Lower Respiratory Infections: Bronchitis / Influenza / Pertussis - Part 1 Flashcards
What differentiates a LRI from a URI?
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)
What are the pertinent questions for LRI? (just read over)
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?
When ordering tests, what should you do?
Order minimally based on s/s
How often do adults vs kids have LRI?
Adults 2-3 times a year
Children 8 a year
What is the #1 cause of a high instance of childhood LRI?
Second-hand smoke
How long do symptoms persist for LRI, and why is this an issue?
Persist for weeks :(
Often viral, so no AB
What differentiates viral and bacterial?
Bacterial = lack of cough, prolonged symptoms, SOB, fever
What are some PMH / PSH / Social Hx / Family Hx?
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.
What are the general s/s of LRTI?
General: Fever, malaise, weakness, fatigue, wt loss (cancer/TB)/gain, headache
What are the EENT of LRTI?
Itchy/watery eyes, discharge, nasal congestion, runny nose, sore throat, post-nasal drip, earache, fullness in ears, facial pain
What are the CV of LRTI?
Chest pain/pressure, dyspnea (rest, exercise, sleep), palpitations
What are the respiratory of LRTI?
Cough: productive / nonproductive, post-tussive emesis, hemoptysis, dyspnea
What are the abdominal of LRTI?
N/V/D, dyspepsia, hematemesis, hematochezia
What are the skin of LRTI?
Rash, lesions, easy bruising
What are the PE findings of LRTI?
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
Why would a patient with a cough have a rash?
Might see petechiae d/t trauma from coughing so much.
What is acute, sub-acute, and chronic cough?
Acute < 3 weeks
Sub-acute 3-8 weeks
Chronic >8 weeks
What separates acute from chronic bronchitis?
Cough more than 3 months over a 2 year period
Treated differently d/t pathology and outcomes
What is the #1 cause of acute bronchitis? What are t he.
VIRAL MC (90-95% of cases), bacterial not as common
What percent of acute bronchitis seek treatment?
90%
How long does acute bronchitis last?
Lasts 5 days to 3 weeks
When do you see bacterial bronchitis?
Immunocompromised patients (which is why this is not common)
What is the sputum production of bronchitis?
Sometimes none
Why is there pain in the chest from palpate the chest for acute bronchitis?
Irritation from coughing can cause pain
What is the pathophys of acute bronchitis?
- direct inoculation of tracheobronchial epithelium
- Hypersensitivity (last 1-3 weeks, sloughed epithelium leading to sputum production, air passages are clogged by this debris and irritation)
What are the viruses that cause acute bronchitis?
Influenza A/B
Adenovirus
Parainfluenza
RSV
Rhinovirus/Picornavirus
Coronavirus
HMNV
What are the bacterial causes of acute bronchitis?
Strep pneumo
H flu
M cat
Same as AOM!!!
What are the atypical causes of acute bronchitis?
B pertussis
C pneumonia
M pneumonia
B bronchiseptica (kettle cough)
typically in immunocompromised
What is the MC of Acute bronchitis?
Influenza A/B
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
What are the symptoms of acute bronchitis?
Cough
Substernal pain
wheezing
Fever (low grade, often absent)
Fatigue
Malaise
Chest tightness
SOB
Dyspnea
Cyanosis
What symptoms are not seen in acute bronchitis?
no URI symptoms
sneezing
throat
these often proceed acute bronchitis
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?
What is wheezing indicative of?
Inflammation
What is rhonchi?
Mucous that clears as you cough (clear lungs afterwords)
What is the difference between stridor and wheezing?
Stridor: inspiratory (blockage)
Wheezing: expiratory
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)
What does adenovirus affect?
Every mucous membrane
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
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
How is acute bronchitis typically diagnosed?
Clinically
When is a CXR indicated for acute bronchitis?
Infant/elderly/unclear exam
Usually unremarkable
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)
What does a CBC typically show for acute bronchitis?
Normal for viral
Sometimes even low
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
What procalcitonin level indicates viral vs bacterial?
> 0.25 mcg/L (non-ICU)
0.5 mcg/L (ICU)
What should you order for a suspected bacterial acute bronchitis?
CBC
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)
If a patient is wheezing, what should you give a patient?
B2 Agonists (albuterol) - if wheezing
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)
When do you avoid Dextromethorphan?
Sputum production
Should instead be used for dry-hacking cough
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
What is Codeine?
Opioid for cough
not shown to be more efficacious
What are the SE of codeine?
Dependence, so many DDI
What is the MOA benzonate
Peripheral acting
Excellent choice even for productive cough
Hinders stretch sensation, decreasing urge to cough
What is the disadvantage of benzoate?
Only for 10+ yo
DO NOT CHEW d/t local anesthesia
What is the MOA of guaifenesin?
Reduces chest congestion facilitating more mucous secretion and increasing sputum production
First-line
What are the s/s of influenza
VARY greatly
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
What are the two main surface proteins that cause influenza?
hemagglutinin
neuraminidase
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
How do you identify the category of the flu?
Based on the surface proteins
What influenza are the most concerning/pathogenic? But what is a positive of these?
Infuenza A, but can be killed easier
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
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
What is the general symptoms of influenza?
fever, HA, fatigue, body aches, pains, N/V/D, myalgia, cough, dyspnea, sore throat, rhinorrhea, cough, dyspnea
What is the general signs in PE of influenza?
lathargic, clear lungs, tachycardia, tenderness
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
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.
What is the mng of the flu?
symptomatic
NSAIDs
Isolation
Rest
Hospitalization if trouble breathing
When do you treat with Tamiflu? What are the ages?
if w/in 48 hours
can be used in kids 2 weeks +
When do you not use zanamivir?
asthmatics because inhaled
when do you use rapivab?
severely sick
when do you use Baloxavir?
high-risk
Tamiflu dosing is based on
Body weight
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
What is flu myst used for?
2-49 years
Live vaccine not for preggos, CF, asthmatics
What is pertussis AKA?
Whooping cough
How do you prevent pertussis?
vaccine
HIGHLY contagious
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
If you have pertussis once, can you get sick again?
Yes :(
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
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)
Stage 1 catarrhal for percussion
1 - 2 weeks
Nasal Congestion
Rhinorrhea
Sneezing
Low grade fever
Tearing
Conjunctival Erythema
Stage 2 Paroxysmal Stage
1 - 10 weeks
Paroxysms of intense coughing with “whoop”
Posttussive vomiting and turning red with coughing
Stage 3: Convalescent Stage
2 - 3 weeks
Chronic cough lasting for weeks
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
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
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”
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
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
What is the gold standard for pertussis?
bacterial culture of nasopharyngeal secretions confirm Bordetella pertussis infection
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
What is the management of pertussis?
Decrease symptoms
Respiratory isolation room (isolation for 5 days after initiation)
maximize nutrition
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)
What is second-line if you can’t tolerate a macrolide? What is this CI in?
Bactrim
< 2 months is CI
What is azithromycin CI in?
Prolonged QT interval
Bradycardia
Heart related problems
What are the complications of pertussis?
Pneumonia
Seizures (lack of O2)
Rib fractures (coughing too much)
Encephelopathy
Hernias
Pnemothorax
Death
Weight loss
Etc
DTaP vs Tdap
DTaP
2,4 and 6 months
TDap every 10 years for adults
