Respiratory CIS Handout Flashcards
Patient populations at risk for exposure and infection with tuberculosis
Close contact with someone who has active TB
Immigrants from endemic areas (<5 yrs ago)
Residents and employees at high risk areas: jail, prison, nursing homes, homeless shelters, healthcare facilities, drug treatment facilities
Medically underserved, low-income populations
IV drug abuse
HIV/AIDS pts as well as other immunocompromised states
The ____________ can be utilized when a pt has a positive TST test with a history of a BCG vaccination
IFN-gamma release assay [in other words, the IGRAs like quantiferon TB gold are NOT affected by BCG administration]
It is more sensitive to a true TB exposure and can guide us to an understanding that the positive result is not due to the BCG vaccination — keep in mind that people who have BCG vaccine will have a TST reaction of 3-19 mm (2-3 mo after vaccine)
> 10 years after vaccine, the TST reaction is typically <10 mm
Signs/symptoms associated with active pulmonary TB
Fever (can be diurnal)
Night sweats
Cough (generally >2weeks; productive or hemoptysis possible)
Weight loss
LAD
Gold standard for dx of TB
Sputum culture
[3 separate morning sputum samples are taken for culture on liquid and solid media; as M.tuberculosis is slow growing, results can take between 6-8 weeks]
Other aspects of clinical dx of active TB include clinical symptoms, risk factors, and radiography
While sputum culture is the gold-standard for dx, sputum staining can also be done. What are the 2 stains that may be used, and what do they indicate?
Rhodamine-auramine stain — initial screening stain for TB
Ziehl-Neelson and/or Kinyun stain — confirmatory AFB stains
Purpose of PPD skin test (aka TST or Mantoux)
Determines if person is currently infected or has previously been infected with M.tuberculosis
NOT utilized to determine a dx, but can support the dx and raise clinical suspicion
Most widely used screening modality for TB
Cost effective, easy to obtain, sensitive (not specific)
Purpose of interferon gamma release assay (IGRA)
Indicates there has been a cellular response to TB
Preferred test in those who have received BCG (as vaccine or for cancer therapy)
May be used in place of TST (without preference) to test recent contacts of persons with infectious TB with special considerations for follow-up testing
On CXR of reactivation T, ______ lesions typically involve the _____ of the lungs
Cavitary; apices
Purpose of the nucleic acid amplification test (NAAT) in TB workup
Utilized in conjunction with a smear that is positive for AFB while cultures are pending
NAAT-TB detects genetic material
NAAT-R detects INH and rifampin resistance
That standard 4 drug therapy includes __________________
The majority of pts require ______ (duration) of continual therapy
Rifampin, Isoniazid, Pyrazinamide, Ethambutol
6 months
Remember to follow your TB pts with CMPs to monitor ____ and ____ function while on 4-drug therapy
______ is also collected to monitor tx efficacy
Kidney; liver
Sputum
Potential side effects of rifampin
Red/orange body fluids
Hepatitis
Steven-Johnson syndrome
[also N/V, rash]
Potential side effects of isoniazid
Hepatitis Peripheral neuropathy (give Vit B6)
[also N/V, rash]
Potential side effects of pyrazinamide
Hepatitis
Hyperuricemia
Urticaria
Joint aches
Potential side effects of ethambutol
Optic neuritis
Color-blindness
Baseline lab evaluation prior to initiating 4-drug therapy for TB should include what?
Measurement of hepatic enzymes (transaminases, bilirubin, alkaline phosphatase)
CBC
Serum creatinine
Uric acid
Counseling and testing for HIV
Visual acuity and red-green color discrimination testing when tx includes ethambutol
[testing for Hep B and C should also be done in pts with epidemiologic risk factors]
Latent TB is clinically silent but can become active. What should you do if you see positive result for PPD or IGRA, and CXR is negative (indicating latent TB)?
Treat with 9 months of isoniazid
What clinical situations regarding TB are we obligated to report in the US?
Persons with confirmed or suspected TB must be reported to state or local public health authority promptly (w/i 24 hrs)
Labs that process diagnostic specimens for TB are also requried to report the isolation of M.tuberculosis complex to the provider and to the public health authority
[The public health authority can provide a link to expert medical consultation for dx or managment; CDC also sponsors regional centers where consultation is available]
TB is most likely to be transmitted in healthcare settings when health care workers and pts come in contact with persons who have unsuspected TB disease, who are not receiving adequate treatment, and who have not been isolated from others.
What are some infection-control measures based on the 3-level hierarchy?
Administrative controls — management measures, minimize areas where exposure may occur
Environmental controls — admit to negative pressure room, use respiratory protective equipment, etc.
Respiratory controls — use respiratory protective equipment and other PPE, pt education, health care worker training, etc.
Why do we admit pts with active TB to negative pressure rooms?
To prevent the spread and reduce the concentration of infectious droplet nuclei
Consists of controlling source of infection by using local exhaust ventilation (e.g., hoods, tents, booths) and diluting/removing contaminated air by using general ventilation. Also controls airflow to prevent contamination of air in other areas adjacent to the source
Cleans air by using high efficiency particulate air filtration (HEPA) or ultraviolet germacidal irradiation
Types of O2 delivery (O2 levels in arterial blood = SaO2 — order pulse ox)
Room air (RA) — FiO2 21%(fraction of inspired oxygen)
Nasal cannula (NC) — 1-6L, FiO2 24-44%
Simple facemask — 6-10L, FiO2 40-70%
Venturi mask — 3-15L, aerosol mask, FiO2 24-50%
Non-rebreather (NRB) — 15 L, bag reservoir, FiO2 80-100%
Considerations for selections of respirators
The overall effectiveness of respiratory protection is affected by:
- The level of respiratory protection selected (e.g., the assigned protection factor)
- The fit characteristics of the respirator model
- The care in using the respirator
- The adequacy of the training and fit-testing program
OMM considerations for acute TB
OMT is a relative contraindication while in the acute phase (e.g., ICU)
While rare, TB can spread to the lymph nodes, causing them to be sore or swollen. Complications from LN involvement include sepsis and fistulas
Areas typically treated with OMT in costochondritis secondary to chronic cough
Pectoralis TP Ribs Sternum Thoracic Chest musculature Quadratus lumborum
Areas typically treated with OMT in bronchitis
Chapmans — bronchus 2nd ICS
Parasympathetics — vagus
Areas typically treated with OMT in pneumonia
Rib restrictions
T/L diaphragm
An OMT consideration in COPD is that bronchospasm and mucous production are mediated through the ______ n.
Vagus
Weber vs. Rinne test
Weber for lateralization:
Normal is if it lateralizes to both ears equally. If it lateralizes to R ear, it is either conduction loss in R ear, or sensorineural loss in L ear
Rinne for air vs. bone conduction:
When pt no longer hears against bone, place in front of ear canal. Normal is AC>BC. If lateralized to R ear, and then AC>BC, suspect sensorineural loss in L ear. If lateralized to R ear, then BC>AC, there is conductive loss in R ear.
The frontal sinuses do not open until after _____ years of age
7
What is cheilitis?
Red cracks at corners of mouth; may be due to B12 or iron deficiency
Clinically relevant landmark for needle decompression of pneumothorax
2nd intercostal space just superior to 3rd rib margin at MCL
[remember that neurovascular bundle runs inferior to each rib, so needles and tubes should be placed superior to the rib margins]
Clinically relevant landmark for chest tube insertion
4th ICS at mid or anterior axillary line just superior to margin of rib 5
Clinically relevant landmark for lower margin of endotracheal tube on CXR
T4
Clinical landmark for thoracentesis
7th ICS
In what conditions might you see clubbing of the fingertips?
Congenital heart disease Interstitial lung disease Bronchiectasis Pulmonary fibrosis Lung abscess Inflammatory bowel disease (IBD) Malignancies (lung cancer) Cystic fibrosis
What conditions might show decreased vs. increased tactile fremitus?
Decreased/absent fremitus: COPD Pleural effusions Fibrosis Pneumothorax Thick chest wall Infiltrating tumor
Increased fremitus:
Pneumonia (increased transmission through consolidated tissue)
Normal diaphragmatic excursion
3-5.5 cm
Name the normal breath sounds
Vesicular
Bronchovesicular
Bronchial
Tracheal
Name the adventitious breath sounds
Crackles (rales) Wheezes Rhonchi Stridor Pleural friction rub
Bronchophony vs. egophony vs. whispered pectoriloquy
Bronchophony = spoken words become louder and clearer (indicates consolidation)
Egophony = the “ee” sounds like “A” with nasal bleating quality
Whispered pectoriloquy = whispers heard louder and clearer
Describe the fever associated with TB
Fever associated with TB is classically diurnal, with an afebrile period early in the morning and a gradually rising temp through the day, reaching a peak in the late afternoon or evening.
Fever subsides during sleep, but night sweats may occur [fever and night sweats are more common among pts with advanced pulmonary TB]
Although a blood count is never diagnostic in the case of TB, _______ and _______ are common.
Neutrophilia is rarely found [iron deficiency anemia may develop with ______ treatment].
Urea and electrolytes are usually normal, although hypocalcemia and hyponatremia are possible in tuberculous meningoencephalitis due to ________. In advanced disease, hypoalbuminemia, hyperproteinemia, and hyperglobulinemia may be present. ESR is usually raised
Normocytic anemia; lymphopenia
Isoniazid
SIADH
