Respiratory Flashcards
Cough
Lots of causes- drugs, cold, PNA, allergies, COPD, asthma, GERD, CHF, tumor, TB, ILD, psychogenic
Red flags- hemoptysis, smoker greater than 45 yrs with new cough, change in cough, voice disturbances, adult 55-80 with 30 PPD hx who currently smoke or have quit in the last 15 years, prominent dyspnea especially at rest or at night, hoarseness, fever, weight loss, peripheral edema with weight gain, troubling swallowing, vomiting, recurrent PNA, abnormal exam or radiograph
TX- underlying cause, smoking cessation, inhaled medications like inhalers, dextromorphin, antihistamines, codeine (last resort), benzontate, increase water intake
Dyspnea
Causes- asthma, COPD, ILD, neuroplasia, pneumonia; ischemic heart disease, CHF, pericarditis; severe anemia; panic disorder
Start with exam! Other symptoms like S3, JVD, edema, breathe sounds, calf tenderness
CXR, CBC, CMP, oximetry/ABG, spirometer
Hemoptysis
Inflammatory cause- bronchitis, bronchiectasis, PNA, TB
Other- neoplasia, cardiac or clotting
Order- CBC, CXR, sputum culture
TX- underlying cause
URI
25% are bacteria in nature
Others-flu (winter/spring), cold (winter/spring), laryngitis (viral), epiglottitis, RSV
Cold- congestion, rhinorrhea, sneezing, scratchy throat; cough up to 8 weeks
Flu- rhinitis, myalgia, fatigue, fever; high fevers
Laryngitis-hoarseness, aphonia, pain with swallowing
Determine cause and TX- antibiotics if bacterial, flu- Tamiflu, relenza, rapivab
Manage symptoms
Covid 19
Asymptomatic or many symptoms
Mainly URI but can include SOB, fever, anosmia, myalgia, GI, respiratory failure
Symptom management
Paxlovid for those 12 and older
Remdesivir for hospitalized
Dexamethasone for hospitalized and severe cases
Acute bronchitis
Self limiting inflammation to trachea and bronchi
Cough, dyspnea, pleurisy
Causes-viral (Covid, rhino; adeno, flu, RSV), pertussis; mycoplasma; chlamydia
If underlying lung disease-consider M catarrhalis, strep pneumonia, HI
Diagnosis of exclusion R/O COLD, asthma, cold
Antibiotics not needed
Short acting beta agonist are DOC
Antitussives, increase fluids, rest
Chronic bronchitis
Chronic persistent cough or sputum for 3 months for 2 years
Periodic exacerbation
HI, strep pneumonia, moraxella catarrhalis, viral
TX- augmentin 875 BID or doxycycline 100 mg BID or TMP-SMX 1 tablet BID, or cefuroximine 500 mg BID for 7 days, or azithryomycin 500 mg X1 then 250 mg X4 days
For more severe disease- biaxin 1000 mg or levaquin 500 daily or moxifloxacin 400 or ceftriaxone 1-2 grams IM or IV daily
Community acquired PNA
Consolidation on CXR
In those healthy less than 60: strep pneumonia, mycoplasma, legionella, chlamydia, flu, HI, staph, group A strep, moraxella
Co morbid: strep pneumonia. Mycoplasma, chlamydia, HI, nosocomial gram negative (nursing home), virus, moraxella, Anaerobes, immunocompromised-CMV/PCP
Pneumococcal PNA
Gram positive
Abrupt onset
Cough-rust colored sputum
Fever, chills, pleuritic chest pain
More subtle symptoms in older- AMS or weakness
Atypical PNA features
Like mycoplasma
HA, sore throat, myalgia, dry cough
Do not gram stain well
Most common in 40 and under
Clinically indistinguishable from pneumococcal pneumonia
Mycoplasma PNA
Sore throat, fever, dry hacking cough,
Complications: sinusitis, OM, erythema multiforme, or nodosum, intravascular hemolysis, meningoencephalitis, toxics psychosis, myocarditis, pericarditis
Relapse occurs in 10%
Chlamydia PNA
Biphasic illness
Young individuals
Severe pharyngitis and laryngitis
Fever
Cough
Physical exam for PNA
No specific signs
Cannot determine type by PE alone
Tachycardia can occur
Check Pulse oximetry
Fever
Increased tactile fremitus, dullness, egophony
Crackles or tales
Bronchial breath sounds
CAP tx
Hydration
Respiratory hygiene
ASA, Tylenol for fever and HA
Smoking cessation
Vaccines!
CAP TX empirical OP
Empirical TX;
-if healthy, no Comorbids, less than 65, no MRSA or pseudomonas-prescribe amoxicillin 1 g TID/azithromycin 500 mg x1, 250 mg daily X4 days/clarithromycin 500 mg BID or 1000 mg Q12 hrs/doxycycline 100 mg BID
-if comorbids present and have used antibiotics in last 3 months prescribe *beta lactam;amoxicillin-clavulanate 500-125 mg TID/amoxicillin-clavulanate 875-125 mg BID/amoxicillin-clavulanate 2000-125 mg PLUS macrolid (azith or clarith) or doxycycline 100 mg BID/cefpodoxime 200 mg BID or cefuroxime 500 mg or cefditoren 400 mg BID PLUS a macrolide/if unable to take beta lactam use levofloxacin 750 mg Q24, moxifloxacin 400 mg Q24, lefamulin 600 mg BID
TX minimum 5 days! Should be afebrile for 48 hours, if documented MRSA or pseudomonas use for 7 days
CAP TX empirical IP non ICU
Without suspicion of MRSA or pseudomonas-combination of beta lactam ie ceftriaxone 1 g IV Q24, or cefotaxime 1 g IV Q8h, cefazoline 600 mg I’ve Q12h + azithromycin 500 mg IV/PO Q24h or doxycycline 100 mg BID or levfloxacin 750 mg PO or IV Q24h, or moxifloxacin 400 mg IV or PO Q24h
-known or suspicion of MRSA-add vanco 15-20mg/kg/dose IV Q8-12 hr then adjust per trough, or linozolid 600 mg IV Q12h
-known or prior infection of pseudomonas, recent hospital stay with IV antibiotics, or strong suspicion of pseudomonas- use combo therapy with antipseudomonas beta lactam-zosyn 4.5g IV Q6h, or cefepime 2 g IV Q8 hr, or ceftazidime 2 g IV Q8h or meropenem 1 g IV Q8h or imipenem 500 mg IV Q6h, PLUS antipseudomonal fluroqionolone-cipro 400 mg IV Q8h, or levofloxacin 750 mg IV Q24h, or doxycycline 100 mg BID if cannot use microlides or fluroqiunolones
Empiric treatment CAP ICU severe
Combo of ceftriaxone 1-2 g IV q24h, cefotaxime 1-2 g IV Q8h, ceftroline 600 mg IV Q12h, or amp-sulbactam 3g Q6h, PLUS azithromycin 500 mg IV Q24h, or levofloxacin 750 mg IV or PO or moxifloxacin 400 mg IV or PO Q24h
Or pseudomonas suspected due to alcohol with NF, chronic bronchiectasis, trachea bronchitis due to CF, mechanical vent, febrile neutropenia with pulm infiltrates, septic shock with OF-zosyn 4.5 IV Q6h, cefepime 2g IV Q8h, imipenem/cilastatin 500 mg IV Q6h, meropenem 1g IV Q8h PLUS levofloxacin 750 mg IVQ24h or cipro 400 mg Q8h
10-14 day therapy
If concern for MRSA-add vanco 15 mg/kg IV Q 12 H or linezolid 600 mg IV BID
CURB 65
Mortality prediction tool for patients with CAP
C-confusion
U- urea >7
R - RR > 30
B- SBP less than 90, DBP less than 60
Over 65
0-1 low risk
2-probably admission versus close OP management
3-5 admission manage as severe
PNA follow up
Telephone call in 24 hrs
Office visit 3-4 days
Cough and fatigue may last 3-4 weeks
Repeat CXR in young adults in 2 weeks, smokers and elderly 4-6 weeks, frail elderly 8 weeks
Clinical failures- poor compliance, resistant organism, unusual pathogens, non infectious causes
Chronic cough
Subacute-cough last 3-8 weeks
Chronic-beyond 8 weeks
Most common cause-post nasal drip, GERD, asthma
History, environmental, swallowing, GI symptoms, CXR, spirometer, CT chest with contrast, spiral CT, barium exam, cardiac eval, bronoscopy, GI eval, CT sinuses
TX-stop offending meds, tx underlying cause, H2 or PPI trial, anti tussives, smoking cessation
Single pulmonary nodule
Common incident finding on CT
Pure sub solid SPN less than 5mm requires no follow up
If 5-8 mm follow fleischner society guidelines on interval CT
Greater than 8mm referral to specialist
OSA
Pause in breathing for 10-90 seconds
Center apnea-absent airflow and respiratory effort due to neurological disease
OSA- due to airway obstruction tongue and soft palate fall backwards
Or mixed
PSG or MSLT to DX
ENT exam
Can cause pulm HTN, HtN, LV dysfunction, arrhythmia, psychomotor defects, hypoxia and hypercapnia, increased risk for MI/CVA
Avoid alcohol, sedatives;weight loss, oxygen therapy, nasal dilators, CPAP, oral appliances, surgery
Rhinosinusitis
Bacteria- Tx with analgesics, saline, antibiotics for symptoms greater than 7 days or worsening, mild disease with antibiotics can be harmful
Chronic- topical nasal steroid and saline
Allergic- avoid allergens, nasal steroids, anti allergy meds
IPF
Relentless progression
Survival 3-5 years
Insidious SOB, dry cough, inspiration rales, clubbing
Specialist referral needed
Lung tx
