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1
Q

Immunizations aim to prevent these major complications of:

  • influenza
  • pertussis
  • invasive pneumococcal disease
A

Influenza: viral/bacterial pneumonia

Pertussis: secondary bacterial pneumonia

IPD: pneumonia, bacteremia, meningitis

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2
Q

Pertussis vaccination is recommended for these individuals:

A
  • routine schedule for infants and children
  • incompletely/unimmunized adults
  • pregnant women in every pregnancy at 27-32 weeks
  • all adults should receive one dose of Tdap if they have not received a pertussis-containing vaccine in adulthood
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3
Q

What is the timing between PCV (Prevnar) and PPV23 (Pneumovax)?

A

Preferred: PCV 13 first –> wait 8 weeks –> PPV 23

If PPV 23 first, wait one year –> PCV 13

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4
Q

Varenicline (Champix):

Benefit:

MOA?
Dosing?
Duration?

A

Benefit: most effective form of smoking cessation

MoA: partial nicotine agonist: reduces withdrawal, blocks reward

Dosing: Start taking one week before quit date
Can continue to smoke until quit date

Days 1-3: 0.5 mg
Days 4-7: 0.5 mg BID
*may increase to 1 mg BID x 12 weeks

Duration: minimum 12 weeks, can extend up to 1 year

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5
Q

Varenicline (Champix):

Precautions:

  • concurrent ETOH?
  • concurrent NRT?
  • concurrent food?
A

ETOH: will enhance ETOH effects, decrease tolerance to ETOH

NRT: can use together but higher chance of adverse reaction/intolerance

Food: take after eating with full glass of water to help with nausea

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6
Q

Varenicline (Champix):

Common and serious side effects

A

Common:
Nausea, insomnia and abnormal dreams
Headache, constipation

Serious: suicidal ideation, depression, agitation

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7
Q

Buproprion (Zyban) for smoking cessation

Benefits?

Contraindications?

A

less effective than Champix

  • helps if concurrent depression
  • delays weight gain post-cessation

Contraindications:

  • personal/family hx of seizure disorder
  • any condition that predisposes to seizures (acute head injury, ETOH withdrawal, eating disorder)
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8
Q

Bupropion (Zyban) for smoking cessation

MOA?
Dosing?
Duration?

A

MOA: dopamine reuptake inhibitor - makes it less pleasurable

Dosing:
Start taking one week before quit date
Can continue to smoke until quit date

Days 1-3: 150 mg SR daily in morning
Day 4 onwards: 150 mg SR BID x 7-12 weeks
8 hours in between doses

Duration:
Minimum 7-12 weeks
-if no significant progress by 7th week: success unlikely
-can extend up to one year

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9
Q

Bupropion (Zyban) for smoking cessation:

-patient counselling points:
timing of doses, food, monitor

A

Will take 1-2 weeks to take effect
Wait 8+ hours between SR dose to prevent seizure risk
Can take with/without food
Monitor mood esp suicidal thoughts

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10
Q

Bupropion (Zyban) for smoking cessation:

Common and serious side effects:

A

Common:
Insomnia, agitation, tremor, headache, weight loss
GI: low appetite, n/v, dry mouth

Serious: seizures, aggression, suicide

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11
Q

Nicotine patch:

  • start at _____ mg/day if smoking >10 cigs/day
  • start at _____ mg/day if smoking <10 cigs/day

Common side effects?

A

21 mg/day if 10+ cigs

14 mg/day if <10 cigs

Side effects:
-skin irritation, insomnia, vivid dreams (can remove patch at night)

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12
Q

Nicotine patch:

patient counselling points:

A

Don’t smoke while using it, no more than 1 patch/time
Don’t cut or trim patch
Rotate sites
*Use of soap will ↑ nicotine absorption from site, rinse with water if symptoms of toxicity
Dispose used nicotine patches out of reach of kids/animals

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13
Q

Nicotine patch:

Contraindications:

CVD considerations:
Pregnancy considerations:

A

Contraindications: severe eczema, psoriasis or skin disorder

CVD: NOT contraindicated in CAD (unlike other NRT) but try to wait >2 weeks after acute MI
*risk of arrhythmias and MI

Pregnancy: try to limit to 16 hours

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14
Q

Nicotine gum:

Contraindications:

CVD considerations:
Pregnancy considerations:

A

Contraindications:
-Dental issue, TMJ syndrome
CAD/recent MI/angina

CVD: avoid –> go with patch
Pregnancy: gum preferred over patch

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15
Q

Nicotine gum and lozenge

Patient counselling re: food

Common side effects?

A

No food or drink (esp acidic eg coffee, soda) for 30 min before and during use

Side effects:
Nausea, heartburn, throat irritation, hiccups
n/v/headache if smoking as well

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16
Q

Nicotine spray and inhaler

Contraindications?

Common side effects?

A 
CAD, recent MI, angina --> consider patch
Reactive airways (asthma)

Side effects:
Throat irritation, cough, rhinitis, dyspepsia

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17
Q

What are the 5 A’s in smoking cessation approach?

A 
ASK about tobacco at every visit
ADVISE to quit
ASSESS willingness to quit
ASSIST implementation plan
ARRANGE following up and cessation counselling
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18
Q

Smoking cessation:

What are some non-pharmacological approaches?

A

Combination therapy (pharm and behavioural) is most effective strategy

Exercise (esp to counteract weight gain)
Hypnosis
CBT
Support groups
Quit now has a phone support group (“quitlines)

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19
Q

Smoking cessation:

What is the first line approach?

Monitoring/follow up?

A

First line approach:

  • combining two forms of NRT (patch + short-acting PRN gum/lozenge) OR
  • varenicline (Champix)

Follow up:

  • 1-2 weeks after starting rx: adherence, side effects
  • 3 months, then annually

Monitor drug levels of some rx after successful quitting (psych meds, methadone, warfarin) –> may need to adjust dose

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20
Q

Acute bronchitis

Risk factors?

Mainly caused by?

A

Risk factors:
URI, smoking, 2nd hand smoke, Chronic aspiration, GERD, allergens

Infectious most common, but can be allergens or irritants
most commonly viral

Viral: adenovirus, influenza, parainfluenza, RSV
Bacterial: Bordetella pertussis (check immunization status in children), Mycobacterium tuberculosis, Corynebacterium diphtheriae, M. pneumonia.

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21
Q

Acute bronchitis

Signs and symptoms:

A

Initially: dry, hacking cough/raspy sounding cough
Progresses to productive cough (usually 1-3 weeks)
-Sore throat,
-Rhinorrhea
-Rhonchi during respiration
-Low grade fever
-Malaise
-Retrosternal pain during deep breathing and coughing

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22
Q

Acute bronchitis

Findings on physical exam:

A

Vitals (should not have tachypnea or high fever)
Resp: crackles, wheezes, rhonchi

*should not have signs of consolidation (dullness with percussion, decreased breath sides, rales, egophony)

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23
Q

Acute bronchitis

3 differential dx:

Diagnostic tests:

A
  • Pneumonia (abnormal VS, signs of consolidation)
  • Pertussis (persistent paroxysmal cough, post-tussive vomiting, inspiratory whoop)
  • Asthma

Diagnostics:

  • COVID-19 swab
  • CXR only if suspect pneumonia
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24
Q

Acute bronchitis:

Management

Role of antibiotics

A

Supportive

  • cough can last 1-3 weeks
  • reassure self-limiting
  • tea, lemon, honey, lozenges, fluids
  • OTC cough medication
  • PRN tylenol (fever/malaise)
  • PRN ventolin if wheezing or underlying chronic resp condition
  • strongly discourage antibiotics
  • only in rare circumstances (high risk of complications, suspect pneumonia, suspect specific pathogen eg pertussis)
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25
What is the definition (timeline) of chronic bronchitis?
chronic productive cough for 3 months in 2 consecutive years
26
What are the 3 cardinal symptoms of COPD?
- dyspnea - chronic cough - sputum production
27
What is the most important risk factor for chronic bronchitis? Other risk factors?
SMOKING! - acute viral infection - cold weather - occupational exposure: coal, fumes, dust, smoke - chronic aspiration/GERD
28
Chronic bronchitis: signs and symptoms:
``` Worsening cough: hacking, harsh, raspy Sputum changes: colour, amount, viscosity *vomiting for children <5 (cannot expectorate) Chest rattle Dysnpea/breathlessness Wheezing Malaise Fever Myalgias Arthralgias ```
29
Differentiating between asthma and chronic bronchitis: Asthma: wheeze is ______, cough is ______ Bronchitis: cough is ______, wheeze is _______
Asthma: wheeze is long standing, cough is late onset Bronchitis: cough is long standing, wheeze is late onset
30
Obstructive sleep apnea RISK FACTORS - meds? - sex? - medical conditions?
Meds: CNS DEPRESSANTS benzos, antipsychotics, opioids, beta blockers, barbiturates, antihistamines, sedative antidepressants, ALCOHOL sex: male Medical: obesity, diabetes, HTN, increased neck circumference, tonsillar hypertrophy, hypothyroidism
31
Obstructive sleep apnea is a risk factor for:
- strokes and cardiovascular disease (nocturnal arrhythmias, acute cardiac events) - diabetes - visceral obesity - traffic accidents
32
OSA in children is mostly caused by _____ and _____
- obesity | - tonsillar/adenoid hypertrophy
33
What is the pathophysiology underlying OSA?
Increased­ tissue thickness of tongue and soft tissues in the pharyngeal cavity, narrows passageway for air to the trachea At night: oropharynx muscle relaxes, causes airway obstruction
34
Questions to ask during subjective assessment of OSA
- daytime sleepiness? - naps? - partner c/o snoring/gasping/snorting? - meds - ETOH - Epworth Sleepiness Scale - men: erectile dysfunction
35
Describe a physical assessment for suspected OSA
- vitals, ht and wt (BMI), waist circumference - ENT: peritonsillar narrowing/hypertrophy, tongue (macroglossia), elongated/enlarged uvula, palate (high arch/narrow palate), nasal polyps, septal deviation - CVS and resp - thyroid - mental status: confusion
36
Diagnostic criteria for OSA: _____ apnea/hypopnea/arousals per hour of sleep in ASYMPTOMATIC patient OR _____ apnea/hypopnea/arousals per hour of sleep in SLEEP DISRUPTED patient
15+ per hour of sleep if asymptomatic 5+ per hour of sleep if symptomatic
37
OSA Management
- CPAP or BIPAP is mainstay - modifiable: diet and exercise (weight loss), smoking cessation, avoid alcohol - dentist for oral appliance - avoid sleeping supine (positioning therapy)
38
Risk factors for TB exposure and latent TB Risk factors for developing active TB
TB exposure and latent TB: - recent or close contact to case of active respiratory TB - travel to country with endemic TB x 3 months - homeless or living in shelters, correctional facility - IVDU or crack cocaine use Developing active TB: - HIV or AIDS - on transplant meds (immunosuppressed) - on hemodialysis - cancer of head and neck - TB in last 2 years - on biologics or tumour necrosis factor for autoimmune--diabetes - daily corticosteroids - heavy ETOH - age <4
39
TB - organism? - transmission? - incubation
- mycobacterium tuberculosis - transmission: inhalation of airborne droplets, depends on prolonged exposure and close contact - incubation: 2 to 10 weeks from infection to positive skin test * disease may not occur for years (or may just stay latent)
40
Assessment for TB - subjective history components - physical exam what lymph nodes are commonly involved?
- Fever, night sweats, chills, or cough, weight loss. - exposure history to someone who has TB. - living situation (including past history of homelessness)? - travel history to endemic areas with TB - IVDU? - HIV status Physical exam: - head to toe - wt - focus on chest and lymphadenopathy LN: anterior/posterior cervical and supraclavicular
41
Tuberculosis: signs and symptoms - systemic? - active respiratory TB disease? - active non-respiratory TB disease?
Systemic: - fever - night sweats - anorexia - unexplained weight loss - fatigue ``` Active respiratory TB disease cough x 2-3 weeks (dry or productive), with or without fever -hemoptypsis -chest pain -SOB ``` Active non-respiratory disease? Systemic symptoms plus -pain, swelling and/or dysfunction of involved body site (eg lymph nodes)
42
What is the gold standard for pulmonary TB testing? Describe steps of TB skin test *what is a positive reading? What should always be offered with every TB test?
sputum for AFB x 3 samples *best done in the morning TB: 0.1 ml intradermal to forearm, read in 48-72 hours positive = 5 mm+ if child <5, immunocompromised, HIV, close contact in lat 2 years otherwise positive = 10 mm + HIV test should be offered with every TB screen
43
Influenza Transmission? Incubation? Viral shedding?
Transmission: droplets (cough/sneeze), direct contact with contaminated surfaces Incubation: 1-4 days Viral shedding: avg 5 days
44
Define antigenic shift vs drift
Antigenic shift: major changes in H and N responsible for epidemics and pandemics Antigenic drift: minor changes in H and N, usually associated with local outbreaks of varying intensity
45
Potential complications of influenza
- Pneumonia (viral vs secondary bacterial) - Otitis media (most common complication in peds) - Acute myositis (extreme tenderness esp legs)-> rhabdomyolysis Severe: ARDS
46
# Define: - acute cough - subacute cough - chronic cough
Acute: 2-3 weeks Subacute: 3-8 weeks Chronic: >8 weeks
47
What are the 3 most common causes of chronic cough? Bonus emerging cause per Curbsiders?
- upper airway cough syndrome - asthma - GERD Bonus: -non-asthmatic eosinophilic bronchitis
48
Timing of chronic cough AM cough: more suggestive of ________ Overnight cough: more suggestive of (3)_______
AM: bronchitis PM: pulmonary edema, asthma, GERD (think lying down)
49
3 key clues in history taking for chronic cough?
- use of ACE-I - URI symptoms - smoking (main cause of chronic cough)
50
If chronic cough is related to allergies, what would you expect on labwork?
CBC: elevated eosinophils | elevated IgE
51
Chronic cough in smoker (current or former): Work up for lung cancer if one or more of these 3 symptoms are present
- new onset of cough/change in "smoker's cough" - cough lasting >1 month after quitting smoking - hemoptysis in absence of infection
52
Pertinent positive physical findings suggestive of PE:
Frequently asymptomatic Vitals: tachypnea, hypoxemia, tachycardia (often not present), hypotension Resp: decreased air entry, rales CVS: increased JVP, loud P2, parasternal heave DVT symptoms
53
Most common symptoms with PE:
dyspnea (73% of symptomatic patients) pleuritic chest pain Dry cough (hemoptysis not common) DVT symptoms **frequently asymptomatic
54
Definition of asthma: _______disorder characterized by:
inflammatory disorder - variable resp symptoms (SOB, tightness, wheezing) - variable airflow obstruction
55
What is the atopy triad?
- asthma - allergic rhinitis - atopic eczeoma
56
ASTHMA -risk factors for development
``` age at onset -allergen exposure urban residence -air pollution -tobacco smoke -recurrent RTI -GERD -obesity -poverty -exposure to ++ levels of certain allergens in childhood ```
57
Asthma pathophysiology Early response: - which cells are involved after exposure to antigen? - which one makes IgE? - what does IgE stimulate? - what causes bronchial hyperresponsiveness?
1. T-helper cells 2. B cells (make IgE) 3. Mast cell degranulation stimulated by IgE --> histamine 4. Eosinophils release toxic neuropeptides
58
Asthma pathophysiology Late response - eosinophils cause: - leads to air trapping and ____ - hypoxemia from ______
eosinophils damage epithelial cells (impairs mucociliary function, mucous plugs) airway obstruction leads to air trapping and hyperinflation hyperventilation causes early hypoxemia without CO2 retention
59
Triggers for asthma exacerbation What rx meds are triggers for asthma?
- viral infections - allergens - smoke - exercise (rare) - stress - pregnancy - hormones ``` Rx meds: beta blockers ACE-I ASA NSAIDS COV2 ```
60
3 common comorbidities for asthma
- rhinitis - chronic sinusitis - GERD
61
Symptoms of asthma: - frequent episodes of (4) - worse at ___ and ____ - triggered by (3) - improve with ______
• Frequent episodes of breathlessness, chest tightness, wheezing or cough • Symptoms worse at night and early morning • Develop with viral URTI, after exercise, exposure to allergens or irritants -in young kids: playing, laughing, crying • Symptoms respond/improve with bronchodilators or corticosteroids
62
Diagnosis of asthma for kids 6+ and adults: - gold standard test - what demonstrates reversibility?
SPIROMETRY FEV1>12% after bronchodilator is evidence of reversibility (higher number = more confident dx)
63
Diagnosis of asthma: - what test to use if spirometry is negative but clinical suspicion is high? - what can cause false neg?
methacholine challenge false neg with: - seasonal asthma - good control on meds - asymptomatic
64
Diagnosis of asthma Aside from spirometry and peak flow, what other diagnostic testing would you include?
CXR (not routine) CBC Allergy testing
65
GINA Asthma guidelines Overuse of SABA (> _____ canisters/year) increases risk of exacerbations SABA > _____ canisters/year increases risk of death
SABA >3/year = increase exacerbation SABA >12/year = increase death
66
GINA Asthma Monitoring follow up: - after initiation of tx: - routine: - minimum review: - in pregnancy: - after exacerbation Assess ______ at EVERY visit
* 1-3 months after starting treatment * Every 3-12 months after (recommend minimum annual review) * In pregnancy: q4-6 weeks * After exacerbation: review within 1 week Reassess and reinforce inhaler technique at EVERY visit
67
Asthma When should you order spirometry?
- at start (confirm dx before starting tx) - after 3-6 months (best lung function) - every 1-2 years
68
GINA Asthma What are the 6 components of self-management?
* Asthma info * Inhaler skills * Adherence * Asthma action plan * Self monitoring of symptoms and peak flow * Regular medical review
69
ASTHMA peak flow: - how often to do? - when to do? - expected to be low when? - expected to be high when?
BID, best of 3 each time - average over 1-2 weeks - do before inhalers - lowest early morning - highest in afternoon
70
ASTHMA MEDS ICS Indication: Example:
* first line controller * regular use Flovent (fluticasone) Pulmicort (budesonide) Alvesco (ciclesonide)
71
ASTHMA MEDS SABA Indication: Example:
SABA * bronchodilator * PRN rescue Ventolin Bricanyl (terbutaline)
72
ASTHMA MEDS ICS-LABA Indication: Example:
ICS-LABA: *first line combo controller reliever Advair (fluticasone + salmeterol) Symbicort (budesonide + formoterol)
73
ASTHMA MEDS LAMA Indication: Example:
LAMA * use regularly WITH ICS * never use alone Spiriva (tiotropium)
74
ASTHMA MEDS LTRA Indication: Example:
LTRA * second line controller * less effective than ICS Singulair (montelukast)
75
GINA ASTHMA ``` Track 1 (preferred): what medication is used: ```
low dose ICS-formoterol (Symbicort) as CONTROLLER AND RELIEVER Step 1-2: PRN Step 3-5: maintenance and reliever (MART)
76
GINA ASTHMA Track 2 (alternative to ICS-formoterol) what medication is used: conditions for use?
ICS as CONTROLLER SABA as RELIEVER only if adherent with daily ICS and NO exacerbations
77
GINA ASTHMA when would you consider short term step up therapy?
for 1-2 weeks with asthma plan during viral infection/allergen exposure
78
GINA ASTHMA Asthma exacerbations -when to seek medical care?
- if need to repeat SABA within 3 hours - if exceed max dose of controller * can quadruple ICS dose (watch max dose of formoterol)
79
GINA ASTHMA uncontrolled asthma -5 things to assess?
- inhaler technique - adherence to inhaler - modifiable risk factors - address other co-morbidities - treatment step up?

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