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88 Cards in this Set
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Chronic cough = ?
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present > 3 weeks
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If increases while supine, consider?
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sinusitis, PND, asthma, GERD
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In an infant, a harsh cough with respiratory distress triggered by feeding suggests?
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double aortic arch
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Household substances that can trigger cough include?
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tobacco smoke, pets, mold, dust, cockroaches, strong cosmetic or cleaning solutions, space heaters (kerosene), or wood burning stoves.
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Dust mite reservoirs include?
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mattresses, box springs, draperies, carpeting, upholstery, stuffed animals, toy
book shelves |
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Hobbies that can also trigger?
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involve use of glue, correction fluids, paints
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With chronic throat clearing, think?
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sinusitis, rhinitis, PND
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Dry, tight cough?
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asthma, allergic rhinitis, foreign body.
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With heartburn, nausea, substernal chest pain or discomfort and sour taste in mouth?
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GERD
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If gagging or choking on food or other objects before onset of cough, consider?
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foreign body aspiration
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If disappears during sleep, possibly?
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psychogenic
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If induced by exercise or cold air exposure, consider?
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irritable airway
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With heartburn, nausea, substernal chest pain or discomfort and sour taste in mouth?
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GERD
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If gagging or choking on food or other objects before onset of cough, consider?
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foreign body aspiration
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Occasionally, after a haircut, how can cough be triggered?
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small hair in the ear canal or a foreign body there
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On PE, note?
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any clubbing or signs of hyperinflation.
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In an infant, consider CF if?
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also has recurrent URIs, 2 or more episodes of pneumonia in one year, FTT or parasinusitis, consider CF.
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Adult with clubbing suffers?
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from chronic hypoxia, maybe + lung CA.
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Asthma?
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=chronic, inflammatory lung disorder of the airways characterized by episodic and reversible symptoms of airflow obstruction and hyperreactivity
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Affects about --% of the US population?
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5
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Asthma is ?
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a reversible, obstructive disorder of the tracheobronchial tree characterized by paroxysmal episodes of respiratory distress interspersed with periods of well-being
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large airway involvement induces?
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wheezing
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Small airway involvement induces?
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dyspnea and cough more than wheezing
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Asthma is an?
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inflammatory process involving mucosal edema, mucus production and increased vascular permeability. Smooth muscle spasm in large and small airways
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Gender incidence?
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most often appears in childhood
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Intrinsic asthma is most common in ?
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adults
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Non-allergenic triggers include?
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exercise induced (5-10 minutes after vigorous activity), workplace triggers such as fumes, dyes, chemicals
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Onset of asthma is often?
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in early adulthood
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Extrinsic asthma?
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there is a history of atopia
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Extrinisic triggers are?
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allergenic in nature, including pollen, pet dander, feathers, dust mite and cockroach excrement, and food additives such as sulfites.
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On history for atopic asthma?
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episodic wheezing, chest tightness, dyspnea, chronic dry cough
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On PE for atopic asthma, look for ?
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signs of allergic rhinitis, nasal polyps
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On auscultation, of asthma?
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evidence of wheezing, exp. Insp or both, with prolongued expiratory phase, but keep in mind that during a severe exacerbation wheeze may be absent,
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other signs or sympt of asthma?
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tachypnes, tachycardia, use of accessory muscles, intercostals retraction, nasal flaring, diaphoresis, diminished breath sounds, hyperresonance to percussion, cyanosis. Pulsus paradoxus appears during severe exacerbation (= > 20 mmHg fall in BP during inspiration)
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Signs of hyperinflation of airways?
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(increased AP: lateral diameter of chest, hyperresonance to percussion, and decreased diaphragmatic excursion)
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liver edge may be palpable with COPD, due to?
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lowered diaphragm from pulmonary hyperexpansion
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Evaluate bronchodilator response with?
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FEV 1 = forced expiratory volume in one second: check before and after inhalation of bronchodilator
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Labs with asthma?
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Sputum exam, prn. May be checked for eosinophilia.
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With viral infection and asthma?
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lymphs increase
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With secondary bacterial infection?
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neutrophils increase.
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If pt is on glucocorticoid therapy, what may happen?
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eos may be depressed, as expected also in pt under stress or with regular epinephrine use.
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Pts with Snyder’s syndrome may experience?
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fatal asthma if use ASA or any NSAID that inhibits cyclooxygenase)
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Poor sign in severe asthma may be the?
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disappearance of wheezing, due to increased airway constriction and pt inability to move enough air volume to create wheeze.
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Measure peak flow?
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PEFR = peak expiratory flow rate.
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For an average adult, PEFR range is?
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400-500.
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Chart is used, based on ?
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height and age, as below:
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Mild obstruction (generally under 300 in an adult): may be treated as outpatient
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Moderate obstruction (100-200 range): hold in office after treatment until improved
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Green peak flow zone?
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80-100% baseline
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Yellow peak flow zone?
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60-80% baseline
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Red peak flow zone?
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below 50-60%
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Peak flow is least accurate at ?
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low flow rates, in elderly, or in adults of small stature.
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Peak flow is a good screening test for predicting ?
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obstructive abnormalities of the large airways.
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Large airway obstruction is assessed via?
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expiratory flow rate and ratio FEV 1 to VC
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VC=?
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(vital capacity, which is the maximum volume of air that can be expired after a full inspiration).
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VC = ?
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sum IC (inspiratory capacity) and ERV ( expiratory reserve volume)
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When FEV 1 is reduced by 50%, pt is usually ?
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dyspneic and hypoxemic on exertion.
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If down to 25% of maximum, pt is?
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SOB at rest.
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Forced expiratory flow after 25-75% vital capacity is expelled (FEF 25-75) is an excellent indicator of ?
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small airway obstruction.
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PEF measures only?
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large airway changes
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DD cough in children?
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bronchiolitis in infancy
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CF ?
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(with malabsorption, FTT, sweat chloride concentration > 60 meQ
l) |
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“cardiac asthma” ?
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= CHF = also with S 3, history of cardiac disease and crackles on auscultation.
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DD cough in elderly?
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COPD, bronchiectasis, CHF, PE, bronchogenic carcinoma, cough secondary to ACE inhibitor use. About 3% of pts develop asthma after age 60. COPD more likely.
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Pulmonary lab can measure carbon monoxide diffusing capactiy: if low, suggests?
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tobacco induced lung disease: do CXR to exclude tumor or signs cardiomegaly).
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DD all ages?
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foreign body aspiration, acute infections such as viral, pneumonia, bronchitis, TB, GERD, AIDS, psychogenic cough, neuromuscular weakness.
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Management goal of asthma is to ?
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keep pts as free from symptoms as possible. Identify and remove triggers, provide desensitization appropriately.
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To treat an asthma episode?
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measure peak flow, then administer nebulized albuterol 5 mg
5 cc: 0.5 cc in 2.5 cc NS, administered over 5 minutes. If not effective, repeat in 15 minutes. |
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How much
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0.2-0.3 cc 1:1000 aqueous solution
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When admission is required, pts usually have what done?
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CXR, ABGs, and evaluation of oxyen saturation. If O 2 sat is available in office setting, check it!
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ABG goal is to maintain the PaO2?
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> 65.
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When PaO2 under 60?
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admin oxygen at 2-4 l
min. |
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Start IV for hydration
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methylprednisone often given, PO steroid started too.
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Complication may be status asthmaticus = severe asthma, unresponsive to usual emergency treatment with imminent ventilatory failure. Mortality risk %?
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1-3% mortality risk. This is a true emergency. May be triggered by usual allergens, emotional crisis, URI, steroid withdrawal. Pt presents anxious, irritable, tachypneic, tachycardic, with labored breathing.
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Closing volume (% of vital capacity) = ?
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volume at which lower lung zones cease to ventilate and maximal midexpiratory flow rate are both measures of early small airway disease, especially early COPD when most indices are normal.
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Check FEV 1 pre and post bronchodilator therapy to determine ?
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airway responsiveness and usefulness or potential efficacy of bronchodilator ongoing therapy.
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PEFR varies per indiv. ?
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Age, sex, height. VC depends on age (< with time), > with > height and good physical fitness level, and lower in women than men with same age and height.
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Spirometry is performed with pt’s?
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nose clipped
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Bronchial provocation testing is performed for pts suspected of?
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bronchial hyperreactivity: asthmatics are more susceptible to methacholine chloride than non-asthmatic pts.
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False negative with bronchial provocation test?
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5-10% asthmatics don’t respond to methacholine challenge testing.
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Pocedure for bronchial provocation test?
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Pt records baseline FEV 1, then via nebulizer, inhales increasing concentration of methacholine chloride
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Bronchial provocation test is +if?
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FEV 1 decreases by 20% or more, the test is +. Inhaled brochodilator is given.
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Bronch Prov Test is performed where?
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under hosp supervision usually, rather than out pt. Setting.
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Pt taking bronch prov test, should refrain from using bronchodilator for?
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8 hours before test and antihistamines for 48 hours before test.
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Obstructive airway disease results in?
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slow loss of ability to expel air from lung
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Baseline PFTs should be measured ?
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6 or more hours after last dose of brochodilator.
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After bronchodilator administration, pt with asthma should improve __%?
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15-20% on PEFR or FEV 1 if no improvement occurs, consider diagnosis of chronic bronchitis or emphysema
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With aging, FEV 1 and FFV are?
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lower. At age 55 for example, in men, 79% of normal and in women, 74%
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