Bronchitis & Pneumonia Flashcards
Bronchitis
cough >5 days
typically 1-3 weeks long
Chronic bronchitis
cough and sputum production most days of the month
***at least 3 months of the year in 2 consecutive . years
Pathophys behind acute bronchitis
self-limited inflammation of bronchi due to upper airway infection
associated w/ viral URI
Etiology of acute bronchitis
VIRAL! (90%)
Bacterial (mycoplasma, chlmaydia, bordetella pertussis)
Which bacterial infection responds to abx tx
bordatella pertussis
Sx of acute bronchitis
cough (+/- sputum) afebrile (unless influenza) chest wall tenderness wheezing mild dyspnea
PE for acute bronchitis
wheezing
bronchospasm (reduced FEV1)
rhonchi (clears w/ coughing)
(-) crackles and signs of consolidation (that is pneumo)
Dx for acute bronchitis
Clinical!
WBC: normal or elevated
CXR: normal/nonspecific
Crackles
pneumonia
Rhonchi
acute bronchitis
Pneumonia is unlikely if all of the following signs are absent
fever (>100.4)
tachynea (>24 breaths/min)
tachycardia (>100 bpm)
evidence of consolidation (crackles, egophony, fremitus)
Tx for acute bronchitis
reassurance
hydration& rest
Sx relief
Sx relief for acute bronchitis
NSAID, ASA, acetaminophen intranasal ipratropium antitussive (dextromethorphan) B2 agonists (albuterol inhaler, SVN) OTC (lozenges, tea, mucolytics) smoking cessation*
Abx for bronchitis
ONLY PERTUSSIS
CXR for bronchitis
not necessary
only used to r/o pneumonia
Whooping cough
pertussis
Phases of pertussis
- Catarrhal: URI sx, fever (1-2 weeks)
- Paroxysmal: persistent paroxysmal cough, inspiratory “whooping”; POST TUSSIVE EMESIS (2-6 wks)
- Convalescent: cough gradually resolves (weeks - months)
Prodrom w/ pertussis
rhinorrhea, mild cough, sneezing
Dx of pertussis
nasopharyngeal secretions – BACTERIAL CULTURE = GOLD STANDAARD
PCR (faster)
Serology (more useful in later phases: 2-8 wks from cough onset)
Tx of pertussis goals
decreases transmission! little effect on sx resolution
Tx for pertussis
supportive
Macrolide
dosage for pertussis
Azithro 500 mg PO, followed by 250 mg for 4 days
Clarithro 500 mg PO BID x 7 days
Erythro 500 mg PO QID x 14 days
Alternative tx for pertussis
Bactrim PO BID x 14 days
Pertussis tx in peds
< 6 mo most need admission/isolation
Sx control
Macrolides
Abx prophylaxis for pertussis
given to close contacts
vaccination (+Tdap booster)
Influenza involes
upper and lower RT
usually self-limited
High risk for influenza
children <2 YO adults >65 YO chronic disease immunosuppressed pregnant (up to 2 wks postpartum) morbidly obese nursing homes/chronic care facilities
Presentation of influenza
fevere h/a myalgia malaise nonproductive cough sore throat nasal d/c
PE for influenza
hot, flushed
febrile
mild cervical LAD
Dx for influenza
RIDT (10-30 min) - more sensitivity
RT-PCR (2-6 hrs) - most sensitive and specific
Viral culture (48-72 hrs) - confirmatory; not used for clinical management
Negative RIDT
during periods of peak influenza activity, negative test does not exclude influenza (make dx clinically)
Tx for influenza
usually improves 2-5 days
antiviral 24-48 hrs of sx onset (Neuraminidase inhibitors: oseltamivir, zanamivir)
Antiviral therapy
reduces sx duration by 1-3 days
Most common complication of influenza
Pneumonia
acute infection of pulmonary parenchyma
pneumonia
What is pneumonia?
inflammation and consolidation of lung tissue from infectious agent; result of virulent organism, large inoculum and/or impaired host defense
Classification of pneumonia
typical vs. atypical
CAP, HAP, VAP
Highest incidence of pneumonia
<4 yo
>60 yo
M>F
African Americans > Caucasians
Transmission of CAP
ASPIRATION from oropharynx * (most common)
inhale droplets
hematogenous spread
extension from infected pleural or mediastinal space
Pathophys behind CAP
proliferation of bacteria in alveoli when macrophages ability is exceeded;
alveolar macrophages initiate an inflammatory response to increase the lower respiratory tract defenses
Most common cause of typical pneumo
Streptococcus pneumoniae
Most common cause of atypical pneumonia
Mycoplasma pneumonia
Causes of atypical pneumo
bacterial, viral, fungal
bacterial: mycoplasma, chlamydophila, legionella, C. psittaci
Viral etiology of pneumona
influenza
RSV
Parainfluenza
adeno
Fungal causes of pneumonia
histoplasmosis
blastomycosis
coccidiodomycosis
Cryptococcus
*unusual in immunocompetent host
Presentation of pneumonia
acute onset * fever * cough * sputum production hemoptysis dyspnea night sweats pleuritic chest pian chest pain, chills, rigors
PE for pneumonia
fever tachypnea: RR>24 hypoxia tachycardic diaphoresis decreased/bronchial breath sounds crackles (rales) Consolidation signs
Consolidation signs
dullness to percussion
increased tactile fremitus
bronchophony
egophony
(+) bronchophony
“99” is louder and clearer
(+) egophony
E heard as “A”
Dx of pneumonia
Leukocytosis w/ left shift (15k-30k)
CXR: infiltrate (lobar consolidation, interstitial infiltrates, cavitation)
Gold standard for pneumonia
infiltrate on CXR
Dx for CAP
CT- not routinely recommended
Microbio testing (sputum, blood culture): very ill/risk factors for unusal organisms
Urine antigen test: legionella and s. pneumo
PCR tests: research studies
Procalcitonin and CRP: inflammatory markers - help distinguish between bacterial and viral
Testing for legionella or S. pneumo
Urine antigen test
Helps distinguish b/w bacterial and viral pneumo
procalcitonin and CRP
Complications of pneumo
bacteremia sepsis abscess empyema respiratory failure
Severity index and admission
Class I-II: probably not
Class III: observation unit
Class IV and V: admit to hospital
CURB-65 score for pneumonia
Confusion urea > 7, BUN >20 RR >30 BP (sys <90 or DBP <60) 65 YO or more
CURB-65 and recommendation
0 &1: outpatient
2: admit
3-5 assess for ICU care
Outpatient uncomplicated pneumo tx
Macrolide: azithro 500 mg PO day 1, 250 mg PO x 4 days
OR
Doxycycline (100 mg BID x 7-10 days)
Tx for complicated pneumo
beta-lactam + macrolide:
Augmentin 500 mg BID + azithromycin
OR
Respiratory fluorquinolone (levofloxacin 750 mg daily x 5 days)
Education to pt on pneumo sx
abx at least 5 days 3 days for fever to resolve 14 days for cough and fatigue 1/3 have sx at 28 days return to work in 6 days
F/u for pneumo
CXR not needed routinely
When to do f/u CXR in pneumonia
7-12 weeks post tx in pts >40 yo or smokers
Risk for pseudomonas
alcoholism CF neutropenic fever recent intubation cancer organ failure septic shock
MRSA risk
end stage renal disease
IV drug abuse
prior abx use
influenza
When to d/c inpatient
min 5 days abx and:
- afebrile 48-72 hrs
- supplemental O2 not needed
- HR <100 bpm
- RR <24
- SBP >90 mmHg
When to have pneumococcal vaccine
> 65 yo
19-64 yo at increased risk (cardiopulm disease, SS, tobacco abuse, splenectomy, liver disease)
Uncomplicated outpt tx
macrolide or doxy
Complicated out patient or non-ICU
macrolide + beta-lactam
OR
resp. fluroquinolone
ICU
beta-lactam + azithro
OR
beta-lactam + fluoroquinolone
If PCN allergy: fluoroquinolone + aztreonam
What is HAP?
48 hrs or more after admission and did not appear to be incubating at time of admission
Risk for HAP
ICU (pseudomonas aeruginosa - worst prognosis)
Mechanical ventilation
VAP
HAP that develops 48-72 hrs after endotracheal intubation
Tx for HAP or VAP
broad spectrum abx
Dx of HAP/VAP
new/progressive infiltrate on imaging AND 2 of the following:
- fever
- purulent sputum
- leukocytosis
Sputum gram stain + culture indicated
Best tx of VAP
avoid acid-blocking meds decontamination of oropharynx selective decontamination of gut probiotics positioning subglottic drainage
Further eval for non-resolving pneumo
chest CT
fiberoptic bronchoscopy
thoracoscopy
open lung bx
Pneumocystis jirovecci aka
pneumocystis carinii; PCP; pneumocystis pneumonia
What is PCP
fungi
what is PCP associated w/
HIV (CD4 count low)
Sx of PCP
fever
cough- nonproductive
progressive dyspnea
extra-pulmonary lesions
Testing for PCP
high LDH
Low CD4
CXR
sputum
Tx for PCP
Bactrim
Alternative tx for PCP
TMP-dapsone
clindamycin-primaquine
pentamidine (best SE profile)
steroids
Prophylaxis for PCP in HIV
hx of previous PCP
CD4 <200
oropharyngeal thrush
Prolphyaxis tx
bactrim
alt: dapsone, pentamidine
What is aspiration pneumonia?
displacement of gastric contents to the lung causing injury and infecftion; gram-negative and anaerobic pathogens
Risk factors for aspiration pneumo
post-op neuro comprovis (CVA, parkinson's, ALS, sedation) anatomical defect or aberrancy
CXR in aspiration pneumo
RLL infiltrate common
Aspiration pneumo tx
supportive
abx: piperacillin/tazobactam OR ampicillin/subactam OR clinda OR moxifloxacin
