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FNP boards > Respiratory disorders > Flashcards

Respiratory disorders Flashcards

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Family Nurse Practitioner (FNP) flashcards
1
Q

What is asthma?

A

Chronic disorder of the lower airways

  • Characterized by variable and recurrent symptoms, airflow obstruction, bronchial hyperresponsiveness, underlying inflammation
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2
Q

Poor asthma control and flare clinical presentation

A
  • Recurrent cough, wheeze, SOB, chest tightness, evidence of air trapping
  • Symptoms worse at night, with exercise, during viral infections, exposure to irritants
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3
Q

Asthma diagnostic testing (diagnosis and monitoring)

A
  • Diagnosis: spirometry → increase of FEV1 by 12% or greater from baseline post SABA use
  • Monitor: peak flow meter
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4
Q

Physical examination findings of asthma and COPD during flare ups

A
  • Hyperresonance on percussion
  • Decreased tactile fremitus wheeze
  • Prolonged expiratory phase of forced exhalation
  • Low diaphragms
  • Increased AP diameter
  • Reduction in FEV1 or peak expiratory flow rate
  • Reduction in arterial oxygen saturation (later finding)
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5
Q

What conditions need to be met in order to make the diagnosis of asthma using spirometry?

A
  • Recurrent cough, wheeze, SOB, and/or chest tightness
  • Symptoms worse at night, exercise, viral respiratory infection, irritants
  • Increase in FEV1 >12% from baseline and/or post SABA use
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6
Q

Classifying and assessing asthma control in youths >12 years and adults

  • Well controlled/intermittent asthma
A
  • Symptoms → <2 days/week
  • Nighttime awakenings → <2x/month
  • Interference with normal activity → none
  • SABA use for symptom control → <2 days/week
  • FEV1 or peak flow → >80% predicted/personal best
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7
Q

Classifying and assessing asthma control in youths >12 years and adults

  • Not well controlled/mild to moderate
A
  • Symptoms → >2 days/week but not daily
  • Nighttime awakenings → 3-4x/month (mild) or >1x/week but not nightly (moderate)
  • SABA use → >2 days/week (mild) or daily (moderate)
  • Interference with normal activity → some limitation
  • FEV1 or peak flow → 60-80%
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8
Q

Classifying and assessing asthma control in youths >12 years and adults

  • Very poorly controlled/severe
A
  • Symptoms → throughout the day
  • Nighttime awakenings → 7x/week (or >4x/week)
  • SABA use → several times per day
  • Interference with normal activity → extremely limited
  • FEV1 or peak flow → <60%
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9
Q

Controller medications for asthma therapy

A
  • ICS → fluticasone, mometasone, budesonide
  • Leukotriene modifiers → montelukast (singulair)
    • Alternative to ICS in mild asthma or add on in moderate/severe
  • ICS/LABA → salmeterol, formoterol
    • For moderate/severe
    • LABA cannot be used without ICS
  • ICS/LAMA → tiotropium
    • Add on for patients with history of flares
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10
Q

When can you step down therapy in asthma control?

A

When asthma symptoms are well controlled and lung function plateaued (FEV1 or PEFR) for at least 3 months

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11
Q

What medication class should be avoided in patients with asthma and hypertension?

A

Beta blockers

  • Mitigate effects of LABAs or SABAs, exacerbate bronchial symptoms via increased bronchial obstruction and airway reactivity
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12
Q

How to manage acute asthma exacerbation in primary care

A
  • Mild to moderate → repeated SABA use up to 4-10 puffs every 20 minutes for first hour, 4-10 puffs every 3-4 hours or 6-10 puffs every 1-2 hours
  • Oxygen therapy to maintain 93-95% saturation
  • OCS for 5-7 days
    • Prednisone 1 mg/kg/day adults or 1-2 mg/kg/day children
  • Increase controller meds (ICS/LABA) for next 2-4 weeks OR start controller med OR high dose ICS for 7-14 days
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13
Q

Signs of a severe asthma exacerbation

A
  • Talking in single words
  • Sitting hunched forward
  • Having respiratory rate >30 breaths/min
  • HR >120 bpm
  • Oxygen saturation <90%
  • PED 50% or less than predicted or best
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14
Q

What is COPD?

A

Not fully reversible, progressive, associated with abnormal inflammatory response of lung to noxious particles/gas

  • Inflammation and narrowing of peripheral airways that lead to decreased lung function
  • Emphysema (destruction of alveoli) common finding
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15
Q

Clinical presentation of COPD

A
  • Recurrent dyspnea, chronic cough, persistent sputum production
    • Sputum production d/t → airway inflammation, smooth muscle constriction, altered lung mechanics
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16
Q

What is required for the diagnosis of COPD?

A
  • History of progressive dyspnea, chronic cough, sputum production, history of tobacco use
  • FEV1:FVC <70%
    • Most sensitive indicator of early airflow limitation
  • Spirometry needed to make clinical diagnosis
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17
Q

GOLD categories of COPD severity (1 though 4)

A
  • GOLD 1 (mild): FEV1 >80% predicted
  • GOLD 2 (moderate): FEV1 50-79% predicted
  • GOLD 3 (severe): FEV1 30-49% predicted
  • GOLD 4 (very severe): FEV1 <30% predicted
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18
Q

GOLD pharmacologic therapy for stable COPD - Group A

  • Low risk for exacerbation
  • Less symptoms
  • One or fewer moderate exacerbations/year
A
  • SABA
  • LABA - salmeterol
  • LAMA - tiotropium
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19
Q

GOLD pharmacologic therapy for stable COPD - Group B

  • Low risk for exacerbations
  • More symptoms
  • One or fewer moderate exacerbations/year
A
  • Long acting bronchodilator and/or LAMA
  • LABA
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20
Q

GOLD pharmacologic therapy for stable COPD - Group C

  • High risk for exacerbation
  • Less symptoms
  • Two or more exacerbations/year
A

LAMA

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21
Q

GOLD pharmacologic therapy for stable COPD - Group D

  • High risk for exacerbation
  • More symptoms
  • Two or more exacerbations/year
A

LAMA

22
Q

Important immunizations for patients with COPD

A
  • Flu (avoid live nasal spray)
  • Pneumococcal for all adults 65+ years or younger adults with risk factors
23
Q

When should the daily use of a long acting bronchodilator be implemented for patients with COPD?

A

Started at moderate severity (group B) and continued throughout every severe COPD (group D)

24
Q

Indications to start oxygen therapy for patients with COPD

A
  • PaO2 <50 mmHg
  • Oxygen saturation <88% with or without hypercapnia PaO2 55-69 mmHg
  • Oxygen saturation 89% in presence of cor pulmonale, right HF, polycythemia (hematocrit >56%)
25
Q

Diagnostic testing of COPD exacerbations

A

Consider obtaining chest x-ray to r/o PNA if presenting with fever and/or low oxygen saturation

26
Q

Treatment of COPD exacerbations

A
  • First line → SABA or SAMA
  • Can add LABA, LAMA, or combination if patient is not currently using one
    • Can also add ICS
  • OCS (I.e. prednisone) for 5-7 days
  • Antibiotics only for suspected bacterial cause of exacerbation
    • Increased purulence or change in volume, breathlessness, cough
27
Q

What is tuberculosis?

A

Bacterial infection caused by mycobacterium tuberculosis

  • Transmitted by aerosolized droplets
  • Wear PPE
28
Q

Tuberculosis clinical presentation

A
  • Cough (dry, uncommon hemoptysis)
  • Unexplained weight loss or anorexia
  • Fever
  • Night sweats
  • Fatigue
29
Q

Tuberculosis diagnostic testing

A
  • Tuberculin skin test (TST)
  • Blood test - quantiferon TB
    • Results available within 24 hours
    • Greater sensitivity for people with immunocompromised or history of BCG vaccine
  • Follow up chest chest x-ray if TST and/or quantiferon is positive
  • Consider sputum culture
30
Q

Tuberculosis treatment

A
  • If positive TST, quantiferon TB, but negative chest x-ray (latent TB) → chemoprophylaxis with isoniazid for 6-9 months
    • Rifampin is alternative
31
Q

Classification of TST reaction

  • When is an induration of >5 mm considered positive?
A
  • People living with HIV or AIDS
  • Recent contact of a person with TB
  • Persons with fibrotic changes on chest x-ray consistent with prior TB
  • Patients with organ transplants
  • Persons who are immunosuppressed for other reasons (taking equivalent of more than 15 mg/day prednisone for >1 month, taking TNF antagonists)
32
Q

Classification of TST reaction

  • When is an induration of >5 mm considered positive?
A
  • People living with HIV or AIDS
  • Recent contact of a person with TB
  • Persons with fibrotic changes on chest x-ray consistent with prior TB
  • Patients with organ transplants
  • Persons who are immunosuppressed for other reasons (taking equivalent of more than 15 mg/day prednisone for >1 month, taking TNF antagonists)
33
Q

Classification of TST reaction

  • Who is considered positive with an induration of >10 mm?
A
  • Recent immigrants (less than 5 years) from high prevalence country
  • Injection drug users
  • Residents and employees of high risk congregate settings
  • Mycobacteriology lab personnel
  • Persons with clinical conditions that place them at high risk
  • Children younger than 4 years old
  • Infants, children, and adolescents exposed to adults in high risk categories
34
Q

Classification of TST reaction

  • Who is considered positive with an induration of >15 mm?
A

Any person (including persons with no known risk factors)

  • Skin testing should only be conducted only in high risk groups
35
Q

Classification of TST reaction

  • Who is considered positive with an induration of >15 mm?
A

Any person (including persons with no known risk factors)

  • Skin testing should only be conducted only in high risk groups
36
Q

Classification of TST reaction

  • Who is considered positive with an induration of >15 mm?
A

Any person (including persons with no known risk factors)

  • Skin testing should only be conducted only in high risk groups
37
Q

What is community acquired pneumonia?

A

Acute lower respiratory tract infection involving lung parenchyma, interstitial tissues, and alveolar spaces

  • Causes: strep pneumo, haemophilus influenza
38
Q

Community acquired pneumonia clinical presentation

A
  • Cough
  • Dyspnea
  • Sputum production
  • Pleuritic chest pain
  • Fatigue and GI upset
  • Elderly → elevated RR, generally feel ill, altered MS
39
Q

Community acquired pneumonia clinical presentation

A
  • Cough
  • Dyspnea
  • Sputum production
  • Pleuritic chest pain
  • Fatigue and GI upset
  • Elderly → elevated RR, generally feel ill, altered MS
40
Q

Community acquired pneumonia clinical presentation

A
  • Cough
  • Dyspnea
  • Sputum production
  • Pleuritic chest pain
  • Fatigue and GI upset
  • Elderly → elevated RR, generally feel ill, altered MS
41
Q

Community acquired pneumonia clinical presentation

A
  • Cough
  • Dyspnea
  • Sputum production
  • Pleuritic chest pain
  • Fatigue and GI upset
  • Elderly → elevated RR, generally feel ill, altered MS
42
Q

Community acquired pneumonia diagnostic testing

A

Presence of abnormal chest x-ray and clinical findings needed to confirm diagnosis

  • Chest x-ray → infiltrates
  • Labs: CBC w/ diff, BUN, creatinine
43
Q

Characteristics that put patients at risk for death if they acquire pneumonia

  • What tool can be used to determine whether hospitalization is needed?
A

Risk factors:

  • 65+ years old
  • Severe electrolyte or hematologic disorder
    • Serum sodium concentration <130
    • Hematocrit <30%
    • Absolute neutrophil count <1,000

Use CURB-65 criteria (score >1 indicates hospitalization)

44
Q

True/false: All first line recommended CAP treatment options should offer activity against strep pneumonia, h influenza, and/or atypical pathogens

A

True - they are the most common organisms implicated in CAP

45
Q

Is shorter course antimicrobial therapy indicated in CAP treatment? How longer before therapy can be discontinued?

A

Yes - treated for minimum of 5 days

  • Before d/c must be afebrile for 48-72 hours and should have no more than one CAP associated sign of clinical instability (elevated HR and RR, hypotension)
46
Q

CAP pharmacotherapy recommendations for patients with no comorbidities and those with comorbidities

A
  • No comorbidities (COPD, DM, renal or HF, asplenia, alcoholism) → oral doxycycline, azithromycin/clarithromycin/erythromycin, or amoxicillin
  • Comorbidities → fluoroquinolone (-floxacin) OR doxycycline, azithromycin/clarithromycin + beta lactam
47
Q

What is acute bronchitis?

A

Condition of lower airway, self limited inflammation

  • Most commonly viral
  • Lasts as long as 4-6 weeks
  • Diagnosis limited to those without chronic airway disease
48
Q

Acute bronchitis clinical presentation

A
  • Cough developed during viral URI but persisted beyond 7-10 days
  • Occasional expiratory wheeze
  • NO fever, crackles, sputum
49
Q

Acute bronchitis treatment and management

A

Symptom management

  • Consider antitussives (dextromethorphan) but avoid in children <8 years
  • SABA if evidence of wheezing and low FEV1 or PEFR

For severe, persistent cough → short course of systemic corticosteroid (prednisone) for 3-5 days

50
Q

Lung cancer clinical presentation

A

Early lung cancer has no identifiable s/s

  • Late stage → fatigue, anorexia, unexplained weight loss
    • Chest discomfort, cough, dyspnea, hemoptysis
    • Hoarseness
51
Q

Lung cancer diagnostic testing/screening recommendations

A

Patients at significant risk should have annual low-dose CT

  • Current smokers aged 55-77 years with at least a 30 pack year history
  • Former smokers of the same ago who have quit within the past 15 years but have the same smoking history

Biopsy needed to confirm diagnosis

FNP boards (20 decks)

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