Pulmonary Clinical Medicine II: Pneumonia, PE, and ARDS Flashcards
What is the most common etiologic agent in community acquired pneumonia?
(Highlighted in his slides)
Streptococcus pneumoniae
What are important considerations when determining the treatment of community acquired pneumonia?
(Highlighted in his slides)
1) Patient history
2) Patient comorbidities
What comorbidity is associated with Alcoholism as a cause of community acquired pneumonia?
Step. pneumonia
Klebsiella Pneumonia
Acinetobacter Spp
Mycobacterium Tuberculosis
(SKAM)
What comorbidity is associated with COPD/Smoking as a cause of community acquired pneumonia?
H. Influenzae P. Aeurginosa Legionella spp. S. Pneumonisae Moraxella Catarrhalis
(SMH LP)
What comorbidity is associated with Structural lung disease (e.g. bronchiectasis) as a cause of community acquired pneumonia?
P. Aeruginosa
Burkholderia cepacia
Staph. Aureus
What comorbidity is associated with CA-MRSA, oral anaerobes, endemic fungi, and M. tuberculosis as a cause of community acquired pneumonia?
Lung abscess
Travel to what region is associated with Histoplasma capsulatum as a cause of community acquired pneumonia?
Ohio or St. Lawrence river valley
Travel to what region is associated with Hantavirus and Coccidioides spp. as a cause of community acquired pneumonia?
SW U.S.
Travel to what region is associated with Burkholderia pseudomallei and avian influenza virus as a cause of community acquired pneumonia?
SE Asia
What factor is associated with Legionella spp. as a cause of community acquired pneumonia?
Recent stay in hotel or cruise ship
Exposure to what animals is associated with H. capsulatum as a cause of community acquired pneumonia?
Bats or birds
Exposure to what animal is associated with Birds as a cause of community acquired pneumonia?
Chlamydia psittaci
Exposure to what animal is associated with Francisella tularensis as a cause of community acquired pneumonia?
Rabbits
Exposure to what animals is associated with Sheep or goat as a cause of community acquired pneumonia?
Coxiella burnetii
What comorbidity is associated with Pseudomonas aeruginosa as a cause of community acquired pneumonia?
Structural Lung Disease (Broncheitasis, CF, Severe COPD)
Immunocompromised
What comorbidity is associated with Staph aureus (MRSA and MSSA) as a cause of community acquired pneumonia?
Injection drug use
Amoxicillin or Doxycycline are given to which patients when treating community acquired pneumonia?
1) No comorbidity
2) No risk factor for P. aeruginosa or MRSA
Amoxicillin-clavulanate, Cefpodoxime, Cefuroxime, Azithromycin, Clarithromycin, or Levofloxacin are given to which patients when treating community acquired pneumonia?
Comorbidity present
What types of pneumonia follow the same consideration in treatment?
(Highlighted in his slides)
What are they increased risk for?
Hospital acquired pneumonia and ventilator acquired pneumonia (HAP and VAP respectively)
- Increased Mortality
- MDR pathogens with MRSA
- MDR pathogens without MRSA
- MRSA alone
What are the early onset etiologies of VAP and HAP?
1) Step pneumonia
2) H. influenzae
3) Enteric gram negative bacilli
What are the late onset etiologies of VAP and HAP?
Staph aureus (often MRSA)
It is common to still give broad spectrum antimicrobial plus metronidazole when empirically covering for?
Aspiration pneumonia
Clindamycin and moxifloxacin are used in the treatment of aspiration pneumonia in what setting?
What is the commonly associated dysfunction in aspiration pneumonia
Primary outpatient
Neurologic Dysfunction
Ceftriaxone + metronidazole or Ampicillin-sulbactam are used in the treatment of aspiration pneumonia in what setting?
Parenteral regimens
What is Transudate?
What are some causes of transudative pleural effusion?
Systemic influences on pleural fluid formation and resorption
1) HF
2) Cirrhosis with ascites
3) Nephrotic syndrome
4) Hypoalbuminemia
What are some causes of Exudative pleural effusion?
Local influences
1) Bacterial Pneumonia
2) Malignancy
3) PE
4) Viral infection
When is thoracentesis indicated for pleural effusions?
When do you combine diuresis with thoracentesis?
When should thoracentesis be done ASAP?
(Highlighted in his slides)
1) All effusions with > 1 cm layering in decubitus view
2) Effusion from HF
3) Effusion from infection
What is used to differentiate exudate and transudate effusions?
(Highlighted in his slides)
Light’s Criteria
What is Light’s Criteria?
Highlighted in his slides
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
What further testing does exudative effusion warrant?
1) pH
2) Glucose
3) CBC with diff
4) Microbiologic studies
5) Cytology (check for malignancy)
Acute respiratory distress syndrome (ARDS) develops rapidly and includes what symptoms?
(Highlighted in his slides)
1) Severe dyspnea
2) Diffuse pulmonary infiltrates
3) Hypoxemia
What is the key diagnostic criteria for ARDS?
Highlighted in his slides
PaO2 / FIO2 ≤ 300 mmHg
(Arterial partial pressure of oxygen in mmHg) / (Inspired O2 fraction)
*FYI normal range is >400 mmHg
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)
1) Alveolar edema and neutrophil inflammation
2) Diffuse alveolar damage
3) Bilateral opacities consistent with pulmonary edema
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)
1) Atelectasis
2) Reduced lung compliance
In the proliferative phase of ARDS, although most patients recover, some will develop?
(Highlighted in his slides)
1) Progressive lung injury
2) Pulmonary fibrosis
What body position may improve oxygenation when a patient is on mechanical ventilatory support?
(Highlighted in his slides)
Prone
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)
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
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)
1) Interstitial and alveolar edema
2) IV fluids
3) Sedation and even paralytic agents
4) Glucocorticoids
What are used for treatment of influenza A and B viruses?
When does it need to be started?
(Highlighted in his slides)
1) Neuraminidase inhibitors
2) Within 48 h of infection
What is the most frequent serious manifestation of both COVID-19 and influenza?
Pneumonia
How does ARDS present in high risk patients?
Highlighted in his slides
Deteriorate rapidly
What are the risk factors for CAP?
alcoholism, asthma, institutionalization, over age 70
decreased cough/gag reflex in elderly
What is the most important thing in making a diagnosis of pneumonia?
History and physical
What is the definition of HAP?
Infection acquired after at least 48hrs of hospitalization
HAP and VAP is at risk for
- Increased Mortality
- MDR Pathogens and MRSA
- MDR Pathogens without MRSA
- MRSA alone
