Midterm Flashcards
Asthma early-phase response
- peaks 30-60 minutes after exposure
- subsides 30-90 minutes later
- primary cause is bronchospasm
asthma late-phase response
- primary cause is inflammation
- histamine and other mediators set up self sustaining cycle
- air trapping and lung hyperinflation occurs
asthma signs and symptoms
- episodic wheezing
- dyspnea (most common)
- chest tightness
- cough
- frequently worse at night
asthma physical exam red flags
- fatigue
- diaphoresis
- cyanosis
- no wheezing
Intermittent asthma
- symptoms: less than or equal to 2 days/week
- night awakenings: less than or equal to 2/month
- use of SABA: less than or equal to 2 days/week
- ADL interference: none
- FEV1: >80% predicted
- FEV1/FVC: normal
- treatment: step 1
mild persistent asthma
- symptoms: >2 days/week but not daily
- night awakenings: 3-4/month
- SABA use: >2/week but not daily and no more than 1/day
- ADL interference: minor
- FEV1: >80% predicted
- FEV1/FVC: normal
- treatment: step 2
moderate persistent asthma
- symptoms: daily
- night awakenings: >1/week, but not nightly
- SABA use: daily
- ADL interference: some limitation
- FEV1: >60% but <80% predicted
- FEV1/FVC: reduced 5%
- treatment: step 3
severe persistent asthma
- symptoms: throughout the day
- night awakenings: often 7/week
- SABA use: several times per day
- ADL interference: extreme limitation
- FEV1: <60% predicted
- FEV1/FVC: reduced >5%
- treatment: step 4 or 5
obstructive lung disease examples
COPD
asthma
bronchiectasis
cystic fibrosis
restrictive lung disease examples
interstitial lung disease
chest wall abnormalities
obesity
ALS
obstructive PFT
- FEV1: reduced
- TLC: normal or increased
- FEV1/FVC: reduced
restrictive PFT
FEV1: normal or reduced
TLC: reduced
FEV1/FVC: normal or increased
inspiratory capacity
inspiratory reserve volume and tidal volume
functional residual capacity
expiratory reserve volume and residual volume
vital capacity
inspiratory reserve volume, tidal volume, and expiratory reserve volume
PFT reversible obstruction definition
increase of 12% or more and 200mL increase in FEV1 or FVC
bronchoprovocation
- methacholine challenge
- mannitol challenge
- exercise testing
- not recommended if FEV1 is <70% predicted
5 components of asthma management
- assess control and severity
- severe versus uncontrolled
- appropriate pharmacology
- address modifiable risk factors and environmental concerns
- self management and education
LABA
- indicated for bronchodilation maintenance
- helps with nocturnal symptoms
short acting anticholinergic
- reduces vagal tone of the airway
- useful for severe exacerbation when combined with SABA
long acting muscarinic agent
- reduces vagal tone of the airway
- works well in COPD
- slow onset of action 60-90 minutes
inhaled corticosteroids
- suppress acute and chronic airway inflammation
- inhibit inflammatory cell migration
- block late phase reaction
- first line maintenance therapy for persistent asthma
leukotriene receptor antagonist
- decreases airway smooth muscle activity
- decreases mucus production
- used in long term control but with variable effect
- alternative to ICS in mild persistent
mast cell stabilizers
- prevent bronchoconstriction
- for prevention and maintenance
- trial of 6-8 weeks needed before effectiveness known
methylxanthines
- causes bronchodilation
- suppresses response of airway to stimuli
- 2nd/3rd line treatment for moderate to severe
- can cause toxicity and drug interactions
step 1 treatment
SABA
step 2 treatment
- low dose ICS
- SABA
step 3 treatment
-low dose ICS and LABA combo
step 4 treatment
-medium dose ICS and LABA
step 5 treatment
medium to high dose ICS/LABA and LAMA
asthma exacerbation treatment
BIOMES
Beta agonists Ipratropium (and IV access) Oxygen Mag Epinephrine Steroids
emphysema
- permanent enlargement of airspace due to alveolar destruction
- increased CO2 retention
- pursed lip breathing
- thin with barrel chest
- accessory muscle use
chronic bronchitis
- extensive bronchial mucus
- daily productive cough for 3 consecutive months
- cyanotic/dusky
- hypoxic
- digital clubbing
- exertional dyspnea
- accessory muscle use
COPD causes
- smoking #1
- occupational dust/chemicals
- air pollution
- genetic factors
- Hx allergies and recurrent bronchitis
- alpha1 antitrypsin deficiency
pack year
(# packs/day) x (# years)
COPD GOLD 1
- mild
- FEV1 greater than or equal to 80% predicted
COPD GOLD 2
-moderate
FEV1: 50-80% predicted
COPD GOLD 3
-severe
FEV1 30-50% predicted
COPD GOLD 4
-very severe
FEV1: <30% predicted
COPD group A treatment
- 0-1 moderate exacerbation but no admission
- mMRC 0-1
- CAT <10
bronchodilator
COPD group B treatment
- 0-1 moderate exacerbation but no admission
- mMRC 2 or more
- CAT 10 or more
LABA or LAMA
COPD group C treatment
- 2 or more moderate exacerbation or 1 or more exacerbation with admission
- mMRC 0-1
- CAT <10
LAMA
COPD group D treatment
- 2 or more moderate exacerbation or 1 or more exacerbation with admission
- mMRC 2 or more
- CAT 10 or more
LAMA
LAMA + LABA (highly symptomatic CAT>20)
ICS + LABA (eos >300)
COPD treatment steroids
- inhaled reduce exacerbation frequency in combination with LABA
- not responsive to oral steroids but a subset of steroid responsive may warrant a trial
COPD treatment antibiotics
- azithromycin as prophylaxis for exacerbation and anti-inflammatory
- macrolide (azithromycin)
- amoxicillin clavulanate
- trimethoprim sulfamethoxazole
- fluoroquinolones (ciprofloxacin)
- doxycycline
COPD treatment when hospitalized
- oxygen
- broad spectrum antibiotics (levofloxacin, ceftriaxone, piperacillin tazobactam)
- usually nebulizers/IV steroids
community acquired pneumonia
- streptococcus pneumonia most common cause
- right middle lobe most common site
- x-ray gold standard for diagnosis
atypical pneumonia
- mycoplasma pneumoniae most common (walking pneumonia) with CXR bilateral patchy infiltrate
- pneumocystis jiroveci in HIV positive
tools to admit pneumonia patient
- PORT score to assess outpatient CAP Tx
- CURB score for admission decision
hospital acquired pneumonia
develops 48 hours after admission
ventilator associated pneumonia
develops 48 hours after intubation
viral pneumonia
- flu like
- patchy infiltrates on CXR
- most common in kids
strep pneumonia
- red-brown rusty sputum
- lobar
- gram + diplococci
H influenzae pneumonia
- COPD patients
- small gram - rods
klebsiella pneumonia
- alcoholics, aspiration
- currant jelly sputum
- encapsulated gram - rod
staph pneumonia
- pink salmon colored sputum
- often nosocomial
- gram + cocci in cluster
mycoplasma pneumonia
- young adults
- CXR looks worse than patient
pseudomonas pneumonia
ICU
immunocompromised
CF patients
legionella pneumonia
- air conditioners
- GI and CNS symptoms that start later
pneumocystitis jiroveci
- HIV patients
- white out CXR
- Tx with bactrim
TB pneumonia
fever, night sweats, weight loss, bloody sputum
pH normal
7.35 - 7.45
PaCO2 normal
35 - 45
HCO3 normal
22 - 26
PaO2 normal
> 80
SaO2 normal
> 95
acidosis causes
increased CO2
decreased HCO3
alkalosis causes
decreased CO2
increased HCO3
respiratory acidosis
decreased pH
increased pCO2
respiratory acidosis with compensation
decreased pH
increased HCO3
metabolic acidosis
decreased pH
decreased HCO3
metabolic acidosis with compensation
decreased pH
decreased pCO2
respiratory alkalosis
increased pH
decreased pCO2
respiratory alkalosis with compensation
increased pH
decreased HCO3
metabolic alkalosis
increased pH
increased HCO3
metabolic alkalosis with compensation
increased pH
increased pCO2
anion gap calculation
Na - (HCO3 + Cl)
decreased anion gap Dx
hypoalbumenemia
hyponatremia
monoclonal protein
elevated anion gap Dx
MUDPILERS
methanol uremia DKA propylene glycol isoniazid intoxication lactic acidosis ethanol rhabdo salicylates
respiratory acidosis causes
- head trauma
- airway obstruction
- pneumonia
- decreased surface area
respiratory alkalosis causes
- hyperventilation
- ascent to high altitude
acute bronchitis
- self limiting inflammation of the tracheobronchial tree due to upper airway infection
- lots of coughing that can last 5 days to 2 weeks (8 weeks not unheard of)
acute bronchitis symptoms
- coughing
- fever is unusual
- wheezing may occur secondary
- 50% have purulent sputum
- important to rule out pneumonia
acute bronchitis cause
- 85% are caused by a virus
- influenza, coronavirus, rhinovirus, RSV
acute bronchitis with bacterial cause
- can occur in patients with tracheostomy or intubated
- mycoplasma pneumoniae
- chlamydia sp.
- bordetella pertussis
acute bronchitis signs
- pharyngeal erythema
- no parenchymal consolidation
- CXR non specific
acute bronchitis treatment
- symptomatic: NSAIDs, tylenol
- OTC cough meds
- Rx cough meds
influenza treatment
-antivirals administered if within 48 hours of symptoms onset
pertussis
- respiratory tract infection caused by bordetella pertussis
- consider for cough lasting more than 3 weeks
- 50% in <2 years old
- no lasting immunity from vaccine or active infection
pertussis catarrhal stage
- 7-10 days
- insidious onset
- mild fever
- hacking cough at night
- coryza
- conjunctivitis
pertussis paroxysmal stage
7-28 days
- spasmodic rapid coughing
- followed by inspiratory stridor
pertussis convalescent stage
- several months
- decreasing severity and frequency of symptoms
pertussis diagnosis
nasopharyngeal culture swab = gold standard
pertussis treatment
-macrolides for all suspected cases
(end in -thromycin)
-prophylaxis for those exposed within 3 weeks
bronchiectasis
- disorder of large bronchial with permanent abnormal dilation and destruction of bronchial walls
- congenital or acquired
- local or diffuse
bronchiectasis causes
- 50% caused by cystic fibrosis
- lung infections
- RA
- localized airway obstruction
bronchiectasis clinical findings
- chronic cough with copious purulent sputum
- hemoptysis
- pleuritic chest pain
- 75% dyspnea/wheezing
- weight loss
- persistent crackles at lung base
- digital clubbing = chronic sign
bronchiectasis imaging
-CT is diagnostic study of choice
bronchiectasis treatment
Acute
- antibiotics
- chest physiotherapy
- inhaled bronchodilator
cystic fibrosis
-use of aerosolized aminoglycoside
RSV
- form of paramyxovirus
- leading cause of hospitalization of children
- highly contagious
RSV presentation
fever rapid breathing cough possible accessory muscle runny nose nasal flaring
RSV treatment
- O2
- hydration
- treat the fever
- ribavirin in extreme cases
- clear nasal passages
bronchiolitis
- generic term for inflammatory processes that affect the bronchioles
- usually caused by RSV
- most common in under 2
- clinical diagnosis
bronchiolitis treatment
- majority can be discharged
- deep nasal suctioning
constrictive bronchiolitis
- common after inhalation injury
- airflow obstruction on PFT
- chronic condition
croup causes
- parainfluenza most common
- also RSV and flu
- bacterial pneumonia may be secondary
children 3-36 months
croup clinical findings
- gradual onset of symptoms
- barking cough
- hoarse voice
- inspiratory stridor
- mild fever
- often at night
croup severity
westley croup score
croup treatment
- mild: humidified air, antipyretics, fluid
- moderate: single dose dexamethasone, nebulized Epi
- severe: repeated nebulized epi with admission if no improvement
- impending respiratory failure: O2, ICU, scheduled epi, IV steroids
epiglottitis
- inflammation of epiglottis and adjacent supraglottic structures
- in children primarily caused by H. influenza type B, strep, and staph
epiglottitis clinical findings
- febrile toxic appearing children with rapid onset
- dysphagia
- drooling
- tripoding
- hot potato voice
epiglottitis treatment
- defer pharyngeal exam
- stabilize airway
- draw labs before ABX
- empiric ABX cefotaxime or ceftriaxone plus clindamycin or vancomycin
