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Clinical Medicine PA 581: Pulmonary > Respiratory Infections > Flashcards

Respiratory Infections Flashcards

Objectives

1
Q

Define acute bronchitis

A
  • Inflammation of the bronchi due to upper airway infection
  • Cough lasting > 5 days
    • Usually 1-3 weeks
    • Usually with sputum production
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2
Q

Acute bronchitis eitology

A
  • Typically viral
  • 60-90% of patients who receive care for bronchitis are given antibiotics
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3
Q

acute bronchitis incidence/risk factors

A
  • 44 per 1000 adults per year (5% of adults)
  • Winter/Fall higher incidence
  • Chronic lung disease at greater risk
  • Chronic illness at greater risk
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4
Q

acute bronchitis Etiology/infectious agents

A
  • Etiology: Viral
    • Influenza A & B
    • Parainfluenza
    • Coronavirus
    • Rhinovirus
    • RSV
    • Human metapneumovirus
  • Difficult to establish exact agent (13-29%)
  • Other pathogens:
    • Mycoplasma Pneumoniae
    • Severe URI symptoms for 4-6 weeks (cough, pharyngitis)
    • Chlamydia Pneumoniae
    • Pertusis
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5
Q

acute bronchitis clinical presentation (signs and symptoms)

A
  • URI type symptoms initially
    • Congestion
    • Nasal drip
    • Facial pressure
  • Develop a cough that persists > 5days
  • Not critical to distinguish acute bronchitis from Viral URI
  • It is critical to distinguish acute bronchitis from pneumonia
  • Sputum Production: 50% of patients
  • Bronchospasm
    • Reduced FEV1
    • Can occur for up to 5 weeks
  • Cough for 10 to 20 days
  • Fever unusual
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6
Q

Acute bronchitis DX

A
  • Diagnosis typically made during your H&P
  • “Clinical Diagnosis”
  • Labs
  • CXR
  • Sputum culture
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7
Q

acute bronchitis dx labs

A

CBC results

  • WBCs typically normal, occasionally slightly elevated
    • Significant Leukocytosis
    • Bandemia
    • A large elevation in WBC’s or a “left shift/bandemia” should prompt CXR to rule out pneumonia
  • Procalcitonin
    • Cytokine stimulation by bacterial infections
    • Helps distinguish bacterial vs viral
    • Reduce Abx exposure in multiple settings
    • Use if can be obtained in a timely manner - may not be possible in a lot of clinics
    • Big idea: Not getting in the office only in hospital, mostly useful in bronchitis and pneumonia
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8
Q

acute bronchitis Dx CXR

A
  • Clear “no acute process” infiltrates or anything else on CXR should raise suspicion for PNA
  • Should get a CXR when:
    • Elevation of WBCs
    • Abnormal vital signs
      • Tachycardia OR bradycardia
      • Tachypnea
      • Fever
      • Physical Exam suggestive of pneumonia
      • AMS
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9
Q

acute bronchitis dx sputum culture

A
  • Takes time, bacterial typically not cause would see polymorphonuclear cells and/or bacterial pathogens if bacterial
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10
Q

actue bronchitis management plan

A
  • Symptom management
    • Pain Relief: NSAID, ASA, Acetaminophen
    • Cough suppressants: codeine, dextromethorphan
    • Short Acting Beta Agonist – if bronchospastic
  • Don’t give bronchitis abx – especially broad spectrum abx
  • Antibiotics
    • Large meta-analyses of 15+ RCT’s showed only a reduction of 0.6 days of cough.
    • This is a marginal reduction considering the potential adverse effects and potential antibiotic resistance
  • “Post infectious bronchospasm”
    • Persistent dry cough for 4-6 weeks
    • Treat with BD’s, sometimes corticosteroids
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11
Q

acute bronchitis special considerations

A
  • Chronic lung disease
    • Episodes of acute bronchitis
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12
Q

pertussis definition

A
  • “Whopping cough”
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13
Q

pertussis incidence/risk factors

A
  • Primarily children pre-vaccine era
  • Resurgence with anti-vaccine movement
  • Highly contagious
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14
Q

pertussis Etiology/infectious agents/basic pathophysiology

A
  • Longer incubation period
    • 1-3 weeks
  • Catarrhal phase
    • Early phase
      • Malaise, rhinorrhea, mild cough
  • Paroxsymal Phase
    • 2nd week of illness
    • Hallmark whooping cough
  • Convalescent Phase
    • Gradual reduction of cough
  • Total Duration of Phases: up to 3 months
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15
Q

pertussis Clinical presentation: signs and symptoms

A
  • Hallmark:
    • Inspiratory whoop
    • Paroxysmal cough
    • Posttussive emesis
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16
Q

pertussis dx

A
  • Clinical definition
    • Cough lasting two weeks without cause + one of these:
      • Paroxysmal coughing
      • Inspiratory whoop
      • Posttussive emesis
  • Tests
    • Nasopharyngeal Culture
    • PCR
    • Serology
      • Antibody titers
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17
Q

pertussis management plan

A
  • Catarrhal phase antibiotics effective - decrease duration/severity of cough
  • Antibiotics in later phases
    • May not reduce duration or severity but may be useful in reducing spread of disease
    • Use if < 2 weeks of symptoms
    • Persistent symptoms at 4 weeks
  • CDC: Empiric antibiotic therapy early
    • Empiric antibiotic therapy early if suspicious for pertussis even while diagnostics are ongoing
  • Antibiotics
    • Macrolides
      • Azithromycin 5 days
      • Clarithromycin 500 mg PO BID x 7 days
    • Bactrim DS alternative
  • Cough suppressants ineffective
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18
Q

pertussis complications

A
  • Pneumonia
  • Otitis Media
  • Cough complications
    • Subconjunctival hemorrhage
    • Hernia
    • Rib fractures
    • Lumbar strain
    • Rare: Intracranial hemorrhage
  • Time lost in school/work
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19
Q

pertussis vaccination recommendation

A
  • Postvaccine: adults 50% of the time
  • DTaP: diptheria, tetanus, pertussis, acellular pertussis
  • Tdap booster
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20
Q

influenza definition

A
  • On Boards the clinical scenario will have short period of time for illness with high fevers typically
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21
Q

influenza incidence/risk factors

A
  • Yearly winter season outbreaks/epidemics
22
Q

Influenza Etiology/infectious agents

A
  • Acutely debilitating
  • Self-limiting
  • Transmission
    • Large droplets: sneezing, coughing
    • Small particle possible
    • Droplet precautions
  • Incubation period
    • 1-4 days
  • Epidemiology:
    • Distinct outbreaks every year
    • Hemagglutinin glycoprotein
    • Neuraminidase glycoprotein
    • Antigenic Shifts
      • Epidemics
    • Antigenic Drifts
    • Influenza A: high propensity for antigenic changes
      • H1, H2, H3 and N1, N2
    • Influenza B only H changes
23
Q

Influenza Clinical presentation: signs and symptoms

A
  • Abrupt onset fever
  • General symptoms: headache, myalgias, malaise
  • URI symptoms
    • NP cough, sore throat, nasal discharge
  • Physical Exam
    • Feverish/hot feeling
    • Flushed
    • Cervical lymphadenopathy
  • Improve after 2-5 days
    • Residual symptoms for weeks
24
Q

Influenza Dx

A
  • Clinical Diagnosis
  • Rapid Antigen: screening: <15 minutes
    • Identifies Influenza A and B
    • Sensitivity 62%, Specificity 98%
    • LAIV false positive
  • Reverse Transcriptase PCR (most sensitive and specific): 2 day, send out lab
  • Timing of tests
    • High viral load 24-48 hours into illness
  • Viral Culture
    • 48-72 hours
25
Q

Influenza management plan

A
  • Neuraminidase inhibitors:
    • Zanamivir: inhaled/intranasal version
    • Oseltamivir (Tamiflu) 75 mg PO BID x 5 days
      • Resistance already exists
    • Duration < 1 day
    • Benefit best within first 24 hours of fever
    • Typically Rx limited to within first 48 hours
    • Treat high risk populations first
    • Do not delay treatment
  • Treatment:
    • Severe illness: double dose of Tamiflu: 150 mg PO BID
    • Avoid cough suppressants
    • NSAIDs for myalgias
    • Antibiotics if secondary bacterial pneumonia expected
    • Infection Control: stay at home!
26
Q

influenza vaccination recommendation

A
  • Formulations:
    • IM Inactivated Influenza vaccine (IIV)
      • Fluarix/Fluzone
    • Intranasal live-attenuated influenza vaccine (LAIV)
      • Flumist
  • Protects against Influenza A (H3N2, H1N1) and Influenza B
  • Allergic reaction potential
    • Immunizing agent itself
    • Other proteins introduced in the production process
      • Animal proteins, antibiotics, preservatives, stabilizers, virus-inactivating compounds, latex
    • Not all allergic reactions to flu vaccine are egg allergy
  • Flu vaccine constituents
    • Gelatin: stabilizer
      • h/o allergy to ingestion of gelatin/gelatin containing foods (marshmallows, gummy candy)
      • Test for gelatin allergy
      • High incidence in Japan
    • Antimicrobials
      • Gentamycin, neomycin, streptomycin, polymyxin B
    • Latex
      • Rubber vial stopper, syringe plunger contacts liquid
  • Flu vaccine produced in fluid from embryonated eggs
    • Egg protein content
      • All current vaccines contain < 1 mcg per 0.5 mL dose
      • Required to list this information
    • Large studies (>4000 patients) have reported safe administration of injective trivalent flu vaccine to patients with egg allergy and included 500 patients with anaphylactic reaction to egg ingestion
  • Flu vaccine alternatives:
    • Trivalent inactivated influenza vaccine (Optaflu) is produced using cultured mammalian cells
      • Approved in EU, Iceland, Norway in 2007
      • Approved in USA in 2012 for individuals > 8 years of age (Flucelvax)
    • Flublok (RIV)
      • Recombinant hemagglutinin influenza vaccine (trivalent egg free)
      • Approved by FDA in 01/2013
        • For patients 18-49
    • Do not miss opportunity to immunize patients with an egg allergy
27
Q

influenza complications

A
  • Pneumonia
    • Primary Viral Pneumonia
    • Secondary Bacterial Pneumonia
      • Hallmark: worsened fevers and symptoms after initial improvement (relapses)
      • S. Pneumoniae, H. Flu, Staph A., CA-MRSA
  • ARDS
  • Myositis/Rhabdomyloysis
    • Rare, but seen in children
    • Tenderness, swelling in legs
  • CNS involvement
    • Encephalopathy (AMS), encephalitis, Guillain-Barre
  • Cardiac
    • ACS/MI, myocarditis, pericarditis
28
Q

Define “chronic cough” + list ddx

A
  • Cough:
    • Acute < 3 weeks
    • Subacute 3-8 weeks
    • Chronic > 8 weeks
  • Irritation of cough receptors
    • Upper Respiratory
    • Lower Respiratory
    • Pericardium
    • Esophagus
    • Diaphragm
    • Stomach
  • Mechanical Receptors
    • Triggers such as touch or displacement
  • Chronic cough:
    • At least 3 months cough in 2 consecutive years
    • Upper Airway Cough Syndrome (PND): #1
      • Allergic
      • Rhinitis
      • Sinusitis
      • Acute nasopharyngitis
    • Asthma: #2 (MCC In Children)
      • “cough variant asthma”
    • GERD
    • Laryngopharyngeal reflux (LPR)
    • Post-infectious (subacute)
    • ACE Inhibitors
    • Chronic Bronchitis
    • Bronchiectasis
    • Lung Cancer
    • Nonasthmatic Eosinophilic Bronchitis
    • Dysphagia/Silent Aspiration
29
Q

Distinguish between upper and lower respiratory tract infections

A
  • Upper respiratory tract:
    • Contains:
      • Nasal cavity
      • Pharynx
      • Larynx
    • Upper respiratory tract infections: Infections of nasal, sinuses, pharynx, larynx
  • Lower respiratory tract:
    • Contains:
      • Trachea
      • Primary bronchi
      • Lungs
    • Lower respiratory tract infections: bronchitis, pneumonia, lung abscesses
30
Q

Epiglottitis

A
  • Inflammation of the epiglottis
  • Life threatening airway obstruction
31
Q

Epiglottitis: Etiology/Patho

A
  • Infection: essentially cellulitis
  • Viral or Bacterial
  • Healthy children = bacterial: Haemophilus influenzae B (Hib) MCC: vaccine
  • Other bacteria: staph, Group A strep, MRSA
  • Adults: broad range of viruses or bacteria
  • Trauma: foreign body, caustic ingestion
32
Q

Epiglottitis Incidence

A
  • Declined rapidly after Hib vaccine
  • Previously 5 per 100,000 children
  • Now 0.6 to 0.8 per 100,000 children
  • 1.6 cases per 100,000 adults
33
Q

Epiglotitis Clinical presentation (signs and symptoms)

A

Medical Emergency!

Objective: make diagnosis before airway obstruction occurs

Young Children:

  • 3 D’s: Dysphagia, Drooling, Distress
  • Respiratory distress, anxiety, tripod/sniffing posture, drooling
  • No cough typically
  • Sudden onset high fever
  • Appear toxic
  • “hot potato voice” muffled speech

Adults:

  • Rapidly developing sore throat or
  • Odynophagia is out of proportion to clinical findings

Physical Exam:

  • Stridor
  • Oropharynx benign
34
Q

Epiglotitis Work Up Algorithm

A

Likely?

  • Stridor, distress
  • Get experts stat! ENT + Anesthesia + Intensivist

Unlikely?

  • Mild symptoms; no stridor or distress
  • Lateral neck radiographs
  • Direct pharyngoscopy (tongue blade)
  • Fiberoptic visualization (expert still needed)
35
Q

Epiglottitis DDx

A
  • Croup (laryngotrachetitis)
  • Uvulitis
  • Peritonsilar/Retropharyngeal Abcesses
  • Foreign body
  • Angioedema
  • Diptheria
36
Q

Epiglotitis Dx

A
  • Blood cultures
    • 70% of Hib in children
    • 0-17% in adults
  • Throat cultures: negative
  • Epilglottic culture: 33-75%
  • Direct Visualization!
    • Fiberoptic Laryngoscopy
  • CBC
  • Lateral Neck X-ray
    • You’ll see a thumb print sign on Xray
37
Q

epiglotitis tx

A
  • # 1: Airway Maintenance
    • Experts! ENT + Anesthesia + Intensivist
    • Location of intubation?
  • Milder Cases? Observe in ICU
    • Daily direct visualization
  • Antibiotics:
    • 3rd gen Ceph: ceftriaxone or cefotaxime AND
    • Antistaph: vanco (if MRSA likely)
    • Duration: 7-10 days
  • *Steroids? No benefit, no longer recommended
  • *Racemic Epinephrine? Not helpful
  • Afterwards?
    • Immune Deficiency workup if vaccinated
38
Q

epiglititis mortality

A
  • Children < 1%
  • Adults < 3.3%
  • Death is due to airway obstruction
  • Most occur en route to hospital or soon after arrival
39
Q

Bronchiectasis: CF

A
  • Most common cause
  • 30,000 in US
  • Caucasian/Northern European Descent
40
Q

CF: Etiology

A
  • Mutation to large gene on chromosome 7
  • CFTR (cystic fibrosis transmembrane conductance regulator)
  • Changes the electrolytes in the respiratory epithelium (Na/Cl)
  • Leads to thicker secretions in the airways
  • Recurrent infections
41
Q

Bronchiectasis: PREVALENCE

A
  • Difficult to assess
  • Estimated 110,000 in US
  • Increases with age
  • Require extensive healthcare resources
42
Q

Bronchiectasis: Pathophys.

A
  • Two factors
    • Infectious insult
    • Host defense defect, impaired drainage, airway obstruction
  • Response causes inflammation, edema, cratering, ulceration, neovascularization of airways
  • Permanent dilation, destruction of major bronchi and bronchiole walls
  • Recurrent infections leads to further scarring
43
Q

Bronchiectasis - Etiology

A
  • *First step, figure out cause of bronchiectasis if able
    • Post-obstructive PNA
  • Airway obstruction
    • Foreign body aspiration
    • Carcinoid Tumor
  • Chronic Aspiration
  • Immune Deficiency
    • Hypogammaglobulinemia
    • Low levels of IgG, IgA, IgM
  • Can get replacement therapy (IVIG)
  • Immunosuppression (transplant)
  • Cystic Fibrosis
    • 7% diagnosed in adulthood
    • Upper lobe involvement
  • Young’s syndrome
    • Bronchiectasis, sinusitis, obstructive azoospermia
    • Decline, close to nonexistent
    • Young’s related to mercury
  • Rheumatic Disease/Autoimmune
    • RA, sjorgren’s syndrome
  • Dyskinetic cilia
    • Primary Ciliary Dyskinesia
  • Pulmonary infections
    • Nontuberculous Mycobacterial infection
      • MAC
    • Enlarged lymph nodes/damaged airways
    • AIDS patients
    • Mycoplasma
  • GERD association/?Causal
  • Allergic bronchopulmonary aspergillosis (ABPA)
    • Asthma resistant to bronchodilator
    • Central airway bronchiectasis
    • Hyperimmune response
  • Smoking: no true causation found although patients with COPD or reduced lung function may accelerate disease
  • Tracheobronchomalaci
44
Q

Bronchiectasis – signs/symptoms

A
  • Frequent “bronchitis”/cough
    • Months to years
  • Daily cough of purulent sputum
    • Thick sputum
  • Hemoptysis – can be massive in acute infection with injury to superficial mucosal neovascular bronchial arterioles
  • Pleurisy
  • Shortness of breath
  • Single episode of severe infection also possible presentation
45
Q

Bronchiectasis – physical exam

A
  • Crackles
  • Rhonchi
  • Wheezing
  • Digital clubbing is rare – 2%
46
Q

Bronchiectasis - CXR

A
  • Platelike atelectasis
  • Dilated thickened airways (tram or parallel lines, ring shadows on cross-section)
47
Q

Bronchiectasis - HRCT

A
  • HRCT (high resolution computed tomography)
  • 1.0 – 1.5 mm cross sectionals
  • Airway dilation
  • Tram lines
  • Lack of tapering airways toward periphery
  • Bronchial wall thickening
  • ‘Tree-in-bud”: linear branching markings
  • Varicose constrictions
  • Ballooned cysts at the end of the bronchus
48
Q

Bronchiectasis: WORK UP

A
  • HRCT
  • Sputum Culture
  • Swallow evaluation
  • Autoimmune panel
  • Bronchoscopy with BAL, biopsy if able
  • Ig Levels (all classes and subclasses)
  • Alpha1 Antitrypsin
  • Test for CF in right patient groups
  • Aspergillus IgE and IgG
  • Spiro with Pre and Post Bronchodilator
  • 6MWT
  • PPD
49
Q

Bronchiectasis – bronchoscopy

A
  • Identify obstruction
    • Foreign body, tumor, structural deformity, extrinsic compression by lymph nodes
    • Broncheoalveolar lavage (BAL)
      • Confirms Mycobacterium avian infection (MAI)
      • Biopsy can confirm ciliary dyskinesia
      • Can localize bleeding
50
Q

Bronchiectasis – PFT/Spiro

A
  • Provides a functional assessment
  • Obstructive impairment most common, but sometimes low FVC is seen in advanced disease
    • low FEV1
    • preserved FVC
    • FEV1/FVC ratio < 70%
  • *Most commonly obstructive but you can see restrictive as well
  • *Not a specific test
51
Q

DDX - Bronchiectasis

A
  • Acute Bronchitis
    *

Clinical Medicine PA 581: Pulmonary (9 decks)

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