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Clin Med Exam 3 PULM > Infectious Disorders: PNA, TB, Bronchi, Bronchio, Epiglottitis, Croup > Flashcards

Infectious Disorders: PNA, TB, Bronchi, Bronchio, Epiglottitis, Croup Flashcards

1
Q

Most common cause bacterial CAP worldwide

A

Streptococcus pneumonia

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2
Q

Rate and season of CAP

A

5-6 cases / 1000 ppl (or ~2 million / year in US)

More common in winter
Men / Black ppl
Elderly

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3
Q

Technical differentiation between CAP and hospital-facility acquired pneumonia

A

A person w CAP has not been hospitalized or in long term care facility for at least 14 days

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4
Q

Clinical features CAP

A

1-10 day history increasing cough

Purulent sputum
Pleuritic chest pain

SOB
Tachycardia

Fever
Sweats
Rigors

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5
Q

3 microorganisms that cause 85% of CAP

A

Streptococcus pneumonia
Moraxella catarrhalis
Haemophilus influenza

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6
Q

Physical exam findings CAP

A

Lung Exam:

Rales/Crackles
Increased tactile fremitus (consolidation)

Bronchial breath sounds over an area of consolidation
“Dense consolidation of the lung parenchyma, as can occur with pneumonia, results in the transmission of large airway noises (i.e. those normally heard on auscultation over the trachea… known as tubular or bronchial breath sounds) to the periphery. “

“Altered breath sounds”

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7
Q

What does “dullness to percussion” and/or decreased tactile fremitus indicate on physical exam?

A

Pleural effusion

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8
Q

What physical exam findings indicate lung consolidation

A

Increased tactile fremitus
“special” tests (bronchophony, ego phony, whisper)

Bronchial breath sounds - Dense consolidation of the lung parenchyma, as can occur with pneumonia, results in the transmission of large airway noises (i.e. those normally heard on auscultation over the trachea… known as tubular or bronchial breath sounds) to the periphery.

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9
Q

Consolidation vs effusion?

A

Consolidation occurs when the normally air filled lung parenchyma becomes engorged with fluid or tissue.
In the presence of consolation, fremitus becomes more pronounced.

Fluid, known as a pleural effusion, can collect in the potential space that exists between the lung and the chest wall, displacing the lung upwards. Fremitus over an effusion will be decreased.

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10
Q

Most basic CAP workup

A

H&P
CXR
Pulse Ox

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11
Q

Additional CAP diagnostics

A

Routine Lab: CBC, BMP, LFT
Sputum culture / gram stain
Blood culture
ABG (hospital setting)

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12
Q

CXR findings PNA

A

Lobar or segmental infiltrates

Air bronchograms*
*refers to the phenomenon of air-filled bronchi (dark) being made visible by the opacification of surrounding alveoli (grey/white). It is almost always caused by a pathologic airspace/alveolar process, in which something other than air fills the alveoli.

Pleural effusions

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13
Q

Treatment for pleural effusion?

A

Thoracentesis in hospital setting

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14
Q

CURB 65 scoring to determine outpatient / inpatient treatment of CAP

A

C - Confusion
U - Blood Urea Nitrogen 20mg/L or up
R - Respiratory rate 30/min or up
B - BP < 90 / < or = 60 (89/60 or below)
65 - Age 65 or up

Scores: 
0-1 = outpatient
2 = closely observed outpatient or inpatient observe, depending on risk factors of patient
3 = inpatient
4 or 5 = inpatient / ICU

Other considerations for Hospitalization: HI 5

    • Hemodynamic instability
    • Involvement of more than one lobe
    • 50 yrs + with comorbidities
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15
Q

Outpatient, uncomplicated CAP treatment (previously healthy, no use of antibiotics in past 3 months)

A

7-10 days of:

1st line: Macrolide (clarithromycin, azithromycin)

or

2nd/3rd line: fluoroquinalone

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16
Q

Outpatient CAP treatment for patient with underlying chronic disease or use of antimicrobials in past 3 months

A

7-10 days of:

1st line: Fluoroquinolone (Moxi 400mg, Levo 750mg, Gemi)
or

Alt 1st line: Macrolide (clarithro / azithro) + beta lactam (amoxicillin / augmentin / ceftriaxone / cefotaxime)

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17
Q

Inpatient treatment CAP, non ICU

A

Consider coverage of S. pneumo AND Legionella

1st line: Fluoroquinolone (Moxi 400mg, Levo 750mg, Gemi)

Alt 1st line: Macrolide (azithro / clarithro) + beta lactam (ceftriaxone / cefotaxime)

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18
Q

Inpatient treatment CAP in ICU

A

Beta Lactam (Cefotazime, Ceftriaxone, Ampicillin-sulbactam)
+
Fluroquinolone (Moxi 400mg, Levo750mg)
or (2nd line) Azithromycin

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19
Q

Inpatient pen-allergic ICU CAP treatment

A

Fluoroquinolone + Aztreonam (monobactam)

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20
Q

Treatment if pseudomonas is suspected agent:

A

Fluoroquinolone (Cipro / Levo)
+
Beta Lactam for pneumo/pseudo (Piperacillin / Cefepime / Imipenem / Miropenem

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21
Q

Vaccine recommended for all patients 65 and older

A

PPSV23 AND PCV13

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22
Q

Atypical CAP most commonly found in what populations

A

young adults, living in close proximity

  • college dorms
  • military
  • boarding schools
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23
Q

Most common causes of Atypical CAP

A

1 - Mycoplasma pneumoniae

Chlamydia pneumoniae
Legionella sp. (air conditioning, humidifiers)

Moraxella sp.
Influenza A / B

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24
Q

Clinical features Atypical CAP

A

Low grade fever

Persistent dry cough

Constitutional: malaise, myalgia, headache

“smouldering” illness

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25
Q

Distinctive Mycoplasma findings

A

“Bullous myringitis” - reddened tympanic membrane

Vesicular rash

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26
Q

Distinctive Legionella findings

A

Systemic illness: diarrhea, hyponatremia

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27
Q

Distinctive Chlamydia findings

A

Longer prodrome

Sore throat, hoarseness

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28
Q

Atypical CAP Diagnostic Workup

A

H&P

Dry cough that is not resolving
CXR usually confirms infiltrates

Routine labs usually not too bad (WBC, BMP, sputum)

Treatment usually based on clinical diagnosis alone

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29
Q

Atypical CAP Treatment

A

** No Beta Lactams **

Choose Macrolide, Fluoroquinalone, Tetracycline

Azithro or Clarithromycin  
or Doxycycline (Mycoplasma, Legionella)

Tetracycline if Chlamydia suspected

30
Q

Hospital acquired pneumonia (HAP) and VAP, distinctions

A

Clinical infection more than 48 hours after hospital admission

ICU patients on ventilators at highest risk (VAP) - developed 47-72 hours after endotrachial intubation

31
Q

Patients at risk for HCAP (Healthcare-associated pneumonia)

A 
Within past 30 days:
IV therapy
Chemotherapy
Wound care
Dialysis

Within 90 days:
Acute care hospitalization for 2+ days

32
Q

Causative organisms for HAPs

A

S. Aureus

and Gram Neg Bacilli:

  • Pseudomonas (ICU)
  • Klebsiella
  • E. coli
  • Enterobacter
33
Q

Best Diagnostics for HAPs

A

SPUTUM CULTURE
Blood Cultures

Bronchoalveolar lavage - if can’t obtain sputum culture

34
Q

Early onset (<5 days) HAP treatment, no MDR risk factors

A

Based on Culture and Sensitivity Results

Cetriaxone
Levo
Ampicillin-sulbactam

x8 days

35
Q

Late onset (>5 days) treatment, +MDR risk, HCAP

A

Based on Culture and Sensitivity Results

Cipro or Levo

Cefepime
Ceftazidime

Imipenem
Miropenem

Piperacillin

Vancomycin
Linezolid

36
Q

Indication of a sputum culture / gram stain with ** mixed flora **

A

Aspiration pneumonia

37
Q

Most common cause of bacterial pneumonia in HIV patients

A

Streptococcus pneumo

38
Q

Most common “opportunistic infection” in HIV patients

A

Pneumocystis jiroveci

39
Q

Treatment of choice for pneumonia in HIV patients

A

Bactrim (trimethroprim - sulfamethoxazole)

**prophylaxis indicated in all patients w CD4 counts < 200 **

40
Q

Of the very uncommon fungal pneumonia, which is most common causative agent

A

Histoplasma capsulatum

41
Q

CXR indicative of Histoplasmosis

A

GRANULOMAS

**confirm with bronchoalveolar lavage or biopsy **
or serologic testing

42
Q

Tx Histoplamosis

A

Itraonazole (mild)

Amphotercin B (severe)

43
Q

Primary TB

vs

Progressive Primary TB

vs

Latent TB

A

Primary TB: 10% of persons infected w TB, immune system able to prevent progression. Form granulomas

Progressive primary TB: 5% ppl fail to contain primary infection and progress to active TB

Latent TB: 95% of ppl contain bacterium without becoming symptomatic. Not infectious, asymptomatic.

44
Q

Clinical features TB

A

Dry cough, progressing to productive cough - with or without hemoptysis &raquo_space; 3 weeks +

** Drenching night sweats, weight loss, Posttussive rales**

45
Q

Primary TB Radiography

A

Homogenous infiltrates

“Segmental atelectasis” (collapse of one or several segments of lung)

Lung Cavitations

Hilar/Paratracheal lymph swelling

46
Q

Reactivation TB Radiography

A

Apical fibrocavitary infiltrates

47
Q

Radiography findings in healed primary infection

A

Ghon complexes (calcified primary focus)

Ranke complexes (Ghon + calcified hilar lymph node)

48
Q

Tuberculin Skin Test (TST) PPD reported according to

A

DIAMETER of induration - NOT erythema

Identifies but does not differentiate between active / latent!

49
Q

Definitive diagnosis of TB

A

ID of M. tuberculosis via sputum cultures or DNA/RNA amplification

50
Q

Histologic hallmark of TB

A

Biopsy revealing caseating granulomas (aka, necrotizing granulomas)

51
Q

LTBI Treatment

A

Isoniazid (INH) for 9 months

or Rifampin (RIF) for 4 months

or RIF and Pyrazinamide (PZA) for 2 months - if contact w resistant strains

52
Q

Active TB Tx

A

Isoniazid (INH) + RIF + PZA + Ethambutol (EMB) for 2 months

+

Additional 4 months mutlidrug treatment based on culture sensitivity results

53
Q

Length of multi drug treatment of HIV patients w TB?

A

1 year

54
Q

Prophylaxis TB treatment?

A

INH for 6-12 months

55
Q

Inflammation of airways, characterized by cough

A

Bronchitis

56
Q

> 90% cases of acute bronchitis caused by

A

VIRUSES (including RSV)

** bacterial causes considered in patients w chronic lung diseases (S. pneumo, H. influenza, M. catarrhalis)

57
Q

Is sputum color predictive of bacterial involvement for acute bronchitis?

A

NO

58
Q

Diagnostic studies for acute bronchitis

A

Generally none, unless need to differentiate bronchitis from pneumonia

CXR negative in bronchitis

59
Q

Treatment acute bronchitis

A

Supportive - unless exacerbation of chronic bronchitis»

> > 1st line: 2nd gen cephalosporin
2nd line: or 2nd gen macrolide or Bactrim

60
Q

When are antibiotics indicated for acute bronchitis?

A

Elderly

Underlying cardiopulmonary diseases and cough for +7-10 days

Any immunocompromised patient

61
Q

Inflammation of the bronchioles (airways <2mm diameter)

Primarily illness of young children and infants

A

Acute bronchiolitis

62
Q

Most common cause of Acute Bronchiolitis, and others

A

RSV

Others:
Parainfluenza
Adenovirus
Rhinovirus

63
Q

Clinical features of respiratory distress in pediatrics w acute bronchiolitis

A

Nasal flaring

Tachypnea

Retractions

64
Q

Diagnostic studies - acute bronchiolitis / RSV

A

CBC - usually normal
CXR - normal but can show bronchial thickening / air trapping

Nasal washing for RSV culture ** often done for infants **

65
Q

Treatment / management of RSV

A

If present, consider hospitalization, esp premature infants

+ RIBAVARIN

Supportive measures:
Antipyretics
Nebulized albuterol
IV fluids
humidified O2
Chest physiotherapy?
66
Q

HIB vaccine has decreased incidence of this in children, but can still be found in unimmunized adults or caused by Strep A

A

Acute epiglottitis

67
Q 
Sudden onset high fever
Severe Dysphagia 
Drooling
Muffled voice
Posture compensation
Respiratory Distress
A

Acute epiglottitis

68
Q

Management of Acute Epiglottitis

A

Secure Airway

Broad spectrum 2nd-3rd gen cephalosporins
(Cefotaxime, Ceftriaxone)

Dexaeathasone to reduce inflammation

69
Q

Harsh, barking, cough
Inspiratory stridor
Aphonia
infection with Parainflueza, RSV, other viruses

A

Croup

70
Q

Diagnostic studies for Croup

A

PA (postanterior) Neck Film:
Shows Steeple Sign (subglottic narrowing)

this differentiates croup from epiglottitis

71
Q

Management for Croup

A

Usually only supportive
** Hydration is very important**

Corticosteroids
Humidified O2
Nebulized epinephrine

Clin Med Exam 3 PULM (3 decks)

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