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Fitzgerald Review > Ch 9 Lower Respiratory Tract > Flashcards

Ch 9 Lower Respiratory Tract Flashcards

1
Q

atypical pneumonia/walking pneumonia pathogens

A

Mycoplasma pneumoniae
Chlamydia pneumoniae

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2
Q

Atypical pneumonia (M pneumoniae, C pneumoniae) sx’s

A

less severe sx’s
dry cough
large cough transmitting close proximity (correctional facilities, dorms, long-term care facilities, small offices)

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3
Q

Legionella organism is contracted by

A

inhaling mist or aspirating liquid from contaminated water source
NO evidence for person to person spread

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4
Q

pathogens that cause Community-Acquired Pneumonia (CAP)

A

if no comorbidities: S pneumonia, M pneumoniae, C pneumonia
if co: S p, M.p., C. p. AND H influenzae, Legionella spp

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5
Q

legionella organismal major risk factors for contraction

A

older age, male, smoking, DM

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6
Q

CAP lab orders

A

order:
-CBC with diff (check for anemia and bacterial shift and immune sys responding)
-BUN/Cr (dehydration; poor renal fxn = lesser outcome)
-chest x ray (confirms)

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7
Q

how long for CAP therapy?

A

5 days of antibiotics
- afebrile for 2-3 days before stopping antibiotics (ave 5-7 days)

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8
Q

what antibiotics for CAP with no significant comorbidities? (COPD, DM, renal/heart failure, asplenia, alcohol use disorder)

A

AABCDE
oral: azithromycin, amoxicillin, Biaxin/clarithromycin, doxycycline, or erythromycin

check if >20% rate of resistance in my area

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9
Q

what antibiotics for CAP with significant comorbidities? (COPD, DM, renal/heart failure, asplenia, alcohol use disorder)

A

PO fluoroquinolone (moxi - , levfloxacin)
OR
doxy or azithromycin or clarithromycin PLUS amoxicillin-clavulanate, cefpodoxime, cefuroxime

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10
Q

physical examination of pneumonia

A

-fever (>100.4F)
-tachypnea (24 or more RR)
-crackles or rales (inspiratory, clicking, rattling) does not go away with a cough
-consolidation (dullness to percussion; increased tactile fremitus/tissue density)
-pleuritic friction rub (sharp, localized pain worse with deep breath/cough)

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11
Q

what is the most sensitive and specific finding for pneumonia, esp in children and elderly?

A

tachypnea

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12
Q

how do you determine if a pt needs inpatient care for pneumonia?

A

CURB 65
-Confusion of new onset (delirium, new-onset mental status change)
-blood Urea nitrogen > 19 (hydration status)
-RR 30 or more
-BP SBP < 90 or DBP < 60
-65 years or older

score of:
0-1: outpatient with oral antibiotics
2: consider short stay hospital or watch closely as outpatient, adequate home support. oral or IV antibiotics by severity, GI function, care setting
3-5: require hospitalization possible ICU; IV antib

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13
Q

pulse pressure

A

systolic BP - DBP
ex: 114/70 = 44

40-60 range is healthy
< 40 is bad cardiac output = heart failure

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14
Q

what condition do you assess along with signs of pneumonia?

A

signs of heart failure!
pneumonia dramatically increases right sided heart workload

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15
Q

how is bronchitis similar to pneumonia?

A

everyone with pneumonia will have infected bronchus and lung parenchyma

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16
Q

how long does the continued fatigue and SOB last after pneumonia tx last?

A

few weeks-months

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17
Q

when does the chest x-ray clear up from pneumonia?

A

takes 1-2 months for the lungs to clear up. so don’t need repeat chest x-ray once pneumonia diagnosed has been made

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18
Q

acute bronchitis

A

lower airway inflammation with cough, with or without sputum production
NO fever and tachypnea
lasting >5 days, usually after URI
-only in absence of asthma, COPD or other airway diseases

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19
Q

most likely causative organism for acute bronchitis

A

respiratory tract VIRUSES

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20
Q

acute bronchitis management

A

most resolve without treatment (>75%)

If have a protracted, problematic cough, can give:
-inhaled bronchodilator via MDI (SAMA: ipratropium bromide Atrovent)
or SABA (albuterol, Proventil)
or short course prednisone 40 mg PO QD x 3-5 days

in <5% pts with bacterial pathogens (M pneumonia, C pneumonia): RARE
- oral macrolide (azithromycin, clarithromycin, erythromycin, or doxycycline)

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21
Q

pneumonia vs bronchitis
Fever >100.4F?
tachypnea 24 or more?
consolidation, crackles on chest exam?
cough?

A

Fever >100.4F? pnuemonia

tachypnea 24 or more? pneumonia (difficult with O2 exchange bc of infection of parenchyma of lung)

consolidation, crackles on chest exam? pneumonia

cough? both

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22
Q

asthma defined

A

chronic airway inflammation

airway inflammation first, then bronchospasm follows after

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23
Q

asthma sx’s

A

wheeze, SOB, chest tightness and/or cough due to variable airflow obstruction and bronchial hyperresponsiveness due to airway inflammation

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24
Q

how to diagnose asthma?

A

spirometry needed to diagnose!
peak flow is used for monitoring (not dx)

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25
Q

goals of asthma therapy

A

good control of sx’s and maintain normal activity
-minimize risk of asthma related death, exacerbations

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26
Q

what are the rescue/reliever medications PRN?

A
  • short acting beta 2 agonist (SABA’s)
    albuterol (Proventil)
    p[irbuterol (Maxair_
    levalbuterol ( xopenex)
27
Q

when to use SABA medications?

A

for acute bronchospasm
if use more than 2 days a week, need better control of airway inflammation

28
Q

controller medications for asthma: ICS

A

inhaled corticosteroids (ICS) prevent airway inflammation
preferred controller therapy
used DAILY for control, PRN for reliever

mometasone
fluticasone
budesonide
beclomethasone

29
Q

controller medications for asthma: ICS/LABA

A

ICS= airway inflammation
LABA= prevents bronchoconstriction
used DAILY for control, PRN for reliever

Budesonide + formoterol (Symbicort)
fluticasone + salmeterol (Advair)
Mometasone + formoterol (Dulera)

30
Q

if asthma is NOT adequately controlled with ICS + LABA, what is an add on med and how to use?

A

add in long-acting muscarinic antagonist (LAMA)
Tiotropium bromide (Spirvia). It’s a bronchodilator via cholinergic/muscarinic receptor

NEED consistent daily use for optimal effect

31
Q

during asthma flare, give

A

systemic corticosteroids = provides aggressive tx of inflammation

prednisone 40-60 mg PO x 3-10 days (taper not needed)
prednisolone
methylprednisolone
dexamethasone

32
Q

when do you need steroid taper off?

A

2 weeks or more would cause adrenal suppression so that is when you’d need to taper off. 5-7 days of prednisone for asthma flare is not long enough needed for a taper off

33
Q

controller medications for asthma: leukotriene modifiers (Montelukast/Singulair)

A

prevents the formation of airway inflammation

discourage as 1st line bc BOX WARNING: neuro psych events: anxiousness, depression, hallucinations, insomnia, and SI

34
Q

what med to give if have asthma sx’s < 2 times a month?

A

low dose ICS/formoterol
-can be used as controller AND/OR reliever

35
Q

what med to give if have sx’s 2 or more a month but NOT daily?

A

DAILY low-dose ICS or low-dose ICS/formoterol PRN

36
Q

what med to give if have sx’s most days, or waking up with asthma 1 or more a week?

A

controller: low dose ICS/LABA
reliever: low dose ICS/formoterol PRN or SABA PRN

37
Q

what questions do you want to ask to assess asthma control in 12 and older pt’s to assess?

A

in the past 4 weeks…
1. any daytime asthma sx’s more than 2x/week?
2. any night awakening due to asthma?
3. SABA reliever for sx’s >2x/week?
4. any activity limitation due to asthma?

if 0: well controlled, 1-2: partially, 3-4: uncontrolled

38
Q

when to measure FEV1?

A

at time of diagnosis,
after 3-6 months of controller therapy,
then periodically for ongoing risk assessment

39
Q

what potentially modifiable risk factors for asthma exacerbations

A

-meds: high SABA use, inadequate ICS, poor adherence, wrong inhaler technique
-other med conditions (obesity, chronic rhinosinusitis, GERD, confirmed food allergy, pregnancy)
-exposure (smoking, allergen, air pollution)
-poor lung function (FEV1 < 60%)

40
Q

air trapping conditions and objective findings

A

COPD (exacerbations)
asthma (exacerbations)

-hyper resonance on percussion
-decreased tactile fremitus (excess air in lungs)
-wheeze (expiratory first, then inspiratory later)
-low diaphragms
-increased anteroposterior (AP) diameter = barrel chest in COPD or longstanding poorly controlled asthma

41
Q

if a beta 2 agonist isn’t working too well, think

A

airway inflammation is present! since it is normally a potent bronchodilator

42
Q

FEV1 measures

A

lower airway obstruction and can compare

43
Q

what is COPD (chronic obstructive pulmonary disorder)?

A

includes chronic bronchitis AND emphysema
-irreverisble airflow limitation
-destruction/remodeling of airway and alveoli damage
-SMOKING

44
Q

most common sx’s of COPD

A

chronic cough & sputum production
activity intolerance
dyspnea on exertion!! (worse with exercise)

45
Q

most common COPD risk factors

A

exposure irritants (tobacco use, occupational exposure to irritants)
indoor/outdoor air pollution
family hx of COPD, advancing age
consider dx in any individual who has dyspnea, chronic cough, or sputum production and/or hx of exposure to risk factors

46
Q

goals of COPD

A

relieve sx’s
relieve exacerbations and improve exercise tolerance and health status

exacerbations worsen and deconditions the health

47
Q

COPD diagnosis

A

FEV/FVC < 0.70 AFTER/post bronchodilator use confirms persistent airflow limitation/COPD
spirometry is required for diagnosis

48
Q

what are the questionaires to assess COPD sx’s?

A

COPD assessment test (CAT) or the clinical COPD questionnaire (CCQ)

49
Q

COPD classification of airway limitation

A

GOLD 1: Mild: FEV 80%+
GOLD 2: Moderate: 50-80%
GOLD 3: Severe: 30-49%
GOLD 4: Very Severe: <30%

Gold 3 & 4 is mostly seen in office (1 & 2 hasn’t been diagnosed yet)

50
Q

Meds used in COPD treatment

A

-SABA (albuterol), SAMA (iptratropium bromide) = PRN for relief of bronchopsasm
-inhaled LABA (salmeterol) = DAILY use for protracted duration bronchodilator
-inhaled LAMA = DAILY use for protracted duration bronchodilator and minimizes risk of COPD exacerbation
-ICS = DAILY use for anti-inflammatory, minimizes COPD exacerbation but modest increase in pneumonia risk
-oral theophylline = DAILY use for bronchodilator (NARROW TI and $$)
-oral PDE-4 inhibitor (roflumilast) = DAILY use to min exacerbation but mood destabilization

51
Q

First-line stage for COPD treatment for GOLD 1 & GOLD 2

A

in pt’s with FEV1/FVC < 0.70 post bronchodilators:

GOLD 1 (FEV1>80%) & 2 (50-80%) (mild to moderate) with 1 or less exacerbation per year,

with less sx’s: give SAMA (ipratropium/Atrovent) or SABA (albuterol, proventil) prn

with more sx’s: give LAMA (tiotropium/Spiriva) or LABA (salmeterol /Servent)on set schedule

(LAMA better though)

52
Q

LAMA vs LABA for COPD treatment

A

LAMA has added benefit of minimizing COPD exacerbation

53
Q

**First-line stage for COPD treatment for GOLD 3 & GOLD 4

A

in pt’s with FEV1/FVC < 0.70 post bronchodilators:

GOLD 3 (FEV 30-50%) & 4 (<30%) with 2 or more exacerbations per year:

High exacerbation risk with less sx’s: give LAMA (tiotropium) on set schedule (NOT prn)

High exacerbation risk with more sx’s: give LAMA (tiotropium) or (LABA (salmeterol) + LAMA) or (ICS + LABA) on set schedule

54
Q

causes of COPD exacerbations

A

change in baseline (dyspnea, cough, sputum) that needs change in management

-60% tobacco, air pollution, viral RTI
-40% bacterial (gram - H influ, moraxella catarrhalis) and gram + S. pneumoniae

55
Q

COPD exacerbation treatment

A

-bronchodilators (SABA and/or SAMA prn)
add LABA or LAMA if pt not currently using
- prednisone x 5 days to shorten recovery time, and hypoxemia, and minimize relapse risk
-mixed evidence on antibiotics use (5-7 days)

56
Q

which medication do you avoid with use with ace inhibitors/arbs, esp with CKD and/or dehydration due to hyperkalemia

A

TMP-SMX (bactrim)

57
Q

which medication is vulnerable to destruction by beta-lactamase

A

penicillins (amoxicillin)

58
Q

which medication has QT long elongation, esp in those with higher CVD risk?

A

macrolides (Azithromycin)

59
Q

which medication is a/s with tendon rupture risk, esp when used with systemic corticosteroid?

A

fluoroquinolones (tendon rupture risk increases by 40% when sued with systemic corticosteroids Moxifloxacin

60
Q

which meds have less than 1% cross risk of penicillin allergy?

A

-cephalosporins (cefpodoxime)
-can use cephalosporines in NONanaphylactic reactions

61
Q

antimicrobial therapy in COPD exacerbation in outpatient setting

A

consider risk vs benefit ratio
-PUT on steroid! calms down swelling that produces phlegm
-antib usually not indicated

62
Q

mild to moderate COPD exacerbation in antib therapy

A

-prednisone

IF prescribed, use 1 of these x 5 days:
-Amoxicillin (strep pneumo, Hflue, mcat)
-TMP-SMX (not for comorbities)
-Doxycycline (will take care of the strep pneumo, H flu, Mcat)
-Cephalosporin (cefdinir, cefpodoxime, etc)

63
Q

more severe COPD exacerbation

A

antib debated.. if give, consider risk/benefit ratio
consider severity and comorbidities
give prednisone and..

1 of these for 5 days:
-Beta-lactam: amoxicillin-clavulanate (Augmentin; tough on stomach so don’t give), cephalosporin (easy on stomach; prob best antib choice out of all these), –Macrolides: azithromycin (prolong QT), clarithromycin,
-Fluroquinolones: moxi-, levofloxacin (consider tendon rupture; avoid bc they’re already on a steroid)

64
Q

long term O2 therapy in COPD

A

using it >15 hrs a day (not PRN)
ensure adequate O2 delivery by keeping Sa o2 >90%

Fitzgerald Review (22 decks)

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