Pulmonary 2 Flashcards
Laryngotracheobronchitis - Croup
Viral inflammation of the upper and lower respiratory tract causing respiratory distress.
Etiology: parainfluenza virus type 1/adenovirus/RSV/rhinovirus
Age: children 6 months-3 years
Course: few days mild URI sxs followed by development of a hoarse voice, seal bark-like cough, stridor (at night). Self-limiting (3-7 days).
Severe cases: stridor at rest with nasal flaring and intercostal retractions.
Dx: CXR - look for steeple sign
DDX: with stridor: epiglottitis, foreign body, retropharyngeal abscess, diphtheria
Acute Bronchitis
Self-limited inflammation of the bronchus. Viral infection: A or B, parainfluenza, coronavirus, rhinovirus.
Sx: cough > 5 days with sputum production, may be purulent
PE: afebrile normally, wheezing, rhonchi indicates mucus in upper airways and clears with cough, normal percussion, no changes in voice transmission tests.
No labs or imaging are usually warranted, only if it seems to be developing in pneumonia.
DDx: chronic bronchitis, pneumonia, post-nasal drip, GERD, asthma
Pneumonia Classifications
Acute infection of alveolar spaces and/or interstitial tissue. Distinguish between bacterial, viral (50%), and mycoplasma.
Classifications:
A. community-acquired pneumonia: in US 8th most common cause of death. worse in winter, higher rates in males and AA. Pre-disposing conditions: malnutrition, immunocompromised, smoking, underlying lung disease. Common organisms: RSV, parainfluenza, influenza OR bacterial (s. pneumoniae, HIB, s. aureus, group A strep).
B. 1) hospital-acquired (nosocomial) pneumonia - onset within >48 hours.
2) ventilator-associated pneumonia
3) healthcare-associated pneumonia: occurs after extensive healthcare contact.
Common organisms: E. coli, Klebsiella, enterobacter spp. p aeruginosa, MRSA, HIB
Bacterial Pneumonia
Sx: cough with thick greenish or rust colored mucus, SOB, rapid breathing, sharp pleuritic pain worse with deep breaths, ab pain, severe fatigue.
Sputum: Bloody/rust (pneumococcus); green (pseudomonas, HIB); foul-smelling (anaerobic); currant jelly (klebsiella).
Also: pneumococcus: rigors or severe shaking chills, pleuritic chest pain. Legionella: HA, malaise, anorexia, n/v, diarrhea.
PE: patient LOOKs sick.
HIGH fever, tachycardia, bronchial breath sounds, positive ego phony, dullness to percussion, pallor, cyanosis, wheezes, rhonchi, crackles, increased tactile fremtitis
Streptococcus Pneumoniae
Pneumococcus pneumonia 60-80% Prognosis: mortality 5% Age: 2-50 - 90-95% survive Complications: meningitis, endocarditis Refer if: BUN >70, WBC
Klebsiella Pneumoniae
gram negative bacilli causes aggressive necrotizing lobar pneumonia
risk factors: alcoholism, lam nutrition, DM, COPD, >40yr, hospitalized
Prognosis: 40-60% if untreated
sx: cough, fever, pleuritic chest pain, dyspnea, spreads quickly. Extremely thick exudates that cant be expectorated - currant jelly sputum. Bradycardia.
Haemophilus Influenza
most commonly arises in the winter and early spring.
risk factors: asthma, COPD, smoking, immunocompromised
Staph Aureus
in IV drug abusers and debilitated persons. infx often spread through blood to the lungs from contaminated injection sites.
Legionella Pneumonia
gram negative bacteria - “legionnaire’s disease”
outbreaks from aerosolized organisms from air conditioning system or contaminated shower heads in hotels.
Risk factors: elderly, smokers, immune compromised, alcoholics, renal dz.
Unlike the other pneumonias LP is associated with GI symptoms >50% of the time: anorexia, n/v, diarrhea.
Pneumonia workup
CXR, CBC, CMP, CT, bronchoscopy, thoracentesis may be needed in advanced, unresolving patients.
Prognosis of bacterial Pneumonia
Sxs improve within 3-5 days of treatment. Typical duration of sxs: fever (2-4 days); cough (4-9 days) ; crackles (3-6 days); leukocytosis (3-4 days)
Unresolving sxs consider comorbidities, advancing age, aggressive organism, drug resistant bacteria, misdiagnosis.
Complications: lung abscess, pleural effusion, empyema
Viral Pneumonia
Caused by influenza virus, RSV, parainfluenza virus, adenovirus, paramyxovirus, CMV, varicella zoster, HSV, EBV, coronavirus.
Sx: malaise, HA, myalgia, Chest pain, sore throat, cough with scant sputum, dyspnea
PE: few findings, mild fever. possible to be worse in some patients.
Work up: CBC, CMP, CXR
Prognosis: good in most patients
SARS - severe acute respiratory syndrome
Corona virus
Airborne droplet transmission
Sx: high fever, dry cough, nasal congestion, dyspnea, chest pain, ms/joint pain, diarrhea, HA
Dx with PSR or ELISA
CXR with patchy infiltrates
25% of patients with sARS have residual pulmonary fibrosis
Other complications: organ failure, osteoporosis, depression
Mycoplasma Pneumonia - “Walking Pneumonia”
Difficult to culture, takes 7-21 days to grow
Sx: often benign, slow progression, may look like URI and resolves without treatment.
May have violent attacks of coughing with scant mucus, chills/fever, N/V. Dry cough can persist for a month to 6 weeks.
PE: nontoxic general appearance. Erythematous TMs or bulls myringitis in some pts. Mild pharyngeal erythema but no exudate, minimal or no cervical LA. Auscultation: no findings early but rhonchi, crackles and wheezes may be heard several days later. possible rash
Dx: with PCR, EIA serology
Prognosis: most resolve after several weeks as pt. regains strength.
Pneumocystis jirovecii pneumonia
Fungal infection
Causes mobility and mortality in people that are immune compromised/HIV/AIDS patients.
Sx: insidious onset of malaise, weight loss, night sweats, and low grade fever with dry cough. No expectorating sputum, too thick
More severe sxs: dyspnea, cyanosis, distress, chest pain, productive cough.
Complications: spontaneous pneumothorax and hypoxemia. Can also affect liver, spleen and kidney.
Coccidioidomycosis
Soil fungus - comes in with rain
Sx: self-limited URI, 1-3 weeks after exposure. Mostly subclinical. Fever, cough, chest pain, fatigue, dyspnea, HA, arthralgia, myalgia. May spread to other parts.
PE: crackles, pleural rubs, wheezing, decreased breath sounds from effusions.
Disseminated dz: erythema nodosum, meningitis, endocarditis, osteomyelitis, septic arthritis, synovitis.
Work up: CBC, CXR, skin testing, serology for IgM, sputum culture
Dx: clinical suspicion and history of possible exposure or travel to endemic area.
Prognosis: generally good, poor if pt. is immunocompromised.
Lung Abscess
Complication of pneumonia
necrosis of lung parenchyma, typically as a complication of aspiration or severe bacterial pneumonia.
Sx: history of unresolving pneumonia, fever, cough, your tasting sputum for > 2 weeks, night sweats, weight loss, hemoptysis, pleurisy.
Work up: seen as cavitation on CXR and CT
Pulmonary Tuberculosis
Mycobacterium TB infx that can spread through the lymph nodes and bloodstream to any organ but commonly the lungs. The bacteria live in tubercles in the body.
Sex: M>F 2:1
Age: most 25-44, especially in minorities. Median age otherwise is 62.
To be at risk exposure to organisms must be constant - living or working in close quarters with someone with active TB.
Primary TB infection
Organism enters lungs, inflammatory reaction holds organisms in chack. Only 10% of infected people will develop active disease. Remaining 90% show signs of no infection and cant spread the dz.
Active TB
Sx: Chronic productive cough >3 weeks - yellow/green sputum. hemoptysis, malaise, fatigue, anorexia, weight loss, low grade fever, night sweats.
PE: fever, hypoxia, LA, cachexia, tachycardia, abnormal lung sounds
May progress to TB pleurisy
Lab: PPD test, acid fast stain of sputum, WBC usually normal
Imaging: CXR reveals ipsilateral hillier adenopathy with atelectasis in upper lobes.
14% of cases progress to miliary TB
Pleurisy
Inflammation of the pleura, may lead to pleural effusion. Layers of pleura rub with inhalation, causing sharp pain.
May etiologies: infections, inhaled chemicals, lupus, RA, cancers, congestion: CHF, PE, trauma, abdominal conditions, lung infarction.
Sx: usually sudden onset of pain - stabbing pain, worse with coughing and deep breathing. Leading to rapid shallow breathing, holding breath, splinting of chest. May refer to shoulder or diaphragm. SOB.
PE: Fever if infectious cause, tachycardia
limited chest motion, decreased breath sounds.
