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AANP > Lower respiratory disease > Flashcards

Lower respiratory disease Flashcards

1
Q

Community aquired PNA causitive pathogens

A

people with no sig comorbids
* s. pneumoniae gram+ (most common)
* M. pneumoniae (atypical)
* C. pneumoniae (atypical)
* respiratory virus: influenza a/b, RSV

With comorbids including chronic heart, lung, liver, or renal disease, DM, alcohol use disorder, current malignancy, and/or asplenia
* s. pneumoniae gram+
* h. influenzae gram -
* M. pneumoniae (atypical)
* C. pneumoniae (atypical)
* legionella spp. (atypical)
* respiratory virus: influenza a/b, RSV

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2
Q

M. pneumoniae
C. pneumoniae

A

atypical becasue not revelaed by gram stain
* largely cough transmission
* seen in people working or living in close proximity to others
* atypical pneumonia/walking pneumonia usually characterized by by dry cough, and less severe signs and symptoms

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3
Q

Legonella spp.

A
  • not reveled by gram stain
  • contracted by inhaling mist or aspirating liquid that comes from a water source contaminated with legonella
  • no evidence of person to person spread
  • risk factors for severe legonnaires’ disease = older, male, smoking, DM
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4
Q

CAP treatment
no comorbids

A

dx evaluation: CBC w/diff, BUN/Cr, CXR
* length of therapy minimum 5 days

Causitive agents
* s. pneumoniae gram+ (most common)
* M. pneumoniae (atypical)
* C. pneumoniae (atypical)
* respiratory virus: influenza a/b, RSV

Tx
* doxycyline - best option coves for all likely pathogens
* azithromycin, clarithromycin, erythromycin - many communities have increased resistance to macrolides
* amoxicillin (only covers s. pneumoniae)
* AABCDE ( azithromycin, amoxicillin, biaxin, clarithromycin, doxycyline, erythromycine

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5
Q

CAP treatment with comorbids including COPD, DM, renal or heart failure, asplenia, alcohol use disorder

A

causitive agents
* s. pneumoniae gram+
* h. influenzae gram -
* M. pneumoniae (atypical)
* C. pneumoniae (atypical)
* legionella spp. (atypical)
* respiratory virus: influenza a/b, RSV

TX
* respiratory fluroquinolone (moxi, levofloxacin) - will cover all likell pathogens + restaint s. pne
* doxycline or select macrolide + betalactam (augmentin, cefpodoxime, cefuroxime)

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6
Q

PNA Physical exam findings

A

Tachypnea
* due to impaired gas exchange, possibly contributing to fever
* rate increased at rest and with activity

Crackles/rales
* sudden opening of distal fluid-filled airways
* inspiratory crackling, clicking, rattling sound,often with partial improvement, not full resolution with cough

Consolidation
* cused by bacterial pna
* dullness to percussion (dense=dull)
* increased tactile fremitus - increases with increased tissue density
* cough does nto alter sound

Pleruritic friction rub
* caused by pleural inflammation not always found but more likely with s. pneumo or legonella
* pt reports sharp localized pain, worse with deep breath, movement or cough

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7
Q

CURB-65

A

validated calulation to determine location of care for CAP
* 0-1 outpatinet tx
* 2 - consider short hospital stay or very close watch as out pt
* 3-5 requires hospitalization

  • confusion of new onset
  • BUN >19
  • RR >30
  • BP < 90/60
  • 65 years or older
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8
Q

Acute Bronchitis

A
  • clincal dx
  • lower airway inflammation, usually presenting with cough, with or without sputum, absence of fever and thachypnea, lasting >5 days, typically following URI
  • only in the absence of asthma, copd, or other airway disease (considered exacerbation)

Likely cause
* 95% cuased by virus
* 5 % bacterial m. pneumoniae, c. pneumoniae

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9
Q

Viral acute bronchitis treatment

A
  • > 75% resolve without tx
  • inhaled bronchodilator via MDI
    1. SAMA - ipratropium bromide (atrovent)
    2. SABA - albuterol (use this 1st very rare to be bacterial)
    3. short course of oral corticosteroid - prednisone 40mg daily for 3-5 days
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10
Q

Bacterial Acute bronchitis treatment

A
  • oral macrolide - azythromycine, clarithromycin, erythromycin
  • doxycyline
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11
Q

Asthma assememtn and DX

A
  • heterogenous disease, characterized by chronic airway inflammation
  • airway inflammation 1st then bronchospasm

s/s
* wheeze, SOB, chest tightness and/or cough due to variable airway obstruction and bronchial hyperresponsiveness, triggered by underlying inflammation
* symptoms vary over time, worse at night, or with exercise, viral resp infection, aeroallergens/pulmonary irritants
* airflow obstruction, partially reverable: increasein FEV1>12% and >200ml from baseline after SABA

  • Spirometry is the prefered test for dx
  • peak flow meter used for monitoring
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12
Q

Asthma acute reliver (rescue)

A
  • needed for all with asthma Dx
  • low dose ICS-fomoterol (symbocort) combo of steroid and SABA - reduces risk of exacerbations compared to using SABA alone for rescue. Single inhaler used PRN for rescue or controller therapy as well as rescue
  • SABA - albuterol, pirbuterol, levabuterol - not reccomeded as prefered reliever, should not be used as monotherapy.
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13
Q

Asthma controller medication

A

ICS/LABA
* ICS prevents formation of inflammation, LABA provides long acting bronchodilation
* budesonide + fomoterol (symbicort)
* fluticasone + salemeterol (advir)
* Mometasone + fomoterol (dulera)
-PRN as preferred reliver therapy; daily use as preferred controller therapy

ICS
* ICS with laba preferred over ics alone for reliver or controller
* mometasone, fluticasone, budesonide, beclamethasone

LAMA
* add on if asthma not adequately controlled with ICS/LABA
* bronchodilator via blockage of cholinergic/muscarinic receptors
* requires consistent daily use
* tiotropium bromide (Spiriva)

Systemic Corticosteroids
* used for flare, provides agressive tx of inflammation
* predisone 40-60mg 3-10 days, no taper needed
* no benifit of injectable over PO

Leukotriene modifiers
* monteleukast (singulair)
* not as effective as ICS -use is discurage due to neuropsyciatric side effects

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14
Q

Stepwise asthma treatment

A

Step 1
* symptoms <2x month
* PRN ICS/SABA = symbicort

Step 2
* Symptoms >2x/month but not daily
* PRN ICS/SABA = symbicort

Step 3
* Symtoms most days or waking at night >1/wk
* Daily ICS/SABA (symbicort)

Step4
* Symtoms most days or waking at night >1/wk, or low lung function
* Medium dose ICS/LABA

Step 5
* high dose ICS/LABA and add on therapy LAMA (tiotropium), biologics, or anti IgE

*all steps need reliever therapy ICS/SABA PRN

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15
Q

Ongoing asthma assessment

A
  • score 0=well controlled
  • 1-2 partially controlled
  • 3-4 uncontrolles
  • daytime symptoms >2/wk
  • any nighttime wakening
  • reliver symptoms >2/wk
  • any activity limitiation

risk factors for poor outcome
* measure FEV1 at dx, after 3-6 months of controller therapy, then periodically
* indentify modifiable risk factors - poor inhaler technique, other meical conditions, smoking, poor lung function (FEV1 <60% of predicted

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16
Q

Air trapping

A

COPD - consistently persistant, worsens with exacerbation

Asthma present during exacerbation

Objective findings
* hyperresonance on percussion
* Decreased tactile fremitus - decreases with decresed tissue density
* wheez - usually epiratory first
* low diaphragm
* increased anteriorposterior diameter - mostly in copd or with longstanding poorly controlled asthma

17
Q

COPD

A
  • smoking cessation counselling, advise on physical activity and pulmonary rehan,and updated influenza, pneumococcal, and COVID vaccines are reccomended
  • charcterized by persistant respiratory symptoms and airflow limitation that is due to airwaiy and/or alveolar abnormalities
  • risk factors are long term exposure to irritants nicluding tabacco use
  • most common symtoms are chronic cough, chronic sputum production, activity intollerance, symptoms typically progressive, usually in people with copd risk factor
  • goals of tx - to relieve symtoms, reduce frequency of exacerbations, improve exercise tolerance and overall health
18
Q

Assessment in COPD

A
  • Spirometry required for Dx
  • FEV1: FVC <0.70 post bronchodilator confimrs COPD
  • Classification of severity determined by FEV1
  • CAT or CCQ questionnaire - reccomended for comprehensive assessment of symptoms
19
Q

COPD classification of severity

A

GOLD 1
* mild - FEV1 >80% predicted (probably asymptomatic)

Gold 2
* moderate - FEV1 50 to <80% predicted

Gold 3
* Severe - FEV1 30 to <50% predicted

Gold 4
* ery severe - FEV1 < 30% predicted

20
Q

Medication treatment of COPD

A

Relief of bronchospapsm PRN
* SABA - albuterol
* SAMA - ipatropium bromide

Protracted durration of bronchodilation, minimizes risk of exacerbation, daily use
* LAMA - tiotropium bromide (spiriva)

Protracted durration of bronchodilation, used with ICS and/or LAMA, used daily
* LABA - salmeterol

Antiinflammatory - minimizes risk of exacerbation but with increase in PNA risk, used daily
* ICS

21
Q

Treatments for COPD gold 1-2

A

1 or less exacerbations per year
group a: low exacerbation risk/less symptoms- SAMA/SABA PRN
gold b: low exacperation risk/more symtoms - LAMA or LABA daily

22
Q

Treatment of COPD Gold 3-4

A

2 or more exacerbations per year
group c: high exacerbation risk/less symptoms- LAMA daily
group d: high exacerbation risk/more symptoms - LAMA or LAMA + LABA or ICS+LABA daily

23
Q

COPD exacerbation

A
  • event in the natural course of disease charaterized by a change in pts baseline dyspnea, cough, and/or sputum
  • 60% are triggered by tabacco use, air pollution, or viral RTI
  • 40% triggered by bacterial pathogen (h. influenzae, M. catarrhalis, s. pneumoniae)

Treatment
* continue current regimen, SABA and or SABA, add LABA or LAMA if not already taking
* systemic corticosteroids to shorten recoery time, minimize hypoxemia and relapse risk (prednisone 40mg x5days)
* considere abx - mixed evidence on inpact in outpatient setting

24
Q

Abx selection consideration

A
  • TMP/SMX (bactrim) - avoid with ACE inhibitor/ARB, especially with CKD and or dehydration, due to hyperkalemia risk
  • Penacillin - vulnerable to distruction by beta-lactamase
  • Macrolides - QT prolongation risk, particularly in individuals with higher CVD risk
  • Fluroquinolone - use associated with tendon rupture risk,especially whn used with systemic corticosteroid
  • cephalosporin - less than 1% cross risk with penicillin allergy
25
Q

Outpatient mild - mod COPD exacerbation ABX therapy

A
  • ususally not indicated in outpatient setting
  • if used durration of 5 days
  • doxycycine - no interactions, good coverage
  • cephalosporin - good coverage
  • TMP-SMX - hyperkalemia risk not good for elderly
  • amoxicillin only covers s. pneumonaniae
26
Q

Outpatient severe COPD exacerbation ABX therapy

A
  • role debatable even in severe disease
  • use for 5 days
  • Beta-lactam - augmentin, cephalosporin
  • Macrolide - azithromycin, clarithromycin
  • respiratory flouroquinolone - moxi/levofloacin (covers atypicals)

AANP (20 decks)

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