PNA / Influenza Flashcards
T/F: pneumonia is a disease of the lungs that is characterized by inflammation of the parenchyma
True
Definition: A disease of the lungs that is characterized by inflammation of the parenchyma of the lung (alveoli) and accumulation of abnormal alveolar filling with fluid of lung tissue
**Most commonly caused by infection
What is most commonly caused of infectious pneumonia?
Inhalation of infectious particles!
Other causes:
- Inhalation of oropharngeal or gastric contents
- Hematogenous spread
- Infection from adjacent or contiguous structures
- Direct inoculation
- Reactivation
What two types of classic differentiations can pneumonia be categorized into? What kinds of bugs cause these?
- Typical:
* S. pneumoniae, H. influenzae, S. aureus, group A streptococci, Moraxella catarrhalis, anaerobes, and aerobic gram-negative bacteria - Atypical
* Legionella spp, M. pneumoniae, C. pneumoniae, and C. psittaci (All the weird ones)
What types of things should you ask about when getting a clinical history?
- Age
- Presentation (Acute, Subacute, or Chronic)
- Personal Factors: Smoking History, Alcohol/Drug Abuse. HIV Risk Factors, Occupational History/Allergic History
- Underlying Cardiopulmonary Disease
- Co-Morbidities (Aspiration Risk, IV Drug Use, Pregnancy)
- Drugs (allergies, abuse)
What are some typical presentations of pneumonia? What could you find on physical exam?
Symptoms:
- Fever, cough, SOB, pleuritic chest pain, sputum production, GI symptoms, mental status changes
Physical Exam
- Fever – 80% (may be absent in elderly)
- Tachypnea – 45 to 70%
- Audible crackles
- Evidence of consolidation – bronchial breath sounds, egophany, dullness to percussion
T/F: blood cultures are the most sensitive test to detect pneumonia
False
Blood Cultures – positive in <20% of patients
Sputum Cultures – positive in <10% of patients
What different patterns could exist on an Xray?
- Alveolar
- Lobar
- Multifocal
- Interstitial
- Pleural Effusion
- Nodular
- Millary
- Cavitation
DISCLAIMER: x-ray alone cannot differentiate or confirm diagnosis, but its a good place to start
What is the acronym for all the types of fluids that can fill alveoli?
Poor - Pus
Funny - Fluid
Boy - Blood
Can’t - Cells/Cancer
Piss - Protein
For - Fat (Lipid)
Crap - Calcium
What pneumonia pattern is shown?
Lobar consolidation
What pneumonia pattern is shown?
Multifocal pneumonia
What pneumonia pattern is shown?
Cavitation
What pneumonia pattern is shown?
Miliary pneumonia: from hematogenous spread or tuberculosis
What pneumonia pattern is shown?
Interstitial Pneumonia
What are some differentials for airway diseases?
- Cryptogenic Organizing Pneumonia (COP)
- Allergic Bronchopulmonary Aspergillosus (ABPA)
- Bronchiectasis
- Bronchopulmonary sequestration
- Bronchocentric granulomatosis
What are some differential diagnosis for vascular disease?
- Alveolar Hemorrhage Syndromes
- Eosinophilic lung diseases
- Pulmonary infarction
- Fat emboli
- Vasculitis
- Collagen Vascular Diseases
- Vascular tumors
- Acute chest syndrome in sickle cell crisis
Can you think of some other differentials for parenchymal disease?
- Hypersensitivity pneumonitis (occupational)
- Drug reaction
- Transfusion reaction
- Alveolar proteinosis
- Granulomatous lung diseases
- Lipoid pneumonia
- Pulmonary edema
- Neoplasms
- ARDS
- Radiation pneumonitis
- Idiopathic interstitial pneumonias
What does CAP, HAP, VAP, and HCAP stand for?
- Community Acquired Pneumonia (CAP)
- Hospital (Nosocomial) Acquired Pneumonia (HAP)
- Ventilator Associated Pneumonia (VAP)
- Healthcare-Associated Pneumonia (HCAP)
Strep pneumo is the most common cause of CAP. What are the in-patient and outpatient pharmacologic treatments?
Outpatient Treatment (5 days)
- Macrolide or Doxycyline
- Respiratory Fluoroquinolone
Inpatient Treatment (6 days)
- Non - Intensive Care Unit (ICU)
- Respiratory Fluoroquinolone
- Beta-lactam + Macrolide
- Intensive Care Unit (ICU)
- Beta-lactam + Macrolide
- Beta-lactam + Respiratory Fluoroquinolone
- Consider Anti-MRSA Therapy (Vancomysin)
- 21yoF with 3 days of fevers, chills, cough, and purulent sputum presenting to clinic
- VS: 38.5, 105, 120/80, 24, 92% on RA
- Exam: appears mildly ill, tachycardic, tachypnic, crackles@LLL, dullness@LLL
- WBC 12, nl BMP
What is your diagnosis? What’s the treatment?
Community acquired pneumonia (not hospital related)
Outpatient Treatment
- Macrolide or Doxycyline
- Respiratory Fluoroquinolone
How do you differentiate between the healthcare related HAP / VAP/ HCAP?
Hospital (Nosocomial) Acquired Pneumonia (HAP)
- PNA > 48 Hrs after Hospital Admission
Ventilator Associated Pneumonia (VAP)
- PNA > 48 - 72 Hrs after Endotracheal Tube Intubation
Healthcare Associated Pneumonia (HCAP)
- PNA in a non-hospitalized patient with extensive healthcare contact
- IV Therapy, Wound Care, IV Chemotherapy within 30 days
- Resident of Nursing Home or Long-Term Acute Care (LTAC)
- Hospitalized in Acute Care Hospital > 2 Days with prior 90 Days
- Attendance at Hospital or Hemodialysis Clinic with 30 Days
Explain how HAP / VAP/ HCAP organisms infect the patient? Describe the organisms
- Organism that colonize the oropharynx enter lower respiratory tract (LRT) by micro- or macro-aspiration
- Infections are frequently polymicrobial in origin
- Organisms tend to be Multi-drug Resistant (MDR)
- Gram negative pathogens= “SPACE”
- Serratia
- Pseudomonas*
- Acinetobacter
- Citrobacter
- Enterobacter* or Escherichia coli*
Its important to treat HCAP / VAP / HAP within 48 -72 hours and can last 7- 8 days. What medications would you use?
- Antipseudomonal Agent:
- Beta-Lactam + Beta-lactamase Inhibitor
- 4th Generation Cephalosporin
- Carbopenem
- Plus 1 of the Following:
- Anti-pseudomonal Fluoroquinolone
- Anti-Gram Negative Aminoglycoside
- Plus 1 Anti-MRSA Medication:
- Linezolid
- Vancomycin
Recognize that there are a lot of different viruses that cause respiratory infection. Influenza outbreaks vary and can change properties- what causes this variation in the IFN virus?
IFN viruses undergo periodic changes in the antigenic characteristics of their envelope glycoproteins:
- Hemagglutinin
- Neurominidase
**Major changes in these glycoproteins are referred to as antigenic shifts
**Minor changes in these glycoproteins are referred to as antigenic drifts.
Describe how the pathogenesis of how the influenza virus is initiated and spread
- IFN Hemagglutinin surface glycoprotein binds to sialic acid residues on respiratory epithelial cell surface glycoproteins - Infection Initiation.
- After viral replication, progeny virions are also bound to the host cell membrane.
- Neurominidase cleaves these links to liberate new virons and spread infection.
Which of the following would be the most effective in diagnosis influenza?
- Rapid Antigen Tests
- Immunofluorescence
- Polymerase Chain Reaction (PCR)
- Viral Culture - 48 Hour Culture
- Serologic Testing
These can all be used but PCR is probably best
- Rapid Antigen Tests: not very sensitive
- Immunofluorescence
- Polymerase Chain Reaction (PCR)
- Viral Culture - 48 Hour Culture: too slow
- Serologic Testing: limited
Influenza treatment gives greatest benefit if started within the first 24- 30 hours. What antiviral medication could you give?
Neurominidase Inhibitors - Active against IFN A and B
- Oseltamivir and Zanamivir
- 40yoF, recent f/c/myalgia 1wk prior; improved; now worsening f/c, cough, bloody purulent sputum, dyspnea
- VS: 38.6, 115, 90/60, 32, 80% on RA
- Exam: in distress, crackles at RUL and LLL, decreased breath sounds at LLL
What is wrong? What is the treatment?
Post influenza secondary bacterial pneumonia (Idk it was his example)
Treat inpatient with vancomysin
- 56yoM c/ PMH OLT s/p recent admission for tacrolimus toxicity; 5d f/c, rigors, cough
- VS: 38.8, 120, 80/40, 32, 84% on RA
- Exam: acute distress, accessory muscle usage, tachycardic, tachypnic, diffuse crackles
- WBC 1.5, Plts 20, Na 128, Creat 3.2, INR 5, Fibrinogen 50
What’s the diagnosis? What’s the treatment?
Hospital acquired pneumonia (recent admission, immunocompromised, xray)
- ICU - broad spectrum antibiotics
- Vanco + carbepenem
