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Clin Med IIB Pulmonology > Lower Respiratory Infections: Bronchitis / Influenza / Pertussis - Part 1 > Flashcards

Lower Respiratory Infections: Bronchitis / Influenza / Pertussis - Part 1 Flashcards

1
Q

What differentiates a LRI from a URI?

A

LRI is in the chest area
URI is above the chest

These are connected though - you should still ask URI questions (runny nose, sore throat)

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2
Q

What are the pertinent questions for LRI? (just read over)

A

What is causing it?
Is it acute or chronic?
Is it associated with constitutional symptoms?
Is it serious or constitute an emergency? (SOB, not forming sentences)
What do I need to assess?
What tests do I need to order?
How can I be confident in my diagnosis?
When to treat empirically?
What to prescribe and when are antimicrobials necessary?

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3
Q

When ordering tests, what should you do?

A

Order minimally based on s/s

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4
Q

How often do adults vs kids have LRI?

A

Adults 2-3 times a year
Children 8 a year

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5
Q

What is the #1 cause of a high instance of childhood LRI?

A

Second-hand smoke

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6
Q

How long do symptoms persist for LRI, and why is this an issue?

A

Persist for weeks :(
Often viral, so no AB

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7
Q

What differentiates viral and bacterial?

A

Bacterial = lack of cough, prolonged symptoms, SOB, fever

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8
Q

What are some PMH / PSH / Social Hx / Family Hx?

A

Married / Single - relationship status
Occupation
Social - smoker, if so, how many years, how many per day, ever tried to quit?
Environmental exposure
Recent travel (could lead to PE)
Recent hospitalization (hospital-acquired illnesses) or surgery
Family history - COPD, asthma, cancer, HTN, HLD, etc.

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9
Q

What are the general s/s of LRTI?

A

General: Fever, malaise, weakness, fatigue, wt loss (cancer/TB)/gain, headache

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10
Q

What are the EENT of LRTI?

A

Itchy/watery eyes, discharge, nasal congestion, runny nose, sore throat, post-nasal drip, earache, fullness in ears, facial pain

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11
Q

What are the CV of LRTI?

A

Chest pain/pressure, dyspnea (rest, exercise, sleep), palpitations

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12
Q

What are the respiratory of LRTI?

A

Cough: productive / nonproductive, post-tussive emesis, hemoptysis, dyspnea

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13
Q

What are the abdominal of LRTI?

A

N/V/D, dyspepsia, hematemesis, hematochezia

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14
Q

What are the skin of LRTI?

A

Rash, lesions, easy bruising

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15
Q

What are the PE findings of LRTI?

A

General: NAD
EENT: FULL EXAM
CV: RRR w/o murmur, normal S1/S2, no thrills, rubs, or gallops, peripheral pulses equal throughout.
Neck: Trachea midline, no JVD, no LAD
Respiratory: Inspection /Palpation Percussion / Auscultation
No nasal flaring, no retractions. CTAB, no W/R/R.
What are the Skin: Rashes, lesions, bruising, pedal edema, or clubbing

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16
Q

Why would a patient with a cough have a rash?

A

Might see petechiae d/t trauma from coughing so much.

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17
Q

What is acute, sub-acute, and chronic cough?

A

Acute < 3 weeks
Sub-acute 3-8 weeks
Chronic >8 weeks

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18
Q

What separates acute from chronic bronchitis?

A

Cough more than 3 months over a 2 year period

Treated differently d/t pathology and outcomes

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19
Q

What is the #1 cause of acute bronchitis? What are t he.

A

VIRAL MC (90-95% of cases), bacterial not as common

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20
Q

What percent of acute bronchitis seek treatment?

A

90%

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21
Q

How long does acute bronchitis last?

A

Lasts 5 days to 3 weeks

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22
Q

When do you see bacterial bronchitis?

A

Immunocompromised patients (which is why this is not common)

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23
Q

What is the sputum production of bronchitis?

A

Sometimes none

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24
Q

Why is there pain in the chest from palpate the chest for acute bronchitis?

A

Irritation from coughing can cause pain

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25
What is the pathophys of acute bronchitis?
1. direct inoculation of tracheobronchial epithelium 2. Hypersensitivity (last 1-3 weeks, sloughed epithelium leading to sputum production, air passages are clogged by this debris and irritation)
26
What are the viruses that cause acute bronchitis?
Influenza A/B Adenovirus Parainfluenza RSV Rhinovirus/Picornavirus Coronavirus HMNV
27
What are the bacterial causes of acute bronchitis?
Strep pneumo H flu M cat Same as AOM!!!
28
What are the atypical causes of acute bronchitis?
B pertussis C pneumonia M pneumonia B bronchiseptica (kettle cough) typically in immunocompromised
29
What is the MC of Acute bronchitis?
Influenza A/B
30
What do you need to know for HPI of acute bronchitis?
Nature and duration of cough Fever, malaise Expectoration (amount, consistency, hemoptysis) Breathing problems (dyspnea, stridor) Smoking history Previous respiratory infections, chronic bronchitis/sinusitis Allergies, COPD, Asthma / Comorbidities Hoarseness, rhinitis Medication(s) ACE I Exposure to inhalative noxae Resp tract diseases in family
31
What are the symptoms of acute bronchitis?
Cough Substernal pain wheezing Fever (low grade, often absent) Fatigue Malaise Chest tightness SOB Dyspnea Cyanosis
32
What symptoms are not seen in acute bronchitis?
no URI symptoms sneezing throat these often proceed acute bronchitis
33
What are the PE of acute bronchitis?
General: Lethargic, irritable unable to speak, vitals (,T, RR) ENT: Ears, nose, throat Palpate and transilluminate sinuse CV: Heart, JVD Lungs: Inspection / Percussion / Palpation / Auscultation Wheezing - insp/exp Crackles/Rales Rhonchi - clear w/ cough?
34
What is wheezing indicative of?
Inflammation
35
What is rhonchi?
Mucous that clears as you cough (clear lungs afterwords)
36
What is the difference between stridor and wheezing?
Stridor: inspiratory (blockage) Wheezing: expiratory
37
What are some zebras of acute bronchitis?
Diffuse wheezing with increased respiratory effort (worried about asthma, RSV), use of accessory muscles Stridor (inspiration problems) Sustained heave across left sternal border? RVH Clubbing of digits and peripheral cyanosis? (chronic bronchitis) Bullous myringitis? (atypical) Conjunctivitis, adenopathy, and rhinorrhea? (viral - adenovirus)
38
What does adenovirus affect?
Every mucous membrane
39
What do we need to r/o for acute bronchitis
pneumonia: fever, dyspnea, SOB, productive cough - hear isolated rales) GERD: chronic cough URTI: UACS: upper airway congestion syndrome, chronic drainage, AKA postnasal drip ACEI use Malignancy
40
What are the emergent worries for dx of acute bronchitis?
Pneumonia: (fever, tachypnea, tachycardia) Pulmonary embolism: (dyspnea, tachypnea, thoracic pain, tachycardia) Pulmonary edema: (tachypnea, dyspnea, rales) Status asthmaticus: (expiratory rhonchi, prolonged expiration, wheezing, beware: silent chest) Pneumothorax: (stabbing thoracic pain, asymmetric thoracic motion, unilateral attenuation of breath sounds, hypersonic percussion sound) Foreign Body Aspiration: (dyspnea, inspiratory stridor) CHF
41
How is acute bronchitis typically diagnosed?
Clinically
42
When is a CXR indicated for acute bronchitis?
Infant/elderly/unclear exam Usually unremarkable
43
What labs can you use to dx acute bronchitis?
NP swab / viral panel Influenza, COVID CBC with diff Procalcitonin (to distinguish bacterial vs. nonbacterial) > 0.25 mcg/L (non-ICU) > 0.5 mcg/L (ICU) Blood Culture (if bacterial suspected) Sputum cytology, gram stain, culture (if cough persistent, ill appearing and diagnosis unclear) Bronchoscopy (to exclude foreign body aspiration, TB, tumors, and other chronic diseases)
44
What does a CBC typically show for acute bronchitis?
Normal for viral Sometimes even low
45
If a swab comes back negative, does it r/o acute bronchitis? What about if it comes back normal?
Negative does not r/o Positive confirms
46
What procalcitonin level indicates viral vs bacterial?
> 0.25 mcg/L (non-ICU) > 0.5 mcg/L (ICU)
47
What should you order for a suspected bacterial acute bronchitis?
CBC
48
What is the treatment of acute bronchitis?
Time :( AB not recommended No clear guidelines Symptomatic: Rest Hydration Cough meds: Antitussives, Expectorants (these are not for acute, because we want them to cough it up) Antihistamines (diphenhydramine) Decongestants (phenylephrine)
49
If a patient is wheezing, what should you give a patient?
B2 Agonists (albuterol) - if wheezing
50
What is seen in pneumonia that is not seen in acute bronchitis?
Abnormal lung exams (cxr is clear in acute bronchitis) Rare in healthy adults w/o abnormal VS (HR >100, RR >24, oral temp >38℃, and abnormal lung exam)
51
When do you avoid Dextromethorphan?
Sputum production Should instead be used for dry-hacking cough
52
MOA of dextromethorphan
Acts centrally to elevate the threshold for coughing by acting on the medullary cough center Equally as effective as codeine in reducing cough frequency
53
What is Codeine?
Opioid for cough not shown to be more efficacious
54
What are the SE of codeine?
Dependence, so many DDI
55
What is the MOA benzonate
Peripheral acting Excellent choice even for productive cough Hinders stretch sensation, decreasing urge to cough
56
What is the disadvantage of benzoate?
Only for 10+ yo DO NOT CHEW d/t local anesthesia
57
What is the MOA of guaifenesin?
Reduces chest congestion facilitating more mucous secretion and increasing sputum production First-line
58
What are the s/s of influenza
VARY greatly
59
Pathophys of influenza
Encapsulated, single-stranded RNA viruses The surface proteins hemagglutinin and neuraminidase are critical for virulence Hemagglutinin binds to respiratory epithelial cells, allowing cellular infection. Neuraminidase cleaves the bond that holds newly replicated virions to the cell surface, permitting the infection to spread The hemagglutinin and neuraminidase variants are used to identify influenza A virus subtypes
60
What are the two main surface proteins that cause influenza?
hemagglutinin neuraminidase
61
Why do you still have the symptoms from influenza after treatment?
Treatment only effects neuraminadase, hemagglutinin has already stuck to cells, and will still cause symptoms
62
How do you identify the category of the flu?
Based on the surface proteins
63
What influenza are the most concerning/pathogenic? But what is a positive of these?
Infuenza A, but can be killed easier
64
What is the incubation period of influenza?
Transmission may occur 1 day before the onset of symptoms Viral shedding lasts for approximately 5 to 10 days Most virulent in the first 3 days of symptoms
65
What areas do you see influenza more?
Tropical areas - occurs throughout the year Northern Hemisphere - typically starts in early fall, peaks in mid-February, and ends in the late spring of the following year
66
What is the general symptoms of influenza?
fever, HA, fatigue, body aches, pains, N/V/D, myalgia, cough, dyspnea, sore throat, rhinorrhea, cough, dyspnea
67
What is the general signs in PE of influenza?
lathargic, clear lungs, tachycardia, tenderness
68
What do you use to confirm influenza?
The criterion standard for confirming influenza virus infection is reverse transcription-polymerase chain reaction (RT-PCR) or viral culture of nasopharyngeal or throat secretions Typically just clincal sus and flu swab or NP swab
69
What do you order if concerned for other things for flu?
Chest x-ray to rule out pneumonia Early radiographic findings include no or minimal bilateral symmetrical interstitial infiltrates. Later, bilateral symmetrical patch infiltrates become visible Focal infiltrates indicate superimposed bacterial pneumonia CBC may show leukopenia and lymphocytopenia Ask about exposures, day care, school, work environment, etc.
70
What is the mng of the flu?
symptomatic NSAIDs Isolation Rest Hospitalization if trouble breathing
71
When do you treat with Tamiflu? What are the ages?
if w/in 48 hours can be used in kids 2 weeks +
72
When do you not use zanamivir?
asthmatics because inhaled
73
when do you use rapivab?
severely sick
74
when do you use Baloxavir?
high-risk
75
Tamiflu dosing is based on
Body weight
76
What is a quadrivalent vaccine?
Protects 2 strains of A and 2 strains of B should be used in preggos as it also has protection for fetus
77
What is flu myst used for?
2-49 years Live vaccine not for preggos, CF, asthmatics
78
What is pertussis AKA?
Whooping cough
79
How do you prevent pertussis?
vaccine HIGHLY contagious
80
What is the pathophys of pertussis?
Caused by Bordetella pertussis and Bordetella parapertussis (milder form) Is a gram-negative, aerobic, encapsulated, pleomorphic coccobacilli Spreads by aerosolized droplets Attaches to the respiratory epithelium, starting in the nasal passages and then down to the bronchi and bronchioles
81
If you have pertussis once, can you get sick again?
Yes :(
82
What does pertussis produce?
Toxins A and B B attaches to the cell surface A enters the cell and inactivates the regulation of cAMP ↑ mucus production ↓ phagocytic killing Invasive adenylate cyclase ↑ production of cAMP ↑ mucus formation continuous cycle
83
How long is pertussis and what are the three main stages?
Incubation (4-24 days) Stage 1: catarrhal stage (1-2 weeks) Stage 2: paroxysmal (1-10 weeks) Stage 3: Convalescence stage (2-3 weeks)
84
Stage 1 catarrhal for percussion
1 - 2 weeks Nasal Congestion Rhinorrhea Sneezing Low grade fever Tearing Conjunctival Erythema
85
Stage 2 Paroxysmal Stage
1 - 10 weeks Paroxysms of intense coughing with “whoop” Posttussive vomiting and turning red with coughing
86
Stage 3: Convalescent Stage
2 - 3 weeks Chronic cough lasting for weeks
87
What is important to remember if you are positive for pertussis?
ALL contacts need to be treated and there will need to be report to the health department
88
What is the PE of pertussis in kids > 3 months?
Typically afebrile Coughing (usually in spells or incessantly) Conjunctival hemorrhages and facial petechiae from coughing Rhonchi on auscultation which improve with cough Otherwise, no specific physical exam findings
89
What is the PE of pertussis in kids < 3 months?
Infants < 3mo: Well-appearing → choking Gasp and flail extremities Reddened face Cough may not be prominent May be apneic with bradycardia Whoop “infrequent”
90
What do you need to hook up to a baby if they have pertussis?
Feeding tube, because they cannot eat d/t how bad the cough is
91
How do you dx pertussis?
Clinical diagnosis primarily Suspicion should be high in children with cough for more than 2 weeks Posttussive emesis; inspiratory whoop; paroxysms of coughing Endemic areas No vaccination or reported exposure Chest xray is likely normal Leukocytosis and lymphocytosis on CBC possible
92
What is the gold standard for pertussis?
bacterial culture of nasopharyngeal secretions confirm Bordetella pertussis infection
93
What is important to know about testing for pertussis?
Small window of dx, so if they cough for more than 2 weeks, you will need to order serolgy and will see + IgM
94
What is the management of pertussis?
Decrease symptoms Respiratory isolation room (isolation for 5 days after initiation) maximize nutrition
95
What AB do you use for first-line pertussis? Which is preferred?
Azithromycin and clarithromycin Azithromycin preferred in infants < 1 mo: (risk of IHPS with E-mycin)
96
What is second-line if you can't tolerate a macrolide? What is this CI in?
Bactrim < 2 months is CI
97
What is azithromycin CI in?
Prolonged QT interval Bradycardia Heart related problems
98
What are the complications of pertussis?
Pneumonia Seizures (lack of O2) Rib fractures (coughing too much) Encephelopathy Hernias Pnemothorax Death Weight loss Etc
99
DTaP vs Tdap
DTaP 2,4 and 6 months TDap every 10 years for adults

Clin Med IIB Pulmonology (12 decks)

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