RESPIRATORY REVIEW-CODINA Q BANK

Acute asthma symptoms are treated with short-acting beta-2 agonists (SABAs) such as
albuterol and levalbuterol and should be given 10 to 15 minutes prior to the activity to
prevent vasospasm of the bronchioles and shortness of breath.

Asthma is characterized by bronchospasm and increased mucus production, leading to airflow

limitation. The patient's specific triggers align with exercise-induced asthma and cold-induced
asthma, which are subtypes of asthma.

Fluticasone (inhaled corticosteroid), dupilumab (anti-immunoglobulin E antibody), and

montelukast (leukotriene receptor antagonist/inhibitor) are used for long-term asthma
control.

Yellow zone or peak flow is 50% to 80%; therefore, maintenance therapy such as an inhaled
steroid needs. Maintaining or reducing dosages of the medication regimen would be
appropriate if green zone. If red zone, oxygen should be administered.

When percussed over normal lung tissue, resonance is heard.

Hyperresonance is heard with emphysema.

Lobar consolidation, with bacterial pneumonia.

Pleural effusion will percuss a dull tone.

Acute bronchitis, which is most often caused by a virus or inhalation of an irritant. Stay
hydrated and get plenty of rest. An antitussive such as benzonatate may be ordered, as well as
a bronchodilator (e.g., albuterol) for wheezing. Because most acute bronchitis cases are caused
by a virus, a sputum culture is not indicated, and antibiotic therapy would not be effective.

A tuberculosis skin test (Mantoux test) with an area of induration >15 mm is considered
positive in a person with no known risk factors. Redness without induration is a negative
result. The presence of a rash represents an allergic reaction to the test.

Pulse paradoxus is the primary physical sign of cardiac tamponade, which can be caused by
respiratory illnesses such as asthma and emphysema due to increased positive pressure in the
thorax..

The CURB-65 Score for Pneumonia Severity estimates mortality of community-acquired

pneumonia to help determine if a patient should be admitted for treatment. Criteria are age >65
years, confusion (mental status changes), blood urea nitrogen >19.6 mg/dL, respirations >30
breaths/minute, and blood pressure <90/60 mmHg.

Chronic bronchitis is defined by a cough for a minimum of 2 consecutive years with excessive
mucus production for at least 3 or more months. Wheezing, and coarse crackles

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Severe asthmatic exacerbation -call 911, administer epinephrine, and begin a nebulizer
treatment. Parenteral steroids, antihistamines, and H2 antagonists (cimetidine) can also be
administered.

Roflumilast (Daliresp) is a selective phosphodiesterase-4 inhibitor that is known to cause

adverse psychiatric reactions such as insomnia, depression, and suicidal ideationThis
medication is given for severe chronic pulmonary disease.

A pulmonary embolism presents with a sudden onset of dyspnea and cough that produces
pink-tinged sputum. A feeling of impending doom, tachycardia, and pallor.

The gram-positive organism found in Streptococcus pneumoniae is the most common cause of
death in outpatients.

Pseudomonas aeruginosa is common in cystic fibrosis patients.

Haemophilus influenzae, a gram-negative organism, is most common in smokers or chronic

obstructive pulmonary disease patients.

Mycoplasma pneumoniae is an atypical pneumonia with a low-grade fever and gradual onset.

A hallmark sign of pertussis is an inspiratory “whooping” sound that is worse at night and
posttussive vomiting may be seen. Order erythromycin Macrolides, a mucolytic (guaifenesin),
and frequent small meals. Tdap can be administered to children aged 11 to 18 years when no
illness is present. Macrolide antibiotics, such as erythromycin and azithromycin, are the
treatment of choice for pertussis. A nasopharyngeal swab for Bordetella pertussis culture or a
polymerase chain reaction test is the standard method to diagnose pertussis.

Emphysema presents with shortness of breath, minimal cough, and decreased heart and lung
sounds. Patients use pursed-lip breathing and use of accessory muscles is prominent.

Viral upper respiratory infections (URI) are common, especially in small children. Symptoms
include acute fever, sore throat, nasal congestion, teary eyes, and headache. An appropriate
treatment plan is ibuprofen for fever and aches, increased fluids, rest, hand-washing, and
antitussives for cough.

Rrecurrent episodes of wheezing, shortness of breath, and coughing, particularly during spring
and fall, suggest the possibility of both asthma and allergic rhinitis. While both conditions can
exhibit a seasonal pattern, the presence of wheezing and shortness of breath in this case more
strongly supports the diagnosis of asthma. Allergic rhinitis primarily manifests with
symptoms such as sneezing, nasal congestion, and itchy, watery eyes.

The recommended treatment for acute exacerbations of COPD is short-acting

bronchodilators, such as albuterol or ipratropium, to relieve bronchospasm and improve
airflow. Inhaled corticosteroids may be used in patients with severe COPD, but they are not
recommended for routine use in acute exacerbations.

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Fluticasone nasal spray (Flonase),-intranasal corticosteroids, is commonly used as the first-line
treatment for moderate to severe allergic rhinitis.

Spirometry is the gold standard assessment measure for evaluating treatment success and
monitoring asthma control in patients with asthma by assessing airway hyperreactivity.
Performed every 1 to 2 years as part of a health maintenance program, it provides objective
measurements of lung function by assessing forced expiratory volume in one second (FEV1)
and forced vital capacity (FVC).

Peak expiratory flow rate can be used by the patient (or family) to monitor daily changes in
airflow, but it is not as comprehensive as spirometry.

Chronic obstructive pulmonary disease is characterized by progressive airflow limitation due to

chronic bronchitis or emphysema; it is not typically triggered by exercise or cold air.

Pneumonia presents with symptoms such as fever, productive cough, and chest pain.

Oseltamivir, an antiviral medication belonging to the neuraminidase inhibitor class, is

recommended as post-exposure prophylaxis for individuals with significant exposure to
influenza. It is effective against both influenza A and influenza B viruses. This medication can
help prevent or reduce the severity of influenza symptoms if taken within a specified time
frame after exposure.

Daytime sleepiness is the most suggestive symptom of obstructive sleep apnea, as it is a

common consequence of disrupted sleep. Insomnia, frequent nightmares, and morning
headaches may also be associated with sleep apnea.

Croup is characterized by a barking cough, stridor (especially during inspiration), and

respiratory distress. It is typically caused by a viral infection, most commonly parainfluenza
virus.

Bronchiolitis typically presents with wheezing, crackles, and respiratory distress in infants.

Pneumonia often presents with fever, productive cough, and focal lung findings on
examination.

Tiotropium is the first-line treatment for COPD.

Albuterol and ipratropium are short-acting bronchodilators that may be used for acute
exacerbations or as rescue medications.

Fluticasone/salmeterol is a combination inhaled corticosteroid and long-acting beta agonist that

may be used in more severe cases but is not the first-line treatment for COPD.

Sudden-onset pleuritic chest pain, dyspnea, and decreased breath sounds on one side of the
chest, pneumothorax should be suspected. Pneumothorax is the accumulation of air in the
pleural space, causing lung collapse.

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Lung cancer, which is a common malignancy associated with smoking, persistent cough,
hemoptysis, weight loss, cachexia. The mass in the right upper lobe.

Pulmonary embolism is a potential complication of immobility, surgery, trauma, or

hypercoagulable states.

Bronchiectasis is a chronic lung disease characterized by permanent dilation of the bronchi

and bronchioles, which can lead to recurrent infections and bronchial obstruction.

In a pediatric patient presenting with chronic cough, sputum production, recurrent respiratory
infections, and reversible airflow limitation on pulmonary function tests, asthma should be
suspected.

Cystic fibrosis can present with chronic cough, sputum production, and recurrent respiratory
infections, it is associated with non-reversible airflow limitation and other characteristic clinical
features. Cystic fibrosis is a genetic disorder that affects multiple organ systems, including the
respiratory system. While wheezing and coughing can be present in patients with cystic fibrosis,
this condition typically presents earlier in life, with symptoms such as failure to thrive,
recurrent respiratory infections, and pancreatic insufficiency. Cystic fibrosis, who is
experiencing an acute exacerbation of respiratory symptoms and a decline in lung function,
treatment with oral antibiotics is recommended to target the likely bacterial infection causing
the exacerbation.

GOLD Grade 2, Group B, on LABA therapy, which is an appropriate initial treatment.

Adding ICS to the existing LABA regimen is the appropriate next step for a patient with
persistent symptoms despite LABA therapy.

Triple therapy with a LABA, a LAMA, and ICS would be more aggressive than necessary for
this patient, as triple therapy is typically reserved for GOLD Grade 3 or 4 patients or those with
frequent exacerbations.

In a child with moderate persistent asthma who is already on low-dose ICS as maintenance
therapy but continues to have frequent exacerbations, adding a LABA to the current regimen is
recommended.

SABAs are used for relieving acute asthma symptoms, not for improving long-term asthma
control.

Anticholinergic medications, such as ipratropium bromide, are primarily used for treating
acute exacerbations of asthma or chronic obstructive pulmonary disease, not as maintenance
therapy.

The GOLD guidelines classify COPD based on the severity of airflow limitation (Grades 1 to 4)
and the risk and symptoms (Groups A to D). The severity of airflow limitation is determined by
the post-bronchodilator FEV1 as a percentage of the predicted value: Grade 1 (Mild): FEV1

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≥80% predicted; Grade 2 (Moderate): 50% ≤FEV1 <80% predicted; Grade 3 (Severe): 30%
≤FEV1 <50% predicted; Grade 4 (Very Severe): FEV1 <30% predicted. The risk and symptom
grouping are determined by the frequency of exacerbations and symptoms.

For mild persistent asthma, the initial treatment recommended by GINA is a daily low-dose
ICS. (A less-preferred option is daily low-dose ICS with SABA as needed,

SABAs are primarily used for quick relief of acute symptoms and not as the primary controller
medication for persistent asthma.

A combination of ICS and LABA would be more appropriate for moderate persistent asthma.

The first step in MDI use is shaking (if required) and priming the device. The user then exhales
completely before positioning the device for use (which involves placing it near or in the mouth,
depending on the design). After positioning the MDI, the user begins to inhale and then
immediately activates the device. The user continues to breathe in for 3 to 5 seconds, holds the
breath for 5 to 10 seconds, and then exhales.

Community-acquired pneumonia (CAP)the initial treatment depends on the severity of the

illness and the risk of antibiotic resistance. In this case, ceftriaxone and azithromycin are
appropriate initial therapies,. A chest x-ray may be used to evaluate for pneumonia and can
reveal the typical lung consolidation.

Vancomycin and cefepime are typically reserved for severe cases of CAP or cases with
suspected antibiotic-resistant pathogens.

Levofloxacin is effective against both bacterial and atypical pathogens, but it is not typically
used as an initial therapy for uncomplicated CAP.

A throat swab is needed for a rapid strep test, which is used to diagnose streptococcal
pharyngitis.

A blood culture may be used to assess for systemic infection; however, there is no indication of
sepsis or systemic bacterial infection in this patient.

Pulmonary function testing assesses lung function and is used to diagnose and manage chronic
lung diseases like chronic obstructive pulmonary disease (COPD) and asthma,

Spirometry measures airflow and is typically used in diagnosing and managing chronic lung
diseases like asthma and COPD.

Acute bronchitis is typically caused by viral infections. Amoxicillin-clavulanate is a first-line

antibiotic for acute bronchitis, but if the patient does not improve after 5 to 7 days, a different
antibiotic may be necessary. Azithromycin (Zithromax) is a macrolide antibiotic that is
effective against many of the bacteria that cause respiratory infections. It has a long half-life,
allowing for once-daily dosing and a shorter duration of treatment.

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Levofloxacin (Levaquin) is a fluoroquinolone should be reserved for more serious infections,
such as pneumonia, due to their potential for serious side effects, such as tendinitis and tendon
rupture.

Pleural effusion is less likely as it typically presents with decreased breath sounds rather than
crackles.

Pneumothorax would present with decreased or absent breath sounds and additional
symptoms like sharp chest pain.

Azithromycin is a macrolide antibiotic often used as first-line therapy for atypical pneumonia
due to its effectiveness against causative organisms such as Mycoplasma pneumoniae and
Chlamydophila pneumoniae.

Amoxicillin is commonly used in typical community-acquired pneumonia caused

by Streptococcus pneumoniae, not atypical pneumonia.

The patient to rinse the mouth, take a deep breath, and cough forcefully into the container to
ensure that the specimen originates from deep within the lungs. Rinsing the mouth helps to
remove food particles or other contaminants that might interfere with the sample analysis.

Fluoroquinolones cover typical and atypical CAP pathogens and are recommended for
outpatient treatment in patients with comorbidities.

CPAP therapy is the first-line treatment for moderate to severe obstructive sleep apnea
(OSA), especially with symptoms such as those experienced by the patient. It works by
maintaining an open airway during sleep through a steady stream of air. Sleeping in a lateral
position can reduce the severity of OSA for some individuals,

The intermittent coughing, "funny feeling" in the throat, refusal to eat, and wheeze on
auscultation can all be indicative of a foreign body lodged in the esophagus or possibly
aspirated into the airway. A lateral neck x-ray is a first-line diagnostic approach, as it can help
identify radiopaque objects in the esophagus or trachea.

For a child aged 1 year or older and weighing between 10 and 15 kg, the recommended dose of
Oseltamivir (Tamiflu) for the treatment of influenza is 30 mg twice daily for 5 days. In
children weiging more than 15 kg but no more than 23 kg, the correct dose is 45 mg, twice
daily. Children weighing more than 23 kg, but no more than 40 kg should take 60 mg twice
daily. Children weighing more than 40 kg (or any patient aged 13 years or older) should take
75 mg, twice daily.

The preferred treatment for moderate persistent asthma is a low-dose ICS. (A low-dose ICS
combined with a long-acting beta-agonist [LABA] or LTRA is a less-preferred alternative.)

Polysomnography at a sleep center is the gold standard for diagnosing obstructive sleep
apnea (OSA). Given the patient's symptoms of excessive daytime sleepiness, loud snoring,

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observed apneic episodes, and risk factors like a BMI of 33, increased neck circumference, and a
higher Mallampati score, a full overnight polysomnography would be the most appropriate
diagnostic test.

Intermittent asthma is characterized by symptoms that occur ≤2 days per week, with two or
fewer nocturnal awakenings per month.

Mild persistent asthma typically presents with symptoms more than twice a week, but not
daily, and three to four nighttime awakenings per month.

Moderate persistent asthma includes daily symptoms with more than one nocturnal
awakening weekly, but not nightly.

Severe persistent asthma involves continuous daily symptoms with frequent nocturnal
awakenings.

Rinsing the mouth after using a maintenance inhaler, especially those containing
corticosteroids, is essential to prevent side effects like oral thrush, a fungal infection of the
mouth. While it is essential to shake the inhaler before use, shaking it for 30 seconds is
excessive. Most inhalers require a few shakes to mix the medication.

Peak-flow meters for home use provide readings in green, yellow, and red zones, with each
zone corresponding to a current peak flow as a percentage of "personal best" peak flow. A
reading in the green zone corresponds to a current peak flow of 80% to 100% of the personal
best and indicates adequate control with current management. Readings in the yellow zone
correspond to current peak flows in the range of 50% to 79% of the personal best and indicate
worsening asthma symptoms that require action. The red zone corresponds to current flows
below 50%, which reflect a medical emergency. For readings in the yellow zone, the patient
should take the prescribed relief medication(s) and then repeat peak-flow measurement. If
readings return to the green zone within an hour, the patient should continue to monitor
symptoms but can otherwise resume the current management plan. If readings do not return to
the green zone, additional actions are necessary, including contacting the provider. Any reading
in the red zone requires not only immediate medication administration per the asthma action
plan but also immediate contact with the provider and potentially proceeding to the ED
(particularly in the presence of signs of cyanosis or difficulty speaking).

Peak-flow meters measure the force of the exhale, reflecting how well air moves out of the
lungs. Proper use involves taking three consecutive measurements, recording the highest result,
and comparing that with a known "personal best." Readings in the green zone indicate well-
controlled asthma. A reading in the yellow zone indicates worsening symptoms, which
requires the patient to act in accordance with the asthma action plan, usually by taking a quick-
relief medication and then reassessing with the meter. A reading in the red zone suggests a
medical emergency and may warrant calling 911.

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Percussion is a diagnostic technique used to assess the underlying tissues in the thorax.
Different sounds are produced depending on the density of the underlying structures. Dullness
is produced when percussing over an area that is denser, such as in the presence of
pneumonia, where there may be consolidation of lung tissue with fluid and inflammatory cells.
Hyperresonance is typically observed in conditions in which there is an increase in air within
the lung, such as pneumothorax or emphysema.

Flatness might be heard over solid areas like muscles or bones, but not typically over lung
tissue.

Tympany is a drum-like sound that might be heard over a gastric air bubble or intestinal gas,
not over lung tissue.

Whispered pectoriloquy refers to the phenomenon in which sounds whispered by the patient
become more distinct and louder during auscultation over an area with consolidation, such
as a fluid-filled or solid mass in the lung tissue. This occurs because sound waves travel more
efficiently through solid or liquid than through air. In normal lung tissue, whispered sounds
would be faint or inaudible during auscultation. An air-filled cavity would likely diminish
the sound rather than enhance it. Pneumothorax (air in the pleural space) would lead to
decreased or absent breath sounds, not enhanced whispered sounds.

In COPD, both the FVC and the FEV1 are typically decreased.

Increased FVC and decreased FEV1 could be consistent with a restrictive pattern overlying an
obstructive pattern but do not align with COPD alone. Increased FVC and normal FEV1 are
inconsistent with COPD and could suggest hyperventilation. Decreased FVC and increased
FEV1 are not typical findings in any common respiratory disorder and do not correlate with the
finding of COPD.

Tuberculosis often manifests with a productive cough and night sweats, weight loss and the x-
ray may show cavitary lesions in the upper lobes or hilar lymphadenopathy, not a dense coin
lesion.

A lung abscess might exhibit a cavitary appearance on x-ray, but it often results from aspiration
and is usually accompanied by foul-smelling sputum and signs of a more acute infection.