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STEP 2 Pulmonary > Pulmo. Pneumonia (09-24) (2) > Flashcards

Pulmo. Pneumonia (09-24) (2) Flashcards

1
Q

Pneumonia.
initial workup of fever and SpO2? 2

A

xray and SpO2

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2
Q

Pneumonia. initial workup. If xray negative?

A

–> bronchitis

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3
Q

Pneumonia. initial workup. If xray positive with cavitation?

A

–> If CXR is positive and there is cavitation –> cavitary lesion –> CT scan either fungus or TB or abscess.

Abscess: 3rd generation cephalosporins and clindamycin.

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4
Q

Pneumonia. initial workup. in xray positive with consolidation?

A

–> assess exposure to hospital.
HCAP –> pip-tazo and vancomycin.
CAP –> refer to empirical treatment table.

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5
Q

Pneumonia. initial workup. if HIV/AIDS?

A

–> sputum silver stain –> treat with TMP-SMX +/- steroids.

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6
Q

Pneumonia.
Classification. Community acquired?

A

non-hospitalized setting.

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7
Q

Pneumonia.
Classification. Health care assoc. pneumonia?

A

within 90 days of visiting healthcare.

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8
Q

Pneumonia.
Classification. Hospital-acquired?

A

develops >/= 48 hours after hospital admission.

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9
Q

Pneumonia.
Classification. ventilator acquired?

A

> /=48 hours after endotracheal intubation.

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10
Q

Pneumonia. Community.
most common mo?

A

step. pneumonia

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11
Q

Pneumonia. Community.
how acquired?

A

by aerosol inhalation and colonizes the nasopharynx

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12
Q

Pneumonia. Community.
clinical presentation?

A

Asymptomatic. Fever, cough. Rusty sputum

Aggressive serotypes or risk factors (age>65 or immunosuppression) –> severe disease.

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13
Q

Pneumonia. Community.
In children what mos?

A

Viral in < 5yo
cause: RSC

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14
Q

Pneumonia. Community.
Moraxella catharallis.

A

.

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15
Q

Pneumonia. Community.
H. influenza in what?

A

COPD

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16
Q

Pneumonia. Community.
Pseudomona aeruginosa. in what patients?

A

structural lung disease or CF

Suspect in chemo pts, green sputum.
Gram negative oxidase positive rod.

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17
Q

Pneumonia. Community.
Legionella. in what patients?

A

immunosupressed

Gram negative rod that stains poorly since it becomes intracellular.

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18
Q

Pneumonia. com. Legionella. epidemiology?

A

contaminated water: hospital/nursing, travel (hotel, cruise) - esp within 2 weeks

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19
Q

Pneumonia. com. Legionella. clinical? 5

A

> 38,8C
brady relative to high fever
Neuro symptoms (esp. confusion)
GI (vomiting, diarrhea, cramps)
Pulmonary symptoms delayed

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20
Q

Pneumonia. com. Legionella. diagnostics?

A

Hyponatremia
xray - pathy unilobular or interstitial infiltrates
Sputum gram stain - PMNs, few/no mo/s
URINE LEGIONELLA ANTIGEN

Hepatic dysfunction
Hematuria and proteinuria

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21
Q

Pneumonia. com. Legionella. treatment?

A

resp. fluoroquinolones or newer macrolides

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22
Q

Pneumonia. com. Legionella. unresponsivness to what?

A

unresponsive to beta-lactam and AMG

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23
Q

Pneumonia. com. Legionella. Diagnosis. the most common to diagnose?

A

urine antigen

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24
Q

Pneumonia. com. Legionella. Diagnosis.
Take culture from bronchoscopy

A
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25
Q

Pneumonia. com. Klebsiella in what patients?

A

alcoholics

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26
Q

Pneumonia. com.
Staph aureus in what patients?

A

post viral

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27
Q

Pneumonia. com.
Cl. psittachi in what patients?

A

birds (parrots)

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28
Q

Pneumonia. Influenza A and B.
Clinical?

A

● Fever, malaise, myalgias, and headache.
● Rhinorrhea, sore throat, nonproductive cough.
● Pharyngeal erythema on examination.

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29
Q

Pneumonia. com.
Cl. trachomatis in what patients?

A

staccato cough and eosinophils

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30
Q

Pneumonia. Influenza A and B. diagnosis?

A

swab

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31
Q

Pneumonia. Influenza A and B. Treatment?

A

No risk factors for influenza complications –> do not require
diagnostic testing and treated symptomatically.

● With risk factors (age >65, chronic medical problems,
pregnancy) –> oseltamivir the first 48 hours.

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32
Q

Pneumonia. Influenza A and B. prophylaxis?

A

vaccine

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33
Q

Pneumonia. Influenza A and B. Complications. 5 groups.

A

Influenza pneumonia

Secondary bacterial pneumonia by staphylococcus aureus and streptococcus pneumonia

Muscle: myositis and rhabdomyolysis.

Heart: myocarditis and pericarditis.

CNS: encephalitis and transverse myelitis.

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34
Q

Pneumonia. Influenza A and B. Complications. Influenza pneumonia. presentation and treatment?

A

Acute worsening of symptoms. Hypoxia.
x ray: Bilateral diffuse interstitial infiltrate.

Treatment: hospitalization with supplemental oxygen
and antiviral treatment required.

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35
Q

Pneumonia. Influenza A and B. Complications. strep/staph pneumo.

A

Strep is more common and more
gradual than staph.

Severe, necrotizing, and rapidly progressive with
staphylococcus aureus.

C/P: high fever, hypotension, dyspnea, hemoptysis, and confusion.

CXR: shows lobar or multilobar infiltrates with or without cavitation.

Treatment in the ICU and broad-spectrum antibiotics (vancomycin or linezolid) are given.

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36
Q

Pneumonia. what patients are at risk for influenza complications? table

A

Age >65
Pregnant/2 weeks postpartum
Chronic disease (pulm, cardio, renal, hepatic)
Immunosupression
morbid obesity
Native americans
Nursing home/chronic care residents

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37
Q

Pneumonia. Mycoplasma. what pneumonia?

A

mcc atypical

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38
Q

Pneumonia. Mycoplasma. assoc with what presentation?

A

erythema multiforme

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39
Q

Pneumonia. Mycoplasma. what agglutinin?

A

COLD

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40
Q

Pneumonia. Mycoplasma. what method for diagnosis?

A

PCR

41
Q

Pneumonia. Mycoplasma. accompanied by what manifestation?

A

extrapulmonary (GIT)

42
Q

Pneumonia. Mycoplasma. epidemiology? 3

A

respiratory droplets

close quarters/YOUNG (school, military)

Fall or winter

43
Q

Pneumonia. Mycoplasma. clinical? 3

A

INDOLENT headache, malaise, fever, PERSISTENT DRY COUGH

PHARYNGITIS (nonexudative)

Macular/vesicular rash

44
Q

Pneumonia. Mycoplasma. diagnostics?

A

Normal wbc
subclinical HEMOLYTIC anemia (cold agglutinins)
Interstitial infiltrates

45
Q

Pneumonia. Mycoplasma. treatment?

A

usually empiric
MACROLIDE or resp fluoroquinolones

46
Q

Pneumonia. Immunocompromised. what causes mo/s?

A

fungal
TB
PCP - TMP-SMX +/- steroids

47
Q

Pneumonia. Immunocompromised. Diagnosis?

A

CXR: lobar, interstitial, or cavitary infiltrate.

CT scan used in the immunocompromised.

48
Q

Pneumonia. Immunocompromised. treatment?

A

Smoking cessation.

Influenza and pneumococcal vaccination.

Repeat CXR in patients above the age of 50 to assess for malignancy
between 6 to 12 weeks post treatment of single episode of pneumonia.

49
Q

CURB65. what stands for?

1 point for every

A

Confusion
Urea > 20
Resp. >= 30k/min
BP s<90 or d<60
age >= 65

50
Q

CURB65.
if 0 points –>?

A

low mortality
Outpatient treatment

51
Q

CURB65.
if 1-2 points –>?

A

intermediate mortality
Likely inpatient treatment

52
Q

CURB65.
if 3-4 points –>?

A

High mortality
Urgent inpatient admission;

Possibly ICU if score > 4

53
Q

Empiric treatment CAP. outpatient? 2

A

Macrolide or doxycyline (healthy)

resp. Fluoroquinolones or beta lactam + macrolides (comorbidities)

54
Q

Empiric treatment CAP. outpatient in healthy what abs?

A

Macrolide or doxycyline (healthy)

55
Q

Empiric treatment CAP. outpatient in comorbidities what abs?

A

resp. Fluoroquinolones or beta lactam + macrolides (comorbidities)

56
Q

Empiric treatment CAP. Inpatient (nonICU).

A

Fluoroquinolones i.v

beta lactam + macrolides i.v

57
Q

Empiric treatment CAP. Inpatient (ICU). treatment

A

beta lactam + macrolides i.v

beta lactam + Fluoroquinolones i.v

58
Q

Empiric treatment CAP. what 1 abs can be also used outpatient?

A

amoxicillin (ospamox)

59
Q

Empiric treatment CAP. why avoid fluoroquinolones in elderly?

A

C. difficile infection, tendon rupture, and
aortic dissection (in those with aortic aneurysm, Marfan, Ehlers-danlos, advanced atherosclerosis, uncontrolled HTN).

Other ADRs of quinolones: encephalopathy, peripheral neuropathy, and QT interval prolongation.

60
Q

Empiric treatment CAP. If sepsis?

A

vancomycin + ceftriaxone.

61
Q

Empiric treatment CAP. Strong suspicion of pseudomonas?

A

Strong suspicion of pseudomonas: cefepime & levofloxacin.

62
Q

Hospital pneumonia. causes? 2 in general mentioned

A

MRSA
Pseudomona

63
Q

Hospital pneumonia. treatment. 2 abs

A

vanco and piptaz

64
Q

Hospital pneumonia. treatment, if no vanco?

A

linezolid

65
Q

Hospital pneumonia. treatment, if no piptaz?

A

meropenem

66
Q

CAP in school aged children. Lobar vs bilateral. lobar cause?

A

step pneumonia

67
Q

CAP in school aged children. Lobar vs bilateral. bilateral cause?

A

mycoplasma
Chlamydia pneumonia

viruses (rare)

68
Q

CAP in school aged children. Lobar vs bilateral. lobar clinical?

A

abrupt fever, cough, chest pain
Incr. WOB
Focal crackles

69
Q

CAP in school aged children. Lobar vs bilateral. bilateral clinical?

A

Fever, malaise, sore throat

PROLONGED, gradually worsening cough

Patient can often continue normal activities

Bilateral cracles, wheezing

70
Q

CAP in school aged children. Lobar vs bilateral. lobar treatment?

A

Oral amoxicilin (outpatient)

I/v ampicillin or ceftriaxone (if hospitalized)

71
Q

CAP in school aged children. Lobar vs bilateral. bilateral treatment?

A

Macrolides eg azytromycin

72
Q

Ventilator pneumonia. main cause?

A

leakage around the cuff

73
Q

Ventilator pneumonia. risk factors table?

A

Acid supression (PPI, H2R blocker, antacid)
Supine position
Pooled subglotic secretions
Paralysis/excessive sedation
Excessive patient movement while intubated
Frequent ventilator circuit changes

74
Q

Ventilator pneumonia. evaluation. what first instrumental?

A

chest x ray –> abnormal

75
Q

Ventilator pneumonia. evaluation. abnormal xray –> ?2

A

low resp tract CULTURE and MICROSCOPY

76
Q

Ventilator pneumonia. evaluation. while waiting culture. GIVE EMPIRIC. what 3 points about m/os coverage?

A

Gram positive coverage

Anti-pseudomonal and gram negative coverage

Consider MRSA coverage

77
Q

Ventilator pneumonia. evaluation. started empiric. Got negative cultures –>

A

discontinue antibiotics and evaluate for other causes

78
Q

Ventilator pneumonia. evaluation. started empiric. positive cultures with clinical improvement –>

A

narrow antibiotics according to culture results

79
Q

Ventilator pneumonia. evaluation. started empiric. positive cultures withOUT clinical improvement –>

A

likely Vent assoc pneumo

Consider changing abs.

Assess vent assoc pneumo complications (eg abscess, empyema)

Consider evaluating for other causes

80
Q

Ventilator pneumonia. presentation?

A

New pulmonary infiltrates

incr. resp. secretions

Signs of worsened respiratory status, such as worsening oxygenation, lower
tidal volumes, and increased inspiratory pressure.

Systemic signs of infection, such as fever, leukocytosis, and tachycardia.

81
Q

Ventilator pneumonia. causes what gram positive COCCI?

A

MRSA, streptococcus

82
Q

Ventilator pneumonia. causes what gram negative?

A

pseudomonas, E coli, klebsiella

83
Q

Ventilator pneumonia. why may be used CT?

A

to evaluate vent assoc pneumo (VAP) complications

84
Q

Ventilator pneumonia. prevention regarding position in bed?

A

Elevation of the head of the bed at 30-45 degrees to reduce retrograde
movement of gastric secretions.

Semirecumbent position.

85
Q

Ventilator pneumonia. prevention regarding secretions?

A

Continuous or intermittent suction of subglottic secretions to prevent pooling
above the endotracheal cuff.

86
Q

Ventilator pneumonia. prevention regarding patient movement?

A

Minimization of patient transport to prevent movement of the endotracheal tube.

87
Q

Ventilator pneumonia. prevention regarding gastric secretion medications?

A

Limited use of gastric acid inhibitors ((PPI or H2 blockers)) to reduce the burden of microorganisms in gastric secretions.

88
Q

Recurrent pneumonia. Involving same region of lung. 2 groups causes?

A

Local airway obstruction

Recurrent aspiration

89
Q

Recurrent pneumonia. Involving different regions of lung, causes? 3

A

Immunodeficiency (HIV, leukemia, CVID)

Sinopulmonary disease (CF, immotile cilia)

Noninfectious (vasculitis, BOOP = bronchiolitis obliterans with organizing pneumonia)

90
Q

Recurrent pneumonia. Involving same region of lung.
Local obstruction causes? 2

A

Extrinsic bronchial compression (neoplasm, adenopathy)

Intrinsic bronchial obstruction (bronchiectasis, foreign body)

91
Q

Recurrent pneumonia. Involving same region of lung.
Recurrent aspiration (region may vary depending on body position) 3 causes

A

Seizures
Alcohol or drug use
GERD, dysphagia

92
Q

Recurrent pneumonia. diagnosis?

A

Diagnosis by CT scan of the chest.

93
Q

Repeat x ray following pneumonia.
cia toks faktas:
In patients age >50, repeat chest X-ray to assess for malignancy is generally recommended between 6 and 12 weeks after treatment of FIRST pneumonia.

A

.

94
Q

V/Q in pneumonia. what mechanism? what filled, what about oxygen?

A

Alveoli filled with INFLAMMATORY EXUDATE, this leads to hypoxemia due to marked impairment of alveolar ventilation in affected portion of the lungs.

95
Q

V/Q in pneumonia. what V/q impairment?

A

The result is right-to-left intrapulmonary shunting, which leads to V/Q mismatch.

96
Q

V/Q in pneumonia. How hypoxemia may be corrected?

A

Hypoxemia may be corrected with increase in FiO2 on mechanical ventilation, but in case of large intrapulmonary shunting it might be difficult to correct to correct hypoxemia with supplemental oxygen

97
Q

Effect of positioning in pneumonia. affected lung UPward?

A

affected lung: decr. blood flow and poor ventilation of the affected lung (decr. both perfusion and ventilation)

normal lung: Gravity incr. blood flow to unaffected lung, leading to adequate gas exchange (incr. both perfusion and ventilation)

98
Q

Effect of positioning in pneumonia. affected lung downward?

A

normal lung: good ventilation, but decr. blood flow (decr. perfusion, incr. ventilation)

Gravity incr. blood flow but pneumonia causes decr. gas exchange (incr. perfusion, decr. ventilation)

99
Q

Any lung malignancy CT chest first. Never bronchoscopy even signs of obstruction

CT precedes bronchoscopy of recurrent pneumonia due to tumor obstruction.

A

.

STEP 2 Pulmonary (30 decks)

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