Respiratory Cases Flashcards
classifications of asthma
intermittent: sx 2/week or less, 2/mo or less nocturnal awakenings
mild: sx > 2/week, 3-4/mo nocturnal awakenings
moderate: daily sx, >1/mo nocturnal awakenings
severe: sx throughout the day, nocturnal sx every night
order of workup for asthma (after you’ve done thorough h&p of course)
- PFTs
- If PFTs are normal -> methacholine challenge or ASA challenge
- CXR -> r.o PNA/COPD/ca
stepwise approach to asthma tx
- exercise induced: PRN SABA
- PRN low ICS
- PRN low ICS + LABA
- daily low ICS + LABA
- daily med ICS + LABA
- daily high ICS + LABA
all steps get PRN SABA
if asthma is well controlled, PRN SABA should not be used more than
1/week
what class of drug is Symbicort
what condition is it commonly used for
ICS/LABA combo
asthma
when are peak flow meters used
daily at home
when are PFTs done
for initial dx and when indicated for another reason
no formal guidelines
when are systemic steroids used for asthma
only for acute exacerbation
PE findings of COPD (2)
expiratory wheezing
prolonged expiratory phase of respiration
CXR findings of COPD (2)
increased AP diameter
flattened diaphragm
what diagnostic tools are used to assess/stage COPD
subjective: mMRC/CAT
objective: PFTs
when are sputum cultures recommended for acute exacerbations of bronchitis (5)
complicated attack
failed abx
suspect atypical
immunocompromised
homeless or group living
IVDU
not first line soc!
what 3 organisms mc cause acute exacerbations of bronchitis
h.flu
strep pneumo
m.cat
what is the timeline for tamiflu administration
w.in 48 hr of sx onset
what is the most effective rescue med for COPD
SAMA/SABA combo -> Combivent
when are abx recommended for acute exacerbation of bronchitis in COPD pt
moderate to severe exacerbation -> 2 out of 3:
-increased dyspnea
-increased sputum volume/viscosity
-increased sputum purulence
when would you use azithromycin for acute bronchitis flare in COPD pt
uncomplicated flare
no rf
age > 65 yo
FEV1 > 50% predicted
top 3 abx recommended for uncomplicated acute bronchitis attack
- azithromycin
- clarithromycin
- cefuroxime
duration of abx for uncomplicated acute bronchitis attack
5-7 days
how do you define a complicated acute bronchitis attack
1 or more rf:
age > 65 yo
FEV1 < 50% predicted
2 or more exacerbations/year
cardiac dz
what 3 abx are used for complicated acute bronchitis attack
- moxifloxacin
- levofloxacin
- augmentin
in a nutshell summary of outpatient (uncomplicated) abx for acute bronchitis attack
most: macrolide OR 2nd/3rd gen cephalo
high risk w.o pseudo risk: augmenting OR fluoroquinolone
high risk w. pseudo risk: fluoroquinolone
in a nutshell summary of inpatient (complicated) abx for acute bronchitis attack
pseudo risk: fluoroquinolone or 3rd gen cephalo
no pseudo risk: IV cefepime, ceftazidime, zosyn
what class of drug is a Spiriva
LAMA
what 2 drugs are commonly used for COPD
Combivent (SABA/SAMA) -> rescue
Spiriva (LAMA) -> daily
how often should FEV1 be monitored in COPD pt
annually
tx to consider for COPD pt who presents w. sx of acute bronchitis attack, but has poorly managed pharm for COPD, and is non toxic AF
delay abx prescribing
increased COPD tx x 3-4 days
if no improvement -> rx abx
are systemic steroids recommended for COPD
not really ever… unless super super sick
CENTOR criteria
do you need to flu swab an otherwise healthy pt who presents > 48 hr after sx onset
probs not -> won’t give tamiflu outside this window, so why swab?
what meds might you prescribe for viral URI (2)
OTC APAP PRN
f.u for viral URI in peds if RSV (+)
1-2 days
f.u for viral URI in peds if RSV (-)
1 week
indications for emergent care in kiddo w. viral URI
difficulty breathing
AMS
toxic AF
poor feeding/hydration
no improvement
maxillary tooth pain
high fever
virus mc responsible for viral URI
rhinovirus
also: flu, adenovirus, enterovirus, rev
what lung sound is associated w. PNA
crackles
who gets a ddimer
low risk for PE
what PE could you do to assess for DVT
leg exam
if positive -> US deep veins
why might you do a CT in PNA pt.
r.o PE and PNA
what pathogens are mc associated w. HAP (6)
pseudomonas
acinetobacter
s.aureus
h.flu
klebsiella
e.coli
definition of HAP
develops > 48 hr after admission
2 major rf for HAP (besides hospital admit)
ventilation
aspiration
you should base abx tx for HAP on (3)
risk for MRSA
risk for pseudomonas
local antibiogram
denver health antibiogram guidelines for HAP tx
cefepime 2 g IV q 8 hr
indications for addition of IV vanco:
VAP
hx MRSA infxn
IV abx in past 90 days
indications for addition of IV vanco + amikacin:
severely ill w. septic shock
mod-severe pcn allergy: levofloxacin
clinical stability criteria for HAP (5)
afebrile x at least 24 hr
no unexplained tachy
WBC nl or improving
O2 needs improving or at baseline
tolerating PO
step down po abx choice for clinically stable HAP patients
levofloxacin
what tool is used to assess PNA disposition (2)
CURB 65
SIRS
sepsis/SIRS criteria
temp: < 36 OR > 38
HR: > 90 bpm
tachypnea: > 20 OR PaCO2 < 32
WBC: < 4,000 OR > 12,000
q hr sepsis bundle (5)
- measure lactate
- obtain cultures
- abx
- rapid admin of crystalloid
- vasopressor
t/f: all pt’s who meet SIRS criteria should be considered septic
f!
