chapter 27: lower respiratory stuff Flashcards
Acute bronchitis
usually from viruses, but also irritants and asthma
-3 week cough
-NO fluid build up in lungs from consolidation
-may have fever, hoarseness, aches, dyspnea, pain
-gol of treatment is to relieve symptoms and prevent pneumonia
Perussis
Super contgious infection caused by Bordetella pertussis which attaches to and damages cilia
-TDAP vaccine is super important
“Whooping cough” –> might not be present in teens and adults –> happens more at night
contagious from onset to 3rd week or 5 days aft antibiotics
Pertussis phases
1) 1-2 weeks URT infection and nonproductive cough
2) weeks 2-10 paroxysyms of coughs
3) 2-3 weeks = weakness and less severe cough
Treatment do’s and dont’s for pertussis
-diagnose with cultures and PCR
-treat with macrolide or trimethoprim/sulfamethoxazole
-give antibiotics to ppl who were exposed too
-no cough suppressants or antihistamines
-no corticosteroids or bronchodilators
Pneumonia
-what?
why?
entryways
acute infection of lung parenchyma
-typically happens when immune defenses are compromised or overwhelmed –> chronic diseases make it worse
Pathogens enter lungs in 3 ways:
1. aspiration of normal flora from nasopharynx or oropharynx
2. inhalation of microbes in air (mycplasma pneumoniae)
3. hematogenous spread from other infection (streptococcus aureas from endocarditis)
Community acquired pneumonia (CAP)
Not from hospital (no hospitalization within 14 days)
Use CURB-65 to decide wheteher to treat in hospital
Confusion
U: BUN>20
Respiratory rate >30
Blood pressure <90/60
65 or older
Hospital acquired pneumonia (HAP)
-nonintubated patient –> 48+ hrs after admission
-ventilator associated pneumonia (VAP) –> 48+ hrs after intubation
Empiric antibiotics to treat
Viral and bacterial pneumonia
Viral
-most common
-mild to life threatening
Bacterial
-often hospitalized
Mycoplasma pneumonia has traits of viral and bacterial –> “atypical”
Aspiration Pneumonia
-stuff from moth or stomach enters lungs
-LOC, NG tubes, and swallowing issues
-usually more than one bacteria involved –> need antibiotics for G- and MRSA
-if acidic stuff from stomach causes issues –> “chem/noninfectious” –> no antibiotics
Necrotizing Pneumonia
-rare complication of lung infection turning tissue into thick liquid
-absesses and cavitization are possible
-resp failure and airway bleeding
-don’t really know reasons for it
-Staphylococcus, Klebisella, and Streptococcus involved
-long term antibiotics and possibly surgery
Opportunistic pneumonia
in immunocompromised patients
-protein malnourishment, HIV, radiation/chemo, long term corticosteroids
PJP pneumonia = fungal - slow, subtle onset
-tachycardia, fever, tachypnea, dyspnea, nonproductive cough, hypoxemia
-spreads to other organs (liver, bone marrow, lymph nodes, spleen, thyroid)
-doesn’t respond to antifungals–> use bactrim or sptra
CMV (herpes) can cause pneumonia
Pathophysiology for pneumonia
inflammation, neutrophils, edema, fluid leaks, hypoxemia
Atelectasis (nothing in alveoli) causes shortness of breath
Consolidation (fluid in alveoli) impairs gas exchange –> with treatment/time, macrophages get rid of this stuff
Manifestations of pneumonia
cough, fever, chills, dyspnea, tachypnea, and pleuritic chest pain
-cough may or may not be productive with any color of sputum
Old ppl might just be confused and have hypothermia rather than fever
Chest sounds of pneumonia
-course or fine crackles
If consolidation:
-bronchial breath sounds
-egophony
-increased fremitus
If pleural effusion
-dullness to percussion
Complications of pneumonia
MDR pathogens
atelectasis
pleurisy (inflammation of plaura)
pleural effusion
Bacteremia (bacterial blood infection)
pneumothorax (air in pleura makes lungs collapse)
acute respiratory failure
sepsis/septic shock
RARE:
-lung abscess (S. aureas and G-)
-emphysema (need antibiotics and drainage)
Diagnostic studies for pneumonia
history, phys exam and xray are enough to get started
-thoracentesis or bronchoscopy can get fluid for testing if patient isn’t responding to treatments
-ABGs and WBC assessment
-sputum sample to treat specific bacteria
Treatment of pneumonia
-antibiotics (should help in 48-72 hrs if uncomplicated)
-follow up xray in 6-8 weeks
-O2, analgesics, antipyretics as needed
-activity if tolerable
***usually not much you can do for viral pneumonia - resolves on its own in 3-4 days –> antiviral stuff can help if pneumonia from influenza or herpes
drug therapy for pneumonia
-empiric antibiotics including stuff to fight MDR pathogens and G- and G+
-switch to oral meds ASAP
-Get ppl out of hospital ASAP
-patient should be afebrile for 48-72 hrs before stopping treatment
Nutrition therapy for pneumonia
HYDRATION!!!!!!! –> thins and loosens secretions
Small, frequent meals to get enough cals for heightened metabolism –> eating can be hard bc shortness or breath
positions that prevent aspiration
upright and side-lying
ways to prevent pneumonia post op
-early mobilization
-incentive spirometer
-oral hygiene 2x a day with chlorhexidine swabs
Tuberculosis
infection caused by mycobacterium tuberculosis
-usually affects lungs, but can affect any organ
-kills poor people and HIV
Resistance is a huge problem –> MDR-TB (first line drugs) and XDR-TB (all the rest, including fluoroquinolones)
Mycobacterium tuberculosis facts
-contagion
-G+, aerobic, acid fast bacillus
-tiny droplets airborne (not super contagious though)
-humans are only reservoirs
-once in bronchioles/alveoli, Ghon lesion/focus forms (calcified TB source) to kill it (usually successful)
Classification of TB
Primary = initial immune response fails and disease progresses (“active”) w/in 2 yrs of infection
Reactivation = happens more than 2 yrs later
Latent = what it sounds like –> can be activated with immunosuppression, diabetes, bad nutrition, pregnancy, stress, aging, disease
How long after infection do symptoms show up?
cough progression
early symptoms
late symptoms?
2-3 weeks (except when it is acute)
starts dry then becomes productive
fatigue, malaise, weight loss, fever, chest pain
dyspnea and hemoptysis
*sometimes night sweats
TB presentation in old or HIV ppl
HIV: less likely to have signs of infection
-symptoms sometimes wrongly attributed to PJP
old ppl
-sometimes only display change in mental status
Miliary TB
widespread dissemination of the mycobacterium
-causes swelling of lymph, liver, spleen
-from primary or LTBI TB
Pleural TB
-extrapulmonary
-from primary or LTBI
-chest pain, fever, cough, PLEURAL EFFUSION
-emphysema not as common
-diagnosed with biopsy and AFB cultures
Potts syndrome
TB in spine
TB skin test
-use purified protein derivative (PPD) for M tuberculosis
-check 2-3 days later for induration (no redness)
-5 mm = positive
-2 step testing w/ Mantoux TST for baseline
Interferon-y release assays
-blood tests that detect INF-y release fom T cells
-only require one visit and are more accurate
-can’t differentiate bt LTBI and active
How accurate are chest xrays for TB diagnosing?
What about bacteriologic studies?
-chest xrays aren’t great
-gold standard! –> 3 specimen 8-24 hrs apart –> can take a long time though
How long are TB ppl contagious?
-if sputum smear is positive, they’re contagious for first 2 weeks after starting treatment
Drug therapy for TB
Initial and continuation phase
Initial:
-4 drug regimen for 8 weeks
-isoniazid, rifampin, pyrazinamide, ethambutol
Continuation:
-2 drugs for 18 weeks
-isoniazid and rifampin
CAUTION: ALC AND ISONIAZID DON’T MIX
-nonviral hepatitis is a possible side effect
Drug treatment for MDR and XDR TB
-guided by sensitivity testing
MDR
-usually 5 drugs for 6 months
-then 4 drugs for 18-24 months
Sirturo and Deltyba treat MDR and XDR
Directly observed therapy (DOT)
-Watch them take the meds
-Nonadherance is big issue with spread of MDR-TB
-can use combo pills to make it easier for ppl
Latent TB drug treatment
-usually only need 1 drug (typically isoniazid for 9 months)
-6 month regimen is less effective, but better for adherence
-ppl w/ HIV or fiberobtic chest lesions need full 9 months
-3 month of isoniazid AND rifapentine if no MDR
-4 month rifampin if resistant to isoniazid
Bacille Calmette-Guerin (BCG) vaccine
-live attenuated strain of Mycobacterium bovis
Not used so much in U.S.
-no help with pulmonary TB
-interferes with TB skin test
-no effect on IGRA though
Who do you report positive TB tests to?
public health authorities
3 things to do if someone comes into ER with suspected TB
- airborne precautions (fitted HEPA masks)
- chest xray, sputum smear, culture
- drug therapy
Ambulatory care
-its ok to go home if fam is already exposed
-sputum for AFB every month until 2 in a row are neg
-reduce exposing others –> spend time outside
-stick to drug regimen
-teach how to recognize relapses
-STOP SMOKING
