Clinical Approach to Pneumonia/Pleural Effusion/ARDS, Pneumothoraces/Tuberculosis, and Pulmonary Function Tests Flashcards
What is seen on physical exam and chest radiograph of a patient with a Pneumothorax?
PE: unilateral chest expansion, dec. tactile fremitus, dec. breath sounds, mediastinal shift, cyanosis
Radio: pleural air present
What is the difference between Primary, Secondary, Traumatic, and Iatrogenic, and Tension Pneumothoraxes?
P: in absence of underlying lung disease
- seen in tall, thin boys/men (10-30)
- rupture of subpleural apical blebs
S: complication of pre-existing pulmonary disease
T: due to penetrating or blunt trauma
I: may follow procedures
Tension: due to PENETRATING trauma, lung infection, cardiopulmonary resuscitation, mechanical ventilation
- pressure in pleura exceed alveolar/venous pressure
- lung compression/reduced venous return
What is the difference in presentation between a small and large pneumothorax and how can they be treated?
What are 3 findings (T/H/MS) that should cause suspicion of tension pneumothorax?
Small (< 15% of hemithorax): physical exam findings are normal save for mild tachycardia
- Tx: cautious observation
- Tx: supplemental oxygen can inc. reabsorption rate
Large: diminished breath sounds, dec. tactile fremitus, dec. chest movement noted
TP: marked tachycardia, hypotension, mediastinal shift
How are small-bore catheters and Heimlich valves used for penumothorax pts?
How should a patient be treated symptomatically?
- can use small-bore catheter to aspiration drain pleural air in primary pneumothoraxes that are large/progressive
- small-bore chest tube with one-way Heimlich valve provide protection against tension pneumothorax (can be used for Palliative care)
- pt. should be treated symptomatically for cough/chest pain w/serial chest radiography every 24 hours for 3 days
all patients with secondary or worse pneumothoraxes should receive a chest tube placement –> guide with finger
Pulmonary Tuberculosis
What are 4 risk factors for infection (HE/I/D/T), what is seen on chest radiography, and how does it stain on culture?
RF: household exposure, incarceration, drug use, travel to endemic area
Sx: WL, fever, night sweats, productive cough
Radio: pulmonary opacities, mostly APICAL
Stain: acid-fact bacilli on culture (+ for M. tuberculosis)
What is the difference between Primary Tuberculosis, Latent Tuberculosis, and Active Tuberculosis?
PT: lymphatic/hematogenous dissemination
- usually clinically/radiographically silent
- T-cells/MO surround organism in granuloma
- contained but NOT eradicated
LT: no active disease/cannot transmit to others
- reactivation can occur if immunity is compromised
AT: develops in 6% with LT, 50% within 2 yrs of PT
- inc. activation risk associated with diverse conditions
What are 4 risk factors for the development of Drug-resistance TB (I/CI/UT/N)?
What is the difference between drug-resistant, multidrug-resistant, and extensively drug-resistant TB?
RF: immigration from country w/drug-resistant TB, contact with infected persons, unsuccessful prior TB therapies, and nonadherence to TB treatment
DR: resistant to first-line drugs: isoniazid or rifampin
MDR: resistant to both isoniazid and rifampin, and possibly other agents
EDR: resists isoniazid, rifampin, fluoroquinolones, and aminoglycosides/capreomycin
What are common signs and symptoms of Tuberculosis? (3)
Which symptom is most common?
- chronic cough is MOST common pulmonary symptom
- also blood-streaked sputum
- dyspnea unusual unless extensive disease
- pt appears chronically ill and malnourished on physical exam
- no physical findings specific for TB on chest examination
How is Tuberculosis diagnosed?
- definitive diagnosis requires positive cultures or indication of TB by DNA/RNA amplification for 3 CONSECUTIVE MORNINGS
- can use sputum induction with 3% hypertonic saline for patients who cannot produce sputum or when smear is negative for acid-fast bacilli
- do for 3 CONSECUTIVE DAYS
What are the traditional imaging findings associated with primary tuberculosis (UI/HLNE/SA)?
What are two other findings on radiography of pts. with tuberculosis?
TF: small unilateral infiltrates, hilar LN enlargement, and segmental atelectasis
- can also see Pleural Effusion and cavitary lesions
What TB radiography findings are commonly seen in elderly pts and immunocompromised pts?
What is Miliary TB?
Elderly: lower lobe infiltrates with/without pleural effusion (LL TB can masquerade as pneumonia or lung cancer)
IC: lower lung zone, diffuse, miliary infiltrates; pleural effusions; hilar and mediastinal LN involvement
Miliary = diffuse small nodular densities seen with hematologic or lymphatic dissemination of organism
Which 4 pts would see a positive TB skin test with induration > 5mm? (HIV/RC/FC/OT)
Which 6 pts would see a positive TB skin test with induration > 10mm? (RI/DU/MLP/RHR/MC/C)
(+) > 5mm = HIV (+) pts, recent contact with infected person, pts w/fibrotic changes (past TB), pts. with organ transplant (other immunosuppressed pts)
(+) > 10 mm
- recent immigrants (< 5 yrs) from area w/high prevalence
- HIV (-) drug users
- mycobacterium lab personnel
- residents of high-risk congregate areas (incarceration/nursing home)
- persons with medical conditions
- children < 4, or kids exposed to high-risk adults
Tuberculosis Treatment
What are the 4 basic principles of treatment and what is the usual 4 drug regimen pts. are started on (I/R/P/E)?
- administer multiple meds that damage organism
- safe, effective therapy in shortest time possible
- ensure adherence to therapy
- add at least 2 new agents to regimen when failure is suspected
UR: isoniazid, rifampin, pyrazinamide, ethambutol
Pulmonary Sarcoidosis
Who does it affect and when, what is seen on biopsy, and what symptoms does it present with?
What does diagnosis require?
- affects US female African Americans and Northern white Europeans most during 3rd-4th decades
biopsy = NONCASEATING GRANULOMAS
- systemic disease with 90% of pts. w/lung issues
Sx: fever, malaise, dyspnea of insidious onset; some pts. come to attention by abnormal CXR (bilateral hilar and right paratracheal Lymphadenopathy)
Dx: requires histological demonstration of NONCASEATING granulomas on biopsy
Pulmonary Sarcoidosis
What is the difference between these radiographic stages:
Stage 1
Stage 2
Stage 3
Stage 4
S1: variable; bilateral hilar adenopathy ALONE
S2: hilar adenopathy and parenchymal involvement
S3: parenchymal involvement ALONE
- PI = diffuse reticular infiltrates commonly
- also focal infiltrates, nodules, cavitation
S4: advanced fibrotic changes in UPPER LOBES
- FLUFFY WHITE NODULAR AREAS
What are the 3 components of Pulmonary Function Testing?
- Spirometry with flow volume curves/loops
- FVC, FEV1, FEV1/FVC ratio
- obstructive lung disease = FEV1/FVC < 0.7
- Lung volumes and capacities
- use body plethysmography
- TLC and RV
- Diffusing capacity of lung for CO (DLCO)
- measure gas exchange through alveolar wall
What are Bronchodilator Therapy and Bronchoprovocation?
BT: only used in obstructive lung disease to see if it is REVERSIBLE
- give B2-agonist like Albuterol
- (+) = > 12% inc. in FEV1 or FVC AND volume inc. > 200 mL
- Yes? = asthma, No? = COPD or other disease
BP: use if PFT normal but still suspect asthma
- give methacholine challenge = bronchoconstriction
- (+) = > 20% reduction in FEV1 at or before admin
What are 4 common Obstructive Lung Diseases? (C/A/B/B)
COPD (chronic bronchitis or emphysema)
Asthma
Bronchiectasis
Bronchiolitis
What are 4 common Restrictive Lung Diseases? (ACW/D/I/N)
Abnormalities of chest wall/pleura - kyphosis, scoliosis, obesity Drugs Interstitial Lung Disease Neuromuscular Disease - ALS, Guillain-Barre syndrome, Myasthenia gravis
Obstructive Lung Disease PFT
What does it look like on Spirometry, Lung Volume and Capacity, DLCO, and Bronchodilator Response?
S: FEV1/FVC < 0.7
- curve is CONCAVE with SCOOPED PATTERN
LV: TLC and RV INCREASED (air trapping)
D: could be normal (asthma/bronchitis) or low (emphysema)
BR: reversible = > 12% inc. in FEV1 or FVC AND > 200 mL inc. in absolute volume
- YES? = asthma
- NO? = COPD or other obstructive lung disease
Restrictive Lung Disease PFT
What does it look like on Spirometry, Lung Volume and Capacity, and DLCO?
S: FVC < 80% predicted, FEV1/FVC is normal or > 0.7
- curve is PEAKED, STEEPLE, WITCH’s HAT PATTERN
LV: TLC and RV DECREASED
D: could be normal (neuromuscular/chest wall abnormality) or low (ILD)
What is Mixed PFT Patterns and how does it present?
- have signs of both restrictive and obstructive lung disease
- presents with FEV1/FVC ratio that is LOW and TLC that is LOW (< 5th percentile)
What are risk factors for development of MDR-resistant Gram (-) AND MRSA? (H/Abx/I/NAS/FT/GAS/CB)
hospitalization 2+ days in previous 90 days Abx use in previous 90 days immunosuppression non-ambulatory status feed tube use gastric acid suppression severe COPD/bronchiectasis
What are risk factors for development of Nosocomial MRSA? (H/Abx/CD/PM/CHF/GAS)
hospitalization 2+ days in previous 90 days Abx use in previous 90 days chronic hemodialysis in previous 30 days prior MRSA infection congestive heart failure gastric acid suppression
What are risk factors for development of Community-Acquired MRSA? (IN/GH/N/ER/I/Y/SM)
cavitary infiltrate/necrosis gross hemoptysis neutropenia erythematous rash concurrent influenza young, previous healthy status summer month onset
What is Community-Acquired Pneumonia (CAP) and what is its most common cause?
What are 4 other Typical pneumonia causes (HI/SA/KP/PA) and what are 3 Atypical pneumonia causes (MP/CP/L)?
- pneumonia acquired OUTSIDE the hospital setting or long-term facility (MCC = Strep pneumoniae)
T: H. influenza, S. aureus, Klebsiella, Pseudomonas
A: Mycoplasma, Chlamydia pneumoniae, Legionella
- also respiratory viruses
What are general risk factors for Community-Acquired Pneumonia (A/A/I/I/A) and what two factors in the ELDERLY put them at greater risk?
G: alcoholism, asthma, immunosuppression, institutionalization, and age > 70 yo
E: decreased cough and gag reflexes
What CAP organisms do these activities place people at risk of acquiring:
- travel to Ohio/St. Lawrence river valley
- travel to SW United States
- travel to Southeast Asia (2)
- local influenza activity (3)
- stay in hotel or cruise ship in previous 2 wks
- exposure to bats/birds
- histoplasma capsulatum
- coccidioides spp
- burkholderia pseudomallei, avian flu virus
- influenza virus, s. pneumoniae., s. aureus
- legionella spp.
- h. capsulatum, (just birds = chlamydia psittaci)
What is key to diagnosing Community-Acquired Pneumonia?
What diagnostics are used to check for CAP?
HISTORY and PHYSICAL EXAM
Dx: CXR (2 view chest), US, Labs (sputum culture, blood culture, CBC, PCR, antigen studies)
What drugs would you use for a CAP pt. with NO comorbidities, like P. aeruginosa/MRSA or hospitalization with parental Abx in last 90 days? (A/D)
amoxicillin or doxycycline
What drugs would you use for a CAP pt. with comorbidities present? (A/C/C/A/C/L)
amoxicillin, cefpodoxime, cefuroxime, azithromycin, clarithromycin, levofloxacin
What CAP organisms are associated with these comorbidities:
- alcoholism (2)
- COPD (3)
- post-influenza
- immunocompromised
- injection drug use
- Strep. pneumoniae, H. influenza
- H. influenza, M. catarrhalis, Strep. pneumoniae
- Strep. pneumoniae, Staph. aureus
- Pseudomonas aeruginosa
- Staph. aureus
What are risk factors for:
Pseudomonas and MSRA (IO/RH/ABX)
Pseudomonas with CAP (CI/ABX/SLD/REO)
Pseudomonas with HAP (IL/WHI)
PM:
- prior isolation of either organism on culture
- recent hospitalization AND parenteral Abx 90 days
PC:
- compromised immune system
- recent prior Abx use
- structural lung abnormalities
- repeated exacerbation of OLD (Abx/steroid use)
PH:
- inc. age, length of mech. vent, Abx at admission
- admission to ward with high incidence of organism
What 5 things that would indicate a patient may be suffering from VAP? (WV/LI/NI/NF/NL)
VAP = type of HAP that develops more than 48 hrs after endotracheal intubation
- difficulty weaning off of ventilator
- lack of improvement overall
- new infiltrates on CXR
- new fevers
- new changes in baseline data = LABS
What 5 drugs are used to treat VAP (HAP) pts with low risk of MRSA? (C/PT/M/L/V)
What drugs can be added if:
- more severe disease (V/C/PT/M)
- Legionella suspected (L/A)
- Pseudomonas/MDR Gram (-) suspected (C/L/T/A)
cefepime, piperacillin-tazobactam, meropenem, levofloxacin, vancomycin (for suspected MRSA)
- vancomycin + cefepime
- sub cefepime for (piperacillin or meropenem)
- add levofloxacin or azithromycin
- add ciprofoxacin, levofloxacin, tobramycin, amikacin
Aspiration Pneumonia
What is it and what 4 organisms are primarily responsible for infection (PA/GPC/GN/SA)?
How is it commonly treated? (Abx/M)
- macro-aspiration with acute aspiration pneumonitis that becomes a pneumonia later on
O: primary anaerobes, Gram (+) cocci, Gram (-) bacteria, Strep. anginosis
Tx: broad spectrum Abx + metronidazole
Aspiration Pneumonia
What are the treatments for:
- Primary outpatient (C/M)
- Parenteral regimens (C+M/AS)
- Alternative Parenteral regimens (IT/E)
- clindamycin or moxifloxacin
- ceftriaxone + metronidazole or ampicillin-sulbactam
- imipenem-tazobactam or ertapenem
How is a Pleural Effusion diagnosed using imaging and physical exam?
What is the indication for doing Thoracentesis on Pleural Effusions, and what should be done if Heart Failure or infection is thought to be the cause?
- often an area of EGOPHONY just superior to effusion (borderline between tympani and dullness) that, once detected, can confirm with CXR, CT, or US
I: all effusions with > 1 cm of layering in DECUBITUS pos.
HF: try diuresis; thoracentesis should be done if effusions are asymmetrical, fever, chest pain
I: parapneumonic effusion, due thoracentesis ASAP
How much fluid would need to be aspirated using thoracentesis for re-expansion pulmonary edema to occur?
> 1.5 liters
- other thoracentesis complications include pneumothorax and hemothorax
What is Light’s Criteria and what does it tell us?
- consider pleural effusion exudative if it fulfills at least 1 of the three following criteria:
- protein pleural fluid/serum protein ratio > 0.5
- pleural LDH > 2/3s of lab NUL for serum LDH
- pleural/serum LDH ratio > 0.6
transudative effusions typically do NOT meet any of these criteria
Once Light’s Criteria has determined a PE to be exudative, what tests should be run on the fluid next? (pH/G/C/C/MS)
- test fluid for pH, glucose, CBC w/diff, cytology, microbial studies
What are the 3 parts of Acute Respiratory Distress Syndrome and what is the 4 key diagnostic criteria for this condition (Berlin Criteria)?
- severe dyspnea, diffuse pulmonary infiltrates, hypoxemia
Dx: PaO2/FiO2 < 300 mmHg
- also diffuse bilateral infiltrates on CXR
- absence of elevated left atrial pressure
- acute onset within 1 wk of clinical insult
What is the difference in PaO2/FiO2 and PEEP between Mild, Moderate, and Severe ARDS?
Mild:
- PaO2/FiO2 > 200, but < 300
- PEEP/CPAP > 5 cm H2O
Moderate:
- PaO2/FiO2 > 100, but < 200
- PEEP/CPAP > 5 cm H2O
Severe:
- PaO2/FiO2 < 100 mmHg
- PEEP > 5 cm H2O
What are major risk factors for ARDS? (S/P/T/MBT/GAS/DO)
- more than 80% result from:
sepsis, pneumonia, trauma, multiple blood transfusions, gastric acid suppression, drug overdose
individuals with MORE than 1 predisposing factor have a greater risk for developing ARDS
Exudative Phase of ARDS
What is it characterized by, what symptoms due pts. present with (H/T/D/HC), and what is seen on CXR?
- characterized by alveolar edema and neutrophil inflammation, with hyaline development due to DIFFUSE ALVEOLAR DAMAGE
- edema causes atelectasis and reduced lung compliance
Sx: hypoxemia, tachypnea, progressive dyspnea, and hypercarbia (inc. pCO2 due to loss of exchange
CXR = bilateral opacities consistent with pulmonary edema
Proliferative Phase of ARDS
When does it typically occur, what do patients develop, and what two symptoms persist through this phase (D/H)?
- typically lasts from day 7-21 after inciting event
- some patients develop progressive lung injury and pulmonary fibrosis
Sx: dyspnea and hypoxemia often persist
Fibrotic Phase of ARDS
When does it usually occur, what are pts at inc risk for (P/rLC/iPD), and what is pulmonary dead space?
- in pts who do NOT recover within 3-4 wks of initial pulmonary event; requires prolonged ventilatory support and/or supplemental O2
- inc. risk of pneumothorax, red. lung compliance, and inc. pulmonary dead space
PD: volume of ventilation that takes away from total lung volume in each breath (less tidal volume overall)
Mechanical Ventilatory Support for ARDS
What tidal volume/PEEP should be used and what position should pts. be put in?
- pts. typically require mechanical ventilatory support due to hypoxemia and inc. work of breathing (overdistension can inc. injury)
- low tidal volumes (<6 mL/kg) are combined with use of PEEP at levels that strive to MINIMIZE ALVEOLAR COLLAPSE and achieve adequate oxygenation with the lower required FiO2
- pts get improved oxygenation by being in the PRONE POSITION
ARDS Ancillary Therapies
When should ARDS pts receive IV fluids, what neuromuscular help do most patients require, and what drugs should NOT be used with ARDS patients?
- pts. should only receive IV fluids IF NEEDED to achieve adequate CO and tissue O2 delivery (inc. risk of interstitial and alveolar edema)
- most pts. will require sedation and even paralytic agents (help reduce mortality)
- no evidence for use of glucocorticoids or NO in ARDS
Influenza Virus
When does it occur, what are its symptoms (R/ST/C/C), and how is it distinguished from other respiratory illnesses (F/F/M/M)?
- outbreaks begin in cooler months, usually in early winter and lasting 4-5 weeks in a given community
Sx: rhinorrhea, sore throat, conjunctivitis, and cough beginning 48-72 hrs after exposure
- distinguished by greater degree of fever, fatigue, myalgia, and malaise (hypoxia can be significant)
Influenza Virus
What age ranges are flu complications typically seen in, and what respiratory symptoms arise from infection?
- complications seen in those <5 and >65 yo
- also in pregnant women and chronic disorders
Sx: pneumonia is MOST COMMON complication
- either due to primary influenza or 2nd bacterial pneumonia
Influenza Virus
What is the most common Extrapulmonary complication and what are 3 other complications of disease (RS/MP/CD)?
MC: MYOSITIS (seen more often in Influenza B)
- other symptoms include Reye’s Syndrome, myo/pericarditis, and CNS disease
Influenza Virus
How is it treated? (O/Z)
- NEURAMINIDASE INHIBITORS are used for influenza A and B viruses
- Oseltamivir and intranasal zanamivir
- if started within 48 hr of infection, inhibitors result in resolution of symptoms 1-2 days sooner than is the case without treatment
SARS-CoV-2
What is its incubation period, what is its most serious manifestation, and what is a major complication that this can lead to?
- incubation can be as long as 14 days but most occur 4-5 days after exposure
- pneumonia is the most frequent serious manifestation of infection
there are NO specific clinical features yet to reliably distinguish COVID-19 from other infections, though dyspnea several days after onset is suggestive of disease
- ARDS is the major complication in pts. with severe disease and can manifest shortly after the onset of dyspnea
SARS-CoV-2
What are major risk factors for the development of disease? (CVD/DM/HTN/CLD/C/CKD/O/S)
cardiovascular disease diabetes mellitus hypertension chronic lung disease cancer chronic kidney disease obesity smoking
