Pulmonary Flashcards
How is a cough classified?
Length of time it has occurred
Acute: Less than 3 weeks
Sub-Acute: 3-8 weeks
Chronic: Over 8 weeks
What are the four common etiologies for an acute cough lasting less than 3 weeks?
Acute respiratory infection (bronchitis), exacerbation of COPD/asthma, pneumonia, pulmonary embolism
What are the 7 common etiologies for a sub-acute to chronic cough?
GERD, asthma, infection (atypical pneumonia, pertussis), Ace Inhibitors (dry cough after 1-3 weeks), chronic bronchitis (smokers), bronchiectasis (chronic cough, viscid sputum, bronchial wall thickening on CT), and lung CA (less than 2%)
A 34-year-old non-smoker Who is otherwise healthy has been diagnosed with acute bronchitis. His symptoms have persisted for the past four days. What’s an appropriate treatment for him?
Likely viral. Treat symptomatically.
What are the three most common bugs in community acquired pneumonia?
Strep pneumo - 14% - rust colored sputum; most common cause of death from Pneumonia
Mycoplasma pneumoniae - 16% - most common
Chlamydophila pneimoniae - 12%
What characteristics should make the nurse practitioner suspect that a pneumonia is secondary to DRSP?
Recent antibiotic exposure
In what cases would you suspect DRSP?
Older, sicker patients with recent antibiotic exposure
1) Age over 65
2) Beta-lactam, Macrolide, or respiratory quinolone therapy in the three months prior
3) alcoholism
4) medical comorbidities
5) immunosuppressive illness or therapy
6) exposure to a child in daycare
What patient is most likely to harbor an atypical pathogen?
1) 19 year old type 1 diabetic
2) A 27-year-old with asthma; recent sinus infection treated with Augmentin
3) A 39-year-old smoker of one pack per day
4) A 48-year-old who has teenagers in the household
A 48-year-old who has teenagers in the household.
The other three options are indicative of DRSP
What are the usual clinical signs and symptoms in a patient who has pneumonia?
Cough 90%, purulent sputum production, fever - more than 80%, chills 40-50%, shortness of breath - over 24 BPM, pleuritic chest pain - over 30%, increased respiration and heart rate (older patients), leukocytosis 15-30000/mm
Guidelines for treatment of pneumonia. What is the first choice for an individual who is healthy with no anabiotic exposure in the last 3 months?
Macrolide x 5 days (azithromycin or clarithromycin) or doxycycline BID daily
Discourage quinolone use initially!
If DRSP is suspected, what is the treatment guidelines for pneumonia?
Respiratory quinolone x 5 days
(-floxacin)
Or beta-lactam (PCN or cephalosporin) PLUS macrolide
Or beta-lactam plus doxycycline
What is the criteria for hospital admission for patients with pneumonia?
CRB 65 C= confusion R= respiratory rate above 30 B= BP under 90 systolic or under 60 diastolic 65 = age over 65
Who should get the pneumococcal vaccine? (PPSV23)
Adults 19 to 64 who are at increased risk of pneumococcal disease (Individuals with chronic diseases)
Who should get the PCV 13 (Prevnar) Plus the PPSV23 (after 1 year)
All adults over 65 years old
Those aged 19 to 64 with asplenia, immunocompromise conditions, CSF leaks, cochlear implant’s, advanced CKD, steroid use
* Not recommended for healthy adults under 65
What is the definition of COPD?
A common preventable and treatable disease; persistent airflow limitation, usually progressive, enhanced chronic inflammatory response of the airways and lung to noxious particles or gases
Exacerbations and comorbidities contribute to severity
4th leading cause of death
What are the risk factors for COPD?
Cigarette smoke, occupational dust and chemicals, environmental tobacco smoke, indoor and outdoor air pollution, genes, infections, socioeconomic status, aging populations
What are the symptoms of COPD?
Chronic and progressive dyspnea, cough, and sputum production that varies from day to day
The dyspnea is progressive, persistent, and worsens with exercise.
The cough may be intermittent and unproductive
The chronic sputum production is common
What are the differential diagnoses for COPD?
COPD - midlife on that, slow progression of symptoms; history of exposure to lung irritants
Heart failure - dilated heart, pulmonary Edema, no airflow limitation
asthma - early in life on that usually, wide variation in symptoms from day today, symptoms may worsen in early a.m. or evening nighttime, history of allergic rhinitis/eczema/family history
tuberculosis - any age; infiltrate on chest x-ray. Sputum confirmation
How do you diagnose COPD?
Symptoms: shortness of breath, chronic cough, sputum
Exposure to risk factors: Tobacco, occupation, indoor /outdoor pollution
**Spirometry is required to establish diagnoses
What confirms a diagnoses of COPD?
Spirometry: Post bronchodilator shows FEV1/FVC ratio less than .70
What is an FVC?
Forced vital capacity = Max volume of air exhaled during a forceful maneuver
What is an FEV1?
Forced expired volume in one second: maximal volume of air expired and one second after maximal inspiration; how quickly long as can be emptied
What is the normal FEV1/FVC ratio in healthy adults?
0.7-0.8
Recommended treatment for mild COPD
Short acting bronchodilator PRN (-terol)
What is the recommended treatment for moderate COPD?
Short acting bronchodilator when needed
Regular treatment with one or more long acting bronchodilators (-terol)
Rehabilitation
What is the treatment for severe COPD?
Short acting bronchodilator when needed
Regular treatment with one or more long-acting bronchodilator’s
Rehabilitation
Inhaled glucocorticoids if significant symptoms, long function response, or if repeated exacerbations (-one; -ide)
Short acting bronchodilator use is associated with greater risk of arrhythmias and new users. Which arrhythmias?
Atrial fibrillation; atrial flutter
This puts patients at risk for a CVA
What are the adverse affects of anti-cholinergics?
Urinary retention/BPH, increased intraocular pressure (contraindicated in glaucoma), dry mouth, constipation, confusion
What is the treatment for COPD exacerbations?
Oral steroids. Chronic you should be avoided due to unfavorable risk to benefit ratio. Causes increased blood sugar, mood instability, and osteopenia.
*Prednisones 40 mg x 5 days
What is the single most effective intervention for preventing exacerbations of COPD?
Smoking cessation
What is the single most effective intervention for preventing the progression of COPD?
Smoking cessation
Health promotion for COPD
Smoking cessation
Regular exercise
Pneumonia and influenza vaccines
What characteristic best distinguishes asthma from COPD?
1) severity of shortness of breath
2) need for rescue medicine
3) use of steroids for exacerbations
4) presence of inflammation
The presence of inflammation. Asthma is a disease of inflammation no matter how mild or severe!
What is included in effective asthma management?
Prevention. Regularly scheduled visits depending on the level of control.
What are the triad of symptoms for suspected asthma?
Wheezing, cough, chest tightness/SOB
What is included in the history of suspected asthma?
The triad of symptoms, Family history of asthma or personal history of other atopic disease, history of variable respiratory symptoms, predictable pattern of respiratory symptoms when exposed to a precipitate such as URI, mold, exercise, stress. Night symptoms
What are the differential diagnoses of asthma?
GERD, COPD, heart failure, obesity, panic disorder, bronchogenic carcinoma
How do you diagnose asthma?
Variable Expiratory airflow limitation (FEV1/FVC ratio)
Respiratory symptoms
What are the two kinds of asthma?
Intermittent and persistent
How do you differentiate between intermittent and persistent asthma?
How often the patient has symptoms
How is intermittent asthma classified by symptoms and what is the treatment?
Less than two times per week. Treated with a short acting beta agonist. If SABA is used more than two times per week step up the therapy to a low dose in hailed steroid
How is mild persistent asthma classified and what is the treatment?
Low-dose inhaled steroid daily and a SABA for PRN use
If the SABA is used more than two times per week you step up therapy to a medium dose inhaled steroid
How is moderate persistent asthma classified and what is the treatment?
Patient is having daily symptoms. Pre-scribe a medium does inhaled steroid plus A long acting beta agonist.
Use a SABA for rescue.
If the SABA is used more than twice per week step up therapy to high dose inhaled steroid plus LABA
Consider referral
What medication does every asthma patient have to have?
A short acting bronchodilator
How often should asthma patients be followed up with?
1 to 3 months after initiating treatment
Every 3 to 12 months for routine follow-up
After an exacerbation see patient one week later
What is considered in the health promotion of a patient with asthma?
Flu and pneumonia vaccine, regular exercise
Asthma action plan
The patient should know the name of meds and how to use inhaler properly. Know when to use rescue med
A 70-year-old smoker presents with right unilateral wheezing. A chest x-ray demonstrates right enlarged hilar nodes. What should be done next?
A CT chest with contrast.
Pick a test that is quick, cheap, noninvasive, and you can do in the office
A patient who was on lisinopril developed a cost. What finding in this patient supports a diagnoses of ace inhibitor related cough?
Cough started four days after lisinopril was begun
A 24-year-old college student who is otherwise healthy and a non-smoker has community acquired pneumonia pneumonia. She was taking Augmentin for the past three days and her fever persists. How should she be managed?
Stop Augmentin and start azithromycin. Macrolide is the first line treatment in otherwise healthy patients with community acquired pneumonia
What in hell medication combo creates the greatest risk of sudden death in an asthma patient?
Do not use a long acting beta agonist without a steroid in asthma patients
A 63-year-old patient with COPD complains of a pounding heart after taking his inhaler which one is least likely the culprit?
The steroid
A 78-year-old male smoker with stage to COPD has received a prescription for ipatropium. What problem is likely after he begins the ipratropium?
Increased intraocular pressure given a history of glaucoma.
Anti-cholinergics cause an increase in IOP
A 55-year-old patient was diagnosed with pneumonia seven days ago and was started on Levaquin. He has had a normal temperature for two days but complains of fatigue and lingering cough. How should this be handled?
Have him continue to rest for another 3 to 5 days. Patient needs time!
A patient who has moderate persistent asthma takes fluticasone twice daily but is still having symptoms what medication listed below will be a little benefit in the management of this patient wheezing and coughing?
1) Theiphylline
2) Albuterol
3) Tiotropium
4) Salmeterol
Theophylline and Tiotropium.
The other two are examples of a SABA and a LABA and are helpful and treatment of asthma
