Lung infections

Question 1

Acute bronchitis usually due to ___? It’s clinical course is ___? Post infectious cough occurs ___? CXR appears ___?

Answer 1

viruses
self resolving
3-8 weeks after infection resolves
normal

Question 2

In chronic bronchitis you have ____ mucus production and change of ___? Why? How is air flow reduced? CXR?

Answer 2

increased
character of sputum

increased mucus production/decreased clearance

increased mucus production and inflammation

unchanged/normal

Question 3

Mucus production and chronic inflammation in chronic bronchitis may lead to ___?

Answer 3

permanent lung damage

Question 4

chronic bronchitis management

Answer 4

bronchodilators
corticosteroids
antibiotics

Question 5

What PFTs are decreased in chronic bronchitis?

Answer 5

FEV1 and VC

Question 6

What do you see on a lung exam for chronic bronchitis?

Answer 6

crackles, ronchi, wheezing

Question 7

describe the common infection in chronic bronchitis. What are the most common organisms?

Answer 7

bacterial colonization of tracheobronchial tree

H influenza
S pneumonia
M catarrhalis

Question 8

when is the flu considered infectious?

Answer 8

one day before -> 7 days after illness onset

Question 9

When do you treat the flu empirically ASAP?

What are the two medications used to treat and what is their effect?

Answer 9

• underlying chronic conditions
• pregnancy
• very young (65)

Tamiflu (oseltamivir)(pill) and Relenza (Zanamivir)(inhaled)
Most effective if given within 2 days after onset
Reduce severity of symptoms and length of illness by 1 day

Question 10

Pneumonia CXR

Answer 10

Filling of airways with pus and inflammation

Question 11

What are the clinical features of pneumonia and when do they present?

Answer 11

Acute presentation: within 2 weeks
Fever, chills
Dyspnea
Purulent sputum
Hemoptysis (possible)
Pleuritic chest pain 
Tachypnea/tachycardia

Question 12

Pneumonia lung exam findings

Answer 12

Rales

Occasional pleural rub

Question 13

How do the clinical features of pneumonia differe in elderly patients

Answer 13

Fever occurs mainly in younger pop
Confusion
Cough and sputum production may be absent

Question 14

What is CAP? Which organisms are most common? Which present atypically?

Answer 14

Community acquired pneumonia
S. Pneumonia
H influenza

Atypically:
M pneumonia
C pneumonia
L pneumophilia

Question 15

How do you decide whether to hospitalize or not?

Answer 15

CURB-65

Confusion
Uremia (BUN> 20)
Respiratory (RR>/30)
Blood pressure (systolic // old age

Get a point for each one
0- low risk
1- consider Rx at home

Consider hospitalization 2 points (or close out pt)
Hospitalize
3- hospitalize
4,5- hospitalize, ICU

Question 16

Pneumonia APs. what are the nosocomial ones? Define them.

Answer 16

CAP

Nosocomial:
HCAP- occurs 48 hours or more after admission
->hospitalized for at least 2 days within 90 days of the infection
->received IV, chemo or wound care 30 days prior to infection

VAP- occurs 48 - 72 hours after ventilation

Question 17

HCAP most common microbio

Answer 17

S aureus
Pseudomonas
Klebsiella
Enterobacter

Question 18

VAP

Answer 18

‘ESKAPE’

Enterobacter
S aureus
Klebsiella
Acinetobacter
Pseudomonas 
Enterococcus

Question 19

Pneumonia treatment. Follow up CXR after how long?

Answer 19

Find out what type of pneumonia you are dealing with and treat accordingly ASAP
-> prognosis influenced by how fast antibiotics are started

Outpatient CAP:

• most commonly, azithromycin and levaquin
• doxy given less often, not effective against atypical so

In patient:

• for CAP: ceftriaxone+azithromycin or levaquin even alone
• Nosocomial: vancomycin + coverage for pseudomonas

Follow up CXR 6 - 8 weeks after initial to make sure pneumonia is clearing

Question 20

Note the possible source of pneumonia: GI sxs, bradycardia, confusion, liver and renal manifestations

Answer 20

Legionella

Question 21

Note the possible source of pneumonia: Post-influenza

Answer 21

S Auereus

Question 22

Note the possible source of pneumonia: Aspiration

Answer 22

Mouth anaerobes

Question 23

Note the possible source of pneumonia: Alcoholism

Answer 23

Aspiration (mouth anaerobes), gram -

Question 24

Note the possible source of pneumonia: Sickle cell disease

Answer 24

Encapsulated organisms

Question 25

Note the possible source of pneumonia: HIV+

Answer 25

Pneumocystis, tb, ‘typicals’

Question 26

Note the possible source of pneumonia: Recent immigrant, incarcerated

Answer 26

TB

Question 27

Note the possible source of pneumonia: cystic fibrosis

Answer 27

Most often pseudomonas, S aureus

Question 28

Bronchiectasis. How is a diagnosis established?

Answer 28

Abnormal dilatation and desctruction of the bronchial walls

Clinically and radiographically

Question 29

Clinical features of bronchiectasis. PE/Lung exam findings

Answer 29

Similar features with COPD:

• dyspnea
• cough with sputum, hemoptysis

Crackles>Ronchi>wheezing
Clubbing

Question 30

Bronchiectasis microbio; Lady Windermere syndrome microbio

Answer 30

gram negs more often isolated in sputum

S aureus less common

Lady windermere syndrome: middle lobe bronchiectasis and mycobacterium avium complex infection due to voluntary cough suppression

Question 31

Cystic fibrosis

Answer 31

Autosomal recessive
Abnormal CFTR gene on long arm of chromosome 7
- gene codes for CL- channel on epithelial cells

Defect: decreased Cl- permeability -> dehydration of secretions

Question 32

CF diagnostic criteria

Answer 32

Family history
Positive sweat test (Cl- >60 mEq/L)
Chronic obstruction to airflow
Exocrine pancreatic insufficiency

Question 33

Acute bronchitis microbio

Answer 33

H flu
Strep pneumonia
M pneumonia

Question 34

CF manifestations

Answer 34

Pulmonary disease
Nasal polyps 
Pancreatic insufficiency 
Glycosuria 
Intestinal symptoms 
Cirrhosis 
Heat prostration

Question 35

CF treatment

Answer 35

Mucolytics 
Postural drainage physiotherapy 
Anti inflammatory
Bronchodilators 
When needed - antibiotics 
Gene therapy on the rise