Pulmonary I Highlights Flashcards
List 2 common causes of chronic cough in adults:
1) Smoking
2) Post infectious (CAP, bronchitis, etc.)
List 2 of the least common causes of chronic cough in adults
1) Lung abscess
2) MTB
CAP is a(n) _________ infection of pulmonary _______________, acquired outside the hospital
acute; parenchyma
S. pneumoniae is one of the typical bacteria that causes what?
CAP
True or false: opportunistic organisms can cause CAP
True (also: atypical + typical bacteria & viral causes)
What respiratory virus that causes CAP is a current outbreak in China?
Human metapneumovirus
What are the 2 most common detected pathogens in CAP?
1) Streptococcus pneumoniae (pneumococcus)
2) Respiratory viruses
CAP causes:
1) Why has there been a decline in S. pneumoniae incidence?
2) What helped COVID-19 decline since the pandemic?
1) Vaccination
2) Vaccination
What can help defend against Influenza and other respiratory viruses [causes of CAP]
Vaccination for Influenza, and RSV
List at least 4 risk factors for CAP
1) Age (extremes)
Exposure (occupation, season, endemic)
2) Chronic comorbidity (highest risk = COPD)
3) Viral RTI
4) Impaired airway protection
5) Modifiable
6) Other lifestyle factors
1) What age range is a risk factor for CAP?
2) What 3 factors go into exposure risk for CAP?
3) What chronic comorbidity has the highest risk for CAP?
1) Extreme ages (young and old)
2) Occupation, season, endemic
3) COPD
List the important Sx of Bacterial CAP (lobar consolidation): Pneumococcus
Fever, cough, and sometimes with chills and rigors
What are 2 common abnormal vital signs that suggest pneumonia?
1) Fever (not always present)
2) Tachypnea (increased rate; pt will say SOB)
Exam findings with lobar pneumonia: typical bacterial CAP:
+/- Parapneumonic ______________ (dullness to percussion, decreased BS, increased tactile fremitus)
effusion
Abnormal breath sounds are also called?
Adventitious
Typical bacterial CAP:
1) What labs are req. for Dx?
2) What may help diagnose CAP if in doubt?
3) Diagnostic cultures and antigen testing only in ______________ CAP
1) None required for diagnosis
2) PA and lateral CXR
3) severe (treated inpatient)
Typical Bacterial CAP:
1) What labs are not often performed in non-severe CAP (treated in outpatient setting)?
2) What does pneumococcus look like on sputum gram stain?
3) What is not visualized on gram stain? (hint: obvious)
4) How is legionella visualized via lab values? [during outbreak or severe cases]
1) Optional labs
2) G+ cocci in pairs
3) Atypical bacteria
4) Legionella: hyponatremia, urinary antigens
Typical bacterial CAP: If severe or increased risk of mortality + co-morbid conditions, or increased risk for MRSA/Pseudomonas and patient admitted, then _______, _______, and ___________ testing are performed
labs, rads, and antigen
What do SNOUT And SPIN mean in the context of lab tests? (mnemonics)
SNOUT: Sensitive test Negative rules OUT the condition
SPIN: Specific test Positive rule IN the condition
CAP Dx: PA and lateral CXR appearance can suggest etiology, but is not _____________
reliable alone
What are 2 potential Sx of mycoplasma-induced CAP?
AOM & bullous myringitis
What is a common atypical bacteria that causes CAP?
Mycoplasma
Patients presenting with normal ________ and normal __________ are unlikely to have CAP
VS (vitals???); pulmonary exam
Take home message: S/S are not specific for ______, and _______is a DDX for most respiratory illnesses
CAP; CAP
1) Anodds ratio(OR) is a___________ that quantifies the strength of the______________ between two events, A and B.
2) The odds ratio is defined as the ratio of theoddsof _____________ taking place in the presence of B
1) statistic; association
2) event A
What 2 things do you base your decision on regarding what type of care (inpatient vs outpatient) to do for a pt w. CAP?
1) Clinical judgment
+
2) Validated clinical tools: assess risk of mortality
IDSDA recommends using ______________ (PSI); other outpatient guidelines recommend using _________ or CRB-65
Pneumonia Severity Index (PSI); CURB-65
What tool for scoring pneumonia mortality risk is favored by IDSA? What is the goal?
Pneumonia severity index or PORT score; det. envt. of care
IDSA says severe CAP = ____ major or ____+ minor criteria
1 major or 3+ minor
List the CURB 65
Confusion
Urea level (> 7 mmol/L or 20 mg/dL)
Respiratory rate > 30/min
Blood pressure SBP < 90 or DBP < 60
Age 65 +
Where is severe CAP treated?
Inpatient, usually ICU admission
For all CAP patients, inpatient or outpatient, at least __________day course of Rx recommended followed by evaluation for clinical recovery
5-day
True or false: macrolides are generally not appropriate monotherapy for low-risk CAP
True; resistance is high in most places
1) What is the Initial Empiric Management for CAP for pts who are outpatient, low risk, and without comorbidities
2) Who are considered low risk?
3) When should you re-evaluate a pt? Why?
1) Monotherapy (amox, doxy, azithro/ clarithro)
2) Ppl with no recent abx/ hospitalizatons in past 90d, no prev. isolate, no comorbidities
3) After 5 days of therapy for stable VS, MS, and able to eat
What are the 2 main options for Initial Empiric Management for CAP for pts who are outpatient with comorbidities?
1) Combined therapy: (augmentin or ceftriaxone) + (macrolide or dozy)
or
2) Monotherapy (resp. fluroquinolone)
What are the 2 main Empiric Management options for Non-Severe CAP for pts who are inpatient/ general ward?
*(no risks for MRSA or Pseudomonas also)
1) Combined therapy (Ceftriaxone IV + Macrolide PO/IV)
or
2) Monotherapy: resp. fluroquinolone
What is the Empiric Management Tx for Severe CAP for pts who are inpatient/ general ward?
*(no risks for MRSA or Pseudomonas also)
Combined therapy
(ceftriaxone + macrolide or resp. fluroquin.)
1) Should you use systemic corticosteroids in non-severe CAP?
2) What about in severe CAP?
1) Not recommended routine adjunct therapy in non-severe CAP
2) Adjunct corticosteroids in adults with severe CAP reduced 30 day all cause mortality, ICU and hospital stay, and no increase in adverse events
Abrupt onset “hit by a Mack truck” is a main Sx of what?
Influenza
What are 3 signs of influenza?
1) Influenza pneumonia
2) Acute worsening
3) RSV (bronchiolitis): wheezing
Influenza exam:
1) CC?
2) Onset?
3) Duration?
4) Timing
5) Character?
1) Flu-like
2) Abrupt
3) Days, 10+ days
4) Worsening symptoms
5) “Viral syndrome” + progressive pulmonary symptoms
Influenza exam:
1) A/A?
2) Radiation?
3) Associated Sx?
1) A/A: activity/supportive
2) Uncomplicated influenza to pulmonary, secondary bacterial, ARDS
3) Fever, HA, myalgias, URI progressing to LRT involvement with progressive dyspnea
For PJP pneumonia, list the:
1) CC
2) Onset, duration, + timing
3) Character
1) Acute SOB, cough, fever
2) Acute onset with progressive symptoms over days to weeks
3) Acute dry non-productive cough in at risk patient
PJP pneumonia:
1) A/A
2) Radiation
3) Assoc. Sx (2)
1) N/a
2) N/A
3) Progressive SOB/dyspnea, dry non-productive cough
Diffuse interstitial pulmonary infiltrates on CXR and ground glass appearance on CT are characteristic of what?
PJP
Fungal CAP:
1) What is a risk?
2) Where is it common? (give 3 locations and their assoc. etiologies)
“probably important to know”
1) Risk = Travel or activity
2)
a) Ohio/Mississippi river valley: blastomycosis
b) Desert SW USA,: San Joaquin Valley Fever (Valley Fever) coccidiomycosis
c) Birding or caving (bats): histoplasmosis
Histoplasmosis (potential cause of fungal CAP) is endemic & seen in ___________ and _______________ valley agriculture workers
Miss. and Ohio river
Fungal CAP: Cryptococcus neoformans is common in _________________, rare in healthy ppl
AIDS/immunosuppressed
1) What causes fungal pneumonia pathology?
2) What are the 2 Tx options?
1) Immune response to fungus
2) Fluconazole or itraconazole
What is the big difference between Pneumococcal conjugate vaccines (PCV) and Pneumococcal polysaccharide vaccine (PPSV)?
1) Pneumococcal conjugate vaccines (PCV) = durable mucosal immunity
2) Pneumococcal polysaccharide vaccine (PPSV) = not result in mucosal immunity
pneumococcal vax:
In adults 65+, PCV 15 is followed in how long by PPSV 23?
1 year
pneumococcal vax:
In high risk patients after childhood vaccination, PCV 15 followed in PCV 15 followed in ____________ (min of ____ weeks if clinically indicated) by PPSV 23
1 year (min of 8wks)
1) Any patient 6 months + not allergic to vaccine can be given what influenza vax?
2) Ages 2-49 (with exceptions) can get what vax?
1) Inactivated influenza vaccine (IIV3) or RNA influenza vaccine (RIV3)
2) Live attenuated influenza vaccine (LAIV)
True or false: RSV, Covid-19, and Influenza vaccines may not be given at same time. Explain
FALSE; RSV, Covid-19, and Influenza vaccines may be given at same time
-If choose to obtain separately, no minimum waiting time between jabs
Acute bronchitis:
1) If in patients with COPD, it would be characterized as what?
2) In asthma, this might trigger what?
1) If in patients with COPD - would be characterized as Exacerbation of COPD (ECOPD)
2) An asthma exacerbation
Acute bronchitis: What is it important to rule out? How is this done?
1) Pneumonia
2) Look for:
-Moderate to severe ill-appearing
-Dyspnea/DOE (resp. distress more likely indicate pneumonia vs bronchitis)
If you think a pt has acute bronchitis, but they have a lot of respiratory distress and abnormal vital signs, what should you suspect?
Pneumonia (DDx)
Is most acute bronchitis bacterial or viral?
Viral
“Supportive care and symptom management for viral infection” is the Tx for what?
Acute bronchitis
What may have adverse side effects w. acute bronchitis?
Decongestants/antihistamines
________________ combined with guaifenesin may provide symptomatic relief for acute bronchitis
Benzonatate (Tessalon pearls)
What is the recommendation regarding B2 agonist use for bronchitis?
Conflicting data, evidence does not support routine use, may benefit some patients with underlying pulmonary disease (asthma, copd)
What is a good herbal Tx for acute bronchitis?
Honey for acute cough in children over 12 months of age
Acute Bronchitis: Clinical summary
1) Cough and cold OTC meds should not be prescribed or recommended for respiratory illnesses in children under ___________ (Honey) (AAP)
2) You should consider using what 3 things to manage acute bronchitis symptoms?
1) < 4 y/o
2) Tessalon, guaifenesin, &/or honey
1) Bronchiolitis is associated with what?
2) Who is it mainly a problem in?
1) RSV (respiratory syncytial virus)
2) Infants and toddlers
Anaerobic pneumonia and lung abscess:
1) Onset, duration, timing
2) Location
3) Character
4) A/A
1) Insidious onset, persistent and progressive symptoms
2) Lungs
3) Cough with foul smelling purulent sputum
4) N/a
Anaerobic pneumonia and lung abscess:
1) Radiation
2) Assoc. Sx (at least 4)
1) Spread from primary site in lungs to adjacent, empyema; pleural effusion may result in systemic spread/symptoms
2)
a) Constitutional: fever, weight loss, malaise
b) Poor dentition, periodontal disease (altered oral flora w/ increased anaerobes)
c) Altered MS (ETOH, drugs, Anesthesia, Sz)
d) D/o of swallowing due to esophageal disease or neurologic d/o (stroke), NG tube, intubation
Anaerobic pneumonia and lung abscess:
1) What would imaging show if there’s a lung abscess?
2) DDxs?
3) What does necrotizing pneumonia look like?
4) What is empyema?
1) Solitary cavitary lesion surrounded by consolidation
2) Lung cancer, pulmonary MTB, infarction, granulomatosis with polyangiitis (Wegner)
3) Multiple areas of cavitation within an area of consolidation
4) Purulent pleural effusion
List the 1st and 2nd line Txs for anaerobic pneumonia
1) 1st line: Clindamycin (IV until improv., then PO) or Augmentin
2) 2nd line: Pen G IV + Metronidazole PO/ IV
What is Mendelson Syndrome?
“probably need to remember”
Acute aspiration of gastric contents
1 hospital acquired infection is what?
UTI
