Pneumonia and flu

Question 1

1. Definition and Features of Pneumonia (PNA)

Answer 1

A disease of the lungs that is characterized by inflammation of the parenchyma of the lung (alveolar wall) and accumulation of abnormal alveolar filling with fluid of lung tissue. Most commonly caused by infection

Question 2

Describe lung protective defenses

Answer 2

Lower airways usually remain organism-free due to pulmonary host defense mechanisms: Innate (Nonspecific) and Acquired (Specific).
Lower airways usually remain organism-free due to pulmonary host defense mechanisms: Innate (Nonspecific) and Acquired (Specific).

Question 3

2. Pneumonia Pathogenesis

Answer 3

Pneumonia is caused by: Inhalation of infectious particles, Inhalation of oropharngeal or gastric contents, Hematogenous spread, Infection from adjacent or contiguous structures, Direct inoculation or Reactivation. Pneumonia occurs when hosts ability to fight pathogens is compromised
Pneumonia is caused by: Inhalation of infectious particles, Inhalation of oropharngeal or gastric contents, Hematogenous spread, Infection from adjacent or contiguous structures, Direct inoculation or Reactivation. Pneumonia occurs when hosts ability to fight pathogens is compromised

Question 4

Clinical presentation of pneumonia

Answer 4

fever, chills, pleuritic chest pain, dyspnea and cough that can be productive of sputum (bacterial infections) or with minimal sputum (atypical vs viral).

Question 5

pneumonia physical exam

Answer 5

Fever, tachypnea, tachycardia, hypoxia, cyanosis. Lungs have crackles, rhonchi, bronchial breath sounds, egophony, dullness to percussion

Question 6

Basic Tests for all patients with suspected pneumonia pneumonia

Answer 6

CXR, CBC, CMP (complete metabolic profile), blood gas or pulse oximetry

Question 7

CXR results in pneumonia

Answer 7

NOT sufficient to pneumonia, but helps. Lobar consolidation, interstitial infiltrates and cavitation

Question 8

What can fill alveoli?

Answer 8

mnemonic: poor funny boy cant piss for crap: Pus, fluid, blood, cells/cancer, protein, fat, calcium

Question 9

CXR pattern and possible pathogens

Answer 9

Focal/ large pleural effusion: bacteria. Cavitary: bacterial abscess, fungi, acid-fast bacilli. Miliary: acid-fast bacilli, fungi. Rapid progression/ multifocal: Legionella spp, pneumococcus, staphylococcus. Interstitial: viruses, pneumocystis, mycoplasma, chlamydia. Mediastinal widening without infiltrate: inhalation anthrax

Question 10

3. Pneumonia Classifications or Types

Answer 10

Community Acquired Pneumonia (CAP), Hospital (Nosocomial) Acquired Pneumonia (HAP), Ventilator Associated Pneumonia (VAP), Healthcare-Associated Pneumonia (HCAP)

Question 11

Community acquired pneumonia description

Answer 11

Begins Outside the Hospital . Diagnosed < 48 Hrs after Hospital Admission . Patient is not a resident in a long-term facility for > 14 days or more before the onset of symptoms

Question 12

Most common causes of CAP

Answer 12

Bacteria: strep pneumonia, H. Influenza, M. Catarrhalis, Staph aureus, Group A strep. Less common: legionella, Mycoplasma, chlamydia

Question 13

CAP treatment

Answer 13

Outpatient: Macrolide or Doxycyline (60 rs or comorbid dsease). Inpatient ICU: Beta-lactam + Macrolide, Beta-lactam + Respiratory Fluoroquinolone. Inpatient non-ICU: Respiratory Fluoroquinolone , Beta-lactam + Macrolide

Question 14

Definitions of HAP, VAP and HCAP

Answer 14

HAP: PNA>48hrs after hospital admission. VAP: PNA > 48 - 72 Hrs after Endotracheal Tube Intubation. HCAP: PNA in a non-hospitalized patient with extensive healthcare contact (hospitalization within 90 days of infection, long term care facility,
HAP: PNA>48hrs after hospital admission. VAP: PNA > 48 - 72 Hrs after Endotracheal Tube Intubation. HCAP: PNA in a non-hospitalized patient with extensive healthcare contact (hospitalization within 90 days of infection, long term care facility,

Question 15

What is unique about HAP, VAP and HCAP organisms

Answer 15

•Infections are Frequently Polymicrobial in Origin and tend to be multi-drug resistant. Organisms that colonize oropharynx enter lower respiratory tract by micro/macro aspiration

Question 16

HAP, VAP and HCAP common pathogens

Answer 16

gram negative (SPACE): Serratia, Pseudomonas, Acinetobacter, Citrobacter, Enterobacter or Escherichia coli. Gram positive: Methicillin-Resistant Staphylococcus Aureus - MRSA

Question 17

HAP, VAP and HCAP treatment

Answer 17

For drug resistant strains: Antipseudomonal Agent: Cephalosporin or Carbopene.
Plus 1 of the Following: Anti-pseudomonal Fluoroquinolone or Anti-Gram Negative Aminoglycoside. Plus 1 Anti-MRSA Medication: Linezolid or Vancomycin

Question 18

4. Differential diagnosis of PNA

Answer 18

Airway diseases: Organizing pneumonia, Allergic Bronchopulmonary Aspergillosus (ABPA), Bronchiectasis
, Bronchopulmonary sequestration, Bronchocentric granulomatosis. Vascular disease: eosinophilic lung disease, fat emboli, vasculitis, vascular tumors. Parenchymal diseases: drug rxn, granulomatous lung disease, pulmonary edema, neoplasm, ARDS, idiopathic interstitial pneumonia.

Question 19

6. Basics of PNA Treatment

Answer 19

Determine severity of disease (pneumonia severity index), do further testing if severely ill or immunocompromised, or inpatient/ deteriorating

Question 20

Pneumonia severity index and mortality

Answer 20

class 1- 0.1% mortality. Class II: 0.6%. Class III: 2.8%. Class IV: 8.2%. Class V: 29.2%

Question 21

Which pneumonia severity classes require admission?

Answer 21

class IV and V

Question 22

Further testing for severely ill or immunocompromised with suspected pneumoni

Answer 22

Sputum gram stain/culture, blood culutre, urinary Ag testing

Question 23

Further inpatient testing

Answer 23

HIV serology, mycoplasma serology, chlamydia serology, fungal serology, test for TB, gram stains.

Question 24

Further testing for deteriorating patient despite therapy for pneumonia

Answer 24

Bronchoscopy, biopsy, bacterial serology, fungal serology, evaluate for CHF, pulm embolism, neoplasm, CT disease

Question 25

Treatment of pneumonia in patients who are not severely ill and with few risk factors

Answer 25

Broad spectrum empiric antibiotic therapy

Question 26

List major viral groups that cause respiratory infections

Answer 26

Orthomyxovirus (influenza), paramyovirus, picornaviruses, herpes viruses, adenovirus, coronavirus, papilloma virus, hantavirus

Question 27

Antigenic shift vs drift

Answer 27

Shift: major changes in hemagglutinin and neurominidase associated with epidemics and pandemics. Drift: minor changes in H and N associated with localized outbreaks

Question 28

•Understand Influenza (IFN) Pathogenesis

Answer 28

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.

Question 29

• Know Influenza Clinical Features

Answer 29

Fever, lethargy, lack of appetite, coughing, wheezing, runny nose, sore throate, diarrhea, nausea, vomiting

Question 30

Complications of influenza

Answer 30

primary IFN pneumonia, secondary bacterial pneumonia, myositis, CNS involvement

Question 31

Diagnosis of influenza

Answer 31

clinical, rapid Ag tests, immunofluorescence, PCR, viral culture, serology

Question 32

Basics of IFN Prevention and Treatment

Answer 32

Prevention: vaccine. Treatment: Adamantanes are antivirals against IFN A. Neurominidase inhibitors are antivirals against IFN A and B. Treatment will shorten duration and severity