Respi Flashcards
Diagnostic criteria of Chronic Fatigue Syndrome
Clinically evaluated, unexplained fatigue > 6 mo, NOT alleviated by rest, impacts lifestyle
AND > 4 of the following
1) impair short term memory/concentration = Dec function
2) New H/A
3) sore throat
4) tender cervical/ axillary lymph node
5) muscle pain
6) multi-joint pain with NO swelling/ erythema
7) unrefreshing sleep
8) post exertional malaise > 24 hr
DDx of Fatigue
SO FATIGUE-D S - substance abuse O - obstructive sleep apnea F - Failure (CHF) A - anemia T - tumor I - infection G - GI malabsorption U - uremia E - endocrine (DM, hypothyroid) D - depression
Initial assessment of Fatigue
Hx: review meds (Amiodarone and others), EtOH, sleep habits, associated symptoms, sex, eating, bowels, exercise
PE: lymphadenopathy - Abdo (liver, spleen size) - Neuro(reflexes)
Lab: CBC, CRE, extended lytes Ferritin LFTs, TSH, FBG CK, ESR Urine (protein, blood, glucose) Urine pregnancy test (Female)
blood test to diagnose celiac disease
IgA
anti-TTG
anti-EMA
Biopsy
Diagnostic criteria of RA
At least 4 of the following
1) morning stiffness around joints for > 1 hr
2) arthritis >= 3 joint areas (soft tissue swelling)
3) arthritis of hand joints (wrist, MCP, PIP)
4) symmetric arthritis, bilateral involvement PIP, MCP, or MTP joints
5) Rheumatoid nodules
6) serum rheumatoid factor elevated
7) radiographic changes on hands and wrist views (erosions, decalcification)
Shingle vaccines options
Zostavax® II (LZV) Shingrix® (RZV)
Schedule 1 dose 2 doses, 2-6 months apart
Route Subcutaneous lntramuscular
Dose 0.65 mL 0.5 mL
What is the painful complication of herpes zoster that can be prevented by vaccines?
decrease post herpetic neuralgia 2/3
also decrease shingles by 51%
COPD diagnosis criteria
Spirometry - fixed post bronchodilator FEV1/FVC < 0.7 or FEV1/FVC < lower limits of normal values
(repeat in few months if FEV1/FVC 0.6-0.8)
What are the indications to check alpha-1 antitrypsin when diagnosing COPD?
1) If < 65 y/o with COPD OR
2) with a smoking history of < 20 pack years
What is the management for alpha-1 anti-trypsin deficiency (AATD)?
1) treat COPD
2) consider exogenous AAT in non-smoker/ex-smoker
3) vaccination with Hep A/B, pneumococcal & influenza
How to prevent AECOPD? (***single most effective intervention)
- *** smoking cessation
- annual influenza + pneumococcal (+booster @5 yrs) vaccine
- review puffer technique + action plan
- negative repercussions of inactivity **ESOB not life threatening
- stay indoors when air quality is poor
Symptoms of “Mild” COPD
- SOB w/ hurried walk
- recurrent chest infection
- FEV1 > 80%
Symptoms of Moderate COPD
- SOB requiring resting ~ 100m (few mins)
- limits in daily activities
- exacerbations requiring corticosteroids +/- abx
- FEV1 50-79%
Symptoms of Severe COPD
- breathless after dressing
- Resp/cardiac failure
- FEV1 30-49%
What are the common causes of AECOPD?
- Infection (50%) >>> H. influenza, S. pneumonia, Moraxella catarrhalis - CHF - irritants - PE - MI - anemia
Management of AECOPD
- Use Ventolin (SABD) + LAAC (long-acting anticholinergic, Spiriva)
- *** moderate to severe AECOPD: 30-40mg prednisone/d x 5 d, no taper
- increased purulence (or mod to severe symptoms): abx (CRP <40 likely does NOT need abx)
What are the risk factors of pseudomonas with AECOPD?
What is the treatment?
FEV1 < 35% predicted
chronic steroids
constant purulent sputum
Ciprofloxacin 500-750mg BID
What is the pharmacotherapy approach to mild COPD?
Mild: SABD prn only
(SABA short acting beta2 agonist - Salbutamol [Ventolin] 1-2 puffs QID prn, Terbutaline (Bricanyl) OR
SAMA muscarinic antagonist - Ipratropium [Atrovent] 2 puff QID prn)
pharmacotherapy for Moderate/Severe COPD with low risk of AECOPD (CAT >10, mMRC>2, <=1 mod AECOPD in past 12 months)
1) LAMA (preferred) or LABA
»_space; Tiotropium (Spiriva) 1 cap/ 2 puffs inhaled QD
2) LAMA/LABA
»_space;
3) LAMA/LABA/ICS (inhaled corticosteroid)
Goal of Oxygen therapy for COPD
The goal of oxygen therapy is to maintain
PaO2 ≥ 60 mmHg or SpO2 ≥ 90% at rest, on exertion and during sleep
Etiology of Atrial fibrillation
Cardiac > HTN > valvular disease > coronary artery disease (CAD) > congestive heart failure (CHF) > cardiomyopathy > pericarditis > myocarditis > sick sinus syndrome NON-Cardiac > Thyrotoxicosis > infection (e.g. pneumonia) > COPD > OSA > PE > Obesity > Diabetes > GERD > stress Substance > Alcohol > cocaine > NO association with caffeine
How to diagnose new Atrial fibrillation?
ECG
CBC (anemia/infection), INR, Cr, lytes, LFTs, TSH, A1C, (glucose, lipids)
Echo
Consider Holter 24hr to 30d
Stress test, CXR, sleep study, six minute walk test
What are the symptoms of unstable Afib at ER
Rapid A-fib with hypotension
ACS
Pulmonary edema
How to manage unstable A-fib at Emergency
1) Urgent rate control (IV Diltiazem, metoprolol, verapamil, digoxin)
2) Immediate OAC (NOAC/heparin) then Cardioversion
3) after cardioversion, anticoagulation for 4 weeks, consider long-term anticoagulation based on CHADS-65
Indications of A-fib rate control vs. rhythm control
*** No difference in mortality
First-line: Rate control (< 100bpm)
»_space; Exception (Rhythm control first):
- highly symptomatic
- multiple recurrences
- extreme impairment in QOL
- arrhythmia induced cardiomyopathy
>> Early AFib (<=12 months) with risk factors: ( elderly, TIA, HF, HTN, DM, severe CAD, CKD
s/e of amiodarone
pulmonary fibrosis
need periodic LFTs
need monitor TSH
First line meds for rate control of A-fib
- beta-blocker: atenolol 50-150mg QD; Bisoprolol 2.5-10mg daily; metoprolol 25-200mg BID
- Non-dihydropyridine CCB (NOT in CHF): Diltiazem, verapamil
What is CHADS-65 rule?
People with paroxysmal or persistent A-fib needs to start OAC if
1) Age >=65 OR
2) CHADS2 >=1
What are included in CHADSS-65?
CHADS2: 1 point for each
- CHF
- HTN
- Age > 75 y/o
- DM
- Stroke/TIA - get 2 points
when do the people with (paroxysmal or persistent) A-fib need to take ASA?
Age < 65 y/o
AND CHADS=0
AND has CAD or vascular disease
When should we choose Warfarin instead of NOAC for A-fib patients?
Valvular A-Fib (mechanical prosthetic valve, rheumatic mitral stenosis, moderate-severe non-rheumatic mitral stenosis)
What can increase INR of the patients on warfarin?
1) diarrhea
2) worsening heart failure
3) fever
4) impaired liver function
Asthma diagnosis criteria for children > 6 years old
1) patient + Family history
2) MUST have spirometry and in its absence, a positive methacholine or exercise challenge test or sufficient peal expiratory flow variability
Spirometry (preferred)
»_space; decreased FEV1/FVA < 0.8-0.9
»_space; Increase FEV1 12% with bronchodilator
PEF - peak expiratory flow (alternative)
»_space; increase >=20 % with bronchodilator
Methacholine
»_space; PC20 < 4mg/mL ( 4-16 borderline, > 16 negative)
Exercise
»_space; decrease FEV1 >= 10-15% post exercise
**for accuracy, discontinue ICS +/- LABA 24 hr prior to spirometry
Diagnosis criteria of Adult asthma
1) Patient + Family history
2) Must have spirometry/positive methacholine/exercise challenge test/ sufficient peak expiratory flow (PEF) variability
Spirometry (preferred)
»_space; decreased FEV1/FVA < 0.75 - 0.8
»_space; Increase FEV1 12% with bronchodilator
PEF - peak expiratory flow (alternative)
»_space; increase 60L/min (min 20 %) with bronchodilator
»_space; diurnal variation > 8% if measured BID
Methacholine
»_space; PC20 < 4mg/mL ( 4-16 borderline, > 16 negative)
Exercise
»_space; decrease FEV1 >= 10-15% post exercise
**for accuracy, discontinue ICS +/- LABA 24 hr prior to spirometry
Diagnosis criteria of Asthma in children < 6 years old
Require all three of the following during >= 2 episodes # Documentation of airflow obstruction: (cough/dyspnea/wheeze) by M.D. or parents # Documentation of reversibility of airflow obstructions by M.D. or parents # No clinical evidence of an alternative diagnosis
What is the management of asthma attack in children < 6 years old ?
1) mild symptoms: 4 puffs salbutamol, reassess 30min
2) moderate symptoms:
»_space; 4 puff salbutamol, can repeat 2-3 doses, reassess in 60 min
»_space; Oral steroid (dexamethasone 0.15-0.6mg/kg max 50mg) 1 dose, reassess in 3-4 hours
pathogen of AECOPD
- H. Influenza
- S. Pneumoniae
- M. Catarrhalis
Complicated COPD (gram negative)
- Klebsiella
- pseudomonas
causes of AECOPD
- infection (50%)
- CHF
- irritant
- PE
- MI
- anemia
management of AECOPD
- mild: Ventolin (SABA) + Spiriva (LAMA antimuscarinic antagonist)
- mod to severe: 30-40mg prednisone/d x 5d, no taper
- Triple therapy: SABA only –> LAMA –> LAMA/LABA –> LAMA/LABA/ICS –> oral therapy (macrolide, Roflumilast)
when to add Abx for AECOPD
2-3 of Winnipeg criteria - sputum purulence - sputum volume - dyspnea OR CRP > 40
management of Asthma COPD overlap
ICS/LABA +/- LAMA
prevention strategy of AECOPD
- smoking cessation - single most effective
- vaccination: annual influenza + pneumococcal (booster q5yr) vaccine
- review puffer technique + written action plan
- Negative repercussion of inactivity (?) / pulmonary rehabilitation/ exercise therapy
- stay indoor when air quality is poor
DDx of COPD
- asthma
- CHF
- GERD
- TB
- Bronchiolitis (obliterative + diffuse panbronchiolitis)
- alpha-1 antitrypsin deficiency
features of complicated /high risk COPD
- FEV1 < 50%
- = or > 4 exacerbations/yr
- cardiac disease
Abx: Amoxicillin/Clavulanate, Levofloxacin, Moxifloxacin
AECOPD at risk of pseudomonas
- FEV1 < 35% predicted
- chronic steroid use
- constant purulent sputum
Abx: Ciprofloxacin
treatment for dyspnea in COPD
- O2 supplement: goal sat > 90%, no benefit in mortality
- acupuncture
- active mind-body therapy
- Yoga
- Tai chi
- opioid (palliative)
dysphagia + cough triggered by eating/ drinking
Eosinophilic esophagitis
chronic wet cough, clubbing, FTT, recurrent pneumonia, onset in infancy
bronchiectasis, cystic fibrosis
diagnostic test of cystic fibrosis
- Sweat (chloride) test
- genetic test : mutations in the CFTR gene
Asthma maintenance management
Always ICS as 1st -line management, Do not use SABA as regular monotherapy, always with ICS
(Except for children 1-5 y/o: SABA +/- ICS)
For > 12 y/o : can use ICS/LABA (Symbicort) as reliever
Lung cancer screening criteria for smokers/ ex-smokers
NO chest x-ray for screening
1) Age 55-74
2) 30 pk/yr smoker, current or quit < 15 yrs ago
Annual low-dose chest CT up to 3 times
