Pulmonary (12%) Flashcards by Laura Gardner

What infectious organism most commonly causes PNA in an immunocompromised patient/a patient with structural abnormalities (i.e. cystic fibrosis, bronchiectasis)?

Pseudomonas aeruginosa

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On PE of a pt with pleural effusion, what should be observed with percussion?

Fremitus?

Breath sounds?

Dullness

Decreased

Decreased breath sounds

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Are foreign body aspirations more common on the right or left side? Why?

Right side: due to wider, shorter, more vertical right mainstem bronchus

Position may also influence location

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What are some examples of medications that can be used for long term/chronic control of asthma?

Which is the drug of choice?

Which is best for cold air/exercise?

Which is best for allergic rhinitis/ASA induced asthma?

Inhaled corticosteroids {drug of choice for long term, persistent}: Beclomethasone, Flunisolide, Triamcinolone

Longa Acting B2 Agonists (LABA) {bronchodilator}: Salmeterol, Formoterol

Mast Cell Modifiers {good for cold air and exercse}: Cromolyn, Nedocromil

Leukotrine modifiers/receptor antagonists (LTRA) {good for allergic rhinitis/ASA induced asthma}: Montelukast, Zafirlukast, Zileuton

Theophylline

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______ is a risk factor for developing asthma

Atopy

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What infectious orgnaism is most commonly responsible post-viral infxn (i.e. influenza) PNA?

Staphylococcus aureus

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In regards to timeline/timeframe, what is the difference between hospital acquired vs community acquired PNA in a pt who is admitted?

If developed PNA within 48 hours of admission, PNA is CAP

If developed PNA >48 hours post-admission, the PNA is hospital acquired

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What is the clinical course of IRDS with or without tx?

2-3 days

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_____ ______ leads to decreased fat absorption which in turn leads to steatorrhea, bulky (pale/dark), foul-smelling stools, weight loss, and Vitamin ____, ____, _____, ____ deficiency in a patient with CF.

Pancreatic insufficiency

pale

A, D, E & K

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What abx therapy is recommended as 1st line for patients with CAP, ICU?

Beta lactam + macrolide

Beta lactam + Broad spectrum FQ

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What is the mainstay of tx fro acute bronchiolitis?

Supportive, humidified O2 is the mainstay of tx

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What is the recommended course of managment for CF?

Airway clearance tx with bronchodilators, mucolytics, abx, and decongestants

Pancreatic enzyme replacement and supplementation of fat soluble vitamins (A,D,E & K)

Lung and pancreatic transplantation

Immunizations: pneumococcal, influenza

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What abx therapy is recommended as 1st line for patients with hospital acquired PNA?

Anti pseudomonal Beta Lactam and anti-pseudomonal AG or FQ

(Anti-Pseudomonal B-lactams: Piperacillin/tazobactam (Zosyn), Cefepime (Maxipime); lmipenem (Primaxin), Meropenem (Merrem), Ceftazidime)

+Vacomycin if suspect MRSA

Add Levofloxacin or Azithromycin if Legionella is suspected

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Gastric aspiration of a foreign body may cause what condition?

Acute Respiratory Distress Syndrome (ARDS)

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What is Samter’s triad?

Asthma

Nasal Polyps

ASA/NSAID allergy

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If a pt presents c/o fever, URI sx x1-2 days, and respiratory distress, what should be at the top of your DDx?

Acute bronchiolitis

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Patients with CF are infertile ____% of the time

95%

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In a pt with croup, what is seen on frontal cervical XR?

Steeple sign (subglottic narrowing of trachea), in 50% of pts

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On PE of a pt with PNA, what should be observed with percussion?

Fremitus?

Breath sounds?

Dullness to percussion

Increased tactile fremitus

Bronchial breath sounds, EGOPHANY

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What test is the single best predictor of dz in children w/ acute bronchiolitis?

Pulse ox (<96% admit to hospital)

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What infectious organism should be suspected in a patient with PNA and comorbid HIV or was a recent transplant recipient?

CMV

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Cystic fibrosis is an autosomal (recessive/dominant) inherited d/o of defective Cystic Fibrosis Transmembrane Receptor (CFTR) protein, which prevents _______ transport (water movement out of the cell), which leads to buildup of thick, viscous, mucus in what organs?

CF is a(n) (restrictive/obstructive) lung disease and (endocrine/exocrine) gland dysfunction.

recessive

chloride

lungs, pancreas, liver, intestines, and reproductive tracts

obstructive

exocrine (ex. pancreatic insufficiency)

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What time of year is acute bronchiolitis most common in?

Fall and spring

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What are three examples of atypical organisms that can cause PNA?

Chlamydophila Mycoplasma Legionella

Suspect CF if a full term infant who presents with a ____ \_\_\_\_\_ What is this due to? What else may a pt present with if they have CF?

meconium ileus (due to obstruction of intestine with meconium) Children may present with failure to thrive

Aspiration PNA is usually caused by what infectious organism? Most commonly presents in what lobe?

Anaerobes R lower lobe

What infectious organism causes PNA and is known to cause severe illness in ETOHics, debilitated pts, pts with chronic illness, and is associated with cavitary lesions?

*Klebsiella pneumoniae*

If a pt's sputum is foul-smelling, what infectious organism should be suspected to be the cause of the pt's PNA?

Anaerobes

What are the three main components of asthma pathophysiology?

Airway hyperreactivity: Extrinsic (Allergic), Intrinsic (Idiosyncratic) Bronchoconstriction Inflammation

When will a pt present with IRDS? What will they present with?

Shortly postpartum respiratory distress (tachypnea, tachycardia, chest wall retractions, expiratory grunting, nasal flaring, cyanosis)

What is another name for infant respiratory distress syndrome (IRDS)?

Hyaline membrane dz

On PE of a pt with PTX or obstructive lung dz, what should be observed with percussion? Fremitus? Breath sounds?

Hyperresonance Decreased Decreased breath sounds

If a CXR shows upper lobe (especially R upper lobe) w/ bulging fissure and cavitations, what infectious organism should be suspected to be the cause of the pt's PNA?

Klebsiella

If a pt's sputum is described as "currant jelly", what infectious organism should be suspected to be the cause of the pt's PNA?

Klebsiella

The PCV13 Pneumococcal conjugate vaccine is administered to children at what ages?

2, 4, 6, 12-15 months of age

If a pt's sputum is green, what infectious organism should be suspected to be the cause of the pt's PNA?

H. Flu, pseudomonas

What is the most common cause of viral PNA in children and infants?

RSV and parainfluenza

What abx therapy is recommended as 1st line for patients with CAP, inpatient?

Beta lactam + macrolide (or doxycycline) OR broad spectrum FQ

What is the most common acute complication of acute bronchiolitis? What is the most common complication seen later in life?

otitis media with S. pneumoniae asthma

In what situations would a child be given the PPSV23 Pneumococcal Polysaccharide vaccine (Pneumovax)

If they have a chronic dz

What is the most common cause of community acquired PNA?

*Streptococcus pneumoniae*

What is the 2nd most common cause of CAP?

*Haemophilus influenzae*

What is the primary test done in the dx of a pt with CF? What would be seen on CXR of a pt with CF? PFTs? What is the definitive test for dx, especially if sweat test is -? What organisms most commonly grow on sputum Cx?

**ELEVATED SWEAT CHLORIDE TEST**: ~60 mmol/L on two occasions after administration of Pilocarpine (*Pilocarpine is a cholinergic drug that induces sweating*) **CXR**: ***_bronchiectasis_*** (_CF MC cause ofbronchiectasis in US_) {***tram track appearance, signet ring sign***}; hyperinflation of the lungs **PFTs**: obstructive (often irreversible), May be a mixed with a restrictive pattern **DNA analysis**: definitive test (especially if sweat testing is -) **Sputum cx**: often grow Pseudomonas aeruginosa, Haemophilus injluenzae, or Staph aureus.

What is the most common viral cause of PNA in adults?

Influenza

What is asthma caused by?

Reversible hyperirritability of the tracheobronchial tree which leads to airway inflammation and bronchoconstriction

What is the most common chronic childhood disease?

Asthma

When does surfactant production begin in a neonate? When is enough surfactant produced?

24-28 weeks By 35 weeks

What is the MC cause of atypical/walking PNA?

*Mycoplasma pneumoniae*

What are two ways to dx a pt with an aspirated foreign body? Which one provides direct visualization and ability to remove FB?

**_Bronchoscopy_** provides direct visualization and ability to remove FB **CXR** (regional hyperinflation) _{(photo shows aspirated dental crown!)}

What abx therapy is recommended as 1st line for patients with aspiration PNA (anaerobes)?

Clindamycin or Metronidazole or Augmentin

What are some examples of medications that can be used as an adjunct to traditional asthma management?

IV Magnesium (bronchodiliator) Heliox Ketamine Omalizumab (anti-IgE antibody, used in severe uncontrolled asthma)

When is Ribavirin Rx'd to patients with Acute bronchiolitis?

Ribavirin ± administered if severe lung or heart dz or in immunosuppressed patients

What is the recommended tx for IRDS?

Exogenous surfactant given to open alveoli CPAP

Acute bronchiolitis is a (lower/upper) respiratory tract infxn of the (small/large) airways, that leads to the proliferation/necrosis of the bronchiolar epithelium, which produces obstruction from the sloughed epithelium, increased mucus plugging, and submucosal edema leading to ____ \_\_\_\_ ______ and variable obstruction.

lower small peripheral airway narrowing

What is the stepwise approach to tx of asthma? When is step down recommended?

Step down recommended if pt has controlled sx for \>3 months

What infectious agent is the most common cause of croup?

Parainfluenza virus type 1 ## Footnote *Can also be caused by adenovirus, RSV, and rhinovirus*

What is the best way to prevent acute bronchiolitis?

hand washing!

Croup is caused by inflammation to the (lower/upper) airway, whcih leads to swelling of the \_\_\_\_\_\_, resulting in stridor, \_\_\_\_\_\_, and what kind of cough?

upper airway trachea hoarseness "BARKING" cough

If a pt's sputum is rusty (blood-colored), what infectious organism should be suspected to be the cause of the pt's PNA?

Strep pneumoniae

What will be noted on pulmonary examination of a child with asthma?

Prolonged expiration with wheezing and hyperresonace

What infectious organism causes PNA that is **not** transmitted person to person, but rather is associated with outbreaks related to CONTAMINATED WATER SUPPLIES (air conditioners, cooling towers, etc)?

*Legionella pneumoniae*

What fungal etiology should be suspected in a pt with PNA who is immunocompromised?

Pneumocystis jirovechi (carinii) {PCP}

What is the best and most objective way to assess asthma exacerbation severity and patient response in the ED?

Peak Expiratory Flow Rate

What are some examples of quick relief medications for acute exacerbations of asthma? 1st line? Most effective and fastest?

B2 Agonists (SABA) {bronchodilators}: 1st line tx, most effective and fastest {2-5 min} [Albuterol] Anticholinergics (Antimuscarinics) {central bronchodilators}: [Ipratropium] Corticosteroids {antiinflammatory}: [Prednisone, Methylprednisolone]

Elderly pts with PNA may not present with respiratory sx, fever, or increased WBC, but instead may present with \_\_\_\_\_\_

AMS/depressed mental fxning

What are some potential risk factors for being born with hyaline membrane disease? ## Footnote *(i.e. race? sex? type of delivery? maternal conditions? what else?)*

**Caucasian**, **males** (*2x MC*), **C-section** delivery (*infant stress during delivery causes cortisol production in infant*), **perinatal infxns**, **multiple births** (*especially if premature*), **maternal DM** (*high insulin delays surfactant production*)

Patients with CF typically have recurrent respiratory infections, due to infectious organisms _________ and ____ \_\_\_\_\_

Pseudomonas and Staph aureus

What is the most common cause of acute bronchiolitis?

RSV

What is the classic triad of asthma?

Dyspnea Wheezing Cough (especially at night)

What abx therapy is recommended as 1st line for patients with CAP, outpatient?

Macrolide or Doxycycline +FQ if pt has comorbidities

How to manage mild croup? Moderate? Severe?

**Mild** (*no stridor at rest, no respiratory distress*): cool humidifier, hydration, dexamethsone provides significant relief **Moderate** (*stridor at rest with mild to moderate retractions*): Dexamethasone PO or IM, +/- Nebulized epinephrine; observer 3-4 hour, d/c home if improved **Severe** (*stridor at rest with marked retractions*): Dexamethasone and nebulized epinephrine and hospitalization

What is the gold standard diagnostic study for asthma? The finding?

Pulmonary function test reversible obstruction

What is the most common single cause of death in the 1st month of life?

Infant respiratory distress syndrome (hyaline membrane dz)

If a pt presents with severe asthma and/or status asthmaticus, what will be noted on PE?

inability to speak in full sentences PEFR \<40% predicted altered mental status (ominous) pulsus paradoxus (inspiratory JSBP\>10) cyanosis, "tripod" position, "silent chest" (no air exchange), tachycardia, severe tachypnea

When should you hospitalize a pt with PNA?

mulitlobar PNA, (+) neutropenia, or have comorbidities that may complicate treatment

What is IRDS/Hylaine membrane dz? What is it due to?

dz of premature infants secondary to insufficient surfactant production

What fungal organism should be suspected in a pt with PNA who is from the Ohio/Mississippi River basin and who may have also come into contact with bird/bat droppings?

Histoplasma capsulatum

There is an increased incidence of CF in patients of what race/descent? What is the avg life expectancy of a pt with CF?

Northern europeans, caucasian 36.8 years

What will be seen on CXR in a pt with IRDS?

bilateral diffuse reticular ground-glass opacities + air bronchograms domed diaphragms

What condition is described below? "young with bronchiectasis, pancreatic insufficiency, growth delays, and infertility"

Cystic fibrosis (CF)

Acute bronchiolitis is most commonly seen in patients aged \_\_\_\_-\_\_\_\_ after ____ infxn

2 months - 2 years viral infxn (i.e. RSV, adenovirus)

\_\_\_\_\_\_\_ are given to infants to help mature lungs if premature delivery expected (between 24 - 36 weeks)

Corticosteroids

CF may also lead to developing what other chronic conditions?

Pancreatitis, CF-induced Diabetes Mellitus, Biliary disease

In a pt with IRDS, there is a \_\_\_\_% survival rate w/ tx and normal return of lung fxn w/in \_\_\_\_

90% 1 month