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- Example: Man with a long history of smoking presents with dyspnea, increased sputum production, change in sputum character, coughing, and wheezing.
- Most likely an acute exacerbation of COPD. Defined by three things: increase in coughing, change in sputum character (producing sputum or change in color), and something else.
- Must assess oxygenation (pulse ox, ABG) and watch for signs of hypoxemia (cyanosis)
- Test for reversibility = increase in FEV1 of > 12% or 200 mL. Signals asthma instead of COPD.
- Appropriate acute treatment:
- Bronchodilator (act fast – albuterol, ipratropium is an anticholinergic that may be synergistic),
- Systemic corticosteroids (need hours to work, but reduces length of exacerbation and relapses).
- Give oxygen to keep PaO2 > 60 mm Hg and SaO2 > 90%.
- Antibiotic if increased or purulent sputum – pneumococcus, H flu, Moraxella Catarrhalis. If severe, think klebsiella or pseudomonas.
- Management of acute asthma and COPD exacerbation both include oxygen, bronchodilators, systemic steroids
- Interventions to reduce exacerbations:
- Smoking cessation – won’t reverse existing COPD, but will reduce rate of worsening
- Long-acting bronchodilator,
- Inhaled corticosteroid,
- Influenza and pneumococcal vaccine
- COPD generally:
- Consider alpha 1 antitrypsin deficiency in Caucasians with emphysema before age 45
- Earliest symptom is cough with white sputum. Becomes yellow or green with bacterial or viral infection.
- Dyspnea is the primary presenting symptom – by the time it starts, FEV1 is at 50% and COPD has been present for years.
- Normal FEV1/FVC > 0.7 With COPD, FEV1/FVC < 0.7. – both are reduced, but FEV1 is especially reduced.
|0||At risk||cough and sputum|
|Vaccines and risk factors|
|1||Mild COPD||FEV1/FVC < 0.7|
FEV1 is still > or = 80% predicted.
|Short-acting bronchodilator |
(albuterol + ipratropium, an anticholinergic)
|2||Moderate||FEV1/FVC < 0.7|
FEV1 is 50-80% predicted.
|Short-acting bronchodilator + long-acting|
(salmeterol + tiotropium, oral methylxanthines)
|3||Severe||FEV1/FVC < 0.7|
FEV1 is 30-50% predicted.
|Short-acting bronchodilator + long acting bronchodilator + inhaled steroids |
(fluticasone, triamcinolone, mometasone)
– fewer side effects than systemic.
Reduces freq of exacerbations, won’t help decline.
Think Steroids for Severe COPD
|4||Very Severe||FEV1/FVC < 0.7|
FEV1 is <30 or <50% predicted w/ chronic hypoxemia.
(PaO2 < 55mmHg or
SaO2 < 88% at rest or
PaO2 < 60 if polycythemia or signs of RHF)
|Short-acting bronchodilator + long-acting bronchodilator + inhaled steroids + long term oxygen |
-must be worn 15 hrs/day.
The only intervention that improves mortality!
- Signs and symptoms:
- Itchy eyes, nasal congestion, and discharge, often seasonal but not always.
- Mucosa of nasal turbinates is swollen (boggy) w/ pale blue-gray color.
- Secretions are thin and watery, but can be purulent like a bacterial infection.
- Can have fatigue, malaise, allergic shiners.
- Exposure to foreign proteins → IgE produced and coats mast cells → 2nd exposure causes mast cell degranulation → immediate release of histamine, production of leukotrienes and prostaglandins.
- Avoid allergens if at all possible
- Antihistamines: NOT FOR ASTHMA – only for allergies
- = includes diphenhydramine, chlorpheniramine, and hydroxyzine
- – can cause sleepiness and anticholinergic effects (dry eyes, dry mouth, blurred vision, urinary retention).
- Be careful with elderly
- Second generation
- = loratadine, desloratadine, fexofenadine, and cetirizine
- – less penetration into CNS, so less sedation (except cetirizine)
- – oral or intranasal, constrict blood vessels.
- Usually Oral – can cause sympathetic side effects.
- Can also get rebound hyperemia and worsening of symptoms with chronic use or discontinuation.
- Corticosteroid nasal sprays:
- Most effective treatment for long-term management of mild-moderate symptoms.
- Side effects = pharyngitis, nose bleeds, URIs.
- Require 2-4 weeks to kick in.
- Leukotriene inhibitors:
- for both allergic rhinitis and persistent asthma.
- Oral corticosteroids:
- Only for severe allergies
- Desensitization therapy:
- requires lots of shots
Conjunctivitis: caused by bacteria or viruses (most), or allergies or chemicals.
- usually strep, staph, H flu, Moraxella, and pseudomonas.
- No blurring of vision, only minor discomfort.
- Usually resolves within 2 weeks but can give sulfonamides.
- Viral = epidemic keratoconjunctivitis (pink eye):
- most often adenovirus.
- Usually have a fever, malaise, pharyngitis, and preauricular lymphadenopathy.
- Red eyes, lots of watery discharge.
- Give sulfonamides to prevent secondary bacterial infection.
- Maybe weak topical steroids to treat corneal infiltrates.
- Usually lasts 2 weeks.
- itching, tearing, redness, stringy discharge, sometimes photophobia.
- Treat w/ oral or topical antihistamines or anti-inflammatory eye drops.
Acute bronchitis: Inflammation of the tracheobronchial tree in response to infection, allergy, irritant → increased mucous production and airway hyperresponsiveness
- Often occurs with URI – viruses and atypical bacteria (chlamydia pneumonia and mycoplasma) are the most common causes.
- Can have wheezes, rales, rhonchi
- Usually self-limited and lasts < 2 weeks, but the cough can last > 2 months
- Abx usually not useful, except with pertussis. Can do bronchodilators for airway hyperreactivity. Cough meds might be useful.
Rhinosinusitis = inflammation of nasal mucosa and 1+ paranasal sinuses – occurs w/ obstruction of drainage.
- Acute < 4 weeks, chronic >12 weeks, subacute in between.
- Can also have acute exacerbation of chronic.
- Basically like an URI, but doesn’t resolve after 7 days in adults or 10 days in kids.
- May also have tooth or facial pain, unilateral maxillary sinus tenderness, or worsening of symptoms after initial improvement
- Acute bugs: Strep pneumo + H flu. Kids also get Moraxella.
- Treat w/ amoxicillin and bactrim. Then try the pneumonia meds
- Chronic bugs: anaerobes are more common
- Usually benign and self-limited.
- Most important to r/o more serious conditions like epiglottitis (H flu), peritonsillar abscess, and to diagnose group A strep infection.
- Most often viral, especially with cough and runny nose
- Petechiae on tonsils or palate → Group A strep or EBV
- Group A strep is a common cause – 15% of adult cases and 30% of kids.
- Abrupt onset
- petechiae on tonsils and/or palate
- cervical adenopathy
- no cough
- Might also see sandpaper rash.
- Can have peritonsillar abscess (also with other bugs – must drain surgically)
- Rapid strep test. If negative, culture for a day or two. If either positive, penicillin.
- RF, glomerulonephritis (regardless of treatment!), toxic shock, meningitis, bacteremia, abscess
- EBV can look like GAS, with petechiae, etc.
- Also see hepatosplenomegaly, generalized lymphadenopathy. See atypical lymphocytes.
- In kids and young adolescents:
- consider atypical pneumonia bugs (chlamydia and mycoplasma), along with arcano bacterium haemolyticus
Pneumonia: Inflammation or infection of the lower respiratory tract, involving distal bronchioles and alveoli.
- Pneumonia = infection of the lungs.
- Pneumonitis = inflammation of the lungs from non-infectious source (chemicals, radiation, autoimmune, blood)
- Suspect pneumonia with prolonged fever and signs of pulmonary consolidation on the exam.
- Also, evaluate for pneumonia if abnormal vital signs. Can present atypically in elderly and in patients with chronic lung disease
- Pneumonia symptoms:
- productive cough, fever, pleuritic chest pain, dyspnea. Rapid breathing in young, altered mental status in old people.
- Physical Exam:
- look for ronchi or rales, egophony → focal lung consolidation, dullness to percussion → pulmonary effusion
- CXR, sputum gram stain and culture, blood cultures
- CXR is gold standard, but normal xray does not rule it out. Can be normal early in disease or if dehydrated.
- Cultures have low sensitivity (many false negatives), but positive result can guide treatment
- Potential complications:
- bacteremia, sepsis, parapneumonic pleural effusions, pneumonia
- Typical: Most common in very young and older patients
- Most often strep pneumo – acute onset, rusty sputum, fever and chills, lobar infiltrate. Give penicillin.
- H flu: underlying COPD. Give cefuroxime.
- Moraxella catarrhalis
- Staph aureus – often follows viral infections (influenza). Give erythromycin.
- Atypical: More often in adolescent and YA’s. Tend to cause bilateral, diffuse infiltrates
- Mycoplasma pneumoniae – Can ID with direct fluorescent antibody testing on sputum.
- Chlamydia pneumoniae,
- Legionella pneumophila – often have diarrhea, too. Can ID with direct fluorescent antibody testing on sputum or with urinary antigen testing. Give erythromycin.
Health-care associated pneumonia
- Risk factors:
- intubation (oropharyngeal is less risky than nasopharyngeal), NG tube feeding, preexisting lung disease, multisystem failure.
- Reduce risk by keeping the head of the bed elevated during tube feedings, infection control techniques (purel, etc).
- CA pathogens plus aerobic gram negatives (psuedomonas, klebsiella, acinetobacter), and gram + cocci like staph aureus. Incidence of drug resistant bugs (MRSA) is increasing.
- Pneumocystis jiroveci in AIDS patients – see ground glass on CXR
- Apical consolidation in TB
- Aspiration pneumonia → right lower lobe
- Determine if the patient needs inpatient or outpatient treatment – toxic appearance, accessory muscle use, low O2 sat, tachycardia, hypotension, altered mentation?
- If respiratory distress → ABGs
- If low O2 sat → oxygen via nasal canula
- Pneumonia Severity Index – assigns patients a risk category based on age, comorbid illnesses, specific exam and lab findings.
- High risk: cancer, liver dz, renal dz, CHF, diabetes
- Physical exam: tachypnea, fever, hypotension, tachycardia, altered mental status
- Labs: low pH, low serum sodium, low HCt, low O2 sat, high glucose, high BUN, pleural effusion on CXR
- Treat low risk: Classes 1 and 2 as an outpatient, higher risk (3,4,5) in hospital
- Start abx:
- Healthy patients w/ CA pneumonia:
- Macrolide (azithromycin, clarithromycin)
- If in an area w/ high macrolide resistance:
- Flouroquinolone (levofloxacin, moxifloxacin)
- Beta lactam + macrolide
- Hospitalized patients w/ CAP who don’t need ICU – give IV abx
- Flouroquinolone (levofloxacin, moxifloxacin)
- Beta lactam + macrolide
- HA pneumonia requires broader abx – don’t use macrolide or fluoroquinolone alone!
- Beta-lactam + fluoroquinolone
- Beta-lactam + aminoglycoside
- MRSA → vancomycin
- Healthy patients w/ CA pneumonia:
- Duration of therapy:
- Strep pneumo: 72 hours afebrile
- 2 weeks for S aureus, pseudomonas, klebsiella, anaerobes, M pneumo, C pneumo, legionella
- Strep pneumo
- Up to 30% get bacteremia! If so, ⅓ die – or 60% in elderly!
- Pleural effusion in 40% – do thoracentesis w/ gram stain + culture. 5% will get empyema → drain with chest tube or surgery.
- Pneumovax for 65 yrs and older, and for any adult with cardiopulmonary disease, smokers, and immune-compromised patients.
- Revaccinate in 5 yrs if known to have rapid decrease in antibodies – nephritic syndrome, renal failure.
- Influenza for 6 months and older
- Obstruction of Eustacean tubes, often from URI → infection.
- Typically S pneumo, H flu, Moraxella catarrhalis.
- Viral infection with serous otitis can set the stage for acute bacterial infection.
- Seen in preschool kids most often
- fever, ear pain, decreased hearing, vertigo, tinnitus
- decreased membrane mobility or fluid behind ear – red tympanic membrane isn’t enough!
- Usually resolves on its own! Treat w/ abx (amoxicillin) if prolonged, recurrent, or severe symptoms.
- – mastoiditis, bacterial meningitis, brain abscess, subdural empyema
- Infection of external auditory canal, can have severe pain.
- Often staph, strep, skin flora. Swimmer’s ear = pseudomonas
- Patients w/ diabetes are at risk for invasive otitis media caused by pseudomonas
- – must debried and give 4-6 weeks of abx