Pulmonology Flashcards
Mycoplasma pneumoniae / Chlamydophila pneumoniae Tx
Macrolides or Flouroquinolones
- Azithromycin x5 days (500mg d1, 250mg d2-5)
OR
- Doxycycline 100mg bid x7-14 days
OR
- Levofloxacin 500mg qd x7-14 days
Bordetella pertussis Tx
Macrolides
- Azithromycin x5 days (500mg d1, 250mg d2-5)
OR
- Clarithromycin 500mg bid x7 days
if macrolides not tolerated
- Bactrim DS 1 bid x7 days
Acute Bronchitis Tx of Symptoms
- pain, myalgias, HA
- Tylenol or NSAIDs
- OTC mucolytics, antihistamines, decongestants
- Mucinex D, Alka Seltzer, Tylenol Cold and Sinus
- wheezing
- Beta-2 agonists: Albuterol HFA 1-2 inhalations q4-6h PRN wheezing
- anti-tussics
- Benzonatate (Tessalon Perles) 100-200mg tid PRN cough
- Promethazine DM 1-2tsp q4-6h PRN cough
- Promethazine w/ codeine syrup 1-2tsp q6h
- Hydrocodone homatropine 5/1.5 1 tab q6h (adults)
- Capmist DM (dextromethorphan, guiafenesin, pseudoephedrin) 1 tab q6h
MCC - rapid onset, frequent cause of 2’ pneumonia post-influenza
Streptococcus pneumoniae (G+ cocci)
“pneumoncoccal pneumonia”
history of recent skin infection - very ill,
also frequent cause of post-influenza pneumonia
Stapholococcus aureus (G+ cocci)
pneumoia in pre-existing pulmonary disease, COPD, cystic fibrosis
Haemophilus influenzae (G- rod)
pneumonia in alcoholics, COPD patients, healthcare facility associated
Klebsiella pneumoniae (G- rod)
milder w/ gradual onset, “atipical/walking pneumonia”, close quarters
Mycoplasma pneumoniae (short rod w/ no cell wall)
fever of 102.2, GI symptoms: abdominal pain, NAV, diarrhea,
Broad: chest pain, neurologic abnormalities, hyponatremia, hepatic dysfunction,
water transmission
Legionella pneumophila (G- bacillus)
AIDS (w/ low CD4 counts), immunosuppressed, cytotoxic drug therapy, CA
Pneumocystis jirovecii
MC viral primary pneumonia agent
Influenza virus
1-6 days after rash, male, pregnant, smoker, immunosuppressed,
(uncommon complication in immunocompetent children)
Varicella virus
strains more common in immunocompromised, pregnant, transplant pts.
- Aspergillus- found in mold in soil worldwide
- Cryptococcus- found in pigeon droppings
- Histoplasma capsulatum- Ohio, Missouri and Mississippi River regions in soil that has bird and bat droppings
- Coccidioides- found in soil in SW U.S.
MDR risk factors
- on antibiotics > 90 days
- hospitalized > 5 days
- high rates of abx resistance in community or hospital
- immunosuppressed patient
- septic shock
- MDR pathogens variable
- yellow, green, blood tinged (rust colored)
- minimal sputum
- “currant jelly”
- foul tasting/smelling
- Strep pneumoniae
- Mycoplasma pneumoniae
- Klebsiella pneumoniae
- Anaerobes
SABAs
- proair
- proventil
- ventolin
- xopenex
LABAs
NOT monotherapy
- Salmetorol
- Formoterol
ICSs
decrease symptoms and exacerbations
improve lung function
reduce inflammation and hyperactivity in airways
- mist:
- Alvesco, Flovent, QVAR
- powder:
- Asmanex, Flovent Diskus, Pulmicort
- nebulized:
- Pulmicort
Other Bronchodilators
- Ipratropium (Atrovent): short acting anticholinergic
- second line for asthma, effective in elderly, more for COPD
- Titotropium (Spiriva): long acting anticholinergic
- not FDA approved for asthma, may add on to ICS + LABA
- Leukotriene modifiers
- not as effective as ICS or LABAs
- Montelukast (Singulair), Zafirlukast, Pranlukast
- Zileuton
- Theophylline - not commonly used, may be added for uncontrolled
- Omalizumab - monoclonal antibody binds to IgE
Gold A Tx
- SABA (albuterol, levalbuterol) as needed
- Anticholinergic
- Ipratropium (Atrovent): short-acting
- Titotropium (Spiriva), Aclinidium (Tudorza): long-acting
Gold B Tx
- LABA
- Salmeterol (Serevent)
- Formoterol (Foradil)
- Arfemotorol (Brovana)
- Indaceterol (Arcapta)
- Vilanterol + Olodaterol (Straverdi Respimat)
Gold C or D Tx
- Inhaled Corticosteroids (ICS)
- NOT monotherapy
- Use with LABA or long-acting anticholinergic
- Beclomethason (QVAR), Budesonide (Pulmicort), Fluticasone (Flovent), Mometasone (Asmanex)
- ICS + LABA Combo
- Symbicort (Budesnide + Formoterol)
- Advair (Fluticasone + Salmeterol)
- Breo Ellipta (Fluticasone + Vilanterol)
Severe or Refractory Disease Tx
(Gold D w/ high-risk mortality)
Triple Therapy
- LABA + long-acting anticholinergic + ICS
- ex: Fluticasone + Salmeterol + Titotropium
- If still refractory or developing country (decr. cost)
- Methylxanthine: low-dose theophylline
- PDE-4 Inhibitors
- decreases airway inflammation, relaxes smooth muscle
- Roflumilast
O2 Therapy
- generally continuous 2L/min w/ goal O2 sats 88-92% or titrate to PaO2 60
- chronic respiratory failure: 15+ hours daily
- PaO2 <= 55% or SaO2 <= 88%: continuous
- GOLD:
- recommended when PaO2 56-59/60
and
- pulmonary HTN, peripheral edema (CHF), or polycythemia (hematocrit > 55%)