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Primary care of adults 2 > Cough, PNA, Bronchitis (12 Qs w/COPD and asthma) > Flashcards

Cough, PNA, Bronchitis (12 Qs w/COPD and asthma) Flashcards

1
Q

What is an “acute cough”

A

< 3 weeks

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2
Q

What is a “persistent” or “subacute” cough?

A

3-8 weeks

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3
Q

What is a “chronic” cough?

A

> 8 weeks

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4
Q

Where is the cough center?

A

In the medulla

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5
Q

Leading etiologies of cough for infants

A
  • infection
  • Structural
  • GERD
  • Tracheobronchial malacia
  • Tracheoesophageal malacia
  • Vascular ring
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6
Q

Leading etiologies of cough for Toddlers

A
  • infection
  • Foreign body (FB)
  • Airway irritation Second hand smoke
  • Reactive airways dz - suspect asthma but dx unconfirmed
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7
Q

Leading etiologies of cough for school age

A
  • infection
  • Asthma
  • Allergic rhinitis w/ rhinorrhea
  • Sinusitis
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8
Q

Leading etiologies of cough for adolescents

A
  • Infection
  • Smoking
  • Habit cough
  • Asthma, allergies
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9
Q

Leading etiologies of cough for adults

A
  • Infection
  • Smoking
  • Habit cough
  • Asthma
  • Malignancy
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10
Q

Leading etiologies of cough for older adults

A

-Infection

-Pneumonia

  • Aspiration
  • CHF

-Obstructive lung Dz

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11
Q

1981 study - what is typically the cause of a nonproductive chronic cough?

A
  • Post nasal drip: 41% of the time
  • Asthma: 24%
  • GERD: 21%
  • Chronic Bronchitis: 5%
  • Bronchiectasis: 4% - irreversible. Caused by destruction of muscle & elastic tissue in airway
  • Miscellaneous: 4%
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12
Q

Red flags for cough - what are you worried about?

A
  • Acute distress: ? Foreign Body
  • Severe Asthma
  • Pneumonia
  • Heart Failure -esp L sided. Pulmonary edema – if you hear wheezing, red flag for pulmonary effusion
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13
Q

What Hx do you want to get on a cough?

A
  • Type
  • Duration
  • Patterns : time of year, after meal, etc.
  • Aggravating/alleviation factors
  • Is it getting better or worse? Weather, activity, etc
  • Associated with shortness of breath? Comorbidity – heart problem, etc.
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14
Q

What do you want to know about sputum?

A
  • Color: not as imp as we used to think; blood (TB, pneum); black in coal miner, smoker; off white or purulent from eosinophils
  • Character
  • Amount
  • Odor
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15
Q

What are some important types / classifications of pneumonia?

A
  • Community-acquired pneumonia (CAP) vs. Hospital-acquired (nosocomial) pneumonia (HAP)
    • CAP and healthcare-associated pneumonia (HCAP) – outpatient
    • HAP
  • Morpological class (or by location): Bronchopneumonia vs. lobar pneumonia
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16
Q

Common etiologies of pneumonia

A

Bacteria, viruses, fungi, mycoplasma, chlamydia

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17
Q

What is the difference between broncho and lobar pneumonia?

A

Broncho: scattered

Lobar: localized

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18
Q

Risk factors for CAP

A
  • Smoking
  • Alcoholism
  • Occupational dust exposure
  • Other comobidities (COPD, cystic fibrosis, HIV, viral respiratory tract infection etc)
  • History of childhood pneumonia, Unemployment
  • Demographics: age, single marital status, men,
  • Use of PPI, H2 blockers, corticosteroid

PPI changes gastric pH –> more favorable to bacteria

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19
Q

Pneumonia: what are the typical pathogens?

A

Strep pneumonia, H flu, Staph aureus, Moraxella catarrhalis

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20
Q

Pneumonia: what are the atypical pathogens?

A

Mycoplasma pneumonia, chlamydia pneumonia, Legionella (Can serve as co pathogens in up to 40% of patients -esp if traveling. Water borne.)

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21
Q

Pneumonia: what pathogens are common in the U.S.?

A

Strep pneumoniae, Staph Aureus, Haemophilus influenzae, Pseudomonas aeruginosa

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22
Q

Typical vs atypical CAP presentation

A

Historically, typical = more typical presentation, respiratory symptoms.

Atypical – maybe fever, but no resp Sx. Distinction not so meaningful anymore. Almost 20-60% is gram+, so we often treat empirically.

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23
Q

If the pt is previously healthy, what pathogen do you suspect in CAP?

A

S. pneumoniae

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24
Q

If the pt is alcoholic, what pathogen do you suspect in CAP?

A

S. pneumoniae, oral anaerobes, TB (mycobacterium tuberculosis)

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25
Q

If the pt had a pre-existing viral infection, what pathogen do you suspect in CAP?

A

Staph. aureus or S. pneumoniae

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26
Q

If the pt has chronic bronchitis, what pathogen do you suspect in CAP?

A

Haemophilus influenzae or S. pneumonia

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27
Q

If the pt has AIDS, what pathogen do you suspect in CAP?

A

Pneumocystis carinii, cytomegalovirus, TB

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28
Q

What viruses cause pneumonia?

A
  • Influenza A and B
  • Parainfluenza
  • Respiratory syncytial virus (RSV)

Most likely bacterial unless immunocompromised pt

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29
Q

What elements of a patient’s history would lead you to suspect uncommon microbes / what should you ask about to r/o uncommon microbes?

A
  • Recent travel
  • Ill contacts
  • Exposure to birds, bats, rabbits, farm animals
  • ETOH
  • HIV
  • COPD
  • Structural Lung Disease
  • Prolonged cough (pertussis)
  • Aspiration
  • Bioterrorism: plague
30
Q

Where does antibiotic resistance come from?

A
  • Misuse
  • Overuse
  • Inadequate use
31
Q

What is the significance of MIC (minimum inhibitory concentration)?

A
  • The smallest concentration of antibiotic that inhibits the growth of organism
  • They help, but hard to standardize
  • < 2mg/ml sensitive
  • 4 mg/ml intermediate
  • >8mg/ml resistant
  • Higher levels of resistance affects outcomes, mortality

In future – hopefully develop more reliable measures for this kind of test.

32
Q

CAP patients should not receive the same antibiotic within ___ months

A

3

33
Q

Characteristics of CA-MRSA pneumonia

A
  • Severe necrotizing bilateral pneumonia - not commonly seen but should know about it.
  • More common in USA than Europe
  • Clonal disease (from staph) - copies from dna sequence of SA
  • Very different from strains of MRSA causing nosocomial pneumonia (HA-MRSA)
34
Q

What is CAP-MRSA linked to?

A

Previous viral illness - seen in flu season

Linked to toxins produced by the bacteria

35
Q

Clinical presentation of CAP

A
  • Look ill
  • Fever - not everyone has fever
  • Cough, with sputum production
  • Pleuritic chest pain
  • Hypoxic (maybe confused, agitated especially in elderly)
  • Elevated CRP
  • Tachycardia/tachypnea
  • RR> 30 - stronger predictor than temp
  • Crackles/rales, egophony, etc
  • Dullness to percussion
  • Confusion (legionella)
  • Erythema multiform (mycoplasma)
36
Q

Diagnostic tests you might order for pneumonia

A
  • CXR - PA and lateral - gold standard!
  • Sputum gram stain and culture prior to Abx, optimum, not always possible - only small percentage can get adequate sputum for sample. Only end up w/mouth bacteria.
  • Severe CAP: Blood cultures

If can’t do CXR and don’t want to send them to ER, can empirically treat if your clinically believe it to be pneum.

37
Q

When might you suspect severe pneumonia?

A
  • ETOH Use
  • Leukopenia
  • COPD
  • Asplenia
  • Pleural effusion
  • Cavitary infiltrates
38
Q

Limitations to CXRs for pnemonia Dx

A
  • may not show infiltrate initially, treat anyhow, image can always be repeated.
  • don’t tell the pathogen, only the extent and if there is effusion, and even then these films often miss pleural effusions
39
Q

Vital signs in pneumonia

A

80% febrile, tachypnea, tachycardia

40
Q

Why might you order urine antigen testing with pneumonia?

A

suspected legionella, strep pneumonia, fungal infection

41
Q

What is the significance of pleural effusion on a CXR in pneumonia?

A

poor outcome

Get thoracentesis with specimen sent for gm stain, culture, cytology, glucose and protein

42
Q

When might you admit a patient with pneumonia?

A
  • Pneumonia Severity Index (PSI) - high -more in research
  • CURB-65 Score (?2, def 3-5)
  • Use port score ( pg. 396 Goroll)
43
Q

What should you do if a pneumonia pt is wheezing?

A

Albuterol inhaler

(same if CB -no antibiotic, but yes inhaler)

44
Q

What is a CURB-65 assessment?

A

Popular and easy to use
5 assessments:

  • CONFUSION DUE TO PNEUMONIA (1 point)
  • Urine - BUN > 19 mg/dL (> 7 mmol/L) (1 point) FVD
  • RR_>_ 30 (1 point)
  • B/P <90 SYSTOLIC OR _<_60 DIASTOLIC (1 point)
  • AGE >65 (1 point)
  • ICU CARE >3
45
Q

What do CURB-65 scores mean?

A
  • 0-1 point: Low severity (mortality <3%), outpatient tx is usually appropriate
  • 2 points: Moderate severity (mortality 9%), hospitalization should be considered
  • 3-5 points: High severity (mortality 15-40%). Hospitalization is indicated, and need to assess for possible ICU admission (especially score 4 or 5)
46
Q

Limits of PSI and CURB-65

A

Don’t account for

  • social structure
  • ETOH use/ abuse
  • Drug intoxication
  • Other medical conditions
47
Q

General interventions recommended for pneumonia

A
  • Rest, that means in bed, especially during acute phase
  • Avoid smoking or secondhand smoke
  • Respiratory isolation (face mask)
  • Good handwashing
  • Nutritious diet with increased fluids
  • Sterilize toothbrush, good oral hygiene
48
Q

Use of antibiotics and O2 therapy in pneumonia - when and how long?

A
  • 10-14 days
  • Oxygen therapy usually for hospitalized patients
49
Q

What are the recommended empiric antibiotics for CAP outpatient in previously healthy and no use of Abx within the previous 3 months?

A

A macrolide (azithromycin, clarithromycin, or erythromycin)

OR

Doxycyline

50
Q

What are the recommended empiric antibiotics for CAP outpatient in presence of comorbidities* or use of antimicrobials within the previous 3 months?

* (chronic heart, lung, liver or renal disease; diabetes ;alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs)

A

A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg])

OR

A β-lactam (first-line agents: high-dose amoxicillin, amoxicillin-clavulanate; alternative agents: ceftriaxone, cefpodoxime, or cefuroxime) PLUS a macrolide (azithromycin, clarithromycin, or erythromycin)*

51
Q

Viral pneumonia: what is first line antiviral recommended?

A

Zanamivir, Relenza

(for Type A flu, MDI)

52
Q

Viral pneumonia: what is second line antiviral recommended?

A

combo: Oseltamivir (Tamiflu): Adamantane (Rimatadine)

Comment: Tamiflu resistance emerged in USA during 2008-2009

53
Q

Other antivirals that may be given for viral pneumonia

A
  • Acylovir (Zovirax) - Needs to be given IV
  • Ribavirin (Virazole) - For RSV as aerosol (children); Never give in pregnancy !!! Class X
54
Q

Important consideration when treating viral pneumonia

A

Patients with viral pneumonia are often superinfected and will need treatment for bacterial organisms.

Try to get sputum sample and nasal swabs

Often found in hospital as we typically assume bacterial

55
Q

What f/u care is needed for pneumonia?

A
  • Know signs of increasing respiratory distress, seek immediate medical attention
  • Follow up with phone call in 24 hours
  • If not improved in 48 hour, definite call back
  • Office visit in 2 weeks
  • X-ray in 6-12weeks for patients over 60 and for those who smoke, otherwise no need for x ray. Don’t order earlier than 2mths – or may not see change

F/U call next day: ask about: fever (should be gone in 2-3days); SOB; signs of dehydration (dry sticky mouth, urination, sunken eyes); what if 14 days later they hurt when breathe in – may be pleurisy – give 2wks of nsaids

56
Q

When should you refer / consult in a patient with pneumonia?

A
  • Immunocompromised, signs toxicity or hypoxia
  • Poor prognostic signs ( >65, RR>30, B/P < 90 systolic or B/P < 60 diastolic
  • Temp >101F - young, temp 104, doesn’t want to go to ER, probably can tx in clinic (use judgment), but maybe someone w/102, comorbidities… may send.
  • Altered mental status
  • Extrapulmonary infections
  • WBC <4,000 or greater than 30,000
  • Suspicion of pneumocystis carinii pneumonia (PCP)

Recurrent: think of neoplasm/mass - need bronchoscopy

57
Q

What vaccines should pts at risk for pneumonia get and how often?

A

Pneumo: Q 5 years

Flu: annually

58
Q

Can Flu and pneumovax be given at the same time?

A

Yes! But different arms

59
Q

What if your patient is allergic to eggs? Do you give the vaccine?

A
  • Don’t give if allergy to eggs, however, patients can now go to allergist and get flu shots under controlled environment. There are levels of egg allergies – must way risk/benefit
60
Q

Association between smoking and pneumonia

A
  • More colds and more severe
  • Decreased immunity
  • Increased alveolar vascular permeability
  • More colonization of flora in lower airway
  • Smokers are more likely to develop pneumonia, TB, flu, varicella pneumonitis**
  • Smokers should be targeted for flu and pneumococcal vaccine
61
Q

What if a patient, a smoker, develops the typical rash of chicken pox?

A

needs prompt treatment with oral acylovir and careful observation for pneumonitis**

** potentially fatal

62
Q

What is acute bronchitis?

A
  • Bronchi inflammation 2o URI, self-limited, usually viral …
63
Q

What organisms typically cause acute bronchitis?

A
  • Viruses: adenovirus, coronavirus, influenza, coxsackievirus etc
  • yet 60% are Rx ABx! Not helpful! Though some may take into acct hx and what’s happening . E.g., very old, holiday is coming, hx pneumonia…
64
Q

What are some possible bacterial causes of acute bronchitis?

A
  • CAP
  • Mycoplasma pneumoniae
  • Chlamydophila pneumoniae
  • Bordetella pertussis
65
Q

What is the typical clinical presentation of acute bronchitis?

A
  • cough >5 d (1-3 wk), usually abrupt onset, consistent
  • Sputum: +/- productive, may be clear, white, yellow, green or tinged with blood (purulent mucus ¹ bacterial)
  • Wheezing, rhonchi, rales (document location)
  • Other sxs: malaise, fever, tachycardia hoarseness, chest pain.

Usually at least 10 days

66
Q

DDx for acute bronchitis

A
  • Chronic bronchitis – most days of month at least 3 mths
  • Pneumonia
  • URI/Influenza
  • Asthma
  • GERD
  • PND
67
Q

Diagnostic tests in acute bronchitis

A

Chest X-ray: r/o others
Blood and sputum culture
Procalcitonin is emerging

68
Q

Procalcitonin: what are the ranges of results and what do they mean?

A
  • PCT <0.10mcg/L: strongly discourage Abx
  • PCT <0.25mcg/L: discourage Abx
  • PCT >0.25mcg/L: encourage Abx
  • PCT >0.50mcg/L: strongly encourage Abx

Procalcitonin. Not in PC, but emerging area. Expensive, more for research purposes right now. Differentiates bacterial vs viral infection.

69
Q

How should acute bronchitis be treated?

A
  • Sxs management: Acetaminophen, ASA, antihistamine-decongestants
  • Antitussive tx (guaifenesin, Dextromethorphan, Hydrocodone, codeine, Benzonatane)-s/e
  • Bronchodilators (abuterol) – if wheezing
  • Abs (eg. Azithromycin, Erythromycin, Clarithromycin, Levofloxacin etc) - if needed! But one of most common causes of Abx abuse
70
Q

Pneumonia vs acute or chronic bronchitis: what are the common Sx, and which are typically only pneumonia?

A

Common: cough, sputum, fever, wheezing

Pneumonia: tachypnea, tachycardia, fever, cough

Primary care of adults 2 (15 decks)

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