Respiratory Flashcards
1
Q
COVID-19: Overview
A
- 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
2
Q
Lung Cancer: Overview
A
- 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)
3
Q
Horner syndrome
A
pupil construction w/ ptosis
4
Q
Acute Carbon Monoxide Poisoning: Overview
A
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
5
Q
Pulmonary Emboli: Overview
A
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
6
Q
Impending Respiratory Failure (Asthmatic Exacerbation: Overview
A
- 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)
7
Q
Normal Findings: Breath sounds
1. Lower lobes
2. Upper lobes
A
- Vesicular breath sounds (soft and low)
- Bronchial breath sounds (louder)
8
Q
Normal Findings: Respiratory Rate
A
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
9
Q
Definition: Tachypnea
A
- ↑ RR
- Many causes including ↑ O2 demand, hypoxia, and ↑ PaCO2
Many conditions can cause tachypnea:
- pain
- fear
- fever
- physical exertion
- asthma
- pneumonia
- PE
- hyperthyroidism
10
Q
Normal Findings: Egophony
A
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
11
Q
Normal Findings: Tactile Fremitus
A
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
12
Q
Normal Findings: Whispered Pectoriloquy
A
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
13
Q
Normal Findings: Percussion
- Normal
- Tympany or hyperresonance
- Dull
A
- 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
14
Q
Normal Findings: Pulmonary Function Testing - Definition
A
GOLD STANDARD for asthma and COPD (pre- and post- bronchodilator)
- Measures obstructive vs restrictive dysfunction
15
Q
Normal Findings: Pulmonary Function Testing - Forced Expiratory Volume in 1 second (FEV1)
A
Amount of air that a person can forcefully exhale in 1 second
16
Q
Normal Findings: Pulmonary Function Testing - Forced Vital Capacity (FVC)
A
Total amount of air that can be exhaled during FEV1 test
17
Q
Normal Findings: Pulmonary Function Testing - FEV1/FVC ratio
A
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
18
Q
Normal Findings: Pulmonary Function Testing - Obstructive dysfunction
A
Reduction in airflow rates
Ex: Asthma, COPD (chronic bronchitis and emphysema), bronchiectasis
19
Q
Normal Findings: Pulmonary Function Testing - Restrictive dysfunction
A
Reduction of lung volume d/t ↓ lung compliance
Ex: Pulmonary fibrosis, pleural disease, diaphragm obstruction
20
Q
Chronic Obstructive Pulmonary Disease (COPD)
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
5. Treatment Considerations
A
- 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+)
21
Q
COPD: Treatment (based on classification)
A
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!
22
Q
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?
A
- 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
23
Q
COPD: General Treatment (nonpharmacologicals)
A
- 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
24
Q
COPD: Management of Stable COPD (goals of treatment)
A
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
25
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
26
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
27
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)
28
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
29
COPD: Air Travel
Some pt w/ COPD can become hypoxemic during air travel; supplemental O2 may be needed
30
COPD: Supplementation w/ antioxidants
Vitamins C, E, zinc, and selenium shown to improve muscle strength among COPD pts
31
COPD: "Blue bloater"
pt w/ chronic bronchitis w/ bluish tinge to skin (d/t chronic hypoxia and hypercapnia)
32
COPD: "Pink puffer"
pt w/ emphysema w/ pink skin color (adequate oxygen saturation, thin, and tachypneic + accessory muscles to breath + pursed-lip breathing
33
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
34
COPD: Chronic Bronchitis
coughing w/ excessive mucus production for at least ≥3 months for a minimum of ≥ 2 consecutive years
- airway hypersecretion and inflammation
35
COPD: Emphysema
Irreversible enlargement and alveolar damage w/ loss of recoil → chronic hyperinflation of lungs
- Expiratory respiratory phase is markedly prolonged
36
COPD: Asthma
Airway inflammation → hyperreactivity
- contribution of each disease (chronic bronchitis, emphysema, and asthma) varies in each individual
37
Common Lung Infections: Community-Acquired Pneumonia in Adults
1. Definition/Etiology
2. Common Pathogens
3. Clinical Presentations
4. Labs/Diagnostics
1. 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)
2. - 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-)
3. - 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
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)
4. - 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
** 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)
38
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
39
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
40
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)
41
Common Lung Infections: Viral pneumonia influenza, RSV + S/S
- fever
-cough
- pleurisy
- SOB
- scanty sputum production
- Myalgias
- ↓ breath sounds, rales
42
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
43
Common Lung Infections: Tuberculosis + s/s
- coughing lasting ≥ 3 weeks
- pleuritic chest pain
- hemoptysis
- fatigue
- weight loss
- anorexia
- fever/chills
- night sweats
44
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
45
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)
46
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
47
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!
48
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
49
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
50
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
51
Atypical Pneumonia
1. Definition/Etiology
2. Common Pathogens
3. Clinical Presentation + PE
4. Lab/Diagnostics
5. Treatment
1. infection of lungs by atypical bacteria
- more common in children and young adults
- seasonal outbreaks (summer/fall)
- highly contagious
- AKA "walking pneumonia"
2. - M. pneumoniae
- Chlamydophila pneumonia
- Legionella pneumoniae
- Chlamydia psittaci
3. - 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
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
5. - 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
52
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
53
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
54
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
55
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)
56
Acute Bronchitis
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
5. Complications
1. 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
2. - 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
PE:
- Lungs: ranges from clear to severe wheezing (prolonged expiratory phase), rhonchi
- Percussion: resonant
- CXR: to r/o pneumonia: normal
- Afebrile to low-grade
4. - 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
5. - Asthma exacerbation (↑ risk of status asthmaticus)
- Pneumonia from 2º bacterial infection (pneumococcus, mycoplasma, others)
57
Pertussis
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostics
1. 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
2. ** 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
3. - 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
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Pertussis
4. Treatment/Prevention + monitoring
5. Complications
4. 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
5. - Sinusitis
- otitis media
- penumonia
- fainting
- rib fractures, etc
59
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)
60
Pertussis: Stage 2 (treatment effectiveness)
Paroxysmal coughing
- lasts 2-4 weeks
- treatment has little influence on ds but is useful to prevent ds spread
61
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
62
Pertussis
4. Treatment/Prevention + monitoring
5. Complications
4. 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
5. - Sinusitis
- otitis media
- penumonia
- fainting
- rib fractures, etc
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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
64
Why emphasize importance of adequate fluid intake?
Best mucolytic, thins out mucus
65
What can lung cancer present as?
Recurrent pneumonia d/t mass blocking bronchioles
66
Common cold (Viral Upper Respiratory Infection [URI])
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
5. Complications
1. 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
2. - 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
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
3. Clinical diagnosis
4. ** 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
5. - acute sinusitis
- acute otitis media
67
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?
1. 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
2. - immigrants (from high-prevalence countries)
- migrant farm workers
- illegal drug users
- homeless
- inmates of jails
- nursing homes
- adult living facility residents
- HIV- infected
- immunocompromised
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
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Tuberculosis:
5. Clinical Presentation
6. Treatment Plan
5. - 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)
6. - 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)
- 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
69
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
70
TB: Drug Adverse Effects
1. Isoniazid (INH)
2. Ethambutol (ETH)
3. Pyrazinamide (PZA)
4. Rifampin (RIF)
1. Give w/ pyridoxine (vit B6) to ↓ risk of peripheral neuritis, neuropathy, hepatitis, seizures
2. Optic neuritis, rash; AVOID if pt has eye problems; eye exam at baseline
3. Hepatitis, hyperuricemia, arthralgias, rash
4. Hepatitis; thrombocytopenia; orange-colored tears, saliva, and urine; drug interactions
71
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
72
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
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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
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TB Labs: What is it and result meanings
1. Tuberculosis Skin Test
2. Blood Tests for TB
1. 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)
2. - 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 and T-SPOT are available at public health clinics
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TB Labs: What is it and results
3. Sputum Tests for TB
3. - 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
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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
77
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)
78
Asthma
1. Definition/Etiology
2. Treatment Goals
1. 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
2. - 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
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Asthma
3. Clinical Presentation
4. Objective Findings
5. Trigger Factors
3. - 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
4. - 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
80
Asthma:
6. Treatment plan
- Initial visit vs Nebulizer tx
6. 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)
81
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
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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)
83
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
84
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)
85
Asthma meds: Inhaled corticosteroids
1. Examples
2. Side/Adverse effects
1. - Triamcinolone (Azmacort) BID
- Budesonide (Pulmicort) BID
- Fluticasone (Flovent) BID
2. Oral thrush (gargle or drink water after use)
- use w/ spacer
- HPA axis suppression, glaucoma, others
86
Asthma meds: Long-acting beta2- agonists
1. Examples
2. Side/Adverse effects
1. - Salmeterol (Serevent) BID
- Formoterol (Foradil) BID
2. - 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
87
Asthma meds: Combination of ICS w/ LABA
1. Examples
2. Side/Adverse effects
1. - Salmeterol-fluticasone (Advair HFA, Advair Diskus) BID
- Budesonide-formoterol (Symbicort)
- Mometasone-formoterol (Dulera)
2. 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
88
Asthma meds: Leukotriene receptor antagonists/inhibitors
1. Examples
2. Side/Adverse effects
1. - Montelukast (Singulair) daily
- Zafirlukast (Accolate) BID
- Zileuton (Zyflo) daily
2. - Neuropsychological effects
- agitation
- aggression
- depression
* Monitor LFTs with zileuton
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Asthma meds: Mast cell stabilizers (cromoglycates)
1. Examples
2. Side/Adverse effects
1. - Cromolyn sodium (Intal) QID
- Nedocromil sodium (Tilade) QID
2. - Cromolyn (Intal) and nedocromil (Tilade) inhalers have been DISCONTINUED in US; cromolyn for nebulization still available
90
Asthma meds: Methylxanthines
1. Examples
2. Side/Adverse effects
1. - Theophylline (not used often) daily; starting dose 300 mg/day BID
2. - Sympathomimetic
- Avoid w/ seizures, HTN, stroke
- Severe drug interactions; monitor drug levels
91
Asthma meds: Immunomodulators
1. Examples
2. Side/Adverse effects
1. Omalizumab (xolair)
2. - Anaphylaxis can occur w/ first dose or after long-term use
92
Asthma meds: Anti-immunoglobulin E antibodies
1. Examples
2. Side/Adverse effects
1. Dupilumab (Dupixent)
2. - Be equipped and prepared to tx anaphylaxis when starting this drug
- higher risk of TIA, CVA, MI, emboli
93
Asthma meds: Systemic oral corticosteroids
1. Examples
2. Side/Adverse effects
1. - Prednisone
- Prednisolone
- Methylprednisolone
2. - Short course for 3-4 days
- If used >4 days, requires weaning
- used for exacerbations
94
Asthma Classification (≥ 12 years): GINA 2020 update
1. Intermittent
2. Mild Persistent
3. Moderate Persistent
4. Moderate-to-severe Persistent
1. Step 1: Intermittent
Symptoms: 2x or less/week
Nighttime awakenings: 2x/month
SABA Use: 2x or less/week
FEV1 (% predicted): >80%
Tx: SABA PRN
2. 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
3. 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
4. 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
95
Asthma Stepwise Approach (GINA 2020) Treatment:
Step 1
Step 2
Step 3
Step 4
Step 5
First-line drugs: ICS → treat lung inflammation
1. S/s < 2x/month → Low dose ICS w/ formoterol PRN
Alternative: SABA w/ low-dose ICS
2. S/s >2 x/month but less than daily → Low-dose ICS daily
- OR lose-dose ICS w/ formoterol PRN
3. 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)
4. S/s most days or waking w/ asthma >1x/week (low lung fx)
→ Medium-dose ICS-LABA daily
- Refer for expert advice
5. S/s most days or waking w/ asthma >1x/week (low lung fx)
→ Refer for phenotypic assessment
- Add anti-IgE
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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)
1. Low-dose ICS-formoterol PRN
Alternative: low-dose ICS w/ SABA
2. - Low-dose ICS daily
- OR low-dose ICS-formoterol PRN
3. Low-dose ICS-LABA daily
- OR medium-dose ICS
- OR low-dose ICS + LTRA
4. Medium-dose ICS + LABA daily
- refer for expert advice
5. 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
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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?
1. 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!
2. 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
3. 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)
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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
99
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
100
Asthmatic Exacerbation
1. Clinical presentation
2. Treatment
3. Discharge vs ED referral
1. 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
2. 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)
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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
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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)
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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)
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Chest X-ray Appearance
1. Air
2. Bones
3. Metals
4. Tissue
5. Fluid
6. Tissues visible
1. appears as black color (low density so less absorption) over lung fields
2. Appear as white to gray
3. bright white (high absorption)
4. different grayish shades (medium absorption)
5. grayish to whitish
6. Trachea, bronchus, aorta, heart, lungs, pulmonary arteries, diaphragm, gastric bubble, ribs
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Chest X-ray: Abnormal conditions
1. Emphysema
2. Lobar pneumonia/bacterial pneumonia
3. TB
4. Left ventricular hypertrophy (LVH)/cardiomyopathy
5. Silhouette sign
1. black color in hilum (above clavicles); a lot of black color in hyperinflated lungs, blunted costovertebral angle (CVA; diaphragm flat instead of dome shaped)
2. Grayish to white areas on a lobe or lobes of lung (consolidation) from purulent fluid
3. Upper love w/ cavitation 9black round holes), fibrosis (scarring), and pulmonary infiltrates (fluid) in active TB disease
4. heart occupies >50% of chest diameter; it is enlarged
5. Displacement of normal silhouette in chest film
Ex: displacement of para-aortic line can be caused by aortic aneurysm or dissection/rupture
