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X Clin Med II Exam 2 > Bronchitis and Pneumonia > Flashcards

Bronchitis and Pneumonia Flashcards

1
Q

How to classify acute bronchitis

A

Cough > 5 days (typically 1-3 wks)

Usually lower respiratory

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2
Q

How to classify chronic bronchitis

A

Cough and sputum production on most days of the month

At least 3 mos of the year in 2 consecutive yrs

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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

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4
Q

Etiology of acute bronchitis

A

Viral (90%)- influenza, parainfluenza, coronavirus, rhinovirus, RSV, human metapneumovirus
Bacterial uncommon- M pneumonia, C pneumoniae, B pertussis

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5
Q

What is the only bacterial pathogen that should be treated with abx for acute bronchitis?

A

Bordetella pertussis

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6
Q

Presentation of acute bronchitis

A 
Cough (maybe sputum production)-purulent sputum not predictive of bacterial infection
Usually afebrile (unless influenza)
Chest wall tenderness
Wheezing
Mild dyspnea
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7
Q

What is seen on a physical exam in acute bronchitis?

A

Wheezing
Bronchospasm (reduced FEV1)
Rhonchi (clears with coughing)
Negative for crackles and signs of consolidation

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8
Q

Different types of crackles

A

Fine (hair between fingers)

Coarse (velcro)

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9
Q

When is pneumonia unlikely?

A 
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
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10
Q

Tx for acute bronchitis

A

Hydration and rest
Symptomatic relief (NSAIDs, intranasal ipratropium, antitussives, B2 agonists, lozenges etc)
Smoking cessation

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11
Q

Is a CXR necessary for acute bronchitis?

A

No, not necessary in most cases (r/o pneumonia)

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12
Q

What is pertussis?

A

“whooping cough” caused by bordetella pertussis

Prolonged progressive cough

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13
Q

Stages of pertussis

A

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)

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14
Q

Gold standard for diagnosis of pertussis

A

Bacterial culture from nasopharyngeal secretions

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15
Q

When is serology used?

A

For diagnosis in later phases

2-8 wks from cough onset

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16
Q

Tx of pertussis

A

Empiric therapy used while obtaining diagnostic test for confirmation
Abx decreases transmission but has little effect on symptom resolution

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17
Q

What is the CDC recommended antibiotic regiment of pertussis in adults?

A

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

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18
Q

Treatment of pertussis in peds

A

Most kids <6 mos need admission

Otherwise sx control and abx

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19
Q

Who receives abx prophylaxis for pertussis?

A

Close contacts (it must be reported to state health dept)

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20
Q

High risk populations of influenza

A 
Kids <2
Adults >65
Underlying chronic disease
Immunosuppressed
Pregnant (up to 2 wks postpartum)
Morbidly obese
Resident of nursing home/chronic care facility
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21
Q

Presentation of influenza

A

Abrupt onset of fever, HA, myalgia and malaise (nonproductive cough, sore throat, nasal discharge less common)

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22
Q

Diagnostic tests for influenza

A

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

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23
Q

Tx of influenza

A

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

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24
Q

Most common complication of influenza

A

Pneumonia

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25
Q

What is pneumonia?

A

Acute infection of pulmonary parenchyma

Inflammation and consolidation of lung tissue from infectious agent

26
Q

Classifications of pneumonia

A

Source based: community acquired, hospital acquried and ventilator associated
Symptom based: typical and atypical

27
Q

Epidemiology of CAP

A

Men>women
African Americans>Caucasians
Incidence highest at extremes of ages (<4 and >60)

28
Q

How is CAP transmitted?

A

Aspiration from the oropharynx is most common
Inhalation of contaminated drops
Hematogenous spread
Extension from infected pleural or mediastinal space

29
Q

Pathophysiology of CAP

A

Proliferation of microbial pathogens at the alveolar level when the capacity of macrophages to kill is exceeded

30
Q

Etiology of CAP

A

Typical is bacterial (mostly streptococcus pneum)

Atypical is bacterial (mostly mycoplasma pneumoniae), viral or fungal (unusual in immunocompetent host)

31
Q

Risk factors of CAP

A

General: asthma, immunosuppression, advanced age, alcoholism, institutionalization
Pneumococcal (dementia, seizure disorder, heart failure, cerebrovascular disease, alcoholism, tobacco, COPD, HIV)

32
Q

Clinical presentation of CAP

A

Acute onset fever and cough (typical)

Can also be sputum, hemoptysis, dyspnea, night sweats, pleuritic chest pain, chest pain, chills, rigor

33
Q

Atypical presentation of CAP

A

Subacute onset of viral prodrome, nonproductive cough, low grade fever, HA, myalgia, malaise, confusion, weakness, delirium etc

34
Q

What is seen on the physical exam in CAP?

A

Fever, tachypnea, hypoxia, tachycardia, diaphoresis, decreased breath sounds, crackles, signs of consolidation

35
Q

Gold standard for diagnosis of CAP

A

Infiltrate on plain chest radiograph (lobar consolidation, interstitial infiltrates, cavitation)
Others like leukocytosis with left shift

36
Q

Complications of CAP

A

Bacteremia, sepsis, abscess, empyema, respiratory failure

37
Q

What is CURB-65?

A

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)

38
Q

What is the best predictor of a good outcome for CAP?

A

Right site of care

39
Q

Duration of abx for outpatient care of CAP

A

At least 5 days

40
Q

What pt reassurance is necessary for outpatient tx?

A

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

41
Q

When do you need a follow up CXR?

A

Not routinely

7-12 wks post tx in pts > 40 yo or smokers

42
Q

Outpatient tx for uncomplicated CAP (typical and atypical)

A

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

43
Q

What is complicated CAP?

A

Pts with recent abx use, COPD, liver or renal disease, cancer, DM, chronic heart disease, alcoholism, asplenia or immunosuppression

44
Q

Outpatient tx for complicated CAP

A

Combo of beta-lactam (Augmentin 500 mg BID) plus macrolide (azithromycin)
OR
Respiratory fluoroquinolone (levofloxacin 750 mg daily for 5 days)

45
Q

Inpatient tx for CAP

A

Minimum of 5 days of abx and afebrile for 48-72 hrs, supplemental 02, HR <100, RR<24, SBP>90
In order to discharge

46
Q

Who needs a pneumococcal vaccine?

A

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)

47
Q

What is hospital acquired pneumonia?

A

48 hrs or more after admission and did not appear to be incubating at time of admission

48
Q

Who is at the highest risk for HAP?

A

ICU (psuedomonas)

Mechanical ventilation

49
Q

What is ventilator associated pneumonia?

A

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

50
Q

Diagnosis of HAP and VAP

A

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

51
Q

Best tx strategy of VAP

A 
Prevention!
Avoidance of acid-blocking meds
Decontamination of oropharynx
Probiotics
Positioning
Subglottic drainage
52
Q

What should be considered with non-resolving pneumonias?

A 
Atypical infection (viral/fungal)
Aspiration
CHF
Cancer
Fibrosis
*further eval
53
Q

What is pneumocystic jirovecii pneumonia?

A

PCP
Was considered protozoan and now fungi
Associated with HIV (low CD4)
Leading diagnosis of AIDS defining condition

54
Q

Sxs of PCP

A

Fever, nonproductive cough, progressive dyspnea, extra-pulmonary lesions

55
Q

What is seen on the tests in PCP

A

High LDH, low Cd4, CXR, sputum

56
Q

Tx for PCP

A

Bactrim is preferred

57
Q

When do you consider prophylaxis for PCP?

A

Risk factors in pts with HIV (history of previous PCP, CD4<200, oropharyngeal thrush)
Bactrim is preferred

58
Q

What is aspiration pneumonia?

A

Displacement of gastric contents to lung causing injury and infection by gram-negative and anaerobic pathogens

59
Q

Risk factors for aspiration pneumonia

A

Post-opertion, neurologic compromise, anatomical defect or aberrancy

60
Q

What is commonly seen on a CXR in aspiration pneumonia?

A

RLL infiltrate

61
Q

Abx for aspiration pneumonia

A

Piperacillin or ampicillin or clindamycin or moxifloxacin

X Clin Med II Exam 2 (6 decks)

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