Pulm Flashcards
Asthma definition and types
Asthma: chronic inflammatory disease characterized by bronchial hyperresponsiveness, episodic exacerbations, & reversible airflow obstruction
▪︎5-10% of US population, black > white
PATHO: inflammatory disease driven by T-helper 2 (TH2)
▪︎♂ > ♀ in patients <18yo cells in individuals w/ a genetic predisposition
Allergic Asthma (MC): begins w/ intermittent symptoms
➀ airway hyperreactivity
in childhood & usually associated w/ atopy
➁ inflammation
▪︎IgE-mediated type 1 hypersensitivity to an allergen ➂ bronchoconstriction
▪︎mast cell degranulation & histamine release
Risk Factors: ATOPY**
Nonallergic Asthma (uncommon): onset >40yo, not
▪︎family hx, tobacco smoke
related to atopy, poor response to standard treatment
▪︎obesity, pollution, male
Nitric Oxide (NO): eosinophilic airway inflammation associated w/ asthma leads to up-regulation of NO synthase in the respiratory mucosa, which generates ⇡ amounts of NO gas in the exhaled breath
Occupational Asthma (OA): begins in adulthood, induced by immunologic/nonimmunologic stimuli in the workplace
▪︎Immunologically-Mediated OA: IgE & non-IgE-mediated responses following chronic exposure & respiratory
sensitization to high or low molecular weight agents (e.g., flour, latex)
▪︎Nonimmunologic, Irritant-Induced Asthma (IIA): chronic, caused by multiple exposures to an irritant (e.g., chlorine,
dyes & bleaches, tobacco/wood smoke) *reactive airway dysfunction syndrome (RADS) is acute form of IIA
TRIGGERS:
Allergic (Extrinsic) Asthma: Nonallergic (Intrinsic) Asthma:
▪︎cardinal risk factor ⇢ atopy ▪︎viral respiratory infections, cold air, exercise, GERD
▪︎environmental: pollen, dust mites, animal dander, mold ▪︎ASA/NSAIDs, beta blockers, stress & anxiety
Asthma Exacerbation: a typically reversible episode of lower airway obstruction (bronchospasm) characterized by a worsening of asthma symptoms within a short period of time & accompanied by a change in baseline lung function
Status Asthmaticus: severe exacerbations that progress rapidly & do not respond to standard acute asthma therapy
Asthma sx
4 classic sx: wheezing, cough, SOB, chest tightness
HX: pattern of respiratory symptoms that occur following exposure to triggers (e.g., allergen, exercise, viral infection) & resolve w/ trigger avoidance or asthma medication
PE: widespread, high-pitched, musical wheezes
▪︎MC w/ expiration, characteristic of asthma
▪︎usually absent between exacerbations
Other possible findings:
▪︎prolonged expiratory phase
▪︎hyperinflation, hyperresonance to percussion
Severe (exacerbation/status asthmaticus):
▪︎tachypnea >30, tachycardia >120bpm
▪︎accessory muscle use, tripod, diaphoresis
▪︎poor air movement ⇢ “silent chest”
▪︎pulsus paradoxus (SBP ⇣ >12mmHg w/ inspiration)
Signs of impending respiratory failure
Cyanosis
inability to maintain respiratory effort
depressed mental status
SPO2 less than 90
PEF less than 25%
PaCO2 greater than 40
Asthma dx
DX: asthma S/SXS + reversible airflow obstruction
Pulmonary function tests (PFTs):
➀ Spirometry ⇢ obstructive pattern
⇣ FEV1/FVC ratio, ⇣ FEV1, FVC ~normal
FEV1 > 70 = mild
FEV1 50-70 = moderate
FEV1 35-50% = severe
FEV1<35% = very severe
➁ Bronchodilator response ⇢ reversible obstruction
⊕reversibility = ⇡ FEV1 ≥12% after SABA
➂ Bronchoprovocation ⇢ airway hyperresponsiveness
▪︎provocative stimulus (e.g., inhaled methacholine,
inhaled mannitol, exercise)
⊕hyperresponsiveness = ≥20% ⇣ FEV1 after stimulus
Nitric Oxide: fraction exhaled NO ⇢ FENO
⊕ = ⇡ FENO (≥40-50ppb) *normal level does not exclude asthma
DX: asthma exacerbation ⇢ ABG
▪︎initial: respiratory alkalosis, +/- hypoxemia
▪︎late/severe: respiratory acidosis, PaO2 <60mmHg,
PaCO2 >40-45mmHg
Peak expiratory flow (PEF):
▪︎best method to assess exacerbation severity/response
▪︎normal ~400-600 L/min, differs w/ age & sex
Severe obstruction ⇢ <200 L/min
PEF ≤50% predicted
Asthma tx
Initiating TX: based on frequency & severity of symptoms, Monitoring: routine f/u q1-6mo depending on symptom severity
history of exacerbations, & results of PFTs & adequacy of control; assess symptoms over last 4wks each visit
▪︎LABAs NEVER USED AS MONOTHERAPY, ALWAYS W/ ICS* ▪︎inadequate response ⇢ always check inhaler technique*
TX:
1. SABA PRN ⇢ all patients*
▪︎nighttime awakenings ≤2x/m
2. + low-dose ICS
3. + low-dose ICS/LABA
4. + medium-dose ICS/LABA
5 + high-dose ICS/LABA
6+ high-dose ICS/LABA + PO steroids
IV magnesium ⇢ indications: life-threatening exacerbations or severe exacerbations w/ no improvement after 1h of intensive
SABA MOA and meds
Albuterol (ProAir HFA, ProAir RespiClick, Ventolin HFA, Proventil HFA)
Levalbuterol (Xopenex)
MOA: binding at beta-2 receptors causes relaxation of bronchiole smooth muscle/bronchodilation
Indications: ALL PATIENTS W/ ASTHMA, used PRN for acute symptoms (quickly reverses bronchospasm)
Caution: CVD, glaucoma, hyperthyroidism, seizures, diabetes
ADRs: nervousness, tremor, tachycardia, palpitations, cough, hyperglycemia, hypokalemia
SAMA meds, MOA, ADR
Ipratropium (Atrovent HFA)
MOA: block constricting action of acetylcholine at M3 receptors in bronchial smooth muscle resulting in bronchodilation; also ⇣ mucus secretion
Indications: may be used in combination w/ SABAs during exacerbations
Warnings: Myasthenia gravis, narrow-angle glaucoma, urinary retention, BPH, bladder neck obstruction
ADRs: dry mouth, blurred vision, thirst, dry eyes
Inhaled Corticosteroids (ICS) meds, MOA, ADR
Fluticasone (Flovent HFA/Diskus, Arnuity Ellipta)
Budesonide DPI (Pulmicort Flexhaler)
Beclomethasone (Qvar)
Mometasone (Asmanex HFA)
Ciclesonide (Alvesco HFA)
MOA: block late-phase reaction to allergen, reduce airway hyperresponsiveness, potent & effective anti-inflammatory medications; ⇣ symptoms, ⇡ lung function, improve QOL, & reduce risk of exacerbations
Indications: FIRST LINE for long-term maintenance therapy, initiated in step 2
Contraindications: primary treatment of status asthmaticus or acute episodes of asthma
Warning: high doses for prolonged periods may cause adrenal suppression; ⇡ risk of fractured, stunted growth in children
ADRs: dysphonia (difficulty speaking), sore throat, reflex cough, oral candidiasis, bronchospasm
Monitoring: s/sxs of thrush, adrenal insufficiency, BMD
PO Steroids meds, MOA, ADR
Methylprednisolone
Prednisone
Prednisolone
Indications: short courses used for acute exacerbations
IV ⇢ indicated in patients w/ impending or actual respiratory arrest or intolerant to PO steroids
ADRs: HTN, hyperglycemia, sodium/fluid retention
Leukotriene Receptor Antagonists (LTRAs) meds, MOA, ADR
Montelukast (Singulair)
Zafirlukast (Accolate)
Zileuton (Zyflo)
MOA: inhibit leukotriene mediators of airway inflammation; help ⇣ airway edema, constriction, & inflammation
▪︎Montelukast: inhibits leukotriene D4
▪︎Zafirlukast: inhibits leukotriene DR & E4
▪︎Zileuton: a lipoxygenase inhibitor & inhibits leukotriene formation
Indications: effective for exercise-induced asthma & aspirin-induced asthma
Contraindications (zafirlukast, zileuton): hepatic impairment
Warnings: neuropsychiatric events (aggression, agitation, hallucinations, depression, suicidality)
ADRs: HA, dizziness, ⇡ LFTs
Mast Cell Stabilizers meds, MOA, ADR
Cromolyn sodium
Nedocromil sodium
MOA: prevent release of inflammatory mediators from mast cells
Indications: prophylaxis before exercise or allergen exposure, effective 1-2h after dose
ADRs: throat irritation, cough
Methyl-xanthines meds, MOA, ADR
Theophylline
MOA: blocks phosphodiesterase causing ⇡ cAMP & release of epinephrine from adrenal medulla cells; results in bronchodilation but also causes diuresis, CNS/cardiac stimulation, & gastric acid secretion
Indications: least desirable option for add-on therapy d/t significant ADRs, drug interactions, & need for close level monitoring *narrow TI ⇢ toxicity causes arrhythmias & seizures
Warnings: may exacerbate CVD, hyperthyroidism, PUD, & seizure disorders
ADRs: N/V, HA, tachycardia, insomnia, tremor, nervousness
Anti-IgE monoclonal antibody meds, MOA, ADRs
Omalizumab (Xolair)
MOA: inhibits IgE binding to IgE receptor on mast cells & basophils; prevents activation/release of mediators in the allergic response
Indications: IgE 30-700IU/mL, ⊕skin test to perennial allergen, & incomplete symptom control w/ ICS
BOXED WARNING: anaphylaxis
ADRs: injection site reactions, arthralgias, generalized pain, dizziness, fatigue
Anti-IL5 monoclonal antibodies meds, MOA, ADR
Mepolizumab (Nucala)
Reslizumab (Cinqair)
Benralizumab (Fasenra)
MOA: IL5 is a major cytokine responsible for growth, differentiation, recruitment, activation, & survival of eosinophils which are associated w/ inflammation & an important component in asthma pathogenesis
Indications:
▪︎Mepolizumab ⇢ peripheral blood eosinophils ≥150/µL
▪︎Reslizumab ⇢ peripheral blood eosinophils ≥400/µL
▪︎Benralizumab ⇢ peripheral blood eosinophils ≥150/µL
BOXED WARNING: anaphylaxis
ADRs: injection site reactions, HA, human anti-human antibody (HAHA) development, fever, hypersensitivity
Anti-IL4 monoclonal antibody meds, MOA, ADR
Dupilumab (Dupixent)
MOA: inhibits IL4 & IL13 type 2 cytokines that play a key role in allergy & asthma through blockade of IL4 receptor; reduces asthma exacerbations, enables PO steroid tapering, & improves lung function
Indications: peripheral blood eosinophils ≥150/µL
Warnings: arthralgia including gait disturbances, eosinophilia & vasculitis
ADRs: HAHA development, injection site reactions, conjunctivitis, keratitis, oral HSV infection
Acute Bronchiolitis definition, sx, dx, tx
*infection & inflammation of the bronchioles
Etiologies: RSV MCC
*Rhinovirus, Adenovirus, Influenza virus, Parainfluenza virus
Risk Factors: infants 2mo-2yrs MC affected
*<6mo in age, exposure to cigarette smoke, lack of breastfeeding, prematurity (<37wks), crowded conditions (day care)
sx
Viral prodrome (fever, URI sxs) for 1-2d 🡪 respiratory distress
*wheezing, tachypnea
*nasal flaring, cyanosis
*retractions, rales
Signs of severity:
*hypoxemia
*apnea
*respiratory failure
dx
Clinical
CXR: *nonspecific
*hyperinflation, peribronchial cuffing or thickening, atelectasis
*not routinely performed but may be used to r/o other causes
Nasal washings 🡪 monoclonal antibody testing
*pulse ox single best predictor of disease in children
tx
*supportive measures
*humidified oxygen
*IV fluids
*nebulized saline/racemic epi
*antipyretics
ADMIT:
*O2 sat <95-96%, <3mo, RR >70, nasal flaring, retractions, to atelectasis on CXR
Prevention in high-risk:
*Palivizumab during the first year of life for children <29wks, symptomatic chronic lung disease of prematurity, congenital heart disease, neuromuscular difficulties, immunodeficiency
Bronchiectasis definition, patho, causes, sx
Bronchiectasis: irreversible & abnormal dilation of bronchial tree that produces chronic respiratory symptoms
Acute Exacerbation: a deterioration in symptoms that require a change in regular treatment (e.g., adding antibiotics, ⇡ airway clearance techniques)
PATHO: 2 requirements
➀ an infectious insult
➁ impaired drainage, airway obstruction, or defect in host defense
Acquired bronchial obstruction: Congenital anatomical defects:
▪︎FB aspiration, tumors, COPD ▪︎bronchomalacia, bronchial cyst
▪︎hilar LAD (TB, histoplasmosis, sarcoidosis)
▪︎cartilage deficiency (Williams-Campbell)
▪︎allergic bronchopulmonary aspergillosis (ABPA)
Viral infections: adenovirus, influenza, HSV
Immunodeficiency states: Bacterial infections: S. aureus, pseudomonas
▪︎chronic granulomatous disease, IgG/IgA deficiency
Abnormal secretion clearance: ▪︎non-TB mycobacteria (MAC MC), smoking
▪︎primary ciliary dyskinesia (Kartagener syndrome)
▪︎cystic fibrosis ⇢ MC congenital cause
Classic S/SXS: chronic productive cough w/ mucopurulent & tenacious sputum + HX of exacerbations
▪︎cough most days of the week for months to years
▪︎cough (98%), daily sputum production, dyspnea
▪︎rhinosinusitis, hemoptysis, recurrent pleurisy
MC Exam Findings: crackles (MC, 75%), wheezing, digital clubbing (2%)
Bronchiectasis dx, tx
LABS: CBC, IgG, IgM, IgA, sweat chloride test for CF, sputum smear/culture for bacteria, mycobacteria, & fungi
PFTs: obstructive impairment MC
▪︎normal/⇣ FVC, ⇣ FEV1, ⇣ FEV1/FVC
CXR (nondiagnostic): linear atelectasis, dilated & thickened airways (tram or parallel lines, ring shadows on cross section), irregular peripheral opacities that may represent mucopurulent plugs
Multidetector CT (MDCT) or HRCT:
▪︎lack of tapering of bronchi (tram track appearance)
▪︎signet-ring sign: dilated, air-filled bronchus & pulmonary artery ⇢ airway-to-arterial ratio ≥1.5
▪︎airway visibility within 1cm of a costal pleural surface or
touching the mediastinal pleura
tx
▪︎smoking cessation
▪︎regular chest physiotherapy to clear secretions
▪︎nebulized hypertonic saline
Exacerbation prevention ⇢ ABX
▪︎indications: ≥3 exacerbations/year
▪︎duration: at least 3mo
⊖Pseudomonas ⇢ macrolide (azithromycin)
*sputum stains/culture to r/o
non-TB mycobacteria first
⊕Pseudomonas ⇢ inhaled ABX (tobramycin)
▪︎alt: aztreonam, colistin
⊕non-TB mycobacteria ⇢ triple ABX therapy
▪︎macrolide + rifampicin + ethambutol x1y
Other therapies in select patients:
▪︎bronchodilators, steroids
Vaccines: influenza annually, pneumococcal
Croup (Laryngeo-tracheitis) definition, sx, dx, tx
*inflammation of the larynx & subglottic airway
MC 6mo-6yrs; esp. in fall & winter
Etiologies:
*Parainfluenza type 1 MCC
*RSV (2nd MCC); adenovirus, rhinovirus
sx
*”seal-like barking” cough
*inspiratory stridor, hoarseness
*dyspnea, low-grade fever
URI sxs (coryza) 🡪 prior, during, or after
dx
Clinical dx
Frontal cervical x-ray:
*steeple sign
tx
Mild (no stridor at rest, no respiratory distress):
*supportive ⇢ cool humidified air mist, hydration, oxygen if SpO2 <92%
*dexamethasone
Moderate (stridor at rest w/ mild-mod retractions):
*dexamethasone PO or IM + supportive
*nebulized Epi
*observe 3-4hrs
Severe (stridor at rest w/ marked retractions):
*dexamethasone + nebulized Epi + hospitalization
Cystic Fibrosis definition, sx, dx, tx
Autosomal recessive exocinopathy
MC in Caucasians & Northern Europeans
PATHO: mutation in the CFTR gene leads to abnormal chloride & water transport across exocrine glands throughout the body, leading to thick, viscous secretions of the lungs, pancreas, sinuses, intestines, liver, & GU tract
sx
Infancy:
*meconium ileus (bowel obstruction)
*FTT
*diarrhea from malabsorption (may lead to rectal prolapse)
Pulmonary:
*MCC of bronchiectasis in the US (cough, sputum)
GI:
*malabsorption of fat-soluble vitamins ADEK
*steatorrhea, diarrhea
*recurrent pancreatitis (may lead to pancreatic insufficiency)
*distal intestinal obstruction
*biliary cirrhosis
*infertility due to azoospermia
*sinusitis
dx
Elevated sweat chloride (test of choice, most accurate)
*admin of pilocarpine (cholinergic drug = sweating)
*(+) = Cl ≥60mmol/L on 2 occasions
CXR: bronchiectasis, hyperinflation of the lungs
PFT: obstructive pattern
*hyperinflation: ↑ TLC, RV, RV/TLC, FRC
*obstruction: ↓ FEV1 (greater decrease), FVC, FEV1/FVC
DNA analysis: genotyping is not as accurate as sweat chloride testing because there are more types of mutations than those tested w/ genotyping
Low fecal elastase
tx
Antibiotics often needed
*macrolides (azithromycin, clarithromycin)
*cephalosporins (cefuroxime, cefixime)
*Amoxicillin-clavulanate
*FQs
*inhaled aminoglycosides
Airway clearance treatment
*inhaled bronchodilators, decongestants
*mucolytics
*inhaled recombinant human DNA (breaks down large amounts of DNA in the respiratory mucus that clogs up the airways)
Supportive:
*pancreatic enzyme replacement
*vitamin supplementation (ADEK)
*vaccinations (pneumococcal, flu)
*lung transplant
*pancreatic transplant
Foreign Body Aspiration definition, sx, dx, tx
Occurs when a foreign body enters the airways & causes choking
MC food – can be life-threatening
80% in mainstem or lobar bronchus right > left
Risk Factors: institutionalization, advanced age, poor dentition, alcohol, sedative use
sx
*inspiratory stridor (if high in airway)
*wheezing
*decreased breath sounds (if low in airway)
dx
CXR (expiratory radiograph)
*regional hyperinflation of the affected side
ABG: necessary for appropriately evaluating ventilation, may be useful for following the progression of respiratory failure when it is of concern
tx
Remove foreign body w/ a bronchoscope
*rigid bronchoscopy (children)
*flexible (adults)
Complications: pneumonia, ARDS, asphyxia
Nasal Foreign Body definition, sx, dx, tx
Button batteries & paired disc magnets can cause serious damage to nasal structures & merit urgent removal
MC children
sx
*persistent foul-smelling purulent unilateral nasal discharge in a young child
*absence of other respiratory sxs
dx
Visualization through PE
Sometimes 🡪 rigid or flexible fiberoptic endoscopy
Plain radiographs (button batteries, magnets)
tx
Removal w/ nasal speculum & Hartmann nasal forceps
*oxymetazoline prior to removal – shirks mucous membrane
Otolaryngology referral: non-visualized posterior FBs, impacted FBs, unsuccessful initial attemps at FB removal
Foreign Body in Ear definition, sx, dx, tx
Insects must be immobilized prior to removal 🡪 drown w/ mineral oil or viscous lidocaine before attempting removal
sx
Irrigation of the external ear can be uncomfortable for the child
Aggressive flushing can cause tympanic membrane perforation, so caution is advised while irrigating
dx: Visualization through PE
tx
Removal w/ warm irrigation w/ syringe, alligator forceps
*after each flush 🡪 check the external canal for retained FB fragments (can occur w/ insects)
*topical pain agents: benzocaine-anti-pyrene
Ocular Foreign Body definition, sx, dx, tx
Any object embedded in or adhering to the conjunctiva or cornea
Intraocular penetration can occur w/ seemingly minor trauma, particularly when FB result from high speech machines (drills, says, metal-on-metal), hammering, or explosions
sx
Metallic FB 🡪 rust ring
Trapped under lid 🡪 corneal abrasions (worsen w/ blinking)
dx
*slit-lamp exam w/ fluorescein staining w/ cobalt light illumination
Globe penetration 🡪 x-ray or CT
tx
*first 🡪 install topical anesthetic
*then 🡪 removal attempt w/ irrigation
*can attempt to remove w/ swab after visualization
Intraocular FB 🡪 immediate surgical removal by ophthalmologist
*systemic & topical abx indicated
Rust ring 🡪 treat as corneal abrasion
*ring will resorb gradually on its own
Hyaline Membrane Disease (Respiratory Distress Syndrome) definition, sx, dx, tx
Common problem in preterm infants (<30wks)
PATHO: deficiency of pulmonary surfactant in an immature lung resulting in high surface tension leading to instability of the lung at end-expiration, low lung volume, & decreased compliance 🡪 hypoxemia d/t atelectasis
Surfactant expressed in lung starting around 20th week of gestation
sx
*preterm infant!!!!!
Signs of respiratory distress:
*tachypnea
*nasal flaring
*expiratory grunting
*intercostal, subxiphoid, & subcostal retractions
*cyanosis
dx
CXR:
*low lung volume
*diffuse reticulogranular ground glass appearance
*air bronchograms
ABGs:
*hypoxemia that responds to oxygen admin
*PCO2: initially nml/slightly elevated *increases as disease worsens
*progression 🡪 hyponatremia
tx
*antenatal corticosteroids in all preterm infants (betamethasone IM x2)
Initial management
*positive pressure (nCPAP, NIPPV)
*supplemental oxygen
Surfactant administration
*endotracheal intubation
Bacterial Tracheitis “Bacterial Croup” definition, sx, dx, tx
*Invasive exudative bacterial infection of the soft tissues of the trachea
MCC: staphylococcus aureus
MC ages 3-5yrs
sx
“croup that doesn’t respond to croup tx”
*viral prodrome *cold-like sxs
*airway obstruction: stridor, barky cough, respiratory distress
*fever, odynophagia, dysphagia, hoarseness
*TOXIC APPEARING
dx
x-ray: “steeple sign”
endotracheal intubation & bronchoscopy
*used to confirm dx & obtain bacterial cultures
tx
*clindamycin or vancomycin PLUS a second-generation cephalosporin should be started promptly
*supportive measures
Pneumonia types/causes, MC ages
Community Acquired Pneumonia (CAP):
*S. pneumo MCC overall
Neonates (<28d):
Bacterial: group B strep & E. coli MC, Listeria monocytogenes, Chlamydia trachomatis (seen >2wks)
Viral: CMV, HSV
1-3mo: viral MC
Bacterial: S. pneumoniae, C. trachomatis, Bordetella pertussis
Viral: RSV, parainfluenza viruses
3mo-5yrs: viral MC
Bacterial: S. pneumoniae, H. flu (rare b/c vac), S. aureus, S. pyogenes, Mycoplasma pneumoniae
Viral: RSV (MC), rhinovirus, influenza, parainfluenza viruses, coronavirus, adenovirus
> 5yrs: bacterial MC
Bacterial: S. pneumoniae, M. pneumoniae, Chlamydia pneumoniae
Viral: influenza
Uncommon CAP pathogens in peds: M. catarrhalis, Klebsiella, Legionella, Pseudomonas
HAP (≥48h of admit): gram (-) rods, S. aureus (MRSA)
Special Populations:
Cystic Fibrosis: S. aureus, Pseudomonas, H. flu
Pneumonia sx
*FEVER + COUGH
*tachypnea, retractions, nasal flaring, grunting
Neonates/young infants: difficulty feeding, restlessness, fussiness
Neonates/infants/<5y: fever + leukocytosis may be only s/sxs
Older children/adolescents: pleuritic chest pain
PE: crackles, ↓ breath sounds, +egophony, +bronchophony, +whispered pectoriloquy, ↑ tactile fremitus,
Pathogen-specific s/sxs:
M. pneumoniae: often associated w/ extrapulmonary sxs (HA, photophobia)
Legionella: hyponatremia, GI sxs (diarrhea)
Atypicals: M. pneumoniae, Chlamydia, Legionella
Clues to Etiology:
Wheezing: atypical or viral
Afebrile: C. trachomatis
Sputum:
S. pneumo: rust-colored
S. aureus: salmon-colored
Klebsiella: currant jelly sputum
*M. pneumoniae MCC of “walking pneumonia”
Pneumonia dx
Clinical dx – other testing can be done for confirmation
CXR:
*lobar: bacterial
*interstitial: viral
Labs: only for hospitalized pts
*CBC: WBC >15,000 suggests bacterial
*CRP: >35-60mg/L suggests bacterial
*Procalcitonin: elevation suggests bacterial
*electrolytes: assess degree of dehydration
Microbiological Testing in Hospitalized Pts:
*blood culture
*sputum gram stain/culture
*PCR, immunofluorescence
Gram stain:
*S. pneumoniae: gram + diplococci
*H. flu: gram (-) coccobacilli
*S. aureus: gram + cocci in clusters
*Moraxella: gram (-) diplococci
*Klebsiella: plump gram (-) rods
*Pseudomonas: thin gram (-) rods
Indications for Admission:
*infants <3-6mo (exception: viral or C. trachomatis)
*hypoxemia; SpO2 <90% on room air
*dehydration
*mod/severe respiratory distress
*complications (effusion, abscess, etc.)
Pneumonia tx
CAP:
Neonates: ampicillin + gentamicin
*C. trachomatis: erythromycin
Outpatient, >3mo: amoxicillin +/- azithromycin
*PCN allergy: clindamycin, levofloxacin
Inpatient, >3mo: ampicillin +/- azithromycin
*PCN allergy: clindamycin, levofloxacin
Complicated: clindamycin + ceftriaxone
ICU: vancomycin + ceftriaxone
Atypical: typical tx + azithromycin
HAP: aminoglycoside (usually gentamicin) + (Bactrim, meropenem, ceftazidime, cefepime, or clindamycin)
VACCINATIONS:
PCV13: pts 6wks-5yrs
*2, 4, 6, 12-15mo
PPSV23: all pts ≥65yrs, younger pts w/ conditions that increase the risk for developing complications
RSV definition, sx, dx, tx
MCC of lower respiratory tract infections in children worldwide; virtually all children contract it by age 3
Leading cause of pneumonia & bronchiolitis in infants
sx
*rhinorrhea
*wheezing/cough *can persist months
*low-grade fever
*nasal flaring & retractions
*nail bed cyanosis
dx
Nasopharyngeal secretions RSV antigen test
CXR: diffuse infiltrates
tx
Indications for hospitalization: moderate tachypnea w/ feeding difficulties, visible retractions, & oxygen desaturation
*supportive: albuterol via nebulizer, antipyretics, humidified oxygen
*steroids (controversial)
*sxs resolve within 5-7d
Palivizumab (Synagis) Prophylaxis:
*infants born ≤28wks, 6d gestational age & <12mo at the start of RSV season
*infants <12mo w/ chronic lung disease of prematurity
*infants ≤12mo w/ hemodynamically significant CHD
*infants/children <24mo w/ chronic lung disease of prematurity necessitating medical therapy within 6mo prior to the beginning of RSV season
Also suggested for:
*infants <12mo w/ congenital airway abnormality or neuromuscular disorder that decreases the ability to manage airway secretions
*infants/children <24mo w/ cystic fibrosis
*infants/children <24mo who are profoundly immunocompromised
*infants/children <24mo undergoing cardiac transplantation during RSV season
