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Diagnosis & Mgmt 1 > Lower Respiratory Diseases > Flashcards

Lower Respiratory Diseases Flashcards

1
Q

How is an acute cough defined?

A

less than 3 weeks

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2
Q

How is a subacute cough defined?

A

3-8 weeks

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3
Q

How is a chronic cough defined?

A

more than 8 weeks

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4
Q

What are potential harms that can result from a chronic cough?

A

Anxiety, fatigue, insomnia

Myalgia, rib fracture, and urinary incontinence

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5
Q

How is acute bronchitis defined?

A

A self limiting inflammation of the trachea and major bronchi that presents as cough lasting 1-3 weeks in the absence of pneumonia

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6
Q

What pathogens usually cause acute bronchitis?

A

Mainly Viral: RSV, Rhinovirus, Coronavirus, Influenza A and B and Parainfluenza

Infrequently Bacterial: Mycoplasma, pertussis and C. Pneumo

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7
Q

How does acute bronchitis present?

A

Cough- dry or productive

Low grade temp

Wheezing

Rhonchi- coarse rattling expiration

Normal vital signs

May have runny nose

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8
Q

What is needed to make an acute bronchitis diagnosis?

A

H & P

Infrequently: CXR

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9
Q

What are some red flags with acute bronchitis?

A

Abnormal vital signs

Rhales or signs of consolidation on chest examination

evidence of hypoxemia (eg, pulse oxygen assessment)

mental confusion

signs of systemic illness

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10
Q

What should be done if a secondary infection is suspected with acute bronchitis?

A

CBC with diff

CXR PA and Lateral

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11
Q

What are the differential diagnosis for acute bronchitis?

A

Asthma

Foreign body

Influenza

Pertusssis

PNA (pneumonia)

Sinusitis

Severe acute respiratory syndrome

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12
Q

How should children with acute bronchitis be treated?

A

Children under 6 - 14 y.o.—not much evidence to support use of OTC

1 y.o.

warm humidified air, fluids, nasal saline and bulb suction prn

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13
Q

How should adults with acute bronchitis be treated?

A

Dextromethorphan with Guaifenesin (mucinex DM)–best support

Codeine agents—narcotics suppress cough center brain,

tussin-x if they can’t sleep

Not recommended for children

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14
Q

What should be prescribed for acute bronchitis with a bronchospastic cough/ wheeze?

A

beta-2-agonists (albuterol)

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15
Q

What analgesic should be prescribed for acute bronchitis? (if necessary)

A

Acetaminophen

Ibuprofen

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16
Q

How is influenza defined?

A

Acute respiratory illness caused by Influenza A or B virus, occurs in outbreaks and epidemics worldwide, mainly in the winter season

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17
Q

How is influenza transmitted?

A

Large droplet transmission through sneezing and coughing,

Easily spread

Close contact as large droplets do not remain suspended in the air and travel short distances

Incubation 1-4 days

Viral shedding 48 hours up to 10 days after symptoms

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18
Q

What is the clinical presentation of the flu?

A

ACUTE ONSET

High temp

Myalgia

Fatigue

Cough

Rhinorrhea

Headache

N/V

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19
Q

What is expected upon physical exam for the flu?

A

Vital signs: elevated temp, tachycardia, tachypnea

HEENT: glassy eyes, mild conjunctivitis, watery discharge; erythematous TM; turbinate’s swollen moderate amt of clear discharge

Neck: non-tender cervical lymphadenopathy

Chest: CTA bilaterally, possible wheeze if hx of asthma or RAD

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20
Q

How is the flu treated?

A

Symptom management unless at high risk for complications

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21
Q

Who is at high risk for complications from the flu?

A

high risk for complications

  • Younger than 2 or older than 65
  • Chronic pulmonary, cardiovascular, renal, hepatic, metabolic, neurodevelopmental, intellectually disabled, HIV,
  • morbidly obese (BMI >40),
  • residents nursing home
  • American Indians/Alaska natives
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22
Q

What are the differential diagnosis for the flu?

A

RSV

Pneumonia

Severe strep pharyngitis

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23
Q

What diagnostic tests are available for the flu?

A

Rapid influenza

Nasal swab

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24
Q

Who is approved to take Tamiflu?

A

Treatment of flu for 2 weeks+

Prophylaxis for 1 yr+

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25
Q

Who is approved to take Relenza?

A

Treatment: 7yrs+

Prophylaxis: 5yrs+

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26
Q

What is a side effect of Tamiflu?

A

Makes people crazy and GI upset.

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27
Q

What side effect should be monitored for with Relenza?

A

Allergic reaction: oropharyngeal or facial edema

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28
Q

What are potential complications of the flu?

A

Pneumonia

Myositis/Rhabdomyolysis

Encephalitis

Guillian Barre- neuropathy toes to head

Reye’s syndrome- kids who have viral infection and take aspirin get liver damage and encephalitis

Toxic Shock Syndrome

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29
Q

How can the flu be prevented?

A

The flu vaccine, either live or not.

Give larger dose to elderly due to decreased immune system response

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30
Q

When can the first flu shot be given to a person?

A

6 months old

Need two shots, one month apart, the first time only.

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31
Q

How long does it take for the flu vaccine to be effective?

A

14 days

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32
Q

Can you get the flu from the flu shot?

A

NO!!!!

Can get an immune reaction which is fever and aches, but this is NOT the flu

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33
Q

Who should not get the flu vaccine?

A

Severe egg allergy (mild is ok)

History of sever reaction to the vaccine

For the live vaccine: No one less that 2 years old, immunocompromised, asthma, COPD, recent live vaccine, recent steroid use

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34
Q

What is pneumonia?

A

Lower respiratory infection that is usually accompanied by cough, fever, malaise and abnormalities on cxr

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35
Q

What are the typical agents that cause CAP?

A

Gram pos: S.pneumo, S.aureus, Group A Step.

Gram neg: H.influenza, M.cattarrhalis, Pseudomonas, K. pneumonia

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36
Q

What are the most likely agents causing CAP in an alcoholic?

A

K.pneumoniae and M.cattarrhalis

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37
Q

What are the most likely agents causing CAP post flu?

A

S. aureus and H. influenza

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38
Q

What are the most likely agents causing CAP in a COPD patient?

A

Moraxella catarrhalis (beta lactamase producing)

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39
Q

What risk factors will make you treat pneumonia aggressively?

A

Age > 65years

Presence of coexisting illness: COPD, bronchiectasis, malignancy, DM, CHF

chronic renal failure,

chronic alcohol abuse, chronic liver disease, malnutrition

cerebrovascular disease,

Post-splenectomy,

hx hospitalization in past year

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40
Q

What is the clinical presentation of pneumonia?

A

Fever

Malaise

Pleuritic chest pain

Dyspnea

Cough with and without sputum production

Nausea, vomiting, diarrhea

Mental status changes

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41
Q

What do you expect to find on physical exam with pneumonia?

A

Vital signs, febrile, tachycardia, tachypnea

Chest; audible rales (fine crackles) or diminished breath sounds

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42
Q

What physical findings are warning signs that a patient with pneumonia has an increased risk for mortality?

A

Respiratory rate > 30 (tachypnea)

Diastolic blood pressure 125

Temp 40° C (104°F)

Confusion or decreased LOC

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43
Q

What lab findings are warning signs that a patient with pneumonia has an increased risk for mortality?

A

WBC 30 x 10 (9)

PaO2 50 RA

Creatinine >1.2, BUN >20

Chest x-ray: multi lobular, pleural effusion, presence of a cavity

HCT

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44
Q

What are the differential diagnosis for pneumonia?

A

Pulmonary Emboli

CHF

Pulmonary tumor

Inflammatory lung disease

Acute or chronic bronchitis

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45
Q

What is the gold standard for diagnosing pneumonia?

A

Chest x-ray

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46
Q

What criteria need to be met to order a chest x-ray in pneumonia?

A

One of the following:
temp over 100,
HR over 100,
RR over 20

Two of the following:
decreased breath sounds, crackles,
absence of asthma

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47
Q

What are big risk factors for getting CAP?

A

COPD

Aspirations

lung abscess

smoking

alcoholism

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48
Q

What is the recommended treatment for CAP for a healthy adult with no antibiotic use in the past 3 months?

A

Macrolides: Zithromax, clarithromycin, Erythromycin

OR

Doxycycline

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49
Q

What is the recommended treatment for CAP for an adult with co-morbidities and antibiotic use in the past 3 months?

A

Floroquinolones: Levofloxin, moxifloxacin

OR

Macrolide with high dose Augmentin: Ceftriaxone, Cefpodoxime, Cefuroxime

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50
Q

What is the dosing and follow up for CAP in a healthy adult?

A

Azithromycin- 3 options based on compliance

Zpak:
500 mg on day one

250mg days 2-5

Tripak:
500mg for 3 days

Single dose:
2g microsphere formula

Follow up: 24-48 hours

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51
Q

What should happen if the patient doesn’t show improvement with CAP?

A

If no improvement in 48 hours, consider further testing and maybe change to a fluoroquinolone

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52
Q

Who should get the pneumonia vaccine?

A

All people over 65 yo

19-64 years old with DM, CHF, COPD or Asthma.

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53
Q

What are the most likely agents causing nosocomial pneumonia?

A

P aeruginosa

Klebsiella species

E. coli

Acinetobacter species

Staph aureus—especially MRSA

Strep pneumonia

H flu

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54
Q

How should Nursing Home Acquired Pneumonia be treated?

A

Like CAP, but aggressively because it spreads quickly.

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55
Q

What are common co-morbidities with Nursing home acquired pneumonia?

A

parkinsons, dementia/alzheimers

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56
Q

What is the recommended pneumococcal vaccine series for children?

A

4 Doses of PCV-13

2, 4, 6, 12-15 months

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57
Q

Why does the age of the child matter when diagnosing CAP?

A

Important in determining the possible etiologies

58
Q

What is considered tachypnea for a child younger than 2 months?

A

more than 60 breaths/min

59
Q

What is considered tachypnea for a child 2-12 months?

A

more than 50 breaths/min

60
Q

What is considered tachypnea for a child 1-5 years old?

A

more than 40 breaths/min

61
Q

What is considered tachypnea for a child older than 5 years?

A

more than 20 breaths/min

62
Q

What are the signs of respiratory distress in children?

A

Tachypnea- very important

Dyspnea

Retractions (suprasternal, intercostal or subcostal)

Nasal flaring

Apnea

Altered mental status

Pulse ox 90% room air

63
Q

What is needed to diagnose CAP in children?

A

Influenza (if in community)

RSV

CXR (PA and lateral) if not responding to tx, or considering other things like a pleural effusion

64
Q

When should an infant be hospitalized for CAP?

A

If they have:
apnea

grunting

poor feeing

O2 sat 70

65
Q

When should an older child be hospitalized for CAP?

A

If they are:
grunting

unable to tolerate PO intake

O2 sat is 50

66
Q

When should any child be hospitalized for CAP?

A

If they have comorbidities or the family is unable to provide proper observation/care

67
Q

What is usually prescribed for CAP, presumed to be bacterial, in a child under 5 years?

A

Amox 90mg/kg in 2 divided doses

OR

Amox clavulanate: 90mg/kg in 2 divided doses

68
Q

What is usually prescribed for CAP, presumed to be atypical, in a child under 5 years?

A

Azithromycin 10mg/kg day 1, and 5 mg/kg days 2-5

OR

Clarithromycin 15mg/kg in 2 divided doses

69
Q

What is usually prescribed for CAP, presumed to be bacterial, in a child over 5 years?

A

Amox 90mg/kg in 2 divided doses

OR

Amox clavulanate: 90mg/kg in 2 divided doses

AND

Macrolide

70
Q

What is usually prescribed for CAP, presumed to be atypical, in a child over 5 years?

A

Azithromycin 10mg/kg day 1, and 5 mg/kg days 2-5

OR

Clarithromycin 15mg/kg in 2 divided doses

Can use erythromycin or doxy for 7yo and up

71
Q

What management is needed when treating a child with CAP?

A

Re-evaluate in 48 hours

Educate on need to monitor respiratory status, fluid intake, signs and symptom of dehydration

Supportive care

Reason to call or rtc sooner

72
Q

How can CAP be prevented in children?

A

Vaccinations: PCV-13, Influenza, and HIB

Hand washing

Promote breastfeeding

Avoid exposure to smoke

73
Q

How is bronchiolitis defined?

A

acute inflammation, edema and necrosis of epithelial cells of the small bronchioles

74
Q

What is the usual cause of bronchiolitis in children?

A

most commonly RSV,

then adenovirus,

can also be parainfluenza, rhinovirus, influenza

75
Q

For RSV: What is the incubation period, usual season and progression?

A

Incubation: 4-6 days

Season: late fall to early sling

Beings with URI and progresses over 3-7 days

Usually affects people under 2 yo

76
Q

What is clinical presentation of bronchiolitis in kids?

A

Hx of URI

Fever usually no higher than 102 F

Decreased appetite

Cough

Large amount of clear rhinorrhea

77
Q

What is expected to be found on physical exam of brochioltits in kids?

A

Considered the happy wheezers

Usually febrile, tachypneic and tachycardic

Mild conjunctivitis, and pharygitis

Anterior cervical lymphadenopathy

Scattered wheezing- like a washing machine due to inflammation

Abdominal distention due to hyperinflation

78
Q

What diagnostic tests can be done for bronchiolitis in kids?

A

Rapid RSV-nasal swab

Rarely CXR or CBC

79
Q

What is the differential for bronchiolitis in kids?

A

Asthma

Pneumonia

Aspiration foreign body

Croup

Cystic Fibrosis

Congenital heart disease

80
Q

What is expected to be found on CXR for a child with bronchiolitis?

A

lung hyperinglation with a flattened diaphragm

81
Q

How is mild bronchiolitis treated?

A

Treat symptoms at home

Force fluids, antipyretics

Normal saline nasal spray with suctioning

82
Q

How is moderate/severe bronchiolitis treated?

A
83
Q

What are reasons to hospitalize a child with bronchiolitis?

A

Stridor

Apnea

Tachypnea >60 breaths per minute at rest

Hypoxia

Poor feeding

Decreased sensorium

Parent unable to manage at home

84
Q

How can bronchiolitis be prevented? Who is a candidate for this?

A

Palivixumab (synagis); monoclonal antibody to prevent RSV

Given to premature babies born in RSV months. Is very $$$

85
Q

What is the child with bronchiolitis at risk for later in life?

A

Potential for recurring wheezing in childhood

Increased risk of asthma going forward

86
Q

How is pertussis defined?

A

Highly contagious acute respiratory illness caused by Bordetella pertussis.

Aka Whooping cough

87
Q

How long is the incubation period of pertussis?

A

7-10 days after exposure but maybe up to 3 weeks

88
Q

What is the clinical presentation of pertussis?

A

URI

Persistent cough

Low grade temp

Paroxysmal cough

Post tussive emesis

Cyanosis, sweating, prostration and exhaustion after coughing

Adolescent/Adult- Persistent paroxysmal cough

89
Q

What do you expect to find on physical exam of a child with pertussis?

A

HEENT: mildly injected conjunctivae, with watery discharge; rhinorrhea

Chest: CTA bilaterally

Skin: petechial from coughing

90
Q

How can you make the diagnosis for pertussis?

A

Culture with specimen from nasal swab

Most reliable in the catarrhal stage first 1-2 weeks

91
Q

What is the differential diagnosis for pertussis?

A

Pneumonia

GERD

Cystic fibrosis

Asthma

Foreign body

92
Q

What is the management for pertussis?

A

Zithromax

Alternative Clarithromycin > 1mo of age

Most effective if tx in early stage, after that will decrease transmission but not course of the illness

93
Q

What should be done to prevent pertussis?

A

Post-exposure prophylaxis for all close contacts, with or without immunity

Immunization: Tdap for over 6 years and DTap for under 6 years

94
Q

How is the DTaP vaccine recommended for?

A

all children 6 weeks through 6 years of age

95
Q

When is the Tdap booster recommended? How many?

A

single booster dose for adolescents 11-12 years old

96
Q

Which adults should be targeted for Tdap vaccine?

A

Tdap should replace next Td vaccine, especially for adults with children

97
Q

What is cystic fibrosis?

A

Multi-systemic progressive illness with varying degrees of severity

Manifests in COPD, GI disorder and exocrine dysfunction

Autosomal recessive

The median predicted survival for CF patients in the United States was 36.8 years

Generally lungs ok at birth, and then they become thick. If recurrent lung infection/ failure to thrive, suspect CF.

98
Q

What is the pathology of cystic fibrosis?

A

Defect in the CF transmembrane conductance regulator protein (CFTR) which is expressed in epithelial cell and blood cells.

CFTR defect causes defective ion transport, airway surface liquid depletion and defective mucociliary clearance

99
Q

What are the expected physical exam findings for the lungs in cystic fibrosis?

A

Lungs at birth normal

Marked impermeability to chloride and sodium reabsorption

Mucous is vicious and leads to decreased motility

Leads to lung infections

100
Q

What are the expected physical findings for the GI with cystic fibrosis?

A

Meconium ileus (first 2 weeks of life)- thicker meconium leads to intestinal blockages

Failure to thrive due to pancreatic enzyme insufficiency

101
Q

What are the expected physical findings for the endocrine in cystic fibrosis?

A

Recurrent acute pancreatitis

DM

102
Q

How is cystic fibrosis diagnosed?

A

Sweat test and genetic (newborn) screening

103
Q

What is ciliary dyskinesia?

A

Autosomal recessive

Impairment in mucociliary clearance

Defect in cilia in airway, leads to ciliary immotililty or ciliary dyskinesia

104
Q

What are the clinical manifestations of ciliary dyskinesia?

A

Respiratory Infections

Rhinosinusitis

Nasal polyps

Otitis media

Situs inversus 50%

Decreased fertility

Associated with transposition of the great vessels

105
Q

What is a pleural effusion?

A

Fluid collection between visceral pleura and the parietal pleura and gravitates to dependent part of lung

Occurs when the rate of fluid production in the lungs exceeds the rate of fluid absorption

106
Q

What are the two types of pleural effusions?

A

Transudative effusion

Exudative effusions

107
Q

What is a transudative effusion? What are common causes?

A

associated with pressure filtration without capillary injury

Heart failure and liver cirrhosis common causes

108
Q

What is an exudative effusion? What are common causes?

A

“inflammatory fluid” leaking between cells.

Pneumonia and malignancy most common causes

109
Q

What are possible causes of pleural effusions?

A

Atelectasis, Cirrhosis, CHF, Cardiovascular dysfunction, Malignant disease, Nephrotic syndrome- b/c extra fluid, Pneumonia, RA, DM, Lupus, Viral Illness

110
Q

What is the common clinical presentation of a pleural effusion?

A

Dyspnea

Non-productive cough

Pleuritic chest pain

Activity intolerance

Asymptomatic

111
Q

What are typical respiratory physical exam findings you would expect for a pleural effusion?

A

Diminished or absent breath sounds

Decreased respiratory excursion

Absent tactile fremitus

Dullness to percussion

Egophony

Friction rub

112
Q

What are typical cardiovascular physical exam findings you would expect for a pleural effusion?

A

JVD

S3

113
Q

What are typical abdominal physical exam findings you would expect for a pleural effusion?

A

hepatospelnomegaly

ascities

114
Q

What are typical differential diagnosis for pleural effusions?

A

Pneumothorax

CHF

Neoplasm

Trauma

TB

115
Q

How is a pleural effusion diagnosed?

A

CXR- sensitive with more than 500 mL fluid

Ultrasound- very sensitive

116
Q

What is the treatment of a pleural effusion?

A

Thoracentesis recommended in all patients with more than a minimal pleural effusion

(i. e., larger than 1 cm height on lateral decubitus radiograph, ultrasound, or CT) of unknown origin*
* Not usually recommended in the case of heart failure

Can help determine the cause of PE

117
Q

What is Pleurisy (pleuritis)?

A

Inflammation of the pleura with or without pleural effusion

Pain caused by pleural layers rubbing together

Not a diagnosis, related to localized or systemic disease process

Rarely malignant cause

Most commonly related to viral or bacterial infection like TB, Pulmonary infarct, or Lupus.

118
Q

What is the clinical presentation of pleurisy?

A

May have preceding viral or bacterial infection, so ask about recent illness

Pain with breathing

Sharp, stabbing shooting pain

Usually localized, can radiate to shoulder

Pain increases with inspiration

Will feel better lying on affected side to limit lung expansion

119
Q

What is expected to find in the respiratory physical exam with pleurisy?

A

Pneumothorax

Rib fracture

Costochondritis

Vertebral fracture

Nerve root pain from herpes

Cardiac etiology

120
Q

What diagnostic testing is need for pleurisy?

A

CBC looking for leukocytosis or leukopenia

CXR looking for pneumonia, pneumothorax, effusion

Chest CT Scan: if unsure of cause

121
Q

How is pleurisy treated?

A

Treat underlying infection

Depending on etiology co-manage with pulmonary

Use of NSAID or corticosteroids maybe appropriate

122
Q

What is sarcoidosis?

A

Multisystem, inflammatory, granulomatous disease

Involves lungs and intrathoracic lymph nodes in 90% of affected individuals

123
Q

What is the pathophysiology of sarcoidosis?

A

Alveolitis usually proceeds granuloma

Initial cause unknown, the alveolitis begins to accumulate T cells and macrophages

The activation of macrophages leads to the development of fibrosis

familiar pattern, but not genetic

124
Q

What is the clinical presentation of sarcoidosis?

A

Usually will present with non-specific symptoms

Dry cough

Dyspnea

Chest pain

Fever

Fatigue

Anorexia

Weight loss

Nasal congestion, polyps, stridor

Skin nodules

Vision: blurry, eye pain, severe redness

125
Q

What are the differential diagnosis for sarcoidosis?

A

Hypersensitivity pneumonitis

Asbestosis

Silicosis

Infection

Lymphoma

Wagner’s granulomatosis

126
Q

What is TB?

A

Is an airborne infectious disease caused by Mycobacterium tuberculosis, that remains alive outside of the host for relatively long period

Drug resistance cases have increased, despite decrease in overall TB

127
Q

What is the pathophysiology behind TB?

A

TB spread by direct contact and indirectly by airborne transmission

Once inhaled, bacteria travel to lung alveoli and establish infection

128
Q

What is latent TB?

A

LTBI is the presence of M. tuberculosis organisms (tubercle bacilli) without symptoms or radiographic evidence of TB disease.

If untreated: 5-10% will progress to TB

Asymptomatic and non infectious

129
Q

When is TB detectable after being infected?

A

8–12 wks after infection, immune response limits activity; infection is detectable

130
Q

How is latent TB detected?

A

TST- skin test, wheal must be

131
Q

If a patient has been positive on a TST, how do you re-test TB?

A

No TST

Do a chest x-ray

132
Q

What does a positive TST test look like?

A

induration at site of wheal

133
Q

What happens with pregnant mothers infected with TB?

A

TST is ok, no CI

Should have chest radiographs ASAP, and consult to determine appropriate treatment

134
Q

What is BCG?

A

BCG is a anti-TB vaccine given to infants/children in endemic countries

Vaccine wanes over time

Their TSH should be interpreted the same as non-vaccinated people , but some concerned for false positive, so do IGRA

135
Q

Which TB test is preferred?

A

TST is preferred over IGRA

Routine testing is not recommended

136
Q

How is LTBI and active TB distinguished on testing?

A

LTBI- no physical findings or symptoms, but will have positive TST/IGRA results. CXR are normal. Respiratory specimens/cultures are negative.

TB- symptomatic and positive TST/IGRA results. CXR is abnormal. Respiratory specimens/cultures are positive.

137
Q

What is the 12 week (3 month) treatment for TB?

A

Isoniazid (INH) and Rifapentine (RPT) taken once weekly

Based on body weight

138
Q

Who is not recommended for the 12 week treatment?

A

children under 2 yo

HIV taking ART therapy

Presumed resistant TB

Pregnant, expecting to become pregnant

139
Q

What screening should be done after treated for TB?

A

Don’t require repeat testing

Receive regular symptom screen

140
Q

What are the symptoms of active TB?

A

Fever

cough

chest pain

weight loss

night sweats

hemoptysis

fatigue

decreased appetite

141
Q

How is TB detection in children different than adults?

A

May not have the classic signs

CXR findings subtle

Symptoms: malaise, failure to thrive or weight loss, and recurrent PNAs

Diagnosis & Mgmt 1 (7 decks)

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