Respiratory disorders Flashcards
What is asthma?
Chronic disorder of the lower airways
- Characterized by variable and recurrent symptoms, airflow obstruction, bronchial hyperresponsiveness, underlying inflammation
Poor asthma control and flare clinical presentation
- Recurrent cough, wheeze, SOB, chest tightness, evidence of air trapping
- Symptoms worse at night, with exercise, during viral infections, exposure to irritants
Asthma diagnostic testing (diagnosis and monitoring)
- Diagnosis: spirometry → increase of FEV1 by 12% or greater from baseline post SABA use
- Monitor: peak flow meter
Physical examination findings of asthma and COPD during flare ups
- 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)
What conditions need to be met in order to make the diagnosis of asthma using spirometry?
- 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
Classifying and assessing asthma control in youths >12 years and adults
- Well controlled/intermittent asthma
- 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
Classifying and assessing asthma control in youths >12 years and adults
- Not well controlled/mild to moderate
- 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%
Classifying and assessing asthma control in youths >12 years and adults
- Very poorly controlled/severe
- 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%
Controller medications for asthma therapy
- 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
When can you step down therapy in asthma control?
When asthma symptoms are well controlled and lung function plateaued (FEV1 or PEFR) for at least 3 months
What medication class should be avoided in patients with asthma and hypertension?
Beta blockers
- Mitigate effects of LABAs or SABAs, exacerbate bronchial symptoms via increased bronchial obstruction and airway reactivity
How to manage acute asthma exacerbation in primary care
- 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
Signs of a severe asthma exacerbation
- 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
What is COPD?
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
Clinical presentation of COPD
- Recurrent dyspnea, chronic cough, persistent sputum production
- Sputum production d/t → airway inflammation, smooth muscle constriction, altered lung mechanics
What is required for the diagnosis of COPD?
- 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
GOLD categories of COPD severity (1 though 4)
- 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
GOLD pharmacologic therapy for stable COPD - Group A
- Low risk for exacerbation
- Less symptoms
- One or fewer moderate exacerbations/year
- SABA
- LABA - salmeterol
- LAMA - tiotropium
GOLD pharmacologic therapy for stable COPD - Group B
- Low risk for exacerbations
- More symptoms
- One or fewer moderate exacerbations/year
- Long acting bronchodilator and/or LAMA
- LABA
GOLD pharmacologic therapy for stable COPD - Group C
- High risk for exacerbation
- Less symptoms
- Two or more exacerbations/year
LAMA
GOLD pharmacologic therapy for stable COPD - Group D
- High risk for exacerbation
- More symptoms
- Two or more exacerbations/year
LAMA
Important immunizations for patients with COPD
- Flu (avoid live nasal spray)
- Pneumococcal for all adults 65+ years or younger adults with risk factors
When should the daily use of a long acting bronchodilator be implemented for patients with COPD?
Started at moderate severity (group B) and continued throughout every severe COPD (group D)
Indications to start oxygen therapy for patients with COPD
- 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%)
Diagnostic testing of COPD exacerbations
Consider obtaining chest x-ray to r/o PNA if presenting with fever and/or low oxygen saturation
Treatment of COPD exacerbations
- 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
What is tuberculosis?
Bacterial infection caused by mycobacterium tuberculosis
- Transmitted by aerosolized droplets
- Wear PPE
Tuberculosis clinical presentation
- Cough (dry, uncommon hemoptysis)
- Unexplained weight loss or anorexia
- Fever
- Night sweats
- Fatigue
Tuberculosis diagnostic testing
- 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
Tuberculosis treatment
- If positive TST, quantiferon TB, but negative chest x-ray (latent TB) → chemoprophylaxis with isoniazid for 6-9 months
- Rifampin is alternative
Classification of TST reaction
- When is an induration of >5 mm considered positive?
- 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)
Classification of TST reaction
- When is an induration of >5 mm considered positive?
- 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)
Classification of TST reaction
- Who is considered positive with an induration of >10 mm?
- 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
Classification of TST reaction
- Who is considered positive with an induration of >15 mm?
Any person (including persons with no known risk factors)
- Skin testing should only be conducted only in high risk groups
Classification of TST reaction
- Who is considered positive with an induration of >15 mm?
Any person (including persons with no known risk factors)
- Skin testing should only be conducted only in high risk groups
Classification of TST reaction
- Who is considered positive with an induration of >15 mm?
Any person (including persons with no known risk factors)
- Skin testing should only be conducted only in high risk groups
What is community acquired pneumonia?
Acute lower respiratory tract infection involving lung parenchyma, interstitial tissues, and alveolar spaces
- Causes: strep pneumo, haemophilus influenza
Community acquired pneumonia clinical presentation
- Cough
- Dyspnea
- Sputum production
- Pleuritic chest pain
- Fatigue and GI upset
- Elderly → elevated RR, generally feel ill, altered MS
Community acquired pneumonia clinical presentation
- Cough
- Dyspnea
- Sputum production
- Pleuritic chest pain
- Fatigue and GI upset
- Elderly → elevated RR, generally feel ill, altered MS
Community acquired pneumonia clinical presentation
- Cough
- Dyspnea
- Sputum production
- Pleuritic chest pain
- Fatigue and GI upset
- Elderly → elevated RR, generally feel ill, altered MS
Community acquired pneumonia clinical presentation
- Cough
- Dyspnea
- Sputum production
- Pleuritic chest pain
- Fatigue and GI upset
- Elderly → elevated RR, generally feel ill, altered MS
Community acquired pneumonia diagnostic testing
Presence of abnormal chest x-ray and clinical findings needed to confirm diagnosis
- Chest x-ray → infiltrates
- Labs: CBC w/ diff, BUN, creatinine
Characteristics that put patients at risk for death if they acquire pneumonia
- What tool can be used to determine whether hospitalization is needed?
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)
True/false: All first line recommended CAP treatment options should offer activity against strep pneumonia, h influenza, and/or atypical pathogens
True - they are the most common organisms implicated in CAP
Is shorter course antimicrobial therapy indicated in CAP treatment? How longer before therapy can be discontinued?
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)
CAP pharmacotherapy recommendations for patients with no comorbidities and those with comorbidities
- 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
What is acute bronchitis?
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
Acute bronchitis clinical presentation
- Cough developed during viral URI but persisted beyond 7-10 days
- Occasional expiratory wheeze
- NO fever, crackles, sputum
Acute bronchitis treatment and management
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
Lung cancer clinical presentation
Early lung cancer has no identifiable s/s
- Late stage → fatigue, anorexia, unexplained weight loss
- Chest discomfort, cough, dyspnea, hemoptysis
- Hoarseness
Lung cancer diagnostic testing/screening recommendations
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
