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
