapy

150
Q

GOLD 1st line recommendations for pharmacologic therapy: GOLD 3 / SEVERE

high exacerbation risk/less symptoms

A

SABA or SAMA PRN
+
scheduled LAMA for controller therapy

151
Q

GOLD 1st line recommendations for pharmacologic therapy: GOLD 4 / VERY SEVERE

high exacerbation risk/more symptoms

A

SABA or SAMA PRN
+
scheduled LAMA/LABA combo

OR

scheduled ICS/LABA combo

OR

scheduled ICS/LABA/LAMA combo

152
Q

Stepping up of COPD medications, generally (4)

A
  1. SABA or SAMA PRN
  2. Add LAMA or LABA scheduled
  3. Definitely LAMA on schedule
  4. Add ICS to LABA or LAMA, or can do triple therapy (LABA/LAMA/ICS)
153
Q

Which tends to be more preferable for COPD controller therapy, a LABA or a LAMA?

A

LAMA, as this has dual action in providing protracted bronchodilation AND reduces risk for COPD exacerbation

154
Q

your pt with COPD is having persistent breathlessness and DOE. They are currently on LABA monotherapy. What is your next step?

A

Add a second bronchodilator – in this case, a LAMA

155
Q

your pt with COPD is having persistent breathlessness and DOE. They are currently on LABA/ICS combo. What is your next step?

A

Add LAMA triple therapy

156
Q

your pt with COPD just had another COPD exacerbation resulting in ER visit. They are currently on LABA monotherapy. What is your next step?

A

LABA/LAMA combination

or,

LABA/ICS combination

157
Q

your pt with COPD just had another COPD exacerbation resulting in ER visit. They are currently on LABA/ICS combo therapy. What is your next step?

A

Add LAMA for triple therapy

or, switch to LABA/LAMA

158
Q

your pt with COPD just had another COPD exacerbation resulting in ER visit. They are currently on LABA/LAM/ICS triple therapy. What is your next step?

A
  • consider add roflumilast (oral PDE-4 inhibitor)

- consider add a macrolide antibiotic

159
Q

majority (>60%) of COPD exacerbations are caused by (3)

A

> 60%

  • tobacco use
  • air pollution
  • viral respiratory illness

less commonly, triggered by bacterial pathogens

160
Q

how would you define a COPD exacerbation

A

an event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum beyond day-to-day variability that is sufficient to warrant a change in management

161
Q

pharmacologic management of a COPD exacerbation (4)

A
  • SABA/SAMA PRN
  • add a LABA or a LAMA if they are not currently using
  • systemic corticosteroids short-term (prednisone 40mg PO QD x5-7 days)
  • consider antimicrobial therapy x5-7 days
162
Q

a minority (<40%) of COPD exacerbations are caused by a bacterial infection. what are the (3) most common causative pathogens when this occurs?

A
  • haemophilus influenzea
  • M. catarrhalis
  • strep pneumoniae

these are the same bugs that can cause sinusitis, otitis media, and 2 of them commonly cause pneumonia (not M. catarrhalis which rarely affects lower respiratory tract unless there is underlying lung disease like COPD)

163
Q

almost ALWAYS in COPD exacerbation you are going to prescribe a short course of _______, and rarely will you need ______

A

always systemic steroids (prednisone x5-7 days)

rarely antibiotics

164
Q

which antibiotic should you avoid use when a patient is on an ACE or ARB due to hyperkalemia risk

A

TMP/SMX
(Bactrim)

(in reality, if they have good kidneys and need short term for a UTI, is ok. However, could really get in trouble if CKD)

165
Q

which antibiotics should you avoid in individuals with higher CVD risk d/t risk for QT prolongation

A

macrolides

e.g., azithromycin, clarithromycin,
erythromycin

166
Q

which antibiotics are associated with a risk of tendon rupture

A

fluoroquinolones

e.g., moxifloxacin, levofloxacin

167
Q

fluoroquinolones risk for tendon rupture is increased when a patient is also taking what other class of medications

A

systemic corticosteroids

168
Q

which antibiotics have a <1% cross-risk in penicillin allergy

A

cephalosporins

e.g., cefpodoxime

169
Q

in mild-moderate COPD exacerbation, antimicrobial therapy is usually not indicated but if prescribed, would choose one of the following (4)

A

BEST OPTIONS:

  • doxycycline (covers broadly)
  • cephalosporin (e.g., cefdinir, cefpodoxime; covers broadly)

LESS GOOD OPTIONS:
- TMP-SMX (not great, because usually they have comorbid HTN or CKD and this poses risk for hyperkalemia)

  • amoxicillin (not great, often destroyed by the beta lactamase from H. flu and M. cat)
170
Q

in severe COPD exacerbation, consider prescribing one of the following oral antibiotics (3)

A

BEST CHOICE:
cephalosporin (e.g., cefdinir, cefpodoxime)

ALL CHOICES:
- beta lactam (e.g., amoxicillin-clavulanate [Augmentin] or a cephalosporin [cefdinir, cefpodoxime]

  • macrolide (azithromycin, clarithromycin)
  • respiratory fluoroquinolone (moxifloxacin, levofloxacin, gemifloxacin)

*** she avoids Augmentin because it is really hard on the stomach, and hard to eat during a COPD exacerbation

**she avoids macrolides because risk for QT prolongation and clarithromycin is a CYP450 inhibitor and interacts with 50% of common medications

*** she avoids respiratory fluroquinolones due to tendon rupture risk because they will ALSO be taking a systemic corticosteroids with their COPD exacerbation

171
Q

which objective finding is common to ALL stages of COPD

A

FEV1/FVC ratio <0.70

172
Q

what is the role of chest xray in someone with COPD exacerbation?

A

should be obtained in someone with COPD exacerbation only with concern for concomitant pneumonia

e.g., fever and/or low SaO2

173
Q

are cough suppressants a good idea in lower airway diseases like COPD?

A

NO! you do not want to suppress a cough as this is the body’s physiologic way of opening blocked airways

we can help control the cough by ridding of the underlying inflammation with oral steroids as needed

174
Q

what is the therapeutic goal of oxygen therapy in COPD

A

maintain SaO2 >90%

175
Q

indication for use of oxygen therapy in COPD is needing to use >_____ hrs/day

A

> 15 hrs/day

176
Q

indications for use of home oxygen in COPD

A
  • PaO2 <55mmHg OR an SaO2 <88% with or without hypercapnia
  • PaO2 between 55-60 mmHg OR SaO2 = 88% if there is evidence of pulmonary hypertension or peripheral edema suggesting cardiac failure, or polycythemia on labs (Hct >55%)
177
Q

if you truly want to help someone with an anti-cough agent in COPD exacerbation, what should you consider?

A

guiafenesin (Mucinex, a mucolytic)

however, the BEST mucolytic is hydration

Mucinex will not help in someone who is dry, they need to continue drinking a lot of water

do not use anti-tussives!

178
Q

what is the benefit of getting a chest xray even if you feel positive someone has pneumonia?

A

baseline imaging to assess for improvement if not getting better in first days of antibiotic therapy

it is not standard of care to treat without an xray even if it feels certain

179
Q

symptoms of asthma

A
  • wheezing
  • breathlessness/SOB
  • chest tightness
  • cough (dry, irritating)
180
Q

before you are positive the diagnosis is asthma, you can bill for it under ….

A

reactive airway diesase

181
Q

cells that secrete histamine in allergic/atopic reactions

A

mast cells

182
Q

triad of asthma

A
  • airflow obstruction
  • bronchiole hyperresponsiveness (s/t histamine)
  • inflammation (s/t immune cells in the area)
183
Q

what causes bronchoconstriction in asthma attack

A

histamine release (histamine stimulates smooth muscle cells to cause bronchoconstriction)

184
Q

(2) conditions commonly comorbid with asthma

A
  • seasonal allergies (allergic rhinitis)

- eczema (atopic dermatitis)

185
Q

some folks with asthma have their asthma triggered by this common OTC medication

A

NSAIDs or aspirin

3-5% of folks with asthma have ASA sensitivity, good to check

186
Q

what does FEV1 measure

A

how much air can be exhaled by rapid and forceful complete exhalation in 1 second

187
Q

in asthma diagnosis, expect ____% improvement in FEV1 after administration of a SABA

A

12-15%

188
Q

(2) possible tests for asthma if spirometry results are not definitive

A

refer to specialist for bronchoprovocation tests either methacholine or exhaled nitric oxide test

189
Q

diagnostic evaluation of suspected asthma

A

spirometry

LABS: CBC with diff (look for eosinophilia, r/o anemia), ESR (inflammation), IgE serum testing, alpha 1 antitrypsin deficiency

REFERRAL: Consider allergy skin testing to identify triggers

IMAGING: Can consider chest xray to r/o pneumonia, COPD, atelectasis; should be normal in asthma

190
Q

(2) reasons to consider referring someone with asthma to a specialist/pulmonlogist

A
  1. had a life-threatening exacerbation (e.g., admitted to hospital, ICU, intubation)
  2. unresponsive to therapies
191
Q

diagnostic criteria for chronic bronchitis

A
  • recurrent cough with or without sputum production
  • present on most days for a minimum of 3 months per year
  • minimum of 2 successive years
192
Q

only (2) ways to decrease mortality in COPD

A
  • smoking cessation
  • oxygen therapy

everything else is symptom control

193
Q

what is emphysema?

A

abnormal permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of their walls

(aka… alveolar destruction)

this takes place d/t WBC reaction to injury (e.g., environmental pollution, smoking)

results in progressive hyperinflation of the lungs

194
Q

how is emphysema diagnosed

A

xray

195
Q

% of emphysema cases caused by smoking tobacco

A

80% (20% environmental)

196
Q

possible manifestations of COPD on physical exam

A

EARLY SIGNS

  • hyperinflation of the lungs
  • wheezes/crackles
  • prolonged expiratory time
  • decreased breath sounds (diminished air movement d/t air trapping)

LATE SIGNS

  • tripod positioning
  • use of accessory muscles
  • pursed lip breathing
  • clubbing and cyanosis
  • decreased O2 sats with ambulation
  • heart failure
  • barrel chest = increased AP diameter
  • distant or muffled heart sounds
  • weight loss
197
Q

Diagnostic evaluation of COPD

A

** spirometry**

LABS: CBC with diff (look for elevated RBCs, elevated WBCs with eosinophilia), IgE/IgG, alpha-1 antitrypsin deficiency

IMAGING: chest xray to r/o other causes & demonstrate disease severity

198
Q

why might you see elevated RBCs (polycythemia) in someone who smokes?

A

Body’s response to all the carbon monoxide taking the place of where oxygen should be on your RBCs, body feels hypoxic so produces more RBCs. Will see erythrocytosis.

199
Q

S/s of an acute COPD exacerbation

A
  • SOB at rest
  • unable to lie flat d/t dyspnea
  • agitated, “feeling of impending doom”
  • RR >30
  • use of accessory muscles to breath
  • inspiratory/expiratory wheezing
  • tachycardia
200
Q

type of pneumonia specific to folks with alcohol abuse disorder

A

klebsiella pneumonia

201
Q

s/s TB

A
  • weight loss
  • night sweats
  • fever
  • cough
  • hemoptysis
202
Q

(2) most common causes of upper lobe consolidation on chest xray

A
  • TB

- aspiration pnuemonia

AGPCNP Board Prep (21 decks)

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