Pulmonary Flashcards
Acute Bronchitis: Clinical Presentation
Cough: dry and non-productive, then turns productive: may be purulent
URI symptoms
Fatigue
Fever- from bacterial infection (more common in smokers or COPD)
Burning in chest
crackles, wheezes
chest wall pain
perform
Acute Bronchitis: How to Dx
Only get a chest x-ray if there is tachypnea, hypoxia, fever, abnormal lung exam, High suspicion of pneumonia or heart failure
- consider ppd, sputum culture, CBC, viral panel, influenza titer, pertussis testing if local outbreak,
Acute bronchitis: DDx
-common cold
-acute rhinosinusitis
-pneumonia
-influenza
-TB
-Asthma
-Pertussis
-bronchiectasis
-chronic cough
-heart failure
Acute Bronchitis: Pharm/ Non-pharm treatments
Non-pharm
- increase fluids, use humidifier, rest, stop smoking, avoid second hand smoke, consider honey (older than 1),
Pharm
- NO ROUTINE PERSCRIPTION for abx, antivirals, antitussives, inhaled beta-agonists, inhaled anticholinergics, inhaled or oral corticosteroids, NSAIDs, or other treatment.
- If causative agent is bacterial use antibiotics
- IF influenza is cause use antiviral
-use decongestants and antihistamines unless the cause is sinusitis or allergies
-Bronchodilators if wheezing or prior history of asthma.
Acute Bronchitis: Follow up
7 days if not improved, refer to pulmonologist if symptoms do not improve after 4 weeks
Acute Bronchitis: Normal course
symptoms may persists 3-4 weeks
Acute Bronchitis: possible complications
pneumonia, chronic cough, chronic bronchitis, secondary bacterial infection, bronchiectasis
Pertussis: Clinical Presentation
-Paroxysms of coughing
-inspiratory whoop
-posttussive vomiting
-conjunctival hemorrhage or facial petechiae from intense coughing
- weightloss and dehydration
Young infants: minimal or no cough, gag, gasp, apnea, bradycardia, poor feeding, oxygen desaturations, and cyanosis
Adolescents and adults: usually afebrile with persistent nonproductive cough
Pertussis: Stages
Stage I: Catarrhal (1-2 weeks)
- the insidious onset of nonspecific respiratory symptoms: nasal congestion, rhinorrhea, sneezing, and mild cough
- malaise, conjunctival suffusion, lacrimation, low-grade or no fever
Stage II: Paroxysmal (2-8 weeks, up to 10 weeks)
- coughing spells increase in severity in the first 2 weeks and become violent, frequent, and spasmodic. The coughing spells can remain intense for up to a month before gradually lessening. Episodes of coughing may last several minutes.
- cough may be more prominent at night
- posttussive vomiting is common and sensitive and specific finding pertussis
Stage III: Convalescent (8-12)
- cough subsides and disappears over weeks to months
-The characteristic cough can return up to several months later if another URI is acquired
Pertussis: How to diagnose
Cough >3 weeks and patients older than 4 months obtain serology (IgG antibodies, best 2-12 weeks after cough onset)
cough <3 weeks obtain PCR (of Bordetella pertussis; up to 3 weeks after cough began) and culture
Nasopharyngeal culture Gold Standard; best when done within first 2 weeks of symptoms
-In complicated cases can use an x-ray
Pertussis: DDx
- viral infections, TB, pneumonia, reactive airway disease, croup, CF, FB, GERD, Allergic or infectious sinusitis
Pertussis: pharm and non-pharm
Non-pharm
-supportive therapy, (oxygen, cool humidifier, suctioning, fluids, and nutritional support
-good handwashing
-rest
-keep home free of irritants such as smoke, dust, and chemical fumes
- consider hospitalizations for infants younger than 6 months, pre-me, and comorbidities
-isolation of affected people with droplet precautions
-REPORT to public health authorities
Pharm
-COUGH MEDS NOT recommended
-macrolides are the choice of treatment: Azithromycin
-Allergy to macrolides: use Bactrim
-provide antibiotics to all household members of the patient
-
Pertussis: Follow-up care
based on age and severity of illness
Pertussis: Expected course
full recovery 2-3 months
Pertussis: Complications
-secondary bacterial pneumonia
-otitis media
-cough syncope
-seizures
-pulmonary hypertension
-acute anoxic encephalopathy
-failure to. thrive
-resp failure
-syncope
Tuberculosis: Clinical Presentation
Active TB
-fever, cough lasting >3 weeks, hemoptysis, weight loss, pleural pain, loss of appetite, chills, night sweats,
Extrapulmonary TB
-symptoms depend on area of body affected, most common are lymphatic system, pleural, urogenital tract, bone and joints, central nervous system
Latent TB infection
-asymptomatic, cannot spread disease, positive TB skin or blood test, may progress to active disease
Tuberculosis: How to diagnose
Interferon gamma-release assays (IGRA)
-not affected by prior TB vaccination
TB skin test
-recommended when IGRA not available or too expensive
- is affected by BCG
- Interpreting TST: measure palpable area of induration, >5mm pos. in immunosupression, >10 pos. in children less than 4, immigrants, injection drug users. > 15 mm in ppl without risk factors
If positive test obtain a chest x-ray
-if chest x-ray negative diagnose with latent TB
- if chest x-ray positive look for airway opacities, cavities, pleural effusions
Sputum for acid-fast bacilli (AFB) smear/culture
-bronchoscopy if cannot obtain sputum
- if AFB pos. dx with active TB
Tuberculosis: DDx
lung cancer, lymphoma, mycobacterium infections, sarcoidosis, lung abscess, pneumonia, fungal infection, inflammatory disease
Tuberculosis dx: Pharm and Non-pharm
Non-pharm
-infection transmission prevention covering mouth to cough and sneeze, frequent hand washing, etc., Support for the patient’s family living with the disease, wear surgical masks when they leave home or have visitors
Pharm
-drug-resistant TB requires longer treatment and different medication (fluoroquinolones and macrolides)
-combo med available
-treat all patient’s with latent TB
-
Tuberculosis dx: Pharm and Non-pharm
Non-pharm
-infection transmission prevention covering mouth to cough and sneeze, frequent hand washing, etc., Support for the patient’s family living with the disease, wear surgical masks when they leave home or have visitors
Pharm
-drug-resistant TB requires longer treatment and different medication (fluoroquinolones and macrolides)
-combo med available
-treat all patients with latent TB
-For newly diagnosed TB: isoniazid (INH), Rifampin (RIF), Pyrazinamide (PZA), Ethambutol (EMB) combination for 8 weeks then (INH) and (RIF) for 18 weeks, less time for patients with HIV
For latent TB infection
-Isoniazid (9 months, used for HIV, child 2-11 years, pregnant pts)
-Isoniazid ( 6 months, can be more cost-effective and greater adherence)
- INH and Refapentine 3 months duration; best for >12 years old,
-RF - used in patients who cannot tolerate INH, or have INH resistant strain,
TB: Follow-up care
-sputum test monthly until 2 AFB cultures are negative; if sputum is not negative after 8 wks longer treatment required,
- Repeat AFB culture 4 months after to ensure no remission
- All patients with TB should undergo HIV testing
TB- complications
pneumothorax, bronchiectasis, malignancy, thromboembolism, resp. failure, septic shock, hemoptysis, destruction of lung tissue, and death may occur in untreated disease
Pneumonia- Clinical presentation
Cough (often productive), fever (100.4 or greater), tachypnea, tachycardia, malaise/fatigue, sudden chills, chest pain, sputum production, increased respirations, and pulse, diminished breath sounds, consolidation on percussion, egophony (e to a changes), bronchophony (voice sounds are louder and clearer than normal), whispered pectoriloquy, tactile fremitus, older adults present with weakness, mental changes, or history of falls
Pneumonia- how to diagnose
PA and lateral chest x-ray (infiltrates present)
pulse oximetry
CBC with diff
Gram stain and sputum specimen (recommended in patients with severe disease , MRSA, and pseudomonas)
Influenza testing
Blood cultures
pneumonia: DDx
acute bronchitis, bronchiolitis, asthma, croup, HF, Bronchogenic carcinoma, TB, pneumonitis
Pneumonia: Pharm and non Pharm
non-pharm
- hydration with increased fluids, rest, pt edu. about the disease, treatment, and emergency
Pharm
-analgesia for pain
-empiric antibiotic treatment based on pt age, comorbidity, immunization status, risk factors
Pedi
-<3-6 months- likely requires hospitalization
>3 months+ immunized = amoxicillin
-Preschool + immunized= amoxicillin
-School+immunized= amoxicillin or macrolide (azithromycin)
-Adolescent +immunized= amoxicillin or macrolide
Adult
-Outpatient+healthy+no recent abx= amoxicillin or azithromycin or doxycycline
-outpatient+healthy+ recent abx= Resp fluoroquinolone (Levofloxicin) OR macrolide (azithromycin), PLUS high dose amoxicillin OR augmentin
-outpatient + comorbidities +no recent abx= augmentin or cephalosporin AND macrolide or doxy OR mono therapy with fluroquinolone
-Outpatient + comorbidities+ recent ABX= resp. fluoroquinolone OR macrolide PLUS amoxicillin or augmentin or cefpodoxime, cefprozil, or cefuroxime
Pneumonia: follow up care
within 24-72 hours as condition warrants
follow-up x-ray in 4-6 weeks in smokers and patients older than 40
Pneumonia: normal course
improvement should take place in 48-72 hours
pneumonia: Complications
empyema, resp failure, adult resp distress, sepsis, necrotizing pneumonia, endocarditis, meningitis, death
COPD: clinical presentation
persistent progressive dyspnea, cough and/or sputum,
EARLY: exam likely normal or prolonged expiratory wheezing on forced exhalation
Progression: increased resonance on percussion, decreased breath sounds, wheezes, crackles in lung bases and distant heart sounds
SEVERE: barrel chest
END STAGE: tripod position
COPD: how to diagnose
-Structured interviews and questionnaires
-spirometry FEV1/FVC ratio <70% gold standard post bronchodilator
-chest x-ray
-cbc, bnp, ecg, ppd
COPD: ddx
asthma, HF, pneumonia, bronchiectasis, lung cancer, TB
COPD: Pharm non-pharm treatment
non-pharm
-pulmonary rehab, delf management edu, cardiovascular exercise, regular assessment of inhaler use, adequate nutrition, noninvasive ventilator support
Pharm
Maintenance meds
-Before making med changes verify med adherence and inhaler technique
- start patient on single or combo bronchodilator
- flu vaccine
-pneumonia vaccine
- Oxygen for Sa02 <88%
- Do not use dry powder inhalers in ppl with sensitivity to milk protein
Acute exacerbation management
- bronchodilators, SABA (-terol) with or without SAMA (-tropium) are recommended
-systemic steroids are used to improve lung function and decrease recovery time in acute exacerbation
- if there are bacterial symptoms you can use augmentin, a macrolide or tetracycline
- sputum testing
COPD: follow-up care
every 3-6 months for stable disease , monthly for unstable disease
-if hospitalized follow up within one month after
COPD: Complications
-frequent pulmonary infections
-acute bronchospasm
-resp. failure, acute or chronic
- A-fib
-pulmonary hypertension
-lung cancer
Asthma: clinical presentation
Inflammatory Disorder of the airways
- expiratory wheezing
-SOB
-tachypnea
-tachycardia
-non productive cough
-chest tightness
-hyperresonance
-prolonged expiration
- acessory muscle use in severe asthma attack
-sudden nocturnal dyspnea
-decreased exercise tolerance
Asthma: classifications
Mild intermittent: <2 days per wk or <2 nights per month, exacerbations brief
mild persistent: >2 times/wk, but less than 1 time per day or <2 nights per month
mod. persistent: daily symptoms or more than 3-4 nights per month
severe persistent: continual symptoms or frequent nighttime symptoms.1 night per month
Asthma: How to diagnose
spirometry
pulmonary function test
consider allergy testing
peak flow monitoring
methacholine challenge test
serologic testing to measure IgE antibodies for specific allergens (food and environment)
find trigger with skin test
Asthma: non pharm and pharm
Non-pharm
-peak flow monitoring
-avoidance of triggers
-keep windows closed during pollen season
-control heart burn
-achieve a healthy weight and maintain exercise
-smoking cessation
-asthma action plan
Pharm
-inhaled steroids are the mainstay of treatment like fluticasone
-NEVER use LABA alone, should only be used with long-acting steroid
Asthma: Overview of Therapy
mild intermittent: short-acting bronchodilator for exacerbations
mild persistent:
-preferred- low dose ICS and SABA
Mod persistent:
low to medium ICS and LABA, and SABA for exacerbations
severe persistent: high dose ICS and LABA AND oral corticosteroid, and SABA for exacerbations
