Lower Respiratory Infections - Part 1 - Exam 1 Flashcards
How long do you need to be coughing in order to be considered acute? subacute? chronic?
Acute: < 3 weeks (viruses, bacterial infections, COPD exacerbations)
Subacute: 3 - 8 weeks (post-infectious cough)
Chronic: > 8 weeks (COPD, GERD, PND)
What are some important history questions to ask your pt when they present with a cough?
Occupation
Smoking status (including vape, marijuana)
Environmental exposures/recent travel
Recent hospitalizations, surgeries, do they live in a facility
Family history of chronic coughing issues (asthma, cancer)
New medications
What is acute bronchitis defined as? When are the most cases present? What is the MC underlying cause?
Self-limiting inflammation of the bronchi (< 3 weeks)
usually in the fall/winter months
Viruses
What is the pathophys behind acute bronchitis?
virus/bacteria/irritant get into airway ->
inflammation of airway -> exudate production -> bronchospams/cough
What are the 2 sequential phases of acute bronchitis? How long do each last?
- Direct inoculation of tracheobronchial epithelium -> typical presentation -> lasts 1-5 days
- Hypersensitivity of the airway receptors -> responsible for persistent s/s -> last 1-3 weeks
What causes increased sputum production in hypersensitivity of airway receptors? What can this lead to?
Sloughed epithelium
Air passages clogged by debris and irritation
What are the viral causes of 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
What are the atypical causes of acute bronchitis?
B pertussis (1-12%)
C pneumonia (0-6%)
M pneumonia (0-6%)
B bronchiseptica
What are some s/s that would make you think this is an emergent situation?
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
T/F: It is necessary if you suspect acute bronchitis to order a CXR to confirm.
FALSE!!! clinical dx is acceptable
When would you order a CXR in acute bronchitis? What will it look like?
if the exam was unclear/unsure, in an infant, elderly population
except to see a normal CXR
What lab studies would you want to order if you suspect acute bronchitis?
NP swab +/- viral panel
CBC with diff
procalcitonin
blood culture
sputum cytology
bronchoscopy
You have a pt with acute bronchitis, what would you expect their CBC with diff to show?
lymphopenia and leukopenia
What does the procalcitonin level tell you? What are the levels specifically?
to rule in or out a bacterial infection
if the number is higher than 0.25 think bacterial infection
> 0.25 mcg/L (non-ICU)
> 0.5 mcg/L (ICU)
When would you order a sputum cytology?
will also gram stain and culture if cough persistent, ill appearing and diagnosis unclear)
Why would you order a bronchoscopy?
to exclude foreign body aspiration, TB, tumors, and other chronic diseases)
What is the tx for symptomatic acute bronchitis?
rest, hydration, cough medication, antihistamines, decongestants, albuterol if wheezing
Which antitussives are central acting? peripheral?
dextromethorphan
benzonatate
______ is the MC non-opioid agent used for cough
dextromethorphan
_____ MOA acts centrally to elevate the threshold for coughing by acting on the medullary cough center
dextromethorphan and codeine
antitussive are classified as ___________
NMDA receptor antagonist
**What antitussive it is possible to overdose on?
codeine
What drug class is benzonatate in? Is it central or peripheral?
procaine derivative
peripheral
_______ inhibits pulmonary stretch receptors and decreases the reflex in the lungs which causes the urge to cough
benzonatate
What drug class is guaifenesin?
expectorants
______ increase mucous secretion or increase airway water to facilitate mucus expulsion from the airways.
guaifenesin
guaifenesin ______ sputum volume and _____ sputum viscosity
increases sputum volume
decreases sputum viscosity
What is the CI to guaifenesin?
hypersensitivity
**What should a pt with the flu lung’s sound like?
lungs should be normal/ have normal lung sounds
What are the different strains of the flu? Which 2 are more common? Which one is the worst?
ABCD
A and B are most common
A is worse than B
What is the flu composed of? What are the 2 surface proteins that are critical for virulence?
Encapsulated, single-stranded RNA viruses
hemagglutinin and neuraminidase
______ binds to respiratory epithelial cells, allowing cellular infection
Hemagglutinin
______ cleaves the bond that holds newly replicated virions to the cell surface, permitting the infection to spread
Neuraminidase
**Who are the number 1 carriers that transmit pertussis to babies?
human adults
How is the flu spread? What is the incubation period?
Spreads from human to human via respiratory contact vs fomites (objects or materials which are likely to carry infection, such as clothes, utensils, and furniture)
incubation period ranges from 1 to 4 days
Flu: Viral shedding lasts for approximately ______. Most virulent in the first _____ of symptoms
5 to 10 days
3 days
In the northern hemisphere when is the peak of flu season? What is the typical season?
peaks in mid-February
early fall and ends in late spring the following year
How do you dx flu?
clinical suspicion
then rapid flu or NP swab
The criterion standard for confirming influenza virus infection is ______ or _______
reverse transcription-polymerase chain reaction (RT-PCR)
viral culture of nasopharyngeal or throat secretions
**When would you treat someone with antivirals if you suspect the flu? What is the tx? What do you need to get before prescribing the appropriate medication?
Has to be within the first 48 hours of symptoms!!!
Oseltamivir (Tamiflu) 75 mg bid X 5 days (adolescent/adult)
BMP to check renal function
What is the prophylactic tx for flu?
Oseltamivir (Tamiflu) 75 mg qd X 10 days (adolescent/adult)
Which flu antiviral is indicated for high-risk pts?
Oseltamivir (Tamiflu)
Zanamivir (Relenza)
Rapivab (Peramivir) (IV only)
Baloxavir marboxil (Xofluza)
Baloxavir marboxil (Xofluza)
T/F: oseltamivir and zanamivir have activity against influenza A and B viruses (including H1N1)
True!! Adamantes were used to treat flu A (no coverage for B) but no longer used/recommended for flu
How effective is the flu vaccine at preventing infection? When does it start taking effect?
Vaccination provides approximately 50 - 70% efficacy against Influenza A and B
Immunity is effective after 10 to 14 days
What type of vaccine is the flu? What type of vaccine is the nasal spray vaccine?
inactivated virus
live, attenuated influenza virus
Who is indicated for the nasal spray vaccine?
Indicated only for healthy people aged 2-49 years who are not pregnant
What is the MC form of pertussis? What pt population tends to get it a more severe form?
bordetella pertussis
pts under 2 years old
T/F: You only need to get one dose of the pertussis vaccine to be immune for life.
FALSE!! does NOT provide lifelong immunity and need to get booster shots
What is pertussis caused by? What is the milder form? Gram + or -?
Bordetella pertussis and Bordetella parapertussis (milder form)
gram (-) aerobic, encapsulated, coccobacilli
**Why does pertussis sound like a “whooping cough?”
Attaches to the respiratory epithelium, starting in the nasal passages and then down to the bronchi and bronchioles - produces toxins, destroys respiratory cells, causes microaspirations
aka the pathophys
In pertussis, toxin ___ attaches to the cell surface. toxin ____ enters the cell and inactivates the regulation of cAMP. What happens as a result?
B
A
↑ mucus production
↓ phagocytic killing
What happens in pertussis as a result of invasive adenylate cyclase?
↑ production of cAMP
↑ mucus formation
If you have NEVER had a flu vaccine and you are between the ages of ____ and ____, what is the recommendation?
6 months and 8 years need to get 2 flu vaccines at least 4 weeks apart
pertussis is a _____ disease divided into 3 stages. Name the 3 stages. How long does each stage last?
6 week disease
catarrhal, paroxysmal, and convalescent stages
each lasting 1-2 weeks
What are the s/s of catarrhal stage pertussis?
1 - 2 weeks
Nasal Congestion
Rhinorrhea
Sneezing
Low grade fever
Tearing
Conjunctival Erythema
What are the s/s of paroxysmal stage pertussis?
1 - 10 weeks
Paroxysms of intense coughing with “whoop”
Posttussive vomiting and turning red with coughing
What are the s/s of convalescent stage pertussis?
2 - 3 weeks
Chronic cough lasting for weeks
What is the worst stage in pertussis?
Stage 2: Paroxysmal Stage
What will the lungs should like with a pt who has pertussis? What is a common facial PE finding?
Rhonchi on auscultation which improve with cough
Conjunctival hemorrhages and facial petechiae from coughing
When should you suspect pertussis in a child?
cough more than 2 weeks!
in an endemic area
no vaccination
Posttussive emesis; inspiratory whoop; paroxysms of coughing
What does a CXR look like on a pt with pertussis? CBC?
CXR is likely normal
leukocytosis and/or lymphocytosis is possible
**What is the gold standard to dx pertussis?
bacterial culture of nasopharyngeal secretions confirm Bordetella pertussis infection
Pertussis will have _____ detected in NP secretion
Polymerase chain reaction (PCR) detection in NP secretions
The NP swab/PCR will be positive for pertussis around _____ weeks from start of cough. Once you start abx, when will a pt test negative?
4 weeks
Become negative w/in 5 days of antibiotic therapy
______ can be done in the later phases to confirm the diagnosis of pertussis
Enzyme immunoassays
What is abx tx for pertussis?
Azithromycin!!
**What is the abx tx for pertussis in an infant who is less than 1 month old? Why?
Azithromycin preferred in infants < 1 mo: (risk of IHPS with E-mycin) Infantile hypertrophic pyloric stenosis which can lead to an obstruction and violent vomiting
______ is the alternative abx for pertussis in adults who cannot tolerate macrolides
Bactrim (TMP-SMX)
Why do you avoid Bactrim in infants who are less than 2 months old?
risk for kernicterus (elevated bilirubin)
Should you treat close contacts of people infected with pertussis? If so, with what?
YES!! empirically treat with azithromycin
**What is the dosing schedule for azithromycin for a pertussis infection?
Azithromycin 500 mg on day 1, 250 mg subsequently qd for 5 days
______ is a pertussis complication that is more likely in infants
Pneumonia
What pertussis vaccine is recommended for young children? for adults? When should pregnant women receive _____ vaccine
DTap is for chilDren
Tdap is for adulTs
Tdap between 27-36th week of pregnancy
