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Pulmonology > ClinMed Pneumonia > Flashcards

ClinMed Pneumonia Flashcards

1
Q

Pneumonia definition

A

infection of the lower respiratory tract (distal airways, alveoli, and interstitium of the lung)

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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

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3
Q

World’s leading cause of death in children under 5?

A

pneumonia

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4
Q

Most common cause of hospital admissions other than women giving birth?

A

pneumonia

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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
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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
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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
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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
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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
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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
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11
Q

physical exam signs of pneumonia

A
  • fever >100.4
  • cough w/ or w/o sputum
  • tachypnea
  • tachycardia
  • hemoptysis
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12
Q

chest exam signs of pneumonia

A
  • dullness to percussion
  • increased fremitus
  • rhonchi
  • rales
  • egophony
  • abdominal tenderness
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13
Q

crackles

A
  • aka rales
  • intermittent and brief
  • crackling, clicking or rattling
  • heard during inspiration
  • can be fine or course
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14
Q

fine crackles

A

soft, high-pitched, and brief

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15
Q

course crackles

A

-louder, lower pitched crackles

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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
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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)
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18
Q

cause of wheezing

A

passage of air through narrowed airways

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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
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20
Q

community acquired pneumonia (CAP)

A

occurs outside of hospital or onset begins <48 hrs after admission

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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
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22
Q

nosocomial-hospital acquired pneumonia (HAP)

A

developed >48 hrs after admission, excluding pneumonia present at time of admission

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23
Q

ventilator-associated pneumonia

A
  • type of HAP

- develops <48-72 hrs after ET intubation

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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
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25
Q

What are the typical bacteria that cause pneumonia in adults?

A
  • S. pneumonia
  • H. flu
  • S. aureus
  • Group A strep
  • M. catarrhalis
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26
Q

what is the most common pathogen that causes pneumonia in adults?

A

streptococcus pneumoniae

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27
Q

what are atypical bacteria that cause pneumonia in adults?

A
  • mycoplasma pneumonia
  • legionella sp.
  • chlamydophyla pneumonia
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28
Q

what are some viruses that can cause pneumonia in adults?

A

influenza A and B

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29
Q

which pathogens are responsible for pneumonia in the first 3 mos of life?

A
  • group B strep

- e. coli

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30
Q

most common cause of pneumonia in the first 5 yrs of life?

A

viruses:
- RSV
- parainfluenza
- influenza
- adenovirus
- rhinovirus

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31
Q

pathogens more likely to cause pneumonia after the age of 5?

A
  • incidence of pneumonia decreases in general
  • bacterial pathogens increase
  • ex:
  • s. pneumoniae
  • chlamydiophila pneumoniae
  • mycoplasma pneumoniae
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32
Q

manifestations of CAP

A
  • 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
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33
Q

exam findings of CAP

A
  • 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
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34
Q

differential diagnosis for CAP

A
  • acute bronchitis
  • acute exacerbation of chronic bronchitis
  • heart failure
  • PE
  • hypersensitivity pneumonitis
  • radiation pneumonitis
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35
Q

possible labs to run for CAP

A
  • 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
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36
Q

What is considered a good-quality specimen for a gram stain w/ CAP?

A
  • more than 25 WBC and <10 epithelial cells

- difficult for elderly

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37
Q

what are the indications for an ABG in a patient w/ CAP?

A

hypoxemia

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38
Q

what is the expected CBC result in a patient w/ CAP?

A

leukocytosis

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39
Q

when is a CXR indicated for pneumonia? (view is PA and lateral)

A
  • hypoxemia
  • respiratory distress
  • failure of abx therapy
  • hospitalized patients
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40
Q

purpose of CXR in diagnosis of pneumonia

A
  • 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
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41
Q

CXR results in patient w/ lobar pneumonia

A
  • local

- seen in s. pneumoniae, h. flu, and legionella

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42
Q

CXR results of bronchopneumonia

A
  • multifocal/lobular patchy infiltrates

- seen in staph, legionella, gram neg,. mycoplasma, chlamydia, viruses

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43
Q

CXR results of interstitial pneumonia

A
  • fine, diffuse, granular infiltrates

- seen in infulenza, CMV, pneumoncystis carinii

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44
Q

CXR results of lung abscess

A
  • lung tissue and cavity formation

- seen in anaerobes

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45
Q

CXR results of nodular lesion

A
  • multiple or single nodular legions

- seen w/ histoplasmosis, coccidiomycosis, cryptococosis

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46
Q

mortality rate of pneumonia

A
  • 12-14% if hospitalized
  • 35% in ICU
  • 1-5% if not hospitalized
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47
Q

indices used to determine if a patient w/ CAP should be admitted to the hospital?

A
  • pneumonia severity index (PSI)
  • CURB-65
  • they can’t determine if pt should be in ICU
48
Q

pneumonia severity index (PSI)

A
  • 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
Q

CURB-65 stands for?

A
  • C: confusion
  • U: BUN >19mg/dL
  • R: RR > 30
  • B: BP < 90/60
50
Q

what is CURB-65?

A
  • 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
Q

two general guidelines for abx therapy in tx of CAP

A

prompt initiation of medication to which the etiologic pathogen is susceptible

52
Q

how do you treat CAP?

A
  • do not delay initial abx treatment if ordering labs

- use empiric logic based on acuity, risk factors and local abx resistance patterns

53
Q

possible meds for CAP tx

A
  • if healthy: macrolide, doxycycline

- if comorbid conditions: fluoroquinolone, macrolide

54
Q

monitoring parameters w/ CAP

A
  • 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
Q

vaccines available in US for CAP

A
  • pneumococcal conjugate vaccine (Prevnar13)

- pneumococcal polysaccharide vaccine (Pneumovax23)

56
Q

indication for prevnar13

A
  • infants: series of 4 doses

- >65: 1 dose if not previously immunized

57
Q

indication of pneumovax23

A

adults > 65: 1 dose at least 1 year after prevnar13 or every 5 years

58
Q

who is at risk of HCAP?

A
  • 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
Q

causative pathogens of HCAP

A
  • s. pneumoniae
  • p. aeruginosa
  • gram neg. bacteria
60
Q

significance of being infected w/ a resistant organism

A

worsened mortality and morbidity

61
Q

symptoms associated w/ HCAP

A

resemble CAP but more subtle:

  • cough
  • altered mental status
  • anorexia, weakness, restlessness, agitation, falling, incontinence
  • dyspnea less common
62
Q

signs associated w/ HCAP

A
  • diminished or absent responsiveness
  • fever
  • tachycardia, tachypnea
  • sputum production
  • wheezes/crackles
  • noisy, wet breathing
63
Q

what is the 2nd most common cause of infection among hospital inpatients and leading cause of death d/t infection?

A

nosocomial pneumonia

64
Q

how to distinguish nosocomial pneumonia from CAP?

A
  • different infectious causes

- different abx susceptibility patterns (higher incidence of drug resistance)

65
Q

what is the primary cause of nosocomial pneumonia?

A

microaspiration

66
Q

risk factors of VAP

A
  • 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
Q

What is the frequency of VAP?

A
  • 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
Q

pathogenesis of VAP

A
  • 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
Q

What are the most important multi-drug resistant pathogens that cause nosocomial pneumonia?

A
  • p. aeruginosa

- MRSA

70
Q

clinical manifestations of VAP

A

generally same as CAP:

  • fever
  • leukocytosis
  • increase respiratory secretions
  • pulmonary consolidation
  • tachypnea, tachycardia, worsening oxygenation, increased minute ventilation
71
Q

reasonable clinical criteria for diagnosing VAP

A

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
Q

Major difference between VAP and CAP

A

VAP has a markedly lower incidence of atypical pathogens except legionella

73
Q

treatment of VAP

A
  • empiric treatment started once diagnostic specimens obtained
  • once etiology diagnosis is made, modify abx for specific pathogen if needed
74
Q

hospital acquired pneumonia (HAP)

A

develops more than 48 hrs after admission to the hospital in a non-intubated patient

75
Q

HAP is similar to what

A

VAP

76
Q

difference b/w HAP and VAP

A

HAP:

  • lower frequency of non-multi drug resistant pathogens (monotherapy)
  • better underlying host immunity
77
Q

General pneumonia bugs

A
  • gram +
  • gram -
  • other
  • viral
  • fungal
  • HIV
78
Q

gram + bugs

A
  • strep pneumonia

- staph aureus

79
Q

characteristics of strep pneumoniae infection

A
  • rust colored sputum**
  • pleurisy
  • chest exam: signs of consolidation, dullness to percussion, increased tactile fremitus, egophoony, inspiratory rales
  • CXR: lobar pneumonia
80
Q

predisposing factors associated w/ strep pneumoniae infection

A
  • alcoholism
  • asthma
  • HIV
  • chronic cardiopulmonary disease
  • hematologic disorders (sickle cell, splenectomy)
81
Q

What is the most common cause of atypical pneumonia in adults?

A

mycoplasma pneumoniae

82
Q

characteristics of a mycoplasma pneumoniae infection?

A
  • younger patients (college students)
  • flu-like symptoms
  • causes bulbous myringitis***, myalgia, skin rash
  • PE: normal w/ consolidation and possible crackles/rhonchi
83
Q

mycoplasma pneumonia is also known as what

A

walking pneumonia

84
Q

general gram negative bugs

A
  • m. cat
  • h. flu
  • klebsiella pneumonia
  • e. coli
  • pseudomonas aeruginosa
85
Q

gram negative infections assoicated w/ pnumonia

A
  • chronically ill and/or immunocompromised
  • usually d/t aspiration of contaminated secretions
  • major source of HAP
86
Q

m. cat

A
  • diplococci
  • preexisting lung disease
  • elderly
  • corticosteroid or immunosuppressive therapy
87
Q

h. flu

A
  • coccobacilli
  • follows URI
  • chronic cardiopulm disease
  • COPD, bronchiextasis, CF, ETOH, DM
88
Q

klebsiella pneumoniae

A
  • associated w/ cavity lesions
  • encapsulated rods
  • ETOH abuse
  • DM
  • Current jelly sputum***
  • aspiration pneumonia
89
Q

e. coli

A
  • rarely community acquired

- common in infants 0-2 mos old (birth canal)

90
Q

pseudomonas aeruginosa

A
  • immunocompromised
  • CF
  • bronchiectasis
  • aspiration pneumonia
  • green sputum
91
Q

general “other” types of pneumonia

A
  • mycoplasma pneumoniae
  • legionella pneumoniae
  • chlamydia pneumoniae
  • anaerobes
92
Q

legionella pneumonae infection high points

A
  • associated w/ contaminated water sources
  • similar symptoms yet sicker:
  • toxic
  • neuro sx
  • has urine antigen testing
93
Q

chlamydia pneumonia infection high points

A
  • similar to mycoplasma infection but longer lasting
  • sore throat w/ hoarseness
  • more common in closed populations
94
Q

anaerobic pneumonia high points

A
  • foul-smelling purulent sputum
  • do not do sputum culture other than by transthoracic (no oral flora contamination)
  • imaging: lung abscess, necrotizing pneumonia, empyema
95
Q

lung abcess

A

thick-walled solitary cavity surrounded by consolidation and air-fluid level

96
Q

necrotizing pneumonia

A

multiple areas of cavitation w/i an area of consolidation

97
Q

empyema

A

presence of purulent pleural fluid and may accompany lung abcess or necrotizing pneumonia

98
Q

general viral bugs

A
  • influenza

- RSV

99
Q

viral pneumonia

A
  • 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
Q

overall, what are the leading causes of viral pneumonia?

A
  • influenza a

- RSV

101
Q

other causes in adults and children of viral pneumonia

A
  • adults: inluenza a, b, c, H1N1, adenovirus, parainfluenza, and coronavirus
  • children: same as above plus rubeola and RSV
102
Q

misc. other viral causes of pneumonia

A
  • CMV (immunocompromised)
  • varicella
  • herpes
  • enterovirus
  • EBV
103
Q

tx of viral pneumonia

A
  • antivirals
  • rest
  • increase fluids
  • no ETOH/smoking
  • breathing exercises
  • antipyretics and antitussives for symptoms
104
Q

general fungal bugs

A
  • histoplasma capsulatum
  • blastomycosis
  • coccidiodes immitis
105
Q

facts about fungal infections in pneumonia

A
  • inhalation of spores is usual mechanism
  • may disseminate after infecting lung
  • azoles are tx
106
Q

histoplasmosis

A
  • 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
Q

CXR in histoplasmosis

A
  • 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
Q

tx of histoplasmosis

A
  • nothing at first

- then amphoteracin, sporanox, azoles

109
Q

blastomycosis

A
  • 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
Q

coccidiomycosis

A
  • geographical: CA, AX, NM, TX
  • most resolve spontaneously
  • organisms in soil
111
Q

S/S of coccidiomycosis

A
  • 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
Q

CXR in coccidiomycosis

A
  • lymphadenopathy

- may have abscess in lung - need tx

113
Q

What bugs are associated w/ HIV related pneumonia? (3)

A
  • aspergillus
  • cryptococcus
  • p. carinii/Jiroveci
114
Q

cryptococcus

A
  • sporadically in southern OK

- associated w/ bird (pigeon) droppings** in soil

115
Q

bugs associated w/ ETOH (3)

A
  • s. pneumo
  • gram - bacilli
  • anaerobes
116
Q

bugs assoicated w/ IVDU (3)

A
  • staph
  • Tb
  • anaerobes

Pulmonology (11 decks)

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