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AGPC 4 > Pulmonary Infections > Flashcards

Pulmonary Infections Flashcards

1
Q

What is bronchophony?

A

abnormal transmission of sounds from the lungs or bronchi (“99” heard louder and more understandable than usual) => ALWAYS pathological

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2
Q

What are the normal pulmonary findings?

A

vesicular sounds on periphery, no adventitious sounds, resonance on percussion, symmetric tactile fremitus

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3
Q

What are the usual pulmonary findings with hypoinflation (e.g., pneumonia, mass, abscess)?

A

bronchial sounds on periphery, dullness on percussion, increased tactile fremitus, egophony (“E” sounds like “A”), whispered pectoriloquy (patient’s spoken word sounds louder), adventitious sounds (ronchi = snoring, rales/crackles = bubbling)

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4
Q

What are the usual pulmonary findings with hyperinflation (emphysema, asthma attack)?

A

hyper-resonance on percussion, decreased tactile fremitus, adventitious sounds (wheezing)

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5
Q

What are the usual pulmonary findings with community-acquired pneumonia?

A

low-grade temperature, decreased lung sounds, dullness on percussion, increased tactile fremitus, egophony, bronchophony, whispered pectoriloquy

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6
Q

What is the most common cause of community-acquired pneumonia?

A

Strep pneumoniae (60% of the time)

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7
Q

What is the best initial test for suspected pneumonia?

A

chest x-ray - pneumonia is not a clinical Dx/requires confirmation on CXR (infiltrate must be present and confirms Dx) => CXR does not indicate severity of infection or the etiology (causative organism) of the infection

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8
Q

What is an alternative test if CXR is negative but clinician has high suspicion of pneumonia?

A

CT scan of chest - provides greater definition of abnormalities

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9
Q

After confirming Dx of pneumonia, what is the best next step in management?

A

assess severity to determine which Abx to start - based on CURB-65 and clinical judgment

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10
Q

What is the CURB-65?

A

score 1 point for each of the following:
=> Confusion
=> Uremia (BUN > 19 mg/dL)
=> Respiratory distress (RR > 30/min or SOB)
=> BP low (SBP < 90 mmHg)
0-1 can go home - >= 2 should be hospitalized
clinical judgment - need to consider functional status of PT (living situation, ability to take meds, etc.)

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11
Q

What is the empiric coverage for pneumonia in a patient with no comorbidities and no previous Abx Tx (i.e., less likely to have been infected with a resistant strain)?

A

macrolides (azithromycin, clarithromycin, erythromycin) OR doxycycline => do not stop Abx until PT is afebrile for 48 hours (7 days usually acceptable and fever will reduce by 2 days)

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12
Q

What is the empiric coverage for pneumonia in a patient with comorbidities and/or has been treated with Abx in the past 3 months?

A

respiratory fluoroquinolone (levoflxacin, moxifloxacin, gemifloxacin) OR beta-lactam (high dose amoxicillin, amoxicillin/clavulanate, cefuroxime/Ceftin) + macrolide or doxycycline

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13
Q

What types of coverage are needed for pneumonia?

A

all types of organisms (Gram+, Gram-, atypicals)

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14
Q

What are the side effects of macrolides?

A

increased Q-T interval and diarrhea (erythromycin more likely than others to cause diarrhea)

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15
Q

In which PTs should fluoroquinolones be avoided?

A

those with bone disease, tendonitis, prolong QT interval

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16
Q

What are the differences between the two pneumococcal vaccines?

A

PCV13 - conjugated vaccine (produces more robust antibody response) and PPSV23 - covers a greater number of serotypes

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17
Q

Which PTs should receive PPSV23 vaccine?

A

those at intermediate risk - younger adults (< 65 YO) with comorbid conditions: cigarette smokers; chronic heart, liver or lung disease; asthma; DM; alcoholics

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18
Q

Which PTs should receive PCV13?

A

those at high risk - adults > 65 YO and those with immunocompromising conditions (HIV, cancer, anatomic asplenia, CSF leak)

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19
Q

Which organism causes tuberculosis?

A

Mycobacterium tuberculosis - aerobic, slow-growing bacilli transmitted via respiratory droplets

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20
Q

What are the S and S of TB?

A

indolent onset of low-grade fever, cough, fatigue; night sweats; sputum blood-tinged (hemoptysis); decreased lung sounds; dullness on percussion; increased tactile fremitus; egophony; whispered pectoriloquy

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21
Q

Which PTs are at highest risk for TB?

A

recent (< 5 years) immigrants from developing countries, people living with HIV (regardless of CD4 count), prisoners, homeless, IV drug users, healthcare workers, those with impaired immunity, those living in crowded conditions (TB transmission requires close and prolonged contact)

22
Q

Why are apical lobes of the lung more susceptible to TB?

A

higher oxygen tension in upper lungs (suggestive of TB, but not diagnostic)

23
Q

What is primary TB?

A

initial infection but no symptoms (too early to transmit)

24
Q

What is primary active TB?

A

infected, showing symptoms (e.g., coughing and fever), and able to transmit disease => approximately 5% of patients

25
Q

What is latent (dormant) TB?

A

body is able to contain the disease (positive PPD and Interferon Gamma Release Assay [IGRA] tests but negative CRX and no symptoms) => infected but not infectious

26
Q

What is secondary (reactivated) TB?

A

conditions that break down immunity (e.g., HIV or cancer) and physical stress break down body’s ability to contain TB - breaks down cell wall of granuloma so that infection can spread (reactivation most common in first 3-5 years) => PT is infected and infectious (positive PPD, Interferon Gamma Release Assay [IGRA], and CRX)

27
Q

What is the management of PTs with symptoms of TB and a positive CXR?

A

isolate PT until sputum culture negative 3X

28
Q

What is a granuloma?

A

macrophages create wall of T-cells around TB bacteria - organism is alive but contained

29
Q

What is acid-fast staining?

A

stain that affixes to organism (bleach will not clear)

30
Q

What is the best initial test in PT with suspected TB?

A

CXR (apical/upper lobes of lungs - will show cavitary lesions) - suggestive, not diagnostic => after CXR, sputum for acid-fast stain (will stain but is not sensitive since all organisms in family will stain) => start Tx

31
Q

Why is sputum culture not used for initial diagnosis of TB?

A

may take 4-6 weeks to grow - thick/waxy wall of organism and wall being created by macrophages take long to penetrate => “gold standard” - confirms diagnosis and used for drug susceptibility testing

32
Q

Why isn’t purified protein derivative (PPD) test diagnostic for TB?

A

Monteux test is only used for silent or latent TB (not active TB) - once PT tests +, will always test +

33
Q

What is the recommended Tx for active TB?

A

RIPE for at least 6 months (organism hard to kill and bacteria very slow growing):
=> Rifampin (RIF) - R = red eyes and tears (only Abx that can cause contraceptive failure)
=> Isoniazid (INH) - N = neurology symptoms (peripheral neuropathy due to washing out of pyridoxine/B6)
=> Pyrazinamide (PZA)
=> Ethambutol (ETM) - E = eye problems (optic neurities - stop med or decrease dose)
ALL cause hepatotoxicity

34
Q

What is the best method to assure adherence to Tx for TB?

A

DOT = directly observed therapy

35
Q

When is a PPD test indicated?

A

to screen asymptomatic patients at risk for latent TB: recent immigrants, immunocompromised, prisoners, health care workers, homeless, nursing home residents, alcoholics, close contacts of PTs with TB => once positive never needs to be repeated (will always be positive)

36
Q

When is a PPD considered positive?

A

=> > 5 mm induration (HIV, organ transplant recipients, steroid users, close contacts of those with active TB)
=> > 10 mm induration (recent immigrants, prisoners, health care workers, homeless, nursing home residents, alcoholics)
=> > 15 mm induration (those with no risk factors - should not be screened)

37
Q

What is the recommended treatment for latent TB (PPD +, CXR -, and no symptoms)?

A

INH for 9 months (especially those who have converted from negative to positive within 2 years)

38
Q

What is interferon gamma release assay (IGRA)?

A

blood test for TB - 2 tests available: Quantiferon-TB Gold and T-SPOT TB => measure exposure to M. tuberculosis (do not distinguish between active and latent TB)

39
Q

When is interferon gamma release assay (IGRA) indicated?

A

when PT is unlikely to return for results of PPD, more specific (does not cross react with BCG) => not approved in children < 5 YO

40
Q

What are the differentials for subacute cough?

A

=> GERD - heartburn, sour taste, hoarseness, positional cough (treat with PPI)
=> cough variant asthma - induced by cold or exercise (test with spirometry)
=> post-nasal drip - frequent throat clearing and Hx of allergic rhinitis (responds to Tx with nasal corticosteroids and decongestants)
=> pertussis - paroxysmal cough and post-tussive vomiting

41
Q

What organism causes pertussis?

A

Bordetella pertussis - spread via respiratory droplets

42
Q

What are the phases of infection with pertussis?

A

=> early (catarrhal) phase - 6 days - non-specific symptoms but tests are most specific in this period
=> paroxysmal - 6 weeks - children (“whooping” cough, post-tussive vomiting) and adults (prolonged cough and post-tussive vomiting)
=> convalescent period - 6 weeks

43
Q

What is the best Dx test for pertussis?

A 
#1 nucleic acid amplification test (NAAT) by  polymerase chain reaction (PCR) - sensitivity declines after 4 weeks and with recent Abx use
#2 culture - requires specific medium and 7-10 days to grow (sensitivity declines after 2 weeks and with recent Abx use)
=> CXR only to rule out pneumonia
44
Q

What is the best Tx for pertussis?

A

Azithromycin (Z-pak) for 5 days - reduces spread => need to treat close contacts

45
Q

Who should be vaccinated against pertussis?

A

those 19 and older (Tdap - NOT DTap) as a single booster (regardless of timing of Td)

46
Q

What is the next stage in management of a PT with symptoms of TB and abnormalities on a CRX?

A

place on respiratory isolation until infection is ruled in (positive acid-fast stain and culture) or out - PTs with confirmed TB can be treated at home => PT should wear surgical mask when seeing visitors or leaving home

47
Q

What should be the management of family member of PTs with confirmed TB?

A

asymptomatic - screen with PPD; symptomatic - CRX and sputum studies

48
Q

What is the best indicator of infectivity with TB?

A

acid-fast stain

49
Q

When should a negative PPD be repeated?

A

only in the case of close contact with active pulmonary TB or in the case of ongoing potential exposure to active pulmonary TB

50
Q

What is the two-step PPD?

A

performing two PPD tests within one week of each other => only recommended for patients who are being tested for the first time

51
Q

What is the rationale for a two-step PPD?

A

some people’s T-cells “remember” TB exposure better than other people’s - most people will respond to a PPD test with an induration within 48 hours => re-testing a week after stimulates the memory-impaired T cells to better “recall” the previous exposure and indurate (called “boosting”)

52
Q

What do positive PPD and IGRA indicate?

A

latent, asymptomatic TB (not active pulmonary disease)

AGPC 4 (22 decks)

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