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NP 801 NP Theory 2 > Chronic Respiratory > Flashcards

Chronic Respiratory Flashcards

1
Q

Definition, r/t, pathology

COPD

A
  • Common, preventable + tx disease
  • Pts have persistent respiratory symptoms + airflow limitation d/t airway +/or alveolar abnormalities from exposure to noxious particles or gases
  • R/t chronic airway irritation, mucus production, pulmonary scarring
  • Cigarette smoke/ genetic disposition → airway inflamm → INC mucus prod → ↓ mucus function
  • Leads to airway obstruction + dyspnea
  • ↑ predisposition to respiratory infxns
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2
Q

Can you have asthma, emphysema, and chronic bronchitis?

A

YES
asthma + chronic bronchitis
Emphysema + chronic bronchitis

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3
Q

Common COPD s/s

A
  • SOB
  • Chronic cough
    • May be intermittent and may be unrpoductive
    • Recurrent wheeze
  • Chronic Sputum production
    • Any pattern of chronic sputum may indicate COPD
  • Dyspnea
    • Progressive over time
    • Progressively worse with exercise
    • Persistent
  • Recurrent lower respiratory tract infections
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4
Q

Chronic bronchitis s/s

A
  • ↑ swelling + mucus (phlegm or sputum) prod in airways
  • Mucusy/Smokers cough
  • Results in chronic productive cough for 3 mos in each of 2 successive years
  • Wet, chronic cough
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5
Q

Emphysema s/s

A
  • Destruction/ damage to lung parenchyma/alveol to air trapping in lungs
  • Reduces SA for gas exchange
  • Dry cough
  • SOB
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6
Q

Intra + extrathoracic

COPD differentials

A

Intrathoracic
* Asthma (if condition improves with fast acting bronchodilator)
* CHF
* Malignancy (smokers)
* TB
* Post-infectious process
* Interstitial lung disease
Extrathoracic
* Chronic rhinitis – feel like I have to clear my throat all time (chronic cough)
* GERD (chronic cough)
* Post-nasal drip syndromes
* Medications (ACEi)

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7
Q

COPD diagnostics
GOLD standard
categories FEV1

A
  • Spirometry required to establish dx
  • FEV1:FVC ratio must be < 0.7 in post bronchodilator test (in asthma, breathing improves after this test)
  • Classification of severity determined by FEV1 (for tx)

Look at severity + s/s assessment

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8
Q

COPD diagnostics excluding spirometry

A
  • O2 saturation (esp in chronic)
  • CXR (not dx but helpful to r/o diffs)
  • Chest CT – only if dx is in doubt
  • CBC, BMP, ABG, EKG
    • ↑ Hgb + HCT to compensate (extra RBCs to tissues) polycythemia (end stage)
  • Alpha-1 antitrypsin deficiency screening: 1x screening 4 all pts
    • Screen pts who develop COPD < 45 y.o. or strong FMHx of COPD
    • Can see in elev, liver disease
  • Usually dx ppl w/COPD >50yo
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9
Q

Stable COPD pharm txs

A
  • Bronchodilators: mainstay tx
  • Short-acting
    + SABA: albuterol (PRN)
    + SAMA: Ipratropum (PRN/4x a day)
    + Both effective in improving lung fx
  • Long-acting (can be used independently)
    + LABA: Salmeterol/form (BID)
    + LAMA: Triotropium (QD)
    + Both sx control, LAMAs > on reducing exacerbations
    + think about pt preference, cost, SEs
  • Theophylline
    + Rarely used d/t narrow therapeutic index + SEs

Antimuscarinics: think anticholinergic SEs

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10
Q

COPD pharm txs 3rd line/other tx options

A

INH corticosteroids 3rd line tx in COPD
* Not monotherapy (INC PNA risk)
- Use these in pts w/serum eosinophils elevated
- Hx of hospitalizations for COPD
- >/= 2 mod exacerbations of COPD/yr
- Hx of, or concomitant asthma
* Triple therapy (OCS + LAMA + LABA)
- Dose: 1 puff daily
- HIGH COST for each, this is cost alternative
Additional options
* Phosphodiesterase inhibitos
- Roflumilast – once daily PO therapy for bronchitis associated COPD
- Reduce inflammation
- Not recommded as monotherapy
* PO glucocorticoids
- Used to tx acute exacerbations
- Long term O2 therapy
ONLY therapy for COPD shown to ↓ mortality
+ Goal: correct hypoxemia (PaO2 > 60 or SpO2 > 90)
+ Increased survival, prevent progression of pulm HTN, improves alertness, motor speed, + hand grip

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11
Q

COPD nonpharm tx #1?

A

smoking cessation

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12
Q

COPD nonpharm txs (other)

A
  • Lifestyle modifications, ID + avoiding RFs, advanced directives
  • Education
    • Disease course, prognosis
    • Preventative measures avoiding URI, flu, + PNA vaccines
    • Importance of physical activity
    • Breathing exercises
    • Med use: when + how
    • When to seek tx
      (↑ color/amt sputum; ↓ fx ability; ↑ SOB; fever)
    • Nutrition
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13
Q

COPD when to refer

A
  • Stage IV
  • Disease onset < 40yrs
  • Frequent exacerbations (2+) despite optimal tx
  • Need for O2
  • Onset of co-morbid illness
  • Possible indication for surgery
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14
Q

COPD risk factors

A
  • Host factors
  • Tobacco
  • Occupation
  • Indoor/outdoor pollution
  • AAT deficiency raises your risk for lung + other diseases (dx at early age)
  • FMHx of COPD: low birthweight, childhood respiratory infxns etc.
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15
Q

Overall COPD Maangement algorithm

A
  • Confirm DX w/ spirometry
  • Evaluate severity based on GOLD category (FEV1)
  • Evaluate sx + risk for exacerbation
    • Various tools available
  • Determine GOLD group (A, B, C, D)
  • Make pharm tx
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16
Q

Goals of COPD therapy

A
  • Inhaler teaching
  • Intervention shown t improve QOL
  • Components
    • Upper + lower ext conditioning
    • Exercise/endurance training
    • Breathing retraining + adaptive mechanisms
    • Nutrition
    • Med adherence
    • Psychological support
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17
Q

Acute COPD exacerbations
Triggers

A
  • Respiraotry infxns trigger ~70% of exacerbations
    • viral or bacterial
  • Environmental pollution
    • allergies
  • PE (pulm effusion)
  • Unknown etiology
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18
Q

Acute COPD clinical s/s

A
  • Acute onset or worsening of respiratory sx (over several hrs – days)
    • Dyspnea
    • Cough
    • Sputum prod
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19
Q

Acute COPD objective findings

A
  • Wheezing
  • Tachypnea
    SEVERE
  • Difficulty speaking d/t respiratory effort
  • Use of acc. Mm
  • Paradoxical chest wall/abd movements
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20
Q

When to consider alternative dx from acute COPD exacerbation?

A
  • Constitution sx (fever, malaise)
  • Chest pain/ pressure
  • Edema
  • Crackles on exam
  • Risk for embolic disease/ coronary event
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21
Q

Acute COPD exacerbation differentials

A
  • PNA
  • PTX (COPD RF)
  • CHF (Pleural effusion)
  • Cardiac arrhythmia
  • PE (pulm embolism)
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22
Q

Acute COPD exacerbations diagnostics

A
  • Mild: Clinical assessment + SpO2
  • Mod-severe
    • Consider ED referral depending on setting + severity
    • CXR
    • CBC/BMP
      ABG (if in ED w/resp failure)
  • Labs to r/o other dxs
    • EKG, BNP, troponin, D-dimer, influenza/ covid/infxn etiology
23
Q

Acute COPD pharm txs

A
  • Bronchodilator therapy – ↑ dose/ frequency of existing therapy
    • Add anticholinergic if not already used
    • Nebulizer can be helpful
    • Albuterol, atrovent
  • Steroids – consider in mod/severe exacerbation – breathlessness interfering w/daily activities
    • PO prednisone 40mg x 5days
  • ABXs – recommended in outpts w/mod cough or severe exacerbation of COPD who have ↑ cough + sputum purulence (GOLD guidelines)
  • Target likely pathogens (H. influenzae, M. catarrhalis, + S. PNA)
24
Q

When to consider hospitalization for acute COPD

A
  • Marked ↑ in tensity of s/s such as sudden resting dyspnea
  • Severe underlying COPD
  • New physical signs (cyanosis, peripheral edema)
  • Failure to respond to initial management
  • Significant co-morbidities
  • Hx of frequent exacerbations/ hospitalizations
  • DX uncertainty
  • Frailty
  • Insufficient home support
25
Q

Acute COPD RFs

A
  • Adv age
  • Prod cough
  • Duration of COPD
  • Hx of abx therapy
  • COPD related hospitalization w/in last yr
  • Serum eosinophil count > 300
  • Theophylline therapy
  • Chronic mucus hypersecretion
  • Co-morbidities (ischemic heart disease, chronic heart failure, DM)
  • Severity of COPD + hx prior exacerbations
26
Q

Post-hospitalization F/U post-acute COPD

A
  • Ability to cope in usual environment
  • Measure FEV1 (check after exacerbation for baseline)
  • Understanding of tx regimen
  • INH technique
  • Need for LTOT for pts w/severe COPD
  • Consider Pulm rehab
  • Think about palliative care in severe disease
27
Q

Assess Readiness to change (5 As)

A
  • Ask – ID all tobacco users
  • Advise patient to quit, using clear, strong, and personalized messages
  • Assess patient’s willingness to make a quit attempt in next 30 days
  • Assist in developing quit plan (date to quit, meds, behavioral changes)
  • Arrange a F/U contact
    • F/U on or after quit date
28
Q

Meds for smoking cessation

A
  • Bupropion (welbutrin/Zyban)
    • Contraind. for ppl who had seizure in their life
    • Also antidepressant
    • Appetite suppressant
    • ↑ anxiety (not for smokers triggered by anxiety)
  • Varenicline (Chantix)
    • Better for quitting smoking
    • Nausea common SE, vivid dreams, ↑ SI/depression
  • Nicotine replacement therapy
    • Gum, patch, lozenge, nasal spray
  • Electronic nicotine delivery services – vaping (not the best option)
  • Supportive resources
    • Quitline, apps, etcs
29
Q

Smoking cessation quit plan

A
  • Set quit date (can be significant holiday/date)
  • Tell family + friends to gain support
    • Around ppl who smoke (influence)
    • Pt dependent
  • Remove all cigarettes + related objects out of house
  • Review past quit attempts + anticipate challenges
  • Anticipate triggers
  • Provide support
  • Recommend pharm therapy
30
Q

Common smoking habit triggers

A
  • Can be a/w a social event or routine thing
  • Coffee in AM
  • Get together with friends
  • Stress induced
  • Instead of using cigarette/ put something else in hand (healthy food)
31
Q

Popcorn lung

A
  • Bronchiolitis obliterans
  • Damage + inflamm of bronchioles → scarring
  • Vapes contain diacetyl (same ingredient in microwave popcorn but INH)
32
Q

Why are vapes not a good thing?
What if person is hesitant to quit smoking d/t weight?

A
  • Hesitant to quit b/c of weight gain
    • Snack on something while quitting
      ENDS – vaps
  • Thought to be safer d/t lack of tobacco + tar
    • Still contains volatile substances
    • Nicotine levels are variable (could be more)
  • Often used as method to quit or cut down on cigarette smoking
    • Not approved, Limited evidence, Harm reduction, Dual use issue
  • Youth use e-cigs more
    • Screen this separately
    • May not consider vaping smoking – be specific
33
Q

Etiology, Transmission, active/dormancy

Tuberculosis

A
  • Caused by mycobacterium TB
  • Transmissible by airborne droplets from pts w/active respiratory disease
  • Disease can be active any time
34
Q

Latent TB

A

Latent
* Initially controlled by host defenses + remains latent
* Pt not infectious when disease is latent
* Has potential to become active infxn at any time
* Immune system able to keep TB at bay

35
Q

Active TB
Clinical findings

A
  • 80% of active TB infxns initially latent
    • Cough
    • Hemoptysis
    • Weight loss
    • Fever
    • Night sweats
      (+) Tb + has these = active
36
Q

Would you give someone w/ previously (+) TB a TST test?
Why?

A

NO
Pt will get a reaction

37
Q

What? Purpose to detect positive

Tuberculin Skin Test (TST)

A

Test has greater risk of exposure, ↑ positive predictive value (likelihood of true +)
- (+) IF ≥ 5mm
- PPD (Purified Protein Derivative)
- Mantoux technique (Intradermal INJ in inner forearm)
- Causes a hypersens rxn in persons previously exposed to M. TB
- Must be read 48-72hrs after placement
+ Measure indurated area

38
Q

If TST (-) → repeat testing indications

A
  • If (-), repeat testing is indicated if:
    + Exposure to active Tb within the last 8 weeks
    + Continued occupational exposure-annual testing
    + Two Step testing/ “booster phenomenon”
    (initial test reignites response to TB → another test 6wks later (+) b/c exposed long ago)
39
Q

TB screening: IGRA

A

Confirm (+) TST
* Interferon gamma release assay (IGRA)
- Indicates a cellular immune response
- Blood test – 2 different assays available
+ QuantiFERON + T. SPOT
- Can be used in place of TST
* Conversion generally occurs w/in 4-7wks of exposure
* Lower false (+) rate than TST

  • > 95% specific (low false +); sensitivity (high false negative) diminished by HIV infxn
40
Q

Persons w/BCG vaccine
Which test to detect that they have it?
Time estimate for person to be (+) w/this

A
  • Those vaccinated in last 10yrs will most likely have a (+) TST after 10yrs, rxn typically < 10mm
  • Use of IGRA testing can help determine a true positive in those w/hx of BCG vaccination
41
Q

Indication for BCG vaccine

A
  • In countries where prevalence of TB is moderate to high, neonatal vaccination is recommended
  • With low prevalence, not recommended
42
Q

Preferred treatment for TB

A

Rifampin
* Better adherence + less hepatotoxic than INH (4 mos tx)

43
Q

INH tx TB

A
  • INH can cause hepatitis + peripheral neuropathy
    • Check LFTS regularly
    • Consider pyridoxine supplementation to help prevent neuropathy
44
Q

Active TB pharm txs

A
  • 4 regimens available + complex
    • DOT (directly observed therapy)
      • Someone observes them taking meds every time
      • Do this to be compliant
      • Long duration
      • Drug resistant TB
      • Need to finish full tx
  • Tx done by ID or TB clinic
  • Pts should minimize contacts + use surgical mask recommended until non-infections
45
Q

Multi-drug resistant TB pharm tx
if TX fails?

A
  • DOT recommended/required
  • Susceptibility testing should guide tx
  • Surgery considered for tx failure
46
Q

Tx goal for TB

A

catch ppl w/latent TB + tx early on  preventing spread of TB in community

47
Q

Who should be screened for TB?

A
  • Persons at ↑ risk of new infxn – all should be screened
    • Close/casual contacts of persons w/untreated active tB
    • Illicit drug users
    • Residents or employees of homeless shelter/correctional facility
    • Healthcare workers in some situations
48
Q

Latent TB infection screening (who?)
Aka risk for disease progression
High, moderate, low risk

A
  • High risk (test all)
    • HIV/immunocompromised
    • head/neck cancer
    • lymphoma
    • leukemia
    • renal failure on dialysis
    • evidence of healed TB on CXR
  • Moderate risk (test patients in groups with increased prevalence)*
    • DM
    • chronic systemic glucocorticoids
  • Slightly increased risk (test patients in groups with increased prevalence):
    • underweight
    • smoker
    • CXR with solitary granuloma
  • Groups with increased prevalence
    • homeless
    • IVDU
    • contact with active TB
    • those born in countries with increased TB incidence (>100/100,000)
      * Screening of low-risk persons is discouraged due to risk of false positive results
      * Routine screening of all HCP is no longer recommended
49
Q

Interpretation of TST

A
50
Q

TB test (+), now what

A
  • +/- order confirmatory testing
  • Must rule out active TB prior to initiating treatment
  • Clinical history and physical exam for any s/s of TB
  • Order a CXR
    • If any abnormalities patient will require sputum acid fast bacillus smears
      * Tx is different in active vs latent disease
  • Refer to ID for management
  • Consider HIV testing
51
Q

TST vs. IGRA
preference?

A
  • If low-intermediate risk of progression to active disease: IGRA preferred (fewer false positives)
  • If** high risk **of progression: either is acceptable
  • IGRA especially useful if pt unlikely to return for reading of TST and for those with a hx of BCG vaccine
  • If IGRA unavailable or too costly then TST is acceptable
52
Q

Refined ABCD assessment tool stable COPD

A
53
Q

USPSTF lung cancer screening recommendation

A
  • Annual screening for lung cancer with **low-dose CT **in adults aged 50 to 80 years who have a 20 PPY smoking Hx + currently smoke or have quit w/in past 15 yrs.
  • Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery
54
Q

Harms of lung cancer screening

A
  • Risk for false(+) results +
  • Risk forincidental findings → cascade of testing + tx → more harms, including anxiety of living w/lesion that may be cancer
  • Overdx of cancer + risk of radiation

NP 801 NP Theory 2 (7 decks)

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