PNA and influenza

Question 1

Define pneumonia

most common cause?

Answer 1

1) inflammation of parenchyma (alveoli)
2) accumulation of abnormal alveolar filling with fluid

caused by infection

Question 2

Why are lungs considered protective defenses?

Answer 2

1) lungs exposed to particulate matter and microbes in upper airway
2) lower airways organism free but NOT STERILE
3) MICROASPIRATION allows materials/microbes to enter lower resp tract

Question 3

Causes of infectious pneumonia (6)

Answer 3

1) inhalation of infectious particles ** (develops into CAP for Legionella/M tuberculosis)
2) inhalation of oropharngeal/gastric contents
3) hematogeneous spread (blood stream infectious)
4) infection from adjacent/contiguous structures
5) direct inoculation
6) reactiv

Question 4

Mechanism of pneumonia

Answer 4

1) decr host ability to fight against microbial pathogens
2) leads to impaired mechanical (cilia, mucous), humoral, and cellular host defenses

Question 5

Clinical presentation

Main symptoms of infectious pneumonia

Answer 5

1) infection = high fever, chills
2) skin = clammmy/blue = hypoxia/hypoxemia
3) pleuritic chest pain
4) Low blood pressure, high HR due to incr metabolims and incr vascular resistance due to fever
5) cough with sputum/phlegm
6) SOB

Question 6

Production of sputum vs. minimal sputum indicates what type of pneumonia

Answer 6

sputum = bacterial

minimal sputum = atypical vs viral

Question 7

Clinical history of pneumonia

Answer 7

1) elderly = atypical because may not have cough
2) atypical PNA = young patients (most common d/t fatigue)
3) Acute < 7 days, subacute 7-14, chronic > 14

Question 8

Risk factors for PNA

Answer 8

1) alcohol

2) HIV
3) welder/farmer/wood worker

4) mineral oil –> oil destroys cilia in airways
5) social factors
6) COPD
7) Drugs= IVDU (macrobid/nitrofurantoin/methotrexate)

Question 9

Vital signs of pneumonia

Answer 9

1) fever
2) tachypnea
3) tachycardia
4) hypoxia

Question 11

Pulmonary exam for pneumonia

Answer 11

1) crackles
2) rhonchi
3) bronchial breath sounds
4) egophony
5) dullness to percussion

Question 12

Tests to order for pneumonia

Answer 12

1) CXR
2) CBC
3) CMP
4) Blood gas/pulse ox

Question 13

Can radiographic features differentiate etiology of pneumonia?

Answer 13

RADIOGRAPHIC FEATURES ALONE CAN’T DIFFERENTIATE ETIOLOGY OF PNEUMONIA

NOT SUFFICIENT TO CONFIRM DIAGNOSIS

Question 14

What can fill alveoli?

Answer 14

Poor = pus

Funny = fluid

Boy = blood

Can’t = cells/cancer

Piss = proteins

For = fat/lipid

Crap = calcium

Question 15

What are key features of pneumonia on CXR

Answer 15

1) lobar consolidation
2) interstitial infiltrates
3) cavitation

Question 17

DDx of Pneumonia Airways Diseases

Answer 17

1) crytogenic organizing pneumonia = rare interstitial lung disease
2) allergic bronchopulmonary aspergillosus
3) bronchiectasis = destruction of airway due to chronic infection and/or assoc with genetic abnormalities (cystic fibrosis)
4) bronchopulmonary sequestration
5) bronchocentric granulomatosis

Question 18

Pneumonia DDx Vascular Diseases

Answer 18

• Alveolar Hemorrhage Syndromes = destroy basement membrane of capillary bed

• Eosinophilic lung diseases = idiopathic or drug related
• Pulmonary infarction”
• Fat emboli = Fat to lungs is pro-inflamm; from trauma
• Vasculitis
• Collagen Vascular Diseases = scleroderma, lupus, RA
• Vascular tumors”
• Acute chest syndrome in sickle cell crisis

Question 20

If bronchiectasis is localized to right middle lobe and patient is aged (70’s, Caucasian descent)

Answer 20

= Lady-windermere syndrome (non-tuberculosis mycobacterial disease)

Question 21

Pneumonia DDx of parenchymal diseases

Answer 21

1) hypersensitivity pneumonitis = type of ILD = allergic reaction due to birds

Question 22

Answer 22

Consolidation with air bronchograms

Question 23

Answer 23

Right upper lobe obstruction with alveolar filling spaces

Air fluid level (straight line) on left lung

Cavitation on right and pneumonia on left = bacteria

Question 24

Answer 24

Right sided pleurla effusion and every lung field is involved (reticular pattern = lacy like pattern = interstitial pattern = miliary pneumonia) = disseminated tuberculosis

Question 25

Answer 25

Dense consolidation of right upper lobe Some consolidation in right lower lobe

Question 26

Answer 26

interstitial pneumonia Reticular fine pattern

Question 27

Answer 27

mediastinal widening = hila on right and left (fluffiness of hila) à vascular pouch is widened = inhalational anthrax

Question 28

Answer 28

normal CXR that can lead to S pneumonia PNA = filled with fluid and ARDS

Question 29

Initial management

Answer 29

1) is patient immunocompromised/severe disease - sputum gram stain - but still start antibiotic immediately within first 60 min to decr mortality - urinary antigens 2) inpatient - HIV - thoracentesis = analysis of pleural effusion - nasal swab for fluid or viral multiplex - quantiferon for TB 3) deteriorating patient without cause - bronchoscopy - transthoracic apirate

Question 30

Treatment of PNA pathogen directed vs. empiric therapy

Answer 30

1) broad spectrum empiric antibiotic therapy first 2) then after you figure out PNA etiology --\> tailor antibiotics

Question 31

Types of pneumonia (4)

Answer 31

1) Community acquired pneumonia 2) Nosocomial acquired pneumonia/ 3) ventilator assoc pneumonia 4) healthcare assoc pneumonia

Question 32

Community acquired pneumonia 1) how do you get it

Answer 32

outside the hospital diagnosed \< 48 hrs after hospital admission (cannot be in facility for \>14 days)

Question 33

Community acquired pneumonia most commonly caused by:

Answer 33

Bacteria most common - strep pneumo (30-60%) and atypical organisms (10-20%)

Question 34

CAP treatment outpatient

Answer 34

1) macrolide or doxycycline 2) respiratory fluoroquinolone 3) beta-lactam + macrolide

Question 35

CAP treatment inpatient

Answer 35

1) Non ICU = respiratory fluoro or beta lactam + macrolide 2) ICU = beta lactam + macrolide, beta lactam + resp fluoro

Question 36

Nosocomial acquired pneumonia how do you get?

Answer 36

PNA \> 48 hrs after hospital admission

Question 37

Ventilator associated pneumonia how do you get?

Answer 37

PNA \> 48-72 hrs after endotracheal tube intubation

Question 39

Key features of HAP, VAP, HCAP organisms

Answer 39

1) polymicrobial, MDR organisms colonize oropharynx 2) enter lowe resp tract by micro/macro aspiration

Question 40

MDR pathogens gram negatives

Answer 40

SPACE 1) serratia 2) pseudomonas 3) acinetobacter 4) citrobacter 5) enterobacter or e coli

Question 41

MDR gram positive

Answer 41

MRSA

Question 42

How do you treat HAP, VAP, HCAP?

Answer 42

1) Antipseudomonal agent = cephalosporin or carbopenem 2) + 1 of either = anti-pseudomonal fluoroquinolone or anti-gram neg aminoglycoside 3) + 1 of either anti-MRSA = linezolid or vancomycin