Lower Respiratory Diseases Flashcards
(141 cards)
1
Q
How is an acute cough defined?
A
less than 3 weeks
2
Q
How is a subacute cough defined?
A
3-8 weeks
3
Q
How is a chronic cough defined?
A
more than 8 weeks
4
Q
What are potential harms that can result from a chronic cough?
A
Anxiety, fatigue, insomnia
Myalgia, rib fracture, and urinary incontinence
5
Q
How is acute bronchitis defined?
A
A self limiting inflammation of the trachea and major bronchi that presents as cough lasting 1-3 weeks in the absence of pneumonia
6
Q
What pathogens usually cause acute bronchitis?
A
Mainly Viral: RSV, Rhinovirus, Coronavirus, Influenza A and B and Parainfluenza
Infrequently Bacterial: Mycoplasma, pertussis and C. Pneumo
7
Q
How does acute bronchitis present?
A
Cough- dry or productive
Low grade temp
Wheezing
Rhonchi- coarse rattling expiration
Normal vital signs
May have runny nose
8
Q
What is needed to make an acute bronchitis diagnosis?
A
H & P
Infrequently: CXR
9
Q
What are some red flags with acute bronchitis?
A
Abnormal vital signs
Rhales or signs of consolidation on chest examination
evidence of hypoxemia (eg, pulse oxygen assessment)
mental confusion
signs of systemic illness
10
Q
What should be done if a secondary infection is suspected with acute bronchitis?
A
CBC with diff
CXR PA and Lateral
11
Q
What are the differential diagnosis for acute bronchitis?
A
Asthma
Foreign body
Influenza
Pertusssis
PNA (pneumonia)
Sinusitis
Severe acute respiratory syndrome
12
Q
How should children with acute bronchitis be treated?
A
Children under 6 - 14 y.o.—not much evidence to support use of OTC
1 y.o.
warm humidified air, fluids, nasal saline and bulb suction prn
13
Q
How should adults with acute bronchitis be treated?
A
Dextromethorphan with Guaifenesin (mucinex DM)–best support
Codeine agents—narcotics suppress cough center brain,
tussin-x if they can’t sleep
Not recommended for children
14
Q
What should be prescribed for acute bronchitis with a bronchospastic cough/ wheeze?
A
beta-2-agonists (albuterol)
15
Q
What analgesic should be prescribed for acute bronchitis? (if necessary)
A
Acetaminophen
Ibuprofen
16
Q
How is influenza defined?
A
Acute respiratory illness caused by Influenza A or B virus, occurs in outbreaks and epidemics worldwide, mainly in the winter season
17
Q
How is influenza transmitted?
A
Large droplet transmission through sneezing and coughing,
Easily spread
Close contact as large droplets do not remain suspended in the air and travel short distances
Incubation 1-4 days
Viral shedding 48 hours up to 10 days after symptoms
18
Q
What is the clinical presentation of the flu?
A
ACUTE ONSET
High temp
Myalgia
Fatigue
Cough
Rhinorrhea
Headache
N/V
19
Q
What is expected upon physical exam for the flu?
A
Vital signs: elevated temp, tachycardia, tachypnea
HEENT: glassy eyes, mild conjunctivitis, watery discharge; erythematous TM; turbinate’s swollen moderate amt of clear discharge
Neck: non-tender cervical lymphadenopathy
Chest: CTA bilaterally, possible wheeze if hx of asthma or RAD
20
Q
How is the flu treated?
A
Symptom management unless at high risk for complications
21
Q
Who is at high risk for complications from the flu?
A
high risk for complications
- Younger than 2 or older than 65
- Chronic pulmonary, cardiovascular, renal, hepatic, metabolic, neurodevelopmental, intellectually disabled, HIV,
- morbidly obese (BMI >40),
- residents nursing home
- American Indians/Alaska natives
22
Q
What are the differential diagnosis for the flu?
A
RSV
Pneumonia
Severe strep pharyngitis
23
Q
What diagnostic tests are available for the flu?
A
Rapid influenza
Nasal swab
24
Q
Who is approved to take Tamiflu?
A
Treatment of flu for 2 weeks+
Prophylaxis for 1 yr+
25
Who is approved to take Relenza?
Treatment: 7yrs+
Prophylaxis: 5yrs+
26
What is a side effect of Tamiflu?
Makes people crazy and GI upset.
27
What side effect should be monitored for with Relenza?
Allergic reaction: oropharyngeal or facial edema
28
What are potential complications of the flu?
Pneumonia
Myositis/Rhabdomyolysis
Encephalitis
Guillian Barre- neuropathy toes to head
Reye’s syndrome- kids who have viral infection and take aspirin get liver damage and encephalitis
Toxic Shock Syndrome
29
How can the flu be prevented?
The flu vaccine, either live or not.
Give larger dose to elderly due to decreased immune system response
30
When can the first flu shot be given to a person?
6 months old
Need two shots, one month apart, the first time only.
31
How long does it take for the flu vaccine to be effective?
14 days
32
Can you get the flu from the flu shot?
NO!!!!
Can get an immune reaction which is fever and aches, but this is NOT the flu
33
Who should not get the flu vaccine?
Severe egg allergy (mild is ok)
History of sever reaction to the vaccine
For the live vaccine: No one less that 2 years old, immunocompromised, asthma, COPD, recent live vaccine, recent steroid use
34
What is pneumonia?
Lower respiratory infection that is usually accompanied by cough, fever, malaise and abnormalities on cxr
35
What are the typical agents that cause CAP?
Gram pos: S.pneumo, S.aureus, Group A Step.
Gram neg: H.influenza, M.cattarrhalis, Pseudomonas, K. pneumonia
36
What are the most likely agents causing CAP in an alcoholic?
K.pneumoniae and M.cattarrhalis
37
What are the most likely agents causing CAP post flu?
S. aureus and H. influenza
38
What are the most likely agents causing CAP in a COPD patient?
Moraxella catarrhalis (beta lactamase producing)
39
What risk factors will make you treat pneumonia aggressively?
Age > 65years
Presence of coexisting illness: COPD, bronchiectasis, malignancy, DM, CHF
chronic renal failure,
chronic alcohol abuse, chronic liver disease, malnutrition
cerebrovascular disease,
Post-splenectomy,
hx hospitalization in past year
40
What is the clinical presentation of pneumonia?
Fever
Malaise
Pleuritic chest pain
Dyspnea
Cough with and without sputum production
Nausea, vomiting, diarrhea
Mental status changes
41
What do you expect to find on physical exam with pneumonia?
Vital signs, febrile, tachycardia, tachypnea
Chest; audible rales (fine crackles) or diminished breath sounds
42
What physical findings are warning signs that a patient with pneumonia has an increased risk for mortality?
Respiratory rate > 30 (tachypnea)
Diastolic blood pressure 125
Temp 40° C (104°F)
Confusion or decreased LOC
43
What lab findings are warning signs that a patient with pneumonia has an increased risk for mortality?
WBC 30 x 10 (9)
PaO2 50 RA
Creatinine >1.2, BUN >20
Chest x-ray: multi lobular, pleural effusion, presence of a cavity
HCT
44
What are the differential diagnosis for pneumonia?
Pulmonary Emboli
CHF
Pulmonary tumor
Inflammatory lung disease
Acute or chronic bronchitis
45
What is the gold standard for diagnosing pneumonia?
Chest x-ray
46
What criteria need to be met to order a chest x-ray in pneumonia?
One of the following:
temp over 100,
HR over 100,
RR over 20
Two of the following:
decreased breath sounds, crackles,
absence of asthma
47
What are big risk factors for getting CAP?
COPD
Aspirations
lung abscess
smoking
alcoholism
48
What is the recommended treatment for CAP for a healthy adult with no antibiotic use in the past 3 months?
Macrolides: Zithromax, clarithromycin, Erythromycin
OR
Doxycycline
49
What is the recommended treatment for CAP for an adult with co-morbidities and antibiotic use in the past 3 months?
Floroquinolones: Levofloxin, moxifloxacin
OR
Macrolide with high dose Augmentin: Ceftriaxone, Cefpodoxime, Cefuroxime
50
What is the dosing and follow up for CAP in a healthy adult?
Azithromycin- 3 options based on compliance
Zpak:
500 mg on day one
250mg days 2-5
Tripak:
500mg for 3 days
Single dose:
2g microsphere formula
Follow up: 24-48 hours
51
What should happen if the patient doesn't show improvement with CAP?
If no improvement in 48 hours, consider further testing and maybe change to a fluoroquinolone
52
Who should get the pneumonia vaccine?
All people over 65 yo
19-64 years old with DM, CHF, COPD or Asthma.
53
What are the most likely agents causing nosocomial pneumonia?
P aeruginosa
Klebsiella species
E. coli
Acinetobacter species
Staph aureus—especially MRSA
Strep pneumonia
H flu
54
How should Nursing Home Acquired Pneumonia be treated?
Like CAP, but aggressively because it spreads quickly.
55
What are common co-morbidities with Nursing home acquired pneumonia?
parkinsons, dementia/alzheimers
56
What is the recommended pneumococcal vaccine series for children?
4 Doses of PCV-13
| 2, 4, 6, 12-15 months
57
Why does the age of the child matter when diagnosing CAP?
Important in determining the possible etiologies
58
What is considered tachypnea for a child younger than 2 months?
more than 60 breaths/min
59
What is considered tachypnea for a child 2-12 months?
more than 50 breaths/min
60
What is considered tachypnea for a child 1-5 years old?
more than 40 breaths/min
61
What is considered tachypnea for a child older than 5 years?
more than 20 breaths/min
62
What are the signs of respiratory distress in children?
Tachypnea- very important
Dyspnea
Retractions (suprasternal, intercostal or subcostal)
Nasal flaring
Apnea
Altered mental status
Pulse ox 90% room air
63
What is needed to diagnose CAP in children?
Influenza (if in community)
RSV
CXR (PA and lateral) if not responding to tx, or considering other things like a pleural effusion
64
When should an infant be hospitalized for CAP?
If they have:
apnea
grunting
poor feeing
O2 sat 70
65
When should an older child be hospitalized for CAP?
If they are:
grunting
unable to tolerate PO intake
O2 sat is 50
66
When should any child be hospitalized for CAP?
If they have comorbidities or the family is unable to provide proper observation/care
67
What is usually prescribed for CAP, presumed to be bacterial, in a child under 5 years?
Amox 90mg/kg in 2 divided doses
OR
Amox clavulanate: 90mg/kg in 2 divided doses
68
What is usually prescribed for CAP, presumed to be atypical, in a child under 5 years?
Azithromycin 10mg/kg day 1, and 5 mg/kg days 2-5
OR
Clarithromycin 15mg/kg in 2 divided doses
69
What is usually prescribed for CAP, presumed to be bacterial, in a child over 5 years?
Amox 90mg/kg in 2 divided doses
OR
Amox clavulanate: 90mg/kg in 2 divided doses
AND
Macrolide
70
What is usually prescribed for CAP, presumed to be atypical, in a child over 5 years?
Azithromycin 10mg/kg day 1, and 5 mg/kg days 2-5
OR
Clarithromycin 15mg/kg in 2 divided doses
Can use erythromycin or doxy for 7yo and up
71
What management is needed when treating a child with CAP?
Re-evaluate in 48 hours
Educate on need to monitor respiratory status, fluid intake, signs and symptom of dehydration
Supportive care
Reason to call or rtc sooner
72
How can CAP be prevented in children?
Vaccinations: PCV-13, Influenza, and HIB
Hand washing
Promote breastfeeding
Avoid exposure to smoke
73
How is bronchiolitis defined?
acute inflammation, edema and necrosis of epithelial cells of the small bronchioles
74
What is the usual cause of bronchiolitis in children?
most commonly RSV,
then adenovirus,
can also be parainfluenza, rhinovirus, influenza
75
For RSV: What is the incubation period, usual season and progression?
Incubation: 4-6 days
Season: late fall to early sling
Beings with URI and progresses over 3-7 days
Usually affects people under 2 yo
76
What is clinical presentation of bronchiolitis in kids?
Hx of URI
Fever usually no higher than 102 F
Decreased appetite
Cough
Large amount of clear rhinorrhea
77
What is expected to be found on physical exam of brochioltits in kids?
Considered the happy wheezers
Usually febrile, tachypneic and tachycardic
Mild conjunctivitis, and pharygitis
Anterior cervical lymphadenopathy
Scattered wheezing- like a washing machine due to inflammation
Abdominal distention due to hyperinflation
78
What diagnostic tests can be done for bronchiolitis in kids?
Rapid RSV-nasal swab
Rarely CXR or CBC
79
What is the differential for bronchiolitis in kids?
Asthma
Pneumonia
Aspiration foreign body
Croup
Cystic Fibrosis
Congenital heart disease
80
What is expected to be found on CXR for a child with bronchiolitis?
lung hyperinglation with a flattened diaphragm
81
How is mild bronchiolitis treated?
Treat symptoms at home
Force fluids, antipyretics
Normal saline nasal spray with suctioning
82
How is moderate/severe bronchiolitis treated?
83
What are reasons to hospitalize a child with bronchiolitis?
Stridor
Apnea
Tachypnea >60 breaths per minute at rest
Hypoxia
Poor feeding
Decreased sensorium
Parent unable to manage at home
84
How can bronchiolitis be prevented? Who is a candidate for this?
Palivixumab (synagis); monoclonal antibody to prevent RSV
Given to premature babies born in RSV months. Is very $$$
85
What is the child with bronchiolitis at risk for later in life?
Potential for recurring wheezing in childhood
Increased risk of asthma going forward
86
How is pertussis defined?
Highly contagious acute respiratory illness caused by Bordetella pertussis.
Aka Whooping cough
87
How long is the incubation period of pertussis?
7-10 days after exposure but maybe up to 3 weeks
88
What is the clinical presentation of pertussis?
URI
Persistent cough
Low grade temp
Paroxysmal cough
Post tussive emesis
Cyanosis, sweating, prostration and exhaustion after coughing
Adolescent/Adult- Persistent paroxysmal cough
89
What do you expect to find on physical exam of a child with pertussis?
HEENT: mildly injected conjunctivae, with watery discharge; rhinorrhea
Chest: CTA bilaterally
Skin: petechial from coughing
90
How can you make the diagnosis for pertussis?
Culture with specimen from nasal swab
Most reliable in the catarrhal stage first 1-2 weeks
91
What is the differential diagnosis for pertussis?
Pneumonia
GERD
Cystic fibrosis
Asthma
Foreign body
92
What is the management for pertussis?
Zithromax
Alternative Clarithromycin > 1mo of age
Most effective if tx in early stage, after that will decrease transmission but not course of the illness
93
What should be done to prevent pertussis?
Post-exposure prophylaxis for all close contacts, with or without immunity
Immunization: Tdap for over 6 years and DTap for under 6 years
94
How is the DTaP vaccine recommended for?
all children 6 weeks through 6 years of age
95
When is the Tdap booster recommended? How many?
single booster dose for adolescents 11-12 years old
96
Which adults should be targeted for Tdap vaccine?
Tdap should replace next Td vaccine, especially for adults with children
97
What is cystic fibrosis?
Multi-systemic progressive illness with varying degrees of severity
Manifests in COPD, GI disorder and exocrine dysfunction
Autosomal recessive
The median predicted survival for CF patients in the United States was 36.8 years
Generally lungs ok at birth, and then they become thick. If recurrent lung infection/ failure to thrive, suspect CF.
98
What is the pathology of cystic fibrosis?
Defect in the CF transmembrane conductance regulator protein (CFTR) which is expressed in epithelial cell and blood cells.
CFTR defect causes defective ion transport, airway surface liquid depletion and defective mucociliary clearance
99
What are the expected physical exam findings for the lungs in cystic fibrosis?
Lungs at birth normal
Marked impermeability to chloride and sodium reabsorption
Mucous is vicious and leads to decreased motility
Leads to lung infections
100
What are the expected physical findings for the GI with cystic fibrosis?
Meconium ileus (first 2 weeks of life)- thicker meconium leads to intestinal blockages
Failure to thrive due to pancreatic enzyme insufficiency
101
What are the expected physical findings for the endocrine in cystic fibrosis?
Recurrent acute pancreatitis
DM
102
How is cystic fibrosis diagnosed?
Sweat test and genetic (newborn) screening
103
What is ciliary dyskinesia?
Autosomal recessive
Impairment in mucociliary clearance
Defect in cilia in airway, leads to ciliary immotililty or ciliary dyskinesia
104
What are the clinical manifestations of ciliary dyskinesia?
Respiratory Infections
Rhinosinusitis
Nasal polyps
Otitis media
Situs inversus 50%
Decreased fertility
Associated with transposition of the great vessels
105
What is a pleural effusion?
Fluid collection between visceral pleura and the parietal pleura and gravitates to dependent part of lung
Occurs when the rate of fluid production in the lungs exceeds the rate of fluid absorption
106
What are the two types of pleural effusions?
Transudative effusion
Exudative effusions
107
What is a transudative effusion? What are common causes?
associated with pressure filtration without capillary injury
Heart failure and liver cirrhosis common causes
108
What is an exudative effusion? What are common causes?
"inflammatory fluid" leaking between cells.
Pneumonia and malignancy most common causes
109
What are possible causes of pleural effusions?
Atelectasis, Cirrhosis, CHF, Cardiovascular dysfunction, Malignant disease, Nephrotic syndrome- b/c extra fluid, Pneumonia, RA, DM, Lupus, Viral Illness
110
What is the common clinical presentation of a pleural effusion?
Dyspnea
Non-productive cough
Pleuritic chest pain
Activity intolerance
Asymptomatic
111
What are typical respiratory physical exam findings you would expect for a pleural effusion?
Diminished or absent breath sounds
Decreased respiratory excursion
Absent tactile fremitus
Dullness to percussion
Egophony
Friction rub
112
What are typical cardiovascular physical exam findings you would expect for a pleural effusion?
JVD
S3
113
What are typical abdominal physical exam findings you would expect for a pleural effusion?
hepatospelnomegaly
ascities
114
What are typical differential diagnosis for pleural effusions?
Pneumothorax
CHF
Neoplasm
Trauma
TB
115
How is a pleural effusion diagnosed?
CXR- sensitive with more than 500 mL fluid
Ultrasound- very sensitive
116
What is the treatment of a pleural effusion?
Thoracentesis recommended in all patients with more than a minimal pleural effusion
(i. e., larger than 1 cm height on lateral decubitus radiograph, ultrasound, or CT) of unknown origin*
* Not usually recommended in the case of heart failure
Can help determine the cause of PE
117
What is Pleurisy (pleuritis)?
Inflammation of the pleura with or without pleural effusion
Pain caused by pleural layers rubbing together
Not a diagnosis, related to localized or systemic disease process
Rarely malignant cause
Most commonly related to viral or bacterial infection like TB, Pulmonary infarct, or Lupus.
118
What is the clinical presentation of pleurisy?
May have preceding viral or bacterial infection, so ask about recent illness
Pain with breathing
Sharp, stabbing shooting pain
Usually localized, can radiate to shoulder
Pain increases with inspiration
Will feel better lying on affected side to limit lung expansion
119
What is expected to find in the respiratory physical exam with pleurisy?
Pneumothorax
Rib fracture
Costochondritis
Vertebral fracture
Nerve root pain from herpes
Cardiac etiology
120
What diagnostic testing is need for pleurisy?
CBC looking for leukocytosis or leukopenia
CXR looking for pneumonia, pneumothorax, effusion
Chest CT Scan: if unsure of cause
121
How is pleurisy treated?
Treat underlying infection
Depending on etiology co-manage with pulmonary
Use of NSAID or corticosteroids maybe appropriate
122
What is sarcoidosis?
Multisystem, inflammatory, granulomatous disease
Involves lungs and intrathoracic lymph nodes in 90% of affected individuals
123
What is the pathophysiology of sarcoidosis?
Alveolitis usually proceeds granuloma
Initial cause unknown, the alveolitis begins to accumulate T cells and macrophages
The activation of macrophages leads to the development of fibrosis
familiar pattern, but not genetic
124
What is the clinical presentation of sarcoidosis?
Usually will present with non-specific symptoms
Dry cough
Dyspnea
Chest pain
Fever
Fatigue
Anorexia
Weight loss
Nasal congestion, polyps, stridor
Skin nodules
Vision: blurry, eye pain, severe redness
125
What are the differential diagnosis for sarcoidosis?
Hypersensitivity pneumonitis
Asbestosis
Silicosis
Infection
Lymphoma
Wagner’s granulomatosis
126
What is TB?
Is an airborne infectious disease caused by Mycobacterium tuberculosis, that remains alive outside of the host for relatively long period
Drug resistance cases have increased, despite decrease in overall TB
127
What is the pathophysiology behind TB?
TB spread by direct contact and indirectly by airborne transmission
Once inhaled, bacteria travel to lung alveoli and establish infection
128
What is latent TB?
LTBI is the presence of M. tuberculosis organisms (tubercle bacilli) without symptoms or radiographic evidence of TB disease.
If untreated: 5-10% will progress to TB
Asymptomatic and non infectious
129
When is TB detectable after being infected?
8–12 wks after infection, immune response limits activity; infection is detectable
130
How is latent TB detected?
TST- skin test, wheal must be
131
If a patient has been positive on a TST, how do you re-test TB?
No TST
Do a chest x-ray
132
What does a positive TST test look like?
induration at site of wheal
133
What happens with pregnant mothers infected with TB?
TST is ok, no CI
Should have chest radiographs ASAP, and consult to determine appropriate treatment
134
What is BCG?
BCG is a anti-TB vaccine given to infants/children in endemic countries
Vaccine wanes over time
Their TSH should be interpreted the same as non-vaccinated people , but some concerned for false positive, so do IGRA
135
Which TB test is preferred?
TST is preferred over IGRA
Routine testing is not recommended
136
How is LTBI and active TB distinguished on testing?
LTBI- no physical findings or symptoms, but will have positive TST/IGRA results. CXR are normal. Respiratory specimens/cultures are negative.
TB- symptomatic and positive TST/IGRA results. CXR is abnormal. Respiratory specimens/cultures are positive.
137
What is the 12 week (3 month) treatment for TB?
Isoniazid (INH) and Rifapentine (RPT) taken once weekly
Based on body weight
138
Who is not recommended for the 12 week treatment?
children under 2 yo
HIV taking ART therapy
Presumed resistant TB
Pregnant, expecting to become pregnant
139
What screening should be done after treated for TB?
Don't require repeat testing
Receive regular symptom screen
140
What are the symptoms of active TB?
Fever
cough
chest pain
weight loss
night sweats
hemoptysis
fatigue
decreased appetite
141
How is TB detection in children different than adults?
May not have the classic signs
CXR findings subtle
Symptoms: malaise, failure to thrive or weight loss, and recurrent PNAs
