Pulmonary Disorders Flashcards
What is Community Acquired Pneumonia and what are the 2 most common causes?
1. acquired outside of the hospital setting & patient is not a resident of a long term care facility OR
2. patient that was ambulatory prior to admission who develops pneumonia within 48 hours of initial hospital admission
1. Streptococcus pneumoniae
2. Haemophilus influenzae
What is Hospital Acquired (nosocomial) Pneumonia?
pneumonia occurring > 48 hrs after hospital admission
often caused by Pseudomonas, MRSA
Atypical Pneumonia Organisms: Mycoplasma
MYCOPLASMA:** ear pain, **bullous myringitis, erythematous pharynx or TM. Persistent nonproductive cough
Send _serum cold agglutins_ as part of the diagnostic workup
Atypical Pneumonia Organisms: Chlamydophila
hoarseness, fever ⇒ respiratory symptoms after a few days
send IgM, IgG titers
Atypical Pneumonia Organisms: Legionella
Legionella: associated with GI Sx, î LFTs, hyponatremia
send legionella urine antigens + PCR
Chest XRAY of typical pneumonia** vs. **atypical pneumonia
typical pneumonia: lobar pneumonia
atypical pneumonia: diffuse, patchy interstitial or reticulonodular infiltrates
Diagnostic Workup of Pneumonia
A. CXR/CT Scan: CXR resolution may lag behind clinical improvment for weeks. A pleural effusion may be present (usually exudative)
- abscess formation ⇒ S. aureus, Klebsiella, anaerobes
- Upper lobe (especially R upper lobe) with bulging fissure, cavitations ⇒ Klebsiella
B. Sputum (gram stain/culture): utility debated. Gross sputum may reveal clues to pathogen
Physical Exam of Pneumonia
dullness to percussion
INCREASED fremitus
Bronchial breath sounds, EGOPHONY*
Treatment for CAP outpatient
Macrolide or Doxycycline 1st line**
Fluoroquinolones are only used first line if comorbid conditions/recent Abx use
Treatment for CAP, inpatient
ß lactam + macrolide (or doxycycline)
OR
broad spectrum FQ
What is the PCV13 Pneumococcal conjugate vaccine? (Prevnar)
What is Asthma?
reversible hyperirritability of the tracheobronchial tree ⇒ airway inflammation & bronchoconstriction
MC chronic childhood disease (10%)
1/2 develop < 10 y of age, another 1/3 by 40 yo
atopy is a risk factor*
What is Samter’s Triad?
1. asthma
2. nasal polyps
3. ASA/NSAID allergy
associated with atopic dermatitis
Pathophysiology of asthma
1. AIRWAY HYPERREACTIVITY:
extrinsic (allergic); associated with increased IgE
intrinsic (idiosyncratic): nonallergic triggers: infection (viral, URI), pharmacologic, occupational, exercise, emotional, cold air
2. BRONCHOCONSTRICTION: airway narrowing secondary to smooth muscle constriction, bronchial wall edema, and thick mucus secretion, collagen deposition, smooth muscle/mucosal hypertrophy
(brochoconstriction leads to air trapping)
decreased expiratory airflow
3. INFLAMMATION: secondary to cellular infiltration (T lymphocytes, neutrophils, eosinophils) & their pro-inflammatory cytokines (leukotrienes)
increased histamine from mast cells
Clinical Manifestations of Asthma
Classic Triad
1. dyspnea 2. wheezing 3. cough (esp @ night)
Physical Examination
1. prolonged expiration with wheezing, hyperresonance to percussion, decreased breath sounds, tachycardia, tachypnea, accessory muscle use
2. _severe asthma and status asthmaticus:_ inability to speak in full sentences, PEFR < 40% predicted, altered mental status, pulsus paradoxus (inspiratory, decreased SBP > 10), cyanosis, “tripod” position, “silent chest” (no air exchange)
Diagnostic Studies for Asthma
A. PULMONARY FUNCTION TEST: GOLD STANDARD
reversible obstruction (decreased FEV1, decreased FEV1/FVC)
B. Bronchoprovocation: methacholine challenge test (> 20% decrease in FEV1) + Bronchodilator challenge test ( > 12% increase in FEV1)
C. Peak Expiratory Flow Rate (PEFR): best and most objective way to assess asthma exacerbation severity & patient response in ED (PEFR > 15% from initial attempt = response to treatment)
D. Pulse Oximetry: < 90% indicative of respiratory distress
E. ABG
F. CXR: usually not helpful but can be used to rule out other etiologies
Management of Asthma: Quick Relief of Acute Exacerbation (Rescue Drugs)
1. Short Acting ß2 agonists (SABA): 1st line treatment
Albuterol
MOA: bronchodilator
SE: ß1 cross reactivity: tachycardia/arrhythmias, muscle tremors, CNS stimulation, hypokalemia
2. Anticholinergics
Ipratropium
MOA: central bronchodilator, inhibits nasal mucosal secretions
SE: thirst, blurred vision, dry mouth, urinary retention, dysphagia, acute glaucoma, BPH
3. Corticosteroids
predniose, methylprednisolone, prednisolone
MOA: anti-inflammatory. all but the mildest exacerbations should be discharged on a short course of oral corticosteroids (3 - 5 days)
SE: immunosuppression, catabolic, hyperglycemia, fluid retention, osteoporosis, growth delays
Management of Asthma: Long-Term (chronic control) maintenance
1. Inhaled Corticosteroids (ICS)
beclomethasone, flunisolide, triamcinolone
- Drug of choice for long term persistent asthma*
- MOA: cytokine & inflammation inhibition*
- SE: thrush*
2. Long-Acting ß2 Agonists (LABA)
Salmeterol, ICS/LABA Combo:Symbicort (Budesonide, Formoterol), Advair diskus (Fluticasone/ Salmeterol)**
- long acting ß2 agonists added to steroids ONLY if persistent asthma is not controlled with ICS alone*
- NOT used in acute exacerbations and LABAs are NOT used alone*
3. Mast Cell Modifiers
Cromolyn, Nedocromil
MOA: inhibits mast cell and leukotriene-mediated degranulation. used as prophylaxis only
inhibits acute phase response to cold air, exercise, sulfites
4. leukotriene modifiers/receptor antagonists (LTRA)
montelukast, zafirlukast, zileuton
useful in asthmatics with allergic rhinitis/aspirin induced asthma. prophylaxis only
SE: minimal, increased LFTs, HA, GI myalgias
Management of Asthma: adjuncts
IV Magnesium
bronchodilator
(decreased Ca2+-mediated smooth muscle contraction)
Heliox
decreases airway resistance because helium + oxygen is lighter than room air
Ketamine
IV anesthetic that has sedative, analgesic, and bronchodilator effects. may be useful as an induction, sedative agent in young, otherwise healthy population of intubated patients
OMALIZUMAB:
anti-IgE antibody** (inhibits IgE inflammation) **used in severe, uncontrolled asthma
Classification of Mild Persistent Asthma
- Sx > 2 days/week (but not daily)
- SABA use > 2 days/week (but not more than 1x per day)
- nighttime awakenings 3 - 4x per month
- minor limitation with activity
- FEV1 > 80% predicted
- FEV1/FVC normal
Management: inhaled SABA prn + low dose ICS
Classification of Moderate Persistent Asthma
- Sx daily
- SABA use daily
- nighttime awakenings > 1x/wk (but not nightly)
- some limitation with activity
- FEV1 60 - 80% predicted
- FEV1/FVC reduced by 5%
Management: Low dose ICS + LABA
or
Increase ICS dose (medium)
- or*
- Add LTRA*
Classification of Severe Persistent Asthma
- Sx throughout the day
- SABA use several times a day
- nighttime awakenings often, usually nightly
- extremely limited activity
- FEV1 < 60%
- FEV1/FVC reduced by > 5%
Management: High dose ICS + LABA
+ Omalizumab (anti-IgE drug)
Step Down/Step Up System for Asthma
What is a pneumothorax?
air in the pleural space
increasingly positive pleural pressure causes collapse of the lung
Types of Pneumothorax: Spontaneous
atraumatic and idiopathic. due to bleb rupture
1. Primary: no underlying lung disease*. mainly affects _t_all, thin men 20 - 40 yo, smokers, + family history of pneumothroax
2.
Types of Pneumothorax: traumatic
- iatrogenic: during CPR, thoracentesis, PEEP (ventilation), subclavian line placement
- other trauma: car accidents, etc.
Types of Pneumothorax: Tension
any type of pneumothorax in which the positive air pressure pushes lungs, trachea, great vessels & heart to the CONTRALATERAL SIDE
- immediately life-threatening*
- MC seen during trauma, mechanical ventilation or resuscitative efforts*
Clinical Manifestations of Pneumothorax
- Chest pain: usually _pleuritic, unilateral,_ non-exertional & sudden in onset; Dyspnea
- PHYSICAL EXAM
- Hyperresonance to percussion, decreased fremitus, decreased breath sounds over affected side
- unequal respiratory expansion, tachycardia, tachypnea
- tension pneumothorax: increased JVP, pulsus paradoxus, hypotension
Diagnosis of Pneumothorax
CXR with expiratory view preferred
– decreased peripheral lung markings (due to collapsed lung tissue)
– + companion lines (visceral pleural line running parallel with the ribs)
– deep sulcus sign on supine chest radiograph (air collection basally and anteriorly)
What is Pertussis? (whooping cough)
highly contagious infection secondary to Bordatella pertussis
- rarely seen due to widespread vaccination. Gram negative coccobaccillus.*
- MC seen in children < 2 yo*
Clinical Manifestations of Pertussis (whooping cough)
catarrhal phase ⇒ paroxysmal phase ⇒ convalescent phase
1. catarrhal phase: URI Sx lasting 1 - 2 weeks. most contagious during this phase
2. paroxysmal phase: severe paroxysmal coughing fits with inspiratory whooping sound after fits
+** **post coughing emesis
may develop subconjunctival hemorrhage from the increased pressure due to coughing fits
3. convalescent phase: resolution of cough (coughing stage may last up to 6 wks)
Diagnosis of Pertussis (whooping cough)
- PCR of nasopharnygeal swab: GOLD STANDARD. performed in the first 3 wks of Sx onset
- Lymphocytosis* 60 - 80% lymphocytes on differential. WBC count may be as high as 50,000
What is acute bronchiolitis?
lower respiratory tract infection of the small ariways ⇒ proliferation/necrosis of the bronchiolar epithelium produces obstruction from the sloughed epithelium. increased mucus plugging & submucosal edema leading to peripheral airway narrowing & variable obstruction
What is the MC cause of acute bronchiolitis?
respiratory synctial virus (RSV) (50 - 70%) RSV part of parayxovirus family*
other: adenovirus, influenza, parainfluenza, + mycoplasma pneumonia, chlamydia trachomatis
What are the risk factors for acute bronchiolitis?
infants < 2 yo MC affected (esp ~ 2 months)
- < 6 months of age exposure ot cigarettes, lack of breastfeeding, premature (< 37 wks gestation) & crowded conditions*
- MC in fall and spring*
Clinical Manifestations of acute bronchiolitis
fever, URI Sx 1 - 2 days ⇒ repiratory distress
(wheezing, tachypnea, nasal flaring, cyanosis, retractions + rales)
Management of acute bronchiolitis
1. supportive: humidified O2 mainstay of treatment
delivered by mask, tent, or hood. IV fluids. Acetaminophen/ibuprofen for fever. mechanical ventilation if severe.
2. Medications:** **play a limited role
+ ß agonists, + nebulized racempic epi
corticosteroids NOT indicated unless history of reactive airway disease
3. Ribavarin + administered if severe lung or heart disease or in immunosuppressed patients
Prevention for Acute Bronchiolitis
Palivizumab prophylaxis may be used in increased risk groups
HAND WASHING
RSV is highly contagious and is transmitted via direct contact with secretions and self-inoculation by contaminated hands
What is acute epiglottitis?
inflammation of epiglottitis that may interfere with breathing
medical emergency
Causes of acute epiglottitis
HAEMOPHILUS INFLEUNZAE TYPE B (Hib) MC***
reduced incidence due ot Hib vaccination. may rarely be caused by Streptococcus pneumoniae, S. aureus, GABHS
- MC in children 3 mnths - 6 yrs*
- Males 2x MC*
- DM is a risk factor in adults…*
Diagnosis of acute epiglottitis
- Laryngoscopy: definitive Dx** provides direct visualization but may provoke spasm
Cherry red epiglottits with swelling
- Lateral cervical radiograph: THUMB SIGN
- if high suspicion, do not attempt to visualize the epiglottits with a tongue depressor in children
Clinical Manifestations of acute apiglottitis
3 Ds - Dysphagie, Drooling, Distress
fever, odynophagia, inspiratory stridor, dyspnea, hoarseness, muffled voice, _tripoding_
suspect in pt with rapidly developing pharyngitis, muffled voice & odynophagia (painful swallowing) out of proportion to physical findings
What is laryngotracheitis (croup)?
inflammation MC secondary to acute viral infection of the UPPER AIRWAY (larynx, subglottis, trachea)
⇒
subglottic larynx/trachea swelling
- ⇒*
- stridor, BARKING cough, hoarseness*
What is the MC cause of laryngotracheitis (croup)?
PARAINFLUENZA type 1 MC cause**
also…adenovirus, RSV, rhinovirus, etc. Diptheria rare
15% of children experience croup in childhood (MC 6 months - 6 yrs)
MC in fall/winter
Diagnosis of laryngotracheitis (croup)
clinical Dx (once epiglottitis and foreign body aspiration are excluded)
Frontal cervical radiograph: STEEPLE SIGN** (subglottic narrowing of trachea) - 50%
Management of laryngotracheitis (croup)
- Mild: (no stridor at rest, no respiratory distress): cool, humidified air mist, hydration
Dexamethasone provides significant relief as early as 6 hours after single dose
-
Moderate: (stridor at rest with mild to moderate retractions): Dexamethasone PO or IM + supportive treatment + nebulized Epi
* should be observed for 3 - 4 hours of clinical intervention* - Severe: (stridor at rest with marked retractions) Dexamethasone + nebulized Epi and hospitalization
What is the organism for tuberculosis and how can you get it?
Mycobacterium tuberculosis
chronic infection leading to granuloma formation
inhalation of airborne droplets ⇒ mycobacterium reaches the alveoli & are ingested by alveolar macrophages
On a CXR where are the MC places for TB to occur? (reactivation, primary, and miliary TB)
- Reactivation: apical (upper lobe)
- Primary TB: middle/lower lobe
- Miliary TB (widespread dissemination): CXR shows small millet-seed like nodular lesion (2 - 4 mm)
Miliary TB is TB spread outside the lungs. What are some names for this?
Potts Dz is Tb to the spine
Scrofula is Tb to the cervical lymph nodes
Mycobacterium avium complex (MAC)
Mycobacterium avium and intracellulare
Transmission: soil/water (NOT person to person)
Sx occur RARELY in immunocompetent pts.
seen in HIV when CD4 < 50**
Clinical Manifestations of Mycobacterium Avium Complex (MAC)
- Pulmonary Infection: in immunocompetent: cough with sputum, fever, weight loss, bronchiectasis
- Disseminated: (in HIV pts) FUO, sweating, weight loss, fatigue, diarrhea, dyspnea, RUQ pain
- Lymphadenitis in children: cervical submandibular/maxillary
What is another name for enterobiasis?
Pinworms!!
Diagnosis and Mangement of enterobiasis (pinworms)
Dx: scotch tape test (early in AM) to look for eggs under a microscope
Management: Albendazole or Mebendazole
none are used in children < 2 yo
