respiratory/pulmonary Flashcards
pulmonary disorder s/s
cough, SOB, pain in chestt
differentiate dx for cough
pneumonia
bronchitis.
postnasal drip
heart failure
SOB link to respiratory issue s/s
clubbing
barrel chest
cyanosis
pursed-lip breath
hemoptysis
chronic bronchitis treatment
its s a viral treatment with fluid and rest
also advise the pt that the cough can lass as long as 21 days
heart failure chest x ray result
when an x-ray show bilateral congestion most likely is heart failure
most common pathogen in CAP
strep pneu
patient with a penicillin allergy with ATB for CAP
doxycycline 100mg daily
clarithromycin 500mg bid
azithromycin 500mg 1st day then 250mg daily
doxycycline produce GI symptoms
stop doxycycline and give a macrobile azithromycin or clarithromycin
levofloxacin contraindication (quinolones)
impaired bone formation contraindicated in age<18
prolonged QT torsade de pointe
dehydration
history of the biceps Tendon
pregnancy
bupropion
increase risk of seizure
primary
secondary
Tertiary
prevention
screening
treatment
pneumonia
infection and inflammation of the alveoli
Dx of pneumonia
a chest x-ray will show infiltrates, consolidation or opacity
ATS/IDA guideline for CAP treatment without comorbidities
1-Amoxicillin 1g (1000mg) 3 times a day: Best evidence
2-Doxycycline 100mg twice daily-conditional recommendation- low quality evidence
3-Macrolide (azithromycin, clarithromycin SR or ER)-conditional recommendation- mod quality evidence
CAP in pt with comorbidities can be managed with combination therapy or monotherapy guidelines do not specify preference
-chronic disease of major organ system(heart, lung, liver, kidney) or malignancy
-alcoholism
-Asplenia (The absence of a spleen)
ATS/IDA guideline for CAP treatment with comorbidities
-combination therapy
Amoxicillin/clavulanate or Cefpodoxime or cefuroxime
PLUS
Macrolide or Doxycycline
-Monotherapy
Respiratory fluoroquinolone (levofloxacin,moxifloxacincin, gemifloxacin)
pt with CAP test positive for influenza should be still treated with ATB
YES
guideline recommended treated for bacteria
viral/bacterial pneumonia often occurs
How long should should the pt with CAP BE TREATED
usually 5-10days
At least 5 days plus clinical improvement
-normalization of vitals and adequate dietary intake
follow up imaging is no longer recommended in patients with expected clinical improvement
pneumonia prevention
vaccination
pneumonia
influenza one dose annually
Sars-Cov2-primary series plus booster
what is the implication of increased tactile fremitus and dullness to percussion in a person with pneumonia?
Increased intensity of tactile fremitus generally occurs as a result of increased density within the lung tissue. This commonly occurs as a result of lung consolidation, which refers to the replacement of the air within healthy lung tissue with another substance; either inflammatory exudate, blood, pus, or cells.
COPD which guidelines should you know
2022 global initiative for chronic obstructive lung disease (GOLD) guidelines
when to suspect COPD
history/physical finding
-chronic tobacco use or noxious lung exposure from pollution, indoor stove, occupational
-genetic factors, family hystory or childhood predispositions
symptoms
presence of chronic productive cough with frequent lower respiratory tract infection
COPD -WHEN TO SUSPECT
Physical exam often normal may have barrel chest, wheezing. pursed lip breathing. decrease breath sounds
COPD DX
spirometry is required for Dx
post-bronchodilator FEV1/ FVC ration <0.7
in other words, the pt can forcefully expel less than 70% of the air in their lungs even after using a bronchodilator
COPD TREATMENT
-Beta-agonists produce bronchodilation by stimulating beta receptors in the heart and
lungs End in -TEROL
-Inhaled antimuscarinics prevent bronchoconstriction by blocking the action of acetylcholine at muscarinic receptors
End in TROPIUM
-COMBO AGENTS
SAMA+SABA
LAMA+LABA
LABA+ICS
LABA+LAMA+ICS
SABA SHORT ACTING BETA ANTAGONIST
Albuterol
levalbuterol
onset <5mn
duration 4-6 hours 8hours
LABA long-acting BETA ANTAGONIST
Salmeterol
onset 10-20mn
duration 12-24hrs
SAMA SGORT ACTING MUSCARIN ANTAGONIST
Ipratropium (Atrovent)
duration 6hours
LAMA
Tiotropium (Spiriva)
duration 24hours
nb. work well with long-acting beta-agonists
prescribing strategy for stable COPD
-SAMA PRN OR SABA prn
-LABA AND LAMA PLUS RESCUE MED
-ICS+( LABA or LAMA)
-ICS + (LABA and/or LAMA)
COPD EXECERBATION KEY SYMPTOMS and management
increase dyspnea
-Mild
SABA Albuterol
-Moderate
SABA +ATB (5-7days) and/or oral corticosteroid
-severe
ED or hospitalization
severe SOB, mental status change, low BP
considered differentia dx
pneumonia-CXR
-pulmonary embolism-D-dimer, chest CT,PE protocol
-Afib /flutter-ECG
pleural effusion-CXR
COPD comorbidities
-cardiovascular disease (HF, CAD, tachyarrhythmias, afib,
-metabolism syndrome
-osteoporosis
-depression/anxiety
-lung cancer
SUPRACLAVICULAR LYMPH NODES is associated with high rates of malignancy
Right
-lungs
-mediastinum
-Esophagus
left
-Abdominal Malignancy
stomach
gallbladder, liver, pancreas, ovaries, prostate
lung cancer screening guidelines
USPSTF RECOMMENDATION
adult aged 50-80 years who have >20 pack-year smoking history AND currently smoke OR quit within the past 15 years
screen Annually with low-dose CT
ASTHMA S/S
Wheeze, SOB, chest tightness, and cough varies in intensity over time
s/ occurs or worsens at night with exercise viral infection, exposure to allergens, or irritants, hard laughing or crying, stress,
personal family history of asthma, atopic disease, eczema
Asthma dx criteria
presence of asthma feature (history)
reversible airway obstruction
spirometry demonstrates airways are at least partially reversible after SABA > 12% improvement from baseline or Fev>200ml or after 4 weeks on ICS
nothing else could be causing symptoms
NB pick flow is use for monitoring not for dx
using symbercort as rescue is not FDA approve.NEVER answer Symbercort as rescue on exam
nb when asthma pt out of control
the drug to add is steroid to the SABA like Budesonide
when rescue steroid don’t work
increase to moderate dose
Long acting bronchedilator
never use alone in asthma can cause sudden death
always combine with steroid
why is Timolol contraindicated in pt with asthma
is a beta blocker that can xce bronchoconstriction in pt with asthma
SABA
Albuterol
levabulterol
inhaled steroid suffix one
flucasone
monetasome budesonide
Asthma treat
1-interminittent
SABA rescue prn
no symptoms most day< 2 weeks
-persistent
daily low dose ICS plud SABA prn
or PRN low-dose ICS/SABA comb (symbicort)
risk factors for asthma related death
-history of intubation /ventilation or hospitalization for asthma in a last year
- not currently using ICS poor adherence to ICS SABA overuse (1 canister/month)
psychiatric disease, psychosocial problems
-lack of an asthma action plan
risk factors for asthma related death
-history of intubation /ventilation or hospitalization for asthma in a last year
- not currently using ICS poor adherence to ICS SABA overuse (1 canister/month)
psychiatric disease, psychosocial problems
-lack of an asthma action plan
Asthma severity
Mild intermittent
-symptoms < ou egale 2 days /weeks or
< ou egale 2 nights /month
exacerbation is brief
mild persistent
symptoms > 2 times/week but not daily
or
3-4 times/month at nighttime
moderate persistent
daily symptoms or
>1 night/week, but not nightly
severe persistent
symptoms throughout the day often 7 night /week
most common pathogen implication in pneumonia
0-4years viral
>5 bacterial: atypical pathogen (mycoplasma and Chlamydophila
rust-colored sputum is associated with strep pneumonia but scant watery sputum is associate with atypical pathogen
patient with penicillin allergy can take
tetracyclines -doxycycline
quinolones-ciprofloxacin
Macrolides -clarithromycin, azithromycin,
aminoglycosides(gentamicin
glycopeptides(vancomycin
ATB to avoid with penicillin allergy
cephalosporin
beta-lactam ATB
cefazolin
cephalexin
cefuroxime,cefoxitin
ceftriaxone
ceftazi
