Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
50 Cards in this Set
- Front
- Back
Common cause of pneumonitis
|
acid aspiration; vasculitis; auto-immune process;
i.e. (includes NON-infectious processes) |
|
Normal respiratory flora (commensals)
that can cause pneumonia Oropharynx: name organisms |
streptococci, anaerobes
|
|
Normal respiratory flora (commensals)
that can cause pneumonia Nasopharynx: name organisms |
streptococci, staphylococci, non-typeable haemophilus, moraxella species
|
|
Normal respiratory flora (commensals)
that can cause pneumonia Bronchopulmonary tree: name organisms |
sterile below the carina
|
|
Exogenous pathogens present only transiently in respiratory tract that can cause pneumonia:
|
Respiratory viruses, Streptococcus pneumoniae, Haemophilus influenzae (type b & others), Neisseria meningitidis, Streptococcus pyogenes, others
|
|
Exogenous pathogens usually gain access to respiratory tract via ________________ or _______________
|
droplet transmission (cough/sneeze)
or contiguous spread (unwashed hands to face after touching items contaminated with respiratory secretions) |
|
What reflex prevents large particulate matter from reaching central airways?
|
Epiglottic reflex
|
|
What reflex causes material that reaches trachea or major bronchi to be expelled?
|
Cough reflex
|
|
What encourages turbulence and particle deposition on mucosal surfaces?
|
Sharp angles of central airways
|
|
Mucociliary escalator:
- covers which portion of respiratory tract? - mucus contains which antimicrobial compounds? |
Cilia present on cells from nose to terminal bronchioles
Moves mucous up towards larynx where expelled Mucus contains antimicrobial compounds (lactoferrin, lysozyme, secretory IgA) |
|
Host Defense: Alveoli
Alveolar lining fluid contains substances which are opsonins or are directly microbicidal: Name them |
surfactant,
fibronectin, immunoglobulin, complement, free fatty acid, iron-binding proteins |
|
Host Defense: Alveoli
4 macrophage populations for phagocytosis, antigen processing, cytokine release: |
Alveolar macrophages – primary phagocyte
Interstitial macrophages Dendritic cells Intravascular macrophages |
|
T/F
1) No mucociliary defenses in the alveoli T/F 2) T- and B-lymphocytes are not present in submucosa and nearby BALT |
1) True
2) False |
|
Host Defense: Immune Response
Non-immune lung: - opsonization by? - phagocytosis by? |
opsonization by complement from capillaries
phagocytosis by PMNs from capillaries or alveolar macs |
|
Host Defense: Immune Response
Immune lung: - opsonization by? - phagocytosis by? |
opsonization by IgA from plasma cells lining the respiratory epithelium or by IgG from capillaries
phagocytosis by PMNs from capillaries or alveolar macs |
|
Risk Factors for Pneumonia
Name 4 categories |
Disruption of mechanical/anatomical barriers
Inc. exposure to pathogens Immune Deficiency Iatrogenic manipulations |
|
Risk Factors for Pneumonia
1. Disruption of anatomical or mechanical barriers (cilia dysfunction, altered secretions, airway obstruction) Give examples |
- Smoking (most common)
- Congestive heart failure - COPD/asthma |
|
Risk Factors for Pneumonia
2. Increased exposure to pathogens Give examples |
Crowding (jail, housing, day care, winter months)
Aspiration (in hospital, post-CVA, alcoholism, seizure disorder) |
|
Risk Factors for Pneumonia
3. Immune deficiencies Give examples |
Lack of breastfeeding (infants)
Age – very young and elderly Diabetes HIV |
|
Risk Factors for Pneumonia
4. Iatrogenic manipulations - bypass host defenses Give examples |
Bronchoscopy (even with most advanced hygiene control)
Sedation Medical immunosuppression |
|
Pneumonia: Clinical presentation - symptoms:
Name "classic" acute CAP symptoms: Name "other" less specific symptoms: |
Classic acute CAP:
Fever + SOB Productive cough (80%) Pleuritic chest pain (30-46%) Other symptoms: Fatigue (91%) Anorexia (71%) Sweats (69%) Chills (40-70%) |
|
Pneumonia: Clinical presentation - signs
Name the signs: |
Fever (68-78%)
Tachypnea (45-69%) Rales (78%) – (crackles) common; Bronchial breath sounds suggesting consolidation (29%) Leukocytosis with left shift |
|
Pneumonia: Clinical presentation - signs
What do you need to consider when taking a CXR of a patient with possible pneumonia? |
Infiltrate on CXR may be absent in the presence of volume deficit; high false negative rates for dry/volume depleted patients
|
|
Clinical presentation:
Pneumonia in the elderly? |
non-specific complaints, delirium, dyspnea
|
|
Clinical presentation:
Aspiration pneumonia? |
poor dentition,
history of loss of consciousness or poor airway control, occurs in dependent lobes, may be sudden onset after a meal, often polymicrobial with anaerobes |
|
Clinical presentation:
Atypical pneumonia (chlamydia, mycoplasma, legionella)? |
“walking pneumonia”,
may have more gradual onset, less sputum production, more often diffuse infiltrates |
|
Clinical presentation:
Post-obstructive pneumonia? |
occurs distal to a bronchial obstruction (usually cancer),
more likely to be gram negative, anaerobic and polymicrobial, often recurrent unless obstruction is relieved |
|
Streptococcus pneumoniae
Predominant etiologic agent of children or adult CAP? Gram _____ ? Colonizes the ______of 5-10% of adults and 20-40% of children What factors increase mortality? |
Predominant etiologic agent of adult CAP
Gram positive diplococcus Colonizes the nasopharynx of 5-10% of adults and 20-40% of children High mortality (15% overall; 30% in chronically ill patients) Mortality increased with increased number of lobes involved, age, and associated comorbidities. |
|
Streptococcus pneumoniae
Virulence factors? How does it cause most of its damage? |
Virulence factors
- Polysaccharide capsule (protects from opsonization & phagocytosis) Produces few toxins; most of its damage is done by eliciting an intense inflammatory response |
|
Haemophilus influenzae pneumonia
Majority of isolates are type ___? What disease is H. influenza pneumonia commonly associated with? T/F Resistance is common across all classes of beta-lactam |
Majority of isolates are either type b or unencapsulated
Associated with chronic lung disease (COPD) F Resistance is common through a beta-lactamase mechanism, creating resistance to penicillin, ampicillin, and 1st generation cephalosporins, but SUSCEPTIBLE to higher-level beta-lactams |
|
Moraxella (Branhamella) catarrhalis
What organism is this commonly confused with on gram stain? Where does it commonly colonize? To where is the infection known to spread? T/F Resistance is rising across all classes of beta-lactam |
Indistinguishable from Neisseria on gram stain
Colonization of nasopharyngeal mucosa; 66% of infants are colonized; 1-5% of adults are colonized Contiguous spread to middle ear, sinuses or lower tract F Like H. influenzae, resistance by a beta-lactamase, making them resistant to penicillin, ampicillin, and 1st generation cephalosporins, but SUSCEPTIBLE to higher-level beta-lactams |
|
Staphylococcus aureus
What other infections is staph. aureus pneumonia commonly associated with? T/F In otherwise healthy children and adolescents, it is associated with a mild pneumonia What toxin is associated with cavitation and tissue necrosis? T/F Pleural effusion and empyema are common Initial treatment of choice? |
Associated with high rates of skin and soft tissue infection
False Associated with severe, necrotizing pneumonia in otherwise healthy children and adolescents PVL toxin (Panton-Valentin Leukocidin) is associated with cavitation and tissue necrosis True Pleural effusion and empyema are common Initial treatment = vancomycin |
|
Atypical organisms
What 3 organisms are associated with atypical presentations of CAP? What would a chest radiograph show? Clinical presentation? Treatments? |
Legionella pneumophila, Chlamydia pneumoniae, and Mycoplasma pneumoniae are the 3 organisms Associated with atypical presentations of CAP
Chest radiographs may show a diffuse interstitial infiltrate Clinical presentation may be more indolent, with dry cough Generally treatable with macrolide, fluoroquinolone, or doxycycline |
|
Which of the atypicals is associated with severe pneumonia with extrapulmonary manifestations?
|
Legionella may be associated with more severe pneumonia with extrapulmonary manifestations
|
|
Pleural effusion and empyema
T/F Most are small, uncomplicated, and resolve without drainage. |
Most are small, uncomplicated, and resolve without drainage.
|
|
Pleural effusion and empyema
What are indications for evaluating with thoracentesis? |
If its thickness is >1cm on a lateral decubitus film,
or For persistent, unexplained fever |
|
Pleural effusion and empyema
How are they commonly evaluated if their thickness is >1cm on a lateral decubitus film or for persistent, unexplained fever? |
Thoracentesis
|
|
Empyema
Definition? What must you do if empyema is found? What should be considered when pleural fluid pH is <7.0, glucose is <40, or gram stain is positive. |
The presence of pus in the pleural space.
Empyema must undergo chest tube drainage. Chest tube drainage should also be considered when pleural fluid pH is <7.0, glucose is <40, or gram stain is positive. |
|
CAP Diagnosis
History? Physical? |
History
Evaluate for risk factors Physical examination Include oxygen saturation by pulse oximetry |
|
CAP Diagnosis
Lab Data? |
Laboratory data:
- Blood and sputum culture - HIV testing for patients age 15-54yo - CBC If hospitalized: - Other blood chemistries - Arterial blood gases in patients with more severe respiratory compromise - Testing for etiology Radiographic data - Chest Radiograph, including decubitus film if effusion is present |
|
Testing for Etiologic Agents of Pneumonia
When do you test for blood cultures? |
Before antibiotics
At onset of illness; repeat if persistent fever Yield: 15% among hospitalized patients |
|
Testing for Etiologic Agents of Pneumonia
Expectorated sputum (gram stain + culture) - when do you test sputum? |
Before antibiotics for best yield
|
|
You should only check induced sputum when you suspect what 2 organisms?
For what 2 reasons would you order a fiberoptic bronchoscopy? |
M. tuberculosis and P. carinii
1) For detection of anatomic lesions in suspected postobstructive pneumonia 2) For deep culture +/- biopsies for non-resolving pneumonia or when unusual pathogens are suspected |
|
Testing for Etiologic Agents of Pneumonia II
This test is acceptable adjunct; it can make diagnosis faster than culture in most cases; Sensitivity about 75%, specificity about 90% It can make diagnosis even when cultures negative (i.e. when antibiotics started prior to cultures) What test is this? |
S pneumoniae urinary antigen
|
|
CAP Treatment:
What 2 major categories of treatment are often used? |
Supportive (BP support / Ventilator)
Antibiotics (Empiric, Pathogen-directed) |
|
Empiric adult CAP treatment: preferred antibiotics
Outpatient ? General medical ward ? Intensive care unit ? |
Outpatient:
- macrolide - fluoroquinolone with enhanced activity against S. pneumo (e.g. levo/ moxi/gatifloxacin) - doxycycline General medical ward: - (ceftriaxone or cefotaxime) plus macrolide - (amp-sulbactam or pip-tazo) plus macrolide - enhanced fluoroquinolone Intensive care unit - (ceftriaxone or cefotaxime or amp-sulbactam or pip-tazo) plus (macrolide or enhanced fluoroquinolone) |
|
Prevention of CAP
4 strategies? Which is most important? |
Hand hygiene (VERY important)
Active Immunization (Hib for H. influ b, Prevnar, Pneumovax -adults, Influenza - adults+peds) Passive Immunization – breast milk Avoid exposures that thwart defense mechanisms of the respiratory tract (tobacco smoke, crowding, etc.) |
|
Hospital-acquired pneumonia
Onset? Factors which compromise defenses? (name 6) Which class of bacteria predominate? |
Onset 48-72hrs after admission
Factors which compromise host defenses: - Altered mental status - Poor nutritional status - Decreased clearance of secretions - Respiratory tract obstruction - Diminished lung expansion - Endotracheal intubation, bypassing host defenses Altered host commensal flora, with gram-negative predominance Increased presence of drug-resistant bacteria Mortality 20-70% |
|
Hospital Acquired Pneumonia
Which organism is of interest because of its rise in resistance? |
Acinetobacter
|
|
HAP Prevention
What are some prevention strategies? |
- Hand washing / careful cleaning of equipment
- Aspiration precautions - Avoidance of unnecessary sedation - Head of bed elevation in high-risk patients - Aggressive healthcare worker influenza vaccination - Avoidance of unnecessary gastric acid blockade |