ClinMed Pneumonia Flashcards
1
Q
Pneumonia definition
A
infection of the lower respiratory tract (distal airways, alveoli, and interstitium of the lung)
2
Q
General cause of pneumonia
A
caused by proliferation of microbial pathogens at the alveolar level and the host’s response to those pathogens
3
Q
World’s leading cause of death in children under 5?
A
pneumonia
4
Q
Most common cause of hospital admissions other than women giving birth?
A
pneumonia
5
Q
How do pathogens that cause pneumonia enter the body?
A
- aspiration of microorganisms from oropharynx
- hematogenous spread
- inhalation of pathogen
- extension from an infected pleural or mediastinal space
6
Q
What are mechanical protective factors of host defense against pneumonia?
A
- hairs and turbinates in nares
- branching architecture of tracheobronchial tree
- mucociliary clearance
- gag reflex and cough mechanism
- normal flora
- alveolar macrophages
7
Q
What is the role of alveolar macrophages in preventing pneumonia?
A
- initiate inflammatory response to bolster lower respiratory tract infections
- when capacity to ingest or kill microorganisms is exceeded, pneumonia manifests
8
Q
What is the host inflammatory response to proliferation of microorganisms in the respiratory system?
A
- fever
- peripheral leukocytosis
- increased purlulent secretions
- alveolar capillary leakage
- capillary leaking results in radiographic infiltrate and rales on auscultation
- hypoxemia from alveolar filing
- decreased lung compliance
9
Q
risk factors for pneumonia
A
- recent URI
- children <2; elderly >70
- smoking
- EtOH abuse
- lung disease or other serious disease
- toxic inhalation
- difficulty coughing d/t stroke or other condition
- difficulty swallowing
- immunosuppresion
- malnutrition
- ICU admission; intubation
10
Q
symptoms of pneumonia
A
- acute onset of fever, cough w/ or w/o sputum, dyspnea
- Others: rigors, sweats, chills, chest discomfort, pleurisy, hemoptysis, fatigue, myalgia, anorexia, headache, abdominal pain
11
Q
physical exam signs of pneumonia
A
- fever >100.4
- cough w/ or w/o sputum
- tachypnea
- tachycardia
- hemoptysis
12
Q
chest exam signs of pneumonia
A
- dullness to percussion
- increased fremitus
- rhonchi
- rales
- egophony
- abdominal tenderness
13
Q
crackles
A
- aka rales
- intermittent and brief
- crackling, clicking or rattling
- heard during inspiration
- can be fine or course
14
Q
fine crackles
A
soft, high-pitched, and brief
15
Q
course crackles
A
-louder, lower pitched crackles
16
Q
cause of crackles
A
- air opens small airways that are sticky or adherent w/ fluid, mucous or pus
- d/t abnormalities in lung parenchyma or airways
17
Q
wheeze
A
- aka sibilant wheeze
- continuous sound heard during inspiration or expiration
- high pitched, musical, like a hiss
- occur in smaller bronchi (asthma)
18
Q
cause of wheezing
A
passage of air through narrowed airways
19
Q
rhonchi
A
- AKA sonorous wheeze
- continuous sound heard during inspiration or expiration
- loud, low, coarse sound like a snore
- tend to occur from larger bronchi
- clear w/ cough
20
Q
community acquired pneumonia (CAP)
A
occurs outside of hospital or onset begins <48 hrs after admission
21
Q
healthcare-associated pneumonia (HCAP)
A
- subset of CAP
- occurs in non-hospitalized patient w/ healthcare contact
- ex: recent hospitalization, dialysis, resident in nursing home, home infusion care, home wound care, immunocompromised
22
Q
nosocomial-hospital acquired pneumonia (HAP)
A
developed >48 hrs after admission, excluding pneumonia present at time of admission
23
Q
ventilator-associated pneumonia
A
- type of HAP
- develops <48-72 hrs after ET intubation
24
Q
what are atypical organisms?
A
- cannot be cultured on standard media or seen in Grams stain
- resistant to all beta-lactam agents
- treat w/ macrolide, fluoroquinolone or tetracycline
25
What are the typical bacteria that cause pneumonia in adults?
- S. pneumonia
- H. flu
- S. aureus
- Group A strep
- M. catarrhalis
26
what is the most common pathogen that causes pneumonia in adults?
streptococcus pneumoniae
27
what are atypical bacteria that cause pneumonia in adults?
- mycoplasma pneumonia
- legionella sp.
- chlamydophyla pneumonia
28
what are some viruses that can cause pneumonia in adults?
influenza A and B
29
which pathogens are responsible for pneumonia in the first 3 mos of life?
- group B strep
| - e. coli
30
most common cause of pneumonia in the first 5 yrs of life?
viruses:
- RSV
- parainfluenza
- influenza
- adenovirus
- rhinovirus
31
pathogens more likely to cause pneumonia after the age of 5?
- incidence of pneumonia decreases in general
- bacterial pathogens increase
- ex:
- s. pneumoniae
- chlamydiophila pneumoniae
- mycoplasma pneumoniae
32
manifestations of CAP
- indolent
- febrile w/ tachycardia
- possible chills/sweats
- cough w/ or w/o sputum
- possible SOB
- possible pleurisy
- GI symptoms (nausea, vom., diarrhea)
- possible fatigue, HA, myalgia, arthralgia
33
exam findings of CAP
- vary w/ degree of pulmonary consolidation and pleural effusion
- increased RR
- use of accessory muscles
- possible increased (consolidation) or decreased (pleural effusion) tactile fremitus
- dull percussion
- crackles
- possible pleural friction rub
34
differential diagnosis for CAP
- acute bronchitis
- acute exacerbation of chronic bronchitis
- heart failure
- PE
- hypersensitivity pneumonitis
- radiation pneumonitis
35
possible labs to run for CAP
- gram stain and sputum culture (obtain before abx)
- blood cultures
- CBC w/ diff
- CMP
- ABG
- pneumococcal and legionella urinary Ag test (not time sensitive to starting abx)
- CRP
- procalcitonin
36
What is considered a good-quality specimen for a gram stain w/ CAP?
- more than 25 WBC and <10 epithelial cells
| - difficult for elderly
37
what are the indications for an ABG in a patient w/ CAP?
hypoxemia
38
what is the expected CBC result in a patient w/ CAP?
leukocytosis
39
when is a CXR indicated for pneumonia? (view is PA and lateral)
- hypoxemia
- respiratory distress
- failure of abx therapy
- hospitalized patients
40
purpose of CXR in diagnosis of pneumonia
- confirm the diagnosis and help assess severity and response to therapy over time
- lag behind signs and sx, so needs repeated in 24-48 hrs
41
CXR results in patient w/ lobar pneumonia
- local
| - seen in s. pneumoniae, h. flu, and legionella
42
CXR results of bronchopneumonia
- multifocal/lobular patchy infiltrates
| - seen in staph, legionella, gram neg,. mycoplasma, chlamydia, viruses
43
CXR results of interstitial pneumonia
- fine, diffuse, granular infiltrates
| - seen in infulenza, CMV, pneumoncystis carinii
44
CXR results of lung abscess
- lung tissue and cavity formation
| - seen in anaerobes
45
CXR results of nodular lesion
- multiple or single nodular legions
| - seen w/ histoplasmosis, coccidiomycosis, cryptococosis
46
mortality rate of pneumonia
- 12-14% if hospitalized
- 35% in ICU
- 1-5% if not hospitalized
47
indices used to determine if a patient w/ CAP should be admitted to the hospital?
- pneumonia severity index (PSI)
- CURB-65
- they can't determine if pt should be in ICU
48
pneumonia severity index (PSI)
- aka patient outcomes research team (PORT) score
- used to ID patients at low risk of dying and therefore the need for hospitalization or not
- if categorized as 1-3, treat as outpatient
- if categorized as 4-5, admit to hospital
49
CURB-65 stands for?
- C: confusion
- U: BUN >19mg/dL
- R: RR > 30
- B: BP < 90/60
50
what is CURB-65?
- used to ID need for hospitalization in patients > 65 w/ CAP
- 0-1: outpatient
- 2: short in patient stay
- 3-5: admit, possible ICU
51
two general guidelines for abx therapy in tx of CAP
prompt initiation of medication to which the etiologic pathogen is susceptible
52
how do you treat CAP?
- do not delay initial abx treatment if ordering labs
| - use empiric logic based on acuity, risk factors and local abx resistance patterns
53
possible meds for CAP tx
- if healthy: macrolide, doxycycline
| - if comorbid conditions: fluoroquinolone, macrolide
54
monitoring parameters w/ CAP
- fever and leukocytosis usually resolves in 2-4 days
- CXR abnormalities resolve in 4-12 weeks (re do in 4-6 weeks)
- relapse or recurrence could indicate underlying neoplasm
55
vaccines available in US for CAP
- pneumococcal conjugate vaccine (Prevnar13)
| - pneumococcal polysaccharide vaccine (Pneumovax23)
56
indication for prevnar13
- infants: series of 4 doses
| - >65: 1 dose if not previously immunized
57
indication of pneumovax23
adults > 65: 1 dose at least 1 year after prevnar13 or every 5 years
58
who is at risk of HCAP?
- nursing homes
- undergone IV therapy (chemo) or wound care w/i 30 days
- hospitalized for >2 days w/i 90 days
- attended hospital or hemodialysis center w/i 30 days
59
causative pathogens of HCAP
- s. pneumoniae
- p. aeruginosa
- gram neg. bacteria
60
significance of being infected w/ a resistant organism
worsened mortality and morbidity
61
symptoms associated w/ HCAP
resemble CAP but more subtle:
- cough
- altered mental status
- anorexia, weakness, restlessness, agitation, falling, incontinence
- dyspnea less common
62
signs associated w/ HCAP
- diminished or absent responsiveness
- fever
- tachycardia, tachypnea
- sputum production
- wheezes/crackles
- noisy, wet breathing
63
what is the 2nd most common cause of infection among hospital inpatients and leading cause of death d/t infection?
nosocomial pneumonia
64
how to distinguish nosocomial pneumonia from CAP?
- different infectious causes
| - different abx susceptibility patterns (higher incidence of drug resistance)
65
what is the primary cause of nosocomial pneumonia?
microaspiration
66
risk factors of VAP
- colonization of the oropharynx w/ pathogenic microoganisms
- aspiration of these organisms from oropharynx into lower respiratory tract
- compromise of the normal host defense mechanisms
67
What is the frequency of VAP?
- highest risk in first 5-14 days of mechanical ventilation
| - cumulative risk of patients ventilated for as long as 30 days is as high as 70%
68
pathogenesis of VAP
- ET tube can damage tracheal mucosa --> facilitates tracheal colonization
- pathogenic bacteria form on tubes surface that protects them from abx and host defenses
- ET tube may prevent large vol. aspiration
- overwhelming of host defenses
69
What are the most important multi-drug resistant pathogens that cause nosocomial pneumonia?
- p. aeruginosa
| - MRSA
70
clinical manifestations of VAP
generally same as CAP:
- fever
- leukocytosis
- increase respiratory secretions
- pulmonary consolidation
- tachypnea, tachycardia, worsening oxygenation, increased minute ventilation
71
reasonable clinical criteria for diagnosing VAP
New and persistent (>48) or progressive radiographic infiltrate + 2 of the following:
- temp >38 degrees C or <36 degrees C
- leukocytosis >10,000
- leukopenia <5,000
- purulent tracheal secretions
- gas exchange degradation
72
Major difference between VAP and CAP
VAP has a markedly lower incidence of atypical pathogens except legionella
73
treatment of VAP
- empiric treatment started once diagnostic specimens obtained
- once etiology diagnosis is made, modify abx for specific pathogen if needed
74
hospital acquired pneumonia (HAP)
develops more than 48 hrs after admission to the hospital in a non-intubated patient
75
HAP is similar to what
VAP
76
difference b/w HAP and VAP
HAP:
- lower frequency of non-multi drug resistant pathogens (monotherapy)
- better underlying host immunity
77
General pneumonia bugs
- gram +
- gram -
- other
- viral
- fungal
- HIV
78
gram + bugs
- strep pneumonia
| - staph aureus
79
characteristics of strep pneumoniae infection
- rust colored sputum**
- pleurisy
- chest exam: signs of consolidation, dullness to percussion, increased tactile fremitus, egophoony, inspiratory rales
- CXR: lobar pneumonia
80
predisposing factors associated w/ strep pneumoniae infection
- alcoholism
- asthma
- HIV
- chronic cardiopulmonary disease
- hematologic disorders (sickle cell, splenectomy)
81
What is the most common cause of atypical pneumonia in adults?
mycoplasma pneumoniae
82
characteristics of a mycoplasma pneumoniae infection?
- younger patients (college students)
- flu-like symptoms
- causes bulbous myringitis***, myalgia, skin rash
- PE: normal w/ consolidation and possible crackles/rhonchi
83
mycoplasma pneumonia is also known as what
walking pneumonia
84
general gram negative bugs
- m. cat
- h. flu
- klebsiella pneumonia
- e. coli
- pseudomonas aeruginosa
85
gram negative infections assoicated w/ pnumonia
- chronically ill and/or immunocompromised
- usually d/t aspiration of contaminated secretions
- major source of HAP
86
m. cat
- diplococci
- preexisting lung disease
- elderly
- corticosteroid or immunosuppressive therapy
87
h. flu
- coccobacilli
- follows URI
- chronic cardiopulm disease
- COPD, bronchiextasis, CF, ETOH, DM
88
klebsiella pneumoniae
- associated w/ cavity lesions
- encapsulated rods
- ETOH abuse
- DM
- Current jelly sputum***
- aspiration pneumonia
89
e. coli
- rarely community acquired
| - common in infants 0-2 mos old (birth canal)
90
pseudomonas aeruginosa
- immunocompromised
- CF
- bronchiectasis
- aspiration pneumonia
- green sputum
91
general "other" types of pneumonia
- mycoplasma pneumoniae
- legionella pneumoniae
- chlamydia pneumoniae
- anaerobes
92
legionella pneumonae infection high points
- associated w/ contaminated water sources
- similar symptoms yet sicker:
- toxic
- neuro sx
- has urine antigen testing
93
chlamydia pneumonia infection high points
- similar to mycoplasma infection but longer lasting
- sore throat w/ hoarseness
- more common in closed populations
94
anaerobic pneumonia high points
- foul-smelling purulent sputum
- do not do sputum culture other than by transthoracic (no oral flora contamination)
- imaging: lung abscess, necrotizing pneumonia, empyema
95
lung abcess
thick-walled solitary cavity surrounded by consolidation and air-fluid level
96
necrotizing pneumonia
multiple areas of cavitation w/i an area of consolidation
97
empyema
presence of purulent pleural fluid and may accompany lung abcess or necrotizing pneumonia
98
general viral bugs
- influenza
| - RSV
99
viral pneumonia
- inflammatory disease of the lungs d/t a viral infection
| - most result from exposure of a susceptible non-immune person to infection in the form of aerolized secrestions
100
overall, what are the leading causes of viral pneumonia?
- influenza a
| - RSV
101
other causes in adults and children of viral pneumonia
- adults: inluenza a, b, c, H1N1, adenovirus, parainfluenza, and coronavirus
- children: same as above plus rubeola and RSV
102
misc. other viral causes of pneumonia
- CMV (immunocompromised)
- varicella
- herpes
- enterovirus
- EBV
103
tx of viral pneumonia
- antivirals
- rest
- increase fluids
- no ETOH/smoking
- breathing exercises
- antipyretics and antitussives for symptoms
104
general fungal bugs
- histoplasma capsulatum
- blastomycosis
- coccidiodes immitis
105
facts about fungal infections in pneumonia
- inhalation of spores is usual mechanism
- may disseminate after infecting lung
- azoles are tx
106
histoplasmosis
- geographically: ohio river valley, MO, OK
- associated w/ bird/bat guano, cave exploration/soil
- self limiting
- fever, HA, non-productive cough 2 weeks after exposure
107
CXR in histoplasmosis
- may look horrible (5 lobe pneumonia)
- scarring of lymph nodes
- granulomatos dz (looks like tb)
- body walls off granulomas so will look like hard calcifications
108
tx of histoplasmosis
- nothing at first
| - then amphoteracin, sporanox, azoles
109
blastomycosis
- may affect skin
- usually in persons from Mississippi
- lives in soil - hunters get it
- flu like illness
- can go to skin, bone, cns
- present similarly to histoplasmosis
110
coccidiomycosis
- geographical: CA, AX, NM, TX
- most resolve spontaneously
- organisms in soil
111
S/S of coccidiomycosis
- erythema nodosum and multiforme in 10-50%
- many may be asymptomatic
- symptoms could include fever, pleuritic SP, dry cough and SOB
- disseminated can lead to CNS changes, lymphadenopathy and skin changes
112
CXR in coccidiomycosis
- lymphadenopathy
| - may have abscess in lung - need tx
113
What bugs are associated w/ HIV related pneumonia? (3)
- aspergillus
- cryptococcus
- p. carinii/Jiroveci
114
cryptococcus
- sporadically in southern OK
| - associated w/ bird (pigeon) droppings** in soil
115
bugs associated w/ ETOH (3)
- s. pneumo
- gram - bacilli
- anaerobes
116
bugs assoicated w/ IVDU (3)
- staph
- Tb
- anaerobes
