Term
|
Definition
| trachea, bronchi and bronchioles |
|
|
Term
| Regions of the lung where gas exchange with blood occurs is known as |
|
Definition
the respiratory zone
composed almost entirely of alveolar ducts and their alveoli
separate and distinct circulation
Capillaries occupy 70-80% of alveolar surface area exchange rate |
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Term
|
Definition
active
transpulmonary pressure is negative
the volume of the thorax expands bc of descent of the diaphragm and tghe elevation of the ribs caused by the contraction of several muscles |
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Term
|
Definition
passive
at rest the tendency of the lungs get smaller and is balanced by the tendency of the chest wall to expand |
|
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Term
|
Definition
| nuclear medicine scan to diagnose pulmonary embolism |
|
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Term
|
Definition
IV contrast injected into femoral artery to diagnosis Pulmonary embolism
|
|
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Term
|
Definition
| pulmonologist visualizes bronchi & does biopsies for diagnosis |
|
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Term
|
Definition
“Standard routine” study in lung disease when looking for a diagnosis
Lung cancer may NOT be seen on CXR until advanced disease.
NOT a screening test for Lung Cancer |
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Term
|
Definition
| Easy bedside test Allows rapid determination of % oxygenation of patient NORMAL range: 96-100% sat on RA Less than 88%, pt requires oxygen |
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Term
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Definition
| Better at detecting subtle changes Valuable in characterizing diseases of the chest wall, pleura, hilum, and mediastinum Contrast is needed if suspecting Cancer or masses High-resolution CT Spiral CT |
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Term
|
Definition
Provides information about ventilation and perfusion (V/Q)
Can be done in ER
Used in the detection of PE and evaluation of lung function in patients considered for lung resection
Gallium imaging
NOT precise if patient has underlying COPD or moderate obstructive disease or cardiomyopathy |
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Term
|
Definition
“Gold standard” for diagnosis of PE
Other uses: detect A-V malformation
assessment of arterial invasion by neoplasm |
|
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Term
|
Definition
Flexible bronchoscopy is an essential tool in the diagnosis and management of many pulmonary diseases.
Provides direct visualization of the airways
May be rigid or fiberoptic (flexible)
Indications: Done by pulmonologist to get tissue diagnosis, Abnormal CXR, Hemoptysis, Opportunistic lung infections (e.g. PCP), Retained secretions and mucous plugs, Unexplained cough > 6 weeks,Cancers of course
Contraindications: pt is too unstable, Uncooperative patient
Unstable angina, Uncontrolled cardiac arrhythmias and HTN, Refractory hypoxemia (despite supplemental oxygen, Lack of bronchoscopy expertise, MI, tracheal stenosis |
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Term
|
Definition
Removal of air or fluid from the pleural space: may be done at bedside in ER/room
DIAGNOSIS
Most common causes of pleural effusion: cancer, CHF, pneumonia, TB, HIV
Contraindications: uncooperative patient, coagulation disorders
Complications: Pneumonthorax, hemopneumothorax, hemorrhage, hypotension, pulmonary edema
Indications:Determining the cause of a pleural effusion, Therapeutic removal of pleural fluid in the event of respiratory distress, Aspirating small pneumothoraces when the risk of recurrence is small (eg, postoperative without lung injury), Instilling sclerosing compounds (eg, tetracycline) to obliterate the pleural space |
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Term
Pleura Fluid Analysis
Transudative |
|
Definition
CHF
Nephrotic syndrome
Hypoalbuminemia
Cirrhosis
Atelectasis
Peritneal dialysis
Super vena cava obstruction |
|
|
Term
Pleura Fluid Analysis
Exudative |
|
Definition
Hemorrhage
Infection
Inflammation
Malignancy
Iatrogenic
Connective tissue disease
Endocrine Disorder |
|
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Term
| Pulmonary Function Tests (PFT) |
|
Definition
Provides objective data on:
Type of disease
Severity of disease
Changes in the disease
Response to treatment
Will give 3 categories of information:
Lung volumes: provides a measurement of the size of the various compartments in the lung
Flow rates: measures maximum flow in the airways
Diffusing capacity: indicates how readily gas transfer occurs from the alveoli to the pulmonary capillary blood |
|
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Term
| Total Lung Capacity (TLC): |
|
Definition
| volume of gas in the lungs at the end of maximum inspiration (IRV + TV + ERV + RV) |
|
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Term
|
Definition
| the amount of air breathed in (inspired) or out (expired) during normal respiration (spontaneous breath) |
|
|
Term
| Inspiratory Reserve Volume (IRV): |
|
Definition
| The additional air that can be inhaled after a normal tidal breath in |
|
|
Term
| Functional Residual Capacity (FRC): |
|
Definition
| the amount of air left in the lung at end of normal breathing exhalation (ERV + RV) |
|
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Term
|
Definition
| the amount of air that can be forced out of the lungs after a maximal inspiration (IRV + TV + ERV) |
|
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Term
|
Definition
| the amount of air left in the lung after a maximal exhalation (never expired) |
|
|
Term
| Inspiratory Capacity (IC): |
|
Definition
| the volume that can be inhaled after a tidal breathe – out (TV + IRV) |
|
|
Term
| Expiratory Reserve Volume (ERV): |
|
Definition
| the amount of additional air that can be breathed out after normal expiration |
|
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Term
|
Definition
Tests airflow rates
Lung volumes
Ability of lungs to transfer gas across the alveolar-capillary membrane
Correct Technique:
Deep, full maximal inspiration
Forced full exhalation
Proper duration of effort
Absence of coughs and/or extra breaths |
|
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Term
|
Definition
Assess type and extent of lung dysfunction
Diagnose causes of dyspnea and cough
Detection of early evidence of lung dysfunction
Longitudinal surveillance in occupational settings
Follow up of response to therapy
Pre-op assessment
Disability evaluation |
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Term
|
Definition
Can assess lung function by analyzing pH, partial pressure of O2, and partial pressure of CO2
It is necessary for the body to maintain the blood pH within a very narrow range: 7.35-7.45.
A deviation would alter enzyme function as well as create significant cardiovascular disturbance and possible death.
The body maintains this pH balance with buffer systems as well as concerted actions of the lungs and kidneys.
The main buffer system utilized by the body is the bicarbonate buffer system.
ABGs measure pH, PaCO2, PaO2, and HCO3
ABGs look at 2 categories:
Oxygenation
Acid-Base Balance |
|
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Term
|
Definition
Derived from CO2:
CO2 dissolves in H2O --> forms carbonic acid --> dissociates into bicarbonate and H+
Respiration allows H+ to be removed by the lungs as CO2 – acid base balance is maintained by the lungs |
|
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Term
|
Definition
Derived from Sources other than CO2:
Metabolic products of sulfur and phosphorus containing compounds
Lactic acid
Keto acids (acetoacetate and beta hydroxybutyrate)
Excreted by the Kidneys:
One quarter of the circulating blood passes through the kidneys every minute.
Acid base balance is maintained in the kidney (and the lungs) |
|
|
Term
| Bicarbonate Buffer System |
|
Definition
The bicarbonate buffer system is unique:
It has a huge buffering capacity because it communicates with air - (it is an open system)
This is in contrast to other buffers of the body which operate in a closed system
Open system can vent to the outside world whereas a closed system must do all of the work internally and requires greater effort to maintain steady state |
|
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Term
| Henderson-Hasselbalch Equation |
|
Definition
DEFINITIONS
log H+ = pH and H+ are inversely proportional
As H+ increases, pH decreases
As H+ decreases, pH increases
pH = HCO3- /pCO2
The lungs and kidney continuously work to adjust pCO2 and bicarbonate to maintain a normal pH
pCO2 = the Respiratory Component because it depends upon the rate of respiration
HCO3- = the Metabolic Component because its plasma concentration is maintained by the kidney, and is affected by amount of nonvolatile acids made |
|
|
Term
| Arterial Blood Gases – Normal Values |
|
Definition
pH = 7.35 – 7.45
pCO2 = 35 – 45 mm Hg (partial pressure of CO2)
HCO3- = 22 – 26 mEq/L (calculated from the Henderson-Hasselbalch Equation)
pO2 = 80 – 100 mmHg (partial pressure of O2)
O2 Saturation = 95 – 100% (the percentage of hemoglobin saturated with O2) |
|
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Term
|
Definition
A process associated with a Decrease in pH and an Increase in H+ concentration
pH < 7.35 |
|
|
Term
|
Definition
A process associated with an Increase in pH and a Decrease in H+ concentration
pH > 7.45 |
|
|
Term
|
Definition
8–14 ; high anion gap metabolic acidosis has anion gap > 14
High anion gap metabolic acidosis: MUDPILES
Methanol ingestion
Uremia – increased BUN
Diabetic ketoacidosis
Propylene glycol (Paraldehyde)
Iron & Isoniazides
Lactic acidosis
Ethanol & Ethylene glycol
Salicylates & Starvation
Causes of high anion gap metabolic acidosis:
Increased nonvolatile acids
Toxins/medications
Decreased renal excretion of acid |
|
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Term
| Causes of normal anion gap metabolic acidosis |
|
Definition
Loss of bicarbonate from GI tract or kidney – anion gap is not increased, because there is increased reabsorption of chloride anion to maintain electroneutrality
Normal anion gap acidosis: HARDUPS
Hyperalimentation
Acetazolamide
Renal Tubular Acidosis
Diarrhea
Uretero-Pelvic Shunt
Post-Hypocapnia
Spironolactone |
|
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Term
|
Definition
Primary disorder involves a loss of nonvolatile acid (HCL) or secretion of H+ by the kidneys
Causes of metabolic alkalosis:
Gastric loss of HCL
Vomiting
Nasogastric Suction
Renal loss of H+
Some diuretics
Increased Aldosterone (Conn’s Syndrome);
Increased Cortisol (Cushing’s Syndrome) |
|
|
Term
|
Definition
Nasal Cannula: Low O2 range; 1-6 L/min; COPD, general oxygen needs
Simple face mask: Medium O2 range, General O2 needs
Non-rebreather: High O2 range; 8-12L/min; high O2 emergency needs |
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Term
|
Definition
Definition: An infection of the pulmonary parenchyma
May involve only interstitial tissue or alveoli, alveoli and adjacent bronchi, or even entire lobe
May cause patchy infiltrations, full lobe consolidation, accumulation of pus (abscess), necrotic cavities
Types:
Community acquired pneumonia
Hospital acquired pneumonia
HIV related pneumonia
Anaerobic pneumonia and lung abscess |
|
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Term
| Various Ways to Classify Pneumonia |
|
Definition
Classic Pneumonia: shaking chills, purulent sputum
Atypical Pneumonia: insidious onset, scant sputum
Community-Aquired (CAP)
Hospital-Acquired (HAP) (Nosocomial)
Anatomic: Broncho, Lobar, or Interstitial pneumonia
Pathogenic: Primary, secondary, hematogenous, metastatic
Etiologic: Bacterial vs Viral; ID infective agent by name
Anaerobic Pneumonia: mixed flora, feculent breath
Empyema: purulent exudate in the pleural space
Lung Abscess |
|
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Term
| Community acquired pneumonia |
|
Definition
Most deadly infectious dz in US
Sixth leading cause of death
2-3 million cases diagnosed/yr
Begins outside of hospital or within 48 hours of admission
CAP usually develops after inhalation of oropharyngeal secretions or inhalation of infected aerosols
Combined with
Breakdown of normal host defense mechanisms – (cough reflex, mucociliary clearance mechanism, immune response)
Or
Very large inoculum or highly virulent pathogen
Can be classified as
Classic CAP
Atypical CAP |
|
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Term
| Classic Community acquired pneumonia |
|
Definition
Streptococcus pneumoniae most common cause
Acute onset of:
Fever, sweats, chills, rigors
Cough productive with purulent sputum (classic “rust colored sputum”)
Dyspnea
Pleuritic CP
Many patients appear acutely ill
Tachypnea, tachycardia
Rales, crackles
Dullness to percussion over effusion or consolidation
Increased tactile fremitus over consolidation
Lab: 2 blood cultures at 2 different sites, CBC, ABG, Chem panel, HIV serology
CXR – may show: Alveolar lobar or segmental infiltrates, Consolidation, Air bronchograms, Pleural effusion |
|
|
Term
| Atypical Community acquired pneumonia |
|
Definition
Mycoplasma pneumoniae most common
Others
Viruses
Chlamydia pneumoniae
Legionella
More commonly seen in young healthy adults
Pulmonary symptoms generally less abrupt and relatively mild as compared to CCAP
Non-productive cough
Low grade fever
Aches, fatigue
Lab:Generally not done, WBC may be up, Organisms usually not identified on sputum gram stain/culture
RAD:Diffuse infiltrates, Lower lung zones typically effected bilaterally/segmentally |
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Term
| Community Acquired Pnemonia Treatment |
|
Definition
Make your decision based upon the suspected organism; patient allergy; comorbidities; drug interactions; convenience/compliance & cost
Streptococcus pneumoniae, gram (+) diplococci
Preferred: Penicillin G, amoxicillin
Not requiring hospitalization – alternatives:
Macrolides: Clarithromycin & Azithromycin
Doxycycline
Flouroquinalones (with enhanced activity against S. Pneumo)
Patient requiring hospitalization
Broad spectrum beta-lactam and a macrolide or Extended spectrum beta-lactam and a flouroquinalone |
|
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Term
|
Definition
Pneumococcal vaccination
>65
Chronic illness
Immunocompromised vaccinate and re-vaccinate 6 years after 1st
Influenza annually
>65
Residents of long term care facilities
Heart or lung disease, other co-morbids
Health care workers |
|
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Term
Pneumonia findings by pathogen
Mycoplasma Pneumoniae |
|
Definition
Low grade fever
Cough
Bullous myringitis |
|
|
Term
| Pneumonia findings by pathogen: Legionella pneumoniae |
|
Definition
COPD or heart dz
Hyponatremia
Diarrhea |
|
|
Term
Pneumonia findings by pathogen
Chlamydia pneumoniae
Streptococcus pneumoniae
Klebsiella pneumoniae |
|
Definition
Chlamydia pneumoniae:
Longer prodrome
Sore throat, hoarseness
Streptococcus pneumoniae:
Single Rigor
Rust colored sputum
Klebsiella pneumoniae:
Currant jelly sputum
Lobar pneumonia
severe illness with rapid onset and often fatal |
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Term
| Type of patient = Type of pathogen |
|
Definition
Alcoholic:
Klebsiella
COPD:
Haemophilus
Cystic Fibrosis:
Pseudomonas
Healthy young adults:
Mycoplasma
Chlamydia
Air conditioning/water:
Legionella
< 1 year old:
RSV
>2 year old:
Parainfluenza |
|
|
Term
| Hospital Acquired Pneumonia |
|
Definition
Occurs more than 48 hours after admission
Second most common cause of nosocomial infection
Most common cause of death from nosocomial infection
Very high mortality if ventilated
Promoted by:
Instrumentation of upper airway – NG/ET tubes
Dirty hands/equipment
Treatment with broad spectrum abx – promotes resistance
Patient factors – malnutrition, age, altered mental status, underlying dz
Most common organisms
Staph aureus (MRSA)
Pseudomonas – mechanical vent, debilitated, previous abx – most common in ICU and carries worst prognosis
Signs & Sxs:Fever, Leukocytosis, New or progressive infiltrate, Other symptoms associated with pneumonia |
|
|
Term
Hospital Acquired Pneumonia
Labs & RAD |
|
Definition
Lab
Blood cultures from 2 sites
ABG/Pulse ox
Chemistry
Thoracentesis for pleural fluid analysis in those with effusions
Rad
Non specific – differs by the pathogen
Range from patchy infiltrates to lobar consolidation with air bronchograms to diffuse alveolar or interstitial infiltrates
Pleural effusions, cavitations |
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Term
| Hospital Acquired Pneumonia Treatment |
|
Definition
Usually empiric – then tailored if c&s becomes available
If mild 2nd/3rd gen cephalosporin and macrolide or a combination of beta lactam and beta lactamase inhibitor
If ICU or ventilated combo of abx directed at most virulent organisms – especially pseudomonas, acinetobacter, enterobacter
An aminoglycoside or flouroquinalone + antipseudomonal penicillin or cephalosporin or aztreonam if MRSA suspected add vancomycin |
|
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Term
|
Definition
Pneumocystic jiroveci is most common pathogen
Others common in HIV patients are:
Strep pneumonia
Haemophilus
Pseudomonas
TB
Fungals more common
Signs & Sxs:Fever, Tachypnea/tachycardia, SOB, Cough – usually non-productive, Bacterial pneumonia usually causes more acute/abrupt/fulminant sx.Viral, fungal, mycobacterial are more insidious
Labs: Decreased lymphocytes, Decreased CD4 (less than 200 typical), Staining of sputum from induction or lavage will show pathogen
RAD:Most common pneumocystis and usually presents radiographically as diffuse perihilar infiltrates without effusions.
Treatment
Trimethoprim/sulfamethasoxasole (Bactrim DS) TOC
Prophylax those with prior infections and those with CD4 <200
Prohylax with same as TOC or inhaled pentamidine |
|
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Term
| Anaerobic Pneumonia & Lung Abscess |
|
Definition
Usually caused by aspiration of oropharyngeal secretions
Those predisposed are those with:
Depressed levels of consciousness
Impaired deglutination
Poor dental and oral hygeine
Organisms are prevotella melaninogenica, peptostreptococcus, fusibacterium nucleatum, and bacteriodes species
Signs & Sxs
Poor dental/oral hygeine
Fever, weight loss, malaise
Foul smelling purulent sputum
Symptoms are insidious and usually by the time tx is sought abscess, empyema, or necrotizing pneumonia may be present |
|
|
Term
Anaerobic Pneumonia & Lung Abscess
Lab, RAD & Tx |
|
Definition
Lab
Cultures from sputum inappropriate due to contamination from large amounts of mouth flora
If organism definition required need transthoracic aspiration, thoracentesis, or bronchoscopy with brushings
Usually not done because anaerobic infx usually respond well to empiric therapy
Rad
Lung abscess appear as thick-walled solitary cavity surrounded by consolidation – usually has air-fluid level
R/O other causes of cavitary lung dz
TB, cancer, Wegener’s
Necrotizing pneumonia is distinguished by multiple cavitations within an area of consolidation
Empyema is characterized by the presence of purulent pleural fluid
Treatment
Penicillins previous TOC now 20% resistant& Clindamycin
Treat until radiographic improvement (may take more than a month) |
|
|
Term
|
Definition
Mixed flora on Gram stain suggests an anaerobic infection
Anaerobic infections are often confirmed by feculent breath
Initial CXR in dehydrated patients may not show an infiltrate (Hydrate and repeat CXR w/in 24 hrs)
Elderly patients with fever, confusion, nl CXR - DDx: pneumonia
CAP complicating influenza is typically caused by Staph. aureus
Hx of URI (viral-like syndrome) in close household contacts preceding CAP is suggestive of Mycoplasma infection |
|
|
Term
| Acute Bronchitis or Tracheobronchitis |
|
Definition
Clinical condition caused by acute inflammation of trachea and bronchi
Presents with cough with or without production
Irritants like dust and smoke
Most often viral: 90% by rhinovirus, coronavirus, RSV
In patients with chronic lung dz and/or smokers – bacteria also common
Symptoms may be preceded by upper respiratory infection
PE may be normal or with rhonchi and wheeze
No signs of pulmonary consolidation
CXR normal – reserve for suspicion of other disease – to differentiate from pneumonia
Fever may or may not be present
Symptomatic to control cough, discomfort, and fever
CONTROLLED STUDIES DO NOT SUPPORT USE OF ANTIBIOTICS |
|
|
Term
| Respiratory Syncytial Virus (RSV) |
|
Definition
Paramyxovirus that causes annual outbreaks of pneumonia, bronchiolitis, tracheobronchitis
Annual epidemics in winter and spring
Incubation period 5 days
Inoculation through nose/eyes/lungs
Contributes to recurrent OM and URI’s
Risk factors
Premature infants
Male gender
Age <6 mos
Day care exposure
Treatment
Hydration
Humidification of inspired air
Ventilatory support as needed
Ribavirin, bronchodilators, corticosteroids widely used
Search for effective vaccine is ongoing |
|
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Term
|
Definition
The only respiratory pathogen that produces its most serious illness at a time when specific maternal antibody is present
Infants who have received a past live vaccine for RSV had more severe disease
For these two reasons must have immune mediated component |
|
|
Term
|
Definition
Nonspecific inflammation of terminal bronchioles
Common in infants and children, can be severe, usually caused by RSV (most common) or adenovirus
In adults acute infectious type rare, usually chronic progressive
Two pathologic variants
Constrictive bronchiolitis
Chronic inflammation, concentric scarring causing luminal obstruction, progressive clinical course unresponsive to steroids
Proliferative bronchiolitis
Lymphocytes, polyps, macrophages obstruct the bronchioles – when this exudate extends to alveoli it is termed bronchiolitis obliterans |
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|
Term
|
Definition
Highly contagious dz. Spread by respiratory route
Epidemics in fall or winter
Antigenic types A,B,C
type A is most common
Difficult to diagnose in the absence of epidemic – resembles many other illnesses
Abrupt onset of:Chills, Fever, Malaise, Myalgias,Cough, Coryza, Cervical lymphandenopathy, Pharyngeal injecton, flushing, conjunctival redness
Lab:Leukopenia common, Proteinuria possibly, Rapid tests for influenza antigens from nasal or throat swabs widely available
Complications:Causes necrosis of respiratory epithelium which predisposes to secondary bacterial infection.
Elderly, HIV, patients with co-morbid illnesses and pregnant are at high risk for complications and serious disease, Reyes syndrome: Do not give kids w/a fever ASA |
|
|
Term
| Prevention and Tx of Influenza |
|
Definition
Vaccination in Oct-Nov annually
Age >50
Children and teenagers receiving chronic asa therapy
Co-morbid illness
Nursing home
Pregnant women during 2-3 trimester
Health care workers
TX:
Supportive, use acetaminophen rather than asa for children with fever/aches |
|
|
Term
|
Definition
Young children in fall and early winter
Most commonly caused by parainfluenza virus serotypes
Signs & Sxs
URI symptoms followed by barking cough
May have labored breathing signs
+/- fever
Presence of cough and absence of drooling favor diagnosis of croup over epiglottis
Imaging
Lateral neck radiograph should show supraglottic narrowing secondary to edema and a normal epiglottis; "Steeple sign"
Not routinely done in classic presentation |
|
|
Term
|
Definition
Treatment
Based on symptoms
Supportive therapy, minimal handling
Hydration
O2
Nebulized racemic epinephrine
Glucocorticoids
Disposition
If symptoms resolve within 3 hours can be safely discharged
If sx’s persist or repeat racemic epinephrine tx’s needed – hospitalize, closely observe, nebulized tx’s prn
Prognosis
Most improve uneventfully within a few days
If hospitalized patient sx’s persist more than three days – probably other reason for obstruction |
|
|
Term
| Bacterial tracheitis (pseudomembranous croup) |
|
Definition
Usually staph aureus
Results in inflammatory edema, purulent secretions, and pseudomembranes
Signs & Sxs:high fever, toxicity, progressive airway obstruction unresponsive to standard croup therapy
Lab:Elevated WBC with left shift; Tracheal cultures reveal organism
Rad
Lateral neck – severe subglottal/tracheal narrowing – normal epiglottis
Bronchoscopy
Normal epiglottis and presence of copious purulent tracheal secretions
Treatment:Intubation likely needed; Frequent suctioning, IV antibiotics; ICU monitoring |
|
|
Term
|
Definition
Infection of subglottis with viral or bacterial pathogen
Rapidly developing sore throat
Odynophagia out of proportion to oropharyngeal findings on exam
Laryngoscopy is generally safe in adults BUT not in children
Will see a swollen, erythematous epiglottis
Tx: Initial treatment is admit for IV abx/steroids
Cefuroxime, Dexamethasone
Airway management |
|
|
Term
| Classic childhood epiglottitis |
|
Definition
Severe life-threatening
Haemophilus influenza type b
Age 2-7
Sudden onset high fever
Drooling
Muffled voice
Severe dysphagia
Upright with neck extended – tripod
CBC, blood cultures
Lateral neck x-ray – thumb sign
Secure airway
IV ceftriaxone 7-10 days |
|
|
Term
|
Definition
Caused by the gram neg bacteria bordetella pertussis
Called whooping cough
Transmitted by respiratory droplets
50% cases before age 2
Neither disease or immunization confers life long immunity
Classic sx’s last 6 weeks divided in 3 stages"
Catarrhal stage – Insidious onset of sneezing coryza, anorexia, malaise, hacking night cough
Paroxysmal stage – Bursts of rapid, consecutive coughs followed by a deep, high pitched inspiration (whoop)
Convalescent stage – begins 4 weeks after onset of illness and is marked by decrease in frequency and severity of cough paroxysms |
|
|
Term
| Pertussis Lab, Prevention and Tx |
|
Definition
Lab: WBC elevated - 15-20,000, 60-80% Lymphocytes, Can culture and isolate organism from nasopharyngeal swabs on Bordet-Gengou agar medium
Prevention:DTaP recommended for all infants
Treatment:
Macrolides:
Erythromycin
Azithromycin
Clarithromycin |
|
|
Term
|
Definition
Mycobacterium tuberculosis - viable organisms inhaled by susceptible host
Transmitted by airborne droplets
Latent TB infection – no symptoms/not contagious/positive PPD
Consider TB in all HIV-infected patients with undiagnosed pulmonary disease
Personal Respirators-->Use in areas where there is an increased risk of exposure such as TB isolation rooms, rooms where cough-inducing procedures are done, homes of infectious TB patients |
|
|
Term
| “Miliary” (resembling millet seed) TB |
|
Definition
a form of Primary infection going directly into disease where immune system doesn’t stop dissemination throughout lung
CXR:Miliary TB:Multiple 1-3mm nodules throughout lungs – hematogenous, lymphatic spread |
|
|
Term
|
Definition
TB disease can also spread outside of the pulmonary system, including meninges, bone, pericardium, peritoneum, skin, etc
Symptoms are:
fatigue, weight loss, anorexia, low grade fever, and drenching night sweats
Often have cough that becomes productive, sometimes hemoptysis
Sometimes no symptoms, sometimes only wasting
May note posttussive apical rales
Clinical Findings Of TB Disease:Acid-fast bacilli on stain of sputum & Cultures and DNA probes of sputum
A disease of poverty and population
A disease of the immunocompromised
A disease You and I can contract as care givers |
|
|
Term
|
Definition
Ghon complex – calcified primary focus
Ranke complex – calcified primary focus and calcified hilar lymph node
Indicate healed primary infection
CXR:Infiltrates, hilar, paratracheal lymph node enlargement, segmental atelectasis, cavitations with primary progressive disease
Reactivation TB: Fibrocavitary apical disease, nodules, infiltrates of posterior apical segments, upper segment of lower lobes |
|
|
Term
|
Definition
> 5 mm
HIV positive
Contacts of individuals with active TB
Persons with CXR consistent with old healed TB
Organ transplants, immunosupressed
>10 mm
Military
Recent immigrants (<5yrs)
IV drug users
Residents/employees of high risk congregate settings (nursing home, hosp, correctional facilities, shelters)
>15mm
All other persons
Must have the ability to react to TB before skin test can react
Anergy - the inability to react to skin test because of immunosuppression |
|
|
Term
|
Definition
ALL possible or proved cases should be reported to local and state public health departments
Treatment should be done by experienced providers
Close follow-up for compliance essential - Noncompliance is the major cause of treatment failure and drug resistance
Isoniazid (INH), Rifampin, Pyrazinamide (can use multiple drugs at a time)Streptomycin is contraindicated in pregnancy
BCG (bacillus Calmette-Guerin) vaccine is recommended only when INH can’t be used (i.e. children exposed frequently to untreated population)
Properly treated patients are usually cured with less than 5% recurrence; NONCOMPLIANCE is major cause of Tx failure |
|
|
Term
|
Definition
Fungal infections increasing
Due to increasing use of broad spectrum antibiotics and increasing number of immunodefecient patients
Some pathogens cause disease primarily in immunocompromised hosts while some endemic fungi commonly cause disease in both |
|
|
Term
|
Definition
Caused by inhalation of Histoplasma capsulatum – fungus isolated from contaminated soil
Linked to bird droppings and bat exposure, common along river valleys
Endemic to the Ohio, Missouri,Mississippi River valleys
Most individuals with histoplasmosis are asymptomatic
Those who develop clinical manifestations are usually immunocompromised
Past infection can leave calcifications on CXR
Acute: epidemics, fever, pulmonary complaints, 1 week to 6 mos. Rarely fatal
Dissemated: fever, wt loss, dyspnea, organ involvement, usually fatal within 6 weeks, usually immunocompromised
Chronic progressive pulmonary:usually in older patients with COPD
Itraconazole 200-400mg per day is TOC |
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Term
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Definition
Results from inhalation of coccidiodes organisms – a mold that grows in soil
Endemic in the soil in many regions of the southwestern USA, in Mexico, and South and Central America
In endemic areas, very common opportunist infection in HIV -infected patients
Malaise, fever, backache, headache, cough
Arthralgia, periarticular swelling of knees and ankles, and erythema nodosum
CXR varies from Pneumonitis to Cavitation
Endospores demonstrable in sputum for diagnosis
Serology testing also useful – IgM antibodies
Tx: Amphotericin B, Fluconazole, Itraconazole |
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Term
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Definition
Occurs most often in men of the south central and midwestern USA and Canada during outside recreational activity
Pulmonary infection often asymptomatic, but if disseminated often see skin lesions with verrucous cutaneous lesions with abrupt down sloping border
Can also affect bone and urogenital system
Cough, moderate fever, dyspnea, chest pain
Organism is found in expectorated sputum
Itraconazole is TOC 100-200mg daily for 2-3 mos |
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Term
|
Definition
Fungal pathogen that colonizes the tracheobronchial tree
Can cause a unique condition of Allergic Bronchopulmonary Aspergillosis |
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Term
| Allergic Bronchopulmonary aspergillosis |
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Definition
Pulmonary hypersensitivity due to allergy to fungal antigens that colonize the tracheobronchial tree
This condition should be considered when a patient with a history of asthma develops worsening of symptoms, wheezing, bronchospasm
Marked by fleeting pulmonary infiltrates, eosinophilia, high levels of IGE, and Aspergillus precipitans in the blood
This characteristically waxes and wanes with gradual improvement over time but can potentially progress to end stage fibrotic lung disease.
Treatment
Prednisone 1mg/kg tapered slowly over several mos
Itraconazole 200mg daily for 16 weeks |
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Term
| 4 common pulmonary diseases associated with inflammation |
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Definition
1. Asthma
2. Allergic Rhinitis
3. Sinusitis
4. COPD
Irritants:
1. cigarette smoke
2. pollutants
3. infections
4. chronic immunologic stimulation |
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Term
|
Definition
an inflammatory disease of the airways characterized by hyper-responsiveness of the tracheobronchial tree to various stimuli
Reversible: (Early Phase only) If the bronchoconstriction, edema, and mucous production can be controlled
Irreversible: with recurrent attacks & fibrosis.
Episodic: cough, dyspnea, wheezing lead to airway obstruction
A genetic predisposition is recognized;Strongest identifiable factor is atopy
Atopic triad
Asthma
Eczema
Seasonal rhinitis |
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Term
|
Definition
Chronic inflammatory disorder of the airways
Denudation of airway epithelium
Airway edema
Mast cell activation
Inflammatory cell infiltration
Hypertrophy of mucus glands and bronchial smooth muscle
Results in………
Airway hyper-responsiveness
Airflow limitation
Mucus plugging
Respiratory sx’s |
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Term
| Asthma is now understtod to be a CHRONIC Inflammatory Dz |
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Definition
Obstructive Airway Disease with 3 components:
Inflammation
Airway hyper-responsiveness
Allergic or Immunologic Mediated |
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Term
|
Definition
Children will “outgrow” asthma
Nobody dies from asthma
Asthma never damages the lungs
It is okay to have asthma and wheeze daily
You can’t participate in sports if you have asthma
Intermittent Asthma can’t hurt me |
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Term
| Asthma Provocative Stimuli |
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Definition
Allergens:(Seasonal and Environmental)
Pharmacologic stimuli:Coloring agents in food; Beta blockers;
Aspirin triad:rhinitis leading to rhinosinusitis with nasal polyps developing Asthma
Environmental: ozone, dust, pollen, molds
Occupational Factors: work and/or leisure: metal, wood, vegetable dust, paint, latex, plastics etc… |
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Term
| Triggering Factors of Asthma |
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Definition
Infection: respiratory viruses more than bacterial such as RSV, Rhinovirus and Influenza
Exercise: Thermal Change
increase in minute ventilation leads to post-exertional obstruction
Emotional stress: modification of Vagal efferent airway reactivity? Hyperemia & microvascular engorgement of bronchial circulation activity
Allergic: dust mites, cockroaches, cats, seasonal pollens |
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Term
|
Definition
Slow-onset asthma = but progressive over 6 hours to days = 80% of cases
Female > males
Triggered by URI’s
Slower response to Tx
Rapid-onset asthma = less than 6 hour deterioration = less than 20% of cases
Males > females
Exercise, allergens, stress,
Faster response to Tx |
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Term
| Asthma Signs and Symptoms |
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Definition
Cough, worse particularly at night
Wheezing
Shortness of breath
Chest tightness
Sputum production
Decreased exercise tolerance
Nasal mucosal swelling
Increased secretions
Eczema, atopic dermatitis
Hunched shoulders – use of accessory muscles
Highly variable:Wheezing, SOB, Chest tightness, Cough, Usually worse at night |
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Term
| Asthma Physical Exam – Critical findings |
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Definition
Tachypnea: > 20 inhalations per minute
Tachycardia: > 100 bpm
Pulsus paradoxus : pulses don’t match
Use of accessory muscles: cervical strap muscles, abdominal breathing, etc |
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Term
|
Definition
Fast acting Beta2-agonist inhaled
Albuteral HFA
Proventil HFA
Ventolin HFA
ProAir HFA
Epinepherine injection |
|
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Term
|
Definition
Pulse Oximetry: indicates acute oxygenation status above 98%
Pulmonary function studies: PFT’s are standard – FEV1/FVC ratio, Peak expiratory flow (PEF or PEFR)
CXR: Usually normal in “pure” acute asthmatic(Little value)
All patients suspected of new asthma diagnosis or new SOB should have a CXR
Definitely: get a CXR for suspected Pneumothorax, Pneumonia, Pneumomediastinum, CHF
Unresponsive to treatments – going to get an ADMISSION
CBC with differential
WBC count: Leukopenia (decreased): immunosuppressed
Leukocytosis (increase): infection or corticosteroids
ECG/(EKG):Pt over 40 years old, Hx of cardiac disease, Associated chest pain/pressure, Any person in severe distress |
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Term
|
Definition
Spirometry
(FEV1, FVC, FEV1/FVC) pre & post bronchodilator
Obstruction is indicated by an FEV1/FVC of <75%-decreased
Reversibility is indicated by 12% increase in FEV1 post bronchodilator – absence of improvement is not proof of irreversible airflow obstruction |
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Term
| Peak Expiratory Flow Meters |
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Definition
Handheld device designed for home monitoring
Establishes variability, severity, provides patient and clinician with objective means to guide treatment
Daily measurements should be taken in the am before bronchodilator administration and in the PM after bronchodilator |
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Term
| Asthma Attack Differential Diagnosis |
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Definition
Cardiovascular
Heart valve disease, CHF, MI, chest pain r/o
Pulmonary
Asthma, infection, pulmonary embolism, COPD
Foreign body, laryngeal edema others….
Cancer
Primary from Lung
Metastasis from other primary within the lung
Pleural effusion with metastasis from other primary
Allergy, ANAPHYLAXIS
GERD (Gastroesophageal reflux disease) |
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Term
|
Definition
A specific allergy evaluation is recommended for all patients with persistent level of disease activity
Serum (blood) test: (specific but not sensitive)
Food allergens
Respiratory allergens (Zoned for US areas)
CBC show elevated Eosinophils
RAST can be performed for specific allergens: foods, perennial allergens of cat, dog, dust mite, cockroach and alternaria, etc. |
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Term
|
Definition
Allergic (Extrinsic)- Immunologic (IgE) reaction to environmental allergens
Idiosyncratic (Intrinsic)- unrelated to allergens
Exercised Induce
Industrial
Occupational Asthma |
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Term
| Allergic Asthma (Extrinsic) |
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Definition
Pt usually has a history of:
IgE immunologic reactivity
Positive Skin Test
History of Allergic Rhinitis
History of Urticaria
History of Eczema |
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Term
| Idiosyncratic/Intrinsic asthma |
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Definition
No personal or Family Hx of allergies
May develop bronchospasms after exposure to exercise, cold air, URI, or occupational stimuli
Negative skin reactions to intradermal injections
Normal serum levels of IgE |
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Term
|
Definition
Proper warm-up and cool-down may prevent or reduce the incidence of exercised-induced asthma
Symptoms exacerbate with exercise
Symptoms exacerbate cold weather or high humidity
Symptoms:
Wheezing
Coughing
Shortness of breath
Early during exercise routine
Out of proportion than expected |
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Term
| Industrial & Occupational Asthma |
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Definition
Occupational exposure: (ask patient specifics)
Military history
Cleaning / Painting industry
Mining industry
Irritants (household sprays, paint fumes Etc.)
A variety of high and low molecular weight compounds are associated with the development of occupational asthma, such as insects sprays, plants fertilizers, latex, gums, diisocyanates, anhydrides, wood dust, and fluxes. |
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Term
|
Definition
Two types of Asthma:
1. Intermittent asthma
2. Persistent
Mild persistent asthma
Moderate persistent asthma
Severe persistent asthma |
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Term
|
Definition
Intermittent symptoms occurring less than once a week
Brief exacerbations
Nocturnal symptoms occurring less than twice a month
Asymptomatic with normal lung function between exacerbations
No daily medication needed
FEV1 or PEF rate greater than 80%, with less than 20% variability |
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Term
|
Definition
Symptoms occurring more than once a week but less than once a day
Exacerbations affect activity and sleep
Nocturnal symptoms occurring more than twice a month
FEV1 or PEF rate greater than 80% predicted, with variability of 20-30% |
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Term
| Moderate persistent asthma |
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Definition
Daily symptoms
Exacerbations affect activity and sleep
Nocturnal symptoms occurring more than once a week
FEV1 or PEF rate 60-80% of predicted, with variability greater than 30% |
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Term
|
Definition
Continuous symptoms
Frequent exacerbations
Frequent nocturnal asthma symptoms
Physical activities limited by asthma symptoms
FEV1 or PEF rate less than 60%, with variability greater than 30% |
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Term
|
Definition
Pulmonary function studies:
Peak Flow Meter (done at home or in office)
Complete PFT’s (done in office/clinic)
Pulse Oximetry
Imaging Studies
CXR
CT Scan of the sinus’s
Labs
Not routinely done
Increased Eosinophil count on CBC with diff
Increased Total serum immunoglobulin E levels greater than 100 IU
H. Pylori testing/questioning
Serum Allergy Testing / Skin allergy testing (RAST) |
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Term
| How are pulmonary functions affected with Asthma? |
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Definition
FEV1: reduction
FVC( forced vital capacity): decreased
RV (residual volume): increased
FRC (functional residual capacity): doubles
TLC: increases
PEF: reduction |
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Term
| Asthma Treatment is Based on |
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Definition
Classification
Classify the severity of asthma before treatment; based on symptom prevalence & on measurement of lung function |
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Term
| Asthma Quick – relief medications |
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Definition
B-adrenergic agents
Anticholinergic agents
Corticosteroids |
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Term
|
Definition
The most effective bronchodilators during exacerbations
TOC for acute symptoms
Relax airway smooth muscle, increase airflow, reduce symptoms
Effectively prevents EIB when given before exercise
Inhaled is preferred method – IV or SQ administration only when unable to administer by inhalation (age, mechanical factors)
Scheduled daily dosing not recommended – if needed then that means you need to step up there long term therapy
S/E – tachycardia, increased BP
Albuterol – Proventil, Ventolin – MDI, nebulizer solution, oral
Pirbuterol – Maxair – MDI
Terbutaline – Brethine – oral, injection |
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Term
|
Definition
Epinephrine
Isoproterenol
Metaproterenol
Isoethrine
Pirbuterol
Terbutaline
Racemic Albuterol
Most commonly prescribed
Albuterol
Xopenex
Adrenaline
Isuprel
Alupent
Bronkosol
Maxair
Brethine
Proventil, Ventolin |
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Term
| Beta 2 adrenergic receptors |
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Definition
Bronchial smooth muscle relaxation
Inhibit mast cell secretion
Suppression of edema
Systemic side effects of Tremor, nervousness, palpitations, K+ decrease, glucose increased
NOTE: All of the above mechanisms are blocked by oral antihypertensive β-blockers |
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Term
| Specific Mechanisms for Rx drugs |
|
Definition
B-Agonists (inhaled):
Short
Relaxes bronchial smooth muscle by action on beta2-receptors, with little effect on cardiac muscle contractility
long acting
Relieves bronchospasm by relaxing smooth muscles of the bronchioles in conditions associated with bronchitis, emphysema, asthma, or bronchiectasis. Effect also may facilitate expectoration |
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Term
|
Definition
Reverses bronchospasm in vagally mediated bronchospasm – but not allergy or EIB
Decreases mucus gland hypersecretion
May help in acute bronchospasm but usually no clear role in long term asthma
TOC for bronchospasm due to β-blockers and the treatment of COPD
Ipatropium bromide – Atrovent – MDI, nebulizer solution |
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Term
| Ipatropium Bromide – Atrovent |
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Definition
IB is an atropine analog
Blocks the muscarinic pathway
Decreases vagal tone in the airways through antagonism of muscarinic receptors and inhibition of vagally mediated reflexes
Chemically related to atropine.
Has antisecretory properties and, when applied locally, inhibits secretions from serous and seromucous glands lining the nasal mucosa
Only 50% of patients who are asthmatic bronchodilate with ipratropium
Used primarily in conjunction with beta-agonists for severe exacerbations.
No additive or synergistic effects observed with long-term treatment of asthma
Used to Treat COPD/Emphysema |
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Term
|
Definition
Effective primary treatment in acute excacerbations
Use in all patients with mod-severe excacerbations
Speed rate of resolution of symptoms and reduce relapses
“Bursts” for outpatient
IV if concerns about altered GI absorption – but oral as effective as IV generally |
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Term
| Long term control medications |
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Definition
Anti inflammatory agents
Long acting bronchodilators
Leukotriene modifiers |
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Term
|
Definition
Inhaled corticosteroids
Properties result in decreased airway responsiveness, improvement in airflow, few sx’s and exacerbations
Preferred agent for long-term control
First-line for persistent asthma
Local side effects
Cough, dysphonia, oropharyngeal candidiasis
Incidence reduced by use of spacer, mouth washing
Systemic side effects
Adrenal suppression, osteoporosis etc.
Possible with high-dose inhalation therapy – but uncommon |
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Term
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Definition
Pure Steroids
Asmanex Aerobid
Azmacort QVar
Flovent Pulmicort
Combination Steroid with + long acting B2 agonist
Advair = steroid + salmeterol
Symbicort= steroid + formoterol
Dulera = steroid + formoterol |
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Term
| Dry Powder Inhalers vs Metered Dose Inhalers |
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Definition
DPI - patients must turn, click and inhale fast and deeply (Some are positional dependent)
MDI - patients must shake the canister before each activation, trigger the canister at the beginning of a slow, steady and deep breath inhaled over 3-5 sec and then held for an additional 10-15 seconds, using a chamber device |
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Term
|
Definition
Budesonide – Pulmicort – turbihaler – dry powder
Fluticasone – Flovent – MDI and rotadisk
Triamcinalone acetonide – Azmacort – MDI |
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Term
|
Definition
| Most effective in achieving prompt control during exacerbations |
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Term
|
Definition
Prevent the release of mediators from mast cells that cause airway inflammation and bronchospasm.
Indicated for maintenance therapy of mild-to-moderate asthma or prophylaxis for exercise-induced bronchospasm.
Cromolyn (Intal) |
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Term
| β-adrenergic agents (long acting) |
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Definition
Bronchodilation for 12 hours
Not effective in acute exacerbation – slow onset of action
Should not be used in place of anti-inflammatory therapy – but in addition to
May reduce dosage of anti-inflammatory needed by half
Salmetrol – Serevent – diskus
Formoterol – Foradil – aerolizer
Sustained release albuterol – proventil repetabs – oral
Long acting β-agonist available with steroid
Fluticasone/salmetrol – advair diskus |
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Term
| Phosphodiesterase Inhibitors |
|
Definition
Theophylline
Not used much anymore
Mild bronchodilation, enhance mucociliary clearance, diaphragmatic contractility
Adjuvant therapy in mod/severe
Narrow toxic/therapeutic range – monitor serum levels
Decrease/increase clearance by many drugs
Side effects - many |
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Term
|
Definition
| refers to severe bronchospasm that does not respond to aggressive therapies within 30 to 60 minutes |
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Term
| PE findings for Status asthmaticus |
|
Definition
Is the Patient Able to Speak?
Mild = sentences
Moderate = phrases
Severe = words
Tachypnea: > 20 inhalations per minute
Tachycardia: > 100 bpm
Pulsus paradoxus : pulses don’t match
Use of accessory muscles: cervical strap muscles, abdominal breathing, etc
Tx:Maintain the airway at all times, Maintain SaO2 > 90%
Medications, Re-assess lungs: auscultate, Monitor your patients!!!Oxygen, Inhaled short acting B2-agonist: albuterol, Proventil
Levalbuterol (Xopenex) short acting general rule: for adults, not children <6 Y/O
Epinephrine injection/IM if not responding
Intubation if Respiratory Failure |
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Term
|
Definition
Epinephrine (inhaled or Injected)
Adrenergic agent:
has BOTH alpha & beta effect
Cardiovascular system:
Heart Rate increase,
Blood pressure increase
Pulmonary system:
Respiratoy Rate decrease due to broncho-dilation
Terbutaline
longer acting B2 agonist
Oral or Injected Intramuscular |
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Term
|
Definition
Mild exacerbation: PEF >80% and only minimal symptoms and signs of airway obstruction
Mod/Severe Exacerbation signs & sx’s –
Speech
Breathlessness
Increased resp rate
Use of accessory muscles
Change in mental status
Decreased O2 sat
PEF or FEV1 50-80 moderate, <50 severe
All immediately receive:
O2 – maintain SaO2 >90%
High doses inhaled B agonist
Via nebulizer or MDI at least 3 in first hour
May mix with Ipatropium via nebulizer first dose
Monitor peak flow after each tx
Corticosteroids – systemic early
You must be prepared to maintain protected airway if needed |
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Term
| Prevention of Asthma Attacks |
|
Definition
Treatment with Inhaled Steroid
Treatment with combination B-agonist & inhaled steroid
Elimination of causative agents from the environment
Stop smoking
Treatment of concurrent disorders
Rhinitis
Sinusitis
GERD
All asthma patients should get
Pneumococcal vaccine
Annual influenza vaccine |
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Term
|
Definition
Two beta-agonist canisters/year
Two doses of beta-agonists/week
Two nocturnal awakenings/month
Two unscheduled visits to Dr./year
Two prednisone bursts/year |
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Term
|
Definition
Allergy shots have been shown to:
Reduce the likelihood of developing asthma
Reduce the severity of disease
Improve overall quality of life
Reduce medication requirements
Decrease utilization of health services |
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Term
| Asthma Goals of Treatment |
|
Definition
Treatment: Gain control
Long-term control: long acting B-agonists, inhaled steroids,leukotriene modifiers
Quick relief: more aggressive combo therapy or follow appropriate steps then modify up
Education: diet, exercise, monitoring, compliance, avoidance, hygiene, weight loss
Vaccinations: prevent influenza and Strep pneumoniae |
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Term
| Risk Factors for Death from Asthma |
|
Definition
Asthma History
Previous severe exacerbation (ICU or intubation)
Two or more hospitalizations for asthma in the past year.
Hospitalization or an ED visit for asthma in the past month
Social History
Low socioeconomic status or inner-city residence
Serious psychosocial problems: iIlicit drug use (cocaine, heroin)
Comorbidities
Cardiovascular, COPD, emphysema, pulmonary fibrosis, chronic psychiatric disease
Use of >2 MDI short-acting beta2-agonist canisters per month
Current use of or recent withdrawal from systemic corticosteroids
Difficulty perceiving asthma symptoms or severity of exacerbations |
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Term
| Asthma Assessment/Monitoring |
|
Definition
Periodic assessments to all asthma patients
Spirometry
Initial assessment, after peak flows stabilized, and at least every 1-2 years
F/U visits
Every 6 months or sooner if needed
Action plan
Every patient must have written action plan based on s/s and PEF |
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|
Term
Asthma Action Plan
Green Zone: Doing well |
|
Definition
No cough, wheeze, chest tightness, or SOB during day or night
Peak flow 80% or more of best
Take all RX as directed |
|
|
Term
Asthma Action Plan
Yellow Zone: Getting worse |
|
Definition
Cough, wheeze, chest tightness or SOB – or
Waking at night due to sx – or
Can do some, but not all usual activities – or
Peak flow 50-80%
Add quick relief med, keep taking green zone med
If return to green zone p 1 hr take quick relief med q4h x24-48h. Double dose of inhaled steroids
If no return to green zone see red zone |
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|
Term
Asthma Action Plan
Red Zone: |
|
Definition
Very short of breath – or
Quick relief meds have not helped – or
Cannot do usual activities – or
Peak flow <50%
Go to hospital now! |
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