Lower Respiratory Infections Flashcards
what are some respiratory defense mechanisms the body has to prevent disease?
- upper airway?
- lower airway?
- specific to the alveoli?
upper airway
- structures: turbinates & glottis help to limit influx of pathogens
- reflexes: sneezing and coughing to remove pathogens
- normal flora: within the saliva, IgA
lower airway
- strucutres: the multiple branching patterns (liklihood of traveling ALL the way through the turns is lower) & the mucocilliary defense (beating the mucus up to expel the trapped pathogens)
alveoli
- the fluid lining the alveoli: contains lysosomes, fatty acids, IgG & surfactant
** normal immune function response of macrophages, PNM, lymphocytes also play a role**
Acute Bronchitis
- etiology
Bronchitis = infection of the bronchi
-
MAJORITY OF BRONCHITIS IS VIRAL!!!!!
- influenza a & b
- parainfluenza
- RSV
- coronavirus
- adenovirus - Bacterial Bronchitis (less common)
- mycoplasma pneumoniae
- chalymida pneumoniae
Acute Bronchitis
- clinical manifestations (signs and symptoms)
often –> the first few days it seems just like a URTI
symptoms
- KEY IS –> cough > 5 days
(sputum, hemoptysis, wheezing all possible)
- absence of constitutional symptoms (these would point towards pneumonia or flu)
- chest wall pain from the cough
remind pts. that the cough may last weeks even if they are getting better
signs
- URTI findings (can occur together)
- wheezing
- rhonchi on auscultation (cleared when the cough)
** rhonchi = snoore sound**
Acute Bronchitis
- diagnosis
- clinical diagnosis
- CHEST XRAY NOT NEEDED
it wont help you dx. UNLESS you are r/o pneumonia
if you do one –> it might look normal
Acute Bronchitis
- treatment
VIRAL
- self-limiting illness
BACTERIAL
- we dont rx. abx. (self-limiting)
- supportive measures
- NSAIDS
- inhaled SABA in adults +/- helpful (no kids)
DO NOT GIVE
- abx.
- central cough suppressants
- mucolytics
Bronchiolitis
- etiology
- population at risk
- risk factors
- treatment & prevention
infection and inflammation of the bronchioles
etiology
- RSV is most common
population at risk
- most common in kids under 2 years old
- hospitalizations occur in kids under 6 months
risk factors
- premature babies
- kids under 2 & kids with other respiratory issues (immunocomp.)
treatment
- supportive measures
prevntion
- for at risk kids can give pavlizumab during RSV season
PPP: symptoms of URI with low fever & respiratory distress (cough, wheeze, accessory muscle use, flaring, crackles, etc.)
Pertussis
- etiology
- population at risk
- symptoms (3 s’s for 3 stages)
- treatment
- prevention
etiology
- bordatella pertussis gram neg. bacteria
- extremely contagious
population at risk
- unimmunized individuals
- infants < 6 months
symptoms
1. prodromal phase
- catarrhal stage 1-3 weeks (sneezing, cough, runny nose)
- paroxysmal phase
- intermittent cough with whoop on inspiration
- cyanosis and sweating to accompany
- post-tussive emesis possible (adults) - convalescent phase
- cough for 4-6 weeks
- worse with activity
- worse with viral infections that come on
treatment
- macrolides (azithromycin) & treat contacts
- for infants less that 1 year – admit
prevention
VACCINE PREVENTABLE DISEASE!!!!
Pneumonia
- overview
- epidemiology
infection of the parencymal tissue in the lung
- the alveoli
- the interstitium
3 “flavors’”
- community acquired: within commnity or within first 48 hours of hospital
- hospital acquired: happens more than 48 hours after admitted
- ventilator acquired: on vent and acquired > 48 hours after
epidemiology
- 1/4 require hospital admission
- 4-5 cases/1000 people
- streptococcus pneumoniae is most common pathogen (CAP)
Pneumonia
- vaccine
4 types
PCV 13: for kids
PCV 15: kids or adults 65+ or adults 18+ with conditions
PCV 20: adults 65+ or adults 18+ with conditions
PCV 23: polysaccharide for specific populations of kids 2-18 with conditions or adults 19+ who got PCV 15
** ensure they also get flu and cvid vaccines too**
Pneumonia
- risk factors
- structural lung conditions
- COPD
- asthma
- pulmonary disease
- tobacco use
- viral pneumonia already
- obstruction - aspiration
- intubated
- swallow disorder
- stroke
- NG tube
- seizure
- alcoholism - Hematogenous
- bacteremia: spread from blood to lung
- indewelling device: spread - Extremes of age
- 65+ & under 3 - comorbidities
- DM
- renal and liver disease
- COVID - immunosuppresion
Communit Acquired Pneumonia (CAP)
- etiology
Bacterial
- most common = streptococcus pneumoniae
- H. flu
- m. catt
- staph. aureus
- group A strep
** Atypical**
- mycoplasma
- chalymida
- legionella
Viral
- influenza A & B
- parainfluenza
- RSV
** 50% of the time we do not know the pathogen because pts. are treated outpt. and we don’t culture**
CAP
- signs and symptoms
(percussion, fremitus & breath sound findings & adventicious sounds)
symptoms
- cough (productive usually)
** mucopurulent –> think typical pathogens**
** scant/watery –> think viral or atypical pathogens**
- fever, chills & fatigue
- pleuritic chest pain (hurts to inhale)
- dyspnea
- GI symptoms (kids)
- AMS (eldery)
signs
- fever
- tachypnea
- tachycardia
- rales (aka crackles)
- dull to percussion (fluid filled sound)
- increased fremitus (feel the vibrations more than you should)
- breathe sounds bronchial (because consolidation–air filled with something else), egophony( hear ee as ay)
CAP
- when to do xray
- chest xray findings
- other tests to consider
when to do xray (you think its pneumonia)
- abnormal vital signs (O2 low)
- consolidation findings on exam
- rales/crackles on exam
- elderly symptoms of pneumonis (may not have fever)
- if pt. is significantly dehydrated the inflitrates may not show up — hydrate them!!!
chest x-ray findings
- inflitrates in lobes
- silhouette sign + –> boarders of the heart are not well defined becuase of the infiltrates
other tests to consider
- sputum cultures
- blood culutres
- uriniary antigen for leginella or penumococcal
- ** only if severe CAP or exposure outbreak**
CAP
- treatment
- outpatient empiric
- outpatient empiric high risk
- note on floroquinolons
- consider the pathogen of infection
- healthy, young no abx use? –> typicals
- healthy, young? –> atypicals
- abx use, DM, burn pt? –> pseudomondas risk
- known MRSA or IVDU> –> MRSA
emperic therapy outpatient
-amoxicillin
- doxycycline
- macrolide if resistance < 25%
empiric therapy outpatient high risk adult
(those at risk for MRSA, pseudomonas, have comorbidities)
1 of these…
- amoxicillin-clavulanic acid
- cefuroxime
- cefotaxime
PLUS
1 of these – macrolide
- azithromycin
- clairythromycin
- doxycycline
could give floroquinolones monotherapy
- but tendon ruputure, resistance, neuropathy, QT prolong
treating pneumonia in kids
CAP
by age
< 1 month — inpatient
- ampucillin and gentamicin +/- cefortaxime
- if chalymida concern –> add erythromycin
1-3 months – probs. inpatient
- amoxicillin (or azythro.)
- chalymida concern –> add erythromycin
3montsh - 5 years
- amoxicillin
school aged
- ** macrolide**
Viral Pneumonia
- etiology
- symptoms
- exam findings
- x ray findings
- treatment
etiology
- flu a & b
- RSV
- adenovirus
- covid
- rhinovirus
- parainflu.
signs and symptoms
- cough (can be nonproductive)
- fever and constitutional
- JOINT AND MUSCLE PAIN
- dyspnea
exam findings
- fever
- generalized rails/rhonchi
xray findings
- PATCHY INFILTRATES
- lobar infiltrates are rare
treatment
- supportive measures onl
- if its flu –> treat with oseltamavir
Strep. Pneumo Pneumonia
- risk factors
- clinical signs (culutres)
- signs on x ray
risk factors
- chronic cardiac disease
- chronic pulmonary disease
- viral URI
- SMOKER
clincal signs
- sudden onset of sickness
- fever and rigor
- sputum: rust colored
x-ray findings
- lobar infiltrates
** treat like outpatinet CAP**
Staph Aureus Pneumonia
- risk factors
- clinical signs
- x ray findings
- treatment
risk factors
-MRSA risk
- previous URI or flu right before
- bactermia risk (indwelling, IVDU)
clinical signs
- gradual onset
- purulent sputum
x ray
- patchy multilobar infiltrates
- possible empyema or abcess (cavitary lesions)
treatment
- MSSA: antistaph. (naphcillin, oxicillin, flucloxicin)
- MRSA: vacomycin or linezolid
H. Flu Pneumonia
- risk factors
- clinical signs
- x ray findings
- treatment
risk factors
- elderly (pre-vaccine)
- COPD
- bronchiectasis
- CF
- not immunized
clincial signs
- graudal onset
- normal pneumonia symptoms
- sputum shows gram - coccobacilli
x ray
- pacthy infiltrates
- possible pleural effusion
treatment
- amoxicillin (if its not beta-lactamase producing)
- 2nd or 3rd ceph. or amoxicillin-clavulanate acid
mycoplasma pneumoniae pneumonia & chalymidophilia pneumoniae
- risk factors
- clinical signs
- x ray findings
- treatment
risk factors
- college, military or places of close contact
clinical signs
- they might appear ok – miniaml symptoms
- **headache and sore throat ** are specific (sore throat key for chalymida)
- bullous myrigitis
x ray findings – mycoplasma
- reticulonodular pattern
- pathcy areas of consolitations
x ray findings – chalymida
- patchy subsegmenatl infiltrates (in same segments)
treatment
- macrolides or tetracyclines
pseudomonas pneumonia
- population at risk
- chest findings
- treatment
population at risk
- immunocompromised
- recent abx use in 3 months
- cirrhosis
- ** structural lung disease (CF)**
- COPD exacerbations
** signs and sympomts appear same as normal CAP**
chest x ray findings
- diffuse bilateral infiltrates (bad looking)
- pleural effusion possible
- cavitation possible
treatment
- 2 fold
- 1. antipseudomonas penicillin
- 2. cipro or levo (fluroquinolones) OR aminoglycosides
klebsiella pneumoniae pneumonia
- risk factors
- clinical presentation
- x ray
- treatment
risk factors
- alcoholics
- DM
- severe COPD
clincal presentation
- red current jelly sputum
- productive cough with chills and fatigue
x-ray
- lobar infiltrates
treatment
- 3/4 gen. cephalosporins OR
- fluroquinolones OR
- carbapenems
anaerobic species pneumonia
- organisms
- risk factors
- clincial presentation
- x ray findings
- treatment
bugs
- fusobacterium
- prevotella
- porphyromonas
- peptostrepo.
risk factors
- predisposed to aspiration
- poor detition (these come from mouth flora)
clinical
- indolent sympomts (WL, fever, malaise)
- foul smelling sputum
x ray
- infiltrates in the dependent lower lungs
- cavitary lesions
- pleural effusions
treatment
- pipercillin-taz. or ampucillin -sulbact. (inpt cover pseudo.)
- amoxicillin-clav. (outpt.)
PCP pneumonia
- clincal
- x ray
- treatment
pneumocystis jirovecci
- hiv pts. or chronic immunosuppresion
- dry cough
- elevated LDH
x ray
- diffuse bilateral interstitial infiltrates
treatment
- bactrium
