Pulmonary/Resp Disorders Flashcards
pulmonary embolism
cough, frothy pink tinged sputum. “IMPENDING DOOM”
impending respiratory failure (asthma pt)
RR >25bpm, tachy, cyanosis, “quiet” lungs no wheezing.
Adrenaline injected STAT, call 911. 02 4-5L, albuterol.
after tx, good sign is breath sounds and wheezing.
normal findings of lungs
upper lobes: bronchial breath sounds (louder)
lower lobes: vesicular (soft and low)
normal egophonys
normal: “eee”
abnormal “bah”
normal “eee is louder over the large bronchi” vs lower lobe
tactile fremitus
normal: stronger vibrations on the upper lobes
whispered pectoriloquy
patient to whisper “99 or 1-2-3”
normal: voice lounder upper lobes, muffled lower lobes
abnormal: clear sounds lower, muffled upper
percussion
normal: resonance
tympany or hyperresonace: COPDY, emphsema
dull: pneumonia with consolidation, pleural effusion (liquid or tumor), solid organ (liver)
pulmomary fxn tests
obstructive dysfuncion - reduction in airflow
asthma, copd
restrictive- reduction of lung volume dt decreased lung compliance
ie; pulmonary fibrosis, pleural disease
COPD
includes both emphysema and chronic bronchitis
loss of elastic recoil of the lungs and alveolar damage
risk: smoking and age
chronic bronchitis
cough with excessive mucus 3 months or more
for a minimum of 2 or more consecutive years
emphysema
permanent alveolar damage
expiratory respiratory phase is longer
risk: smoking, age, occupation, alpha 1 trypsin deficiency
classic case: elderly male, smoker, c/o sob during exertion. frequent cough, yellow sputum, barrel chest, weight loss (emphysema).
objective: >AP diameter,
copd general tx
smoking cession
flu, penumococcal vaccine
pulmonary drainage
copd medications
1st line: anticholinergics Ipatropium (atrovent) or tiotropium (spiriva)
and/or
b2 agonist: salmetrol (serevent), formoteral, albuterol (combivent)
2nd line: prednisoe (medrol dose pack), fluticason, adviar
copd medications safety
albuterol (b2 agonist)- careful with htn, hyperthyroid
anticholingergics (atrovent, spiriva), avoid if narrow angle glaucoma, bhp, bladder neck obstruction dt vasoconstriction
long term use of corticosteroids >6mos= risk of pneumonia
when treating COPID, pick antibiotic doxy or fluoro (agains H. influenza gram -
true
CAP
bacterial infection s. pneumoniae h.influenze m. catarrhalis cystic firbosis
classic case: elder with high fever, productive cough, rust colored sputum, pleuritic chest pain
objective: rhonchi, wheeze, crackles, dullness on percussion
INCREASE tactile fremitius and egophany
xray is gold standard for diagnosing CAP ( NOT sputum), repeat 6 wks after clearing
cxr lobar consolidation
tx of CAP
Macrolide or doxy (tetracycline)
with comorbidity (kidney, chf, liver) fluroquinolonie as ONE drug therapy (leva, gemi, maxi)
or
high dose amoxi (augmentin) plus macrolide
curb 65
confusion, urea in blood, rr>30bpm, blood pressure
prevention of pneumonia
flu for everyone >50 yo
pneumovax if >65 yo
healthy patients - one lifetime dose at 65 yo
prevent of pneumonia for high risk patients
pneumovax booster in 5-7 years
19 yo if asplenia
atypical pneumonia
children/young adults
“walking pneumonia” highly contagious
M. Penumoniae
C. Penumoniae
Legionella pneumoniae- found in moisture (water, air conditioners)
classic case; youg adult several weeks fatigue, coughing non productive, cold like s/s.
wheezing, pus in throat, diffuse interstitial infiltrates on X-ray.
medications: macrolide (same as 1st line CAP), anitussive prn (dextromethorphan, tessalon perles)
acute bronchitis
aka treacheobronchitis, usually viral and self limiting
tx: fluids, antitusstives (dextromethorphan, tessalon perles, f
guaifensin prn, albuterol, if severe medrol dose pack
pertussis
bacterial
whopping cough
last 2 weeks or longer, “hacking cough”, may vomit.
labs: nasopharyngeal swab (PCR), ELISA, cbc
tx: marcolides
TDAP booster
typical vs atypical pneumonia
typical: (CAP) older pt. high fever (>100.4), productive cough, rust colored sputum, chest pain
* S. pneumoniae, H. inlfluenzae, M. catarrhalis
atypical: children/young adults. fatigue, nonproductive cough, low grade fever (cold like s/s)
* *M. pneumonia, C. pneumoniae, Legionella penumonaie
COPD 1st line
atrovent add salmeterol if poorly controlled
COPD plus smoker
most likely H. Influenza
if healthy adult has cough for >2-3 weeks and previously treated with antibiotic, assume pertussis. r/o pneumonia
true
what age tdap vs td
11 and up
best mucolytic
fluid
afrin dosage
bid up to THREE days only. >3 days=rebound rhinitis medicamentosa
common cold s/s and tx
s/s: acute fever, sore throat, sneezing, clear mucus (coryza.
tx: fluids, rest, acetaminonphen, nsaids
oral decongestants- sudafed/psudoephedrine
topical nasal decong-afrin
antitussives (robitussin/dextromethorphan)
antihistamine (diphenhydramine/benadryl)
TB
lungs most common (85%)
latent TB: not infectious.
reactived TB on cxr
cavitations and adenopathy and graulomas on the hila of the lungs
prior BCG vaccine
if >5 yrs since last bcd, a positive TB is most likely a TB infection
first line rx TB
isoniazid
rifampin
miliary TB
affects multiple organs, more common
infectious TB or reactivated TB
90 % are reactived in US dt low immunity
tx plan for TB
report TB to local health department
all TB test for HIV
use 4 drugs, INH, rifampin, ehtambutal, and pyrazidamide tid (then narrow down drugs after C&S)
classic case: adult c/o fever, night sweats, cough, weight loss (late sign), blood in cough ( late sign)
warning for ethambutal rx
can cause optic neuritis. avoid if pt has abnormal vision (blindness, etc)
medications INH for tb (hiv vs non hiv)
non hiv- INH 300 mg for 9 months
HIV- for 12 mos
chest baseline liver fxn and monitor
PPD test result
look for induration, NOT RED!. i.e.: bright red color but no induration = negative
5mm or less: HIV, immunocompromised, previous TB on chest X-ray, child with close TB contact
10mm or less: recent immigrant, child 15mm- no known risk factor for TB
tb skin test
mantoux. inject .1ml of 5th-ppid sub dermal.
tb blood test
quantiFERon-tb gold or t-spot (aka igra). blood test measure y-interferon.
igra-results available in 24 hours. use if hx of previous bcg vaccine
TB
hiv
recent contacts with infectious TB
chest x ray with fibrotic changes ( previous tb)
any child who had close contact or has tb symptoms (
TB
recent immigrants last 5 years (asia, africa, latin america, india, pacific islands)
child
asthma
reversible airway obstruction caused by inflammation of the bronchial tree.
goal: less than 2 days/week of rescue medication (albuterol)
objective -wheezing with prolonged expirator phase, tacky
asthma medication
“rescue’
short acting b2 agonist
albuterol (ventolin HFA)
pirbuterol (Maxair)
levalbuterol (xopenex)
2 inhalations q 4-6 hrs prn
onset: 15-30 min, lasts 4-6 hours
long term asthma medication
take every day
long acting b2 agonist (LABA), bid.
LABA- increase death with asthma
LABA not to be used as rescue drugs
LABA rx
salmeterol (serevent) bid
formeterol (foradil) bid
salmetrerol plus fluticasone (advair)
sustained release theophylline
acts as bronchodilator
monitor: macdrolides, quinolones, anticonvsulants, chest blood level
use of spacer or chamber.
1st line tx for asthmatic exacerbation
adrenaline injection
long term inhaled steroids recommendation
supplement calcium with bit D 1500mg for menopausal women ( high risk osteoporosis), bone density (males and females), eye exams (risk of cataracts/glaucoma)
asthma tx in a nutshell
1) every pt on b2agonist (albuterol)
2) inhaled corticosteroids (Triamcinolone/azmacort, Fluticasone/flovent bid. (oral thrush risk, rinse with h20)
3) add b2 long actin (salmeterol or combo, adviar)
4) add leukotriene inhibitors, theophilline, or mast cell
asthma exacerbation
PEF
PEF
measure effectiveness of tx. blow hard during expiration using spirometer (3 times). highest value is PR
HAG (heigh, age, gender)
spirometer paramters
green - 80-100% (maintain or reduce medications) yellow (50-80%), increase therapy red zone (
step 1
>80% PEF, s/s
albuterol (ventolin) prn
step 2
>80%
>2 days/ week symptoms
albuterol (ventolin) PLUS
ICS (fluticasone/flovent)
triamcinolone (azmacort)
risk of oral thrush
step 3
PEF 60-80, daily s/s
albuterol
ICS
LABA
ICS
(fluticasone/flovent)
triamcinolone (azmacort)
LABA- salmeterol (ADVAIR)
step 4
high dose ICS (fluticasone/flovent)
triamcinolone (azmacort)
LABA- salmeterol (ADVAIR)
oral corticosteroid ( prednisone) daily
exercise asthma
use 2 puffs of saba (albuterol/ventolin, levalbuterol/xopenex, pirbuterol/maxair) 10-15 min before exercise. last 4 hours
