Respiratory

Question 1

COVID-19

Answer 1

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

Question 2

Lung cancer

Answer 2

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

Question 3

Carbon monoxide poisoning

Answer 3

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

Question 4

Pulmonary emboli

Answer 4

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.

Question 5

Impending respiratory failure (Asthmatic exacerbation)

Answer 5

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).

Question 6

Breath sounds

Answer 6

Lower lobes: Vesicular breath sounds (soft and low)
Upper lobes: Bronchial breath sounds (louder)

Question 7

Normal respiratory rate

Answer 7

14-18
Small increase in CO2 will increase RR
High levels of CO2 will depress RR

Question 8

Causes of tachypnea

Answer 8

Increased oxygen demand, hypoxia, and increased PaCO2.
Pain, fear, fever, physical exertion, asthma, pneumonia, PE, and hyperthyroidism.

Question 9

Egophony

Answer 9

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.

Question 10

Tactile Fremitus

Answer 10

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.

Question 11

Whispered Pectoriloquy

Answer 11

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.

Question 12

Percussion

Answer 12

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.

Question 13

Pulmonary Function Testing

Answer 13

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

Question 14

COPD Presentation

Answer 14

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

Question 15

Chronic bronchitis

Answer 15

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

Question 16

Emphysema

Answer 16

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.

Question 17

COPD treatment

Answer 17

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.

Question 18

primary care for COPD

Answer 18

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.

Question 19

SABAs are contraindicated for who?

Answer 19

(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.

Question 20

Anticholinergics Contraindications

Answer 20

(ipratropium [Atrovent], tiotropium [Spiriva]):

Avoid if patient has narrow-angle glaucoma, benign prostatic hyperplasia (BPH), or bladder neck obstruction.

Question 21

COPD exacerbations

Answer 21

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

Question 22

First-line treatment for mild COPD (group A)

Answer 22

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

Question 23

Community-Acquired Pneumonia

Answer 23

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

Question 24

Pneumococcal Vaccines

Answer 24

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.

Question 25

Atypical Pneumonia

Answer 25

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

Question 26

Acute Bronchitis

Answer 26

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

Question 27

Pertussis

Answer 27

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

Question 28

Common Cold (Viral Upper Respiratory Infection)

Answer 28

Self-limiting infection (range of 4–10 days). Most contagious from days 2 to 3

Nasal turbinates: Swollen with clear mucus

Treat symptoms;

Question 29

Tuberculosis

Answer 29

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

Question 30

TB Types

Answer 30

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

Question 31

TB drug side effects

Answer 31

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

Question 32

Treatment of LTBI

Answer 32

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.

Question 33

Mantoux test

Answer 33

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

Question 34

Asthma

Answer 34

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

Question 35

Asthma treatment

Answer 35

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

Question 36

Exercise induced Asthma

Answer 36

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.

Question 37

Asthma exacerbation treatment

Answer 37

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).

Question 38

PEF

Answer 38

Blow hard three times, highest one is recorded
Need height, age, gender; use HAG mnemonic