upper resp infection and pneumonia HYHO Flashcards
what is coughing stimulated by?
by stimulation of irritant receptors located largely in the larynx, trachea, and major bronchi.
-minor receptors in the UR tract (sinus and pharynx) and chest (pleura, pericardium and diaphragm) ->travel by vagus and phrenic nerve)
clinical features of pneumonia
- Cough (79-91%) (with or without sputum production)
- Fatigue (90%), malaise
- Fever and dyspnea (75%)
- Rigors
- Pleuritic chest pain
- Anorexia
- Preceding viral illness common
PE findings pneumonia
- Increased work of breathing, retractions
- Adventitious breath sounds (crackles, rhonchi, wheezing)
- Positive special testing (tactile fremitus, egophony, dullness to percussion, bronchophony)
- Hypoxemia
what is the most common cause of chronic cough in healthy, nonsmokers with a normal CXR
Upper Airway Cough Syndrome (UACS)
- Include diagnoses such as allergic rhinitis and bacterial sinusitis
what is the second most common cause of chronic cough?
-asthma/COPD
what is the 3rd most common cause of chronic cough?
-GERD
what is the most sensitive and specific test for diagnosis of reflux disease
is 24-hour esophageal pH monitoring
*not required to diagnose GERD
1st line treatment for GERD
a 4-week trial of proton pump inhibition (PPI) which is both diagnostic and therapeutic
*endoscopy if doesn’t improve
what are other differential dx of cough?
D. Postnasal drip E. Medication side effect (e.g., angiotensin-converting enzymes [ACE] inhibitors) F. Congestive heart failure (CHF) G. Malignancy H. Smoking (cigarettes, cannabis) I. Pollution
differential dx of infectious causes of cough and congestion
A. Common cold/URI/viral syndrome B. Pharyngitis C. Sinusitis D. Bronchitis E. Influenza F. Pneumonia 1. CAP 2. Aspiration pneumonia 3. TB (tuberculosis) 4. Opportunistic organisms (e.g., PCP)
Acute bronchitis=>
inflammation of the tracheobronchial tree, often activated by some trigger (e.g., infectious, allergic or
an irritant) that leads to increased mucous production and airway hyperesponsiveness) often as a result of an upper
respiratory infection or “head-cold,” it is a diagnosis of exclusion after more severe causes have been ruled out. Commonly
presents in the healthy adult primarily as a cough of 1-3 weeks duration.
when is acute bronchitis more frequently seen?
winter months (NOV-FEB)
what are viral and bacterial causes of URI?
- Most common etiology of URI is viral (e.g., influenza, parainfluenza, adenovirus, coronavirus, rhinovirus, other viruses
- Bacterial causes: Mycoplasma pneumoniae, Chlamydia pneumoniae and Bordetella pertussis have been implicated as
bacterial causes for URI’s.
what can recurrent acute bronchitis be misdiagnosed as?
asthma
what are other symptoms of URI
fever, malaise, rhinorrhea or nasal congestion, sore throat,
wheezing, dyspnea, chest pain, myalgias, and arthralgias.
what kind of infection do conjunctivitis and adenopathy suggest?
adenovirus
what is the most common presentation of URI?
productive (purulent) sputum production
*the color is not diagnostic of presence of bacterial infection
what is the treatment for acute bronchitis?
- self limited
- antibiotics not recommended (only for high risk or suspicion of CAP is high)
- prescription influenza treatment within 48 hrs
- bronchodilators
- antitussives
prevention of acute bronchitis
- Proper handwashing, avoidance of tobacco/other pulmonary irritants, instruction to cough into elbow
instead of coughing into hands, and the proper and appropriate utilization or avoidance of antibiotics for treatment.
Rhinosinusitis:
- Inflammation/infection of nasal mucosa and of one or more paranasal sinuses.
- Sinusitis occurs from obstruction of the normal draining mechanisms of the sinus tracks, can be subdivided into:
- Acute: symptoms lasting < 4 weeks
- Subacute: symptoms lasting 4-12 weeks
- Chronic: symptoms lasting >12 weeks
recurrent or acute rhinosinusitis
- Four or more episodes of acute rhinosinusitis per year, with interim resolution of symptoms.
when do most viral URI improve?
7-10 days
after how many days should you consider a case of bacterial rhinosinusitis
-after 7 days of symptoms in adults or 10 days in children
what bacterial are associated with acute bacterial sinusitis in adults
- S pneumoniae and H. influenza
what bacterial are associated with acute bacterial sinusitis in children
H. inf. and
Moraxella catarrhalis
diagnosis of rhinosinusitis
- Presence of purulent nasal discharge, maxillary dental or facial pain, unilateral maxillary sinus tenderness, and worsening
symptoms after initial improvement.
what is considered first line therapy for rhinosinusitis
Amoxicillin & trimethoprim-sulfamethoxazole (10 to 14 days)
what is considered second line therapy for rhinosinusitis
amoxicillin-clavulanic acid,
second- or third-generation cephalosporins (cefuroxime, cefaclor, cefprozil, and others), fluoroquinolones, or second-
generation macrolides (clarithromycin, azithromycin).
what can provide symptomatic relief for rhinosinusitis
- Oral or nasal (topical) decongestants provide symptomatic relief (do not exceed 3 days of therapy to prevent rebound
vasodilation that worsen symptoms.
pharyngitis
- Inflammation of the pharynx and/or tonsils.
- Majority of cases are viral.
- Most cases in adults are benign and self-limited.
- Must r/o more severe causes of throat pain (e.g., epiglottis, retropharyngeal abscess, paritonsillar abscess,
and group A beta hemolytic Streptococcus (GAS).
what is peak age for pharyngitis
4-7 yrs
what is the pathogenesis of pharyngitis
Mycoplasma pneumoniae, Chlamydia pneumoniae, and Arcanobacterium are common causes amongst teens/young
adults.
what causes causes 15% of all adult pharyngitis, and approximately 30% of all pediatric cases.
group A strep
what are PE findings with group A strep infection
abrupt onset of sore throat and fever, tonsillar and/or
petechiae on the palate, tender cervical adenopathy, and absence of cough.
- GAS can also cause an erythematous, sandpaper-like (scarlatinaform) rash.
what is infectious mono causes by?
Epstein-Barr virus, is extremely difficult to distinguish clinically
from GAS infection.
how do you diagnose group A strep infection?
by rapid antigen testing (rapid Strep) or by throat culture (which is considered the gold
standard for diagnosing GAS).
what is the CENTOR criteria and how do you use it?
- A guideline for diagnosing GAS without performing rapid Strep or throat culture.
- A point is given for each of the following criteria:
- Absence of cough; enlarged/tender anterior cervical adenopathy; fever of 100.4 F or higher; and tonsillar
swelling/exudates. - One additional point is added if patient is between 3 and 14 years of age and one point is deducted if patient is
age 45 years or greater. - 0-1 points; recommend no further testing and no antibiotic indicated.
- 2-3 points; perform rapid strep or throat culture and treat with antibiotic if positive.
- 4 or more; consider empiric antibiotic treatment.
what is the treatment for GAS
- Penicillin is the antibiotic of choice for GAS pharyngitis (10-day course of penicillin V or intramuscular pen G benzathine)
- For penicillin allergic patients, treatment options include cephalasporins and macrolides.
Community-Acquired Pneumonia (CAP)
acute infection of pulmonary parenchyma outside of health care setting
(e.g., nursing homes, hemodialysis centers, recently hospitalized).
Nosocomial pneumonia
acute infection of the pulmonary parenchyma acquired in health care settings (hospital
acquired pneumonia* [HAP], & ventilator-associated pneumonia [VAP]).
- HAP => pneumonia acquired > 48 hours after hospital admission
- VAP => acquired > 48 hours after endotracheal intubation
what is the most common cause of sepsis?
pneumonia
risk factors for pneumonia
- extremes of age
- immunosuppresion/compromise
- chronic disease
- preceding viral URI (influenza)
- smoking, alcohol, opiates
- lifestyle factors
- altered consciousness
- impaired airway protection
most common organism pneumonia
- S. pneumoniae (pneumococcus) is the most common bacterial cause.
- Up to 62% of cases no causal organism identified.
most common CAP organism
o S. pneumo
o Legionella
diagnostic testing for pneumonia
- Leukocytosis with leftward shift or leukopenia.
- Elevated inflammatory markers (ESR, CRP, and procalcitonin).
- Chest imaging is generally required to make the diagnosis (presence of an infiltrate).
- CT may be considered for immunocompromised patients who cannot mount a typical inflammatory response and thus
have a negative chest x-ray.
Noninfectious illnesses that mimic CAP or co-occur and present with pulmonary infiltrate and cough:
- CHF with pulmonary edema.
- Pulmonary embolism.
- Pulmonary hemorrhage.
- Atelectasis.
- Aspiration or chemical pneumonitis.
- Drug reactions.
- Lung cancer.
- Collagen vascular diseases.
- Vasculitis.
- Acute exacerbations of bronchiectasis.
- Interstitial lung diseases (eg, sarcoidosis, asbestosis, hypersensitivity pneumonitis, cryptogenic organizing pneumonia).
Streptococcus pneumoniae:
Classically targets the elderly, young and those with immune-depressing conditions (e.g., HIV, sickle cell disease, transplant
recipient, asplenia).
- Symptoms include sudden onset rigors, sputum, pain, fevers and classic lobar infiltrates.
- Classic lab abnormalities include elevated LFT’s, hyponatremia and leukocytosis.
- Responds to penicillins, macrolides, and fluoroquinolones to varying degrees.
staph aureus
- May cause empyema, extensive infiltrates on CXR.
Methicillin Resistant Staph Aureus (MRSA):
- Especially healthcare related pneumonias, recent antibiotic use (esp. fluoroquinolones) within the past 3-months,
recent hospitalization and immunosuppression.
Younger, healthier persons, h/o skin/soft tissue infections, contact sports, IV/IM drug use, crowded living conditions,
men who have sex with men.
- Can be severe, assoc. w/ necrotizing &/or cavitary pneumonia, empyema, gross hemoptysis, septic shock, and
respiratory failure, (commonly related to a USA-300 clone strain).
Klebsiella:
- Classically in alcoholics and aspiration.
- Lobar infiltrates, rigors, abscess.
- Current jelly hemoptysis (BOARD QUESTION STEM!).
Pseudomonas:
- Ill patients, CF, elderly, recently hospitalized patients, antibiotic use, severe COPD.
- Causes severe disease, multiple infiltrates, systemic illness (cyanotic, confused, fever).
- Not a CAP.
- Antibiotic resistance is common (usually treated with more than 1 agent).
Haemophilus influenza:
- Elderly, sickle cell, immunocompromised, splenectomy.
- Are in children (d/t HIB vaccine).
- Chest pain, effusions, multilobar disease.
Moraxella catarrhalis:
- Similar to H. inf, typically indolent course w/cough, prod sputum, pleuritic CP with infiltrate usually diffuse on CXR.
Legionella:
- Elderly (up to 10% cause of CAP-most common atypical agent in elderly), smokers, immunosuppressed.
- Causes GI sympt, hyponatremia, broad spectrum of pulm symptoms.
- Commonly seen, throughout the year (others decrease in summer).
- When suspected, send UA for legionella antigen to dx.
- Associated with “itis” (e.g., sinusitis, pancreatitis, myocarditis, pyelonephritis).
- CXR findings: patchy infiltrate, hilar adenopathy, pleural effusions.
Chlamydophilia:
- May mimic Legionella on CXR, but lacks GI symptoms.
- Milder illness; sore throat, fever, np cough, rhonchi/rales.
Mycoplasma:
.
- “Walking pneumonia”, sore throat, headache.
- Occurs in cycles (every 4-8 years).
- Lacks the GI symptoms.
- Rashes, neurological symptoms, arthralgias.
- Chest pain, bullous myringitis
pneumonia viruses
- Flu, coronaviruses (MERS-CoV-middle eastern respiratory syndrome coronavirus), etc.
- Wide range of symptoms; benign to fatal.
- Most likely cause of pandemic (1918 Spanish flu).
- Because of the risk, cover for HAP (health acquired pneumonia) with MRSA & GNR coverage.
- Diagnosis can be complicated because of dementia, effects of medications, prior strokes and pt is non-verbal.
- Most common pathogens ; S. pneumo, H. inf, gram neg rods, viral influenza d/t close quarters.
- Atypical organisms (mycoplasma and leigionella) are less common in this population.
CAP uncomplicated outpatient treatment:
macrolide (azithromycin or clarithromycin)
OR
tetracycline (doxycycline)
CAP outpatient treatments in patients with significant comorbidities/failed first-line treatment:
macrolide + penicillin/lactamase
OR
fluoroquinolone (levofloxacin or moxifloxacin)
The PSI/PORT score (Pneumonia Severity Index)
assigns patients to 5 risk categories based upon age and measurable
derangements with groups 1-3 being outpatient candidates and 4-5 generally being inpatients (generally ICU).
Curb-65 measures-
Confusion, Uremia > 7, Respiratory rate > 30, Blood pressure < 90 systolic, or < 60 diastolic, age > 65.
ambulatory care for pneumonia
- Most patients who are otherwise healthy with normal vital signs (PSI scores of 1-2 and CURB-65 scores of 0, or a CURB-
65 score of 1 if age >65).
when do you admit somebody for pneumonia?
- Oxygen sats <92% on RA (and a significant change from baseline).
- PSI scores of >3 and CURB-65 >1 (or CURB-65 score >2 if age >65)..
- Early signs of sepsis, rapidly progressive illness, suspected infections with aggressive pathogens that require close
monitoring of symptoms, unable to take oral medication, cognitive or functional impairment, social limits preventing
return to the hospital.
when do you admit somebody to ICU with pneumonia
- Respiratory failure requiring mechanical ventilation, sepsis, altered mental status, hypotension requiring fluids or
vasopressor support multilobar infiltrates, persistent high fever, RR > 30, WBC < 4,000.
what is the expected course for pneumonia?
- Most patients improve in 3 to 5 days of antibiotics.
- 50% of patients still have symptoms at 30 days (chest pain, malaise, dyspnea, cough)..
what are the three primary pillars for preventing CAP?
1- Smoking cessation
2- Influenza vaccination for all patients
3- Pneumococcal vaccination for at-risk patient
what are the 3 main golas of manipulative treatment for pneumonia?
- Reduced parenchymal lung congestion.
- Reduced sympathetic hyper-reactivity to the parenchyma of the lung.
- Increased mechanical thoracic cage and diaphragmatic motion.
what does Effective manipulative treatment aim to optimize:
- Thoracic cage motion.
- Improve diaphragmatic function.
- Enhance lymphatic drainage (open thoracic inlet first).
- Stabilize autonomic influences.
Parasympathetics pneumonia
OA, AA, C2.
Increased tone = thinning of secretions and relative bronchiole constriction.
Sympathetics pneumonia : .
T2-T7
Increased tone = thickened secretions and bronchiole dilation
Motor pneumonia: .
C3-C5
Phrenic nerve to the diaphragm; irritation caused by decreased excursion and overuse
chapmans point bronchi
Intercostal space between 2nd & 3rd ribs at
sternocostal junction
T2 midway between SP & tip of TP
chapmans point upper lung
Intercostal space between the 3rd & 4th ribs at
the sternocostal junction
Space between the TPs of the T3 & T4, midway
between the SP & tip of the TP
chapmans point lower lung
Intercostal space between the 4th & 5th ribs at
the sternocostal junction
Space between the TPs of T4 & T5, midway
between the SP & tip of the TP
