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Pulmonary > TB/PNA > Flashcards

TB/PNA Flashcards

1
Q

Labs and diagnostics of TB

A
  • definitive diagnosis by culture x 3
  • AFB smears are presumptive evidence of active TB
  • small homogeneous infiltrate in upper lobes by car
  • PPD shows exposure: not diagnostic for active dz
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2
Q

TB medication regimen

A

Isoniazid 300mg, rifampin 600mg, pyrazinamide 1.5-2 gm and ethambutol 15mg/kg OR
streptomycin 15mg/kg IM
-If the drug is fully susceptible to INH and RIF then the 4th drug can be dropped
-

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3
Q

How long do you treat TB for?

A

Isoniazid, rifampin and pyrazinamide daily x 2 months, then 4 months of INH and RIF daily

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4
Q

How long do you treat a HIV infected person for?

A

9 months

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5
Q

How do you monitor therapy for TB treatment

A
  • weekly sputum smears & cultures for 1st 6 weeks
  • then monthly until negative cultures
  • continued sxs or + cultures after 3 months should raise suspicion of drug resistance
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6
Q

Baseline eval before initiating TB tx

A

LFTs**, cbc, crt

  • if normal baseline labs do not need monthly labs but should be questioned about sxs of drug toxicity
  • patients taking ethambutol should be tested for visual acuity and red-green color perception **
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7
Q

Positive skin test for TB should:

A
  • 6 months INH (healthy or health care worker)
  • a + test is 5mm for HIV person, contacts of a known case, or with chest film typical for TB
  • a + test is 10mm for immigrants from high prevalence areas, high risk groups including health care workers
  • a + test is 15 mm for all other not in high prevalence groups
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8
Q

Tx of CAP in health < 60 yr adults

with no recent abs therapy

A

A macrolide like Zithromax,

clarithromycin or erythromycin or doxy

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9
Q

tx of Cap with patients with other health problems (COPD, DM, HF or cancer or > 60 years age)

A

Fluoroquinolone (levo) gemifloxacin or moxifloxacin

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10
Q

Inpatient ICU management

A

-o2 as indicated
-beta lactam (rocephin, unasyn)
-for pseudomonas infection use antipseudonomal beta-lactam -pip tax, cefepime, imipenem PLUS cipr or levo or the above beta lactim with amino glycoside and azith. OR
thea bove beta-lactam + aminoglycoside and an antipneumococcal fluoroquinolone

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11
Q

what do you add for CAP methicillin resistant staph?

A

vanc or linezolid

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12
Q

HAP

A

pneumonia that occurs 48 hours or more after admission.

most likely causes: staph aureus, strep pneum, and haemophilus influenza

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13
Q

VAP

A

arises more than 48-72 hours after intubation.

pseudomonas is most causative organism

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14
Q

HCAP

A

any pt hospitalized in an acute care hospital for 2 or more days within 90 days of the infection, or received iV abs therapy, chemotherapy or wound care within past 30 days or attended a hospital or hemodialysis clinic.

organisms: staph aureus, pseudomonas, but less strep pneum, haemophilus influenza and MRSA

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15
Q

What is a pneumothorax?

A

gas in the pleural space that raises pleural pressures and can impair respiration, resulting in “collapsed lung

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16
Q

S & S pneumothorax

A

chest pain, dyspnea, cough

  • hyperresonance on affected side
  • diminished breath sounds and diminished fremitus on affected side
  • mediastinal shift toward the unaffected side (tension)
  • hypotension
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17
Q

What is diagnostic for pneumo?

A

CXR

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18
Q

Mngt of pneumo

A
  • < 20% pneumothorax in asymptomatic patient requires no intervention
  • chest tube is used 1st if available: in emergency needle thoracostomy
  • chest tube placement: 4th or 5th ICS, MAL
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19
Q

Labs and diagnostics for Pulmonay embolism

A
  • VQ scan
  • ABG: hypoxemia )sat < 90%, paO2 < 8o mm Hg)
  • Hypocapnia (pCO2 < 35) due to reflexive hyperventilation
  • spiral Ct/D-dimer
  • pulmonary agniography when clinical data and VQ scan contradictory or if those at significant risk from anticoagulation have high probability VQ scan
20
Q

Management of PE

A
  • o2
  • IV fluids in those with hypotension and reduced CO
  • worsening hypercapnia with progressive obtundation is indicated for intubation
  • heparin followed by continuous infusion or maintain a PTT of 1.5-2x normal. begin coumadin simultaneously to an INR of 2-3
  • fibrinolytics therapy in those with hemodynamic compromise or shock before starting fibrinolytics/thrombolytics, PT and PTT must be < 2x normal
21
Q

Adult Respiratory distress syndrome. Labs and Diagnostics

A
  • refractory hypoxemia is hallmark feature ** 02 therapy does not help
  • chest x-ray may be whited out or have diffuse bilateral infiltrates
22
Q

Management of ARDS

A

-mechanical ventilation with PEEP
-TV 5-7 ml/kg BW
-peak inspiratory flow 1-1.2 L as needed
Peep 10
-tx underlying infection

23
Q

what is the difference between SIMV/IMV and assist-control

A

both have preset tidal volume and respiratory rate but with AC client can trigger the machine and if triggered the machine delivers the preset tidal volume.

if on IMV/SIMV: if have an extra breath then gets to draw own volume

24
Q

SIMV/IMV

synchronized intermittent mandatory ventilation

A

pt gets a present number of breaths at a preset tidal volume but can take his own breaths at whatever tidal volume he pulls

25
Q

CPAP

A

breathing spontaneously but at a pressure greater than atmospheric

26
Q

pressure support

A

inspiratory effort totally unassisted but at a preset amount of airway pressure is delivered with each breath

27
Q

positive end expiratory pressure (PEEP)

A

maintains intrathoracic airway pressure above atmospheric throughout expiration

28
Q

FIO2

A

RaO2 is 21%. give lowest amount to provide acceptable pa02 (>60) high concentrations over long periods of time are toxic to lung tissue

29
Q

TIdal Volume

A

amount of gas delivered per breath. vent: 5-7 ml/kg of ideal body weight. higher TV increase alveolar ventilation (usually 300-500)

if weening from ventilator don’t touch the tidal volume

30
Q

when are they ready to be weened from the ventilatory?

A

sitting at 40%
-hemodynamically stable
-on SIMV
when breathing on own switch to SIMV from AC

31
Q

typical vent settings

A 
FI02: 100%
mode: Ac
rate: 12
TV: 5-7 ml/kg 
no peep support
32
Q 
Airflow rates:
FVC
FEV1
FEV25-75
PEFR
A

reduced with obstructive dz

33
Q

Volumes
TLC
FRC
RV

A

reduced with restrictive dz such as pneumonia, sarcoidosis, cystic fibrosis, pulmonary fibrosis

restrictive dz are characterized by poor volumes

34
Q

Pleural effusions

A

classified into transudates or exudates. to be an exudate pleural effusion must have 1 or more of following:

  • pleural fluid protein to serum protein ration > 0.5
  • pleural fluid LDH to serum LDH ration > 0.6
  • pleural fluid LDH greater than 2/3 the upper limit of normal serum LDH

transudates have none of these features

35
Q

Types of pleural effusions

A

transudates
exudates
empyema
hemorrhagic

36
Q

characterisitc sign of pleural effusion

A

cxr with blunting/shadowing of costophrenic angle

37
Q

Most common pathogens in pneumonia in the elderly

A

Strep pneum, gram negative bacilli (haemophilus influenza, moraxella catarrhalis, klebsiella) and staph aureus

38
Q

CXR findings in elderly with pneumonia

A

May have multiple presentations based on the offending pathogen

  • bacterial pneumonia can present with either bronchopneumonia, lobar pneumonia or other locations on the cxr
  • viral pneumonia may present as bilateral interstitial infiltrates
  • aspiration pneumonia may be localized to the right middle lobe or show diffuse involvement
39
Q

+ PPD but -cxr

A

if young and health care worker then treat for 6 months.

if not young and healthy or not health care worker then don’t treat for just a +PPD. would repeat cxr in 6 months

40
Q

pseudomonas is most common causative organism in VAP. How do you cover?

A
  • beta-lactam. pip-taz + cipro or levo
  • pip-taz + aminoglycoside + azithromycin
  • pip-taz + aminoglycoside + antipneumococcal fluoroquinolone
  • for CA- MRSA coverage: add vanc or linezolid
41
Q

what do people with PE die from usually?

A

failure of R ventricle. can’t handle the forces through the pulmonary artery

42
Q

how can pleural effusion exudates be described?

A

-may result from alterations in local factors that determine formation and abosrption of pleural fluid

an exudate is any fluid that filters from the circulatory system into lesions or areas of inflammation. It may also result from alteration in local factors that determine formation and absorption of pleural fluid

43
Q

A pleural effusion is likely exudative if what ratio is found?

A

ratio of pleural fluid protein to serum protein is greater than 0.5

44
Q

when reviewing the cxr of someone with restrictive lung dz what is usually NOT seen?

A

-widened rib spaces

45
Q

what tx plan would you order for your patient with known restrictive lung dz?

A
  • o2 therapy
  • pulmonary rehab
  • steroids

Pulmonary (2 decks)

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