PULM Part 1 Flashcards
Spontaneous Pneumothorax (Primary & Secondary)
Patho
- Accumulation of ____ in the pleural space
• Primary – occurs in the ____ of underlying lung disease
o Rupture of subpleural apical ______ in response to ____ negative intrapleural pressures
o Family history and cigarette smoking
• Secondary – complication of _____ pulmonary disease
Epidemiology: Primary: tall, thin boys and men between 10-30 yo
Diagnostics
Primary:
• Generally (especially in smaller pneumothorax) lab findings will be ____
• Chest x-ray will demonstrate the visceral _______
Treatment
Primary:
• In a stable patient with a small (<15%) pneumothorax, _____ alone may be appropriate
• Supplemental oxygen can facilitate reabsorption of the air
• With larger pneumothorax, need ______ of air (can use ______ or small bore chest tube)
Misc.
Potential for recurrence:
Primary:
• About 30% of patients will have another spontaneous pneumothorax
• With recurrence, referral for ______. (bleb resection, pleurodesis) is appropriate
• No long-term complications in most patients
• All patients should quit _______
• Avoid high altitudes, scuba diving
air absence blebs high preexisting normal pleural line observation aspiration catheter surgery smoking
Tension Pneumothorax
Patho
• The pressure of air in the ________ exceeds pressure throughout the respiratory cycle
• Occurs most commonly with penetrating ____, severe lung infection, or positive-pressure ventilation
• A check valve- mechanism allows air to enter the space on inspiration, but does not allow it to exit on expiration
• Increases the _______ pressure
Traumatic (iatrogenic and non-iatrogenic)
• Traumatic – results from penetrating or blunt trauma
• Iatrogenic – may follow procedures such as thoracentesis, biopsy, or PEEP
S/S
• Should be noted in the presence of marked _____, _______, and mediastinal or tracheal shift
Epidemiology
Diagnostics
Chest x-ray will show large amount of air on ______ side, contralateral shift of ______
Tx
• Needs immediate ________
• Either with ____ bore needle, or if available immediate chest tube placement thoracostomy
pleural space trauma intrathoracic tachycardia hypotension affected mediastinum decompression large
ASTHMA
Patho
______ inflammatory disorder of the airways
No single histopathologic feature is pathognomonic, common findings
• ______ cell infiltration with eosinophils, neutrophils and lymphocytes (especially T lymphocytes)
• Goblet cell _____
• Sometimes with plugging of small airways with thick ____
• Collagen deposition beneath the basement membrane
• ______ of bronchial smooth muscle
• Airway edema
o Airway inflammation underlies disease chronicity and contributes to airway hyper responsiveness and airflow limitation
• Mast cell activation
• Denudation of airway epithelium
Strongest predisposing factor is _____
• Exposure to inhaled allergens increases airway inflammation, hyper-responsiveness and symptoms
• Symptoms may develop immediately or 4-6 hours after exposure (late asthmatic response)
________ is increasingly recognized as a risk factor
Nonspecific Precipitants
• Exercise
• URI
• Rhinosinusitis
• PND
• Aspiration
• GERD
• Changes in weather
• stress
Products of combustion
• _____ crack cocaine, meth and other agents
• Increases asthma symptoms and the need for medications and reduces lung function
Air _____
• Increased respirable particles, ozone, SO1, NO1
• Precipitate asthma symptoms and increase emergency department visits and hospitalizations
Drugs
• ____, NSAIDS, tartrazine dyes or other medications
Occupational
• Various agents in the workplace and may occur weeks to years after initial exposure and sensitization
Catamenial
• Menstrual cycle
____ induces bronchoconstriction
• Begins during exercise or within 3 minutes after its end; peaks within 10-15 minutes and then resolves by 60 minutes
• Thought to be airways attempt to warm and humidify an increased volume of expired air during exercise
Cardiac Asthma
• Wheezing precipitated by decompensated heart failure
Cough variant asthma
• Has cough instead of ________ as predominant symptom
chronic inflammatory hyperplasia mucus hypertrophy atopy obesity tobacco pollution ASA exercise wheezing
ASTHMA
S/S Characterized by
• episodic _______
• Difficulty in breathing
• Chest tightness
• Cough
Frequency of asthma symptoms is highly variable
• Some have infrequent brief attacks
• Others may suffer nearly continuous symptoms
May occur spontaneously or be precipitated or exacerbated by many different triggers as discussed above
Frequently worse at _____
Circadian variations in bronchomotor tone and bronchial reactivity reach their nadir between 3 Am and 4 am increasing symptoms of bronchoconstriction.
- Wheezing or a prolonged expiratory phase during normal breathing correlates well with the presence of airflow obstruction.
- Chest examination may be normal between exacerbations in patients with mild asthma
- During severe asthma exacerbations, airflow may be too limited to produce _____
- Only clue may be globally ______ breath sounds with prolonged ______
- _______ shoulders and use of accessory muscles of respiration suggest an increased work of breathing
Physical Examination signs that increase the probability of asthma • \_\_\_\_ asthma o \_\_\_\_\_ mucosal swelling o Secretion increases o \_\_\_\_\_\_ o Eczema o Atopic dermatitis o Other allergic skin disorders
wheezing night wheezing reduced, expiration hunched allergic nasal polyps
ASTHMA
diagnostics:
Lab findings:
• Most of the time labs are normal. Can do ___ to look for anemia, allergy testing etc
• Arterial blood gas measurements may be normal during ____ asthma
o Respiratory ______ and increase in the alveolar-arterial oxygen difference (A-a-Do2) are common
• During severe exacerbations _______ develops and the PaCO2 returns to normal
• Combination of increased PaCO2 and respiratory acidosis may indicate impending respiratory failure and need for mechanical ventilation
PFTs
• Spirometry before and after administration of a short acting bronchodilator
• Determine the presence and extent of airflow obstruction and whether it is immediately reversible
• Airflow obstruction is indicated by a _______ FEV1/FVC ratio
• Significant reversibility of airflow obstruction is defined by an increase of 12% or more and 200ml in FEV1 or FVC after inhaling a short-acting bronchodilator
• A positive bronchodilator response strongly confirms the diagnosis of asthma but a lack of responsiveness in the pulmonary function laboratory does not preclude success in a clinical trial of bronchodilator therapy
• Severe airflow obstruction results in significant _______ with an increase in residual volume and consequent reduction in FVC
o ◦Results in a pattern that may mimic a restrictive ventilatory defect
Bronchial Provocation testing
• With inhaled _____ or methacholine
• May be useful when asthma is suspected but spirometry is nondiagnostic
• Not recommended if the FEV1 is less than 65% of predicted
• A positive methacholine test is defined as a ___ in the FEV1 or 20@ or more at exposure to a concentration of 16mg/ml or less
• A negative test has a negative predictive value for asthma of 95%
• Exercise challenge testing may be useful in patients with EI bronchospasm
Peak Expiratory Flow
• Handheld devices designed as personal monitoring tools
• Can establish peak flow variability, quantify asthma severity and provide both patient and clinician with measurements to base treatment on
• Predicted values vary with age, height, and gender
• Comparison with reference values is less helpful than comparison with the patient’s own baseline
• PEF shows diurnal variation
• Lowest on first awakening and highest several hours before the ______ of the waking day
• Should be measured in the ___ before bronchodilator and afternoon after bronchodilator
• 20% change in readings or from day to day suggest inadequately controlled asthma
• Values less than 200 L/min indicate severe airflow obstruction.
Additional testing:
CXR
• Usually normal or show only hyperinflation
• May include bronchial wall ______
• Diminished peripheral lung vascular _____
• Indicated when pneumonia, another disorder mimicking asthma or complication such as pneumothorax
Skin testing
• Assesses sensitivity to environmental allergens
• Can identify atopy in patients with persistent asthma
CBC mild alkalosis hypoxemia reduced air trapping histamine fall midpoint AM thickening shadows
ASTHMA TREATMENT
Step 1: Preferred : _____ PRN
Step 2: Preferred: ____ - dose ICS
Alternative: ______, ______, _____, or ______
Step 3: Preferred: EITHER low dose ____ + either _____, _____, or ______ OR
_____ dose ICS
Step 4: Preferred: _____ dose ICS and _____
Alternative: ____ dose ICS + either ___ or _____
step 5: Preferred ___ dose ICS + ___
Alternative: ___ dose ICS + either ____ or ______
Step 6: Preferred: ___ dose ICS + ____ + oral ____________
Alternative: ___ dose ICS + either ____ or _____ + oral ____________
LIFE THREATENING:
Treatment should be started immediately
immediately recieve:
________, high doses of an __________ , _______
LONG TERM CONTROLLER MEDICATIONS
1. Anti-inflammatory
• Corticosteroids:
o Oral/IV: ___________, hydrocortisone, prednisone
o Most ______ and consistently effective anti-inflammatory agents
o Most effective in achieving prompt control of asthma during _______ or when initiating long-term asthma therapy in patients with ____ symptoms
o Alternate-day treatment is preferred to daily treatment
o ______ and vitamin __ should be initiated to reduce bone loss
o BMD after 3 or more months of systemic use can guide use of bisphosphonates for tx of steroid induced osteoporosis
o Rapid D/C may precipitate adrenal insufficiency
• ________________
o Preferred, first line agents
o Inhalation chamber and mouth washing decreases local side effects and systemic absorption
Cough, dysphonia, oropharyngeal ________
o Dry powder inhalers are not used with an inhalation chamber
o ______effects may occur with high-dose inhaled therapy
Adrenal suppression, osteoporosis, skin thinning, easy bruising and cataracts
2. Long Acting Bronchodilators
• Mediator Inhibitors
o ______ sodium, _____
- in patients with ____ persistant or _______ asthma
- inhibit both early and late asthmatic response to allergens and EI asthma
-effective when taken ____ exercise or exposure, not when symptoms present
• Long-acting beta-2 agonists
o ________, formoterol
o When added to ___ and ____ daily doses of inhaled corticosteroid, provide control equivalent to what is achieved by doubling the inhaled corticosteroid dose
o Should not be used as ______
No anti-inflammatory effect and monotherapy associated with increased risk of severe or fatal asthma attacks
o Combination available: Formoterol and budesonide
• Anticholinergics
o Long acting anticholinergic _______: add-on therapy for patients who have either a bronchodilator response or a positive _______ challenge that is not adequately controlled with a low dose inhaled corticosteroid
o Improved PEF, FEV1 and symptom control
• Phosphodiesterase Inhibitors
o Theophylline
o Theophylline serum concentrations need to be monitored closely owning to the medications _____ toxic-therapeutic range, Individual differences in metabolism, and the effects of many factors on drug absorption and metabolism
3. Leukotriene modifiers
• contribute to airway obstruction and asthma symptoms y contracting airway smooth muscle, increasing vascular permeability and mucus secretion and attracting and activating airway inflammatory cells
• _____ (Zyflo)
• Zafirlukast (Accolate – although this med is being discontinued) and ______ (Singulair) are cysteinyl leukotriene receptor antagonists
SHORT ACTING BRONCHODILATORS
Short acting bronchodilators
• ______, levalbuterol, bitolterol, pirbuterol and ______
-most effective during _________
- as effective as oral or parental therapyin relaxing smooth muscle
-fewer side effects
• Presents exercise-induced bronchoconstriction
Anticholinergics
• ___________
• Inhaled drug of choice for patient with intolerance to beta-2-agonists or with bronchospasm due to beta-blocker medications
SABA low cromolyn, LTRA, nedocromil, theophylline ICS, LABA, LTRA, theophylline medium medium, LABA medium, LTRA, theophylline high, LABA high, LTRA, theophylline high, LABA, systemic corticosteroid high, LTRA, theophylline, systemic corticosteroid
oxygen
inhaled SABA
systemic corticosteroids
methylprednisolone potent exacerbations, severe calcium, vitamin D inhaled corticosteroids systemic cromolyn, nedocromil mild exercise induced before salmeterol low, medium monotherapy tiotropium methacholine narrow zileuton montelukast albuterol, terbutaline acute exacerbations ipratropium bromide
HAP/VAP
Patho
Definition: Hospital-Acquired Pneumonia (HAP): occurs after at least ___ hours of hospitalization
• ________ is the primary route of infection to the lungs
• Bacteria: _______, _______
•Ventilator-Associated Pneumonia (VAP): occurs after _-__ hours of endotracheal intubation
S/S VAP •Needs to be diagnosed early: mortality is 25-50% •Reasonable to start treatment if: •1) New lung \_\_\_\_ AND •2) One of the following: •\_\_\_\_\_ •\_\_\_\_\_ tracheobronchial secretions •Leukocytosis •\_\_\_\_\_ respiratory rate •Decreased tidal volume •Increased minute ventilation •Decreased oxygenation
Epidemiology
Diagnostics
_______
Tx
The local _______ is very important, as hospital to hospital can differ in terms of MDR resistance
• Usually give _ antibiotics for HAP patients
• Everything is __
• Once an organism is identified, rapidly ____ antibiotics
• De-escalation based on culture data is critical
1) One of the following for pseudomonal and gram negative (-) coverage:
• Anti-pseudomonal _______ (_________ or ceftazidime)
• _________/Tazobactam (_____)
• _________ (any except ertapenem)
• _______ for anaphylactic penicillin allergy
PLUS
2) Double pseudomonal coverage (as it is so often resistant) with one of the following:
• Anti-pseudomonal _______ (______ or ______ )
• _____(tobramycin, gentamicin, or amikacin)
• In severe patients, if Pseudomonas is resistant to cefepime or zosyn, more likely to be resistant to cipro, so usually ________ is the best choice
PLUS
3) Broad gram positive (+) coverage with one of the following:
• _________ or _______
48 microaspiration MRSA, pseudomonas 48-72 infiltrate fever purulent increased sputum culture antibiogram 2 IV narrow
cephalosporine, cefepime piperacillin zosyn carbapenem aztreonam
fluoroquinolone (cipro or levofloxacin)
aminoglycoside
aminoglycoside
vancomycin
linezolid
Pneumonia
S/S:
• Acute or subacute onset of fever, cough, dyspnea, +/- sputum production
• Sweats, chills, rigors, chest discomfort, pleurisy, hemoptysis, fatigue, myalgias, anorexia, headache, abdominal pain
• PE findings: ______ temp (can have hypothermia or other atypical sxs in the elderly), ______, tachycardia, oxygen desats. Inspiratory _____, bronchial breath sounds, dullness to percussion if _____ pneumonia
Strep. Pneumoniae: MCC of ___ in inpatient, outpatient and ICU setting
• _________:
o Can be used to effectively rule out S.pneumo
• Most commonly forms a _____ pneumonia
• BUZZ WORDS - “____ colored sputum” “single shaking ____”
Mycoplasma Pneumoniae
• Not ____ on gram stain, hard to culture so won’t show up on sputum culture results
• Has no ____
• MCC of “_____________”
• Antibodies against M. pneumoniae antigens can cross react with human brain cells and erythrocytes (possible _____/_______ issues)
• Usually a dry cough
• BUZZ WORDS: “_______”, “____ looks worse than clinical picture”
Chlamydophila Pneumonia
• ___ PNA: dry cough, malaise, _______ of gradual onset over 3-4 weeks
• Does not differ significantly by _____
• Not seen on gram stain
Legionella
• Legionnaire’s disease: resp _____
o Transmitted by inhalation of contaminated aerosolized ____
o High ____ often with relative bradycardia (_____ sign)
o _______
o Mild __ abnormalities
o __ symptoms (diarrhea)
o CXR findings vary; however, rapidly progressive, asymmetric ____ alveolar infiltrates in the _____ lobes are characteristic.
Diagnosis: check ___ Legionella antigen
] Tx: give a ______ or ______
o Buzz words: “relative _______” and “associated __ symptoms”
• Pontiac fever
o Fever, malaise, chills, fatigue, and headache, with NO respiratory complaints
o Usually no antibiotics needed, self-limited
Viral pneumonia
• ______ MCC
elevated
tachypnea
crackles
lobar
CAP urine antigen test LOBAR rusty chill
visible cell wall walking pneumonia hemolysis neurologic bullous myringitis x-ray
headache
mild
season
infection water fever Faget's hyponatremia LFT GI fluffy lower urine quinolone, macrolide bradycardia GI
influenza
- Treatment of suspected MRSA pneumonia
• _______
• _____
• Everything is __
vancomycin
linezolid
IV
TB
Patho
• TB is spread through ______droplets
• At this point, enough antigen has been produced to stimulate a cellular immune response
• Cellular immune response: CD4 and CD8 T cells attempt to ____ the infection and/or kill infected cells
• At this point, 2 things can happen:
1. Latent TB: The immune system is able to successfully contain the infection (but not ______ it). Macrophages and T cells _____ areas of infection, thereby preventing the infection from spreading. These walled off areas of infection are called ________
2. Active TB: The immune system is not able to contain the infection within granulomas and it spreads throughout the body
S/S
In active TB, you’ll more often see the classic symptoms you may associate with TB:
• _____
• Night _____
• Weight loss
• _______ (hallmark)
• Don’t forget about extrapulmonary TB: occurs in 15-20% of cases, especially in children or the __________ (50% of cases in people with HIV!):
• Spine (Pott’s disease)
• CNS
• Lymph nodes (Scrofula when it involves the neck)
• Pericardium
• Pleura
• Joints
• Intestines
• GU system
• Pretty much anywhere
• Or everywhere – miliary TB (hemotagenously disseminated TB)
Epidemiology
Diagnostics Who to test?
• Feels just fine
• Is he from somewhere where TB is endemic?
• Is risk of reactivation high?
o Does he have HIV?
o Otherwise (or about to be) immunosuppressed (on chemo, TNF inhibitors, getting HD)
• ^^^ if YES THEN TEST
YES you can have active TB and a negative TST or IGRA
•They only provide collateral information in this setting
TWO TESTS:
1. Tuberculin skin test (TFT)
• TST is performed by injecting 0.1 ml of tuberculin purified protein derivative (___) intradermally into the inner surface of the forearm.
• 48-72 hours later, the _____ of induration (NOT erythema) is measured:
- 5 mm is positive for: ____, ____ transplant, other immunosuppressed people
- 10 mm is positive for: recent ______ from areas with high TB incidence, health care workers, the _____, and people with hematologic or head/neck malignancies, ____ failure,or _____
- 15 mm is positive for: people with no known ________
• How it works: TB antigens are injected into the skin. If you have memory cells from a prior TB exposure, those immune cells will react to the antigens by producing a lot of cytokines and lot of inflammation.
• That inflammation causes the induration which is measured
• False negatives can occur due to being _________: if you’re immune system can’t mount an inflammatory response, the test will be negative
• False positives can occur due to ___ vaccination (especially if recent) and non-tuberculous mycobacterial infections
• And remember: _______ the size of your cutoff for a positive result 10 mm vs 15 mm, for example) will increase sensitivity and decrease specificity. Increasing the cutoff will do the reverse.
- Interferon gamma release assay
________ : often initial test ordered
• In elderly patients, lower lobe _____ with or without ______ are frequently encountered.
• Lower lung tuberculosis may masquerade as _______ or _____ cancer. A “_____ ” pattern.
• In elderly patients, lower lobe infiltrates with or without pleural effusion are frequently encountered.
• Lower lung tuberculosis may masquerade as pneumonia or lung cancer.
Tx Latent TB:
• _______, ______ isoniazid and _______
• Always rule out active TB before starting tx for latent because if you give latent TB regimen (_______) to someone with active TB, you risk development of drug _______ to TB
• Get a CXR before starting
Active TB:
• 2 months: intensive phase
o RIPE: ______, _______, ______, _______
• Continuation phase
o 4 months of i______ and ____ alone
TB tx in patients with HIV:
• There are often drug-drug interactions between TB medications and antiretrovirals – check before prescribing
• Duration of treatment is longer for patients with HIV not on HAART (the continuation phase is extended to 7 months)
• Remember that TB can look different in HIV: _______ and ____ TB are much more common and symptoms can progress more quickly
Start patient on HAART
• What happens: About 1-4 weeks after starting HAART, patients can develop fevers, worsening lymphadenopathy, and new infiltrates. Essentially this is due to comparative recovery of the immune system on HAART and a robust inflammatory response as the recovering immune system tries to respond to the TB.
• The lower someone’s CD4 count is to start, the greater the risk.
• What to do about it: IRIS is usually self-limited and treated with supportive care. In severe cases, steroids can be considered, although there isn’t much data to support their use (except in TB meningitis)
Pregnant women:
• ______, _______, and _____ for 2 months followed by isoniazid and rifampin for additional 7 months
• _________ should only be used if resistance to other drugs because teratogenicity with pyrazinamide has not been clearly defined
Monitoring on LATENT TB
• 20% of people have an increase in LFTs with RIPE therapy
• Stop treatment if:
• ________ and AST > __X increase above upper limit of normal
• _____ and AST > X increase above upper limit of normal
• _____ abnormal LFTS and AST > ___X increase above upper limit of normal
• After improvement in LFTs, can restart medications. Reintroduce ______ first (+/- ethambutol). Then ____. May avoid __________
Misc.
aerosolized contain eliminate wall off granulomas
fever
sweats
hemoptysis
immunocompromised
PPD diameter HIV organ immigrants homless renal diabetes risk factors
immunosuppressed
BCG
decreasing
chest radiograph infiltrates pleural effusion pneumonia lung miliary
isoniazid, rifampicin, rifapentin
monotherapy
resistance
rifampin, isoniazid, pyrazinamide, ethambutol
isonazid, rifampin
extrapulmonary, CNS
isoniazid, rifampin, ethambutol
pyrazinamide
asymptomatic 5 symptomatic 3 baseline 3 rifampin INH pyrazinamide
Drug side effects of TB drugs:
• This TB drug can cause optic neuritis, usually reversible with discontinuation of the drug: ______
• This drug can cause peripheral neuropathy: ________
• This drug can cause gout flares: _______
• This drug turns bodily fluids orange: ________
• This drug can cause a Lupus like syndrome: ______ , Start patients on ______ (vitamin ___) to prevent this side effect while on INH
• This drug can cause thrombocytopenia: _______
• This drug can cause polyarthralgias: _____ AND _______
• This drug has a LOT of drug-drug interactions: _______
• These drugs can cause LFT abnormalities: all of them
• _______ > _______ > ______»_space; ethambutol
ethambutol isoniazid pyrazinamide rifampin isoniazid pyridoxine, B6 rifampin rifampin, pyrazinamide rifampin pyrazinamide, isoniazide, rifampin
Pleuritis
Patho
• Irritation of the ________
• In healthy patients generally due to either ___. or ______ respiratory infection
S/S • _____, ____ brief pain
• Pain is made worse by ______, coughing, movements
• When the central portion of the diaphragmatic parietal pleura is irritated, pain radiates to ________
• If pleural _____, ____ in the pleural space, or pleural _______ is present, further evaluation needed
Epidemiology
Diagnostics
___ to rule out other problems
Prevention
Tx • Treat the underlying condition • \_\_\_\_\_ for pain relief and to reduce inflammation o \_\_\_\_\_ • Antitussives o \_\_\_\_\_\_\_ Misc.
parietal pleura
viral, bacterial
localized, sharp
sneezing
ipsilateral shoulder
effusion, air, thickening
CXR
NSAIDs
indocin
codeine
Influenza
Patho
• Flu spreads thru _____ sneezed or coughed by infected persons
• Virus enters ________
• _______ on outer envelope binds to cell membrane sialic acid
• This begins entry of virus into cell
• It uncoats and starts to replicate
• New virions formed in the cell have sialic acid incorporated into outer envelope
• _______ cleaves sialic acid
• Virus recovers its ability to infect other cells
S/S •
Incubation period of __ days
• Usually in fall and winter
• Followed by onset of respiratory and systemic symptoms
• ___: rhinitis, cough, sore throat
Systemic manifestations
• Headache
• Malaise
• Anorexia
• Severe myalgia
• High fever (often with chills)
• ____ sxs (photophobia, pain on eye movement)
From picture: headache, fever, muscle tiredness, aches, runny or stuffy nose, coughing, vomiting
Epidemiology
Diagnostics
Lab findings:
• ______
• _______
Rapid influenza diagnostic tests (RIDTs)
• Screening test
• Results in 15 mins
• 10 different tests approved
• Sensitivities are 50-70%
• Specificities 90-95%
• Use nasal secretions from a scab
• Some newer ones can utilize throat swabs
• Tests: Quidel, Quickvue
Prevention
Tx
• Prevent disease: flu vaccination
• Vaccines are inactivated whole virus, H and N, or split-product immunogenic vaccines
Antiviral drugs: ________ inhibitors
• Oseltamivir
• Zanamivir
• Peramivir
Symptomatic therapy to reduce discomfort
Misc.
Vaccine:
Indications:
• Adults and children with chronic cardiac or respiratory diseases requiring medical care
• Residents of nursing homes and long-term care facilities
• Healthy people > 65 yo
• Any patient with health problems
• Pt admitted to a hospital for kidney disease, cystic fibrosis, diabetes, anemia, or severe asthma
• Immunosuppressed pts
• Medical staff or family who give care to high-risk patients
• Travelers to foreign countries where there is flu
• Groups of individuals living in close quarters
Contraindications:
• Contraindicated in persons with hypersensitivity to _______s (except they have an egg free form now!), acute ______ illness OR __________ (low platelet count), relative contraindication in patients with history of _________ Syndrome
Patient education:
• Best to get before exposed
• Can take up to 2 weeks to take effect
• May not protect against all strains
droplets upper resp tract hemagglutinin neuradiminase 1-4 URI ocular
leukopenia
proteinura
neuramindinase
chicken eggs
febrile
thrombocytopenia
guillan-barre syndrome
COPD
Patho
•Chronic obstruction to airflow due to ______ and/or ________
–______- RV and FRC elevated
–________–TLC elevated (mainly emphysema)
–¯elastic recoil pressure ® dynamic collapse of airways during expiration ®ineffective cough mechanism and pursed lips breathing (emphysema)
– compliance (emphysema)
– airway resistance
–Prolonged forced expiratory time (N=<6 seconds)
S/S •
–Characteristically present in the fifth or sixth decade of life
Complaints of:
• Excessive ____
• _____ production
• Shortness of breath
• Symptoms have often been present for __ years or more
• _____ is noted initially only on heavy exertion
• But as the condition progresses, it occurs with mild activity
• Severe disease, dyspnea occurs at rest
Physical signs of COPD –
• _____ - in early disease present on forced expiration, later present in inspiration and expiration
• Prolonged forced expiratory time (> _ seconds)
• Hyperinflation: ¯ cardiac dullness, liver dullness displaced downwards, A-P chest diameter, ¯ heart and breath sounds, ____r sign
• _______ crepitations/crackles (lung bases)
• Pursed lips breathing ( ¯ dynamic airway collapse)
• Use ______ respiratory muscles
• Signs of _______ and pulmonary HTN
- As the disease progresses: two symptom patterns tend to emerge
- Historically: “______” and “______”
- Most have evidence of both disorders and their clinical course may involve other factors such as central control of ventilation and concomitant sleep-disordered breathing.
- _______, pulmonary _____, _______and chronic respiratory failure characterize the late stage of COPD
A hallmark of COPD is the periodic exacerbation of symptoms beyond normal day-to-day variation, often including
• increased _____,
• an increased frequency or severity of ____ and
• –increased _____ volume or change in sputum character
These exacerbations are commonly precipitated by infection; more often _____ than _____
• Or environmental factors
• Exacerbations of COPD vary widely in severity but typically require a change in regular therapy
Epidemiology •
30% of smokers develop COPD
• Increased prevalence in low birth weight and low socioeconomic status
• ________ is clearly the most important cause of COPD in North America and western Europe
Diagnostics
Laboratory Findings:
Spirometry
• provides objective information about pulmonary function and assesses response to therapy
–Early -Only reveal evidence of abnormal _____ volume and reduced ______ flow rate
–Later - Reduction in ____
and ratio (FEV1% or FEV1/FVC)
–Severe - ___ is markedly reduced, Marked increase in residual volume, increase in ___, Elevation of the RV/TLC ration indicative of air trapping, particularly in emphysema
Arterial Blood Gas
Early: characteristically show no abnormalities ___ in COPD other than an increased A-a-Do
ECG
• May show sinus _______
chronic bronchitis, emphysema
air trapping
hyperinflation
cough
sputum
10
dyspnea
rhonchi
6
hoover
inspiratory
accessory
cor pulmonale
pink puffers
blue bloaters
pnuemonia
hypertension
cor pulmonale
dyspnea
cough
sputum
viral, bacterial
cigarette smokng
closing midexpiratory FEV1 FVC TLC
early
tachycardia
COPD
Tx
_________ : The single most important intervention in smokers with COPD is to encourage smoking cessation
Ambulatory Patients
Supplemental Oxygen
• Oxygen Therapy: Supplemental oxygen for patients with resting ______ is the only therapy with evicence of improvement in the natural history of COPD
• _________ analysis preferred over oximetry to guide initial oxygen therapy
• Hypoxemic patients that benefit most from home O2 therapy are those with pulmonary _______, chronic ________, erythrocytosis, impaired cognitive function, exercise ______ , nocturnal _______ or morning headache
____ bronchodilators
• Improve symptoms, exercise tolerance and overall health status
• Aggressiveness of therapy should be matched to the severity of the patient’s disease
• D/C in patients who experience no symptomatic improvement
• Most commonly prescribed short acting bronchodilators are ____ and _______ (anticholinergic) delivered by MDI or as an inhalation solution by nebulizer.
o ________ is generally preferred to the short-acting beta-2-agonists as a first line agent because of its longer duration of action and absence of sympathomimetic side effects
• Short acting beta-2-agonists
o –There does not appear to be any advantage of scheduled use of short acting beta-2-agonists compared with as needed administration.
• Long acting beta-2-agonists and anticholinergics
o Bronchodilation equivalent or superior to ipratropium
o Decrease ______ or hospitalizations and improve dyspnea
• Corticosteroids inhaled
o Reductions in frequency of COPD exacerbations and increase in self-reported functional status in COPD pts
o ___ first line because no effect on mortality or decline in lung function
o Combo therapy with ____ reduces frequency of exacerbations and improves self-reported functional status in COPD pts
• Corticosteroids oral
o Generally not responsive to oral corticosteroid therapy
o There may be a subset of steroid-responsive COPD patients more likely to benefit from long-term oral or inhaled corticosteroids.
• Oral theophylline
o ___ line for pts with COPD not controlled with inhaled –anticholinergic, beta-2-agonist, and corticosteroid therapies
• ABX
o _______ , _____ , Cephalosporin, _____ , amoxicillin-clavulanate
o Used to treat and improve outcomes slightly: acute _____ , ____ bronchitis, to prevent acute exacerbations of ____ bronchitis
o –Patients with a COPD exacerbation associated with increased sputum ______ accompanied by ______ or an increase in the quantity of sputum are thought to benefit the most from antibiotic therapy.
• Pulmonary rehabilitation
o Graded aerobic exercise programs, training of inspiratory muscles, abdominal breathing exercises
SURGERY
___________
–Requirements:
• Severe lung disease, limited activities of daily living, exhaustion of medical therapy, ambulatory status, potential for pulmonary rehabilitation, limited live expectancy without transplantation, adequate function of other organ systems and a good social support system
Lung Volume reduction surgery
• Reduction pneumoplasty
• Surgical approach to relieve _____ and improve ______ tolerance in patients with advanced diffuse ______ and lung hyperinflation
______
Misc.
smoking cessation hypoxemia arterial blood gas hypertension cor pulmonale intolerance restlessness
inhaled
SABAs, ipratropium bromide
ipratropium bromide
exacerbations not LABA 4th doxycycline, trimethoprim, cephalosporin, macrolide exacerbations, acute, chronic purulence, dyspnea
lung transplantation dyspnea exercise emphysema bullectomy
