plum Flashcards
what is associated with asthma name 5 symptoms and signs
nasal polyps worse at night sensitivity to aspirin eczema or atopic dermatitis increased expiratory phase
what is a the best initial test in acute Asthma excerabation
peak expiratory flow
what can Asthma exclusively present as
cough
what is most accurate test to diagnose Asthma in a patient and what parameter would you assess
PFT and diagnosis with
decrease FEV1/FVC
decrease FEV1
decrease FVC
asthma
if you patients PFT shows to be symptomatic what is next and how will it show to conclusive with asthma
normal pft
give patient metacholine
measures FEV1 decreases more than 20% diagnostic for asthma
asthma
if patient is symptomatic what diagnostic drug would administer and what will the PFT show
Albuterol increase 12% or 200 FEV1
what drug should never be used alone in asthma or cold
LABA must be with ics
asthma
define as intermittent mild, moderate, sever and explain the step up method of therapy
intermitten
s/s day <2x/week or Night <2x/mo FEV1 80%
- tx short acting beta albuterol as needed
Mild
s/s > 2x/week but <1x /day or Night < 1x/ week FEV1 80% SABA and ICS
moderate
s/s >1x/day or >1x/wk FEV1 61x/day or frequent FEV1< 60%
tx increase dose of drugs or increase only ICS
Refractory
oral steroids
best initial drug for long term control ASTHMA
ICS
what test best quantify asthma exacerbation
PEF ( from patients normal PEF) ABG for (A-a) gradient
First steps in managing Asthma Exacerbation
Oxgen
Albuterol -nebulizer
prednisone IV ( takes 4 hours to work)
ipratropium
SPO2 is kept at in Asthma
equal or greater than 90%
asthma
how to you quantify if the patient gets better
what is your next step
no wheezing
no increase O2 demand
PEF > 70%
Tx–> send home mediator dose Albuterol and oral steroids
Asthma patient no change after treatment for exacerbation what next step
send to wards
IV steroids
Mediator dose inhaler Albuterol
asthma
S/S of patient getting worse
increasing CO2 or normalizing CO2 patient should be hyperventilating blowing off CO2 –> shows patients is getting week and entering respiratory failure
decrease lung sounds–. Patient is tiring
PEF< 50%
increase 02 demand
salvage therapy asthma exacerbation
MG- relieve bronchospasm - pt not responses to albuterol while waiting for steroids
epinephrine last resort
what test helps to differentiate asthma and COPD
bronchodilator test
or metacholine challenge both positive in asthma
asthma
what is a the treatment for a patient not responding exacerbation treatment and is rapidly declining
TX send ICU, mechanical intubation and ventilation
IV steroid and continuous nebulizer albuterol
COPD chest x ray findings
increase AP diameter
flattened diaphragm
long narrow heart shadow
COPD
most accurate diagnostic test and findings
PFT
FEV1/FVC ration <70 %
decrease FEV1 and decrease FVC
increase TLC because of increase RV
DCLO in asthma and in COPD
asthma normal or increase
COPD decreased
S/S of COPD exacerbation
increase CO2
compensatory increase in HCO3
hypoxia
EKG for COPD
RV an RA hypertrophy
MAT and atrial fibrillation
what treatment improves mortality and delays progression
smoking cessation and
at home oxygen treatment
O2 indication COPD
PO2< 55% SAT<88% OR PO2<66% or SAT ,90% with : pulmonary HTN, high HCT, or cardiomyopathy, S/S right sided heart failure
what vaccination should both COPD and Asthma patients receive
influenzas
pneumoccal
best prognostic factor for COPD
FEV1
treatment method for COPD step up
all medical therapy fails
- SABA
2 SABA + long acting muscarinic blocker (tioropium, ipratropium) - SABA +LAMA+LABA
- SABA+LAMA+LABA+ICS
- SABA+LAMA+LABA+ICS+ THEOPHYLLINE
- SABA+LAMA+LABA+ICS+ THEOPHYLLINE+ ORAL CORTICOSTEROIDS
- lung transplant
Bactertia that cause pneumonia in COPD patients
strep.pneuo
H. influenza
M. cataorrhalis
COPD exacerbation drugs
02
Albuterol
ipratropium
steroids
antibiotics
antibiotic of choice COPD
macroclides: azithromycin, clarithromycin (warfirn)
cephalosporin: cefuroxime , cefixime, cefaclor
amoxicllin/calvuanlic acid
quinolones
Alternative
doxycycline
COPD exacerbation management AFTER TREATMENT
improving
no change
worsening +s/s
- improving –> send home PO steroids, MDI inhaler
- no change –> PO steroids nebulizer inhalers
- worse–> ICU increase CO2, decrease lung sounds
IV steroids, continuous nebulizer, intubate
most common cause of bronchiectasis
cystic fibrosis
COPD patient with catrostophic worsening of s/s
pneumothorax
etiology bronchiectasis
cystic fibrosis tb pneumonia immune deficiency + panhypogammaglobunemia ABPA, dyskinetic cilia syndrome collagen vascular disease like Rh
S/S of bronchiectasis
high volume purulent sputum hemopytosis--> bc rupture of blood vessels can present as emergency - greatest complication foul smelling sputum resistance to antibiotic treatment recurren persistant pneumonia
bronchiectasis best initial test
most accurate and diagnostic test
chest x ray - dilated thickened bronchi not diagnostic
resolution ct most accurate and diagnostic
BRONCHIECTASIS
treatment methods
chest physiotherapy (cupping clapping) + postural drainage => dislodge plugged up bronchi
treat each infections episode as they arise , same antibiotic as COPD
specific microbiologic diagnosis preferred- sputum culture
signs of superimposed infection on bronchiectasis
fever, chest pain, changed in quality an quantity of sputum
community acquired pneumonia
is defined as
pneumonia occurring before hospitalization or within 40 hours of hospitalization
most common cause of CAP
strepococcus pneumonia
best initial test for all pneumonia
chest x ray
Tests for pneumonia in admitted patients triage
- chest x ray
- CBC and differentials, BUN, creatinine, glucose, electrolytes and ) O2 stat
- 2 pretreatment blood culture
- sputum gram stain (all patients) and culture of sputum (hospitalized pt)
- start antibiotics broad spectrum
typical pneumonia causes and presentation
atypical pneumonia and presentation
strep pneumo kielbsella staph areus anerobic, gram negative rods h. influenza lobar consolidtion
interstitial infiltrates mycoplasma CMV RSV legionella coxeilla chlamydia pneumonia+ psitacci
Pneumonia previously healthy no antibiotics for the last 3 months and no comorbities (outpatient
azithromycin or clarithromycin (warfin)
or doxycycline
Pneumonia out patient comorbidities and antibiotics last 3 months
levofloxacin or moxifloxacin
Pneumonia in patient treatment
levofloxacin or moxifloxacin (respiratory floroquinlones
or ceftatriaxone or azithromycin
Pnemonia reasons to hospitlize
hypotension <90 mmhg
RR >30 or P02 <60 mmhg or pH< 7.35
pulse >125pm
confusion, comorbities COPD, CHF, renal failure , liver failure
temp >104
BUN >30 Na< 130 mml/L , glucose >250 mg/dl
hospital aquired pneumonia
definiton
occurs 48 Hours after admission
or 90 days within hospitalization
most common cause of HAP
gram negative bacteria
pseudomonas or e.coli
HAP management
therapy centred around therapy for gam negative bacilli
antipseudomonal cephalosporins –>
1. cefepime, or ceftazidime
2. antipseudomonal penicillin : pipercillin/tazobactam
3. carbapenem: imipenem, meropenem, or doripenem
pipercillin and ticarcillin always used with betalactamase inhibitor
ventilator associated pneumonia
pathophysiology
name 3 S/S
no mucociliary clearance, no cough and postive peep prevents fever and or rising abc new filtrate on chest x ray purulent secretions coming form the tracheal tube
how to culture VAP pneumonia
BAL
bronchoaveolar lavage–> bronchoscope passed into lungs
VAP Pneumonia drug treatment regimen
3 drug combo 1.Cephalosporin (ceftazidime or cefepime) OR penicillin (piperacillin/tazobactam) OR carbapenem (imipenem) 2. Aminoglycoside OR fluoroquinolone 3. Vancomycin OR linezolid
change initial therapy when identified
which drug is inactivated by surfactant
daptomycin
lung abscess etiology
patients with large volume of oral/pharyngeal content with poor dentation not adequately treated
stroke with loss of gag reflex
seizures
intoxication
endotracheal intubation
foul smelling sputum
best initial test diagnosis of lung abscess with and finding on exam
most accurate test
test for specificitc microbiologic etiology
chest xray - cavity with air fluid level
chest CT most accurate
micro aetiology lung biopsy by bronchoscopy or transtracheal aspiration
lung abscess drugs treatment
clindamycin (anaerobic)
or penicillin until cavity gone
young Adult patient with chronic lung disease
couch sputum hemopytosis brochietasis
wheezing dyspnea , recurrent infections sinus pain nasal pain
cystic fibrosis in young adult
pancreatitis in cystic fibrosis
beta cells spread
infertile man ( azoospermia) missing vas deferens infertile female think cervical mucus altered menstral cycle
cystic fibrosis
best diagnostic test and parameters for diagnosis
which test is not accurate
increased sweat chloride test
pilocarpine increase sweat
chloride levels > 60 meq/l diagnostic
not accurate CFTR is not accurate b.c to many mutations
treatment cystic fibrosis
antibiotic in bronchiectasis - sputum culture is essential to guide therapy
- inhaled recombinant human deoxyribonucleauses
breaks up clogged up air way secreted by neutrophils - inhaled bronchodilators ( albuterol)
- pneumococcal vaccine
- lung transplant all other treatment failures sever disease
- ivacaftor increases the activity of CFTR in the 5% of patients who have a specific mutation
asthmatic patient with recurrent episodes of brown flecked sputum and transient infiltrates on chest x ray
ABPA
APBA
etiology
most commonly effected patients
signs and symptoms
hypersensitive reaction to fungal antigens colonize at bronchial tree
*asthma/atopy,
hempytosis, bronchiectasis, foul smelling sputum, recurrent chest infection
APBA
diagnostic tests
- Peripheral eosinophilia
- Skin test reactivity to aspergillus antigens
- Precipitating antibodies to aspergillus on blood test
- Elevated serum IgE levels
- Pulmonary infiltrates on chest x-ray or CT
ABPA chest x ray findings
lobar infiltrates- eosinophilic pneumonia
bronchiectatsis
APBA
oral steroid prednisone sever cases
inhaled steroids not effective
itraconazole for recurrent episodes
Pneumonia
- Hemophilus influenzae
- Staphylococcus aureus
- Klebsiella pneumoniae
- Anaerobes
- Mycoplasma pneumoniae
- Chlamydophila pneumoniae
- Legionella
- Chlamydia psittaci
- Coxiella burnetii
- COPD
- Recent viral infection (influenza)
- Alcoholism, diabetes
- Poor dentition, aspiration
- Young, healthy patients
- Hoarseness
- Contaminated water sources, air conditioning, ventilation systems
- Birds
- Animals at the time of giving
Pleural effusion
thoracentsis anatomical location
maximum amount of fluid allowed to be removed
midaxillary line above the rib –> to avoid damage to intercostal artery, nerve, intercostal vein
2 interocostal spaces below level of fluid
remove max 1 Litre of fluid
pneumonia dry not productive cough
atypical pneumonia
less sputum because infects interstial space not alveoli
s/s that distinguish pneumonia from bronchitis
Dyspnea, high fever, and an abnormal chest x-ray are the main ways to distinguish pneumonia from bronchiti
bronchitis no fever,
sputum gram stain “adequate” criteria
> 25 wbc and < less than 10 epithelial cells
aspiration pneumonia anatomical location when lying flat
upper lobe
stroke patient develops chronic infection with over several weeks with large volume sputum that is foul smelling. Also has several pounds during this time.
lung abscess
aids patient with dry cough, dyspnea I exertion, fever, cd4 count <200 /ul
- what is best initial test and what will the lab finding show
- name 2 other test that can also be of diagnostic use
- what is the most accurate diagnostic taste
pneumocystis pneumonia P. Jiroveci
1. chest x ray–> will show bilateral interstitial infiltrates
2. A-a gradient can also be diagnostic alternative to chest x ray -> demonstrates hypoxia (increased A-) gradient
Decrease LDH most likely NOT P.J
LDH always increased in disease
3. most accurate testis BAL
aids patient is diagnosed with pneumocystis pneumonia P. Jiroveci a chest x ray has been performed what is the next best step
sputum stain for pneumocystis pneumonia P. Jiroveci
aid patient pneumocystis pneumonia P. Jiroveci is negative for sputum stain what is the next best step
negative sputum test then should be followed with a BAL
pneumocystis pneumonia P. Jiroveci
- best initial therapy for treatment and prophylaxis
- if patient has toxicity to best treatment what is alternative
- TMP/SMX
- clindamycin and primaquine
or
Pentamidnine
- define sever pneumocystis pneumonia P. Jiroveci
- what tx is required to decrease mortality
- how is mild PCP treated and defined
- pO2 below 70 or an A-a gradient above 35
- steroids added to tx
- atovaquone and defined as mild hypoxia
patient diagnosed with pneumocystis pneumonia P. Jiroveci being treated with TMP/SMX demonstrate
G6PD bite cells
- Klebsiella pneumoniae
- Anaerobes
- Mycoplasma pneumoniae
- Legionella
- Pneumocystis
1.
- Hemoptysis from necrotizing disease, “currant jelly” sputum
- Foul-smelling sputum, “rotten eggs”
- Dry cough, rarely severe, bullous myringitis 4.Gastrointestinal symptoms (abdominal pain, diarrhea) or CNS symptoms such as headache and confusion
- AIDS with <200 CD4 cells
