Hollier Pulmonary 2017

Advanced Practice Education Associates
Pulmonary
Disorders
Pulmonary
Overview
Cough (many etiologies)
Pneumonia
COPD
Asthma
14 Copyright 2017 Advanced Practice Education Associates

Pulmonary
COUGH
Question
A 36 year old patient presents with CC cough.
What is the most important question to ask him?
________________________________________________________________
Why? ___________________________________________________________
Cough Differential
Acute (< 3 weeks) Chronic (> 8 weeks)
Acute respiratory infection Asthma: 2nd most common cause
(Bronchitis, sinusitis, PND)
Exacerbation of COPD, GERD: 1st, 2nd, or 3rd most common (depends on
asthma who you read)
Pneumonia Infection: Pertussis, atypical pneumonia
Pulmonary embolism ACE inhibitors: dry cough 1-3 weeks after starting
Others Chronic bronchitis (almost always smokers)
Bronchiectasis (chronic cough, viscid sputum,
bronchial wall thickening on CT scan)
Lung cancer: < 2% of cases
A Day In Clinical Practice
A 24 year old college student who is a non-smoker and otherwise healthy has
been diagnosed with pertussis. Whats an appropriate treatment for her?
1. Doxycycline 100 mg BID x 7 days

2. Azithromycin 500 mg day 1, 250 mg days 2-5
3. Amox/clavulate 875 mg BID x 5 days
4. Treat symptomatically
Community Acquired PNEUMONIA (CAP)

Associated with morbidity and mortality especially in older adults
Etiology
3 most common Bugs in CAP
1. S. pneumoniae (pneumococcal pneumonia) (14%) produces rust-colored
sputum; Most common cause of death from pneumonia
Atypical organisms (cause atypical pneumonia):

2. M. pneumoniae (16%) (the other most common pathogen)
3. Chlamydophila pneumoniae (12%)
4. Other bugs including viral pathogens
Copyright 2017 Advanced Practice Education Associates 15

Pulmonary
Community Acquired Pneumonia (ambulatory)

Drug Resistant Atypical Pathogens
S. pneumoniae (Mycoplasma,
Chlamydophila, Legionella)
Age > 65 years, patients with At Risk Young, otherwise healthy,
co-morbids, recent (3 months) Populations non-smokers, community
antibiotic exposure, outbreak
alcoholics,
immunosuppressed, exposure
to child in daycare
Chest x-ray is gold standard Diagnosis Chest x-ray is gold standard
Abrupt onset with fever, chills, Symptoms Low grade fever, cough,
cough, pain in side or chest, chills, HA, malaise, rash, joint
rust colored sputum, *Older aches, arrhythmias
patients exhibit fewer
symptoms (confusion,
absence of fever)
Mandell, LA, Wunderink, RG, Anzueto, A, et al. Infectious Diseases Society of America/American Thoracic Society
consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl
A 54 year old patient who is otherwise healthy and takes no meds has been
diagnosed with CAP. Whats an appropriate treatment for her?
1. Levofloxacin 750 mg daily x 5 days

2. Azithromycin 500 mg day 1, 250 mg days 2-5
3. Amox/clavulanate 875 mg BID x 5 days
Exam Takers:
Answer EVERY exam question based on either:
1) a clinical guideline,
2) a standard of care, or
3) evidence based intervention.
Whatever you do.
Dont answer EXAM questions based on what you see done in clinical practice...
IDSA and ATS 2007 Guidelines for Treatment of Pneumonia

Summary of Treatment Options:
1. Macrolide or doxy for most patients
If DRSP is suspected:
2. Resp quinolone: Moxifloxacin, Gemifloxacin, Levofloxacin
3. Beta lactam (PCN or Ceph) plus macrolide or doxy

Pulmonary
A 55 year old patient was diagnosed with pneumonia 7 days ago and was started
on levofloxacin. He has had normal temperature for the past 2 days but
complains that he feels tired and is still coughing. How should this be handled?
1. Order a chest x-ray

2. Continue antibiotic for 3 more days
3. Start a different antibiotic
4. Have him continue to rest for another 3-5 days
Which characteristic is the LEAST likely to prompt the nurse practitioner to

consider hospital admission for an adult patient who has pneumonia?
1. Confusion since onset of pneumonia symptoms

2. Respiratory rate 30/minutes
3. Blood pressure 80/50
4. Age = 55 years old
Pneumococcal Vaccines - PCV 13, PPSV 23

PPSV23 (cdc.gov, 2016)
Adults 19-64 years who are at increased risk of pneumococcal disease
(asthma, COPD, CV Dx, etc.)
PCV13, then PPSV23 (in 1 year)
*All Adults 65 years
Aged 19-64 with asplenia, immunocompromising conditions, CSF leaks,
cochlear implants, plus an additional PPSV23
CDC.gov (2015)
Whats your exam strategy for immunizations?

Dont memorize the schedule!!! It changes every year!
Know which patients would profit from receiving the immunization (vulnerable
population)
In practice, have the CDC Vaccine Schedule app on your smart phone!
(And, upgraded and its free!)
Additional Notes:

Pulmonary
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

2016 Global Initiative for Chronic Obstructive Lung Disease (GOLD)
A report by NHLBI and WHO to define, diagnose, and treat COPD
www.goldcopd.org/
Key Indicators of COPD

Dyspnea: that is progressive (worsens over time, persistent and
characteristically worse with exercise
Chronic cough: Initially may be intermittent, may be unproductive, then
present every day throughout the day
Chronic sputum production: common (production of sputum for 3 or more
months in 2 consecutive years)
Consider COPD if age 40, perform spirometry, presence of multiple indicators
increases likelihood of COPD
Diagnosis for COPD:

Symptoms: shortness of breath, chronic cough, sputum
Exposure to risk factors: tobacco, occupation, indoor/outdoor pollution
Spirometry: Required to establish diagnosis (FEV1/FVC ratio < .70)
Differential Diagnosis for COPD:

Diagnosis Clinical Characteristics
COPD Mid-life onset
Slow progression of symptoms
History of exposure to lung irritants
Heart Failure Dilated heart, pulmonary edema on chest x-ray
No airflow limitation
Asthma Early in life onset usually
Wide variation in symptoms from day to day
Symptoms may worsen in early AM or evening/nighttime
Atopic history (allergic rhinitis, eczema), family history
Tuberculosis Any age; infiltrate on chest x-ray
Need sputum confirmation
Additional Notes:

Pulmonary
GOLD Staging System The Global Initiative for COPD

Classification of Severity of Airflow Limitation in COPD
(Based on Post-Bronchodilator FEV1)
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
FVC = forced vital capacity; volume of air forcibly exhaled from the point of max
inspirations
FEV1 = volume of air exhaled during the first second of the maneuver
FVC/FEV1 = the ratio
*Age, gender, height, race taken into account with reference values
www.goldcopd.org/
Which patient is most characteristic of someone who has COPD?
1. 25 years old, smoker, cough > 1 year

2. 35 years old, history of asthma, cough > 1 year
3. 45 years old, smoker, chest pain and SOB with exercise
4. 65 years old, house painter, smoker, cough with SOB
Therapeutic Options: COPD Medications

Beta2 -agonists
Short-acting beta2-agonists
Long-acting beta2-agonists
Anticholinergics
Short-acting anticholinergics
Long-acting anticholinergics
Combination short-acting beta2-agonists + anticholinergic in one inhaler
Combination long-acting beta2-agonists + anticholinergic in one inhaler
Methylxanthines
Inhaled corticosteroids
Combination long-acting beta2-agonists + corticosteroids in one inhaler
Systemic corticosteroids
Phosphodiesterase-4 inhibitors
www.goldcopd.org/
Additional Notes:

Pulmonary
Chronic Obstructive Pulmonary Disease (COPD)

Bronchodilators
Beta agonists (cause bronchodilation):
1. Short acting beta agonists (SABAs work 4-6 hours)
Examples: albuterol, levalbuterol
Suffix is "terol"
"Rescue med (works immediately; effects last for about 4 hours)
2. Long acting beta agonists (LABAs work 12-24 hours)
Example: salmeterol (Serevent)
Suffix is "terol"
Not a rescue med (takes 10-20 minutes to work) but works for 12 hours
NEWER----24 HOURS!!!!!
indacaterol (Arcapta Neohaler), olodaterol (Striverdi Respimat),
vilanterol (in combo with fluticasone, in combo with umeclidinium)
Inhaled Anticholinergics
Produce a little Bronchodilation
Works by preventing bronchoconstriction (yeah, ok it bronchodilates a
little)
Examples: ipratropium (Atrovent), tiotropium (Spiriva), aclidinium
(Tudorza Pressair), umeclidinium (Incruse Ellipta), glycopyrrolate
(Seebri Neohaler)
Suffix is "tropium"
Combos: with SABA, LABA
May cause constipation, increased IOP
Anticholinergic Medications
Anticholinergic Side Effects
Memory impairment, confusion, hallucinations, dry mouth, blurred vision, urinary
retention, constipation, tachycardia, acute angle glaucoma
"An Ode to an Anticholinergic Med"

Oh this drug, it makes me pink, Sometimes, I can't think or even blink.
I can't see,
I can't pee,
I can't spit,
I can't (**it) ("defecate")
Combinations of Meds
3. Steroids plus LABA
Best in COPDers with FEV1 < 60% predicted
Works by reducing inflammation
Examples: fluticasone, mometasone, budesonide, others
Suffix is one or ide
Best in combo with bronchodilators

Pulmonary
4. LABA plus LAAC (Long Acting Anticholinergic)

Combo Dosing Frequency Cost
Olodaterol/Tiotropium (Stiolto Respimat) Daily $315.68
Vilanterol/Umeclidinium (Anoro Ellipta) Daily $280.95
Prescribing Strategy for COPD

1. Short acting anticholinergic PRN or SA Beta2 PRN, then
2. Long acting anticholinergic or LABA; plus rescue med, then
3. ICS + LABA or LA anticholinergic; plus rescue med, then
4. ICS + LABA and/or LA anticholinergic; plus rescue med
*Theophylline is an alternate treatment but not preferred (relatively inexpensive).

**PDE4: phosphodiesterase inhibitor (roflumilast, Daliresp) used to reduce
exacerbations for patients with chronic bronchitis, severe airflow limitation and
frequent exacerbations not controlled by LABAs.
A 65 year old male who has COPD has been using his albuterol inhaler several
times daily for the past 3 days. His mucus has become brown and he feels low
energy. He is afebrile. What is the most likely cause for this change in his
status?
1. Community acquired pneumonia

2. Acute bronchitis
3. COPD exacerbation
4. Bronchiectasis
Exacerbations
Definition from www.goldcopd.org/
An acute event characterized by a worsening of the patients respiratory

symptoms beyond the normal day to day variations and leads to a change in
medication
Oral Steroids for Exacerbations

Shorten recovery time
Improve lung function (FEV1) and arterial hypoxemia (PaO2)
Reduce the risk of early relapse, treatment failure, and length of hospital stay
A dose of 40 mg prednisone per day for 5 days is recommended
Oral Steroids
CHRONIC use should be avoided!!!
Unfavorable risk to benefit ratio

Pulmonary
Common Co-Morbidities Associated with COPD

Diseases Implications
HTN, hyperlipidemia, CAD, Multiple medications
tachyarrhythmias
Osteoporosis Possibility for drug-
drug interactions
Depression and anxiety Possibility of drug-
disease interactions
Metabolic syndrome/DM More complex patients
Lung cancer
What is the single most effective intervention for preventing exacerbations of

COPD?
1. Starting medications early in the course of the disease

2. Use of anticholinergic meds
3. Regular exercise; flu, pneumococcal vaccines
4. Quitting smoking
What is the single most effective intervention for preventing the progression of
COPD?
1. Starting medications early in the course of the disease

2. Use of anticholinergic meds
3. Regular exercise; flu, pneumococcal vaccines
4. Quitting smoking
Health Promotion
Smoking cessation is the single most effective and cost effective intervention
to reduce the risk of COPD and its progression.
Encourage smoking cessation at each visit!!!
Its never too late to quit!
Encourage regular exercise
PPSV immunization
Influenza immunization annually
Additional Notes:

Pulmonary
ASTHMA
Exercise Induced Bronchospasm (EIB)
Guideline from the National Asthma Educations and Prevention Program
Expert Panel Report 3
Asthma is a disease of inflammation!!!
1. Establish Asthma Diagnosis

Symptoms of recurrent airway obstruction from history and exam
Cough
Wheezing
SOB
Chest tightness
Spirometry
Symptoms are predictable (Amelies Pearl)
Spirometry is used to demonstrate:
1. presence of asthma.
2. presence of airway obstruction.
3. presence of airway constriction.
4. long term benefits of treatment.
2. Classify Asthma Severity:
Intermittent Asthma
Intermittent
Components of Severity
Ages 0-4 years Ages 5-11 years Ages 12 years
Symptoms 2 days/week
Nighttime awakenings 0 2 x/month
SABA* use for symptom control
Impairment
2 days/week
(not to prevent EIB*)
Interference with normal activity None
Lung function Normal FEV1 Normal FEV1
between between
Not applicable exacerbations exacerbations
FEV1* (% predicted) > 80% > 80%
FEV1/FVC* > 85% Normal
Asthma exacerbations requiring 0-1/year
Risk
oral systemic corticosteroids

Consider severity and interval

Pulmonary
Persistent Asthma
Mild Moderate Severe
Ages Ages Ages Ages Ages Ages Ages Ages Ages
0-4 5-11 12 0-4 5-11 12 0-4 5-11 12
years years years years years years years years years
> 2 days/week but not daily Daily Throughout the day
1-2 3-4 > 1 x/week but not
3-4 x/month > 1 x/week Often 7 x/week
x/month x/month nightly
>2 > 2 days/week but
days/week not daily and not
Daily Several times per day
but not more than once on
daily any day
Minor limitation Some limitation Extremely limited
> 80% > 80% 60-80% 60-80% < 60% < 60%
Not Not Not
applicable applicable Reduced applicable Reduced
> 80% Normal 75-80% < 75%
5% 5%
exacerb.
in 6
months, or
wheezing
4 x per
year lasting 2/year Generally, more frequent and intense events indicate greater severity.
> 1 day
AND risk
factors for
persistent
asthma
3. Initiate Medication:
Preferred Meds
Intermittent Asthma Persistent Asthma
SABA as needed Low dose ICS
Low dose ICS plus LABA, or
Medium dose ICS
Medium dose ICS plus LABA
Alternate Meds
Intermittent Asthma Persistent Asthma
SABA as needed Cromolyn, LTRA, or theophylline
Low dose ICS plus LTRA, theophylline,
or zileuton
Medium dose ICS plus LTRA,
theophylline, or zileuton
4. Asthma Action Plan:

Sample action plan:
www.nhlbi.nih.gov/health/public/lung/asthma/asthma_actplan.pdf
Loads of education!!!

Pulmonary
5. Follow up Appointment:
Asthma care is very variable
Every 2-6 weeks while gaining control
Every 1-6 months to monitor control
Every 3 months if step down is anticipated
Spirometry at least every 1-2 years; more frequently if asthma not well
controlled
Follow-up visits:
Assess & monitor asthma control
Review medication technique & adherence; assess side effects; review
environmental control
Maintain, step up, or step down medication
Review asthma action plan, revise as needed
Schedule next follow-up appointment
Bronchodilators
Every asthma patient MUST HAVE a rescue med!!!
short acting beta agonist (SABA)
This is a safety issue!
Exercise Induced Bronchoconstriction (EIB)

Treat before exercise
SABA for most patients
Consider: ICS (EIB is often marker of inadequate asthma control)
Expert Panel Report 3 www.nhlbi.nih.gov/guidelines/asthma
A 30 year old who has asthma has used low dose steroid inhaler twice daily with
good control for the past 3 months. In the last week, he has had to use his
inhaler 2-3 times daily for wheezing. What is the best plan to help alleviate his
symptoms?
1. Add oral steroid once daily for 5 days

2. Add ipratropium twice daily
3. Increase steroid inhaler to medium dose
4. Discontinue the steroid, add a LABA
Whats another good option?_________________________________________
Health Promotion
Pneumococcal immunization
Influenza immunization annually
Encourage regular exercise

Pulmonary
Patient Education
Knows how to use asthma action plan
Patient knows names of his meds, checks expiration dates
Uses inhaler properly, knows when empty
Knows when to use rescue meds
Additional Notes:

Pulmonary
CHECK YOUR KNOWLEGDE
Mr. Jones has a 20 pack year smoking history. He presents with right posterior
wheezing. He is otherwise asymptomatic. What should the nurse practitioner do
next?
1. Prescribe an albuterol inhaler

2. Order chest CT contrast
3. Order pulmonary function tests
4. Order chest x-ray
Mr. Jones chest x-ray demonstrates right hilar nodes. What should the nurse
practitioner do next?
1. Refer to pulmonology
2. Order chest CT with contrast
3. Treat with 750 mg levofloxacin for 5 days
4. Repeat chest x-ray in 2 weeks
In which patient is a chest x-ray indicated today?
1. A 45 year old smoker with possible acute bronchitis

2. A 56 year old with resolving pneumonia (diagnosed 1 week ago)
3. A 65 year old with COPD in clinic for routine follow up appointment
4. A 75 year old who feels well but has had cough for 7 weeks
A 30 year old has persistent asthma. What are essential components of his plan
of care? Select all that apply.
1. Asthma action plan

2. Flu and pneumococcal immunizations
3. Rescue inhaler
4. Long acting beta agonist
What characteristic describes a cough associated with ACE inhibitor use?
1. It usually begins within 1-2 weeks after starting an ACE inhibitor

2. It usually begins after 4-8 weeks of use
3. A different ACE inhibitor probably will not produce the same cough
4. It occurs more frequently in patients who have asthma or COPD

Pulmonary
Every effort should be made to decrease asthma exacerbations. What is the

most important reason for this?
1. Prevent progressive loss of lung function

2. Minimize missed work/school days
3. Cost avoidance when exacerbations occur
4. Prevention of osteopenia and/or osteoporosis
Asthma or COPD or BOTH?

Asthma COPD
Consider steroid first line for treatment
Anticholinergics usually relieve symptoms
Disease is typically progressive
LABA alone is safe
Diagnosis usually made as an adult
Needs rescue inhaler
A 24 year old college student (otherwise healthy, non-smoker) has community

acquired pneumonia diagnosed by chest x-ray (taken 48 hours ago). She has
taken amoxicillin with clavulanate 875 mg BID for the past 48 hours. How should
she be managed?
2 days ago: Today:
BP: 120/72 BP: 130/80
HR: 96 bpm HR: 100 bpm
Temp: 103F Temp: 102.2F
RR: 24/min RR: 24/min
O2 Sat: 92% O2 Sat: 94%
1. Repeat chest x-ray, CBC

2. Start levofloxacin daily
3. Continue this plan for another 24 hours
4. Stop amoxicillin with clavulanate and start 100 mg doxycycline BID for
7 days.
A 63 year old patient with COPD complains of a pounding heart after taking his
inhaler. Which one is the least likely culprit?
1. Steroid
2. Albuterol
3. Ipratropium
4. Salmeterol

Pulmonary
A 24 year old patient presents with white plaques on the buccal mucosa, palate,
and tongue. What medication is the most likely reason for this finding?
1. Oral levofloxacin
2. Inhaled albuterol
3. Inhaled fluticasone
4. Inhaled ipratropium
Mr. Boudreaux, a 78 year old male smoker, has Stage II COPD. He presents to
the nurse practitioner today with complaints of nocturia and the sensation of
incomplete emptying of his bladder. How should this be handled?
Med List:
Losartan 50 mg, 12.5 HCTZ
Amlodipine 5 mg daily
Tamsulosin 0.8 mg (Flomax) daily
Atorvastatin 10 mg (Lipitor)
Albuterol inhaler 2 puffs PRN SOB
Tiotropium (Spiriva) once daily
1. Refer to urology
2. Increase tamsulosin to BID
3. Stop tiotropium, add salmeterol
4. Lifestyle modifications for urinary complaints
A 30 year old female patient with moderate persistent asthma has temperature of
102F, bilateral wheezes, mild SOB, and purulent sputum. How should she be
managed today?
Meds: Fluticasone/salmeterol BID, Albuterol PRN, Amlodipine 5 mg,

levothyroxine 88 mcg daily, metformin 1000 mg BID
1. Order nebulized albuterol, treat with doxycycline

2. Treat with ciprofloxacin, nebulized albuterol every 4-6 hours as
needed
3. Treat as acute bronchitis, use oral steroids only
4. Treat as pneumonia with levofloxacin, use nebulized albuterol every
4-6 hours as needed for wheezing

Pulmonary
Suppose the patient in the previous question was pregnant. How could she be
managed?
Meds: Fluticasone/salmeterol BID, Albuterol PRN, Amlodipine 5 mg,

levothyroxine 88 mcg daily, metformin 1000 mg BID
1. Levofloxacin 750 mg daily x 5 days

2. Azithromycin 500 mg day 1, 250 mg days 2-5, 1000 mg amoxicillin
BID
3. Amox/clavulanate 875 mg BID x 5 days
What are the most common side effects(s) of long term inhaled steroid use?
1. Osteoporosis and GERD

2. Hypertension and diabetes
3. Hyperkalemia and diabetes
4. Cataracts and osteopenia
Resources for Pulmonary
CareOnPoint (COP): www.careonpoint.com

Clinical Guidelines in Primary Care; Amelie Hollier, DNP, FNP-BC, FAANP
(2016)
Breath sounds: easyauscultation.com
Additional Notes:

Hollier Pulmonary 2017

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Advanced Practice Education Associates

14 Copyright 2017 Advanced Practice Education Associates

A Day In Clinical Practice

1. Doxycycline 100 mg BID x 7 days

Community Acquired PNEUMONIA (CAP)

Atypical organisms (cause atypical pneumonia):

Copyright 2017 Advanced Practice Education Associates 15

Community Acquired Pneumonia (ambulatory)

A Day In Clinical Practice

1. Levofloxacin 750 mg daily x 5 days

IDSA and ATS 2007 Guidelines for Treatment of Pneumonia

16 Copyright 2017 Advanced Practice Education Associates

A Day In Clinical Practice

1. Order a chest x-ray

A Day In Clinical Practice

Which characteristic is the LEAST likely to prompt the nurse practitioner to

1. Confusion since onset of pneumonia symptoms

Pneumococcal Vaccines - PCV 13, PPSV 23

Whats your exam strategy for immunizations?

Copyright 2017 Advanced Practice Education Associates 17

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Key Indicators of COPD

Diagnosis for COPD:

Differential Diagnosis for COPD:

18 Copyright 2017 Advanced Practice Education Associates

GOLD Staging System The Global Initiative for COPD

A Day In Clinical Practice

Which patient is most characteristic of someone who has COPD?

1. 25 years old, smoker, cough > 1 year

Therapeutic Options: COPD Medications

Copyright 2017 Advanced Practice Education Associates 19

Chronic Obstructive Pulmonary Disease (COPD)

"An Ode to an Anticholinergic Med"

20 Copyright 2017 Advanced Practice Education Associates

4. LABA plus LAAC (Long Acting Anticholinergic)

Prescribing Strategy for COPD

*Theophylline is an alternate treatment but not preferred (relatively inexpensive).

A Day In Clinical Practice

1. Community acquired pneumonia

An acute event characterized by a worsening of the patients respiratory

Oral Steroids for Exacerbations

Copyright 2017 Advanced Practice Education Associates 21

Common Co-Morbidities Associated with COPD

A Day In Clinical Practice

What is the single most effective intervention for preventing exacerbations of

1. Starting medications early in the course of the disease

A Day In Clinical Practice

1. Starting medications early in the course of the disease

22 Copyright 2017 Advanced Practice Education Associates

Asthma is a disease of inflammation!!!

1. Establish Asthma Diagnosis

A Day In Clinical Practice

Spirometry is used to demonstrate:

2. Classify Asthma Severity:

oral systemic corticosteroids

Copyright 2017 Advanced Practice Education Associates 23

4. Asthma Action Plan:

24 Copyright 2017 Advanced Practice Education Associates

Exercise Induced Bronchoconstriction (EIB)

A Day In Clinical Practice

1. Add oral steroid once daily for 5 days

Whats another good option?_________________________________________

Copyright 2017 Advanced Practice Education Associates 25