Pulmonology

Question 1

Mycoplasma pneumoniae / Chlamydophila pneumoniae Tx

Answer 1

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

Question 2

Bordetella pertussis Tx

Answer 2

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

Question 3

Acute Bronchitis Tx of Symptoms

Answer 3

• 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

Question 4

MCC - rapid onset, frequent cause of 2’ pneumonia post-influenza

Answer 4

Streptococcus pneumoniae (G+ cocci)

“pneumoncoccal pneumonia”

Question 5

history of recent skin infection - very ill,

also frequent cause of post-influenza pneumonia

Answer 5

Stapholococcus aureus (G+ cocci)

Question 6

pneumoia in pre-existing pulmonary disease, COPD, cystic fibrosis

Answer 6

Haemophilus influenzae (G- rod)

Question 7

pneumonia in alcoholics, COPD patients, healthcare facility associated

Answer 7

Klebsiella pneumoniae (G- rod)

Question 8

milder w/ gradual onset, “atipical/walking pneumonia”, close quarters

Answer 8

Mycoplasma pneumoniae (short rod w/ no cell wall)

Question 9

fever of 102.2, GI symptoms: abdominal pain, NAV, diarrhea,

Broad: chest pain, neurologic abnormalities, hyponatremia, hepatic dysfunction,

water transmission

Answer 9

Legionella pneumophila (G- bacillus)

Question 10

AIDS (w/ low CD4 counts), immunosuppressed, cytotoxic drug therapy, CA

Answer 10

Pneumocystis jirovecii

Question 11

MC viral primary pneumonia agent

Answer 11

Influenza virus

Question 12

1-6 days after rash, male, pregnant, smoker, immunosuppressed,

(uncommon complication in immunocompetent children)

Answer 12

Varicella virus

Question 13

strains more common in immunocompromised, pregnant, transplant pts.

Answer 13

• 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.

Question 14

MDR risk factors

Answer 14

• on antibiotics > 90 days
• hospitalized > 5 days
• high rates of abx resistance in community or hospital
• immunosuppressed patient
• septic shock
• MDR pathogens variable

Question 15

• yellow, green, blood tinged (rust colored)
• minimal sputum
• “currant jelly”
• foul tasting/smelling

Answer 15

• Strep pneumoniae
• Mycoplasma pneumoniae
• Klebsiella pneumoniae
• Anaerobes

Question 16

SABAs

Answer 16

• proair
• proventil
• ventolin
• xopenex

Question 17

LABAs

Answer 17

NOT monotherapy

• Salmetorol
• Formoterol

Question 18

ICSs

Answer 18

decrease symptoms and exacerbations

improve lung function

reduce inflammation and hyperactivity in airways

• mist:
  
  • Alvesco, Flovent, QVAR
• powder:
  
  • Asmanex, Flovent Diskus, Pulmicort
• nebulized:
  
  • Pulmicort

Question 19

Other Bronchodilators

Answer 19

• 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

Question 20

Gold A Tx

Answer 20

• SABA (albuterol, levalbuterol) as needed
• Anticholinergic
  
  • Ipratropium (Atrovent): short-acting
  • Titotropium (Spiriva), Aclinidium (Tudorza): long-acting

Question 21

Gold B Tx

Answer 21

• LABA
  
  • Salmeterol (Serevent)
  • Formoterol (Foradil)
  • Arfemotorol (Brovana)
  • Indaceterol (Arcapta)
  • Vilanterol + Olodaterol (Straverdi Respimat)

Question 22

Gold C or D Tx

Answer 22

• 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)

Question 23

Severe or Refractory Disease Tx

(Gold D w/ high-risk mortality)

Answer 23

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

Question 24

O2 Therapy

Answer 24

• 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%)