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Resp Flashcards

1
Q

Immunizations aim to prevent these major complications of:

  • influenza
  • pertussis
  • invasive pneumococcal disease
A

Influenza: viral/bacterial pneumonia

Pertussis: secondary bacterial pneumonia

IPD: pneumonia, bacteremia, meningitis

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2
Q

Pertussis vaccination is recommended for these individuals:

A
  • routine schedule for infants and children
  • incompletely/unimmunized adults
  • pregnant women in every pregnancy at 27-32 weeks
  • all adults should receive one dose of Tdap if they have not received a pertussis-containing vaccine in adulthood
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3
Q

What is the timing between PCV (Prevnar) and PPV23 (Pneumovax)?

A

Preferred: PCV 13 first –> wait 8 weeks –> PPV 23

If PPV 23 first, wait one year –> PCV 13

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4
Q

Varenicline (Champix):

Benefit:

MOA?
Dosing?
Duration?

A

Benefit: most effective form of smoking cessation

MoA: partial nicotine agonist: reduces withdrawal, blocks reward

Dosing: Start taking one week before quit date
Can continue to smoke until quit date

Days 1-3: 0.5 mg
Days 4-7: 0.5 mg BID
*may increase to 1 mg BID x 12 weeks

Duration: minimum 12 weeks, can extend up to 1 year

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5
Q

Varenicline (Champix):

Precautions:

  • concurrent ETOH?
  • concurrent NRT?
  • concurrent food?
A

ETOH: will enhance ETOH effects, decrease tolerance to ETOH

NRT: can use together but higher chance of adverse reaction/intolerance

Food: take after eating with full glass of water to help with nausea

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6
Q

Varenicline (Champix):

Common and serious side effects

A

Common:
Nausea, insomnia and abnormal dreams
Headache, constipation

Serious: suicidal ideation, depression, agitation

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7
Q

Buproprion (Zyban) for smoking cessation

Benefits?

Contraindications?

A

less effective than Champix

  • helps if concurrent depression
  • delays weight gain post-cessation

Contraindications:

  • personal/family hx of seizure disorder
  • any condition that predisposes to seizures (acute head injury, ETOH withdrawal, eating disorder)
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8
Q

Bupropion (Zyban) for smoking cessation

MOA?
Dosing?
Duration?

A

MOA: dopamine reuptake inhibitor - makes it less pleasurable

Dosing:
Start taking one week before quit date
Can continue to smoke until quit date

Days 1-3: 150 mg SR daily in morning
Day 4 onwards: 150 mg SR BID x 7-12 weeks
8 hours in between doses

Duration:
Minimum 7-12 weeks
-if no significant progress by 7th week: success unlikely
-can extend up to one year

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9
Q

Bupropion (Zyban) for smoking cessation:

-patient counselling points:
timing of doses, food, monitor

A

Will take 1-2 weeks to take effect
Wait 8+ hours between SR dose to prevent seizure risk
Can take with/without food
Monitor mood esp suicidal thoughts

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10
Q

Bupropion (Zyban) for smoking cessation:

Common and serious side effects:

A

Common:
Insomnia, agitation, tremor, headache, weight loss
GI: low appetite, n/v, dry mouth

Serious: seizures, aggression, suicide

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11
Q

Nicotine patch:

  • start at _____ mg/day if smoking >10 cigs/day
  • start at _____ mg/day if smoking <10 cigs/day

Common side effects?

A

21 mg/day if 10+ cigs

14 mg/day if <10 cigs

Side effects:
-skin irritation, insomnia, vivid dreams (can remove patch at night)

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12
Q

Nicotine patch:

patient counselling points:

A

Don’t smoke while using it, no more than 1 patch/time
Don’t cut or trim patch
Rotate sites
*Use of soap will ↑ nicotine absorption from site, rinse with water if symptoms of toxicity
Dispose used nicotine patches out of reach of kids/animals

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13
Q

Nicotine patch:

Contraindications:

CVD considerations:
Pregnancy considerations:

A

Contraindications: severe eczema, psoriasis or skin disorder

CVD: NOT contraindicated in CAD (unlike other NRT) but try to wait >2 weeks after acute MI
*risk of arrhythmias and MI

Pregnancy: try to limit to 16 hours

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14
Q

Nicotine gum:

Contraindications:

CVD considerations:
Pregnancy considerations:

A

Contraindications:
-Dental issue, TMJ syndrome
CAD/recent MI/angina

CVD: avoid –> go with patch
Pregnancy: gum preferred over patch

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15
Q

Nicotine gum and lozenge

Patient counselling re: food

Common side effects?

A

No food or drink (esp acidic eg coffee, soda) for 30 min before and during use

Side effects:
Nausea, heartburn, throat irritation, hiccups
n/v/headache if smoking as well

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16
Q

Nicotine spray and inhaler

Contraindications?

Common side effects?

A 
CAD, recent MI, angina --> consider patch
Reactive airways (asthma)

Side effects:
Throat irritation, cough, rhinitis, dyspepsia

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17
Q

What are the 5 A’s in smoking cessation approach?

A 
ASK about tobacco at every visit
ADVISE to quit
ASSESS willingness to quit
ASSIST implementation plan
ARRANGE following up and cessation counselling
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18
Q

Smoking cessation:

What are some non-pharmacological approaches?

A

Combination therapy (pharm and behavioural) is most effective strategy

Exercise (esp to counteract weight gain)
Hypnosis
CBT
Support groups
Quit now has a phone support group (“quitlines)

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19
Q

Smoking cessation:

What is the first line approach?

Monitoring/follow up?

A

First line approach:

  • combining two forms of NRT (patch + short-acting PRN gum/lozenge) OR
  • varenicline (Champix)

Follow up:

  • 1-2 weeks after starting rx: adherence, side effects
  • 3 months, then annually

Monitor drug levels of some rx after successful quitting (psych meds, methadone, warfarin) –> may need to adjust dose

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20
Q

Acute bronchitis

Risk factors?

Mainly caused by?

A

Risk factors:
URI, smoking, 2nd hand smoke, Chronic aspiration, GERD, allergens

Infectious most common, but can be allergens or irritants
most commonly viral

Viral: adenovirus, influenza, parainfluenza, RSV
Bacterial: Bordetella pertussis (check immunization status in children), Mycobacterium tuberculosis, Corynebacterium diphtheriae, M. pneumonia.

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21
Q

Acute bronchitis

Signs and symptoms:

A

Initially: dry, hacking cough/raspy sounding cough
Progresses to productive cough (usually 1-3 weeks)
-Sore throat,
-Rhinorrhea
-Rhonchi during respiration
-Low grade fever
-Malaise
-Retrosternal pain during deep breathing and coughing

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22
Q

Acute bronchitis

Findings on physical exam:

A

Vitals (should not have tachypnea or high fever)
Resp: crackles, wheezes, rhonchi

*should not have signs of consolidation (dullness with percussion, decreased breath sides, rales, egophony)

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23
Q

Acute bronchitis

3 differential dx:

Diagnostic tests:

A
  • Pneumonia (abnormal VS, signs of consolidation)
  • Pertussis (persistent paroxysmal cough, post-tussive vomiting, inspiratory whoop)
  • Asthma

Diagnostics:

  • COVID-19 swab
  • CXR only if suspect pneumonia
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24
Q

Acute bronchitis:

Management

Role of antibiotics

A

Supportive

  • cough can last 1-3 weeks
  • reassure self-limiting
  • tea, lemon, honey, lozenges, fluids
  • OTC cough medication
  • PRN tylenol (fever/malaise)
  • PRN ventolin if wheezing or underlying chronic resp condition
  • strongly discourage antibiotics
  • only in rare circumstances (high risk of complications, suspect pneumonia, suspect specific pathogen eg pertussis)
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25
Q

What is the definition (timeline) of chronic bronchitis?

A

chronic productive cough for 3 months in 2 consecutive years

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26
Q

What are the 3 cardinal symptoms of COPD?

A
  • dyspnea
  • chronic cough
  • sputum production
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27
Q

What is the most important risk factor for chronic bronchitis?

Other risk factors?

A

SMOKING!

  • acute viral infection
  • cold weather
  • occupational exposure: coal, fumes, dust, smoke
  • chronic aspiration/GERD
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28
Q

Chronic bronchitis:

signs and symptoms:

A 
Worsening cough: hacking, harsh, raspy
Sputum changes: colour, amount, viscosity
*vomiting for children <5 (cannot expectorate)
Chest rattle
Dysnpea/breathlessness
Wheezing
Malaise
Fever
Myalgias
Arthralgias
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29
Q

Differentiating between asthma and chronic bronchitis:

Asthma: wheeze is ______, cough is ______

Bronchitis: cough is ______, wheeze is _______

A

Asthma: wheeze is long standing, cough is late onset

Bronchitis: cough is long standing, wheeze is late onset

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30
Q

Obstructive sleep apnea RISK FACTORS

  • meds?
  • sex?
  • medical conditions?
A

Meds: CNS DEPRESSANTS benzos, antipsychotics, opioids, beta blockers, barbiturates, antihistamines, sedative antidepressants, ALCOHOL

sex: male

Medical: obesity, diabetes, HTN, increased neck circumference, tonsillar hypertrophy, hypothyroidism

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31
Q

Obstructive sleep apnea is a risk factor for:

A
  • strokes and cardiovascular disease (nocturnal arrhythmias, acute cardiac events)
  • diabetes
  • visceral obesity
  • traffic accidents
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32
Q

OSA in children is mostly caused by _____ and _____

A
  • obesity

- tonsillar/adenoid hypertrophy

33
Q

What is the pathophysiology underlying OSA?

A

Increased­ tissue thickness of tongue and soft tissues in the pharyngeal cavity, narrows passageway for air to the trachea
At night: oropharynx muscle relaxes, causes airway obstruction

34
Q

Questions to ask during subjective assessment of OSA

A
  • daytime sleepiness?
  • naps?
  • partner c/o snoring/gasping/snorting?
  • meds
  • ETOH
  • Epworth Sleepiness Scale
  • men: erectile dysfunction
35
Q

Describe a physical assessment for suspected OSA

A
  • vitals, ht and wt (BMI), waist circumference
  • ENT: peritonsillar narrowing/hypertrophy, tongue (macroglossia), elongated/enlarged uvula, palate (high arch/narrow palate), nasal polyps, septal deviation
  • CVS and resp
  • thyroid
  • mental status: confusion
36
Q

Diagnostic criteria for OSA:

_____ apnea/hypopnea/arousals per hour of sleep in ASYMPTOMATIC patient

OR

_____ apnea/hypopnea/arousals per hour of sleep in SLEEP DISRUPTED patient

A

15+ per hour of sleep if asymptomatic

5+ per hour of sleep if symptomatic

37
Q

OSA Management

A
  • CPAP or BIPAP is mainstay
  • modifiable: diet and exercise (weight loss), smoking cessation, avoid alcohol
  • dentist for oral appliance
  • avoid sleeping supine (positioning therapy)
38
Q

Risk factors for TB exposure and latent TB

Risk factors for developing active TB

A

TB exposure and latent TB:

  • recent or close contact to case of active respiratory TB
  • travel to country with endemic TB x 3 months
  • homeless or living in shelters, correctional facility
  • IVDU or crack cocaine use

Developing active TB:

  • HIV or AIDS
  • on transplant meds (immunosuppressed)
  • on hemodialysis
  • cancer of head and neck
  • TB in last 2 years
  • on biologics or tumour necrosis factor for autoimmune–diabetes
  • daily corticosteroids
  • heavy ETOH
  • age <4
39
Q

TB

  • organism?
  • transmission?
  • incubation
A
  • mycobacterium tuberculosis
  • transmission: inhalation of airborne droplets, depends on prolonged exposure and close contact
  • incubation: 2 to 10 weeks from infection to positive skin test
  • disease may not occur for years (or may just stay latent)
40
Q

Assessment for TB

  • subjective history components
  • physical exam

what lymph nodes are commonly involved?

A
  • Fever, night sweats, chills, or cough, weight loss.
  • exposure history to someone who has TB.
  • living situation (including past history of homelessness)?
  • travel history to endemic areas with TB
  • IVDU?
  • HIV status

Physical exam:

  • head to toe
  • wt
  • focus on chest and lymphadenopathy

LN: anterior/posterior cervical and supraclavicular

41
Q

Tuberculosis: signs and symptoms

  • systemic?
  • active respiratory TB disease?
  • active non-respiratory TB disease?
A

Systemic:

  • fever
  • night sweats
  • anorexia
  • unexplained weight loss
  • fatigue
Active respiratory TB disease
cough x 2-3 weeks (dry or productive), with or without fever
-hemoptypsis
-chest pain
-SOB

Active non-respiratory disease?
Systemic symptoms plus
-pain, swelling and/or dysfunction of involved body site (eg lymph nodes)

42
Q

What is the gold standard for pulmonary TB testing?

Describe steps of TB skin test
*what is a positive reading?

What should always be offered with every TB test?

A

sputum for AFB x 3 samples
*best done in the morning

TB: 0.1 ml intradermal to forearm, read in 48-72 hours
positive = 5 mm+ if child <5, immunocompromised, HIV, close contact in lat 2 years
otherwise positive = 10 mm +

HIV test should be offered with every TB screen

43
Q

Influenza

Transmission?
Incubation?
Viral shedding?

A

Transmission: droplets (cough/sneeze), direct contact with contaminated surfaces
Incubation: 1-4 days
Viral shedding: avg 5 days

44
Q

Define antigenic shift vs drift

A

Antigenic shift: major changes in H and N responsible for epidemics and pandemics
Antigenic drift: minor changes in H and N, usually associated with local outbreaks of varying intensity

45
Q

Potential complications of influenza

A
  • Pneumonia (viral vs secondary bacterial)
  • Otitis media (most common complication in peds)
  • Acute myositis (extreme tenderness esp legs)-> rhabdomyolysis

Severe:
ARDS

46
Q

Define:

  • acute cough
  • subacute cough
  • chronic cough
A

Acute: 2-3 weeks
Subacute: 3-8 weeks
Chronic: >8 weeks

47
Q

What are the 3 most common causes of chronic cough?

Bonus emerging cause per Curbsiders?

A
  • upper airway cough syndrome
  • asthma
  • GERD

Bonus:
-non-asthmatic eosinophilic bronchitis

48
Q

Timing of chronic cough

AM cough: more suggestive of ________

Overnight cough: more suggestive of (3)_______

A

AM: bronchitis

PM: pulmonary edema, asthma, GERD (think lying down)

49
Q

3 key clues in history taking for chronic cough?

A
  • use of ACE-I
  • URI symptoms
  • smoking (main cause of chronic cough)
50
Q

If chronic cough is related to allergies, what would you expect on labwork?

A

CBC: elevated eosinophils

elevated IgE

51
Q

Chronic cough in smoker (current or former):

Work up for lung cancer if one or more of these 3 symptoms are present

A
  • new onset of cough/change in “smoker’s cough”
  • cough lasting >1 month after quitting smoking
  • hemoptysis in absence of infection
52
Q

Pertinent positive physical findings suggestive of PE:

A

Frequently asymptomatic

Vitals: tachypnea, hypoxemia, tachycardia (often not present), hypotension
Resp: decreased air entry, rales
CVS: increased JVP, loud P2, parasternal heave

DVT symptoms

53
Q

Most common symptoms with PE:

A

dyspnea (73% of symptomatic patients)

pleuritic chest pain
Dry cough (hemoptysis not common)
DVT symptoms

**frequently asymptomatic

54
Q

Definition of asthma:

_______disorder
characterized by:

A

inflammatory disorder

  • variable resp symptoms (SOB, tightness, wheezing)
  • variable airflow obstruction
55
Q

What is the atopy triad?

A
  • asthma
  • allergic rhinitis
  • atopic eczeoma
56
Q

ASTHMA

-risk factors for development

A 
age at onset
-allergen exposure
urban residence
-air pollution
-tobacco smoke
-recurrent RTI
-GERD
-obesity
-poverty
-exposure to ++ levels of certain allergens in childhood
57
Q

Asthma pathophysiology

Early response:

  • which cells are involved after exposure to antigen?
  • which one makes IgE?
  • what does IgE stimulate?
  • what causes bronchial hyperresponsiveness?
A
  1. T-helper cells
  2. B cells (make IgE)
  3. Mast cell degranulation stimulated by IgE –> histamine
  4. Eosinophils release toxic neuropeptides
58
Q

Asthma pathophysiology

Late response

  • eosinophils cause:
  • leads to air trapping and ____
  • hypoxemia from ______
A

eosinophils damage epithelial cells (impairs mucociliary function, mucous plugs)

airway obstruction leads to air trapping and hyperinflation

hyperventilation causes early hypoxemia without CO2 retention

59
Q

Triggers for asthma exacerbation

What rx meds are triggers for asthma?

A
  • viral infections
  • allergens
  • smoke
  • exercise (rare)
  • stress
  • pregnancy
  • hormones
Rx meds:
beta blockers
ACE-I
ASA
NSAIDS
COV2
60
Q

3 common comorbidities for asthma

A
  • rhinitis
  • chronic sinusitis
  • GERD
61
Q

Symptoms of asthma:

  • frequent episodes of (4)
  • worse at ___ and ____
  • triggered by (3)
  • improve with ______
A

• Frequent episodes of breathlessness, chest tightness, wheezing or cough
• Symptoms worse at night and early morning
• Develop with viral URTI, after exercise, exposure to allergens or irritants
-in young kids: playing, laughing, crying
• Symptoms respond/improve with bronchodilators or corticosteroids

62
Q

Diagnosis of asthma for kids 6+ and adults:

  • gold standard test
  • what demonstrates reversibility?
A

SPIROMETRY

FEV1>12% after bronchodilator is evidence of reversibility (higher number = more confident dx)

63
Q

Diagnosis of asthma:

  • what test to use if spirometry is negative but clinical suspicion is high?
  • what can cause false neg?
A

methacholine challenge

false neg with:

  • seasonal asthma
  • good control on meds
  • asymptomatic
64
Q

Diagnosis of asthma

Aside from spirometry and peak flow, what other diagnostic testing would you include?

A

CXR (not routine)
CBC
Allergy testing

65
Q

GINA Asthma guidelines

Overuse of SABA (> _____ canisters/year) increases risk of exacerbations

SABA > _____ canisters/year increases risk of death

A

SABA >3/year = increase exacerbation

SABA >12/year = increase death

66
Q

GINA Asthma Monitoring follow up:

  • after initiation of tx:
  • routine:
  • minimum review:
  • in pregnancy:
  • after exacerbation

Assess ______ at EVERY visit

A
  • 1-3 months after starting treatment
    • Every 3-12 months after (recommend minimum annual review)
    • In pregnancy: q4-6 weeks
    • After exacerbation: review within 1 week

Reassess and reinforce inhaler technique at EVERY visit

67
Q

Asthma

When should you order spirometry?

A
  • at start (confirm dx before starting tx)
  • after 3-6 months (best lung function)
  • every 1-2 years
68
Q

GINA Asthma

What are the 6 components of self-management?

A
  • Asthma info
    • Inhaler skills
    • Adherence
    • Asthma action plan
    • Self monitoring of symptoms and peak flow
    • Regular medical review
69
Q

ASTHMA peak flow:

  • how often to do?
  • when to do?
  • expected to be low when?
  • expected to be high when?
A

BID, best of 3 each time

  • average over 1-2 weeks
  • do before inhalers
  • lowest early morning
  • highest in afternoon
70
Q

ASTHMA MEDS
ICS

Indication:

Example:

A
  • first line controller
  • regular use

Flovent (fluticasone)
Pulmicort (budesonide)
Alvesco (ciclesonide)

71
Q

ASTHMA MEDS

SABA

Indication:

Example:

A

SABA

  • bronchodilator
  • PRN rescue

Ventolin
Bricanyl (terbutaline)

72
Q

ASTHMA MEDS

ICS-LABA

Indication:

Example:

A

ICS-LABA:

*first line combo controller reliever

Advair (fluticasone + salmeterol)
Symbicort (budesonide + formoterol)

73
Q

ASTHMA MEDS

LAMA

Indication:

Example:

A

LAMA

  • use regularly WITH ICS
  • never use alone

Spiriva (tiotropium)

74
Q

ASTHMA MEDS

LTRA

Indication:

Example:

A

LTRA

  • second line controller
  • less effective than ICS

Singulair (montelukast)

75
Q

GINA ASTHMA

Track 1 (preferred):
what medication is used:
A

low dose ICS-formoterol (Symbicort)
as CONTROLLER AND RELIEVER

Step 1-2: PRN
Step 3-5: maintenance and reliever (MART)

76
Q

GINA ASTHMA

Track 2 (alternative to ICS-formoterol)

what medication is used:
conditions for use?

A

ICS as CONTROLLER
SABA as RELIEVER

only if adherent with daily ICS and NO exacerbations

77
Q

GINA ASTHMA

when would you consider short term step up therapy?

A

for 1-2 weeks with asthma plan during viral infection/allergen exposure

78
Q

GINA ASTHMA

Asthma exacerbations
-when to seek medical care?

A
  • if need to repeat SABA within 3 hours
  • if exceed max dose of controller
  • can quadruple ICS dose (watch max dose of formoterol)
79
Q

GINA ASTHMA

uncontrolled asthma
-5 things to assess?

A
  • inhaler technique
  • adherence to inhaler
  • modifiable risk factors
  • address other co-morbidities
  • treatment step up?

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