Respiratory disease Flashcards
Typical characteristics of COPD
Smoker/exsmoker, rarely symptoms before 35y, common with chronic productive cough, persisten/progressive breathlessness. Uncommon with waking up at night or significant diurnal variability. FEV ad FEV/FVC ration never return to normal with drug therapy.
Typical characteristics of bronchial asthma
Possibly a smoker. Commonly onset < 35y. Uncommon w chronic productive cough. Breathlessness is varible. Common w waking up at night and significant diurnal variability. Probably return of Fev, FEV/FVC ratio after drug tx
What are the risk factors of COPD
- Smoking 2. Occupation ( organic, inorganic dust, chemical agent, fumes) 3. Pollution (smoke. pipe, water pipe) 4. Genes, deficiency of alpha 1 antitrypsin. 5. Low birth weight, resp. inf. 6. Asthma 7. Aging and female gender 8. Socioeconomic status (poor nutrition, infectious air, pollutants)
What will spirometry show in COPD
Post- bronchodilator FEV1/FVC <0,70
What is the definition of COPD
A common preventable and treatable disease, is characterized by persistent resp sx and airflow limitation that is due to airway and or alveolar abnormalities usually caused by significant exposure to noxious particles and gases.
What are the sx of COPD
- Dyspnea: progressive over time, worse w exercise, persistent
- Chronic cough ( often the first symptom) w sputum production
What do you have to think about when interviewing a COPD pat?
NB! The symptoms may be under-reported!
Dx of COPD
- Sx + risk + spirometry
- spirometry is required to establish dx, post bronchodilator FEV1/FVC < 0,7 confirms the presence of airflow limitation
How can you assess a COPD pat?
- Modified medical research council dyspnea scale (mMRC) = dyspnea in rest and activity
- COPD assessment test (CAT) = impact on life and changes over time
- More than or at 2 /1 are leading to hospital admission
What increase the risk of exacerbations in COPD?
- Increasing airflow limitation increase risk
- Comorbidities: cardiovascular disease, osteoporosis, depression and anxiety, skeletal muscle dysfunction, metabolic sd, lung cancer
What are the main goals of treatment in COPD?
- Sx: Relieve sx, improve exercise tolerance, improve health status
- Risk: Prevent disease progression, prevent and treat exacerbations and reduce mortality
Treatment of category A COPD
- Bronchodilator
- Continue, stop or try alternative class of bronchodilator
Tx of cat B COPD
- Long acting bronchodilator (LABA or LAMA)
- LAMA + LABA if persistent sx
Tx of cat C COPD
- LAMA
- LAMA + LABA if further exacerbation
- LAMA + ICS (inhaled corticosteroids)
Tx of cat D COPD
- LAMA
- LAMA + LABA
- LABA + ICS
- LAMA + LABA + ICS
- Consider macrolide
- Consider roflumitest if FEV1 < 50% and pat has chronic bronchitis
How is non-pharmacologic mx of COPD
A. 1) Smoking cessation 2) Physical activity 3) flu vaccine, pneumococcal vaccine
BCD. Same + pulmonary rehabilitation
What is the NB! of COPD?
- Often coexist w other disease that may have a significant impact on disease course. They should be treated per usual standard regardless of the presence of COPD
- Comorbidities are often under diagnosed and are ass w poor health status and Px.
- Ensure simplicity of treatment and to minimize polypharmacy
What is pneumonia and how is it classified?
Infection of lung parenchyma. Divided into two types: C ommunity-acquired (CAP) and nosocomial, which includes hospital-acquired(HAP) and ventilator-associated(VAP).
○ HAP: acquired >48h after hospital admission
○ VAP:acquired >48h after intubation
○ CAP:Any other setting
What are the pathogens of pneumonia?
Pathogens are bacterial, viral or fungal. CAP organisms tend to be typical or atypical bacteria, or respiratory viruses.
Typical: S.pneumoniae (most common), H.influenzae, M.catarrhalis, S.aureus, GAS
○ Atypical: Legionella, mycoplasma, chlamydia pneumoniae or psitacci
○ Viral: InfluenzaA/B, rhinoviruses, parainfluenza, adenoviruses, RSVetc.
Risk factors of pneumonia?
old age,various comorbidities (especiallyCOPD), viral respiratory tract inf , impaired airway protection and smoking / alcohol
What are the symptoms of pneumonia?
Symptoms are grouped into pulmonary and systemic.
○ Pulmonary: Cough, dyspnea, pleuritic chest pain, tachypnea, unusual breath sounds (rales, rhonchi)
○ Systemic: Fever, chills, fatigue, malaise etc. ‒ general symptoms of infection.
dx of pneumonia
Diagnosis requires demonstration of infiltration on CXR, alongside above symptoms. Get both lateral and AP X-rays.
How do you assess severity of pneumonia?
w CURB-65 and pneumonia severity index (PSI, but require ABG so not so useful in primary care setting)
- Confusion
- Urea nitrogen in blood >7mmol/L
- RR>30
- BP <90 systolic or <60 diastolic
- > 65yearsorolder.
One point for each positive measurement, risk of death increases with each, from 0.6% with one point to 27.8% with 4 or 5 points.
.
How should you mx pneumonia according to the points in CURB-65?
■ 0-1 point: Outpatient
■ 2 points: Short hospitalisation or outpatient with close followup
■ 3-5: Hospitalise, consider ICU
■ Additionally, patients with a PaO2 >92% should generally be hospitalised
What is the outpatient tx of pneumonia?
Outpatient treatmentgenerally revolves around empiric antibiotics.
■ Specific drug is typically determined by local resistance rates to S. pneumonia for various drugs. Macrolides (azithromycin, clarithromycin) and doxycycline are commonly used.
■ 5 to 7 days is usually enough, but all patients should be improving and afebrile for >48h before stopping treatment.
What is acute bronchitis?
Lower RT inf involving the large airways, without evidence of pneumonia and not in the setting of COPD. Smoking is a major risk factor.
What cause acute bronchitis?
Most often caused by viruses: Influenza A/B (most common), parainfluenza, coronaviruses, rhinoviruses, RSV. Note overlap with causative viruses of viral pneumonia.
How to dx acute bronchitis?
Should be suspected in patients with cough for >4 days, often longer, with no clinical signs of pneumonia. The diagnosis is usually clinical, but if you suspect pneumonia, it may be useful to rule that out with a CXR series. Because there is no consolidation in bronchitis, it usually doesn’t show up on X-rays.
DDx for cough
Be aware of some specific ones: 1. postnasal drip syndrome (harmless, usually happens after a common cold), 2. GERD, 3. asthma, 4. ACEi use, 5. pulmonary embolism, 6. lung cancer.
tx of acute bronchitis
UpToDate actually recommends hot tea. Disease is usually self-limited and passes in 1-3 weeks, so the key points here are reassurance and excluding other conditions.
■ Antibiotics are not useful, with the exception of pertussisbronchitis. Smoking cessation may help. Anti-cough medicine can be used if the coughing is very bothersome.
What is sinusitis?
Symptomatic inflammation of the nasal cavity and paranasal sinuses.
Usually caused by a virus, usually resolves or improves on its own in 7-10 days (but often doesn’t if it’s bacterial),
Usually uncomplicated - but it can have serious sequelae.
You also want to be on the lookout for recurring sinusitis, which may indicate other problems.
Sx of sinusitis
Generally presents as a common cold with some additional features: Fever (though commonly absent or brief if viral), headache, feeling of heaviness, purulent nasal discharge, and so on.
tx for sinusitis?
Treatment is largely symptomatic. Paracetamol/ibuprofen/etc for pain relief and antipyretic effect, decongestants may also be useful.
when should you suspect bacterial sinusitis?
If duration is >10 days or has gotten better, then worse again, think bacterial causes. This is somewhat more serious, because it may progress with complications ‒ although it usually doesn’t.
what should you look out for in bacterial sinusitis?
Look for symptoms affecting nearby structures: Persistent high fever, periorbital inflammation/ erythema, cranial nerve palsies, abnormal eye movement, proptosis, vision changes, meningeal signs, and so on.
What should you do if pat does not have good follow up or illness lasts more than 1 week? (sinusitis)
If the patient does not have good followup options or the illness lasts more than 1 week (so ~17 days in total), start a 5-day course of antibiotics. Amoxicillin or amoxicillin-clavulanate. Doxycyclinecan be used in penicillin allergy.
What is acute otitis media?
Acute OM is marked by the presence of fluid in the ear and inflammation of middle ear mucosal membranes. It occurs more often in children, because they have short Eustachian tubes-> easier access to middle ear for bacteria.
What are the sx of acute otitis media?
Ear pain and decreased hearing are most common.
dx of acute otitis media
- On otoscopy, you will typically see a tympanic membrane that bulges outwards.
This is the most important clinical finding for diagnosis. It may also be erythematous, or yellowish, cloudy etc. ‒ this indicates fluid in the middle ear. - If the membrane has ruptured, you may also see discharge in the ear canal.
- You can test for conductive hearing loss with a Weber test (tuning fork placed at vertex of the skull. Since liquid transmits sound better than air, the sound will be heard better in the affected ear.The hearing loss may persist for a long time after the initial infection has passed.
why is it important w correct dx in acute otitis media
Accurate diagnosis is important, because it occurs very often, and misdiagnosis constitutes a major source of antibiotic overprescribing.
what is the ddx of acute otitis media?
Otitis externa, ear trauma, throat infections or foreign body.
tx of acute otitis media
Treatment varies somewhat by national guidelines, but Nessler had a patient like this and she recommended antibiotics as standard treatment. Amoxicillin, or amoxicillin-clavulanate. Kids <2y should be treated with antibiotics, though this varies somewhat by country.
why should you be on lookout for complications of otitis media?
- the middle ear is close to a lot of important things, such as the brain.
- Mastoiditis is very serious ‒ tenderness of the mastoid process, lethargy, malaise,
- lack of response to ABx therapy, carries a risk of spreading to the CNS.
- Chronic suppurative OM should be referred to infectious disease specialist or otolaryngologist.
- Facial nerve paralysis may occur.
what causes otitis externa?
S. aureus, P.aeruginosa (swimmers ear), s. pyogenes
