93 terms

Respiratory - primary care

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What are clinical features of bronchitis?
1. cough
2. +/- chest discomfort
3. +/- SOB
4. +/- fever
How long does the cough of bronchitis last?
1-2 weeks
(often more than 1 month)
How do you treat bronchitis?
Cough suppressants
Bronchodilators
What is the triad of asthma?
Airway inflammation
Airway hyperresponsiveness
Reversible airway obstruction
What is the most common type of asthma?
Extrinsic
How does extrinsic asthma present?
Young age
Atopic patients
What meds can trigger asthma?
Beta blockers
Asthma
What are clinical features of asthma?
Intermittent symptoms
1. SOB
2. Wheezing
3. Chest tightness
4. Cough
What is asthma worse?
At night
What are signs of impending respiratory failure?
Paradoxic movement of the diaphragm and abdomen on inspiration
How do you diagnose asthma?
PFTs
Decreased FEV1
Decreased FEV/FVC <.75
What FEV1/FVC ratio is suggestive of asthma?
<.75
What is the quickest method to diagnose asthma?
Peak flow
What does to bronchoprovocation test use?
Methacholine
What is a short acting beta-agonist?
Albuterol
How long does albuterol last?
4-6 hours
How long does it take albuterol to kick in?
2-5 minutes
What is a long acting beta-agonist?
Salmeterol
What is salmeterol good for?
Night time
Exercise induced asthma
What are side effects of inhaled corticosteroids?
Sore throat
Thrush
Hoarseness
When do you use supplement oxygen with asthma?
O2 sat <90%
How often tdo mild intermittent patients have symptoms?
2+ times/ week
How often do moderate persistent patients have symptoms?
Daily symptoms
Frequent exacerbations
What long term control medications are indicated for moderate persistent asthma?
Daily inhaled corticosteroid (low dose)
how often do severe persistent patients have symptoms?
Continual
Frequent exacerbations
limited physical activity
What long-term control medications are indicated for severe persistent asthma
Daily inhaled corticosteroid (high dose)
LABA
How do you diagnose chronic bronchitis?
Clinical diagnosis
Chronic cough productive of sputum (3mo/yr for 2 consecutive years)
How do you diagnose emphysema?
Pathologic diagnosis
What is seen in emphysema?
Permanent enlargement of air spaces distal to terminal bronchioles due to destruction of alveolar walls
What type of emphysema is seen in smokers?
Centrilobular emphsema
-destruction limited to respiratory bronchioles
What lung zones are affected with centrilobular emphsema?
Upper lung zones
When do you see panlobular emphysema?
Alpha-1 antitrypsin deficiency
Can chronic bronchitis and emphysema coexist?
Yes
What causes almost 90% of case of COPD?
Tobacco smoke
What is the pathogenesis of chronic bronchitis?
Excessive mucous production narrows airways
-Inflammation/scarring in airways
-Enlargement in mucous glands
-Smooth muscle hyperplasia
What causes destruction of alveolar walls in tobacco related emphysema?
Relative excess in protease activity (elastase)
What is elastase?
Released from PMNs and macrophages
-digests lungs
What role does tobacco have on elastase?
Increases activated PMNs and macrophages
-inhibits alpha-1 antitrypsin
-increases oxidative stress by free radical production
How do pink puffers sit?
Tend to lean forward
How do pink puffers breathe?
Tachypnic with prolonged expiration through pursed lips
Do pink puffers or blue bloaters tend to use accessory muscles?
Pink puffers
-seem distressed
What Forced expiratory time is a sign of emphysema?
Greater than 6 seconds
What FEV1 is suggestive of severe disease?
<50%
What does COPD do to TLC, RV, FRC?
Increases
What Peak expiratory flow is a positive screen for COPD?
<350L/min
How long after quitting do respiratory symptoms improve?
1 year
How often do patients with COPD need pneumovax?
Every 5-6 years
How do you divide between acute and chronic cough?
3 weeks
How does a cough caused by GERD present?
Nocturnal
Lying flat, reflux worsened
How do you treat postnasal drip?
1st generation antihystamine
Decongestant prep
What kind of virus is influenza?
Orthomyxovirus
What antigenic types of orthomyxovirus cause the flu?
Antigenic types A and B
What are vanamivir and ostelmivir?
Neurominadase inhibitors
What is the most common pathogen in community acquired pneumonia?
Strep. pneumo
What are the most common pathogens in nosocomial pneumonia?
Gram-negative rods
S. aureus
What are the two recommended methods of prevention of pneumonia?
1. influenza vaccine
2. pneumococcal vaccine
What are the chances that vital signs would be completely normal with pneumonia?
<1%
What bacteria are smokers more likely to have causing pneumonia?
H. flu
What causes most cases of community acquired pneumonia?
Aspiration of oropharyngeal secretions
What are symptoms of pneumonia?
Acute onset of fever and shaking chills
Cough productive of thick, purulent sputum
Pleuritic chest pain
Dyspnea
What are signs of pneumonia?
tachycardia/ tachypnea
Inspiratory crackles
Pleural friction rub
What causes atypical CAP?
Mycoplasma pnemoniae
How does atypical onset present?
Insidious onset
DRY cough
Fevers without chills
Bullous myringitis
What are signs of atypical CAP?
Pulse temperature dissociation
Wheezing
What does a CXR of atypical CAP show?
Diffuse reticulonodular infiltrates
Absent or minimal consolidations
What does multilobular consolidation on CXR suggest?
Very serious CAP
how long after succesful treatment do CXR changes lag?
6 weeks
How do you test for legionella?
Urinary antigen assay
When do you use a silver stain?
Fungi
PCP
What is first line treatment for CAP in older adults and patients with comorbidities?
2nd or 3rd generation cephalosporin
When should a thoracentesis be performed?
Effusion >1cm
What pathogen often causes pneumonia in alcoholics?
Klebsiella
When is legionella common?
Organ transplant patients
Renal failure patients
Chronic lung disease
Smokers
What is the pathophysiology of primary TB?
Bacili inhaled
Ingested by alveolar macrophages
Granulomas form
When does secondary TB happen?
When hosts immunity is weakened
Where does secondary TB manifest itself?
Oxygenated portion of the lungs
(apical/posterior segments)
How does secondary TB spread?
Hematogenous or lymphatic spread
What are the symptoms of primary TB?
Usually asymptomatic
Which form of TB is active?
Secondary
How does secondary TB present?
Constitutional symptoms
Fever
Night sweats
Weight loss malaise
What suggests advanced TB?
Hemoptysis
What is the progression of secondary TB?
Cough progresses from dry to purulent sputum
What is miliary TB?
Hematogenous spread of the tubercle bacili
What does CXR of TB show?
Upper lobe infiltrates with cavitation
What are Ghon's complex and Ranke's complex?
Evidence of healed primary TB
What is Ghon's complex?
Calcified primary focus
What is Ranke's complex?
Calcified primary focus and calcified hilar lymph node
How do you diagnose tuberculosis?
Sputum culture
3 morning sputum specimens (culture 4-8 weeks)
How can you detect specific mycobacterial DNA more rapidly?
PCR
What size induration is suggestive of latent TB?
>15mm
When is >5mm a positive PPD?
HIV
Close contact with TB
Radiographic evidence of primary TB
What is 1st line for TB?
Rifampin Isoniazid
Pyrazinamide
Ethambutol x 2 months
Rifampin
Isoniazid x 4 months
What is prophylactic treatment for latent TB?
9 months of INH after active TB excluded