Respiratory Flashcards
Criteria for pneumonia admission?
CURB-65: 2
CRB-65- 1
Hypotension requiring vasopressors or Respiratory failure requiring mechanical ventilation = ICU
Outpatient pneumonia treatment?
5 days usually sufficient
- No comorbidities: Amoxicillin, Doxycycline, or Macrolide if resistance <25%
- Comorbidities: Chronic heart, liver, lung, kidney disease, or immunocompromised [ DM, asplenia, alcoholic, malignancy ] or IV AB use in the last 3 months: single agent respiratory quinolone [Levo,Moxi,Gemi] or Beta lactam + macrolide
Beta lactam= Augmentin, cefuroxime, cefpodoxime, Cefdinir
Indication for steriods in pneumonia
CAP related septic shock refractory to fluid resuscitation and vasopressor
Pneumonia vaccine indications?
1- 65 years or older
2- 19-64 with underlying condition
Spirometry interpretation for FEV1/FVC ratio and FEV1?
Obstructive: FEV1/FVC <0.7 or <70%
Use bronchodilator
Post-bronchodilator: increase 12% AND at least 200ml of FEV1 is suggestive for asthma, otherwise it’s COPD
Rule of oral steroid in COPD exacerbation
Short term low dose oral steroid increase time between exacerbation
IV steriod steroid reserved for poor GI absorption or altered mental status
Prevention of Exercise induced asthma?
1- 15 mins before exercise SABA or ICS/formoterol use
2- 15 mins Warm up before exercise
3- if persistent symptoms: Maintenance with daily ICS, daily LTRA montelukast, or Mast-cell stabilizer before exercise
Cystic fibrosis [ a disease of exocrine gland function] treatment
1- ADEK vitamins supplements
2- Pancreatic enzyme replacement
3- Long term Hypertonic saline use for patients 6 years or older
For acute exacerbation:
1- bronchodilator
2- deoxyribonuclease
3- antibiotic with anti pseudomonas coverage
4- chest physical therapy
Anti-igE [ Omalizumab ] criteria in asthma?
Match all of the following:
1- Allergic asthma as determined by positive skin test or RAST test
2- ig-E within therapeutic tange
3- Age 6 years or older
4- Severe persistent symptoms [ step 4 ] not controlled by other means ( high ICS and LABA ]
Cough variant asthma treatment
ICS
Aspirin-exacerbated respiratory disease
1- Samster Triad: asthma + chronic rhinosinusitis with nasal polyposis + Aspirin allergy
2- minutes to 2hr > develop asthma attack + rhinorrhea and nasal congestion + conjunctival irritation + scarlet flush of head and neck
3- prevention: avoid COX-1I , when NSAIDs use, use selective COX-2 inhibitor: Meloxicam, Celecoxib
Asthma treatment in pregnancy
1- all are safe
2- the greatest safety profile among SABA is Albuterol
3- Try to avoid prolonged use of systemic steroids in the first trimester
4- one third may have worsening of their asthma control
Asthma in children
1- chronic use of ICS more than 3 months in prepubertal aged children can suppress growth velocity
3- monitor for Neuropsychiatric symptoms if u start montelukast [ sleep disturbance, anxiety, aggressiveness, irritability ]
4- Nebulizer not superior to MDI in both acute and chronic management of asthma in children
When to suspect A1 antitrypsin deficiency in patients with COPD and do screening
1- Caucasian
2- under age of 45
3- strong family history of COPD
Indications for home oxygen therapy in COPD
Measure with pulse oximetry ( breathing room air at least 30 mins )
Severe resting hypoxemia :
1- Po2 55mmHg or less, SaO2 88% or less
2- 56-59 or 89 PLUS one : Hematocrit >=55%, cor pulmonale signs, or pulmonary hypertension
Use at least 15hrs a day, with range 88-92%
Infectious mononucleosis organism and complications
EBV (kissing disease)
Acute hepatitis 75% but usually mild and subclinical
Splenomegaly
Bronchiolitis indications to admission
1- RR >70
2- toxic appearance
3- Poor feeding
4- Lethargy
5- SaO2 <95%
Red flags for acute pharyngitis
1- Muffled voice
2- Drooling and Stridor
3- Trismus and crepitus
4- history of penetrating trauma (fishstick)
5- bulging pharygneal wall
6- Tripoid positing
7- Hypoxemia
Rule of Abx on GAS pharyngitis complications ( GN, and ARF )
Prevent Rheumatic fever, but NOT GN
Spontanous vs Tension pneumothorax and TRACHEA
- Shifted to same side in Spontanous
- Shifted to the opposite site in Tension
Tension pneumothorax needle decompression site?
1- Adult: 4th or 5th ics anterior to midaxillary line
2- pedia: 2nd intercostal space midclavicular line
Pleural effusion
Transudate and Exudate
Transudate:
Pleural:serum protein: 0.5 or less
Pleural:serum LDH: 0.6 or less
Pleural fluid LDH: <2/3 upper limit of normal serum LDH
Causes: heart failure, cirrhosis, nephrotic, pulmonary embolism, hypothyroidism, Amylodosis
PE and DVT (VTE)
Treatment:
Hemodynamic unstable or right ventricular compromise:
- Thrombolysis
Stable with no contraindications:
- LMWH
- DOAC
Stable with contraindications:
IVC filter
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DOAC is the preferred due to compliance, and it is not-inferior to LMWH in trials. Some trials also showed lower risk of VTE in the DOACs group
Factors when LMWH is considered over DOACs
1- concerns about drug interactions with DOACs
2- patient preference
3- GI malignancy ( LMWH or Apixaban ); both associated with lower risk of GI bleeding than rivaroxiban or edoxiban
4- Gastritis or enteritis “poor absorption; DOACs abosrbed in the stomach and proximal small bowel”
Duration:
1st episode: 3 months
Recurrence: 6 months
Provoked (strong VTE risk factor such as bedridden, malignancy): indefinite;
Factors to choose to stop: bleeding complications, patient quality-of-life reasons
