FM Respiratory

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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.
  • Exam:
    • 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.

0At riskcough and sputum
Normal spirometry
Vaccines and risk factors
1Mild COPDFEV1/FVC < 0.7
FEV1 is still > or = 80% predicted.
+/- symptoms
Short-acting bronchodilator
(albuterol + ipratropium, an anticholinergic)
2ModerateFEV1/FVC < 0.7
FEV1 is 50-80% predicted.
+/- symptoms
Short-acting bronchodilator + long-acting
(salmeterol + tiotropium, oral methylxanthines)
3SevereFEV1/FVC < 0.7
FEV1 is 30-50% predicted.
+/- symptoms
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
4Very SevereFEV1/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)
+/- symptoms
Short-acting bronchodilator + long-acting bronchodilator + inhaled steroids + long term oxygen
-must be worn 15 hrs/day.
The only intervention that improves mortality!

Consider surgery

Allergic rhinitis

  • 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.
  • Mechanism:
    • 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.
  • Treatment:
    • Avoid allergens if at all possible
    • Antihistamines: NOT FOR ASTHMA – only for allergies
      • First-generation
        • = 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)
    • Decongestants
      • – 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.

  • Bacterial:
    • 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.
  • Allergic:
    • itching, tearing, redness, stringy discharge, sometimes photophobia.
    • Treat w/ oral or topical antihistamines or anti-inflammatory eye drops.
  • Chemical

Acute bronchitis

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
  • Treatment:
    • 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.
    • Complications:
      • 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. 

  • Etiology:
    • 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
  • Diagnosis:
    • 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
Community-Acquired 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).
  • Pathogens:
    • 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)
      • Doxycycline
      • 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
  • 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

Otitis media

  • Etiology:
    • 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
  • Symptoms:
    • fever, ear pain, decreased hearing, vertigo, tinnitus
  • Diagnosis:
    • decreased membrane mobility or fluid behind ear – red tympanic membrane isn’t enough!
  • Treatment:
    • Usually resolves on its own! Treat w/ abx (amoxicillin) if prolonged, recurrent, or severe symptoms.
  • Complications:
    • – mastoiditis, bacterial meningitis, brain abscess, subdural empyema

Otitis externa

  • Etiology:
    • 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

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