PULMO-CAP, RAD Flashcards
infection or inflammation affecting the parenchyma of the lung.
Histology- alveolitis with exudates in the alveolar space
5.6 million cases annually, 1.1 million hospitalizations
Avg. hospital mortality 12%,
1-2% mortality for outpatients
Community Acquired Pneumonia
SNF or hospitalized 90 days
Hospital visit or dialysis 30 days
Chemo, wound care, iv meds in 30 days
VAP (ventilator associated pneumonia)
HCAP (Health care associated pneumonia)
Pathogenesis
o Direct inhalation of organisms
o Aspiration of oral contents
o deposits after hematogenous spread
o Direct penetration from a contiguous/contact site
Clinical manifestations
Cough fever sputum production chest pain dyspnea
o May viral prodrome
o May onset with shaking chills
o May prodrome with malaise,
headache, dry cough, abdominal pain, nausea or diarrhea
o Elderly patients may have odd symptoms or no symptoms at all
• Physical findings
Tachypnea
tachycardia
o Signs of consolidation
o Crackles only or normal sounds, Local aveoli
o Other parts of the exam may give a hint as to cause (dentition, clubbing)
What is present in a Lab workup?
Chest x-ray
Sputum for Gram stain and culture (look for absence of epithelial cells)
o Blood cultures
o CBC with differential, procalcitonin
o Legionella and pneumococcal urinary antigens (no cough), PCR for virus,
atypical pathogens- foreign, travel, IMC, fungal
o ? Bronchoscopy
o ABG- hypoxia, inc acid/base imbalance
o In > 50% of cases where they look hard no organism is ever found, <10% with standard workup
• Decision to hospitalize “art of medicine”
o Age > 65 years o Coexisting illness (alcoholism, COPD, diabetes) o Leucopenia, marked leukocytosis o Evidence of respiratory failure o Septic appearance o Lack of support at home
o ICU admission if:
SBP < 90
Multilobar disease, “double PNA” dec O@
PAO2/FIO2< 250- ABG
• Prophylaxis
Pneumococcal vaccine
anyone with chronic cardiopulmonary disease, renal disease, asplenia, HIV, age > 65
both PCV13 and PPSV23 given sequentially to all adults aged ≥65 years and to adults of any age who have underlying conditions
o Influenza vaccine
Age > 6 months
under 8 need two flu shots the first year vaccinated
You cannot get the flu from the flu shot
if sick, likely from prev. encounter. Split into lego pieces cannot form together to form flu.
Only major contraindication is allergy to chicken eggs
• Lung abscess
Results from aspiration of oral contents
Alcoholics, IVDA, altered mental status (CVA)
Poor oral hygiene
Hematogenous spread
o Sputum odor! o Gram stain shows mixed normal flora o Usually a polymicrobial infection o May require surgical drainage o Antibiotics needed to cover anaerobes and oral flora Clindamycin, Flagyl plus cephalosporin o Treatment needs to be prolonged
What are factor that inc risk of Penicillin-resistant and drug-resistant pneumococci?
Age > 65 years
• β-Lactam therapy within the past 3 months
• Alcoholism
• IMC (or w/ steroids)
• comorbidities
• Exposure to a child in a daycare center
What are factor that inc risk ofEnteric Gram-negative organisms?
- nursing home
- cardiopulmonary disease
- comorbidities
- Recent ABX therapy
What are factor that inc risk P aeruginosa
- bronchiectasis, lung structure
- Corticosteroid (>10 mg prednisone/day)
- Broad-spectrum ABX > 7 days in the past month
- malnutrition
What is organism and treatment for Outpatient CAP with No Cardiopulmonary Disease and No Modifying Factors
American/ATS • S pneumoniae • C pneumonia (alone or as mixed infection) • M pneumonia • H influenza • Viruses • Miscellaneous o Moraxella catarrhalis, Legionella spp, M tuberculosis, endemic fungi
Therapy
• Macrolide (azithromycin or clarithromycin) – OR –
• Doxycycline
What is organism and treatment for Outpatient CAP With Cardiopulmonary Disease and/or Modifying Factors
same enteric G- bacilli- not good Therapy-cover resistace, assist PCN • Selected β-lactam (cefpodoxime, cefuroxime, high-dose ampicillin (tid), amoxicillin/clavulante) - PLUS –
• Macrolide or doxycycline
- OR –
• Antipneumococcal quinolone alone qd (cardiac, tendon tears, c. diff)
What is organism and treatment for Hospitalized Patients with CAP w/ pseudomonal risk?
Probable organisms • SCHM • Aerobic Gram-negative bacilli • Legionella spp • Respiratory viruses o S aureus, M catarrhalis, M tuberculosis, endemic fungi
Therapy
• Selected β-lactam with antipneumococcal activity (ceftriaxone, cefotaxime, ampicillin/sulbactam, high-dose ampicillin), IV
- PLUS –
• Macrolide (choose oral or IV) or doxycycline (choose oral or IV)
- OR –
• Antipneumococcal quinolone alone, IV
What is organism and treatment for Hospitalized Patients with Severe CAP, Patients with no pseudomonal risk factors:
• S pneumoniae (including PRSP) • Legionella spp • H inflluenzae • Enteric Gram-negative organisms • S aureus • M pneumoniae or C pneumoniae • Respiratory viruses • Miscellaneous o M tuberculosis, endemic fungi
Therapy
• Macrolide or antipneumococcal quinolone, IV
- PLUS –
• Selected β-lactam with antipneumococcal activity (ceftriaxone, cefotaxime, ampicillin/sulbactam)
DELAYS or wrong= death
shotgun approach
What is organism and treatment for Hospitalized Patients with Severe CAP, Patients with no pseudomonal risk factors:
Patients with pseudomonal risk factors:
• S pneumonia (including PRSP) • Legionella spp • H influenza • Enteric Gram-negative organisms • S aureus • M pneumoniae or C pneumoniae • Respiratory viruses • Miscellaneous o M tuberculosis, endemic fungi
Therapy
• Ciprofloxacin PLUS antipseudomonal, antipneumococcal β-lactam (imipenem, meropenem, cefepime, piperacillin/tazobactam)
- OR –
• Nonpseudomonal quinolone (levofloxacin, gatifloxacin, moxifloxacin) or macrolide
PLUS antipseudomonal, antipneumococcal β-lactam (imipenem, meropenem, cefepime, piperacillin/tazobactam) PLUS aminoglycoside
Other types of PFTs available
Methacholine challenge
6 minute walk
Oxygen desaturation/titration study
Altitude study
Measurements of muscle strength (MVV, MIP, MEP)
Cardiopulmonary exercise test to determine the cause of dyspnea
Hyoxemia
High altitude V/Q < 1 Shunts- alveoli perfused but bronchi vessels cant get O2, obstructed so no air transfer Diffusion limitation Hypoventilation (elevated PaCO2)
Restrictive Lung Disease
Gold standard – Low Total Lung Capacity (TLC)
Less than 80% predicted
Restriction - parenchymal
lung tissue that results in a loss of parenchyma,
stiff (low compliance), and may result in abnormal gas exchange (hypoxemia) and eventually hypoventilation (high PaCO2)
Scarring post-infection, related to inhaled irritants (asbestos), or intrinsic process.
Compliance Curve
Normal – deflection point, smooth up.
Stiff or flat – parenchymal or pleural or chest wall (pulmonary fibrosis, pleural thickening, edema, stiff chest wall), delation
High – poor lung tissue – floppy (emphysema)
Do all patients with a low FVC (forced vital capacity) on spirometry have restrictive lung disease?
Do all patients with a low TLC (total lung capacity have restrictive disease?
Yes
No
Gas Exchange (V/Q) perfusion
heterogeneity of V/Q in all lungs.
Normal lung V/Q = 1
Obstruction V/Q < 1
Pulmonary vascular disease V/Q > 1
IPF Idiopathic pulmonary fibrosis
6th- 7th decade,
M>W,
smokers
S/S Gradual onset dyspnea, dry cough
Dry crackles on exam, interstitial changes on HRCT
Not due to other illness
IPF treatment
Supportive care (oxygen, pulm rehab) Anti-esoph reflux treatment Pirfenidone (anti-fibrotic) Nintedanib (TK inhibitor) Lung transplant
Sarcoid
Idiopathic illness of young adults
Non-caseating granulomas many organs
Blacks> whites
Pulmonary- restrictive disease or asymptomatic abnormal
CXR
Other Organs can be affected Cardiac (sudden death) Bone (always) Liver (always but doesn’t cause illness) Renal, including stones Eyes Skin (e nodosum) CNS
Sarcoid
Almost always requires a biopsy
referred to pulmonary
Treatment (if any)
Steroids
Extra-Parenchymal
Pectus excavatum Kyphoscoliosis-progressive and severe, leading to impairment of lung function and restriction Flail chest – acute Pleural disease Pleural effusions Ankylosing spondylitis
Obesity
Impairs lung excursion
Compresses diaphragms
Impairs inspiratory capacity
obesity-hypoventilation syndrome
Abdominal Processes
Distended bowel /obstruction
Trauma
Peritonitis
Compartment syndrome
Neuro-Muscular Diseases
ALS
Almost always progressive
Ascending paralysis
Progressive worsening of lung capacity – FVC followed
Daiphragmatic Paralysis
Unilateral or bilateral Trauma Surgery Idiopathic – maybe viral Can resolve Presents with dyspnea and/or recurrent atelectasis and pneumonias
Work of Breathing
physical activity driven by the drive to breathe by nerves to the respiratory muscles (diaphragm, intercostals, accessory) overcoming elastic load (lung compliance) and resistive load (airways).
In normal lungs, resting work of breathing is 3% of energy expenditure; whereas, at maximum exercise it is 10%
stiff lungs or obstructive diseases, the work is much greater
Dyspnea/Restriction
Primary symptom is dyspnea
Activation of stretch receptors from stiff lung leads to symptoms
stiff lung and work= drive to keep a normal PaO2 and PaCO2, the respiratory pattern is tachypnea,, small TV
Control of Ventilation
Drives to breathe:
Chemosensors: (hypoxemia, CO2, pH) in brainstem and carotid bodies
Mechanoreceptors: lung tissue, stretch
O2/CO2 homeostasis
