Pulmo. Pneumonia (09-24) (2) Flashcards
Pneumonia.
initial workup of fever and SpO2? 2
xray and SpO2
Pneumonia. initial workup. If xray negative?
–> bronchitis
Pneumonia. initial workup. If xray positive with cavitation?
–> If CXR is positive and there is cavitation –> cavitary lesion –> CT scan either fungus or TB or abscess.
Abscess: 3rd generation cephalosporins and clindamycin.
Pneumonia. initial workup. in xray positive with consolidation?
–> assess exposure to hospital.
HCAP –> pip-tazo and vancomycin.
CAP –> refer to empirical treatment table.
Pneumonia. initial workup. if HIV/AIDS?
–> sputum silver stain –> treat with TMP-SMX +/- steroids.
Pneumonia.
Classification. Community acquired?
non-hospitalized setting.
Pneumonia.
Classification. Health care assoc. pneumonia?
within 90 days of visiting healthcare.
Pneumonia.
Classification. Hospital-acquired?
develops >/= 48 hours after hospital admission.
Pneumonia.
Classification. ventilator acquired?
> /=48 hours after endotracheal intubation.
Pneumonia. Community.
most common mo?
step. pneumonia
Pneumonia. Community.
how acquired?
by aerosol inhalation and colonizes the nasopharynx
Pneumonia. Community.
clinical presentation?
Asymptomatic. Fever, cough. Rusty sputum
Aggressive serotypes or risk factors (age>65 or immunosuppression) –> severe disease.
Pneumonia. Community.
In children what mos?
Viral in < 5yo
cause: RSC
Pneumonia. Community.
Moraxella catharallis.
.
Pneumonia. Community.
H. influenza in what?
COPD
Pneumonia. Community.
Pseudomona aeruginosa. in what patients?
structural lung disease or CF
Suspect in chemo pts, green sputum.
Gram negative oxidase positive rod.
Pneumonia. Community.
Legionella. in what patients?
immunosupressed
Gram negative rod that stains poorly since it becomes intracellular.
Pneumonia. com. Legionella. epidemiology?
contaminated water: hospital/nursing, travel (hotel, cruise) - esp within 2 weeks
Pneumonia. com. Legionella. clinical? 5
> 38,8C
brady relative to high fever
Neuro symptoms (esp. confusion)
GI (vomiting, diarrhea, cramps)
Pulmonary symptoms delayed
Pneumonia. com. Legionella. diagnostics?
Hyponatremia
xray - pathy unilobular or interstitial infiltrates
Sputum gram stain - PMNs, few/no mo/s
URINE LEGIONELLA ANTIGEN
Hepatic dysfunction
Hematuria and proteinuria
Pneumonia. com. Legionella. treatment?
resp. fluoroquinolones or newer macrolides
Pneumonia. com. Legionella. unresponsivness to what?
unresponsive to beta-lactam and AMG
Pneumonia. com. Legionella. Diagnosis. the most common to diagnose?
urine antigen
Pneumonia. com. Legionella. Diagnosis.
Take culture from bronchoscopy
Pneumonia. com. Klebsiella in what patients?
alcoholics
Pneumonia. com.
Staph aureus in what patients?
post viral
Pneumonia. com.
Cl. psittachi in what patients?
birds (parrots)
Pneumonia. Influenza A and B.
Clinical?
● Fever, malaise, myalgias, and headache.
● Rhinorrhea, sore throat, nonproductive cough.
● Pharyngeal erythema on examination.
Pneumonia. com.
Cl. trachomatis in what patients?
staccato cough and eosinophils
Pneumonia. Influenza A and B. diagnosis?
swab
Pneumonia. Influenza A and B. Treatment?
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.
Pneumonia. Influenza A and B. prophylaxis?
vaccine
Pneumonia. Influenza A and B. Complications. 5 groups.
Influenza pneumonia
Secondary bacterial pneumonia by staphylococcus aureus and streptococcus pneumonia
Muscle: myositis and rhabdomyolysis.
Heart: myocarditis and pericarditis.
CNS: encephalitis and transverse myelitis.
Pneumonia. Influenza A and B. Complications. Influenza pneumonia. presentation and treatment?
Acute worsening of symptoms. Hypoxia.
x ray: Bilateral diffuse interstitial infiltrate.
Treatment: hospitalization with supplemental oxygen
and antiviral treatment required.
Pneumonia. Influenza A and B. Complications. strep/staph pneumo.
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.
Pneumonia. what patients are at risk for influenza complications? table
Age >65
Pregnant/2 weeks postpartum
Chronic disease (pulm, cardio, renal, hepatic)
Immunosupression
morbid obesity
Native americans
Nursing home/chronic care residents
Pneumonia. Mycoplasma. what pneumonia?
mcc atypical
Pneumonia. Mycoplasma. assoc with what presentation?
erythema multiforme
Pneumonia. Mycoplasma. what agglutinin?
COLD
Pneumonia. Mycoplasma. what method for diagnosis?
PCR
Pneumonia. Mycoplasma. accompanied by what manifestation?
extrapulmonary (GIT)
Pneumonia. Mycoplasma. epidemiology? 3
respiratory droplets
close quarters/YOUNG (school, military)
Fall or winter
Pneumonia. Mycoplasma. clinical? 3
INDOLENT headache, malaise, fever, PERSISTENT DRY COUGH
PHARYNGITIS (nonexudative)
Macular/vesicular rash
Pneumonia. Mycoplasma. diagnostics?
Normal wbc
subclinical HEMOLYTIC anemia (cold agglutinins)
Interstitial infiltrates
Pneumonia. Mycoplasma. treatment?
usually empiric
MACROLIDE or resp fluoroquinolones
Pneumonia. Immunocompromised. what causes mo/s?
fungal
TB
PCP - TMP-SMX +/- steroids
Pneumonia. Immunocompromised. Diagnosis?
CXR: lobar, interstitial, or cavitary infiltrate.
CT scan used in the immunocompromised.
Pneumonia. Immunocompromised. treatment?
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.
CURB65. what stands for?
1 point for every
Confusion
Urea > 20
Resp. >= 30k/min
BP s<90 or d<60
age >= 65
CURB65.
if 0 points –>?
low mortality
Outpatient treatment
CURB65.
if 1-2 points –>?
intermediate mortality
Likely inpatient treatment
CURB65.
if 3-4 points –>?
High mortality
Urgent inpatient admission;
Possibly ICU if score > 4
Empiric treatment CAP. outpatient? 2
Macrolide or doxycyline (healthy)
resp. Fluoroquinolones or beta lactam + macrolides (comorbidities)
Empiric treatment CAP. outpatient in healthy what abs?
Macrolide or doxycyline (healthy)
Empiric treatment CAP. outpatient in comorbidities what abs?
resp. Fluoroquinolones or beta lactam + macrolides (comorbidities)
Empiric treatment CAP. Inpatient (nonICU).
Fluoroquinolones i.v
beta lactam + macrolides i.v
Empiric treatment CAP. Inpatient (ICU). treatment
beta lactam + macrolides i.v
beta lactam + Fluoroquinolones i.v
Empiric treatment CAP. what 1 abs can be also used outpatient?
amoxicillin (ospamox)
Empiric treatment CAP. why avoid fluoroquinolones in elderly?
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.
Empiric treatment CAP. If sepsis?
vancomycin + ceftriaxone.
Empiric treatment CAP. Strong suspicion of pseudomonas?
Strong suspicion of pseudomonas: cefepime & levofloxacin.
Hospital pneumonia. causes? 2 in general mentioned
MRSA
Pseudomona
Hospital pneumonia. treatment. 2 abs
vanco and piptaz
Hospital pneumonia. treatment, if no vanco?
linezolid
Hospital pneumonia. treatment, if no piptaz?
meropenem
CAP in school aged children. Lobar vs bilateral. lobar cause?
step pneumonia
CAP in school aged children. Lobar vs bilateral. bilateral cause?
mycoplasma
Chlamydia pneumonia
viruses (rare)
CAP in school aged children. Lobar vs bilateral. lobar clinical?
abrupt fever, cough, chest pain
Incr. WOB
Focal crackles
CAP in school aged children. Lobar vs bilateral. bilateral clinical?
Fever, malaise, sore throat
PROLONGED, gradually worsening cough
Patient can often continue normal activities
Bilateral cracles, wheezing
CAP in school aged children. Lobar vs bilateral. lobar treatment?
Oral amoxicilin (outpatient)
I/v ampicillin or ceftriaxone (if hospitalized)
CAP in school aged children. Lobar vs bilateral. bilateral treatment?
Macrolides eg azytromycin
Ventilator pneumonia. main cause?
leakage around the cuff
Ventilator pneumonia. risk factors table?
Acid supression (PPI, H2R blocker, antacid)
Supine position
Pooled subglotic secretions
Paralysis/excessive sedation
Excessive patient movement while intubated
Frequent ventilator circuit changes
Ventilator pneumonia. evaluation. what first instrumental?
chest x ray –> abnormal
Ventilator pneumonia. evaluation. abnormal xray –> ?2
low resp tract CULTURE and MICROSCOPY
Ventilator pneumonia. evaluation. while waiting culture. GIVE EMPIRIC. what 3 points about m/os coverage?
Gram positive coverage
Anti-pseudomonal and gram negative coverage
Consider MRSA coverage
Ventilator pneumonia. evaluation. started empiric. Got negative cultures –>
discontinue antibiotics and evaluate for other causes
Ventilator pneumonia. evaluation. started empiric. positive cultures with clinical improvement –>
narrow antibiotics according to culture results
Ventilator pneumonia. evaluation. started empiric. positive cultures withOUT clinical improvement –>
likely Vent assoc pneumo
Consider changing abs.
Assess vent assoc pneumo complications (eg abscess, empyema)
Consider evaluating for other causes
Ventilator pneumonia. presentation?
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.
Ventilator pneumonia. causes what gram positive COCCI?
MRSA, streptococcus
Ventilator pneumonia. causes what gram negative?
pseudomonas, E coli, klebsiella
Ventilator pneumonia. why may be used CT?
to evaluate vent assoc pneumo (VAP) complications
Ventilator pneumonia. prevention regarding position in bed?
Elevation of the head of the bed at 30-45 degrees to reduce retrograde
movement of gastric secretions.
Semirecumbent position.
Ventilator pneumonia. prevention regarding secretions?
Continuous or intermittent suction of subglottic secretions to prevent pooling
above the endotracheal cuff.
Ventilator pneumonia. prevention regarding patient movement?
Minimization of patient transport to prevent movement of the endotracheal tube.
Ventilator pneumonia. prevention regarding gastric secretion medications?
Limited use of gastric acid inhibitors ((PPI or H2 blockers)) to reduce the burden of microorganisms in gastric secretions.
Recurrent pneumonia. Involving same region of lung. 2 groups causes?
Local airway obstruction
Recurrent aspiration
Recurrent pneumonia. Involving different regions of lung, causes? 3
Immunodeficiency (HIV, leukemia, CVID)
Sinopulmonary disease (CF, immotile cilia)
Noninfectious (vasculitis, BOOP = bronchiolitis obliterans with organizing pneumonia)
Recurrent pneumonia. Involving same region of lung.
Local obstruction causes? 2
Extrinsic bronchial compression (neoplasm, adenopathy)
Intrinsic bronchial obstruction (bronchiectasis, foreign body)
Recurrent pneumonia. Involving same region of lung.
Recurrent aspiration (region may vary depending on body position) 3 causes
Seizures
Alcohol or drug use
GERD, dysphagia
Recurrent pneumonia. diagnosis?
Diagnosis by CT scan of the chest.
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.
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V/Q in pneumonia. what mechanism? what filled, what about oxygen?
Alveoli filled with INFLAMMATORY EXUDATE, this leads to hypoxemia due to marked impairment of alveolar ventilation in affected portion of the lungs.
V/Q in pneumonia. what V/q impairment?
The result is right-to-left intrapulmonary shunting, which leads to V/Q mismatch.
V/Q in pneumonia. How hypoxemia may be corrected?
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
Effect of positioning in pneumonia. affected lung UPward?
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)
Effect of positioning in pneumonia. affected lung downward?
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)
Any lung malignancy CT chest first. Never bronchoscopy even signs of obstruction
CT precedes bronchoscopy of recurrent pneumonia due to tumor obstruction.
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