Test 3 Flashcards
Cystic firbrosis leads the excessive production and accumulation of thick, tenacious mucus in the tracheobronchial tree secondary to ____________________________.
Inadequate hydration of the periciliary fluid layer (sol layer)
Partial obstruction leads to what?
Over distention of the alveoli
Complete obstruction leads to ____________________.
Patchy areas of atelectasis and in some cases bronchiectasis
What are the predominant features of CF in the advanced stages?
- Excessive bronchial secretions
- Bronchial obstruction
- Hyperinflation of the lungs
What are the major respiratory pathologic or structural changes associated with CF? (6)
- Excessive production and accumulation of thick, tenacious mucus in the tracheobronchial tree secondary to inadequate hydration of the periciliary layer.
- Partial bronchial obstruction (mucus plugging)
- Hyperinflation of the alveoli
- Total bronchial obstruction (mucus plugging)
- Atelectasis
- Bronchiectasis
What is the most common fatal inherited disorder in childhood?
Cystic Fibrosis
What type of gene disorder is CF?
Autosomal recessive gene disorder caused by mutations in a pair of genes located in Chromosome 7
Under normal conditions, every cell in the body has _______ chromosomes.
46 chromosomes - 23 pairs
More than _________ different mutations in the gene that encodes for the cystic fibrosis transmembrane conductance regulator have been described.
1700
The most common genetic defect linked to CF involves the absence of three base pairs in ___________ that codes for phenylalanine on chromosome 7 (band q31.2)
Codon 508 (ΔF508)
The absence of three base pairs in codon 508 (ΔF508) accounts for ___________ of patients with CF tested.
70-75%
The abnormal expression of the CFTR results in what?
Abnormal transport of sodium and chloride ions across many types of epithelial surfaces, including those lining the bronchial airways, intestines, pancreas, liver ducts, and sweat glands.
The CFTR mutations that is classified a gating defect means ________________.
The channel does not open
The CFTR mutations that is classified as conductance defect means
________________.
The channel is open, but chloride does not move effectively.
Because CF is a recessive gene disorder, the child must inherit _______ copies of the defective gene disorder.
2 copies, one from each parent to have the disease
If both parents carry the CF gene, the possibility of their children having CF follows the ________________.
Standard Mendelian Pattern
When both parents carry a CF gene mutation, there is a _____ in four chance that the chid will have CF.
One.
1/4
It is estimated that how many Americans are unknowing, symptomless carriers of the mutant CF gene?
10 million
According to the CF Foundation, CF affects about how many children and adults in the US and how many worldwide?
US - 30,000
Worldwide - 70,000
About ______ new cases of CF are diagnosed each year in the US.
1000
More than ___% of patients are diagnosed with CF by newborn screening.
90
More than ____% of the patient population with CF are 18 years or older.
50
What is the median age of survival for individuals with CF?
In the late 30s, but many patients with CF live into their 40s and beyond.
CF occurs most often in what race?
Caucasians (1:3000)
The diagnosis of CF is based on what three things?
- Clinical manifestations associated with CF
- Family history of CF
- Lab findings
What two criteria must be met to diagnose CF?
- Clinical symptoms consistent with CF in at least one organ
- Clinical evidence of CTFR dysfunction
What is classified as clinical evidence of CTFR dysfunction?
- Elevated sweat chloride greater than 60 mEq/L (on two occasions)
- Molecular diagnosis (genetic testing). Presence of two disease-causing mutations in CFTR.
- Abnormal nasal potential difference
Newborn screening for CF has been part of the newborn genetic testing protocol in all 50 states since _____.
2011
Most infants with CF have an elevated blood level of immunoreactive trypsin, which can measured by ________________.
- Radioimmunoassay
- An enzyme-linked immunoassay
Immunoreactive trypsin is also called what?
Trypsin-like immunoreactivity or serum trypsin
The immunoreactive trypsin level (IRT) is measured from the ___________ collected on all newborn infants on the Guthrie cards.
blood dots
The CF screening protocol varies among states and will identify more than ____% of infants wit CF.
90
What is the most common CF protocol?
Perform DNA screening for 32 to 85 of the most common CF mutations on 2-5% of the samples with the highest IRT levels
The diagnosis of CF is established by what?
A positive sweat test and/or genetic analysis for CF mutations
What identifies a newborn as a CF carrier?
Negative or normal sweat test
_________________ is the gold standard diagnostic test for CF.
Sweat test or sweat chloride test
The sweat test is a reliable test for the identification of about ____% of patients with CF.
98
CF Pancreas Mnemonic
Chronic Respiratory Disease
Failure to Thrive
Polyps
Alkalosis, Metabolic
Neonatal intestinal obstruction
Clubbing of fingers
Rectal prolapse
Electrolyte increase in sweat
Aspermia/absent vas deferens
Sputum: Staphylococcus aureus, Pseudomonas aeruginosis
What does the sweat test measure?
Amount of sodium and chloride in the patient’s sweat
During the sweat test procedure, a small amount of a colorless, odorless sweat-producing chemical is applied to the patient’s arm or leg. What is this chemical called?
Pilocarpine
How many times is the sweat test usually done?
Twice
How is sweat produced during a sweat test?
An electrode is attached to the chemically prepared area, and a mild electric current is applied to stimulate sweat production.
Although the sweat glands of patients with CF are microscopically normal, the glands secrete up to ________ the normal amount of sodium and chloride.
FOUR TIMES
In both infants and adults, a sweat chloride concentration greater than _______ is considered to be a diagnostic sign of CF.
60 mEq/L
With a sample of the patient’s _______________, a genetic test can be performed to analyze DNA for the presence of CFTR gene mutations.
Blood or cheek cells
Most of the diagnostic laboratories in the US are able to screen for at least ________ of the most common mutations.
30-100
What is the sweat test interpretations?
Infants 6 mo. or YOUNGER
Normal: Less than or equal to 29 mmol/L
Intermediate: 30-59 mmol/L
Abnormal: Greater or equal to 60 mmol/L
Infants Older than 6 mo, Children & Adults
Normal: Less than or equal to 39 mmol/L
Intermediate: 40-59 mmol/L
Abnormal: Greater or equal to 60 mmol/L
It is estimated that genetic testing can confirm CF in about how many of the patients tested?
90-96%
As the sodium and chloride ions move across the epithelial cell membrane, they generate what is called an __________________.
Electrical Potential Difference
Define Electrical Potential Difference.
The amount of energy required to move an electrical charge from one point to another.
Where can the nasal potential difference be measured?
With a surface electrode over the nasal epithelial cells lining the inferior turbinate
What does an increased nasal potential difference suggest?
CF
The nasal potential difference is recommended for what type of patients?
Patient with clinical features of CF who have borderline or normal sweat test values and nondiagnostic CF genotyping.
If desired, a fetus can be tested for CF by amniocentesis during what trimester?
First
Fetal cells are tested for the presence of CF mutations and identified as what?
- CF affected
- CF carrier
- Normal
___________________ is very important in all cases of prenatal testing for CF to explain the uncertainty or residual risk to prospective parents.
Genetic counseling
Explain fecal fat test.
It measures the amount of fat in the infant’s stool and the percentage of dietary fat that is not absorbed by the body.
Infants with CF and pancreatic insufficiency will have a fecal elastance of ____________.
Less than 50 µg/g
What is the normal fecal elastance value?
Greater than 300 µg/g
What is the stool fecal fat test used to evaluate?
How the liver, gallbladder, pancreas and intestines are functioning.
What are the major anatomic alterations of the lungs associated with CF? (3)
- Bronchospasm
- Excessive bronchial secretions
- Atelectasis
Define spontaneous pneumothorax.
No obvious injury could have caused the pneumothorax.
Side note: Once you’ve have one, there’s about a 50% chance that it will recur.
Describe the physical examination of a CF patient.
- Increased RR (Tachypnea)
- Increased HR and BP
- Use of accessory muscles of inspiration/expiration
- Pursed-lip breathing
- Cyanosis
- Digital clubbing
- Peripheral edema and venous distention
- Diminished heart and breath sounds
- Decreased or increased tactile fremitus
- Hyperresonant percussion note
- Bronchial breath sounds
- Crackles
- Wheezing
-Spontaneous pnuemothorax
What would an ABG look like for a patient MILD TO MODERATE CF?
Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis)
What would an ABG look like for a patient SEVERE STAGE CF?
Chronic Ventilatory Failure with Hypoxemia (Compensated Respiratory Acidosis)
What are the abnormal lab test associated with CF?
Increased hematocrit and hemoglobin
Increased WBC
Hypoxemia makes the blood produce more blood cells
What are some radiologic findings of CF? (8)
- Translucent (dark) lung fields
- Depressed or flattened diaphragm
- Right ventricular enlargement (Cor pulmonale)
- Areas of atelectasis or fibrosis
- Tram tracks
- Bronchiectasis (often a secondary complication)
- Pnuemothorax (spontaneous)
- Abscess formation
About _____% of men with CF are infertile.
99
Nasal polyps are seen in between _________ of patients with CF.
10% and 30%
What is meconium ileus?
Obstruction of the small intestine of the newborn that is caused by the impaction of thick, dry, tenacious meconium, usually at or near the ileocecal valve.
What are the primary goals for patients with CF?
- Prevent pulmonary infections
- Reduce the amount of thick bronchial secretions
- Improve airflow
- Provide adequate nutrition
Hypoxemia may NOT respond well to oxygen therapy when ____________ is present.
True or capillary pulmonary shunting
What are keys to reversing consolidation caused by mucous plugging?
Deep breathing and effective cough
When do you want to administer bronchodilators to CF patients?
- Before patient receives chest physiotherapy or exercise
- Before patient receives inhaled nebulized hypertonic saline, antibiotics and/or dNASE to offset bronchial constriction
What are recommended bronchodilators for CF?
SABA - Albuterol
LABA - Salmeterol and Formoterol
What is Ivacaftor’s brand name?
Kalydeco
What may be used to hydrate thick mucus in the airways of patients with CF who are 6 years of age or older, have a chronic cough or have a reduced FEV1?
Inhaled hypertonic saline
Inhaled hypertonic saline is usually given with a bronchodilator how often?
Twice a day.
What medication has not been proven to be effective in treating patients with CF?
Inhaled N-acetylcysteine
Drugs that help mutated CFTR reach the epithelial cell surface where the CFTR protein normally functions as a transmembrane regulator of chloride movement out of the cell and sodium transport into the cell.
Correctors
Drugs that help mutated CTFR function more effectively at the epithelial cell surface transporting chloride out of the cell and inhibiting the movement of sodium into the cell.
Potentiators
An oral potentiator molecule that has been proved effective to improve cell function and clinical status in patients with CF with the G551D mutation.
Ivacaftor (Kalydeco)
Which of the following organisms are commonly found in the tracheobronchial tree secretions of patients with. CF?
- Staphylococcus
- Haemophilus influenzae
- Pseudomonas aeruginosa
About 80% of all patients with CF demonstrate a deficiency in which of the following vitamins?
D, A, K, E
Bronchiectasis is an acquired disorder of the major bronchi and bronchioles characterized by what?
Chronic dilation and distortion of one or more bronchi
Bronchiectasis is commonly limited to a lobe or segment and is commonly found in which part of the lungs?
Lower lobes
Reid classification subdivides bronchiectasis into what following three patterns?
- Varicose (fusiform)
- Cylindrical (tubular)
- Cystic (saccular)
The bronchi are dilated and constricted in an irregular fashion, ultimately resulting in a distorted bulbous shape.
Varicose (fusiform) bronchiectasis
The bronchi progressively increase in diameter until they end in large, cystlike sacs in the lung parenchyma.
Cystic (saccular) bronchiectasis
The bronchi are dilated and rigid and have regular outlines similar to a tube.
Cylindrical (tubular) bronchiectasis
With cylindrical (tubular) bronchiectasis, X-ray shows that the dilated bronchi fail to taper for _______ generations and then appear to end abruptly because of mucous obstruction.
6-10
Which form of bronchiectasis causes the greatest damage to the tracheobronchial tree?
Cystic (saccular) bronchiectasis
With cylindrical (tubular) bronchiectasis, the bronchial walls becomes composed of _______ alone.
Fibrous tissue,
Cartilage, elastic tissue and smooth muscle are all absent
What are the major pathologic or structural changes associated with bronchiectasis? (7)
- Chronic dilation and distortion of bronchial airways
- Excessive production of often foul-smelling sputum
- Bronchospasm
- Alveoli hyperinflation
- Atelectasis
- Parenchymal consolidation and fibrosis
- Hemoptysis secondary to bronchial arterial erosion
Most causes of bronchiectasis include some combination of ____________ and ______________.
Bronchial obstruction and infection
In developed countries, ______________ is the most common causes of bronchiectasis in children.
CF
In the US, the incidence of NCFB is about _______________.
4.2 per 100,000 young adults
The low incidence of NCFB in developed countries is most often attributed to what?
Early medical management.
What is the most common causes of NCFB?
Pulmonary infection
The causes of bronchiectasis are commonly classified in what following categories?
- Acquired bronchial obstruction
- Congenital anatomic defects
- Immunodeficiency states
- Abnormal secretion clearance
- Miscellaneous disorders
A routine chest radiograph of bronchiectasis may reveal what? (11)
- Overinflated lungs
- Marked volume loss
- Increased opacities
- Dilated fluid-filled airways
- Crowding of the bronchi
- Translucent (dark) lung fields
- Depressed and flattened diaphragms
- Long and narrow heart pulled down by diaphragm
- Enlarged hearted when heart failure present
- Tram tracks
- Areas of consolidation and/or atelectasis may or may not be seen
What has replaced bronchograms as the gold standard for the diagnosis of NCFB?
HR-CT (High-Resolution Computed Tomogram)
The diagnosis of bronchiectasis is made on the basis of what three things?
- Internal diameter of the bronchus that is wider than its adjacent pulmonary artery
- Failure of the bronchi to taper
- Visualization of bronchi in the outer 1-2 cm of lung fields
The HR-CT is used to better clarify the findings of the chest radiograph and standard CT scans, and allows ____________ of airway abnormalities that cannot be identified on routine films of the chest.
Lung Mapping
What can be used to determine if the bronchiectasis demonstrates primarily an obstructive or restrictive lung pathophysiology?
Spirometry
What can be used to determine if the patient has mild, moderate or severe gas exchange compromise?
ABG
You will see pursed-lip breathing in bronchiectasis patients when their pathology is primarily ___________________.
Obstructive
State the clinical manifestations of bronchiectasis. (4)
- Excessive bronchial secretions
- Bronchospasm
- Consolidation
- Increased alveolar-capillary membrane thickness
What is the hallmark of bronchiectasis?
Chronic cough with large production of foul-smelling sputum
Which anaerobic organisms are commonly cultured from the sputum of bronchiectasis patients?
- Haemophilus influenzae
- Streptococcus
- Psuedomonas aeruginosa
The productive cough seen in patients with bronchiectasis is triggered by __________________.
The large amount of secretions that fill the trachebronchial tree
The subepithelial mechanoreceptors are found in the trachea, bronchi and bronchiole but are predominantly located ____________.
In the upper airways
What are chest assessment findings in bronchiectasis that is primarily obstructive?
- Decreased tactile and vocal fremitus
- Hyperresonant percussion note
- Diminished breath sounds
- Wheezing
- Crackles
What are chest assessment findings in bronchiectasis that is primarily restrictive? (5)
- Increased tactile and vocal fremitus
- Bronchial breath sounds
- Crackles
- Whispered pectoriloquy
- Dull percussion note
How does a PFT look for a moderate or severe bronchiectasis patient?
Everything normal or DECREASED.
RV/TLC ratio normal
Bronchiectasis: Hematology
- Increased hematocrit and hemoglobin
- Elevated WBC if patient is acutely infected
Parallel or curved opacity lines of varying length caused by bronchial wall thickening.
Tram tracks
Which type of bronchiectasis would tram-track opacitites most likely be seen in?
Cylindrical bronchiectasis
What is the general treatment plan for bronchiectasis?
Control pulmonary infections, airway secretions and airway obstruction and preventing complications
USE OF CORTICOSTEROIDS IS DISCOURAGED WITH BRONCHIECTASIS.
JUST KNOW
What are some airway clearance techniques used for bronchiectasis?
- Directed cough
- CPT (Postural drainage)
- Suctioning
- PEP
- High-frequency chest wall oscillation
What are the major pathologic or structural changes associated with pnuemonia? (3)
- Inflammation of the alveoli
- Alveolar consolidation
- Atelectasis
Atelectasis is often associated with patients who have ___________________.
Aspiration pneumonia
What are some causes of pneumonia? (9)
- Bacteria
- Viruses
- Fungi
- Protozoa
- Parasites
- TB
- Anaerobic organisms
- Aspiration
- Inhalation of irritating chemicals such as chlorine
Polymorphonuclear leukocytes move into the infected area and engulf and kill invading bacteria on the alveolar walls. What is this called?
Surface phagocytosis
Taken together, pneumonia and influenza combined are the _________ leading cause of death among Americans.
eigth
Taken together, pneumonia and influenza combined are the _________ leading cause of death among Americans over the age of 65.
sixth
It is estimated that ____________ Americans die of pneumonia each year.
50,000
What is the leading cause of morbidity and mortality in children beyond the neonatal period?
Pneumonia
Pneumonia often mimics a __________________.
Cold or flu
What is characterized by a patchy pattern of infection that is limited to the segmental bronchi and surrounding lung parenchyma?
Bronchopneumonia
Bronchopneumonia usually involves both lungs and is often seen in which part of the lung?
Lower lobes
_____________ is a widespread of diffuse alveolar inflammation and consolidation confined to one or more lobes of the lungs.
Lobar pneumonia
Interstitial pneumonia is usually a diffuse and often bilateral inflammation that primarily involves ___________________.
The alveolar septa and interstitial spaces
Which type of pneumonia is typically the end result of a severe or long term bronchopneumonia?
Lobar pneumonia
When both lungs are involved, the condition is sometimes called _______________.
“double pneumonia” by laypersons.
What term is often used to describe a mild case of pneumonia?
Walking pneumonia
What are some risk factors for pneumonia?
- Age over 65 years
- AIDS
- Rib fractures
- Cancer
- Viral respiratory infections
- Prolonged bed rest
- Chronic respiratory disease
__________________ refers to a pneumonia acquired from normal social contact.
CAP - Community-acquired pneumonia
What type of pneumonia accounts for more than 80% of all bacterial pneumonias?
Streptococcus pneumoniae pneumonia
Is streptococcus gram-positive or negative?
Positive
What type of S. pneumoniae organism is the most virulent?
Serotype 3
There are more than ___ types of S. pneumoniae.
80
How is streptcocci generally transmitted?
By aerosol from a cough or sneeze of an infected person.
S. pneumoniae and H. influenzae is commonly cultured from the sputum of patients having an acute exacerbation of ___________.
Chronic bronchitis
What are two major groups of staphylococcus?
- staphylococcus aureus, most responsible for “staph” infections in humans
- staphylococcus albus and staphylococcus epidermidis, part of the normal skin flora
______________ are a common cause of hospital-acquired pneumonia or nosocomial pnueumonia.
Staphylococci, becoming increasingly antibiotic resistant
_____________ is a common inhabitant of human pharyngeal flora.
Haemophilus influenzae
Most strains of S. pneumoniae are sensitive to __________________.
Penicillin and its derivatives
A gram-positive, nonmotile coccus that is found singly, in pairs and in irregular clusters
Staphylococcus
Rod-shaped organisms that are the major gram-negative organisms responsible for pneumonia.
Bacilli
A gram-positive, nonmotile bacterium that occurs singly, in pairs, and in short chains.
Streptococcus
How is staphylococcus aureus transmitted?
By air from a cough/sneeze of an infected person and indirectly via contact with contaminated floors, bedding, floors and clothes.
There are 6 types of H. influenzae, designated A to F, but only type ____ is commonly pathogenic.
B
How does H. influenzae appear on gram stain?
Coccobacilli
Is H. influenzae gram-negative or positive?
Negative
Pneumonia caused by H. influenzae is most often seen where?
Children 1 month to 6 years old.
H. influenzae type B is almost always the cause of _________________.
Acute epiglottitis
How is H. influenzae transmitted? What environment does this organism survive best in?
Via aerosol or contact with contaminated objects. It is sensitive to the cold and does not survive long after expectoration.
Pneumonia associated with Legionella pneumophila is termed…..
Legionnaire’s disease
Organism that multiplies in standing water such as contaminated mud puddles, large air-conditioning systems and water tanks.
Legionella pneumophila
Where can Legionella pneumophila be detected?
- Pleural fluid
- Sputum
- Lung tissue
Where is Legionnaire’s disease commonly seen?
Middle-aged men who smoke
_______________________ have been long associated with lobar pneumonia, particularly in men over 40 an chronic alcoholics of both genders.
Klebsiella pneumoniae
Is Klebsiella pneumoniae gram-positive or negative?
Negative
Klebsiella pneumoniae is a normal inhabitant of the __________________.
Human gatrointestinal tract
Why is the morality of patients with Klebsiella pneumoniae so high?
Because frequent septicemia is a frequent complication
Klebsiella pneumoniae is a common nosocomial disease.
Fact.
A gram-negative diplococcus that commonly colonizes the upper respiratory tract, particularly in children.
Moraxella catarrhalis
What is often found as a cause of acute otitis media in kids and is also associated with exacerbations in adults with COPD?
Moraxella catarrhalis
A highly mobile, gram-negative bacillus. Often found in the GI tract, burns and catheterized urinary tract.
Pseudomonas aeruginosa
________________ is frequently cultured from the respiratory tract of patients who are chronically ill and tracheostomized and is the leading cause of healthcare-associated pneumonia.
Pseudomonas aeruginosa
Where does Pseudomonas aeruginosa thrive?
In dampness, so it is often cultured from contaminated RT equipment.
Describe the sputum of patient with a Pseudomonas infection.
Frequently green and sweet smelling
The mycoplasma organism is the most common cause of ______________.
An acquired atypical pneumonia.
The pneumonia caused by the mycoplasmal organism is commonly described as a _____________.
Primary atypical pneumonia
What are common symptoms of mycoplasma pneumonia?
A cough that tends to come in violent attacks, producing only a small amount of white mucus. Some experience nausea or vomiting and a profound weakness that lasts a long time.
Where is mycoplasma pneumonia commonly seen?
Children and young adults.
Spreads easily at shelters, schools, child-care centers.
A gram-negative bacterium that causes Q fever in humans
Coxiella burnetti
How is Coxiella burnetti spread?
Aerosol from infected people and in living animals such as cattle, sheep and goats.
Which adenovirus serotypes cause viral infections and pneumonia in all age groups?
4, 7, 14 and 21
Mycoplasma organisms are smaller than bacteria, but bigger than ___________.
Viruses
The term atypical refers to what?
- Cannot be identified by bacteriologist test
- Moderate amount of expectorated sputum
- Only moderately elevated WBC
- Lack of alveolar exudate
______________ and _________________ closely resemble the clinical manifestations of those caused by M. pneumoniae.
Chlamydia spp. pneumonia and C.burnetti
Chlamydia is a type of bacterium found where?
In the cervix, urethra, rectum, throat and respiratory tract. Also found in the feces of various birds.
Viruses account for about ___% of all pneumonias, and several are associated with a community-acquired atypical pneumonia.
50
What type of pneumonia tends to start with flu-like symptoms?
Viral pneumonias
Viral pneumonia always carries the risk for development of a secondary bacterial pneumonia
Fact
Minute organisms that aren’t visible by ordinary light microscopy.
Viruses
About ____% of acute upper respiratory tract infections are caused by viruses.
90
___________ are the most common cause of pneumonia in young children.
Respiratory viruses
What disorders belong to the paramyxovirus group?
Parainfluenza, mumps and rubella viruses
Where is RSV most often seen?
Children younger than 12 months and in older adults with underlying heart or pulmonary disease.
Almost all children will be infected with RSV by ___________.
their second birthday.
RSV infections are most commonly seen in patients during when?
During the late fall, winter or early morning spring months.
What major types of parainfluenza virus are the major causes of infection in humans?
1, 2, 3
Which major type of parainfluenza virus is considered a croup type of virus?
Type 1
Which major types of parainfluenza virus are associated with severe infections?
2 & 3
How is parainfluenza transmitted?
By aerosol droplets and by direct person-to-person contact.
The influenza viruses type _______ are the most common cause of viral respiratory tract infections.
A & B
In the US, influenza A & B commonly occur in epidemics during ____________.
Winter months
How is influenza spread?
Person to person by aerosol droplets
What is often the first sign of an epidemic?
Increase in school absenteeism
In what area does influenza survive well in?
Low temperatures and humidity
What is influenza’s incubation period?
1-3 days
Adenovirus type _____ has been related to fatal cases of pneumonia in children.
7
How is adenoviruses transmitted?
Aerosol
Pneumonia caused by adenovirus generally during what seasons?
Fall, winter and spring
A negative single-stranded RNA virus associated with a family of viruses that also include RSV and parainfluenza.
human metapneumovirus (hMPV)
What is the second most common cause of lower respiratory tract infections in young kids?
human metapneumovirus (hMPV)
Pneumonia that occurs 48 hours or more after hospital admission and that was not present at the time of admission.
Hospital-acquired pneumonia, nosocomial pneumonia
In the patients who develops pneumonia 4 to 7 days days of hospitalization, the most common pathogens are ___________.
MRSA
S. pneumoniae and H. influenzae
______________ refers to patient who have been hospitalized in an acute-care hospital within 90 days of the infection, who have resided in a nursing home or long-term facility or who have received parenteral antimicrobial therapy, chemotherapy or wound care within 30 days of pneumonia.
Health care-associated pneumonia (HCAP)
______________ is defined as a pneumonia of infectious disease origin that develops more than 48 to 72 hours after endotracheal intubation.
Ventilator-associated pneumonia
What are common VAI agents? (6)
- P. aeruginosa
- Enterobacter
- Klebsiella
- Acinetobacter spp.
- Stenotrophomonas maltophilia
- S. aureus
Aspiration of gastric fluid with a pH of ______________ causes a serious and often fatal form of pneumonia.
2.5 or less
What are the major cause of anaerobic infections?
Aspiration of oropharyngeal secretions and gastric fluids.
Why is aspiration pneumonitis commonly missed?
Because the acute inflammatory reaction may not begin until several hours after observed aspiration of the gastric fluid.
Mendelson first described aspiration pneumonia as the clinical manifestations of what?
Tachycardia, dyspnea, and cyanosis
Mendelson syndrome is usually confined to aspiration pneumonitis in ________.
Pregnant women
There are at least 3 distinctive forms of aspiration pneumonia, classified according to the nature of the aspirate, clinical presentation and management guidelines, as follows:
- Toxic injury to the lung
- Obstruction
- Infection
What is presumed to be the cause of nearly all cases of anaerobic infection?
Aspiration
What is a good measurement if aspiration is suspected?
Oximetry
Aspiration of gastric contents causes ___________ regardless of the pH level of the aspirate.
Initial hypoxemia
If the PH of the aspirate is _________, the initial injury is rapidly reversible.
Relatively high (greater than 5.9)
What occurs when food is aspirated?
Obliterative bronchiolitis with subsequent granuloma formation occurs
What happens if the pH of an aspirate is low?
Parenchyma damage may occur, with inflammation, edema and hemorrhage.
What is the normal range of unbuffered gastric contents?
1 to 1.5
The regurgitation of stomach contents into the esophagus is known as ____________.
GERD - gastroesophageal reflux disease
GERD is how many more times more prevalent in patients with asthma than in other patients?
Three times more
GERD causes chronic cough in ______ of patients.
10-20%
What are the normal swallowing mechanic phases?
- Oral preparatory
- Oral
- Pharyngeal
- Esophageal
Which two swallowing mechanic phases are considered voluntary stages?
The first two stages.
Respiration is halted during which phase for about 1 second?
Pharyngeal phase
Bolus transit in the esophageal phase lasts how many seconds?
8-20 seconds
Expiration before and after which phase in normal swallowing is believed to serve as an inherent closure and clearance mechanism against penetration of food or liquids in the airway entrance?
Pharyngeal phase
What is the result of an abnormal swallow that can involve the oral, pharyngeal and esophageal phases?
Dysphagia
Define aspiration.
The passage of food or liquid into the trachea via the vocal cords.
What is this test called?
Instilling a deep blue dye into the GI tract and seeing if it can be suctioned from the trachea.
Evans blue dye test
What are some diagnostic test for dysphagia? (4)
- Modified barium swallow
- Video fluoroscopy
- Video-fiberoptic endoscopy
- Modified Evans blue dye test.
If the blue dye from the Evans blue dye test can be suctioned from the trachea, what does that suggest?
Tracheoesophageal fistula
What are the most definitive tests used for identification of the particular phase of the swallow that is dysfunctional?
- Modified barium swallow
- Cine-videofluoroscopy
Aspiration that does not evoke clinically observable adverse symptoms such as overt coughing, choking and immediate respiratory distress.
Silent aspiration
Some patients have silent aspiration after ________.
A stroke
It is estimated that about how many trach or intubated patients aspirate?
55-70%
Patient with chronic pneumonia usually have ______.
Granulomatous inflammation
Granulomas associated with chronic pneumonia are commonly seen in patients with what?
TB and fungal disease
_________ is typically a localized lesion in patients with a normal immune system, with or without regional lymph node involvement.
Chronic pneumonia
Because most fungi are aerobes, the ______ is a prime site for fungal infections.
lung
What are the major pathological or structural change of the lungs associated with fungal diseases? (5)
- Alveolar consolidation
- Alveolar-capillary destruction
- Caseous tubercles or granulomas
- Cavity formation
- Fibrosis and secondary calcification of the lung parenchyma
As many as ______ fungal species may be linked to disease in animals.
300
In plants, what is the most common cause of death and destruction?
Fungal disease
Human fungal disease is also called what?
Mycotic disease or mycosis
What is the most common fungal infection in the US?
Histoplasmosis
What is Histoplasmosis caused by?
Histoplasmosis capsulatum
Where is the prevalence of histoplasmosis especially high?
The major river valleys of the Midwest and South
(Ohio, Michigan, Illinois, Mississippi, Missouri, Kentucky, Tennessee, Georgia and Arkansas)
Histoplasmosis is often called __________.
Ohio Valley Fever
Where is H. capsulatum commonly found?
In soils enriched with bird excreta, such as soil near chicken houses, pigeon lofts, barns and trees where starlings and blackbirds roost. Also may be carried by bats.
What is the incubation period for H. capsulatum?
About 17 days
What is the most common form of histoplasmosis?
Asymptomatic histoplasmosis
This type of histoplasmosis tends to occur in otherwise healthy individuals who have had an intense exposure to H. capsulatum.
Acute symptomatic pulmonary histoplasmosis
What is characterized by infiltration and cavity formation in the upper lobes of one or both lungs?
Chronic pulmonary histoplasmosis
People who have inhaled a large number of spores may develop severe acute pulmonary syndrome, which causes the patient to be extremely SOB. What is this called?
Spelunker lung, it usually develops after excessive exposure to bat shit when individuals explore caves.
Where is disseminated histoplasmosis most often seen?
In very young or very old patients with compromised immune systems.
What is considered the gold standard for detecting histoplasmosis?
Fungal culture test
What is the disadvantage of fungal culture tests?
It takes time for the fungus to grow - 4 weeks. Treatment delays may be fatal for the patient.
What type of test checks for blood serum for antigen and antibodies?
Blood Serology Test
__________ is cause by inhalation of the spores of coccidiodes im motifs, which are spherical fungi carried by wind-borne dust particles.
Coccidioidomycosis
Where is Coccidioidomycosis especially prevalent?
California, Arizona, Nevada, New Mexico, Texas and Utah.
About 80% of the people in __________ have positive coccidiodin skin-test results.
San Joaquin Valley
Which disease is known as “California Fever”, “desert rheumatism” and “Valley Fever”?
Coccidioidomycosis
Chronic progressive pulmonary disease is characterized by modular growths called _______ and cavity formation in the lungs.
Fungomas
Disseminated coccidioidomycosis occurs in about _____ in 6000 exposed persons.
1
With disseminated coccidioidomycosis, skin lesions are commonly accompanied by arthralgia or arthritis, especially in the ankle and knees. What is this condition commonly called?
“Desert bumps”, “desert arthritis” or “desert rheumatism”
_____________ is also called “Chicago disease”, “Gilchrist disease” and North American blastomycosis?
Blastomycosis
Where does blastomycosis occur?
South-central and midwestern US and in Canada.
What is blastomycosis caused by?
Blastomyces dermatitidis
Blastomycosis is most common among __________.
Pregnant women and middle-aged African American men. This disease is also found in dogs, cats and horses.
What is the primary part of entry for B. dermatitidis?
Lungs
_____________ is known as Friedländer bacillus.
Klebsiella pneumoniae
In the absence of a secondary bacterial infection, the inflammation caused by the aspiration of gastric fluids usually becomes insignificant in _________ hours.
Approximately 72 hours (3 days)
Where is cryptococcus most often seen?
In patients with HIV and undergoing steroid therapy. It proliferates in high nitrogen content of pigeon droppings and is readily scattered into the air air dust.
Where is aspergillus found?
Soil, vegetation, leaf detritus, food and compost heaps.
Aspergillus infection occurs in the lungs, where it may be present in the form of _________.
ABPA - allergic bronchopulmonary aspergillosis
What is the most common viral pulmonary complication of AIDS?
CMV - cytomegalovirus
CMV commonly coexists with what?
Pneumocystis jiroveci infection
Mycobacterium avium complex is a serious opportunistic infection that is caused by what two similar bacteria?
Mycobacterium avium & Mycobacterium intercellulare
Where is MAC found?
soil and dust particles
MAC is commonly found in patients that have _______.
AIDS
________________ is general term used for a wide variety of infections caused by the fungi of the genus Aspergillus.
Invasive aspergillosis
The varicella virus usually causes a benign disease in children aged _________.
2-8 years
What is the mortality rate of varicella pneumonia?
About 20%
All species of the genus Rickettsia are unstable outside of the cells except for ________.
R. Burnetti (Q fever)
Small, pleomorphic coccobacilli. They are intracellular parasites possessing both RNA and DNA.
Rickettsiae
How is measles spread?
From person to person by the respiratory route
In _______, China reported the first cause of SARS.
2002
Health officials believe that the cause of SARS is a newly recognized virus strain called ________.
Coronavirus
What is the incubation period for SARS?
2-7 days
What percent of patients who develop SARS require mechanical ventilation?
10-20%
The aspiration of mineral oil, used medically as a lubricant has been known to cause pneumonitis…
Lipoid pneumonitis
Avian influenza A is also called ________.
Bird flu or H5N1
What year was the first avian influenza virus that infected humans directly reported?
1997 in Hong Kong
What type of pneumonia refers to one that causes the death of lung tissue cells within the infected pulmonary parenchyma?
Necrotizing pneumonia
In severe cases, necrotizing pneumonia can result in what?
a lung abscess
What is characterized as a localized air- and fluid-filled cavity, which is a collection of purulent exudate that is composed of liquified white blood cell remains, protein and tissue debris?
Lung abscess
What are the major pathologic or structural changes associated with a lung abscess?
- Alveolar consolidation
- Alveolar-capillary tissue and bronchial wall destruction
- Tissue necrosis
- Cavity formation
- Fibrosis and calcification on the lung parenchyma
- Bronchopleural fistulas and empyema
- Atelectasis
- Excessive airway secretions
Lung abscesses most commonly occur as a complication of what?
Aspiration pneumonia
Anatomically, lung abscesses most commonly develop in what lung regions?
Regions that are dependent in the recumbent position. The right lung is more commonly involved than the left.
What are some physical examination findings of pneumonia?
- Increased RR
- Increased temperature
- Increased HR
- Decreased chest expansion
- Chest pain
- Cyanosis
- Cough, sputum production and hemoptysis
Chest Assessment Findings: Pneumonia
- Increased tactile and vocal fremitus
- Dull percussion note
- Bronchial breath sounds
- Crackles
- Pleural friction rub
- Whispered pectoriloquy
Radiologic Findings: Pneumonia
- Increased density
- Air bronchograms
- Lung abscess and/or air- and fluid-filled cavity
- Pleural effusion/empyema
For bacterial pneumonia, what is the first line of defense? How about for fungal disorders?
Antibiotic
Fungal disorder - antifungal agents
____________ (also called primary infection stage) follows the patient’s first exposure to the TB pathogen, myobacterium tuberculosis.
Primary tuberculosis
When does primary TB begin?
When the inhaled bacilli implants in the alveoli
Unlike in pneumonia, however the lung tissue that surrounds the infected area slowly produces a protective cell wall called a ________.
Tubercle, or granuloma
As TB progresses, the combination of tubercules and the involvement of the lymph nodes in the hilar region are called _____________.
the Ghon complex
When tubercles are detected on a chest radiographic, the initial lung lesions are called what?
Ghon nodules
With a thoracentesis, fluid samples may be examined for what? (8)
- Color
- Odor
- RBC count
- Protein
- Glucose
- LDH
- pH
- Cytology
How long does a tubercle take to form?
2-10 weeks
State the function of the tubercle.
To contain the TB bacilli, thus preventing the further spread of infectious TB organisms.
What two things slowly replace the tubercle when the healing process starts?
Tissue fibrosis and calcification which cause lung tissue retraction and scarring.
Sometimes the calcification and fibrosis cause the bronchi to distort and dilate — that is, to develop bronchiectasis
People with this type of TB do not feel sick or have any TB-related symptoms. They are still infected with TB but do not have clinically active TB.
Dormant TB (also called Latent TB)
Can people with lament TB/dormant TB infect other people?
No.
Which type of TB is used to describe the reappearance of TB months or even years after the initial infection has been controlled?
Reactivation TB
At anytime, TB may become reactivated, especially in what type of patients?
Patients with depressed immune systems.
Most reactivation TB cases are associated with what following risk factors?
- Malnourished individuals
- People in institutional housing
- People living in overcrowded conditions
- Immunosuppressed patients
- HIV
- Alcohol abuse
Where is the most common location of disseminated TB?
Apex of the lungs
Other oxygen-rich areas in the body include the regional lymph nodes, kidneys, long bones, GI tract, brain and meninges.
________ refers to infection from TB bacilli that escape from a tubercle and travel to other sites throughout the body by means of the bloodstream or lymphatic system.
Disseminated TB
In general, the TB bacilli that gain entrance to the blood stream usually gather and multiply in portions of the body that have what?
A higher tissue oxygen tension
What does genital TB affect in males and females?
Males: prostate gland, epididymis, seminal vesicles and testes.
Females: fallopian tubes, ovaries and uterus
The ________ is a frequent site of TB infection, although the hip, knee, wrist and elbow can be involved.
Spine
What is tubercular meningitis caused by?
An active brain lesion TB bacilli into the meninges.
What are some TB complications? (6)
- massive hemoptysis
- pneumothorax
- bronchiectasis
- extensive pulmonary destruction
- malignancy
- chronic pulmonary aspergillosis
When a large number of bacilli are freed into the bloodstream, the result can be the presence of numerous small tubercles — about the size of a pinhead — scattered throughout the body. What type of TB is this?
Military TB
What are the major pathologic or structural changes of the lungs associated with TB? (7)
- Alveolar consolidation
- Alveolar-capillary membrane destruction
- Caseous tubercles or granulomas
- Cavity formation
- Fibrosis and secondary calcification of the lung parenchyma
- Distortion and dilation of the bronchi
- Increased bronchial secretions
In early writings, TB was variously called what?
- Consumption
- Captain of the Men of Death
- White plague
When was the disease named TB?
19th century
According to the CDC, there were _______ new cases of TB were provisionally reported in the US in 2017.
9093
In 2017, an estimated 1 million children became ill with TB. How many died?
230,000
What is the most effective first line anti tuberculosis agent?
Isoniazid
Globally, TB incidence is falling at about __% per year.
3
An estimated _____ lives were saved through TB diagnosis and treatment between 2000 and 2017.
54 million
Which of the following is often prescribed as a prophylactic daily dose for 1 year in individuals who have been exposed to TB bacilli?
Isoniazid
At which size wheal is a tuberculin test considered to be positive?
Greater than 10 mm
Which of the following are known as the first stage of tuberculosis?
Primary Infection stage & Primary TB
An induration less than _____ is a negative result.
5 mm
What induration size is considered suspicious and retesting is required?
5-9 mm
TB: radiographic findings
- Increased opacity
- Ghon nodule
- Ghon complex
- Cavity formation
- Cavity lesion contain an air-fluid level
- Pleural effusion
- Calcification and fibrosis
- Retraction of lung segments or lobe
- Right ventricular enlargement
What does DOT stand for?
Directly Observed Therapy
According to the American Academy of Sleep Medicine, sleep disorders can be classified into how many major groups?
8
What are cardinal features of OSA?
Obstructive apneas, hypopneas, and respiratory effort-related arousals, which are caused by the recurring collapse of the upper airway during sleep.
_____________ is a disorder characterized by the repetitive stopping or reduction of both airflow and ventilatory effort during sleep.
Central sleep apnea
When may a snorting sound called fricative breathing be heard?
At the end of the apneic periods
Central sleep apnea can be classified as what two things?
Primary Central Sleep Apnea or Secondary Central Sleep Apnea
What are some examples of conditions associated with secondary CSA?
- Cheyne-Stokes breathing (CHF)
- Medical conditions
- High altitude periodic breathing
____________-related CSA is the most common.
Hyperventilation
________ is a combination of OSA and CSA.
Mixed apnea
Clinically, patients with predominantly mixed apnea are classified and treated as having _____.
OSA
What are some risk factors associated with OSA? (11)
- Excess weight
- Neck size
- Hypertension
- Anatomic narrowing of upper airway
- Chronic nasal congestion
- Diabetes
- Male sex
- Menopause
- Family history
- Smoking
- Alcohol, sedatives or tranquilizers
Pickwickian syndrome that coexists with COPD is known as what?
Overlap syndrome
What scale is routinely used as a validated measure of daytime sleepiness?
Epworth Sleepiness scale
Sleepiness must be differentiated from fatigue, which can be semiquantitated with the use of what two things?
Fatigue Severity Scale and Visual Analogue Fatigue scale
What is frequently used in physician notes to describe abnormalities of the soft palate and uvula?
Mallampati classification
A specialized sleep test that monitors and records a number of physiologic parameters that occur during sleep.
Polysomnography
What are other names for non-rapid eye movement (non-REM) sleep?
Slow-wave sleep and quiet sleep
During non-REM sleep, ventilation becomes slow and regular during which stage?
Stage N3
Which heart dysrhythmia is associate with CSA?
A-fib
How do you calculate AHI?
Number of apneas and hypopneas divided by TST.
_______ OSA is defined as an AHI between 5 and 15 respiratory events per hour of sleep.
Mild
_______ OSA is defined as an AHI between 15 and 30 respiratory events per hour of sleep.
Moderate
_______ OSA is defined as an AHI of more than 30 respiratory events per hour of sleep and/or an SpO2 below 90% for more than 20% of the TST.
Severe
CVP measures which side of the heart?
Right
PCWP measures which side of the heart?
Left
What are some radiologic findings of OSA?
Right-or left-sided heart failure
_________ is particularly effective in obese OSA patients who demonstrate CO2 retention.
BIPAP
The EPAP portion of BIPAP usually functions as ________.
PEEP
Normally, REM sleep constitutes about what percentage of the TST?
20-25%
During REM sleep, there is paralysis of the:
arm muscles, upper airway muscles, leg muscles and intercostal muscles
How long do normal periods of apnea during REM usually last?
15-20 seconds
Pneumonia or pneumonitis with consolidation is the result of an inflammatory response that primarily affects what?
The gas exchange of the lungs
________ simultaneously detects myobacterium tuberculosis and rifampin resistance directly from the patient’s sputum.
The Xpert MTB/RIF assay
What is the most widely used TB test?
Mantoux tuberculin skin test
The mantoux skin test consists of a intradermal injection of a small amount of a ______.
purified protein derivative (PPD) of the tuberculin bacillus
What should be stressed about a mantoux skin test?
A positive does not mean the patient has active TB, only that the patient has been exposed to the bacillus and has developed cell-mediated immunity.
Which acid fast stain reveals bright red acid-fast bacilli against a blue background?
Ziehl-Neelsen stain
Which acid-fast stain reveals luminescent yellow-green bacilli against a dark brown background?
Fluorescent acid-fast stain, it’s easier to read
How long does it take for results of a sputum culture to come in?
6 weeks
_______ is a whole-blood test used for diagnosing M. tuberculosis infection, including latent TB infection.
QuantiFERON-TB Gold Test
The QuantiFERON-TB mixture is allowed to incubate for how long?
16-24 hours
After the incubation period of the QuantiFERON test has passed, what is it measured for?
The presence of interferon-gamma (IFN-gamma).
What is the most common and arguably the most effective treatment for OSA?
CPAP
During what sleep stage does the EEG become more irregular and is composed of predominantly of theta waves, intermixed with sudden bursts of sleep spindles and one or more K complexes?
Stage N2 (light sleep)
During what stage does the EEG show beta waves and high-frequency, low-amplitude activity?
Eyes open-wake (stage W)
During what stage does the EEG show low-voltage, mixed-frequency activity, alpha waves and theta waves?
Stage N1 (light sleep)
During stage N3, the EEG shows more than ___% delta waves.
50
