Respiratory

Question 1

COVID-19: Overview

Answer 1

• 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

Question 2

Lung Cancer: Overview

Answer 2

• 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)

Question 3

Horner syndrome

Answer 3

pupil construction w/ ptosis

Question 4

Acute Carbon Monoxide Poisoning: Overview

Answer 4

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

Question 5

Pulmonary Emboli: Overview

Answer 5

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

Question 6

Impending Respiratory Failure (Asthmatic Exacerbation: Overview

Answer 6

• 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)

Question 7

Normal Findings: Breath sounds
1. Lower lobes
2. Upper lobes

Answer 7

1. Vesicular breath sounds (soft and low)
2. Bronchial breath sounds (louder)

Question 8

Normal Findings: Respiratory Rate

Answer 8

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

Question 9

Definition: Tachypnea

Answer 9

• ↑ RR
• Many causes including ↑ O2 demand, hypoxia, and ↑ PaCO2

Many conditions can cause tachypnea:
- pain
- fear
- fever
- physical exertion
- asthma
- pneumonia
- PE
- hyperthyroidism

Question 10

Normal Findings: Egophony

Answer 10

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

Question 11

Normal Findings: Tactile Fremitus

Answer 11

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

Question 12

Normal Findings: Whispered Pectoriloquy

Answer 12

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

Question 13

Normal Findings: Percussion
- Normal
- Tympany or hyperresonance
- Dull

Answer 13

• 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

Question 14

Normal Findings: Pulmonary Function Testing - Definition

Answer 14

GOLD STANDARD for asthma and COPD (pre- and post- bronchodilator)
- Measures obstructive vs restrictive dysfunction

Question 15

Normal Findings: Pulmonary Function Testing - Forced Expiratory Volume in 1 second (FEV1)

Answer 15

Amount of air that a person can forcefully exhale in 1 second

Question 16

Normal Findings: Pulmonary Function Testing - Forced Vital Capacity (FVC)

Answer 16

Total amount of air that can be exhaled during FEV1 test

Question 17

Normal Findings: Pulmonary Function Testing - FEV1/FVC ratio

Answer 17

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

Question 18

Normal Findings: Pulmonary Function Testing - Obstructive dysfunction

Answer 18

Reduction in airflow rates
Ex: Asthma, COPD (chronic bronchitis and emphysema), bronchiectasis

Question 19

Normal Findings: Pulmonary Function Testing - Restrictive dysfunction

Answer 19

Reduction of lung volume d/t ↓ lung compliance
Ex: Pulmonary fibrosis, pleural disease, diaphragm obstruction

Question 20

Chronic Obstructive Pulmonary Disease (COPD)
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
5. Treatment Considerations

Answer 20

1. 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
2. • 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

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

3. • Post-bronchodilator FEV1/FVC <0.7 (lung function <70%) = cutoff for diagnosing COPD
4. Depends on classification (see notecard)
5. ** 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+)

Question 21

COPD: Treatment (based on classification)

Answer 21

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!

Question 22

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?

Answer 22

1. SABAs (short-acting beta2-agonists) recommended for all COPD pts, used for intermittent ↑ in dyspnea PRN
2. 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

Question 23

COPD: General Treatment (nonpharmacologicals)

Answer 23

• 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

Question 24

COPD: Management of Stable COPD (goals of treatment)

Answer 24

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

Question 25

COPYD: Management of Exacerbations and Referral

Answer 25

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

Question 26

COPD: Treatment - Bronchodilators Types & Examples
* Safety issues

Answer 26

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

Question 27

COPD: Treatment - Corticosteroids and phosphodiesterase-4 inhibitors

Answer 27

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)

Question 28

COPD: Treatment - Oxygen therapy

Answer 28

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

Question 29

COPD: Air Travel

Answer 29

Some pt w/ COPD can become hypoxemic during air travel; supplemental O2 may be needed

Question 30

COPD: Supplementation w/ antioxidants

Answer 30

Vitamins C, E, zinc, and selenium shown to improve muscle strength among COPD pts

Question 31

COPD: “Blue bloater”

Answer 31

pt w/ chronic bronchitis w/ bluish tinge to skin (d/t chronic hypoxia and hypercapnia)

Question 32

COPD: “Pink puffer”

Answer 32

pt w/ emphysema w/ pink skin color (adequate oxygen saturation, thin, and tachypneic + accessory muscles to breath + pursed-lip breathing

Question 33

COPD: Risk Factors

Answer 33

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

Question 34

COPD: Chronic Bronchitis

Answer 34

coughing w/ excessive mucus production for at least ≥3 months for a minimum of ≥ 2 consecutive years
- airway hypersecretion and inflammation

Question 35

COPD: Emphysema

Answer 35

Irreversible enlargement and alveolar damage w/ loss of recoil → chronic hyperinflation of lungs
- Expiratory respiratory phase is markedly prolonged

Question 36

COPD: Asthma

Answer 36

Airway inflammation → hyperreactivity
- contribution of each disease (chronic bronchitis, emphysema, and asthma) varies in each individual

Question 37

Common Lung Infections: Community-Acquired Pneumonia in Adults
1. Definition/Etiology
2. Common Pathogens
3. Clinical Presentations
4. Labs/Diagnostics

Answer 37

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)

Question 38

Top two bacteria in CAP?
Top two bacterial in atypical pneumonia:

Answer 38

• 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

Question 39

Common Lung Infections: No 1 - Streptococcus pneumoniae + S/S

Answer 39

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

Question 40

Common Lung Infections: Atypical pneumonia + S/S
- What is the number 1 pathogen?

Answer 40

Mycoplasma pneumoniae
- CXR → lobar infiltrates; interstitial to patchy infiltrates
- gradual onset
- low-grade fever
- headache
- sore throat
- cough
- wheezing
- rash (sometimes)

Question 41

Common Lung Infections: Viral pneumonia influenza, RSV + S/S

Answer 41

• fever
  -cough
• pleurisy
• SOB
• scanty sputum production
• Myalgias
• ↓ breath sounds, rales

Question 42

Common Lung Infections: Acute bronchitis + s/s + general tx

Answer 42

• paroxysms of dry and sever cough, interrupts sleep
• cough: dry to productive, light-colored sputum; can lasts 4-6 wks
• no antibiotics!! Treat sx

Question 43

Common Lung Infections: Tuberculosis + s/s

Answer 43

• coughing lasting ≥ 3 weeks
• pleuritic chest pain
• hemoptysis
• fatigue
• weight loss
• anorexia
• fever/chills
• night sweats

Question 44

Common Lung Infections: Pertussis + s/s

Answer 44

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

Question 45

CAP: Treatment Plan for no comorbidity

Answer 45

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)

Question 46

CAP: Treatment Plan if WITH comorbidities

Answer 46

(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

Question 47

CAP: Treatment Plan if poor prognosis

Answer 47

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!

Question 48

CURB-65

Answer 48

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

Question 49

CAP: Prevention

Answer 49

• 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

Question 50

CAP: Prevention: PCV13 & PPSV23 in adults

Answer 50

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

Question 51

Atypical Pneumonia
1. Definition/Etiology
2. Common Pathogens
3. Clinical Presentation + PE
4. Lab/Diagnostics
5. Treatment

Answer 51

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

Question 52

Atypical Pneumonia: M. pneumoniae
- complications
- gold standard

Answer 52

Nonpulmonary complications can occur:
- hemolytic anemia
- meningo-encephalitis
- urcticaria

Gold standard for diagnosis: polymerase chain reaction (PCR) of sputum or oropharyngeal swab

Question 53

Atypical Pneumonia: Chlamydophila pneumoniae
- more common in who?
- most common s/s/clinical presentation?

Answer 53

• More common in school-age children
• usually develops into bronchitis or mild pneumonia

Question 54

Atypical Pneumonia: Legionella pneumoniae
- Found where?
- what type of pneumonia does this bacteria case? morality rate?
- Risk factors?

Answer 54

• 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

Question 55

Atypical Pneumonia: Chlamydia psittaci
- where does this infection usually come from?

Answer 55

Not as common
- a zoonotic infection from infected pet birds (e.g., parrots, parakeets), and poultry (e.g., turkeys, ducks)

Question 56

Acute Bronchitis
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
5. Complications

Answer 56

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)

Question 57

Pertussis
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostics

Answer 57

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

Question 58

Pertussis
4. Treatment/Prevention + monitoring
5. Complications

Answer 58

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

Question 59

Pertussis: Stage 1 (treatment effectiveness)

Answer 59

Catarrhal state
- lasts 1-2 weeks
- If treated in this stage, can shorten ds course (treat within 3 weeks of onset)

Question 60

Pertussis: Stage 2 (treatment effectiveness)

Answer 60

Paroxysmal coughing
- lasts 2-4 weeks
- treatment has little influence on ds but is useful to prevent ds spread

Question 61

Pertussis: Stage 3 (treatment effectiveness)

Answer 61

Convalescent state (lasts 1-2 weeks)
- Treatment goal is to eradicate carriage state/ds spread
- antibiotic will not shorten illness at this stage

Question 62

Pertussis
4. Treatment/Prevention + monitoring
5. Complications

Answer 62

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

Question 63

Differential Diagnoses for Cough

Answer 63

► 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

Question 64

Why emphasize importance of adequate fluid intake?

Answer 64

Best mucolytic, thins out mucus

Question 65

What can lung cancer present as?

Answer 65

Recurrent pneumonia d/t mass blocking bronchioles

Question 66

Common cold (Viral Upper Respiratory Infection [URI])
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
5. Complications

Answer 66

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

Question 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?

Answer 67

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

Question 68

Tuberculosis:
5. Clinical Presentation
6. Treatment Plan

Answer 68

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

Question 69

TB: Directly observed Treatment

Answer 69

• 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

Question 70

TB: Drug Adverse Effects
1. Isoniazid (INH)
2. Ethambutol (ETH)
3. Pyrazinamide (PZA)
4. Rifampin (RIF)

Answer 70

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

Question 71

Recent Mantoux Test (Purified Protein Derivative [PPD]) Converters
- Definition
- Why need treatment?

Answer 71

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

Question 72

Recent Mantoux Test PPD Converters
- Treatment
- Assessment, labs/imaging
- Short course vs long course

Answer 72

• 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

Question 73

TB skin test (Mantoux Test)
- How to read results
- Special population considerations

Answer 73

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

Question 74

TB Labs: What is it and result meanings
1. Tuberculosis Skin Test
2. Blood Tests for TB

Answer 74

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

Question 75

TB Labs: What is it and results
3. Sputum Tests for TB

Answer 75

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

Question 76

TB: Booster Phenomenon

Answer 76

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

Question 77

Which population is at a very high risk for active TB after initial exposure (primary TB)?

Answer 77

Persons w/ HIV infection w/ CD4 <500 or pts who are taking tumor necrosis factor antagonists (or biologics)

Question 78

Asthma
1. Definition/Etiology
2. Treatment Goals

Answer 78

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

Question 79

Asthma
3. Clinical Presentation
4. Objective Findings
5. Trigger Factors

Answer 79

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

Question 80

Asthma:
6. Treatment plan
- Initial visit vs Nebulizer tx

Answer 80

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)

Question 81

Asthma Medications: “Rescue” or “Reliever” Meds

Answer 81

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

Question 82

Asthma Medications: Long-Term Control meds

Answer 82

LABAs (used alone) ↑ risk of death from asthma. Combination of LABA and ICS is safer!

Ex: - Fluticasone x/ salmeterol (Advair)
- Budesonide w/ formoterol (Symbicort)

Question 83

Asthma Medications: Sustained-Release Theophylline (Theo-24)

Answer 83

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

Question 84

Asthma: Spacers or Chambers

Answer 84

Space or chamber (Aerochamber) use is encouraged; will ↑ delivery of aerosolized drug to lungs and minimize oral thrust (for inhaled steroids)

Question 85

Asthma meds: Inhaled corticosteroids
1. Examples
2. Side/Adverse effects

Answer 85

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

Question 86

Asthma meds: Long-acting beta2- agonists
1. Examples
2. Side/Adverse effects

Answer 86

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

Question 87

Asthma meds: Combination of ICS w/ LABA
1. Examples
2. Side/Adverse effects

Answer 87

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

Question 88

Asthma meds: Leukotriene receptor antagonists/inhibitors
1. Examples
2. Side/Adverse effects

Answer 88

1. • Montelukast (Singulair) daily
     - Zafirlukast (Accolate) BID
     - Zileuton (Zyflo) daily
2. • Neuropsychological effects
     - agitation
     - aggression
     - depression

• Monitor LFTs with zileuton

Question 89

Asthma meds: Mast cell stabilizers (cromoglycates)
1. Examples
2. Side/Adverse effects

Answer 89

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

Question 90

Asthma meds: Methylxanthines
1. Examples
2. Side/Adverse effects

Answer 90

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

Question 91

Asthma meds: Immunomodulators
1. Examples
2. Side/Adverse effects

Answer 91

1. Omalizumab (xolair)
2. • Anaphylaxis can occur w/ first dose or after long-term use

Question 92

Asthma meds: Anti-immunoglobulin E antibodies
1. Examples
2. Side/Adverse effects

Answer 92

1. Dupilumab (Dupixent)
2. • Be equipped and prepared to tx anaphylaxis when starting this drug
     - higher risk of TIA, CVA, MI, emboli

Question 93

Asthma meds: Systemic oral corticosteroids
1. Examples
2. Side/Adverse effects

Answer 93

1. • Prednisone
     - Prednisolone
     - Methylprednisolone
2. • Short course for 3-4 days
     - If used >4 days, requires weaning
     - used for exacerbations

Question 94

Asthma Classification (≥ 12 years): GINA 2020 update
1. Intermittent
2. Mild Persistent
3. Moderate Persistent
4. Moderate-to-severe Persistent

Answer 94

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

Question 95

Asthma Stepwise Approach (GINA 2020) Treatment:
Step 1
Step 2
Step 3
Step 4
Step 5

Answer 95

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

Question 96

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)

Answer 96

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

Question 97

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?

Answer 97

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)

Question 98

Asthma: Patient Education

Answer 98

• 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

Question 99

Asthma: Exercise-Induced Bronchoconstriction (Exercise-Induced Asthma)

Answer 99

• 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

Question 100

Asthmatic Exacerbation
1. Clinical presentation
2. Treatment
3. Discharge vs ED referral

Answer 100

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)

Question 101

Asthma: Peak Expiratory Flow Rate

Answer 101

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

Question 102

Asthma: Spirometer Parameters (Zones)

Answer 102

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)

Question 103

Chest X-ray Interpretation: Definition and general concepts

Answer 103

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)

Question 104

Chest X-ray Appearance
1. Air
2. Bones
3. Metals
4. Tissue
5. Fluid
6. Tissues visible

Answer 104

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

Question 105

Chest X-ray: Abnormal conditions
1. Emphysema
2. Lobar pneumonia/bacterial pneumonia
3. TB
4. Left ventricular hypertrophy (LVH)/cardiomyopathy
5. Silhouette sign

Answer 105

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