Acute Respiratory- Adults Flashcards
acute bronchitis
- Acute bronchitis is a lower respiratory tract infection involving the large airways (bronchi), without evidence of pneumonia, that occurs in the absence of chronic obstructive pulmonary disease.
- Self-limited inflammation of the bronchial respiratory mucosa leading to productive or non-productive cough
acute bronchitis: s/s
o Cough persisting > 5 days
o Dry or Productive
o May last several weeks
o +/- wheezes, rhonchi (will clear with cough)
o Fever/systemic symptoms typically absent
o Chest wall tenderness from coughing is common
o Often preceded by URI symptoms
acute bronchitis: diagnostics
o Based on hx and PE
o Focus should be on ruling out more serious illness
o CXR indicated only when clinical features suggest pneumonia
acute bronchitis: differentials
o Pneumonia, COVID, Influenza, etc.
o Postnasal drip/upper airway cough syndrome
o GERD
o Asthma
o COPD
o ACEI use
o Heart Failure
o PE
o Lung Cancer
tx for symptomatic acute bronchitis
o Cough suppressants:
* Dextromethorphan
* Guaifenesin
* Honey
* Codeine
o Humidification
oAntihistamine/Decongestants/Analgesics – if associated URI symptoms or muscle pain from cough
o Inhaled beta-agonists: Albuterol
* If wheezing or underlying lung disease
o Antibiotics are generally NOT indicated
acute bronchitis: pt education
o A nagging cough can last for several weeks
o Antibiotics are not indicated for acute bronchitis
o **You should follow-up in the office if you develop:
* A fever higher than 100.4°F (38°C)
* Chest pain when you cough, trouble breathing, or coughing up blood
* New discolored mucus (getting progressively darker)
* A barking cough that makes it hard to talk
* A cough and weight loss that you cannot explain
- Pneumonia is unlikely if all of the following are absent:
- fever >/ 100.4
- tachypnea >/ 24
- tachycardia >/100
- evidence of consolidation on chest exam: rales, egophony, fremitus
pertussis “whooping cough”
highly contagious
pertussis presentation
o Stage 1: Catarrhal period 1-2 weeks
* Nonspecific malaise, rhinorrhea and mild cough
* Excessive lacrimation and conjunctival injection are usually present
o Stage 2: Paroxysmal coughing fits that can last 2-3 months
* Characteristic “whoop” or barking cough
* Post-tussive syncope or emesis often present
* Otherwise feel well
o Stage 3: Convalescent; less persistent cough lasts 1-2 weeks
pertussis clinical criteria for testing
o Cough lasting >/= 2 weeks, without a more likely diagnosis and at least 1 of the following:
* Paroxysms of coughing
* Inspiratory whoop
* Posttussive vomiting
diagnosis pertussis
choice of testing depends on duration of cough
* culture (nasal swab or aspiration): gold standard
* PCR (nasal swab or aspiration)
* serology
tx of pertussis
o 1st line: Macrolide antibiotics (azithro or clarithromycin)
o 2nd line: Bactrim
o Close contacts should also be treated regardless of immunization history
o Abx treatment does not necessarily improve cough symptoms but reduces transmission to others
complications of pertussis
o Super-Infection (Pneumonia)
o Mechanical r/t severe cough (abd hernia, subconjunctival hemorrhage, rib fractures)
o Morbidity and mortality most common in infants and young children
o Adults can experience significant time away from work/school, social isolation, sleep deprivation, anxiety
pertussis prevention–vaccination
- Tdap: tetanus booster + reduced dose of diphtheria and pertussis approved for age 11-64
1 dose between 11 and 18
1 booster dose between 19 and 64 - Adults > 64 who have not previously received Tdap should receive a single booster
- Pregnant women should receive a Tdap booster btwn 27 and 36 weeks during every pregnancy
pneumonia
- Infection of the lower respiratory tract classified by how it is acquired
pneumonia etiology
o Typical bacteria: Streptococcus pneumoniae (60-70%) (although incidence is decreasing), Haemophilus influenzae, and Moraxella catarrhalis
o Atypical bacteria: Legionella pneumophila, Mycoplasma pneumoniae, and Chlamydophila pneumoniae
o Viruses: Influenza, rhinovirus, adenovirus, COVID-19
pneumonia risk factors
o Older age (>65)
o Smoking
o Alcohol use >80 gm/d (> 5 drinks)
o Comorbidities (COPD/lung disease, CHF, DM, malnutrition, stroke, immunocompromise)
o Viral respiratory infection
o Crowded living conditions
presentation pneumonia
loof for fever, chills, rigors, cough, malaise
presentation pneumonia typical
- age <5 or >40
- onset: abrupt
- cough: productive
- sputum: rusty/purulent
- rigors: often present
- fevers > 39 C
consolidation: present
leukocytosis: 15+, shift
presentation pneumonia: atypical
- age: <40
- onset: gradual
- cough: paroxysmal, non-productive
- sputum: minimal, mucoid
- rigors: absent
- fevers <39 C
- consolidation: often absent
- leukocytosis: often absent
pneumonia diagnosis
o Physical Exam:
* Full HEENT, respiratory exam, cardiac exam
* Significant findings: rales (unilateral= bacterial; bilateral= atypical) that do not clear with cough, bronchial breath sounds, dullness to percussion, egophony (E to A changes)
* Imaging:
* CXR (A/P plus lateral): can be normal in early disease, may show infiltrative changes
pt teaching pneumonia
o Clear directions for antibiotic use
o Follow up in 24 to 48 hours by phone or in person
o Push fluids by mouth
o Use antipyretics prn fever & myalgias
o If constant non-productive cough, try codeine, esp. qhs
tx pneumonias
o IDSA guidelines: monotherapy with Amoxicillin, Doxycycline, or Macrolide if there are risk factors for MRSA, pseudomonas, or comorbidities
o Duration of Treatment
* Outpatient: generally 5 days
follow-up pneumonia
o Clinical follow-up 24-48 hours after initiation of treatment is appropriate
* Assess VS, mentation, appetite
referral to hospitalization: pneumonia
o CURB-65 Calculator– Confusion, Uremia >7, RR >/ 30, BP <90/<60, Age>/65
o Pneumonia Severity Index (PSI) Calculator
pneumonia prevention
o Smoking cessation
o Influenza vaccination
o Pneumococcal vaccination for at risk patients
o Ongoing infection control measures
pneumonia vaccination
PCV20 - Pneumococcal polysaccharide vaccine
* average risk adults >/ 65- one dose
PPSV23
* recommended for adults >/ 65 and persons 19-64 with DM, ETOH, liver disease, cigarette smoker, chronic heart disease
PCV7/13/15/20
* childhood series, adults >/65, adults with immunocompromise, asplenia, CSF leak, cochlear implant, advanced kidney disease
infiltrative changes: typical pneumonia
unilateral: only one side of the lobe is inflamed and will be seen on imaging
infiltrative changes: atypical pneumonia
bilateral– both lower lobes are severely inflammed and will see on imaging
COVID-19: s/s
o Cough
o Fever
o Myalgias
o Headache
o Dyspnea
o Sore throat
o Diarrhea
o N/V
o Chest pain
o Anosmia or other smell abnormalities
o Agnosia or other taste abnormalities
o Rhinorrhea and/or nasal congestion
o Confusion
testing for COVID-19
o Symptoms= test immediately
o Exposed to COVID-19 w/o sx, wait at least 5 full days before testing. Too early = false negative
o If you are in certain high-risk settings*, routine testing programs.
o Consider testing before contact with someone at high-risk for severe COVID-19, especially if you are in an area with a medium or high COVID-19 Community Level.
o **High-risk settings: congregate living, prisons, LTC, hospitals
