NR 601 QUESTIONS AND ANSWERS
Treatment standards (Dunphy p. 383 ✅✅ANSW-Antimicrobial therapy represents the mainstay
of treatment for patients with suspected or confirmed pneumonia. Additional management is
supportive and includes the use of analgesics for relief of chest pain and myalgia, antipyretics to
control fever, increased fluid intake (typically at least 3 L over 24 hours), restricted activity or
bedrest, a position of comfort (usually upright) to facilitate breathing, and humidified air to relieve
irritated nares and pharynx. Expectorants may be indicated to decrease sputum viscosity and clear
airways if a productive cough is present
PATIENT PROFILE
ANTIMICROBIAL AGENT
Uncomplicated CAP
Without recent antibiotic therapy (ATBX)*
Azithromycin (Zithromax) or clarithromycin (Biaxin) or doxycycline (Vibramycin)
With recent ATBX†
Respiratory fluoroquinolone moxifloxacin (Avelox) or levofloxacin (Levaquin)
OR
Azithromycin or clarithromycin PLUS
High-dose amoxicillin (Amoxil) OR
Azithromycin or clarithromycin PLUS
High-dose amoxicillin-clavulanate (Augmentin)
Patient with CAP plus comorbidities: alcoholism; diabetes mellitus; lung/liver/renal diseases
Respiratory fluoroquinolone
OR
Beta-lactam
IV/intramuscular ceftriaxone (Rocephin) or
Cefuroxime (Ceftin)
PLUS
Macrolide
Patient with community-acquired methicillin-resistant S. aureus pneumonia
Vancomycin (Vancocin)
OR
,Linezolid (Zyvox)
Þ Scoring ✅✅ANSW-0-1: Low risk; consider outpatient treatment
2: Brief hospitalization or closely monitored outpatient treatment
≥ 3: Severe, hospitalize and possible ICU
Obstructive & Restrictive Airway Disease (Kahn Academy video and Dunphy
Understand the PFT interpretation for both (Kahn Academyvideo): ✅✅ANSW-Þ
https://www.alphanetbfrg.org/pdfs/Understanding-PFT.pdf
FEV1=forced expiratory volume in the 1st second of expiration Obstructive disease: TLC increases, TV
remains the same, IRV decreases, ERV increases and the RV increases, FVC is the same or decreases,
FRC increases because of the reduction of airflow to the lungs due to obstruction and air trapping.
To diagnose: FVC1/FVC is less than 0.7 (less than 70%) Restrictive lund disease: TV remains the same,
IRV is reduced bc of fibrosis, ERV is reduced, RV is reduced, FVC is reduced, FRC is reduced , TLC is
reduced, FVC is reduced however FVC1 is not as affected as in those with obstructive lung disease, in
restrictive lung disease the FVC1 can be normal The FEV1/FVC ratio is not as affected neither >0.7
(around 75% in the you tube scenario) thus its restrictive • Fibrosis causes stiffness and restrictions
causing reduction in lung volumes and lung capacities
PFT: ✅✅ANSW-Normal FEV 1 /FVC ratio but decreased FVC and FEV 1; decreased total lung
capacity, residual volume, and functional residual capacity. Residual volume-to-total lung capacity
ratio is normal to low.
Know which airway diseases are reversible and irreversible ✅✅ANSW-FEV 1 /FVC ratio before
and after bronchodilator challenge, showing an improvement of 12% and 200 mL, indicates
reversible airway obstruction
COPD: non reversible
Emphysema: non reversible
Asthma: reversible
Obstructive pattern ✅✅ANSW-Þ An FEV1/FVC <70/80% suggests obstructive lung disease.
o Decreased FEV1, normal or decreased FVC, and decreased FEV1/FVC
o Classically, these are the patients with asthma, chronic bronchitis, or emphysema
§ PFTs can help further distinguish between the above three:
,§ Bronchodilator responsiveness - an increase in the FEV1 by 12% following bronchodilator use
suggests asthma
§ Bronchial provocation - inducing asthmatic obstruction of reactive lower airways by administering
methacholine, histamine, or adenosine monophosphate
§ DLCO will be decreased in patients with emphysema, and can be normal or increased in patients
with asthma
o Lower airway obstruction vs. upper airway obstruction
§ Lower airway obstruction typically displays impaired expiratory capacity (see image below), while
upper airway obstruction has impaired inspiratory capacity, which can be evident on the flow
volume loop (seen as flattening of the inspiratory arm).
Restrictive pattern ✅✅ANSW-Þ restrictive lung disease typically has normal or increased
FEV1/FVC
o Decreased TLC, FEV1, and FVC with a normal FEV1/FVC, and a low DLCO
o Typically, these are patients with interstitial lung disease, severe skeletal abnormalities, or
diaphragmatic paralysis
o The flow volume loop is generally normal in appearance, but has low lung volumes
Spirometry (Kahn Academy video and readings)
Know definitions for each spirometry criteria: ✅✅ANSW-Þ Spirometry measures two key factors:
expiratory forced vital capacity (FVC) and forced expiratory volume in one second (FEV1). Your
doctor also looks at these as a combined number known as the FEV1/FVC ratio. If you have
obstructed airways, the amount of air you're able to quickly blow out of your lungs will be reduced.
This translates to a lower FEV1 and FEV1/FVC ratio. Forced vital capacity (FVC). This is the largest
amount of air that you can forcefully exhale after breathing in as deeply as you can. A lower than
normal FVC reading indicates restricted breathing. Forced expiratory volume (FEV). This is how much
air you can force from your lungs in one second. This reading helps your doctor assess the severity of
your breathing problems. Lower FEV-1 readings indicate more significant obstruction.
Spirometry
Þ PFTs can be used in a variety of settings, and they are generally ordered to:
o Look for evidence of respiratory disease when patients present with respiratory symptoms (e.g.
dyspnea, cough, cyanosis, wheezing, etc.).
o Assess for any progression of lung disease.
o Monitor the efficacy of a given treatment.
o Evaluate patients pre-operatively; and
o Monitor for potentially toxic side effects of certain drugs (e.g. amiodarone)
, Þ The components of PFTs include:
o Lung volumes
o Spirometry and flow volume loops
o Diffusing capacity
Þ Know criteria to determine severity (FEV1) ✅✅ANSW-Stage 1 Mild: FEV1≥80% predicted Stage
2 Moderate: FEV1<50% to <80% predicted Stage 3 Severe: FEV1>30% to <50% predicted Stage 4 very
severe: FEV1<30% predicted
Þ Know criteria for diagnosis of obstruction (FEV1/FVC ratio
FEV1/FVC ratio (<70%) ✅✅ANSW-Þ Stage 1: Very mild COPD with a FEV1 about 80 percent or
more of normal.
Þ Stage 2: Moderate COPD with a FEV1 between 50 and 80 percent of normal.
Þ Stage 3: Severe emphysema with FEV1 between 30 and 50 percent of normal.
Þ Stage 4: Very severe COPD with a lower FEV1 than Stage 3, or those with Stage 3 FEV1 and low
blood oxygen levels
Þ Know criteria for diagnosis of reversible vs irreversible ✅✅ANSW-If the patient has an
obstructive defect, the physician should determine if it is reversible based on the increase in FEV1 or
FVC after bronchodilator treatment (i.e., increase of more than 12% in patients five to 18 years of
age, or more than 12% and more than 200 mL in adults). Obstructive defects in persons with asthma
are usually fully reversible, whereas defects in persons with COPD typically are not. If a patient's
prior PFT results are available, they should be compared with the current results to determine the
course of the disease or effects of treatment. According to Dunphy: • FVC=Forced vital capacity is
the total volume exhaled during one spirometry maneuver (patient forcefully exhales into the
spirometer) • FEV1 =volume exhaled in 1 sec (forced expiratory volume over 1 second) • FEV1/FVC
ratio is expressed as a percentage of FVC
TABLE 31.2 Pulmonary Function and Physical Findings in Obstructive and Restrictive Lung Diseases
ParametersAsthmaChronic BronchitisEmphysemaRestrictive DiseaseForced vital capacity
(FVC)NormalNormal to increasedNormal to increasedDecreasedResidual volume (RV)Normal;
increased during attacksIncreasedIncreasedDecreased or normalTotal lung capacity (TLC)Normal to
increasedNormalNormal to increasedDecreasedRV/TLCNormal to
increasedIncreasedIncreasedNormalExpiratory flow ratesNormal to decreasedNormal to
decreasedNormal to decreasedNormal to increasedFEV1/FVCNormal to
decreasedDecreasedDecreasedNormal to increasedBronchodilator response (% change)>15%0%-
15%NoneNoneDiffusing capacityNormal to increasedNormal to decreasedDecreasedNormal or
decreased (depends on type of disease)PaO2Normal; decreased during attackDecreasedNormal in
mild to moderate disease; decreased in severe diseaseNormal or decreasedPaCO2First decreased,
then increased during acute attackIncreasedNormal until advanced di
Treatment standards (Dunphy p. 383 ✅✅ANSW-Antimicrobial therapy represents the mainstay
of treatment for patients with suspected or confirmed pneumonia. Additional management is
supportive and includes the use of analgesics for relief of chest pain and myalgia, antipyretics to
control fever, increased fluid intake (typically at least 3 L over 24 hours), restricted activity or
bedrest, a position of comfort (usually upright) to facilitate breathing, and humidified air to relieve
irritated nares and pharynx. Expectorants may be indicated to decrease sputum viscosity and clear
airways if a productive cough is present
PATIENT PROFILE
ANTIMICROBIAL AGENT
Uncomplicated CAP
Without recent antibiotic therapy (ATBX)*
Azithromycin (Zithromax) or clarithromycin (Biaxin) or doxycycline (Vibramycin)
With recent ATBX†
Respiratory fluoroquinolone moxifloxacin (Avelox) or levofloxacin (Levaquin)
OR
Azithromycin or clarithromycin PLUS
High-dose amoxicillin (Amoxil) OR
Azithromycin or clarithromycin PLUS
High-dose amoxicillin-clavulanate (Augmentin)
Patient with CAP plus comorbidities: alcoholism; diabetes mellitus; lung/liver/renal diseases
Respiratory fluoroquinolone
OR
Beta-lactam
IV/intramuscular ceftriaxone (Rocephin) or
Cefuroxime (Ceftin)
PLUS
Macrolide
Patient with community-acquired methicillin-resistant S. aureus pneumonia
Vancomycin (Vancocin)
OR
,Linezolid (Zyvox)
Þ Scoring ✅✅ANSW-0-1: Low risk; consider outpatient treatment
2: Brief hospitalization or closely monitored outpatient treatment
≥ 3: Severe, hospitalize and possible ICU
Obstructive & Restrictive Airway Disease (Kahn Academy video and Dunphy
Understand the PFT interpretation for both (Kahn Academyvideo): ✅✅ANSW-Þ
https://www.alphanetbfrg.org/pdfs/Understanding-PFT.pdf
FEV1=forced expiratory volume in the 1st second of expiration Obstructive disease: TLC increases, TV
remains the same, IRV decreases, ERV increases and the RV increases, FVC is the same or decreases,
FRC increases because of the reduction of airflow to the lungs due to obstruction and air trapping.
To diagnose: FVC1/FVC is less than 0.7 (less than 70%) Restrictive lund disease: TV remains the same,
IRV is reduced bc of fibrosis, ERV is reduced, RV is reduced, FVC is reduced, FRC is reduced , TLC is
reduced, FVC is reduced however FVC1 is not as affected as in those with obstructive lung disease, in
restrictive lung disease the FVC1 can be normal The FEV1/FVC ratio is not as affected neither >0.7
(around 75% in the you tube scenario) thus its restrictive • Fibrosis causes stiffness and restrictions
causing reduction in lung volumes and lung capacities
PFT: ✅✅ANSW-Normal FEV 1 /FVC ratio but decreased FVC and FEV 1; decreased total lung
capacity, residual volume, and functional residual capacity. Residual volume-to-total lung capacity
ratio is normal to low.
Know which airway diseases are reversible and irreversible ✅✅ANSW-FEV 1 /FVC ratio before
and after bronchodilator challenge, showing an improvement of 12% and 200 mL, indicates
reversible airway obstruction
COPD: non reversible
Emphysema: non reversible
Asthma: reversible
Obstructive pattern ✅✅ANSW-Þ An FEV1/FVC <70/80% suggests obstructive lung disease.
o Decreased FEV1, normal or decreased FVC, and decreased FEV1/FVC
o Classically, these are the patients with asthma, chronic bronchitis, or emphysema
§ PFTs can help further distinguish between the above three:
,§ Bronchodilator responsiveness - an increase in the FEV1 by 12% following bronchodilator use
suggests asthma
§ Bronchial provocation - inducing asthmatic obstruction of reactive lower airways by administering
methacholine, histamine, or adenosine monophosphate
§ DLCO will be decreased in patients with emphysema, and can be normal or increased in patients
with asthma
o Lower airway obstruction vs. upper airway obstruction
§ Lower airway obstruction typically displays impaired expiratory capacity (see image below), while
upper airway obstruction has impaired inspiratory capacity, which can be evident on the flow
volume loop (seen as flattening of the inspiratory arm).
Restrictive pattern ✅✅ANSW-Þ restrictive lung disease typically has normal or increased
FEV1/FVC
o Decreased TLC, FEV1, and FVC with a normal FEV1/FVC, and a low DLCO
o Typically, these are patients with interstitial lung disease, severe skeletal abnormalities, or
diaphragmatic paralysis
o The flow volume loop is generally normal in appearance, but has low lung volumes
Spirometry (Kahn Academy video and readings)
Know definitions for each spirometry criteria: ✅✅ANSW-Þ Spirometry measures two key factors:
expiratory forced vital capacity (FVC) and forced expiratory volume in one second (FEV1). Your
doctor also looks at these as a combined number known as the FEV1/FVC ratio. If you have
obstructed airways, the amount of air you're able to quickly blow out of your lungs will be reduced.
This translates to a lower FEV1 and FEV1/FVC ratio. Forced vital capacity (FVC). This is the largest
amount of air that you can forcefully exhale after breathing in as deeply as you can. A lower than
normal FVC reading indicates restricted breathing. Forced expiratory volume (FEV). This is how much
air you can force from your lungs in one second. This reading helps your doctor assess the severity of
your breathing problems. Lower FEV-1 readings indicate more significant obstruction.
Spirometry
Þ PFTs can be used in a variety of settings, and they are generally ordered to:
o Look for evidence of respiratory disease when patients present with respiratory symptoms (e.g.
dyspnea, cough, cyanosis, wheezing, etc.).
o Assess for any progression of lung disease.
o Monitor the efficacy of a given treatment.
o Evaluate patients pre-operatively; and
o Monitor for potentially toxic side effects of certain drugs (e.g. amiodarone)
, Þ The components of PFTs include:
o Lung volumes
o Spirometry and flow volume loops
o Diffusing capacity
Þ Know criteria to determine severity (FEV1) ✅✅ANSW-Stage 1 Mild: FEV1≥80% predicted Stage
2 Moderate: FEV1<50% to <80% predicted Stage 3 Severe: FEV1>30% to <50% predicted Stage 4 very
severe: FEV1<30% predicted
Þ Know criteria for diagnosis of obstruction (FEV1/FVC ratio
FEV1/FVC ratio (<70%) ✅✅ANSW-Þ Stage 1: Very mild COPD with a FEV1 about 80 percent or
more of normal.
Þ Stage 2: Moderate COPD with a FEV1 between 50 and 80 percent of normal.
Þ Stage 3: Severe emphysema with FEV1 between 30 and 50 percent of normal.
Þ Stage 4: Very severe COPD with a lower FEV1 than Stage 3, or those with Stage 3 FEV1 and low
blood oxygen levels
Þ Know criteria for diagnosis of reversible vs irreversible ✅✅ANSW-If the patient has an
obstructive defect, the physician should determine if it is reversible based on the increase in FEV1 or
FVC after bronchodilator treatment (i.e., increase of more than 12% in patients five to 18 years of
age, or more than 12% and more than 200 mL in adults). Obstructive defects in persons with asthma
are usually fully reversible, whereas defects in persons with COPD typically are not. If a patient's
prior PFT results are available, they should be compared with the current results to determine the
course of the disease or effects of treatment. According to Dunphy: • FVC=Forced vital capacity is
the total volume exhaled during one spirometry maneuver (patient forcefully exhales into the
spirometer) • FEV1 =volume exhaled in 1 sec (forced expiratory volume over 1 second) • FEV1/FVC
ratio is expressed as a percentage of FVC
TABLE 31.2 Pulmonary Function and Physical Findings in Obstructive and Restrictive Lung Diseases
ParametersAsthmaChronic BronchitisEmphysemaRestrictive DiseaseForced vital capacity
(FVC)NormalNormal to increasedNormal to increasedDecreasedResidual volume (RV)Normal;
increased during attacksIncreasedIncreasedDecreased or normalTotal lung capacity (TLC)Normal to
increasedNormalNormal to increasedDecreasedRV/TLCNormal to
increasedIncreasedIncreasedNormalExpiratory flow ratesNormal to decreasedNormal to
decreasedNormal to decreasedNormal to increasedFEV1/FVCNormal to
decreasedDecreasedDecreasedNormal to increasedBronchodilator response (% change)>15%0%-
15%NoneNoneDiffusing capacityNormal to increasedNormal to decreasedDecreasedNormal or
decreased (depends on type of disease)PaO2Normal; decreased during attackDecreasedNormal in
mild to moderate disease; decreased in severe diseaseNormal or decreasedPaCO2First decreased,
then increased during acute attackIncreasedNormal until advanced di
