Study Guide: Module 3 Respiratory PDF

**Study Guide: Module 3 Respiratory** ------------------------------------- ### **I. Patient History** - **A. Subjective Data Collection** - Obtain key subjective data for accurate diagnosis of respiratory complaints: - **Asthma:** - Cough (productive or...

**Study Guide: Module 3 Respiratory** ------------------------------------- ### **I. Patient History** - **A. Subjective Data Collection** - Obtain key subjective data for accurate diagnosis of respiratory complaints: - **Asthma:** - Cough (productive or nonproductive) - Wheezing - Shortness of breath - Trouble breathing - Sputum/mucous production - Anxiety - **Acute Bronchitis:** - Persistent cough (productive or nonproductive) - Substernal pain with inspiration - Nasopharyngeal viral symptoms (early on) - Post-nasal drip - **Pneumonia:** - Chills - Acute onset - Fatigue and malaise - Severe cough (productive in typical pneumonia, dry in atypical pneumonia) - Shortness of breath - Chest pain or pleural effusion pain - Nausea or vomiting - Loss of appetite - **Tuberculosis:** - **Latent TB**: Asymptomatic - **Active TB:** - Severe cough lasting longer than three weeks - Chest pain - Coughing up blood or sputum - Weakness and fatigue - Weight loss - Chills - Fever - Night sweats - **B. Review of Systems** - Investigate pertinent systems to confirm or exclude competing diagnoses: - Upper respiratory infection (common cold) - Gastroesophageal reflux disease (GERD) - Vocal cord dysfunction - Lower respiratory system infections: - Pneumonia - Bronchiolitis - Chronic obstructive pulmonary disease (COPD) - Cardiac conditions - Asthma - Lung cancer - Pulmonary embolism ### ### **II. Physical Examination** - **A. Essential Components of Respiratory Exam** - **General Observation:** - Respiratory rate - Effort of breathing - Use of accessory muscles - Cyanosis - **Inspection:** - Chest shape and symmetry - Skin color and temperature - **Palpation:** - Tracheal deviation - Chest expansion - Tactile fremitus - **Percussion:** - Resonance vs. dullness - **Auscultation:** - Breath sounds (e.g., wheezes, rales, rhonchi) - Vocal resonance (e.g., egophony) - **B. Examination Findings for Specific Conditions:** - **Asthma:** - Wheezing, especially with expiration and not clearing with cough - Diaphoresis, anxiety, shortness of breath - Elevated respiratory rate (\>30) and heart rate (\>120) suggest severe bronchospasm - **Acute Bronchitis:** - Low-grade or absent fever - Persistent cough - Wheezing and rhonchi - **Pneumonia:** - Fever - Severe coughing and shortness of breath - Tachypnea and egophony (key indicators) - General appearance of sickness - **Tuberculosis:** - **Latent TB:** Normal exam findings - **Active TB:** - Fever and cough - Subcutaneous nodules and gray or yellow nodules on the conjunctiva - Lymphadenopathy - Consider extrapulmonary symptoms (rare) ### ### ### ### **III. Differential Diagnoses** - **Consider a broad range of possibilities for respiratory complaints:** - Upper respiratory infection (common cold) - Gastroesophageal reflux disease (GERD) - Vocal cord dysfunction - Lower respiratory system infections: - Pneumonia - Bronchiolitis - Chronic obstructive pulmonary disease (COPD) - Cardiac conditions - Asthma - Lung cancer - Pulmonary embolism ### ### **IV. Diagnosis** - **A. Accurate Identification** - Apply information from history, review of systems, and physical exam to a specific patient case. ### ### **V. Management Plan** - **A. Evidence-Based Research** - Consult latest clinical guidelines: - NIH Asthma Guidelines - CDC guidelines for tobacco use and cessation - **B. Culturally Sensitive Approach** - Consider non-pharmacological and pharmacological management. - Provide relevant client education. - Schedule appropriate follow-up. - **C. Specific Management Considerations:** - **Asthma:** - Management based on symptoms and severity. - Frequent reassessment for adequate control. - Stepwise approach to treatment (see severity classifications and corresponding steps). - Asthma action plan. - Patient education on triggers, medications, and when to seek care. - **Acute Bronchitis:** - Supportive care: - Increased fluid intake - Humidifier use - Hot showers with steam - Smoking cessation (if applicable) - Patient education on viral nature and ineffectiveness of antibiotics. - Reassurance that symptoms typically resolve within three weeks. - **Pneumonia:** - Hospitalization or outpatient treatment based on severity assessment (using tools like Pneumonia Severity Index). - Antibiotics for bacterial pneumonia (amoxicillin as first line). - Antivirals for pneumonia with influenza. - Education about vaccines for prevention. - Patient education: - Warning signs and when to seek emergency care. - Avoid cough suppressants. - Rest, fluids, Tylenol, ibuprofen for symptom relief. - Infection control measures. - Smoking cessation (if applicable). - **Tuberculosis:** - **Latent TB:** - Short course of rifampin-based treatment or longer course of isoniazid therapy. - Patient education on adherence to medication regimen. - **Active TB:** - Referral to infectious disease specialist. - Likely requires hospitalization. - Public health reporting of all cases. - **D. Consultations and Referrals:** - **Asthma:** - Referral to PCP or pulmonologist for uncontrolled symptoms. - Emergency department referral for severe bronchospasm or red flag symptoms. - **Acute Bronchitis:** - Referral to physician or PCP if symptoms worsen or do not improve. - Emergency department referral for red flag symptoms. - **Pneumonia:** - Emergency department referral for high severity scores or red flag symptoms. - **Tuberculosis:** - Referral to health department for all positive TB screens (reportable condition). - Referral to infectious disease specialist for active TB cases. - Primary care involvement for both latent and active TB. - **E. Outcome Measures** - Monitor these factors to evaluate the effectiveness of the management plan: - Symptom improvement or resolution - Medication effectiveness and side effects - Adherence to treatment plans - Lung function tests (e.g., spirometry for asthma) - Patient\'s understanding of their condition and self-management strategies - Patient satisfaction with care ### ### **VI. Shared Decision-Making** - **A. Collaborative Approach** - Engage patients in discussions about: - Preferences - Values - Goals - Provide clear and understandable information about: - Treatment options - Risks - Benefits - Respect patient autonomy and empower them to make informed decisions. ### ### **VII. Study Questions and Answers** - **A. Tuberculosis** - **Q: What is latent TB?** - **A:** Latent TB infection means the bacteria is present in the body but is not actively causing illness. The person is asymptomatic and not infectious. - **Q: What is active TB?** - **A:** Active TB infection means the bacteria is actively multiplying, causing symptoms and making the person infectious. - **Q: List the risk factors for TB.** - **A:** - Immunocompromised individuals - Crowded living conditions (e.g., incarceration, homeless shelters) - Drug use - Inadequate healthcare - Travel to high-TB prevalence countries - Comorbid conditions like diabetes or HIV infection - **Q: What is the treatment for TB?** - **A:** Treatment varies based on whether TB is latent or active and is managed by the local health department or primary care provider. - **Latent TB:** Short-course rifampin-based treatment or longer isoniazid therapy (6-9 months). - **Active TB:** Managed by an infectious disease specialist, often requiring hospitalization. - **Q: When do we screen for TB and what methods are appropriate? When could we see false results with screening?** - **A:** Screening is appropriate for asymptomatic individuals with exposure concerns. Two methods are used: - **TB skin test (TST):** Detectable 2-8 weeks post-infection, read 48-72 hours after administration. False negatives possible in certain populations (young, old, vaccinated, immunocompromised) and with recent infections. False positives possible with BCG vaccination or incorrect administration/interpretation. - **Interferon-gamma release assay (IGRA) blood test:** Higher specificity (75% to \>95%), results usually within 24 hours. Cannot differentiate between latent and active TB. - **B. Asthma** - **Q: What are the risk factors for and symptoms of asthma?** - **A:** - **Risk Factors:** - Genetic predisposition - Environmental exposure to tobacco smoke (in-utero) - Immune system status - Obesity - **Symptoms:** - Cough - Wheezing - Shortness of breath - Trouble breathing - Sputum/mucous production - Anxiety - **Triggers for Asthma Attacks/Exacerbations:** - Allergens - Cold air - Exercise - Irritants (perfumes, deodorant) - Stress - Viruses - Smoking/smoke exposure - Aspirin - **Q: Why do we use spirometry for patients with asthma?** - **A:** Spirometry measures lung function in asthma patients, helping assess airflow obstruction severity and treatment effectiveness. - **Q: What are the classifications of asthma and the treatment of asthma based on its severity?** - **A. Classifications:** - **Intermittent asthma:** Symptoms occur less than twice a week, with short flare-ups and nighttime symptoms no more than twice a month. Individuals with intermittent asthma have a forced expiratory volume (FEV1) of 80% or more, and their peak flow rate varies by less than 20%. Their symptoms typically don\'t affect daily activities. - **Mild persistent asthma:** Symptoms occur 3--6 times weekly, with flare-ups that may affect activity levels. Nighttime symptoms occur 3--4 times a month. FEV1 is 80% or greater, and peak flow varies by less than 20%. - **Moderate persistent asthma:** Symptoms occur daily, and activity levels are somewhat limited by flare-ups. Nighttime symptoms occur 5 or more times a month. FEV1 is 60--80%, and peak flow varies by more than 30%. - **Severe persistent asthma:** Symptoms occur throughout the day, severely limiting activity levels. Nighttime symptoms are frequent. FEV1 is 60% or less, and peak flow varies by more than 30%. - **B. Treatment:** - Treatment for asthma follows a stepwise approach outlined in the NIH Asthma Guidelines, allowing adjustments based on symptom control. - **Key Treatment Considerations:** - For **mild persistent** asthma (Step 2 therapy), recommendations include: - Daily low-dose inhaled corticosteroid (ICS) and as-needed short-acting beta2-agonist (SABA) for quick relief - **Intermittent** as-needed SABA and ICS used one after the other for worsening asthma. One approach is 2--4 puffs of albuterol followed by 80--250 mcg of beclomethasone equivalent every 4 hours as needed. However, patients with low or high symptom perception may not be good candidates for this approach and may benefit more from daily low-dose ICS with as-needed SABA. - For **moderate to severe persistent** asthma already on low- or medium-dose ICS, a single inhaler with ICS-formoterol (SMART therapy) is preferred, used both daily and as needed. This is recommended over higher-dose ICS-LABA daily and as-needed SABA. - When ICS therapy alone doesn\'t control asthma, adding a LABA is recommended over adding a LAMA. However, if a LABA is not an option, adding a LAMA to an ICS is acceptable. - Adding a LAMA to ICS-LABA is recommended for many individuals whose asthma is not controlled with ICS-LABA, as it offers a small potential benefit. - **Important Note:** Pregnancy can impact asthma symptoms, making it crucial to understand how to manage asthma in pregnant patients. - **Q: How do we adjust asthma therapy based on symptoms?** - **A:** Asthma therapy is adjusted based on symptom frequency, severity, and medication response. Regular assessments determine adjustment needs. Referrals to specialists may be necessary for uncontrolled symptoms. - **C. Acute Bronchitis vs. Pneumonia** - **Q: What is the difference between acute bronchitis and pneumonia? What is the difference in the recommended diagnostic testing and treatment regimens for these conditions?** - **A:** - **Acute Bronchitis:** - Inflammation of the trachea and major bronchi, usually viral (90%) - Symptoms last up to 3 weeks - Diagnostic testing often unnecessary - Supportive care treatment (fluids, rest, humidifiers) - Antibiotics generally not recommended - **Pneumonia:** - Infection of lung parenchyma, can be viral, bacterial, or fungal - Varying symptom severity, including fever, cough, shortness of breath - Diagnostic testing: chest x-ray, pulse oximetry, severity assessments (e.g., Pneumonia Severity Index) - Treatment depends on cause and severity: - Bacterial pneumonia: Antibiotics (amoxicillin often first-line) - Viral pneumonia: Supportive care, antivirals if influenza is present - Hospitalization for severe cases - **Key Differentiators:** - **Fever:** More common in pneumonia. - **Egophony:** Strong indicator of pneumonia. - **Chest x-ray:** Helpful for diagnosing pneumonia, not typically needed for bronchitis. - **Q: What is the difference between typical and atypical pneumonia? Treatment?** - **A:** - **Typical Pneumonia:** - Caused by *Streptococcus pneumoniae* - Acute onset, severe symptoms (fever, chills, productive cough, shortness of breath, ill appearance) - Chest x-ray shows consolidation - **Treatment:** Amoxicillin (first-line antibiotic) - **Atypical Pneumonia:** - Caused by *Mycoplasma pneumoniae* - Milder, insidious onset, lingers longer (\"walking pneumonia\") - Affects younger populations - Low-grade fever or no fever - Dry or productive cough - Malaise and fatigue - **Treatment:** Macrolides (preferred antibiotics) - **Q: What is the patient teaching regarding trying to prevent pneumonia? Specifically, what is the recommendation for pneumococcal vaccines?** - **A:** - **Vaccination:** Pneumococcal vaccines are recommended for specific age groups and at-risk individuals (e.g., elderly, immunocompromised). - **Hygiene practices:** Frequent handwashing, covering coughs and sneezes, avoiding sick individuals. - **Smoking cessation:** Significantly reduces pneumonia risk. - **Health maintenance:** Managing chronic conditions and healthy lifestyle. - **Q: When would you consider admission for a patient with pneumonia?** - **A:** - **Severity assessment:** High score on tools like the Pneumonia Severity Index. - **Clinical judgment:** Red flags or concerning features. - **Hypoxemia:** Requiring supplemental oxygen. - **Respiratory distress:** Signs of breathing difficulty. - **Comorbidities:** Underlying conditions increasing complication risk. - **D. Influenza and COVID-19** - **Q: List the prevention and treatment guidelines for COVID-19 and Influenza.** ### **Influenza** - - - - - - - - - - - - - ### **COVID-19** - - Other preventive measures, especially important for those with weakened immune systems, include: - Good hygiene practices - Taking steps for cleaner air - Staying home when sick - **Treatment:** Several antiviral medications are authorized or approved by the FDA to treat mild to moderate COVID-19 in people more likely to get very sick. - **Treatment must be started within 5-7 days of symptom onset to be effective**. - Antiviral medications target the virus to stop it from multiplying, helping prevent severe illness and death. - Available treatment options include: - **Nirmatrelvir with Ritonavir (Paxlovid):** For adults and children ages 12 and older; taken by mouth at home - **Veklury (remdesivir):** For adults and children; given intravenously at a healthcare facility for 3 days - **Molnupiravir (Lagevrio):** For adults; taken by mouth at home