Pulmonary Flashcards
Most important question to ask patient who presents with complaints of coughing?
Length of time he/she has coughed
How many weeks classify a cough as acute or chronic?
Acute is <3 weeks
Chronic is >8 weeks
What is acute bronchitis? Where does it start?
Inflammation of the respiratory tree. Starts in the upper airways & progresses to the lower airways.
What symptoms are lacking with acute bronchitis?
Pt should not have fever, rarely has systemic symptoms such as malaise, fatigue, body aches, or SOB.
What is the most common etiology of acute bronchitis?
Viral
Does acute bronchitis require the use of an ATB for treatment?
No.
*Rationale: Viral does not require the use of an ATB therapy. Is self-limiting & time is what gets these patients better.
What symptom is the most common reason why patients with acute bronchitis seek care?
Cough
*Last symptom to go away & could last 3 wks
Does acute bronchitis need a chest x-ray for diagnosis?
No
What are the symptoms of pneumonia?
Appear sickly, fever, systemic symptoms common (fever, malaise, fatigue), coughing up purulent sputum. Changes in vital signs should also make one thing pneumonia.
What is one finding during physical examination that is common with pneumonia?
Dullness to percussion
What is expected to be found on a chest X-ray when a patient has pneumonia?
Infiltrates
What are two sensitive signs in the elderly with pneumonia?
Tachypnea (increased respirations)
Tachycardia (increased heart rate)
What are the three BUGS responsible for community acquired pneumonia (CAP)?
- S. pneumoniae (Streptococcus pneumoniae)
- M. pneumoniae (mycoplasma pneumoniae)
- Chlamydophila pneumoniae
Which bacteria is the most common cause of death from pneumonia? Which age groups are more at risk?
- S. pneumoniae
2. Very old & very young
What are the atypical organisms that cause atypical pneumonia?
Atypical refers to most common causes
M. pneumoniae, Chlamydophila pneumoniae, & Legionella
What diagnostic tool diagnosis pneumonia?
Chest x-ray
What diagnostic tool should be ordered for an ambulatory pt with pneumonia?
Chest x-ray PA & lateral
order because pt is ambulatory
Does pt with pneumonia require a follow up chest x-ray after initial diagnosis?
If pt is responding well, no need to get a follow up chest x-ray
What are the pneumonia guidelines for hospital admission?
“CRB65”
- Confusion
- Respiratory rate: increased; could be septic
- Blood pressure: SBP <90
- 65: consider age of pt
one or more requires admission
What is the gold standard treatment for S. pneumoniae? What suffix do these drugs end in?
Respiratory quinolone:
Fluoroquinolone
“floxacin”
- Moxifloxacin (Avelox)
- Gemifloxacin (Factive)
- Levofloxacin (Levaquin)
drugs kill above the belt
Why is ciprofloxacin not considered a respiratory quinolone?
Because it kills bacteria below the belt.
If unable to give a respiratory quinolone for S. pneumoniae, what can be ordered?
Beta lactam (any PCN or cephalosporin) + macrolide (“mycin”– Azithromycin) or doxycycline
*Beta lactam examples–> Amoxicillin (Amoxil); Amox with clavulanate (Augmentin)
For atypical pneumonia pathogens in an otherwise healthy patient who hasn’t had ATB in the last 90 days, treat with:
Macrolide (azithromycin or clarithromycin) OR doxycycline
What is a side effect of drugs given for pneumonia?
Drugs prolong QT intervals; QT interval prolongation increases the risk of VTach
How long to give a pneumonia patient ATB?
Always give ATB for 3 more days after pt is clinically stable.
Ex. Pt w/cellulitis in lower legs – 3 more days after the area is no longer red or tender to touch.
Ex. Pt w/sinusitis – 3 more days after its not coming out green & florescent but clear.
*With Pneumonia – 5-10 days – fever usually resolves by day 3 or substantially decreased.
What are the two vaccines given for pneumonia? What do they do?
Pneumococcal vaccines:
- PPSV 23: protects against 23 strands
- PCV 13: new vaccine that’s standard of care from adults >65 –> protects against 13 additional strands
What is COPD and what are some keywords to describe it?
- Disease of the lower airways
2. KEYWORDS: airflow limitation, progressive (worsens over time), inflammatory response
What is the most important risk factor with COPD?
Cigarette smoking –> the more you smoke, more damage over time. Never to late to quit!
How to calculate smoking pack/year history?
- # of packs smoked x years smoked
Ex. 2 packs per day for 10 yrs –> 2 x 10 = 20 pack per year history
*40 pack year smoking history = consider COPD
What is the number one reason patients present to the clinic with COPD?
Shortness of breath
What are three things that help to diagnosis COPD?
- Chronic cough for 2 years
- Study used to make clinical diagnosis –>
spirometry - FEV1/FVC < 70% confirms diagnosis
What are the GOLD stages of COPD?
GOLD Staging System - Classification of severity of airflow limitation in COPD
Gold 1: Mild
Gold 2: Moderate
Gold 3: Severe
Gold 4: Very Severe
*The higher the #, the worse COPD is
What characteristic will always be present in a COPD patient regardless of how mild or severe?
FEV1/FVC ratio <70%
What prescription HAS to be sent home with a patient regardless of how good or bad their COPD is?
Short acting bronchodilator (Ex. Albuterol)
What are the differential diagnosis of COPD?
- Heart Failure
- Angina
- Asthma
- Tuberculosis
What are some of the comorbidities to watch for with COPD?
- Usually has other comorbidities such as HTN, CAD, Tachy arrhythmias
- If taking steroids for COPD – affects bones (osteopenia)
- Depression & anxiety d/t not being able to breathe
- Overweight d/t SOB w/exertion preventing them from being active – might have blood sugar issues b/c of these.
- Smoking = cancer likely
What is the first drug of choice for COPD? Suffix? How does it work? How many groups of meds? Give an example of each.
Beta2 agonists – “terol”
-Stimulates beta receptors. When lungs are stimulated, bronchodilator occurs, opening airways.
- Short acting beta agonists (SABAs) – Albuterol
- Long acting beta agonists (LABAs) – Salmeterol & Formoterol – Ex. Symbicort & Advair
Beta = beta receptors; agonists = stimulant
What is the onset of SABAs and how long do they last?
onset < 2 mins, lasts about 4 hours
What is the onset of LABAs and how long do they last?
onset 10-20 mins, lasts about 12 hours
What drug is referred to as a “rescue medication” for persons with SOB in COPD? What is an example of a drug in this class?
Short acting beta agonists (SABAs)
Ex. Albuterol
What is the second drug of choice for COPD? Suffix? How do they work? How many groups of medications? What is the length of effect for each? Give example of medications in this drug class.
Inhaled anticholinergics - “Tropium”
-DO NOT produce bronchodilator but PREVENTS bronchoconstriction.
- Short acting anticholinergic (SAAC) - Ipratropium (Atrovent) – 6 hours length of effect
- Long acting anticholinergic (LAAC) - Tiotropium bromide (Spiriva) – 24 hours length of effect
What are the side effects of anticholinergics?
Ode to anticholinergic med side effects
“Oh this drug, it makes me pink (causes flushing), sometimes, I can’t think (cognitive changes sometimes seen in older adults) or even blink (staring)”
- I can’t see – increases intraocular pressure
- I can’t pee – causes urinary retention
- I can’t spit – dry mouth
- I can’t sh** – constipation
Which patients should not take anticholinergics?
A patient with Glaucoma
A patient with BPH
- increases intraocular pressure*
- causes urinary retention”
What is the third drug of choice to treat COPD? When is the best time to be prescribed? Works better in combination with which drugs? Give examples of combo drugs.
Inhaled steriods
- Best not first line but better for COPD pts who’s FEV1 begins to drop
- Works better in combination with bronchodilators (Beta2 agonists)
- Ex. Advair, Symbicort, Dulera
- Steroid + LABA (combo inhaler)
What is the prescribing strategy for COPD?
- Short acting anticholinergic PRN OR SA Beta2 PRN
THEN - Long acting anticholinergic OR LABA; plus rescue med
THEN
- Inhaled corticosteroid + LABA or LA anticholinergic; plus rescue med
THEN
- Inhaled corticosteroid + LABA AND/OR LA anticholinergic; plus rescue med
What is the definition of exacerbations?
An acute event characterized by a worsening of the patient’s respiratory symptoms beyond the normal day-to-day variations and leads to a change in medication.
What is the most common reason for COPD exacerbations?
Infection
What are two questions you should ask COPD patients at every visit?
Are you still smoking?
Have you thought about quitting?
Health promotion for COPD patients.
- Stop smoking
- Exercise
- Pneumococal vaccine
- Flu vaccine
Why is asthma not under the COPD umbrella?
Because it’s a REVERSIBLE airway obstruction
What is asthma?
An inflammatory disease – inflammation in the lungs
When does wheezing usually occur in pts with asthma?
Most commonly is during End Expiration
What makes asthma difficult to diagnose?
Because everybody with asthma doesn’t wheeze and everybody who wheezes doesn’t have asthma.
What helps to clue one on an asthma diagnosis?
-Taking a good history
-Family history- asthma has a very strong
familial component
- Famous triad
- Wheezing
- Cough
- Chest tightness
- Shortness of breath
If only given one clue to diagnose asthma, what would it be?
A predictable pattern of respiratory symptoms (wheezing, cough, chest tightness). It’s predictable every time they have a viral upper respiratory infection, every time they go to their neighbor’s house who has a cat or a dog, every time they run outside in cold weather or they exercise in cold weather.
What to look for when diagnosing asthma?
-Variable airflow limitation with FEV1/FVC ratio coupled with symptoms of wheezing, coughing, chest tightness, and/or SOB.
What are the different types of Asthma? What are they characterized by?
- Intermittent asthma – symptoms < twice a week – generally don’t come to clinic b/c symptoms are infrequent.
- Mild persistent asthma – can be mild, moderate, or severe; symptoms > twice a week but not every day, they have mild persistent asthma.
- Moderate persistent asthma – symptoms every day, not all day, but every day. At least once a day they have one of these symptoms –> cough, wheezing, chest tightness, shortness of breath.
What are two differential diagnoses to asthma?
- COPD
- GERD
What other comorbidities might asthma lead to?
- Pts w/asthma don’t typically just have asthma, they have rhinitis or rhinosinusitis, or atopic illnesses like eczema.
- If on steroids –> watch bones
- GERD
- SOB leading to inactivity = weight gain
When developing a treatment plan for asthma, what is important to ask the patient?
How bad their symptoms are and how frequent!
If an asthma patient is having symptoms all day, everyday, what is it important to do?
Refer patient
How to treat intermittent asthma?
SABA PRN - Albuterol
How to treat mild persistent asthma?
Low dose inhaled corticosteroid daily
Ex. Flovent or Budesonide
How to treat moderate persistent asthma?
Either inhaled corticosteroid + LABA
Ex. Advair, Symbicort, or Dulera
OR
Higher dose of inhaled steroid
What should never be prescribed to an asthma patient?
LABA without a steroid on board
Risk of death
