Respiratory Flashcards
When performing whispered pectoriloquy, what would be considered an abnormal finding when the patient says 99?
Hearing it clearly or louder in lower lobes or muffled in upper lobes.
When performing tactile fremitus, as the patient says 99 you should expect what findings?
To feel stronger vibrations in the upper lobes over scapula with softer in the lower. Asymmetrical findings or reversed findings are considered abnormal.
When testing egophony, what is the patient asked to say and what findings do you expect?
“Eee” should be clearly heard and louder over large bronchia. Softer in lower lobes. Hearing “bah” or “aa” is abnormal.
Percussion of normal lung tissue is?
Resonant, loss of resonance indicates consolidation or effusion. Tympany or hyper resonance is found w/ COPD
What is FEV1 and FVC?
FEV1- amt of air that can be forcibly exhaled in 1 second
FVC- the total amt of air exhaled during FEV1
How are FEV1 and FEV measured together and how is that interpreted?
FEV1/FVA ratio: should be >75% (0.75)
Which pulmonary disorders are considered restrictive?
Pulmonary fibrosis, pleural diseases, and diaphragmatic obstruction
Which pulmonary disorders are considered obstructive?
COPD, Asthma, bronchiectasis
What is the diagnostic criteria for chronic bronchitis?
Coughing that lasts >3 months for >2 years (consecutively)
Emphysema is characterized as?
Permanent alveolar damage & loss of elasticity recoil resulting in hyperinflation of the lungs. Expiratory phase is prolonged but less productive
Airway inflammation is the key characteristic of this disease?
Asthma
Is it common for patients to have combined emphysema (COPD), chronic bronchitis and or Asthma?
Yes, emphysema frequently presents with chronic bronchitis as well as ACOS (Asthma-COPD Syndrome)
Young persons, or those with early and aggressive COPD should be tested for what disorder?
Alpha-1 anti-trypsin deficiency (AATD)
-Alpha-a anti-trypsin protects lungs from oxidative and environmental damage
The term “blue-bloater” is used to describe what process?
Patients w/ chronic bronchitis who have bluish tint to their skin due to chronic hypoxia and hypercapnea
Emphysema pts who are termed “pink puffers” generally have what presentation?
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
Chronic bronchitis patients presents with what symptoms?
Chronic productive cough with exp wheezing, Rhonchi and coarse crackles lasting consecutively >2 months in 2 years
Breath sounds with emphysema tend to be?
Quiet or decreased, lack of good air flow. heart sounds may be decreased as well.
The sounds/sensations with tactile fremitus/egophony should be increased or decreased in lower lobes?
Decreased
What CXR findings would you expect with a COPD patient?
Flattened diaphragm and hyperinflation. Bullae can be present and is more of an ominous sign.
List the bronchodilator drugs:
SABAs: albuterol
LABAs: salmeterol, formoterol, vilanterol
SAMAS: Ipratropium
LAMAs: Tiotropium (spiriva), umeclidinium powder (Ellipta), glycopyrrolate (Seebri)
Are long acting corticosteroids recommended as monotherapy with COPD?
No
What additional drug can reduce risk of exacerbations in pts w/ severe COPD?
Phosphdiesterase-4 inhibitors (contraindicated w/ liver disease, high risk psych SA)
Hypoxemia with SpOx <88% should trigger the clinician to order this therapy, which is know to reduced mortality?
Oxygen therapy. Titration keep SpOx 88-92. Continuous is preferred for severe cases, actually improves survival
What vitamins are recommended as supplementation for COPD?
Vit C & E, zinc and selenium can improve muscle strength in COPD
What patients with COPD should NOT be treated with SAMA/LAMA drugs?
Glaucoma, BPH, bladder obstruction
What health promotion teaching is essential for pts w/ COPD?
Smoking cessation, Flu and pneumonia vaccination, and increased physical activity.
According to GOLD guidelines, treatment of Group A COPD who have low risk of exacerbation and minimal symptoms should be?
SABA alone or in combo with SAMA
According to GOLD guidelines, treatment of Group B COPD who are more symptomatic but have a low risk of exacerbation should be?
LAMA, LABA, or SABA(prn)
What are the GOLD guidelines recommended treatment for Group C COPD who is minimally symptomatic but has a high risk of exacerbation?
First line: LAMA, SABA for prn symptoms
What is the GOLD guidelines recommended treatment for Group D COPD who is more symptomatic with a high risk of exacerbation?
Referral to Pulmonology
If a COPD patient has poor relief with SAMA, what should be added?
LAMA
What is the main trigger for COPD exacerbation?
URI
If SABA/SAMA is not controlling symptoms with COPD, what is the next step?
LAMA/LABA- continuing the SABA
Home management of exacerbations often involves what prescribed therapies?
First line: SABA (often combined SAMA)
Oral corticosteroids: Prednisone 40mg q day x 5 days may be added as well
If pneumonia is suspected in a COPD pt (fever, increasing purulence in cough, +CXR), what antibiotics should be considered?
H. Influenzae coverage: Macrolide (azithromycin, clarithromycin) or second gen ceph such as cefdinir for 3-5 days
Pseudomonas: Fluoroquinolones
T/F, performing pulmonary functions is beneficial when a person is having an exacerbation of COPD to gauge progression?
False- do not perform PFTs during an exacerbation, they are difficult for the patient and lack accuracy
Most common pathogen in CAP?
Strep pneumonia or pneumococcus.
Which pathogen is responsible for “walking” pneumonia and what is the typical presentation?
Mycoplasma pneumoniae
CXR with lobular interstitial to patchy infiltrates, gradual onset w/ low grade fever, SOB, pleurisy, sore throat,
Physical exam findings common with pneumonia?
Auscultation: rhonchi, crackles, wheezes
Percussion: dullness over affected lobe
Tactile fremitus/egophony: increased
Whispered words louder
Is sputum C&S recommended for CAP?
No
Guidelines for outpatient CAP treatment without comorbidities?
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
Guidelines for outpatient CAP treatment WITH comorbidities?
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
PPSV23 vaccine (Pneumovax 23) is recommended for which populations?
Adults over 65 if needed
Adults over 50 with high risk or healthcare workers
PCV13 (Prevnar) vaccine is recommended under what situations?
All Children <2yrs and those >2 yrs w/ certain health conditions.
>65 yrs if needed (must be >1 year since PPSV23)
When should a repeated pneumonia vaccine be give to high risk pts (Asplenia, Immunocompromised, Blood Cancer) or those were vaccinated before 65yrs?
In 5-7 years
What are some atypical pneumonia organisms and how do they present?
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
What is the median duration of cough in Acute bronchitis?
18 days. Acute illness is usually 3-10 days
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?
Bordetella pertussis
1st line:
Macrolide Azithromycin 500 Day 1 250x3 days
Or Erythromycin 500mg QID x 14 days
Claithromycin 500mg BID x 7 days
What is the recommended treatment for acute bronchitis?
Symptomatic:
Antitussives (benzonatate, dextromethorphan)
Mucolytic: Guiafenesin
Bronchodilator: SABA
Severe bronchitis, consider oral corticosteroids
Latent TB is infectious, T/F?
False, although can become active Tuberulosis Disease if person becomes immunocompromized
What are the drugs used to treat active TB?
INH (Isoniazid)
Rifampin
PZA (pyrazinamide)
ETH (ethambutol)
Never treat with <3 drugs
What is the gold standard test for diagnosing TB?
Sputum C&S but can take up to 8 weeks
What other tests are used in the diagnosis of TB?
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
How does the CXR of a COPD pt typically appear?
Black above hilum (above clavicles), a lot of black (air- hyperinflation) in lungs, blunted CVA, flat not dome shaped diaphragm
How does the CXR of a someone with TB typically appear?
Upper lobe lesions. Cavitation (black round holes), fibrosis (scarring), and pulmonary infiltrates
How is asthma defined?
Reversible airway obstruction and increased responsiveness to stimuli (both internal and external)
What are some asthma triggers?
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)
What is the classic presentation of an asthma exacerbation?
SOB, cough (often waking at night), wheezing & chest tightness
What are the typical physical exam findings with an asthma exacerbation?
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
How is asthma control monitored?
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.
What is the preferred treatment for exercise induced asthma?
SABA 5-20 minutes prior to exercise
How often can a albuterol nebulizer be given?
Up to 3 treatments every 20 minutes
For the “rescue” approach to asthma control, what medication group is considered Step 1?
SABAs
For long-term control in persistent asthma, what is recommended Step 2 drug class & alternative (in addition to Step 1 rescue)?
Increasing dose inhaled ICS
-Triamcinolone (Azmacort) bid
-Budesonide (Pulmicort) bid
-Fluticasone (Flovent) bid
Alternative:
-leukotriene blocker or cromolyn
LABAs used alone are not recommended due to the increased risk of death, what additional drug is recommended?
ICS- LABA and ICS together are safer
What is recommended to improve delivery of MDI?
A spacer/chamber
Which drugs are common LABAs
Salmeterol (Serevent) BID
Fomoterol (Foradil) BID
What drug is an inhaled mast cell stabilizer and is it available in the US?
Cromolyn (Intel) QID- only by Neb, the MDI has been discontinued
What drugs are combination ICS and LABAs (preferred by GINA 2020)
Salmeterol-fluticasone (Advair)
Formoterol-Budesonide (Symbicort)
Mometasone-formoterol (Dulera)
What drugs are Leukotriene receptor inhibitors?
Montelukast (Singular) QD
Zafirlukast (Accolate) BID
Zileuton (Zyflo) QD
What are some ADRs with Leukotriene inhibitors?
Agitation, depression, aggressions, decreased liver function (monitor LFTs)
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?
Risk of anaphylaxis with first use, although Omalizumab can occur after long term use
What xanthine drug is not prescribed often due to multiple drug interactions and narrow therapeutic window?
Theophylline
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?
Intermittent- Step 1
-Low-dose ICS (GINA, 2020)
W/ reduce SABA
-SABA prn (2007 recommendations)
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?
Mild Persistent (Step 2) Continue Rescue SABA
OPTIONS
-Low dose ICS
-Low-dose ICS + LABA prn
May consider LRTA
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?
Moderate persistent Step 3 Continue Rescue
Options:
-Low dose ICS+LABA
-medium dose ICS
-low dose ICS +LRTA
-Referral to pulmonology/allergy
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?
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
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?
Low dose ICS w/ prn LABA or SABA. GINA does NOT recommend SABA monotherapy as the 2007 recommendations does.
According to GINA, ICS-LABA should be used as reliever as well? True or False
True
What is the ICS/LABA combo drug GINA recommends?
Symbicort (formoterol/budesonide) 2 puffs bid
What drug is a combo LABA/LAMA/ICS?
Trelegy Ellipta for COPD
For acute asthma exacerbation, what is the recommended treatment?
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
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?
Epinephrine 1:1,000 IM
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?
Calcium/Vit D
Why would you recommend a patient taking Isoniazid (INH) supplement with vitamin B6 (pyridoxine)?
To prevent peripheral neuropathy
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?
CAP
What does the CURB 65 criteria include and what does it mean?
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
Lack of bronchial landmarks and a blackened appearing CXR is indicative of what condition?
Pneumothorax
Gram stain is more helpful in differentiating bacterial pneumonia, how would s. Pneumoniae, h. Influenzae, and s. Aureus be described?
S. Pneumonia- Gram + diplococci
H. Influenzae-Gram + cocobacilli
S. Aureus- Gram + tetrads and grapelike clusters
