Respiratory Flashcards
What is going to be that predominant symptom we see on asthma patients?
COUGH
In asthma, what about the order severity in asthma?
Intermittent, mild, moderate, and severe
How are we going to know if our treatment is successful for our pt with asthma?
Have them do peak flow meter at home, but the biggest thing to remember is that we don’t determine the success of their treatment by how often they are using their rescue inhaler. If they say they have only used their inhaler one day a wk and it used to be 5 days a week; well that is wonderful but that doesn’t mean necessarily that we are going to scale back their treatment.
That might just mean that whatever medication they are on must be working really well to control their asthma.
What medication is now the cornerstone treatment of asthma since the update?
Low dose ICS, every patient according to the new guidelines should have a low dose ICS as they have been found to decrease overall mortality in these patients.
What are going to be those three things that will impact peak flow meter reading results?
Height, age and gender. Use the mnemonic “HAG”.
what do bronchodilators end in?
-terol
What do steroids end in?
-sone or -ide
* Examples: Budesonide or fluticasone
For intermittent symptoms of asthma
we are going to use an ICS LABA mix as needed,
when symptoms of asthma increase and become more mild in nature
the pt can start using that low dose ICS daily
and then when asthma symptoms become more moderate
they can utilize an inhaled corticosteroid laba mix daily or they can add on a low dose ICS with a leukotriene receptor antagonist like a Singulair.
Anything in the sever category of asthma
we want to go ahead and refer out to pulmonology for the very best care of the patient. So, if you are in your exam and you are feeling unsure your best bet is to always pick an answer with a low dose inhaled corticosteroid.
asthma intermittent
- : s/s < 2 days/wk OR < 2 nights/mth; brief exacerbations
asthma mild persistent:
*s/s >= 2 days/wk, but < 1/day OR < 2 nights/mth
asthma moderate persistent:
daily s/s OR > 3-4 nights/mth
asthma severe persistent:
continual s/s OR frequent nighttime s/s > 1 night/mth
- Exercise-induced asthma treatment
SABA 15-30 minutes prior to exercise
To diagnosis of COPD, the FEV1/FVC ratio is?
For diagnosis of COPD the FEV1/FVC ration will be < 0.70
What are we going to expect our pt to look like if they have COPD?
Barrel chest, maybe clubbing of the fingers, chronic cough.
What sound will we hear on percussion of a chest of a COPD patient?
Hyper-resonant
What are those 2 things that may make up COPD?
Chronic bronchitis and emphysema.
What is a drug that we expect to give to a chronic bronchitis or emphysema pt that does not have full blown COPD yet?
BRONCHODILATOR
hyperesonant
If the percussion produces a drum-like sound known as hyperresonance, it could indicate air has filled the space around your lungs and is prohibiting them from expanding fully. It may also suggest that air is trapped inside the small airways and alveoli (air sacs) of your lungs.
Group A COPD
group A patients get that SABA (usually albuterol)
Group B COPD
group B patients get a LABA (formoterol)
Group C COPD
group C get the LAMA
Group D COPD
group D usually gets that combination drug with the inhaled corticosteroid
Groups of COPD
Based on all of these things – your symptoms, spirometry results, and exacerbation risk –
Group A: Low risk, fewer symptoms.
Group B: Low risk, more symptoms.
Group C: High risk, fewer symptoms.
Group D: High risk, more symptoms
What if your COPD patient comes in today and says hey “ I have lost 17 pounds” since the last visit a couple of months ago. Are we going to congratulate this pt?
Were they trying to lose weight or was this unintentional because if it is unintentional then something is going on. Unfortunately, it might be cancer.could just be burning so many calories working to breathe that they are not getting enough into their system to account for that calorie loss. So that COPD patient might need to start doing some high calorie, high protein small meals 5-6 times a day to catch up with their nutritional
What cancer is a COPD patient really at high risk for?
Lung cancer.
We are not in the lower lobes anymore, what do we typically see in the upper lobes?
TUBERCULOSIS
So, remember we typically see pneumonia in the lower lobes, and TB in the upper.
With TB we usually require treatment for a long time sometimes up to 1 year.
They usually also need at least 3 drug treatments; it is HEAVY DUTY TREATMENT.
For HIV and immunocompromised patients; at what induration on the TB test are they going to be considered positive for TB?
> 5mm
What about in the general public for TB?
> 15mm of induration
What about in immigrants?
> 10 mm of induration
When does HIV turn into AIDS ?
with CD4 count < 200
What prophylactic abx do we start for that pjp when
that CD4 count is < 200? BACTRIM
How do we confirm a TB diagnosis?
SPUTUM CULTURES
if patient has chronic sinusitis what can they be at risk for?
nasal polyps
What is our first line recommendation for allergic rhinitis?
Hands down AVOID the TRIGGERS. Then we can talk about meds.
What are our first line of meds to give for allergic rhinitis?
Intra Nasal Corticosteroids like Flonase
And what is our second line of treatment?
Antihistamine like a Benadryl.
In what type of patient population do we want to avoid antihistamine at all cause?
Elderly population because we worry about anticholinergic side effects.
What are those anticholinergic side effects that we worry about in the elderly?
Can’t see, can’t pee, can’t spit, can’t poop.
Now if we were looking at some immunoglobulin labs, which immunoglobulin lab usually indicates allergies or more specifically allergic reaction?
IgE.
- Exercise-induced asthma treatment
Prevention
* In pts > 4: albuterol/Ventolin 2 puffs 15-30 minutes before exercise
* In pts < 4: Singular/montelukast take 2 hrs prior to exercise
***asthma classifications
Mild intermittent: < 2 OR < 2 brief
Mild persistent: > 2 but < 1/day OR < 2
Moderate persistent: daily OR > 3-4
Severe persistent: continual s/s OR frequent nighttime > 1 night/mth
- If an asthmatic patient is not relieved by a rescue inhaler, what is the next step?
*
LOW DOSE ICS (Budesonide/Pulmicort or Fluticasone/Flovent)
TB skin test, what is considered positive for patients? For Healthcare workers?
Palpable induration is Measured in mm
o 0mm=negative
o >5mm is positive in people with immunosuppression
o >10mm is positive for kids < 4, high-risk adults/teens, immigrants, nursing homes, IV drug users
* For Healthcare workers?
o >10mm is positive for those who
o >15mm is positive in patients with no known hx or risk factors
What is your next step for a positive test?
Obtain CXR, then sputum culture/AFB or bronch
- What is the gold standard for diagnosing asthma and COPD?
*
- Spirometry (before and after SABA): FEV1/FVC: normal > 80%
- FEV1: forced expiratory volume in 1 second (shows the severity of airflow limitation)
The volume of air that is forcefully exhaled in the first second of exhalation after a deep breath
Assesses for airway obstruction - FVC: forced vital capacity (how much air is left after a max exhale)
COPD s/sx
Signs and symptoms of COPD?
* Chronic dyspnea, chronic cough, chronic sputum production
What are differential diagnoses COPD?
*
Asthma, CHF, pneumonia, bronchiectasis (widened airways with mucus buildup), lung CA, TB
What is the gold standard for diagnosing COPD?
*
Post-bronchodilator spirometry
Mild: FEV1>80%
Moderate: 50-80%
Severe: 30-50%
Very severe: FEV1<30%
- What is considered treatment plan?
*
Categories from GOLD (global initiative for obstructive lung disease)
Category A (GOLD 1-2): minimal s/s
* SABA prn alone; or combo SABA w/ SAMA OR LAMA
Category B (GOLD 1-2): more s/s, low risk of exacerbation
* LABA w/ SAMA. OR LAMA w/ SABA
* May use SABA prn
Category C (GOLD 3-4): minimal s/s, but high risk for exacerbations
* LAMA is 1st line
* If poor control, use combo LABA and LAMA
* Long-term therapy with oral steroids is NOT recommended
Category D
* high risk, refer to pulmonology
Step approach: for COPD
SABA, then add LABA, then add SAMA, then add LAMA
* Purpose of therapy is symptom reduction, decrease exacerbations, improve exercise tolerance, improve overall health status
F/U COPD
- F/U every 3-6 months for stable patients; every month for more unstable pts; f/u within 1 month of discharge of any hospitalizations
- Lung CA: What are the signs and symptoms?
Signs and symptoms
*Hemoptysis, dyspnea, chest pain, shortness of breath, wheezing
Lung CA What are differential diagnoses?
Pneumonia, bronchitis, other CA, infectious granuloma, TB, tracheal tumors, thyroid mass, lung abscess
- Side effects of rescue inhaler
- Increased HR, BP, QT prolongation, ST depression
- Caution in pts with cardiac arrythmias, SZ and hyperthyroidism
- EXTREME caution in pts on MAOIs and beta blockers
- May cause hypokalemia
- May decrease digoxin levels
