FM Respiratory

The FM Respiratory is part of the Family Medicine section provides High Yield information for the USMLE, COMLEX, Medical School, Residency, and in the future career as a Physician. Prepare and Learn Ahead! Educating, Preparing, and Proving high-yield content, quizzes, and medical resources to students who are interested in the medical field.

COPD

• 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.

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

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

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

Pharyngitis

• 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

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.

Others:

• Pneumocystis jiroveci in AIDS patients – see ground glass on CXR
• Apical consolidation in TB
• Aspiration pneumonia → right lower lobe

Treatment:

• 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

Complications

• 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.

Vaccinations:

• 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

Popular Sections

• Medschool Anki
• Best Resources for Med School and Residency
• Clinical Special Tests