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265 Cards in this Set
- Front
- Back
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What are causes of wheezing?
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asthma
heart failure bronchitis COPD poor lung capacity occupational lung disease |
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What are RF for death in asthma?
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-previous admission to an ICU
-previous intubation for asthma -previous sudden severe exacerbation >/= 2 hospitalizations in the last year >/= 3 ED visits in past year hospitalization or visit in the past 1 month >/= 2 MDI SAB in 1 month current use or recent withdrawal of steroids difficulty perceiving symptoms low socioeconomic status psychosocial problems illicit drug use Cardiovascular , chronic lung or psychiatric disease |
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Which illicit drug use is associated with intubation of asthmatics?
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cocaine and heroine
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What findings signify severe asthma?
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-pulsus paradoxus
(inpiratory decrease of SBP by >10mmHg) sitting upright RR >40/min HR >120/min Use of accessory muscles of respiration |
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What PFT values may be used to estimate the degree of airway obstruction in asthmatics presenting to the ED?
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FEV1 - forced expiratory volume in 1 second after maximal inspiration
PEFR - peak expiratory flow rate, started with fully inflated lungs and sustained for minimum of 10ms |
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When is the ABG useful in asthma?
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When reliable pulse oximetry cannot be obtained
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How can ventilation be assessed in asthma?
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End tidal Co2
(high concordance with PaCO2 on ABG) |
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How long after dpi +/- steroids is polymorphonuclear leukocyte demargination seen?
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1-2 hours
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What electrolyte disturbances can be seen with frequent albuteral treatments?
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hypokalemia
hypomagnesemia hypophosphatemia |
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Which patients with asthma should have a CXR?
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Indication of complication (PTX, pneumonia, pneumomediastinum)
-those who do not respond to optimal therapy and require admission -other medical concern |
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What is the best way to measure/monitor the severity of air flow obstruction in asthma?
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serial FEV1 or PEFR
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What ABG values in asthma are concerning?
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PaO2<60, PaCO2>42
all other values must be interpreted in the appropriate context |
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What SpO2 should you maintain in a patient with asthma exacerbation?
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>90%
(>95% if pregnant or heart disease) |
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What is the definition of status asthmatics?
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severe bronchospasm that does not respond to conventional therapies in 20-30 minutes
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What is near fatal asthma?
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That which results in respiratory arrest or respiratory failure (PaCO2 >50mmHg)
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When can heliox be considered?What is the dose?
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PEFR <30% predicted
rapid onset symptoms (<24hours) 60-80% helium with 20-40% oxygen |
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What must be present in a patient with asthma if Bipap is considered?
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Alert mental status
airway reflexes |
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What ventilator strategy is used in asthmatics?
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permissive hypercapnia
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What ventilator settings should be used in asthma?
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6-8cc/kg
-10 breaths/min high FiO2 high inspiratory flow and prolonged expiratory time permissive hyperCo2 (<100mmHg) Maintain pH 7.15-7.2 - can administer bicarbonate for this |
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What are complications of mechanical ventilation in asthmatics?
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hypotension (elevated intrathoracic pressure)
-barotrauma |
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What should be done in an intubated asthmatic who continues to have elevated airway pressures?
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general anaesthesia with isoflurane
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What is the treatment of asthma exacerbation with PEFR <40%
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Albuterol 5mg q 20 min x 3 (or continuous x 1hour) (6-12 puffs)
iprotropium 0.5mg q 20 min x 3 (8puffs) prednisone 40-60mg/day or Methylprednisolone 60-125mg oxygen SpO2 >90%) Mg 2-3 g over 20 min (FEV1 <25% predicted) |
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What is the definition of chronic bronchitis?
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Cough and sputum production for at least 3 months in each of 2 consecutive years
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What is emphysema?
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the destruction of alveoli - a pathologic term
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Briefly describe the pathophysiology of COPD?
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Airflow obstruction and obliteration results in hypoxemia and hypercapnia. Hypoxemia results in thickened vascular wall, this in addition to obliteration results in pulmonary hypertension, polycythemia and right sided HF
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What are quantitative measures of airflow limitation in COPD?
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-FEV1
FEV1/FVC (after airflow limitation is addressed) |
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What is considered very severe COPD?
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FEV1 <30% predicted
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When are more frequent COPD exacerbations seen?
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FEV1 <50% predicted
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What is the definition of a COPD exacerbation?
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-change in the normal baseline cough, sputum or dyspnea
-acute in onset -may warrant change in medication |
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What are reasons for worsening symptoms in COPD?
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-acute exacerbation
-right HF -PE -lobar atelectasis -pleural effusion -dysrhythmia |
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What are PE findings of care pulmonale?
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-Susbsternal/subxiphoid heave
-S4 decreased LV compliancce -S3 LV failure -holosystolic murmur -> tricuspid insufficiency -hepatic congestion -accentuation of the pulmonic component of the 2nd heart sound |
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What should guide your decision to intubate a patient with COPD exacerbation?
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Overall state of patient
progression to fatigue co-morbid illness response to therapy |
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When should ABGs be done in the ED?
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special circumstances such as irregular or unreliable pulse oximetry
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How can waveform capnography be used to differentiate COPD from other causes of acute dyspnea?
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Plateau steepens in proportion to the degree of obstruction
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What is the role of PFTs in COPD exacerbation
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limited utility
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What are the most common dysrhythmias associated with COPD?
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Atrial tachyarrhythmias especially atrial fibrillation and MAT
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What is the treatment for MAT?
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It often resolves with the treatment of the COPD exacerbation itself
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What is BNP?
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A naturally occurring peptide released by the ventricles in response and volume expansion
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Which condition is most commonly mistaken for COPD?
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Cardiogenic pulmonary edema
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How does lobar atelectasis occur?
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mucous plugging of bronchi
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What treatment modalities alter the progression of COPD and decrease mortality?
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smoking cessation
chronic O2 in severe disease |
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Which COPD patients may benefit NIVS?
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-moderate to severe exacerbations
-hypercapnia but no hypoxemia |
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What are initial settings for CPAP?
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5-10cmH20
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What are initial settings for Bipap
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7.5-15cmH20/ 2.5-5cmH20
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What are indications for intubation in COPD exacerbation?
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-respiratory arrest
-worsening LOC -CV instability -worseining dyspnea -severe tachypnea -severe hypoxemia -severe acidosis or hypercarbia -other complications |
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How effective are anticholinergic treatments in COPD?
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As effective as beta agonists (may be used alone or in conjunction with beta agonists
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Do methylxanthines improve outcomes in COPD exacerbations?
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No and they are associated with significant toxicity
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Which patients with COPD exacerbation should receive antibiotics?
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Increase sputum purulence or volume
increased dyspnea require NIVS or VS |
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What antibiotics should be used for outpatient treatment of COPD exacerbation?
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-azithromycin
-clarithromycin (min 10d) |
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What antibiotics should be used in patients with recent antibiotics and COPD exacerbation?
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respiratory quinolone (moxi, gati, levo) or macrolide and beta lactacm (cephalosporin) 2 weeks if mycoplasma/chlamydia
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What are indications for admission in COPD exacerbation?
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-significant worsening from baseline
-symptoms not improved in ED -significant co-morbid disease -severe hypoxemia or hypercapnia 0inability to cope at home |
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What is the most common condition predisposing to secondary spontaneous pneumothorax?
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COPD
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What causes PTX in patients with acquired immunodeficiency?
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p. jiroveci
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What is catamenial PTX?
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A rare disorder where PTX occurs with menses
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What can you do in suspected PTX with a negative CXR?
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expiratory film (however routine use does not increase diagnostic yield)
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What suggests a PTX in a critically ill patient? (i.e. supine)
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Deep sulcus sign (deep lateral costophrenic angle)
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How do you differentiate a PTX from a giant bleb?
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The PTX line is more likely to be parallel to the chest wall
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When does spontaneous pneumomediastinum occur?
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During exertion, particularly with Valsalva maneuver
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What defines a small PTX?
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<20% of the hemithorax
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How are secondary spontaneous pneumothoraxes managed?
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tube thoracostomy
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Should chest tubes be placed on suction?
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No, it is no longer recommended
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What are possible complications of a tube thoracostomy?
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-misplacement
-infection -prolonged pain -re-expansion pulmonary edema -re-expansion hypotension |
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What conditions are associated with pleural effusion?
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CHF
bacterial pneumonia TB PE malignancy uremia myxedema nephrotic syndrome |
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What is a parapneumonic effusion?
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a pleural effusion associated with bacterial pneumonia or bronchiectasis
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What is a transudate?
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Plasma ultra filtrate with very little protein
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What is an exudate?
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Pleural effusion that contains a lot of protein and reflects an abnormality of the pleura itself
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What are the most common causes of an exudative pleural effusion?
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-parapneumonic effusion
-malignancy |
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What are causes of transudative effusions?
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-CHF
-nephrotic syndrome -hepatic cirrhosis -pulmonary embolism -SVC obstruction -peritoneal dialysis -hypoalbuminemia -glomerulonephritis -myxedema |
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On an AP chest, what volume of fluid is required for detection of a pleural effusion?
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250-500cc
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What are Light's criteria?
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a pleural effusion is considered an exudate if it fulfills one or more of the following criteria:
-pleural fluid protein:serum protein is >0.5 pleural fluid LDH: serum LDH >0.6 pleural LDH is greater than 2/3 the upper limit of normal |
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What are reasonable indications for tube thoracostomy in pleural effusion?
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-exudate
-pH <7.00 -glucose <50mg/dL |
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What defines a hemothorax
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Hematocrit >50% of the peripheral blood
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What is the definition of empyema?
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the presence of bacteria on the gram stain
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What is the most common cause of CAP? the 2nd?
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Strep pneumo
haemophilus |
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What are RF for anaerobic pneumonia?
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-risk for aspiration (CNS depression, swallowing difficulty)
-severe periodontal disease -fetid sputum -pulmonary abscess or empyema |
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What are unusual causes of pneumonia
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-hanta virus
-plague -franciscella -chlamydiophylia -coxiella -bordetella |
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what are RF for pneumonia from resistant organisms?
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-Nursing home or extended care facility resident
-HD clinic -hospitalized for 2 or more days 90d prior -antibiotics, wound care or chemo in past 30d |
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What are findings suggestive of TB on X-ray?
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apical infiltrate
infiltrate associated with hilar or mediastinal adenopathy |
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Which patients with pneumonia should have blood cultures?
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-immunocompromised
-severe sepsis -RF for endovascular infection |
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What is an indication for thoracentesis on upright CXR?
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pleural effusion >5cm on upright film
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What tests should be ordered on pleural fluid from pneumonia?
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gram stain
cell count differential pH |
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What are causes of respiratory infections in HIV patients?
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p jiroveci
s pneumonia HIB TB Mycobacterium avium crytococcus rhodococcus |
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When are patients with HIV at risk of opportunistic infection?
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CD4 <200/mm3
(suggested if total lymphocyte found is <1000mm3) |
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What are signs of immunosuppression in patients with unknown HIV status?
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-hairy leukoplakia
-oral candidiasis -weight loss |
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What lab test is elected in AIDS patients with PCP?
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LDH
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Which patients should be isolated for TB?
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-history of exposure to TB
-symptoms - weight loss, night sweats, hemoptysis -high risk features: homeless, IVDU, HIV, immigrant from high risk area |
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which antibiotics are active agains CA-MRSA?
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Vanco
linezolid daptomycin tigacycline TMP-SMX |
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What are empiric antibiotic regiments for CAP in previously healthy individuals?
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-azithromycin 500mgPOx1d, then 250mgPOQD x 4d
-doxycycline 100mg PO BID |
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What is empiric antibiotic therapy for CAP for patients with co-morbidities or antibiotics in the last 1 month? (outpatient)
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levofloxacin 750mg PO QD x 5d
(cefpodoxime and azithro) or amoxicillin-clavulanate |
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What is inpatient therapy for CAP?
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-extended spectrum fluoroquinolone or
macrolide and ampi-sulbactam/ertapenem/ceftriaxone/cefotaxime |
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What antibiotic is added in suspected aspiration pneumonia?
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clindamycin or metronidazole
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What is inpatient therapy for severe pneumonia?
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ceftriaxone + levofloxacin + vancomycin
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What is empiric therapy for pneumonia secondary to pseudomonas?
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cefepime
cipro vancomycin |
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What is the treatment for suspected PCP?
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TMP/SMX IV q6
240/1200mg |
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What is a substitute for TMP-SMX in sulfa allergy?
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pentamidine (may be associated with hypotension and hypoglycaemia)
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What should be added to antibiotics for PCP?
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prednisone 40mg PO BID
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How long do you typically treat for pneumonia?
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10-14d (5d for azithro and levaquin)
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What is the recommended antiviral agent in influenza?
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oseltamivir (active against influenza A and B)
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What is CURB -65
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A score that attempts to predict pneumonia severity
C- confusion U - uremia >6.8mmol/L RR >30/min BP SBP <90, DBP </=60 age >65 0-1 outpatient therapy 2 inpatient >2 ICU |
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What is the definition of ARDS?
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Respiratory failure requiring mechanical ventilation
PaO2/FiO2 <200 new bilateral, diffuse infiltrate without evidence of heart failure, fluid overload or chronic lung disease |
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What is the treatment for ARDS?
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maintain peak airway pressures <35cmH20
low tidal volume permissive hypercapnia, high frequency prolonged inspiration, oscillatory ventilation |
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What factors are believed to contribute to asthma morbidity and mortality?
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Inadequate patient assessment of severity
Inadequate physician assessment of severity undertreatment overuse of prescribed or OTC medications Failure of physicians to consider previous hospitalizations for previous life threatening episodes Failure to initiate corticosteroids early socioeconomic factors environmental influences over reliance of ED for asthma care |
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What is the primary pathologic process of asthma?
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Allergic airway inflammation
IgE mediated inflammation airway remodeling |
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what are physiologic consequences of airflow obstruction?
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increased airway resistance
decreased maximal expiratory flow rates air trapping increased airway pressure VQ imbalance increased work of breathing |
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List potential triggers for asthma?
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Viral pathogens
Exercise Atmospheric pollutants indoor antigens occupational exposure pharmaceutical agents cold air emotional stress |
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What is the clinical triad of asthma presentation?
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cough
dyspnea wheezing |
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What is the triad of aspirin exacerbated respiratory disease?
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ASA sensitivity
Asthma Nasal polyp |
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What is the CAEP classification of acute asthma?
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Near death
Severe Moderate Mild |
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What is a mild asthma exacerbation (acc to CAEP) and how do you treat?
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-exertional dyspnea, cough +/- nocturnal symptoms
-increased use of beta agonists with good response FEV1 or PEFR >60% predicted or best (FEV1 >2.1L or PEFR >300L/min) O2 and beta agonists |
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What is a moderate asthma exacerbation (acc to CAEP) and how do you treat?
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-dyspnea at rest, cough, congested, chest tightness
-nocturnal symptoms -partial relief with beta agonists, beta agonists needed more than q4h FEV1 or PEFR 40-60% of best or predicted (FEV1 1.6-2.1L or PEFR 200-300L/min) O2, beta agonists, consider anticholinergics and corticosteroids |
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What is a severe asthma exacerbation (acc to CAEP) and how do you treat?
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-laboured respirations
-aggitated, diaphoretic -difficulty speaking -tachycardia -no prehospital relief with beta agonists FEV1 or PEFR unable or <40% (FEV 1 <1.6L or PEFR <200L/min) 100% O2 frequent or continuous beta agonists and anticholinergics systemic corticosteroids anticipation of intubation |
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What is a near death asthma exacerbation (acc to CAEP) and how do you treat?
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-exhausted, confused, diaphoretic, cyanotic
-silent chest, decreased effort -falling HR oxygen saturation <90% 100% O2 continuous beta agonists and anticholinergics (with ETT adaptor if intubated) systemic corticosteroids intubation and paralysis |
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What are ECG findings in acute asthma?
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RV strain
Abnormal Ps Nonspecific ST/T changes |
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What is severe acute asthma?
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Bronchoconstriction refractory to outpatient management
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What is fatal asthma?
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Death from severe asthma
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What are the two recognized types of fatal/near-fatal asthma?
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Slow onset - gradual deterioration on top of poorly controlled disease
Rapid onset - progression to life threatening status <3 hours, greater hypercapnia |
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Differential for acute asthma?
|
Cardiac - valvular heart disease, CHF
COPD exacerbation Pulmonary infection - pneumonia, aspergillosis, chronic eosinophilic pneumonia Upper airway obstruction - neoplasm, edema, FB, vocal cord dysfunction Endobronchial disease PE Carcinoid Allergic/anaphylactic GERD NCPE Addisons |
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What are recommendations for steroids in ED treated asthma?
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All patients treated in the ED for an acute episode of asthma should be considered for oral or IV steroids ASAP
(Level I) |
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When should anticholinergic medication be added to beta agonist therapy?
|
Severe acute asthma
May help with moderate asthma B blocker induced bronchospasm |
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Oxygen therapy is used to target what O2 sat?
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>94% (Level IV)
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What are discharge recommendations?
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Pretreatment <25% (PEFR <100L/min) - usually require admission
Post treatment <40%(PEFR <200L/min) - usually require admission Post treatment 40-60% (PEFR 200-300L/min) - possible candidates for discharge Post treatment >60% (PEFR >300L/min) - likely candidates for admission |
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What is the dose of epinephrine IV in asthma?
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load with 200ug-1mg
Start 1ug/min (range 3-20 ug/min) It can also be given subcutaneously 0.2-0.5mL (1:1000) every 20-30 mins x 3 |
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List 2 long acting beta agonists?
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Salmetrol
Formetrol |
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What is the mechanism of steroid in acute asthma exacerbation?
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Inhibit recruitment of inflammatory cells
Inhibit release of inflammatory mediators Restore Beta adrenergic responsiveness |
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What steroid medications can be used in asthma?
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Methylprednisolone 125mg IV q6-8
hydrocortisone 200-500 IV q6-8 prednisone 40-60mg PO once |
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What are potential side effects of short course steroid use?
|
reversible increases in glucose
decreases in potassium fluid retention and weight gain mood alteration HTN PUD Avascular necrosis of the femur Allergic reaction |
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What is the dose of magnesium in severe asthma?
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2-3g over 20min
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What are the adverse effects of magnesium?
|
Warmth
Flushing Sweating Nausea and emesis Muscle weakness Loss of DTR Hypotension Respiratory depression |
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What are possible mechanisms of magnesium in severe asthma?
|
Bronchial smooth muscle relaxation
-calcium channel blockade -inhibition of cholinergic neuromuscular transmission -stabilization of mast cells and t-lymphocytes -stiumulation of nitric oxide and prostacyclin |
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What is the treatment of asthma exacerbations during pregnancy and lactation?
|
Same as non-pregnant'
Fetal heart monitoring in pregnancy |
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What are the benefits of helix?
|
-Heliox has a decreased density and therefore increased laminar flow through the narrowed airways
-improved gas exchange |
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Which patients are considered at risk for asthma relapse?
|
Previous near death episode
Recent ED visit Frequent hospitalization Steroid dependent or recent use Sudden attacks Allergic/anaphylactic triggers Prolonged duration of recent attack Poor compliance or understanding Returning to the same environmental triggers |
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When should patients discharged after ED visits for asthma be seen by their PCP?
|
3-5 days
|
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What is the GOLD collaborators definition of COPD?
|
A disease characterized by airflow limitation:
-not fully reversible -usually progressive -associated with abnormal inflammatory response |
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How dose smoking cessation affect COPD progression?
|
Slows but does not stop or reverse it
|
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List environmental factors linked to COPD?
|
Heavy occupational exposure to dusts
Air pollution from indoor cooking Outdoor air pollution Passive exposure to tobacco smoke Early childhood lower respiratory tract infections |
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Explain the COPD-er with unexpected low PCO2 on ABG?
|
Ventilatory drive is increased as a compensatory mechanism to maintain near normal PaO2 with resultant tachypnea causing decreased PCO2
|
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How is the diagnosis of COPD confirmed?
|
Spirometry:
FEV1<80% predicted FEV1/FVC < 70% |
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What is the CTS COPD classification by lung function
|
At risk - normal spirometry, chronic symptoms
Mild - FEV1/FVC <70%, FEV1 60-79% Moderate - FEV1/FVC <70%, FEV1 40-59% Severe FEV1/FVC <70%, FEV1 <40% predicted |
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What viruses are commonly implicated in COPD exacerbations?
|
Rhinovirus
Respiratory syncytial virus Coronavirus Influenza |
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What are the CTS COPD classification by symptoms/disability?
|
At risk - asymptomatic, chronic cough/sputum
Mild - SOB when hurrying on level ground or walking up a slight hill Moderate - SOB causing the patient to stop walking around 100m Severe - SOB resulting in patient too breathless to leave the house, breathlessness after undressing, chronic resp failure or clinical signs of right heart failure |
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What are the typical bacterial pathogens in COPD and COPD exacerbations?
|
HIB
S pneumo Moraxella Pseudomonas |
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What are the clinical features of chronic bronchitis?
|
Chronic resp failure
cor pulmonale polycythemia and hypoxemia lead to cyanotic appearance Normal thoracic AP diameter Diaphragm not abnormally low severe bronchopulmonary secretions |
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What are the clinical features of emphysema?
|
Thin and anxious
dyspnea and tachycardia accessory muscle breathing auto-peep with pursed lips gross lung over inflation |
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What findings on the ECG may reflect COPD and cor pulmonale?
|
P pulmonale (peaked P waves)
Low QRS voltage Right axis deviation Poor R wave progression |
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What is the possible role for BNP in AECOPD?
|
BNP >100pg/mL increases sensitivity for CHF
BNP <100pg/mL more likely COPD |
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List causes of acute decompensation in patients with COPD?
|
viral infection
bacterial infection atypical bacteria Air pollution PTX PE Lobar atelectasis CHF Pneumonia Trauma Neuromuscular and metabolic disorders Unrelated pulmonary disease Treatment noncompliance Iatrogenic |
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What are indications for long-term oxygen therapy?
|
PaO2<55mmHg
SaO2 <88% PaO2 56-59 and signs of pulmonary hypertension, cor pulmonale or polycythemia |
|
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What vaccines may provide benefit to COPDers?
|
Influenza
Pneumococcus |
|
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What are benefits of NIPPV in COPD?
|
Avoids intubation
Increases pH Reduces PCO2 Reduces dyspnea Reduces mortality |
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What are selection criteria for NIV in COPD?
|
Respiratory distress
RR>25 Use of accessory muscles Respiratory acidosis pH<7.35 PaCO2>45mmHg |
|
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What are exclusions criteria for NIV in COPD?
|
Respiratory arrest
CV instability Uncooperative patient Upper airway obstruction High aspiration risk Recent facial or gastroesophageal surgery Cranifacial trauma, fixed nasopharyngeal abnormmalities Non-fitting mask |
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What signifies failure of NIV?
|
Increasing RR
Lethargy Exhaustion Speechlessness Paradoxical abdominal breathing Falling oxygen saturation |
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What are indications for intubation and invasive ventilation in COPD?
|
Respiratory arrest
Depressed LOC CV instability NIV failure or exclusion criteria Severe dyspnea with use of accessory muscles and paradxical breathing Severe tachypnea Life-threatening hypoxia Severe acidosis and hypercapnia Other complications (sepsis, metabolic abnormalities, pneumonia) |
|
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What are the goals of treatment in COPD?
|
Symptomatic relief
Control exacerbations Improve quality of life Improve exercise capacity |
|
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What are non-infectious causes of sore throat?
|
Kawasaki's
Stevens Johnson Penetrating injury Retained FB Caustic exposure Tumor of the tongue, larynx or thyroid |
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What are systemic viral infections that may manifest in part with a sore throat?
|
Measles
CMV EBV Rubella HIV |
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What is the differential of sore throat and toxic appearance?
|
Epiglottitis
RPA Bacterial tracheitis Kawasaki's |
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What is the differential of sore throat and tripoding?
|
RPA
Epiglottitis Trachitis Laryngotracheobronchitis |
|
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What is the differential of sore throat and torticollis?
|
Parapharyngeal abscess
|
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What is the differential of sore throat and absent or muffled voice?
|
Epiglottitis
RPA Peritonsillar cellulitis |
|
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What increases the likelihood that GABHS is the cause of pharyngitis?
|
Age 5-15
Temperature >38.3 Tonsilar exudates Palatal and uvular petechiae Uvular edema and erythema Tender anterior lymphadenopathy |
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What decreases the likelihood that GABHS is the cause of pharyngitis?
|
Age<3
cough, rhinorrhea, coryza other viral symptoms |
|
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What does the toxin from diphtheriae cause?
|
Myocarditis
Polyneuritis Diffuse focal organ necrosis Vascular collapse |
|
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When must GABHS be treated to prevent rheumatic fever?
|
<9-10 days
|
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What are the Centor criteria?
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Tonsillar exudates
Tender anterior cervical adenopathy History of fever Absence of cough |
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What is the pretest probability of strep throat in children and adolescents?
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Children 20-25%
Adolescents/adults 5-10% |
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What factors are added to the Centor criteria to form the McIsaac Modified Centor Score?
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Tonsillar swelling (of exudates) 1 point
Age <15 1 point Age >/=45 -1point |
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What is the chance of streptococcal infection in patients with various centor criteria?
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0 - 2-3%
1 - 4-6% 2 - 10-12% 3 - 27-28% 4 - 38-63% |
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What pathogens are responsible for chronic or recurrent pharyngitis?
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EBV
Aerobic: Strep Staph HIB Moraxella Anaerobiv Arcanobarcterium hemolyticum bacteroides fusobacterium |
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What is another name for anaerobic pharyngitis?
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Vincent's angina
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When do the centor criteria not apply?
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-patients who are not immunocompetent
-patients with a history of rheumatic fever -outbreaks of GABHS or rheumatic fever -when the endemic rate of rheumatic fever is higher than in the USA |
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What is the treatment for Vincent's angina?
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Pen V or clindamycin
rinse with hydrogen peroxide |
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How should you treat recurrent or chronic pharyngitis?
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Clavulin
Clindamycin Pen V and metronidazole |
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Why do we treat GABHS with antibiotics
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Treatment within 9 days prevents rheumatic fever
The incidence of PSGN is unaffected by antibiotics decreased course of illness by 1 day decreased transmission after 24h of treatment |
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What are the life threatening complications of pharyngitis?
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Airway compromise
sleep apnea local and distal spread of infection deep neck abscesses necrotizing fassciitis bactremia sepsis death |
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What are suppurative complications of GABHS pharyngitis?
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Peritonsillar abscess
deep space abscesses suppurative cervical lymphadenopathy OM sinusitis mastoiditis bacteremia sepsis osteomyelitis empyema meningitis soft tissue infections |
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What are the non-suppurative complications of GABHS pharyngitis?
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scarlet fever
rheumatic rever non-rheumatic myocarditis PSGN erythema nododum Strep TSS |
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What pathogens cause epiglottitis?
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HIB
respiratory viruses strep and staph may cause an epiglottic abscess |
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What is the epidemiology of epiglottitis?
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No age or seasonal prevalence
Males and smokers are more commonly affected |
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What is the antibiotic treatment for epiglottitis?
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1st line: cefotaxime or ceftriaxone
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What is the differential for epiglottitis?
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pharyngitis
mononucleosis lingual tonsillitis deep space abscess diphtheria pertussis croup toxic inhalation angioedema |
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What is the management of adult epiglottitis?
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Airway
-sitting position -most patients do not need intubation -optimal method for intubation -> awake fiberoptic Antibiotics -> ceftriaxone or cefotaxime The role of epi and steroids is unresolved Disposition: stable patients >24 hrs post onset of symptoms, who can handle their secretions -> observe in the ED High risk patients rapidly progressive course immunocompromise DM epiglottic abscess significant enlargement |
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What is the name of a submandibular space infection?
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Ludwig's angina
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What are the 5 potential communicating spaces in the neck that are clinically relevant?
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Peritonsillar
Parapharyngeal - contains the carotid, jugular and cervical sympathetic chain Retropharyngeal - base of the skull to mediastinum Danger - base of the skull to diaphragm Prevertebral |
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Abscesses in which neck spaces communicate with the mediastinum?
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retropharyngeal
danger prevertebral |
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What pathogens are involved in peritonsillar abscesses?
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polymicrobial infection
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What is the clinical presentation of PTA?
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-odynophagia
-dysphagia -trismus -drooling fever malaise dehydration |
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What causes Ludwig's angina?
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Dental disease
mandibular fracture tongue piercing traumatic intubation FB or laceration in the floor of the mouth PTA |
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What is the clinical presentation of RPA?
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sore throat
dysphagia odynophagia drooling muffled voice neck stiffness dysphonia |
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What are PE findings of RPA?
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supine position with neck extended
tender cervical lymphadenopathy tender cervical musculature neck swelling torticolis trismus |
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What is the role of lateral soft tissue neck films in the diagnosis of RPA?
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True lateral films are the most reliable but not sufficiently sensitive. Need CT or MRI to r/o
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What is the treatment of RPA?
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Cellulitis: high dose IV antibiotics (same as PTA)
Abscess: I and D and antibiotics |
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What is the antibiotic treatment of PTA or RPA?
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High dose PNC and metronidazole
Cefoxitin Ampi-sulbactam Clindamycin |
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Name the paranasal sinuses?
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Frontal
Maxillary Ethmoid Sphenoid |
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What pathogens cause acute bacterial sinusitis?
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S pneumonia
HIB M catarrhalis P aeruginosa in HIV and CF |
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What pathogens cause chronic sinusitis?
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anaerobic bacteria
Strep species fungi |
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What pathogens cause sinusitis in immunocompromised patients?
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Rhizopus
Aspergillus Candida Histoplasma Blastomyces coccidioides crytococcus |
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What suggests a bacterial sinusitis?
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Worsening symptoms
Persistent symptoms (after 10 days) double-sick More severe or extrasinus manifestations |
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What is mucormycosis?
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invasive fungal sinusitis
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Which patients should have imaging of their sinuses?
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questionable diagnosis
unresponsive disease investigation of complications chronic or recurrent acute sinusitis |
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What are potential complications of rhino sinusitis?
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facial cellulitis
periorbital cellulitis optic neuritis blindness orbital abscess meningitis cavernous sinus thrombosis brain abscess |
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What is the difference between the mortality from pneumonia in the outpatient setting versus pneumonia requiring admission?
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Outpatient <1%
Inpatient 15% |
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Given the usually sterile environment of the lungs, what is required for the development of clinical pneumonia?
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Defect in host defence mechanism
Presence of a particularly virulent organism Introduction of a large inoculum of organisms |
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How do host defenses of the respiratory tract become compromised?
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Altered LOC
Interventions bypass the upper respiratory tract defences: orotracheal, nasogastric tubes Cigarette smoking damages the mucociliary function viral infections damage the resp epithelium increasing age and decline of mucociliary clearance immunocompromise and HIV |
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Can the diagnosis of pneumonia be made based on clinical findings?
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All rigorous definitions of pneumonia require the finding of pulmonary infiltrate on a chest radiograph
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List indications for CXR in suspected lower respiratory infection?
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Fever
Tachycardia Oxygen desaturation Abnormal lung examination |
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What bacteria area associated with lung abscess?
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anaerobes
aerobic gram negative bacilli S aureus |
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What should you think of with an infiltrate in the presence of hilar adenopathy?
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TB
Fungal disease Malignancy |
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What are noninfectious inflammatory lung processes in the differential for pneumonia?
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mineral dusts (silicosis)
chemical fumes (chlorine, ammonia) toxic drugs (bleomycin) immunologic diseases (sarcoidosis, Goodpasture's) hypersensitivity to environmental agents tumors |
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What are agents that cause typical pneumonia?
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strep pneumo
HIB |
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What agents cause atypical pneumonia?
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mycoplasma
chlamydia viral legionella |
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What are RF for s pneumo pneumonia?
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Think immunocompromise
DM CV disease Alcoholism SCD Splenectomy Malignancy Immunosuppression |
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What is the classic presentation of pneumococcal pneumonia?
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Abrupt onset single shaking chill
fever cough productive of rush colored sputum pleuritic chest pain |
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What is a common risk factor for staph aureus pneumonia?
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IVDU
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What are risk factors for klebsiella pneumonia and what is the classic description of the sputum?
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Alcoholism
DM Chronic illness Currant jelly sputum |
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What is the reservoir for legionella pneumonia?
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aquatic environments
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What is the presentation of Legionnaire's disease?
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Severe systemic illness
Dry cough Pleuritic chest pain Prominent GI symptoms |
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What anaerobic organisms can contribute to pneumonias?
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Bacteroides
Peptostreptococcus Fusobacterium Prevotella |
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What clinical RF suggest anaerobic lung infection?
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Risk factors for aspiration (CNS depression, swallowing dysfunction)
Periodontal disease fetid sputum Pulmonary abscess Empyema |
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When are antibiotics indicated for aspiration pneumonitis?
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New fever
Expanding infiltrate >36 hours after aspiration Unexplained deterioration |
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What is the definition of aspiration pneumonia?
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the development of a radiographically evident infiltrate in patients who are at increased risk for oropharyngeal aspiration
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What are the common sites of aspiration pneumonia?
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In a patient who aspirates in the recumbent position it is the posterior segments of the upper lobes and the apical segments of the lower lobes
In a patient who aspirates in the upright or semi-recumbant positing it is in the basal segments of the lower lobes. |
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What is the most common opportunistic infection in AIDS patients?
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Respiratory
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What pathogens cause respiratory infections at increased rates in patients with AIDS?
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PCP
M tuberculosis S pneumonia H influenza Mycobacterium avium complex CMV Aerobic gram negative bacilli Cryptococcus neoformans Rhodococcus equi |
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What peripheral lymphocyte count is associated with a CD4<200?
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<1000/mm3
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What is the clinical presentation of PCP pneumonia?
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Usually subacute
Nonproductive cough, exertional dyspnea and weight loss |
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What is the classic radiographic finding in PCP pneumonia?
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Bilateral interstitial infiltrates beginning in the perihilar region
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What lab value when elevated should increase the suspicion of PCP pneumonia?
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LDH
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List treatment options for PCP pneumonia
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Trimethoprim-sulfamethoxasole
Pentamidine Clindamycin |
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List indications for steroids in PCP?
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PaO2<70
Aa-gradient >35mmHg |
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What are risk factors for the reactivation of TB?
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DM
Renal failure Immunosuppressive therapy Malnutrition AIDS |
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What causes Q fever?
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Coxiella burnetii
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What are risk factors for Q fever?
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Occupational exposure to cattle or sheep or cats
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What is the presentation of Q fever?
|
Fever
severe headache pneumonia |
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What zoonotic pneumonia is associated with exposure to horses?
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Rhodococcus
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What zoonotic pneumonia is associated with exporue to ill dogs?
|
Bordetella bronchiseptica
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What is the clinical presentation of hantavirus?
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-several day prodrome of fever, myalgia, malaise
-respiratory distress and hypoxia |
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What is the bug and animal source of tularaemia?
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francisella tularensis
rabbits |
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What is the bug and animal in psittacosis?
|
chlamydia psittaci
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list antibiotics used for pseudomonal pneumonia?
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Cefipime
imipenem meropenem pip-tazo high ciprofloxacin aminoglycoside and macrolide |
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What are outpatients therapies for CAP?
(<60, otherwise healthy, therefore atypical pathogens) |
Erythromycin
Doxycycline Clarithromycin Azithromycin Respiratory fluroquinolone |
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What are outpatient therapies for CAP in (patients >60 or with co-morbidities)?
|
Second or third cephalosporin
amoxicillin-clavulanate + macrolide Respiratory fluoroquinolone |
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What is inpatient treatment CAP?
|
B lactam (ceftriazone, cefotaxime, ertapenem) + macrolide
Respiratory fluoroquinolone Aziothromycin alone |
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What is the treatment of suspected aspiration?
|
Pip-tazo
ticarcillin-clavulanate |
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What is the treatment for severe pneumonia?
|
cefotaxime
ceftriaxone cefepime |
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What is the treatment for pneumonia with neutropenia, bronchiectasis or recent hospitalization?
|
anti-pseudomonal beta lactam (cefepime, piperacillin, imipenem) and ciprofloxacin
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What can be used to predict mortality in CAP?
|
CURB-65
C - confusion U - urea >7mmol/L R - respiratory rate >30breaths/min B - blood pressure less than 90mmHg or diastolic <60mmHg Age 65 or older |
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How is the PORT score useful?
|
It predicts the mortality of pneumonia
Class I-III require no hospitalization Class IV and V should be hospitalized |
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What is the Berlin definition of ARDS?
|
-Within one week of known clinical insult
-bilateral opacities not fully explained by effusions, lobar collapse or nodules -respiratory failure not fully explained by cardiac failure or fluid overload. Need objective assessment (echo) to exclude hydrostatic edema oxygenation -mild 200mmHg <PaO2/FiO2 < 300mmHg with PEEP >/=5cmH20 -moderate 100mmHg <PaO2/FiO2 <200mmHg with PEEP >/=5cmH20 -severe PaO2/fiO2 <100mmHg with PEEP >/= 5cmH2O |
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What are conditions associated with ARDS?
|
Sepsis
Shock Toxic gas or smoke inhalation Aspiration pneumonia Drug reactions trauma burns transfusion reaction radiation injury fat embolism |
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What are treatments for ARDS?
|
High inspiratory pressure
PEEP Keep Peak airway pressures at less than 35cmH2O reduce tidal volumes allowing permissive hypercapnia ? inverse-ratio ventilation with prolonged inspiratory time high-frequency oscillatory ventilator prone position inhaled NO, NAC, PGE, ketoconazole and NSAID |
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Define primary pneumothorax
|
occurs in individuals without clinically apparent lung disease
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Define secondary pneumothorax
|
Occurs in the context of an underlying pulmonary disease process
|
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What are risk factors associated with primary spontaneous pneumothorax?
|
Cigarette smoking
Changes in ambient atmospheric pressure Family history Mitral valve prolapse Marfan's syndrome Typically occurs in healthy young men of taller than average height |
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What pulmonary disease processes are associated with secondary spontaneous PTX?
|
airway disease
COPD asthma CF Infections Necrotizing bacterial pneumonia lung abscess PCP TB Interstitial disease Sarcoidosis Idiopathic pulmonary fibrosis lymphangiomyomatosis tuberous sclerosis pneumoconioses Neoplasms Primary lung cancers Pulmonary/pleural mets Pulmonary infarction Endometriosis/Catamenial PTX |
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|
How do you assess for PTX with bedside US?
|
Over the upper anterior chest wall in the midclavicular line and proceeds inferolaterally toward the anterior axillary line. Once the pleural line is identified, the presence of lung sliding during respiration effectively rules out a PTX in the area being scanned
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|
What is the management of primary spontaneous PTX?
|
<20% -observe for 6 hours, repeat CXR to document no increase in size, fu in 24 hours, avoid air travel and underwater diving
>20% aspirate with an IV catheter vs chest tube |
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What is the management of secondary spontaneous PTX?
|
Chest tube with drainage through a water seal device or heilich valve
Suction with pressure of 20cmH2O only if no re-expansion after 24-48 hours Usually resolves within 7 days If air leak persists for >4-7 days then surgery is required |
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|
What is the recurrence rate of spontaneous PTX?
|
Primary - 1 in3
Secondary 39-47% |
|
|
What are causes of exudates?
|
Bacterial pneumonia
Bronchiectasis lung abscess TB Viral illness Primary lung CA mesothelioma pulmonary/pleural metastases lymphoma RA SLE Pancreatitis Subphrenic abscess Esophageal rupture Abdominal surgery Chylothorax Drug reactions Pulmonary infarction Uremia |
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|
What causes a pleural exudate with pH<7.3
|
parapneumonic effusion
malignancy rheumatoid TB systemic acidosis |
|
|
What causes a pleural exudate with pH<7.0
|
empyema
esophageal rupture |
|
|
What causes elevated pleural amylase?
|
pancreatitis
esophageal rupture |
|
|
What is the management of a pleural effusion?
|
diagnostic and therapeutic thoracentesis
Tube thoracostomy for hemothorax, empyema loculation -> streptokinase or urokinase injected by interventional radiologist Empyema that is not drainable -> thoracic surgery (decortication) |
