Respiratory disorders Flashcards
Review normal physiologic pulmonary adaptations to pregnancy
Structural
- Increased subcostal angle
- Increased AP and transverse diameters of the chest
- rib cage expands, volume inside chest stays the same
- 4 cm elevation of the diaphragm
- Total lung capacity remains the same
Functional
- Maternal and fetal metabolic needs = increased gas exchange
- RR remains about the same
- Increase in tidal volume and resting minute ventilation
- Decreased functional residual capacity
- Progesterone stimulates respiratory drive
- makes CO2 chemo receptors more sensitive in brain
- Compensated respiratory alkalosis
- Kidneys decrease bicarb (compensation)
Discuss the effect of pregnancy in a woman with asthma
- 4 - 8% of all pregnancies
- 1/3 improve, 1/3 worsen, 1/3 remain at prepregnancy severity
- Physiologic changes → less ability to compensate
Describe the risks of asthma in pregnancy to both the fetus and the mother
- Pregnancy outcomes excellent in setting of good control
- Fetal compromise with > asthma severity
- Some studies show small increase risk of PEC, PTL, IUGR (even with good control)
- Poor control/severe disease → risk of preterm delivery & preeclampsia
Discuss evaluation asthma during pregnancy
- Peak flow monitoring (Peak Expiratory Flow Rate - PEFR)
- Establish baseline when asymptomatic “personal best”
- Does not change due to pregnancy
- Moderate to severe disease should test BID
Describe pregnancy management of the woman with asthma
- Need for aggressive management to achieve good control
- Starts before conception
- Asthma vs. dyspnea of pregnancy
- Peak flow meter
- Classify severity
- Step up pharmacotherapy
- Refill albuterol
- Refer for additional evaluation and treatment
- Review importance of good control and medication safety
- Prompt reporting if no improvement
- Consider serial growth US and NST’s for pregnant people with moderate to severe asthma during pregnancy
- With intermittent or well-controlled disease, no additional surveillance necessary
Discuss treatment of asthma during pregnancy, including risks of medication use and side effects
- Avoid triggers
- Risks of exacerbations is worse than risk of treatment
- Always have short acting beta agonist (albuterol) inhaler available
- Side effects: tremor, tachycardia, palpitations
- Brand names: ProAir, Proventil, Ventolin
- Dosing: 1-2 inhalations q.4-6 hours PRN
- Albuterol also available as nebulizer solution, syrup, and tablet
- Prednisone/other steroids can be rescue therapy as well
- If not well controlled → start on long-term control medication (inhaled corticosteroid)
- Inhaled corticosteroids in low, medium, and high doses
- Long-acting bronchodilators
- Cromolyn, theophylline, leukotriene modifiers… many more!
- ICS examples: fluticasone, mometasone, triamcinolone, flunisolide, budesonide…etc
Bronchitis
evaluation and management
- Etiology: usually viral
- Antibiotics are not indicated
- Symptoms: cough lasting median 18 days
- Diagnosis: clinical (CXR, flu swab will be negative)
- Treatment: supportive care and symptom management
- Humidifier in bedroom, cough drops
Pneumonia presentation
- Symptoms: productive cough, pleuritic chest pain, dyspnea, shaking/chills
- No increased prevalence in pregnancy
- ICU, intubation, and mortality increase in pregnancy
- Increased risk of PTB, poor growth, fetal loss
- Etiology: usually bacterial, many causative organisms
Pneumonia evaluation and management
Evaluation
- PE
- arterial blood gases (ABG)
- CXR
- sputum for Gram stain and cx
- Blood cx
Management
- REFER due to high risk of PTB and pulmonary edema
- likely hospital admition
Tuberculosis
signs, symptoms and clinical presentation
Cough
Minimal sputum
Low grade fever
Hemoptysis
Weight loss
Tuberculosis
Describe indications for screening for tuberculosis including at-risk populations
Describe diagnostic tests and treatment
Risk factors: born outside the US, elderly, poverty, immunocompromised status, crowded living quarters (prison, group homes etc)
Health-care workers, known contact, foreign-born, PLHIV, working or living in homeless shelters, people with substance use disorders, detainees and prisoners
Tuberculin skin test: the PPD
Interferon-gamma release assays (IGRAs): QuantiFERON-TB Gold or T-SPOT.TB
Tuberculosis
Describe diagnostic tests and treatment
Diagnostics
Tuberculin skin test: the PPD
Interferon-gamma release assays (IGRAs): QuantiFERON-TB Gold or T-SPOT.TB
Treatment
- Latent infection:
- Usually defer treatment to postpartum
- Exceptions: new infection, PLHIV
- Active infection:
- 4 drug regimen for 2 months (bactericidal phase)
- Then 4 month isoniazid and rifampin (continuation phase)
- All medications are compatible with breast feeding
- Be aware of MDR-TB and XDR-TB - risk of untreated disease is higher than risk of drugs
- Treatment is LLOOOONNNGGG: pts needs support
Upper Respiratory Infection
Evaluation and Managment
- Typically caused by virus
- Self-limiting
- OTC medications usually all that is needed
- Give antibiotics if:
- Persistent symptoms for 10 days without improvement
- Severe symptoms or temperature > 102.2 for 3– 4 days
- Worsening symptoms after 5– 6 days of improving symptoms
Antibiotics for sinusitis
Augmentin (amoxicillin-clavulanate)
Cefprozil (Cefzil)
Risk factors for PE
- Personal hx of VTE (2-4 fold increase risk of recurrence)
- Thrombophilia (Acquired and inherited)
- Other (Obesity, HTN, hemoglobinopathies, smoking, operative delivery
- Pregnancy! 4-5x risk of thromboembolism than when not pregnant
Pulmonary Embolism
Evaluation
- Vitals
- Evaluation of cardiorespiratory status → determine if critically ill
- ECG and CXR
- Hemodynamically stable with O2 sat > 80% → evaluate in a carefully ordered fashion, taking into account the possibility of lower extremity DVT and the results of CXR
- Unstable → start anticoagulation immediately
- Lower extremety symptoms (esp L side) → VUS
- if positive → therapeutic anticoagulation
- CXR not typically used in dx → helps select of the next dx test.
- Normal → V/Q scan
- V/Q scan → anticoagulation
- V/Q scan → excludes PE
- Non-dx → do CTPA
