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Pulm > Lecture 3: Lower Respiratory Infections > Flashcards

Lecture 3: Lower Respiratory Infections Flashcards

1
Q

What environmental factor is one of the biggest contributors to childhood cough?

A

Secondhand smoke/air pollution

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2
Q

What CV symptoms could result in cough?

A
  • Chest pain
  • Dyspnea
  • Palps
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3
Q

What are the 4 aspects of a respiratory exam?

A
  • Inspection
  • Palpation
  • Percussion
  • Auscultation
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4
Q

What are the 3 primary etiologies of acute bronchitis?

A
  1. Bacterial/viral infection
  2. Heavy smoking
  3. Allergy
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5
Q

What qualifies as acute bronchitis?

A
  • 5-30 days
  • Self-limiting inflammation of the bronchus

90-95% are viral in nature.

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6
Q

What is the pathophysiology of acute bronchitis?

A
  1. Infection of conducting airway
  2. Inflammation of airway
  3. Exudate production
  4. Bronchospasms
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7
Q

What are the two phases of acute bronchitis pathophysioogy?

A
  1. Direct inoculation of tracheobronchial epithelium (typical symptoms)
  2. Hypersensitivity of airway receptors (persistent symptoms, such as sputum production)
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8
Q

What are the main bacterial causes of acute bronchitis?

A
  • Strep pneumo
  • H flu
  • M cat
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9
Q

What is the primary atypical that causes acute bronchitis?

A

Bordetella pertussis

Also has a similar strain called bordetella bronchiseptica (kennel cough)

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10
Q

What is the primary viral cause of acute bronchitis?

A

Influenza A/B

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11
Q

If a patient has no cough, can they still have acute bronchitis?

A

Yes

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12
Q

What are the primary symptoms of acute bronchitis?

A
  • Cough (nonproductive/mucopurulent)
  • Substernal pain
  • Wheezing
  • Minor fever (38.3-38.9)
  • Fatigue
  • Malaise
  • Chest tightness
  • SOB
  • Dyspnea
  • PND
  • Cyanosis

No URI symptoms like coryza or congestion

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13
Q

What are the general PE findings for acute bronchitis?

A
  • Cough w or w/o bronchospasm
  • Wheezing variable (wheezing might be bronchiolitis)
  • Rhonchi (clears with cough)
  • Sputum variable
  • Fever
  • Chest wall tenderness
  • Symptoms suggestive of URI

Rales/crackles does not clear with cough.

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14
Q

Define stridor vs wheezing

A
  • Stridor is inhalation (#1 is croup, #2 is foreign body)
  • Wheezing is exhalation

Stridor implies an obstructed airway.

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15
Q

What does a sustained heave across the left sternal border suggest?

A

RVH secondary to chronic bronchitis.

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16
Q

What does clubbing of the digits and peripheral cyanosis suggest?

A

Cystic fibrosis or chronic bronchitis

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17
Q

What does bullous myringitis have as an atypical cause?

A

Mycoplasma

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18
Q

What virus can cause conjunctivitis, adenopathy, and rhinorrhea?

A

Adenovirus

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19
Q

What would suggest a LRI is pneumonia over acute bronchitis?

A
  • Fever (acute is low fever)
  • Productive cough w/ sputum
  • Isolated crackles/rales
  • Chest pain
  • Tachycardia
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20
Q

What are the emergent DDx for acute bronchitis?

A
  • PNA
  • PE
  • Pulmonary edema
  • Status asthmaticus
  • Pneumothorax
  • Foreign body aspiration
  • CHF
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21
Q

How do we diagnose acute bronchitis?

A

Clinical exam, since CXR is probably going to be inconclusive or unremarkable.

CXR is mainly for infants, elderly, or an unclear exam.

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22
Q

What lab would suggest bacterial vs non-bacterial etiology for acute bronchitis?

A

Procalcitonin

Elevated above 0.5mcg = ICU and highly likely to be bacterial.

Greater than 0.25mcg suggest bacterial.

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23
Q

How does CBC w/ diff typically present for a viral acute bronchitis?

A

Normal to low, since viral.

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24
Q

What are the two indications for sputum culture?

A
  • PNA pt being admitted to hospital.
  • PNA pt failing standard therapy.
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25
Q

What are the recommended treatments for acute bronchitis?

A
  • Supportive
  • Antitussives/expectorants
  • Antihistamines
  • Decongestants
  • B2 agonists for wheezing.

If cough > 2 weeks with no improvement, consider ABX.

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26
Q

What is dextromethorphan’s class and MOA?

Delsym, Robitussin

A

Centrally-acting non-opioid that elevates the threshold to cough.

It is an antitussive.

Equal efficacy to codeine for cough.

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27
Q

What happens if dextromethorphan is taken in high dosages?

A

Dissociative hallucinogen effects, similar to ketamine.

DXM junkie

28
Q

What age is dextromethorphan contraindicated in?

A

Ages 4 and under.

29
Q

How are codeine and dextromethorphan similar and different?

A

Codine is an opiate, whereas DXM is not.

Both have similar antitussive effects and efficacy.

Codeine has many more drug interactions than DXM.

30
Q

What is benzonatate’s drug class and MOA?

Tessalon pearls

A

Peripheral acting antitussive derived from procaine (anesthetic)

Hinders the sensation to cough by numbing pulmonary stretch receptors.

31
Q

What is the main counseling regarding benzonatate?

A

DO NOT CHEW

Cannot be used in children under 10.

32
Q

What is guaifenesin’s drug class and MOA?

Mucinex, Tussin

A

It is an expectorant that reduces chest congestion by increasing mucus secretion and sputum volume to clear up the airways.

Lower sputum viscosity so you can cough it out better.

33
Q

What is the only contraindication to guaifenesin?

A

Allergy

34
Q

What kind of virus is influenza?

A

Encapsulated single-stranded RNA.

35
Q

What are the two surface proteins that are significant to the influenza virus’s virulence?

A
  • Hemagglutinin: binds to respiratory epithelial cells
  • Neuraminidase: cleaves bonds to allow infection to spread
36
Q

When is influenza transmissible?

A

1 day prior to onset to 10 days.

Most virulent in first 3 days.

37
Q

What is the most pathogenic strain of influenza?

A

Influenza A

38
Q

What are the common symptoms of influenza?

A
  • Fever, HA, fatigue
  • Sore throat, rhinorrhea, nasal congestion
  • Cough, dyspnea
  • N/V/D
  • Myalgia, joint pain, body aches
39
Q

What are the common signs of influenza?

A
  • Lethargic
  • Clear lungs 9/10 (could hear bilateral rales rarely)
40
Q

What is the standard for confirming the presence of a flu virus?

A
  • RT-PCR
  • Viral culture of NP or throat secretions
41
Q

What might prompt us to order a CXR for influenza?

A
  • Presence of rales on PE
  • R/o pneumonia.
42
Q

What CBC findings are typical of influenza?

A
  • Leukopenia
  • Lymphocytopenia
43
Q

How should influenza be managed?

A
  • Supportive care
  • NSAIDs and acetaminophen
  • Antivirals
44
Q

What antivirals are indicated for influenza management?

A
  • Tamiflu/oseltamivir 75mg BID x 5 days
  • Zanamivir/Relenza Inhaler
  • Rapivab/peramivir IV
  • Baloxavir marboxil/Xofluza for high-risk.

Active against both strains if given within 48hrs of onset.

Also works vs H1N1
All of these are neuraminidase inhibitors.

45
Q

How long does it take the flu vaccine to being working well?

A

10-14 days.

46
Q

What is the current standard flu vaccine?

A

Quadrivalent flu vaccine

2 strains of A, 2 strains of B

47
Q

What is flumist?

A

Live, attenuated virus.

Only for use in healthy 2-49.

48
Q

Why is pertussis such an important vaccine?

A

Pertussis is highly contagious and can be fatal in < 2yo.

49
Q

What are the two causative organisms for pertussis and what kind of bacteria is it?

A
  • Bordetella pertussis and parapertussis.
  • Gram-neg, aerobic, encapsulated, coccobacilli
50
Q

How does bordetella pertussis work?

A
  • Toxin B which attaches to cell surface.
  • Toxin A which inactivates cAMP regulation.

Increased mucus production and decreased phagocytic activity, aka can’t get rid of the bacteria.

51
Q

Describe the 6 week disease course of pertussis.

A

Exposure/Incubation (4-24 days)

  1. Stage 1: Catarrhal stage (1-2 weeks)
  2. Stage 2: Paroxysmal stage (1-10 weeks)
  3. Stage 3: Convalescence stage (2-3 weeks)
52
Q

How does the catarrhal stage of pertussis typically present?

A

Viral URI symptoms

53
Q

How does the paroxysmal stage of pertussis present?

A
  • Paroxysms of intense coughing, aka the whooping.
  • Posttussive vomiting and turning red from couging.

The iconic stage that whooping cough is named for.

54
Q

How does the convalescence stage of pertussis present?

A

Chronic cough lasting for weeks.

55
Q

If a patient tests positive for pertussis, what should we document?

A

Must submit a report to health department so they can screen all contacts.

56
Q

What are some PE findings that are specific to pertussis?

A
  • Coughing spells/incessantly
  • Facial petechiae from coughing

Infants < 3mo have more gasping and reddened face over coughing.

57
Q

What criteria should make us highly suspicious of whooping cough?

A
  • Cough > 2 weeks
  • Posttussive emesis
  • Endemic areas
  • No vaccination history.
58
Q

How does a CXR for pertussis present?

A

Clear

59
Q

What CBC findings are typical of pertussis?

A
  • Leukocytosis
  • Lymphocytosis
60
Q

What is the gold standard to diagnose pertussis?

A

Bacterial culture of NP secretions.

61
Q

What diagnostic testing has the smallest window to obtain samples to diagnose pertussis?

A

Cultures must be done within 3 weeks of onset.

Also must be done before ABX given.

62
Q

What would be elevated in a serological test for a positive acute pertussis patient?

A

IgM

63
Q

What is the preferred drug class to treat pertussis? Alternative?

A

Macrolides, preferably Azithromycin in infants under 1mo.

Bactrim is alternative, unless under < 2mo.

Must be started early to reduce symptom severity.

64
Q

Who should be treated for pertussis?

A

Current sick patient and ALL close contacts.

65
Q

What are the contraindications to azithromycin?

A

QT prolongation or proarrhythmic conditions.

66
Q

What is the main complication we are concerned about with pertussis in infants?

A

Pneumonia

Inability to cough out sputum properly.

67
Q

When is Tdap indicated vs DTap?

A

Tdap is for 11+ years old and for pregnant women.

DTap is for 2,4,6, 15-18, and 4-6y.

Pertussis vaccine may only last 5 years.

Pulm (12 decks)

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