ICL 2.4: Lower Airway Infections & Pneumonia Flashcards
65 year old woman presents to ED with productive cough fatigue and fever for 3 days. her temperature is 103F and she looks ill.
The triage nurse already drew labs including blood cultures, inserted a line and ordered a CXR under your name.
CXR shows R upper lobar pneumonia
does the patient have an infection and what is the etiology? do you need to treat her and how?
this points towards infection but we don’t know what’s causing it, we need a workup
probably has pneumonia…
what do you need to ask when taking a history in a patient presenting with cough/SOB?
- duration of symptoms
- associated symptoms: wheezing, chest pain, weightless, fever, edema?
- fever?
- where is the patient coming from? house, hospital, nursing home?
- prior use of antibiotics?
- comorbidities?
- social history: alcohol, drugs, smoking?
- occupational history and exposures
- travel?
history is SO important!
why does the duration of symptoms matter when taking a history of a patient presenting with cough/SOB?
prolonged symptoms suggest underlying chronic lung disease, fungal etiology, noninfectious etiology
short duration goes more with infection, but cannot differentiate between specific etiologies
staph and pneumococcus frequently present after a viral syndrome
what does fever tell you about a patient presenting with cough/SOB?
fever is usually absent in bronchitis, present in pneumonia
but neither absence not absence are diagnostic
what are the myths involving coughs?
- productive cough in itself does not equal infection
- thicker or colored sputum does NOT indicate a bacterial etiology; it could be viral!
- “rusty sputum” does not equal pneumococcus
- blood streaks in sputum do not equal cancer or TB
- hemoptysis DOES requires urgent evaluation
what is the location, cause, testing, and treatment for community acquired pneumonia?
CAP is acquired outside of the hospital; includes nursing homes
caused mainly by pneumococcus, hemophilus and moraxella – can also be caused by viruses, legionella or mycoplasma
specific testing is only used if they’re super sick; treat empirically for 5 days
what is the location, cause, testing, and treatment for hospital/ventilator acquired pneumonia?
HAP/VAP is pneumonia that develops 48 hours after hospital admission
caused by more resistant organisms like MRSA or gram negatives like pseudomonas and klebsiella
obtaining blood and sputum culture is super important; treat empirically followed by de-escalation once you figure out the specific organism for 7 days
when do you do a PE when evaluating a patient presenting with cough/SOB?
don’t jump directly from history to auscultation! first observe, record vitals, palpate and percuss the patient with pulmonary symptoms
pay attention to other systems like swollen painful joints, JVD, leg edema, clubbing, cyanosis
- tactile fremitus
- percussion
- auscultation
what are the different sounds you can hear during lung auscultation and what do they mean?
- rhonchi = secretions in medium sized airways that cause low pitched, rattling lung sounds that often resemble snoring –> can be heard in patients with chronic obstructive pulmonary disease (COPD), bronchiectasis, pneumonia, chronic bronchitis, or cystic fibrosis
- crackles or rales = alveolar disease
- egophony = EE->A signifies consolidated lung
- pectoriloquy = bronchial sounds where vesicular sounds are expected
what is CURB-65?
Ⓒonfusion
Ⓤremia; BUN >20
Ⓡexpirations > 30
Ⓑlood pressure <90 systolic or <60 diastolic
⑥⑤ years+
0-1 points is oupatient
2: inpatient
3-5: ICU
pneumonia severity index (PSI) is more accurate
what’s the problem with using CURB-65?
it’s cookbook medicine! this is not a perfect thing and is a little too cookie cutter
people with dementia or CKD would automatically get a point! this isn’t accurate
what additional concerns would warrant admission in a patient with SOB?
- inability to take oral medications
- cognitive or functional impairment
- social issues that could impair medication adherence or ability to return to care for clinical worsening like substance abuse, homelessness or their residence is far from a medical facility
what is a SMART COP score?
it’s a score that determines the need for intensive respiratory or vasopressor support (IRVS)
it’s 79% specific and 64% sensitive in predicting ICU admission but several elements aren’t always available like PaO2, pH or albumin levels
Ⓢystolic < 90 Ⓜultilobar involvement Ⓐalbumin <3.5 Ⓡespirations >30 Ⓣachycardia > 125 Ⓒonfusion Ⓞoxygen saturation <90 ⓅH < 7.35
65 year old woman presents to ED with productive cough fatigue and fever for 3 days.
Her temperature is 103F and she looks ill but is oriented and conversant
The triage nurse already drew labs including blood cultures, inserted a line and ordered a chest xray under your name.
She lives alone, has well controlled DM, she has not been admitted to a hospital in the past 5 years, she does not smoke. She has 2 grandchildren 5 and 11 that she babysits weekdays. They are both healthy. Used to work in an office, no exposures. No weight loss
On exam RR 20, HR 115, BP 100/65; she has dullness on percussion increased fremitus and rhonchi in right anterior fields, but some can be heard in posterior lung fields too.
Creatinine is 1.3 and BUN 35 mg/dl
- do you want to treat inpatient or outpatient?
- what additional tests do you want?
- how do you treat her?
CAP
1. inpatient because CURB65 score is 2
- no additional testing, treat empirically –> most people with CAP are treated empirically because the workup is disappointing and doesn’t really help that much
- treat with ceftraixone and azithromycin
if she has a contraindication for azithromycin, give doxycycline with the ceftraixone
if she was allergic to penicillin give cephalosporins! macrolides used to be the answer but there is 100% pneumococcal resistance to macrolides in japan and it’s pretty high here in the US too so this isn’t a good choice on its own
if she can’t tolerate cephalosporins, give respiratory quinolones
when do you get a sputum culture?
they’re only done for people who are admitted for severe CAP or if they’re being treated for MRSA or pseudomonas
sputum cultures are NOT for outpatients because by the time you get the results the treatment is done
what is the criteria for a good sputum culture?
expectorated sputum is many times contaminated with oral flora
labs have criteria for sputum rejection based on number of epithelial cells
culture cannot be interpreted and has no value in the absence of clinical data
semiquantitative cultures are preferred (reported as 1+ to 4+)
it is important to obtain sputum before administering antibiotics
cultures can reveal colonizers of respiratory tract that are almost never pathogens and aren’t causing an infection like Candida, coagulase negative staph, enterococci, diphtheroids, some streps
what do blood cultures tell us when evaluating a patient with cough/SOB?
yield is low; only 2-9% BC are positive in pts with CAP
contaminated cultures that show coag negative staphylococci can lead to inappropriate use –> staph aureus from a blood culture is pathogenic so you need to make sure it’s actually coming from the blood and not from contamination
may be associated with prolonged hospital stay
they’re only recommended only if there are risk factors for MRSA and pseudomonas infection because otherwise you’re probably not going to get anything from a blood culture
what are the 2 microbes found in urine antigens?
- legionella
2. streptococcus pneumoniae
when would you do a streptococcus pneumoniae urine antigen test?
recommended in severe CAP (subset of inpatients)
sensitivity ~ 70%
when would you do a legionella urine antigen test?
not for outpatients
it detects only Legionella pneumophila serotype 1 (80% of cases)
70-80% sensitive
useful in outbreaks
recommended in severe CAP (subset of inpatients)
if high suspicion, sputum culture or PCR may be more sensitive
