final - HEENT + Pulm Flashcards
(35 cards)
1
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Objectives
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- Identify common HEENT/Pulmonary complaints in the family practice setting, and diagnosis strategies
- Compare and contrast presentation and treatments for common upper and lower viral, bacterial, allergic and obstructive disease complaints
- Describe appropriate testing and imaging strategies to identify common HEENT and respiratory diseases
- Detail referral strategies for patient failing treatments or with end-of-life needs
2
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case study:
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3
Q
URIs- Upper Respiratory Infections (J0.69)
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- One of the top three most common billed disease in outpt setting.
- defined as self-limited irritation and swelling of the upper airways with associated cough with no proof of pneumonia( fever, chills, SOB) lacking a separate condition to account for the patient symptoms, or with no history of COPD/emphysema/chronic bronchitis
- Can Involves: Nares, sinuses, pharynx, larynx and large airways.
4
Q
URIs
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- Large economic burden on society (days out from work)
- Majority of visits to office are for work/school note
- Most commonly due to a virus- Rhinovirus (80% of infections)
- Other viruses: Adenovirus, Parainfluenza, RSV, enterovirus, coronavirus
- If sudden onset of pharyngitis (fever, pharyngeal exudate, cough)this can be caused 15% of the time by bacterial infection (S. pyogenes, Group A strept (GAS)
5
Q
Risk Factors fort URI
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- Close contact with children: both daycares and schools increase the risk for URI
- Medical disorder: People with asthma and allergic rhinitis are more likely to develop URI
- Smoking is a common risk factor for URI
- Immunocompromised individuals including those with cystic fibrosis, HIV, use of corticosteroids, transplantation, and post-splenectomy are at high risk for URI
- Anatomical anomalies including facial dysmorphic changes or nasal polyposis also increase the risk of URI
6
Q
Treatment Goals: (Supportive Therapy)
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Acetaminophen (650 mg p.o. every four hours as needed or 1,000 mg p.o. every six hours as needed) or NSAIDs:
- For pain, sore throat, symptomatic fever-Not necessary for asymptomatic fever
- Acetaminophen preferred over NSAIDs
Decongestants: Limited short-term benefit in adults
- No benefit in young children
Treatments with limited or inconsistent evidence:
- Some antitussives (dextromethorphan, guaifenesin) in adults
- Ipratropium bromide (Atrovent) nasal spray
- Zinc: zinc gluconate lozenges, zinc acetate lozenges; use of intranasal zinc should be avoided, may lead to permanent loss of smell.
- Echinacea preparations have limited evidence suggesting benefit but insufficient evidence to recommend specific products
- Vitamin C
- Humidifier or vaporizer
7
Q
Complications of URI- Rhinovirus
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- Secondary Bacterial Infections (Considered if Sx last longer than 14 days, purulent discharge, tenderness over the sinuses, periorbital edema)
- POSSIBLE SITES:
- Otitis Media-respiratory mucosal Inflammation causes
- obstruction of eustachian tube allowing bacteria to grow.
- Sinusitis- inflammation causes obstruction
- usually the maxillary sinus
- Reactive airway disease- dysregulates airway smooth
- muscle. T-Helper cells increase mucous production.
- Worse in the immuno-comprised patient- Cystic Fibrosis
- Rhinovirus 57% implicated for respiratory exacerbation.
8
Q
Allergic Rhinitis ( Hay Fever)
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- Pathophysiology: IgE Mediated immune response upon re-exposure to airborne allergen to eyes or nares. Local Mast cells of eye, nose mucosa degranulate, release histamine
- Type 1 Hypersensitivity reaction
- Associated with Atopy( genetic tendency to develop triad of allergic diseases - eczema, allergic rhinitis, asthma )
- S/Sx: Conjunctiva injection, eyelid edema, sneezing, rhinorrhea, boggy bluish nasal turbinate. Dennie-Morgan lines (creases in lower eyelid), allergic shiners( venous stasis), adenoid facies( sunken eyes, open retracted jaw)
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Q
allergic rhinitis tx
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- Treatment ( Avoidance, Pharmacotherapy, Immunotherapy)
- Always start with acknowledging what is the allergen and try to avoid.
- Pharmacotherapy: based on symptoms
- If affecting quality of life start with an intranasal corticosteroid (Flonase, Rhinocort)
- Immunotherapy should be considered for patients with moderate or severe persistent allergic rhinitis that is not responsive to usual treatments, in patients who cannot tolerate standard therapies or want to avoid long-term medication use, and in patients with allergic asthma.
- (SLIT)
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A
11
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SLIT->Preventing Progression to Asthma
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- SLIT (Sublingual Immunotherapy) modifies immune response in allergic children
- Reduces airway hyperreactivity and systemic allergic inflammation
- Shown to prevent transition from allergic rhinitis to asthma
- PAT Study (Jacobsen et al., 2007): 10-year follow-up found SCIT reduced asthma onset
- Cochrane Review (Penagos et al., 2016): SLIT decreases asthma symptoms and prevents new sensitizations
- EAACI Guidelines (2018): Recommend SLIT in children ≥5 years to reduce allergic disease progression
12
Q
Acute Sinusitis (J01.90)
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- In the immunocompetent patient it is almost always viral (rhinovirus) which can develop a secondary bacterial infection
Risks Factors:
- Obstruction of Sinus- Nasal polyp, chronic allergic rhinitis( inflammation), NGT
- Immunocompromised: Diabetes, HIV, prolonged ICU stay, Cystic Fibrosis (inc mucous), Ciliary dyskinesia ( won’t clear mucous)**Greater risk for aggressive Bacterial infection or fungal infection
Treatment:
- Medical drainage:
- Oral alpha-adrengic vascoconstrictor (pseudophedrine 10-14 days)
- Nasal vasoconstrictor: Oxymetazoline ( Afrin no longer than 3 days)
- Nasal Irrigations: Rinse mucous out of the nose ( Nettipot )
- Antibiotics should not be used unless persistent Sx after medical drainage treatment > 7 days or worsening of sx.
- Augmentin (Amoxicillin/Clavulanate) 875mg /125mg q12 x 10 days ( coverage for beta-lactamase-producing Moraxella cararrhalis and Haemophilus influenza)
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Sinusitis- Complications
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- Orbital Involvement- periorbital cellulitis
- Cavernous sinus thrombosis
- Epidural and brain abscess
- Osteomyelitis
14
Q
Laryngitis (Jo4.0)
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- ACUTE VS CHRONIC
- Acute: Most common cause is viral URI (rhinovirus). Usually self-limiting.
- Chronic: Lasts greater than 3 weeks:
- Environmental- cigarette smoke
- Asthma inhalers
- Vocal misuse
- GERD
Treatment:
- Acute: Inhaled humidified air, voice rest
- Chronic: Treat underlying condition- GERD-> PPI, smoking cessation
15
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Pharyngitis. (Jo2.9)
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- Make up 15% of Family Practice office visits
- Most often caused by virus (rhinovirus, adenovirus, coronavirus, RSV)
- 30% Acute pharyngitis is Bacterial- most common Group A beta-hemolytic streptococcus (GABHS) especially between the ages of 5-15, uncommon less than 3
- SX: Odynophagia (pain with swallowing) fever, malaise, HA, halitosis, muffled voice. Tonsils are swollen and red, purulent exudate
- Cough, coryza, diarrhea is more consistent with Viral etiology
16
Q
Pharyngitis- Presentation/Diagnosis
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- Pharyngitis w/
- Tender Posterior cervical LN, palate petechiae, hepatosplenomegaly = Infectious mononucleosis
- Dirty gray, thick membrane that bleeds when peeled = Diphtheria
- Fever, adenopathy, palatal petechia,
- exudate and scarlatiniform rash
- ## (Scarlet fever) = GABHSDiagnostic Testing:
- Monospot-> results in one day
- GABHS rapid Antigen Test, followed by a throat culture
- Modified Centor Score-
- Predict GABHS Pharyngitis
- ( Must have 2 criteria for testing/3 or more treat empirically)
- History of Fever
- Tonsillar exudate
- Absence of cough
- Tender anterior cervical lymphadenopathy
17
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pharyngitis complications
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18
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Pharyngitis- Treatment
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- Suppportive treatment
- Analgesia(NSAIDS/topical analgesics ( lozenges, benzocaine spray)
- Hydration
- Rest
- GABHS-> Penciliin V 500mg 2x/day x 10 days
- or
- Amoxacillin 500mg 2x /day x 10 days
19
Q
Case Study
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- 56 year old male who makes cabinets for a living presents to your practice with dyspnea. Worse this AM after climbing the stairs. He is too short of breath to answer questions. His wife relays his PMHx HTN, HLD, + Smoking history 40-pack years. VS 140/80 HR 99 RR 25 O2sat 85% on room air. PE-chest subcostal retractions, no tactile fremitus, increase resonance with percussion. Expiratory wheeze noted with auscultation. Labs: Hgb 19, Hct 57
20
Q
Important points in this Case Study
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- Tachypnea
- Hypoxia- O2Sat and elevated Hgb
- Accessory muscle use
- No tactile fremitus ( too much air)
- Expiratory wheeze
- History of smoking
- Cabinetry ? Inhaled dust
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22
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Obstructive Lung Disease
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- Characteristics:
- Inflamed and easily collapsible airways
- Obstruction to airflow
- Difficulty exhaling (air trapping)
- Hyperinflated lungs
23
Q
Obstructive Lung Disease
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- COPD-
- Airway obstruction is progressive and not fully reversible.
- Third leading cause of death in the US
- Increased worldwide due to increases in smoking
- Most common etiology is cigarette smoke 80-90% of the cases
- Other etiologies: second-hand smoke and occupational exposure (fumes from welding
- Rare cases- genetic deficiency alpha-1-antitrypsin (consider when emphysema <45 yo and non-smokers
24
Q
Signs/Symptoms COPD
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- Most common initial sx is cough
- Progresses to a daily occurrence.
- Productive thick mucous
- During an exacerbation, sputum color can change and dyspnea can worsen so that eating and talking are made difficult. Usually it is the presenting problem for COPD
- Exacerbations are usually caused by infections
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Pathophysiology- Chronic Bronchitis (J41.0)
- It is Bronchitis with airflow obstruction.
- Defined as :
- Productive cough on most days of the week for at least 3months in 2 consecutive years.
- Hypertrophy/hyperplasia of mucous glands and goblet cells in response to irritants-this causes an obstructions in airflow
- Ciliary dysfunction causes plugging of airways
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Pathophysiology- Emphysema( J43.9)
- Structural abnormality- lose ability to keep airway open and decreases recoil
- Widespread and irreversible destruction of alveolar wall and enlargement of many of the alveoli
- Early stages they can oxygenate properly ( Pink Puffers)
- Prolonged hypoventilation will cause hypoxemic vasoconstriction, which leads to Pulmonary HTN-> RVF-> Cor Pulmonale
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Classification of COPD (J44.9)
- 1ST Spirometry evaluation
- Assessing for COPD- Decreased FEV1, FVC and the ratio FEV1/FVC is less than 0.8 Airway Obstruction
- Assess improvement after bronchodilators Reversibility is defined as increase in FEV1 > 12% or 200ml with SABD. In COPD there may be some improvement but neither will return to normal, indicating a fixed disease.
- Classification with Global Initiative for Chronic Lung Disease (GOLD)
- Group
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Goals of Treatment of COPD
- Goals of treatment of COPD are:
- Prevent and control symptoms
- Reduce the severity and number of exacerbations
- Improve respiratory capacity for increased exercise tolerance
- Reduce mortality
- Initial Therapy Recommendations from GOLD Guidelines:
- 1st Line-> Risk Reduction counseling
- Education of dz
- Smoking cessation
- Avoid pollution or triggers
- Vaccination protection
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Pulmonary Rehabilitation - COPD
- Reduces COPD Sx
- Increases physical activity
- Improves daily life function
- Improves emotional health
- Results-> 90% patients who undergo pulmonary rehab spend fewer days in the hospital
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Intrinsic- Restrictive Lung Disease
- Interstitial Lung Disease- Broad name for mu
- Idiopathic pulmonary fibrosis- progressive breathlessness and cough.
- PE: inspiratory crackles, finger clubbing 25-50% Pts.
- Important for early detection/early treatment
- CT Scan 60-80% specific. Honeycomb lung
- Goals of tx: slow progression of dz, reduce sx, and improve quality of life.
- Oxygen therapy
- Antifibrotic meds/Pulmonary rehab
- Manage comorbidities
- Severe dz- lung transplant
- Sarcoidosis
- Scleroderma
- Drug-induced lung disease
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Extrinsic- Restrictive Lung Disease
- Involve the chest wall, pleura, and respiratory muscles. The pleura is a membrane that covers the inside surface of the rib cage and spreads over the lungs. Diseases of these structures result in lung restriction, impaired function, and respiratory failure.
- Neuromuscular disorders can be extrinsic restrictive lung diseases. Some examples include multiple sclerosis, muscular dystrophy, and amyotrophic lateral sclerosis, better known as ALS. (Normal DLCO w/restrictive pattern)
- a buildup of fluid between the layers of tissue surrounding the lungs, known as a pleural effusion
- Scoliosis, or twisting of the spine
- Obesity
- Myasthenia gravis, or intermittent muscle weakness
- Rib damage, especially fractures
- Diaphragm paralysis
- Kyphosis, or hunching of the upper back
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Asthma (J45.0)
- Condition that causes narrowing of the airways, but is usually reversible
- symptoms, especially in adults, include wheezing, shortness of breath, cough, and chest tightness that are worse at night or early in the morning.
- Pathology:
- Narrowing of airways occur from abnormal sensitivity of cholinergic receptors, which contracts the muscles of the airway. This airway goes into spasm and block airflow. Inflammation to the airway increase mucous production, further blocking airway.
- Mast Cells in the airway are the cause of the initiation of the response.
- Mass cells release, histamine and leukotrienes, which caused smooth muscle contraction, mucus secretion, and white blood cells to move to the area.
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Asthma Exacerbation triggers
- Triggers:
- Allergens- combine with IgE on the surface of mast cells to trigger cytokine release
- Infections- usually viral
- Irritants- smoke, perfume, stomach acid (GERD)
- Exercise-EIA- narrowing of airways from drier, colder air, entering the mouth.
- Stress/Anxiety- mast cells release histamine and leukotrienes and stimulate vagus nerve (which constricts smooth muscle)
- Aspirin/NSAIDS- can trigger 30% of the severe asthma population. sensitive to these foods.
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Obstructive Sleep Apnea (G47.33)
- 1 in every 15 Americans have a form of sleep apnea
- During sleep pauses in breathing can occur that last 10-30 seconds until a certain level of hypoxia is reached that it wakes the patient
- Most prevalent in men over 40
- Risk factors: obesity, large neck, alcohol and sedative use, smokers, chronic rhinitis, prior lung dz or asthma, PCOS( hormonal)
- Complications: Daytime fatigue, inc cardiac effort to compensate hypoxia, risk of metabolic syndrome (insulin resistance , high BP, irregular arrythmia, stroke, MI, fatty liver)
- Tx: Positive airway pressure (CPAP/BiPAP), referral to ENT for surgical intervention, Bariatric surgeon
- Surgical options: TORS (Trans Oral Robitic Surgery) , UPPP (Uvulopalatophyaryngoplasty
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End of Life Discussions
- More than 80 % of those who die annually die an expected death, from a long-term incurable disease
- Patients are more likely to receive palliative /end of life discussions if they are diagnosed with metastatic cancer, then if they have months to live with another incurable disease.
- Disease disparity:
- People with COPD aren’t accessing the care that they need, particularly when compared with people with cancer, despite having similar symptoms
- Idiopathic Pulmonary Fibrosis- not responding to medical mgmt. usual life expectancy is 2-3 years
