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3P/Certification Exam > Respiratory > Flashcards

Respiratory Flashcards

1
Q

When performing whispered pectoriloquy, what would be considered an abnormal finding when the patient says 99?

A

Hearing it clearly or louder in lower lobes or muffled in upper lobes.

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2
Q

When performing tactile fremitus, as the patient says 99 you should expect what findings?

A

To feel stronger vibrations in the upper lobes over scapula with softer in the lower. Asymmetrical findings or reversed findings are considered abnormal.

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3
Q

When testing egophony, what is the patient asked to say and what findings do you expect?

A

“Eee” should be clearly heard and louder over large bronchia. Softer in lower lobes. Hearing “bah” or “aa” is abnormal.

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4
Q

Percussion of normal lung tissue is?

A

Resonant, loss of resonance indicates consolidation or effusion. Tympany or hyper resonance is found w/ COPD

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5
Q

What is FEV1 and FVC?

A

FEV1- amt of air that can be forcibly exhaled in 1 second
FVC- the total amt of air exhaled during FEV1

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6
Q

How are FEV1 and FEV measured together and how is that interpreted?

A

FEV1/FVA ratio: should be >75% (0.75)

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7
Q

Which pulmonary disorders are considered restrictive?

A

Pulmonary fibrosis, pleural diseases, and diaphragmatic obstruction

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8
Q

Which pulmonary disorders are considered obstructive?

A

COPD, Asthma, bronchiectasis

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9
Q

What is the diagnostic criteria for chronic bronchitis?

A

Coughing that lasts >3 months for >2 years (consecutively)

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10
Q

Emphysema is characterized as?

A

Permanent alveolar damage & loss of elasticity recoil resulting in hyperinflation of the lungs. Expiratory phase is prolonged but less productive

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11
Q

Airway inflammation is the key characteristic of this disease?

A

Asthma

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12
Q

Is it common for patients to have combined emphysema (COPD), chronic bronchitis and or Asthma?

A

Yes, emphysema frequently presents with chronic bronchitis as well as ACOS (Asthma-COPD Syndrome)

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13
Q

Young persons, or those with early and aggressive COPD should be tested for what disorder?

A

Alpha-1 anti-trypsin deficiency (AATD)
-Alpha-a anti-trypsin protects lungs from oxidative and environmental damage

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14
Q

The term “blue-bloater” is used to describe what process?

A

Patients w/ chronic bronchitis who have bluish tint to their skin due to chronic hypoxia and hypercapnea

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15
Q

Emphysema pts who are termed “pink puffers” generally have what presentation?

A

Adequate oxygenation, which is why skin is pink. They do have tachypnea, increased WOB, pursed-lip breathing and may have a barrel chest. They tend to be thin

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16
Q

Chronic bronchitis patients presents with what symptoms?

A

Chronic productive cough with exp wheezing, Rhonchi and coarse crackles lasting consecutively >2 months in 2 years

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17
Q

Breath sounds with emphysema tend to be?

A

Quiet or decreased, lack of good air flow. heart sounds may be decreased as well.

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18
Q

The sounds/sensations with tactile fremitus/egophony should be increased or decreased in lower lobes?

A

Decreased

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19
Q

What CXR findings would you expect with a COPD patient?

A

Flattened diaphragm and hyperinflation. Bullae can be present and is more of an ominous sign.

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20
Q

List the bronchodilator drugs:

A

SABAs: albuterol
LABAs: salmeterol, formoterol, vilanterol

SAMAS: Ipratropium
LAMAs: Tiotropium (spiriva), umeclidinium powder (Ellipta), glycopyrrolate (Seebri)

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21
Q

Are long acting corticosteroids recommended as monotherapy with COPD?

A

No

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22
Q

What additional drug can reduce risk of exacerbations in pts w/ severe COPD?

A

Phosphdiesterase-4 inhibitors (contraindicated w/ liver disease, high risk psych SA)

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23
Q

Hypoxemia with SpOx <88% should trigger the clinician to order this therapy, which is know to reduced mortality?

A

Oxygen therapy. Titration keep SpOx 88-92. Continuous is preferred for severe cases, actually improves survival

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24
Q

What vitamins are recommended as supplementation for COPD?

A

Vit C & E, zinc and selenium can improve muscle strength in COPD

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25
Q

What patients with COPD should NOT be treated with SAMA/LAMA drugs?

A

Glaucoma, BPH, bladder obstruction

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26
Q

What health promotion teaching is essential for pts w/ COPD?

A

Smoking cessation, Flu and pneumonia vaccination, and increased physical activity.

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27
Q

According to GOLD guidelines, treatment of Group A COPD who have low risk of exacerbation and minimal symptoms should be?

A

SABA alone or in combo with SAMA

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28
Q

According to GOLD guidelines, treatment of Group B COPD who are more symptomatic but have a low risk of exacerbation should be?

A

LAMA, LABA, or SABA(prn)

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29
Q

What are the GOLD guidelines recommended treatment for Group C COPD who is minimally symptomatic but has a high risk of exacerbation?

A

First line: LAMA, SABA for prn symptoms

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30
Q

What is the GOLD guidelines recommended treatment for Group D COPD who is more symptomatic with a high risk of exacerbation?

A

Referral to Pulmonology

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31
Q

If a COPD patient has poor relief with SAMA, what should be added?

A

LAMA

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32
Q

What is the main trigger for COPD exacerbation?

A

URI

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33
Q

If SABA/SAMA is not controlling symptoms with COPD, what is the next step?

A

LAMA/LABA- continuing the SABA

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34
Q

Home management of exacerbations often involves what prescribed therapies?

A

First line: SABA (often combined SAMA)
Oral corticosteroids: Prednisone 40mg q day x 5 days may be added as well

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35
Q

If pneumonia is suspected in a COPD pt (fever, increasing purulence in cough, +CXR), what antibiotics should be considered?

A

H. Influenzae coverage: Macrolide (azithromycin, clarithromycin) or second gen ceph such as cefdinir for 3-5 days
Pseudomonas: Fluoroquinolones

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36
Q

T/F, performing pulmonary functions is beneficial when a person is having an exacerbation of COPD to gauge progression?

A

False- do not perform PFTs during an exacerbation, they are difficult for the patient and lack accuracy

37
Q

Most common pathogen in CAP?

A

Strep pneumonia or pneumococcus.

38
Q

Which pathogen is responsible for “walking” pneumonia and what is the typical presentation?

A

Mycoplasma pneumoniae
CXR with lobular interstitial to patchy infiltrates, gradual onset w/ low grade fever, SOB, pleurisy, sore throat,

39
Q

Physical exam findings common with pneumonia?

A

Auscultation: rhonchi, crackles, wheezes
Percussion: dullness over affected lobe
Tactile fremitus/egophony: increased
Whispered words louder

40
Q

Is sputum C&S recommended for CAP?

A

No

41
Q

Guidelines for outpatient CAP treatment without comorbidities?

A

1st line:
Amoxicillin 1pm tid x5-7d
OR Doxycycline 100mg BID x 5-7 days
Also: Macrolide Zpack or clarithromycin 500mg bid x 5-7 days

42
Q

Guidelines for outpatient CAP treatment WITH comorbidities?

A

Combination therapy beta-lactam w/ Macrolide (or doxy) ABX 5-7 days (may be up to 10)
Beta lactam:
Augmentin 875/125 BID
Cefuroxime (ceftin)
WITH
Macrolide:
Azithromycin 500mg d1, 250 daily
Doxycycline 100mg BID
OR
Fluoroquinolones
Levovloxacin 750mg QD
Moxifloxacin 400mg QD

43
Q

PPSV23 vaccine (Pneumovax 23) is recommended for which populations?

A

Adults over 65 if needed
Adults over 50 with high risk or healthcare workers

44
Q

PCV13 (Prevnar) vaccine is recommended under what situations?

A

All Children <2yrs and those >2 yrs w/ certain health conditions.
>65 yrs if needed (must be >1 year since PPSV23)

45
Q

When should a repeated pneumonia vaccine be give to high risk pts (Asplenia, Immunocompromised, Blood Cancer) or those were vaccinated before 65yrs?

A

In 5-7 years

46
Q

What are some atypical pneumonia organisms and how do they present?

A

Organisms: Micoplasma Pneumoniae, chlamydophila pneumoniae (school-aged children), and legionella
Presentation: often younger adults/children, rhinorhea/rhinitis, erythematous throat wheezing & rules, and diffuse infiltrates. Often progresses from acute bronchitis to pneumonia

47
Q

What is the median duration of cough in Acute bronchitis?

A

18 days. Acute illness is usually 3-10 days

48
Q

Otherwise healthy patient presents severe hacking cough for over 2 weeks that is worsening. Initially had sx of URI, now has severe uncontrollable cough which is worse at night. Pt is found to produce a with a “whooping” sound noted on inhalation. What is the suspected organism and treatment?

A

Bordetella pertussis
1st line:
Macrolide Azithromycin 500 Day 1 250x3 days
Or Erythromycin 500mg QID x 14 days
Claithromycin 500mg BID x 7 days

49
Q

What is the recommended treatment for acute bronchitis?

A

Symptomatic:
Antitussives (benzonatate, dextromethorphan)
Mucolytic: Guiafenesin
Bronchodilator: SABA
Severe bronchitis, consider oral corticosteroids

50
Q

Latent TB is infectious, T/F?

A

False, although can become active Tuberulosis Disease if person becomes immunocompromized

51
Q

What are the drugs used to treat active TB?

A

INH (Isoniazid)
Rifampin
PZA (pyrazinamide)
ETH (ethambutol)
Never treat with <3 drugs

52
Q

What is the gold standard test for diagnosing TB?

A

Sputum C&S but can take up to 8 weeks

53
Q

What other tests are used in the diagnosis of TB?

A

Sputum NAAT is quickest, turn around is 1-3 days
AFB (Acid fast bacilli) smear: is suggestive but cannot be definitive dx for TB
CXR
PPD: 2 negatives confirms absence, Positive:
>5mm Immunocompromised, >10mm healthcare & high risk, >15mm w/o risk factors

54
Q

How does the CXR of a COPD pt typically appear?

A

Black above hilum (above clavicles), a lot of black (air- hyperinflation) in lungs, blunted CVA, flat not dome shaped diaphragm

55
Q

How does the CXR of a someone with TB typically appear?

A

Upper lobe lesions. Cavitation (black round holes), fibrosis (scarring), and pulmonary infiltrates

56
Q

How is asthma defined?

A

Reversible airway obstruction and increased responsiveness to stimuli (both internal and external)

57
Q

What are some asthma triggers?

A

URI, allergens (airborne & food), smoking exposure, cold air/weather, fumes, emotional and physical stress (exercise), GERD, and ASA/NSAIDS (people w/ nasal polyps more sensitive)

58
Q

What is the classic presentation of an asthma exacerbation?

A

SOB, cough (often waking at night), wheezing & chest tightness

59
Q

What are the typical physical exam findings with an asthma exacerbation?

A

Wheezing- prolonged in exhalation but will be audible in inhalation w/ worsening obstruction. However, with severe bronchoconstriction, lung sounds will be very quiet.
Tachycardic & tachypnic

60
Q

How is asthma control monitored?

A

Use of rescue inhaler: How many times a day or week using, has it changed lately. More than twice a week is a signal of poor control.

61
Q

What is the preferred treatment for exercise induced asthma?

A

SABA 5-20 minutes prior to exercise

62
Q

How often can a albuterol nebulizer be given?

A

Up to 3 treatments every 20 minutes

63
Q

For the “rescue” approach to asthma control, what medication group is considered Step 1?

A

SABAs

64
Q

For long-term control in persistent asthma, what is recommended Step 2 drug class & alternative (in addition to Step 1 rescue)?

A

Increasing dose inhaled ICS
-Triamcinolone (Azmacort) bid
-Budesonide (Pulmicort) bid
-Fluticasone (Flovent) bid

Alternative:
-leukotriene blocker or cromolyn

65
Q

LABAs used alone are not recommended due to the increased risk of death, what additional drug is recommended?

A

ICS- LABA and ICS together are safer

66
Q

What is recommended to improve delivery of MDI?

A

A spacer/chamber

67
Q

Which drugs are common LABAs

A

Salmeterol (Serevent) BID
Fomoterol (Foradil) BID

68
Q

What drug is an inhaled mast cell stabilizer and is it available in the US?

A

Cromolyn (Intel) QID- only by Neb, the MDI has been discontinued

69
Q

What drugs are combination ICS and LABAs (preferred by GINA 2020)

A

Salmeterol-fluticasone (Advair)
Formoterol-Budesonide (Symbicort)
Mometasone-formoterol (Dulera)

70
Q

What drugs are Leukotriene receptor inhibitors?

A

Montelukast (Singular) QD
Zafirlukast (Accolate) BID
Zileuton (Zyflo) QD

71
Q

What are some ADRs with Leukotriene inhibitors?

A

Agitation, depression, aggressions, decreased liver function (monitor LFTs)

72
Q

When starting immunomodulators Omalizumab (Xolair), or anti-immunoglobulin E antibodies Dupilumab (Dupixent), what is a major life-threatening ADR must you prepare the patient for?

A

Risk of anaphylaxis with first use, although Omalizumab can occur after long term use

73
Q

What xanthine drug is not prescribed often due to multiple drug interactions and narrow therapeutic window?

A

Theophylline

74
Q

A patient who has symptoms less that 2 times a week, nocturnal waking less than twice a month and uses rescue inhaler 2 or less times a week with FEV1>80% would be defined as what level of asthma and what step would be appropriate treatment?

A

Intermittent- Step 1
-Low-dose ICS (GINA, 2020)
W/ reduce SABA

-SABA prn (2007 recommendations)

75
Q

A patient who has symptoms more than 2 times a week but not daily, has nocturnal waking 3-4 times a month, uses rescue a few times a week but not daily and has FEV1>80% would be defined as what level of asthma and what step would be appropriate treatment?

A

Mild Persistent (Step 2) Continue Rescue SABA
OPTIONS
-Low dose ICS
-Low-dose ICS + LABA prn
May consider LRTA

76
Q

A patient who has symptoms and use of rescue inhaler daily, nocturnal waking many nights a week (not daily) with FEV1 60-80% would be defined as what level of asthma and what step would be appropriate treatment?

A

Moderate persistent Step 3 Continue Rescue
Options:
-Low dose ICS+LABA
-medium dose ICS
-low dose ICS +LRTA
-Referral to pulmonology/allergy

77
Q

A patient who has symptoms and use of rescue inhaler throughout the day, nocturnal waking throughout the week, with FEV1 <60% would be defined as what level of asthma and what step would be appropriate treatment?

A

Moderate to Severe Persistent (Step 4/5) Continue Rescue
Step 4-Medium dose ICS+LABA OR may consider LRTA+low dose ICS
Step 5- high dose ICS + LABA + LRTA or add Omalizumab if r/t allergies
REFER TO SPECIALIST

78
Q

There are two major asthma treatment guidelines, National Asthma Education & Prevention Program (2007) and Global Initiative for Asthma Management & Prevention (GINA 2020). These guidelines are very similar and both have 5 steps; however, GINA recommends starting stage 1 with this drug?

A

Low dose ICS w/ prn LABA or SABA. GINA does NOT recommend SABA monotherapy as the 2007 recommendations does.

79
Q

According to GINA, ICS-LABA should be used as reliever as well? True or False

A

True

80
Q

What is the ICS/LABA combo drug GINA recommends?

A

Symbicort (formoterol/budesonide) 2 puffs bid

81
Q

What drug is a combo LABA/LAMA/ICS?

A

Trelegy Ellipta for COPD

82
Q

For acute asthma exacerbation, what is the recommended treatment?

A

Albuterol nebulizer, up to 3 every 20 minutes. If improving, d/c home w/ oral steroids (medrol dose pack or prednisone 40mg x 4 days).
If failing to improve or maintain SpOx >90 =911

83
Q

For a patient in severe respiratory distress w/ asthma attack who has failed nebulizer or unable to administer Neb, what emergency drug should be considered?

A

Epinephrine 1:1,000 IM

84
Q

Long-term use of ICS poses risk such as osteoporosis, growth failure in children, glaucoma, cataracts, immune suppression, and HPA suppression. Given this information, what supplement should be recommended to peri-menopausal women?

A

Calcium/Vit D

85
Q

Why would you recommend a patient taking Isoniazid (INH) supplement with vitamin B6 (pyridoxine)?

A

To prevent peripheral neuropathy

86
Q

A patient with acute onset of fever and chills, sharp & stabbing CP, productive cough. L shift
And Lobular consolidation on CXR is likely to be?

A

CAP

87
Q

What does the CURB 65 criteria include and what does it mean?

A

Each of the following earns a point. Anything 2 or greater should be admitted and not managed OP
C-Confusion
U-BUN >19
R- RR >20
B- BP SPB<90
>65 yo

88
Q

Lack of bronchial landmarks and a blackened appearing CXR is indicative of what condition?

A

Pneumothorax

89
Q

Gram stain is more helpful in differentiating bacterial pneumonia, how would s. Pneumoniae, h. Influenzae, and s. Aureus be described?

A

S. Pneumonia- Gram + diplococci
H. Influenzae-Gram + cocobacilli
S. Aureus- Gram + tetrads and grapelike clusters

3P/Certification Exam (14 decks)

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