RESP Flashcards by Tor Hudson

Which bacteria is most commonly cultured in CAP (community-acquired pneumonia)?

Which other organisms are found in CAP?

Streptococcus pneumoniae

It is detected in ~20% of all CAP

Strep. pneumoniae 20%
Haemophilus influenzae 5%
Gram negatives and staph 5%
Atypicals* 20%
Viruses 10%
NO ORGANISM DETECTED 40%

*Legionella, chlamydia, mycoplasma etc.

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Outline the CURB-65 criteria.

CURB-65
Confusion: AMTS 7mmol/L
Resp. rate: >30/min
BP >90/60 (either one or both) 
Blood pressure: 65

NB/ CRB-65 is used in primary care

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What are the “atypical” symptoms of pneumonia?

Atypical pneumonias have more peripheral symptoms:

Diarrhoea, arthralgia, myalgia, skin rash, neutropenia, hepatitis

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How might you differentiate a typical pneumonia from an atypical pneumonia on CXR?

Typical pneumonia: lobar consolidation

Atypical pneumonia: more diffuse consolidation

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What CXR finding is specific to Staphylococcal pneumonia?

Bullae

Staph eats away at lung leaves large holes filled with pus. On CXR you can see the hole and a fluid level within it. These can burst into the pleural space: empyema leading to septicaemia.

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Which organisms cause typical CAP?

What are their features?

Strep pneumoniae - common
Step pyogenes - uncommon, frequent complications such as effusion, empyema, bronchopleural fistulae, pneumothorax, pericardial effusion, pericarditis
Staph - bullae, frequent complications, abx resistant so give flucloxicillin, often follows viral infection eg influenza
Haemophilus influenzae - uncomplicated
Anaerobes - often follow aspiration, typical pneumonia with pleuritic pain, can develop empyema

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How might you differentiate typical pneumonia from atypical on FBC?

Neutrophils

Markedly increased in typical pneumonias, but may be decreased in atypical pneumonia

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What are the signs of typical pneumonia?

Increased temperature
Decreased O2 sats
Increased neutrophils
Increased ESR and CRP

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What does zileuton inhibit?

Anti asthma drug
Inhibits lipoxgenase so stops the formation of leukotrines which cause bronchoconstriction, inflammation and increased mucus

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What do antileukotrines block?

LT-1 receptor

Blocks leukotrines binding which cause bronchoconstriction, inflammation and increased mucus

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What drugs all end in -terol?

Long acting b2 agonists
Metaproterenol- immediate action and lasts 4-6 hrs
Salmeterol, formiterol, indacterol all take 10-20 mins and last 12+hrs

Short acting
Albuterol
Pirbuterol
Levalbuterol

Salbutamol and terbutaline are the exceptions

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What does theophylline do?

Methylxathine
Inhibits PDE so stops AMP being made so stops bronchoconstriction - ie directly relaxes respiratory tract
Used in chronic bronchitis and COPD

Se- nausea, vommiting, flushing, vasodilation, hypotension
May cause excessive cardiac stimulation
Also caffeine!
Theophylline, theobromine

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What is 1st line in COPD and add on on asthma?

Ipratropium bromide 
Tiotropium (longer duration of action)
Antimuscarinic 
Block M1 and M3 so get bronchodilation 
Quaterary dervivative of atropine

Se- excessive dry mouth

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What do you give in severe asthma exacerbation?

Iv magnesium sulphate

Transient flushing 
Lightheaded 
Lethargy 
Nausea 
Burning at iv site

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What are the adverse effects of corticosteroids? Asthma/COPD treatment

Inhaled
Hoarseness 
Pneumonia 
Oral thrush 
Bruising

Systemic 
Fluid retention
Muscle wasting 
Metabolic disturbances
Increase risk of infection

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What are budesonside, ciclesonide, beclomethosone?

All inhaled preps of steroids

Ciclesonide is a prodrug

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What is cromolyn sodium?

Mast cell stabiliser- interfere with antigen- ab reaction of mast cells
Prophylactic control of chronic asthma

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What is omalizumab?

Anti ig E
Binds and inactivates it
Reduces severity and frequency of asthma attacks

Pain and inflammatory reaction at injection site

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What is the PEF In moderate, acute severe, life threatening asthma exacerbation?

moderate 75-51
acute severe 33-50
life threatening asthma

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What is the target O2 in asthmatics?

94-98

NOT 100%

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What is step 1-5 in asthma treatment?

1- short B2
2) - add inhaled steroid
3- add long acting b2- if good response that’s fine
If bad response- increase inhaled steroid. And stop LABA. If inadequate, try theophylline or leukotrine receptor blocker
4- try higher dose of steroid if not on it already. Add 4th drug- either theophylline or leukotrine receptor blocker or oral B2 agonist

5 refers to specialist
Maintain high in hailed steroid
Add oral steroid
Try other drugs to minimise oral steroid dose

NB need to try and get oral in hailed steroid down by 25-50% every 3 months. Lifestyle modification /trigger avoidance may help

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Sign of poor control in asthma

Exercise induced

Night symptoms

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What do you give to acute COPD if initial response to bronchodilators is poor?

Iv theophylline

NB check levels if pt on this ordinarily

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How many deaths in the UK / year from cancer?

161,823
22% lung 
10% bowel 
7% breast 
7%prostate 
53% all other cancers

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What is the 1 year and 5year survival rate for lung cancer?

1: 25% 5: 8%

What is the T stage for lung cancer?

T1 30mm diameter T3 >70mm or invades mediastinum or chest wall or satellite foci with same lobe T4 invades essential structures or spread in different ipsilateral lobe

Node staging lung cancer

NO no involved N1 stations 14-10 N2 station 9-1 N3 supraclavicular node or contralateral nodes (Numbers get smaller higher up you go) 10 is on the carina)

M stage for lung cancer

mo no distant mets M1a In chest eg contralateral lung, malignant pleural effusion M1b extra thoracic - brain bone kidney liver adrenal

When do you operate on lung cancer?

Early stage T1-3 NO-1 mo

When do you do radiotherapy or chemotherapy in lung cancer?

T4 or N2-3 MO Locally advanced

When do you commence palliative chemotherapy with palliative radiotherapy for symptom relief

What is pemetrexed? (Alimta)

Drug used in lung cancer 2nd line Histology defines if it works or not Non small cell carcinoma is better

What are the 2 most common organisisms to get infected with if you have bronchiestasis?

Haemophilius influenzae | Pseudomonas

Typical features of streptococcus pneumoniae

Intense fever, rigors, excruciating pleuritic pain, tachycardia, tachypnoea, cough, rust coloured sputum - 10-20% positive blood cultures - fever breaks on 8th day - complications are common- empyema, meningitis, sepsis. CXR central/segmental consolidation Medical emergency

What are the typical features of strep pyrogens pneumonia?

Uncommon Usually in young after viral infection Complications are frequent- pleural effusion, empyema, pneumothorax, pericarditis, bronchpleural fistular

What are the typical features of haemophilius?

Less invasive | Often URTI

Who gets gram negative bacilli pneumonia?

Usually nosocomial Alcoholics diabeties chronic lung disease immunosuppression Old

``` What is? Thick bloody sputum Old man Comorbidites Multiple upper lobe consolidation with bulging fissures and cavitation ```

Klebsiella

How do people get pseudomonas pseudomallei?

Skin In soil Gram negative

Which pneumoniae are in the lower lobes and rarely have haemoptysis?

E. coli Pseudomonas aeruginosa Acinetobacter

Describe an atypical pneumonia

``` Caused by atypical bacteria Progressive onset Fever no rigors Cough no sputum Headache and muscle pains Diffuse chest crackles Modest leukocytosis Diffuse infiltrates on CXR maybe lower lobe ```

Which atypical pneumonia do you get a macular rash and splenomegaly?

Chlamydia psittaci/pneumoniae

Which atypical pneumonia do you get middle ear infection, haemolytic anaemia and maybe hepatitis, meningitis and pericarditis with?

Mycoplasma pneumonia

Which atypical pneumonia do you get unilateral consolidation, hepatitis, neutropenia and lymphopenia?

Legionella

Which atypical pneumonia do you get CXR dense nodular infiltrates, hepatosplenomegaly and is from a tick vector?

Coxiella burnetii

Risk factor for legionella?

Alcoholism

Treatment with penicillin or other abx what pneumonia have they got?

Streptococcus pneumoniae (resistant organisms)

What can be diagnosed vis agglutins?

Brucella

What is the morbidity if you have 4, 3, 2 and 1 of the CURB65 criteria?

4- 83% 3- 33% 2-23% 1-2.4%

antibiotic therapy | CAP treatment in community

Amoxicillin Or Erythromycin and clarithromycin

Streptococcus pneumoniae

Amoxicillin and benzoyl penicillin Or Erythromycin Clarithromycin

Haemophilius influenzae

Amoxicillin or ampicillin Co amoxiclav Or Cefuroxime Fluroquinolone Cefotaxime

What do you treat staph aureus pneumonia with if pen allergic ?

Rifampin MRSA - linezoild If not pen allergic- flucloxacillin MRSA- vancomycin

What do you treat gram negative enterococcus pneumonia with?

Cefuroxime If pen allergic Fluroquinolone Meropenem

What do you treat pseudomonas aeruginosa pneumonia with?

Ciprofloxacin

What if you are treating pneumonia and the CRP fails to fall >50% within 4-5 days?

Consider treatment failure or complication Wrong abx? Secondary complication? Tb? Fungal?

How long do CXR changes take to resolve in pneumonia ?

6-12w | Longer in elderly

Which viruses can cause pneumonia?

``` Influenza A,B (50% cases) RSV Parainfluenza Measles Adenovirus Chicken pox (5 days after rash) get Millary calcification Afterwards ```

Which viruses can cause bronchitis?

Rhinovirus Adenovirus Influenza A,B

What nosocomial pneumonia do you get if history of trauma?

Streptococcus | Haemophilius

What nosocomial pneumonia do you get if history of prolonged ventilation/coma?

Staphylococcus

What nosocomial pneumonia do you get if history of prolonged intubation/abxs?

Pseudomonas

How do you treat/prevent nosocomial pneumonia?

Cefuroxime | With aminoglycoside eg gentamicin

Who gets lung abscess?

Alcoholic men >50 years old

What nosocomial pneumonia do you get if history of trauma?

Streptococcus | Haemophilius

What nosocomial pneumonia do you get if history of prolonged ventilation/coma?

Staphylococcus

What nosocomial pneumonia do you get if history of prolonged intubation/abxs?

Pseudomonas

How do you treat/prevent nosocomial pneumonia?

Cefuroxime | With aminoglycoside eg gentamicin

Who gets lung abscess?

Alcoholic men >50 years old

What does bordetella pertussis cause?

Whooping cough

How do you treat strep throat?

Streptococcus pyrogens | Pen V for 10 days

What antibiotics do you need for CAP which is not severe?

Amoxicillin AND Erythromycin or clarithromycin or doxycycline

What antibiotics do you need for CAP which IS severe?

Co amoxiclav iv AND Doxycycline PO OR Erythromycin OR Clarithromycin iv OR Levofloxacin plus benzyl penicillin

What are the second generation H1 antihistamines? What should first generation ones not be used?

Loratadine (10mg OD) Desloratadine (5mg OD) Fexofenadine (120mg OD) Cetirizine (10mg OD)

Pharyngitis is usually called ?

Adenovirus

If you are given amoxicillin and you have EBV get what?

Macro papillae rash if you have EBV | Splenomegaly also from EBV

Coup

Parainfluenza Stidor Measles, Dipthera ADL and Steriods neb

Sinusitis

Linked to bronchiestasis | Co amoxiclav

Whooping cough

``` Pertussis Bad Immunisation 100 day cough Produces toxins Caryromycin ```

Epigottisis

2-3 Ceftriaxime Haemophilius influenza b Medical emergency

In CF and pseudomonas infection what do you give?

Tomramycin | In hailed