Respiratory Cases

Question 1

classifications of asthma

Answer 1

intermittent: sx 2/week or less, 2/mo or less nocturnal awakenings
mild: sx > 2/week, 3-4/mo nocturnal awakenings
moderate: daily sx, >1/mo nocturnal awakenings
severe: sx throughout the day, nocturnal sx every night

Question 2

order of workup for asthma (after you’ve done thorough h&p of course)

Answer 2

1. PFTs
2. If PFTs are normal -> methacholine challenge or ASA challenge
3. CXR -> r.o PNA/COPD/ca

Question 3

stepwise approach to asthma tx

Answer 3

1. exercise induced: PRN SABA
2. PRN low ICS
3. PRN low ICS + LABA
4. daily low ICS + LABA
5. daily med ICS + LABA
6. daily high ICS + LABA

all steps get PRN SABA

Question 4

if asthma is well controlled, PRN SABA should not be used more than

Answer 4

1/week

Question 5

what class of drug is Symbicort
what condition is it commonly used for

Answer 5

ICS/LABA combo
asthma

Question 6

when are peak flow meters used

Answer 6

daily at home

Question 7

when are PFTs done

Answer 7

for initial dx and when indicated for another reason

no formal guidelines

Question 8

when are systemic steroids used for asthma

Answer 8

only for acute exacerbation

Question 9

PE findings of COPD (2)

Answer 9

expiratory wheezing
prolonged expiratory phase of respiration

Question 10

CXR findings of COPD (2)

Answer 10

increased AP diameter
flattened diaphragm

Question 11

what diagnostic tools are used to assess/stage COPD

Answer 11

subjective: mMRC/CAT
objective: PFTs

Question 12

when are sputum cultures recommended for acute exacerbations of bronchitis (5)

Answer 12

complicated attack
failed abx
suspect atypical
immunocompromised
homeless or group living
IVDU

not first line soc!

Question 13

what 3 organisms mc cause acute exacerbations of bronchitis

Answer 13

h.flu
strep pneumo
m.cat

Question 14

what is the timeline for tamiflu administration

Answer 14

w.in 48 hr of sx onset

Question 15

what is the most effective rescue med for COPD

Answer 15

SAMA/SABA combo -> Combivent

Question 16

when are abx recommended for acute exacerbation of bronchitis in COPD pt

Answer 16

moderate to severe exacerbation -> 2 out of 3:
-increased dyspnea
-increased sputum volume/viscosity
-increased sputum purulence

Question 17

when would you use azithromycin for acute bronchitis flare in COPD pt

Answer 17

uncomplicated flare
no rf
age > 65 yo
FEV1 > 50% predicted

Question 18

top 3 abx recommended for uncomplicated acute bronchitis attack

Answer 18

1. azithromycin
2. clarithromycin
3. cefuroxime

Question 19

duration of abx for uncomplicated acute bronchitis attack

Answer 19

5-7 days

Question 20

how do you define a complicated acute bronchitis attack

Answer 20

1 or more rf:
age > 65 yo
FEV1 < 50% predicted
2 or more exacerbations/year
cardiac dz

Question 21

what 3 abx are used for complicated acute bronchitis attack

Answer 21

1. moxifloxacin
2. levofloxacin
3. augmentin

Question 22

in a nutshell summary of outpatient (uncomplicated) abx for acute bronchitis attack

Answer 22

most: macrolide OR 2nd/3rd gen cephalo
high risk w.o pseudo risk: augmenting OR fluoroquinolone
high risk w. pseudo risk: fluoroquinolone

Question 23

in a nutshell summary of inpatient (complicated) abx for acute bronchitis attack

Answer 23

pseudo risk: fluoroquinolone or 3rd gen cephalo
no pseudo risk: IV cefepime, ceftazidime, zosyn

Question 24

what class of drug is a Spiriva

Answer 24

LAMA

Question 25

what 2 drugs are commonly used for COPD

Answer 25

Combivent (SABA/SAMA) -> rescue Spiriva (LAMA) -> daily

Question 26

how often should FEV1 be monitored in COPD pt

Answer 26

annually

Question 27

tx to consider for COPD pt who presents w. sx of acute bronchitis attack, but has poorly managed pharm for COPD, and is non toxic AF

Answer 27

delay abx prescribing increased COPD tx x 3-4 days if no improvement -> rx abx

Question 28

are systemic steroids recommended for COPD

Answer 28

not really ever... unless super super sick

Question 29

CENTOR criteria

Answer 29

Question 30

do you need to flu swab an otherwise healthy pt who presents > 48 hr after sx onset

Answer 30

probs not -> won't give tamiflu outside this window, so why swab?

Question 31

what meds might you prescribe for viral URI (2)

Answer 31

OTC APAP PRN

Question 32

f.u for viral URI in peds if RSV (+)

Answer 32

1-2 days

Question 33

f.u for viral URI in peds if RSV (-)

Answer 33

1 week

Question 34

indications for emergent care in kiddo w. viral URI

Answer 34

difficulty breathing AMS toxic AF poor feeding/hydration no improvement maxillary tooth pain high fever

Question 35

virus mc responsible for viral URI

Answer 35

rhinovirus also: flu, adenovirus, enterovirus, rev

Question 36

what lung sound is associated w. PNA

Answer 36

crackles

Question 37

who gets a ddimer

Answer 37

low risk for PE

Question 38

what PE could you do to assess for DVT

Answer 38

leg exam if positive -> US deep veins

Question 39

why might you do a CT in PNA pt.

Answer 39

r.o PE and PNA

Question 40

what pathogens are mc associated w. HAP (6)

Answer 40

pseudomonas acinetobacter s.aureus h.flu klebsiella e.coli

Question 41

definition of HAP

Answer 41

develops > 48 hr after admission

Question 42

2 major rf for HAP (besides hospital admit)

Answer 42

ventilation aspiration

Question 43

you should base abx tx for HAP on (3)

Answer 43

risk for MRSA risk for pseudomonas local antibiogram

Question 44

denver health antibiogram guidelines for HAP tx

Answer 44

cefepime 2 g IV q 8 hr indications for addition of IV vanco: VAP hx MRSA infxn IV abx in past 90 days indications for addition of IV vanco + amikacin: severely ill w. septic shock mod-severe pcn allergy: levofloxacin

Question 45

clinical stability criteria for HAP (5)

Answer 45

afebrile x at least 24 hr no unexplained tachy WBC nl or improving O2 needs improving or at baseline tolerating PO

Question 46

step down po abx choice for clinically stable HAP patients

Answer 46

levofloxacin

Question 47

what tool is used to assess PNA disposition (2)

Answer 47

CURB 65 SIRS

Question 48

sepsis/SIRS criteria

Answer 48

temp: < 36 OR > 38 HR: > 90 bpm tachypnea: > 20 OR PaCO2 < 32 WBC: < 4,000 OR > 12,000

Question 49

q hr sepsis bundle (5)

Answer 49

1. measure lactate 2. obtain cultures 3. abx 4. rapid admin of crystalloid 5. vasopressor

Question 50

t/f: all pt's who meet SIRS criteria should be considered septic

Answer 50

f!