Respiratory / Pulmonary Flashcards
Pneumonia
s/s
- cough, fever, fatigue, pleuritic chest pain
- increased tactile fremitus (felt)
- auscultate egophony which is increased resonance with eeeee that sounds like aaaaa indicating consolidation, decreased lung capacity, and pleural effusion
- auscultate the lungs (crackles/rhonchi, decreased lung sounds over lower lobes with consolidation)
- chest xray looking for areas of consolidation and infiltrates
PNA
diagnosis
- chest xray looking for areas of consolidation and infiltrates
PNA prevention
flu vaccine (# complication is PNA)
pneumococcal vaccines
PNA prevention
When do I give PNA vaccines?
Healthy, immunocompetent persons 65 and older:
* a single dose of PPSV23
Persons with some chronic conditions asthma/copd, etc.:
* a single dose of PPSV23
Chronic kidney disease:
* both PCV13 and PPSV23
Sickle cell and asplenia (no spleen):
* both PCV13 and PPSV23
Immunocompromised:
* both PCV13 and PPSV23
Viral PNA
RSV
dry hacky cough
fatigue
Bacteria PNA
60-80% of PNA
- higher risk is asthma, COPD, cystic fibrosis
atypical PNA
Mycoplasma pneumoniae (walking PNA)
milder more persistent symtoms
typical PNA
Streptococcus PNA
Pneumonia
TX
- 2 main choices (MAD Lung +)
MAD Lung
If patient is healthy and does not meet below criteria, treat with MAD
- Macrolides, such as azithromycin (Zithromax) - low resistance rates
- Amoxicillin (Amoxil)
- Doxycycline
If patient has co-morbidies OR taken any antibiotic in the last 90 days, treat with think
a) LUNG - levofloxacin/Levaquin (fluoroquinolones) - not cipro
OR
b) macrolide / azithromycin with amoxicillin
FOLLOW UP with chest x-ray at 8 weeks
Chronic obstructive pulmonary disease
COPD
Combination of 2 diseases
chronic bronchitis leads to cilia destruction
emphysema destroys alveoli = dyspnea + wheezing
COPD risk factors
occupational hazards
pollution
smoking
COPD
s/s
chronic cough
sputum production
dyspnea
- percussion will be hyperresonate (hyper-expansion with increased thoracic gas)
- feels like they have difficulty taking a good deep breath
COPD
COPD ASSESSMENT TEST = CAT
assessment components
Treat > 10
not used for diagnosis, measures quality of life with COPD and tracks changes over time
0–5 that reflects response, zero indicates no effect on quality of life, whereas a 5 suggests a very significant effect
- how often you cough
- how much mucus is in your cough/chest
- how much tightness you feel in your chest
- how out of breath you feel after walking uphill or climbing stairs
- how much your condition limits your activities at home
- how comfortable or safe you feel leaving your home with COPD
- how well you’re able to sleep
- how much energy you have
0–9 Low
10–20 Medium* significant disruption
21–30 High
31–40 Very high
COPD
Diagnosis
Spirometry
FEV1/FVC ratio
Score < 0.70 or 70% confirms diagnosis
Low FEV1/FVC ratio = obstructive airway disease
High FEV1/FVC ratio = reactive airway disease (asthma)
COPD
Group A = CAT < 10
tx
CAT < 10
0 or 1 exacerbation
Bronchodilators = drugs that open up airway
- TEROL
- SABA: albuterol (short)
- LABA: formoterol (long)
COPD
Group B = CAT >10
tx
CAT >10
0 or 1 exacerbation too (like group A but more significant)
Long Acting Medications:
LAMA: - PIUM = tiotropium
LABA: -TEROL = sameterol
COPD
Group C = CAT < 10
tx
CAT < 10
although CAT is less than 10, there are multiple exacerbations and/or hospitalizations
First Line
LAMA: -PIUM = start here!
Can also add: LABA/LAMA combo (remember LABA is -TEROL)
LABA/LAMA combination drugs
Tiotropium/olodaterol = Respimat = Once daily
Aclidinium/formoterol = Genuair = Twice daily
Umeclidinium/vilanterol = Ellipta = Once daily
Glycopyrronium/indacaterol = Breezhaler = Once daily
or Neohaler = Twice daily
Glycopyrronium/formoterol fumarate = Aerosphere = Twice daily
COPD
Group D = CAT > 10
tx
CAT > 10
multiple exacerbations and/or 1+ hospitalizations
First Line
LABA/LAMA combo
- remember LABA is -TEROL & LAMA is - PIUM
If symptoms are persistent may add ICS
Long Acting Beta Antagonists
LABA examples
salmeterol
formoterol
arformoterol
indacaterol
vilanterol
olodaterol
Long-acting muscarinic antagonists
LAMA
tiotropium
aclidinium
umeclidinium
glycopyrrolate (also called glycopyrronium)
Inhaled Corticosteroids
ICS examples
Beclomethasone Dipropionate
Budesonide
Ciclesonide
Fluticasone Furoate
Fluticasone Propionate
Mometasone
Mometasone Furoate HFA 100 or 200 mcg
COPD exasterbation s/s
increased difficulty breathing
increased sputum amount
increased sputum purulence (pus)
COPD exasterbation mild tx
SABA
COPD exasterbation moderate tx
SABA + antibiotics/steriods
Antibiotics
- macrolide
- tetracycline
COPD exasterbation severe tx
send to hospital
COPD treatment order
Groups A to D
A: bronchodilators SABA or LABA
B: long acting medications LABA or LAMA
C: LAMA
D: LABA/LAMA combo likely with ICS
Asthma
Diagnostic
forced expiratory volume FEV1 = amount of air forced out of lungs in one second
HAG = Height, Age, Gender
- this helps us with expected values
* in children we take into account their weight
Asthma
FEV1 Range
Step 1 & 2: Intermittent to Mild Persistent > 80%
Step 3: Moderate 60% to 80%
Step 4-5: Severe (refer) < 60%
follow-up annually if not more
Asthma rescue inhaler
ICS/LABA combination
- aka Budesonide/formoterol combination (Symbicort)
Asthma
Symptom exacerbation number
Step 1 Tx
Symptoms < 2x per month
Treatment:
1. ICS-LABA PRN
low dose inhaled corticosteroid (ICS) and formoterol
- aka Budesonide/formoterol combination (Symbicort)
Asthma
Symptom exacerbation number
Step 2 Tx
Symptoms < 2x per month, but not daily
L-ICS daily
Treatment:
1. ICS-LABA PRN
low dose inhaled corticosteroid (ICS) and formoterol
- aka Budesonide/formoterol combination (Symbicort)
OR
- ICS-LABA
Budesonide/formoterol combination
Asthma
Symptom exacerbation number or…
Step 3 Tx
Symptoms on most days or waking up 1x/week
Treatment:
ICS-LABA
Budesonide/formoterol combination (Symbicort)
L-ICS with LTRA
Leukotriene receptor antagonist = montelukast = Singulair
- great add on treat, but not an add on treatment
Asthma
Symptom exacerbation number
Step 4 Tx
Refer to pulmonology
Long Acting Beta Antagonists
LABA examples
salmeterol
formoterol
arformoterol
indacaterol
vilanterol
olodaterol
COPD treatment order
Groups A to D
A: bronchodilators SABA or LABA
B: long acting medications LABA or LAMA
C: LAMA
D: LABA/LAMA combo likely with ICS
Long-acting muscarinic antagonists
LAMA
tiotropium
aclidinium
umeclidinium
glycopyrrolate (also called glycopyrronium)
Long Acting Beta Antagonists
LABA examples
salmeterol
formoterol
arformoterol
indacaterol
vilanterol
olodaterol
COPD treatment order
Groups A to D
A: bronchodilators SABA or LABA
B: long acting medications LABA or LAMA
C: LAMA
D: LABA/LAMA combo likely with ICS
Asthma main s/s
cough
How do we determine success of asthma treatment?
Patients monitor symptoms daily and record s/s and reduction of symptoms shows what adjustments need to be made, but it’s not based on rescue inhaler from before
What medication do we not prescribe by itself?
Black Box Warning
Long-acting β-agonists (salmeterol and formoterol) received “black box” warnings because of severe with some associated death
What medication is now the cornerstone of asthma treatment?
- low dose inhaled corticosteroid (ICS) and formoterol
- aka Budesonide/formoterol combination (Symbicort)
- this is also our exacerbation treatment
What if the patient does not have full blown COPD but has symtoms?
presribe bronchodilator (SABA or LABA)
COPD patient loses weight unintentional
Lung cancer is highest risk when pt has COPD (both genders)
- high calorie, high protein, small meals if breathing is too much caloric output
CURB - 65
Confusion
Urea (blood urea nitrogen)
Respiratory rate > 20 or >30 depending on guidelines
BP < 90/60
65 age
1 point each, great than 2 points = admission
Tuberculosis - TB
- appearance on chest xray
consolidation in upper lobes
Tuberculosis - TB
Diagnosis
- Confirmation of the TB diagnosis
◦ Acid-fast bacilli (AFB) smear, plus
◦ Three sputum cultures positive for mycobacterium tuberculosis
Tuberculosis - TB
Mantoux
2 step test with 48-72 hours after the test
- 15 mm + for general public
- 10 mm + for individuals in high-risk settings or recent immigrants from high-risk countries
- 5 mm+ for HIV-positive (CD4 count > 200) or immunocompromised patients taking tumor necrosis factor (TNF) inhibitors (4x)
- note TNF Inhibitors are used to treat certain autoimmune diseases, Rheumatoid arthritis, Ankylosing spondylitis, Psoriatic arthritis
Differentiate mononucleosis from streptococcal pharyngitis (strep)?
- splenomegaly for mono
- palatal petechiae for strep
Streptococcal pharyngitis (strep)
Tx
penicillins
Complication of untreated strep throat
Scarlett fever / Scarlatina (strawberry tongue), Rheumatic fever, Glomerulonephritis
Rheumatic fever is a condition that can inflame or make the heart, joints, brain, and skin swell
Glomerulonephritis is inflammation and damage to the filtering part of the kidneys (glomerulus)
Mononucleosis
Tx
Symptom treatment
When can mono pt play sports?
Spleen ultrasound still enlarged
What if the patient has strep and mono?
Tx
macrolide
cephalosporin
penicillin VK
*not other penicillin to avoid morbilliform rash
Complication of strep throat…
Peritonsillar abscess which is a deviated uvula that are very painful and lead to sepsis
Bronchitis
tx
- 95% are viral, do not treat with antibiotics unless it is pertussis (whooping cough)
*dTap or Tdap prevents pertussis
Sinusitis
tx
Amoxicillin
Augmentin (amoxicillin/clavulanate)
Sinusitis
s/s
upper respiratory s/s
facial pressure
toothache
Allergic Rhinitis
tx
first line: avoid triggers
1. internasal corticosteroids - flonase
2. antihistamines
- diphenhydramine (Benadryl)
*avoid antihistamines in older population
Allergic Reaction labs
IgE
Anticholinergic Side Effects
dry mouth
difficulty peeing - urinary retention
sedating
blurred vision
constipation
tachycardia
confusion
impaired memory
Corticosteroids
classic triad of atopy
asthma
allergy
atopic dermatitis
