Lower Respiratory

Question 1

What are the 2 main etiologies of bronchitis?

Answer 1

Viral & Smoking

Question 2

Bronchitis:
1) List 2 Txs they DON’T benefit from
2) What Tx should you use caution with when the cough is productive?
3) Clinical effectiveness of what Tx has not been well established?
4) What is an accepted Tx?

Answer 2

1) Aerosolized β2-receptor agonists & oral or aerosolized corticosteroids
2) Antitussives (Medicare doesn’t cover)
3) Expectorants
4) Antibiotics (amox. if Sx >5-7days)

Question 3

True or false: you can use antibiotics for bronchitis, but not in chronic bronchitis

Answer 3

True

Question 4

Chronic Bronchitis:
1) Main etiology?
2) What increases?
3) How long does the chronic cough productive of sputum have to last for Dx?

Answer 4

1) Smoking
2) Mucus-secreting goblet cells
3) 3 consecutive months of the year for 2 consecutive years (w/o other known cause)

Question 5

Chronic bronchitis:
1) How were the Sxs summed up in class?
2) Is it usually G+ or G- bacteria?

Answer 5

1) “Blue bloaters, pink puffers”
2) G+; only G- in 5% of cases

Question 6

Chronic bronchitis: List 4 Tx options for simple CB (no risk factors)

Answer 6

1) Azithromycin 500mg PO Qday (PAE; five days of therapy acceptable)
2) Amox/clav. 875mg BID
3) Doxycycline 100mg BID
4) Levofloxacin 500mg Qday

Question 7

1) What are risk factors that can make a case of CB complicated?
2) What Tx option is not available for these cases?
3) How long is Tx? (for both complicated an uncomplicated)

Answer 7

1) Age > = 65, chronic COPD, > 4 exacerbations / year, heart disease, home oxygen use, abx use in past 3 months, corticosteroid use in past month
2) Azithromycin
3) 5-7 days

Question 8

How would you Tx inpatient complicated CB (Chronic bronchitis)? Why?

Answer 8

Levofloxacin 750mg IV daily; empirically covering P. aeruginosa

Question 9

1) 75% of ____________ cases are due to respiratory syncytial virus (RSV) (hint: common in babies).
2) What is the recommended Tx?

Answer 9

1) Bronchiolitis
2) Nebulized hypertonic saline

Question 10

List 3 Txs that are NOT routinely recommended for bronchiolitis

Answer 10

1) Aerosolized β2-agonists
2) Systemically administered corticosteroids
3) Ribavirin

Question 11

List the 2 vaccines and 2 other ways to prevent bronchiolitis. Who is each recommended in?

Answer 11

1) Abrysvo (vaccine)
-Adults ≥60-75 years of age + pregnant pts 32-36 weeks
2) Arexvy (vaccine)
-Adults ≥60-75 years of age
3&4) 2 Monoclonal antibodies:
-Nirsevimab (Beyfortus)
-Palivizumab (Synagis)

Question 12

Differentiate between antigenic drift and shift (important concept for influzena)

Answer 12

1) Drift: point mutations in surface antigens that leads to the variability of seasonal influenza
2) Shift: genetic reassortment culminating in novel surface antigens that leads to a new influenza variant (e.g., avian flu & swine flu)

Question 13

What is the pathophysiology of influenza?

Answer 13

Influenza A antigens
1) Hemagglutinin (H1 – H16): allows entry
2) Neuraminidase (N1 – N9): allows exit

Question 14

Influenza is transmitted via person-to-person inhalation of respiratory droplets.
1) What is the incubation period?
2) What is the infectious period?

Answer 14

1) 1 – 7 days incubation period (average of 2 days)
2) 1 day before symptom onset and up to 7 days after symptom onset; children may be infectious for up to 10 days after onset

Question 15

What condition can happen secondary to influenza?
(hint: flu and this are combined as the 8th leading cause of death in the US
9th leading cause in 2020; not in top 10 all cause mortality for 2021, 2022, 2023)

Answer 15

Secondary bacterial pneumonia

Question 16

What is the gold standard for influenza testing?

Answer 16

Reverse-transcription polymerase chain reaction (RT-PCR)

Question 17

Influenza vaccine:
1) When is a booster dose appropriate?
2) What abt a high dose?
3) Is it safe in pregnancy?
4) Any special notes for immunocompromised pts?

Answer 17

1) Booster dose at least 4 weeks after the initial dose in children between 6 months and less than 9 years of age if no previous vaccination
2) High dose if age > = 65 years old or solid organ transplant
3) Safe during any trimester of pregnancy
4) Immunocompromised patients (e.g., HIV) may benefit from high dose vaccine regardless of age

Question 18

1) Influenza post-exposure prophylaxis should not be given when? What is it called?
2) What ages is it appropriate for?
3) What is another form?

Answer 18

1) Postexposure prophylaxis should not be given if >48 hours has elapsed since exposure
-Oseltamivir
2) FDA said 14 days and older, CDC expanded recommendation for treatment in those less than 14 days
3) Zanamivir

Question 19

Give 5 examples of who to give post-exposure prophylaxis for influenza (Oseltamivir) to

Answer 19

1) Persons at high risk of serious illness and/or complications and cannot be vaccinated.
2) Exposed during the first 2 weeks following vaccination
3) Persons with severe immune deficiency or who may have an inadequate response to vaccination
4) Long-term care facility residents
5) As soon as possible after exposure, ideally no later than 48 hours after exposure

Question 20

Oseltamivir dosing:
1) For adult Tx
2) For adult prophylaxis
3) Exceptions to this?

Answer 20

1) 75mg capsule 2x/day for 5 days
2) 75mg capsule 1x/day for 10 days
3) For control of outbreaks in long-term care facilities and hospitals, give for a minimum of 2 weeks, and continue up to 1 week after the last known case (guideline dosage); up to 6 weeks during a community outbreak (FDA dosage)

Question 21

List and describe 2 groups of influenza Txs discussed in class

Answer 21

1) Cap-dependent endonuclease inhibitor: Baloxavir
2) NA inhibitors: Oseltamivir, Zanamivir, Peramivir

Question 22

Baloxavir (Xofluza):
1) What group of drugs?
2) What is an important interaction to note?
3) Can pregnant/ breastfeeding pts use?
4) List a side effect

Answer 22

1) Cap-dependent endonuclease inhibitor for influenza
2) Chelation w. dairy products
3) Not recommended for patients that are pregnant or breast feeding
4) Increased liver enzymes

Question 23

1) What influenza Tx may reduce the duration of illness in a community setting by approximately 1 day (versus placebo)?
2) What neuropsychiatric complications have been associated with this?

Answer 23

1) Neuraminidase inhibitors
2) Delirium, seizures, hallucinations, and self-injury in pediatric patients (mostly from Japan) have been reported following treatment with oseltamivir and peramivir

Question 24

NA inhibitors (for influenza):
1) Which 2 require renal dosing?
2) Which 2 have GI & neuropsychiatric side effects?

Answer 24

1) Oseltamivir (Tamiflu) & Peramivir (Rapivab)
2) Oseltamivir (Tamiflu) & Peramivir (Rapivab)

Question 26

What 2 things do Oseltamivir (Tamiflu) and Peramivir (Rapivab) have in common? (besides the fact that they are both NA inhibitors for flu)

Answer 26

1) Require renal dosing
2) GI & neuropsychiatric side effects

Question 27

Which 2 NA inhibitors (for flu) are 5 day treatments?

Answer 27

Oseltamivir (Tamiflu) & Zanamivir (Relenza)

Question 28

What is the preferred Tx for influenza in pregnancy?

Answer 28

Oseltamivir (Tamiflu)

Question 29

Which NA inhibitor (for flu) is given via IV for 1 day?

Answer 29

Peramivir (Rapivab)

Question 30

1) Which NA inhibitor (for flu) is given via capsule or solution?
2) Which is via diskhaler?

Answer 30

1) Oseltamivir (Tamiflu)
2) Zanamivir (Relenza)

Question 31

Describe how you dose Oseltamivir for flu Tx

Answer 31

Begin w/in 48hrs of Sx onset:
-75mg BID x 5 days
-Weight-based dose for pediatrics
-CrCl 30 – 60 mL / min: 30 mg BID x 5 days
-CrCl 10 – 30 mL / min: 30 mg Qday x 5 days

Question 32

Describe how you dose Oseltamivir for flu prophylaxis

Answer 32

75mg Qday x 10 days

Question 33

What may happen if antitussives like Benzonatate (Tessalon Perles) are chewed or dissolved?

Answer 33

Oral mucosa anesthesia

Question 34

a) Hydrocodone 10 mg / Chlorpheniramine 8 mg / 5 mL ER (Tussionex)
b) Hydrocodone 5 mg / Homatropine 1.5 mg / 5 mL (Hydromet)
c) Codeine 10 mg / Guaifenesin 100mg / 5 mL
(Cheratussin AC)

1) All 3 have what side effects?
2) Can they be used in peds?

Answer 34

1) Nausea, itching, constipation and respiratory depression
2) The FDA in January 2018 recommended against routine use of codeine/hydrocodone-containing cough/cold products for patients <18 years

Question 35

Bromfed DM:
1) Dose frequency for peds?
2) Type of med?

Answer 35

1) Every 4 hours PRN
2) Antitussive

Question 36

Antitussives:
1) Which is an antihistamine?
2) How would you classify pseudoephedrine?
3) Name one that’s a nonopioid antitussive

Answer 36

1) Brompheniramine
2) Sympathomimetic nasal decongestant
3) Dextromethorphan

Question 37

At what age can you give a pt an antitussive?

Answer 37

≥2 years of age (with caution)

Question 38

List common causes of CAP

Answer 38

S. pneumoniae
S. aureus
H. influenzae
M. pneumoniae, Legionella species, and C. pneumoniae

Question 39

What condition is a concern for people w/ crowded living conditions and poor access to healthcare (e.g., homeless or incarcerated)?

Answer 39

Mycobacterium tuberculosis

Question 40

Pneumonia:
1) People with HIV are opportunistic infections such as ______________ (fungi) and _______________ species.
2) Who else is at risk?

Answer 40

1) Pneumocystis jiroveci; Mycobacterium species.
2) Neutropenic pts; pts with TB

Question 41

Define each type of pneumonia:
1) CAP (community)
2) HAP (hospital)
3) VAP (ventilator)

Answer 41

1) Pneumonia developing outside the hospital or <48 hrs after admission
2) Pneumonia developing >48 hrs after admission
3) Pneumonia developing >48 hrs after endotracheal intubation

Question 42

1) Necrotizing lesions are associated with what type of pneumonia?
2) Name 2 things that are not routine for outpatient CAP

Answer 42

1) Staphylococcal
2) Blood or sputum cultures

Question 43

What is the preferred pneumonia differentiating tool for most current guidelines?

Answer 43

Pneumonia Severity Index
(CURB-65 also relevant tho)

Question 44

What is CURB-65?

Answer 44

Confusion
Uremia (BUN > 20 mg/dL [7.1 mmol/L])
Respiratory rate ≥30 breaths/min
Blood pressure (systolic <90 mm Hg, diastolic ≤60 mm Hg)
Age ≥65 years

Question 45

True or false: major criteria for pneumonia will require ICU support

Answer 45

True

Question 46

List some minor criteria for community-acquired pneumonia

Answer 46

1) RR >30 breaths/ min
2) PaO2/FaO2 ratio <250
3) Confusion/ disorientation
4) Leukopenia (<4000 cells/ ul)
5) Thrombocytopenia (<100,000/ ul)
6) Hypothermia (<36c)
7) Hypotension (req. aggressive fluid resuscitation)
8) Multilobar infiltrates

Question 47

List the major criteria for community-acquired pneumonia

Answer 47

1) Septic shock with need for vasopressors
2) Respiratory failure req. mechanical ventilation

Question 48

For CAP, what tests do you need to get? Why?

Answer 48

1) Gram stain / culture & blood cultures
-To empirically Tx for MRSA or P. aeruginosa
2) Serum procalcitonin levels (not required to start empiric therapy)

Question 49

How should you Tx outpatient CAP (CURB-65 <2; no more than 2 minor criteria) in healthy adults?

Answer 49

1) Amoxicillin – strongest recommendation
2) Doxycycline
3) Azithromycin or clarithromycin
-Pneumococcal resistance to macrolides < 25%

Question 50

How should you Tx adults w/ chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancy; asplenia for outpatient CAP (CURB-65 <2; no more than 2 minor criteria)?

Answer 50

1) Combination therapy:
-Amox./clav. (Augmentin) + azithromycin
-Cefuroxime + doxycycline
2) Monotherapy: Levofloxacin, moxifloxacin, or gemifloxacin

Question 51

How would you Tx inpatient nonsevere CAP (CURB-65 = 2; no more than 2 minor criteria) w/ out risk factors for MRSA or P. aeruginosa?

Answer 51

Combination therapy (IV beta-lactam w/ beta-lactamase inhibitor or cephalosporin + macrolide):
1) Ampicillin / sulbactam + azithromycin
2) No doxycycline; use IV instead of PO
-ceftriaxone acceptable

Question 52

How would you tx inpatient severe CAP (CURB-65 > 2; and 3 or more minor criteria) w/ out risk factors for MRSA or P. aeruginosa?

Answer 52

1) Combination therapy
-IV beta-lactam w/ beta-lactamase inhibitor or cephalosporin + macrolide
-IV beta-lactam w/ beta-lactamase inhibitor or cephalosporin + respiratory fluroquinolone
No monotherapy

Question 53

How would you tx inpatient severe CAP (CURB-65 > 2; and 3 or more minor criteria) with risk factors for MRSA or P. aeruginosa?

Answer 53

1) MRSA
-Vancomycin
-Linezolid
2) P. aeruginosa
-Piperacillin-tazobactam
-Cefepime
-Ceftazidime
-Aztreonam
-Meropenem
-Imipenem

Question 54

Name something not routinely used to Tx CAP

Answer 54

Corticosteroids

Question 55

When is Oseltamivir useful for pneumonia?

Answer 55

Useful independent of duration of illness before diagnosis
Concomitant w/ standard antibiotic therapy

Question 56

How should you begin to Tx HAP / VAP?

Answer 56

Start empirically

Question 57

When do HAP/ VAP pts have a high risk of mortality if there’s risk factors (like if IV antibiotics in past 90 days)?

Answer 57

High risk of mortality:
1) Ventilator support
2) Septic shock

Question 58

1) What is the empiric MRSA therapy for HAP if there’s risk factors (like if IV antibiotics in past 90 days)?
2) What abt if no risk factors?

Answer 58

1) Vancomycin or linezolid
2) Piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem

Question 59

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