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Clin Med II Unit II > 4 Bronchitis & Pneumonia > Flashcards

4 Bronchitis & Pneumonia Flashcards

1
Q

Acute Bronchitis is defined as…

A

Cough > 5 days, typically 1-3 weeks

<5 days = URI

~ 10% of ambulatory care visits each year are for acute bronchitis

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2
Q

Chronic bronchitis is defined as…

A

Cough and sputum production on most days of the month for at least 3 months of the year in 2 consecutive years

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3
Q

Pathophysiology of acute bronchitis

A

SELF-LIMITED inflammation of the bronchi due to UPPER AIRWAY infection

Often associated with viral URI

Different from chronic bronchitis

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4
Q

90% of acute bronchitis is …

A

VIRAL!

Influenza A and B
Parainfluenza
Coronavirus
Rhinovirus
RSV
Human metapneumovirus
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5
Q

Bacterial causes of acute bronchitis are uncommon but if they occur, the main strains are…

A

Mycoplasma pneumonia
Chlamydia pneumoniae
Bordetella pertussis*** The only one that is improved by abx

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6
Q

Clinical presentation of acute bronchitis

A

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

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7
Q

DDx for acute bronchitis

A 
URI
Influenza
PNA
Pertussis
Chronic bronchitis
Asthma
CHF
Postnatal drip
GERD
Bronchogenic tumors
ACE inhibitors
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8
Q

What will you see on physical exam in patients with acute bronchitis

A

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)

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9
Q

Diagnosis of acute bronchitis is most often…

A

A clinical diagnosis

WBC is usually normal or mildly elevated

CXR is usually normal or with nonspecific findings

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10
Q

Pneumonia is unlikely if all of the following findings are absent:

A

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

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11
Q

Treatment for acute bronchitis

A

Patient ed - reassurance, expected course

Hydration and rest

Sx relief (NSAIDS, intranets always Ipratropium, antitussives, ß2 agonists, OTC products)

Smoking cessation

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12
Q

Is it better or worse to common antitussives and expectorants/mucolytics?

A

Avoid the combo

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13
Q

What is the only indication for antibacterial agents in the treatment of acute bronchitis?

A

Pertussis

But somehow 50-90% of patients are given Abx 🤦‍♀️

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14
Q

Summarize all we need to know about acute bronchitis

A

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

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15
Q

Other names for Bordetella pertussis…

A

Pertussis, “Whooping Cough”, “The cough of 100 days”

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16
Q

Prodrome of rhinorrhea, mild cough, sneezing followed by classic prolonged progressive “whooping” cough

A

Pertusssi

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17
Q

What are the three phases of Pertussis?

A

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)

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18
Q

Most contagious phase of pertussis

A

Catarrhal (phase 1)

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19
Q

How do we diagnosis Pertussis?

A

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)

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20
Q

Optimal timing for pertussis Dx via culture

A

0-2 weeks

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21
Q

Optimal timing for pertussis diagnosis via PCR

A

0-4 weeks

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22
Q

Optimal timing for pertussis diagnosis via serology

A

2-8 weeks

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23
Q

What is the best way to treat pertussis?

A

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

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24
Q

The key to pertussis prevention is …

A

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

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25
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
26
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
27
Clinical presentation of influenza
Abrupt onset ``` Fever* Headache* Myalgia* Malaise* Nonproductive cough Sore throat Nasal discharge ```
28
Influenza physical findings
Few Hot, flushed appearing Febrile (ask about last dose of acetaminophen or NSAID) Mild cervical lymphadenopathy
29
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)
30
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
31
7th leading cause of death in the US
Pneumonia Acute infection of pulmonary parenchyma Inflammation and consolidation of lung tissue from infectious agent
32
Source based classifications of pneumonia
Community-acquired (CAP) Hospital-acquired (HAP) Ventilator Associated (VAP)
33
Symptom based classification of pneumonia
Typical Atypical
34
Is PNA more common in men or women?
Men
35
Is PNA more common among African Americans or Caucasians?
African Americans
36
Transmission of CAP is most commonly from ...
Aspiration from the oropharynx*** Inhalation of contaminated droplets Hematogenous spread Extension from infected pleural or mediastinal space
37
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 ```
38
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
39
The possible viral causes of CAP
Influenza (predominant viral cause) RSV Parainfluenza Adenovirus
40
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
41
General risk factors for CAP
``` Asthma Immunosuppression Advanced age (≥70) Alcoholism Institutionalization ```
42
Risk factors for Pneumococcal CAP
``` Dementia Seizure disorder Heart failure Cerebrovascular disease Alcoholism Tobacco smoking COPD HIV ```
43
Clinical presentation of CAP
``` ACUTE ONSET FEVER COUGH Sputum production Hemoptysis Dyspnea Night Sweats Pleuritic pain Chest pain, chills, rigors ```
44
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 ```
45
Physical exam findings in CAP
``` Fever Tachypnea (RR>24) Hypoxia Tachycardia Diaphoresis Decreased/bronchial breath sounds Crackles Signs of consolidation ```
46
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
47
What is Cavitation
A line on CXR indicating fluid filled cavity
48
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)
49
Examples of complications of PNA
``` Bacteremia Sepsis Abscess Empyema Respiratory failure ```
50
Admission based on Pneumonia severity index
Class I and II: probably not Class III: admit for observation Class IV and V: Admit to ICU
51
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
52
Best predictor for a good outcome with CAP?
Right site of care So use the CURB-65 and clinical judgement
53
Do you need a follow up CXR in patients with PNA?
Not routinely | 7-12 weeks post treatment in patients > 40 or smokers
54
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)
55
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)
56
Non-ICU inpatient treatment of CAP
Respiratory fluoroquinolone (levofloxacin or moxifloxacin) OR Anti-pneumococcal betalactam plus a macrolide (Ceftriaxone or ertapenem plus Zpack)
57
ICU treatment of CAP
Ceftriaxone plus zpack OR Ceftriaxone plus resp fluoroquinolone
58
Patients are increased risk for pseudomonas
``` Alcoholics CF Neutropenia fever Recent intubation Cancer Organ failure Septic shock ```
59
Patients at increased MRSA risk
End stage renal disease IVDU Prior abx use Influenza
60
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 ```
61
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)
62
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
63
Definition of ventilator associated pneumonia
A type of HAP that develops more than 48-72 hours after endotracheal intubation
64
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
65
Most the Tx for HAP and VAP is dependent upon...
The institution (look at local resistance patterns)
66
Best treatment of VAP?
PREVENTION ``` Avoidance of acid-blocking meds Decontamination of oropharynx Selective decontamination of the gut Probiotics Positioning Subglottic drainage ```
67
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
68
Symptoms of PCP
Fever (79-100%) Cough (95%) - nonproductive Progressive dyspnea (95%) Extra-pulmonary lesions
69
Test that is 90% sensitive for PCP
High LDH Also look for low CD4 count, “ground glass” on CXR, and sputum culture
70
Treatment for PCP
Bactrim ``` Alternatives: TMP-Dapsone Clindamycin-primaquine Pentamidine (best side effect profile) Steroids ```
71
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
72
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
73
Risk factors for aspiration PNA
Post-operative state (vomiting) Neurologic compromise (CVA, Parkinson’s, ALS, sedation) Anatomical defect Alcoholics
74
Common CXR finding for aspiration PNA
RLL infiltrate (v/c right mainstem bronchus more straight) If aspiration in prone position (alcoholics), may be RUL
75
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

Clin Med II Unit II (7 decks)

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