Module 3 Respiratory Flashcards
What is asthma?
Chronic inflammatory disorder of the airways resulting in episodic reversible narrowing and inflammation of the airways.
What is the pathophysiology of asthma?
Primary event is airway inflammation
Secondary event is airway hyper-responsiveness and airflow obstruction (to a trigger)
What risk factors are associated with asthma?
Genetic, environmental, immune system, obesity
What are the triggers for asthma?
Allergens, cold air, exercise, irritants, stress, virus, smoking/exposure, aspirin
What is the SUBJECTIVE clinical presentation of asthma?
Cough (most common-may be the only symptom), wheezing, SOB, sputum production, anxiety
What is the OBJECTIVE clinical presentation of asthma?
Wheezing (esp with inspiration, diaphoresis, anxiety, breathless, RR ≥30, HR ≥120 (both tachy and tachypnic suggest severe bronchospasm)
What asthmatic symptoms warrant sending a patient to the ER?
Signs of severe bronchospasm
Ex. RR ≥30, HR ≥120
What diagnostics can/should be used for asthma?
Spirometry: helps us know if the treatment is affective
Bronchodilator: a great way to diagnose asthma
What should be included in the physical exam for evaluation of asthma?
General, respiratory (inspection, palpation, auscultation), Skin, cardiovascular
Egophany, fremitus
What are the differential diagnoses for asthma?
URI (croup, vocal cord dysfunction), lower respiratory dysfunction (pneumonia, COPD, cardiac conditions), GERD
What are the different types of asthma?
Intermittent (less than 2 days a week) Mild Persistent (more than 2 days a week) APRN may care for Moderate Persistent (daily) Should be referred/comanaged Severe Persistent (Throughout the day)
How is asthma treated?
Management is based on symptoms, severity, and comorbidities. Develop an action plan
What patient teaching is important for asthma?
Review potential triggers, review emergent situations (when to go to hospital/call doctor)
What complications are associated with asthma?
Sick time for school or work Anxiety/depression Superimposed infection Emphysema Pneumothorax Respiratory failure Heart failure
What pharmacological interventions can be used to assist with smoking cessation?
Nicotine replacement (2 NRTs best bet)
Bupropion (Wellbutrin; Zyban)
Varencline (Chantic)
Nic Vax facilitates nicotine antibody development that prevents nicotine from getting to the brain
Best Nopharm option:“Cold Turkey” is better than tapering
What is the Pathophysiology of Pneumonia?
Acute infection of the pulmonary parenchyma
Protective mechanisms of the lungs such as epithelial cells, cilia and gag reflex- along with the immune system - are compromised
What are the different potential causes of pneumonia?
Bacterial, viral, or fungal
What is atypical pneumonia? How is it usually caused? How does it present?
Atypical is more difficult to detect organism
ex. Chlamydia pneumoniae, Legionella pneumophila, Mycoplasma pneumoniae
Typically caused by: Mycoplasma
Presentation: Milder symptoms, Insidious onset, More resistant and more common in younger population, “Walking pneumonia”
How is typical pneumonia usually caused. How does it present?
Main cause: Streptococcus pneumonae (focus on)
Also caused by: Staphylococcus aureus
Presentation: Acute onset
Chest X-ray (helps determine between typical and atypical
What are the viral causes of pneumonia?
Influenza A or B – 14%
Rhinovirus – 20%
Respiratory syncytial virus (RSV)
Corona Virus
What are the risk factors for pneumonia?
Compromised immune system Smoking Impaired gag reflex or altered level of consciousness Some more susceptible to pneumonia Diabetes and heart disease
What are the differential diagnosis for pneumonia?
Acute bronchitis Asthma COPD exacerbation Heart failure Lung cancer Pulmonary embolism
What subjective data do we see with pneumonia?
Acute onset-feel very sick Fever/Chills, Fatigue, malaise Severe coughing (possibly bloody) With typical cough is productive; atypical cough is dry Shortness of breath* Chest pain (pleural) Nausea or vomiting Loss of appetite
What subjective data do we see with acute bronchitis?
Severe coughing-lingering cough Muscle aches from coughing Sore throat from coughing No shortness of breath Feeling of fullness
What subjective data do we see with viral pneumonia?
Acute onset-lingering cough
Chills, Cough
Body symptoms associated with the virus
What objective data do we see with pneumonia?
Fever Severe coughing Shortness of breath Tachypnea* General appearance of sickness
**What objective data do we see with acute bronchitis?
Low grade fever or no fever
Severe coughing
General appearance of fatigue
Possible: Wheezing, ronchi, rales (but typically clear)
What objective data do we see with viral pneumonia?
Rales Dullness to percussion Increased tactile fremitus Decreased O2 saturation(<90% should be referred or admitted) Bronchial breath sounds - egophony
What diagnostics will be helpful in determining pneumonia vs bronchitis? Which are not helpful?
Helpful: Chest X-ray, Pulse Ox , Pneumonia severity index, Clinical judgment
Not helpful: Sputum analysis, Blood gas, CBC with dif
How is severe community acquired pneumonia defined?
Includes either one major or three minors
Minor Criteria: Respiratory rate>30 breaths/min, PaO2/FIO2 ratio<250, Multilobe infiltrates, Confusion/disorientation, Uremia (blood urea nitrogen level>20 mg/dl), Leukopenia* (white blood cell count <4,000 cells/ml), Thrombocytopenia (platelet count <100,000/ml), Hypothermia (core temperature <36C), Hypotension requiring aggressive fluid resuscitation
Major Criteria: Septic shock with need for vasopressors, Respiratory failure requiring mechanical ventilation, Metlay et al. also recommend the use of pneumonia severity index (PSI) along with clinical judgement.
How should pneumonia be managed?
Hospitalization or not Amoxicillin May need to add antiviral Vaccinations Elderly more vulnerable-need to treat more aggressively
What patient teaching should be reviewed for a patient with pneumonia?
Danger signs: Avoid cough suppressants Rest, fluids, Tylenol or Ibuprofen Avoid people who are sick If you are sick, stay away from others Hand washing Clean and disinfect surfaces Cough and sneeze into elbow Quit smoking and limit contact Health maintenance of chronic conditions
What vaccine options are available for pneumonia?
There are two vaccines that can offer protection against pneumococcal disease: PCV13 and PPSV23
PCV13 is for older than 65 or with comorbidities (ex cochlear). Should not receive within a year of PPSV23.
What is the pathophysiology of TB?
Tuberculosis is caused by the bacteria Mycobacterium Tuberculosis.
What is a latent TB infection?
TB bacteria is living in the body but the host does not become sick, the body is able to fight the bacteria and stop it from growing. People with LTBI are asymptomatic, cannot spread the infection to others, will likely have a positive TB skin test or blood test, and still require latent TB treatment so that the infection does not become active.
What is active TB disease?
The TB bacteria grows and multiplies in the body resulting in active TB. These people are symptomatic, can spread the disease, need TB disease treatment.
What are the risk factors for TB?
HIV infection, Homelessness, Crowded living conditions (incarceration, homeless shelters, Dorms, Nursing homes), Drug use, Inadequate healthcare, Travel to high-risk countries or exposure to persons from high risk areas (Asia, Africa, & Latin America), Comorbid conditions affecting immune function, i.e. DM
What are the differential diagnosis for TB?
Pneumonia
Acute bronchitis
Cancer
What subjective data do we see with latent TB?
No symptoms
What subjective data do we see with active TB?
bad cough that lasts 3 weeks or longer pain in the chest coughing up blood or sputum weakness or fatigue weight loss/no appetite chills/fever/night sweats irregular menses
What objective data do we see with active TB?
May have no physical abnormalities.
Cough
low-grade Fever
Subcutaneous nodules
Small grey or yellow nodules in the conjunctiva
Lymphadenopathy
Genitourinary, skeletal, or CNS symptoms if extrapulmonary infection
What diagnostics can be used for TB?
TB Skin Test (TST) - skin
Interferon-gamma release assays (IGRAs) - blood
Chest X-ray
Sputum cultures
What important information should we know about a TB skin test (Mantoux)?
Detectable 2-8 weeks after infection
Test is read within 48 -72 hours
**False negative may occur – infants and young children, recently received viral vaccination, immunosuppression, recent viral or bacterial infection
**False positives – previous BCG vaccination, incorrect administration or interpretation of the results
What is Interferon-gamma release assays (IGRAs)?
Measure immune reactivity to mycobacterial antigens in the blood
Preferred testing for those previously vaccinated with BCG or high risk of not returning
If significant time has elapsed since BCG, TST can be used for TB screening
Accuracy in immunocompromised patients not established
Advantage: results available in 24 hours, BUT samples must be processed w/in 8-16 hrs
What testing and treatment should occur for positive and negative TB skin tests with and without known exposure?
Negative TB skin test without exposure: No further testing/treatment
Negative TB skin test with exposure: Recheck in approximately 10 weeks
Positive TB skin test without exposure: Chest x-ray – if negative, treat for latent TB; if positive, treat for active TB
Positive TB skin test with known exposure: Chest x-ray – if negative, treat for latent TB; if positive, treat for active TB
How is latent TB managed?
Short course (3-4 months) preferred or long course (6-9 months).
Short course – Rifamycin-based treatment
Long course – isoniazid monotherapy
How is active TB managed?
Refer to the American Thoracic Society, CDC, and Infectious Disease.
Likely will require hospitalization
What referrals should occur for TB?
Public Health Department
Infectious Disease
Primary Care Provider
What education is important with TB?
Disease & prognosis
Risk to others
Treatment
Complications
What should the APRN do when a patient tests positive for TB?
Report all cases of LTBI and Active TB to Health Department
What is acute bronchitis?
Acute and self-limited inflammation of the trachea and major bronchi without bronchial consolidation or underlying cardiopulmonary disease.
Lower respiratory infection that Typically lasts 3 weeks or less
Viral or bacterial
What is the pathophysiology of acute bronchitis?
Edematous changes in the mucous membrane of the tracheobronchial tree, epithelial cell damage, the release of proinflammatory mediators and an increase in secretion.
What are risk factors for acute bronchitis?
Households with small children
Day care centers
Consolidated housing: Older adult living areas, Dormitories, Military housing
What are our differential diagnosis with acute bronchitis?
Simple upper respiratory infection Common cold Reflux esophagitis Acute asthma Bronchiolitis COPD Pneumonia
What diagnostics would be helpful with acute bronchitis?
No diagnostics: For patients with normal vital signs and without tachypnea, tachycardia, rales and egophony likely have acute bronchitis
Some rapid tests available for suspected bacterial infection
Sputum cultures are not helpful
CXR if community acquired pneumonia is suspected
Spirometry
How is acute bronchitis managed?
Rest
Increase fluids
Humidifier or warm shower
Smoking cessation
What patient teaching should occur for acute bronchitis?
CDC recommends referring to bronchitis as a chest cold
Key teaching point: Antibiotics are not needed – increased risk of resistance.
Symptomatic therapy
Duration – up to 3 weeks
Call if symptoms persist or worsen
What complications can be seen with acute bronchitis?
Chronic cough – sleep loss and discomfort
Pneumonia – result of superinfection
Acute respiratory failure – rare
Exercise intolerance – typically chronic bronchitis
Hypoxia – chronic bronchitis
When should a patient be referred with acute bronchitis?
Hospital referral for progressive dyspnea, SPO2 <90 and/or signs of sepsis
A patient suspected of having pneumonia has a clear chest x-ray. Does this exclude pneumonia as a possibility?
No. Chest X-ray can be normal with pneumonia
What systems should be reviewed in a patient having acute fatigue, fever, chills, pain on inspiration and activity, SOB and fever?
Respiratory
Cardiac
Gastrointestinal.
Eyes, Ears, Nose, and Throat
What treatment would be given to a patient with asthma controlled by proventil but exacerbated by pollen currently?
Flovent (fluticasone propionate) 2 puffs every 12 hours (corticosteroid inhaler)
What is the recommended therapy for step 1 (intermittent) asthma?
Short-acting beta 2 agonist
**What patients should receive antivirals?
Patients with influenza that are high risk due to pregnancy, age, or comorbidities
According to the article by Esden, J., which of the following is a reasonable tool to be used in the outpatient setting to determine whether inpatient care is needed in regards to community acquired pneumonia?
CURB-65
A 20-year-old patient presents with persistent dry cough, headache, fatigue and body aches that have worsened over the past month. What is the most likely cause for this patient’s illness?
Mycoplasma pneumonia
**Approximately what percentage of tuberculosis infections cause active disease?
**Are those with latent TB contagious? Do they need treatment?
10%
They are not contagious but do need treatment to prevent active TB
Patients with persistent asthma in Step 2 should have which medication added to their short-acting beta-agonist?
Low dose inhaled corticosteroid (ICS)
**A 25-year-old is healthy, up to date on immunizations, and received BCG as a child. Work requires a TB skin test on hire. Should they be given a Mantoux test?
Yes, but it may not be accurate
Persons who received the BCG vaccine can receive a TST, but according to the CDC TB blood tests are the preferred method of TB testing for people who have received the BCG vaccine.
This is because the BCG vaccine could potentially interfere with the accuracy of the TB skin test (Mantoux test). CDC website.
What are the treatments for atypical, typical, and viral pneumonia?
Atypical- macrolide
Typical- Amoxicillin 1gm TID (first line), doxycycline (if pcn allergy)
Viral- antiviral (if influenza is cause?)
Why do we use the peak flow meter in asthma? Who should use one?
Anyone with an acute or chronic disease that we are worried about potentially worsening condition should have one(i.e. covid, asthma, pneumonia). In addition, anyone on bed rest or post-op would benefit.
Flow meters can give us a baseline if started early on, as well as worsening/improving lung function. It’s most helpful if those using it can keep documentation of their flow meter progress.
If a patient presents to your office with mild persistent asthma, what would that look like? List the subjective and objective information.
Symptoms greater than 2 days/week but not daily, 3-4 nights/month for nighttime awakening, SABA use great than 2 days/week but not daily and more than 1 time per day, minor limitation on daily activity interference, FEV greater than 80 predicted, FEV/FVC normal, Oral systemic corticosteroids greater than or equal to 2 times year, step 2 for treatment. (Copied from Esden article Table 1).
chronic inflammation causes airway hyperresponsiveness and airway obstruction, resulting in the clinical symptoms of coughing, wheezing, shortness of breath, and chest tightness. many individuals with asthma symptoms that began in childhood also have atopic dermatitis (eczema), allergic rhinitis, and/or food allergies.8,9 Individuals who develop asthma later in adulthood are more likely to be female or have a history of smoking (Copied from same article)
Management would be Step 2 which is low dose ICS per table 2 in article.
Discuss moderate asthma. And when would you add systemic corticosteroids?
Moderate persistent = daily symptoms, more than 1/weekly nighttime wakefulness, daily use of SABA, some interference with activities. FEV >60% but <80%. FEV/FVC is reduced by 5%.
A short course of systemic steroids would be added, therapy adjustment needed from low dose ICS increased to moderate /high with considerations for LABA and LTRA based on symptoms and control.
How do we treat a patient with community-acquired pneumonia and a comorbidity?
For outpatient adults with comorbidities such as chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia we recommend (in no particular order of preference) (Table 3):
Combination therapy: B amoxicillin/clavulanate 500 mg/125 mg three times daily, or amoxicillin/ clavulanate 875 mg/125 mg twice daily, or 2,000 mg/125 mg twice daily, or a cephalosporin (cefpodoxime 200 mg twice daily or cefuroxime 500 mg twice daily); AND B macrolide (azithromycin 500 mg on first day then 250 mg daily, clarithromycin [500 mg twice daily or extended release 1,000 mg once daily]) (strong recommendation, moderate quality of evidence for combination therapy), or doxycycline 100 mg twice daily (conditional recommendation, low quality of evidence for combination therapy);
OR d Monotherapy: B respiratory fluoroquinolone (levofloxacin 750 mg daily, moxifloxacin 400 mg daily, or gemifloxacin 320 mg daily) (strong recommendation, moderate quality of evidence).
