Quiz 1 Flashcards
Because Steve is probably going to ask and you haven’t thought about the dyspnea pyramid since December because fuck that thing, what are the parts that make up the base of the pyramid?
Lungs
Vasculature
Airways
Alveoli
Parenchyma
Pleura
Diaphragm
What constitutes the middle of the dyspnea pyramid and what are its components?
Heart
Valves
Plumbing
Pump
Wiring
What constitutes the top of the dyspnea pyramid and what are its components?
Anemia
Anxiety
Acidosis
Neuromuscular weakness
What is a significant distinction between CAP and NAP?
CAP is commonly caused by a set of pathogens that respond to certain drug combinations. Pathogens that are associated with NAP tend to be more difficult to treat as they were acquired in a hospital setting and are therefore more likely to have drug-resistance
What is the story with Health care associated PNA and why do we give a shit?
Category introduced in 2005 with the goal of producing guidelines on nosocomial PNA that would produce criteria which could be utilized to identify patients at risk for developing NAP and treat them accordingly
Didnt fucking work, is no longer a thing. Some people dont know this. Educate them.
A disease process that causes inflammation and affects the gas exchange areas of the lungs which is most commonly caused by infection is called what?
Pneumonia (PNA)
Describe pneumonia
An inflammatory process that primarily affects gas exchange areas of the lungs and is most frequently caused by infection
PNA comes in a lot of flavors. What are some of the most common categories of PNA?
Community acquired PNA (CAP)
Nosocomial PNA (NAP?)
Hospital Acquired PNA (HAP)
Ventilator associated PNA (VAP)
Describe prevalence in regards to epidemiology
The term for the number of people in a given population with the disease
Describe incidence in relation to epidemiology
The rate at which a disease appears
Number of cases per given time period in a given population in a given area
Describe the mortality rates associated with CAP
7% of hospitalized patients
12% of hospitalized patients over the age of 65
Why do we care so much about preventing patients from getting pneumonia in a hospital setting?
Contracting PNA in the hospital particularly post-op significantly increases mortality rates particularly in geriatric populations and we already have enough issues with stupid people not believing medicine works
T/F: the worldwide leading cause of mortality in infants and children is dark wizards with grudges
False. PNA is the worldwide leading cause of mortality in children and infants
Which populations are most at risk for dying from PNA or PNA related complications?
Infants or young children
Geriatric patients
T/F: Lung diseases such as COPD, bronchiectasis and asthma do not increase the risk of CAP
False. Lung diseases such as COPD bronchiectasis and asthma significantly increase the risk of CAP
What non-respiratory comorbidities increase the risk of CAP
Congestive heart failure
Stroke
Diabetes mellitus
Malnutrition
Immunocompromise
T/F: PNA can result from viral respiratory tract infections
True.
Can result in viral pneumonia and secondary bacterial pneumonia
How does impaired airway protection increase CAP risk?
Impaired airway protection can result in micro/macroaspirations which can lead to infection resulting in PNA
Macroaspiration refers to what?
Aspiration of stomach contents
Yummy yummy
Microaspiration refers to what?
Aspiration of upper airway secretions
What can cause impaired airway protection?
Stroke
Seizure
Anesthesia
Drug use
Alcohol use
Medication for sleep
What is dysphagia?
Medical condition characterized by difficulty swallowing
What can cause dysphagia?
Stroke
Esophageal lesions
Dysmotility
What is dysmotility?
Dysmotility is a condition where the muscles and nerves of the digestive system do not work as they should
Why do we care about whether or not a patient has dysphagia?
Difficulty swallowing could result in accidental aspirations increasing the risk for PNA
How is gastroesophageal reflux disease (GERD) related to PNA?
GERD affects the sphincter that separates the the esophagus from the stomach which can result in stomach contents leaking back up into the esophagus where they can potentially be aspirated
What are examples of modifiable risk factors that could increase your chances on contracting PNA?
Drug use (Smoking, alcohol, opioids)
Living conditions (prisons, homeless shelters)
Low income residences
Environmental toxins (solvents, paints, gasoline smoke, fumes)
T/F: combinations of risk factors regarding CAP result in exponential increases in risk of contracting PNA
False. Combinations of risk factors are additive
What is etiology?
The study or theory of the factors that cause disease and the method of their introduction to the host
AKA what causes the disease and how poor saps get it
Describe the first model for pathogenesis of PNA in the alveoli
Pathogens arrive in alveolar space
Pathogens multiply
Alveolar macrophages produce cytokines
Cytokines result in recruitment of neutrophils into alveolar space and cytokines into systemic circulation
Lungs fill up with crap as capillary permeability increases to allow WBCs in to fight infection
Describe the second model for pathogenesis of PNA in the alveoli
The balance between microbial elimination and microbial immigration is tipped in the favor of immigration resulting in infections
What are the defensive “forces” that prevent microbial immigration?
Nostrils filtering crap out
Coughing crap up
Mucociliary escalator moving crap out
Commensal microbes inhibiting pathogen growth
Innate and adaptive host defenses
How do commensal microbes inhibit pathogen growth?
Commensal microbes crowd out the pathogen and take up resources that the pathogen would require to multiple
What are “offensive forces” that aid in microbial immigration
Inhalation
Aspiration
Direct inoculation
Hematogenous spread (spread in the blood)
Activation of dormant infection
Loss of commensal microbes
What are the leukocytes that primarily respond to a bacterial infection in the alveoli?
Neutrophils - kill invaders
Macrophages - remove cellular debris (and kill)
What does the inflammation associated with PNA result in?
Pulmonary capillaries become leaky allowing serum and cells into the alveoli resulting in infiltrates
What is the fancy name for the leukocytes that enter the alveoli as a result of PNA?
Polymorphonuclear leukocytes
Neutrophils, eosinophils and basophils are all examples of what kind of leukocyte?
Polymorphonuclear leukocytes
What do the alveoli fill with during a PNA?
Fluid
RBCs
Polymorphonuclear leukocytes
Macrophages
Alveoli that have been filled with fluid, RBCs, polymorphonuclear leukocytes and macrophages are described as what?
Consolidated
What is the main effect of alveolar consolidation?
Compromised gas exchange
Why is the location of pneumonia an important factor?
Location can be a clue as to the type of pneumonia
A PNA that is limited to the segmental bronchi and surrounding lung parenchyma?
Bronchopneumonia
Describe bronchopneumonia
A PNA that is limited to the segmental bronchi and surrounding lung parenchyma
What happens to the AC membrane with PNA?
The thickness increases which decreases gas exchange
Think ficks law
T/F: Pneumonia does not cause atelectasis
False, consolidation within the alveoli can cause atelectasis
Describe lobar PNA
Infection spreads from one lung segment to another to involve the entire lobe of the lung
Generally results from severe bronchopneumonia
A severe bronchopneumonia can result in what?
Lobar pneumonia
Describe interstitial PNA
Usually diffuse and involves bilateral inflammation
Commonly associated with Mycoplasma pneumonia
What microbe is associated with interstitial PNA?
Mycoplasma pneumonia
“Typical” PNA causing bacteria respond to what drug therapy?
Beta lactam antibiotic therapy
How do typical and non-typical PNA respond to culturing?
Typical bacteria are easily cultured
Atypical bacteria are not easily cultured
Describe the difference in incidence between typical and atypical PNA
Typical PNA has a high incidence
Atypical PNA has a low incidence
What group of microbes are generally associated with atypical bacteria?
Gram negative
What is the significance of bacteria that are gram negative?
They have a “thicker” membrane which prevents antibiotics from entering the microbe as easily
What are the factors that make atypical bacteria that cause PNA difficult to treat
Difficult to culture
Gram negative
Resistant to beta lactam antibiotics
What are some examples of typical bacteria?
Streptococcus pneumoniae
Haemophilus influenza
Moraxella catarrhalis
Staphylococcus aureus
Group A streptococci
What are some typical gram negative bacteria?
Klebsiella spp
E coli
What bacteria is responsible for the vast majority of bacterial PNA infections?
Streptococcus pneumoniae
Accounts for >80% of bacterial PNAs
Describe streptococcus pneumoniae
Gram positive
Nonmotile
Cocci
How is streptococcus pneumoniae transmitted?
Generally in an aerosol via cough or sneeze of an infected individual
What bacteria is commonly seen in sputum cultures from patients with an acute exacerbation of chronic bronchitis?
Streptococcus PNA
What antibiotic is commonly used to fight a streptococcus pneumoniae infection
Penicillin and its derivatives
T/F: strains of staph are part of the normal skin flora
True
When does staphylococcus become an issue?
When it develops antibiotic resistances
What does MRSA stand for?
Methicillin resistant staph aureus
What does MDRSA stand for?
Multiple drug resistant staph aureus
What is MRSAs relation to PNA?
Causes severe PNA
Can cause necrotizing PNA
What patient populations is Haemophilus influenzae cultured in?
Patients with underlying lung disease
COPD or Cystic fibrosis
What does Klebsiella pneumoniae cause?
Severe PNA in patients with underlying diseases
What bacteria can be cultured in patients with underlying lung diseases such as COPD or CF?
Haemophilus influenzae
Patients with what underlying disease are at risk for developing severe PNA from klebsiella pneumoniae?
COPD, diabetes, alcohol abuse
What environmental conditions can result in a legionella pneumonia outbreak?
Contaminated puddles
Large air conditioning systems
Water tanks
T/F: you can contract legionella from drinking contaminated water
False. The contaminated water must be aerosolized and inhaled
Why is identification of PNA causing bugs important?
Targeting the wrong bug could delay treatment resulting in a more serious untreated infection
T/F: Causal pathogens can only be identified about half of the time in regards to PNA which leads to a lack of understanding regarding the pathogenesis of CAP
True
Describe aspiration PNA
Pulmonary result of the entry of material from the stomach or upper respiratory tract into the lower airways
Describe chemical pneumonitis
Aspiration of gastric acid
Can also be caused by inhalation or aspiration of other chemical irritants
Describe necrotizing PNA
Lung tissue cells in parenchyma of infected lung due off resulting in the localized formation of pus and necrosis of the pulmonary parenchyma
What are the three types of aspiration PNA?
Chemical pneumonitis
Obstruction
Infection
Describe lung abscesses formed by necrotizing PNA
Localized air and fluid filled cavity
Carries liquified white blood cell remain, proteins and tissue debris
Contents are encapsulated in a layer of fibrin, inflammatory cells and granulation tissue
What can happen in severe cases of necrotizing PNA?
Abscesses can break through into bronchi or into the pleural space
What does a pneumonia diagnosis generally require?
Demonstration of an infiltrate on chest imaging
Patient displays clinically compatible syndrome such as fever, cough, dyspnea and sputum production
Why can diagnosing PNA be difficult?
Criteria for diagnosis are vague and shared among multiple other cardiopulmonary disorders so remaining attentive to alternate diagnosis is important
How might a patient suffering from PNA present in terms of reported symptoms?
Rapid onset
Fever
Chills (rigors)
Body aches
How could the vitals of patient with PNA present?
Increased RR
Increased temperature
Increased HR
Increased BP
Patients with PNA often describe feeling chest pain. How is chest pain from PNA different from chest pain from other sources?
Pleuritic
Hurts to breath
Non-radiating
How is chest pain from an MI different from chest pain from a PNA?
PNA chest pain is described as sharp when breathing
MI chest pain is constant and radiating through chest, into jaw and arms
Describe the cough associated with PNA
Initially dry/unproductive = barking/hacking
Productive with time
Describe the sputum associated with PNA
Purulent
Blood streaked (due to increased capillary permeability)
A PNA infection would have what effect on percussion of the chest?
Percussions over consolidation would be dull
What sounds might you hear while auscultating a patient with PNA?
Bronchial breath sounds
Crackles
Pleural rub possible
Increased egophony
Whispered pectoriloquy
A PNA infection would have what effect on tactile or vocal fremitus?
Increased due to presence of fluids in lungs
Consolidation in the chest could be confirmed via what auditory testing (having the patient speak)?
Increased egophony
Whispered pectoriloquy
What findings would be demonstrated by a PFT on a PNA patient?
Decreased capacities
Normal or decreased FEV1 and FEV1/FVC ratio
T/F: PFTs are important in diagnosing PNA
False. Unless you really hate your patient for some reason
CXRs are a vital tool for diagnosing PNA. What findings on a CXR would support a PNA diagnosis?
Increased density from consolidation or atelectasis
Air bronchograms
Pleural effusions
Describe air bronchograms
When you can see the conduction airways within the consolidations of the parenchyma
What would the blood gas of someone in the mild to moderate stages of PNA infection look like?
Increased pH
Decreased PaCO2
Decreased HCO3 (but normal)
Decreased PaO2
Decreased Sat
What are the two methods used to determine PNA severity?
Pneumonia Severity Index (imaginative)
CURB-65
Describe the Pneumonia Severity index
5 risk classes
Tells you whether or not to send patient home, admit patient to floors, or admit to the ICU
What would the blood gas of someone in the severe stage of a PNA infection look like?
Decreased pH
Increased PaCO2
HCO3
Decreased PaO2
Decreased Sat
How should patients in risk class I or II be handled according to the pneumonia severity index?
Send home on oral antibiotics
How should patients in risk class III be handled according to the pneumonia severity index?
Evaluate home life factors (ie do they live alone or have a spouse?)
Send home with oral antibiotics or admit for short hospital stay with antibiotics and monitoring
How should patients in risk class IV or V be handled according to the pneumonia severity index?
Hospitalize for treatment
What are the components of CURB 65?
Confusion (y/n)
Blood urea nitrogen (BUN)
RR
BP
Age (>/= 65)
What blood urea nitrogen level would result in a point according to CURB65?
> 20 mg/dL
What RR would result in a point according to CURB 65?
> /= 30
A score of 2 on the CURB65 carries what risk of death?
9%
What blood pressure would result in a point according to CURB65?
Systolic </= 90 mmHg
Diastolic </= 60 mmHg
A score of 0-1 on the CURB65 carries what risk of death?
</= 3%
A score of 3-5 on the CURB65 carries what risk of death?
15-40%
What is the frontline treatment for pneumonia?
Antibiotics
If the diagnosis and antibiotic treatment are successful, how soon should we see improvements? What if the patient does not get better?
2-3 days
Wrong medication was given, wrong diagnosis was given, or additional conditions were not diagnosed
What is the role of an RT in cases of PNA?
Largely supportive
Oxygen - monitor sat and work of breathing
Airway clearance - can they cough effectively? Can they keep up with secretions?
Potentially lung expansion
What factors would require that a PNA patient be admitted to the ICU?
Respiratory failure requiring mechanical ventilation
Septic shock - requires fluids or medication to support blood pressure
