Pneumonia, Influenza, Covid-19, ARDS Flashcards
What are the risk factors for developing MDR gram negative bacterial PNA and MRSA?
hospitalization >2 days in last 90 days
use of abx in last 90 days
immunosuppression
nonambulatory status
tube feedings
gastric acid supression
severe COPD
What are the risk factors for developing MRSA?
hospitalization >2 days in last 90 days
use of abx in last 90 days
chronic hemodialysis in last 30 days
documented hx of MRSA
CHF
gastric acid suppresion
What are the risk factors for Community acquired MRSA?
cavitary infiltrate or necrosis
gross hemoptysis
neutropenia
erythematous rash
concurrent influenza
young, previous healthy
summer month onset
What is the most common cause of community acquired pneumonia?
S. Pneumoniae
What are the risk factors for CAP?
alcoholism, asthma, institutionalization, over age 70
decreased cough/gag reflex in elderly
dementia, sz disorder, HF, Cerebrovascular disease, smoking, COPD, HIV
What is a likely cause of CAP if recent travel to ohio river valley?
travel to southwest USA?
Travel to SE asia?
hotel or cruise?
histoplasma
hantavirus, coccidioides
Burkholderia, avian flu
Legionella
What is the most important thing in making a diagnosis of pneumonia?
History and physical
What is the treatment for pneumonia based upon?
History
consider co-morbidities
What are risk factors for peudomonas and MRSA?
prior isolation of either organism on culture
recent hospitalization AND receipt of parental abx within last 90 days
What are the risk factors of Pseudomonas with CAP?
- compromized immune system
- recent prior abx use
- structural lung abnormalities such as cystic fibrosis or bronchiectasis
- repeated exacerbations of COPD reqiurring glucocorticoids or abx use
What are the risk factors for pseudomonas with HAP?
increased age, ventilation, abx at admission, transfer from unit or icu, admission in ward with high incedence of P. aurgeinosa infections
What is the definition of HAP?
infection acquired after at least 48hrs of hospitalization
When treating HAP and VAP, consider the following risks
- increased mortaloity
- MDR pathogens and MRSA
- MDR pathogens without MRSA
- MRSA alone
What is the definition of VAP?
HAP that develops more than 48hrs after endoracheal intubation
-difficult to wean of ventilator
lack improvement
new infiltrates on xray, new fever
What is aspiration PNA?
Macroaspiration of fluid/food into lungs
usually due to neurologic dysfunction
What is a trasudate pleural effusion and likely cause?
usually from systemic influences on pleural fluid formation and resorption
Left HF, cirrhosis, neprhotic syndrome, myxedema, peritoneal dialysis
What are the causes of exudative pleural effusions?
caused by local influences on pleural fluid formation and reabsorption
bacterial PNA, malignancy, virus, PE, TB, fungus, parasites
How to diagnose a plueral effusion?
When is a thoracentesis indicated?
Thoracentesis
for all effusions with >1cm layer in decubitus view
if effusion suspected r/t HF, then can try diuresis and 75% do so in 48 hrs
if effision suspected to be r/t infection, thorecentesis is done ASAP
What does Light’s Criteria determine?
What are the criteria?
Determines an exudative effusion
- protein pleural fluid/serum protein ratio >.5
- pleural fluid LDH greater than 2/3 of the labs normal upper limit for serum LDH
- pleural/serum LDH ratio >.6
Transudative effusions will not meet any of these criteria
For exudative effusions, pleural fluid should be tested for what?
Ph
glucose
WBC with diff
micro stidues
cytology
What is the definition of ARDS?
severe dyspnea
diffuse pulmonary infiltrates
hypoexemia
What is the key diagnostic feature for ARDS?
PaO2/FIO2 <300mmHg
diffuse bilateral pulm. infiltrates
absence of elevated left atrial pressure
acute onset
What PaO2/FIO2 ratio indicates severe hypoxemia?
What indicates abnormal gas exchange?
<200
<300
What are the risk factors for ARDS?
sepsis
ONA
trauma
blood transfusions
gastric acid suppression
drug overdose
What is the exudative phase of ARDS?
alveolar edema and neutrophil inflammation
diffuse alveolar damage
atelectasis and reduced lung compliance
hypoxemia, tachypnea, progressive dyspnea, hypercarbia due to loss of alveolar exchange
CXR with bilateral opacities consistent with pulmonary edema
What is the proliferative phase of ARDS?
progressive lung injury and pulmonary fibrosis
What is the fibrotic phase of ARDS?
prolonged progressive fibrosis and need for more ventilator support or supplemental O2
increased risk for PTX, increased dead space
In ARDS, alveolar collapse can occur due to alveolar/interstitial fluid accumulation and loss of worsening hypoxemia, therefore low tidal volumes are combined with the use of what to minimize what?
low TV are combined with the use of positive end-expiratory pressure (PEEP) at levels that strive to minimize alveolar collapse and achieve adequate oxygenation with the lowest required FIO2
can also try to improve oxygenation by putting pt in prone position
What are some ancillary therapies for patients with ARDS?
due to interstitial and alveolar edema, limit IV fluids to only as needed
most patients require sedation and even paralytic agent s
Avoid glucocorticoids or NO in ARDS
What are some respiratory complications of influenza?
PNA due to influenza or a secondary bacteria
What is the most common extrapulmonary manifestation of influenza?
Myositis (often in influenza b)
What are the treatments for influenza?
neuramindase inhibitors (inhibit egress of virus from cell)
start within 48hrs of infection and may see resolution of sx 1-2 days sooner
What are risk factos of COVID 19
CVD
DM
HTN
Chronic lung disease
cancer
CKD
obesity
smoking
what are the complications of ARDS associated with COVID19?
patients deteriorate rapidly
important to look at history to identify increased risk of illness severity
what are the three drugs that are used to treat a patient with probable HAP or VAP?
Cefepime
Ciprofloxacin
Vancomycin
treat for 5 days and then decrease regimen
Which drug is great for aerobic and anerobic gram - but not pseudomonas?
Ertapenem
Which drug covers G+ only and can treat MSSA and MRSA?
Which drug covers G+ and G-, anarobes and pseudomonas?
Vancomycin
Fluoroquinolones
What is the empiric treatment for CAP?
Ceftriaxone with Azithromycin
