Term
Chronic Cough
Signs and Symptoms |
|
Definition
The age of the patient, presence of associated signs/symptoms, medical history, medication history (ACE inhibitor), environmental exposures, potential for aspiration, and smoking history may make some causes more likely.
Physical Exam
Signs and symptoms are variable and related to the underlying cause; usually a nonproductive cough with no other signs or symptoms.
Possible signs and symptoms of UACS, sinusitis, GERD, congestive heart failure |
|
|
Term
|
Definition
empiric treatment should be directed at the most common causes (UACS, asthma, GERD, NAEB)
Oral antihistamine/decongestant therapy with a 1st-generation antihistamine should be initial empiric treatment
Centrally-acting antitussive drugs (codeine, dextromethorphan) are recommend for short-term symptomatic relief of coughing in patients with chronic bronchitis
In 2008, the FDA issued a public health advisory stating that OTC cough and cold medicines, including antitussives, expectorants, nasal decongestants, antihistamines, or combinations should not be given to children < 2 years.
The American Academy of Pediatrics does not recommend central suppressants for treating any kind In children < 14 years old, when pediatric recommendations are not available, adult recommendations should be used with caution
Some children no evidence of airway obstruction may benefit from an inhaled β-agonist
With concomitant complaints of heartburn and regurgitation, GERD should be considered as a potential etiology
When indicated, ACE inhibitor therapy should be switched |
|
|
Term
Acute Bronchitis
Sings and Symptoms |
|
Definition
Sudden onset of cough and no evidence of pneumonia, asthma, exacerbation of COPD, or the common cold (3)
Cough is initially dry and unproductive, then productive; later, mucopurulent sputum, which may indicate secondary infection
Dyspnea, wheeze, fever, and fatigue may occur.
Possible contact with others who have respiratory infections (1)
Physical Exam
Fever
Tachypnea
Pharynx injected
Rales, rhonchi, wheezing
No evidence of pulmonary consolidation |
|
|
Term
Acute Bronchitis
Management |
|
Definition
Antibiotics are usually not recommended unless a treatable pathogen has been identified or significant comorbidities are present.
First Line
Amantadine or rimantadine therapy if influenza A is suspected; most effective if started within 24–48 h of development of symptoms [also consider oseltamivir (Tamiflu) or zanamivir
Decongestants if accompanied by sinus condition
Antipyretic analgesic, such as aspirin, acetaminophen, or ibuprofen
Antibiotics if a treatable cause (i.e., pertussis) is identified
Cough suppressant for troublesome cough (not with COPD); guaifenesin with codeine or dextromethorphan
Inhaled beta agonist (e.g., albuterol) or in combination with steroids for cough with bronchospasm
Consider steroids for bronchospasm
Contraindication(s): Doxycycline should not be used during pregnancy or in children |
|
|
Term
Bronchiolitis
Signs and Symptoms |
|
Definition
Irritability
Anorexia
Fever
Noisy breathing (due to rhinorrhea)
Cough
Grunting
Cyanosis
Apnea
Vomiting
Physical Exam
Tachypnea
Retractions
Rhinorrhea
Wheezing
Upper respiratory findings: Pharyngitis, conjunctivitis, otitis |
|
|
Term
|
Definition
supportive to prevent hypoxia and dehydration.
Medication (Drugs)
Oxygen
Nebulized albuterol (0.15 mg/kg) is often tried for acute symptoms Epinephrine aerosols (0.5 mL of 2.25% solution in 3 mL NS)
Corticosteroids:
Oral dexamethasone (1 mg/kg loading dose, then 0.6 mg/kg b.i.d. for 5 days) reduced subsequent hospitalization. Second Line
Antibiotics only if secondary bacterial infection present (rare) |
|
|
Term
|
Definition
2–3 days nonspecific prodromal syndrome with low-grade fever, coryza, rhinorrhea
Onset and recurrence at night when child is sleeping
Symptoms often resolve en route to hospital as child is exposed to cool night air.
Lack of prodrome indicates spasmodic croup.
Physical Exam
Pulse oximetry often is normal because there is no disturbance of alveolar gas exchange.
Overall appearance: Child comfortable or struggling?
Work of breathing: Labored or comfortable?
Sound of breathing and voice: Hoarse, stridor, inspiratory wheezing, short sentences?
Observed/subjective tidal volume: Sufficient for child size? |
|
|
Term
|
Definition
Well established in literature; cornerstones of treatment are immediate nebulized epinephrine and dexamethasone
Racemic or L-epinephrine
Corticosteroids |
|
|
Term
|
Definition
Cough (particularly if worse at night)
Wheeze
Chest tightness
Difficulty breathing
Exam
May be normal
Focus on:
General appearance: Signs of respiratory distress such as use of accessory muscles
Rhinitis, nasal polyps, swollen nasal turbinates
Lower respiratory tract: Wheezing, prolonged expiratory phase
Skin: Eczema |
|
|
Term
|
Definition
Short-acting β-agonist (SABA) for quick relief of acute symptoms and for prevention of exercise-induced bronchospasm
Delivery of SABA and other inhaled agents via “spacer” or holding chamber (Aerochamber, Optichamber, others) provides increased efficacy with decreased side effects when compared to nebulized delivery. Reserve nebulized delivery of medication for those unable to use spacer (infants, those intubated
For long-term control (4):
Inhaled corticosteroids (ICS):
Preferred long-term controller therapy for children and adults with persistent asthma and persistent asthma during pregnancy |
|
|
Term
|
Definition
Patient’s habits with regard to tobacco should be discussed. Also review possible causes of exacerbation (e.g., recent infection) and history of cough, sputum, and dyspnea (1).
Chronic bronchitis: Cough, sputum production, frequent infections, intermittent dyspnea, wheeze, hemoptysis, morning headache, pedal edema
Emphysema: Minimal cough, scant sputum, dyspnea, weight loss, occasional infections
Physical Exam
Rarely diagnostic for COPD (3)
Chronic bronchitis: Cyanosis, wheezing, weight gain, diminished breath sounds, distant heart sounds
Emphysema: Barrel chest, minimal wheezing, accessory muscles used, pursed lip breathing, cyanosis slight or absent, breath sounds diminished |
|
|
Term
|
Definition
Anticholinergics
Ipratropium (Atrovent), tiotropium
(Spiriva): 1 inhalation daily
AND/OR
Long-acting β-agonists:
Salmeterol (Serevent)
Smoking cessation: This is the most important intervention to decrease risk (3).
Mucolytic agents
Aggressive treatment of infections (3)[A]
Treat any reversible bronchospasm.
Home oxygen: May improve survival in hypoxemia and cor pulmonale, and should be initiated early in these conditions if oxygen <89% (8)[A]
Influenza and pneumococcal immunizations
Issues for Referral
Severe exacerbation, frequent hospitalizations, age <40, rapid progression, weight loss, severe disease, or surgical evaluation |
|
|
Term
Pneumonia
Signs and Symptoms |
|
Definition
Chills, headache, malaise, and myalgias
Dyspnea, cough (± purulent sputum production), and pleurisy
GI symptoms
Physical Exam
Vitals: Fever, tachypnea (often > 24 breaths/min), hypoxemia with severe disease
Pulmonary rales and rhonchi and/or friction rub
Enlarged regional lymph nodes |
|
|
Term
|
Definition
Outpatient for most patients; inpatient for infants < 4 months of age or older people or for any patient with diffuse, severe infection (e.g., hypoxemia, hypercarbia, hypotension or shock, ARDS) or significant comorbidity (CHF], [CAD], COPD)
Neuraminidase inhibitors: Influenza A and B:
For children 1–12 years of age: Oseltamivir given within 48 hours of onset can shorten duration of illness and reduce secondary complications (specifically, acute otitis media). Little evidence for prophylactic use For adults: Neuraminidase inhibitors are not recommended for routine use in seasonal influenza, except for life-threatening illness
Seasonal influenza A H1N1 is commonly resistant to oseltamivir. Zanamivir or a combination of oseltamivir and rimantadine or amantadine (e.g., for patients < 7 years old or patients with chronic underlying airways disease) is more appropriate than oseltamivir alone, unless local surveillance data indicate that the virus is likely to be influenza A H3N2 or influenza B (6).
Oseltamivir (Tamiflu): Patients > 12 years of age and adults: 75 mg p.o. q12h × 5 days. Dosage adjusted to 75 mg p.o. q24h in patients in whom the creatinine clearance rate is < 30 mL/min.
Zanamivir (Relenza): Patients > 7 years of age: 10 mg (2 inhalations) inhaled Acyclovir (Zovirax): Pulmonary infections with HSV, herpes zoster, or varicella virus:
Adults: caused by HSV and varicella virus
Ganciclovir (Cytovene): Infection with CMV or HSV:
Most healthy individuals will require only symptomatic treatment and supportive care.
Encourage coughing and deep breathing exercises to clear secretions.
Universal precautions
Respiratory isolation for varicella virus, which is highly contagious (i.e., negative pressure)
Antibiotics for superimposed bacterial infection |
|
|
Term
pulmonary embolism
Signs and Symptoms |
|
Definition
May be nonspecific and include symptoms such as acute unexplained dyspnea, hemoptysis (usually in infarction), pleuritic chest pain, anxiety, and apprehension
Physical Exam
Signs of DVT may or may not be present (Leg swelling or edema).
Tachypnea, focal wheeze
Hypoxia
Tachycardia (HR> 100 bpm)
Distended neck veins/large A wave
Heart: Increased P2 sound
Lungs: Clear, decreased breath sounds or egophony due to pleural effusion
Acute cor pulmonale (shock-systemic hypotension, syncope, cyanosis, right ventricular gallop, pleural friction rub, hemoptysis)
Homan sign (pain elicited with compression of the calf) not sensitive |
|
|
Term
Pulmonary Embolisim
Management |
|
Definition
Oxygen therapy as needed
Maintain cardiovascular and pulmonary function.
Issues for Referral
Recurrent thrombotic events
Failure of anticoagulation, active bleeding, intolerance anticoagulation may require IVC filter.
Catastrophic thrombotic event suggesting antiphospholipid antibody syndrome
Complications
Chronic thomboembolic pulmonary hypertension (CTEPH)
Recurrent DVT or PE, postphlebitic syndrome
Major hemorrhage associated with thrombolytics is 8%; incidence of intracerebral bleed is 2% and is fatal in 50% of cases.
HIT (8-20% mortality)
CURB-65: Confusion, uremia, respiratory, BP, age >65 |
|
|
Term
Lung Cancer
Signs and Symptoms |
|
Definition
May be asymptomatic for most of course
Pulmonary:
Cough (new or change in chronic cough)
Wheezing and stridor
Dyspnea
Hemoptysis
Pneumonitis (fever and productive cough)
Constitutional:
Bone pain (metastatic disease)
Fatigue
Weight loss, anorexia
Fever
Anemia
Clubbing of digits
Other presentations:
Chest pain (dull, pleuritic)
Shoulder/arm pain (Pancoast tumors)
Dysphagia
Plethora (redness of face or neck)
Hoarseness (involvement of recurrent laryngeal nerve)
Horner syndrome
Neurologic abnormalities (e.g., headaches, syncope, weakness, cognitive impairment)
Pericardial tamponade (pericardial invasion)
Physical Exam
General: pain, performance status, weight loss
HEENT: Horner syndrome, dysphonia, stridor, scleral icterus
Neck: Supraclavicular/cervical lymph nodes, mass
Lungs: Effusion, wheezing, airway obstruction, pleural effussion
Abdomen/groin: Hepatomegaly or lymphadenopathy
Extremities: signs of hypertrophic pulmonary osteoarthtopathy, DVT
Neurologic: rule out cognitive and focal motor defects |
|
|
Term
|
Definition
Lab
Initial Lab Tests
Complete blood count (CBC)
BUN, serum creatinine
Liver function tests (LFTs), LDH
Electryolytes
Hypercalcemia (Paraneoplastic syndrome)
Hyponatremia (SIADH)
Sputum cytology
Patient Monitoring
Depends on clinical history, but in general, postoperative visits every 3–6 months in the year after surgery with physical and CXR
Follow-up CT scans as indicated |
|
|
Term
Interstitial Lung Disease
Signs and Symptoms |
|
Definition
Symptoms may include progressive exertional dyspnea and nonproductive cough.
Patients may also present with hemoptysis (due to idiopathic alveolar hemosiderosis) or fatigue.
Obtaining a history of illness duration (acute vs chronic), potential environmental/occupational exposures, travel, and medical conditions (including systemic diseases) is important in assessing the cause of the ILD.
Some cases of lung disease may occur weeks to years after discontinuation of an offending agent.
Physical Exam
Physical findings are usually nonspecific. Some common features include:
Rales
Inspiratory “squeaks”
Clubbing of the digits
Cyanosis in advanced disease |
|
|
