Mod 6 Pneumonia Flashcards
1
Q
what is Pneumonia is commonly characterized as?
A
An infection within the lung parenchyma caused by bacteria, viruses, or fungi (micro bacteria being the most common)
- causes inflammatory response that impairs normal alveolar function (gas exchange)
- pus/fluid buildup in the lungs further impairs gas exchange
2
Q
Why does pneumonia affect immunocompetent patients differently in comparison to immunospressed?
A
Immunocompetent are more suspectible to pathogens leading to:
- Inflammation of the alveoli
- alveolar consolidation
Severe immunosuppression makes pts more prone to
- Atelectasis (particularly in aspiration pneumonia)
- A combo of weak ciliary clerance, thick secretions, and blunted immune response
- Secretions/pathegns accumlate more
3
Q
List 3 classifications of pneumonia
A
- Communities acquired pneumonia [CAP]
- Nosocomial pneumonia
- pneumonia in the immunocompromised host
4
Q
Which pneumonia phenotype is community acquired?
A
CAP
5
Q
which pneumonia phenotype is acquired in the hospital?
A
nosocomial pneumonia
6
Q
which phenotype of pneumonia can be acquired in all settings?
A
pneumonia in a immunocompromised host
7
Q
What demographic group/range is most affected by community acquired pneumonia?
A
Most common in children > 5, becomes progressively more common from age 40 peaking in the elderly.
common w/those w/diseases
- COPD
- Chronic heart disease
- Chronic renal disease
8
Q
What are 2 types of immune dysfunction predisposed (liable) to pneumonia?
A
Both are types of adaptive immunity that use WBCs to protect the body from pathogens
- Humoral immune dysfunction (fast)
- Cell-mediated immune function (longer)
9
Q
Main trait of humoral immune dysfunction?
A
Immunoglobulin deficiencies; basically a lack of antibodies so a crappy immune response
- B cells normally produce antibodies that bind to antigens to get rid of extracellular pathogens: should normally be a fast response
10
Q
Cell-mediated immune function can be characterized by?
A
Events that compromise the immune response
Cancer chemotherapy, organ transplantation, bone marrow transplantation
- Cell mediated immunity uses T cells to destroy cells and stimualtes others to get rid of pathogens
11
Q
What are some clinical manifestations of CAP?
A
Abrupt onset of symptoms like:
- cough
- dyspnea
- pleuritic chest pain
- general symptoms w/infection
and
Abnormalities on physical examination
- i.e hypotension, abnormal breath sounds, or tachycardia etc. etc.
12
Q
What are general symptoms associated w/infection?
broad question don’t worry too much about this one
A
- Shivers
- Malaise (discomfort)
- Myalgia or Arthralgia (muscle vs joint pain/stifness)
- Headache
- Palpitations
- Diarrhea
- Neurological symptoms such as confusion
13
Q
What are the most severe illness/pathogens that causes pneumonia?
A
- Streptococcus pneumoniae
- Legionella
- Staphylococcal pneumonia
- gram-negative infections
14
Q
What phenotype of pneumonia is the most common?
hint its bacterial
A
Streptococcus pneumonia; the most common cause of severe illness and death
15
Q
What is the most common viral cause of CAP?
A
Influenza
16
Q
When is Staphylococcal infection most likely to occur?
A
Following influenza virus infection and IV drug users
17
Q
Where would Legionella outbreaks typically happen/occur?
A
Typically due to water aerosol sources; like showers.
18
Q
mycoplasma pneumonia causes mild illness in which age demographic?
A
Most common between ages 5-17, mild cases under 5
- Causes resp tract infections via resp droplets via coughing and sneezing
19
Q
What is humoral immune deficiency associated with?
A
Bacterial infection
20
Q
What are cell mediated immune defects typically associated with/caused by in pneumonia?
A
viral and fungal infections
21
Q
How would you assess CAP?
i.e Parameters and criteria?
edit refer to slide 15
A
- Severity Assessment; Identifies pts w/risk of mortality w/increasing intensified monitoring and therapy
- CxR
22
Q
How should organ dysfunction be evaluated for community acquired pneumonia [CAP]?
A
[AMA/Infectious Diseases Society of America minor criteria]
- Confusion
- Uremia (declining renal function)
- RR ≥ 30bpm
- Hypotension
- PaO2/FiO2 ≤250
- Multilobar infiltrates
- Leukopenia (insufficient leukocytes/low wbc)
- Thrombocytopenia
- Hypothermia
23
Q
Are CxR’s useful for assessing pneumonia?
A
Yes; They’re essential to confirm new lung shadowing
24
Q
What are characteristics on a CxR that would suggest community acquired pneumonia?
A
Shadowing conforms to lobar pattern
- associated with air bronchograms
- may occupy less than a whole lobe and be patchy, multulobar, and bilateral
- may include pleural effusion, less commonly a pneumothorax as well
- lower lobes are not typically affected
25
Community acquired pneumonia [CAP] management inside the hospital setting?
**Correction of gas exchange and fluid balance**
- Oxygen therapy
- Diuretics
- Fluid management
*Appropriate antibiotics*
26
Community acquired pneumonia [CAP] management outside the hospital setting?
- Rest
- Fluids
- Oral antibiotics
27
Community acquired pneumonia [CAP] oxygen therapy goas?
SpO2 > 92%
- high flow nasal cannula
28
Community acquired pneumonia [CAP] management:
- If there is unacceptable rise of PaCO2, what are your next steps?
Mechanical ventilation should be considered
29
Why is intubation preferred over NIV when pneumonia is suspected?
*follow up w/mike to confirm*
**More precise control** of the Pts breathing and airway management.
- **Easier suctioning of the airway**, especially when there is an accumulation of secretions or mucus in the airways.
30
What is a typical range for duration of antibiotics?
5-7 days in uncomplicated cases.
31
what is the time frame of greatest risk for worsening organ function because of Community acquired pneumonia [CAP]
Risk of Organ failure can occur within **the first 72 hour**
32
How often should a pt w/Community acquired pneumonia [CAP] be re-evaulated?
QD
33
Ask someone about these values: slide 21
34
What is the most preventable risk for pneumonia?
Smoking
35
Community acquired pneumonia [CAP] prevention
- which demographic group is indicated for influenza and pneumococcal vaccination
The elderly and those w/chronic illness
36
Hospital acquired pneumonia [HAP] is defined as?
Pneumonia that occurs > 45hrs after admission that was not incubating at the time of admission.
37
Ventilator acquired pneumonia [VAP] is defined as
pneumonia that arises 48-72hrs after intubation
38
What 2 classifications of pneumonia can be acquired in this same place/time?
HAP and VAP
39
General risk factors of Hospital acquired pneumonia [HAP]
**Age (extremes)**
- Pts < 35 = less prone than elderly
**Type of hospital**
- Teaching hospitals > rural bc of pt complexity
**Type of ward**
- Most common in ICU
40
What are the main sources of Hospital acquired pneumonia [HAP]?
- Healthcare devices
- Environment
- Transfer of microorganisms between pt and staff.
- oropharyngeal and gastric colonization w/subsequent aspiration of their contents into the lungs in pts w/impaired immune system
41
What are risk factors for the development of Hospital Acquired pneumonia [HAP]?
**Host Related**
- nutritional status
- Immunosuppressive treatments
- unplanned extubation
- deep breathing and cough exercises
42
what are environment related risks for health care acquired pneumonia [HAP]
Attention to infection control measures
43
What are some risk factors associated with devices/treatment when considering hospital acquired pneumonia [HAP]?
Use of sedatives and paralytics (should min use)
- gastric overdistension
- intubation/re-intubation
- soiled vent. circuits
- continuous aspiration of subglottic secretions
44
what are the main causes of **gram-negative bacterial pathogens** as risk factors of hospital acquired pneumonia [HAP]?
*don’t waste time on this one if strapped on time*
Streptococcus, Staphylococcus aureus and MRSA account for 35-39% of all cases
other common pathogens:
Klebsiella, Acinetobacter, Pseudomonas aeruginosa, and E.
45
What are treatment therapies for hospital acquired pneumonia [HAP]?
1. admin antibiotics
2. Resp. related treatment
- keep SpO2 > 92% on high flow nasal cannula
- If not enough, intubate -> mech. ventilation
46
ventilator acquired pneumonia [VAP] prevention/precautions/treatments?
- gloves + gown for ETT manipulation
- elevation of [HOB] between 30 - 45 degrees
- provide oral care [Chlorhexidine]
- minimize vent circuit changes if possible
- Ensure cuff pressure
47
Why is cuff pressure important to keep vent. circuits below the level of the mouth?
Prevents condensate draining into the ETT
48
Why is it important to ensure cuff pressure?
prevent micro aspirations
49
Generally, what is aspiration pneumonia?
pneumonia associated w/aspiration of food and gastric contents.
- anaerobic bacterial infection
50
why could aspiration pneumonias be missed?
inflammatory reaction requiring 12-24 hrs to peak
51
What are aspiration pneumonia pts at risk of?
Developing ARDS
52
What are 3 phenotypes of aspiration pneumonia?
1. Toxic injury to lungs (chemical pneumoitis)
2. Obstruction (by fluids/foreign bodies)
3. Infection
53
Aspiration of food is (district from stomach acid) can lead to the formation of what?
- Obliterative bronchiolitis [popcorn lung]
- Granuloma formation
**generally, inflammation?**
- confirm later
54
How does pneumonia w/Immunocompromised hosts differ from CAP or HAP?
Immune status vs. Acquisition
55
pneumonia Immunocompromised hosts is defined as relevant risk for
**opportunistic pathogens**
- fungi
- viruses
- mycobacteria
- parasites
**insert slide 33**
56
Pneumocystis Jirovecii Pneumonia can present with how many possible symptoms?
At least one of the following:
- Fever
- Cough
- Dyspnea on exertion
- Oral candidiasis is typically present
57
Pneumocystis. Jirovecii Pneumonia can occur in pts w/ what helper T cell count?
< 200 CD4 helper T cells per microliter
58
what is the following CxR?
(slide 37)
Pneumocystis Jirovecii pneumonia
59
How does pneumocystis jirovecii pneumonia typically present on a CxR?
Discloses bilateral infiltrates in a perihilar distribution.
Looks like typical pneumonia
60
How is pneumocystis jirovecii pneumonia typically diagnosed?
1. Bronchoalveolar Lavage
2. Sputum sample if not intubated or ventilated
61
Treatment plans for pneumocystis jirovecii pneumonia?
1. Pentamidine (anti-infective agent)
2. Septra (combo antibiotic) sometimes paired w/steroids in pts with acute resp. failure.\
62
Pneumocystis jirovecii pneumonia typically coexists with what complication?
Cytomegalovirus
63
What is a key management step for pneumonia
Severity assessment
64
Is pneumonia restrictive or obstructive
Restrictive
65
Define Nosocomial pneumonia
Hospital acquired pneumonia- from immunocompetent individuals
S. aureus, Pseudomonas, other enteric gram-negative rods
**Arises >48 hours after hospital admission**
66
Define Community Acquired Pneumonia (CAP)
any pneumonia that results from contagious infection outside of a hospital or clinic
Usually from an Immunocompetent individual
67
Define Community Acquired Pneumonia (CAP)
any pneumonia that results from contagious infection outside of a hospital or clinic
Usually from an Immunocompetent individual
68
Comorbidities of Community Acquired Pneumonia [CAP]
COPD
bronchiectasis
Chronic heart disease
Chronic renal diseas
69
What are the two types of immune dysfunction processes?
1. Humoral immune dysfunction
2. Cell-mediated immune dysfunction
70
Humoral immune dysfunction
Immunoglobulin deficiencies (IgE , IgG.)
- Antibodies
Associated with bacterial infection
71
Cell-mediated immune dysfunction
T cells decrease because of immunosuppressants
- From chemotherapy, organ transplantation, bone marrow transplant.
- Associated with **viral and fungal infections (opportunistic infections)**
72
Causes of Cell-mediated immune dysfunction
- T cells decrease because of immunosuppressants
- Form chemotherapy, organ transplantation, bone marrow transplant.
Associated with viral and fungal infections (opportunistic infections)
73
Pathogens associated with CAP
**Streptococcus pneumoniae (Most common)**
- Most important cause of severe illness and death
Legionella
- Staphylococcal Pneumoniae
- Gram-negative infections
74
GOLD standard for CAP diagnosis
Chest X-ray
74
GOLD standard for CAP diagnosis
Chest X-ray
75
Where is fluid buildup normally seen on the CXR for Community acquired pneumonia [CAP]?
In the lower lobes (West zone III)
fluid will go to the gravity dependent areas
76
What things do we judge for the:
Severity assessment for CAP
Confusion
Uremia
RR > 30bpm
Hypotension
P/F <250
Multilobular infiltrates
Leukopenia
Thrombocytopenia
Hypothermia
77
How often to you reevaluate the stability of the patient w/pneumonia?
at least once per day
do all vitals, LOC, ability to eat..etc
78
Main CAP prevention?
smoking cessation
79
Pathogen that is main causative of HAP?
[2]
- Gran-negative bacterial pathogens (pseudomonas aeruginosa)
- Staphylococcus aureus (MRSA)
80
Most important tx of HAP
prompt administration of appropriate antibiotics
get that C+S sputum sample ASAP!
81
Treatment of VAP
- Hand hygiene
**- HOB elevation 30-45 degrees**
assessment fo readiness fo extubate
Oral care
- circuit changes with circuit is dirty
- ETT maintenance (cuff pressure)
- daily sedative interruptions
81
Treatment of VAP
- Hand hygiene
**- HOB elevation 30-45 degrees**
assessment fo readiness fo extubate
Oral care
- circuit changes with circuit is dirty
- ETT maintenance (cuff pressure)
- daily sedative interruptions
82
Describe typical traits and causal agents of Aspiration pneumonia
- can occur when a foreign substance, such as vomit, is inhaled into the lungs
-takes 12-24 hours to peak
- patients with this are at an increased risk of ARDS
83
3 distinctive forms to aspiration pneumonia
- Toxic injury to the lung (chemical- damage done by the acid itself)
- Obstruction
- Infection
Bonus:
Aspiration of food can lead to calcified granulomas (high density spots)
84
Most common infection of pneumonia in the immunocompromised host
Pneumocystis Jirovecii
84
Most common infection of pneumonia in the immunocompromised host
Pneumocystis Jirovecii
85
Which Diagnostic would best indicate pneumonia in the immunocompromised
History
Physical examination
**CXR**
- Blood work and sputum sample
- Bronchoscopy for those with bilateral infiltrates
86
What is the HAP mortality rate?
30-70%
87
Common pathogens for HAP include?
Gram-negative bacteria:
- **Pseudomonas aeruginosa
- E. Coli
- Streptoccous pneumoniae
88
Is bacterial or viral pneumonia more severe?
Bacterial is usually more severe than viral, viral often resolves on its own
89
What’s the difference between viral and bacterial pneumonia?
All pneumonia is inflammation caused by an infection in the lungs. Bacterial tends to be more common due its location of acquirement (hospital).
- Bacterial pneumonia needs antibiotics to be treated, viral presents with flu symptoms which resolve on their own
