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272 Cards in this Set
- Front
- Back
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PEAK FLOW METERS are used for
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MOITORING
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SPIROMETERS are used for
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DIAGNOSING
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What spirometry Indicationer determains asthma and COPD
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reversibility
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What is maximum amount of air that can be exhaled
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VITAL CAPACITY
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WHAT IS THE AMOUNT OF AIR CONTAINED IN THE FULLY EXPANDED LUNG
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TOTAL LUNG CAPACITY
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Volume of air that enters the lung during a normal breath
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Tidal Volume
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Amount of air remaining after maximum expiration
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Residual Volume
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Indicates degree of lung and chest expansion and a good indicator of patient effort
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FVC = Forced Vital Capacity
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Measures the total amount of air that a patient can blow out as rapidly as possible after inhaling as deeply as possible
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FVC = Forced Vital Capacity
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Indicates patency of large airways and indicates both large and small airway function
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FEV1
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Measures the amount of air forcefully blown out during the first second of the effort
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FEV1
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Reduced FEV1/FVC(ratio)
may imply |
airway obstruction
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Indicates large airway patency and is VERY EFFORT DEPENDENT
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PEF
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Measures the highest flow that can be generated by the patient forcefully blowing after fully inflating the lungs
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PEF
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what is the Correct Technique for a PFT
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Deep, full maximal inspiration
Forced full exhalation to FVC Proper duration of effort Absence of coughs &/or extra breaths |
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what is the PFT criteria for a Restrictive airway
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decrease vital capacity (Lung volume); no decrease FEV1:FVC ratio
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what is the PFT criteria for an Obstructive airway
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normal or decrease vital capacity; marked decrease FEV1:FVC ratio <70%
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What are the Restrictive airway D/Os
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1. Neurological d/o
2. Tumors 3. Cavitations 4. Pneumonia 5. Fibrosis |
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what is the Restrictive Pattern
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FEV1/FVC > 80, & FVC is decreased; Actual ratio, not predicted
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What are the Obstructive airway D/Os
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1. Asthma
2. Emphysema 3. Chronic Bronchitis 4. Cystic Fibrosis |
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what is the Obstructive Pattern
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FEV1/FVC < 80
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What Special Test Reflects ability of lung to transfer gas across alveolar/capillary interface
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Diffusing capacity DLCO
--Single-breath carbon monoxide |
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Diffusing capacity DLCO is decreased in what Dz processes
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- emphysema
- diffuse infiltrative lung disease - Pneumocystis |
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Diffusing capacity DLCO is increased in what Dz processes
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- pulmonary hemorrhage
- CHF - asthma (Due to increased pulmonary capillary blood volume) |
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what are the 2 Bronchial Provocation Tests
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- Methacholine challenge
- Inhaled methacholine/histamine |
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Methacholine challenge is used to Evaluate what Dz processes
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- suspected asthma, when baseline spirometer is normal
- unexplained cough |
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What is the MOA of Inhaled methacholine/histamine
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Cause bronchial smooth muscle constriction at lower doses than non-asthmatics
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What constututes and Positive Inhaled methacholine/histamine test
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If FEV1 falls > 20% this constitutes a positive test
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What are the measured components of ABG's
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pH
pCO2 pO2 |
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ABGs look at what 2 categories
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1. Oxygenation
2. Acid-Base Balance |
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What is the MOA Oximetry
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monitors hemoglobin O2 saturation
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Oximetry Accuracy is reduced with
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1. Severe anemia (< 5 g/dL Hgb)
2. Increased presence of metHgb, carboxy-Hbg, intravascular dyes, motion artifact 3. Lack of pulsatile arterial blood flow |
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Immediately apply pressure to ABG puncture site for a MINIMUM of
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5 minutes
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If pt is on anticoagulant therapy (heparin, Coumadin) apply pressure to ABG puncture site for a MINIMUM of
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10 min
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What is the 5th most common symptom for which pts seek care
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Cough
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when evaluating a Chronic or persistent cough, In addition to history & physical examination, a systematic diagnostic approach including
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1. Chest radiograph (CXR)
2. Spirometry, bronchoprovocation 3. Sinus imaging 4. Esophageal pH monitoring |
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What is the duration of Chronic or persistent cough
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> 8 weeks
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What is the duration of Acute cough
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≤ 3 weeks
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What is the duration of Subacute
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3-8 weeks
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What is the Mainstay of treatment for an Acute cough
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nonspecific antitussive therapy
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What is the most common Complications of Chronic Cough
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Feeling that something is wrong
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What are the most common other physiologic symptoms of chronic cough, due to high intrathoracic & intra-abdominal pressure
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- cough syncope
- cardiac dysrhythmias - headache - subconjunctival hemorrhage - inguinal herniation - gastroesophageal reflux |
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what is the most common overall cause of chronic cough
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cigarette smoking
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What is the pathogenic triad of Chronic Cough
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- PND
- asthma - GERD |
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What is the single most common cause of chronic cough in non-smokers
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PND
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Categories of PND include
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Chronic sinusitis
Rhinitis |
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What are the Symptoms of PND
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- Rhinorrhea
- Nasal congestion - Sensation of drainage or tickle in oropharynx - Throat clearing. |
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Pathogenesis of cough in PND involves
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stimulation of afferent receptors in upper airway rather than runoff of secretions into lower airway.
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"cobblestoning" appearance of oropharyngeal mucosa
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PND
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is associated w/ increased likelihood of chronic sinusitis
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Copious sputum
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What type of radiography appears to provide as much information as standard 4-view series in PND
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Single Waters' view
- C-T is more sensitive |
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What is the 2nd most common cause of chronic cough in adults
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Asthma
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subset of asthmatic pts complain exclusively of cough
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Cough-variant asthma
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Proof that asthma is inciting factor in chronic cough requires
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demonstration of a response to directed therapy
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What are the Historical features Asthma
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wheezing, chest tightness, or exertional dyspnea in response to triggers (strong odors or perfumes, cold air, or allergens should suggest diagnosis)
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What are the historical features of GERD
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- exacerbation at night
- in supine position - or after eating (DO NOT reliably differentiate GERD-induced cough from other causes) if chronic cough |
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What itest is use in asthmatic pts to determaine if GERD is also a causes of cough
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24-hour pH probe findings
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A Cough due to ACE inhibitors usually occurs
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within 1 week of starting medication, but may occur as late as 1 year
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Cough resolution may be delayed for up to ________ after discontinuation of the drug.
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1 month
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what Med does not cause cough & therefore are useful therapeutic alternatives
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ARB
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What Dz is characterized by productive cough on most days for 3 months in 2 consecutive years
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Chronic bronchitis
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Chronic bronchitis is caused by
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irritant-induced inflammation or by need to mobilize excessive secretions
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What is the Most common irritant of Chronic bronchitis
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- cigarette smoke
- but occupational exposures or inflammatory bowel disease may also trigger this syndrome |
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What is the Mainstay of treatment for Chronic bronchitis
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avoid offending agents
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Particular vigilance with Chronic bronchitis is warranted when there is a
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change in character of cough or sputum
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A change in character of cough or sputum in Chronic bronchitis may be presenting feature of a
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superimposed bronchogenic carcinoma
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Develops when chronic inflammation or infection leads to progressive airway damage
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Bronchiectasis
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A pt with Bronchiectasis can produce who much sputum per day
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2 tbsp/day.
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evidence of tubular or cystic structures representing dilated, mucus-filled bronchi in a CXR indicates what Dz
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Bronchiectasis
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when do you perform a Chest CT on a pt with Bronchiectasis
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equivocal or negative CXR findings
(Chest CT is a more sensitive tool) |
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A Postinfectious Cough is Usually caused by
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- respiratory viruses
- Mycoplasma species - Chlamydia pneumonia - Pertussis |
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Management of chronic cough typically involves a combination of which simple screening studies
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- CXR
- spirogram |
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What are the Specific diagnostic studies to DIAGNOSIS chronic cough
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- Methacholine provocation
- sinus imaging - or a pH probe - & empiric therapy for the 3 most common entities (rhinitis, asthma, & GERD) |
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Treatment of chronic cough fails in a significant proportion of nonresponders due to
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inadequate intensity or duration of treatment
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In the treatment chronic cough what should be done prior to further investigations
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Evaluation & treatment for
PND asthma and, or GERD |
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In assessing for presence of uncommon causes of chronic cough what test has a relatively higher diagnostic yield & should be performed prior to cardiac tests in absence of cardiac symptoms
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chest CT
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What is the Initial therapy for PND
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antihistamine-decongestant combination
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What are the Older-generation antihistamines
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- dexbrompheniramine maleate
- azatadine maleate |
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Why are the Older-generation antihistamines (dexbrompheniramine maleate or azatadine maleate), superior to second-generation (non-sedating) drugs
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because of their additional anticholinergic activity
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If drowsiness is problematic with the Initial therapy for PND what should be done
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initiated therapy at bedtime, with escalation to BID dosing at a later time
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Second-generation antihistamine are useful primarily in
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- allergic rhinitis syndromes.
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most patients will have a symptomatic response within 1 week with antihistamine-decongestant therapy except for
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chronic sinusitis
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The Presence of bronchial hyperresponsiveness should be demonstrated by provocation testing or
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reliable history prior to use of oral steroids & when bronchodilators alone are ineffective in presence of high clinical suspicion
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What is the maximal therapy in the Tx of GERD in chronic cough a pt
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- Avoid reflux-predisposing foods (fatty foods, chocolate, caffeine, alcohol)
- Tobacco cessation - elevation of head of bed - Not eating within 2-3 hours prior to lying down |
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What is the mainstay of medical therapy for GERD
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Proton pump inhibitors
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What test is performed when maximal therapy for GERD fails
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Ambulatory pH monitoring
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Documentation of persistent symptomatic acid reflux should prompt consideration of
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esophageal fundoplication
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What therapy markedly reduces symptoms of Chronic Bronchitis in > 50% of patients within 1 month
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Smoking cessation
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What drug decrease cough frequency & sputum production most effectively in Chronic Bronchitis
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Ipratropium MDI (2 puffs QID)
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What therapy is useful for Bronchiectasis pts who produce large volumes of sputum & during disease flares
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Chest physiotherapy techniques
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Tx of Bronchiectasis flares may also require
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prolonged antibiotic courses
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The Benefits of treating a chronic cough with what 2 drugs has not been demonstrated
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- beta-agonists
- theophylline |
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What are the Essentials of Diagnosis of asthma
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- Episodic or chronic s/s of airflow obstruction
- SX’S FREQUENTLY WORSE AT NIGHT OR EARLY MORNING - Prolonged expiration & diffuse wheezing - Limitation of airflow on PFT’s or Positive bronchial provocation - Complete or partial reversibility |
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What is a reversible obstructive airway disease
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Respiratory disease of increased irritability of tracheobronchial tree
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What is the Bottom line adverse effect of Asthma
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increased resistance to airflow
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What are the Characteristics of Asthma
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Airway Obstruction
Airway Inflammation Airway Hyper responsiveness All effects not universal, patients are different - Bronchospasm - Mucus plugging |
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What is the Most common chronic disease of childhood
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Asthma
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Theoretically every asthma death is
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preventable
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What appears to play an important roles in the Pathophysiology of asthma
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Sensitization & inflammation
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Regardless of trigger ____________ sustains bronchial hyperactivity
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inflammation
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what is the Hallmark of an asthmatic Allergic Response
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tendency to maintain persistent IgE response after antigen exposure
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What denotes a group of diseases in people with inherited allergic tendencies to develop antibodies to common organic environmental allergens
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Atopy
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What is the Triad Asthma
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Asthma
aspirin sensitivity & nasal polyposis |
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What happens in the early (acute bronchoconstrictive) phase of Airway Hyper responsiveness in Asthma to Antigens
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involves rapid development of reversible airway obstruction to stimuli - Often resolves with bronchodilators
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What happens in the Late Phase of Airway Hyper responsiveness in Asthma to Antigens
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- reaction may occur 6-12 hours later
--Thought to be inflammatory response, responding to anti-inflammatories, but more refractory to bronchodilators |
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What are the causes of Drug-Induced Asthma (non-allergy related)
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- ASA/NSAID 2* altered prostaglandin metabolism
--S/S polyposis nasi & chronic sinusitis - ACE inhibitors - BB |
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What are the Clinical Features of Severe asthma
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use of accessory muscles, distant breath sounds, loud wheeze, hyperresonance, intercostal retractions
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What are the Clinical Features of Mild asthma
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slight tachycardia & tachypnea
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What are the 3 Questions You Must Ask An Asthmatic
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1. Have you ever been Hospitalized due to Asthma
2. Have you ever been intubated due Asthma 3. Have you ever been placed on oral steroids for Asthma |
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What are the Ominous Signs of asthma
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- Fatigue (can get same with marked improvement)
- Pulsus paradoxus (>20 Hg mm) - Diaphoresis & cyanosis - Inaudible breath sounds with diminished wheezing - Unable to stay recumbent |
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What type of cells may you find the in the sputum of an asthma
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eosinophils
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What may the PFT results of an asthmatic pt present
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- may often be normal when asymptomatic
- consistent with typical obstruction dysfunction & partial reversibility w/ bronchodilators (FEV1 improves ≥12% & 200ml OR ≥15% and 200ml in FVC) |
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What is the cornerstone Tx for asthma
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Prevention
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What is the drug of choice for acute bronchospasm
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Beta2 selective agonists
(Inhaled sympathomimetics) |
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What are the Short-acting beta-2 agonists
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Albuterol Inhaler (Proventil, Ventolin Inhaler)
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What are the Long acting beta-adrenoceptor agonists
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SALMETEROL
Formoterol |
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what drug is considered first line maintenance for mod to severe asthma
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Inhaled Corticosteroids
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What are the Inhaled Corticosteroids
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Azmacort (Triamcinolone acetonide)
Aerobid (Flunisolide) Beclovent(Beclomethasone dipropionate) Flovent (Fluticasone propionate) Pulmicort (Budesonide |
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What are the Oral Corticosteroids
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Prednisone
Solu-Medrol |
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which Corticosteroids is used IV
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Solu-Medrol
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What is the Concerns with using Oral Corticosteroids
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hypo -pituitary-adrenal (HPA) axis suppression
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What is the Pediatrics: drug of choice for EIA
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Mast Cell Stabilizers
(Cromolyn & nedocromil) |
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What is the Drug of choice for COPD
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Anticholinergics
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What drug is used in some ERs in combination with beta 2
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Anticholinergics
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What drug is an Anticholinergics
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Ipratropium bromide
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What drug is used for mod to severe patients, especially nocturnal symptoms
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Oral Theophylline
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What drugs may allow elimination of oral & possibly inhaled steroids
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Leukotriene Receptor Antagonists (LTRA)
- Zafirlukast (Accolate) - Montelukast sodium (Singulair) - Zileuton a similar drug |
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What is the Tx plan for Step 4 (Severe Persistent)
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Daily medications
- Anti-inflammatory: inhaled steroid (high dose) AND - Long-acting inhaled bronchodilator AND - Oral steroids; make attempts at reducing systemic steroids |
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What is the Tx plan for Step 3 (Moderate Persistent)
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Daily medications
Either Anti-inflammatory: inhaled steroid (medium dose) OR - Inhaled steroid & long acting bronchodilator esp. for night symptoms |
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What is the Tx plan for Step 2 (Mild Persistent)
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Daily Medications
- Anti-inflammatory: either inhaled steroid or cromolyn (mast cell stabilizer) |
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What is the Tx plan for Step 1 (Mild Intermittent)
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No daily medication needed
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All asthma Patients are Tx with
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short acting bronchodilator inhaled beta2-agonist
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What is the Green Zone Asthma Action Plan
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Doing Well
- No cough, wheeze, chest tightness, or SOB during day or night - Peak flow 80% or more of best - Take all RX as directed |
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What is the Yellow Zone Asthma Action Plan
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Asthma is getting worse
- Cough, wheeze, chest tightness, or SOB, OR - Waking at night due to asthma, OR Can do some, but not all, usual activities OR - Peak flow 50%-80% |
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What is the procedure for a pt in the yellow zone
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- Add: Quick-Relief Medicine-Keep taking your Green Zone medicine
- If your SXs return to green zone p 1 hr: take quick relief RX Q4hrs for 1-2 days Double the dose of your inhaled steroids - If SXs do not return to Green Zone: see Red Zone |
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What is the procedure for a pt in the RED zone
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- Very short of breath, OR
- Quick-relief medicines have not helped, OR - Cannot do usual activities, OR - Peak flow < 50% of best peak flow GO TO HOSPITAL NOW! |
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What is the Beta2-agonist Nebulizer Tx plan
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Up to 3 treatments given over 60-90 min
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What is the alternative for o Peak expiratory flow rate (PEFR) in young & middle aged emergency asthma pts
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Subcutaneous terbutaline
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what med is used to Tx very severe & unresponsive asthma pt
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Corticosteroids (IV)
( if pt is on oral Corticosteroid D/C them) |
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Clinical condition caused by acute inflammation of trachea & bronchi
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Acute Bronchitis or Tracheobronchitis
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If cough for Acute Bronchitis or Tracheobronchitis persist past 7 days consider
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Pertussis
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The Infectious Agent of Acute Bronchitis or Tracheobronchitis is most often _______, so _________ are unwarranted
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viral
ANTIBIOTICS |
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What are the Physical Findings for Acute Bronchitis or Tracheobronchitis
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- PE may be normal or with rhonchi & wheeze
- No signs of pulmonary consolidation - CXR normal - Fever may or may not be present |
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COPD a spectrum of respiratory diseases, _________is a clinical condition,__________ is a pathological entity
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- Chronic Bronchitis
- Emphysema |
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COPD is Characterized by what S/S
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cough
sputum dyspnea airflow limitation & impaired gas exchange |
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term used to describe a process where chronic bronchitis &\or emphysema has led to development of airway obstruction
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COPD
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What are the Risk Factors for COPD
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Cigarette smoking
Passive smoking Heredity α-1-antitrypsin deficiency Ambient air pollution Higher incidence in men, whites Other inhaled substances |
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In Early onset of COPD what is the median onset age for Smokers
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40
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In Early onset of COPD what is the median onset age for NON-Smokers
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53
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Check A1A levels in patients with a family H/O early COPD at what age
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30
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What is the typical History of a COPD Pt
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- Smoking Hx - usually > 40 pack years
- Environmental exposures - Dyspnea - exertional vs rest - Wheezing - Cough characteristics - productive, amount, color, episodic |
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What is the typical Physical Exam presentation of a COPD Pt
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- barrel chest
- Distant or decreased breath sounds - Prolonged expiratory phase - Wheezing on exhalation - normal or wheezing with coarse crackles or prolonged expiration |
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Severe COPD is suggested by:
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1. Accessory muscle use
2. Paradoxical abdominal motion 3. Pursed-lip breathing |
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COPD pts that has Predominant Emphysema have signs of
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lung hyperinflation
weight loss distressed respirations with use of accessory muscles inspiration through pursed lips |
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COPD pts that has Predominant Chronic Bronchitis have signs of
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overweight & cyanotic
usually no signs of distress at rest or use of accessory muscles |
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What are the Chest X-ray finding in COPD
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1. Hyperinflation
- Flattening of hemi diaphragms - Increased AP diameter 2. RV hypertrophy 3. Pulmonary HTN 4. Bullous lung disease 5. Narrowing of cardiac silhouette |
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what is the PFT bottom line in COPD
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Prognosis for patient with severe COPD with FEV1 ≤ 0.75L is a 30% mortality rate at one year & a 95% mortality rate at 10 years
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What condition in a COPD pt suggest chronic hypoxemia & indicates need for ABG & consideration of O2 therapy
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Erythrocytosis
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in Acute exacerbations of COPD what bacterias may found in the sputum
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Streptococcus pneumoniae Haemophilus influenzae,
Moraxella catarrhalis (less frequently) |
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The clinical features for emphysema are
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Older
Tall, Thin Late cor pulmonale mild hypoxemia |
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The clinical features for chronic bronchitis are
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Younger
Stocky, obese Early cor |
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When can the Diagnosis of Chronic Bronchitis can be made
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Diagnosis can only be made when ALL other causes of chronic cough are excluded (i.e. TB, lung cancer, CHF)
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how is a Chronic productive cough Dx
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occur on most days for at least 3 months in each of 2 successive years with other causes of chronic cough excluded
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Abnormal permanent enlargement of air sacs distal to terminal bronchioles, with destruction of alveolar walls & no obvious fibrosis
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Emphysema
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“Glad bags for lungs.”
Abnormal permanent enlargement of airspaces distal to terminal bronchioles |
Emphysema
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What is the Treatment Goal for COPD
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- prevent further damage
- prevent & treat acute exacerbations & maximize current function |
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What meds should be avoided in the Tx of COPD
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cough suppressants
& sedatives |
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What is the Tx for COPD
|
- Prevent further damage by eliminating inhaled irritants
- Improve secretion reduction with bronchodilators - Correct hypoxia with O2 therapy - (Can prolong life)- Use ABGs for adjusting |
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COPD Tx Therapy includes
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Smoking Cessation
β-agonists Anticholinergics Theophylline Corticosteroids Oxygen Antibiotics |
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What med is used for Smoking Cessation
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Anxiolytics (Zyban)
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What is the second line agent for stable COPD
|
β-agonists
Short-acting (Albuterol): 4-6 puffs po QID |
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What is the First line agent for acute exacerbation
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β-agonists
Short-acting (Albuterol): |
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What are the Side effects of Short-acting (Albuterol)
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nervousness
tremors elevated HR |
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What is the primary drug of choice for COPD
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Ipratropium bromide (Atrovent)
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What med is a Controversial agent in COPD
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Theophylline
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When is oxygen therapy warranted in COPD
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pO2 < 55 mm Hg, O2 sat < 89%
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When are antibiotics warranted in COPD
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change in color or consistency of sputum
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What is the Tx for Mild continuous COPD
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Atrovent 2-4 puffs po qid
PRN β-agonist & prior to exercise |
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What is the Tx for Moderate continuous COPD
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Use scheduled β-agonist & Atrovent
Consider use of long-acting β-agonist Consider use of theophylline Consider use of inhaled steroids. |
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What is the Tx for Severe continuous COPD
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Scheduled anticholinergic & β-agonist
Long-acting β-agonist (Serevent) Inhaled corticosteroid Ventolin 4 puffs MDI or neb prn Theophylline May require low dose po steroids May require oxygen @ 2L |
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What are the Complications of COPD
|
Acute respiratory failure
Secondary pneumothorax Multifocal atrial tachycardia(MAT) Pulmonary HTN Cor pulmonale |
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What test is indicated if symptoms suggestive of sleep apnea
|
Polysomnography
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What are the inclusion criteria of a Lung Reduction
|
1. Age < 70
2. FEV1% < 40% predicted 3. pCO2 < 50 4. < 10 mg Prednisone/day 5. No substantial co-morbid illness |
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What are the inclusion criteria of a Lung Transplantation
|
- Physiologic age < 60
- Life expectancy of 12-18 months - Adequate cardiac function with no systemic illnesses - FEV1 < 30% or FEV1/FVC% < 40% - Hypoxemia with pO2 < 55 mm Hg - Presence of hypercarbia |
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Pneumonia is a infection of what
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infection of pulmonary parenchyma
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Pneumonia Involves what parts of the lung
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- interstitial tissue or alveoli
- alveoli & adjacent bronchi - or even entire lobe |
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Pneumonia may cause lung abnormality
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- patchy infiltrations
- full lobe consolidation - accumulation of pus (empyema) - necrotic cavities |
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what is the Most common cause of death due to infectious disease
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Pneumonia
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What are the bodies Mechanical Defenses to pneumonia
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1. Anatomic barriers
2. Aerodynamics - deposition of particles 3. Epithelial cell barriers 4. Mucus 5. Mucociliary escalator |
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What are the bodies Pulmonary Defenses to pneumonia
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- Alveolar macrophages - resident phagocytic cell in airways, alveoli
- Inflammatory response - PMNs, complement and humoral immunity - Specific immune responses for: viruses, fungi & mycobacteria |
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A pt w/ DKA is more susceptible to what type of pneumonia
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S. pneumonia
S. aureus |
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An Alcoholic is more susceptible to what type of pneumonia
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Klebsiella
Anaerobes |
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A pt w/ COPD is more susceptible to what type of pneumonia
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H. flu
M. Cat Legionella |
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A pt w/ HIV, CD4 > 200 is more susceptible to what type of pneumonia
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S. pneumonia
H. Flu TB |
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A pt w/ HIV, CD4 < 200 is more susceptible to what type of pneumonia
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PCP (Pneumocystis jiroveci)
Histo Crypto |
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The Physical finding of periodontal Dz indicates what possible organism
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Anaerobes
Polymicrobial |
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The Physical finding of Bullous myringitis indicates what possible organism
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Mycoplasma pneumoniae
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The Physical finding of Absent gag or altered MS indicates what possible organism
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Polymicrobial aspiration
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15-54 y/o pt with reoccurring pneumonia consider
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HIV
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What preceedure should be done if significant effusion present in pneumonia
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Thoracentesis
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Focal opacity on CXR of CAP indicates
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S. pneumoniae
L. pneumophila C. pneumoniae S. aureus |
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Multifocal opacity on CXR of CAP indicates
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S. aureus
L. pneumophila S. pneumo |
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Interstitial pattern on CXR of CAP indicates what organism
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M. pneumoniae
Viruses Pneumocystis carinii C. psittaci |
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Miliary pattern on CXR of CAP indicates what organism
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M. tuberculosis
Fungi Varicella zoster |
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Cavitation pattern on CXR of CAP indicates what organism
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Mixed aerobic/anaerobic
GNR M. tuberculosis C. neoformans Nocardia Actinomyces |
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What tests should be done on all hospitalized pneumonia patients
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Blood and sputum cultures
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What tests should be done on all ICU pneumonia patients
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Urine Legionella antigen
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“Typical” pneumonia is most commonly caused by
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Strep pneumoniae
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20 y/o F w/ sudden onset of fever, chills, purulent sputum, signs of consolidation, leukocytosis, CXR with patchy or lobar infiltrates, pleuritic chest pain with splinting may be present - they look “sick” indicates
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Strep pneumoniae
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18 y/o M w/ gradual onset, dry cough, abnormalities on CXR despite minimal PE findings other than rales, predominance of extrapulmonary symptoms (dry cough, HA, malaise, myalgias, N/V, diarrhea), may or may not have pleurisy or appear “sick” indicates
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Mycoplasma pneumoniae
“Atypical” Pneumonia |
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“Atypical” Pneumonia is most commonly caused by
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Mycoplasma pneumoniae
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Outpatient, age < 60, no co- morbidity the most common pathogens is
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Streptococcus pneumoniae
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What is the Empirical Treatment for Outpatient, age < 60, no co- morbidity
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macrolide azithromycin (Zithromax) or Doxycycline for 10-14 days
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What is the Empirical Treatment for Outpatient with Comorbidity or >age 60
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beta-lactamase inhibitor (Augmentin) OR
2nd generation cephalosporin (Ceftin) OR beta-lactam Cefuroxime OR IV Ceftriaxone Plus Macrolide or Doxy |
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What is the most common pathogens for Outpatients with Comorbidity or >age 60
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Strep pneumoniae
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Whay is the Empirical IV Treatment for CAP Requiring Hospitalization
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- 2nd or 3rd generation cephalosporin (Zinacef or Rocephin) or β-lactam/β-lactamase inhibitor (Timentin)
- Use or add a macrolide (erythromycin) if Legionnaires is suspected |
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Who should receive the influenza vaccine
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- everyone > 50,
- plus High risk pts, HCWs, families & close contacts with high risk pts |
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Prevention of CAP
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- Influenza vaccine
- Pneumococcal vaccine - Avoid certain circumstances if possible (nursing homes, other institutions) |
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what are the High Risk Patients with CAP
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- Patient’s age > 60
- Co-morbid conditions - Abnormal PE |
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What are the Co-morbid conditions
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- Neoplastic disease
- CHF - CNS - renal - Liver disease |
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What are the Abnormal PE finding for High Risk Patients with CAP
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- Altered MS
- Pulse > 125, RR > 30, Sys BP < 90 - Temp < 35 C or > 40 C |
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What is the most common pathogens for Hospitalized pt's Severely ill with CAP
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Strep pneumoniae
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What is the Empirical IV Treatment for a Hospitalized pt with Severely ill CAP
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combination therapy with macrolide & 3rd generation cephalosporin with antipseudomonal activity (Fortaz) or other antipseudomonal agent (Cipro)
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A Categories of risk score < 90
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send home
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A Categories of risk score > 91
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admit
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What meds are given during a outbreak of influenza A
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Amantadine
or Rimantadine |
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What is the TX for Pneumocystis jirovecii in HIV
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Trimethoprim-sulfamethoxazole
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What is the TX for Tuberculosis
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INH
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If pneumonia occurs > 48 hours after admission if is considered
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Nosocomial pneumonia (HAP):
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If pneumonia occurs < 48 hours after admission if is considered
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CAP
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What are the Organisms that are encountered most frequently & can be referred to as “core pathogens” :
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S. pneumonia
H. influenzae S. aureus Aerobic GN bacilli |
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Most HAP cases result from
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micro aspiration of previously colonized oropharyngeal secretions
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What test should be performed to obtain a good bacteria specimen in HAP
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Fiberoptic bronchoscopy
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sub-type of HAP which occurs in people who are on mechanical ventilation
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Ventilator-associated pneumonia (VAP):
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What is the Empiric treatment for VAP
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should be with a wide spectrum antibiotic or combination, based on patient severity & what has been seen in hospital recently
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What is the Tx for HAP patients on ventilation &/or in ICU
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broad spectrum & an aminoglycoside
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What is the discharge Criteria for HAP
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- Meet criteria for switching to oral antibiotics.
- WBC count < 12 x 109 /L - Stable comorbid illness - Normal oxygenation saturation (> 90% on RA) - if COPD, pO2 > 60 & pCO2 < 45 mm Hg |
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What pneumonia causeing bacteria is described as, often follows an upper respiratory infection, CXR: lobar consolidation, Very common in CAP
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Streptococcus pneumonia
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What is the Drug of choice and Alternative Tx for Streptococcus pneumonia
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- Zithromax
- Alternative: Levofloxacin |
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What pneumonia causeing bacteria is described as, common in alcoholics, diabetics, & HAP
CXR: lobar consolidation, Can cause cavitation & empyema |
Klebsiella pneumoniae
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What pneumonia causes bacteria is described as, Common in CAP, often hitting young adults in summer & fall, Often has an “Atypical” presentation, Complicated by bullous myringitis, CXR: extensive patchy infiltrates
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Mycoplasma pneumoniae
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What pneumonia causes bacteria is described as, Can be CAP or HAP, Often seen in summer or fall with exposure to contaminated construction site, water source, or air conditioner CXR: patchy or lobar consolidation
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Legionella species
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What pneumonia causes bacteria is described as, Often seen in pre-existing lung disease (i.e. smokers), elderly, pts on long term high dose corticosteroids or immunosuppressive therapy (i.e. transplant patients), CXR: patchy infiltrates or occasional lobar consolidation
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Moraxella catarrhalis
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What is the Preferred Treatment and Alternative for Moraxella catarrhalis
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2nd or 3rd generation cephalosporin
Alternative: Amoxicillin-clavulanic acid (Augmentin) Trimethoprim-sulfamethoxazole (Bactrim/Septra) |
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What is the Drug of Choice Legionella species
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Azithromycin (Zithromax)
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What is the Drug of Choice Mycoplasma pneumoniae
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Azithromycin (Zithromax)
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What is the Drug of Choice Klebsiella pneumoniae
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Cefotaxime (Claforan)
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What is the Preferred Treatment for Pneumocystis jiroveci
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Trimethoprim-sulfamethoxazole or pentamidine plus prednisone
- AIDS patients often on chemoprophylaxis of Trimethoprim-sulfamethoxazole & inhaled (aerosolized) pentamidine |
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What pneumonia causes bacteria is described as, Seen in AIDS, immunosuppressive or cytotoxic therapy, & cancer, CXR: diffuse interstitial ^ alveolar infiltrates
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Pneumocystis jiroveci
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What is the Preferred Treatment for Anaerobic Pneumonia & Lung Abscess
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Clindamycin
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What procedure is required for an empyema
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Tube thoracostomy
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What pneumonia causes bacteria is described as, Predisposition to aspirate, Possibly foul-smelling sputum
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Anaerobic Pneumonia
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What is the causative agent of Tuberculosis
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Mycobacterium tuberculosis
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How is Tuberculosis tranmitted
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airborne droplets
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Patients usually have symptoms, are contagious in Infection or Disease Tuberculosis
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TB disease
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TB Disease can be from a
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primary infection, but usually from reactivation
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Pts who have or suspected of having pulmonary or laryngeal TB should be considered infectious if they are
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- Coughing
- Undergoing cough-inducing or aerosol-generating procedures - Have sputum smears positive for acid-fast bacilli - Are not receiving treatment - Have just started therapy, or - Have poor clinical or bacteriological response to therapy |
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Patients are not considered infectious for TB if they met ALL these criteria
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- Adequate therapy received for 2-3 weeks
- Favorable clinical response to therapy, AND - consecutive NEG sputum smear results from sputum collected on different days |
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What are the Administrative Infection Control Measures for TB
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- Consider TB in ALL HIV-infected pts with undiagnosed pulmonary disease
- If TB is suspected, take appropriate precautions to prevent transmission |
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What are the Engineering Infection Control Measures for TB
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- Use ventilation systems in TB isolation rooms to maintain negative pressure & to exhaust air properly
- Use HEPA filtration & ultraviolet irradiation only in conjunction with other infection control measures |
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Personal respiratory protective equipment is use in what areas
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- TB isolation rooms
- Rooms where cough-inducing procedures are done - Homes of infectious TB patients |
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a form of Primary infection going directly disease where immune system doesn’t stop dissemination throughout lung
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“Miliary”(resembling millet seed) TB
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What are calcified primary foci or focus with calcified hilar lymph node
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Ranke complexes
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calcified primary focus
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Ghon complex
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What test is good for diagnosis on individual exposed to TB
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Mantoux (PPD)
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A PPD induration of ≥ 5 mm would be consider POS on class of people
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- HIV infected or at risk for infection
- Close contacts of individuals with TB - Persons with CXR consistent with old healed TB |
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A PPD induration of ≥ 10 mm would be consider POS on class of people
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- Military
- Persons from high risk countries Asia, Africa, Latin American - IV drug users - Medically Underserved, - Low-income populations - Long-term residents - High risk medical patients |
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the inability to react to skin test because of immunosuppression
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Anergy
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The anergy skin test panel consist of
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- Tetanus toxoid
- Mumps - or Candida antigen skin test - & Mantoux at same time |
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What is the major cause of TB treatment failure & drug resistance
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Noncompliance
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TB Drugs SE for
Isoniazid (INH): Rifampin: Ethambutol: Streptomycin: |
- Isoniazid (INH): hepatitis, peripheral neuropathy
- Rifampin: hepatitis, GI bleed - Ethambutol: Optic neuritis - Streptomycin: 8th nerve damage, nephrotoxicity |
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When is the BCG (bacillus Calmette-Guerin) vaccine used and how is interpreted
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- recommended only when INH can’t be used ( children exposed frequently to untreated population)
- specific population who don’t respond to aggressive TB control strategies - Interpret same as person w/out BCG |
