Learning Objectives - Pneumonia

Question 1

Organisms associated with typical pneumonia?

Answer 1

Pneumococcus

Hemophilus

Question 2

Organisms associated with atypical pneumonia?

Answer 2

Chlamydia
Mycoplasma
Legionella
Respiratory viruses

Question 3

Define nosocomial/healthcare-associated pneumonia?

Answer 3

After 72 hours in the hospital or hospitalized in the last 90 days; nursing homes, dialysis centers, home wound care, tube feedings, family member with MDR pathogen

Question 4

What are the dependent zones of the lungs?

Answer 4

Apical segments of the right lower lobe, posterior segments upper lobe

R>L (R more vertical in orientation)

Question 5

Patients at risk for aspiration pneumonia?

Answer 5

Alcoholic use disorder
Seizures
CVA
Drugs
NG/ET tube
Anesthesia

Question 6

Organisms causing aspiration pneumonia?

Answer 6

Oral anaerobes (prevotella, peptostreptococcus, bacteroids), GN rods (Klebsiella), S. aureus

Question 7

Rx PJP pneumonia?

Answer 7

Bactrim

Question 8

Rx TB pneumonia?

Answer 8

RIPE

Question 9

Rx cryptococcal pneumonia?

Answer 9

Amphotericin

Question 10

Rx strongyloides pneumonia?

Answer 10

Albendazole

Question 11

Rx MAC pneumonia?

Answer 11

Macrloides

Question 12

Organisms causing pneumonia in patients with hematologic malignancy/BM transplant?

Answer 12

GN enteric rods
Aspergillus
MRSA
Pseudomonas
CMV
PJP

Question 13

Rx MRSA pneumonia?

Answer 13

Vancomycin

Question 14

What can be used to decide whether or not to hospitalize patients with CAP?

Answer 14

CURB-65

Confusion
blood Urea nitrogen (>19)
RR (>30)
BP (systolic <90, diastolic <60)
Age (65+)

0-1 = outpatient
3+ = inpatient
4-5 = probably ICU

Question 15

Which patients with pneumonia should be directly admitted to the ICU?

Answer 15

Septic shock requiring pressors
Acute respiratory failure requiring intubation and mechanical ventilation
3 minor criteria for severe CAP:
1. RR >30
2. PaO2/FiO2 ratio <250
3. Multilobar infiltrates
4. Confusion/disorientation
5. Uremia (BUN>20)
6. Leukopenic (WBC count <4000)
7. Thrombocytopenia (<100,000)
8. Hypothermia (<32.2 C)
9. Hypotension requiring aggressive fluid resuscitation
10. Non-invasive ventilation (substitutes for RR>30 or ratio <250)

Question 16

Most common cause of pneumonia?

Answer 16

S. pneumonia

Question 17

Rx - uncomplicated CAP, no comorbidities or recent ABX:

Answer 17

Macrolides or doxycycline

Question 18

Rx - uncomplicated CAP, comorbidities or recent ABX:

Answer 18

FQ (levo/moxi), amox/augmentin/3rd gen ceph + macrloide

Question 19

Inpatient Rx - CAP?

Answer 19

FQ

Cef + azithro

Question 20

Rx nosocomial CAP?

Answer 20

Carbapenem
4th gen ceph
Pip/Tazo

Question 21

What does ceftriaxone cover?

Answer 21

Most but not all pneumococci, beta-lactamase producing H. influenzae, MSSA, enterobacter

NOT atypicals

Question 22

What does azithro cover?

Answer 22

Mycoplasma
Chlamdophila
Legionella

Question 23

What does levofloxacin cover?

Answer 23

Most pneumococci, beta-lacatamse producing H. influenzae, MSSA, Enterobacter, Mycoplasma, Chlamydophila, Legionella

Question 24

Why is amp/sulbactam a good choice for CAP aspiration pneumonia?

Answer 24

Activity against oral anaerobes including beta-lactamase producing GN anaerobes

Question 25

List # complications of acute bacterial pneumonia.

Answer 25

1. Bacteremia 2. Sepsis 3. Parapneumonic effusion 4. Empyema 5. Meningitis 6. Metastatic micro-abscesses

Question 26

What is the difference between uncomplicated and complicated parapneumonic effusion?

Answer 26

Uncomplicated: exudative with PMNs, no bacteria, due to inflammation, resolves with ABX Complicated: bacterial invasion into pleural space, increased PMNs, decreased glucose, increased LDH, needs drainage, +/- thrombolytics and surgical lysis of adhesions

Question 27

Indications for pneumococcal vaccines?

Answer 27

Pneumovax 23: >65, immunosuppressed, chronic medical conditions, smoking, alcohol use Prevnar 13: >65, CKD, immunosuppressed

Question 28

Vesicular vs. bronchial breath sounds?

Answer 28

Vesicular: normal, long inspiratory phase, short expiratory phase Bronchial: abnormal, louder, shorter inspiratory phase, louder, prolonged expiratory phase

Question 29

Why are bronchial breath sounds heard in consolidation?

Answer 29

Sound is transmitted through solid or liquid media better than air.

Question 30

Dullness to percussion?

Answer 30

Suggests pleural effusion

Question 31

Hyperresonance to percussion?

Answer 31

Suggests pneumothorax

Question 32

Physical exam findings suggesting consolidation?

Answer 32

Egophany Tactile fremitus Whispered pectoriloquy

Question 33

Findings of effusion?

Answer 33

Dullness to percussion Decreased breath sounds Decreased fremitus

Question 34

When should an ABG be ordered in the setting of suspected pneumonia?

Answer 34

Rarely useful; can be useful if on the fence about intubation or if there is concern for retaining excess CO2

Question 35

Findings of pneumonia on CBC?

Answer 35

Elevated WBCs, PMNs, left shift, absence does not rule out

Question 36

Define a high quality sputum sample.

Answer 36

>25 PMN <10 epithelial cells Per 100 power field

Question 37

In which patients should a Legionella and Strep urinary antigen be ordered?

Answer 37

Severe CAP Admission to ICU Hx of active alcohol use Failed outpatient treatment

Question 38

Pneumonia infiltrates present on CXR may take up to ___ weeks to resolve

Answer 38

12

Question 39

Radiographic findings of pneumonia?

Answer 39

1. Silhouette sign - pus produced by inflammatory response obliterates the normal air-diaphragm interface 2. Focal consolidation 3. Interstitial infiltrates 4. Effusions (most common with pneumococcus)

Question 40

Cause of hypoxia in pneumonia?

Answer 40

V/Q mismatch (affected area of the lung is poorly ventilated and oxygen exchange is limited)

Question 41

DDx - Fever, Dyspnea, Purulent Cough, Hemoptysis

Answer 41

1. Pneumonia 2. Lung cancer 3. Influenza 4. PE Less likely: common cold, acute bronchitis, acute COPD exacerbation, CHF

Question 42

Safe resting O2 saturation?

Answer 42

~92-93%

Question 43

What 4 ways do bacteria get to the lung? Which is most common?

Answer 43

1. Aspiration (most common) 2. Respiratory droplet/airborne inhalation 3. Hematogenous 4. Direct inoculation

Question 44

Empiric therapy for pneumonia?

Answer 44

Ceftriaxone +/- macrolide OR FQ (NOT cipro)

Question 45

When should a CXR be repeated following pneumonia? (indications)

Answer 45

Clinical worsening | Follow-up of a pleural effusion