Nur731 Copd

Front 1

Staging via American Thoracic Society is based on degree of airflow obstruction as indicated by lung function testing using FEV 1are?

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Stage 1 to 3

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Stage I?

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FEV 1 > 50% predicted

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Stage II?

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FEV 1 35
49% predicated

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Stage III?

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< 35% must be admitted rather than managed out pt as above.

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Mortality?

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FEV 1 < 0.75 L: 30% at 2 years

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Acute exacerbations s/s?

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copious purulent mucoid sputum

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Normal to find mix in lower airways of what organisms?

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S. pneumonia, H. flu, Moraxella, and Chlamydia = saprophytes. Acute exacerbations due to any number of these organisms.

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Usual treatment is?

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to give antibiotics early and aggressively at first sign exacerbation.

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Choices od A/B include?

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Augmentin 500 BID, Ceclor 500 TID, Doxy 100 BID, or Bactrim DS BID for 10 days. Zithromax and Biaxin are being used extensively, as Z
pak or Biaxin XL pac. Eryth doesn’t cover H. flu.

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Improvement should be obvious in how long?

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2 days and revaluate, consider changing antibiotic.

Front 11

At time of exacerbation, it is recommended to?

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R/O pneumothorax with a CXR, which can mimic an exacerbation or a new infiltrate. Check ABGs and spirometry.

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What immun for COPD?

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Pneumococcal vaccine q 5 years, flu shot annually.

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If pt gets flu and wasn’t immunized, what do you do?

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Give an antiviral within 72 hours onset symptoms: either Amantidine 200 mg/day (100 mg/day over 65), Rimantadine 100 BID, Relenza or Tamiflu.

Front 14

Medical management of COPD: Goals?

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-reverse acute complications
-prevent disease progression
-D/C smoking

Front 15

Short term management goals?

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Bronchodilators
Anti-inflammatory agents
Oxygen supplementation
Antibiotics

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What's used for acute and long term management?

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Bronchodialators

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Bronchodilators, one of the best is iptatropium bromide (Atrovent) and anticholinergic

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also available combined with albuterol as Combivent

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In addition to bronchodialators, what can be used?

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Antiinflammatories are useful for about 20% of pts.

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In addition to short acting bronchoD, LABA and or inhaled glucocorticosteroids, what can be used?

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steroids, prednisone

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With prednisone, what do you do?

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Limit PO use due to side effects. Monitor improvement after 2 weeks on 20 mg prednisone qd.

Front 21

Theophylline use is controversial. It can improve?

Back 21

cardiac output and improve perfusion in ischemic myocardial muscle and reduce pulmonary vascular resistance, so may be helpful in pts with heart disease or cor pulmonale.

Front 22

Smoking of COPD can be attributed to ?

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80%

Front 23

Rehab and exercise is helpful for pts on optimal medical therapy but still with severe symptoms (dyspneic). Or those with several ER visits, or hosp stays.

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Goal is to use large muscle groups or arm and leg muscles: walking, climbing stairs. Pulmonary muscle rehab is also helpful after lung reduction surgery.

Front 24

Indications for continuous oxygen therapy?

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Hct > 56% (erythrocytosis)

Front 25

Evaluate pts on continuous O2?

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q 6 weeks

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Oxygen is a fire hazard

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caution pt and family.

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What's the criteria for non
continuous O2 use?

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drop in O2 sat to below 88% with minor exertion.

Front 28

Weight for COPD pts?

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25% of all pts with COPD are underweight as are 50% of those hospitalized.

Front 29

Surgical approaches includ?

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Transplantation (under age 60)
Bullectomy
Volume reduction (pneumectomy) to remove 20-30% of each lung

Front 30

Lung carcinoma two classes are?

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NSCLC and SCLC

Front 31

non
small cell (NSCLC) includes?

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squamous cell, adenocarcinoma, and large cell account for 80% tumors

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Small cell (SCLC) is also known as?

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oat cell CA account for 20% cases.

Front 33

Etiology for Lung ca is?

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cigarette smoking = most important cause in US. Leading cause of CA death.

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Most cases present between what ages?

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50
70 years of age.

Front 35

Other causes of lung Ca?

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include exposure to second hand smoke, ionizing radiation (radon gas, therapeutic radiation), heavy metals such as nickel, chromium, industrial carcinogens.

Front 36

SCLC tumors grows how and where?

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bulky and in middle of chest, metastasize early

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Squamous cell tumors arise?

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centrally, adenocarcinoma and large cell grow peripherally

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bronchoaveolar (a type of adenocarcinoma) can be?

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multifocal.

Front 39

Initial symptoms of ca include?

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cough, hemoptysis, dyspnea

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Metastasis indicated by symptoms such as?

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bone pain, weakness of numbness in legs or arms, dizziness, jaundice, skin tumors, lymphadenopathy.

Front 41

20% pts present with?

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clubbing, lymphadenopathy, hepatomegaly.

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5% pts present with?

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Horner’s syndrome, Pancoast’s syndrome, laryngeal nerve palsy, phrenic nerve palsy, skin mets.

Front 43

The most important initial diagnostic test is ?

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CXR

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If CXR is normal and cough persists over 4 weeks in pt who D/Cs smoking, what should be done?

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Order sputum cytology

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Other tests to order in Lung Ca?

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Fiberoptic bronchoscopy

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How Staging done?

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“TNM”:

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T1 =?

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tumor < 3 cm without spread

Front 48

Interstitial lung disease includes many disease states, ranging from?

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alveolitis, granulona (sarcoid). Work up pt presenting with dyspnea, insidious with exertion

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NO orthopnea, cough (dry, nonproductive)

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often bilateral inspiratory crackles, what do you do?

Front 50

Silicosis?

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with H/O exposure to sandblasting over years. Occurs in upper lobes, with high assoc with TB.

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Sarcoidosis?

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systemic disease, unknown cause, tho thought to be due to T
cell activation in the lungs inducing formulation of granulomas.

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Sarcoidosis affects primarily?

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young women.

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3 of 4 pts are anergic.

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condition in which the body of a sensitized person fails to respond to an antigen

Front 54

Often see evidence on routine CXR in form of?

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bilateral hilar adenopathy, pulmonary infiltrates

Front 55

Order?
ACE level serum, usually + refer pt to pulmonology.
Sometimes remission occurs, most pts are managed on?

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PO corticosteroids.

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Asbestosis?

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suspect with H/O work in shipyard, construction, or with brake linings. Annual CXR and spirometry to monitor.

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Hypersensitivity pneumonitis via?

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organic particles in lungs (inhaled) with immunologic attack.

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Radiation induced in 10% of pts treated for lymphoma, lung CA. Onset?

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one month to one year after completing radiation therapy.

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Tuberculosis?

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infectious disease affecting primarily the lungs, though in 15% can affect other organ systems such as skin, kidneys, bones.

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Extrapulmonary sites include?

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anterior lymph nodes (mimics Hodgkin’s), renal TB, CNS, bone, urinary.

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Caused by?

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bacterium Mycobacterium tuberculosis, which usually multiples slowly and remains dormant for years

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TB spread by ?

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inhalation of droplets aerosolized into environment by infected persons

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TB rated?

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worldwide the most significant infectious disease

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RF include?

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+ HIV infection, close contact with infected persons, homeless persons and those living in crowded conditions, IV drug abusers, malnutrition, and health care workers working with high risk populations

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Mantoux PPD considered + when reaction size is?

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5,10,15

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Positive when>/= 5 mm for ?

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HIV infection, or risk for

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Positive, when>/= 10 mm?

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immigrants from Asia, Africa, Latin America
-long term care facility residents, correctional facility residents, and psych institution residents
-underserved populations
-HIV negative IVDU
-those with pre-existing DM, CA, immunosuppressed, extremely thin pts, post gastrectomy, jejunoileal bypass, silicosis, chronic renal failure
-children under 4 years

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Preexisiting conditions in which PPD is + when >/=10?

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DM, CA, immunosuppressed, extremely thin pts, post gastrectomy, jejunoileal bypass, silicosis, chronic renal failure

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TB postitive >/= 15 mm?

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all persons with no risk factors

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Person with TB disease may have no or all of the following symptoms?

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weight loss, chronic productive cough, fatigue, malaise, anorexia, fever, hemoptysis, pleuritic chest pain, lymphadenitis, night sweats

Front 71

Notes on PPD testing?

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1skin must be allowed to air dry after cleansing with alcohol ; ETOH denatures PPD and may read as false -
2 intradermal injection must raise wheal 6-10 mm or result will be unreliable
3 read b/t 48-72 hrs after placement and measure induration with pen perpendi to the long axis of the forearm
4 a + reaction remains + for at least 5 days

Front 72

When do you read PPD?

Back 72

between 48
72 hours after placement and measure induration with pen perpendicular to the long axis of the forearm

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a + reaction remains + for?

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at least 5 days

Front 74

Post exposure: skin test immediately and again after 10 weeks.?

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Skin test usually becomes + 3 weeks (range 2
10) after infection with M. tuberculosis

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Among immunocompetent persons?

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lifetime risk is 8
10% and with + HIV status, risk increases to 8
10% per year and up to 50% after 5 years

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Two step PPD?

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plant as indicated, note reaction. IF negative, plant on opposite arm two weeks later to evaluate for booster effect: if + on second test, true + indicates past infection. Contraindicated to plant PPD in person known to be + ever again.

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What other labs should be ordered?

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Obtain sputum smear for acid fast bacillus, nucleic acid probe testing and cultures for definitive diagnosis,CBC with diff and bronchoscopy

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DD?

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COPD, asthma, pneumonia, cancer, pleurisy, histoplasmosis, silicosis, interstitial lung disease

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Treat persons with + PPD with?

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First line therapy is Isoniazid (INH)

Front 80

INH standard dose is?

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300 mg daily for adults, 10 mg/kg daily for children

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Major adverse reactions for INH are?

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hepatotoxicity (so monitor LFTs) , peripheral neuropathies (so dose Vitamin B6 at 50 mg daily to decrease neuropathy and CNS effects)

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Alternate therapy for TB?

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Rifampin (Rifadine) plus pyrazinamide (check uric acid level) daily for 2 months or twice weekly for 2-3 months

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adverse reactions to Rifampin and pyranzinamide are?

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include hepatotoxicity, thrombocytopenia, flu
like syndrome, drug interactions, body fluids may turn orange red and may permanently stain contact lenses). Check with CDC or thoracic.org for most current recommendations

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Treatment of active TB disease?

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multidrug regimens best based on results of sputum culture

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Multidrug regimens include?

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Streptomycin

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Streptomycin AE?

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(potentially ototoxic, nephrotoxic especially with history of renal dysfunction

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Pyrazinamide AE?

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none noted

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Ethambutol AE?

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(check red
green color vision and baseline visual acuity: secondary adverse reaction may be optic neuritis

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INH, and rifampin AE?

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(interacts with many other drugs including OCPs, corticosteroids, theophylline, anticonvulsants, ketoconazole, anticoagulants, cyclosporine, cardiac glycosides, quinidine, narcotics, methadone, barbiturates, diazepam, verapramil, beta blockers, progestins, chloramphenical)

Front 90

HIV + pts treated for how long?

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1
2 years. Multidrug regimen is used for these pts

Front 91

Drug resistant TB on increase approaching?

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15% in US
Outbreaks of multidrug resistant TB associated with median survival rates of?

Front 92

Back bone of drug tx in COPD stages 2 to 5?

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Tiotropium bromide (Spiriva)
Atrovent
anticholinergics that stop bronchospasms

Front 93

Muscarinic antagonists?

Back 93

like atropine
bronchodialation
has a long onset of action 1/2 hr
best used to avoid rather than to treat COPD bronchospasms, also reduces secretions