Ch10: Lower Respiratory Flashcards
pneumonia is infection of the….
lungs and bronchi
everyone with pneumonia also has….
bronchitis
but not everyone with bronchitis has pneumonia
most-likely causative pathogens in pneumonia depends on whether they have underlying conditions, including: (6)
- COPD
- diabetes
- heart failure
- liver disease
- CKD
- asplenia
- alcoholism
- malignancy
Most likely causative pathogens in someone with CAP without significant comorbidities (6)
BACTERIAL
- Strep pneumoniae (most common)
- M. pneumoniae (atypical)
- C. pneumoniae (atypical)
- Staph aureus
VIRAL
- influenza A or B
- respiratory synctial virus (RSV)
Most likely causative pathogens in someone with CAP and with significant comorbidities (6)
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)
who is likely to have M. pneumoniae or C. pneumoniae pneumonia
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
typical presentation of CAP caused by M. pneumoniae or C. pneumoniae
atypical
“walking pneumonia”
(most commonly from M. pneumoniae)
usually dry cough with less severe signs or symptoms
usually bacterial
how is legionella pneumonia transmitted
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
major risk factors for severe legionella pneumonia disease
- older age
- male
- smoking
- diabetes
with these risk factors, may get very very ill and need ICU
who gets Staph Aureus pneumonia?
largely limited to post-influenza pneumonia
folks who were recently sick with flu
only see this pneumonia occurring after an influenza infection
staph aureus pneumonia
diagnostic evaluation for pneumonia
- CBC with diff
- BUN/Cre
- additional testing based on patient presentation and comorbidity
- chest xray
why do a CBC with diff in someone with pneumonia?
- see if WBCs are responding to infection
- those with anemia do worse than those without
why get BUN/Cre in someone with pneumonia?
- hydration status (BUN)
- those with kidney disease do worse than those without
recommended length of antibiotics for CAP
- 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
Empiric antibiotic options for CAP WITHOUT comorbidities (3)
- doxycycline (best choice per Fitzgerald)
- macrolide (azithromycin, clarithromycin, erythromycin) if local resistance rates are low
- amoxicillin (high dose)
how to determine if azithromycin or other macrolide (e.g., clarithromycin, erythromycin) is a good prescription for someone with CAP?
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
best choice antibiotic for CAP without comorbidities
doxycycline (per Fitzgerald)
Empiric antibiotic options for CAP WITH comorbidities (3)
- respiratory fluoroquinolone (levofloxacin, moxifloxacin)
- doxycycline OR macrolide (azithromycin, clarithromycin) PLUS a beta-lactam such as amoxicillin-clavulanate, cefpodoxime, or cefuroxime
best choice antibiotic for CAP with comorbidities
respiratory fluoroquinolone
levofloxacin, moxifloxacin, gemifloxicin
what are the (3) respiratory fluoroquinolones
levofloxacin, moxifloxacin, gemifloxicin
significance of tachypnea in CAP
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
significance of crackles or rales on respiratory exam in CAP
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
evidence of consolidation in CAP
- 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
pneumonia with consolidation findings is most commonly associated with what etiology…
bacterial pneumonia
most likely to encounter pleuritic friction rub in pneumonia when there is….
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
pleuritic chest pain
localized area of sharp pain worse with deep breath, movement, or cough
may have audible pleural friction rub from movement of inflamed pleural layers
most likely pneumonia types to give you pleural friction rub (2)
- strep pneumoniae
- legionella
Score to help you determine whether CAP can be treated outpatient vs inpatient
CURB 65
CURB 65 scoring
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
CURB65 score where ok to treat CAP at home
0 or 1
2 may consider it with really close monitoring
CURB65 score where need to hospitalize for CAP
3 or higher
always look out for ______ in elderly adults with pneumonia
heart failure
up to 20% of older adults with pneumonia will develop CHF
tactile fremitus [increases vs. decreases] over areas of consolidation
increases
pt follow-up after pneumonia treatment - expected findings?
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
what is the most common pathogen implicated in acute bronchitis
respiratory viruses!!!!!
VIRAL
% of acute bronchitis infections that will resolve without treatment within _____ weeks
> 75% resolve within 2 weeks
how do you diagnose acute bronchitis
clinical!
what is acute bronchitis
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)
acute bronchitis is notably different than pneumonia because presents WITHOUT these (2) symptoms
tachypnea
fever
if present, think pneumonia rather than acute bronchitis
% of acute bronchitis that is caused by VIRUS
> 95%
treatment for acute bronchitis
- > 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)
regimen for a short-course steroid burst
prednisone 40mg PO QD x3-5 days
(3) medication classes helpful for acute bronchitis
- 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
<5% of acute bronchitis is caused by bacteria. which are the (3) most common causative bacterial agents
- M. pneumoniae
- C. pneumoniae
- B. pertussis
in the rare case that you suspect an acute bronchitis is bacterial in origin, what antibiotics would be options? (2)
- oral doxycycline
- oral macrolide (azithromycin, clarithromycin, erythromycin)
pneumonia-like symptoms in a patient who presents with hemoptysis and chest xray which demonstrates RUL infiltrate. you suspect….
tuberculosis
pneumonia with infiltrates…. where?
bilateral or lower lobes
TB with infiltrates… where?
upper lobe
risk factors for TB infection
- 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
clinical presentation of TB
- congested
- productive cough with white/yellow or blood-streaked sputum
- hemoptysis
- chest pain
- fever
- unexplained weight loss
- anorexia
- night sweats
- fatigue
diagnostic testing for TB
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
a common chronic disorder that is complex and characterized by underlying airway inflammation that leads to variable airflow obstruction and bronchial hyperresponsiveness
asthma
which comes first in asthma: airway inflammation or bronchospasm?
airway inflammation
symptoms of asthma
- 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)
most common reason for an asthma flare
viral URI
in order to diagnose asthma, the airflow obstruction needs to be at least partially….
reversible (demonstrated via spirometry)
diagnosis of asthma is based on an increase in _____ by at least _____ from baseline after using a SABA (e.g., albuterol)
FEV1
>12% improvement
_____ is needed for the diagnosis of asthma, versus _____ is used for monitoring (not diagnosing)
spirometry = diagnosis
peak flow meter = monitoring
medication class: mometasone (Asmanex)
inhaled corticosteroid
medication class: fluticasone (Flovent)
inhaled corticosteroid
medication class: budesonide (Pulmicort)
inhaled corticosteroid
medication class: beclomethasone (Qvar)
inhaled corticosteroid
medication class: ciclesonide (Alvesco)
inhaled corticosteroid
what is the role of inhaled corticosteroids in the management of asthma
prevents the formation of airway inflammation
in order to have this effect, requires consistent, daily use
medication class: budesonide + formoterol (Symbicort)
combined inhaled corticosteroid (ICS) + long acting beta agonist (LABA)
medication class: fluticasone + salmeterol (Advair)
combined inhaled corticosteroid (ICS) + long acting beta agonist (LABA)
medication class: mometasone + formoterol (Dulera)
combined inhaled corticosteroid (ICS) + long acting beta agonist (LABA)
medication class: formoterol
long acting beta agonist (LABA)
medication class: salmeterol
long acting beta agonist (LABA)
role of combined ICS + LABA in the management of asthma
ICS = prevents the formation of airway inflammation
LABA = prevents bronchoconstriction
again, this requires consistent, daily use for optimal effect
medication class: montelukast (Singulair)
leukotriene modifier
role of leukotriene modifiers in the management of asthma
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
medication class: tiotropium bromide (Spiriva)
long acting muscarinic antagonist (LAMA)
role of a LAMA in asthma management
LAMAs act as a bronchodilator via the blockage of muscarinic receptors, minimizing the risk of asthma exacerbation
requires consistent, daily use for optimal effect
role of theophylline in asthma management
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
(5) medication classes that are options for use in asthma CONTROLLER therapy
- inhaled corticosteroids (FIRST LINE!)
- long-acting beta2 agonists (LABAs – often combined with ICS)
- leukotriene modifiers
- long-acting muscarinic antagonist (LAMA)
- theophylline
all of the asthma CONTROLLER medications require _____ to be effective
consistent, daily use
rescue medications in asthma are used to relieve what?
acute bronchospasm
all asthma rescue inhalers are this medication class
short-acting beta2 agonist (SABA)
SABA options for asthma rescue therapy
- albuterol (Proventil)
- pirbuterol (Maxair)
- levalbuterol (Xopenex)
use of asthma rescue inhaler >____days/week suggests a need for better control of airway inflammation (except pre-treating before exercise)
> 2days/week
medication recommendation for preventing exercise-induced bronchospasm
use SABA (rescue inhaler) 15-30 minutes before activity
medication class: prednisone
systemic corticosteroid
medication class: prednisolone
systemic corticosteroid
medication class: methylprednisone
systemic corticosteroid
medication class: dexamethasone
systemic corticosteroid
generally, adults need ____ days of prednisone to recover from asthma flare
5-7 days
(2) reasons to taper a steroid
- 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
almost all asthma flares are triggered by…..
viral URI
specific prescription for systemic corticosteroids for asthma flare in adult
prednisone 40-60mg PO QD x3-10 days (typically 5-7)
when to use systemic corticosteroids in asthma management
all asthma flares
majority of adults with asthma seen in primary care will have this diagnosis of severity
moderate persistent
normal FEV1/FVC ratio for 20-39yo
80%
normal FEV1/FVC ratio for 40-59yo
75%
normal FEV1/FVC ratio for 60-80yo
70%
normal chest percussion should be
resonant
with air trapping (COPD and asthma exacerbation), chest percussion will be….
hyperresonant
objective physical exam findings to expect in an asthma exacerbation or COPD (5)
- 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”)
dropping SaO2 is an [early vs. late] sign in asthma flare
LATE
once they cannot bring air in
dropping FEV1 or peak flow is an [early vs. late] sign in asthma flare
EARLY
first, they cannot get air out
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
intermittent asthma
STEPWISE step for someone with intermittent asthma severity
step 1
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
mild persistent
STEPWISE step for someone with mild persistent asthma severity
step 2
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
moderate persistent
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
severe persistent
STEPWISE step for someone with moderate persistent asthma severity
step 3 + short course of oral systemic corticosteroids to relieve the inflammation already present
STEPWISE step for someone with moderate persistent asthma severity
step 4 + short course of oral systemic corticosteroids to relieve the inflammation already present
STEPWISE Approach for Managing Asthma: STEP 1
SABA PRN
STEPWISE Approach for Managing Asthma: STEP 2
SABA PRN
+
Inhaled Corticosteroids (ICS), low dose
STEPWISE Approach for Managing Asthma: STEP 3
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
STEPWISE Approach for Managing Asthma: STEP 4
SABA PRN
+
Inhaled Corticosteroids (ICS), medium dose
+
Long-Acting Beta2 Agonist (LABA), medium dose
STEPWISE Approach for Managing Asthma: STEP 5
SABA PRN \+ Inhaled Corticosteroids (ICS), high dose \+ Long-Acting Beta2 Agonist (LABA), high dose
STEPWISE Approach for Managing Asthma: STEP 6
SABA PRN \+ Inhaled Corticosteroids (ICS), high dose \+ Long-Acting Beta2 Agonist (LABA), high dose \+ Oral corticosteroids
general rule for when to step UP to next Step in STEPWISE Approach for Managing Asthma
use of SABA rescue >2x per week (excluding prevention of EIB)
consider adding this medication for folks with asthma who have allergies in Steps 2-4
subcutaneous allergen immunotherapy with omalizumab
Characterize well-controlled (therapeutic goal) for asthma symptoms
- 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
general rule for when to step DOWN to below Step in STEPWISE Approach for Managing Asthma
consider stepping down if they have been well-controlled (at therapeutic goal) for at least 3 months
general rule for when to have patient RTC for FUP with well-controlled asthma
Q1-6 months to maintain control and monitoring
general rule for when to have patient RTC for FUP with not well-controlled asthma
- consider short course of oral steroids
- step up on stepwise approach
- RTC for re-evaluation in 2-6 weeks depending on severity
(3) validated questionnaires for monitoring control of asthma symptoms
ACT (asthma control test)
ACQ (asthma control questionnaire)
ATAQ (asthma therapy assessment questionnaire)
guidelines name for managing COPD
Gold Guidelines
(4) preventive measures always recommended with COPD
- smoking cessation
- physical activity
- pulmonary rehab
- flu and pneumonia vaccines
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
COPD
COPD symptoms
- chronic cough
- chronic sputum production
- activity intolerance
- progressive symptoms over time
most common COPD risk factors
- TOBACCO (#1)
- occupational exposure to irritants
- air pollution
- family h/o COPD
- advancing age
how do you diagnose COPD on spirometry
FEV1/FVC ratio <0.70 (<70%) post-bronchodilator which confirms persistent airflow limitation of COPD (as opposed to asthma)
(2) standardized questionnaires for determining severity of COPD
- CAT (COPD Assessment Test)
- CCQ (clinical COPD questionnaire)
who should receive screening for alpha-1 antitrypsin deficiency (AATD)
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)
% of patients with COPD who have alpha-1 antitrypsin deficiency (AATD)
3%
Spirometry results for GOLD 1 stage COPD severity
Mild
FEV1/FVC ratio <0.70
FEV1 >80% predicted
Spirometry results for GOLD2 stage COPD severity
Moderate
FEV1/FVC ratio <0.70
FEV1 <80% but >50% predicted
Spirometry results for GOLD3 stage COPD severity
Severe
FEV1/FVC ratio <0.70
FEV1 <50% but >30% predicted
Spirometry results for GOLD4 stage COPD severity
Very severe
FEV1/FVC ratio <0.70
FEV1 <30% predicted
FEV1/FVC ratio required for diagnosis of COPD
<0.70
not reversible with use of bronchodilator
PRN medication options in COPD (2)
SABA inhaler (e.g., albuterol)
or
short-acting muscarinic antagonist (SAMA) e.g., ipatropium
Controller medication options in COPD (5)
- 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
role of SABAs or SAMAs in COPD
relief of a bronchospasm
role of LABA in COPD
protracted duration bronchodilation
role of LAMA in COPD
- protracted duration bronchodilation
- minimizes risk of COPD
role of ICS in COPD
- antiinflammatory
- minimizes risk of COPD exacerbation
use limited by modest increase in risk of pneumonia
Use of inhaled corticosteroids as controller therapy for COPD comes with increased risk of which other respiratory condition
pnuemonia
role of oral theophylline in COPD
bronchodilator
not commonly used
role of oral PDE-4 inhibitor in COPD
minimizes the risk of COPD exacerbation
medication class: roflumilast
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
GOLD 1st line recommendations for pharmacologic therapy: GOLD 1 / MILD
low exacerbation risk, less symptoms
SAMA or SABA PRN
medication class: ipatropium bromide
short-acting muscarinic antagonist (SAMA)
GOLD 1st line recommendations for pharmacologic therapy: GOLD 2 / MODERATE
low exacerbation risk/ more symptoms
SAMA or SABA PRN
+
scheduled LAMA or LABA for controller therapy
GOLD 1st line recommendations for pharmacologic therapy: GOLD 3 / SEVERE
high exacerbation risk/less symptoms
SABA or SAMA PRN
+
scheduled LAMA for controller therapy
GOLD 1st line recommendations for pharmacologic therapy: GOLD 4 / VERY SEVERE
high exacerbation risk/more symptoms
SABA or SAMA PRN
+
scheduled LAMA/LABA combo
OR
scheduled ICS/LABA combo
OR
scheduled ICS/LABA/LAMA combo
Stepping up of COPD medications, generally (4)
- SABA or SAMA PRN
- Add LAMA or LABA scheduled
- Definitely LAMA on schedule
- Add ICS to LABA or LAMA, or can do triple therapy (LABA/LAMA/ICS)
Which tends to be more preferable for COPD controller therapy, a LABA or a LAMA?
LAMA, as this has dual action in providing protracted bronchodilation AND reduces risk for COPD exacerbation
your pt with COPD is having persistent breathlessness and DOE. They are currently on LABA monotherapy. What is your next step?
Add a second bronchodilator – in this case, a LAMA
your pt with COPD is having persistent breathlessness and DOE. They are currently on LABA/ICS combo. What is your next step?
Add LAMA triple therapy
your pt with COPD just had another COPD exacerbation resulting in ER visit. They are currently on LABA monotherapy. What is your next step?
LABA/LAMA combination
or,
LABA/ICS combination
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?
Add LAMA for triple therapy
or, switch to LABA/LAMA
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?
- consider add roflumilast (oral PDE-4 inhibitor)
- consider add a macrolide antibiotic
majority (>60%) of COPD exacerbations are caused by (3)
> 60%
- tobacco use
- air pollution
- viral respiratory illness
less commonly, triggered by bacterial pathogens
how would you define a COPD exacerbation
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
pharmacologic management of a COPD exacerbation (4)
- 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
a minority (<40%) of COPD exacerbations are caused by a bacterial infection. what are the (3) most common causative pathogens when this occurs?
- 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)
almost ALWAYS in COPD exacerbation you are going to prescribe a short course of _______, and rarely will you need ______
always systemic steroids (prednisone x5-7 days)
rarely antibiotics
which antibiotic should you avoid use when a patient is on an ACE or ARB due to hyperkalemia risk
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)
which antibiotics should you avoid in individuals with higher CVD risk d/t risk for QT prolongation
macrolides
e.g., azithromycin, clarithromycin,
erythromycin
which antibiotics are associated with a risk of tendon rupture
fluoroquinolones
e.g., moxifloxacin, levofloxacin
fluoroquinolones risk for tendon rupture is increased when a patient is also taking what other class of medications
systemic corticosteroids
which antibiotics have a <1% cross-risk in penicillin allergy
cephalosporins
e.g., cefpodoxime
in mild-moderate COPD exacerbation, antimicrobial therapy is usually not indicated but if prescribed, would choose one of the following (4)
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)
in severe COPD exacerbation, consider prescribing one of the following oral antibiotics (3)
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
which objective finding is common to ALL stages of COPD
FEV1/FVC ratio <0.70
what is the role of chest xray in someone with COPD exacerbation?
should be obtained in someone with COPD exacerbation only with concern for concomitant pneumonia
e.g., fever and/or low SaO2
are cough suppressants a good idea in lower airway diseases like COPD?
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
what is the therapeutic goal of oxygen therapy in COPD
maintain SaO2 >90%
indication for use of oxygen therapy in COPD is needing to use >_____ hrs/day
> 15 hrs/day
indications for use of home oxygen in COPD
- 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%)
if you truly want to help someone with an anti-cough agent in COPD exacerbation, what should you consider?
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!
what is the benefit of getting a chest xray even if you feel positive someone has pneumonia?
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
symptoms of asthma
- wheezing
- breathlessness/SOB
- chest tightness
- cough (dry, irritating)
before you are positive the diagnosis is asthma, you can bill for it under ….
reactive airway diesase
cells that secrete histamine in allergic/atopic reactions
mast cells
triad of asthma
- airflow obstruction
- bronchiole hyperresponsiveness (s/t histamine)
- inflammation (s/t immune cells in the area)
what causes bronchoconstriction in asthma attack
histamine release (histamine stimulates smooth muscle cells to cause bronchoconstriction)
(2) conditions commonly comorbid with asthma
- seasonal allergies (allergic rhinitis)
- eczema (atopic dermatitis)
some folks with asthma have their asthma triggered by this common OTC medication
NSAIDs or aspirin
3-5% of folks with asthma have ASA sensitivity, good to check
what does FEV1 measure
how much air can be exhaled by rapid and forceful complete exhalation in 1 second
in asthma diagnosis, expect ____% improvement in FEV1 after administration of a SABA
12-15%
(2) possible tests for asthma if spirometry results are not definitive
refer to specialist for bronchoprovocation tests either methacholine or exhaled nitric oxide test
diagnostic evaluation of suspected asthma
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
(2) reasons to consider referring someone with asthma to a specialist/pulmonlogist
- had a life-threatening exacerbation (e.g., admitted to hospital, ICU, intubation)
- unresponsive to therapies
diagnostic criteria for chronic bronchitis
- recurrent cough with or without sputum production
- present on most days for a minimum of 3 months per year
- minimum of 2 successive years
only (2) ways to decrease mortality in COPD
- smoking cessation
- oxygen therapy
everything else is symptom control
what is emphysema?
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
how is emphysema diagnosed
xray
% of emphysema cases caused by smoking tobacco
80% (20% environmental)
possible manifestations of COPD on physical exam
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
Diagnostic evaluation of COPD
** 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
why might you see elevated RBCs (polycythemia) in someone who smokes?
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.
S/s of an acute COPD exacerbation
- 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
type of pneumonia specific to folks with alcohol abuse disorder
klebsiella pneumonia
s/s TB
- weight loss
- night sweats
- fever
- cough
- hemoptysis
(2) most common causes of upper lobe consolidation on chest xray
- TB
- aspiration pnuemonia
