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Clin Med IIB Pulmonology > Lower Respiratory Infections: Part 2 - Pneumonia > Flashcards

Lower Respiratory Infections: Part 2 - Pneumonia Flashcards

1
Q

What is the MC cause of death?

A

Pneumonia

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2
Q

What is the MC reason for hospitalization? Second MC?

A

MC = CHF
Second MC = Pneumonia

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3
Q

What is pneumonia?

A

Inflammation of

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4
Q

How is the pathophys of pneumonia different in bacteria vs viruses?

A

Pneumonia has a lung consolidation, otherwise same pathophys

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5
Q

What is the MC of pneumonia?

A

Strep pneomo (like 95%)

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6
Q

Why do you classify pneumonia and how do you base this?

A

Allows you to know what likely caused it.

Should know the anatomic location\
The mechanism of acquisition
Setting of acquisition

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7
Q

What is the MC anatomic location of pneumonia?

A

Lobar pneumonia
Specifically Right lower lobe S. pneumoniae

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8
Q

When do you see Klebsiella?

A

Upper lobe of alcoholic

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9
Q

When do you see Legionella?

A

Lower lung fields in someone exposed to shower

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10
Q

What do you see in CXR of lobular/bronchopneumonia?

A

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

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11
Q

What typically causes lobular/bronchopneumonia

A

S aureus and other bacteria

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12
Q

What is interstitial pneumonia?

A

Non-productive cough
Focal diffusive
Bilateral, symetrical

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13
Q

What differentiates lobar, bronchopneumonia, and interstitial pneumonia?

A

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

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14
Q

What patients are likely to have aspiration pneumonia?

A

Stroke victims
Swallowing issues
Alcoholics
GERD

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15
Q

What is the MC location of aspiration pneumonia?

A

RLL but RUL can be seen in alcoholics

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16
Q

What is the pathophys of AP?

A

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

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17
Q

What is ventilator associated pneumonia and the concern?

A

ET or tracheal tube

Multidrug resistance is very common

Need to do empiric therapy

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18
Q

What are the MCC organism of ventilator associated pneumonia?

A

Staph auerus (MC)
pseudomonas
ascinetobacter

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19
Q

Pathophys of VAP

A

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

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20
Q

What is community acquired pneumonia and when does it occur? What if this is not the case?

A

CAP Develops in the outpatient setting or within 48 hours of admission to a hospital

All other pneumonia is concerned nosocomial

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21
Q

What are the Nosocomial Acquired Pneumonias and how do they differ?

A

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

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22
Q

What setting is CAP typically treated?

A

Outpatient

23
Q

What is the MCC of CAP?

A

Strep pneumo

other bacteria are mycoplasma, H flu, klebsiella, staph aureus

Viruses: RSV, Parainfluenza, adenovirus

24
Q

What are the sputum for for S pneumo, pseudomonas, klebsiella, aneorbic?

A

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

25
Q

What are the symptoms of pneumonia?

A

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

26
Q

What is the temperature of some1 w/ pneumonia?

A

Hyperthermia (typically >38°C) or hypothermia (<35°C)

27
Q

What is the PE of PNA?

A

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

28
Q

What is the dx diagnosis of PNA?

A

CXR
Can look at CT if it is inconclusive

29
Q

How do you find the causitive organism for PNA?

A

CULTURE

30
Q

If hospitalized (not outpatient) what labs do you order for PNA?

A

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

31
Q

What is good about the Urinary antigen tests forS pneumoniae andLegionella

A

High specificity and

32
Q

What is the #1 lab abnormality in PNA?

A

Abnormal WBC with left shift

33
Q

How to determine inpatient or outpatient treatment?

A

PSI (more accurate) or CURB-65 (easier)

34
Q

What is the CURB 65 criteria?

A

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

35
Q

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?

A

1 = outpatient (RR = 30)

36
Q

How long should ABX be given for CAP?

A

At least 5-7 days AND additional 48 hours after pt becomes afebrile

37
Q

In addition to ABX for pneumonia, what should you do?

A

Rest, hydration
Analgesics (acetaminophen or ibuprofen)
Expectorants
Steroids (still being studied but showing positive effects)

38
Q

If no comrobidities, no ABX w/in the last three months, what do you use? (avg patient)

A

Amoxicillin
Azithromax (often have resistance though)
Doxy

39
Q

If a patient has been treated with ABX the last 3 months or comorbitdiy?

A

Azithromax plus amoxicillin, augmentin, ceftriaxone,

OR

fluroquinolone

40
Q

check over other management of pneumo

A

ok

41
Q

What 3 factors differ nosocomial from CAP?

A

(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

42
Q

What is the MCC of nosocomial PNA? How does this differ from CAP?

A

S pneumo, but we are worried about drug-resistant

43
Q

What are the s/s of nosocomial PNA?

A

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

44
Q

For nosocomial PNA, what do you start on?

A

empiric abx

45
Q

What is kelbsiella seen in?

A

Typically alcoholics

46
Q

What are the s/s of klebsiella?

A

Same as other pneumonia, but red jelly sputum

47
Q

What do you see in CT of klebsiella

A

Ground glass opacities (100%)
Alveolar consolidation
Intralobular reticular opacities
Pleural effusions

48
Q

What is the typical patient with staph pneumonia?

A

COPD patients w/ MRSA

49
Q

How does is staph pneumo differ in CXR?

A

Typically in multiple areas and not one

50
Q

What are the features of mycoplasma?

A

Asymptomatic
Mild cough
Clear CXR

Macrolides
Fluroquinolnes

51
Q

Can viral pneumonia lead to bacterial?

A

Yes, if there is mucous production, bacteria can grow here

52
Q

When do you see pneumocystis Jiroeci

A

HIV patients
Elevated LDH (lactate-dehydrogenase)

53
Q

What is the halmark of CXR and CT of pneumocystis jiroveci?

A

CXR - diffuse, bilateral interstitial infiltrates
CT scan - Hallmark ground glass opacities

54
Q

How do you treat pneumocystis jiroveci?

A

ART initiated if not already
Trimethoprim-sulfamethoxazole (Bactrim)
Prophylaxis
CD4 counts below 200 cells/mcL

Clin Med IIB Pulmonology (12 decks)

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