Pneumonia/lung Abscess /COPD Flashcards
Acute Bronchitis/Tracheitis
Self-limited
clinical finding: COUGH >1 week
No SIRS (no high temp, pulse , rr, or WBC)
Patho: epithelial infection–> inflammation
Cause: mostly virus and less bacteria
Dx:
EARLY: mild URI?
Consider if COUGH > 1-5 days
Abnormal PFTs (↓ FEV1)
Rapid viral tests/PCR for atypical bacteria (usually NOT cost effective)
Tx: not needed if its viral
if +bacteria - pertussis
Adults
» erythromycin 500 mg 4x/day x 1 week
» azithromycin 500 mg day 1 and 250 mg/day after x 4 days or
clarithromycin 500 mg twice daily x 7 days (both are EFFECTIVE and BETTER tolerated)
» Also effective vs. C. pneumoniae and M. pneumoniae
Also small benefits from flue drugs, antihis, beta agonist and mu
colytics
Step Pneumonia
Most deadly infection in the USA , most common cause of Pneumococcal pneumonia
Tx: Penicillin (amoxicillin )
RIsk factors for Community Adquired Pneumonia (CAP)- thin of someone living in a community of homelss people who smoke , drink and have hiv
age, alcohol, smoking, comorbidities, immunodupress, recent vital URI
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Commmunity-acquired vs Hospital Acquired
CAP- diagnosed outside of the hospital or within 48 hrs of admision
HAP is at the hospital after 48 hrs
Symps always think of cough and fever and Cx will show opacities (white fluffys )
sputum mainly seen with HAP
CAP Pathology and host defences
Patho:
ASPIRATION of oropharyngeal contents
INHALATION of aerosolized droplets
BLOODSTREAM infection (less common)
host defenses:
Mucociliary escalator
Alveolar macrophages, immune system factors, neutrophils, immunoglobulins
How does it occur?
DEFECTIVE defense mechanism(s)
Very LARGE infectious INOCULUM (can initiate infection)
Highly VIRULENT pathogen overwhelms host
CAP clinical findings
They look super sick
Fever
Cough (+/- sputum)
Dyspnea
Chest discomfort
Sweats/rigors (SHAKING !!!!1)
Rhonchi/rales
Others
CAP - Classic (lobar) clinical findings
Symps: fever, hypothermia, PRODUCTIVE cough, dyspnea, chest discomfort, sweats and rigors.
Auscultation findings - bronchial sounds, rhonchi, or inspiratory crackles
Percussion- dull
CXR- opacities
Agent: S. Pneumoniae (bacterial mostly)
it can also be due to viruses (sars, influenza)
CAP-Atypical (dangerous) clinical findings – think of your older patients in this category
Loss of appetite
Confusion
Dehydration
Worsening signs/symptoms of other chronic illnesses
Failure to thrive
CAP diagnosis
**50% from physical exam
other 50% from (PA/LAT CXR, CBC, Pulseox/ABG
Pneumococcal Pneumonia
most common found cause of CAP
aka pneumococcal causes CAP
Pneumococcal Pneumonia Predisposing factors
Alcoholism
Asthma
HIV
Sickle cell disease
Splenectomy
PNEUMOCOCCAL PNEUMONIA clinical findings : MOST COMMON CAUSE OF CAP
PT looks much worse than CAP
PRODUCTIVE!!! COUGH–> dullness to percussion
FEVER (much worse than CAP)
Rigors (early)
Dyspnea
Pleuritic chest pain (splinting if significant)
Bronchial breath sounds (early)
(hemoptysis)
GI issues
TIRED, Cyanotic, Elevated RR, Dullness to percussion
***Xray looks consolidation and sometimes effusion on 1 side of the lung !!! **
LABs:
DO gram stain !!!
other include- culture of sputum, urine ag test, procalcitonin
CAP Empiric Tx
initial –> amox or docy
In low rate of macrolide resittance step pneumo –> Oral macro (clari or azithromycin)
comorbid pts : Macrolide or doxycycline (as above) plus an oral beta-lactam (amoxicillin/clavulanate, cefpodoxime, cefuroxime)
» Oral fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin)
Inpatient (not ICU) :
Fluoroquinolone
» Oral therapy (see above)
» IV (moxifloxacin, levofloxacin) OR
Macrolide plus beta-lactam
» Oral therapy (see above)
» IV (ampicillin/sulbactam, cefotaxime, ceftriaxone, ceftaroline)
MRSA risk - vanco or linezolid
ICU patient :
Azithromycin OR
Fluoroquinolone PLUS IV antipneumococcal beta-lactam (cefotaxime, ceftriaxone, ampicillin-sulbactam)
For patients allergic to beta-lactam antibiotics:
» fluoroquinolone PLUS aztreonam
For patients at risk for Pseudomonas infection AND who are critically ill, at increased risk for drug resistance, or if local incidence of monotherapy-resistant Pseudomonas is > 10%, consider adding either
» anti-pseudomonal fluoroquinolone (ciprofloxacin or levofloxacin) OR
» aminoglycoside (gentamicin, tobramycin, amikacin)
What vaccines are important for pts for Astham?
Pneumococcal, influenza and covid , even if they are already in the hospital , it is safe to give simmultaneously
CAP initial treatment
penicillin (G or amox )
for MRSA (Linezoid or vanco)
CAP patients and vaccines they should receive
Should receive vaccine asap simulataneously to lessen the severity of the infection.
Pneumococcal, flue vaccine, and covid
Should hospitalized patients receive at least pneumococcal and influenza vaccines?
yes !!! it would be good for them to lessen the severity.
Can be given simultaneously as soon as the patient is stabilized
When to hospitalize CAP patient in the ICU?
*hint follow CURB65 (meet 2-3)
*Confused
*Uremia (BUN
*Resp rate low
*Blood pressure low
*>65 years old
HAP
diagnoses 48 hrs after hospital admission
These patients have different flora compared to healthy pts or CAP pts
who is at highest risk of HAP
pts att ICU or mechanically vented
in hx for >5 days
in Abs for the past 90 days
Agent: Staph Aureus
Most common cause of HAP and Tx
——Levo if there is no risk for anything else
S aureus (both methysilin sensitive and MRSA)
also Others ( kleisbellam aureginosa, E-coli)
Tx depending on risks:
no risk:
Piper-tazo
Cefepime
Imiperem, Meropenem
Pseudomonas Risk:
same as above plus an Aminoglycoside or a Fluro (levo or cipro)
MRSA risk but nothing else:
everything else from above plus Vanco or Linezolid
HAP symtoms (2 findings)
- fever purulent sputum, leukocytosis and dyspnea
- CXR with opacities
HAP Tx if no risk
“Pencilz Cef levitated to Mero and Im”
Piperacillin -tazo
Cefepine
Levo
Ime or mero
HAP tx if MRSA suspected
same as non risk HAP
PLUS vanco or linezoid
HAP tx of Pseudomonas suspected
SAME as with those with no risk plus an aminoglucoside or Levo (monalisa lifting cup)
HAP tx for those at high risk for MRSA, pseudo and everything else
*hint BIG guns
Vanco or Linezoid
What causes lung absesses?
Symps and CXR finds
hx of predisposition to aspiration , periodontal disease
Symps: fever, malaise, weight loss and foul smell of sputum ewww
CXR -cavitations or effusion on the are affeced (look for fake fruit)
The patient presents with , WEIGHT LOSS, fever and foul smell of sputum, CXR shows fake fruit around the upper lobe , and poor dental hygiene. Patient has Hx of or predisposition to Aspiration.
How do you treat?
A beta lactam/lactamase inhibitor
* all this is, is a penicillin with a betalactamase inhibitor aka Amoxicillin-Claudavante
can also use: carbapenem or Clindamycin
What’s the difference between HAP Lung abscess and CAP?
HAP and and Abccess have sputum but abscess will produce a foul-smelling sputum
while CAP has no sputum
How many CC or ML of pleural fluid do we normally have?
5-15 mL in the normal pleural space
What can cause Transudate pleural effusions and how does it present?
Think of CHF patients and long standing HTN
dyspnea , dullness to percussion, low breath sounds where the effusion is
This will shift the mediastinum
Pneumothorax (air in the pleural space) and symps an PE finds
*hint - mediastinal shift
-UNILATERAL CHEST PAIN and expansion
-hyper-resonant (bc of air)
-CXR- mediastinal shift
-cyanosis
-In tension pneumothorax pt will have hypotension
What will cause Mediastinum to move away form its place?
*hint- think large volumes of air or fluid
Tension Pneumothorax (air)
Massive pleural effusion (CHF) (fluid)
What will cause Mediastinum to move Towards the issue?
Hint - think loss of volume
Atalectasis (collapse of lung due to decreases inflation)
and Hemothorax
** because it wants to fill that void space
CXR symps when suspecting CHF
-long hx of HTN
-Dyspnea (no fever or cough)
-Lateral view –> costophrenic angle blunted , + spine sign (darker), larger heart , -/+ pseudotumor,hilar region looks opaque
PA view—> bat-wing sing with
what is pneumothorax and how to better view it ?
air in the pleural space , order CRX with EXpiratory view (this will decrease the lung to better see the air)
who is at most risk of Spontaneous Pneumothorax? and the common symp
Thin, tall young men or asthmatics
unilateral Chest pain (also dyspnea)
what population does Pneumothorax affect the most?
COPD w/emohysematouos blebs
ASTHMATICS (will show up with unilateral chest pain)
Trauma pts w/ puntures viscera/pleura or broken ribs
How to view a pneumothorax from a CXR
look at visceral pleural line on the borders AFTER you no longer see NO lung markings (vessels)
what two infections can cause Cavitations?
Staphylococci and TB
If TB is suspected, look at symps of fever, night sweats and hemoptysis
If Staphylococci, look at cough and high fever
Three parts of the mediastinum and the things that can be seen in each compartment
Anterior – 3T and L ( teratomas, thyomas (Myasthenia gravis pts), Thyroid and Lymphomas
Medial–masses of the heart, origins of great vessels, tracheam and main bronchi
Posterior– aneurysm of the descending aorta (tearing pain), esophagus masses, tumors of the NERVES, and lymph nodes
Mediastinum masses seen on a lateral view , where would you see them?
Anterior - will kind of cover the retrosternal space and make it opaque
Middle- it be in the middle but not exactly merge with the vertebrae
Posterior- will be kind of middle or bottom but it will!!! look like merging with the vertebrae
If you see a nodule with weird shapes, and messy. benign or malignant
Malignant
<4mm nodule found, benign or malignant ?
benign
what is the best diagnostic tool to find pulmonary embolus since Symps are not evident ?
CT angiograph
Diagnostic tool to see Bronchiectasis
CT showing tram tracks and Thickened walls (Ring like )
What is Bronchiectasis, main cause main symps, and how is this different from Absess?
Bronchiectasis is a congenital dissorder w/ large bronchi, abnormal dilation, and destruction of the bronchial walls
Main cause: Cystic fibrosis (also lung infection, obstructions of aiway, immunodeficiencies, abnormal lung deficiency,
MAin symp: Dyspnea and WHEEZING, chronic cough, hemoptysis, purulent smelly sputum, WEIGHT LOSS AND ANEMIA , and clubbing
** differences Dyspnea and wheez, chronic cough seen in B while LAbsces has low grade fever and extended period of malaise
Bronchiectasis vs Lung absess similarities and differences
Similarities- Wt loss, anemia, sputum and hemoptysis , smelly sputum
Differences:
B–> Dyspnea and wheezing, chronic cough, clubbing
Lung abscess- insidious , low grade fever , extended period of malaise
in which patient would you see a bullae on CXR
COPD with Emphysema
Primary Tx for Bronchiectassi vs Lung absess
LA–> CLINDAMYCIN or Amoxi-Clau (often resistant to PNC)
B–> amox, amox-clau, doxy , Ciprofloxacin , Ceph 2-3 gen
How do you know someone has HAP
diagnoses more than 48hs after admitted
abt 4 days later:
new/worseing on infiltrates seen on cXR,
Fever, leukocytosis, worsening breathing status, purulent sputum (2 o/o 3 seen)
PT with GERD and severe upper abdominal pain, what would you expect to see on CXR? Lets assume he has an Ulcer which is common here
air between the diaphragm and the lungs causes by the ulcers letting air out
