Lower Respiratory Infections: Part 2 - Pneumonia Flashcards
What is the MC cause of death?
Pneumonia
What is the MC reason for hospitalization? Second MC?
MC = CHF
Second MC = Pneumonia
What is pneumonia?
Inflammation of
How is the pathophys of pneumonia different in bacteria vs viruses?
Pneumonia has a lung consolidation, otherwise same pathophys
What is the MC of pneumonia?
Strep pneomo (like 95%)
Why do you classify pneumonia and how do you base this?
Allows you to know what likely caused it.
Should know the anatomic location\
The mechanism of acquisition
Setting of acquisition
What is the MC anatomic location of pneumonia?
Lobar pneumonia
Specifically Right lower lobe S. pneumoniae
When do you see Klebsiella?
Upper lobe of alcoholic
When do you see Legionella?
Lower lung fields in someone exposed to shower
What do you see in CXR of lobular/bronchopneumonia?
Radiographically identified by its patchy appearance, with peribronchial thickening and poorly defined air-space opacities
The pathogens known to cause this pattern of pneumonia are particularly destructive
Frequently lead to abscesses, cavitation, necrosis and pleural effusions
What typically causes lobular/bronchopneumonia
S aureus and other bacteria
What is interstitial pneumonia?
Non-productive cough
Focal diffusive
Bilateral, symetrical
What differentiates lobar, bronchopneumonia, and interstitial pneumonia?
Lobar
Involves single lobe
Unilateral
Middle age - 20-50
Primarily a healthy adult
95% pneumococcal
Limited by anatomic boundaries
Bronchopneumonia
Central bronchi involved
Asymmetrical
Peribronchial cuffing
Extremes of age
Secondary, in sick
S aureus, Strep sp, P aeruginosa, Klebsiella, H flu
Patchy, basal, bilateral around small bronchi
Not limited by anatomic boundaries
Interstitial Pneumonia
Involves interstitial space
Ground glass appearance
Bilateral, symmetrical
What patients are likely to have aspiration pneumonia?
Stroke victims
Swallowing issues
Alcoholics
GERD
What is the MC location of aspiration pneumonia?
RLL but RUL can be seen in alcoholics
What is the pathophys of AP?
Aspiration of gastric content or bacteria enter lung
Inflammatory response
Cavity extend to bronchus
Abscess become encapsulated
Tissues necrotize
Increase production of sputum
Purulent sputum
What is ventilator associated pneumonia and the concern?
ET or tracheal tube
Multidrug resistance is very common
Need to do empiric therapy
What are the MCC organism of ventilator associated pneumonia?
Staph auerus (MC)
pseudomonas
ascinetobacter
Pathophys of VAP
Endotracheal tube placed
Impaired natural protection/clearance system
Contamination/colonization with bacteria
Aspiration of microorganisms into the lungs directly through the ET tube or around the cuff
Lungs contaminated with microorganisms
What is community acquired pneumonia and when does it occur? What if this is not the case?
CAP Develops in the outpatient setting or within 48 hours of admission to a hospital
All other pneumonia is concerned nosocomial
What are the Nosocomial Acquired Pneumonias and how do they differ?
HealthCare Associated Pneumonia (HCAP)
Pneumonia that develops within the first 48 hours of admission to the hospital, meaning it likely developed in an outpatient setting
Hospital Acquired Pneumonia (HAP)
Pneumonia that develops at least 48 hours after admission to a hospital
Ventilator Associated Pneumonia
Pneumonia that develops more than 48 hours after endotracheal intubation or within 48 hours of extubation
What setting is CAP typically treated?
Outpatient
What is the MCC of CAP?
Strep pneumo
other bacteria are mycoplasma, H flu, klebsiella, staph aureus
Viruses: RSV, Parainfluenza, adenovirus
What are the sputum for for S pneumo, pseudomonas, klebsiella, aneorbic?
S pneumoniae- rust-colored sputum
Pseudomonas,Haemophilus and other pneumococci - green sputum
Klebsiella- red currant-jelly sputum
Anaerobic infections - foul-smelling or bad-tasting sputum
What are the symptoms of pneumonia?
Fever (80% of cases)
Dyspnea (45 - 70% cases)
Pleuritic chest pain (30% cases)
Sweats
Chills (40 - 50% cases)
Rigors (15% cases)
Pleurisy
Hemoptysis
Fatigue
Myalgias
Anorexia
Headache
N/V/D
Mental status changes
What is the temperature of some1 w/ pneumonia?
Hyperthermia (typically >38°C) or hypothermia (<35°C)
What is the PE of PNA?
Febrile
Hyperthermia (typically >38°C) or hypothermia (<35°C)
Tachypnea (>24 bpm)
Use of accessory respiratory muscles
Tachycardia or bradycardia
Central cyanosis
Altered mental status
Tracheal deviation
Lymphadenopathy
Adventitious breath sounds, such as rales/crackles, rhonchi, or wheezes
Decreased intensity of breath sounds
Egophony
Whispering pectoriloquy (over consolidation)
Dullness to percussion
Pleural friction rub
What is the dx diagnosis of PNA?
CXR
Can look at CT if it is inconclusive
How do you find the causitive organism for PNA?
CULTURE
If hospitalized (not outpatient) what labs do you order for PNA?
Outpatient management of patients with CAP does not require any additional testing
Hospitalized patients benefit from the following:
Sputum gram stain and culture
NP swab / PCR
Blood cultures
CBC
CMP
ABG (if hypoxemic)
Influenza testing if suspected
Urinary antigen tests forS pneumoniae andLegionella
Thoracentesis with pleural fluid analysis, gram stain and culture
Procalcitonin / CRP - Increased in bacterial infections and septic shock
Bronchoscopy
What is good about the Urinary antigen tests forS pneumoniae andLegionella
High specificity and
What is the #1 lab abnormality in PNA?
Abnormal WBC with left shift
How to determine inpatient or outpatient treatment?
PSI (more accurate) or CURB-65 (easier)
What is the CURB 65 criteria?
Clinical prediction of mortality in CAP and infection of any site
C - Confusion of new onset
U - Blood Urea nitrogen greater than 7 mmol/l (>19 mg/dL)
R - Respiratory rate of >=30 breaths per minute
B - Blood Pressure systolic <90 mmHG or diastolic <60 mmHG
Age ≥ 65 years
Death risk of 30 days increases as the score increases
2 or more = hospitalized
A 45 year-old male presents to the ER today with a one week history of cough, shortness of breath, fever and extreme fatigue. His past medical history includes a history of coronary artery disease in which he has had a stent placed, and hypertension that is somewhat controlled.
Patient is alert and oriented to person, place and time.
Vital signs include BP- 100/80, P - 100, T - 38 C, Resp - 30
Physical Exam reveals diminished breath sounds over the right lower lobe and dullness over this area as well
Chest X-Ray reveals some consolidation in the right lower lobe
Labs are normal with the exception of a blood sugar of 200
What is his CURB-65?
1 = outpatient (RR = 30)
How long should ABX be given for CAP?
At least 5-7 days AND additional 48 hours after pt becomes afebrile
In addition to ABX for pneumonia, what should you do?
Rest, hydration
Analgesics (acetaminophen or ibuprofen)
Expectorants
Steroids (still being studied but showing positive effects)
If no comrobidities, no ABX w/in the last three months, what do you use? (avg patient)
Amoxicillin
Azithromax (often have resistance though)
Doxy
If a patient has been treated with ABX the last 3 months or comorbitdiy?
Azithromax plus amoxicillin, augmentin, ceftriaxone,
OR
fluroquinolone
check over other management of pneumo
ok
What 3 factors differ nosocomial from CAP?
(1) Different infectious causes
(2) Different antibiotic susceptibility patterns, specifically, a higher incidence of drug resistance
(3) Different underlying health status of patients putting them at risk for more severe infections
What is the MCC of nosocomial PNA? How does this differ from CAP?
S pneumo, but we are worried about drug-resistant
What are the s/s of nosocomial PNA?
Acute progression of signs and symptoms similar to CAP
Cough, predominantly with purulent sputum, is most common
Fever
Rigors
Myalgias
Signs of hypoxemia
Hemoptysis
Dyspnea and/or respiratory distress
Physical exam findings same as for CAP, only may appear more acutely ill
For nosocomial PNA, what do you start on?
empiric abx
What is kelbsiella seen in?
Typically alcoholics
What are the s/s of klebsiella?
Same as other pneumonia, but red jelly sputum
What do you see in CT of klebsiella
Ground glass opacities (100%)
Alveolar consolidation
Intralobular reticular opacities
Pleural effusions
What is the typical patient with staph pneumonia?
COPD patients w/ MRSA
How does is staph pneumo differ in CXR?
Typically in multiple areas and not one
What are the features of mycoplasma?
Asymptomatic
Mild cough
Clear CXR
Macrolides
Fluroquinolnes
Can viral pneumonia lead to bacterial?
Yes, if there is mucous production, bacteria can grow here
When do you see pneumocystis Jiroeci
HIV patients
Elevated LDH (lactate-dehydrogenase)
What is the halmark of CXR and CT of pneumocystis jiroveci?
CXR - diffuse, bilateral interstitial infiltrates
CT scan - Hallmark ground glass opacities
How do you treat pneumocystis jiroveci?
ART initiated if not already
Trimethoprim-sulfamethoxazole (Bactrim)
Prophylaxis
CD4 counts below 200 cells/mcL
