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Lectures 1-3 Flashcards

1
Q

What is the pulmonary interstitium?

A

Network of tissue that extends throughout both lungs, including alveolar epithelium, basement membrane, pulmonary capillary endothelium

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2
Q

What does the pulmonary interstitium proved support to?

A

The alveoli and capillary beds for gas exchange

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3
Q

Can the pulmonary interstitium normally be seen on CXR or CT?

A

No, because it is so thin

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4
Q

What happens to the alveoli in idiopathic pulmonary fibrosis?

A

There is fibrosis between alveoli which greatly decreases gas exchange

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5
Q

What is restrictive lung disease?

A

Abnormalities along the interstitium

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6
Q

What is a PFT or pulmonary function test?

A

Non-invasive tests that measure how well the lungs are expanding and contracting and how efficient the exchange of CO2 and oxygen are between the blood and air within the lungs

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7
Q

What are some different types of PFTs?

A

Lung volumes, spirometry, spirometry before and after a bronchodilator, and diffusion capacity for carbon monoxide (DLCO)

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8
Q

What is the lung volume?

A

A measure of air in L or mL

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9
Q

What is the total lung capacity?

A

The volume of air in the lungs after maximal inspiration (includes residual volume)

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10
Q

What is the lungs vital capacity mean?

A

The maximum volume of air that can be exhaled after a maximal inspiration

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11
Q

What is the tidal volume?

A

The volume of air moved in and out during each breath

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12
Q

What is the residual volume?

A

Volume of air remaining in the lungs after a maximal expiration

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13
Q

“Measure of breath”

A

Spirometry

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14
Q

Spirometer

A

An instrument for measuring the air capacity of lungs

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15
Q

What is the most common type of PFT?

A

Spirometry

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16
Q

Spirometry measure the volume of air exhaled (after max inhalation) at specific time points during a forceful and complete _____

A

Exhalation

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17
Q

What are the three important variables generated by spirometry?

A

FVC, FEV1, and their ratio: FEV1/FVC

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18
Q

The value found from spirometry are graded against what?

A

A predicted value

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19
Q

What are the predicted values from spirometry pooled from?

A

Data on a large number of “normal” individuals: no hx of lung disease, no respiratory symptoms, normal CXR, normal EKG

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20
Q

What can help diagnose and differentiate between obstructive lung disease and restrictive lung disease?

A

Spirometry

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21
Q

Spirometry is an important tool is assessing what?

A

Asthma, COPD, cystic fibrosis, pulmonary fibrosis

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22
Q

FVC is what?

A

Maximum amount of air exhaled after a maximal inhalation

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23
Q

What if the FVC is low?

A

THe problem may be a restrictive disorder

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24
Q

FEV1 is what?

A

The amount of air exhaled in the 1st second

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25
Q

What may a reduced FEV1 indicate?

A

Obstructed or narrowed airways

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26
Q

Most people are able to expel __% of their vital capacity in one second

A

70%

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27
Q

The FEV1/FVC ratio is used to identify what?

A

Airflow obstruction (if <70% of predicted)

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28
Q

What can flow volume loops be used for?

A

Strider or unexplained dyspnea

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29
Q

What does a flow volume loop consist of?

A

Forced inspiratory and expiratory maneuver

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30
Q

If the FEV1/FVC ratio is less than 70%, what can that indicate?

A

Obstructive pattern

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31
Q

What diseases are considered obstructive?

A

COPD, asthma

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32
Q

If the FEV1/FVC ratio is >70%, what does that mean?

A

Could be normal or restrictive disease

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33
Q

FEV1 over 70% predicted is (ATS criteria)

A

Mild obstruction

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34
Q

FEV1 60-70%

A

Moderate obstruction

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35
Q

FEV1 50-60%

A

Moderately severe obstruction

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36
Q

FEV1 35-50%

A

Severe obstruction

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37
Q

FEV1 <35% predicted

A

Very severe obstruction

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38
Q

If the DLCO is decreased, what type of obstructive disease can that signify?

A

Emphysema

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39
Q

If the DLCO is normal, which obstructive disease can it be?

A

Chronic bronchitis

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40
Q

If the DLCO is normal or increased, what type of obstructive disease can it be?

A

Asthma

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41
Q

If the DLCO is decreased, what type of restrictive disease can it be?

A

Parenchyma disease

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42
Q

If the DLCO if normal, what type of restrictive disease can it be?

A

Non-parenchymal (chest wall) restriction

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43
Q

the FEV1/FVS ratio will be decreased in which type of lung disease?

A

Obstructive lung disease

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44
Q

THe FVC will be decreased in what type of lung disease?

A

Restrictive lung disease

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45
Q

The DLCO measure what?

A

The overall function of the alveolar-capillary membrane

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46
Q

DLCO can be used to differentiate the etiology of what?

A

Restrictive lung disease

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47
Q

If the DLCO is low it could be due to what?

A

Interstitial lung disease

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48
Q

If the DLCO is normal, can be due to what?

A

Extrathoracic cause of restriction-obesity, chest wall disorder, neuromuscular disorder

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49
Q

Restrictive disease will show what results from a PFT?

A

FEV1/FVC ratio: normal
TLC: low
DLCO: Low

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50
Q

Obstructive disease will show what results from a PFT?

A

FEV1/FVC ratio: Low
FEV1: 46%
Pre vs Post BD: 12% increase
DCLO: Low

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51
Q

The inability to completely fill lungs with air

A

Restrictive pulmonary disease

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52
Q

What is restrictive pulmonary disease characterized by?

A

Reduced lung volumes

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53
Q

Unlike obstructive lung disease, restricted disease are associated with what?

A

A decreased total lung capacity

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54
Q

What are the two divisions of restrictive pulmonary disease?

A

Intrinsic and extrinsic

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55
Q

What are intrinsic restrictive pulmonary diseases?

A

Disease of the lung parenchyma, inflammation or scarring of lung tissue

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56
Q

What are some examples of intrinsic restrictive pulmonary disease?

A

Idiopathic fibrotic disease, pneumoconioses, and sarcoidosis

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57
Q

What are extrinsic restrictive pulmonary diseases?

A

Extra-pulmonary disease involving the chest wall, pleura, and respiratory muscles

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58
Q

What are some examples of extrinsic restrictive pulmonary disease?

A

Obesity, myasthenia gravis , ALS, kyphoscoliosis

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59
Q

What medications can induce interstitial lung disease?

A

Amiodarone, Methotrexate, and Nitrofurantoin

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60
Q

What is the most common diagnosis amount patients with interstitial lung disease?

A

Idiopathic fibrosing interstitial pneumonia

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61
Q

What is the overall prognosis for idiopathic fibrosing interstitial pneumonia?

A

Poor

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62
Q

Potential risk factors for idiopathic fibrosis interstitial pneumonia

A

Smoking, occupational exposure (stone, metal, wood, organic dusts), GERD (due to micro-aspiration)

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63
Q

Clinical features of idiopathic fibrosing interesting pneumonia

A

Insidious dry cough, extensional dyspnea, fatigue, tachypnea

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64
Q

What can be found on physical exam for idiopathic fibrosing interstitial pneumonia

A

Clubbing and inspiratory rales (crackles)

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65
Q

What other pulmonary disease is clubbing common in?

A

Cystic fibrosis, AV fistula, idiopathic pulmonary fibrosis, asbestosis, and malignancies of the lung and pleura

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66
Q

What GI diseases can clubbing be seen in?

A

Chron’s, cirrhosis, ulcerative colitis, and esophageal cancer

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67
Q

What will the PFTs show for idiopathic fibrosing interstitial pneumonia

A

Reduced FVC
Normal or elevated FEV1/FVC ratio
Reduced DLCO
Impaired 6 min walk

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68
Q

Radiographic findings for idiopathic fibrosing interistitial pneumonia

A

CXR: increased reticular markings (IPF, CHF)
CT: diffuse patchy fibrosis with pleural based honeycombing

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69
Q

The diagnosis for idiopathic fibrosing interstitial penumonia can be made based on what?

A

Basis of a characteristic presentation (symptomatology in combo with CT imaging)

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70
Q

What is a more definitive way to diagnose idiopathic fibrosing interstitial pneumonia?

A

Lung biopsy, can help rule out other possible causes as well

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71
Q

What types of supportive care can be given to someone with idiopathic fibrosing interstitial pneumonia?

A

Supplemental home oxygen, vaccinations (flu and pneumo), OP pulmonary rehab programs

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72
Q

What are some medication options for patients with idiopathic fibrosing interstitial pneumonia?

A

Nintedanib: a tyrosine kinase inhibitor

Pirfenidone (Esbriet): an anti-fibrotic drug

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73
Q

What are some surgical options for pts with idiopathic fibrosing interstitial pneumonia?

A

Lung transplant

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74
Q

What are the qualifications for a lung transplant?

A

Age <65
Free of substance abuse (smoking, drugs)
Acceptable BMI range of 20-29

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75
Q

“Occupational lung disease”

A

Pneumoconioses

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76
Q

What is pneumoconioses?

A

Groups of interstitial lung diseases caused by the inhalation and deposition of inorganic particles and mineral dust with subsequent reaction of the lung

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77
Q

Clinically important pneumoconiosis include:

A
  1. Coal worker’s pneumoconiosis
  2. Silicosis
  3. Asbestosis
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78
Q

“Black lung disease”

A

Coal workers pneumoconioses

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79
Q

What is the milder form of coal workers pneumoconioses?

A

Anthracosis

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80
Q

What is coal workers pneumoconioses caused by?

A

Prolonged exposure to coal dust, which is inert and cannot be removed by the body

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81
Q

Leads to inflammation, fibrosis, and sometimes necrosis

A

Coal worker’s pneumoconisoes

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82
Q

What are some symptoms for coal workers pneumoconioses?

A

Chronic cough, fever, and dyspnea on exertion usually develop 10-15 years after exposure

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83
Q

Radiographic findings for coal worker’s pneumoconioses

A

Small, rounded, modular opacities with a preference for the upper lobes

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84
Q

The nodular opacities in coal workers pneumoconioses tend to go where?

A

Upper lobes

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85
Q

What is coal workers pneumoconioses irreversible

A

When larger opacities with progressive massive fibrosis start to occur

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86
Q

What is silica?

A

Silicon dioxide (SiO2)

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87
Q

Silica is commonly found in nature as what?

A

Quartz

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88
Q

What are some uses for silica?

A

Glass, optical fibers porcelain, sand casting

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89
Q

Silicosis

A

Spectrum of pulmonary disease caused by inhalation of crystalline silica

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90
Q

What occupations are commonly effected by silicosis?

A

Mining, masonry, glass manufacturing, foundry work, and sandblasting

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91
Q

What are the various clinical stages of silicosis?

A

Acute chronic, and accelerated silicosis

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92
Q

What is the clinical presentation of silicosis?

A

Cough, dyspnea, sometimes fever or pleuritic chest pain

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93
Q

Evaluation of silicosis consists of what?

A

PFTs:
FEV1: decreased
DLCO: decreased
FEV1/FVC ratio: normal

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94
Q

Radiographic findings of acute silicosis

A

CXR/CT: bilateral, diffuse, ground glass opacities

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95
Q

Radiographic findings of chronic silicosis

A

CXR/CT: small, innumerable, rounded densities

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96
Q

The clinical diagnosis of silicosis is based on 3 key elements:

A
  1. History of silica exposure
  2. Chest imaging consisting with silicosis
  3. Absence of any other diagnosis
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97
Q

What else can be done to diagnose silicosis?

A

Lung biopsy if the diagnosis cannot be made clinically

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98
Q

What are some treatment options for silicosis?

A

Avoid further exposure and supportive care, steroid therapy? Lung transplant

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99
Q

What are some associated complications with silicosis?

A

Mycobacterium infection, aspergillosis, lung cancer, chronic kidney disease

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100
Q

Asbestos

A

Group of naturally occurring fibrous composed of hydrated magnesium silicates used for variety of construction and insulating purposes

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101
Q

Asbestosis

A

Pneumoconiosis caused by inhalational asbestos fibers

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102
Q

What occupations can be effected by asbestosis?

A

Plumbers, construction, shipbuilding, railways, laborers, carpenters, electricians

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103
Q

Clinical presentation of asbestosis

A

Dyspnea on exertion, cough, weight loss

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104
Q

How long are you asymptomatic with asbestosis?

A

Atleast 20-30 years after initial exposure

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105
Q

What can be seen on physical exam for asbestosis?

A

Inspiratory crackles, clubbing

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106
Q

What will the PFTs show for asbestosis?

A

Vital capacity: reduced
Total lung capacity: reduced
DLCO: low

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107
Q

Radiographic findings of asbestosis

A

CXR: thickened pleural and calcified pleural plaques
CT: course honeycombing (in advanced disease), hazy ground glass appearance of peripheral pleural surface

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108
Q

What is needed to diagnose asbestosis?

A

Hx of exposure, chest imaging consistent with asbestosis, absence of any other diagnosis, bronchoalveolar lavage

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109
Q

What are some treatment options for asbestosis?

A

Avoid further exposure, supportive care, steroid therapy, smoking cessation

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110
Q

What is a complication of asbestosis?

A

Malignant mesothelioma

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111
Q

Sarcoidosis

A

Multisystem granulomatous disorder of unknown etiology

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112
Q

What systems are effected with sarcoidosis?

A

Lungs, lymph nodes, eyes, skin, liver, spleen, heart, nervous system, but approximately 90% of pts have lung involvement

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113
Q

What is the characterizing pathology of sarcoidosis?

A

Non-caseating granulomas

114
Q

What population if sarcoidosis more common in?

A

Young black women and northern European whites

115
Q

Clinical presentation of sarcoidosis

A

Cough, progressive worsening dyspnea, atypical chest discomfort, fever/night sweats, weight loss

116
Q

Evaluation of sarcoidosis

A

Serum blood tests, ACE levels, ESR are non-diagnostic

117
Q

Radiographic findings of sarcoidosis

A

CXR: bilateral hilar adenopathy
CT: right paratracheal lymphadenopathy along with bilateral diffuse reticular infiltrates

118
Q

What is a term used to describe the radiographic findings of sarcoidosis?

A

Sarcoid galaxy sign

119
Q

What is needed to diagnose sarcoidosis?

A

Endobronchial US guided biopsy (EBUS), cervical medastinoscopy, VATS lung biopsy

120
Q

What type of lung disease has caseating granulomas?

121
Q

What are some treatment options for sarcoidosis?

A

Close observation for asymptomatic pts, 90% are responsive to a tapering course of oral corticosteroids over 4-6 weeks

122
Q

Restrictive lung diseases are characterized by what?

A

Reduced lung volumes, low TLC, FVC and DLCO

123
Q

Lung transplants may be a viable option for pts with what?

A

End stage IPF and sometimes silicosis

124
Q

Treatment options are limited for restrictive lung disease except what?

A

Sarcoidosis

125
Q

Inflammation of the large airways of the lungs

A

Acute bronchitis

126
Q

Acute bronchitis is self limited to how long?

A

About 1-3 weeks

127
Q

What microbes can cause acute bronchitis?

A

Influenza A&B, parainfluenza, RSV, coronavirus, rhinovirus, adenovirus

128
Q

What are some clinical manifestations of acute bronchitis?

A

Persistent cough 1-3 weeks (w or w/out sputum), low grade fever, wheezing, mild dyspnea, rhonchi-clears with cough, chest pain

129
Q

What are some reasonable indications to order a CXR on someone with acute bronchitis?

A

Tachycardia, tachypnea, fever, hypoxia, dementia, rales, egophony, tactile fremitus, MS changes in pts >75

130
Q

When should a sputum sample be ordered?

A

Unlikely to help with acute bronchitis, unless suspicion for TB

131
Q

PCT

A

Procalcitonin-in health individuals is below the level of detection

132
Q

PCT for acute bronchitis

A

Rises in response to pro inflammatory stimulus especially of BACTERIAL origin

133
Q

What can PCT be an indicator for?

A

Sepsis or pneumonia

134
Q

If the PCT value is <0.25mcg/L

A

Discourage Abx use

135
Q

If the PCT is >0.25mcg/L

A

Encourage Abx use

136
Q

What are the possible treatment for acute bronchitis?

A

Pt education (no Abxs), antitussives, bronchodilators +/-

137
Q

Who should albuterol be used for?

A

Acute bronchitis with wheezing or comorbidities

138
Q

What OTC cough meds can be used for acute bronchitis?

A

Devtromethorphan (DM) and Guaifenesin

139
Q

Dextromethorphan

A

Cough suppressant (Nyquil, Mucinex, Robitussin) in high doses produces similar effects to ketamine and PCP

140
Q

Guaifenesin

A

Expectorant: DayQuil, Mucinex, Robitussin, Guiatuss

Usually used with codeine, dextromethorphan, pseudoephedrine, acetaminophen

141
Q

Rx cough meds used for acute bronchitis

A

Robissutin AC: Guaifenesin with Codein

Tessalon pearles: benzonatate

142
Q

What is a non-narcotic cough suppressant

A

Tessalon Pearles

143
Q

What is a resp illness that affects upper and lower respiratory tracts?

144
Q

Influenza is accompanied by what?

A

Systemic signs and symptoms, sudden onset

145
Q

Influenza is associated with what

A

Morbidity and mortality in certain high-risk populations

146
Q

Who can get complications of influenza?

A

Pregnant women, children, >65, comborbidities

147
Q

What microbes are responsible for influenza?

A

Orthomyxoviridae family, type A B and C

148
Q

What are the further subtypes of influenza?

A

H surface hemagglutinin

N neuraminidase antigens

149
Q

Type A has how many H and Ns?

A

16 H subtypes and 9 N subtypes

150
Q

What are the 3 major subtypes that affect humans?

A

H1, H2, H3, N1 and N2

151
Q

What occur annually and result in outbreaks of variable extent and severity?

A

Antigenic drifts

152
Q

What do antigenic drifts result from?

A

Point mutations in the RNA gene segments

153
Q

Clinical manifestations of influenza

A

Sudden onset, HA, fever, myalgia, cough, sore throat

154
Q

What is used to diagnose influenza

A

Rapid antigen tests, type A and B, nasopharyngeal swabs, immunofluorescence staining, respiratory swab

155
Q

What test is the most sensitive and specific for influenza?

A

Nuclei acid tests- RT-PCR takes 4-6 hours, can differentiate types and subtypes

156
Q

What neuraminidase inhibitors can be used to treat influenza?

A

Zanaminivir (Relenza) inhalation, Oseltamivir (Tamiflu), Peramivir (Rapivab) IV

157
Q

What adamantane agents can be used to treat influenza?

A

Amantadine (Symmetrel) anti-Parkinson’s agent, no longer recommended
Rimantadine (Flumadine) not approved

158
Q

Current influenza vaccines are what?

A

Trivalent or quadrivalent

159
Q

Trivalent vaccine

A

Contains two influenza A virus antigens and one influenza B virus antigen

160
Q

Quadrivalent influenza vaccine

A

Contains two influenza A antigens and tow influenza B antigens

161
Q

Individuals >65 high dose of which vaccine is recommended?

A

Trivalent (FluZone)

162
Q

Tuberculosis microbes

A

Mycobacterium tuberculosis, mycobacterium africanum and mycobacterium bovis

163
Q

What are major contributors to resurgence of TB?

A

Drug resistance, poverty, HIV

164
Q

What are some risk factors for TB?

A

Substance abuse, HIV, nutritional status, household contact, community setting, low SE status, minority

165
Q

How is TB transmitted?

A

Person-to-person via inhalation of droplet nuclei (airborne particles 1-5 microns in diameter)

166
Q

What are some factors associated with the risk to TB transmission

A

Presence of active untreated pulmonary or laryngeal disease, presence of cavitary disease, presence of sputum + for m.tuberculosis AFB

167
Q

What are some risky procedures that can cause transmission

A

Endotracheal intubation, bronchoscope, sputum induction, chest PT, administration or aerosolized rugs, irrigation of TB abscess, autopsy on cadaver

168
Q

What are the 4 things that can happen once you inhale the droplets of m.tuberculosis

A
  1. Immediate clearance of organism
  2. Primary diseasE: immediate onset of active disease
  3. Latent infection
  4. Reactivation disease: onset of active disease many years following a period of latent infection
169
Q

The greatest risk for progression to active disease happens when?

A

In the first 2 years after infection

170
Q

What are the clinical manifestations of primary disease (TB)

A

Fever-most common, fatigue, arthralgias, cough 2-3 weeks, pharyngitis

171
Q

Latent disease (TB)

A

Asymptomatic, mild symptoms

172
Q

Reactivation of TB clinical manifestations

A

Weight loss, night sweats, anorexia, pleuritic or retro sternal chest pain

173
Q

What are some screening tools for TB?

A

TST, PPD, + supports diagnosis, but cannot be used to establish diagnoses

174
Q

What can interfere with TB screening?

175
Q

PPD reading will be positive if its >5mm for these people

A

HIV infected, recent contacts of TB case, persons with fibrotic changes on CXR consistent with healed TB, pts with organ transplants, immunosuppressed

176
Q

PPD reading will be positive if its >10mm for these people

A

Recent arrival to US from high prevalence countries, IVDAs, residents and employees of high-risk congregate settings, mycobacteriology lab personnel, kids under 5,

177
Q

PPD reading will be positive if its >15mm with who?

A

Everyone else

178
Q

What else can be used to diagnose TB?

A

Sputum-either spontaneous or induced, acid-fast bacilli stain, mycobacterium culture, nuclei acid amplification (NAA)

179
Q

What are the 2 major types of interferon gamma release assays available to diagnose TB?

A

QuantiFeron-TB Gold and T-SPOT TB

180
Q

What are the interferon gamma release assays (IGRAs) testing?

A

Immune response to M.tuberculosis, preferred for pts with hx of BCG vaccine

181
Q

What are the goals fo TB treatment?

A

Eradication, prevent transmission, prevent relapse, prevent development of drug resistance

182
Q

What is used to treat TB?

A

Isoniazid, Rifampin, Pyrazinamide, Ethambutol, +/- Streptomycin

183
Q

What is the intensive phase of TB management?

A

4 drugs: Isoniazid, Rifampin, Pyrazinamide, Ethambutol used for 2 mos, taken on empty stomach, need baseline LFTs

184
Q

What type of follow-up care is needed for someone during the intensive phase of TB treatment?

A

Repeat CXR and AFB smear and CX, then monthly after that to asses clinical response

185
Q

What 2 drugs are used in the continuation phase of TB?

A

Isoniazid and Rifampin for 4 additional months

186
Q

When can the continuation phase of TB management be stopped?

A

Until 2 consecutive negative cultures

187
Q

What is the treatment for latent TB?

A

Isoniazid QD 9 mos

Rifampin QD 4 mos

188
Q

MDR-TB

A

Multi drug resistant TB-resistant to atleast isoniazid and rifampin and possibly other chemotherapeutic agents

189
Q

XDR-TB

A

Extensively drug-resistant TB resistant to atleast isoniazid, rifampin and atleast 1 of 3 injectable 2nd line drugs capreomycin, kanamycin, or amikacin

190
Q

Definition of pneumonia

A

Inflammatory condition off the lung affecting predominantly the alveoli

191
Q

What is the pathophys behind pneumonia?

A
  1. Micro-aspiration of organism
  2. Defect in host defense system
  3. Virulence of the organism
192
Q

What is the most common cause of community acquired pneumonia? (CAP)

A

Bacterial pneumonia

193
Q

What are the 5 classifications of pneumonia

A
  1. CAP
  2. Healthcare Associated Pneumonia (HCAP)
  3. Hospital Acquired Pneumonia (HAP)
  4. Ventilator Acquired Pneumonia (VAP)
  5. Aspiration Pneumonia
194
Q

What is community acquired pneumonia? (CAP)

A

Non-hospitalized patient without extensive health care contact

195
Q

What is healthcare associated Pneumonia (HCAP)?

A

Non-hospitalized pt with extensive healthcare contact
Hospitalized in an acute care setting >48 hours last 90 days
Resides in NH or LTC
IV therapy, chemotherapy or wound care <30 days

196
Q

What is hospital acquired pneumonia (HAP)- nosocomial?

A

Pneumonia acquired while hospitalized after >48hours

Early onset <5 days vs late onset >5 days

197
Q

What is ventilator Acquired Pneumonia? (VAP)

A

48-72 hours after endotracheal intubation

198
Q

What is aspiration pneumonia?

A

Relatively large amount of material from the stomach or mouth entering the lungs

199
Q

Hospitalized in an acute care setting >48 hours last 90 days

A

Healthcare associated pneumonia (HCAP)

200
Q

IV therapy, chemo, or wound care <30 days

A

Healthcare associated pneumonia (HCAP)

201
Q

Early onset <5 days vs late onset >5 days

A

Hospital acquired pneumonia (HAP)

202
Q

48-72 hours after endotracheal intubation

A

Ventilator acquired pneumonia

203
Q

What are the most common etiologies of pneumonia?

A

Bacterial* and viral

204
Q

Which types of microbes can effect the immunocompromised? (Pneumonia)

A

Fungus- cryptococcus, histoplasmosis, coccidiodes, aspergillus, pneumocystis jirovecii
Parasites-toxoplasmosis

205
Q

What typical organisms cause bacterial CAP?

A

Strep pneumoniae #1

H.influenzae

206
Q

What atypical organisms cause bacterial CAP?

A

M.pneumoniae #2

C.pneumoniae

207
Q

What are the most common viral pathogens causing CAP?

A

Influenza*** RSV, adenovirus, rhinovirus, parainfluenza, coronavirus, severe acute respiratory syndrome (SARS), middle eastern respiratory syndrome (MeRs)

208
Q

What are some risk factors for CAP

A

Tobacco use, ETOH abuse, altered LOC, age, pulmonary disease, congenital heart disease, malnutrition, immunosuppression diseases and agents, sick cell disease

209
Q

Symptoms of pneumonia

A

Fever, productive or non productive cough, chills, pleuritic pain, hemoptysis, +/- HA, myalgia, body aches, nausea
Infants: poor feeding, restless

210
Q

What are some PE findings for pneumonia

A

Fever, rales/crackles, tachypnea, decreased breath sounds, asymmetric breath sounds, expiratory wheezing, hypoxemia, tachycardia, hypotension

211
Q

What are some typical manifestations for a legionella pneumoniae infection?

A

Diarrhea, abdominal pain, sore throat, congestion, cough, hyponatremia

212
Q

What are the patient characteristics for a klebsiella pneumoniae infection?

A

Alcoholics

213
Q

What is a great diagnostic tool for pneumonia?

A

CXR PA/Lateral

214
Q

Why is the clinical evaluation of pneumonia difficult?

A

No constellation of symptoms or signs that accurately predict CAP >50%; sensitivity and specificity of clinical evaluation for pneumonia is <50%

215
Q

What PE findings can be seen for pneumonia caused by influenza?

A

URI or flu-like symptoms rapid onset

216
Q

What PE findings can be seen for pneumonia caused by other viruses?

A

URI symptoms slow in onset (except flu); diffuse change in breath sounds

217
Q

What PE findings can be seen for pneumonia caused by M.pneumoniae?

A

Abrupt onset, myalgia, abdominal pain, OM, rash, conjunctivitis, sore throat

218
Q

What PE findings can be seen for pneumonia caused by legionella?

A

Abdominal pain, diarrhea, confusion, high fevers, recent travel

219
Q

What PE findings can be seen for pneumonia caused by bacteria?

A

Abrupt onset

220
Q

Sputum type for s.pneumoniae

A

Rust color

221
Q

Sputum type for atypical organisms

A

Non-productive, scant or watery

222
Q

Sputum type of Klebsiella

A

Hemoptysis of currant jelly

223
Q

What is the gold standard for diagnosis of pneumonia?

224
Q

What is the criteria for chest XRay of pneumonia?

A

> 1 of the following:
Temp >100, >100BPM, >20 RR
2 of the following:
Decrease breath sounds, crackles, absence of asthma

225
Q

What is a common CXR finding with strep pneumoniae?

A

Lobar: single lobe or segment/pattern

226
Q

Interstitial and peribronchial CXR findings for what?

A

Viral pneumoniae; PCP

227
Q

Necrotizing Pneumonia CXR findings for what?

A

Aspiration pneumonia, strep pneumoniae, GAS, S.aureus

228
Q

Caseating granuloma

229
Q

What else can be used to diagnose pneumonia?

A

CT scan of the chest, sputum induction

230
Q

CT scan for pneumonia

A

High sensitivity, expensive, high radiation exposure, utilize if will change treatment plan

231
Q

What has limited utility due to technical and patient issues?

A

Sputum induction

232
Q

Expectorated sputum specimens are recommended for hospitalized pts with any of the following criteria:

A

Admitted to ICU, Abx failure, cavitary lesion on CXR, active ETOH abuse, severe COPD or lung disease, immunocompromised host, epidemic pneumonia, pathogen of clinical interest

233
Q

What is a sterile technique obtained form 2-3 different sites using a straight stick?

A

Blood cultures

234
Q

Do all pts get blood cultures with pneumonia?

235
Q

What is the criteria for when to obtain blood cultures? (Pneumonia)

A

ICU admission/severe CAP, leukopenia, ETOH abuse, chronic severe liver disease, cavitary lesion on X-ray, pleural effusion, asplenia, positive pneumococcal urine antigen test (UAT)

236
Q

What organisms can the urine antigen test (UAT) pick up?

A

S. Pneumoniae, legionella

237
Q

What are the pros to the urine antigen test (UAT)?

A

Simplicity; good sensitivity; ability to detect after Abx administrations may stay + for weeks

238
Q

What are some cons for the UAT?

A

Cost; inability to perform susceptibility testing; detects only Legionella type 1; unsure if will change Abx management

239
Q

What organisms can the influenza antigen test for?

A

Influenza A and B

240
Q

What are some pros to the influenza antigen test?

A

Decrease Abx agents; identify for epidemiological purposes; high specificity

241
Q

What are some cons to the influenza antigen test?

A

Cost; high rate of false -; low sensitivity; not superior to physician judgement

242
Q

What organisms can the multiplex PCR test for?

A

M. Pneumoniae, C. Pneumoniae, B, Pertussis; 14 viruses (Influenza, RSV)

243
Q

What are the pros to the multiplex PCR?

A

Rapid quick detection

244
Q

What are the cons to the multiplex PCR?

A

Requires lab; high rate of false +; expense and availability

245
Q

What organisms can the serology test for?

A

C. Pneumoniae, M. Pneumoniae, Legionella

246
Q

What are the pros to the serology test?

A

Standard for diagnosis

247
Q

What are the cons for serology?

A

Not practical; must compare an acute phase vs convalescent serology; + serology may confer present or past infection

248
Q

What are some additional labs to check for pneumonia?

A

CBCD, BMP or CMP, lactic acid, CRP, pro-calcitonin

249
Q

What is needed to diagnose pneumonia OP?

A

Clinical, CXR, organism testing only if will impact Abx management

250
Q

What is needed to diagnose pneumonia as IP?

A

CXR, CBCD, BMP or CMP, +/- CRP, Sed rate or Lactic acid

251
Q

What is needed to diagnose pneumonia in ICU?

A

CXR, blood cultures, UAT Legionella and pneumococcal, sputum, CBCD, BMP, CMP, Lactic acid, +/-CRP or sed rate

252
Q

Macrolide are NOT used for what?

A

Blood, urine, or soft tissue infections

253
Q

What is the OP treatment for someone with pneumonia who was previously healthy and has had no use of antimicrobials within past 3 mos

A

Azithromycin; Clarithromycin; OR Doxycycline

254
Q

What is the OP treatment for pts with pneumonia with comorbidities; immunosuppression; or use of antimicrobials within past 3 mos

A 
Respiratory fluoroquinolone (Moxifloxacin or Levofloxacin) OR
Beta-lactam (Amoxicillin, Augmentin, Cefpodoxime, Cefuroxime) PLUS Macrolide/Doxycycline
255
Q

What is the inpatient, Non-ICU treatment for pneumonia?

A

Moxifloxacin, Levofloxacin IV +/- Glucocorticoids OR

Ceftriaxone, Unasyn IV PLUS Macrolide/Doxycycline +/- Glucocorticoids

256
Q

When can you transition form IV to oral Abx therapy for pneumonia?

A

Clinical improvement and afebrile after 48 hours, transition to similar class and complete treatment total 5-7 days

257
Q

When should the fever improve after start of meds for pneumonia?

A

Should improve within 72 hours

258
Q

Is the persistence of symptoms an indication to extend course of Abx?

259
Q

Routine follow up for pneumonia

A

CXR not indicated if improved clinically, if needed 7-12 weeks out

260
Q

Prevention of pneumonia

A

Smoking cessation, screen fo Influenza vaccine status, screen for pneumococcal vaccine status, at risk population: >65 YO, comorbidities or smoking

261
Q

What is the treatment for HAP/VAP early onset <5 days

A

Ceftriaxone OR Levofloxacin OR Unasyn

262
Q

What is the treatment for HAP/VAP late onset >5days and HCAP?

A

Cefepime OR Ceftazidime OR Meropenem OR Levofloxacin OR Zosyn PLUS
Vanco or Linezolid

263
Q

What are some risks for multip-drug resistant pathogens

A

Antimicrobials therapy in preceding 9 0-days, current hospitalization >5days, High requests of Abx resistance in community or specific hospital unit

264
Q

Definition of aspiration pneumonia

A

Relatively large amounts of material from the stomach or mouth entering the lungs

265
Q

Risk factors for aspiration pneumonia

A

Altered LOC, dysphagia, neurological disorder, mechanical disruption, protracted vomiting, general debility, gastroparesis, ileus

266
Q

What is the treatment for aspiration pneumonia?

A

Supportive IVF +/- ventilator support, +/0 glucocorticoids

267
Q

What is the treatment for aspiration pneumonia if it develops into an infection?

A

Clindamycin IV or Flagyl + Amoxicillin

268
Q

Opportunistic pneumonia microbes

A

TB, MAC, pneumocystis jirovecii, cryptococcus, cytomegalovirus, influenza, kaposi sarcoma, toxoplasmosis

269
Q

What is the most common opportunistic infection associated with AIDS/HIV

A

PCP pneumonia (pneumocystis jirovecii)

270
Q

PCP pneumonia

A

Dramatic decrease since onset of ART therapy and prophylactic therapy

271
Q

What are some risk factors for PCP pneumonia

A

Advanced immunosuppression, previous PCP, oral thrush, recurrent pneumonia, high plasma RNA

272
Q

Symptoms of PCP pneumonia

A

Gradual in onset days to weeks, fever, cough, dyspnea, fatigue, weight loss

273
Q

What are some signs for PC pneumonia?

A

Fever, tachypnea, crack les, Rhonchi, thrush, hypoxemia

274
Q

What labs can be used to diagnose PC pneumonia?

A

CD4 count, ABG, LDH, 1-3-beta-d-glucagon levees, induced sputum

275
Q

What imaging can be used for PCP pneumonia?

A

CXR- diffuse bilaterally interstitial alveolar infiltrates, CT, Gallium citrate scanning, DLCO

276
Q

What will the CXR how for PCP pneumonia?

A

Diffuse bilateral interstitial or alveolar infiltrates

277
Q

What will the CT scan show for PCP pneumonia?

A

Ground glass appearance

278
Q

What is the treatment for mild PCP pneumonia?

279
Q

What is the treatment for moderate PCP pneumonia?

A

TMP-SMX PLUS Prednisone

280
Q

What is the treatment for severe PCP pneumonia?

A

TMP-SMX PLUS Methylprednisolone

281
Q

What are some indications for antimicrobial prophylaxis of PCP?

A

CD4 count <200, oropharyngeal candidiasis, CD4 count % <14

282
Q

What are the prophylaxis options for PCP?

A

TMP-SMX, Dapsone, Atovaquone

Pulmonary (3 decks)

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