Bronchitis and Pneumonia Flashcards
How to classify acute bronchitis
Cough > 5 days (typically 1-3 wks)
Usually lower respiratory
How to classify chronic bronchitis
Cough and sputum production on most days of the month
At least 3 mos of the year in 2 consecutive yrs
Pathophysiology of acute bronchitis
Self-limited inflammation of the bronchi due to upper airway infection-often associated with viral URI
Etiology of acute bronchitis
Viral (90%)- influenza, parainfluenza, coronavirus, rhinovirus, RSV, human metapneumovirus
Bacterial uncommon- M pneumonia, C pneumoniae, B pertussis
What is the only bacterial pathogen that should be treated with abx for acute bronchitis?
Bordetella pertussis
Presentation of acute bronchitis
Cough (maybe sputum production)-purulent sputum not predictive of bacterial infection Usually afebrile (unless influenza) Chest wall tenderness Wheezing Mild dyspnea
What is seen on a physical exam in acute bronchitis?
Wheezing
Bronchospasm (reduced FEV1)
Rhonchi (clears with coughing)
Negative for crackles and signs of consolidation
Different types of crackles
Fine (hair between fingers)
Coarse (velcro)
When is pneumonia unlikely?
When all findings are absent: Fever (>38 C) Tachypnea (>24 breaths/min) Tachycardia (>100 breaths/min) Evidence of consolidation on chest exam Consider chest radiograph for pts with any of these findings or cough longer than 3 wks
Tx for acute bronchitis
Hydration and rest
Symptomatic relief (NSAIDs, intranasal ipratropium, antitussives, B2 agonists, lozenges etc)
Smoking cessation
Is a CXR necessary for acute bronchitis?
No, not necessary in most cases (r/o pneumonia)
What is pertussis?
“whooping cough” caused by bordetella pertussis
Prolonged progressive cough
Stages of pertussis
Catarrhal (1-2 wks of URI sxs/fever)
Paroxysmal (2-6 wks of persistent paroxysmal cough, whooping, emesis)
Convalescent (wks to mos of cough gradually resolving)
Gold standard for diagnosis of pertussis
Bacterial culture from nasopharyngeal secretions
When is serology used?
For diagnosis in later phases
2-8 wks from cough onset
Tx of pertussis
Empiric therapy used while obtaining diagnostic test for confirmation
Abx decreases transmission but has little effect on symptom resolution
What is the CDC recommended antibiotic regiment of pertussis in adults?
Azithromycin (500 mg PO followed by 250 mg for 4 days)
Clarithromycin (500 mg PO BID for 7 days)
Erythromycin (500 mg PO QID for 14 days)
Alternative Bactrim PO BID for 14 days
Treatment of pertussis in peds
Most kids <6 mos need admission
Otherwise sx control and abx
Who receives abx prophylaxis for pertussis?
Close contacts (it must be reported to state health dept)
High risk populations of influenza
Kids <2 Adults >65 Underlying chronic disease Immunosuppressed Pregnant (up to 2 wks postpartum) Morbidly obese Resident of nursing home/chronic care facility
Presentation of influenza
Abrupt onset of fever, HA, myalgia and malaise (nonproductive cough, sore throat, nasal discharge less common)
Diagnostic tests for influenza
Rapid influenza diagnostic tests (10-30 min)- low sensitivity and high specificity
RTPCR (2-6 hrs)- most sensitive and specific
Viral culture (48-72 hrs)-confirmatory
Tx of influenza
Generally get better in 2-5 days (may be 1 wk more)
Antiviral therapy within 24-48 hrs of sx onset-Oseltamavir and Zanamivir- reduce sxs by 1-3 days
Most common complication of influenza
Pneumonia
What is pneumonia?
Acute infection of pulmonary parenchyma
Inflammation and consolidation of lung tissue from infectious agent
Classifications of pneumonia
Source based: community acquired, hospital acquried and ventilator associated
Symptom based: typical and atypical
Epidemiology of CAP
Men>women
African Americans>Caucasians
Incidence highest at extremes of ages (<4 and >60)
How is CAP transmitted?
Aspiration from the oropharynx is most common
Inhalation of contaminated drops
Hematogenous spread
Extension from infected pleural or mediastinal space
Pathophysiology of CAP
Proliferation of microbial pathogens at the alveolar level when the capacity of macrophages to kill is exceeded
Etiology of CAP
Typical is bacterial (mostly streptococcus pneum)
Atypical is bacterial (mostly mycoplasma pneumoniae), viral or fungal (unusual in immunocompetent host)
Risk factors of CAP
General: asthma, immunosuppression, advanced age, alcoholism, institutionalization
Pneumococcal (dementia, seizure disorder, heart failure, cerebrovascular disease, alcoholism, tobacco, COPD, HIV)
Clinical presentation of CAP
Acute onset fever and cough (typical)
Can also be sputum, hemoptysis, dyspnea, night sweats, pleuritic chest pain, chest pain, chills, rigor
Atypical presentation of CAP
Subacute onset of viral prodrome, nonproductive cough, low grade fever, HA, myalgia, malaise, confusion, weakness, delirium etc
What is seen on the physical exam in CAP?
Fever, tachypnea, hypoxia, tachycardia, diaphoresis, decreased breath sounds, crackles, signs of consolidation
Gold standard for diagnosis of CAP
Infiltrate on plain chest radiograph (lobar consolidation, interstitial infiltrates, cavitation)
Others like leukocytosis with left shift
Complications of CAP
Bacteremia, sepsis, abscess, empyema, respiratory failure
What is CURB-65?
Way to predict pt mortality and recommendation for tx
Confusion
Urea>7 mmol/L, BUN>20 mg/dL
Respiratory rate>30 breaths/min
Blood pressure (SBP<90 or DBP<60)
65-age >65
Give 1 pt for everything (admit at 2 and 3+ assess for ICU)
What is the best predictor of a good outcome for CAP?
Right site of care
Duration of abx for outpatient care of CAP
At least 5 days
What pt reassurance is necessary for outpatient tx?
Median resolution time is 3 days for fever, 14 days for cough and fatigue
Many will have sxs for amonth
Return to work about 6 days
When do you need a follow up CXR?
Not routinely
7-12 wks post tx in pts > 40 yo or smokers
Outpatient tx for uncomplicated CAP (typical and atypical)
Azithromycin 500 mg day 1, 4 days of 250 mg
Doxycycline (100 mg BID for 7-10 days)
Uncomplicated means previously healthy, no abx use within past 3 mos
What is complicated CAP?
Pts with recent abx use, COPD, liver or renal disease, cancer, DM, chronic heart disease, alcoholism, asplenia or immunosuppression
Outpatient tx for complicated CAP
Combo of beta-lactam (Augmentin 500 mg BID) plus macrolide (azithromycin)
OR
Respiratory fluoroquinolone (levofloxacin 750 mg daily for 5 days)
Inpatient tx for CAP
Minimum of 5 days of abx and afebrile for 48-72 hrs, supplemental 02, HR <100, RR<24, SBP>90
In order to discharge
Who needs a pneumococcal vaccine?
Pts >65
Pts 19-64 at increased risk for pneumococcal infection and/or serious complications of infection (cardiopulm disease, sickle cell, tobacco use, splenectomy, liver disease)
What is hospital acquired pneumonia?
48 hrs or more after admission and did not appear to be incubating at time of admission
Who is at the highest risk for HAP?
ICU (psuedomonas)
Mechanical ventilation
What is ventilator associated pneumonia?
A type of HAP that develops more than 48-72 hrs after endotracheal intubation
Diagnosis of HAP and VAP
New and progressive infiltrate on lung imaging AND at least 2 of the following (fever, purulent sputum, leukocytosis)
Indicated to do sputum gram stain and culture
Best tx strategy of VAP
Prevention! Avoidance of acid-blocking meds Decontamination of oropharynx Probiotics Positioning Subglottic drainage
What should be considered with non-resolving pneumonias?
Atypical infection (viral/fungal) Aspiration CHF Cancer Fibrosis *further eval
What is pneumocystic jirovecii pneumonia?
PCP
Was considered protozoan and now fungi
Associated with HIV (low CD4)
Leading diagnosis of AIDS defining condition
Sxs of PCP
Fever, nonproductive cough, progressive dyspnea, extra-pulmonary lesions
What is seen on the tests in PCP
High LDH, low Cd4, CXR, sputum
Tx for PCP
Bactrim is preferred
When do you consider prophylaxis for PCP?
Risk factors in pts with HIV (history of previous PCP, CD4<200, oropharyngeal thrush)
Bactrim is preferred
What is aspiration pneumonia?
Displacement of gastric contents to lung causing injury and infection by gram-negative and anaerobic pathogens
Risk factors for aspiration pneumonia
Post-opertion, neurologic compromise, anatomical defect or aberrancy
What is commonly seen on a CXR in aspiration pneumonia?
RLL infiltrate
Abx for aspiration pneumonia
Piperacillin or ampicillin or clindamycin or moxifloxacin
