Table Of Contents
Upper Respiratory Infection (URI)
|Presentation||Common pathogens||Risk Factors||Physical Exam||Treatment||Complications|
1: sore throat
2-3: nasal symptoms (congestion, rhinorrhea)
seasonal: W/F months
|cervical lymph node adenopathy|
normal lung sounds
Ie: cough suppressants, nasal decongestants, Humidifier, Benadryl
Lower respiratory infection
|Presentation||Common Pathogen||Risk Factors||Physical Exam||Diagnosis||Treatment|
|same as URI|
Cough persists > 5 days
bacterial cause with the following
@ risk populations
|lung sounds: wheezing|
|CXR is for the following:|
abnormal lung sounds
patients > 75 yrs
cough > 3 weeks
but give SABA for wheezing
acute bronchitis + cough for > 20 days:
get a CXR
Allergic Bronchopulmonary Aspergillosis (ABPA)
- – Ventilatory support with low tidal volume of 6 mL/kg
- – PEEP to keep the alveoli open
- – Prone positioning of the patient’s body
- – Possible use of diuretics and positive inotropes, such as dobutamine
- – Transfer the patient to the ICU if not already there
- – Steroids are NOT effective in cases of ARDS.
- intermittent – symptoms < 2/wk; @night <2/mo, asymptomatic and normal PEF blw excerbations
- mild persistent – symptoms > 2/wk, but < 1/day; @ night > 2/mo
- mod persistent – need daily SABA; @night >1/wk, acute exacerbation > 2/wk
- severe persistent – continual symptoms that limit physical activity; @ night – frequent
- Step 1 – intermittent: select SABA PRN
- Step 2 – mild persistent: + low dose inhaled corticosteroid
- Step 3 – moderate-persistent: +High dose inhaled corticosteroid + LABA
- Step 4 – Severe persistant:
- Step 1 – intermittent: select SABA PRN
FVC/FEV1 in normal >.7.
In COPD, ratio is < .7 indicating obstruction.
Reversibility is defined as an increase in FEV1 greater than 12% or 200 mL.
|COPD Stage 0||At Risk||Normal spirometry + cough/sputum||Vaccines and address risk factors (smoking, occupational dust or chemicals)|
|COPD Stage I||Mild||FEV1/FVC <.7, FEV1 >80% predicted, with or without symptoms||Inhaled Short acting bronchodilators (B2 agonists, albuterol, anticholinergics, ipratropium)|
|COPD Stage II||Moderate||FEV1/FVC <.7, FEV1 50-80% predicted, with or without symptoms||SAB + Inhaled Long acting bronchodilators (Salmeterol, tiotropium)|
|COPD Stage III||Severe||FEV1/FVC <.7, FEV1 30-50% predicted, with or without symptoms||SAB/LAB + Inhaled steroids (reduce frequency of exacerbations but no rate of decline of lung function) (Fluticasone, triamcinolone, mometasone)|
|COPD Stage IV||Very Severe||FEV1/FVC <.7, FEV1 <30% predicted or FEV1<50% predicted with chronic hypoxemia||SAB/LAB/LS + Long term oxygen therapy and consider surgical interventions|
O2 Therapy if:
– PaO2<55 or SaO@< 88% at rest
– PAO2 < 60 or SaO2<90% with confirmed polycythemia, pulmonary HTN or peripheral edema suggesting heart failure
O2 therapy is only intervention shown to decrease mortality and must be work 15 h/d
|COPD Exacerbation||Common Causes:|
Pneumococcus, Haemophilus influenza, Moraxella catarrhalis
Gram neg. (Klebsiella, Pseudomonas)
|Reduce COPD exacerbations:|
Vaccinations (influenza and pneumococcal), smoking cessation counseling, education about current medications and proper usage
|Oxygen, bronchodilators, and systemic corticosteroids. Objective levels of oxygenation using pulse ox. or arterial blood gas measurements should be performed. Hypoxemia should be addressed by providing supplemental oxygen.|
Target O2 saturation:
88% to 92 % or PaO2 levels at about 60 mmHg
Systemic steroids shorten course of exacerbation and may reduce risk of relapse.
40 mg prednisolone (or equivalent) for 10 to 14 days
- Lowers Mortality:
- Chronic Therapy:
- – Tiotropium or ipratropium inhaler
- – Albuterol inhaler
- – Pneumococcal vaccine: Heptavalent vaccine, Pneumovax
- – Influenza vaccine: Yearly. Inactivated injections only.
- – Smoking cessation (IMPROVES SURVIVAL)
- – Long-term home oxygen if the pO2 < 55 or the oxygen saturation is < 88 % (IMPROVES SURVIVAL)
- – Pulm rehab: improves the quality of life but NOT a survival
- – consider roflumilast (PDE-4 inhibitor) for severe COPD NOT responding to 1st line Rx
- Risk Factors:
- Wells Score for DVT and PE:
- After calculating pretest probability (using Wells) of “low probability”, next step:
- After calculating pretest probability (using Wells) of “intermediate probability”, next step:
- After calculating pretest probability (using Wells) of “high probability”, next step:
- If the CXR is ABnormal in a pt with suspected PE, what is next best test to do:
- For a V/Q scan to be accurate, the chest x-ray must be Normal
- Types of VTE therapy and their indications/contraindications:
- – SQ LMWH –> AVOID in severe renal failure
- – SQ Fondaparinus –> AVOID in severe renal failure
- – IV UFN (2nd line): most useful in hemodynamically UNstable pts; pts w/ renal failure
- – New oral anticoagulants (NOAC) monoRX (e.g. rivaroxaban or apixaban) –> AVOID BMI > 40, eGFR < 30ml/min/1.7 m2
- – warfarin–> INR of 2-3; overlap 4-5 days w/ parenteral anticoagulants; 2 therapeutic INR measurements 24 apart
- – LMWH for 2° prevention of VTE in Pts w/ cancer
- – IV or catheter-directed thrombolysis for massive iliofemoral DVT and risk of limb loss
- – IV thrombolytic Rx for PE: shock or cardiac arrest; PE assoc. w/ ↓BP and no contraindications
- – embolectomy: massive PE and shock when anticoagulant or thrombolytic Rx is unsuccessful or contraindicated
- – IVC filter: unstable PE and strong contraindications to anticoagulation.
overall the patient appears ill
clear lung sounds
|Flu swab test|
if within 48hrs (Tamiflu) * be careful of resistance
vaccine associated Guillan Barre
Acute febrile Dz
|Presentation||Common Pathogen||Pathogenesis||Risk Factor||Diagnostic||Treatment||Vaccines|
|Most contagious 2 weeks|
catarrhal stage of pertussis:
paroxysmal stage of pertussis:
paroxysmal coughing fits with a distinct “whooping” characteristic sound
Convalescent stage of pertussis:
regression of symptoms
paroxysmal cough may return
|Bordatella pertussis||bacteria attaches to cilia and releases toxin|
toxin damages cilia
immobilization of mucus
|Macrolides (up to 7 days)|
or Bactrim (if macrolides are not tolerated well)
Tdap: booster vaccine
|sharp, localized chest pain upon inspiration||pleural effusion|
- Most Accurate: Thoracentesis
- Order the following tests on pleural fluid:
- 3 important parameters for EXUDATE pleural effusion fluid:
- Etiology of TRANSUDATE pleural effusion fluid:
- Effusions that DO NOT NEED to be aspirated:
- DDx of pleural effusion:
- – Small pleural effusions: do not need therapy. Diuretics can be used, especially for those caused by CHF.
- – For larger effusions: especially those caused by infection (empyema), a chest tube for drainage is placed.
- – If the effusion is large and recurrent from a cause that cannot be corrected, pleurodesis is performed.
Cephalosporin (pseudo coverage) *ceftaroline
macrolide + doxycycline
FQ, macrolides + amoxicillin
|HAP||Gram – rods|
|pcn: Zosyn ( or cefepime) + FQ + Vanco/Linezolid|
Ventilator-associated pneumonia (VAP)
- Initial: CXR – which always shows enlarged lymph nodes (bilateral hilar adenopathy, reticular opacities). There may be interstitial lung disease in addition to the nodal involvement.
- Most accurate: Lung or LN Bx showing noncaseating granulomas
- Other tests:
- 1- The majority (95%) of cases are obstructive sleep apnea (OSA) from fatty tissues of the neck blocking breathing.
- 2 – A small number of patients will have CENTRAL sleep apnea, which is ↓ a respiratory drive from the central nervous system.
- Severe sleep apnea is defined as > 30 apneic periods an hour.
- – weight loss and CPAP or BiPAP.
- – If this is not effective, surgical resection of the uvula, palate, and pharynx can be performed.
- Central SA
- – avoiding alcohol and sedatives.
- – may respond to acetazolamide, which causes metabolic acidosis. This may help drive respiration.
- – Some patients respond to medroxyprogesterone, which is also a central respiratory stimulant.
- Active TB:
- (+) fever
- cough > 3 weeks
- night sweats
- weight loss
- Active TB:
- Acid-fast stain
- Interferon-gamma release assay (IGRA) (Quantiferon):
- IGRA is an in-vitro blood test that is used for the detection of latent TB.
- The indication for an IGRA is the same as for a PPD.
- The main difference is that the IGRA is more specific than a PPD.
- There are no false positives on an IGRA with previous BCG infection.
- IGRAs have a 90 percent sensitivity for previous TB exposure.
- A positive test is treated with INH alone.
- A positive IGRA does not mean active infection.
- As with a PPD, a positive IGRA confers only a 10% lifetime risk of TB.
- Specific toxicities of anti-TB drugs:
- Require anti-TB Rx > 6 months: