Pulmonary Disorders

Pulmonary Disorders

  1. Drugs
    “terol”
    “one or “ide”
    “tropium”
    Beta Agonists (LABA and SABA)
    Steroid
    Inhaled anticholinergic
  2. A 36 year old patient presents with a CC cough. What is the most important question to ask him? Why? How long have you coughed?
    Answer helps build DD.
  3. Acute Cough < 3 weeks Differential Diagnosis
  4. Acute Respiratory Infection (Bronchitis, sinusitis, PND) Exacerbation of COPD, asthma
    Pneumonia
    PE
    Others
  5. Chronic Cough > 8 weeks
    Differential Diganosis
    Asthma
    GERD
    Infection: Pertussis, atypical pneumonia
    ACE Inhibitors: dry cough 1-3 weeks after starting
    Chronic Bronchitis (almost always smokers)
    Bronchiectasis
    Lung Cancer
  6. A 24 year old college student who is a non-smoker and otherwise healthy has been diagnosed with pertussis. What’s an appropriate treatment for her? Azithromycin 500 mg day 1, 250 mg days 2-5
  7. Community Acquired Pneumonia (CAP) Associated with morbidity and mortality especially in older adults
  8. 3 most common “bugs” in CAP  1. S. pneumonia (pneumococcal pneumonia) produces rust colored sputum
    Atypical Organisms
    2. M. Pneumoniae
    3. Chlamydophila pneumonia
    4. Others: viral pathogens, legionella
  9. Drug Resistant S. Pneumoniae (DRSP) At Risk Populations
    Diagnosis
    Symptoms
  10. Age > 65 years, patients with comorbid conditions, recent abx exposure (3 months), immunosuppressed, alcoholics, exposure to child in day careCxray is gold standard Abrupt onset with fever, chills, cough, pain in side or chest, rust colored sputum *older adults exhibit fewer symptoms (confusion, absence of fever)
  11. Atypical Pathogens
    At Risk Populations
    Diagnosis
    Symptoms
    Young, otherwise healthy, non smokers, community outbreakCxray is gold standard Low grade fever, cough, chills, headache, malaise, rash, joint aches, arrythmias
  12. A 54 year old patient who is otherwise healthy and takes no meds has been diagnosed with CAP. What’s an appropriate treatment for her? Azithromycin 500 mg day 1, 250 mg days 2-5
  13. IDSA and ATS 2007 Guidelines for Treatment of Pneumonia
    Summary of Treatment Options
    1. Macrolide or doxy for most patients
    If DRSP is suspected
    2. Respiratory quinolone “floxacin”
    3. Beta lactam (PCN or Ceph) plus macrolide or doxy (for quinolone allergy or pregnant)
  14. A 55 year old patient was diagnosed with pneumonia 7 days ago and was started on levofloxacin. He had a normal temperature for the past 2 days but complains that he feels tired and is still coughing. How should this be handled? Have him continue to rest for another 3-5 days
  15. What characteristic is least likely to prompt the NP to consider hospital admission for an adult patient who has pneumonia? 1. Confusion since onset of pneumonia symptoms
    2. RR > 30/min
    3. BP 80/50
    4. Age = 55 yr
  16. Age
  17. PPSV23 Adults 19-64 years who are at increased risk of pneumococcal disease (asthma, COPD, CV dx, etc)
  18. PPCV13  All adults 65 and older
    Aged 19-64 with asplenia, immunocompromising conditions, CSF leaks, cochlear implants, plus an additional PPSV23 (1 year)
  19. Which patients would profit from receiving the pneumococcal immunizations? Vulnerable populations
  20. Key Indicators of COPD 1. Dyspnea: that is progressive
    2. Chronic Cough: initially may be intermittent, may be unproductive, then present every day throughout the day
    3. Chronic sputum production: common (production of sputum for 3 or more months in 2 consecutive years)Consider COPD for age 40 or older, perform spirometry, presence of multiple indicators
  21. Diagnosis for COPD Symptoms: SOB, chronic cough, sputum
    Exposure to risk factors: tobacco, occupation, outdoor/indoor pollution
    Spirometry: required to establish diagnosis (FEV1/FVC ratio <0.70)
  22. Differential Diagnosis for COPD COPD
    Heart Failure
    Asthma
    Tuberculosis
  23. GOLD Staging System (Based on post-bronchodilator FEV1) GOLD 1
    GOLD 2
    GOLD 3
    GOLD 4
  24. 1: Mild FEV1 > or equal to 80% predicted
    2: Moderate 50% < FEV1 <80% predicted
    3: Severe 30% < FEV1 < 50% predicted
    4: Very Severe FEV1 < 30% predictedHAG is taken into account for reference values (age, gender, height)
  25. COPD Medications: Therapeutic Options Beta 2 Agonists: SABA and LABA
    Anticholinergics: long and short acting
    Combination SABA + anticholinergic
    Combinations LABA + Anticholinergic
    Methylxanthines
    Inhaled corticosteroids
    Combination LABA + corticosteroid in inhaler
    Systemic Corticosteroids
    Phosphodiesterase-4 inhibitors
  26. Bronchodilators Beta Agonists (agonist = stimulant) causes bronchodilation
    1. Short acting beta agonists: work 4-6 hours, “terol”, rescue med/works immediately
    2. Long acting beta agonists: work 12-24 hours, “terol” not a rescue med/takes 10-20 min to work, example: salmeterol, newer meds that work for 24 hours (indacaterol, olodaterol, vilanterol)
  27. Inhaled Anticholinergics Produce “a little” bronchodilation
    Works by preventing bronchoconstriction
    “tropium”
    Combos: SABA, LABA
    May cause constipation, increased IOP
  28. Anticholinergic Medication Side Effects Memory impairment, confusion, hallucinations, dry mouth, blurred vision, urinary retention, constipation, tachycardia, acute angle glaucoma
  29. An Ode to an Anticholinergic Med Oh this drug, it makes me pink. Sometimes I can’t think or even blink. I can’t see, I can’t pee, I can’t spit, I can’t **it.
  30. Combinations of Meds Steroids plus LABA
    Best in COPDers with FEV1 < 60% predicted
    Works by reducing inflammation
    “one” or “ide” suffix
    Best in combo with bronchodilators
    LABA plus long acting anticholinergic
  31. Prescribing Safety for COPD 1. Short acting anticholinergic prn or SABA prn then
    2. Long acting anticholinergic or LABA plus rescue med then
    3. ICS + LABA or LA anticholinergic plus rescue med then
    4. ICS + LABA and/or LA anticholinergic plus rescue med*Theophylline is an alternate treatment but not preferred
    PDE4: roflumilast, used to reduce exacerbations for patients with chronic bronchitis, severe airflow limitation and frequent exacerbations not controlled by LABAs
  32. COPD Exacerbation An acute event characterized by a worsening of the patient’s respiratory symptoms beyond the normal day to day variations and leads to a change in medication
  33. Oral Steroids for Exacerbations Shorten recovery time
    Improve lung function (FEV1) and arterial hypoxemia (PaO2)
    Recue the risk of early relapse, treatment failure, and length of hospital stay
    A dose of Prednisone 40 mg x 5 days is recommendedChronic oral steroid use should be avoided!!!!
    Unfavorable risk to benefit ratio
  34. Common Co-morbidities associated with COPD and their implications HTN, hyperlipidemia, CAD, tachyarrythmias: multiple medicationsOsteoperosis: possibility for drug-drug interactionsDepression and anxiety: possibility of drug-disease interactions

    Metabolic syndrome/DM: more complex patients

    Lung Cancer

  35. Health Promotion Smoking cessation is the single most effective and cost effective intervention
    Encourage smoking cessation at each visit
    It’s never too late to quit
    Encourage regular exercise
    PPSV Immunization
    Influenza immunization annually
  36. Asthma Disease of inflammation
  37. Establish asthma diagnosis Symptoms of recurrent airway obstruction from history and exam
    *cough
    *wheezing
    *SOB
    *chest tightness
    *Spirometry
    *”symptoms are predictable”
  38. Spirometry is used to demonstrate: Presence of Airway Constriction
  39. Classify Asthma Severity See p. 23 and 24 for classifying severity of intermittent and persistent asthma
  40. Initiating Medication Preferred Meds
    Intermittent Asthma: SABA prn
    Persistent Asthma: Low dose ICS, Low dose ICS plus LABA or Medium dose ICS, Medium dose ICS plus LABAAlternate Meds
    Intermittent Asthma: SABA prn
    Persistent Asthma: Cromolyn, LTRA, or theophylline; low dose ICS plus LTRA, theophylline, or zileuton; medium dose ICS plus LTRA, theophylline, or zileuton
  41. Asthma Action Plan Every asthma patient should leave the office with an asthma action plan.
  42. Follow up Appointments for asthma Asthma care is very variable
    Every 2-6 weeks while gaining control
    Every 1-6 months to monitor control
    Every 3 months if step down is anticipatedSpirometry at least every 1-2 years, more frequently if asthma not well controlled
  43. Follow up visits Assess and monitor asthma control
    Review medication technique and adherence, assess side effects, review environmental control
    Maintain, step up, or step down medication
    Review asthma action plan, revise as needed
    Schedule next f/u appointment
  44. Bronchodilators Every asthma patient must have a rescue med!!!!
    This is a safety issue.
  45. Exercise Induced Bronchoconstrcition Treat before exercise
    SABA for most patients
    Consider: ICS if using SABA more than twice weekly (EIB is often marker of inadequate asthma control)
  46. Health Promotion Pneumococcal immunization
    Influenza immunization regularly
    Encourage regular exercise
  47. Patient Education Know how to use asthma action plan
    Patient knows names of his meds, checks expiration dates
    Uses inhaler properly, knows when empty
    Knows when to use rescue meds
  48. Pulmonary Emboli Sudden onset of dyspnea and coughing
    Other symptoms include tachycardia, pallor, and feelings of impending doom
    Patients have a history of atrial fibrillation, estrogens, surgery, pregnancy, long bone fractures, or prolonged inactivity
  49. Impending Respiratory Failure (asthmatic patients) Presents with tachypnea (greater than 25/min), tachycardia or bradycardia, cyanosis, and anxiety.
    Appears exhausted, fatigued, diaphoretic, and sues accessory muscles with breathing.
    Physical exam reveals cyanosis and “quiet” lungs.
    Tx Plan: Adrenaline injection stat. Call 911. Oxygen at 4-5 L/min, albuterol nebulizer, parenteral steroids, antihistamines
    Good sign after tx: presence of breath sounds and wheezing
  50. Vesicular Breath Sounds Lower lobes
    Soft and low
  51. Bronchial breath sounds upper lobes
    louder
  52. Egophony Will hear “eee” clearly instead of “bah”
    “eee” sound is louder over large bronchi, softer over lower lobes
  53. Tactile Fremitus Patient says “99” while provider uses finger pads to palpate lungs and feel for vibrations
    Stronger vibrations palpable on the upper lobes and softer vibrations on lower lobes
  54. Whispered Pectoriloquy Patient says “99” while comparing both lungs. If there is lung consolidation, the whispered words are easily heard on the lower lobes of the lungs.
    Voice louder and easy to understand in upper lobes, voice sounds are muffled in the lower lobes
  55. Percussion Use the middle or index finger as the pleximeter finger one hand. The finger on the other hand is the hammer.
    Normal: Resonance
    Tympany or hyperresonance: COPD, emphysema
    Dull tone: bacterial pneumonia, pleural effusion, solid organ like the liver
  56. Chronic Bronchitis Coughing with excess mucous production for at least 3 or more months for a minimum of 2 or more consecutive years
  57. SABA safety issues Use with caution if patient has hypertension, angina, and/or hyperthyroidism. Avoid combining with caffeinated drinks.
  58. Cxray in CAP Gold standard for diagnosis
    Repeat within 6 weeks to document clearing
    Results show lobar consolidation in classic bacterial pneumonia
    Post tx cxray to show clearing of infection
  59. Poor prognosis (Refer for hospitalization in CAP)
    CURB-65 criteria
    Confusion
    BUN > 19.6
    RR > 30
    SBP < 90
    DBP < 60
    Age equal to or > 65
  60. Pertussis Also known as whooping cough
    Caused by Bordetella pertussis
    Coughing illness of at least 14 days duration with one of the following findings: paroxysmal coughing, inspiratory whooping, post tussive vomiting without apparent cause
  61. Stages of Pertussis Catarrhal
    Paroxysmal
    Convalescent
    Most infectious period is early in the disease (catarrhal stage) up to 21 days of cough
  62. Pertussis Labs Nasopharyngeal swab for culture and PCR
    Pertussis antibodies by ELISA
    CBC: elevated WBCs and marked lymphocytosis
    Cxray negative
  63. Pertussis Treatment First Line: Marcrolides
    Z Pack x 5 days
    Clarithromycin BID x 7 days
    Chemoprophylaxis for close contacts. Respiratory droplet precautions.
    Antitussives, mucolytics, rest, hydration.
    Frequent small meals.
  64. Common Cold
    Viral URI self limiting infection ranging 4-10 days
    more common in crowded areas and small children
    most cases occur during winter months
    highly contagious
  65. Viral URI treatment plan Symptomatic treatment.
    Increase fluids and rest. Frequent handwashing.
    Analgesics: Tylenol or NSAID prn pain/fever
    Oral decongestants prn (Sudafed)
    Topical nasal decongestants BID up to 3 days prn (Afrin)
    Antitussives prn (dextromethorphan)
    Antihistamines prn nasal congestion (Benadryl)
  66. Tuberculosis An infection caused by Mycobacterium tuberculosis bacteria
    Most common site of infection is the lungs (85%)
    Most contagious forms are pulmonary TB, pleural TB, and laryngeal TB
    CXR with show cavitations and adenopathy and granulomas on the hila of the lungs
  67. TB High Risk Populations Immigrants from high-prevalence countries
    Migrant Farm Workers
    Illegal Drug Users
    Homeless
    Inmates of Jails and nursing homes
    HIV infected
    Immunocompromised
  68. Latent TB infection an intact immune system causes macrophages to sequester bacteria in the lymph nodes in the form of granulomas
    not infectious
  69. Prior BCG Vaccine Hx of BCG vaccination is not a contraindication for tuberculin testing
    If more than 5 years have elapsed since last vaccination, a + TB skin test most likely caused by TB infection
  70. Miliary TB Also known as disseminated TB disease
    Infects multiple organ systems
    CXR will show classic “milia seed” pattern
  71. Multidrug-Resistant TB Bactria resistant to at least 2 of the best anti-TB drugs, isoniazid and rifampicin (these drugs are considered first-line drugs)
  72. Direct Observed Treatment (DOT) Mandatory for noncompliant patients
    Success dependent on medication compliance
    How: patient is observed by a nurse when he or she takes the medications
  73. Reactivated TB infection or active TB disease latent bacteria become reactivated due to depressed immune system
    majority of TB cases of active disease in U.S. are reactivated infections
  74. TB treatment plan Report TB to local health department for contact tracing ASAP. A reportable disease
    All active TB patients should be tested for HIV infection
    Initial regimen for suspected TB before C&S results are available. Use 4 drugs: INH, rifampin, ethambutal, and pyrazidamide three times a week.
    Narrow down number of medications after C&S results reveal most effective drugs
    Several tx regimens are available. Check TB website.
  75. Ethambutol warning Causes optic neuritis.
    Avoid if patient has abnormal vision Recent PPD Converters and/or Latent TB infection
  76. Definition: person with a hx of negative PPD results who then converts to a positive PPD. Higher risk of active disease within first 1-2 years of seroconversionAssess for signs and symptoms of TB
    Order CXR
    HIV neg: INH 300 mg daily x 9 months
    HIV pos: INH 300 mg daily x 12 months
    Check baseline LFT and monitor
  77. TB skin test Look for induration (feels harder)
    Red color is not as important
    If PPD result is a bright red color but not indurated this is negative.
  78. TB skin test
    Induration less than or equal to 5 mm 
    HIV +
    Recent contact with infectious TB cases
    CXR with fibrotic changes consistent with previous TB disease
    Any child who had close contact or has TB symptoms (before age 5)
    Immunocompromised
  79. TB skin test
    Induration greater than or equal to 10 mm
    Recent immigrants from high prevalence countries
    Child less than for years of age or children/adolescents exposed to high risk adult
    IV drug user
    health care worker
    homeless
    employees or residents from high risk congregate settings (jail, nursing home)
  80. TB skin test
    Induration greater than 15 mm
    persons with no known risk factors for TB
  81. Blood Tests for TB QuantiFERON-TB Gold or T-SPOT TB test
    IGRA test results: available in 24 hours, only one visit required, preferred with hx of BCG vaccination
  82. Sputum tests for TB Sputum for PCR
    Sputum C&S and AFB: takes from 3-6 weeks
  83. Booster Phenomenon a person with latent TB infection can have a false negative reaction to the TB skin test if they have not been tested for many years
    -2 step TB skin testing is recommended by the CDC
  84. Anergy Testing Used for patients suspected of being immunocompromised to rule out false negative results.
  85. Peak Expiratory Flow Rate Measures effectiveness of treatment, worsening symptoms, and exacerbations. During expiration, patient is instructed to blow hard using the spirometer (3 times). The highest value is recorded. PEF is based on HAG.
  86. Spirometer Parameters Green Zone: 80-100% expected volume
    Maintain or reduce medications
    Yellow Zone: 50-80% expected volume
    Maintenance therapy needs to be increased or patient is having acute exacerbation
    Red Zone: Below 50% expected
    If still below 50% after tx, call 911. If in resp distress give epi injection, call 911.
  87. Chronic use of high dose inhaled steroids Can cause osteoporosis, mild growth retardation in children, glaucoma, cataracts, immune suppression, hypothalamic-pituitary-adrenal suppression, and other effects
  88. First line treatment for severe asthmatic exacerbation or respiratory distress Adrenaline injection
  89. Most common side effects of long-term inhaled steroid use Cataracts and osteopenia
    annual eye exams needed since higher risk of cataracts and glaucoma

 

 

Pulmonary Disorders

 

 

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