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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
Q

Summarize Pertussis

A

“Whooping cough”

Bacterial etiology (Bordetella pertussis)

Treated with abx (including close contact prophylaxis)

Must be reported to health dept

Vaccination is key to prevention

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26
Q

High risk populations for Influenza

A

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

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27
Q

Clinical presentation of influenza

A

Abrupt onset

Fever*
Headache*
Myalgia*
Malaise*
Nonproductive cough
Sore throat
Nasal discharge
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28
Q

Influenza physical findings

A

Few

Hot, flushed appearing

Febrile (ask about last dose of acetaminophen or NSAID)

Mild cervical lymphadenopathy

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29
Q

Dx testing for influenza

A

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)

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30
Q

Influenza treatment

A

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

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31
Q

7th leading cause of death in the US

A

Pneumonia

Acute infection of pulmonary parenchyma

Inflammation and consolidation of lung tissue from infectious agent

32
Q

Source based classifications of pneumonia

A

Community-acquired (CAP)

Hospital-acquired (HAP)

Ventilator Associated (VAP)

33
Q

Symptom based classification of pneumonia

A

Typical

Atypical

34
Q

Is PNA more common in men or women?

A

Men

35
Q

Is PNA more common among African Americans or Caucasians?

A

African Americans

36
Q

Transmission of CAP is most commonly from …

A

Aspiration from the oropharynx***

Inhalation of contaminated droplets

Hematogenous spread

Extension from infected pleural or mediastinal space

37
Q

Most common bacterial cause of CAP

A

Strep pneumo***

Others:
H flu*
Klebsiella pneumoniae
M catarrhalis*
Staph aureus
Group A strep
Anaerobes
Aerobic gram-negative bacteria
38
Q

Most common etiology of Atypical CAP

A 
Bacterial:
MYCOPLASMA PNEUMONIAE (walking PNA)
Chlamydophila pneumoniae
Legionella pneumonphila
C psittaci

Viral (predominantly influenza, or RSV in kids)

Fungal

39
Q

The possible viral causes of CAP

A

Influenza (predominant viral cause)
RSV
Parainfluenza
Adenovirus

40
Q

What are the four types of fungal CAP?

A

Histoplasmosis (birds/bats)
Blastomycosis (soil assoc)
Coccidiodomycosis (valley fever)
Cryptococcus

All are unusual in an immunocompetent host

41
Q

General risk factors for CAP

A 
Asthma
Immunosuppression
Advanced age (≥70)
Alcoholism
Institutionalization
42
Q

Risk factors for Pneumococcal CAP

A 
Dementia
Seizure disorder
Heart failure
Cerebrovascular disease
Alcoholism
Tobacco smoking
COPD 
HIV
43
Q

Clinical presentation of CAP

A 
ACUTE ONSET
FEVER
COUGH
Sputum production
Hemoptysis
Dyspnea
Night Sweats
Pleuritic pain
Chest pain, chills, rigors
44
Q

Clinical presentation for atypical CAP

A 
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
Q

Physical exam findings in CAP

A 
Fever
Tachypnea (RR>24)
Hypoxia
Tachycardia
Diaphoresis
Decreased/bronchial breath sounds
Crackles
Signs of consolidation
46
Q

Diagnosing CAP

A

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
Q

What is Cavitation

A

A line on CXR indicating fluid filled cavity

48
Q

Other Dx tests for CAP

A

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
Q

Examples of complications of PNA

A 
Bacteremia
Sepsis
Abscess
Empyema
Respiratory failure
50
Q

Admission based on Pneumonia severity index

A

Class I and II: probably not

Class III: admit for observation

Class IV and V: Admit to ICU

51
Q

What are the components of CURB-65

A 
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
Q

Best predictor for a good outcome with CAP?

A

Right site of care

So use the CURB-65 and clinical judgement

53
Q

Do you need a follow up CXR in patients with PNA?

A

Not routinely

7-12 weeks post treatment in patients > 40 or smokers

54
Q

Outpatient treatment for uncomplicated CAP

A

(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
Q

Outpatient treatment of complicated CAP

A

(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
Q

Non-ICU inpatient treatment of CAP

A

Respiratory fluoroquinolone (levofloxacin or moxifloxacin)

OR

Anti-pneumococcal betalactam plus a macrolide (Ceftriaxone or ertapenem plus Zpack)

57
Q

ICU treatment of CAP

A

Ceftriaxone plus zpack

OR

Ceftriaxone plus resp fluoroquinolone

58
Q

Patients are increased risk for pseudomonas

A 
Alcoholics
CF
Neutropenia fever
Recent intubation
Cancer
Organ failure
Septic shock
59
Q

Patients at increased MRSA risk

A

End stage renal disease

IVDU

Prior abx use

Influenza

60
Q

When being treated inpatient, CAP patients cannot be discharged until minimum of 5 days abx and…

A 
Afebrile for 48-72 hours
Supplemental O2 not needed
Heart rate < 100
RR < 24
SBP ≥ 90
61
Q

Keep preventions for CAP

A

Smoking cessation

Vaccinations
• Influenza for all patients
• Pneumococcal for patients ≥ 65, adults with increased risk (CVD, sickle cell, tobacco use, splenectomy, liver disease)

62
Q

Definition of Hospital-Acquired Pneumonia

A

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
Q

Definition of ventilator associated pneumonia

A

A type of HAP that develops more than 48-72 hours after endotracheal intubation

64
Q

Diagnosis of HAP and VAP

A

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
Q

Most the Tx for HAP and VAP is dependent upon…

A

The institution (look at local resistance patterns)

66
Q

Best treatment of VAP?

A

PREVENTION

Avoidance of acid-blocking meds
Decontamination of oropharynx
Selective decontamination of the gut
Probiotics
Positioning
Subglottic drainage
67
Q

Pneumonia associated with HIV

A

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
Q

Symptoms of PCP

A

Fever (79-100%)
Cough (95%) - nonproductive
Progressive dyspnea (95%)
Extra-pulmonary lesions

69
Q

Test that is 90% sensitive for PCP

A

High LDH

Also look for low CD4 count, “ground glass” on CXR, and sputum culture

70
Q

Treatment for PCP

A

Bactrim

Alternatives:
TMP-Dapsone
Clindamycin-primaquine
Pentamidine (best side effect profile)
Steroids
71
Q

When should you consider PCP prophylaxis in HIV+ individuals?

A

Hx of previous PCP
CD4 count <200
Oropharyngeal thrush

Preferred: Bactrim
Alternative: Dapsone or aerosolized pentamidine

72
Q

Displacement of gastric contents to the lung causing injury and infection

A

Aspiration pneumonia

Typically from gram-negative and anaerobic pathogens b/c associated with GI contents

73
Q

Risk factors for aspiration PNA

A

Post-operative state (vomiting)
Neurologic compromise (CVA, Parkinson’s, ALS, sedation)
Anatomical defect
Alcoholics

74
Q

Common CXR finding for aspiration PNA

A

RLL infiltrate (v/c right mainstem bronchus more straight)

If aspiration in prone position (alcoholics), may be RUL

75
Q

Preventing and treating aspiration PNA

A

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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