COPD, Pneumonia, Asthma

What is the most common type of pneumonia?
pneumococcal

What type of patients get pneumoccoccal pneumonia?
HIV, splenectomy, sickle cell, alcoholics, asthmatic

What are the S&S of pneumococcal?
PRODUCTIVE COUGH, FEVER, pleuritic chest pain

What will you find of CXR with pneumococcal pneumonia?
consolidation mostly unilateral; +/- pleural effusions

How do you pneumococcal pneumonia for outpatient?
amoxicillin
if PCN allergy: macrolide/fluroquinolone

How do you treat pneumoncoccal pneumonia in patient?
IV therapy of PCN G, ceftriaxone

if PCN allergy or PCN resistant: vanco or levofloaxacin

In what setting do you always Gram stain?
hospital; almost never in office

What are the types of Gram – pneumonia?
H. flu; Klebsiella, E. coli, Pseudomonas

What type of patients gets H flu pneumonia?
smokers, COPD, following URTI

How do you treat H flu pneumonina?
amoxicillin/clavulante, cefotaxime
ceftriaxone
cefuroxime
Z pack
Bactrim

What type of patients get Klebsiella pneumonia?
alcohol abuse, DM, hospital

How do you treat Klebsiella pneumonia?
third gen cephalosporins

What type of patients usually get E. coli pneumonia?
hospital patients

How do you treat E coli. pneumonia?
3rd gen cephalosporins or Bactrim

What types of patients get Pseudomonas pneumonia?
CF, bronchiestasis, hospital acquired

What do you find on CXR with Pseudomonas pneumonia?
BILATERAL INFILTRATES

How do you treat Pseudomonas pneumonia?
antipseudomonal beta-lactam plus aminoglycoside
OR
ciprofloxacine plus aminoglycoside

Give some features of M. pneuma pneumonia?
hard to culture,usually cannot find in Gram stain (will only see inflammatory cells)
long incubatio period but can cause epidemics in camps
“atypical” presentaiton
insidious onset’

What are the S&S of M. pneumo pneumonia?
fever, malaise, HA, cough (insidious)
COUGH chest sore but not pleuritic pain, fevers/chills combo
NO ADENOPATHY

What is something confusing about M. pneumo pneumonia?
It will appear on PE nothing bad but the CXR will show tons of infiltrates

How do you determine if something is M. pneumo pneumonia?
PE and CXR—> treat

How do you treat M. pneumo pneumonia?
usually don’t-> no need to it is self limiting
however, if you do:
-macrolide and tetracycline (NO KIDS)
other drugs: fluoroquinolone

How do you treat S. aureus pneumonia?
MSSA–> nafcillin, oxacillin OR cephalosporin (cefazol)

MRSA –> vanco, linezolid

Who gets S. aureus pneumonia?
long term care resident, CF, IVDU, bronchiestasis

Who is affected by Legionairre’s disease?
immunocompromised, smokers, chronic lung disease

What are the S&S of Legionaire’s disease?
scant sputum, pleuritic chest pain, these people LOOK REALLY SICK, fever

What will you find of Gram stain of Legionaire’s
PMNs but not organism

What are the lab findings of Legionaire’s?
decreased Na, increase LFT, increased CK, proteinuria, pyuria, hematuria, leukocytosis, thrombocytopenia

What will you find on CXR for Legionaire’s?
in 1/3 patients:
– unilateral CXR infiltrates —> focal patchy infiltrates or consolidation
pleural effusion

How do you dx Legionaire’s disease?
urine antigen test

– others:
— sputum (takes a long time)
— serologic antibody test (need to seroconvert –> 3 months)

How do you treat Legionaire’s disease?
Z pack, clarithromcin, LEVOFLOXACIN, MOXIFLOXACIN

What are the classic things said about viral pneumonia?
starts with URTI and “moves to chest”

What types of viruses cause pneumonia most commonly?
influenza, RSV, adenovirus

What are the S&S of viral pneumonia?
just like bacterial

How do you treat viral pneumonia?
in influenza A or B —> ostelatomivir, zanamivir
if influenza A —> amantadine or rimantadine
—**MUST BE WITHIN 48 HOURS

if not –> supportive care only

When do you not admit for pneumonia?
younger (less than 65 y/o)
mild illness
no comorbidities that are significant (CVD, malignancy, immunocomprised)

What do you use to admit a patient?
CURB -65
– confusion
-uremia (BUN >19)
– respirations >30
– BP (<90 or <60) age 65 and older

How long is pneumonia therapy?
3 days usually get a big response
if IV can move to PO after this time
5 days minimum but depends on response
NO changing meds unless culture comes back or patient is getting worse

How long do you treat CAP patients?
5 days or until no fever X48-72 hours

How do you treat someone will CAP with the following conditions:
-healthy and has not taken abx for 3 months
oral macrolide (clarithromycin or azithromycin) or doxycycline
*treat empirically*

How do you treat someone will CAP with the following conditions:
-patient with comorbidity or use of abx in last 3 months
*must use different abx class*
*treat empirically*
oral fluroquinolone (moxifloxacin, gemifloxacin)
OR
oral macrolide ( Z pack etc) PLUS beta-lactam like –> augmentin/2 gen cephalosporin/amoxicillin

How do you treat someone will CAP with the following conditions:
patient is hospital
fluroquinolone (oral – moxi, gemifloxacin)
OR
fluroquinolone (IV) –> moxifloxacin, levo, cirpo)
OR
macrolide + beta lactam –> augmentin, ampicillin

How do you treat someone will CAP with the following conditions:
– patient in ICU
Z pack
OR
fluoroquinolone + anti-pneumococcal beta lactam (cefataxine, ceftrazone, ampicillin-sulbactam)

if at risk of Pseudomonas:
-anti-pnuemococcal, anti-pseudomonal beta lactal (piperacillin-taxobactam, cefepime, imupinem)
PLUS
ciprofloxacin or levofloxacin (fluoroquinolone)
OR

beta- lactam (above) PLUS amino glycoside
PLUS
Z pack or respiratory fluoroquinolone

If patient is at risk for MRSA what do you add to their drug therapy?
vanco or linezolid

What do you want to do in order to confirm aspiration pneumonia?
check for glucose in secretion, lipid laden macrophages

Aspiration pneumonia are usually what kind of infections?
polymicrobial
– Gram + aerobe in healthy people
– Gram – aerobe and Pseudomonas in hospitalized

How do you treat aspiration pneumonia in CAP admitted patients?
*treat empirically*
clindoamycin or ampicillin-tazobact

How do you treat aspiration pneumonia in seriously ill paitntes?
(intubated)**worryy about anaerobes or Pseudo)
pipericillin- tazobactam OR
tiacarcillin-calvulanate
OR
imiperum

What is HAP?
occurs when the patient has been there for 48 hours
-if occurs within the first 4 days —> good change it is drug susceptible
-if occurs after the first 4 days –> good chance it is MDR

What are the usual pathogens in HAP?
S. pneumo or H. flu

MRSA is common too

What the biggest cause of hospital infections?
aerobic Gram –
Pseudo, E coli, Klebsiella

What are the S&S of HAP?
new/worsening infiltrates and
FEVER, LEUKOCYTOSIS, PURULENT SPUTUM
– need 2/3 in order to be it

How do you treat HAP if low MRSA risk?
ceftriaxone (IV)
OR
Fluoroquinolones (genti, moxi, levo, cipro)
OR
ampicillin-sulbactam
OR
piperacillin-tazobactam
or
Ertapenem

How do you treat HAP if high MRSA risk?
need multiple drugs:
anti-psuedomonal agent or beta-lactam/beta-lactamase inhibitor
PLUS
antipseudomal fluoroquinolone or aminoglycoside
PLUS
vancomycin or lindezolid

Describe a pink puffer
-dyspnea
-age >50
-rare cough
-thin
-normal Hbg
-+/- decreased PaO2
-hyperinflation

Describe a blue bloater
-productive cough
-late 30s/40s
-mild dyspnea (with exercise?)
overweight
cyanotic
NOISY CHEST (wheezes, rhonchi)
increase Hbg

How do you treat COPD?
-O2! only thing that can revere hypoxemia
-STOP SMOKING
-b2 agonist
—> only symptomatic relief though
-theophylline
—> phosphodiesterase inhibitor
-Pulm rehab
-hydration
-cough training
-Abx:
—> for exacerbations, for prophylactix
———> doxycycline, Bactrim, cefproxil, cefpodoxine, Z pack, augmentin, cipro
– Sx
—-> lung volume decrease, lung transplant, bullectomy

What predicts the 5 year survival of COPD?
FEV1

What is a major risk factor for asthma?
obesity, allergies

What is confirmatory of asthma?
strong response when doing the bronchodilator response study

What is another test to do if the bronchodilator response test is negative?
bronchial provocation test (where you give histamine)
a 20% reduction in FEV is positive for asthma

What are the 4 components of dx according to the NAEPP?
1. Assess and monitor asthma severity and control
2. patient education
3. control environmental factors and comorbidities
4. pharmocologic control

What does it mean by asthma severity and control?
Asthma severity:
– via physicial examination (PFT, FEV etc)

Asthma control:
– impairment
-risk of exacerbation

What are quick reliever drugs?
– direct relaxation of smooth muscle promoting increased breath
–> RELIEVERS

What are long term drugs?
—> CONTROLLERS
alternative airflow/airway inflammation
take daily

What does the NAEPP suggest about asthma therapy?
Daily anti-inflammatory drugs with ICS is key to treat persistent asthma

Name the long term drug therapy for asthma
ICS, mediator inhibitors, beta 2 agonists, anticholinergics, phosphodiesterase inhibitors, leukotriene inhibitors, omalizumab, vaccines, immunotherapy

What do long term corticosteroids do?
reduce long term and acute inflammation

When do you use oral corticosteroids?
with exacerbation

When do you use mediator inhibitors
mild medium asthma

FOR LONG TERM THERAPY ONLY – DO NOT USE FOR EXACERBATIONS
use only before never after

What does mediator inhibitors do?
modulate mast cell mediated release and eosinophil recruitment

Give some examples of mediator inhibitors?
cromolym and nedocromil and iprantium

LABA Should never be used as…? Why?
long term mono therapy

no anti-inflammatory capabilities

When do you use anticholinergics?
With corticosteroids when not controlled

What is an example of an anticholinergic?
tiotropium

Give an example of a phosphodiesterase inhbiit
theophylline

What is the downside of theophylline?
lots of side effects

When do you use phosphodiesterase inhibitors?
with nocturnal symptoms or add on with severe asthma that is not controlled

Give some examples of leukotriene modifier
montelukast, zileuton, zafirlukast

What does leukotriene modifiers do?
prevent smooth muscle contraction

What does Omalizumab do?
binds IgE without activating the mast cell

-used for those mostly who have concurrent allergies (over 12 only)

name some quick action meds
beta agonist
anticholinergic
Corticosteroids

What is the cornerstone to quick action medication
use of SABA

What are anticholinergics not good for in the short term?
not good for allergy or exercise induced asthma

What do anti-cholinergics do?
prevents bronchospasms

Are anti-cholinergics usually mono therapy or combination
combination with beta blockers

What are NOT good for short term use?
phosphodiesterase inhibitors

What do you give for a mild exacerbation that the PEF is greater than 80%
beta 2 agonist alone
+/- inhaler steroid/ oral steroid

What do you give for moderate exacerbation?
need to reverse hypoxemia and reverse obstruction, decrease recurrence of exacerbation

correct hypoxemia with oxygen
beta 2 agonist and oral steroids — EARLY

What do you give for severe exacerbation?
oxygen oxygen oxygen (to prevent asphyxia the most common cause of death in asthma patients)

discharge when peak flow >60% predicted

check for dehydration

When is someone in the green zone of their action plan?
breathing is good
no cough or wheeze
can work and play
sleeps well at night

peak flow is over 80% best

When is someone in the yellow zone of their action plan?
some problems breathing
cough, wheeze or chest tight
problems working or playing
wake at night

peak flow between 50-80%

using quick relief >2 X per week call dr

When is someone in the red zone of their action plan?
lots of problems breathing
cannot work or play
getting worse instead of better
medicine is not helping

peak flow is less than 50%

What do you do, according to the action plan, if someone is in yellow?
continue controlled medication and add more meds; check at 1 hour (using peak flow and symptoms)

What do you do, according to the action plan, if someone is in red?
call ambulance if cannot get out of the red zone in 15 minutes
if troubles walking due to SOB or lips and fingers turn blue

Asthma control test of less than 19
means the asthma is not under control

What is a well controlled asthma patient appear like?
– <2 days/week symptoms - <2 times/ month night time awakening - no interference with normal activity - 80% peak flow
– 0-1 exacerbations per year

What is a not well controlled asthma patient appear like?
– < 2 days/week symptoms - 1-3 times/ week night time awakening -some interference with normal activity - > 2 days/ week use of SAB
– 60-80% peak flow
– >2 exacerbations per year

What is a very poorly controlled asthma patient appear like?
– throughout the day symptoms
– >4 times/ week night time awakening
– extreme interference with normal activity
– several times per day use of SAB
– <60% peak flow - >2 exacerbations per year

What is step 1 (intermitted asthma) in all patients?
SABA prn

What is step 2 drug in 12 and older (asthma)?
low dose ICS

afternative:
cromolyn, leukotriene, nedocromil, theophylline

What is step 2 drug in 5-11 (asthma)?
low dose ICS

afternative:
cromolyn, leukotriene, nedocromil, theophylline

What is step 2 drug in 0-4 (asthma)?
low dose ICS

afternative:
cromolyn, montelukast

What is step 3 drug in 0-4 (asthma)?
medium dose ICS

What is step 4 drug in 0-4 (asthma)?
medium dose ICS + eitehr LABA or montelukast

What is step 5 drug in 0-4 (asthma)?
high dosed ICS + either LABA or montelukast

What is step 6 drug in 0-4 (asthma)?
high dose ICS +either LABA or montelukast

systemic corticosteroids

What is step 3 drug in 5-11 (asthma)?
EITHER:
low dose ICS+ either LABA, LTRA or theophylline

OR

medium dose ICS

What is step 4 drug in 5-11 (asthma)?
medium dose ICS+ LABA

alternatives:
medium dose ICS + eitehr LTRA or
theophylline

What is step 5 drug in 5-11 (asthma)?
high dose ICS + LABA

alternative
high dose ICS +either LTRA or theophylline

What is step 6 drug in 5-11 (asthma)?
high dose ICS + LABA + oral steroids

alternative
high dose ICS +either LTRA or theophylline + oral steroids

What is step 3 drug in >12(asthma)?
low dose ICS+ LABA

Alternative:
medium dose ICS + either LTRA, theophylline or zileuton

What is step 4 drug in >12 (asthma)?
medium dose ICS+ LABA

alternatives:
medium dose ICS + eitehr LTRA or theophylline or zileuton

What is step 5 drug in >12 (asthma)?
high dose ICS + LABA

AND consider:
omalzumab for allergy patients

What is step 6 drug in >12 (asthma)?
high dose ICS + LABA + oral steroids

AND
consider omalizumab for patients who have allergies

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