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AP Exam 4 (UPenn) > Respiratory > Flashcards

Flashcards in Respiratory Deck (25):
1

Structural pulmonary adaptations in pregnancy

-As uterus enlarges, level of diaphragm elevates to a peak of 4cm @ 37wks
-AP and transverse diameter of thorax and chest circumference increase, and subcostal angle widens.
-Changes allow lung volume and inspiratory capacity to inc by 5-10%
-Total lung capacity preserved throughout pregnancy

2

URI caused by viruses

-common cold
-otitis media
-sinusitis
-pharyngitis
-bronchitis
-pneumonia

*pregnant women with common cold at inc risk for developing sinusitis and otitis media d/t congestion from hormonal effects on nasal mucosa

3

Treatment for URI

-Self limiting, generally resolves within 3-10 days
-OTC meds for symptom relief
-Acetaminophen for pain
-Cough suppressants
-Decongestants
-Antihistamines
-Expectorants

Pregnant women with the following should be treated with Antibiotics:
- s/s for 10 days w/o improvement
- severe s/s or temp >102.2 for 3-4 days
- worsening s/s after 5-6 days of improving s/s

4

Functional pulmonary changes in pregnancy

-Maternal and fetal metabolic needs = increased gas exchange
-RR stays the same
-Increase in tidal volume and resting minute ventilation
-Decreased functional residual capacity
-Progesterone stimulates respiratory drive -- increased level of progesterone --> hypothalamus to accept lower level of PCO2 at ~32mmHg (vs. normal 40mmHg) --> this change favors transfer of CO2 from fetus to the mother
-Compensated respiratory alkalosis -- Mild hyperventilation to blow off excess CO2 begins in early pregnancy (prevents maternal acidosis) --> pregnant woman feels SOB even without exertion

5

Sinusitis treatment

- Augmentin and cefzil
- Saline nasal spray or saline nasal irrigation
- short term nasal corticosteroids (beclomethasone)
- intranasal cromolyn sodium

6

Bronchitis

- URI of large airways and manifests as cough that persists 10-20 days
- Etiology: usually caused by virus and abx therapy not indicated
- Can lead to pneumonia, women who's s/s worsen or persist should be reevaluated
-Treatment: supportive care and symptom management

7

Asthma

- Chronic inflammatory airway disease characterized by increased reactions of airway inflammation and bronchoconstriction to multiple stimuli such as allergens, irritants, stress, physical exertion
- Most common lung disease in pregnancy, prevalence 4-8%
-For pregnant women with asthma, 1/3 improve, 1/3 stay the same, 1/3 worsen

8

Asthma s/s

- wheezing
- coughing, esp that worsens at night
- chest tightness
- SOB

9

Asthma maternal & fetal complications

- Well controlled asthma not associated with significant risk to mother or fetus
- Magnitude of perinatal risk r/t severity of maternal asthma

Uncontrolled asthma -->
Maternal complications
-HTN
-Preeclampsia
-PTL/PTB
-Death (rarely)

Fetal complications:
-Stillbirth
-Fetal growth restriction
-Prematurity
-LBW

10

Asthma evaluation

Differential dx:
-Physiologic dyspnea of pregnancy (but does not have coughing at night, wheezing, chest tightness, or airway obstruction)
-Reactive airway disease
-URI
-Pneumonia
-GERD

-Obtain history of triggers
-Symptom characteristics
-Meds used currently or in the past for s/s relief
-For women with moderate to severe asthma, evaluate respiratory function at time of initial prenatal visit and periodically throughout pregnancy.
-Test peak expiratory flow rate (PEFR) with peak flow meter. Establish baseline when asymptomatic, "personal best" *peak flow does not change d/t pregnancy*
-People with moderate to severe disease should test peak flow BID

11

Asthma management

Main goal: prevent hypoxic episodes in mother, which can cause oxygen deprivation in fetus

-Avoid triggers
-Monitor lung function
-Assess severity
-Pharmacologic therapy * vast majority of asthma meds are safe to use in pregnancy and breastfeeding*
--> then monitor lung function, assess severity, repeat.
-Consider serial growth US and NST's for pregnant people with moderate to severe asthma during pregnancy
-With intermittent and well-controlled disease, no additional surveillance necessary

12

Asthma pharmacologic tx

Rescue therapy
-SABA: albuterol, 1-2 inhalations q4-6hrs PRN
-all people with asthma should have albuterol inhaler with them **don't hesitate to refill for people**
-Prednisone/other steroids can be rescue therapy

Long term control meds
-Inhaled corticosteroids (ICS) in low, medium, high doses-- i.e. budesonide* preferred in pregnancy.
Other ICS: fluticasone, mometasone, triamcinolone, flunisolide,
-Long acting bronchodilators
-Cromolyn, theophylline, leukotriene modifiers

13

Asthma step-wise treatment

Step 1: mild-intermittent asthma
-short-acting inhaled beta-agonist: albuterol

Step 2: mild-persistent asthma
-daily low-dose inhaled corticosteroid: Budesonide

Step 3: Moderate intermittent asthma
1. Daily low-dose ICS + long-acting beta2 agonist PRN
2. Medium dose ICS

Step 4: Severe persistent asthma
-Increase ICS and addition of oral corticosteroids considered


14

Pneumonia Management

Dx:
-CXR
-Flu swab
-ABGs
-Sputum for gram stain and culture

Management: treatment setting by clinical condition, hospital admission generally recommended

Bacterial pneumonia treatment:
-empirical antibiotics-- macrolide + beta-lactam
-AVOID quinolones (levofloxacin, gatifloxacin, moxifloxacin)
-If MRSA pneumonia, vanco or linezolid


Viral pneumonia treatment:
-Flu: treat w/ antivirals
-Varicella pneumonia: acyclovir IV, ICU admit
-PJP (HIV+): Bactrim +/- steroids, ART

15

Pneumonia maternal and fetal risks

Maternal risks:
-no increased prevalence, but increased ICU, intubation and mortality with pregnancy

Fetal risks:
-PPROM
-fetal compromise

16

Pneumonia prevention

-Pneumococcal vaccine indicated for heart, kidney, liver, lung (including asthma), HIV, cancer, diabetes, smoking, s/p splenectomy, and more
-Probably safe, but not routinely given in pregnancy

17

Pneumonia causes, s/s

-Etiology: usually bacterial, many causative organisms. Most common pathogens -- 1. streptococcus pneumoniae, 2. haemophilus influenzae

-Can occur independently or may follow viruses such as influenza, bronchitis, common cold, varicella, PJP (opportunistic infection in HIV)

-S/s: fever, productive cough, pleuritic chest pain, dyspnea, shaking/chills

18

Tuberculosis etiology, risk factors

Etiology: mycobacterium tuberculosis

Risk factors:
-Born outside of US
-elderly
-poverty
-immunocompromised
crowded living quarters (group home, prison)

-Infection is often contained and remains dormant for long periods of time
-Can subsequently cause clinical disease
-Poor pregnancy outcomes w/ untreated active disease, minimal risk with latent disease

19

TB s/s

-Cough
-minimal sputum
-low grade fever
-hemoptysis
-weight loss

20

TB testing

Screen everyone at risk:
-health care workers
-known contact
-foreign born
PLHIV
-working/living in homeless shelter
-people w/ substance abuse disorders
-detainees and prisoners

Testing:
-PPD
-Interferon-gamma release assays: quantiferon-TB gold or T-SPOT.TB
- if +, eval for active TB with thorough PE and CXR after 1st tri

21

TB treatment

Latent infection:
-Usually defer tx to postpartum
-Exceptions: new infection, PLHIV

Active infection:
-4 drug regimen for 2 months (bactericidal phase)
-4 month isoniazid and rifampin (continuation phase)
-All are compatible with BF
-Treatment is long! Pt needs support

22

Pulmonary Embolism S/S

-Chest pain
-SOB
-Feeling of apprehension
-Hemoptysis
-Unexplained tachycardia

23

Risk factors for PE

-Thrombophilia
-Previous thromboembolism
-Obesity
-Parity
-Smoking
-SCD
-Heart disease
-Systemic lupus
Varicose veins
-Immobility
-ART
-Hyperemesis gravidarum
Preeclampsia
Multiple gestation
Postpartum period

24

PE Dx

Differential dx:
-MI
-Anxiety/panic attack
-Asthma attack
-CHF
-Pneumonia

Dx:
-EKG
-CXR
-V/Q
-CTPA

25

PE treatment

Low-molecular weight heparin --
Enoxaparin (lovenox): 1 mg/kg SQ BID