Week 5 Respiratory Flashcards by Danielle Chambers

What organism is the main cause of pharyngitis?

Group A Strep (GAS)

streptococcus pyogenes

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What might GAS cause? (2)

post streptococcal glomerulonephritis

acute rheumatic fever (now rare in US)

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What is the presentations of GAS pharyngitis throat pain?

usually severe

often worse on 1 side

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What is the initial treatment of GAS pharyngitis?

amoxicillin 20mg/kg/dose (max 500 mg/dose) given BID

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How many days should amoxicillin be given for GAS pharyngitis?

10 days

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Why should azithromycin be avoided in GAS pharyngitis?

strep rapidly develops resistance to macrolides

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When should azithromycin be considered for GAS pharyngitis?

if PCN allergy

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What is the newly recognized cause of pharyngitis?

fusobacterium necrophorum pharyngitis

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What organism is endemic in adolescents and young adults and may cause up to 10% of pharyngitis in this age group?

fusobacterium necrophorum pharyngitis

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What is a life threatening complication of fusobacterium necrophorum pharyngitis?

Lemierre Syndrome

mortality 5%

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What is significant about the presentation of F. necrophorum pharyngitis?

lac of cough

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What do you use for the treatment of F. necrophorum pharyngitis?

clindamycin or

PCN + metronidazole

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What cough should you not suppress?

a productive cough

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When should you typically suppress a cough?

if cough is tiring or sleep-limiting

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When should you use antitussives for cough?

non-productive

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What should be given for productive coughs?

expectorants

mucolytics

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How should benzonatates (tessalon) be taken?

should be Swallowed without chewing

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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)

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What is the MOA of dextromethorphan (Robutussin)?

inhibits the central (medullary) cough center

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What type of medication is Guaifenesin (glyceryl guaicolate)?

cough-expectorant

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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

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What medication is a sulfhydryl group that opens disulfide bonds in mucoproteins thereby reducing viscosity?

N-Acetylcysteine (NAC, Acetadote, mucomyst)

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What is an example of a cough-mucolytic?

N-Acetylcysteine (NAC, Acetadote, mucomyst)

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How is N-Acetylcysteine (NAC, Acetadote, mucomyst) administered?

administer via aerosolization or nebulization

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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?

What risk class is considered high?

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)