Pulmonary Clinical Medicine II: Pneumonia, PE, and ARDS

Question 1

What is the most common etiologic agent in community acquired pneumonia?

(Highlighted in his slides)

Answer 1

Streptococcus pneumoniae

Question 2

What are important considerations when determining the treatment of community acquired pneumonia?

(Highlighted in his slides)

Answer 2

1) Patient history

2) Patient comorbidities

Question 3

What comorbidity is associated with Step. pneumonia and H. influenzae as a cause of community acquired pneumonia?

Answer 3

Alcoholism

Question 4

What comorbidity is associated with Step. pneumonia, M. catarrhalis, and H. influenzae as a cause of community acquired pneumonia?

Answer 4

COPD

Question 5

What comorbidity is associated with P. aeruginosa, Burkholderia cepacia, and Staphylococcus aureus as a cause of community acquired pneumonia?

Answer 5

Structural lung disease (e.g. bronchiectasis)

Question 6

What comorbidity is associated with CA-MRSA, oral anaerobes, endemic fungi, and M. tuberculosis as a cause of community acquired pneumonia?

Answer 6

Lung abscess

Question 7

Travel to what region is associated with Histoplasma capsulatum as a cause of community acquired pneumonia?

Answer 7

Ohio or St. Lawrence river valley

Question 8

Travel to what region is associated with Hantavirus and Coccidioides spp. as a cause of community acquired pneumonia?

Answer 8

SW U.S.

Question 9

Travel to what region is associated with Burkholderia pseudomallei and avian influenza virus as a cause of community acquired pneumonia?

Answer 9

SE Asia

Question 10

What factor is associated with Legionella spp. as a cause of community acquired pneumonia?

Answer 10

Recent stay in hotel or cruise ship

Question 11

Exposure to what animals is associated with H. capsulatum as a cause of community acquired pneumonia?

Answer 11

Bats or birds

Question 12

Exposure to what animal is associated with Chlamydia psittaci as a cause of community acquired pneumonia?

Answer 12

Birds

Question 13

Exposure to what animal is associated with Francisella tularensis as a cause of community acquired pneumonia?

Answer 13

Rabbits

Question 14

Exposure to what animals is associated with Coxiella burnetii as a cause of community acquired pneumonia?

Answer 14

Sheep or goat

Question 15

What comorbidity is associated with Pseudomonas aeruginosa as a cause of community acquired pneumonia?

Answer 15

Immunocompromised

Question 16

What comorbidity is associated with Staph aureus (MRSA and MSSA) as a cause of community acquired pneumonia?

Answer 16

Injection drug use

Question 17

Amoxicillin or Doxycycline are given to which patients when treating community acquired pneumonia?

Answer 17

1) No comorbidity

2) No risk factor for P. aeruginosa or MRSA

Question 18

Amoxicillin-clavulanate, Cefpodoxime, Cefuroxime, Azithromycin, Clarithromycin, or Levofloxacin are given to which patients when treating community acquired pneumonia?

Answer 18

Comorbidity present

Question 19

What types of pneumonia follow the same consideration in treatment?

(Highlighted in his slides)

Answer 19

Hospital acquired pneumonia and ventilator acquired pneumonia (HAP and VAP respectively)

Question 20

What are the early onset etiologies of VAP and HAP?

Answer 20

1) Step pneumonia
2) H. influenzae
3) Enteric gram negative bacilli

Question 21

What are the late onset etiologies of VAP and HAP?

Answer 21

Staph aureus (often MRSA)

Question 22

It is common to still give broad spectrum antimicrobial plus metronidazole when
empirically covering for?

Answer 22

Aspiration pneumonia

Question 23

Clindamycin and moxifloxacin are used in the treatment of aspiration pneumonia in what setting?

Answer 23

Primary outpatient

Question 24

Ceftriaxone + metronidazole or Ampicillin-sulbactam are used in the treatment of aspiration pneumonia in what setting?

Answer 24

Parenteral regimens

Question 25

What are some causes of transudative pleural effusion?

Answer 25

1) HF
2) Cirrhosis with ascites
3) Nephrotic syndrome
4) Hypoalbuminemia

Question 26

What are some causes of Exudative pleural effusion?

Answer 26

1) Malignancy
2) PE
3) Viral infection

Question 27

When is thoracentesis indicated for pleural effusions?

When do you combine diuresis with thoracentesis?

When should thoracentesis be done ASAP?

(Highlighted in his slides)

Answer 27

1) All effusions with > 1 cm layering in decubitus view
2) Effusion from HF
3) Effusion from infection

Question 28

What is used to differentiate exudate and transudate effusions?

(Highlighted in his slides)

Answer 28

Light’s Criteria

Question 29

What is Light’s Criteria?

Highlighted in his slides

Answer 29

At least one of the following:

1) Pleural fluid/serum protein ratio > 0.5
2) Pleural fluid LDH greater than two-thirds of the laboratory normal upper limit
3) Pleural/serum LDH ratio > 0.6

Question 30

For which type of effusion should pleural fluid also be tested for pH, glucose, CBC with differential, microbiologic studies, and cytology?

Answer 30

Exudative effusions

Question 31

Acute respiratory distress syndrome (ARDS) develops rapidly and includes what symptoms?

(Highlighted in his slides)

Answer 31

1) Severe dyspnea
2) Diffuse pulmonary infiltrates
3) Hypoxemia

Question 32

What is the key diagnostic criteria for ARDS?

Highlighted in his slides

Answer 32

PaO2 / FIO2 ≤ 300 mmHg

Arterial partial pressure of oxygen in mmHg) / (Inspired O2 fraction

Question 33

What is the exudative phase of ARDS characterized by?

There is subsequent development of hyaline membranes from?

What does CXR reveal?

(Highlighted in his slides)

Answer 33

1) Alveolar edema and neutrophil inflammation
2) Diffuse alveolar damage
3) Bilateral opacities consistent with pulmonary edema

Question 34

In the exudative phase of ARDS, the alveolar edema, which is most prominent in the dependent portions of the lung, causes?

(Highlighted in his slides)

Answer 34

1) Atelectasis

2) Reduced lung compliance

Question 35

In the proliferative phase of ARDS, although most patients recover, some will develop?

(Highlighted in his slides)

Answer 35

1) Progressive lung injury

2) Pulmonary fibrosis

Question 36

What body position may improve oxygenation when a patient is on mechanical ventilatory support?

(Highlighted in his slides)

Answer 36

Prone

Question 37

In ARDS, alveolar collapse can occur due to alveolar/interstitial fluid accumulation and loss of surfactant which worsens hypoxemia, therefore how is this prevented with mechanical ventilatory support?

(Highlighted in his slides)

Answer 37

Low tidal volumes are combined with the use of positive end-expiratory pressure at levels that strive to minimize alveolar collapse and achieve adequate oxygenation with the lowest required FIO2

Question 38

Pts with ARDS have increased pulmonary vascular permeability leading to?

Therefore, what should they receive only as needed in order to achieve adequate cardiac output and tissue O2 delivery?

What do most patients require as an ancillary therapy?

What should be avoided in the treatment of ARDS?

(Highlighted in his slides)

Answer 38

1) Interstitial and alveolar edema
2) IV fluids
3) Sedation and even paralytic agents
4) Glucocorticoids

Question 39

What are used for treatment of influenza A and B viruses?

When does it need to be started?

(Highlighted in his slides)

Answer 39

1) Neuraminidase inhibitors

2) Within 48 h of infection

Question 40

What is the most frequent serious manifestation of both COVID-19 and influenza?

Answer 40

Pneumonia

Question 41

How does ARDS present in high risk patients?

Highlighted in his slides

Answer 41

Deteriorate rapidly