NU566 Midterm Review

NU566 Midterm Review

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Purdue University Global

NU566 NP I – Introduction to Primary Care for the Nurse Practitioner

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Neurological Disorders Review for Clinical Practice

Head Trauma and Intracranial Hemorrhage

Traumatic brain injuries require immediate assessment because different types of intracranial bleeding present with unique clinical patterns and require different management approaches. Early identification of neurological deterioration can prevent permanent disability or death.

Intracranial hemorrhages are classified according to their location and the blood vessels involved.

Subdural Hematoma

A subdural hematoma occurs when blood accumulates between the dura mater and arachnoid membrane, usually because of tearing of bridging veins.

This type of hemorrhage commonly occurs after falls or minor head injuries, especially among older adults.

Clinical Features of Subdural Hematoma

Patients may develop:

• Gradual worsening headache

• Confusion

• Changes in mental status

• Weakness or neurological deficits

• Progressive decline in consciousness

Because symptoms may develop slowly, subdural hematomas can be missed initially, particularly in elderly patients.

Risk factors include:

• Advanced age

• Anticoagulant therapy

• Frequent falls

• Brain atrophy

Epidural Hematoma

An epidural hematoma occurs when blood accumulates between the skull and dura mater, typically due to rupture of the middle meningeal artery following temporal bone trauma.

Unlike subdural hematomas, epidural hematomas often progress rapidly and require emergency treatment.

Classic Presentation of Epidural Hematoma

A typical clinical pattern includes:

• Brief loss of consciousness after trauma

• A temporary period of recovery called a lucid interval

• Rapid neurological deterioration afterward

The lucid interval occurs because the patient temporarily improves before increasing intracranial pressure causes worsening symptoms.

Headache Disorders in Clinical Practice

Headaches are among the most common neurological complaints evaluated by healthcare providers. Although many headaches are benign, identifying specific headache patterns helps differentiate primary headache disorders from potentially serious neurological conditions.

Primary headaches occur without an underlying structural abnormality and include:

• Migraine headaches

• Tension headaches

• Cluster headaches

Migraine Headaches

Migraines are neurological disorders characterized by recurrent episodes of moderate to severe headache, often accompanied by sensory symptoms.

Common Features of Migraine

Typical symptoms include:

• Unilateral throbbing headache

• Nausea and vomiting

• Sensitivity to light (photophobia)

• Sensitivity to sound (phonophobia)

• Worsening pain with physical activity

Some patients experience an aura before headache onset, which may include:

• Visual disturbances

• Tingling sensations

• Speech changes

Common Migraine Triggers

Migraine episodes may be triggered by:

• Stress

• Sleep deprivation

• Hormonal fluctuations

• Certain foods

• Alcohol consumption, including red wine

• Bright lights

Identifying individual triggers can help patients reduce headache frequency.

Cluster Headaches

Cluster headaches are severe primary headaches that occur in recurring patterns or “clusters.” They are more common among middle-aged men.

Clinical Characteristics

Patients often report:

• Severe unilateral orbital pain

• Tearing of the affected eye

• Nasal congestion

• Restlessness

• Recurrent attacks occurring at similar times

Unlike migraine patients who often prefer a quiet, dark environment, individuals experiencing cluster headaches are frequently unable to remain still because of intense pain.

Treatment of Cluster Headaches

High-flow oxygen therapy is considered one of the most effective acute treatments.

Other treatment options may include:

• Triptans

• Preventive medications

• Avoidance of known triggers

Seizure Disorders

Seizures occur because of abnormal electrical activity within the brain. Correct classification of seizure type is essential because treatment depends on seizure characteristics and underlying causes.

Seizures may be classified as:

• Focal seizures

• Generalized seizures

• Absence seizures

Absence Seizures

Absence seizures are brief episodes of impaired awareness caused by abnormal electrical activity throughout the brain.

They occur most commonly in children but can occur at any age.

Characteristics of Absence Seizures

Patients may demonstrate:

• Sudden staring episodes

• Brief interruption of activity

• Lack of response during the episode

• Rapid return to normal awareness

• No postictal confusion

Episodes usually last only a few seconds.

Because symptoms may appear subtle, absence seizures can sometimes be mistaken for daydreaming or inattentiveness.

Driving Restrictions After Seizures

Patients diagnosed with seizures must follow state-specific driving regulations.

Driving restrictions vary depending on:

• Local laws

• Seizure frequency

• Type of seizure disorder

• Physician recommendations

Many regions require a seizure-free period before driving privileges are restored.

Healthcare providers should counsel patients regarding safety precautions and legal requirements.

Multiple Sclerosis

Multiple sclerosis (MS) is a chronic autoimmune disease involving inflammation and demyelination of the central nervous system.

The immune system attacks myelin, the protective covering surrounding nerve fibers, disrupting communication between the brain, spinal cord, and body.

Clinical Presentation of Multiple Sclerosis

MS commonly affects women between 20 and 40 years of age, although it can occur in individuals of any age.

Symptoms vary depending on the location of demyelinating lesions.

Common manifestations include:

• Vision problems

• Muscle weakness

• Numbness or tingling sensations

• Fatigue

• Balance difficulties

• Coordination problems

• Bladder dysfunction

A common early symptom is optic neuritis, which may present with:

• Eye pain

• Reduced vision

• Difficulty distinguishing colors

Diagnosing Multiple Sclerosis

There is no single laboratory test that confirms multiple sclerosis.

Diagnosis is based on a combination of clinical findings and diagnostic studies.

Diagnostic Evaluation May Include:

• Neurological examination

• Magnetic resonance imaging (MRI)

• Cerebrospinal fluid analysis

• Evoked potential testing

MRI findings commonly demonstrate areas of demyelination called plaques or lesions.

Relapsing-Remitting Multiple Sclerosis

Relapsing-remitting MS is the most common disease pattern.

It is characterized by:

• Episodes of neurological symptoms (relapses)

• Periods of partial or complete recovery (remission)

Symptoms may return during flare-ups because inflammation damages nerve pathways.

Treatment of Acute MS Exacerbations

Acute MS relapses are commonly treated with high-dose intravenous corticosteroids, such as methylprednisolone.

Corticosteroids help by:

• Reducing inflammation

• Shortening relapse duration

• Improving recovery

For long-term disease management, some patients receive disease-modifying therapies, including monoclonal antibody medications.

Parkinson Disease

Parkinson disease is a progressive neurodegenerative disorder caused primarily by reduced dopamine production within the basal ganglia.

Dopamine deficiency affects movement control and results in characteristic motor symptoms.

Cardinal Features of Parkinson Disease

The four major motor symptoms include:

• Resting tremor

• Bradykinesia (slowed movement)

• Rigidity

• Postural instability

These symptoms may develop gradually and worsen over time.

Additional Parkinson Disease Manifestations

Patients may experience:

• Shuffling gait

• Difficulty initiating movement

• Freezing episodes

• Reduced facial expression

• Soft speech

• Balance problems

Cogwheel Rigidity

Cogwheel rigidity refers to a ratcheting sensation during passive movement of a joint and is a classic examination finding in Parkinson disease.

Parkinson-Plus Syndromes

Parkinson-plus syndromes are neurological disorders that resemble Parkinson disease but involve additional neurological features.

Postural instability, early falls, and rapid progression are more commonly associated with these conditions.

Huntington Disease

Huntington disease is an inherited neurodegenerative disorder caused by a genetic mutation affecting chromosome 4.

The disease causes progressive degeneration of brain cells responsible for movement, cognition, and behavior.

Clinical Features of Huntington Disease

Patients may develop:

• Choreiform movements (“dance-like” involuntary movements)

• Cognitive decline

• Personality changes

• Depression or psychiatric symptoms

• Progressive dementia

Because Huntington disease is inherited in an autosomal dominant pattern, each child of an affected parent has a 50% chance of inheriting the condition.

Myasthenia Gravis

Myasthenia gravis is an autoimmune neuromuscular disorder caused by impaired communication between nerves and muscles.

The condition affects voluntary skeletal muscles and produces fluctuating weakness.

Symptoms of Myasthenia Gravis

Common manifestations include:

• Ptosis (drooping eyelids)

• Diplopia (double vision)

• Difficulty swallowing

• Weak facial muscles

• Fatigable muscle weakness

Symptoms typically worsen with activity and improve after rest.

A key clinical feature is that muscle strength decreases with repeated use.

Central Nervous System Infections

Neurological infections require prompt recognition because delays in treatment may result in permanent neurological damage or death.

Major infections include:

• Meningitis

• Encephalitis

Aseptic Meningitis

Aseptic meningitis refers to inflammation of the meninges without bacterial infection. Viral infections are the most common cause.

Symptoms Include:

• Headache

• Fever

• Neck stiffness

• Photophobia

• General discomfort

Most viral cases improve with supportive treatment.

Bacterial Meningitis

Bacterial meningitis is a medical emergency requiring immediate antibiotic therapy.

Common causes in adults include:

• Streptococcus pneumoniae

• Neisseria meningitidis

Patients may present with:

• Fever

• Severe headache

• Neck stiffness

• Altered mental status

• Sensitivity to light

Empiric antibiotic therapy is usually started before culture results are available because delays increase mortality risk.

Viral Encephalitis

Viral encephalitis involves inflammation of brain tissue and can cause severe neurological complications.

Herpes simplex virus (HSV) is the most common cause of sporadic viral encephalitis.

Clinical Features Include:

• Fever

• Confusion

• Seizures

• Behavioral changes

• Altered consciousness

Early administration of intravenous acyclovir improves outcomes in suspected HSV encephalitis.

Bell’s Palsy

Bell’s palsy is an acute paralysis of the facial nerve (cranial nerve VII), resulting in sudden unilateral facial weakness.

Symptoms May Include:

• Facial drooping

• Difficulty closing one eye

• Altered taste sensation

• Facial weakness

Most patients recover significantly within three to six months.

Early corticosteroid treatment improves the likelihood of recovery.

Guillain-Barré Syndrome

Guillain-Barré syndrome (GBS) is an acute autoimmune disorder affecting peripheral nerves.

The immune system damages nerve pathways, resulting in progressive weakness.

Clinical Presentation of Guillain-Barré Syndrome

Typical symptoms include:

• Symmetric ascending weakness

• Tingling sensations

• Reduced reflexes

• Difficulty walking

Weakness usually begins in the legs and progresses upward.

Respiratory Monitoring in Guillain-Barré Syndrome

Respiratory failure is a serious complication of GBS.

Patients require close monitoring of:

• Respiratory strength

• Oxygenation

• Ability to protect the airway

Rapid deterioration may require mechanical ventilation

Pulmonary Disorders Review for Clinical Practice

Pulmonary disorders are among the leading causes of illness and death worldwide. Conditions such as chronic obstructive pulmonary disease (COPD), asthma, pneumonia, tuberculosis (TB), obstructive sleep apnea (OSA), lung cancer, and upper respiratory infections require early recognition and evidence-based management to prevent serious complications. A thorough history, physical examination, diagnostic testing, and timely intervention enable healthcare providers to improve respiratory function and patient outcomes.

Evaluating Common Respiratory Symptoms

Respiratory symptoms often overlap across multiple conditions, making a comprehensive clinical assessment essential. Healthcare providers should evaluate symptom duration, smoking history, occupational exposures, medication use, environmental triggers, and associated systemic symptoms to identify the underlying cause.

Chronic Cough

A chronic cough is defined as one that persists for more than eight weeks. Although it is a common complaint in primary care, identifying its underlying cause is essential for effective treatment.

The most common causes include:

• Upper airway cough syndrome (postnasal drip)

• Asthma

• Gastroesophageal reflux disease (GERD)

• Chronic bronchitis

• ACE inhibitor medications

• Smoking-related lung disease

Patients should be assessed for cough characteristics, sputum production, hemoptysis, weight loss, wheezing, and exposure to respiratory irritants.

ACE Inhibitor-Induced Cough

ACE inhibitors, including captopril, enalapril, and lisinopril, may cause a persistent dry cough because they increase bradykinin levels.

Important clinical points include:

• The cough is usually nonproductive.

• Symptoms may develop weeks or months after therapy begins.

• The cough generally resolves after discontinuing the medication.

• Switching to an angiotensin receptor blocker (ARB) often eliminates symptoms.

Recognizing medication-induced cough prevents unnecessary diagnostic testing.

Anxiety-Related Shortness of Breath

Not every patient with dyspnea has a pulmonary disorder. Anxiety and panic disorders frequently produce symptoms that mimic respiratory disease.

Patients may experience:

• Rapid breathing

• Chest tightness

• Feeling unable to take a deep breath

• Dizziness

• Palpitations

Because life-threatening cardiopulmonary conditions can present similarly, clinicians should first exclude serious medical causes before attributing symptoms to anxiety.

Gastroesophageal Reflux Disease (GERD) and Chronic Cough

GERD is a frequent but often overlooked cause of chronic cough.

Acid reflux can irritate the larynx and upper airway, producing coughing even in patients who do not report classic heartburn symptoms.

Clinical suspicion should increase when cough:

• Worsens after meals

• Occurs primarily at night

• Improves with acid-suppressing therapy

Managing reflux often improves respiratory symptoms.

Upper Respiratory Disorders

Upper respiratory illnesses are among the most common reasons for outpatient visits. Although many are self-limiting, accurate diagnosis helps guide appropriate treatment and prevents unnecessary antibiotic use.

Allergic Rhinitis

Allergic rhinitis develops after exposure to environmental allergens that trigger an IgE-mediated inflammatory response.

Common allergens include:

• Pollen

• Dust mites

• Mold spores

• Animal dander

Typical symptoms include:

• Sneezing

• Nasal congestion

• Runny nose

• Itchy eyes

• Postnasal drip

First-line treatment typically includes intranasal corticosteroids and oral or intranasal antihistamines. Decongestants may provide temporary symptom relief but should not be used long term because of rebound congestion.

Viral Respiratory Infections

Most upper respiratory infections are viral and resolve without antibiotics.

Healthcare providers should educate patients regarding:

• Adequate hydration

• Rest

• Symptom management

• Appropriate use of antiviral medications when indicated

Avoiding unnecessary antibiotics helps reduce antimicrobial resistance.

Direct Fluorescent Antibody (DFA) Testing

Direct fluorescent antibody testing detects viral antigens in respiratory specimens.

Although polymerase chain reaction (PCR) testing has become the preferred diagnostic method because of higher sensitivity, DFA testing may still be used in selected healthcare settings for rapid diagnosis.

Influenza

Influenza is an acute viral respiratory illness that can lead to severe complications, particularly in older adults, young children, pregnant individuals, and immunocompromised patients.

Common symptoms include:

• Fever

• Chills

• Muscle aches

• Headache

• Fatigue

• Dry cough

• Sore throat

Early treatment with antiviral medications reduces symptom duration and decreases the risk of complications.

Antiviral Therapy

Oseltamivir (Tamiflu) is most effective when started within 48 hours of symptom onset.

Benefits include:

• Shorter illness duration

• Reduced hospitalization risk

• Lower incidence of complications in high-risk patients

Oseltamivir is approved for treatment of influenza in infants as young as two weeks of age.

Community-Acquired Pneumonia (CAP)

Community-acquired pneumonia remains a leading cause of hospitalization worldwide.

The most common bacterial cause is Streptococcus pneumoniae.

Clinical Presentation

Patients frequently present with:

• Fever

• Productive cough

• Dyspnea

• Pleuritic chest pain

• Fatigue

• Crackles on lung examination

Older adults may present atypically with confusion or functional decline rather than fever.

Diagnosis

Evaluation commonly includes:

• Chest radiography

• Pulse oximetry

• Complete blood count

• Sputum culture when indicated

Empiric antibiotic therapy should be selected based on patient age, comorbidities, local resistance patterns, and illness severity.

Hospital-Acquired (Nosocomial) Pneumonia

Hospital-acquired pneumonia develops 48 hours or more after hospital admission and is associated with higher morbidity because resistant organisms are more common.

Frequent pathogens include:

• Methicillin-resistant Staphylococcus aureus (MRSA)

• Pseudomonas aeruginosa

• Other gram-negative bacteria

Because culture results require time, broad-spectrum antibiotics are usually initiated first and later adjusted based on microbiology findings.

CURB-65 Severity Assessment

The CURB-65 score helps estimate mortality risk in patients with community-acquired pneumonia and assists clinicians in determining the appropriate treatment setting.

The score evaluates:

• C – Confusion

• U – Blood urea nitrogen

• R – Respiratory rate

• B – Blood pressure

• 65 – Age 65 years or older

Higher scores indicate increased mortality risk and often support hospital admission.

Tuberculosis (TB)

Tuberculosis remains a major global infectious disease caused by Mycobacterium tuberculosis. Early diagnosis and treatment reduce transmission and improve patient outcomes.

Tuberculin Skin Test Interpretation

The tuberculin skin test (Mantoux test) should always be interpreted by measuring induration, not redness.

An induration of 5 mm or greater is considered positive in high-risk individuals, including:

• People living with HIV

• Recent contacts of active TB cases

• Organ transplant recipients

• Severely immunocompromised patients

Causes of False-Negative TB Tests

Certain conditions can reduce the accuracy of TB skin testing, including:

• Long-term corticosteroid therapy

• Advanced HIV infection

• Severe burns

• Immunosuppressive disorders

• Recent viral illness

Clinical judgment remains essential when interpreting results.

Tuberculosis Treatment

Isoniazid (INH) remains one of the cornerstone medications used to treat active and latent tuberculosis.

Patient education should emphasize:

• Taking medication exactly as prescribed

• Completing the entire treatment course

• Avoiding alcohol because of liver toxicity

• Reporting symptoms such as jaundice, fatigue, or abdominal pain immediately

Pyridoxine (Vitamin B6) Supplementation

INH interferes with vitamin B6 metabolism and may cause peripheral neuropathy.

Pyridoxine supplementation is recommended, particularly for patients at higher risk, including:

• Older adults

• Pregnant individuals

• Patients with diabetes

• Individuals with malnutrition

• Patients with chronic kidney disease

Asthma

Asthma is a chronic inflammatory airway disease characterized by reversible airflow obstruction and bronchial hyperresponsiveness. Airway inflammation causes intermittent episodes of wheezing, coughing, chest tightness, and shortness of breath. Although asthma cannot be cured, appropriate treatment helps patients maintain normal lung function and reduces the risk of severe exacerbations.

Early diagnosis and long-term disease management are essential for preventing emergency department visits, hospitalizations, and permanent airway remodeling.

Common Symptoms of Asthma

Asthma symptoms vary in frequency and severity but commonly include:

• Wheezing

• Persistent or recurrent cough

• Chest tightness

• Shortness of breath

• Symptoms that worsen at night or early morning

Common asthma triggers include:

• Respiratory infections

• Allergens (dust mites, pollen, pet dander)

• Exercise

• Cold air

• Tobacco smoke

• Air pollution

• Emotional stress

Unlike COPD, airway obstruction in asthma is usually reversible with bronchodilator therapy.

Moderate Persistent Asthma

Patients with moderate persistent asthma experience symptoms that interfere with daily activities and require ongoing controller therapy.

Typical findings include:

• Daily asthma symptoms

• Nighttime symptoms more than once each week

• Increased use of rescue inhalers

• Forced Expiratory Volume in one second (FEV₁) between 60% and 80% of the predicted value

Treatment generally includes both long-term controller medications and quick-relief rescue therapy.

Long-Acting Beta₂-Agonists (LABAs)

Long-acting beta₂-agonists provide prolonged bronchodilation but should never be used alone in patients with asthma.

Current treatment guidelines recommend combining LABAs with inhaled corticosteroids because monotherapy increases the risk of severe asthma attacks.

Examples include:

• Salmeterol

• Formoterol

Combination inhalers improve symptom control while reducing exacerbation risk.

Short-Acting Beta₂-Agonists (SABAs)

Short-acting beta₂-agonists rapidly relax airway smooth muscle and are considered first-line rescue medications for acute asthma symptoms.

Albuterol remains the most commonly prescribed SABA.

Possible side effects include:

• Tremor

• Palpitations

• Tachycardia

• Nervousness

Frequent reliance on rescue inhalers may indicate poorly controlled asthma and should prompt reassessment of maintenance therapy.

Monitoring Theophylline Therapy

Although theophylline is prescribed less frequently today, it remains an option for selected patients.

Because theophylline has a narrow therapeutic index, routine monitoring is required.

The recommended therapeutic serum concentration is:

• 5–15 mcg/mL

Higher levels significantly increase the risk of:

• Cardiac arrhythmias

• Seizures

• Nausea

• Vomiting

Regular monitoring helps prevent toxicity.

Chronic Obstructive Pulmonary Disease (COPD)

COPD is a progressive respiratory disorder characterized by persistent airflow limitation that is not fully reversible. The disease includes chronic bronchitis and emphysema, both of which gradually impair lung function.

Smoking remains the leading cause of COPD, although occupational exposures and genetic conditions also contribute.

Early diagnosis and smoking cessation are the most effective strategies for slowing disease progression.

Chronic Bronchitis

Chronic bronchitis is defined by a productive cough lasting at least three months per year for two consecutive years.

Inflammation of the airways leads to excessive mucus production and narrowing of the bronchial tubes.

Common findings include:

• Chronic productive cough

• Wheezing

• Frequent respiratory infections

• Cyanosis

• Progressive shortness of breath

As the disease advances, patients may develop chronic respiratory failure due to persistent hypoxemia and carbon dioxide retention.

Emphysema

Emphysema involves permanent destruction of alveolar walls, resulting in reduced gas exchange and air trapping.

Patients commonly present with:

• Progressive dyspnea

• Barrel-shaped chest

• Decreased breath sounds

• Weight loss

• Reduced exercise tolerance

Hyperinflation of the lungs increases the work of breathing and contributes to respiratory muscle fatigue.

GOLD Stage 1 COPD

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) classifies COPD severity using spirometry.

Stage 1 (Mild COPD) is defined by:

• Post-bronchodilator FEV₁ ≥80% of predicted

• Persistent airflow obstruction

• Mild respiratory symptoms

Early smoking cessation and vaccination significantly improve long-term outcomes.

Alpha-1 Antitrypsin Deficiency

Alpha-1 antitrypsin deficiency is an inherited disorder that predisposes individuals to early-onset emphysema.

Healthcare providers should consider testing in patients who:

• Develop COPD before age 45

• Have minimal smoking history

• Have a family history of emphysema

• Present with unexplained liver disease

Early diagnosis allows for targeted treatment and family screening.

Long-Term Oxygen Therapy

Long-term oxygen therapy improves survival in patients with severe chronic hypoxemia.

Clinical benefits include:

• Improved quality of life

• Better exercise tolerance

• Reduced pulmonary hypertension

• Increased survival

Patients who meet guideline criteria should generally receive oxygen therapy for at least 15 hours daily.

Lung Cancer

Lung cancer remains the leading cause of cancer-related mortality worldwide. Prognosis depends heavily on early detection, making prompt evaluation of suspicious symptoms essential.

Major Risk Factors

Although cigarette smoking is the strongest risk factor, other contributors include:

• Secondhand smoke exposure

• Radon gas

• Asbestos

• Occupational chemical exposure

• Family history

• Air pollution

Smoking cessation remains the most effective method of reducing lung cancer risk.

Common Types of Lung Cancer

The two most frequently encountered non-small cell lung cancers include:

Adenocarcinoma

Characteristics include:

• Most common lung cancer overall

• Occurs in smokers and nonsmokers

• Often develops in peripheral lung tissue

Squamous Cell Carcinoma

Characteristics include:

• Strongly associated with smoking

• Usually arises in central airways

• May produce chronic cough and hemoptysis

Accurate histological diagnosis guides treatment selection.

TNM Staging System

The TNM staging system evaluates cancer severity using three components:

• T: Primary tumor size and invasion

• N: Regional lymph node involvement

• M: Presence of distant metastasis

For example:

T1N0M0 indicates:

• Small localized tumor

• No lymph node involvement

• No distant metastasis

Staging helps determine prognosis and treatment options.

NU566 Midterm Reviewa

Horner Syndrome

Apical (Pancoast) lung tumors may compress sympathetic nerves, producing Horner syndrome.

Classic findings include:

• Ptosis

• Miosis

• Anhidrosis

Recognizing this triad may facilitate earlier diagnosis of apical lung malignancies.

Smoking Cessation

Smoking cessation is the single most effective intervention for reducing respiratory and cardiovascular disease.

Quitting smoking lowers the risk of:

• COPD progression

• Lung cancer

• Coronary artery disease

• Stroke

• Peripheral arterial disease

Healthcare providers should address smoking cessation during every patient encounter.

Counseling Patients to Quit

Patients in the preparation stage have decided to stop smoking and are actively planning to quit.

They may have:

• Selected a quit date

• Purchased nicotine replacement therapy

• Discussed quitting with family members

• Developed a cessation plan

Behavioral counseling combined with medication produces the highest long-term success rates.

Varenicline Therapy

Varenicline is one of the most effective medications for smoking cessation.

Treatment is typically initiated one week before the planned quit date to reduce nicotine cravings and withdrawal symptoms.

Patients should be monitored for:

• Nausea

• Sleep disturbances

• Mood changes

Nicotine Gum

Nicotine gum should be used correctly to maximize nicotine absorption.

Patients should follow the “chew and park” method:

1. Chew until a tingling sensation develops.

2. Place the gum between the cheek and gum.

3. Repeat the process until the nicotine is absorbed.

Eating or drinking immediately before use may reduce effectiveness.

Health Benefits After Smoking Cessation

Smoking cessation produces immediate and long-term health benefits.

Benefits include:

• Improved taste and smell

• Better lung function

• Lower blood pressure

• Reduced cardiovascular risk

• Improved circulation

• Decreased cancer risk

• Increased life expectancy

Even patients who quit later in life experience substantial health improvements.

Obstructive Sleep Apnea (OSA)

Obstructive sleep apnea is characterized by repeated episodes of upper airway obstruction during sleep, leading to intermittent hypoxia and fragmented sleep.

Untreated OSA increases the risk of hypertension, heart disease, stroke, diabetes, and motor vehicle accidents.

Major Risk Factors

Risk factors include:

• Obesity

• Male sex

• Older age

• Large neck circumference

• Craniofacial abnormalities

• Family history

A neck circumference of 17 inches or greater in men is associated with increased OSA risk.

Continuous Positive Airway Pressure (CPAP)

Continuous Positive Airway Pressure (CPAP) is the first-line treatment for moderate to severe OSA.

Benefits include:

• Improved sleep quality

• Reduced daytime fatigue

• Better blood pressure control

• Lower cardiovascular risk

• Improved cognitive function

Treatment pressures generally range from 5 to 20 cm H₂O, depending on patient needs.

Surgical Referral

Patients who cannot tolerate CPAP or have significant anatomical airway obstruction may benefit from referral to an otolaryngologist.

Potential surgical options include:

• Uvulopalatopharyngoplasty (UPPP)

• Laser-assisted uvulopalatoplasty

• Maxillomandibular advancement

• Hypoglossal nerve stimulation (selected patients)

Appropriate patient selection is essential for successful surgical outcomes.

Frequently Asked Questions (FAQs)

What is the difference between asthma and COPD?

Asthma is a chronic inflammatory disease characterized by reversible airway obstruction, whereas COPD causes persistent, progressive airflow limitation that is not fully reversible. Asthma often begins earlier in life and is commonly triggered by allergens or exercise, while COPD is most strongly associated with long-term smoking or exposure to harmful airborne particles.

What is the most common cause of chronic cough?

A chronic cough lasting more than eight weeks is most commonly caused by:

• Upper airway cough syndrome (postnasal drip)

• Asthma

• Gastroesophageal reflux disease (GERD)

• Chronic bronchitis

• ACE inhibitor medications

A comprehensive clinical evaluation helps determine the underlying cause.

Why do ACE inhibitors cause a persistent cough?

ACE inhibitors increase bradykinin levels, which can irritate the respiratory tract and trigger a persistent dry cough. The cough usually resolves after discontinuing the medication and switching to an angiotensin receptor blocker (ARB), when appropriate.

What is the first-line treatment for moderate persistent asthma?

Current clinical guidelines recommend an inhaled corticosteroid (ICS) combined with a long-acting beta₂-agonist (LABA) as the preferred controller therapy for most patients with moderate persistent asthma. Rescue therapy with a short-acting beta₂-agonist (SABA) is also used for acute symptom relief.

Why should LABAs never be used alone in asthma?

LABAs should not be used as monotherapy because they increase the risk of severe asthma exacerbations and asthma-related death. They should always be prescribed in combination with an inhaled corticosteroid.

What is the therapeutic range for theophylline?

The recommended therapeutic serum concentration for theophylline is 5–15 mcg/mL. Levels above this range increase the risk of serious adverse effects, including seizures and cardiac arrhythmias.

What are the early symptoms of COPD?

Early symptoms of COPD often include:

• Chronic productive cough

• Progressive shortness of breath

• Wheezing

• Increased mucus production

• Reduced exercise tolerance

Early diagnosis and smoking cessation can slow disease progression.

Who should be tested for Alpha-1 Antitrypsin Deficiency?

Testing should be considered for patients who:

• Develop COPD before age 45

• Have emphysema despite little or no smoking history

• Have a family history of emphysema or liver disease

• Present with unexplained airflow obstruction

Early diagnosis allows for targeted management and family screening.

How many hours per day should patients use long-term oxygen therapy?

Patients with severe chronic hypoxemia who meet clinical criteria generally benefit from using supplemental oxygen for at least 15 hours per day, which has been shown to improve survival and quality of life.

What are the major risk factors for lung cancer?

The strongest risk factor is cigarette smoking. Other important risk factors include:

• Secondhand smoke exposure

• Radon gas

• Asbestos exposure

• Occupational carcinogens

• Air pollution

• Family history of lung cancer

What are the warning signs of lung cancer?

Possible symptoms include:

• Persistent cough

• Coughing up blood (hemoptysis)

• Chest pain

• Unexplained weight loss

• Shortness of breath

• Hoarseness

• Recurrent respiratory infections

Persistent or unexplained symptoms require prompt medical evaluation.

What is Horner syndrome?

Horner syndrome is caused by disruption of the sympathetic nerves supplying the face and eye. The classic triad includes:

• Ptosis (drooping eyelid)

• Miosis (constricted pupil)

• Anhidrosis (reduced sweating)

It may occur in patients with apical (Pancoast) lung tumors.

What is the most effective way to reduce the risk of COPD and lung cancer?

Smoking cessation is the single most effective intervention. Quitting smoking slows COPD progression, lowers the risk of lung cancer, improves lung function, and reduces cardiovascular disease risk.

How does CPAP help patients with obstructive sleep apnea?

Continuous Positive Airway Pressure (CPAP) keeps the upper airway open during sleep, reducing episodes of airway collapse. Regular CPAP use improves sleep quality, decreases daytime fatigue, lowers blood pressure, and reduces cardiovascular complications associated with obstructive sleep apnea.

When should patients with obstructive sleep apnea be referred for surgery?

Surgical evaluation may be appropriate for patients who:

• Cannot tolerate CPAP therapy

• Have significant anatomical airway obstruction

• Continue to experience severe symptoms despite conservative treatment

Treatment decisions should be individualized based on clinical findings and sleep study results.

References

American Academy of Sleep Medicine. (2024). Clinical practice guidelines. https://aasm.org/clinical-resources/practice-standards/practice-guidelines/

American Thoracic Society. (2024). Patient education series. https://www.thoracic.org/patients/

Global Initiative for Asthma. (2025). Global strategy for asthma management and prevention. https://ginasthma.org

Global Initiative for Chronic Obstructive Lung Disease. (2025). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. https://goldcopd.org

Jameson, J. L., Fauci, A. S., Kasper, D. L., Hauser, S. L., Longo, D. L., & Loscalzo, J. (Eds.). (2022). Harrison’s principles of internal medicine (21st ed.). McGraw-Hill. https://accessmedicine.mhmedical.com

NU566 Midterm Review

National Cancer Institute. (2024). Lung cancer treatment (PDQ®)–Health professional version. https://www.cancer.gov/types/lung

National Heart, Lung, and Blood Institute. (2024). Asthma. https://www.nhlbi.nih.gov/health/asthma

National Heart, Lung, and Blood Institute. (2024). COPD. https://www.nhlbi.nih.gov/health/copd

National Heart, Lung, and Blood Institute. (2024). Sleep apnea. https://www.nhlbi.nih.gov/health/sleep-apnea

NU566 Midterm Review

World Health Organization. (2024). Chronic respiratory diseases. https://www.who.int/health-topics/chronic-respiratory-diseases

World Health Organization. (2024). Tuberculosis. https://www.who.int/news-room/fact-sheets/detail/tuberculosis