TB/PNA Flashcards
Labs and diagnostics of TB
- 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
TB medication regimen
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
-
How long do you treat TB for?
Isoniazid, rifampin and pyrazinamide daily x 2 months, then 4 months of INH and RIF daily
How long do you treat a HIV infected person for?
9 months
How do you monitor therapy for TB treatment
- 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
Baseline eval before initiating TB tx
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 **
Positive skin test for TB should:
- 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
Tx of CAP in health < 60 yr adults
with no recent abs therapy
A macrolide like Zithromax,
clarithromycin or erythromycin or doxy
tx of Cap with patients with other health problems (COPD, DM, HF or cancer or > 60 years age)
Fluoroquinolone (levo) gemifloxacin or moxifloxacin
Inpatient ICU management
-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
what do you add for CAP methicillin resistant staph?
vanc or linezolid
HAP
pneumonia that occurs 48 hours or more after admission.
most likely causes: staph aureus, strep pneum, and haemophilus influenza
VAP
arises more than 48-72 hours after intubation.
pseudomonas is most causative organism
HCAP
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
What is a pneumothorax?
gas in the pleural space that raises pleural pressures and can impair respiration, resulting in “collapsed lung
S & S pneumothorax
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
What is diagnostic for pneumo?
CXR
Mngt of pneumo
- < 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
Labs and diagnostics for Pulmonay embolism
- 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
Management of PE
- 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
Adult Respiratory distress syndrome. Labs and Diagnostics
- refractory hypoxemia is hallmark feature ** 02 therapy does not help
- chest x-ray may be whited out or have diffuse bilateral infiltrates
Management of ARDS
-mechanical ventilation with PEEP
-TV 5-7 ml/kg BW
-peak inspiratory flow 1-1.2 L as needed
Peep 10
-tx underlying infection
what is the difference between SIMV/IMV and assist-control
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
SIMV/IMV
synchronized intermittent mandatory ventilation
pt gets a present number of breaths at a preset tidal volume but can take his own breaths at whatever tidal volume he pulls
CPAP
breathing spontaneously but at a pressure greater than atmospheric
pressure support
inspiratory effort totally unassisted but at a preset amount of airway pressure is delivered with each breath
positive end expiratory pressure (PEEP)
maintains intrathoracic airway pressure above atmospheric throughout expiration
FIO2
RaO2 is 21%. give lowest amount to provide acceptable pa02 (>60) high concentrations over long periods of time are toxic to lung tissue
TIdal Volume
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
when are they ready to be weened from the ventilatory?
sitting at 40%
-hemodynamically stable
-on SIMV
when breathing on own switch to SIMV from AC
typical vent settings
FI02: 100% mode: Ac rate: 12 TV: 5-7 ml/kg no peep support
Airflow rates: FVC FEV1 FEV25-75 PEFR
reduced with obstructive dz
Volumes
TLC
FRC
RV
reduced with restrictive dz such as pneumonia, sarcoidosis, cystic fibrosis, pulmonary fibrosis
restrictive dz are characterized by poor volumes
Pleural effusions
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
Types of pleural effusions
transudates
exudates
empyema
hemorrhagic
characterisitc sign of pleural effusion
cxr with blunting/shadowing of costophrenic angle
Most common pathogens in pneumonia in the elderly
Strep pneum, gram negative bacilli (haemophilus influenza, moraxella catarrhalis, klebsiella) and staph aureus
CXR findings in elderly with pneumonia
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
+ PPD but -cxr
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
pseudomonas is most common causative organism in VAP. How do you cover?
- beta-lactam. pip-taz + cipro or levo
- pip-taz + aminoglycoside + azithromycin
- pip-taz + aminoglycoside + antipneumococcal fluoroquinolone
- for CA- MRSA coverage: add vanc or linezolid
what do people with PE die from usually?
failure of R ventricle. can’t handle the forces through the pulmonary artery
how can pleural effusion exudates be described?
-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
A pleural effusion is likely exudative if what ratio is found?
ratio of pleural fluid protein to serum protein is greater than 0.5
when reviewing the cxr of someone with restrictive lung dz what is usually NOT seen?
-widened rib spaces
what tx plan would you order for your patient with known restrictive lung dz?
- o2 therapy
- pulmonary rehab
- steroids
