Respiratory Flashcards
Asthma
- Bronchial hyper responsiveness
- Chronic airway inflammation
- Airways constrict in response to various triggers (mites, molds, furry animals, pollens, coils air, exercise)
Presentation:
- Dyspnea, cough (often worse at night), chest tightness and wheezing
- Severe symptoms
- Tachypnea, tachycardia, prolonged expiratory phase of respiration, poor air movement or a “quiet” chest, tripod breathing
Diagnosis:
- Spiromtery measures a person’s forced expiratory volume and their force vital capacity
- Measure spiromtery before and after bronchodilator administration
- Reduced FEV1/FVC ratio of <0.7 indicates airflow obstruction
- An increase of FEV1 or FVC of >10% after administration of a bronchodilator is highly suggestive of asthma
REMEMBER: 7:10 AM (FEV1/FVC ratio of <0.7 = obstruction, increase of >10% After Medication (bronchodilator) = Asthma
Asthma Classifications
Step 1: All of the following
- Daytime symptoms < 2 days/week
- Night time awakenings due to asthma symptoms < 2/month
- Normal FEV1
- Exacerbations <1/year
Step 2:
- Daytime asthma symptoms 3 to 6 days per week
- Night time awakenings due to asthma symptoms 2 to 4 times per month but not more than once weekly
- Minimal Interference with normal activities
- Two or more exacerbations per year, requiring oral glucocorticoids
Step 3:
- Daily asthma symptoms
- Night time awakenings more than once per week
- Occasional limitation in normal activity
- Evidence of airway obstruction outside of an asthma exacerbation (for example: FEV1 between 60 and 80 % predicted)
Step 4:
- Frequent limitation in normal activity due to asthma symptoms
- Nightly awakenings
- Evidence of moderate to severe airway obstruction (FEV1 <60% predicted)
Asthma treatment
All patients with asthma, regardless of classification, should have access to a PRN bronchodilator/reliever therapy.
Step 1:
- Option 1: PRN low-dose ICS-Formoterol
- Formoterol: Long acting beta agonist with fast onset, contraindicated as monotherapy
- Option 2: PRN low dose ICS-SABA
- Option 3: PRN SABA
Step 2:
- Option 1: PRN Low-dose ICS-Formoterol
- Option 2: Maintenance with (daily or BID) low-dose ICS + reliever with PRN ICS-SABA or PRN SABA
Step 3:
- Option 1: Maintenance AND reliever therapy with low-dose ICS-formoterol
- Option 2: Maintenace with low-dose ICS-LABA + reliever it’s PRN ICS-SABA or PRN SABA
- Option 3: Maintenance with low-dose ICS + LAMA or LTRA + reliever with PRN ICS-SABA or PRN SABA
Step 4:
- Option 1: Maintenance AND reliever therapy with medium-dose ICS-Formoterol
- Option 2: Maintenace with medium-dose ICS-LABA + reliever with PRN ICS-SABA or PRN SABA
- Option 3: Maintenance with medium-dose ICS + LAMA or LTRA + reliever with PRN ICS-SABA or PRN SABA
Risk factors for asthma exacerbations
Insufficient asthma symptom control, history of asthma exacerbations on the current treatment plan, smoker, allergen exposure, previous intubation or asthma requiring ICU admission, low FEV1 (especially <60% predicted), obesity, food allergy, chronic rhinosinusitis, and poor compliance or inhaler technique.
Asthma treatment step up / step down approach
If asthma is poorly controlled, step up therapy and if asthma is well controlled for 3 to 6 months, step down therapy.
- Well controlled asthma is defined as symptoms of asthma occurring no more than twice a week, no night time awakenings due to asthma symptoms and no activity limitation due to asthma symptoms.
Chronic Obstructive Pulmonary Disease (COPD)
- Preventable and treatable airway disease characterized by persistent respiratory symptoms, usually caused by significant exposure to noxious particles or gases
- Chronic bronchitis, emphysema and chronic obstructive asthma
Risk factors:
- Cigarette smoking (biggest risk factor), second hand smoke, fumes, dust
Presentation:
- Classic symptoms include dyspnea, chronic productive cough and sputum production
Diagnosis:
- Typical symptoms of COPD and an FEV1/FVC ration less than 0.7 that is irreversible with a bronchodilator, as made evidence by the use of spirometry.
COPD treatment
Determine the CAT (COPD Assessment Test) score first
Group A: Less symptomatic (CAT <10) and a low risk of exacerbations (0-1 exacerbations within the last year that did not require hospitalization)
- LAMA, plus PRN SABA (preferred)
- LABA, plus PRN SAMA-SABA or SABA
- PRN SAMA-SABA or SABA
Group B: More symptomatic (CAT score of 10 or more) with low risk of exacerbations (0-1 exacerbations within the last year that did not require hospitalization)
- LAMA-LAVA dual bronchodilator therapy, plus PRN SABA
Group E: High risk of exacerbations (2 or more exacerbations or >1 hospitalization for exacerbation)
- LAMA-LABA dual bronchodilator therapy, plus PRN SABA
Group E with high peripheral eosinophil levels (>300/microL): High risk of exacerbations (2 or more exacerbations or >1 hospitalization for exacerbation)
- ICS-LAMA-LABA, plus PRN SABA
COPD Treatment GOLD recommended thresholds
- Patients with exacerbations and <300 eosinophils
- Likely favorable response to ICS
- May have exacerbations with cessation of ICS
- Patients with exacerbations and >100 but <300 eosinophils
- May have favorable response to ICS
- Patients with exacerbations and <100 eosinophils
- Unlikely to have favorable response to ICS
REMEMBER: “I before I” (Ipratropium is a short acting muscarinic, Tiotropium is a long acting muscarinic)
Asthma Exacerbations
- Incident of worsening symptoms and lung function that may occur from a trigger such as an upper respiratory infection, allergen, irritants lack of medication compliance, or for an unknown reason.
Symptoms:
- Wheezing, cough, chest tightness, shortness of breath.
Treatment:
- Prompt initiation of SABA
- Nebulized albuterol (2.5mg): Every 20 minutes up to 3 doses in 1 hour
- MDI albuterol (90mcg): 4 to 8 puffs every 20 minutes up to 3 doses in 1 hour.
- Oral glucocorticoids are indicated for moderate to severe asthma exacerbations and for those that do not completely improve with an inhaled fast acting bronchodilator
- Typical example of outpatient burst of oral glucocorticoids: Prednisone 40 to 60mg/day for 5 to 7 days.
Symptoms of COPD Exacerbation
- Increase in symptoms of dyspnea, cough and sputum production
Treatment:
- Prompt initiation of SABA or SABA-SAMA combination
- Commonly administered SABA-SAMA combination is Nebulized ipratropium (0.5mg), combined with albuterol (2.5mg) in 3mL solution
- Systemic glucocorticoids (typically prednisone 40 to 60 mg/day for 5 to 14 days)
- Antibiotics indicated for most patients with COPD exacerbations.
- IF low risk for poor outcome: Treat with macrolide or second or third generation cephalosporin
- IF high risk for poor outcome: Fluoroquinolone, or augmentin may be appropriate if there is no risk for pseudomonas infection
- Risk factors for poor outcomes: age 65 or older, FEV1 <50% predicted, 2 or more COPD exacerbations in the past 12 months, on continuous oxygen, or comorbidities including heart failure or ischemic heart disease.
- Treat with Fluoroquinolone: history of pseudomonas infection in the past 12 months, broad spectrum antibiotic use within the last 3 months or chronic systemic glucocorticoids.
Community Acquired Pneumonia
- An acute infection of the pulmonary parenchyma that was acquired in the community
Risk factors:
- Age, chronic commorbidities (COPD was highest correlation, viral respiratory infection, smoking, crowded living conditions, low income settings, environmental toxins)
Most common pathogens:
- Steptococcus pneumoniae and respiratory viruses
Presentation:
- Spectrum of presentation and severity:
- Fever, cough, SOB, fatigue, chills, anorexia
- Severe: Respiratory distress, sepsis
- Physical exam:
- Tachypnea, crackles, Rhonchi, tactile fremitus, egophony, dullness to percussion
- INCREASE in fremitus (chest vibration): indicates consolidation
- Vowel “e” sounds like a nasal-y “a” (as in “say”): Indicates consolidation
Diagnosis:
- Infiltrate visualized on CXR, with correlating clinical symptoms of pneumonia
- Lobar consolidations, interstitial infiltrates and/cavitations
ATS/IDSA pneumonia treatment options
- Patients who are <65 years old, without comorbidities or smoking and who have not used antibiotics within 3 months:
- Monotherapy with amoxicillin
- Patients 65 years or older, active smoker, immunocompromised, commorbidities or those who have recently use antibiotics:
- Combination therapy with a beta lactam PLUS a microlide or Doxycycline
- Fluoroquinolone as monotherapy (Levofloxacin, Moxifloxacin)
- Penicillin allergy:
- Monotherapy with either a microliter or doxycycline if local resistance is <25%
- Combination therapy with a third-generation cephalosporins plus either a macrolide or doxycycline
Inpatient treatment indicated:
- Septic shock, respiratory failure, inability to maintain oral intake, concern about treatment compliance, mental illness, cognitive or functional impairment, homeless or rural living, <92% oxygen saturation on room air (if this is a significant change from patients baseline)
CURB-65
C: Confusion
U: Urea — Urea >7 (BUN >20)
R: Respiratory Rate — > 30 per minute
B: Blood pressure — SBP <90 or DBP <60
65: Age — >65 years
Pneumococcal Vaccination
- All adults > 50 years old or those at least 19 who are at risk for pneumonia or severe complications from infection
- NP Boards still uses 65 and older
Risk factors:
- Alcohol use disorder
- Chronic heart disease
- Chronic lung disease
- Chronic liver disease
- Diabetes
- Sickle cell disease
- Current cigarette smoking
- Increased risk of meningitis (patients with known CSF leak or cochlear implant)
- Immunocompromised
- History of pneumococcal infection
NEVER received pneumococcal conjugate vaccine or vaccine status unknown?
- PCV15, PCV20, or PCV 21 for all adults 50 years or older
- PCV15: Followed by a dose of PPSV23 one year later
- PCV20 or PCV21: Additional vaccination NOT recommended
Tuberculosis
Caused by Mycobacterium Tuberculosis
- Spread through aerosol droplets and may result in:
- Immediate clearance of bacteria
- Primary disease
- Latent Infection
- Reactivation/Post-primary
Symptoms of TB:
- Symptoms present in one-third of cases, including fever and chest pain.
- Chest radiograph often normal, or hilar lymphadenopathy, pleural effusion or consolidation may be seen
Symptoms of reactivation or post primary TB:
- May experience cough, weight loss, fatigue, chest pain, dyspnea, hemoptysis, fever and/or night sweats
- Most have abnormalities on chest radiograph, up to 90% involving the apical and posterior segments of the upper lobes
Diagnosis:
- Chest radiograph
- Three sputum specimens should be submitted for Acid-fast Bacilli (AFB) smear, mycobacterial culture and NAA testing
- Tubercullin skin test used to support diagnosis
Treatment:
- Isoniazid, Rifampin, Ethambutol and Pyrazinamide
Tubercullin Skin Test
Induration >5mm:
- Patients with HIV infection, recent close contact to a person with known active TB, patients with a chest x-ray consistent with prior TB, patients with organ transplant and other immunosuppressive patients
Induration >10mm:
- Patients with clinical conditions that increase risk of TB infection, people born in countries where TB disease is common, IV drug users, residents and employees of high risk congregate settings, mycobacteriology laboratory workers, people <90% of ideal body weight, children <5 years of age or infants, children and adolescents exposed to adults at high risk
Induration >15mm:
- Patients who do not meet any of the above criteria
Lung Cancer
- Lung cancer is a leading cause of cancer related death and smoking cessation is most beneficial
Presentation:
- Cough with hemoptysis, dyspnea, weight loss
Diagnosis:
- Pathological evaluation of either the pleural fluid or with a tissue
Screening and prevention:
- Low Dose CT
- Adults (50 to 80 years) with at least a 20-pack history of smoking and either currently still smoking or quit smoking within the last 15 years should have an annual low-dose CT scan
- Pack history: Calculated by multiplying the number of packs of cigarettes smoked per day by the number of years smoked.
- Once the patient has reached 15 years smoke free, or if the patient has a limited life expectancy, discontinue annual CT
- Smoking Cessation
- Smoking cessation should be addressed at every visit
- Three step approach
- Ask about smoking habits, advices to quit smoking, offer support/treatment
Treatment for smoking cessation
- Behavior support
- Pharmacotherapy
- Varenicline (Chantix)
- Nicotine replacement therapy
- Nicotine Patch (long acting)
- Nicotine gum (short acting)
