Week 11 Respiratory Flashcards
bronchitis patho
- edema and inflamed mucous membranes of the trachea and bronchioles
- release of pro-inflammatory mediators and increase in secretions
acute bronchitis clinical manifrestions & majority of etiology is?
- cough lasting 5+ days
- nasal congestion, h/a
- Dyspnea→ inflammation in the airways.
- Purulent or non-purulent sputum
- URI before bronchitis
- Low grade fever at onset
- chest wall pain
- VS normal, no consolidation
- wheezes, rhonchi
majority viral!!
Indications for chest xray for acute bronchitis
- NOT needed for mild or classic cases
- get xray if (sx’s of pneumonia):
- Dyspnea, bloody/rusty sputum
- HR > 100
- RR > 24
- oral temp > 100ºF (37.8ºC)
- Focal consolidation, egophony, or fremitus
- If >75 yrs, have subtle sx’s of pneumonia and might not have fever or elevated HR
bronchitis management
- Education
- no antibiotics - mostly viral infection
- Smoking cessation
- Supportive care
- Rest, fluids, hydration, stream inhalation • Medications
- Avoid OTC antitussives and antihistamines in ages < 4 yrs old
- honey > 1 yrs
- Improve in 2-3 weeks
influenza sx’s in adults vs children
- both have: fever, myalgia, headache, nausea
- adults: coryza, cough, eye burning, tearing
- children: rhinitis, conjunctivitis, HIGHER fever, lymphadenopathy
- normal lung exam
High-Risk Groups for flu-related complications, therefore, need flu chemoprophylaxis with antiviral medication
- children < 5 yrs old, esp < 2 yrs old
- immunodeficiency or chronic medical conditions (COPD, CVD, DM, renal/neuro/hem disorders)
- < 19 yrs on chronic aspirin therapy
- _>_65+ yrs
- pregnant women + 2 wks post partum
- African Indians
- alaskan natives
- lives in nursing home or chronic care facilities
what are the chemoprophylaxis meds (neuraminidase inhibitor) should be considered for high risk pts who have been exposed to someone with flu w/in last 48 hrs
- oseltamivir (Tamiflu)
- > 3 months yrs
- zanamivir (Relenza)
- > 5 years yrs
- Taken daily for the duration of exposure = shortens duration by 12-24 hrs
- not effective if taken after 48 hrs
most common typical pathogen of pneumonia
Streptococcus pneumoniae
- all age groups (90% in children)
most common atypical pathogens of pneumonia
mycoplasma and chlamydia pneumonia
- NO consolidation
- school age and adolescents
exam findings of pneumonia
- Tachypnea**
- Tachycardia
- Consolidation**
- Decreased O2 saturation
- Crackles, rales, bronchial, asymmetric breath sounds
- Dullness to percussion, incr tactile fremitus
- ego phony, bronchophony
- whisper pectoriloquy
On chest xray for pneumonia, how to differentiate b/t viral and bacteria?
**might be normal the first 24 hrs
Typical pneumonia: Lobar consolidation
bacterial: lobular consolidation, cavitation, large pleural effusion
Atypical/viral pneumonia: Bilateral, diffuse infiltrates, NO CONSOLIDATION
what is the CURB - 65 criteria?
Assesses the severity of pneumonia:
- Confusion
- Urea/BUN > 20
- RR _>_30
- SBP < 90 OR DBP < 60
- > 65 yrs
1 pt each. severity; send inpatient or outpt
- 0-1: outpatient
- 2: short inpatient or closely monitored supervised outpatient
- 3+: inpatient admission, consider ICU admin
if chest x ray is negative for pneumonia
- can still treat for PNA if clinical presentations is suggestive!!
- may not show up for the first 24 hrs
- if have strong suspicion, treat!
initial treatment for outpatients with CAP
- no comorbidites → Amoxicillin, Doxycycline or macrolide (if local pneumococcal resistance < 25%)
- yes comorbidities → amoxicillin/clavulanate or cephalosporin AND macrolide/doxy
- OR just fluoroquinolone
complications of pneumonia
- Pleural effusion
- consider if worsening after 3 days of antibiotics or worsening dyspnea or cough
- Empyema - collection of pus in pleural space
- need to be drained
- bacteremia
- sepsis
pneumonia prevention
- PCV13 if > 65 yrs, then 1 yr later get PPSV 23
- if got PPSV23 at > 65yrs, then 1 yr later get PCV13
- if got 23, have to wait 5 yrs for the next 23
pneumonia sx’s in pediatrics
- **tachypnea**
- Respiratory distress
- nasal flaring, retractions, rales
- *Signs of consolidation
- Lower lobe pneumonia
- Abd pain, vomit
- Poor feeding, irrit, letharagy
- Viral pneumonia
- More common age 1 month to 5 yrs
- Gradual onset of fever, cough, nasal congestion
- More common age 1 month to 5 yrs
evaluating pneumonia in peds
- Ask about immunizations, maternal health, and birth complications in neonates
- NO chest xray
- Imaging and labs if mild → outpatient
- Blood cultures if moderate - severe
- Viral culture for flu considered if flu season
- sputum culture if have sputum
- chest xray if dx is unclear in infants/young
management of pneumonia in peds
- Hospitalization
- < 3 months: fever, poor intake, pulmonary conditions
- > 3 months: respiratory distress, poor feeding, <90% O2, toxic appearing, doesn’t respond to antibiotics
- everyone: issues at home
- Outpatient treatment
-
No antibiotic treatment if:
- < 4 yrs old with mild symptoms
- flu and no evidence of bacterial pneumonia
- if not improving in few days → consider chest x ray
- < 5 yrs → Amoxicillin 90 mg
- > 5 yrs → Azithromycin
- Prevention
- Immunizations / flu shots / pneumococcal / pertussis
-
No antibiotic treatment if:
indications for hospitalization in peds for pneumonia
- Moderate - severe pneumonia:
- respiratory distress-retractions tachypnea, hypoxemia
- O2 sat < 90%
- altered mental status
- Suspicion of MRSA
- Underlying cardiopulmonary conditions, metabolic disorders, neurologic disorders or developmental delay
- Infants less than 4 to 6 months old
risk factors for primary pneumothorax
- spontaneous rupture of pulmonary or sub pleural bleb in pleural space
- Age 20-30, male, smoking, tall stature, thin body habitus, underlying lung disease
secondary pneumothorax
- Lung disease
- Connective tissue disease
- lung cancer
pneumothorax symptoms/on exam
- May be asymptomatic
- Sudden
- Chest pain
- Unilateral/Sharp/Pleuritic
- Dyspnea, tachycardia, diaphoresis
- Tracheal deviation
- cyanosis
- Hyper resonnance to percussion
- decrease lung expansion
pneumothorax diagnostics
- Chest xray of PA and lateral during inspiration but only 50% sensitive
- Visceral pleural line outlining edge of lung, absence of lung markings
- CT gold standard
pneumothorax management (primary vs secondary)
- Tension → Medical emergency ! ED
- Primary
- < 2 cm between lung and chest wall and stable; no breathlessness → observation
- Any size with breathlessness or > 2 cm → ED
- needle aspiration
- Risk factors
- male, tall, thin.
- Smokers
- Secondary
- Refer to ED
- Smoking cess
- Can recur
- Can’t travel by airline
- Needle aspiration or chest tube
- Refer to ED
most common cause of Pulmonary Embolism
deep vein thrombosis
risk factors for PE
- 40% no predisposing RF’s
- DVT or history of DVT or PE
- Cancer
- Immobilization (surgery, longdistance travel)
- Pregnancy/postpartum
- Medications/hormones
- Obesity
- > 60
- Blood clotting disorder
- Infection
- Autoimmune disease
- A-fib or MI within past 3 months
- Smoking
sx’s of PE
- SOB
- tachypnea
- sharp stabbing chest pain, worsen with inhalation
- hypotension
- tachycardia
- hemoptysis
- sx’s of DVT before PE
diagnostics of PE
Dx: CT angiography (CTPA)
D-dimer useful for excluding but not confirming PE [if + → get CTPA]
- Prediction models (Wells, PERC) to guide diagnostic testing
- Chest x-ray
- ECG
- Pulse oximetry
- ABG
- Ventilation/perfusion (V/Q) lung scan
- Anticoagulation
- CBC, PT/INR, BUN, C
PE management
- Anticoagulation ASAP
- # 1 LMWH
- unfractionated heparin
- warfarin
- rivaroxaban
- Long-term therapy
- Eliquis or xarelto
- warfarin (heparin to warfarin bridge) x 3 months
2 criteria testings for PE
Well’s criteria
PERC rule
most common bacterial CAP in adolescents?
mycoplasma pneumoniae
D. 48- 72 hours
For a child treated for uncomplicated pneumonia as an outpatient, when should a repeat chest xray be obtained to document clearance for pneumonia?
CXR NOT needed to document clearance of pneumonia
upper respiratory infection (common cold) sx’s
c/b rhinovirus (100 different types)
- starts with a scratchy sore throat, fatigue, mild fever, and runny nose, cough, possibly conjunctivitis
- peak around day 3 and 5; resolve by day 10. Cough last to resolve
URI management
- Supportive
- hydration, rest
- Infants
- normal saline or saline nasal drops
- humidifier
- elevate the head of the bed.
- > 6 yrs & adults = OTC cough suppressants or decongestants c
- Tylenol or acetaminophen for sore throat or a mild fever.
bronchiolitis
- RSV most common
- < 2 yrs old
- winter
- inflammation bronchiolar epithelium and edema of submucosa, excessive mucus production
bronchiolitis sx’s
- Fever
- Rhinorrhea
- Cough
- Wheezing
- Respiratory distress
- Grunting • Nasal flaring • Retractions
bronchiolitis diagnosis
- Based on history and exam findings
- Labs or imaging not needed
- < 2 months = get Urine culture
- increased risk of UTI
- Assess severity
- Risk factors for severe:
- Infants < 3 months
- Prematurity
- Immunodeficiency
- infants/children with cardiopulmonary disease
- Risk factors for severe:
- Pulse oximetry
- RSV culture
bronchiolitis management
- Hospitalization if
- Severe respiratory distress (grunting, retractions, RR >70)
- HR > 180
- O2 sat < 90%
- < 3 months
- Premature
- Poor oral intake
- Tx: Supportive care
- Hydration, nasal suctioning, humidification, fever control, elevate head
- Nebulized saline
- Education
- When to bring child back in, lethargic not feeding well
- s/sx of resp distress
- At risk of asthma or wheezing in future but most recover in 5-7 days
epiglottis
- HIB vaccine prevention
- abrupt onset EMERGENCY! do not examine throat
- Age 1-5
- Severe respiratory distress
- No barking cough
- fever
- Tripod position
- Drooling
- Toxic appearing
- muffled voice
epiglottitis diagnostics & management
- order blood cultures
- early consult with otolaryngologist and anesthesiologist
- establish airway and start antimicrobials
- NO SUPINE
- admin IV broad spectrum ampicillin/sulbactam, cefotaxime, ceftriaxion
- O2 & respiratory support
