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98 Cards in this Set
- Front
- Back
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cough: acute & chronic |
acute cough is less than 3 weeks subacute cough is 3- 8 weeks chronic cough is more than 8 weeks |
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what can excess or chronic cough result in? |
- anxiety, fatigue, insomnia - myalgia, rib fracture, urinary incontinence |
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cough |
- most coughs are acute, self limiting 90% of coughs are viral respiratory infections look at the clinical picture and history
coughs lasting greater than 3 weeks & do not respond to treatment need investigation |
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acute bronchitis |
- inflammation of bronchioles and airways
usually results from an infection such as cold or flu |
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acute bronchitis: symptoms |
- nasal and pharyngeal symptoms often present at onset and subside 3-4 days
cough - sputum may be clear or mucoid/purulent - purulence does not necessarily signify bacterial infection - prominent and progressive - typically lasts 10-20 days - may produce substernal burning with inspiration
no fever (or ow grade) if present then consider pneumonia or influenza
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acute bronchitis: diagnosis |
typically based on history and physical. infrequent need for diagnostic testing
chest radiograph: resting pulse > 100/min, respiratory rate greater than 24 or temp greater than 38 C rales or signs of consolidation on chest exam evidence of hypoxemia mental confusion signs of systemic illness older age (> 75 years)
if concerned other etiology (or secondary infection) CBC with differential chest xray PA and lateral |
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acute bronchitis: treatment, cough |
- dextromethophran with guiafenesin - codeine agents - honey and or pectin lozenges - warm, humidified air - fluids - nasal saline rinses - inhalers - beta 2 agonists, if bronchospastic, cough/ airflow obstruction |
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acute bronchitis: treatment, other |
- analgesics PRN - smoking cessation: at a minimum until symptoms are cleared smoking increases incidence of bronchitis (acute and chronic) as well as secondary bacterial pneumonia |
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what about antibiotics with acute bronchitis treatment? |
key is patient education - no significant benefit with antibiotics - 1/2 day reduction in antibiotic group - modest impact in prevention of PNA in elderly
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pertussis |
- commonly transmitted from asymptomatic infected adult to children - highly contagious: attack rates up to 80 % in household members - lingering cough after upper respiratory infection could cause pertussis 10- 30% of the time |
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pertussis: treatment |
preferred:
Azithromycin 500 mg x 1, 250 mg x 4 Erythromycin 500 mg QID x 14 days Clarithromycin 500 mg BID x 7 days
alternate TMP-SMX, 1 DS BID x 14 days |
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what are the two types of pneumonia? |
1. community acquired (CAP) 2. health care associated: hospital, nursing home |
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community acquired pneumonia (CAP) presentation |
fever cough dyspnea pleuritic chest pain mental status change localized crackles tachycadia |
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community acquired pneumonia (CAP): pathogens |
S. Pneumoniae Influenza Mycoplasma Chalymdia Legionella Adenovirus |
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community acquired pneumonia (CAP): diagnostics, outpatient |
CBC with differential Comprehensive metabolic pannel (CMP) Radiograph
microbial testing not routinely required for outpatient management |
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community acquired pneumonia (CAP): diagnostics, inpatient |
- CBC with differential - CMP - radiograph - sputum culture and gram stain (GS) - blood cultures - urinary antigens - influenza - ABG - bronchoscopy (if indicated) |
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community acquired pneumonia (CAP): physical findings associated with increased mortality
important |
- respiratory rate greater than 30 per minute - diastolic blood pressure less than 60 mm Hg OR systolic blood pressure less than 90 mm Hg - pulse greater than 125 bpm - temperature less than 35 or greater than 40 C - confusion or decreased LOC |
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community acquired pneumonia (CAP): lab and xray findings associated with increased mortality
important |
- WBC less than 4 or greater than 30 x 10 (9) - PaO2 less than 60 or PaCO2 greater than 50 room air - creatinine greater than 1.2 , BUN greater than 20 - Chest x-ray: multi lobular, pleural effusion, presence of a cavity (bacterial abscess, TB, fungi) - HCT less than 30 or Hgb less than 9 - arterial pH less than 7.35 - evidence of sepsis |
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pneumonia management decision making |
- think about if you want to hospitalize your patient or keep them outpatient - PSI and CURB-65 are prediction tools to help you determine the severity |
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CURB- 65 |
C: confusion U: blood urea nitrogen is greater than or equal to 20 mg/dL R: respiratory rate greater than or equal to 30/ min B: systolic BP is less than 90 mm Hg or diastolic less than or equal to 60 mmHg 65 patients greater than or equal to 65 |
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CURB 65 scoring: 0 |
Score: 0 Mortality %: 0.6 Risk level: low suggestion site of care: outpatient |
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CURB 65 scoring: 1 |
Score: 1 Mortality %: 2.7 Risk level: low suggestion site of care: outpatient |
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CURB 65 scoring: 2 |
Score: 2 Mortality %: 6.8 Risk level: moderate suggestion site of care: short inpatient/ supervised outpatient
follow up within 24-48 hours |
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CURB 65 scoring: 3 |
Score: 3 Mortality %: 14 Risk level: Moderate to high suggestion site of care: inpatient |
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CURB 65 scoring: 4-5 |
Score: 4-5 Mortality %: 27 Risk level: High suggestion site of care: inpatient/ ICU |
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CAP: risk factors for death |
- age greater than 65 years - presence of coexisting illness - COPD, bronchiectasis, malignancy - DM - CHF - Chronic renal failure - chronic alcohol abuse, chronic liver disease, malnutrition - cerebrovascular disease - post - splenectomy - history of hospitalization in past year |
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CAP: outpatient treatment, meds for healthy individuals with no recent antibiotic use |
- azithromycin: 500 mg on day one followed by four days of 250 mg a day (zpak) - clarithromycin: 1 gm daily x 7 days; 250 mg BID x 7- 10 days
FDA advisory because of QT prolongation |
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CAP: outpatient treatment with other co-morbidities and recent antibiotic use |
- quinolone Levaquin 500 mg x 7- 14 days or 750 mg x 5 days Moxifloxicin 400 mg x 7 -14 Gemifloxacin 320 mg x 5-7 days
- B- lactam plus macrolide Amox- Clav 2 gm BID x 7-10 days + Azithro 500 mg x 1 then 250 mg PO daily x 4 days |
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CAP: outpatient treatment, when do you check in? |
re- evaluate in 24- 48 hours - may not see improvement in 24 hours but want to ensure there's no deterioration - smoking cessation - supportive measures |
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CAP: outpatient treatment, what do you do if you do not see improvement within 48 hours? |
- further testing because it could be something else (ie not CAP) - address self- care further, not resting/ alcohol - is hospitalization needed? - are atypicals covered: M. pneumonia, C. pneumonia or legionella macrolides, cover all 3 - antibiotic change
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how can we prevent CAP? |
vaccinate - influenza - pneuococcal |
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Tuberculosis (TB) transmission |
a person may contact pulmonary tuberculosis from inhaling droplets from a cough or sneeze by an infected person
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TB: screening |
- person who have spent time with someone with TB - HIV+ or other immunocompromised people - people with symptoms of TB - person from enemic regions ( Asia, Africa, Eastern Europe, Russia, Caribbean, Latin America) - Substance user, homeless, incarcerated - People who live/work where TB is more common |
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TB: diagnostic testing |
Mantoux Tuberculin Skin Test (TST) - purified protein derivative (PPD) - if infected, rxn is detectable 2- 8 weeks after infection - read 48- 72 hours - measure induration in mm |
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TST interpretation: greater than or equal to 5 mm of induration |
- HIV- infected persons - Recent contacts of a person with infectious TB - fibrotic changes on CXR consistent with prior TB - organ transplant recipients - persons who are immunosuppressed for other reasons (eg taking equivalent of 15 mg/ day of prednisone for 1 month or more. also those taking TNF alpha agonists |
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TST interpretation: greater than or equal to 10 mm of induration |
- recent immigrants (within the last 5 years) from high - prevalence countries - injection drug users - residents or employees of high- risk congregate settings (prisons, jails, long- term care facilities for the elderly, hospitals and other health care facilities, residential facilities for patients with AIDS, and homeless shelters) - mycobacteriology laboratory personnel - Persons with clinical conditions previously mentioned - children younger than 4 years of age - infants, children, or adolescents exposed to adults at high risk for TB disease |
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TST interpretation: greater than or equal to 15 mm of induration |
Persons with no known risk factors for TB Testing is not recommended in this group but if greater than 15 mm the patient needs a workup for positive active or latent infection |
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Two step TST testing |
there's potential for a delayed response
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TB: Diagnostic testing
what is the test? list the three FDA approved tests What are the possible results? |
interferon- gamma release assays (IGRAs) blood tests measure immune reactivity to specific mycobacterium antigens
3 FDA approved tests in the US 1. QuantiFERON- TB Gold test (QFT- GIT) 2. QuantiFERON- TB Gold- in-Tube test (QFT- GIT) 3. T. SPOT TB Test
results are reported as positive, negative, or indeterminate - results reported as positive, negative, or indeterminate
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Pros of IGRAs |
advantages of IGRAs - single visit - not affected by booster phenomenon, single test is adequate - less subject to reader bias than TST - unaffected by BCG and most environmental mycobacteria |
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Disadvantages of IGRAs |
- blood sample must be processed within 8- 16 hours - venous access/ phlebotomy can be difficult in some - Indeterminate results that we haven't figured out how to handle - limited data on some groups including children under 5, recent exposure, immunocompromised, those who will be tested repeatedly - cost: lab fee over $100 assuming out of pocket |
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TB: diagnostic tests |
TST or IGRA: positive then Chest radiograph then Assess for signs and symptoms of active TB decide if latent or active |
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latent TB infection (LTBI) |
- LTBI is the presence of M. tuberculosis organism (tubercle bacili) without symptoms or radiographic evidence of TB disease - without treatment, 5-10% will progress to TB disease at some point in their life - Persons with LTBI are asymptomatic and not infectious |
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Active TB: diagnostic testing |
- sputum - smear - DNA probe (NAAT)
if it's active TB then do a sputum or smear AFB culture because it takes 6 weeks to get full AFB |
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Active TB: signs and symptoms |
fever, cough, chest pain, weight loss, nights sweat, hemotysis, fatigue, decreased appetite
chest radiograph may be normal in persons with advanced immunosuppression or extrapulmonary disease
respiratory specimens are usually smear or culture positive
May be negative in people with extrapulmomary disease or minimal or early pulmonary disease However, may be negative in person with extrapulmonary disease or minimal or early pulmonary disease
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Differentiated between LTBI and TB disease |
LTBI: no symptoms findings suggestive of TB positive TST or IGRA, chest radiograph normal, respiratory specimens are smear and culture negative
Active TB: fever, cough, chest pain, night sweats, hemoptysis, fatigue TST or IGRA result usually positive, CXR usually abnormal, smear or culture positive |
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LTBI: Treatment
important |
several regimens and dosing schedules - isoniazid (INH): 6 or 9 months (daily or twice weekly) - isoniazid (INH) with Rifapentine: 3 months (weekly) - rifampin 4 months (daily) |
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Active TB: treatment |
initial treatment requires 4 drugs
INH + RIF + PZA + EMB for 2 months > INH+ RIF for 4 months (total treatment is 6 months)
adherence and side effect management are key
manage or monitor in conjunction with ID and/or public health |
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Asthma: risk factors |
- genetic - atopy (hyperallergic) - obesity - tobacco use including second hand smoke - environmental exposures |
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Asthma: triggers |
pet cockroaches dust mites environmental chemicals tobacco smoke cold air pollen or other allergens GERD exercise |
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Asthma: history |
symptoms: coughing, wheezing, shortness of breath, chest tightness
symptom patterns severity/level of control family history |
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Asthma: physical examination |
chest exam (may be normal) - wheezing - hyperexpansion of the thorax - use of accessory muscles - appearance of hunched shoulder, chest deformity - boggy, swollen nasal mucosa
atopic dermatitis, eczema, or other allergic skin conditions |
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diagnostic testing |
- peak flow - spirometry - pulmonary function testing |
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Lung volume Vt IRV ERV RV |
Vt: tidal volume normal breathing in and out 500- 600 ml IRV: max inhale (inspiratory) 3,000 ml ERV: exhale everything 1,200 ml RV: 1,200 ml |
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Time volume vs flow volume loop |
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Normal flow volume loop |
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Mild obstructive pattern |
remember that the top part of the graph is exhalation and the bottom part is inhalation. this is mild obstructive pattern because the pt cannot exhale more than 70% of their FVC in less than 1 second ( = FEV1) |
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reversible obstruction |
this is a reversible obstruction because it will eventually return to normal |
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restrictive pattern |
the pt cannot breathe in (the bottom part of the graph) normally |
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Pulmonary function testing: other components |
DLCO = diffusion capacity of carbon monxide measures ability to exchange air/gasses after exhale to look for diffusion
decreased DLCO = COPD, pulmonary fibrosis because there's not a lot of diffusion in the lungs |
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Asthma: spirometry |
pinch nose and blow into a machine
results are adjusted for - gender - age - height - ethnic origin |
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Asthma: spirometry vs peak flow |
spirometry: measures speed and volume over time. Provide more accurate and detailed picture of pulmonary function
peak flow: measures the maximum or peak speed of air as it is forcibly expelled (best for monitoring) |
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spirometry: define the key components
FEV1 FVC FEV1/ FVC ratio |
FEV1: forced expiratory volume in 1 second volume of air expired in first second during maximal expiration
FVC: Forced Vital Capacity - total volume of air expired after full inspiration
FEV1/ FVC ratio: ratio of expired air to the volume |
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spirometry: interpretation
know this |
look up predicted level for patient background then compare to this chart. Obstructive: can't get air out to entire capacity but can breathe in Restrictive: cannot get the air in |
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Asthma: spirometry, how is reversibility determined? |
- reversibility is determined by an increase in FEV1 of greater than 200 mL or 12 % from baseline measure after inhalation of a short acting beta 2 agonist (SABA)
- some studies indicate that an increase of 10% of the predicted FEV1 after inhalation of a SABA may have higher likelihood of separating patients who have asthma from those who have COPD. |
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goals of asthma management |
- achieve and maintain control of symptoms - maintain normal activity levels, including exercise - maintain pulmonary function as close to normal as possible - prevent asthma exacerbations - avoid adverse effects from asthma medications - prevent asthma mortality |
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asthma severity: key evaluation components |
- frequency of asthma symptoms - nighttime awakening - short acting beta agonist use (SABA) - interference with normal activity - lung function - history of intubations and/or hospitalizations
how often are you having nighttime symptoms? ask if pt has to be intubated and/or hospitalized with a pulmonologist |
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asthma: impairment, intermittent symptoms: nighttime awakenings: short acting beta agonist use for symptom control (not prevention): interference with normal activity: lung function: exacerbations requiring oral systemic corticosteroids: |
asthma: impairment, intermittent symptoms: less than or = to 2 days/ week nighttime awakenings: less than or = to 2x/ month short acting beta agonist use for symptom control (not prevention): less than or = to 2 daysa week interference with normal activity: none lung function: formal FEV1 bt exacerbations, FEV1 greater than 80, predicted, FEV1/ FVC normal exacerbations requiring oral systemic corticosteroids: 0 to 1/ year consider severity may fluctuate over time for patients in any severity category, relative annual risk of exacerbations may be r/t FEV1 |
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asthma: impairment, persistent, mild symptoms: nighttime awakenings: short acting beta agonist use for symptom control (not prevention): interference with normal activity: lung function: exacerbations requiring oral systemic corticosteroids: |
asthma: impairment, persistent, mild symptoms: more than 2 days/ week not daily nighttime awakenings: 3 to 4x month short acting beta agonist use for symptom control (not prevention): more than 2 days/ week not daily, more than 1x on any day interference with normal activity: minor limitation lung function: FEV1 greater 80% predicted, FEV1/FVC normal exacerbations requiring oral systemic corticosteroids: greater than or equal to 2 / year consider severity and interval since last exacerbation frequency and severity may flux over time relative annual risk of exacerbations may be r/t FEV1 |
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asthma: impairment, persistent, moderate symptoms: nighttime awakenings: short acting beta agonist use for symptom control (not prevention): interference with normal activity: lung function: exacerbations requiring oral systemic corticosteroids: |
asthma: impairment, persistent, moderate symptoms: daily nighttime awakenings: more than 1x week, not nightly short acting beta agonist use for symptom control (not prevention): daily interference with normal activity: some limitation lung function: FEV1 >60 but less 80% predicted, FEV1/ FVC reduced 5% consider severity, relative annual risk of exacerbation may be r/t FEV1 exacerbations requiring oral systemic corticosteroids: |
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asthma: impairment, persistent, severe symptoms: nighttime awakenings: short acting beta agonist use for symptom control (not prevention): interference with normal activity: lung function: exacerbations requiring oral systemic corticosteroids: |
asthma: impairment, persistent, severe symptoms: throughout the day nighttime awakenings: often 7x week short acting beta agonist use for symptom control (not prevention): several times per day interference with normal activity: extremely limited lung function: FEV1 < 60% predicted, FEV1/ FVC reduced greater than 5% exacerbations requiring oral systemic corticosteroids: |
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treatment: stepwise approach step 1 |
SABA PRN |
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treatment: stepwise approach Step 2 |
mild low dose ICS alternate LTRA (leukotriene receptor antagonist) cromolyn theophylline |
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treatment: stepwise approach step 3 |
moderate
low ICS + LABA or moderate ICS alternate: low dose ICS + either LTRA, theophylline, or zileuton
PRN SABA |
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treatment: stepwise approach step 4/5 |
high dose ICS + LABA +/- omalizaumab + steroid
PRN |
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rules of two: maintenance therapy if... |
- use rescue inhaler > 2 times/ week - awaken due to asthma > 2 times/ month more than 2 times a year - refill a quick- relief inhaler - receive a burst of oral steroids - have unscheduled acute asthma care (ie ED visit) |
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medications to tx asthma what forms do the meds come in? what are the major two categories of the medications? |
medications come in: - powders - solution - MDI: mist d/t propellant
two major categories of medications are: - long term control - quick relief (aka rescue inhalers) |
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medications to treat asthma: quick relief or rescue inhalers |
short acting brochodilators (SABA) - albuterol, pirbuterol, levalbuterol - need for rescue inhaler indicated exacerbations and/or inadequate control - address the underlying factors/ triggers and need for change in treatment regimen |
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medications to treat asthma: long term control |
- taken daily over a long period of time - if effective control, pt should not have symptoms - used to reduce inflammation, relax airway muscles, and improve symptoms and lung fxn
inhaled corticosteroids (ICS) long acting beta agonists (LABA) leukotriene modifiers (LTRA)
inhaled corticosteroids improve asthma control more effectively in children and adults than any other single long-term controller medication |
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medications to treat asthma: long term control-- corticosteroids |
corticosteroids: inhaled corticosteroid (ICS) is the cornerstone of asthma pharmacotherapy - budesonide (pulmicort) - fluticasone (flovent) - beclomethasone (Qvar, Vanceril)
oral/ systemic corticosteroids for acute exacerbations
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medications to treat asthma: long term control-- LABA
combo inhalers |
long acting brochodilators (LABA): longer duration of action, slower onset can be steroid sparing 60% in fluticason dose while still maintaing overall asthma control - formoterol (foradil) 12+ hours - salmeterol (serevent) 12+ should not be used as monotherapy
combination inhalers inhaled corticosteroid (ICS) + LABA - formoterol/budesonide (symbicort) - salmeterol/ fluticasone (advair diskus or HFA) |
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correct MDI technique |
exhale, keep few inches away, push once and inhale, hold in mouth for 10 seconds then do it again |
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correct diskus technique |
patients breath to propel, powder, no spacer do not shake |
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medications to treat asthma: nebulizer |
- machine produces a mist of the medication - used for severe asthma episodes (or for small children) - no evidence that nebulizer treatment is more effective than an inhaler used with a spacer |
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medications to treat asthma: leukotriene receptor antagonists |
leukotriene receptor antagonist (LTRA) - monolukast (singulair) - zafirlukast (accolate) - zileuton (zyflo)
less effective than ICS or LABA considered third line, add on when intermitted SABA are insufficient (2nd line) |
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exacerbations |
exacerbations can usually be managed in an outpatient setting - be aggressive in treatment and know when to refer - severe exacerbations are potentially life threatening
goal: relieve airflow obstruction and hypoxemia quickly and plan for the prevention of future exacerbations or relapses
primary therapies - repeated SABS - systemic corticosteroids - supplemental O2 |
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Asthma action plan |
tailor to meet individual needs educate patients and families about all aspects of plan recongnizing symptoms - medication benefits and side effects - proper use of inhalers and peak expiratory flow (PEF) meters |
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asthma follow up visits |
- assess asthma control, medication technique, action plans, adherence, patient concerns - spiromtery: at least annually or more PRN - determine if therapy should be adjusted |
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when to refer to an asthma specialist |
- pts not responding to tx -pt has had an exacerbation requiring hospitalization or intubation - immunotherapy or other immunomodulators are considers, or additional tests are indicated to determine a role of allergy |
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what are the two categories that make up COPD? what are the definitions |
COPD is composted of: chronic bronchitis: chronic, persistent cough greater than 3 months each year for two years emphysema: permanent abnormal enlargement of air spaces distal to terminal bronchioles of alveolar walls without fibrosis |
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mechanisms underlying airflow, limitations in COPD |
small airways disease - airway inflammation - airway fibrosis, luminal plugs - increased airway resistance
parenchymal destruction - loss of alveolar attachments - decreased of elastic recoil
both lead to airflow limitations |
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risk factors for COPD |
genes exposures to particles: - tobacco smoke - occupational dusts, organic and inorganic - indoor air pollution from heating and cooking with biomass in poorly ventilated dwellings - outdoor air pollution
lung growth and development gender age respiratory infections socioeconomic status asthma/bronchial hyperreactivity chronic bronchitis |
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symptoms of COPD |
- dyspnea: progressive, persistent and characteristically worse with exercise - chronic cough: may be intermittent and unproductive - chronic sputum production: COPD patients commonly cough up sputum |
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COPD: physical findings |
- increased AP diameter - clubbing - use of accessory muscles - pursed lipped breathing - increased resonance to percussion - diminished breath sounds - JVD - edema - hepatomegaly |
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diagnosis and assessment: key points |
considered in any patient who has dyspnea, chronic cough or sputum production and hx of exposure to risk factors for the disease - spirometry is required to make the diagnosis - post- bronchodilator FEV1/ FVC < 0.7 confirms the presence of persistent airflow limitation and thus COPD |
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differential diagnosis: COPD vs asthma |
COPD - onset is in mid-life - symptoms slowly progressive - long smoking hx
Asthma - onset early in life (often childhood) - symptoms vary from day to day - symptoms worse at night/ early morning - allergy, rhinitis, and/or eczema also present - family hx of asthma |
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COPD: other diagnostic testing list and describe |
- chest x-ray: seldom diagnostic but valuable to exclude alternative dx and establish presence of significant comorbidities - lung volumes & diffusing capacity: to characterize severity but not essential to patient management - oximetry and ABG: oximetry to evaluate need for supplemental oxygen therapy - alpha 1 antitrypsin deficiency syndrome: perform when COPD develops in patients of caucasian descent under 45 years or with a strong family history of COPD |
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diagnosis and assessment: key points |
- determine disease severity - impact on the patient's health status - risk of future events - assess & treat co-morbidities |
