Respiratory Flashcards
COVID-19: Overview
- Infection caused by SARS-CoV-2
- sx appear 2-14 days after exposure
S/S
- fever
- chills
- headache
- myalgia
- cough
- SOB
- accompanied by fatigue, diarrhea, N/V
- sudden loss of taste and/or smell
- cold-like sx: sore throat, nasal congestion, and rhinitis
Pt w/ underlying medical conditions (e.g., heart/lung ds) → higher risk of developing serious complications → Hospitalization
- Most have mild illness, able to recover at home
Call PCP for testing instructions and treatment
- Close contacts need to self-quarantine for ~10-14 days
Lung Cancer: Overview
- Most pts already have advance cancer on presentation
- Most common type: Non-small-cell lung CA (85%)
- Screening: Annual low-dose CT (LDCT) of lung ; recommended for 55-80 who are chronic smokers (or quit smoking <15 years previously)
Sx depends on location(s) and tumor metastases
- Cough (50-75%) in smoker or former smoker, persistence should ↑ suspicion
- Hymoptysis
- dyspnea
- chest (some; described as a dull, achy, persistent pain)
- some have shoulder/bone pain
- recurrent pneumonia on same lobe (may be sign of local tumor obstruction)
- can present w/ weight loss, anorexia, fatigue, and fever
- Horner syndrome (present in some pts)
Horner syndrome
pupil construction w/ ptosis
Acute Carbon Monoxide Poisoning: Overview
Mild-mod cases s/s
- headache (most common sx)
- accompanied by nausea, malaise, and dizziness
- Some cases, may resemble viral URI
- sx variable and can range from mild confusion to coma
- may be cherry-red appearance of skin/lips (insensitive sign)
Severe toxicity:
- seizures
- syncope
- coma
Dx based on hx and PE w/ ↑ carboxyhemoglobin level measured by cooximetry of ABG; VBG may be used but less accurate
Pulmonary Emboli: Overview
Etiology:
- any condition that ↑ blood clot risk will ↑ risk of PE
- Hx of Afib, estrogen therapy, smoking, surgery, CA, pregnancy, long-bone fractures, and prolonged inactivity
S/s
- sudden onset of dyspnea and cough (usually older adult)
- cough may be productive of pink-tinged frothy sputum
- tachycardia
- pallor
- feelings of impending doom
Impending Respiratory Failure (Asthmatic Exacerbation: Overview
- An asthmatic pt present w/ tachypnea (RR >20)
- tachycardia or bradycardia
- cyanosis
- anxiety
- appears exhausted, fatigued, and diaphoretic
- uses accessory muscles
PE
- cyanosis
- “quiet” lungs w/ no wheezing or breath sounds
- When speaking, pt may only speak 1-2 words (cannot form complete sentence d/t need to breathe)
Tx:
- Adrenaline injection STAT! → Call 911!
- Oxygen supplementation (4-5 L/min)
- albuterol nebulizer
- parenteral steroids
- antihistamines (diphenhydramine)
- H2 antagonist (cimetidine)
Good sign after tx:
- breath sounds and wheezing present (sign of bronchi opening)
- usually d/c w/ oral steroids for several days (e.g., Medrol dose pack)
Normal Findings: Breath sounds
1. Lower lobes
2. Upper lobes
- Vesicular breath sounds (soft and low)
- Bronchial breath sounds (louder)
Normal Findings: Respiratory Rate
Adults: 14-18 breaths/min
- women tend to have ↑ RR than men
- A very small ↑ in partial pressure of carbon dioxide (PaCO2) will affect RR but high levels of carbon dioxide (>70-80 mmHg) can depress respiration and cause headaches, restlessness, unconsciousness, and death
Definition: Tachypnea
- ↑ RR
- Many causes including ↑ O2 demand, hypoxia, and ↑ PaCO2
Many conditions can cause tachypnea:
- pain
- fear
- fever
- physical exertion
- asthma
- pneumonia
- PE
- hyperthyroidism
Normal Findings: Egophony
Normal:
will hear “eee” clearly instead of “bah.” “Eee” sound is louder over large bronchi d/t larger airways (better at transmitting sounds); lower lobes have a softer-sounding “eee”
Abnormal: will hear “bah” sound
Normal Findings: Tactile Fremitus
Instruct pt to say “99” or “1, 2, 3” ; use finger pad sto palpate lungs and feel for vibrations
Normal : Stronger vibrations are palpable on upper loves and soft vibrations on lower lobes
Abnormal : findings are revered; may palpate stronger vibrations on one lower lobe (i.e., consolidation); asymmetric findings are always abnormal
Normal Findings: Whispered Pectoriloquy
Instruct pt to whisper “99” or “1, 2, 3” ; compare both lungs
- If there is long consolidation, whispered words are easily heard on lower lobes of lung
Normal : voice louder and easy to understand in upper lobes; void sounds are muffled on lower lobes
Abnormal : clear voice sounds in lower lobes are muffled sounds on upper lobes
Normal Findings: Percussion
- Normal
- Tympany or hyperresonance
- Dull
- Use middle or index finger as pleximeter finger on one hand; finger on the other hand is the hammer
Normal : Resonance is heard over normal lung tissue
Tympany or hyperresonance: occurs w/ COPD, emphysema (overinflating); if empty, stomach area may be tympanic
Dull tone: bacterial pneumonia w/ lober consolidation; pleural effusion (fluid or tumor); a solid organ, such as liver, sounds dull
Normal Findings: Pulmonary Function Testing - Definition
GOLD STANDARD for asthma and COPD (pre- and post- bronchodilator)
- Measures obstructive vs restrictive dysfunction
Normal Findings: Pulmonary Function Testing - Forced Expiratory Volume in 1 second (FEV1)
Amount of air that a person can forcefully exhale in 1 second
Normal Findings: Pulmonary Function Testing - Forced Vital Capacity (FVC)
Total amount of air that can be exhaled during FEV1 test
Normal Findings: Pulmonary Function Testing - FEV1/FVC ratio
Proportion of a person’s vital capacity that the person is able to expire in 1 second.
- Normal: ≥75%
Post-bronchodilator FEV1/FVC <0.7 (lung function <70%) is cutoff score for COPD
Normal Findings: Pulmonary Function Testing - Obstructive dysfunction
Reduction in airflow rates
Ex: Asthma, COPD (chronic bronchitis and emphysema), bronchiectasis
Normal Findings: Pulmonary Function Testing - Restrictive dysfunction
Reduction of lung volume d/t ↓ lung compliance
Ex: Pulmonary fibrosis, pleural disease, diaphragm obstruction
Chronic Obstructive Pulmonary Disease (COPD)
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
5. Treatment Considerations
- chronic lung ds characterized by permanent loss of elastic recoil of lungs, alveolar damage, airflow limitations, chronic inflammation, and changes in pulmonary vasculature
- Most common cause: chronic cigarette smoking w/ highest incidence among men >40 years
- Most pt have mixed emphysema and chronic bronchitis; one or the other may predominate
- many have asthmatic component, overlaps COPD → asthma-COPD overlap syndrome (ACOS)
- Pulmonary HTN (cor pulmonale) may develop in later stages
** COPD = 4th leading cause of death in US - Most characteristic s/s: Chronic and progressive dyspnea
- middle-aged to older adult with hx of many years of cigarette smoking presents w/ hx of viral URI → exacerbated COPD sx
- worsening dyspnea
- accompanied by chronic gough, productive of large amounts of tenacious sputum
- walking up stairs or physical exertion worsens dyspnea
- “blue bloater”
- “pink puffer”
- may be barrel chest
- Most characteristic s/s: Chronic and progressive dyspnea
PE:
- Emphysema component → ↑ anterior-posterior diameter, ↓ breath and heart sounds; use of accessory muscles to breathe; pursed-lip breathing, weight loss
- Chronic bronchitis component → chronic cough productive of large amounts of sputum; lung auscultation → expiratory wheezing, rhonchi, and coarse crackles
- Percussion: Hyperresonance
- Tactile fremitus and egophony: ↓
- CXR: flattened diaphragms w/ hyperinflation; bullae sometimes present
- Post-bronchodilator FEV1/FVC <0.7 (lung function <70%) = cutoff for diagnosing COPD
- Depends on classification (see notecard)
- ** Low BMI is associated w/ worse outcomes in COPD pts; consider nutritional supple (e.g., Ensure) in underweight pts
- When treating COPD, pick antibiotics that has coverage against both H. influenzae (Gram-) and Streptococcus pneumoniae (Gram+)
COPD: Treatment (based on classification)
Treatment of COPD: GOLD Guidelines (2020)
Group A (minimally symptomatic COPD; low risk of exacerbation
- SABA alone or in combination w/ SAMA/anticholinergic
- combination therapy preferred (more effective) but monotherapy is acceptable
Group B (More symptomatic; low risk of exacerbations)
- LAMA or LABA or SABA for symptom relief PRN
Group C (minimally symptomatic; high risk of future exacerbations)
- First line: LAMA
- SABA for sx relief PRN
Group D (More symptomatic; high risk of future exacerbations)
- High risk → Refer to pulmonologist!
COPD: Treatment Tips:
1. Which medication is recommended for all COPD w/ and used for intermittent ↑ in dyspnea PRN?
2. Which med would you add if pt has poor sx relief w/ SABA/SAMA?
- SABAs (short-acting beta2-agonists) recommended for all COPD pts, used for intermittent ↑ in dyspnea PRN
- If pt has poor sx relief w/ short-acting anticholinergic/short-acting muscarinic antagonist (SAMA; ipratropium [Atrovent]) → Add a SABA
- First-line for Group A: SABA or short-acting anticholinergic (SAMA); if poor relief on single agent, add a second agent. If SABA, add short-acting anticholinergic (Atrovent)
- If on short-acting bronchodilators are not controlling sx → start on LAMA or LABA based on pt preference; continue using SABA PRN
- DO NOT USE LABAs (salmeterol, formoterol) for rescue tx
COPD: General Treatment (nonpharmacologicals)
- Smoking cessation is VERY IMPORTANT
- Options include → nicotine patches or gum, bupropion (Zyban) or varenicline (Chantix), pt education and behavioral counseling
- Annual influenza vaccination; give pneumococcal vaccine (PPSV23 [Pneumovax]) and PCV13 [Prevnar]); administer 12 months apart
- Pulmonary hygiene (e.g., postural drainage) or pulmonary rehab
- Treat lung infections aggressively
Nonpharm should be in accordance w/ inidivdualized assessment of sx and exacerbation risk
- smoking cessation (can include pharm treatment)
- Physical activity
- influenza vaccination annually
- Pneumococcal vaccination
- Pulmonary rehabilitation
COPD: Management of Stable COPD (goals of treatment)
Once diagnosed, effective management should be based on individualized assessment of current sx and future risks
- ↓ sx
Relieve sx
- improve exercise tolerance
- improve health status AND prevent ds progression
- Prevent and tx exacerbations
- ↓ mortality
COPYD: Management of Exacerbations and Referral
COPD exacerbation: an acute event characterized by a worsening of pt’s respiratory sx that is beyond normal day-to-day variations → change in medication
- If have mod-severe exacerbation (↑ dyspnea, ↑ sputum/viscosity, ↑ sputum purulence) → should be HOSPITALIZED; higher risk of death
- Most common cause: respiratory tract infections (viral or bacterial)
- Higher risk for Haemophilus influenzae PNA, suspect 2º bacterial infection if acute onset of fever, purulent sputum, ↑ wheezing, and dyspnea
- Assess pulse o2 saturation
- Mainstay therapy: SABA, can be combined w/ short-acting anticholinergic/SAMA ; if at home, use inhalers w/ spacer device. If needed, add PO corticosteroids (prednisone 40 mg daily x 5 days)
- CXR useful in excluding alternative dx (e.g., pneumonia, PE, pneumothorax)
- EKG and cardiac troponins → aid in dx of exciting cardiac problems
- Spirometry not recommended during exacerbation d/t difficulty in performing and measurements are not accurate enough
Treatment options (Abx):
- Macrolide (azithromycin, clarithromycin) or 2nd-gen cephalosporin (cefuroxime, cefdinir, cefpodoxime) x 3-5 days
- If at risk for Pseudomonas → ciprofloxacin or levofloxacin w/ sputum for C&S
*** Strongly enforce stringent measures against active cigarette smoking; pt hospitalized d/t COPD exacerbations are at ↑ risk for DBT and PE; thromboprophylactic measures should be enhanced
Referral
- Mod-sev COPD
- Severe exacerbation or rapid progression
- Age <40 years
- Weight loss
COPD: Treatment - Bronchodilators Types & Examples
* Safety issues
SABAs: albuterol, levalbuterol (Xopenex), pirbuterol (Maxair), metaproterenol
** May cause adverse cardiac SE (palpitations, tachycardia); use w/ caution if pt has HTN, angina, and/or hyperthyroidism
- Avoid combining w/ caffeinated drinks
Long-acting beta-agonists (LABAs): Salmeterol, formoterol, vilanterol
Short-acting anticholinergics (SAMAs): Ipratropium (Atrovent)
Long-acting muscarinic antagonists (LAMAs) or long-acting anticholinergics: Tiotropium bromide (Spiriva), umeclidinium powder (Ellipta), glycopyrrolate (Seebri Neohaler); available as combination LAMA + LABA formulations
Anticholinergics (ipratropium [Atrovent], tiotropium [Spiriva)
- Avoid if pt has narrow-angle glaucoma, BPH, or bladder neck obstruction
COPD: Treatment - Corticosteroids and phosphodiesterase-4 inhibitors
Long-term monotherapy w/ oral corticosteroids is NOT recommended
Selective phosphodiesterase-4 inhibitor roflumilast (Daliresp) indicated to ↓ COPD exacerbation risk in pts w/ severe COPD
- NOT a bronchodilator
CONTRAINDICATIONS:
- mod-severe liver impairment
- associated w/ ↑ psychiatric adverse reactions (e.g., insomnia, depression, suicidal ideation, weight loss)
COPD: Treatment - Oxygen therapy
Long-term O2 therapy is recommended for chronic hypoxemia (pulse O2 sat [PaO2] ≤55 mm Hg) or if PaO2 is ≤88%)
Titrate O2 so that PaO2 is 88-92%; continuous O2 therapy preferred for COPD w/ chronic severe hypoxemia
- improved survival w/ continuous O2 us compared w/ NOC O2 use
COPD: Air Travel
Some pt w/ COPD can become hypoxemic during air travel; supplemental O2 may be needed
COPD: Supplementation w/ antioxidants
Vitamins C, E, zinc, and selenium shown to improve muscle strength among COPD pts
COPD: “Blue bloater”
pt w/ chronic bronchitis w/ bluish tinge to skin (d/t chronic hypoxia and hypercapnia)
COPD: “Pink puffer”
pt w/ emphysema w/ pink skin color (adequate oxygen saturation, thin, and tachypneic + accessory muscles to breath + pursed-lip breathing
COPD: Risk Factors
RF:
- Chronic smoking (etiology up to 90% of COPD cases; >40 years old)
- Occupational exposure (e.g., coal dust, grain dust) (10-20% of cases)
- Alpha-1 anti-trypsin deficiency (AATD): pt have severe lung damage at earlier ages : alpha-1 trypsin protects lungs from oxidative and environmental damage; WHO recommends all pt w/ a diagnosis of COPD should be screened x1
COPD: Chronic Bronchitis
coughing w/ excessive mucus production for at least ≥3 months for a minimum of ≥ 2 consecutive years
- airway hypersecretion and inflammation
COPD: Emphysema
Irreversible enlargement and alveolar damage w/ loss of recoil → chronic hyperinflation of lungs
- Expiratory respiratory phase is markedly prolonged
COPD: Asthma
Airway inflammation → hyperreactivity
- contribution of each disease (chronic bronchitis, emphysema, and asthma) varies in each individual
Common Lung Infections: Community-Acquired Pneumonia in Adults
1. Definition/Etiology
2. Common Pathogens
3. Clinical Presentations
4. Labs/Diagnostics
- Lung infection → inflammatory changes and damages to lungs
- Bacterial causes most death in outpt: S. pneumoniae (Gram+)
- Most common cause of focal infiltrate on CXR (lobar pneumonia) - S. pneumoniae or pneumococcus (Gram+)
- H. influenzae (Gram-) → most common in smokers, COPD
- atypical bacteria (Mycoplasma pneumoniae)
- Respiratory viruses (e.g., influenza, parainfluenza, respiratory syncytial virus [RSV])
- Cystic fibrosis: #1 bacterial is Pseudomonas aeruginosa (Gram-)
- S. pneumoniae or pneumococcus (Gram+)
- older adult: sudden onset of high fever >100.4 Fº
- chills
- anorexia
- fatigue
- accompanied by productive cough w/ purulent sputum (rust-colored sputum seen w/ streptococcal PNA)
- sharp stabbing chest pain (pleuritic chest pain)
- coughing and dyspnea
- tachypneic
- older adult: sudden onset of high fever >100.4 Fº
Elderly pts may have atypical sx:
- afebrile or low-grade
- no cough or mild cough
- weakness/fatigue
- confusion
Objective findings:
- Auscultation: rhonchi, crackles, wheezing
- Percussion: Dullness over affected lobe
- Tactile fremitus and ego phony: ↑
- Abnormal whispered pectoriloquy (whispered words louder)
- GOLD STANDARD: CXR (definitive test) for diagnosing CAP; not sputum culture → shows lobar consolidation in classic bacterial PNA
- Order posttreatment CXR to ensure infection clearance
- Repeat within 6 wks to document clearing
- CBC → leukocytosis (>10.5 x 10^9 L) w/ possible “left shift” (↑ band forms)
NOT recommended: Sputum for C&S and Gram stain ; not recommended to identify etiologic diagnoses but are an option for outpt w/ severe CAP
- GOLD STANDARD: CXR (definitive test) for diagnosing CAP; not sputum culture → shows lobar consolidation in classic bacterial PNA
** If you suspect CAP but pt has neg CXR/radiograph → obtain CT chest; consider if immunocompromised pt (d/t unable to mount strong inflammatory response)
Top two bacteria in CAP?
Top two bacterial in atypical pneumonia:
- S. pneumoniae
- H. influenzae
** COPD/smoker w/ pneumonia, more likely to have H. influenzae - M. pneumoniae
- Chlamydia pneumoniae
*** Rust-colored or blood-tinged sputum means S. pneumoniae more likely
Common Lung Infections: No 1 - Streptococcus pneumoniae + S/S
Gram+
- Acute onset high fever and chills
- productive cough
- large amount of green to rust-colored sputum
- pleuritic chest pain w/ cough
- Crackles, ↓ breath sounds, dull
- CBC: leukocytosis, ↑ neutrophils; band forms may be seen
Common Lung Infections: Atypical pneumonia + S/S
- What is the number 1 pathogen?
Mycoplasma pneumoniae
- CXR → lobar infiltrates; interstitial to patchy infiltrates
- gradual onset
- low-grade fever
- headache
- sore throat
- cough
- wheezing
- rash (sometimes)
Common Lung Infections: Viral pneumonia influenza, RSV + S/S
- fever
-cough - pleurisy
- SOB
- scanty sputum production
- Myalgias
- ↓ breath sounds, rales
Common Lung Infections: Acute bronchitis + s/s + general tx
- paroxysms of dry and sever cough, interrupts sleep
- cough: dry to productive, light-colored sputum; can lasts 4-6 wks
- no antibiotics!! Treat sx
Common Lung Infections: Tuberculosis + s/s
- coughing lasting ≥ 3 weeks
- pleuritic chest pain
- hemoptysis
- fatigue
- weight loss
- anorexia
- fever/chills
- night sweats
Common Lung Infections: Pertussis + s/s
Aka Whooping cough
- Intermittent cough becoming more severe w/ inspiratory whoop
- may be followed by posttussive vomiting
- cough worse at night
- persists ≥ 2-6 weeks
- infants do not “whoop”
- minimal cough followed by vomiting
- apnea more common
CAP: Treatment Plan for no comorbidity
If previous health w/ no risk factors for drug-resistant S. pneumoniae infection, MRSA, or pseudomonas + no recent hospitalization of parental abx within past 90 days:
First-line agents (beta-lactam or doxycycline):
- Amoxicillin 1 mg PO TID x 5-7 days
- Doxycycline 100 mg PO BID x 5-7 days
Alternative (macrolides)
- Azithromycin (Z-pack) daily x 5 days
- Clarithromycin BID or extended-release 1,000 mg daily (do not use if >25% macrolide resistance)
CAP: Treatment Plan if WITH comorbidities
(e.g., alcoholism; congestive heart failure [CHF]; chronic heart, lung, liver, or kidney disease; antibiotics in previous 3 months; diabetes, splenectomy/asplenia) or high rates (>25%) of macrolide-resistant S. pneumoniae:
Combination therapy (beta-lactam and macrolide):
- Amoxicillin clavulanate (Augmentin) 1,000/62.5 mg PO BID OR
- Cephalosporin cefpodoxime (Vantin) or cefuroxime (Ceftin) + azithromycin (Z-pack) clarithromycin (Biaxin) 500 mg BID x 5-7 days
Alternative (respiratory fluoroquinolone; duration 5-7 days)
- Moxifloxacin (Avelox) 400 mg PO daily
- Gemifloxacin (Factive) 400 mg PO daily
CAP: Treatment Plan if poor prognosis
REFER FOR HOSPITALIZATION!
Elderly: ≥ 60 years, acute mental status changes, CHF
- multiple lobar involvement
- acute mental status change
- alcoholics (aspiration pneumonia)
Pt meets the “CURB-65” criterion for hospital admission!
CURB-65
A tool used to assess whether a pt needs hospitalization
- Each factor is worth 1 point
- If >1 point → Refer for hospitalization
C - Confusion
U - Uremic (BUN >19.6 mg/dL)
R - RR >30
B - BP <90/60 mmHg
≥ 65 years
CAP: Prevention
- Influenza vaccine for all persons >50 years or if in contact w/ persons who are at higher risk of death from pneumonia (healthcare workers, others)
- Pneumococcal polysaccharide vaccine (Pneumovax) if >65 years or with high-risk condition ; can use in younger ages if high risk of death from pneumonia
CAP: Prevention: PCV13 & PPSV23 in adults
Pneumococcal Vaccines (Adults
PCV13 (pneumococcal conjugate vaccine: Prevnar 13)
- recommended for all children <2 or >2 w/ certain medical conditions
- Adults ≥ 65 can use vaccine (discuss and decide w/ clinician); space at least 1 year apart from PPSV23
PPSV23 (pneumococcal polysaccharide vaccine: Pneumovax 23; Pnu-Imune 23)
- recommended
→ Health patients:
- Single dose of PPSV23 is usually sufficient at age 65 years (lifetime)
- 60-70% effective in preventing invasive ds caused by serotypes in vaccine
Underlying disease
- 50% effective
Severely Immunocompromised
- Only 10% effective
Recommended for: special situations (as follows); can give to persons as young as 19 years
- impaired immunity (splenectomy, asplenia, or diseased spleen; alcoholics/cirrhosis of liver; HIV infection; chronic renal failure)
- preexisting heart and lung disease (asthma, congenital heart disease, emphysema, others)
- blood disorders (Sickle cell anemia, Hodgkin’s lymphoma, multiple myeloma)
High-risk patients → Repeat vaccines in 5-7 years (boosts antibodies)
- if first dose was given before age 65
- asplenia, chronic renal failure ( give at 19 years old)
- Immunocompromised states
- Blood cancers: Lymphoma, Hodgkin’s ds, leukemia
Atypical Pneumonia
1. Definition/Etiology
2. Common Pathogens
3. Clinical Presentation + PE
4. Lab/Diagnostics
5. Treatment
- infection of lungs by atypical bacteria
- more common in children and young adults
- seasonal outbreaks (summer/fall)
- highly contagious
- AKA “walking pneumonia” - M. pneumoniae
- Chlamydophila pneumonia
- Legionella pneumoniae
- Chlamydia psittaci
- M. pneumoniae
- gradual onset of sx
- several weeks of fatigue
- accompanied by coughing, mostly nonproductive
- headache
- low-grade fever
- hx of cold before onset of bronchitis (sore throat, clear rhinitis, and low-grade fever)
* older pt may have more severe disease
- gradual onset of sx
PE:
- Auscultation: wheezing and diffused crackles/rales
- Nose: clear mucus (may have rhinitis of clear mucus)
- Throat: erythematous w/out pus or exudate
- CXR: diffuse interstitial infiltrates (up to 20% have pleural effusion)
- CBC: may be WNL
- If suspect infection w/ Legionella → urinary antigen test of L. pneumophilia
- Consider testing for Legionella if pt fails outpt therapy for CAP, have severe pneumonia, or travels
- Azithromycin (Z-pack) x 5 days
- Levofloxacin (Levaquin) 750 mg x 5-7 days
► Alternatives: Doxycycline 100 mg PO BID x 7-10 days OR
► Clarithromycin (Biaxin) 500 mg PO BID x 7-10 days
- Antitussives (dextromethorphan, Tessalon Perles, honey) PRN
- ↑ fluids and rest
- Azithromycin (Z-pack) x 5 days
Atypical Pneumonia: M. pneumoniae
- complications
- gold standard
Nonpulmonary complications can occur:
- hemolytic anemia
- meningo-encephalitis
- urcticaria
Gold standard for diagnosis: polymerase chain reaction (PCR) of sputum or oropharyngeal swab
Atypical Pneumonia: Chlamydophila pneumoniae
- more common in who?
- most common s/s/clinical presentation?
- More common in school-age children
- usually develops into bronchitis or mild pneumonia
Atypical Pneumonia: Legionella pneumoniae
- Found where?
- what type of pneumonia does this bacteria case? morality rate?
- Risk factors?
- Found in areas w/ moisture such as those that are air conditioned (hospitalize, more sever w/ ↑ mortality)
- Causes Legionnaires’ disease; fatality rate 10% (up to 25% fatality for healthcare-associated infections)
RF:
- ≥ 50 years
- smoking
- chronic lung disease (e.g., COPD)
- immune system disorders
- underlying illnesses such as diabetes, renal failure, or hepatic failure
Atypical Pneumonia: Chlamydia psittaci
- where does this infection usually come from?
Not as common
- a zoonotic infection from infected pet birds (e.g., parrots, parakeets), and poultry (e.g., turkeys, ducks)
Acute Bronchitis
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
5. Complications
- Acute viral (sometimes bacterial) infection of bronchi → inflammatory changes in trachea, bronchi, and bronchioles → ↑ reactivity of the upper airways
- usually self-limited
- AKA tracheobronchitis
Causes include:
- adenovirus
- influenza (winter/spring)
- coronavirus
- respiratory syncytial virus
parainfluenza
- human metapneumovirus
- young, adult male
- cough that keeps pt up at night; mainly drug but can be productive of either purulent or nonpurulent sputum
- frequent paroxysms or coughing
- may have low-grade fever
- may have chest pain w/ cough
- may have wheezing and rhonchi (cleared w/ coughing)
- median duration of cough: 18 days (1-3 weeks)
- hx of cold before onset of bronchitis sx
- young, adult male
PE:
- Lungs: ranges from clear to severe wheezing (prolonged expiratory phase), rhonchi
- Percussion: resonant
- CXR: to r/o pneumonia: normal
- Afebrile to low-grade
- Tx is symptomatic; ↑ fluids and rest
- stop smoking if smoker
- dextromethorphan BID-QID
- Tessalon Perles (benzonatate) TID PRN (antitussives)
- guaifenesin (PRN (expectorant/mucolytic)
- For wheezing → albuterol inhaler (Ventolin) QID or nebulized treatment PRN
- If severe wheezing → consider short-term oral steroid
- Tx is symptomatic; ↑ fluids and rest
- Asthma exacerbation (↑ risk of status asthmaticus)
- Pneumonia from 2º bacterial infection (pneumococcus, mycoplasma, others)
- Asthma exacerbation (↑ risk of status asthmaticus)
Pertussis
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostics
- Aka “whooping cough”
- Caused by Bordetella pertussis (Gram-)
Coughing illness of at least 14 days duration w/ once of the following:
- paroxysmal coughing
- inspiratory whooping (or posttussive vomiting) w/out apparent cause
- can last from few weeks to months
- unvaccinated children & adults w/ expired vaccinations are at risk for pertussis
- Neonates & infants are at highest risk of death
THREE STAGES:
- catarrhal
- paroxysmal
- convalescent
- ** Suspect pertussis in previously “health” pt w/ severe hacking cough >2 weeks
- initial sx: low-grade fever and rhinorrhea and mild cough (catarrhal stage)
- cough becomes severe w/ inspiratory “whooping” sound
- pt may vomit afterwards
- cough is worse at night
- infants have atypical presentation → no whoop w/ minimal to no cough; apnea is more common in infants - Nasopharyngeal swab for culture (best time to collect is 0-2 weeks following cough)
- Polymerase chain reaction (PCR) may provide accurate results up to 4 wks
- Pertussis antibodies by ELISA
- CBC: ↑ WBCs and marked lymphocytosis (up to 80% lymphocytes in WBC diff)
- CXR: should be negative; if positive, d/t 2º bacterial infection
- Nasopharyngeal swab for culture (best time to collect is 0-2 weeks following cough)
Pertussis
4. Treatment/Prevention + monitoring
5. Complications
- Administer course of abx to close contacts within 3 wks of exposure; treatment and chemoprophylaxis use the same doses and antibiotics
First line: Macrolides
- Azithromycin (Z-pack) 500 mg on day 1, then 250 mg daily from days 2-5 (drug of choice for very young infants)
- Erythromycin 500 mg QID x 14 days
- Clarithromycin (Biaxin) BID x 7 days
- Macrolides given to infants <1 month of age: Monitor for infantile hyperpyloric stenosis (IHPS) and other adverse events ; if ≥ 2 months, an alternative to macrolides is trimethoprim-sulfamethoxazole
- Chemoprophylaxis for close contacts: respiratory droplet precautions needed
- Antitussives, mucolytics, rest, and hydration; frequent small meals
Prevention:
- Age 11-18 (and 18y ears to adulthood) → Tdap; instead of Td
- Sinusitis
- otitis media
- penumonia
- fainting
- rib fractures, etc
- Sinusitis
Pertussis: Stage 1 (treatment effectiveness)
Catarrhal state
- lasts 1-2 weeks
- If treated in this stage, can shorten ds course (treat within 3 weeks of onset)
Pertussis: Stage 2 (treatment effectiveness)
Paroxysmal coughing
- lasts 2-4 weeks
- treatment has little influence on ds but is useful to prevent ds spread
Pertussis: Stage 3 (treatment effectiveness)
Convalescent state (lasts 1-2 weeks)
- Treatment goal is to eradicate carriage state/ds spread
- antibiotic will not shorten illness at this stage
Pertussis
4. Treatment/Prevention + monitoring
5. Complications
- Administer course of abx to close contacts within 3 wks of exposure; treatment and chemoprophylaxis use the same doses and antibiotics
First line: Macrolides
- Azithromycin (Z-pack) 500 mg on day 1, then 250 mg daily from days 2-5 (drug of choice for very young infants)
- Erythromycin 500 mg QID x 14 days
- Clarithromycin (Biaxin) BID x 7 days
- Macrolides given to infants <1 month of age: Monitor for infantile hyperpyloric stenosis (IHPS) and other adverse events ; if ≥ 2 months, an alternative to macrolides is trimethoprim-sulfamethoxazole
- Chemoprophylaxis for close contacts: respiratory droplet precautions needed
- Antitussives, mucolytics, rest, and hydration; frequent small meals
Prevention:
- Age 11-18 (and 18y ears to adulthood) → Tdap; instead of Td
- Sinusitis
- otitis media
- penumonia
- fainting
- rib fractures, etc
- Sinusitis
Differential Diagnoses for Cough
► Bacterial pneumonia
- fever, tachypnea, or tachycardia, productive cough, CXR w/ lobar consolidation; may have pleuritic chest pain w/ cough
► Postnasal drip
- Ticklish sensation in back of throat, clearing throat often, cough worsens when supine; may have rhinosinusitis w/ purulent PND
► Asthma
- SOB or dyspnea, wheezing, dry cough; sx respond to albuterol or SABA
► GERD
- Heartburn after large/fatty meals or w/ empty stomach; worsens when supine; cough may be present
► Heart Failure
- SOB/dyspnea, worsens w/ exertion or physical activity, pitting edema, dry cough; PE may show S3, elevated JVD
► Pulmonary Embolism
- New onset of dyspnea, hemoptysis, pleuritic chest pain
- VS tachycardia, tachypnea
- may have signs of DVT
► Lung cancer
- Cough in person w/ risk factors such as long-term cigarette smoking (≥30 pack-year hx); weight loss
► ACE inhibitor use
- Nonproductive cough in person w/ HTN, diabetes, or CKD
- can start within1 week of starting medication
Why emphasize importance of adequate fluid intake?
Best mucolytic, thins out mucus
What can lung cancer present as?
Recurrent pneumonia d/t mass blocking bronchioles
Common cold (Viral Upper Respiratory Infection [URI])
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
5. Complications
- Self-limiting infection (4-10 days)
- most contagious from days 2-3; highly contagious
- most common in crowded areas & small children
- Transmission by respiratory droplets & fomites
- Most occurrence in winter months - acute onset of fever
- sore throat
- frequent sneezing in early phase
- accompanied by nasal congestion
- runny eyes
- rhinorrhea of clear mucus (coryza)
- may c/o headache
- acute onset of fever
PE:
- Nasal turbinates: Swollen w/ clear mucus (may also have blocked tympanic membrane)
- Anterior pharynx: reddened
- Cervical nodes: smooth, mobile, and small or “shotty” nodes (≤0.5 cm) in submandibular and anterior cervical chain
- Lungs: clear
- Clinical diagnosis
- ** spontaneous resolution expected within 4-10 days
- treat sx: ↑ fluids and rest; wash hands frequently
- Analgesics (acetaminophen) or NSAIDs for fever and aches PRN
- oral decongestants (e.g., pseudoephedrine [ Sudafed]) PRN
- topical nasal decongestants (e.g., Afrin) can be used BID up to 3 days PRN only; do NOT use for >3 days d/t risk of rebound nasal congestion (rhinitis medicamentosa)
- antitussives (e.g. dextromethorphan [Robitussin]) PRN
- antihistamines (e.g., diphenhydramine [Benadryl]) for nasal congestion PRN - acute sinusitis
- acute otitis media
- acute sinusitis
Tuberculosis:
1. Definition
2. High-risk populations
3. What is latent TB infection? Miliary TB? MDR TB? Reactivated TB infection?
4. Why is knowing prior BCG vaccine important?
- Infection caused by Mycobacterium tuberculosis
- most common site of infection is lungs (85%)
- other sites: pleurae, kidneys, brain, lymph nodes, adrenals, and brone
- most contagious forms are pulmonary TB, pleural TB, and laryngeal TB (coughing spreads aerosol droplets)
- CXR (reactivated TB) will show cavitations and adenopathy and granulomas on hila of lungs - immigrants (from high-prevalence countries)
- migrant farm workers
- illegal drug users
- homeless
- inmates of jails
- nursing homes
- adult living facility residents
- HIV- infected
- immunocompromised
- immigrants (from high-prevalence countries)
3.
Latent TB infection (LTBI) → an intact immune system causes macrophages to sequester bacteria in lymph nodes (mediastinum) in form of granulomas; not infectious
Miliary TB → AKA disseminated TB disease
- infects multiple organ systems
- more common in younger children (<5 years) and elderly
- CXR: classic “milia seed” pattern
Multidrug-resistant TB (MDR TB) or extensively drug-resistant TB
- bacteria resistant to at least 2 of the best anti-TB drugs–isoniazid (INH) and rifampin) ← first-line drugs
Reactivated TB infection or active TB disease (infectious)
- latent bacteria become reactivated d/t depressed immune system
- most TB cases (80%) of active disease
Prior Bacillus Calmette-Guerin (BCG) vaccine:
- may cause false-positive to TB skin test
- TB blood tests are preferred method of testing for people who received the BCG vaccine
- use Quantiferon-TB GOLD in-tube test (QFT-GIT), T-spot TB test
Tuberculosis:
5. Clinical Presentation
6. Treatment Plan
- high-risk population pt c/o:
- fever
- anorexia
- fatigue
- night sweats
- w/ mild nonproductive cough (early phase)
- aggressive infections (later sign) → productive cough w/ blood-stained sputum (hemoptysis)
- weight loss (late sign)
- high-risk population pt c/o:
- REPORTABLE DISEASE! Report to local health department
- All active TB pt → TEST of HIV infection
- When TB bacteria are actively replicating and damaging body → TB disease (sx of pulmonary/pleural TB: blood-tinged sputum/cough, night sweats, and weight loss)
- initial regimen for suspected TB before C&S are available:
► FOUR DRUGS:
- isoniazid (INH)
- rifampin (RIF)
- ethambutol (ETH)
- pyrazinamide (PZA)
- REPORTABLE DISEASE! Report to local health department
- duration of tx for active TB is 6-9 months
- tx depends on whether pt has drug-resistant TB or drug-susceptible TB
- MDR TB → resistant to more than 1 anti-TB drug and at least to isoniazid (INH) and rifampin (RIF)
- Refer pt to TB expert
- Several tx regimens are available → Consult w/ CBC TB website
TB: Directly observed Treatment
- Mandatory for noncompliant pts
- success is dependent on med compliance
How: pt is observed by nurse when they take meds → mouth, cheek, and area under tongue are checked to make sure pill was swallowed adequately
TB: Drug Adverse Effects
1. Isoniazid (INH)
2. Ethambutol (ETH)
3. Pyrazinamide (PZA)
4. Rifampin (RIF)
- Give w/ pyridoxine (vit B6) to ↓ risk of peripheral neuritis, neuropathy, hepatitis, seizures
- Optic neuritis, rash; AVOID if pt has eye problems; eye exam at baseline
- Hepatitis, hyperuricemia, arthralgias, rash
- Hepatitis; thrombocytopenia; orange-colored tears, saliva, and urine; drug interactions
Recent Mantoux Test (Purified Protein Derivative [PPD]) Converters
- Definition
- Why need treatment?
Recent PPD converter: a person w/ hx of negative PPD results, then converts to positive PPD
- higher risk of active TB disease (up to 10%) within first 1-2 years after seroconversion
- Treatment ↓ risk that latent TB infection (LTBI) will progress to TB disease
Recent Mantoux Test PPD Converters
- Treatment
- Assessment, labs/imaging
- Short course vs long course
- Shorter duration (3-4 months) rifamycin-based treatment for LTBI is now preferred over longer duration treatment (6-9 months)
- Assess s/s of TB (cough, night sweats, weight loss); if s/s present → active TB disease
- LTBI do NOT have s/s and canNOT spread infection
► CXR (pt should not have upper lobe cavitations and mediastinal adenopathy) → Classic findings are pulmonary nodules and/or cavitations (round black holes) on upper lobes w/ or w/out fibrotic changes (scars)
► W/ RML PNA, look for consolidation (white-colored area) on RML, which is located at about same lvl as R break on front of chest - Baseline LFTs, monitor
- Check alcohol use if on INH
- Consultation w/ TB expert if known source of TB infection has drug-resistant TB
Short-course regimens include:
- Once-weekly isoniazid + rifapentine x 3 months
- Daily rifampin x 4 months (preferred for HIV-neg adults/children)
- Daily isoniazid + rifampin x 3 months
** Never tx TB w/ fewer than 3 drugs
Generally, preventive tx for LTVI is encouraged for those <35 years; after 35 years, much higher risk of liver damage from INH chemoprophylaxis. Asess risk vs benefits and discuss w/ pt
TB skin test (Mantoux Test)
- How to read results
- Special population considerations
Look for induration (feels harder); red color is NOT as important
- If PPD result is a bright-red color but is NOT induration (skin feels soft) → NEGATIVE result
Induration of ≥ 5 mm:
- HV
- Recent contact w/ infectious TB cases
- CXR w/ fibrotic changes consistent w/ previous TB ds (cavitations on upper lobes)
- Immunocompromised (e.g., organ transplant, bone marrow transplant, renal failure, pts on biologic drugs)
Induration of ≥ 10 mm:
- Recent immigrants (within past 5 years_ from high-prevalence countries (Latin America, Asia [except Japan], Africa, India, Pacific Islands)
- Child <4 years or children/adolescents exposed to high-risk adult
- IV drug user, healthcare worker, homeless
- Employees or residents from high-risk congregate settings (jails, nursing homes)
Induration of ≥ 15 mm:
- person w/ no known risk factors for TB
** 9.5 mm → If falls under 10 mm group, then negative (be definition) unless pt has s/s and/or CXR findings suggestive of TB
** Tuberculin skin test is considered both valid and safe to use throughout pregnancy
** Younger children are more likely than older children to develop life-threatening forms of TB ds
TB Labs: What is it and result meanings
1. Tuberculosis Skin Test
2. Blood Tests for TB
- Mantoux test/TB skin test (TST): Inject 0.1 mL of 5TU-PPD subdermally
- Do NOT use tine test (has not been used for many years) - QuantiFERON-TB Gold in-tube test of the T-SPOT TB test (also known as interferon-gamma release assays [IGRAs]) → blood test measuring gamma-interferon (from lymphocytes)
- IGRA test results → available within 24 hrs (only one visit required); if hx of previous BCG vaccination, IGRA blood tests preferred
- QuantiFERON-TB Gold in-tube test of the T-SPOT TB test (also known as interferon-gamma release assays [IGRAs]) → blood test measuring gamma-interferon (from lymphocytes)
** QuantiFERON-TB and T-SPOT are available at public health clinics
TB Labs: What is it and results
3. Sputum Tests for TB
- Early morning deep cough specimen; collect for 3 consecutive days
- Sputum nucleic acid amplification (NAAT) is a rapid test (1-3 days)
- GOLD STANDARD: C&S – for diagnosing pulmonary TB infection; can take up to 8 weeks to grow
- Acid-fast bacilli (AFB) smear: POsitive AFB is not diagnostic, but is suggestive of TB infection; it is a rapid test, results can be obtained 1-2 days → helps to strengthen diagnosis of TB before sputum C&S results are available (takes up to 8 weeks for result)
- Order sputum for NAAT, C&S, and AFB smear if you suspect active TB infection
TB: Booster Phenomenon
Person w/ LTBI can have false-neg reaction to tuberculin skin test (TST) or the PPD if they have not been tested for many years
Two-step tuberculin skin testing is recommended by the CDC:
- When TST/PPD is done the first time, if there is no reaction → may be false negative
- Repeat PPD (1-2 weeks later); positive reactions mean pt has LTBI (booster phenomenon)
- Follow up w/ CXR and inquire about s/s; if no s/s of active TB ds and negative CXR, offer LTBI prophylaxis
- If second PPD is negative, means person has a true negative test result (does not have TB infection)
** According to CDC, on avg, ~10 contacts are listed for each index persons w/ infectious TB
Which population is at a very high risk for active TB after initial exposure (primary TB)?
Persons w/ HIV infection w/ CD4 <500 or pts who are taking tumor necrosis factor antagonists (or biologics)
Asthma
1. Definition/Etiology
2. Treatment Goals
- Resp ds characterized by chronic airway inflammation; defined by hx of resp s/s that vary overtime (wheezing, SOB, chest tightness, cough) accompanied by variable expiratory airflow limitation
- REVERSIBLE airway obstruction and ↑ responsiveness to stimuli (internal or external)
- Genetic disposition w/ positive fam hx of allergies, eczema, and allergic rhinitis (atopy or atopic hx)
- Exacerbations can be life-threatening
- R/O allergic asthma → refer for allergy testing
- R/O GERD, rhinitis, sinusitis, and stress
* NOT a strong risk factor for acquiring COVID-19 - Can perform usual “normal” activities w/ no limitations (e.g., attend school full time, play ‘normally’, work full time, no job absence d/t asthmatic s/s)
- prevent exacerbation
- minimal use of rescue meds (<2 days/week albuterol use)
- Avoid ED visits/hospitalization
- Maintain near-normal pulm functions (↓ permanent lung damage); prevent loss of lung function
- For children → prevent reduced lung growth
- Can perform usual “normal” activities w/ no limitations (e.g., attend school full time, play ‘normally’, work full time, no job absence d/t asthmatic s/s)
Asthma
3. Clinical Presentation
4. Objective Findings
5. Trigger Factors
- young-adult w/ asthma c/o worsening s/s after a recent bout of URI
- using albuterol inhaler more than normal (≥3x/day)
- SOB
- wheezing
- chest tightness
- sometimes accompanied by dry cough at night and early morning (~3am), interrupts sleep
- young-adult w/ asthma c/o worsening s/s after a recent bout of URI
- Lungs: wheezing w/ prolonged expiratory phase; as asthma worsens, wheezing occurs during both inspiration and expiration; with severe bronchoconstriction, breath sounds are faint or inaudible
- Cardiovascular: tachycardia, rapid pulse
- Lungs: wheezing w/ prolonged expiratory phase; as asthma worsens, wheezing occurs during both inspiration and expiration; with severe bronchoconstriction, breath sounds are faint or inaudible
Asthma:
6. Treatment plan
- Initial visit vs Nebulizer tx
- Initial visit: assess asthma control to determine if therapy should be adjusted
- at each visit, assess asthma control, proper med technique, pt adherence, and concerns
Nebulizer treatments:
- give up to 3 albuterol tx Q20min PRN
- alternative is albuterol metered-dose inhaler (MDI) used w/ a spacer (equivalent to nebulizer)
- short course of PO corticosteroids may be needed for exacerbations
- if low-dose inhaled corticosteroids (ICS), add LABAs (or ↑ dose to medium-dose ICSs only)
Asthma Medications: “Rescue” or “Reliever” Meds
One ONE drug class used for rescue (traditional strategy): SABAs
- under GINA 2020, preferred reliever is combination ICS-formoterol (LABA) + SABA as alternative
SABA in MDI, MIDI w/ spacer, or by nebulizer
- Albuterol (Ventolin HFA) or pirbuterol (Maxair) → 2 inhalations Q4-6 hrs PRN
- Levalbuterol (Xopenex HFA): 2 inhalations Q4-6 hrs PRN; less likely to cause cardiac stimulation (fewer palpitations, less tachycardia)
QUICK Onset (15-30 mins) and lasts 4-6 hours
- Used for quick relief (of wheezing) but does NOT tx underlying inflammation
- W/ nebulizer, give up to 3 treatments Q20mins PRN; short course of PO corticosteroids may be needed for exacerbations (Medrol Dose Pack)
- Used for tx of exercise-induced asthma
Asthma Medications: Long-Term Control meds
LABAs (used alone) ↑ risk of death from asthma. Combination of LABA and ICS is safer!
Ex: - Fluticasone x/ salmeterol (Advair)
- Budesonide w/ formoterol (Symbicort)
Asthma Medications: Sustained-Release Theophylline (Theo-24)
Drug class: Methylxanthine
- used as adjunct drug
- act as bronchodilator
Monitor levels to ↓ risk of toxicity; drug has multiple drug interactions including:
- macrolides, quinolones
- cimitidine
- anticonvulsants (phenytoin, carbamazepine [Tigerton])
- Check blood levels: normal is 12-15 mg/dL
Asthma: Spacers or Chambers
Space or chamber (Aerochamber) use is encouraged; will ↑ delivery of aerosolized drug to lungs and minimize oral thrust (for inhaled steroids)
Asthma meds: Inhaled corticosteroids
1. Examples
2. Side/Adverse effects
- Triamcinolone (Azmacort) BID
- Budesonide (Pulmicort) BID
- Fluticasone (Flovent) BID
- Triamcinolone (Azmacort) BID
- Oral thrush (gargle or drink water after use)
- use w/ spacer
- HPA axis suppression, glaucoma, others
Asthma meds: Long-acting beta2- agonists
1. Examples
2. Side/Adverse effects
- Salmeterol (Serevent) BID
- Formoterol (Foradil) BID
- Salmeterol (Serevent) BID
- Warn pts of ↑ risk of asthma deaths; not to b used as rescue drug
- do NOT use along w/ asthmatics, USE AS LABA + ICS combinations
- Warn pts of ↑ risk of asthma deaths; not to b used as rescue drug
Asthma meds: Combination of ICS w/ LABA
1. Examples
2. Side/Adverse effects
- Salmeterol-fluticasone (Advair HFA, Advair Diskus) BID
- Budesonide-formoterol (Symbicort)
- Mometasone-formoterol (Dulera)
- Salmeterol-fluticasone (Advair HFA, Advair Diskus) BID
- Preferred GINA 2020 med is ICS-formoterol for reliever (rescue drug) or daily as treatment (Steps 1, 2, 3)
** chronic use of high-dose inhaled steroids → osteoporosis, growth failure in children, glaucoma, cataracts, immune suppression, HPA axis suppression, etc
- Consider calcium w/ vit D 1,200 mg tabs daily for menopausal women + other high-risk pts for osteoporosis (males on medium0 to high-dose ICS)
- Consider bone-density testing in M or F who are on chronic steroids to R/O osteopenia or osteoporosis
- ANNUAL eye exams if on long-term steroids, since ↑ risk of cataracts and glaucoma
Asthma meds: Leukotriene receptor antagonists/inhibitors
1. Examples
2. Side/Adverse effects
- Montelukast (Singulair) daily
- Zafirlukast (Accolate) BID
- Zileuton (Zyflo) daily
- Montelukast (Singulair) daily
- Neuropsychological effects
- agitation
- aggression
- depression
- Neuropsychological effects
- Monitor LFTs with zileuton
Asthma meds: Mast cell stabilizers (cromoglycates)
1. Examples
2. Side/Adverse effects
- Cromolyn sodium (Intal) QID
- Nedocromil sodium (Tilade) QID
- Cromolyn sodium (Intal) QID
- Cromolyn (Intal) and nedocromil (Tilade) inhalers have been DISCONTINUED in US; cromolyn for nebulization still available
Asthma meds: Methylxanthines
1. Examples
2. Side/Adverse effects
- Theophylline (not used often) daily; starting dose 300 mg/day BID
- Sympathomimetic
- Avoid w/ seizures, HTN, stroke
- Severe drug interactions; monitor drug levels
- Sympathomimetic
Asthma meds: Immunomodulators
1. Examples
2. Side/Adverse effects
- Omalizumab (xolair)
- Anaphylaxis can occur w/ first dose or after long-term use
Asthma meds: Anti-immunoglobulin E antibodies
1. Examples
2. Side/Adverse effects
- Dupilumab (Dupixent)
- Be equipped and prepared to tx anaphylaxis when starting this drug
- higher risk of TIA, CVA, MI, emboli
- Be equipped and prepared to tx anaphylaxis when starting this drug
Asthma meds: Systemic oral corticosteroids
1. Examples
2. Side/Adverse effects
- Prednisone
- Prednisolone
- Methylprednisolone
- Prednisone
- Short course for 3-4 days
- If used >4 days, requires weaning
- used for exacerbations
- Short course for 3-4 days
Asthma Classification (≥ 12 years): GINA 2020 update
1. Intermittent
2. Mild Persistent
3. Moderate Persistent
4. Moderate-to-severe Persistent
- Step 1: Intermittent
Symptoms: 2x or less/week
Nighttime awakenings: 2x/month
SABA Use: 2x or less/week
FEV1 (% predicted): >80%
Tx: SABA PRN - Step 2: Mild persistent
Symptoms: >2 days per week but not daily
Nighttime awakenings: 3-4x/month
SABA Use: ≥2 days/week but not daily
FEV1 (% predicted): >80%
Tx: Low-dose ICS - Step 3: Moderate Persistent
Symptoms: Daily
Nighttime awakenings: >1x/week but not nightly
SABA Use: Daily
FEV1 (% predicted): 60-80%
Tx: Low-dose ICS + LABA or medium-dose ICS - Step 4 or 5 (Moderate-to-severe persistent or severe persistent)
Symptoms: Throughout the day
Nighttime awakenings: Often; 7x/week
SABA Use: Severe times/day
FEV1 (% predicted): <60%
4 Tx: Medium-dose ICS + LABA
5 Tx: High-dose ICS + LABA: add anti-IgE omalizumab if allergies
** Memorize!
Ex: Step 3 → FEV1 of 60-80%
- If FEV1 is >80%, it is either intermittent to mild persistent asthma; check night awakenings; if occur <2 x/month → intermittent asthma
Asthma Stepwise Approach (GINA 2020) Treatment:
Step 1
Step 2
Step 3
Step 4
Step 5
First-line drugs: ICS → treat lung inflammation
- S/s < 2x/month → Low dose ICS w/ formoterol PRN
Alternative: SABA w/ low-dose ICS - S/s >2 x/month but less than daily → Low-dose ICS daily
- OR lose-dose ICS w/ formoterol PRN - Symptoms most days, or waking w/ asthma >1x/week or more
→ Low-dose ICS-LABA daily
- OR medium-dose ICS
- OR low-dose ICS + leukotriene receptor antagonist (LTRA) - S/s most days or waking w/ asthma >1x/week (low lung fx)
→ Medium-dose ICS-LABA daily
- Refer for expert advice - S/s most days or waking w/ asthma >1x/week (low lung fx)
→ Refer for phenotypic assessment
- Add anti-IgE
Asthma Treatment per Global Initiative (2020):
1. S/s < 2x/month
2. S/s ≥2x/month, but less than daily
3. S/s on most days or waking w/ asthma once/week or more
4. S/s on most days or waking w/ asthma once/week or more (low lung function)
5. S/s on most days or waking w/ asthma once/week or more (low lung function)
- Low-dose ICS-formoterol PRN
Alternative: low-dose ICS w/ SABA - Low-dose ICS daily
- OR low-dose ICS-formoterol PRN
- Low-dose ICS daily
- Low-dose ICS-LABA daily
- OR medium-dose ICS
- OR low-dose ICS + LTRA - Medium-dose ICS + LABA daily
- refer for expert advice - Refer for phenotypic assessment; add anti-IgE
*** As asthmatic pt how many times they use their albuterol SABA inhaler; if using >2x/week → poorly controlled asthma or having an exacerbation
Asthma treatment Summary:
1. Every pt should be on what med according to 2007 guidelines?
2. Per GINA 2020, what med is preferred for reliever/rescue?
3. Per GINA 2002, what can be used as both maintenance and rescue? Which specific med is recommended?
- SABA (albuterol) PRN; starting in Step 2, add Low-dose ICS
In step 3, add LABA to low-dose ICS (use combination meds Advair, Symbicort); continue using SABA as PRN drug
*** SABA is the ONLY rescue drug class! ALL asthmatics need a SABA for PRN use! - ICS-formoterol or ICS-LABA
- Albuterol or SABA monotherapy is discouraged; but can be used an alternative rescue drug
- GINA does NOT advise against their use as an add-on reliever/rescue drug - ICS-LABA can be used as both maintenance (daily) treatment and rescue inhaler; extra inhalations can be used for breakthrough asthma sx
- For severe persistent asthma → Refer to asthma specialist
- GINA recommends budesonide or beclomethasone as ICSs and formoterol as LABA (Symbicort)
Asthma: Patient Education
- Review inhaler technique (use spacer if pt has problems)
- Teach about rescue meds and long-term controller meds
- Develop a written asthma action plan; partner w/ pt and fam
- Control and limit exposure to allergens if allergic asthma; consider immunotherapy w/ allergist
- Teach how to use spirometer; recognize worsening
Asthma: Exercise-Induced Bronchoconstriction (Exercise-Induced Asthma)
- Acute bronchoconstriction occurring during or immediately after exercise
- up to 90% of asthmatics may have exercise-induced bronchoconstriction (EIB)
- Leukotrienes, histamine, and interleukin levels are increased
- Premedicate 5-20 mins before exercise w/ 2 puffs of SABA (albuterol [Ventolin], levalbuterol [Xopenex], pirbuterol [Maxair])
- Effect will last up to 4 hours
Asthmatic Exacerbation
1. Clinical presentation
2. Treatment
3. Discharge vs ED referral
- Respiratory distress:
- tachypnea, using accessory muscles (intercostals, abdominal) to breathe, talk in brief/fragmented sentences, severe diaphoresis, fatigue, agitation
Lungs:
- Minimal to no breath sound audible during lung auscultation
- Peak expiratory flow (PEF) <40%; lips/skin is blue-tinged (cyanosis)
- Check O2 saturation
- Use supplemental oxygen
- Give nebulizer treatment → Albuterol 0.5% solution by nebulizer Q20-30 mins up to 3 doses
- If unable to use inhaled bronchodilators → give 1;1,000 solution IM
After nebulizer treatments → Listen for breath sounds
- If inspiratory and expiratory wheezing present → good sign (signals opening up of airways)
- if lack of breath sounds or wheezing after a nebulizer treatment → bad sign, pt is NOT responding → Call 911!
REFER TO ED/Call 911:
- If poor to no response to nebulizer tx (PEF <40% of expected)
- If no response to nebulizer tx, impending resp arrest, give Epi-Pen STAT!
** Recognize resp failure!
- Severe resp distress: tachypnea, disappearance of or lack of wheezing, accessory muscle use, diaphoresis, and exhaustion
** During severe asthmatic exacerbation, heard to heart breath sounds; you may NOT hear wheezing → give albuterol nebulizer tx and listen for wheezing (indicates airways are opening)
Asthma: Peak Expiratory Flow Rate
Measures effectiveness of treatment, worsening sx, and exacerbations
- During expiratory, pt is instructed to blow hard using spirometer 3 times; highest value is recorded (personal best)
- PEF based on height, age, and gender or HAG
- Mnemonic: HAG = Height, age, gender***KNOW
Asthma: Spirometer Parameters (Zones)
Green zone: 80-100% of expected volume
- No wheeze or cough; sleeps through night; can work and play
- Continue daily controller meds
Yellow zone: 50-80% of expected volume
- Mild wheeze, tight chest, coughing at night
- Exposure to known trigger or first signs of a cold
- Continue green zone meds and add or ↑ dose
Red zone: <50%
- Breathing hard and fast, nasal flaring, trouble speaking
- In children, ribs showing from using accessory muscles
- Administer oxygen
- First line tx: Albuterol by MDI w/ spacer or nebulizer
- Onset of action <5 mins
- If not effect → CALL 911!
** Pulse ox ≤ 90% is indicated of severe asthmatic episode and severe hypoxemia → Call 911!
** A near-normal pulse ox may present in pt w/ impending respiratory failure d/t hypercapnia (bedside capnometry might be better method to monitor)
Chest X-ray Interpretation: Definition and general concepts
Xrays: radiation (gamma rays) that pass through human body and hit a metal target (film cassette)
- depending on type of tissue density, they are absorbed differently
* Darker the color → lower the tissue density (e.g., air on lungs)
- Xrays can be plain or contrasted
- in PA view → xray goes through back to front; spinal column more visible at this view
- in AP (anterior-posterior) view → x-ray goes through front of chest toward back
- lateral view → view form side of chest
- Systemic approach of reading chest films should be followed every time; compare present films with old films (if available)
Chest X-ray Appearance
1. Air
2. Bones
3. Metals
4. Tissue
5. Fluid
6. Tissues visible
- appears as black color (low density so less absorption) over lung fields
- Appear as white to gray
- bright white (high absorption)
- different grayish shades (medium absorption)
- grayish to whitish
- Trachea, bronchus, aorta, heart, lungs, pulmonary arteries, diaphragm, gastric bubble, ribs
Chest X-ray: Abnormal conditions
1. Emphysema
2. Lobar pneumonia/bacterial pneumonia
3. TB
4. Left ventricular hypertrophy (LVH)/cardiomyopathy
5. Silhouette sign
- black color in hilum (above clavicles); a lot of black color in hyperinflated lungs, blunted costovertebral angle (CVA; diaphragm flat instead of dome shaped)
- Grayish to white areas on a lobe or lobes of lung (consolidation) from purulent fluid
- Upper love w/ cavitation 9black round holes), fibrosis (scarring), and pulmonary infiltrates (fluid) in active TB disease
- heart occupies >50% of chest diameter; it is enlarged
- Displacement of normal silhouette in chest film
Ex: displacement of para-aortic line can be caused by aortic aneurysm or dissection/rupture
