NR 661 Week 4 VISE Assessment,Familiarize Yourself

Know presentation, DX and Management Diagnoses List 1. Acute bronchitis- DESCRIPTION Acute cough due to inflammation of the bronchioles, bronchi, and trachea; usually follows an upper respiratory infection or ex ...

Know presentation, DX and Management Diagnoses List 1. Acute bronchitis- DESCRIPTION Acute cough due to inflammation of the bronchioles, bronchi, and trachea; usually follows an upper respiratory infection or exposure to a chemical irritant. ETIOLOGY  Adenovirus  Rhinovirus  Influenza A and B  Parainfluenza RISK FACTORS  Upper respiratory infection  Air pollutants  Smoking and/or secondary exposure  Reflux esophagitis  Allergy  Chronic obstructive pulmonary disease  Acute and chronic sinusitis  Infants  Older adults  Immunosuppression ASSESSMENT FINDINGS  Cough: dry and nonproductive, then productive; may be purulent  URI symptoms  Fatigue  Fever due to bacterial infection; more common in smokers and patients with COPD  Fever due to viral cause (unusual after first few days)  Burning sensation in chest  Crackles, wheezes  Chest wall pain DIFFERENTIAL DIAGNOSIS  Pneumonia  Tuberculosis  Asthma DIAGNOSTIC STUDIES  Decision criteria for chest radiographs: tachypnea, hypoxia, fever, abnormal lung exam  Only consider chest X-ray if high index of suspicion for pneumonia or superimposed heart failure  Consider PPD: expect negative results  PREVENTION  Smoking cessation  Avoid known respiratory irritants  Treat underlying conditions that contribute to risk (asthma, gastroesophageal reflux disease, etc.)  Influenza immunization for high-risk populations NONPHARMACOLOGIC MANAGEMENT  Increase fluid intake  Use humidifier  Rest  Smoking cessation  Consider honey in children older than 1 year  Patient education about disease, treatment, expected cause of cough, and emergency actions PHARMACOLOGIC MANAGEMENT  Cough suppressants for nighttime relief  Avoid antihistamines  Antibiotics if organism is bacterial  Antivirals if influenza diagnosed  Decongestants and antihistamines are ineffective unless sinusitis or allergy is underlying  Bronchodilators if wheezing or prior history of asthma Although antibiotics are commonly prescribed, they are NOT recommended. ACUTE BRONCHITIS PHARMACOLOGIC MANAGEMENT Class Drug Generic name (Trade name®) Dosage How Supplied Comments Cough Suppressants Suppress cough in the medullary center of the brain dextromethorphan/guaifenesi n Adult: 10 mL q 4 hr Max: 4 doses in 24 hours Children 6-12 years: 5 mL q 4-6 hr; Max: 4 doses in 24 hr Children <6 years: not recommended  Do not use if taking an MAO inhibitor or for 2 weeks after stopping an MAO inhibitor  Contraindicated in Parkinson’s disease  Potential drug interaction with some SSRIs  Avoid in patients who are having difficulty clearing Robitussin DM secretions various generics Dextromethorphan 10 mg/5 mL Guaifenesin 100 mg/5 mL Although antibiotics are commonly prescribed, they are NOT recommended. ACUTE BRONCHITIS PHARMACOLOGIC MANAGEMENT dextromethorphan Adult and ≥12 years: 10 mL q 6-8 hr prn for cough Max: 4 doses in 24 hr Children 6-12 years: 5 mL every 6- 8 hr prn for cough Max: 4 doses in 24 hr 4-6 years: 2.5 mL every 6-8 hr prn for cough Max: 4 doses in 24 hr  Do not use if taking an MAO inhibitor or for 2 weeks after stopping an MAO inhibitor  Contraindicated in Parkinson’s disease  Potential drug intervention with some SSRIs  Avoid in patients who are having difficulty clearing secretions  Do not use if on a sodium restricted diet Delsym Dextromethorphan 15 mg/5 mL (alcohol free/orange or grape flavor) Adult: 10 mL q 12 hr Children 6-12 years: 5 mL q 12 hr Children 4-6 years: 2.5 mL q 12 hr codeine/guaifenesin Adults and children ≥ 12 years: 10 mL q 4 hr prn cough Max: 6 doses in 24 hr Children 6-12 years: 5 mL q 4 hr prn cough Max: 6 doses in 24  Do not use if taking an MAO inhibitor or for 2 weeks after stopping an MAO inhibitor  Contraindicated in Parkinson’s disease  Potential drug interaction with Although antibiotics are commonly prescribed, they are NOT recommended. ACUTE BRONCHITIS PHARMACOLOGIC MANAGEMENT hr some SSRIs  Schedule V medication  Avoid in patients who are having difficulty clearing secretions  Avoid narcotic cough suppressants in patient with COPD or asthma  May be habit forming  May aggravate constipation Robitussin AC Each 5 mL contains 100 mg guaifenesin and 10 mg codeine Antitussives Topical anesthetic effect on the respiratory stretch receptors benzonatate Adults and children > 10 years: 100-200 mg TID prn cough Max: 600 mg daily  Do not break or chew capsule - can produce local anesthesia and may reduce patient’s gag reflex  Monitor for dizziness, drowsiness and visual changes  Begins to act in 15- 20 minutes and lasts for 3-8 hours  Avoid use in patients sensitive to or taking agents with PABA - possible adverse CNS effects Tessalon Caps: 100 mg, 200 mg Expectorants guaifenesin Adult: 200-400 mg PO q 4 hr prn Max: 2400 mg/day Children 2-5  Caution if nephrolithiasis  Caution in patients Although antibiotics are commonly prescribed, they are NOT recommended. ACUTE BRONCHITIS PHARMACOLOGIC MANAGEMENT years: 50-100 mg. PO q 4 hr prn Max: 600mg/ day Children 6-11 years: 100-200 mg PO q 4 hr prn Max: 1200 mg/day Children ≥12 years: 200-400 mg PO q 4 hr prn; Max: 2400 mg/day. under 6 years  Take with plenty of water; do not cut/crush/chew ER tab Short-Acting Bronchodilator s albuterol Inhalation: Adult Dose: metered-dose inhaler (MDI) or dry powder inhaler (90 mcg/actuation): 2 inhalations q 4 to 6 hr as needed Metered-dose inhaler (100 mcg/actuation): Acute treatment: 1 to 2 inhalations; additional inhalations may be necessary if inadequate relief however patients should be advised to promptly consult health care provider or seek medical attention if no relief from acute treatment Maintenance (in combination with corticosteroid therapy): 1 to 2 inhalations TID-QID  Inhalation: o Metered- dose inhalers: Shake well before use; prime prior to first use, and whenever inhaler has not been used for >2 weeks or when it has been dropped, by releasing 3 to 4 test sprays into the air (away from face). HFA inhalers should be cleaned with warm water at least once per week; allow to air Although antibiotics are commonly prescribed, they are NOT recommended. ACUTE BRONCHITIS PHARMACOLOGIC MANAGEMENT Max: 8 inhalations daily Dry powder inhaler (200 mcg/inhalation): Acute treatment: 1 inhalation (200 mcg) as needed; Max: 4 inhalations (800 mcg)/day; patient should be advised to promptly consult health care provider or seek medical attention if prior dose fails to provide adequate relief or if control of symptoms lasts <3 hr Maintenance (in combination with corticosteroid therapy): 1 inhalation (200 mcg) q 4-6 hr; Max: 4 inhalations (800 mcg)/day Nebulization solution: 2.5 mg TID-QID as needed; Quick relief: 1.25 to 5 mg q 4-8 hr as needed (NAEPP 2007) Pediatric: Inhalation: Metered-dose inhaler or dry powder inhaler (90 mcg/actuation) quic k relief: refer to adult dosing for all dry completely prior to use. A spacer device or valved holding chamber is recommende d for use with metered- dose inhalers.  Storage o Metered- dose inhalers (HFA aerosols): Store at 15°C to 25°C (59°F to 77°F). Do not store at temperature >120°F. Do not puncture. Do not use or store near heat or open flame.  Ventolin HFA: Discard when counter reads 000 or 12 months after removal from protective pouch, whichever comes first. Store with mouthpiece down.  Use with caution in patients with Although antibiotics are commonly prescribed, they are NOT recommended. ACUTE BRONCHITIS PHARMACOLOGIC MANAGEMENT ages Metered-dose inhaler (100 mcg/actuation): Children 6 to 11 years: Acute treatment: 1 inhalation; additional inhalations may be necessary if inadequate relief; however, patients should be advised to promptly consult health care provider or seek medical attention if no relief from acute treatment Maintenance (in combination with corticosteroid therapy): 1 inhalation; may increase to maximum of 1 inhalation QID Children ≥12 years and adolescents: refer to adult dosing impaired renal disease, hyperthyroidism, diabetes, glaucoma CONSULTATION/REFERRAL  Refer to pulmonologist if symptoms not improved after 4 weeks FOLLOW-UP  7 days if not improved or if condition worsens  High-risk groups (i.e., those with co-existing disease) warrant quicker follow-up EXPECTED COURSE  Shorter symptom duration if causative agent is rhinovirus or coronavirus  Symptoms may persist 3-4 weeks POSSIBLE COMPLICATIONS  Pneumonia  Chronic cough 2. Acute laryngopharyngitis DESCRIPTION An acute inflammation of the pharynx/tonsils. The most common cause of acute pharyngitis is viruses. Accurate diagnosis and treatment of Strep pharyngitis is important to prevent rheumatic fever, poststreptococcal glomerulonephritis, to reduce transmission, and to limit complications, such as peritonsillar abscess, lymphadenitis, and mastoiditis ETIOLOGY Causes Viral* Bacterial  Rhinovirus  Adenovirus  Parainfluenza  Epstein-Barr virus (mononucleosis)  Respiratory syncytial virus  Group A beta-hemolytic  Streptococcus**  Haemophilus influenzae  Mycoplasma pneumonia  Chlamydia pneumoniae  Neisseria gonorrhoeae  No pathogen can be isolated in many cases * Most common etiology ** Common depending on time of year INCIDENCE  Prevalent in school age population, but occurs in all age groups (5-18 years most common)  Occurs in 5-15% of adults and 20-30% of children  More common during winter months RISK FACTORS  Age  Exposure during Group A beta-hemolytic Streptococcus (GABHS) infection outbreaks  Family history of rheumatic fever places higher risk if GABHS is untreated ASSESSMENT FINDINGS  Sore throat and pharyngeal edema  Tonsillar exudate and/or enlarged tonsils  Malaise  Clinical findings are not specific for diagnosis of bacterial or viral illness. The signs and symptoms of strep pharyngitis and other etiologies overlap, and an accurate diagnosis based on clinical findings alone is difficult  Suggestive of Strep: o Cervical adenopathy o Fever >102° F (38.8° C) o Absence of other upper respiratory findings (cough, nasal congestion, etc.) o Petechiae on soft palate o “Beefy red” tonsils o “Sandpaper” rash (bridge of nose, neck, and/or torso) o Abdominal pain, headache o Streptococcal tonsillitis has a distinct odor  Suggestive of viral infection: o Concurrent conjunctivitis,