Week 5 Respiratory Flashcards
What organism is the main cause of pharyngitis?
Group A Strep (GAS)
streptococcus pyogenes
What might GAS cause? (2)
post streptococcal glomerulonephritis
acute rheumatic fever (now rare in US)
What is the presentations of GAS pharyngitis throat pain?
usually severe
often worse on 1 side
What is the initial treatment of GAS pharyngitis?
amoxicillin 20mg/kg/dose (max 500 mg/dose) given BID
How many days should amoxicillin be given for GAS pharyngitis?
10 days
Why should azithromycin be avoided in GAS pharyngitis?
strep rapidly develops resistance to macrolides
When should azithromycin be considered for GAS pharyngitis?
if PCN allergy
What is the newly recognized cause of pharyngitis?
fusobacterium necrophorum pharyngitis
What organism is endemic in adolescents and young adults and may cause up to 10% of pharyngitis in this age group?
fusobacterium necrophorum pharyngitis
What is a life threatening complication of fusobacterium necrophorum pharyngitis?
Lemierre Syndrome
mortality 5%
What is significant about the presentation of F. necrophorum pharyngitis?
lac of cough
What do you use for the treatment of F. necrophorum pharyngitis?
clindamycin or
PCN + metronidazole
What cough should you not suppress?
a productive cough
When should you typically suppress a cough?
if cough is tiring or sleep-limiting
When should you use antitussives for cough?
non-productive
What should be given for productive coughs?
expectorants
mucolytics
How should benzonatates (tessalon) be taken?
should be Swallowed without chewing
What is non-opioid antitussive that is the d-isomer of the codeine analog of levorphanol but lacks the analgesic and addictive properties?
dextromethorphan (Robutussin)
What is the MOA of dextromethorphan (Robutussin)?
inhibits the central (medullary) cough center
What type of medication is Guaifenesin (glyceryl guaicolate)?
cough-expectorant
What is the MOA of Guaifenesin (glyceryl guaicolate)?
increases respiratory tract secretions
helps loosen phlegm and bronchial secretions
reduces secretion viscosity
increases efficiency of mucociliary mechanism
What medication is a sulfhydryl group that opens disulfide bonds in mucoproteins thereby reducing viscosity?
N-Acetylcysteine (NAC, Acetadote, mucomyst)
What is an example of a cough-mucolytic?
N-Acetylcysteine (NAC, Acetadote, mucomyst)
How is N-Acetylcysteine (NAC, Acetadote, mucomyst) administered?
administer via aerosolization or nebulization
What organism causes pertussis (whooping cough)?
Bordatella pertussis
What do they call Pertussis in China?
cough of 100 days
What are the atypical presentations that are very common in Pertussis?
completely or partially immunized patients
adolescents or adults
What population usually experiences complications of pertussis?
infants less than 6 months old
What is the classic presentation of cough that occurs frequently?
paroxysmal cough
post-jussive emesis occurs frequently
What has caused the increase in pertussis incidence?
waning immunity (maybe as short as 3-6 years? worse with newer "acellular" vaccines (vs. older "whole cell")
Why is the whole cell pertussis vaccine no longer used?
many severe complications
When should you consider pertussis?
in ALL children with cough longer or equal to 14 days
What is the treatment for pertussis?
erythromycin
How long should erythromycin be given for pertussis to prevent relapse?
14 days
What are the alternative agents for pertussis?
clarithromycin
azithromycin
trimethoprim/sulfamethoxazole (bactrim)
What is the MOA of decongestants?
sympathomimetics (alpha agonists)
produce vasoconstriction
What can happen with prolonged use of decongestants? (>3-5 days)
may produce rebound congestion
therefore limit dose and frequency
What is a topical long acting decongestant? (up to 12 hours)
Oxymetazoline HCl (Dristan) Xylometazoline (Otrivin)
What is significant about systemic decongestants?
much lower incidence of rebound decongestion
results typically last longer than topicals
What decongestant has restrictions by law behind the counter?
pseudoephedrine
Why does pseudoephedrine have law restrictions?
used in the illegal making of methamphetamine
What is MOA on alpha 1 and beta receptors of systemic decongestents?
potent selective alpha 1 agonist = vasoconstriction
activate beta receptors at HIGHER concentrations
What are the phenylephrine CVS side effects? (Vicks)
htn
arrhythmia (rare)
stroke (rare)
What are the phenylephrine CNS side effects? (Vicks)
headache
anxiety
tremor
restlessness
What are the pseudoephedrine (sudafed, dimetap) CVS side effects?
htn
palpitations
tachycardia
stroke (rare)
What are the pseudoephedrine (sudafed, dimetap) CNS side effects?
headache
insomnia
nervousness
excitability
What should be avoided in htn?
BOTH phenylephrine and pseudoephedrine
What are examples of systemic decongestants?
phenylephrine(Vicks Sinex) and pseudoephedrine (Sudafed, Contac, Dimetap)
What medications are used for immediate-type hypersensitivity reactions?
antihistamines
All antihistamines have varying degrees of what, which provides varying degrees of usefulness?
anticholinergic and antimuscarinic activity
What is the MOA of antihistamines?
reversible, competitive H1- receptor antagonists
reduce or prevent physiologic effects of histamine release
Antihistamines have no effect on what?
pre-released histamine
What antihistamines bind toperipherpl & CNS receptors producing sedation?
first-generation agents
What is significant about second-generation antihistamine agents?
are peripherally selective-therefore much less sedating
What are examples of 1st generation antihistamine agents?
ethanolamines (Diphenhydramine-Benadryl)
Phenothiazines (Promethazine-Phenergan)
Piperazines (Hydroxyzine-Vistaril)
What are examples of 2nd generation antihistamines?
Phthalazinone (azelastine-Astelin)
Piperazine (Cetirxine-zyrtec)
Piperidines (lartadine-claritin, desloratadine-Clarinex, fexofenadine-allegra)
What medication is an active metabolite of hydroxyzine?
Piperazine-cetirizine (Zyrtec)
What medication is an active metabolite of loratadine?
desloratadine (clarinex)
What medication is contraindicated in those hypersensitive to loratadine (Claritin)?
desloratadine (clarinex)
What medication is contraindicated in those hypersensitive to hydroxyzine (Vistaril)?
Citrizine (Zyrtec)
What is important to remember about all antihistamines with varying degrees of sedation? (4)
usually less with 2nd generation
caution against driving or tasks require alertness
supervise children in hazardous activities
avoid co-administration of other CNS depressants (drugs or alcohol)
What are the potential adverse effects of promethazine (Phenergan)?
may cause potentially fatal respiratory depression (not reversed by naloxone)
may lower seizure threshold
contraindicated in children less than 2 years
May prolong QT-interval
IV/SQ administration may cause tissue necrosis
What is the key for influenza?
Prevention! promote and practice annual immunization
What medication is chemoprophylaxis against s/s of influenza A OR treatment of uncomplicated RTI Influenza A?
Amantadine (Symmetrel)
What medication is chemoprophylaxis against s/s of Influenza A and B OR treatment of uncomplicated RTI influenza A/B?
Oseltamivir (Tamiflu)
What may decrease effective of Oseltamivir (Tamiflu)?
emergence of resistance
When should treatment be started with oseltamivir (tamiflu)?
begin within 2 days of onset of the flu symptoms
What medication is prophylaxis of the flu in patients older than 5 years of age for influenza A&B?
Zanamivir (Relenza)
What mediation is treatment of the flu A&B in patients older than 7 years of age?
Zanamivir (Relenza)
What mediation is prophylaxis and treatment of influenza A in adults AND prophylaxis against influenza A in children?
Rimantadine (Flumadine)
When should rimantadine (Flumadine) be given?
begin as soon as possible after symptoms appear, preferably within 48 hours of onset and continue for 7 days
What is the dose of rimantadine if renal function is <10 in elderly or nursing home patients
reduce to 100-mg daily
What are the common organisms of community-acquired pneumonia?
streptococcus pneumonia
haemophilus influenzae
What treatment should be given if gram positive cocci in clusters on gram stain?
possible staph aureus
add vancomycin
What should be considered if positive cocci pairs or chains on gram stain?
possible strep pneumo
What should be considered if gram negative?
pseudomonas sp.
consider adding anti-pseudomonal agent (Pip/Tazo, cefepime, imipenem)
What is a good specimen on gram stain findings?
FEW epithelial cells
many epithelial cells-mouth specimen
What are 2 other gram stain findings that may make pneumonia more likely?
Many WBCs
Many organisms with single morphology
What is significant about community acquired pneumonia organisms?
generally NOT multi-drug resistant
What are the factors that determine if pt is assigned to risk class I or MORE (II-V)
older than 50 years
h/o co-existing condition (neoplastic disease, liver disease, CHF, cerebrovascular disease, renal disease)
Any abnormalities such as AMS, resp >30, systolic BP <90, Temp <35 or >40 and pulse greater than 125
What algorithm is used to determine severity of pneumonia?
Pneumonia severity index (PSI)
How is age calculation in PSI algorithm?
men >50
women >50 - 10
What characteristics add 10 pts to severity scale?
nursing home resident CHF cerebrovascular disease renal disease pulse >125 glucose >250 Hematocrit <30% oxygen saturation less than 90%
What characteristics add 30 points to pneumonia severity scale?
neoplastic disease
arterial pH <7.35
What characteristics add 20 points to the pneumonia severity scale?
liver disease AMS Respirations >30 Systolic BP <90 BUN >30 Sodium <130
Which risk class are considered “low”?
I-III
What risk class is considered moderate?
IV
What risk class is considered high?
V
Based on algorithm what is the mortality of risk class V
27%
Based on the algorithm what is the mortality of class IV?
9.3%
Based on algorithm what is the risk of mortality of Class I?
0.1%
According to the CAP treatment algorithm what are absolute contraindications to outpatient treatment?
hypoxemia
hemodynamically unstable
active coexisting condition during hospitalization
inability to tolerate oral medications
What is the empiric abx treatment for inpatient typical pneumonia?
3rd generation cephalosporin (rocephin?) + macrolide (azithromycin?) OR doxycycline
What is the empiric abx treatment for inpatient ATYPICAL pneumonia?
beta lactam-beta lactase inhibitor + macrolide/doxycycline
What is new pneumonia after 3-5 days as inpatient?
hospital acquired pneumonia (HAP)
What is significant about HAP and what should be done?
greater likelihood of multi-drug resistance. may need to consider adding vancomycin
What provides broader MDR coverage for HAP?
high dose Pip/Tazo (Zosyn)
Cefepime (Maxipime)
Imipenum/cilastin (Primaxin)
