Clinical Med Part 2 (Tyler) Flashcards
What is the overall mortality of pneumonia?
- 10%
What microbes have the highest incidences of mortality?
- Gram negative and S. aureus
What are some outpatient microbial causes of pneumonia?
- S. pneumoniae
- M. pneumoniae
- H. influenzae
- C. pneumoniae
- Respiratory viruses
What are some non-ICU microbial causes of pneumonia?
- S. pneumoniae
- M. pneumoniae
- C. pneumoniae
- H. influenzae
- Legionella spp
- Respiratory viruses
What are some ICU microbial causes of pneumonia?
- S. pneumoniae
- S. aureus
- Legionella spp
- Gram negative bacilli
- H. influenzae
- Respiratory viruses
What is the most common cause of community acquired pneumonia?
- S. pneumoniae
What are some causes of typical pneumonia?
- S. pneumoniae
- H. influenzae
- S. aureus
- Klebsiella pneumoniae and P. aeruginosa
What are some causes of atypical pneumonia?
- M. pneumoniae
- C. pneumoniae
- Legionella spp
- Respiratory viruses
What are some general risk factors for community acquired pneumonia?
- Alcoholism
- Asthma
- Immunosuppression
- Institutionalization
- Age over 70
What is a risk factor for pneumonia specifically in the elderly?
- Lack of a cough/gag reflex due to muscle weakness
What are some risk factors for the pneumococcal pneumonia?
- Dementia
- Seizure disorders
- Heart failure
- Cerebrovascular disease
- Alcoholism
- Tobacco smoking
- COPD
- HIV infection
Who does enterobacteriaceae tend to infect?
- Those that have recently been hospitalized and/or received antibiotic therapy or who have comorbidities like alcoholism, heart failure, or renal failure
Who has a problem with P, aeruginosa?
- Patients with severe structural lung disease like bronchiectasis, cystic fibrosis, or severe COPD
What are some risk factors for Legionella?
- Diabetes
- Hematologic malignancy cancer
- Severe renal disease
- HIV infection
- Smoking
- Male gender
- Recent hospital stay or cruise
What are some fungi that could cause pneumonia?
- Histoplasma capsulatum
- Coccidioides immits
How is pneumonia diagnosed?
- CXR
- Point of care ultrasound (POCUS)
- Bronchoscopy
- Tissue biopsy
What labs are used to help in the diagnosis of pneumonia?
- Sputum gram stain and culture
- Blood culture
- CBC
- PCR and antigen studies
- Procalcitonin
What is the general appearance of someone with pneumonia?
- Fever
- Hypothermia
- Malaise
- Most appear ill
- Alert to obtundent
What does the respiratory exam look like with pneumonia?
- Adventitious sounds
- Tachypnea
- Hypoxia
- Chest movement
- Cough
- Inspiratory crackles
- Bronchial breath sounds
What does a cardiac exam look like with pneumonia?
- Tachycardia
- Hypo- or hypertension
- Exacerbations of heart failure
What is the treatment of pneumonia?
- Based on history
- Use the ATSA/IDSA guidelines for management and treatment of CAP
- Use CURB-65 to help determine level of morbidity
What are the risk factors for Pseudomonas with CAP?
- Compromised immune system
- Recent prior antibiotic use
- Structural lung abnormalities (cystic fibrosis or bronchiectasis)
- Repeated exacerbations of COPD requiring frequent glucocorticoid and/or antibiotic use
What are some risk factors for Pseudomonas with HAP?
- Increased age
- Length of mechanical ventilation
- Antibiotics at admission
- Transfer from a medical unit or ICU
- Admission to a ward with high rate of Pseudomonas
What is hospital acquired pneumonia?
- Infection acquired after at least 48 hours of hospitalization
What is the treatment for HAP?
- There is a higher morbidity and mortality rate than CAP
- Need for a treatment for broadened scope of organisms is greater
What are some considerations in HAP and VAP?
- Increased mortality
- MDR pathogens and MRSA
- MDR pathogens without MRSA
- MRSA alone
What is healthcare associated pneumonia?
- Used to identify patients at risk for infection with MDR pathogens
- Classification has been very sensitive and lead to inappropriate antibiotic use
What is ventilator associated pneumonia?
- Type of HAP that develops more than 48 hours after endotracheal intubation
What are some clues to VAP?
- Difficult to wean off ventilator
- Persistent lack of improvement overall
- New infiltrates on CXR
- New fevers
- New changes in baseline data: CBC, CMP, etc
What is aspiration pneumonia?
- Most pneumonia arises following the aspiration of microorganisms from the oral cavity or nasopharynx
What are some risk factors for aspiration pneumonia?
- Neurologic disorders
- Reduced consciousness
- Esophageal disorders
- Vomiting
- Witnessed aspiration
Who is aspiration pneumonia suspected in?
- A lethargic, obtundent, or unconscious patient, esp those who have been vomiting
- Stroke patients with swallowing dysfunction
- Elderly
- Patients with multiple sclerosis and bulbar symptoms
What are the most likely considered pathogens in aspiration pneumonia?
- Agents from oral cavity and pharynx
- Primarily anaerobes
- Gram positive cocci
- Gram negative bacteria
- S. anginosus group
What are some clinical findings of aspiration pneumonia?
- Indolent symptoms
- Predisposing condition for aspiration
- Absence of rigors
- Failure to recover likely pulmonary pathogens with cultures of expectorated sputum
- Sputum that has a putrid odor, which is diagnostic of anaerobic infection
What imaging is seen in someone with aspiration pneumonia?
- CXR showing involvement of dependent portions of lung or segments obstructed by malignancy, stricture, or foreign body
- CXR or CT showing pulmonary necrosis with lung abscess or empyema
What is the treatment for aspiration pneumonia?
- Clindamycin (primarily outpatient)
- Ceftriaxone and metronidazole
- Ampicillin-sulbactam
- Imipenem- tazobactam
- Ertapenem
What is a pleural effusion?
- Excess fluid accumulation in the pleural space
What causes a transudate?
- Systemic influences on pleural fluid formation and resorption
- Left ventricular failure, cirrhosis
- Nephrotic syndrome
- Myxedema
- Peritoneal dialysis
What causes an exudate?
- Local influences on pleural fluid formation or resorption
- Bacterial pneumonia
- Malignancy
- Viral infection
- PE
- TB
- Fungal or parasitic infections
What are the two most common causes of pleural effusion?
- Heart failure
- Pneumonia
How is the diagnosis for pleural effusion made?
- Plain film radiographs
- CT chest
- Ultrasound
- Often an area of egophony just superior to the effusion
When is a thoracentesis done?
- If effusions are asymmetrical, fever, chest pain, or failure to resolve
What are some complications with a thoracentensis?
- Pneumothorax
- Hemothorax
- Re-expansion pulmonary edema
- Spleen/liver laceration
What is the Light’s criteria used for?
- Used to tell of exudates fulfill at least one of the criteria
What is the Light’s criteria?
- Protein pleural fluid/serum protein ratio (>0.5)
- Pleural fluid LDH greater than two-thirds of the laboratory normal
- Pleural/serum LDH ratio >0.6
Do transudative effusions typically meet the Light’s criteria?
- No
What else should be tested for exudative effusions?
- pH
- Glucose
- WBC count with diff
- Microbiologic studies
- Cytology
What is the definition of ARDS?
- Acute respiratory distress that includes:
- Severe dyspnea
- Diffuse pulmonary infiltrates
- Hypoxemia
What is a key diagnostic for ARDS?
- Diffuse bilateral pulmonary infiltrates on CXR
- PaO2/FiO2 <300 mmHg
- Absence of elevated left atrial pressure
- Acute onset within 1 week of a clinical insult or new or worsening respiratory symptoms
What is the PaO2/FiO2 ratio?
- Common measure of oxygenation and is most often employed in ventilated patients
What do values under 300 mmHg represent in the PaO2/FiO2?
- Abnormal gas exchange
What are the risk factors for ARDS?
- Sepsis
- Pneumonia
- Trauma
- Multiple blood transfusions
- Gastric acid aspiration
- Drug overdose
- Older age
- Chronic alcohol abuse
- Metabolic acidosis
- Pancreatitis
What is the exudative phase of ARDS?
- Characterized by alveolar edema and neutrophil infiltration
- Diffuse alveolar damage
- Atelectasis and reduced lung compliance
- Hypoxemia, tachypnea, progressive dyspnea, and hypercarbia
- CXR reveals bilateral opacities consistent with pulmonary edema
What is the proliferative phase of ARDS?
- Lasts from 7 to 21 days after inciting insult
- Some develop progressive lung injury and have evidence of pulmonary fibrosis
What is the fibrotic phase of ARDS?
- Most recover within 3-4 weeks but some experience fibrosis
- INcreased risk of pneumothorax, reductions in lung compliance, and increased pulmonary dead space
What is the treatment for ARDS?
- Treatment of underlying medical condition that caused lung injury
- Minimizing iatrogenic complications
- Prophylaxis to prevent venous thromboembolism and GI hemorrhage
- Prompt treatment of nosocomial infections
- Adequate nutritional support
How can we minimize the alveolar collapse and achieve adequate oxygenation?
- Put patient into prone
- Low tidal volumes and positive end expiratory pressure
What are some ancillary therapies with ARDS?
- Patients have pulmonary vascular permeability leading to interstitial and alveolar edema
- Receive IV fluids only as needed
- Most patients require sedation and even paralytic agents
- Avoid the use of glucocorticoids
What are the clinical manifestations of the influenza virus?
- Sudden onset respiratory illness (symptoms in 48-72 hours of exposure)
- Rhinorrhea
- Sore throat
- Conjunctivitis
- Cough
What does the physical exam show of the influenza virus?
- Non-localizing rales, rhonchi, and wheezing
How is influenza distinguished from other respiratory illnesses?
- Greater degree of accompanying fever, fatigue, myalgia, and malaise
Who are influenza complications more common in?
- Young children <5
- Elderly
- Pregnant women in second or third trimester
- Patients with chronic disorders
What are some respiratory complications with influenza?
- Pneumonia
What are some extrapulmonary complications with influenza?
- Myositis (influenza B)
- Reye’s syndrome
- myo/pericarditis
- CNS disease
What is found in laboratory testing for influenza?
- RT-PCR of respiratory samples is most sensitive for detecting influenza
- Rapid tests can yield results quicker but are as sensitive
What is the treatment for influenza?
- Neuraminidase inhibitor for influenza A and B
- If started within 48 hours of infection, symptoms can resolve 1-2 days sooner
What are the risk factors for COVID?
- CV disease
- Diabetes
- HTN
- Chronic lung disease
- Cancer
- Chronic kidney disease
- Obesity
- Smoking
