Respiratory Flashcards
COVID-19
Pathogen: SARS-CoV-2 virus
S&S: can occur 2-14 days after exposure
FEver, chills, HA, myalgia, N/V
Can loose taste or smell
Worse if prior respiratory dz
Lung cancer
Screening: Low dose CT if age 55-80 and former smoker
S&S: Cough, hemoptysis, dyspnea, fatigue, weight los, anorexia, fever. Dull, achy chest pain
Signs to look for:
Persistent cough in smoker or former smoker
Recurrent pneumonia (may be tumur in that lung)
Horner syndrome (pupil constriction with ptosis)
NSCLC most common
Carbon monoxide poisoning
S&S: most common, headache
nausea, malaise, and dizziness
Can be like viral URI
Mild confusion to coma
Dx: elevated carboxyhemoglobin level from cooximetry of an arterial blood gas
Pulmonary emboli
Clot in lung
Risk factors: any condition that increases clotting (AF, estrogen, smoking)
S&S: Sudden onset of dyspnea and coughing. Productive of pink-tinged frothy sputum. Tachycardia, pallor, and feelings of impending doom.
Impending respiratory failure (Asthmatic exacerbation)
S&S: tachypnea (>20 breaths/min), tachycardia or bradycardia, cyanosis, and anxiety. uses accessory muscles to help with breathing. “quiet” lungs with no wheezing or breath sounds audible. Trouble talking
Tx: Adrenaline injection stat. Call 911. Oxygen at 4 to 5 L/min; albuterol nebulizer treatments; parenteral steroids, antihistamines (diphenhydramine), and H2 antagonist (cimetidine).
Breath sounds
Lower lobes: Vesicular breath sounds (soft and low)
Upper lobes: Bronchial breath sounds (louder)
Normal respiratory rate
14-18
Small increase in CO2 will increase RR
High levels of CO2 will depress RR
Causes of tachypnea
Increased oxygen demand, hypoxia, and increased PaCO2.
Pain, fear, fever, physical exertion, asthma, pneumonia, PE, and hyperthyroidism.
Egophony
Normal: Will hear “eee” clearly instead of “bah.” The “eee” sound is louder over the large bronchi because larger airways are better at transmitting sounds; lower lobes have a softer-sounding “eee.”
Abnormal: Will hear “bah” sound.
Tactile Fremitus
Instruct patient to say “99” or “one, two, three”; use finger pads to palpate lungs and feel for vibrations going down back
Normal: Stronger vibrations are palpable on the upper lobes and softer vibrations on lower lobes.
Abnormal: The findings are reversed; may palpate stronger vibrations on one lower lobe (i.e., consolidation); asymmetric findings are always abnormal.
Whispered Pectoriloquy
Instruct patient to whisper “one, two, three.” Compare both lungs. If there is lung consolidation, the whispered words are easily heard on the lower lobes of the lungs.
Normal: Voice louder and easy to understand in the upper lobes. Voice sounds are muffled on the lower lobes.
Abnormal: Clear voice sounds in the lower lobes or muffled sounds on the upper lobes.
Percussion
Normal: Resonance is heard over normal lung tissue.
Tympany or hyperresonance: Occurs with chronic obstructive pulmonary disease (COPD), emphysema (overinflating). If empty, the stomach area may be tympanic.
Dull tone: Bacterial pneumonia with lobar consolidation, pleural effusion (fluid or tumor). A solid organ, such as the liver, sounds dull.
Pulmonary Function Testing
Gold standard for asthma and COPD
Forced expiratory volume in 1 second (FEV1): Amount of air that a person can forcefully exhale in 1 second.
Forced vital capacity (FVC): Total amount of air that can be exhaled during the FEV1 test.
FEV1/FVC ratio: Proportion of a person’s vital capacity that the person is able to expire in 1 second. Normal values are ≥75%. Post-bronchodilator FEV1/FVC <0.7 (lung function <70%) is the cutoff score for COPD
COPD Presentation
S&S: Chronic and progressive dyspnea
FEV1/FVC <0.7 - cut off
Typically caused by smoking
Can be mixture of chronic bronchitis & emphysema
Can be asthma–COPD overlap syndrome (ACOS).
Barrel chested - increase AP lateral
Percussion: Hyperresonance
Tactile fremitus and egophony: Decreased
Chest x-ray (CXR): Flattened diaphragms with hyperinflation; bullae sometimes present
Chronic bronchitis
Coughing with excessive mucus production for at least 3 or more months for a minimum of 2 or more consecutive years. May have expiratory wheezing, rhonchi, and coarse crackles.
“blue bloater” - bluish tinge to their skin (due to chronic hypoxia and hypercapnia
Emphysema
Irreversible enlargement and alveolar damage with loss of elastic recoil result in chronic hyperinflation of the lungs. Expiratory respiratory phase is markedly prolonged.
“pink puffer” - pink skin color (adequate oxygen saturation), thin, and tachypneic and uses accessory muscles to breath and pursed-lip breathing.
COPD treatment
GOLD Guidelines
Group A
Minimally symptomatic COPD (low risk of exacerbations)
SABA alone or in combination with 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 (but high risk of future exacerbations)
LAMA is first line; SABA for symptom relief PRN
Group D
More symptomatic (high risk of future exacerbations)
High risk; refer to pulmonologist
SABAs: Albuterol, levalbuterol (Xopenex), pirbuterol (Maxair)
Long-acting beta-agonists (LABAs): Salmeterol, formoterol, vilanterol
Short-acting anticholinergics or 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 plus LABA formulations.
primary care for COPD
Smoking cessation
Annual influenza vaccination; give pneumococcal vaccine (PPSV23 [Pneumovax]) and PCV13 [Prevnar]); administer 12 months apart.
Pulmonary hygiene (e.g., postural drainage) or pulmonary rehabilitation
Treat lung infections aggressively.
SABAs are contraindicated for who?
(albuterol, levalbuterol, or metaproterenol)
May cause adverse cardiac side effects (palpitations, tachycardia). Use with caution if patient has hypertension, angina, and/or hyperthyroidism. Avoid combining with caffeinated drinks.
Anticholinergics Contraindications
(ipratropium [Atrovent], tiotropium [Spiriva]):
Avoid if patient has narrow-angle glaucoma, benign prostatic hyperplasia (BPH), or bladder neck obstruction.
COPD exacerbations
Most common cause, respiratory infections
suspect secondary bacterial infection if acute onset of fever, purulent sputum, increased wheezing, and dyspnea.
If increased dyspnea, increased sputum/viscosity, increased sputum purulence) -> hospitalizaion
SABAs are mainstay therapy
First-line treatment for mild COPD (group A)
Either a SABA or a short-acting anticholinergic (or SAMA). If poor relief on single agent, add a second agent. If on SABA, add short-acting anticholinergic (Atrovent).
If short-acting bronchodilators are not controlling symptoms, next step is to start patient on a long-acting bronchodilator (LAMA or LABA) based on patient preference. Continue using SABA as needed
Community-Acquired Pneumonia
The bacteria causing the most deaths in outpatients is S. pneumoniae (gram positive). It is the most common cause of focal infiltrate on a CXR (lobar pneumonia).
S&S: sudden high fever, chills, anorexia, and fatigue. Productive cough with sputum. Sharp stabbing chest pain (pleuritic chest pain) with coughing and dyspnea
Dx: CXR gold standard, repeat within 6 weeks to show clearing
tx: First-line agents (amoxicillin or doxycycline
Alternative macrolide (azithromycin or clarithromycin)
IF comorbidity or high rates of resistance: Combination therapy (beta-lactam plus macrolide or doxycycline): Amoxicillin–clavulanate + Azithromycin
Poor prognosis (refer for hospitalization):
Elderly: Age 60 years or older, acute mental status changes, CHF
Multiple lobar involvement
Acute mental status change
Alcoholics (aspiration pneumonia)
Patient meets the “CURB-65” criterion for hospital admission
C (confusion)
U (blood urea nitrogen >19.6 mg/dL)
R (respiration >30 breaths/min)
B (blood pressure <90/60 mmHg)
Age 65 years or older
Pneumococcal Vaccines
PCV13 (pneumococcal conjugate vaccine: Prevnar 13) recommended for all children <2 years or >2 years with certain medical conditions. Adults aged ≥65 years can use the vaccine (discuss and decide with their clinician). Space at least 1 year apart from PPSV23.
PPSV23 (pneumococcal polysaccharide vaccine: Pneumovax 23, Pnu-Imune 23) recommended. Give first if over 65.
If PPSV23 administered prior to age 65, administer another dose of PPSV23 at least 5 years apart. If after 65, usually good for lifetime.
Atypical Pneumonia
Seasonal outbreaks (summer/fall). Highly contagious. Also known as walking pneumonia.
M. pneumoniae: Nonpulmonary complications may occur (e.g., hemolytic anemia, meningo-encephalitis, urcticaria). Gold standard for diagnosis is polymerase chain reaction (PCR) of sputum or oropharyngeal swab
Chlamydophila pneumoniae: More common in school-age children;
Legionella pneumoniae: Causes a severe type of pneumonia called Legionnaires’ disease.
S&S: several weeks of fatigue, accompanied by coughing that is mostly nonproductive. Gradual onset of symptoms. History of a cold before onset of bronchitis.
Tx:
Azithromycin (Z-Pack) × 5 days
Levofloxacin (Levaquin) 750 mg PO × 5 to 7 days
Acute Bronchitis
Usually self-limited, may last 1-3 weeks
Cause: viral and sometimes bacterial
S&S: Cough that is keeping him awake at night. wheezing and rhonchi (clears with coughing). May report history of a cold before onset of bronchitis symptoms.
Tx:
Symptom management
Dextromethorphan, tessalon perles
Guaifenesin
Albuterol for wheezing
Pertussis
Whooping cough
Caused by Bordetella pertussis bacteria (gram negative)
Coughing at least 14 days’ w/: paroxysmal coughing OR inspiratory whooping (or posttussive vomiting) without apparent cause. Apnea is more common in infants.
First stage: Catarrhal stage (lasts 1–2 weeks). If treated at this stage, can shorten disease course (if treated within 3 weeks of onset).
Second stage: Paroxysmal coughing (lasts 2–4 weeks). Treatment has little influence on disease but is useful to prevent disease spread.
Third stage: Convalescent stage (lasts 1–2 weeks). Treatment goal is to eradicate carriage state/disease spread. Antibiotic will not shorten illness at this stage.
Dx: nasal swab, PCR or ELISA
Tx:
First-line: Macrolides - Azithromycin (Z-Pack), Erythromycin, Clarithromycin
Macrolides given to infants <1 month of age: Monitor for infantile hyperpyloric stenosis (IHPS)
Treat close contacts within 3 weeks exposure
Common Cold (Viral Upper Respiratory Infection)
Self-limiting infection (range of 4–10 days). Most contagious from days 2 to 3
Nasal turbinates: Swollen with clear mucus
Treat symptoms;
Tuberculosis
Caused by Mycobacterium tuberculosis
Most common site of infection is the lungs
Reportable disease
S&S: Fever, anorexia, fatigue and night sweats w/ cough
Later sign: blood-stained sputum
Very late sign: Weight loss
If active TB - test for HIV
Dx: Mantoux test
Quantiferon gold
Sputum C&S gold standard, NAAT, AFB
CTX
Tx: Never treat with fewer than 3 drugs: isoniazid (INH), rifampin (RIF), ethambutol (ETH), pyrazinamide (PZA)
Treatment duration is 6-9 months
MDR TB - refer to a specialist
TB Types
Latent TB - granulomas found, not infectious
Miliary TB - aka disseminated TB disease. Infects multiple organs
Multidrug-resistant TB - resistant to at least two of the best drugs
Reactivated TB infection - Latent TB becomes reactivated
BCG vaccine - can cause false positives on skin tests
TB drug side effects
Isoniazid (INH): Give with pyridoxine (vitamin B6) to decrease risk of peripheral neuritis, neuropathy, hepatitis, seizures.
Ethambutol (ETH): Optic neuritis, rash. Avoid if patient has eye problems. Eye exam at baseline.
Pyrazinamide (PZA): Hepatitis, hyperuricemia, arthralgias, rash
Rifampin (RIF): Hepatitis; thrombocytopenia; orange-colored tears, saliva, and urine; drug interactions
Treatment of LTBI
Once-weekly isoniazid plus rifapentine × 3 months
Daily rifampin × 4 months (preferred for HIV-negative adults/children)
Daily isoniazid plus rifampin × 3 months
preventive treatment for LTBI is encouraged for those <35 years of age. After 35 years of age, much higher risk of liver damage from INH chemoprophylaxis.
Mantoux test
Inject 0.1 mL of 5TU-PPD subdermally.
Looking for induration, not redness
Positive if:
≥5 mm:
HIV-infected persons
Recent contact with infectious TB cases
CXR with fibrotic changes consistent with previous TB disease (cavitations on the upper lobes)
Immunocompromised
≥10 mm:
Recent immigrants (past 5 years) from high-prevalence countries (Latin America, Asia [except Japan], Africa, India, Pacific islands)
Child <4 years of age or children/adolescents exposed to high-risk adult
Injection drug user, healthcare worker, homeless
Employees or residents from high-risk congregate settings (jails, nursing homes)
≥15 mm:
Persons with no known risk factors for TB
Asthma
Chronic Airway inflammation
S&S: SOB, wheezing, chest tightness. Cough that wakes from sleep. Respiratory symptoms can have an internal or external trigger (URI, dust, smoke, exercise, stress).
Exacerbations can be life threatening
Tx: Assess asthma control
Every patient needs PRN SABA - rescue inhaler (albuterol or levalbuterol)
NExt add low-dose ICS
Next use LABA + ICS (Fluticasone with salmeterol (Advair), budesonide with formoterol (Symbicort))
May need short course of steroids for exacerbation
Asthma treatment
Stepwise:
Step 1
Symptoms less than two times a month
Low-dose ICS with formoterol PRN (alternative is SABA with low-dose ICS)
Step 2
Symptoms two times a month or more, but less than daily
Low-dose ICS daily or low-dose ICS with formoterol PRN
Step 3
Symptoms most days, or waking with asthma once a week or more
Low-dose ICS–LABA daily or medium-dose ICS or low-dose ICS + leukotriene receptor antagonist (LTRA)
Step 4
Symptoms most days, or waking with asthma once a week or more (low lung function)
Medium-dose ICS–LABA daily; refer for expert advice
Step 5
Symptoms most days, or waking with asthma once a week or more (low lung function)
Refer for phenotypic assessment; add anti-IgE
Exercise induced Asthma
Premedicate 5 to 20 minutes before exercise with two puffs of a SABA (albuterol [Ventolin], levalbuterol [Xopenex], pirbuterol [Maxair]). Effect will last up to 4 hours.
Asthma exacerbation treatment
Give nebulizer treatment: Albuterol 0.5% solution by nebulizer every 20 to 30 minutes up to three doses. If unable to use inhaled bronchodilators, give epinephrine 1:1,000 solution intramuscularly (IM).
After nebulizer treatment(s): Listen for breath sounds. If inspiratory and expiratory wheezing is present, this is a good sign (signals opening up of airways). If there is a lack of breath sounds or wheezing after a nebulizer treatment, this is a bad sign (patient is not responding). Call 911.
Discharge: For moderate-to-severe exacerbations, Medrol Dose Pack or prednisone tabs 40 mg/day × 4 days (no weaning necessary if 4 days or less and not steroid dependent). Continue medications and increase dose (or add another controller drug).
PEF
Blow hard three times, highest one is recorded
Need height, age, gender; use HAG mnemonic
