Lecture 7 (pneumonia mediastinal)-Exam 3 Flashcards
Acute bronchitis:
* What is it?
* Nearly all causes are what?
* What is it the most common cause of ? ⭐️
* What are typical symptoms?
- Inflammation of tracheobronchial tree in patients without chronic lung disease
- Nearly all cases are viral
- It is the most common cause of hemoptysis
- Typical symptoms: cough w/or w/o fever or sputum production
Acute bronchitis:
* Dx is what?
* Treatment is what?
* What is the prognosis?
* Rarely progress into what?
- Diagnosis is clinical, CXR is negative
- Treatment is supportive (No ABX)
- Prognosis is excellent
- Rarely can progress to pneumonia
background info: low yield
Community Acquired Pneumonia (CAP)
* What is the most common of?
* In the United States, CAP accounts for over what?
* CAP is the second most common cause of what?
* How many people are hospitalized?
* Nearly 9 percent of patients hospitalized with CAP will be what?
General Pneumonia Facts:
* _ leading cause of death
* in 50-80% of causes, what is not found?
* What sx is usually not corralated with pneumonia?
* How many causes of pneumonia?
* Healthy older child or adult: pneumonia can be reasonably excluded with what?
* What is insensitive for distinguishing bacterial vs other pneumonia? ⭐️
* What plays almost no role in source suspect? ⭐️
General pneumonia facts:
- What is the pathophysio of pneumonia (including the organisms)?
- Cycle of what acceleates inflammation and bacteria growth?
- In cases of CAP or HAP, trigger may be what?
- An inflammatory event resulting in epithelial and/or endothelial release of cytokines, chemokines, and catecholamines, some of which may selectively promote the growth of certain bacteria such as Streptococcus pneumonia and P. aeruginosa(hospital acciquired)
- Cycle of inflammation, enhanced nutrient availability, and release of potential growth factors further accelerates inflammation and growth of bacteria, which then may become dominant
- In cases of CAP or HAP, trigger may be a viral infection compounded by microaspiration of oropharyngeal organisms
General Pneumonia Facts
- Mediators released by macrophages and neutrophils may create what? What can the sxs be?
- Bacterial pneumonia->
- While atypical organisms->
- Mediators released by macrophages and neutrophils may create an alveolar capillary leak resulting in impaired oxygenation, hypoxemia which leads to worsening dyspnea
- Bacterial pneumonia-> intense inflammatory response -> productive cough
- While atypical organisms -> less intense reaction -> mild dry cough
What is community accquired pneumonia?
refers to an acute infection of the pulmonary parenchyma acquired outside of the hospital.
What is nosocomial pneumonia? What are the two types?
Nosocomial pneumoniarefers to an acute infection of the pulmonary parenchyma acquired in hospital settings and encompasses both hospital-acquired pneumonia(HAP) and ventilator-associated pneumonia(VAP).
* HAP refers to pneumonia acquired ≥48-72 hours after hospital admission.
* VAP refers to pneumonia acquired ≥48-72 hours after endotracheal intubation.
Health care-associated pneumonia (HCAP; no longer preferred) referred to what?
referred to pneumonia acquired in health care facilities (eg, nursing homes, hemodialysis centers) or after recent hospitalization.
* The term HCAP was used to identify patients at risk for infection with multidrug-resistant pathogens. However, this categorization may have been overly sensitive, leading to increased, inappropriately broad antibiotic use and was thus retired. In general, patients previously classified as having HCAP should be treated similarly to those with CAP.
What is the pathophysio of pneumonia?
- What is empyema?
- What is an abscess?
- What is pneumonia vs pneumonitis
- What is bronchitis?
- What is bronchiolitis?
Risk Factors of CAP:
* age?
* Chronic comorbidities?
* Viral resp tract infections?
Risk factors of CAP:
* Impaired airway protection?
* What type of substance use?
* What are some other factors?
The most commonlyidentified causes of CAP can be grouped into four categories:
- Typical bacteria
- Atypical bacteria
- Viruses
- Fungal (It is RARE)
CAP:
* What are the common organisms? ⭐️⭐️⭐️⭐️
Streptococcus pneumoniae (typical), Pseudomonas aeruginosa, and respiratory viruses are the most frequently detected pathogens in patients with CAP.
* However, in a large proportion of cases (up to 62 percent in some studies performed in hospital settings, no pathogen is detected despite extensive microbiologic evaluation
Typical bacteria – cultured by
standard methods
* Know the top three for sure ⭐️⭐️⭐️
What does atypical mean? What are the most common bacteria for atypical bacteria? ⭐️⭐️⭐️⭐️
What are the most common respiratory viruses? ⭐️⭐️⭐️
HHARRP CI
Other Associations with Pathogens
* Cystic fibrosis:
* Young adults, college:
* Air conditioning/aerosolized water:
* Postsplenectomy:
* Leukemia/lymphoma:
* Children<2:
* 1-2 year:
Typical – Clinical Presentation
* What type of onset?
* Resp, cardio, PV?
* What does the lungs sound like, percuss like, special tests?
* Hypoxemia can result from what?
- Abrupt onset -> productive cough with purulent sputum & pleuritic chest pain
- SOB
- Tachypnea, tachycardia, pallor and cyanosis
- Crackles (rales), dullness to percussion over consolidation or effusion, bronchial breath sounds, Egophony, increased tactile fremitus
- Hypoxemia can result from the subsequent impairment of alveolar gas exchange
Under slide: The great majority of patients with CAP present with fever. Other systemic symptoms such as chills, fatigue, malaise, chest pain (which may be pleuritic), and anorexia are also common
Atypical – Clinical Presentation
* What causes (2)?
* Often associated with what?
* Causes 10-30% of CAP in who?
* MCC of pneumonia in who?
* What are the sx?
* What is less common?
* Often what?
Atypical – Clinical Presentation
* Variable, tends to be “atypical” usually what?
* Associated with what?
* Infants & children?
* What causes bronchiolitis and croup?
* What is walking pneumonia? ⭐️
Under slide:
32 YO healthy patient – one week of low grade fever, sore throat, and intractable cough
Minimal sputum production
Able to continue to work
No sick contacts, recent travel, or evidence of altered immune system
PE reveals a mildly ill-appearing patient with diffuse wheezes on lung exam
Primary care physician prescribes empiric antibiotics for CAP with complete resolution
“Walking pneumonia” syndrome
Typical – Labs
* What happens with WBC?
* What are some labs that are high?
* What cultures should you do?
* Check what in urine?
- Leukocytosis with a leftward shift, or leukopenia are also findings that are mediated by the systemic inflammatory response.
- Inflammatory markers, such as the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and procalcitonin may rise, though the latter is largely specific to bacterial infections.
- Blood cultures and sputum cultures
- Check urine strep and legionella antigen
Under slide: CAP is also the leading cause of sepsis; thus, the initial presentation may be characterized by hypotension, altered mental status, and other signs of organ dysfunction such as renal dysfunction, liver dysfunction, and/or thrombocytopenia.
Typical - Diagnostics
* What does the xray show?
Under slide:
* Radiographic findings consistent with the diagnosis of CAP include lobar consolidations, interstitial infiltrates, and/or cavitations. Although certain radiographic features suggest certain causes of pneumonia (eg, lobar consolidations suggest infection with typical bacterial pathogens), radiographic appearance alone cannot reliably differentiate among etiologies.
* For selected patients in whom CAP is suspected based on clinical features despite a negative chest radiograph, we obtain computed tomography (CT) of the chest. These patients include immunocompromised patients, who may not mount strong inflammatory responses and thus have negative chest radiographs, as well as patients with known exposures to epidemic pathogens that cause pneumonia (eg,Legionella). Because there is no direct evidence to suggest that CT scanning improves outcomes for most patients and cost is high, we do not routinely obtain CT scans when evaluating patients for CAP.
Atypical - diagnostics
* Clinical Diagnosis with what?
* What type of tests are there?
* What does the CXR show?
* Unfortunately what?
Atypical - CXR
* What does it show?
* Infiltrates are nothing more than WBCs and fluid. May be negative if
* Repeat the initial x rays if
Typical manifestations based on pathogen: ⭐️⭐️⭐️⭐️
* Mycoplasma:
* Pneumocystis jirovecii:
* Legionella:
- Mycoplasma - Low grade fever, cough, bullous myringitis (ear infection) , and cold agglutinins (rare blood disorder that causes your immune system to attack your RBC’s)
- Pneumocystis jirovecii - Slower onset. Immunosuppressed, increased lactate dehydrogenase, more hypoxemic than appears on CXR, interstitial infiltrates
- Legionella - Chronic cardiac and pulmonary disease, hyponatremia, bradycardia, and diarrhea
Typical manifestations based on pathogen: ⭐️⭐️⭐️⭐️
* Chlamydia:
* Strep pneumo:
* Klebsiella:
- Chlamydia - Longer prodrome, sore throat, hoarseness
- Strep pneumo - Single rigor, rust-colored sputum
- Klebsiella - Currant jelly sputum, chronic illness-ETOH
PSI calculator and CURB 65 (OP vs IP management)
* Two scoring systems used to assess what?
* PSI is more or less accurate for low-risk patients?
* Which one is easier to calculate and interpret at the point of care?
- Two scoring systems used to assess the severity of pneumonia
- PSI is more accurate for low-risk patients
- CURB-65 is easier to calculate and interpret at the point of care
CURB65
* What are the different components?
* What is the point scale for each?
under slide:
* Temperature is also concerning: < 35 (95F) or > 40 (104)
* Automatic hospitalization: Hypotension & Hypoxia (90%)
What is the Severity Corresponding to Level of Care for pneum?
pneum
Who is ambulatory care for? What is the PSI and CURB65 score?
- Most patients who are otherwise healthy with normal vital signs (apart from fever) and no concern for complication are considered to have mild pneumonia and can be managed in the ambulatory setting.
- These patients typically have PSI scores of I to II and CURB-65 scores of 0 (or a CURB-65 score of 1 if age >65 years).
pneum
Hospital admission:
* What type of patient? What are the score?
* What type of patients may also warrant hospitalization to closely monitor the response to treatment?
* Practical concerns that may warrant hospital admission include what?
pneum
Intensive Care Unit (ICU) Admission
* What patients should be here?
The presence of three of these criteria warrants ICU admission: list all 9
Fill in ⭐️⭐️⭐️
CAP Treatment – General Guidelines
* Since etiology of CAP is rarely known at the outset of treatment, initial therapy is usually what?
* What does this treatment cover?
* Treatment of aspiration pneumonia is based upon what?
* Presentation to clinic for evaluation may require admission to the hospital with associated symptoms such as what?
- Since etiology of CAP is rarely known at the outset of treatment, initial therapy is usually empirical and designed to cover the likeliest pathogens
- Covers the likely pathogens, risk of antimicrobial resistance, severity of illness, site of care, and risk of infection with specific bacteria such as MRSA and P. aeruginosa
- Treatment of aspiration pneumonia is based upon several factors, including site of acquisition, normal or abnormal chest radiograph, and additional variables such as illness severity, and risk of infection with an MDR pathogen
- Presentation to clinic for evaluation may require admission to the hospital with associated symptoms such as fever, shortness of breath and chest x-ray results
CAP Treatment – Outpatient
* Usually, initiate coverage that includes what?
* Does not consider the risk of infection with what?
* Generally, if patients have been treated with a drug from a particular class of antibiotics within the previous three months, what should the antibiotic be?
- Usually, initiate coverage that includes atypical organisms as well as S. pneumonia
- Does not consider the risk of infection with P. aeruginosa or MRSA particularly significance in the outpatient setting
- Generally, if patients have been treated with a drug from a particular class of antibiotics within the previous three months, drugs from a different class should be used to minimize resistance issues
CAP txt-outpatient
* Those without comorbidity or resistance risk factors, what antibiotics can be given? ⭐️
* What is recommended if there are no contraindications to amoxicillin or doxycycline and there is documented low risk of macrolide resistance
- Those without comorbidity or resistance risk factors, macrolides, amoxicillin alone or tetracycline (doxycycline) is recommended
- Monotherapy with a macrolide is recommended if there are no contraindications to amoxicillin or doxycycline and there is documented low risk of macrolide resistance
Types of macrolides – azithromycin, clarithromycin, erythromycin
CAP Treatment – Inpatient
* What are the inpatient tests?
* When initiating treatment for infection with P. aeruginosa, use what?
* Presence of all three risk factors is not required for what?
* Main consideration for determining initial empiric treatment of hospitalized CAP patients are what?
* Hospitalization alone is not considered a significant risk factor for what?
CAP Treatment – Inpatient
* What do you need to treat with if non-severe and no risk factors?
- Treatment should consist of either a combination of a beta-lactam and a macrolide or monotherapy with a
respiratory fluoroquinolone - If contraindications to such, then beta-lactam together with a doxycycline may be used
- Treatment with a combination of a beta-lactam and a macrolide or a fluroquinolone alone results in lower
mortality than monotherapy with a beta-lactam
CAP Treatment – Inpatient
* What do you need to treat with if severe and no risk factors?
Should receive combination therapy with either a beta-lactam and a macrolide or a beta-lactam and a respiratory fluoroquinolone
CAP Treatment – Inpatient
* What do you need to treat with if non-severe and with risk factors?
under slide:
Without suspicion for MRSA or Pseudomonas
* -combination therapy with ceftriaxone plus macrolide. Doxycycline may be used as an alternative to a macrolide
* Monotherapy with a respiratory fluoroquinolone is an appropriate alternative for patients who can not receive a beta-lactam plus a macrolide
With suspicion for MRSA or pseudomonas
Piperacillin-tazobactam(4.5 g every 6 hours)or
●Imipenem(500 mg every 6 hours)or
●Meropenem(1 g every 8 hours)or
●Cefepime(2 g every 8 hours)or
●Ceftazidime(2 g every 8 hours; activity against pneumococcus more limited than agents listed above)
PLUS
●Ciprofloxacin(400 mg every 8 hours)or
●Levofloxacin(750 mg daily)
Treatment - Atypical
* What do you tx if bacterial suspected?
- Erythromycin/Azithromycin for M. pneumoniae & Legionella
- Doxycycline for Chlamydia
Treatment - Atypical
* What is the txt if influenzae is suspected?
- Antivirals if antigen positive and within treatment window
* Neuraminidase inhibitors – oseltamivir (Tamiflu) and zanamivir - reduce severity of symptoms given in first 48 hrs of onset
* Amantadine & rimantadine are no longer recommended - resistance - Supportive measures (analgesics, fluids, cough suppressants)
The primary pillars for the prevention of CAP are what (4)*
- Smoking cessation (when appropriate)
- Influenza vaccination for all patients
- Pneumococcal vaccination for at-risk patients
- SARS-CoV2 (Covid-19 Vaccine)
Influenza Vaccine
* What are the two options?
* What is the delivery method (2)? What time during the year?
* Prevention based on what?
* Recommended especically for who?
* Contraindicated if hypersen to what?
* immunity begins when?
Pneumococcal Vaccine
* Pneumococcal infections (eg, pneumonia, bacteremia, meningitis) are an important cause of what?
* What are the two types of pneumococcal vaccines?
Fill in ⭐️⭐️
Clinical presentation of HAP (Nosocomial)
* What are the sxs?
* What are the organisms? ⭐️
Like CAP along with new or progressive lung infiltrate and fever/leukocytosis/leukopenia, altered mental status, pleuritic chest pain and purulent secretions.
Organisms
* Methicillin Resistant Staph. Aureus
* Pseudomonas aeruginosa (usually associated with late-onset HAP) ⭐️
* Gram negative bacilli
How do you dx HAP?
- Clinical diagnosis supported with a gram stain and sputum culture.
- Chest X-Ray as well
Ventilator Associated Pneumonia and HAP Treatment
* Most patients with HAP or VAP should receive what?
a ten-day course of antibiotics, but a shorter or longer duration may be indicated, depending upon the rate of improvement of clinical, radiologic, and laboratory parameters.
What is the empiric antimicrobial agents for VAP and HAP?
HIV-related Pneumonia
* What is the most common issue of pulmonary disease?
* What organisms are the most cases of bacterial pneumonia in pts with AIDS?
* What is secondary to HIV disease?
* What also occurs at an increase frequency?
PCP:
* What are the sx?
* What does the x-ray show?
* What happens to lymphocytes?
* What about CD4?
- Fever, tachypnea, dyspnea, and nonproductive cough
- Chest x-ray shows diffuse or bilateral perihilar infiltrates
- Lymphopenia
- Low CD4 count below 200
Treatment and Prognosis: PCP
* What are the antibiotics?
* What happens if not treated?
* Prophylaxis of Bactrim is needed for who?
* What are other txts?
* Depending on immune state, mortality may reach what?
Complications of Pneumonia
* What is pleural effusion?
* Can compromise what?
- inflammation leads to exudation of fluid into pleural space
- can compromise lung function
Complications of Pneumonia
* What are absecess/cavitary lession?
- circumscribed focus of liquefactive necrosis within lung tissue
- associated with necrotizing Staph or Strep infections or Gram-neg rods (e.g. aspiration)
Quick Associations to know!
Step pneumoniae
* What is the freq, sputum color and organism morpology?
* What does the x-ray look like?
Quick Associations to know!
Legionella:
* What are the symptoms?
* What are the contaminated sources?
* Its common to see these patients returning from what?
Quick Associations to know!
Klebsiella pneumoniae
* What is it associated?
* What type of sputum?
* What does the x-ray look like?
Quick Associations to know!
Mycoplasma pneumoniae:
* Who is it common in?
* Referred to as what?
* What is common symptom?
* What type of hemolysis?
* What does the x-ray look like?
Quick Associations to know!
Haemophilus influenzae
* Common in who?
* _ abuse
* The leading cause of what?
* What does the x-ray look like?
What is this?
Elevated Hemidiaphragm
under slide: Could be due to enlarged liver
Bilateral Paralysis (systemic disorder)
* Patients have marked what?
* What is markedly decreased?
* Usually due to what?
* What is the management?
Under slides: NIP, PIP – neg/pos inspiratory pressure – they will have both decreased NIP/PIP.
Pleuritic chest pain-Parietal Pleura
* Somatic sensory innervation: What is the cervical and costal pleura inn by? What about mediastinal pleura? What about diaphragmatic pleura?
Pleuritic chest pain-Visceral Pleura
* Sensory fibers only detect what?
* Do not detect what?
* Autonomic nerve supply from what?
Pleuritic chest pain
* Which pleura does and does not contain sensory nerve endings for pain?
Pleural Fluid
* Produced by what?
* Absorbed by what?
* This is a collection of fluid between what?
* Fluid also drains from what? Returns from what?
* What is created in the pleural space?
* Under normal circumstances in the body, what is presented?
Pleural Effusion
* The problem arises when?
- The problem arises when too much fluid accumulates between the linings - this is termed a pleural effusion.
fill in
What are the two types of pleural effusions? why does it happen?
- Transudate
- Exudate
Pleural effusion
* Exudative fluid turns into what when pus is noted?
* Pus most commonly from what?
* If that fluid has a ph <7.2 then it now becomes what?
Exudative fluid turns into an empyema when pus is noted.
* Collection of pus most commonly from bacterial pneumonia.
* If that fluid has a ph <7.2 then it now becomes complicated and needs chest tube drainage.
Pleural Effusion
* What causes serous (hydrothorax)
* What causes blood (hemothorax)
* What causes pus (empyema or pyothorax)
* What causes chyle (chylothorax)
Pleural Effusion
* What happens in the noraml breath?
* Increased pressure in the vasculature of the lungs may cause what? What does this prevent?
* Build-up of fluid presses on the lung, making it difficult to do what?
* What finally happens to the lungs?
Causes of Pleural Effusion: empyema
* What is in the pleural space?
* What type of infection?
* What needs to be done?
* What can be present?
* Penetrating _
* Empyema necessitatis?
Causes of Pleural Effusion: hemothorax
* What is in the pleural fluid?
* from what? (3)
Causes of Pleural Effusion: Chylous effusion ⭐️⭐️
* Instead of normal pleural fluid, it’s what?
* Caused by what?
* What type of effusion?
* High in what?
* Can be caused by what?
* What is a syndrome that can occur?
Causes of Pleural Effusion: Chyliform effusions
* Low in what?
* high in what?
* Uncommon, develops after what?
* What is it due to?
Evaluation: pleural effusions
* What does the history show?
* What does the physical show?
Diagnostic testing for pleural effusion: Chest X-Ray
* What does it show?
* What is required for upright films? What about lateral? ⭐️
Diagnostic Testing: pleural ultrasound
* requires what?
* Can help guide what?
* It is especially good to look for what?
- Requires at least 3 ml of fluid to be identifiable
- Can help guide interventional procedures
- It is especially good to look for loculated effusions.
What is the most sensitive imaging for pleural effusion? How much fluid do you need?
Indications for Thoracentesis
* New or old finding?
* Question the need for what?
* However, what has not response to diuresis?
* Likely indicated in most patients with what?
* Thoracentesis may be what?
* US is used in what?
Pleural Fluid Analysis
* Performed through what?
* What are the levels you need to look for? (3) If any of those levels are level then what must you do? If all of them are normal then what do you do?
Transudate
* Why does it happen?
Exudate:
* Why does it happen?
Pleural Fluid Tests-protein
* Most transudates have what?
* What level can be a possible Tuberculous pleural effusion?
* What level can it be to consider Waldenström’s macroglobulinemia and multiple myeloma?
Pleural Fluid Tests-LDH ⭐️⭐️⭐️
* >1000 IU/L characteristically found in what?
* Pneumocystis jirovecii pneumonia: What is the are the ratio measures?
* Urinothorax: What are the levels measures?
Pleural fluid TESTS: glucose ⭐️
* All other exudates have what?
* All transudates =
Exudative Effusion
* What does culture/stain show?
* What is the glucose level?
* What is the cytology show?
* What is the ph?
Malignant Effusions
* What are the clinical features?
* What are the most common cancers?
* What does the pleual fluid show?
EXUDATIVE EFFUSIONS
fill in⭐️
Fill in ⭐️
BEYOND THORACENTESIS: Pleural biopsy
* Most helpful in evaulaing for what? ⭐️⭐️
* Limited unility for what?
* What might be helpful?
BEYOND THORACENTESIS: Thoracoscopy
* Most helpful in evaluating for what?
Treatment
* pleural effusions?
* Hemithorax involved empyema?
* Malignant effusion?
What are the indications for chest tube?
Mediastinitis
* What is it?
* most common cause of what?
* What are other causes?
Operative Risk Factors for Mediastinitis?
Mediastinitis: What are the clinical findings?⭐️
Mediastinitis: What are more clinical findings?
* What sign is present?⭐️
Microbiology of Mediastinitis
* What bacteria is present?
What is the txt of Mediastinitis?
Esophageal Perforation
* What are some causes?
Pneumo-mediastinum 2nd to Ruptured Esophagus
* What does x-ray show?
* What does the patient present with?
- Radiographic hallmarks include mediastinal widening, air in mediastinal, pneumo-or hydropneumothorax
- Patient usually presents with neck pain & subcutaneous emphysema as most common perforation site is at level of crico-pharyngeal muscle
