HYHO SPE 3-2 URI and Pneumonia Flashcards
Physical exam findings of URI/pneumonia
- inc work of breathing (retractions)
- adventitious breath sounds (crackles, rhonchi, wheezing)
- positive special testing (tactile fremitus, egophony, dullness to percussion, bronchophony)
- hypoxemia
Differential diagnosis of noninfectious causes of cough (x9)
- Upper Airway Cough Syndrome (UACS)
- - most common cause of chronic cough in HEALTHY, NON-SMOKERS with a normal CXR - Asthma/COPD
- - second most common cause of chronic cough - Gastroesophageal reflux (GERD)
- Postnasal drip
- Medication side effect (e.g. ACE inhibitors)
- Congestive Heart Failure (CHF)
- Malignancy
- Smoking
- Pollution
What is the most sensitive and specific test for diagnosis of reflux disease (i.e. GERD)
24-hour esophageal pH monitoring
What is the most common cause of a chronic cough in healthy, nonsmokers with a normal CXR?
Upper airway cough syndrome (UACS)
First line of treatment for GERD
4 week trial of PPI (proton pump inhibitor) – is both diagnostic and therapeutic
Differential diagnosis of infectious causes of cough and congestion (x6)
- Common cold/URI/Viral syndrome
- Pharyngitis
- Sinusitis
- Bronchitis
- Influenza
- Pneumonia
a) CAP (community-acquired pneumonia)
b) Aspiration pneumonia
c) TB
d) Opportunistic organisms (e.g. PCP = pneumocystis pneumonia)
Most common etiology of URI is?
Viral – influenza, parainfluenza, adenovirus, coronavirus, rhinovirus
Bacterial causes of URI?
- Mycoplasma pneumoniae
- Chlamydia pneumoniae
- Bordetella pertussis
What are the two phases of URI?
- Initial Phase – cough and systemic symptoms secondary to infection/inflammation; fever absent or low grade
- Protracted phase – evidence of reactive airway disease in patient’s w/o prior pulmonary disease; in some patients, cough persists secondary to bronchial hyperresponsiveness and lasts >/= 2-4 weeks
Things to monitor/take into consideration during a physical exam for URI
- Monitor for abnormal vitals (e.g. fever, BP, tachycardia, tachypnea)
- Consider high risk patients (e.g. hx of heart or lung dz, severity of symptoms, low oxygen sat on pulse ox)
- Lung findings (e.g. rales, rhonchi, wheezes)
* * in most cases PE is unremarkable and often normal** - Conjunctivitis and adenopathy suggest adenovirus infection (this finding is not specific)
Is the color of the suptum diagnostic of a bacterial URI?
NO! Color of sputum is NOT diagnostic of the presence of a bacterial infection
For treatment of bronchitis do you use antibiotics? If so, in what circumstances?
Antibiotics are NOT recommended routinely.
Use only in high risk patients (those with heart, lung, kidney disease or immunosuppression)
or when suspicion for CAP is high despite normal CXR
or in suspected cases of B pertussis, Mycoplasma, or Chlamydia infection
What condition presents with inflammation/infection of nasal mucosa and of one or more paranasal sinuses?
Rhinosinusitis
Sinusitis can be subdivided into acute, subacute, and chronic. What are the durations of each?
Acute: s/s lasting < 4 wks
Subacute: s/s lasting 4 - 12 wks
Chronic: s/s lasting > 12 wks
Definition of recurrent acute rhinosinusitis
4 or more episodes of acute rhinosinusitis per year with interim resolution of symptoms
Most viral URI’s improve in 7-10 days. If symptoms don’t improve, what should you consider?
Consider case of BACTERIAL rhinosinusitis after 7 days in adults, and 10 days in children
Most common organisms causing acute bacterial sinusitis in adults vs children
Adults: S. pneumoniae & H. influenza
Children: Moraxella catarrhalis & H. influenza
Criteria for diagnosis of Rhinosinusitis
- Presence of purulent nasal discharge
- Maxillary dental or facial pain
- Unilateral maxiallary sinus tenderness
- Worsening symptoms after initial improvement
First-line treatment for rhinosinusitis
Amoxicillin & trimethoprim-sulfamethoxazole
10 -1 4 days
Second-line treatment for rhinosinusitis
– use of initial treatment fails or if patient has severe, recurrent disease
Treatments include:
– Amoxillin-clavulanic acid
– 2nd or 3rd-generation cephalosporins (cefuroxime, cefaclor, cefprozil)
– fluoroquinolones or 2nd-gen macrolides (clarithromycin, azithromycin)
In suspected cases of pharyngitis, what must be ruled out?
R/O more severe causes of throat pain (e.g., epiglottis, retropharyngeal abscess, paritonsillar abscess, and group A beta hemolytic strep (GAS)
Incidence of pharyngitis is most common in what populations? What is the etiology in these groups?
Most common in PEDIATRIC populations (peak between 4 - 7 years)
30% of all pediatric cases d/t GAS (group A strep)
Modified CENTOR criteria for diagnosis of GAS without performing rapid strep test or throat culture
A point is given for each of the following criteria:
- absence of cough
- enlarged/tender anterior cervical adenopathy
- fever of 100.4 F or higher
- tonsillar swelling/exudates
- one additional point added if patient is btwn 3 - 14 yo or one point is deducted if pt is age 45 or older
0-1 points = recommend no further testing and NO antibiotic indicated
2-3 points = perform rapid strep or throat culture and treat w/ Abs if positive
4 or more points = consider empiric antibiotic treatment
What is the gold standard for diagnosing GAS?
~Throat culture~
diagnosis can also be made by rapid antigen testing (rapid Strep)
What is the treatment of choice for GAS pharyngitis? What if the patient has an allergy to this treatment?
Penicillin is antibiotic of choice for GAST pharyngitis (10 day course of penicillin V or intramuscular pen G benzathine)
If pt has penicillin allergy –> can treat w/ cephalasporins and macrolides
What condition is part of a DDx of nearly all respiratory illnesses?
Community acquired pneumonia (CAP)
Define CAP
Community-acquired pneumonia –> acute infection of pulmonary parenchyma OUTSIDE of health care setting (e.g. nursing home, hemodialysis centers, recently hospitalized)
Define nosocomial pneumonia
Nosocomial pneumonia –> acute infection of the pulmonary parenchyma acquired INSIDE health care setting (hospital-acquired pneumonia [HAP], and ventilator-associated pneumonia [VAP])
Criteria for HAP and VAP
HAP (hospital-acquired penumonia) = pneumonia acquired > 48 hours after hospital admission
VAP (ventilator-associated pneumonia) = acquired > 48 hours after endotracheal intubation
Most common pathogens causing CAP
- S. pneumoniae
2. Legionella
Diagnostic markers for CAP (x4)
- Leukocytosis w/leftward shift or leukopenia
- Elevated inflammatory markers (ESR, CRP, procalcitonin)
- Chest imaging (presence of infiltrate)
- CT for immunocompromised patients (they can’t mount a typical inflammatory response and thus have a negative chest x-ray)
DDxs (non-infectious illnesses that mimic CAP or co-occur and present with pulmonary infiltrate and cough)
- CHF w/pulmonary edema
- Pulmonary emoblism
- Pulmonary hemorrhage
- Atelectasis
- Aspiration or chemical pneumonitis
- Drug reactions
- Lung cancer
- Collagen vascular diseases
- Vasculitis
- Acute exacerbations of bronchiectasis
- Interstitial lung diseases (e.g., sarcoidosis, asbestosis, hypersensitivity pneumonitis, cryptogenic organizing pneumonia)
Streptococcus pneumonia – typical organism causing pneumonia
- Who does it target
- S/S
- Classic lab abnormalities
- Medications
Who: classically targets elderly, young, and immunocompromised people (e.g., HIV, Sickle cell, transplant recipient)
S/S: sudden on set of rigors, sputum, pain, fevers, and classic lobar infiltrates
Labs: elevated LFTs, hyponatremia, leukocytosis
Meds: responds to penicillins, macrolides, and fluoroquinolones to varying degrees
What bacterial pneumonia-causing agent may cause empyema and extensive infiltrates on CXR?
Staph aureus
What bacterial pneumonia-causing agent is related to recent antibiotic use (esp. fluoroquinolones) w/in past 3 months; recent hospitalization and immunosuppression
Methicillin resistant staph aureus (MRSA)
What bacterial pneumonia-causing agent presents with the following characteristics:
- affects younger, healthier persons, men who have sex with men, in crowded living conditions,
- patients have hx of skin/soft tissue infections
- IV/IM drug users
- those who play contact sports
- can be severe, assoc w/ necrotizing & cavitary pneumonia, empyema, gross hemoptysis, spetic shock, and resp failure
Community acquired methicillin resistant staph aureus (CA-MRSA)
What bacterial pneumonia-causing agent has the following characteristics:
- classically in alcoholics and aspiration
- lobar infiltrates, rigors, abscess
Klebsiella
** currant jelly hemoptysis is KEY
What bacterial pneumonia-causing agent has the following characteristics:
- ill patients, CF, elderly, recently hospitalized, assoc w/antibiotic use, severe COPD
- causes severe disease, multiple infiltrates, systemic illness (cyanotic, confused, fever)
- NOT a CAP
- antibiotic resistance is common
Pseudomonas
What bacterial pneumonia-causing agent has the following characteristics:
- elderly, sickle cell, immunocompromised, splenectomy
- are in children (d/t HIB vaccine)
- chest pain, effusions, multilobar disease
Haemophilus influenza
What bacterial pneumonia-causing agent has the following characteristics:
- similar to H. inf
- typically indolent course w/cough, prod sputum, pleuritic CP w/infiltrate usually diffuse on CXR
Moraxella catarrhalis
What are the four main agents causing atypical pneumonias
- Legionella
- Chlamydophilia
- Mycoplasma
- Viruses
Characteristics of legionella caused atypical pneumonia
- who does it affect
- s/s
- when does it occur
- associated conditions
- CXR finding
Who: elderly, smokers, immunosuppressed
S/S: GI symptoms, hyponatremia, broad spectrum pulm symptoms
When does it occur: commonly seen throughout year, some decrease in summer
Associated conditions: “itis” (e.g., sinusitis, pancreatitis, myocarditis, pyelonephritis)
CXR findings: patchy infiltrate, hilar adenopathy, pleural effusions
Big difference between legionella and chlamydophilia caused atypical pneumonias
Chlamydophilia may mimic legionella on CXR but does NOT have GI symptoms
Also chlamydophilia causes a milder illness, sore throat, fever, np cough, rhonchi/rales
What atypical pneumonia-causing agent has the following characteristics:
- “walking pneumonia”, sore throat, headache
- occurs in cycles (every 4-8 years)
- lacks GI symptoms
- rashes, neuro symptoms, arthralgias
- chest pain, bullous myringitis
Mycoplasma
Treatment of CAP uncomplicated outpatient
Macrolide (azithromycin or clarithromycin)
OR
Tetracycline (doxycycline)
Treatment of CAP outpatient in pts with significant comorbidities/failed first-line treatment
Macrolide + Penicillin/lactamase
OR
Fluoroquinolone (levofloxacin or moxifloxacin)
What is a PSI/PORT score
Pneumonia Severity Index (PSI) assigns patients to 5 risk categories based upon age and mesurable derangements with:
groups 1-3 = outpatient candidates
groups 4-5 = inpatients (generally ICU)
What is CURB-65
score for pneumonia severity that measures
Confusion Uremia > 7 Respiratory rate > 30 Blood pressure < 90 systolic or < 60 diastolic Age > 65
Three primary pillars for prevention of CAP
- Smoking cessation
- Influenza vaccination for all patients
- Pneumococcal vaccination for at risk patients
Three main goals for manipulative treatment in pneumonia
- Reduce parenchymal lung congestion
- Reduce sympathetic hyper-reactivity to the parenchyma of the lung
- Increase mechanical thoracic cage and diaphragmatic motion
What are the respiratory system affects of increased parasympathetic tone (think about secretions and bronchioles)
Parasympathetics (OA, AA, C2)
Increased tone = thinning of secretions and relative bronchiole constriction
What are the respiratory system affects of increased sympathetic tone (think about secretions and bronchioles)
Sympathetics (T2 - T 7)
Increased tone = thickened secretions and bronchiole dilation
Chapman’s points for bronchi
Anterior: Intercostal space between 2nd & 3rd ribs at sternocostal junction
Posterior: T2 midway between SP & tip of TP
Chapman’s points for upper lungs
Anterior: Intercostal space btwn 3rd & 4th ribs at sternocostal junction
Posterior: Space btwn TPs of T3 & T4, midway btwn the SP & tip of the TP
Chapman’s points for lower lungs
Anterior: intercostal space btwn 4th & 5th ribs at sternocostal junction
Posterior: space btwn TPs of T4 & T5, midway btwn SP & tip of TP
