Pulmonology Flashcards
Decision to hospitalize for pneumonia
Confusion Uremia (BUN > 7mmol/L) Resp rate greater than or equal to 30 BP <90 systolic/less than or equal to 60 diastolic Age greater than or equal to 65
Empirical abx recommendations in pneumonia for previously healthy pts with no abx use in prior 3 mos
Azithromycin 500 mg PO x1 dose then 250 mg PO q24h x4 days OR
Clarithromycin 500 mg PO BID or clarithro ER 1 gm PO q24h x 7days OR
Doxycycline 100 mg PO BID 5-7 days
Empirical abx recommendations in pneumonia for comorbidities
Levo 750 mg PO q24h x 5 days
Amoxicillin-clavulanate 1000/62.5 mg 2 tabs PO BID
What is considered a comorbidity for pneumonia tx?
Chronic heart, lung, liver, renal dz DM Alcoholism CA Asplenia Immunosuppression Recent abx use
Empirical abx recommendations in pneumonia for areas with high rate (>25%) macrolide-resistant S. pneumoniae
Choose alternative
What are suggestive findings of an “atypical” pneumonia?
No clinical or laboratory features reliable distinguish from typical
Little sputum
Not “consolidating” (CXR, ausculatation)
Poor response to beta-lactams
Mild, intermittent asthma
Day sx 2x/wk
Night sx 2x/mo or less
Lungs fine between attacks
Mild, persistent asthma
Day sx 2+/wk
Night sx 2+/mo
Interfere with daily activities
Moderate, persistent asthma
Day sx daily
Night sx 1+/wk
Interfere with daily activities
Severe, persistent asthma
Day sx daily
Night sx frequent
Daily activities limited
What is the maximum amount of usage for a SABA?
No more than 3-4 times/day
Step 1 asthma tx
For intermittent asthma
SABA
Step 2 asthma tx
For mild persistent asthma
SABA
Low-dose ICS
Alternatives: Sustained-release theophylline or cromone or leukotriene modifier
Step 3 asthma tx
For moderate persistent asthma SABA Low-to-medium dose ICS + LABA Alternatives: Medium-dose ICS + sustained-release theophylline OR Medium-dose ICS + LABA OR High-dose ICS OR Medium-dose ICS + leukotriene modifier
Step 4 asthma tx
For severe persistent asthma High-dose ICS + one or more of the following, if needed: Sustained-release theophylline Leukotriene modifier LABA Oral glucocorticosteroid
Presentation of controlled asthma
Nl physical activity
SABA use < 4x/wk
Daytime sx < 4 days/wk
Nighttime sx <1 night/wk
Presentation of uncontrolled asthma
Some interruption with activities
SABA use 4 or more x/wk
Daytime sx 4 or more days/wk
Nighttime sx 1 or more nights/wk
Presentation of dangerously uncontrolled asthma
Difficulty talking Reliever inhaler does work as usual OR Relief lasts < 2hrs Daytime sx all the time Nighttime sx every night
Examples of SABAs
Salbutamol
Fenoterol
Examples of anticholinergics for asthma
Ipratropium bromide
Tiotropium
Examples of LABAs for asthma
Formoterol
Salmeterol
Examples of ICS
Ciclesonide
Beclomethasone
Budesonide
Fluticasone
Common sx in pts with pulmonary embolism
Dyspnea Chest pain (pleuritic mmore common than non-pleuritic) Apprehension Hemoptysis Sweating/diaphoresis Syncope Palpitations Wheezing Leg pain Leg swelling
Work up for PE
Well's score: 1.5 pts for major surgery within 4 wks 3.0 alternative dx less likely 1.5 tachycardia Score of 2-6= moderate probability Then, order D-dimer and/or CT chest CBC CMP ABGs CXR once stable
Tx of PE
Thrombolytics rarely used. Consider IV heparin if surgery is a possibility or severe renal failure
Heparin- initial bolus based on wt, followed by an infusion, until aPTT at goal
Warfarin initiated and titrated until maintaining INR of 2-3 and then continued for at least 3-6 mos
Supportive care with IV fluids, oxygen, nutrition
Pts are discharged once stable with INR >2
Outpatient tx of PE
LMWH > IV heparin
Once-daily > twice-daily
Choice between fondaparinux and LMWH should be based on cost, availability, and familiarity of use
What are alternative to warfarin for prophylaxis and tx of PE?
Apixaban
Dabigatran
Rivaroxaban
Edoxaban
F/u after PE tx- First thromboembolic event occurring in the setting of reversible RFs, such as immbobilization, surgery, or trauma
Warfarin therapy for at least 3 mos up to 6 mos
F/u after PE tx- pts who have PE and preexisting irreversible RFs, such as deficiency of antithrombin III, protein S and C, factor V Leiden mutation, or the presence of antiphospholipid antibodies
Long-term anticoagulation
F/u after PE tx if recurrent thrombosis despite treatments?
Vena Cava filter
What is the preferred initial phase regimen for TB?
Combo of isoniazid, ethambutol, and pyrazinamide
What should be done after the initial regimen for TB?
Tx is specific to the sputum culture results. Pt needs to be quarantined from the public and immune compromised until no longer contagious
Continue isolation until sputum smears are neg for 3 consecutive determinations (usually after 2-4 wks of tx)
Stage 1 COPD
Mild COPD
80% nl lung function
Stage 2 COPD
Moderate COPD
50-80% nl lung function
Stage 3 COPD
Severe COPD
Typically involves severe restraint of respiration, tininess of breath, and frequently COPD exacerbations
30-50% nl lung function
Stage 4 COPD
Very severe COPD
Become very severe and risky, thus decreases the QOL with vital COPD exacerbations
Lung function FEV1 levels might be lower than 30%
Tx of mild COPD
Active reduction of risk factor(s): influenza vaccine
SABA PRN
Tx of moderate COPD
Influenza vaccine
SABA PRN
One or more LABAs PRN
Pulmonary rehab
Tx of severe COPD
Influenza vaccine SABA PRN One or more LABAs PRN Pulmonary rehab ICS if repeated exacerbations
Tx of very severe COPD
Influenza vaccine SABA PRN One or more LABAs PRN Pulmonary rehab ICS if repeated exacerbations Add long-term O2 if chronic respiratory failure Consider surgical treatments
Specific treatments of COPD and doses
Albuterol: 2 puffs q4-6h prn
Advair: one puff every 12 hrs
Albuterol/ipratropium: 2 puffs q8h
Quit smoking!
Pathophys of ARDS
Necrosis
Tissue destruction
Influx of leukocytes
Dilatation of blood vessels
Tx of ARDS
Treat the underlying condition, along with supportive care, mechanical ventilation, and conservative fluid management. Antibiotic therapy that is broad enough to cover suspected pathogens is essential
Mortality rates of ARDS
30-40%
Acute bronchitis
Inflammation of the bronchial tubes (bronchi) from the trachea into the small airways for <3 wks. Most occur in fall and winter
Etiology of acute bronchitis
90% is caused from viral infections or irritation of bronchial tubes and NOT from bacterial infections.
MC organisms of acute bronchitis
Parainfluenza
RSV
Coronavirus
Influenza A or B
Prognosis of acute bronchitis
Almost always self-limited in individuals who are otherwise healthy
Complications of acute bronchitis
10%: bacterial superinfection
PNA in 5% of chronic bronchitis pts, reactive airway dz
Prevention of acute bronchitis
Quit smoking
Avoid inhaling chemicals or other irritants that may harm your lungs
Steer clear of infection
Wash your hands
S/sx of acute bronchitis
Cough Sputum production Fever- usually only with flu Sore throat Nasal congestion HA Fatigue Rare- N/V/D
PE of acute bronchitis
Fever- rare and usually a sign of influenza- R/o pneumonia
General malaise
Mild injection of posterior pharynx and nares
Diffuse wheezes, high-pitched continuous sounds or nl lung sounds
