4 Bronchitis & Pneumonia Flashcards
Acute Bronchitis is defined as…
Cough > 5 days, typically 1-3 weeks
<5 days = URI
~ 10% of ambulatory care visits each year are for acute bronchitis
Chronic bronchitis is defined as…
Cough and sputum production on most days of the month for at least 3 months of the year in 2 consecutive years
Pathophysiology of acute bronchitis
SELF-LIMITED inflammation of the bronchi due to UPPER AIRWAY infection
Often associated with viral URI
Different from chronic bronchitis
90% of acute bronchitis is …
VIRAL!
Influenza A and B Parainfluenza Coronavirus Rhinovirus RSV Human metapneumovirus
Bacterial causes of acute bronchitis are uncommon but if they occur, the main strains are…
Mycoplasma pneumonia
Chlamydia pneumoniae
Bordetella pertussis*** The only one that is improved by abx
Clinical presentation of acute bronchitis
Cough +/- sputum production
Presence of purulent sputum is not predictive of bacterial infection or response to abx
Usually afebrile (unless influenza)
Chest wall tenderness (later in the course of infection)
Wheezing (not usually related to exertion)
Mild Dyspnea
DDx for acute bronchitis
URI Influenza PNA Pertussis Chronic bronchitis Asthma CHF Postnatal drip GERD Bronchogenic tumors ACE inhibitors
What will you see on physical exam in patients with acute bronchitis
Wheezing
Bronchospasm —> Reduced FEV1 (if you do PFTs)
Rhonchi (musical wheezing), often clears with coughing
Negative for crackles or signs of consolidation (if you hear, more likely to be PNA)
Diagnosis of acute bronchitis is most often…
A clinical diagnosis
WBC is usually normal or mildly elevated
CXR is usually normal or with nonspecific findings
Pneumonia is unlikely if all of the following findings are absent:
Fever (>38C or >100.4F)
Tachypnea (>24 breaths/min)
Tachycardia (>100bbm)
Evidence of consolidation on exam
Consider CXR for patients with any of these findings or cough lasting >3 weeks
Treatment for acute bronchitis
Patient ed - reassurance, expected course
Hydration and rest
Sx relief (NSAIDS, intranets always Ipratropium, antitussives, ß2 agonists, OTC products)
Smoking cessation
Is it better or worse to common antitussives and expectorants/mucolytics?
Avoid the combo
What is the only indication for antibacterial agents in the treatment of acute bronchitis?
Pertussis
But somehow 50-90% of patients are given Abx 🤦♀️
Summarize all we need to know about acute bronchitis
Inflammation of the airways
Characterized by cough > 5 days
Usually viral (doesn’t matter if sputum is colored)
CXR not necessary in most cases
Supportive measures and patient ed
Other names for Bordetella pertussis…
Pertussis, “Whooping Cough”, “The cough of 100 days”
Prodrome of rhinorrhea, mild cough, sneezing followed by classic prolonged progressive “whooping” cough
Pertusssi
What are the three phases of Pertussis?
Phase 1: Catarrhal (URI Sx and fever, 1-2 weeks)
Phase 2: Paroxysmal (persistent paroxysmal cough and post-tussive emesis, 2-6 weeks)
Phase 3: Convalescent (cough gradually resolves, lasts weeks to months)
Most contagious phase of pertussis
Catarrhal (phase 1)
How do we diagnosis Pertussis?
Nasopharyngeal secretions
• Bacterial culture ** GOLD STANDARD
• Polymerase chain reaction (PCR) - faster, with higher sensitivity and specificity (can do at same time as culture)
Serology - more useful for diagnosis in later phases (2-8 weeks from cough onset)
Optimal timing for pertussis Dx via culture
0-2 weeks
Optimal timing for pertussis diagnosis via PCR
0-4 weeks
Optimal timing for pertussis diagnosis via serology
2-8 weeks
What is the best way to treat pertussis?
If suspected, empiric therapy may be initiated while obtaining a Dx test for confirmation
Abx treatment decreases transmission but has little effect on symptom resolution
Adults: Supportive care + Macrolide (alternative: Bactrim)
Children: 69% of kids <6 months need admission/isolation; Sx control and macrolide abx
The key to pertussis prevention is …
Vaccination - booster now recommended as adolescent (Tdap)
Abx prophylaxis if close contact exposure at home, work, school, daycare
Dx is reportable to state health dept
Summarize Pertussis
“Whooping cough”
Bacterial etiology (Bordetella pertussis)
Treated with abx (including close contact prophylaxis)
Must be reported to health dept
Vaccination is key to prevention
High risk populations for Influenza
Children < 2 y/o
Adults ≥ 65 y/o
Underlying chronic disease (pulm, CV, renal, hepatic, hematologists, metabolic, neurologic)
Immunosuppressed
Pregnant (up to 2 weeks postpartum)
Morbidly obese
Residents of nursing homes/chronic care facilities
Clinical presentation of influenza
Abrupt onset
Fever* Headache* Myalgia* Malaise* Nonproductive cough Sore throat Nasal discharge
Influenza physical findings
Few
Hot, flushed appearing
Febrile (ask about last dose of acetaminophen or NSAID)
Mild cervical lymphadenopathy
Dx testing for influenza
Rapid influenza test (RIDT) - 10-30 min
• lots of false negatives so Dx usually clinical
RT-PCR - 2-6 hours (more sensitive/specific)
Viral culture - 48-72 hours (confirmatory but not used for initial clinical management)
Influenza treatment
Generally improve in 2 to 5 days (may last 1 week or more)
Antiviral therapy within 24-48 hours of onset of Sx
• Oseltamivir (Tamiflu)
• Zanamivir (Relenza)
Antiviral therapy reduces symptom duration by approx 1-3 days
7th leading cause of death in the US
Pneumonia
Acute infection of pulmonary parenchyma
Inflammation and consolidation of lung tissue from infectious agent
Source based classifications of pneumonia
Community-acquired (CAP)
Hospital-acquired (HAP)
Ventilator Associated (VAP)
Symptom based classification of pneumonia
Typical
Atypical
Is PNA more common in men or women?
Men
Is PNA more common among African Americans or Caucasians?
African Americans
Transmission of CAP is most commonly from …
Aspiration from the oropharynx***
Inhalation of contaminated droplets
Hematogenous spread
Extension from infected pleural or mediastinal space
Most common bacterial cause of CAP
Strep pneumo***
Others: H flu* Klebsiella pneumoniae M catarrhalis* Staph aureus Group A strep Anaerobes Aerobic gram-negative bacteria
Most common etiology of Atypical CAP
Bacterial: MYCOPLASMA PNEUMONIAE (walking PNA) Chlamydophila pneumoniae Legionella pneumonphila C psittaci
Viral (predominantly influenza, or RSV in kids)
Fungal
The possible viral causes of CAP
Influenza (predominant viral cause)
RSV
Parainfluenza
Adenovirus
What are the four types of fungal CAP?
Histoplasmosis (birds/bats)
Blastomycosis (soil assoc)
Coccidiodomycosis (valley fever)
Cryptococcus
All are unusual in an immunocompetent host
General risk factors for CAP
Asthma Immunosuppression Advanced age (≥70) Alcoholism Institutionalization
Risk factors for Pneumococcal CAP
Dementia Seizure disorder Heart failure Cerebrovascular disease Alcoholism Tobacco smoking COPD HIV
Clinical presentation of CAP
ACUTE ONSET FEVER COUGH Sputum production Hemoptysis Dyspnea Night Sweats Pleuritic pain Chest pain, chills, rigors
Clinical presentation for atypical CAP
Subacute onset Viral prodrome Nonproductive cough Low-grade fever HA Myalgia/arthralgia Malaise Absence of pleurisy/rigors
In older patients: Confusion Weakness FFT Delirium Abdominal pain Tachypnea Diarrhea Nausea/vomiting
Physical exam findings in CAP
Fever Tachypnea (RR>24) Hypoxia Tachycardia Diaphoresis Decreased/bronchial breath sounds Crackles Signs of consolidation
Diagnosing CAP
Leukocytosis (15,000-30,000 per mm3) with left shift
CXR - Infiltrate on plain CXR** (Gold standard)
• Lobar consolidation
• Interstitial infiltrates
• Cavitation
Sometimes CXR results may lag behind Sx so use clinical judgement
What is Cavitation
A line on CXR indicating fluid filled cavity
Other Dx tests for CAP
CT chest (not routine)
Microbiological testing (sputum, blood) if very ill/risk factors
For Legionella and S. pneumo: Urine antigen tests
PCR tests (generally limited to research studie)
Serology (out of favor)
Inflammatory markers (procalcitonin and CRP)
Examples of complications of PNA
Bacteremia Sepsis Abscess Empyema Respiratory failure
Admission based on Pneumonia severity index
Class I and II: probably not
Class III: admit for observation
Class IV and V: Admit to ICU
What are the components of CURB-65
Confusion Urea > 7 mmol/L, BUN > 20 mg/dL Respiratory Rate ≥ 30 Blood pressure (SBP<90, DBP≤60) 65: Age >65
1 point for each of the above
0-1 points treat outpatient
2 points admit to hospital
3-5 points assess for ICU care
Best predictor for a good outcome with CAP?
Right site of care
So use the CURB-65 and clinical judgement
Do you need a follow up CXR in patients with PNA?
Not routinely
7-12 weeks post treatment in patients > 40 or smokers
Outpatient treatment for uncomplicated CAP
(Previously healthy, no abx use in past 3 months)
Macrolide (Z-pack 500mg day one, 250 mg days 2-5)
OR
Doxycycline (100 mg BID x 7-10 days)
Outpatient treatment of complicated CAP
(Recent abx, COPD, liver/renal disease, cancer, DM, CHD, alcoholic, asplenia, immunosuppressed)
Combo of beta-lactam plus macrolide (ie Augmentin 500 + Z-pack)
OR
Respiratory fluoroquinolone (levofloxacin 750 mg daily x 5 days)
Non-ICU inpatient treatment of CAP
Respiratory fluoroquinolone (levofloxacin or moxifloxacin)
OR
Anti-pneumococcal betalactam plus a macrolide (Ceftriaxone or ertapenem plus Zpack)
ICU treatment of CAP
Ceftriaxone plus zpack
OR
Ceftriaxone plus resp fluoroquinolone
Patients are increased risk for pseudomonas
Alcoholics CF Neutropenia fever Recent intubation Cancer Organ failure Septic shock
Patients at increased MRSA risk
End stage renal disease
IVDU
Prior abx use
Influenza
When being treated inpatient, CAP patients cannot be discharged until minimum of 5 days abx and…
Afebrile for 48-72 hours Supplemental O2 not needed Heart rate < 100 RR < 24 SBP ≥ 90
Keep preventions for CAP
Smoking cessation
Vaccinations
• Influenza for all patients
• Pneumococcal for patients ≥ 65, adults with increased risk (CVD, sickle cell, tobacco use, splenectomy, liver disease)
Definition of Hospital-Acquired Pneumonia
48 hours or more after admission and did not appear to be incubating at the time of admission
Highest risk:
• ICU (pseudomonas has worst prognosis)
• Mechanical ventilation
Definition of ventilator associated pneumonia
A type of HAP that develops more than 48-72 hours after endotracheal intubation
Diagnosis of HAP and VAP
New or progressive infiltrate on lung imaging and at least 2 of the following clinical features:
• Fever
• Purulent sputum
• Leukocytosis
Sputum gram stain and culture are indicated
Most the Tx for HAP and VAP is dependent upon…
The institution (look at local resistance patterns)
Best treatment of VAP?
PREVENTION
Avoidance of acid-blocking meds Decontamination of oropharynx Selective decontamination of the gut Probiotics Positioning Subglottic drainage
Pneumonia associated with HIV
Pneumocystis jirovecii (PCP)
Strong correlation with low CD4 count
Considered a protozoan for many years, now considered fungal
Transmission unknown but leading diagnosis of AIDS
Symptoms of PCP
Fever (79-100%)
Cough (95%) - nonproductive
Progressive dyspnea (95%)
Extra-pulmonary lesions
Test that is 90% sensitive for PCP
High LDH
Also look for low CD4 count, “ground glass” on CXR, and sputum culture
Treatment for PCP
Bactrim
Alternatives: TMP-Dapsone Clindamycin-primaquine Pentamidine (best side effect profile) Steroids
When should you consider PCP prophylaxis in HIV+ individuals?
Hx of previous PCP
CD4 count <200
Oropharyngeal thrush
Preferred: Bactrim
Alternative: Dapsone or aerosolized pentamidine
Displacement of gastric contents to the lung causing injury and infection
Aspiration pneumonia
Typically from gram-negative and anaerobic pathogens b/c associated with GI contents
Risk factors for aspiration PNA
Post-operative state (vomiting)
Neurologic compromise (CVA, Parkinson’s, ALS, sedation)
Anatomical defect
Alcoholics
Common CXR finding for aspiration PNA
RLL infiltrate (v/c right mainstem bronchus more straight)
If aspiration in prone position (alcoholics), may be RUL
Preventing and treating aspiration PNA
Aspiration precautions
Swallow evaluation
Elimination of offending etiology if possible
Supportive care
Proper monitoring
Abx: Piperacillin/tazobactam OR ampicillin/sulbactam OR clindamycin or moxifloxacin
