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Tintinalli Section 8 - Pulmonary Emergencies > S8C68 - CAP, aspiration PNA, non-infectious pulmonary infiltrates > Flashcards

S8C68 - CAP, aspiration PNA, non-infectious pulmonary infiltrates Flashcards

1
Q

PNA: defn by environment

A
  • CAP: pt not hospitalized or in LTC facility 14d before sx
  • HAP: 48h after hosptial admission
  • VAP: 48h after ETT intubation
  • HCAP: pt hospitalized for >2d w/in past 90d, nursing home resident, pt receiving home IV Abx tx, dialysis pt, pt receiving wound care or chemo, immunocompromised pt
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2
Q

PNA: pathogens

A
  • pneumococcus (strep pneumo) most common
  • viral
  • atypical: mycoplasma, chlamydophila, legionella (MCL)
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3
Q

PNA: sx

A

-atypical: mild, non-productive cough

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4
Q

PNA: tx (General principles)

A
  • CAP: should cover at least strep pneumo and legionella
  • strep pneumo: increasing PCN resistance in some areas, if concerned about resistance treat with vanco, imipenem, or newer resp fluoroquinolone
  • atypicals: lack a cell wall therefore beta-lactams do not work, tx with macrolide or respiratory fluoroquinolone
  • new fluoroquinolones (moxi/levo/gemi) have cvg against typical bacteria and atypical sources
  • in-pt PNA should be covered for atypicals and cell-walled bacteria (eg. fluoroquinolones )
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5
Q

Strep Pneumo

A
  • sudden onset, fever, rigors, c/p, productive cough, dyspnea
  • gram +, encapsulated diplococci
  • lobar infiltrate, occassionally patchy or pleural effusion
  • elderly and
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6
Q

Staph Aureus PNA

A
  • gradual onset productive cough, fever, dyspnea, may follow viral illness
  • gm + cocci in clusters
  • patchy, multilobar infiltrate, empyeme, abscess
  • pts with chronic lung dz, cancer, risk for aspn PNA
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7
Q

Klebsiella pneumonia

A
  • sudden onset, rigors, dyspnea, c/p, bloody sputum, more common in EtOH or nursing home pts
  • gm - encapsulated paired coccobacilli
  • upper lobe infiltrate, abscess
  • may be assoc with HSV labialis
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8
Q

Pseudomonas aeruginaosa PNA

A
  • recently hospitalized, debilitated, immunocompromised with fever, dyspnea, cough, severe PNA
  • gm - coccobacilli
  • patchy infiltrate with frequent abscess, bilateral lower lobe
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9
Q

H. flu

A
  • gradual onset, fever, dyspnea, c/p
  • COPD/elderly
  • gm - encapsulated coccobacilli
  • patchy, basilar infiltrate
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10
Q

Legionella pneumophila

A
  • f/c, h/a, malaise, dry cough, dyspnea, anorexia, diarrhea, n/v
  • no organism visible
  • multiple patchy nonsegmented infiltrates, occasional cavitation and pleural effusion
  • atypical
  • legionella urine antigen testing should be done in ICU pts, alcoholics, or recent travel hx (2w)
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11
Q

Moraxella catarrhalis

A
  • cough, fever, sputum, c/p
  • more common in COPD
  • gm - diplococci
  • diffuse infiltrates
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12
Q

Chlamydophila pneumo

A
  • gradual onset, fever, dry cough, wheeze, sinus sx, sore throat
  • no organism visible
  • patchy subsegmental infiltrates
  • atypical
  • may lead to adult asthma
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13
Q

Mycoplasma pneumoniae

A
  • URTI and LRTI, nonproductive cough, bullous myringitis, h/a, malaise, fever
  • no visible organism
  • reticulonodular pattern, patchy densities
  • atypical
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14
Q

Anaerobic organisms

A
  • gradual onset, putrid sputum, EtOH
  • purulent sputum
  • consolidation of dependent portion of lung, abscess
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15
Q

Alcoholics and PNA

A

-strep pneumo still most common but consider klebsiella and h flu

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16
Q

Diabetics and PNA

A
  • 2-3x more likely to die from PNA
  • consider: S. aureus, mucor, gm - , and mycobacterium
  • strep pneumo and legionella have increased mortality
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17
Q

Pregnancy and PNA

A
  • varicella PNA can be severe

- treate with acyclovir

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18
Q

PNA in elderly

A
  • mortality rate 40%
  • legionella more common in elderly
  • do not present with typical signs/symptoms
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19
Q

PNA and nursing home Pts

A
  • nursing home pt with one of the following 8 has a 33% chance of having PNA:
    1. incr HR
    2. RR >30
    3. temp >38
    4. somnolence, decr LOC
    5. confusion
    6. crackles on ausc
    7. absence of wheeze
    8. incr WBC
  • s. pneumo most likely cause, as well as gm- bacilli and h. flu
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20
Q

HIV and PNA

A
  • strep pneumo most common cause
  • pseudomonas (also assoc with neutropenia, CVC, burns, CF, bronchiectasis pts)
  • opportunistic infxns: TB, c. neoformans, histoplasma capsulatum, PCP if
21
Q

Transplant pts and PNA

A
  • susceptible to gm - bacilli (pseudomonas), s aureus, legionella, klebsiellya, e. coli, fungi
  • after 6mo post op: h. flu and strep pneumo
22
Q

Tx for CAP: out-pt

A

Uncomplicated Pt:
-macrolide: clarithromycin XL 1000mg PO OD x 7d
or Azithro 500mg PO d1 then 250mg OD d2-5
-tetracycline: doxycycline 100mg BID x10-14d (2nd line)

Pt with comorbidities:
-fluoroquinolone: levofloxacin 750mg OD x5d
or moxifloxacin 400mg OD 7-14d
-beta-lactam PLUS macrolide:
amox-clav 2g BID PLUS azithro 500mg d1 then 250mg d2-
**can use a third gen cephalosporin instead of amox-clav

23
Q

Tx of CAP: in-patient

A

-fluoroquinolone: levofloxacin 750mg IV
or Moxifloxacin 400mg IV

-cephalosporin PLUS macrolide:
CTX 1g IV PLUS azithromycin 500mg IV

-may use another 3rd gen ceph in combination with a macrolide OR doxycycline

24
Q

Tx of HCAP (Health care associated PNA) 3 drug regimen

A

Antipseudomonal cephalosporin PLUS fluoroquinolone PLUS anti-MRSA:
-cefepime or ceftazidime PLUS ciprofloxacin PLUS vanco

Antipseudomonal ceph PLUS fluoro PLUS anti-MRSA:
-imipenem OR meropenem PLUS cipro PLUS vanco

Beta-lactam and inhibitor PLUS antipseudomonal fluoroquinolone PLUS anti-MRSA (p485):
-pip-taz PLUS cipro PLUS vanco

**an aminoglycoside may be substitued in place of fluoroquinolone, levofloxacin can be substituted for ciprofloxacin, linezolid can be substituted for vanco

25
Q

Tx for PNA - ICU

A
  • cephalosporin PLUS macrolide: CTX 1g IV plus azithro 500mg IV
  • cephalosporin PLUS fluoroquinolone: CTX PLUS moxifloxacin 400mg IV OR levofloxacin 750mg IV

-fluoroquinolone PLUS monobactam or lincosamide:
moxi or levo PLUS aztreonam or clinda

-add an anti-MRSA drug if HCAP or MRSA:
vanco or linezolid

26
Q

PNA - in-patient tx - risk of pseudomonas

A

-beta-lactam and inhibitor PLUS fluoroquinolone:
pip-taz 3.375 mg IV PLUS cipro 400mg IV

-monobactam plus fluoroquinolone:
aztreonam 1g IV PLUS moxi or levo

-anti-MRSA drug (add if HCAP or MRSA risk):
vanco 10-15mg/kg IV or linezolid 600mg IV

27
Q

Do not use fluoroquinolones in pts with:

A

Myasthenia gravis

28
Q

CURB 65 rule:

A
  1. presence of confusion
  2. Uremia >7mmol/L
  3. RR >30
  4. Blood pressure of diastolic 65 years old
29
Q

Aspiration PNA

A
  • typical species: s pneumo, s aureus, h flu, enterobacteriaceae and pseudomonas if hospital acquired
  • Abx covereage should include anaerobic coverage

-begins with an aspiration pneumonitis, if symptoms continue for for >24-48h then consider Abx tx

Aspiration pneumonitis:

  • mild/mod sx >48h: levo or clinda or moxi or amox-clav
  • SBO or use of anacids/PPI: levo or CTX or moxi or pip-taz or cetrazidime

Aspiration PNA:

  • CAP: moxi or clinda or amox-clav
  • HCAP/periodontal dz/EtOH/putrid sputum: CTX PLUS clinda, or pip-taz or ampicillin-sulbactam or cefepime PLUS clinda or levo PLUS clilnda
30
Q

CXR findings: general

A
  • interstitial infiltrate: fine, diffuse, linear
  • alveolar infiltrate: ill-defined or reticular density representing fluid or abnormal cells in alveoli
  • ground glass appearance: multiple finely granular densities
31
Q

CXR findings: CHF

A
  • cephalization
  • kerley B lines (thickening of interlobular septa)
  • interstitial edema
  • thickening of fissures
  • alveolar edema
  • pleural effusitons
32
Q

CXR findings: PE

A
  • cardiac enlargement
  • normal
  • pleural effusion
  • elevated hemidiaphragm
  • pulmonary artery enlargement
  • atelectasis
  • parenchymal pulmonary infiltrates
33
Q

CXR findings: Aspn PNA

A

-alveolar infiltrates in a dependent lobe

34
Q

CXR findings: Allergic bronchopulmonary aspergillosis

A
  • branching band-like opacities

- alveolar infiltrates

35
Q

CXR findings: eosinophilic lung dz

A

-alveolar and interstitial infiltrates

36
Q

CXR findings: pneumonitis

A
  • diffuse micronodular interstitial infiltrates

- maybe ground glass densities in lower/mid lungs

37
Q

CXR findings: acute interstitial pneumonitis

A
  • b/l interstitial infiltrates

- sometimes patchy alveolar densities and ground glass

38
Q

CXR findings: ARDS

A

-patchy peripheral infiltrates

39
Q

CXR findings: sarcoidosis

A
  • hilar lymph node enlargement

- diffuse parenchymal interstitial pulmonary infiltrates

40
Q

CXR findings: bronchiolitis obliterans with organizing PNA

A
  • inflm of bronchioles leading to organizing PNA w/o infxn
  • occurs with immunocompromised conditions, CTD, SLE
  • patchy alveolar infiltrates
  • occassionally cavitation
41
Q

CXR findings: Wegener Granulomatosis

A

-alveolar infiltrates, nodules, cavities

42
Q

CXR findings: goodpastures syndrome

A
  • antiglomerular basement antibody dz

- diffuse b/l predominately alveolar densities

43
Q

CXR findings: churg-strauss vasculitis, allergic granulomatosis

A

-systemic vasculitis of unknown cause primarily affecting lungs and eventually skin, neuro, renal, GI, heart

  • b/l peripheral, patchy, alveolar infiltrates
  • nodules
44
Q

CXR findings: radiation pneumonitis

A
  • hazy ground glass densities to marked patchy infiltrates or homogenous consolidation
  • air bronchograms
45
Q

CXR findings: chemical pneumonitis

A

-diffuse alveolar, and interstitial infiltrates

46
Q

CXR findings: bronchiolar carcinoma

A
  • butterfly distribution of alveolar infiltrates

- may be unilateral

47
Q

CXR findings: bronchoalveolar cell carcinoma

A
  • peripheral alveolar infiltrates that do not respond to Abx

- peripheral mass or nodule

48
Q

CXR findings: fat emboli

A

-interstitial prominence, interstitial edema

49
Q

CXR findings: alveolar hemorrhage

A

-focal/diffuse alveolar infiltrates

Tintinalli Section 8 - Pulmonary Emergencies (9 decks)

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