Nonpharmacologic Management Essay Examples
Nonpharmacologic Management Essay Examples
Know presentation, DX and Management
Diagnoses List
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
Nonpharmacologic Management Essay Examples
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/guaifenesin
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 secretions
Robitussin DM
various generics
Dextromethorphan 10 mg/5 mL
Guaifenesin 100 mg/5 mL
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 hrChildren 6-12 years: 5 mL q 4 hr prn cough
Max: 6 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 interaction with 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 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.
Caution if nephrolithiasis
Caution in patients under 6 years
Take with plenty of water; do not cut/crush/chew ER tab
Short-Acting Bronchodilators
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
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) quick relief: refer to adult dosing for all 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
Inhalation:
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 dry completely prior to use. A spacer device or valved holding chamber is recommended for use with metered-dose inhalers.
Storage
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 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
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:
Cervical adenopathy
Fever >102° F (38.8° C)
Absence of other upper respiratory findings (cough, nasal congestion, etc.)
Petechiae on soft palate
“Beefy red” tonsils
“Sandpaper” rash (bridge of nose, neck, and/or torso)
Abdominal pain, headache
Streptococcal tonsillitis has a distinct odor
Suggestive of viral infection:
Concurrent conjunctivitis, nasal congestion, hoarseness, cough, diarrhea or viral rash
Modified Centor Clinical Prediction Rule for Group A Strep infection
Tonsillar exudates
+1 point
Tender anterior chain cervical adenopathy
+1 point
Fever by history
+1 point
Age <15 years
+1 point
Age 15-45
0 points
Age >45
-1 point
Cough (almost always excludes Streptococcus)
-1 point
3-4 points: treat empirically for Strep infection
2 points: rapid Strep test, treat if positive
1 point: unlikely Strep
0 or -1 points: do not test or treat
DIFFERENTIAL DIAGNOSIS
Upper respiratory illness
Tonsillitis
Mononucleosis
DIAGNOSTIC STUDIES
Rapid antigen strep test (95-99% specific).
The swab should be taken from the tonsils, tonsillar fossa, and the posterior pharyngeal wall. Good specimen is essential
In children and adolescents, negative rapid antigen test should be confirmed with a throat culture. Confirmation not necessary in adults due to lower risk for the development of acute rheumatic fever
10% of patients with mononucleosis have concomitant Strep infection
Antistreptolysin (ASO) titer should not be ordered to diagnose acute infection (ASO detects past infection)
PREVENTION
Avoid contact with infected people during outbreaks
Good hand washing, especially during cold weather months
Teach patients not to share drinking glasses, eating utensils, etc.
Prompt treatment of patients with family history of rheumatic fever
NONPHARMACOLOGIC MANAGEMENT
Gargling with warm salt water
Increased fluid intake
Patient education about disease, course and treatment
Change toothbrush after treatment
PHARMACOLOGIC MANAGEMENT
Antipyretics/analgesics (acetaminophen, ibuprofen) are adjunctive treatment for fever and throat pain
Empiric treatment of asymptomatic household contacts of strep pharyngitis patients is not routinely recommended
For Strep pharyngitis, amoxicillin and penicillin V (10 days) are drugs of choice. For penicillin-allergic children, cephalexin/cefadroxil/clindamycin (10 days) or macrolides (5 days) are recommended
Antibiotics no benefit in treatment of nonstrep pharyngitis infections. Exceptions are Corynebacterium diphtheriae, Neisseria gonorrhoeae, and others
Medication (based on patient’s age or weight)
Treatment
Penicillin G
One IM injection
Penicillin V
Amoxicillin
Requires 10 days of treatment
First-generation
cephalosporins
Requires 10 days of treatment
Second-generation
cephalosporins
5 days of treatment
Azithromycin (for PCN allergy); limited efficacy against Streptococcal infection and should only be used for patients with documented history of PCN anaphylaxis or hives
12 mg/kg dose daily x 5 days
Clindamycin 7 mg/kg TID x 10 days for resistant/chronic recurrent Streptococcal infection
Mupirocin BID-TID to nasal mucosa for carrier
STREPTOCOCCUS A PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
Penicillin Bacterial;
Bactericidal: inhibits cell wall mucopeptide synthesis; inhibits beta-lactamaseGeneral comments
Indicated for infections caused by penicillinase-sensitive microorganisms
Generally well tolerated; watch for hypersensitivity reactions
Clavulanate broadens spectrum of coverage
Consider amoxicillin/clavulanate if failure after 72 hours
Give in divided doses
Amoxicillin and Penicillin V are considered first-line agents in most cases, unless other antibiotic exposure in the last 90 days
The course of treatment is 10 days for all beta-lactam antibiotics, but FDA has approved 5-day course of cefdinir and cefpodoxime
penicillin V potassium
Adult: 500 mg 2-3 times daily for 10 days
Children: 250 mg PO BID-TID for 10 days
Adolescents: 500 mg PO BID for 10 days
Lactation: Safe
Give 1 hour before and 2 hours after meals
Pen V K
Tablet: 250 mg, 500 mg
Oral Solution: 125 mg/5 mL, 250 mg/5 mL
penicillin G benzathine
Adult: 1.2 million units IM for 1 dose
<27 kg: 0.6 million units IM for 1 dose
≥27 kg: 1.2 million units IM for 1 dose
Lactation: Safe
Do not confuse Bicillin L-A with Bicillin C-R
Do not confuse penicillin G benzathine with penicillamine or penicillin G procaine. They are NOT interchangeable
Very painful injection if not combined with Penicillin G procaine (Ex. 900,000 units of Penicillin G benzathine + 300,000 units of Penicillin G procaine = 1.2 million units)
Bicillin L-A
Injection: 600,000 units/mL, 1.2 million units/2 mL
NOT FOR IV USE
amoxicillin
Adult: 500-875 mg PO q 12 hr for 10-14 days (higher dosing for severe infections)
Children:
>40 kg: dose for 10 days
50 mg/kg once daily for 10 days
Max: 1 g/day
Alternate: 25 mg/kg BID for 10 days
Max: 500 mg/dose
GI side effects
Amoxicillin is not stable in the presence of beta lactamase producing organisms
DO NOT USE IF HISTORY OF HIVES OR ANAPHYLAXIS TO PENICILLIN
Decrease dose for renal impairment
Children’s dose of amoxicillin should never exceed maximum adult dose
Amoxil
Caps: 250 mg, 500 mg
Tabs: 500 mg, 875 mg
Suspension: 250 mg/5 mL;
400 mg/5 mL
Pediatric drops: 50 mg/mL
Moxatag
775 mg ER Tab daily for 10 days
continued
STREPTOCOCCUS A PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
Macrolides
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrestGeneral comments
Effective treatment for S. pyogenes in the presence of penicillin allergy
Associated with higher rates of GI side effects
Age, weight and severity of infection determine dose in children
Local antibiotic resistant rates should be considered prior to prescribing.
azithromycin
Adult:
Usual: 500 mg daily for 3 days
Alternative: 2 g as a single dose or 500 mg on day 1 and 250 mg days 2-5Children >6 months old:
Usual: 10 mg/kg once daily for 3 days or 10 mg/kg on day 1 and 5 mg/kg days 2-5
Max: 500 mg daily
Lactation: Safety Unknown
First-line for penicillin allergic (Type I allergic reaction)
Consider clindamycin, if failure after 48-72 hours
Avoid concomitant use of aluminum or magnesium containing antacids
Cautious use if renal or hepatic impairment
Hypersensitivity reactions may recur after initial successful symptomatic treatment
Zithromax
Tabs: 500 mg, 250 mg
Powder: 2 g/bottle
Suspension: 100 mg/5 mL,
200 mg/5 mL
clarithromycin
Adult: 250 mg PO q 12 hr for 10 days
Children 6 months and older:
15 mg/kg/day PO divided q 12 hr for 10 days
Max: 250 mg/dose
Cautious use in patients with either renal or hepatic dysfunction
Clarithromycin may be involved in drug reactions involving CYP 450 system; special care when prescribing concurrently with 3A4 substrate medications
Common side effect is an abnormal taste in mouth while taking tablet or suspension
Biaxin
Coated tabs: 250 mg, 500 mg
Biaxin XL
Coated tabs extended release: 500 mg
Other Antibacterials
Bacteriostatic or bactericidal, inhibits protein synthesisGeneral comments
Half-life is 2.4-3 hours
Carries a black box warning for C. difficile associated diarrhea
clindamycin
Adult: 300 mg PO q 8 hr for 10 days
Children: 7 mg/kg/day PO divided q 8 hr for 10 days
Max: 300 mg/dose
Adolescents: 150-300 mg PO q 6 hr
Max 300 mg per dose
Lactation: Probably Unsafe
May cause exfoliative dermatitis
Caution in hepatic dysfunction
Only use if other antibiotics have been unsuccessful
Use in patients with initial bacterial failure who are penicillin/cephalosporin allergic with Type I reaction; consider use in patients who failed therapy with ceftriaxone (used in conjunction with tympanocentesis)
continued
STREPTOCOCCUS A PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
Cleocin
Injection: 150 mg/mL
Tabs: 75 mg, 150 mg, 300 mg
Capsule: 150 mg, 300 mg
Solution: 75 mg/5 mL
Granules for solution: 75 mg/5 mL
Cautious use in patients with hepatic, renal impairments, colitis
Side effects include pseudo-membranous colitis, C. difficile diarrhea
Take with a full glass of water
First Generation Cephalosporins
Arrests bacterial growth by inhibiting bacterial cell wall synthesisGeneral comments
Caution if recent antibiotic associated colitis
cephalexin
Adult: 500 mg PO q 12 hr for 10 days
Children >1 year of age:
25-50 mg/kg/d in 2-4 divided doses for 10 days
Max: 500 mg q 12 hr
Cautious use in patients with history of hives or anaphylaxis to penicillin
Dosage reduction needed for renal impairment
Give without regard to meals
PT should be monitored in patients at risk: renal or hepatic impairment, poor nutritional state
After mixing suspension, store in refrigerator for up to 14 days
Keflex
Caps: 250 mg, 500 mg, 750 mg
Tablets: 250 mg, 500 mg
Suspension: 125 mg/5 mL,
500 mg/5 mL
cefadroxil
Adult: 1 g PO daily in divided doses q 12 hr for 10 days
Children: 30 mg/kg PO divided q 12 hr for 10 days
Cautious use in patients with history of hives or anaphylaxis to penicillin
Dosage reduction needed for renal impairment
No dosage reduction needed for geriatric patients
Duricef
Caps: 500 mg, 1000 mg,
Tabs: 1000 mg
Suspension: 250 mg/5 mL,
500 mg/5 mL
CONSULTATION/REFERRAL
Evidence of acute renal failure and reddish, tea-colored urine (2-3 weeks post infection) may indicate acute poststreptococcal glomerulonephritis
Tonsillar edema and upper airway obstruction
Peritonsillar abscess
Tonsillectomy is not recommended to reduce the frequency of Strep pharyngitis
FOLLOW-UP
None usually needed
Patient no longer considered contagious after 24 hours on antibiotic
Follow-up culture not recommended, may be done to assure compliance
EXPECTED COURSE
Peak fever and pain on days 2 and 3
Lasts 4-10 days
POSSIBLE COMPLICATIONS
Upper airway obstruction
Acute post-Strep glomerulonephritis after Streptococcal infection
May develop sloughing of skin on fingertips and toes in weeks following Strep infection
Acute maxillary sinusitis
DESCRIPTION
Also known as: (Acute Rhinosinusitis, Recurrent Acute Rhinosinusitis, Chronic Rhinosinusitis)
Inflammation of at least one paranasal sinus due to bacterial, viral, or fungal infection; or allergic reaction. Annually, acute bacterial rhinosinusitis costs more than $3 billion and accounts for more outpatient antibiotic prescriptions than any other diagnosis. The terms sinusitis and rhinosinusitis are used interchangeably because inflammation of the sinus cavities and nasal cavities are usually concurrent.
Classification
Acute rhinosinusitis (ARS): symptoms <12 weeks
Recurrent ARS (RARS): at least three episodes of acute bacterial rhinosinusitis in a year
Chronic rhinosinusitis (CRS): symptoms of varying severity >12 weeks. Further classified with or without nasal polyps; abnormal findings on CT scan or nasal endoscopy
ETIOLOGY
Bacterial
Acute
sinusitis
Streptococcus pneumoniae species (most common)
Haemophilus influenza (common in smokers)
Moraxella catarrhalis
Viral
Rhinovirus
Coronavirus
Influenza A and B
Parainfluenza virus
Respiratory syncytial virus
Chronic
sinusitis
Gram-negative more likely
Staphylococcus aureus
Pseudomonas aeruginosa
Anaerobic organisms
Vast majority of rhinosinusitis cases are due to viruses, NOT bacteria. Viral URIs usually precede ba
