PULSUS PARADOXUS
DROP IN SBP GREATER THAN 10 MMHG DURING INSPIRATION
OCCURS IN SEVERE ASTHMA
CARDIAC TAMPONADE, CONSTRICTIVE PERICARDITIS
RIGHT VENTRICLE MI
RESTRICTIVE CARDIOMYOPATHY
SPUTUM
DIFF DIAGNOSIS
HEMOPTYSIS -TB PE CA
YELLOW GREEN , PURULENT -BRONCHITIS
RUST-PNEUMOCOCCAL PNA
PINK FROTHY -PE
FETID PURULENT-ANAEROBIC INFECTION
MUCOPURULENT -BACTERIAL PNA
FOAM, SEROUS, MUCOPURULENT-BRONCHIECTASIS
CHRONIC COUGH
CA
GERD
ASTHMA
TB
ILD
CONGENITAL HEART DISEASE
ACE. BB.AMIODARONE
HF
DYSPNEA
DIFF DIAGNOSES
PNA
COPD
PULMONARY HTN
CYSTIC FIBROSIS
ANEMIA
OBESITY
DYSPNEA AND COUGH
DIAGNOSTICS
CBC
ABGS
A1AD
PO2 <92% CHECK ABGS
CXR
SPIROMETRY-GOLD STANDARD
FEV1
FVC
?BNP IF HF
PPD-IF TB
ETIOLOGY RISK FACTORS
COPD UMBRELLA TERM FOR BRONCHITIS
BRONCHIOLITIS
EMPHYSEMA
NEW IS ASTHMA- COPD OVERLAP SYNDROME (ACOS)
RISK :
AGE
TOBACCO SMOKING, TOXIC PARTICLES
WOOD BURNING + BIOMASS FUELS
SIGNIFICANT ECONOMIC BURDEN
AIAD GENETIC -LIVER AND LUNG LIVER STORES CANNOT RELEASE AIA,
INFECTION NEUTROPHIL ELASTASE DAMAGES LUNG TISSUE, AIA SHOULD BE RELEASED FROM LIVER WHEN >NEUTROPHILS TO PROTECT LUNGS. CIRRHOSIS 2/2 AIA BUILD UP IN LIVER
WOMEN > MEN- MAY BE OUTDATED INFO
COPD AND SECONDHAND SMOKE, FIRST HAND SMOKE
SPUTUM PRODUCTION
EXPOSURE TO SMOKE
DOE OR AT REST
CLINICAL PRESENTATION
WHEEZING ON FORCED EXPIRATION
**INCREASED RESONANCE ON PERCUSSION
**DIMINISHED BREATH SOUNDS
**CRACKLES BASES,
CHEST TIGHTNESS
FATIGUE,
COUGH -PROD OR NON PROD
BARREL CHEST
TRIPOD POSITION
ACCESSORY MUSCLES
DIMISHED BREATH SOUNDS
CLUBBING ***OF FINGERS
PURSEDLIP BREATHING
copd
emphysema
bronchitis
BRONCHITIS- INFLAMMATION OF BRONCHIAL WALL CELLS, HYPERPLASIA MUCOUS GLANDS
NARROWING SMALL AIRWAYS
EMPHYSEMA-PERMANENT
ABNORMAL ENLARGEMENT OF AIR SPACES DISTAL TO TERMINAL BRONCHIOLES,ALVEOLI WALL DESTRUCTION- MERGE TOGETHER
HYPERCAPNIA MORE COMMON IN EMPHYSEMA
ASTHMA CAN GO ON TO BE OBSTRUCTIVE( REMODELING)
CALLED ASTHMA-COPD OVERLAP SYNDROME ACOS
DIAGNOSTIC CRITERIA
SPIROMETRY:NOT FULLY REVERSIBLE AIRFLOW LIMITATION (***FEV1/FVC<0.7
POST BRONCHODILATION- GOLD STANDARD TEST
SOME DONT HAVE THIS -HAVE FEV1 DECLINE BUT FEV1/FVC RATIO >0.7
PFTS
USE OF TOOLS
CATQ
MMRQ
TESTS
CXR, 6 MINUTE WALK, CBC,BNP, EKG, PPD ,PO2<92% ABG
A1ATD TEST
CT SCAN NOT DIAGNOSTIC
ABGS NOT SPECIFIC TO COPD
GOLD CRITERIA 2020
The gold standard for diagnosis of COPD is post-bronchodilator spirometry.
Classification of Severity In patients with FEV1/FVC <0.70
GOLD 1: Mild
FEV1 ≥80% predicted
GOLD 2: Moderate
50% ≤ FEV1 <80% predicted
GOLD 3: Severe
30% ≤ FEV1 <50% predicted
GOLD 4: Very Severe
FEV1 <30% predicted
GOLD Guidelines 2020
BNP IF HF
PPD IF TB
PO2 <92 % ABG
SPIROMETRY
EKG -CAD
ALPHA 1 ANTITRYPSIN ( AATD)
FEV1/FVC<0.70 =DIAGNOSIS
COPD GOLD STANDARD EASY
ALL ARE FVC/FEV1 RATIO <0.7
NORMAL IS 0.7-0.8 ( 70-80 %)
GOLD 1 MILD >80%
GOLD 2 MOD 50-79
GOLD 3 SEVERE 30-49
GOLD 4 VERY SEVERE <30
COPD TREATMENT
PHARM CLASSES BETA AGONISTS MADE FROM EPINEPHRINE, BETA 2 RECEPTORS ON BRONCHIAL SMOOTH MUSCLE w LESS TACHYCARDIA
SABA
B-EROLS
BRONCHODILATORS -SHORT ACTING BETA AGONISTS “B-EROLS”
SABA NOT RECOMMENDED REGULAR
INCREASE cAMP + ANTAGONISE BRONCHOCONSTRICTION.>FEV1
SABA AND LABA* S/E >HR, <K+, > O2 CONSUMPTION HF PATIENTS
*LAST 4-6 HOURS
*LEVALBUTEROL
*SALBUTAMOL(ALBUTEROL)
TERBUTALINE bricanyl
FENOTEROL
INH,NEB, ORAL FORMS
GOLD 2020
LABA M-EROLS
LABA “M-EROLS” LAST *12 HOURS OR MORE,CAN HAVE PRN SABA TOO
FORMOTEROL BID PERFOROMIST
INDACATEROL-DAILY ARCAPTA NEB
SALMATEROL-BID SEREVENT DISKUS*
OLODATEROL- DAILY STRIVERDI RESPIMAT MDA
ARFORMOTEROL- BROVANA NEB
( ANTICHOLINERGICS/) ANTIMUSCARINIC ANTAGONISTS
SAMA AND LAMA “IUMS” AND GLYCOPYRRALATE
LOOK AT NEW GUIDELINE FLASHCARD GOLD 2023
BLOCK ACETYLCHOLINE BRONCHOCONSTRICTION SMOOTH MUSCLE M3 RECEPTORS, AND M2 ( SAMA)
BROMIDES MEASURED DOSE INHALERS LAST 6-9 HOURS
SAMA
*IPRATROPIUM BROMIDE
OXITROPIUM BROMIDE
LAMA “IUMS”
ACLIDINUM BROMIDE TUDORZA PRESSAIR DPI
GLYCOPYRROLATE SEEBRI CAP
*TIOTROPIUM SPIRIVA
UMECLIDINIUM INCRUSE ELLIPTA GLAUCOMA
COPD COMBINATIONS
SAMA + SABA
LAMA + LABA
ICS + LABA
PG TO KNOW
IPRATROPIUM /ALBUTEROL+ DUONEB
TIOTROPIUM-OLDATEROL STIOLTO*
INDACATEROL-GLYCOPYRROLATE UTIBRON
GLYCOPYRROLATE/FORMETEROL BEVESPI
BUDESONIDE + FORMOTEROL SYMBICORT
FLUTICASONE + SALMETEROL ADVAIR DISKUS
VILANTEROL + FLUTICASONE BREO ELLIPTA DPI
LABA + ICS + LAMA = TRELEGY
PDE4 INHIBITOR
CCS ORAL
ACOS +LABA + ICS
THEOPHYLLINE-S/E++
PDE 4 ROFLUMILAST/DALIRESP S/E++
PREDNISONE (40 MG X 5 DAYS APEA 2019)
METHYLPREDNISONE
GOLD - DO NOT SUPPORT LONG TERM MAINTENANCE OCS ADVERSE EVENTS AND DEPENDENCY
PTS WITH ACOS BENEFIT FROM LABA + ICS
ADVAIR SYMBICORT BREO ELLIPTA
NO LEUKOTRIENE MODIFIERS IN COPD NO EFFICACY
COPD NEW MGT GUIDELINES
INITIAL* TREATMENT
GROUP A 0 OR 1 MOD EXCACERBATIONS
MMRC 0-1 CAT<10= 0-1
BRONCHODILATORS
ARE:
BETA AGONISTS
ANTICHOLINERGICS
THEOPHYLLINE
GROUP B MMRC>2 , CAT >10
LABA + LAMA
GROUP E LABA + LAMA
CONSIDER ICS IF EOS >300
GROUP E 2 OR MORE MOD EXCACERBATIONS OR > 1-> HOSPITALIZATION
GOLD SEVERITY INDEX COPD
EXCACERBATION MGT
SABA WITH OR WITHOUT SAMA
INITIATE MAINTENANCE THERAPY WITH LABA ASAP
ADD ICS IF FREQUENT EXCACERBATIONS +>EOS LEVELS
SEVERE :
OCS FOR 5 DAYS
ABX :
COMORBIDITIES
QUINOLONE
GOLD 2023
COPD NON PHARM
Pulmonary rehabilitation is indicated for all patients to decrease symptoms and improve functional status
Self-management education
Cardiovascular exercise
Regular assessment of inhaler technique
Adequate nutrition
SMOKING CESSATION
NO TUSSINS
ANNUAL FLU
PNEUMOCOCCAL VACCINE 19 AND UP
OXYGEN IF SAO2<88% OR AT 88% WITH POLCYTHEMIA, HF
POLYCYTHEMIA IS HEMATOCRIT >55%
COPD RED FLAGS
COR PULMONALE
FEVER
REFERRALS
RIGHT SIDED HEART FAILURE 2/2 BACK UP PULMONARY ARTERY CONGESTION
FIRST SIGN IS EDEMA
LAST SIGN IS PULMONARY CONGESTION (FLASH PULMONARY EDEMA)
FLUID IN RIGHT ATRIUM GETS BACKED UP
REFER TO
PULMONOLOGIST
PALLIATIVE CARE
PULMONARY REHAB
URI
RISK FACTORS ETIOLOGY
ADULTS 2-3 X YEAR, SELF LIMITING
>200 COMMON COLD VIRUSES
RISK FACTORS
POOR HAND WASHING
AIRWAY NASAL DAMAGE
CHILDREN GROUPS /CROWDED PLACES
AUTOIMMUNE DISORDER
ADENOID /TONSILLECTOMY ( PART OF IMMUNE SYSTEM
SMOKING
SINUSITIS
ALLERGIC RHINITIS
BRONCHITIS
FLU
TREATMENT
ANTIHISTAMINES AMINES
BROMPHENIRAMINE DIMETAPP
CHLORPHENIRAMINE chlor-trimeton
BENADRYL -DIPHENHYDRAMINE
PAIN RELIEVERS
TYLENOL
ADVIL
DECONGESTANT FRINS
OXYMETAZOLINE -AFRIN- REBOUND CONGESTION >3 DAYS
(PHENYLEPHRINE - SUDAFED PE USELESS)
PSEUDOEPHEDRINE SUDAFED
ETIOLOGY
W>MEN. 1 IN 13 PEOPLE IN US
EPISODIC BUT PERMANENT
ALL ABOUT AIRWAY INFLAMMATION AND IT’S SEQUELAE:
NARROWING AND INCREASED MUCUS PROD, SMOOTH MUSCLE CONTRACTION OF AIRWAYS
VARIOUS STIMULI, VIRAL, COLD ALLERGANS EXERCISE
MOST COMMON RESPIRATORY DISORDER AMONG ALL AGE GROUPS
WOMEN ASTHMA DEATH RATE >MEN
TH1 (GOOD FIGHTS INFECTION) AND TH2 (BAD -OVEREACTS) INVOLVED. HYGIENE THEORY BASED ON HI PREVALENCE IN KIDS
GENETIC: *IGE MEDIATED HYPERSENSITIVITY
ASTHMA DEFINED
AIRWAY INFLAMMATION
REVERSIBLE OBSTRUCTION
CHRONIC INFLAMMATION CAUSES AIRWAY REMODELING +
IRREVERSIBLE DETERIORATION OF AIRWAY FUNCTION
RESPONSE TO EXPOSURE CAN RANGE FROM SEVERAL HOURS TO 12 HOURS
ASPIRIN INDUCED ASTHMA IS A THING, NSAIDS ALSO ( *PROSTAGLANDIN INHIBITORS) COX 2 INHIBITORS FINE
GINA 2020
ASTHMA MEASURES AND DIAGNOSTIC TESTING
PHENOTYPES
DIAGNOSTIC HALLMARK OF ASTHMA IS REVERSAL OF OBSTRUCTION AFTER GIVING A BRONCHODILATOR
N NON ALLERGIC PANGRANULOCYTOSIS
A ALLERGIC -ECZEMA, CHILD USE ICS EOS
A ADULT ONSET W>MEN REFRACTORY TO CCSTEROIDS
A ASTHMA W OBESITY REVERSIBLE NO INFLAMM
A ASTHMA W PERSISTENT AIRFLOW LIMITATION-AIRWAY REMODELING
NAAAA
AASTHMA
ATOPY- EXAGERRATED RESPONSE TO ALLERGENS
FAMILY HISTORY-PARENT
EXCACERBATION
ALLERGEN
POOR AIR QUALITY
EXERCISE
COLDNESS
URBAN
ASTHMA SYMPTOMS
*WHEEZE
*HYPERRESONANCE ON PERCUSSION
ACCESSORY MUSCLE USE
PROLONGED EXPIRATION
*CHEST TIGHTNESS
*SOB
*COUGH
REVERSED BY BRONCHODILATOR
YELLOW MUCUS ( EOSONOPHIL PEROXIDASE)
FEV1 REDUCED
FEV1/FVC RATIO <
NOCTURNAL DYPSNEA
AWAKENING DYSPNEA
ACUTE RESP INFECTION
ASPIRATION
CHF
PE
MED INDUCED COUGH ASPIRIN INDUCED ASTHMA IS A THING, NSAIDS ALSO ( PROSTAGLANDIN INHIBITORS) COX 2 INHIBITORS FINE
DIAGNOSTIC TESTING
4 MAIN
PULMONARY FUNCTION TEST
PEAK FLOW MONITORING ( EXPIRATORY FLOW RATE)
FE NO TEST
PROVOCATION TEST-TREADMILL
CT? CHEST
METHACHOLINE CHALLENGE TEST (PULMON)
PEAK FLOW TESTING
MEASURES EXPIRATORY FLOW,
VERY SENSITIVE TO CHANGES IN RESPIRATORY TUBULES , REFLECTS INFLAMMATION
USEFUL FOR ASTHMA
NOT USEFUL FOR COPD OR PNA
ASTHMA SEVERITY SCALE
DAYS WEEK
NIGHTS A MONTH
ASTHMA SEVERITY
A.MILD INTERMITTENT
B. MILD PERSISTENT
C. MODERATE PERSISTENT
D.SEVERE PERSISTENT
A . 2 OR LESS DAYS A WEEK
2 OR LESS NIGHTS A MONTH
B. 2 OR MORE D/W BUT NOT DAILY. <2 N/M
C. DAILY. >3-4N/M
D. CONTINUAL. FREQUENT N/M
ASTHMA ACTION PLAN
PART ONE SHOWN ONLY, THERE IS ANOTHER PART
SIGNED WITH PCP
ASSTHMA TRACK ONE AND TWO
TRACK ONE PREFERRED
FIRST ASSESS ,CONFIRM DX, COMORBIDITIES, INHALER TECHNIQUE,PT GOALS
STEP1-2 SX <4-5 DAYS A WEEK
MAINTN: LOW DOSE ICS -FORMOTEROL PRN ? DULERA
STEP 3 SX MOST DAYS, WAKING W AST 1 XWEEK OR MORE
MAINT: MEDIUM DOSE ICS FORMOTEROL + PRN LO DOSE ICS-FOR
STEP 4 SX DAILY + WAKE IX WEEK OR >LO LUNG FUNCTION
MAIN SAME AS STEP 3 BUT MAY ADD OCS SHORT COURSE
IF UNCONTROLLED STEP 5: ADD ON LAMA
REFER PHENOTYPIC ASSESSMENT + BIOLOGIC THERAPY,
CONSIDER HI DOSE ICS-FORMOTEROL IS *PERFOROMIST - LABA
ICS AND LABA
ASTHMA TRACK 2 ALTERNATIVE
SAME ASSESS
STEP 1 SX < 2 X MONTH
MAINT: TAKE ICS WITH SABA PRN ONLY
STEP 2 SX 2 X MONTH OR MORE BUT < 4-5 DAYS A WEEK
MAINT: LO DOSE ICS + PRN ICS -SABA OR SABA
STEP 3 SX MOST DAYS + WAKING 1X WEEK OR MORE
MAIN:LO DOSE ICS - LABA + PRN SABA OR ICS- SABA
STEP 4 SX DAILY + WAKING 1X WEEK + LOW LUNG FUNCTION
,MAIN: MED/HI DOSE ICS- LABA ,MAY NEED OCS SHORT DOSE
STEP 5 : ADD ON LAMA ,PHENOTYPE + BIOLOGIC REFER
CONSIDER HI DOSE ICS -LABA
ASTHMA NON PHARM
SMOKING CESSATION ( 1 IN 4 ASTHMATICS SMOKE)
AVOID TRIGGERS
PEAK FLOW MONITORING AND JOURNAL
ACTION PLAN
WEIGHT MGT,
CORECT INHALER TECHNIQUE
EXERCISE PLAN
CONTROL HEARTBURN
FOLLOW UP
AND REFERRAL
ALLERGIST
RD
MSW
FOLLOW UP 4-6 WEEKS OR SOONER IF NOT IMPROVING
ASTHMA GERIATRIC CONSIDERATIONS
LUNG CHANGES
BETA BLOCKER
MED COST
LUNG CANCER
WORLD WIDE LEADING CAUSE OF DEATH RELATED TO CANCER
SURVIVAL RATE ALL STAGES 15% AT 5 YEARS
HIGHEST IN BLACKS AND WHITES
EARLY DIAGNOSIS 50% SURVIVAL RATE
90% SMOKING
10
SYMPTOMS
CHANGE IN COUGH ( SMOKERS) WARRANTS CXR OR CT SCAN
HOARSE THROAT
CHEST PAIN
URIS
PLEURAL/PERICARDIAL EFFUSION
LUNG CA
KNOW THIS
USPSTF GUIDELINES FOR CA SCREENING
AGED 55-80
30 PACK YEAR HISTORY
CURRENT SMOKER OR QUIT IN LAST 15 YEARS
ANNUAL
LDCT- LO DOSE COMPUTED TOMOGRAPHY
DC ANNUAL SCREENING IF QUIT>15 YEARS OR HEALTH PROBLEM THAT < LIFE EXPECTANCY OR ABILITY/WILLING FOR SX
DIFF DX
CARDIAC -CHF CARDIOMYOPATHY
INFECTION-PNA, URI
IPF
METASTATIC CANCER
SARCOIDOSIS
MESOTHELIOMA
CRACKLES THROUGHOUT ON INSPIRATION
DULLNESS WITH DECREASED FREMITUS DUE TO PLEURAL THICKENING
CONSOLIDATION-PECTORILOQUY
LOW GRADE FEVER 14-21 DAYS
PLEURITIC CHEST PAIN
NIGHT SWEATS
RETROSTERNAL AND DULL INTERSCAPULAR PAIN
REACTIVATION TB
LATENT TB IF HEALTHY 5-10% RISK OF REACTIVATION
HIV, OTHER CONDITIONS MUCH> RISK OF REACT
DIURNAL FEVER- ABSENT IN AM, PROGRESSES THRU DAY
COUGH GETS WORSE, HEMOPTYSIS, CAN OCCUR EXTRA LUNG
JOINTS BONE, LYMPH CNS
PAINFUL ULCERS IN MOUTH
ANOREXIA
TB DIAGNOSTIC S
TST TUBERCULIN SKIN TEST READ AT 48-72 HOURS
>=5MM IN HIV OR RECENT CLOSE CONTACT, IMMUNOSUPP-15 mg/month, TRANSPLANT
>=10 MM HEALTH CARE WORKERS DRUG USERS
>= 15 MM NO RISK PERSON
2 TESTS 1-3 WEEKS APART
TST IN HEALTH CARE SETTING,
2ND test INCREASE >=5MM IF BASELINE 0MM IF KNOWN EXPOSURE
INDURATION NOT REDNESS
3 CULTURES AFB SPUTUM -FLASE NEGATIVES
POSITIVE SMEAR NOT DIAGNOSTIC MAY BE MYCOBACTERIUM NOT TUBERCULOSIS
TB CLASSIFICATION SYSTEM
CT CHEST
SPUTUM CYTOLOGY
CBC CHEM
REFER TO PULMONOLOGY WHO WILL BIOPSY FOR ONCOLOGY
LATENT TB
EXPOSURE , TB INFECTION, NO DISEASE
POSITIVE TST
T SPOT AND QUANTIFERON GOLD POSITIVE
CXR NO FINDINGS
LFTS BASELINE FOR THERAPY
NO SYMPTOMS
NOT CONTAGIOUS
DRUGS
INH RIFAMPIN
DOT COMPLIANCE, MSW HOMECARE
LABS -MEDS METABOLIZED IN LIVER
MALNOURISHED PREGNANT, GIVE PYRIDOXINE ( VIT B6) AS INH INHIBITS SYNTHESIS OF B6
ELDERLY -PRESENT WITH DYSPNEA FATIGUE, NOT FEVER NIGHT SWEATS
REFER TO TB CLINIC,ID
ACUTE BRONCHITIS
DIAGNOSIS OF CLINICAL PRESENTATION ONLY PERSISTENT COUGH 1-3 WEEKS
INFLAMMATION OF TRACHEA AND LARGE AIRWAYS,
NOT IN LUNGS LIKE PNA
SELF LIMITING
LARGE CAUSE OF MD VISIT-10% AMBULATORY CARE IN US
FALL AND WINTER
MOST COMMON CAUSE VIRAL -USU SUSPECTS
(RHINOVIRUS, ENTEROVIRUS, INFL A & B, PARA , CORONAVIRUS, RSV, HUMAN METAPNEUMOVIRUS - RESPIRATORY VIRAL PANEL BY PCR-polymerase chain reaction MOLECULAR TEST LIKE NAATS )
BACTERIA RARE
MYCOPLASMA PNEUMONIAE , BORDATELLA PERTUSSIS
AIR POLLUTANTS
INFANTS
ELDERLY
IMMUNOCOMPRISED
ALLERGIES
SMOKING/SEONDARY
ASSESSMENT FINDINGS
COUGH, DAY 3 ON W OR W/O SPUTUM APPEARS AFTER 3 DAYS
PHARYNGITIS DAY 1-3
NASAL DISCHARGE DAY 1-3
SPUTUM MAY BE PURULENT - NOT SIGN OF INECTION- EPITHELIAL SHEDDING
PERSISTENT COUGH AVERAGE 18 DAYS
COUGH DOMINANT , MAY HAVE WHEEZING AND MILD DYSPNEA
1/3 HAVE FEVER INITIAL FEW DAYS
BURNING IN CHEST, RIB PAIN FROM COUGH
CLEARS WHEEZE OR RHONCHI WITH COUGH
CAN DEVELOP PNA, BACTERIAL SUPERINFECTION
SMOKERS /COPD/BACTERIAL INFECTION > RISK FEVER
PERTUSSIS HAVE WHOOP PAROXYSMAL COUGH
HEART FAILURE
PERTUSSIS -USUALLY FOLLOWED BY WHOOP, POST COUGH EMESIS, OUTBREAK AREA
URI FLU
BRONCHIECTASIS
PNA - FEVER RALES DULL PERCUSSION, AMS
ACUTE BRONCHITID
S
DIAGNOSTIC TESTS
BASED ON H&P
R/O PNA, FLU, TB
RESPIRATORY PCR PANEL
PPD
DONT USUALLY DO THIS BUT IF SUSPECT BACTERIA
PROCALCITONIN
CRP
WHEN TO GET CXR
DYSPNEA ,
BLOODY /RUST COLOR SPUTUM
HR >100BPM
RR >24,
>TACTILE FREMITUS, EGOPHONY OR FOCAL CONSOLIDATION
NON PHARM
REST
FLUIDS
HONEY
HOT TEA
LOZENGES
HUMIDIFIER
NASAL SPRAY SALINE
PHARM
SYMPTOM MGT
COUGH SUPPRESSANT
DEXTROMORPHAN/GUAIFENESIN 10 MLq4-ROBITUSSIN
DELSYM 10 ML BID-NIGHTTIME HAS TYLENOL
ANTITUSSIVE
BENZOANATE TESSALON 100-200TID PRN CALM THE COUGH REFLEX
EXPECTORANT
GUAIFENESIN 200-400 PO Q 4 -MUCINEX
TYLENOL 650 Q 4-6
IF ALLERGY RELATED -1ST GENERATION ANTIHISTAMINE-BENADRYL
NO ABX, 90% VIRAL
ABX IF ETIOLOGY IS PERTUSSIS
EDUCATION
red flgs
WHY NO ABX, LASTS 3-4 WEEKS -REALISTIC EXPECTATION
BE UTD WITH VACCINES,
HAND WASHING
STOP SMOKING
RED FLAGS
WORSE DYPSNEA
COUGH> 4 WEEKS(3)
acute bronchitis
geriatric considerations
R/O PNA IMPORTANT
IF CO MORBIDITIES PRESENT MAY BE MORE THAN SYMPTOM MGT
PATHOGENS
STREP PNEUMONIAE MOST COMMON IN CAP
STREP PNEUMONIAE is PNEUMOCOCCAL PNEUMONIA
GROUP A STREPTOCOCCUS CAN CAUSE FULMINANT PNA EVEN IN IMMUNOCOMPETENT PTS
MYCOPLASMA PNEUMONIAE IS MOST COMMON ATYPICAL PNA
STAPHYLOCOCCUS PNA IS MORE COMMON POST FLU V. YOUNG AND OLD
PNA AND SPUTUM
STREP/PNEUMOCOCCAL = RUST COLORED SPUTUM
MYCOPLASMA PNA- CLEAR SPUTUM ATYPICAL
CLAMYDOPHILA PNA-CLEAR SPUTUM ATYPICAL
THICK DISCOLORED SPUTUM = BACTERIAL PNA??
COUGH
INFILTRATES
SPUTUM PRODUCTION SOMETIMES
CAP PNA
2019 ATS/IDSA GUIDELINES
AMOXICILLIN 1 GM TID 10 DAYS . WITHOUT COMORBIDITIES ( EXCLUDES SMOKING)
AUGMENTIN IF CO MORBIDITIES
STREP PNA IS USUALLY A PATHOGEN . AMOXIL IS NARROW
MYCOPLASMA PNA
OTHER NAME
POPULATION
MOST COMMON ATYPICAL PNA,
WALKING PNA
YOUNG ADULTS
DX
RESPIRATORY TUBULES PERMANENTLY ENLARGED
CHRONIC PRODUCTION OF PURULENT MUCUS
5 AS
PULMONARY EMBOLUS
OC
RECENT SURGERY
RECENT TRAUMA
RECENT TRAVEL
IRREGULAR HEARTBEAT
SOB
TACHYCARDIA
PINK FROTHY SPUTUM
EKG ABNORMALITIES
LOW O2 SAT
PUL EMBOLI
MEDIASTINITIS
HYPERVENTILATION
PLEURITIS
SALICYLATE INTOXICATION
LUNG TRAUMA
MUSCULOSKELETAL PAIN
VENOUS DOPPLER -SOURCE
ECG
LABS:
PT/PTT/INR
D-DIMER
CHEM_ RENAL FAILURE
PULONARY EMBOLUS
ANTICOAGULATION
REF TO CARDIOLOGIST - ATRIAL FIB
REF TO HEMATOLOGIST- CLOTTING DISORDERS
EKG CHANGES IN PULMONARY EMBOLUS
S1Q3T3
LMWH: LOVENOX 1MG/KG/HR Q 12 FOR 5 DAY OVERLAP W COUMADIN OR ARIXTRA FONDAPARINUX
INR TARGET 2-3
RIVOROXABAN XARELTO 15 MG BID FOR 3 WEEKS->20 MG DAILY
APIXABAN ELIQUIS 10 MG BID 1 WEEK THEN 5 MG BID
ELIQUIS AND XARELTO DONT NEED PARENTERAL THERAPY FIRST- GOOD FOR RENAL FAILURE PTS
ANTICOAGULANTS
DOACS
APIXABAN ELIQUIS
EDOXABAN SAVAYSA
DABITRAGRAN PRADAXA NO REVERSIBLE AGENT,NO USE IN CAD
RIVOROXABAN XARELTO
PE LENGTH OF TREATMENT
3 MONTHS
SURGERY OC TRAVEL IDIOPATHIC
CANCER, FOR GOOD
CLOTTING DISORDERS
FACTOR 5 LEIDEN DISEASE
PROTEIN C AND PROTEIN S DEFICIENCY
APS ANTIBODY ANTIPHOSPHOLIPID SYNDROM
ANTI THROMBIN DEFICIENCY
PROTHROMBIN MUTATION
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