Lower Respiratory Tract Disorders

Question 1

Community acquired pneumonia

Answer 1

lung / bronchi infection, caused by pathogens acquired while residing in community NOT in acute care

causative agents–> #1 S. PNEUMONIAE,
M. PNEUMONIAE, C PNEUMONIAE = ATYPICAL

Question 2

What are symptoms associated with S. pneumoniae CAP?

Answer 2

COMPS
conjunctivitis
otitis media
meningitis
pneumonia
sinusitis

Gram-positive diplococci

Question 3

What treatmens can be used for a previously healthy patient with S. pneumoniae CAP?

treatments also apply to H. influenzae, M. pneumoniae, adenovirus

Answer 3

Oral doxycycline 100 mg bid or
oral Azythromycin / erythromycin

can remember: ABCDE = azithro, biaxin (clarithro), doxycycline, erythromycin

Question 4

What treatments can be used for patients with CAP who have co-morbidities such as COPD, diabetes, renal or heart failure?

Answer 4

Respiratory floriquinolone PO
or
Doxycycline, azithromycin, clarithromycin PLUS beta lactam such as amoxicillin, amoxicillin clauv, PO or ceftriaxone IM

Question 5

Name and describe physical exam findings common in Pneumonia ?

Answer 5

Tachypnea - increased rate 2/2 impaired gas exchange
Crackles or rales - occurs from sudden opening of distal fluid filled airways
Consolidation - MOST OFTEN 2/2 pna but may be blood, DULLNESS TO PERCUSSION, INCREASED TACTILE FREMITUS NOT ALTERED BY COUGH
Pleuritic friction rub - 2/2 pleural inflammation, sharp/localized pain that is WORSE with deep breath, movement or cough

Question 6

What is the CURB-65 criteria associated with pneumonia?

Answer 6

calculated for mortality risk / appropriate treatment
C = CONFUSION, NEW ONSET
U= BUN >19
R= RESPIRATORY RATE OF 30 OR MORE
B= BLOOD PRESSURE <90 SYSTOLIC, <60 DIASTOLIC

AGE 65 OR OLDER

0-1 = outpatient treatment
2= consider short hospital stay, oral or parenteral antbx
3-5= hospitalization, consider icu need? parenteral antbx

Question 7

Acute bronchitis

Answer 7

lower airway inflammation, presents with cough with/without sputum production, lasting >5 days, usually follows URI

PE: resonance to percussion = normal, ronchi will clear w/ cough, clear auscultation

Tx- humidifier, increase fluids, analgesics if fever
Bacterial tx = macrolides, doxy or bactrim

Question 8

What are you most likely to find on a chest xray of someone with TB?

Answer 8

An infiltrate in the right upper lobe

Question 9

When is hospitalization recommended in asthma patient?

Answer 9

FEV1 less than 30% predicted

Peak flow is less than 60 liters/ minute

Question 10

What are omnious signs of asthma ?

Answer 10

fatigue
absent breath sounds
paradoxical chest / abdominal movement
inability to maintain recumbency 
cyanosis

Question 11

Is asthma a restrictive or obstructive disease?

Answer 11

obstructive

INFLAMMATORY DISEASE CAUSING DIFFICULTY BREATHING

Question 12

STEP 1 TREATMENT OF ASTHMA

Answer 12

Short acting beta2 agonist SABA = albuterol or levalbuterol
PRN
relaxes bronchial muscles

Question 13

STEP 2 TREATMENT OF ASTHMA

Answer 13

low dose inhaled corticosteroid ICS = budenoside PULMICORT, fluticasone FLOVENT, triamcinolone AZMACORT

Question 14

STEP 3 TREATMENT OF ASTHMA

Answer 14

Low dose ICS + long active beta2 agonist LABA
salmeterol or perforomist 
combination preparations = 
FLUTICASONE + SALMETEROL = ADVAIR
FORMOTEROL + BUDESONIDE = SYMBICORT

Question 15

NAME SOME INHALED CORTICOSTEROIDS

Answer 15

FLOVENT
PULMICORT
MOMETASONE

PREFERRED CONTROLLER TREATMENT FOR PERSISTENT ASTHMA
CONSISTENT DAILY USE

Question 16

NAME ICS / LONG ACTING BETA AGONISTS COMBOS FOR ASTHMA

Answer 16

BUDESONIDE + FORMOTEROL = SYMBICORT
FLUTICASONE + SALMETEROL = ADVAIR
MOMETASONE + FORMOTEROL = DULERA

IF controlled with ICS alone, no need to use the above

Question 17

What is a leukotriene modifier used for asthma?

Answer 17

MONTELUKAST OR SINGULAIR

added benefit of allergic rhinitis support
more often used in conjunction with ICS

Question 18

Name asthma relieving medications

Answer 18

SABAs = albuterol, levalbuterol or xopenex

BETA AGONISTS ACTIVATE BETAS IN AIRWAYS = DILATION AND RELAXATION OF AIRWAYS

Question 19

What treatment is used in mild to moderate COPD exacerbation in outpatient setting?

Answer 19

Gram +/- coverage = doxycycline and TMP-SMX/ bactrim
(+ = s.pneumoniae, - = h.influenzae, moraxella, h. parainfluenzae)
Cephalosporin
Amoxicillin

Question 20

What treatments are used in MORE SEVERE cases of outpatient COPD exacerbation ?

Answer 20

Beta lactam = Amoxicillin-clavulanate, Cephalosporin

Macrolide = azithromycin, calrithromycin

Respiratory fluoroquinolone = REALLY SICK, moxifloxacin, levofloxacin HIGH RISK OF TENDON RUPTURE ESPECIALLY IF ON PREDNISONE TOO

Question 21

What is FVC?

Answer 21

volume of gas forcefully expelled from lungs after maximal inspiration

Question 22

What is FEV1?

Answer 22

volume of gas expelled in FIRST SECOND of FVC maneuver

Question 23

How do you characterize obstructive lung disease?

Answer 23

Reduced AIRFLOW RATES = FEV1, FVC, PEFR

lung volumes within NORMAL RANGE OR LARGER

Question 24

How do you characterize restrictive lung disease ?

Answer 24

TLC, FRC, RV

reduced volumes and expiratory flow rates ^

Question 25

What is TLC?

Answer 25

volume of gas in lungs after maximal inspiration

Question 26

What is FRC?

Answer 26

Functional residual capacity

Question 27

What is RV?

Answer 27

Residual volume

volume of gas remaining in lungs following maximal expiration

Question 28

PNEUMONIA PEARLs in ELDERLY

Answer 28

classic signs of disease may be absent
anorexia / poor appetite
decreased ADLs
Tachypnea 
fever 
confusion / MS changes 
Earliest sign in elderly = tachypnea then SOB 
Aspiration pneumonia usually RML

Question 29

Pertussis

Answer 29

whooping cough
bordetella pertussis
early symptoms = runny nose, low grade fever, occasional cough
late = cough followed by WHOOP, vomiting during cough, exhaustion after
TX- azithromycin, clarithromycin, erythromycin
NO COUGH MEDS
tdap in 3rd trimester pregnancy women ***