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178 Cards in this Set
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In pneumonia The microbes gain access to the respiratory tract by 1 of 3 ways.
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1. Small volume aspiration from the oropharynx
2. Inhaled in droplets 3. From Hematogenous spread (rarely) Spread from a infected pleural or mediastinal space (rarely) |
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What phase/pathophysiology of this is of pneumonia?
-composed of proteinaceous exudate and bacteria. |
1st Initial phase
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What phase/pathophysiology of this is of pneumonia?
-exudate with the addition of erythrocytes and neutrophils with the occasional bacteria |
2nd Red Hepatization;
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What phase/pathophysiology of this is of pneumonia?
-predominantly neutrophils and fibrin. The erythrocytes have been lysed and the bacteria are usually absent. |
3rd Gray Hepatization;
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What phase/pathophysiology of this is of pneumonia?
-macrophages are the predominant cell type with an absence of bacteria and other inflammatory products. |
Resolution;
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Diagnosis?
fever Tachycardia Chills or sweats Cough productive or nonproductive. Dyspnea GI symptoms of Nausea, Vomiting, or Diarrhea may also have fatigue, headache, myalgias, and or arthralgias, body aches |
Pneumonia
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What test do you order fot pneumonia?
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WBC-sepsis?
CBC x-ray |
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How do you classify the severity of pneumonia patient.
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The Pneumonia Severity Index (PSI), and the CURB-65
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WHom do you admit to the hospital ?
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young/old- both immunocomprimised,
repiratory shock patients |
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What are the criterias for Curb-65?
What do you use it for? |
Eval severity of pneumonia patients.
Confusion = 1 point Urea, BUN > 19 = 1 point Respiratory rate >30 = 1 point Blood Pressure < 90/60 = 1 point > 65 years of age = 1 point with a score of 2 the 30 day mortality is 9.2% and they should be admitted. Patients with a score of 3 or greater have a mortality rate of 22%. |
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What is the CURB-65 rate for this patient?
45 years old male with a BP is 80/50 RR 34 Urea, BUN 18 No confusion |
2 due to BP and and RR
9.2% of mortality Sever pneumonia Criteria: Confusion = 1 point Urea, BUN > 19 = 1 point Respiratory rate >30 = 1 point Blood Pressure < 90/60 = 1 point > 65 years of age = 1 point with a score of 2 the 30 day mortality is 9.2% and they should be admitted. Patients with a score of 3 or greater have a mortality rate of 22%. |
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What is the CURB-65 rate for this patient?
67 year old male presenting to the ER with confusion, pnemunia, BP 100/80, RR 32, Urea, BUN is 21 |
4 22% mortality
Age is high, confused, BUN is high, respiratory rate is high. Sever pneumonia Normal criteria: Confusion = 1 point Urea, BUN > 19 = 1 point Respiratory rate >30 = 1 point Blood Pressure < 90/60 = 1 point > 65 years of age = 1 point with a score of 2 the 30 day mortality is 9.2% and they should be admitted. Patients with a score of 3 or greater have a mortality rate of 22%. |
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What is Yonts severity index?
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Hypoxic?
Signs of systemic infection? Comorbidities? History? |
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Test to get for pneumonia
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1. CBC
2. Urine test: for Strep. pneumoniae and Legionella are available and have a high sensitivity and specificity. 3. x-ray |
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Birth to 1 months
pneumonia etilogies and TX inpatient/putpatient |
Group B strep, listeria, coliforms, Staph aureus, Pseudomonas, Viruses; CMV, Rubella, Herpes Simplex.
OUtpatinet N/a INpatient: Ampicillin + Gentamicin |
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Pneumonia etilogies, TX out/inpatient for:
1-3 months |
C. trachomatis, RSV, parainfluenza, Bordetella, S. pneumoniae
OUtpatient: Erythromicin or Azithromicin Inpatient: Azithromicin, Cefotaxime if febrile |
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Pneumonia etilogies, TX out/inpatient for:
4 months- 5 years |
S. pneumonia, H. flu, mycoplasma, S. aureus
Outpatient: Amoxicillin Inpatient: Cefotaxime + Azithromicin |
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Pneumonia etilogies, TX out/inpatient for:
5 years-15 years |
Mycoplasma, Chlamydophila pneumonia, S. pneumonia, Mycobacterium tuberculosis
OUTpatient: Amoxicillin + Clarithromicin or Azithromicin Inpatient: Ceftriaxone + Azithromicin |
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Pneumonia etilogies, TX out/inpatient for:
Adult CAP |
Streptococcus pneumonia, Haemophilus influenza, Staphyloccous aureus
Outpatinet: Azithromicin or Resp Floroquinolone Inpatient: Ceftriaxone + Azithromicin or Resp Floroquinolone |
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Community Acquired Pneumonia (CAP)
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An infection that a patient acquires in the community or any setting other than a health care setting.
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Health Care Associated Pneumonia (HCAP)
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An infection that occurs when patients are exposed to organisms different from those in the community because of the patient’s interaction with healthcare facilities.
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Hospital Acquired Pneumonia (HAP?
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A parenchymal infection that a patient contracts after being hospitalized.
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Ventilator Associated Pneumonia (VAP)
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A parenchymal infection that a patient contracts after being placed on a ventilator
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Aspiration Pneumonia;
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An infection that occurs after the patient aspirates stomach contents in the respiratory system.
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Pneumonia in the Cystic Fibrosis patient
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A different infection secondary to the environment of the CF lung. The amount of infections and the organisms differ from CAP.
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Pneumonia in HIV patients
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differ in the fact that the immune systems inhibits fighting the infections and the list of organisms can be different from the immunocompetent patient.
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MOst common organisms of CAP?
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MOst common form
There are two types of CAP, typical and atypical Streptococcus pneumonia, Haemophilus influenza, Staphyloccous aureus, Klebsiella pneumonia, Pseudomonas aeruginosa. |
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What is the most common pneumonia in cystic fibrosis patients?
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Pseudomonas aeruginosa.
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MOst common ATYPICAL organisms of CAP?
Why are they atypical? |
"walking pneumonia"
Mycoplasma pneumoniae, Chlamydophila (formerly Chlamydia) pneumoniae, Chlamydophila psittaci, Legionella pneumophila, Francisella tularensis, and Coxiella burnetii. Atypicals are intrinsically resistant to B-lactam agents. May present atypically, and sometimes referred to as walking pneumonia. Can also be caused by viruses, fungi, and protozoans. |
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Risk Factors for CAP?
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Alcoholism
Asthma Immunosuppression insitiutionalization > 70 years of age |
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Treatment for adult CAP out/inpatient?
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Uncomplicated outpatients can be treated with macrolides in one drug management like Azithromycin. Recent antibiotic usage might require the usage of a respiratory flouroquinolone like Levaquin or Avelox.
INpatinet: Uncomplicated inpatient treatments can include Ceftriaxone + Azithromycin or a respiratory flouroquinolone. |
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Health Care Associated Pneumonia (HCAP)
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A new class of pneumonias that represents patients with co-morbid diseases being exposed to resistant bacteria.
Resistant microbes are becoming more common. Methicillin resistant Staph. aureus (MRSA) is becoming more and more common. Exposure to health care facilities increase the chances the someone will be exposed to unique virulent microbes like pseudomonas |
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Qualifications of a HCAP
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1. Patients with intravenous therapy, wound care, or intravenous chemotherapy within the last 30 days.
2. living in long-term care facility or nursing home. 3. Hospitalized for 2 or more days in the past 90 days. 4. Has attended hospital or hemodialysis clinic within the previous 30 days. |
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what organism?
An opportunistic microbe that loves warm and moist environments. It thrives in situations where catheters and endotracheal tubes are used. |
Pseudomonas
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Pseudomonas TX
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Pulmonary Infections require double gram negative antibiotic coverage (two different classes of antibiotics that cover gram negatives used at the same time like fluoroquinolones and aminoglycosides)
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A strain of Staphylococcus aureus that is resistant to the beta-lactam class of antibiotics. They are becoming difficult to treat.
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MRSA
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MRSA TX
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MRSA pneumonias are covered/treated with Linezolid or Vancomycin
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MRSA resistant to what class of antibiotics?
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beta-lactam
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DOUBLE gm - coverage treatments.
Drug choices 1 & 2. |
1st drug choice being a antipseudomonal cephalosporin (Cefepime, or Ceftazidime) or an antipseudomonal carbapenems (Imipenem, or Meopenem) or beta-lactam/beta-lactamase inhibitor (Piperacillin/Tazobactum) zosyn
2nd drug choice being a Flouroquinolone (Ciprofloxacin or Levofloxicin) or aminoglycoside (Amikacin, Gentamicin, or Tobramycin) |
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What happens if you push the vancomycin too fast
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Red man syndrome.
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Hospital Associated Pneumonia (HAP) happens when?
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Hospital acquired pneumonia is a pneumonia that occurs 48 hours after admission to the hospital
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Ventilator Associated Pneumonia (VAP) TX
what microbes don't need to cover in TX? |
Don't cover anaerobes.
Presentation is most commonly fever and infiltrates on CXR. Cultures may be easier to obtain secondary to possibility of bronchoscopy. Empiric coverage includes Carbapenem or Zosyn + Flouroquinolone or aminoglycoside. |
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Aspiration Pneumonia
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Aspiration is an accidental movement of gastric contents in the respiratory tract.
Occurs commonly when patients are obtunded or have loss control of the swallowing mechanism. Aspiration places anaerobic bacterial in the respiratory tract. This can cause a pneumonia by unusual culprits. Aspiration pneumonia is one of the most deadly complications from stroke. |
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What pneumonia is one of the most deadly complications from stroke.
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aspiration pneumonia
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Stroke cause what kind of deadly pneumonia complication?
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Aspiration pneumonia
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Aspiration pneumonia organisms and TX
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Common bacteria; Anaerobes 34%,
Gram Positive Cocci 26%, S. milleri 16%, Klebsella pneumonia 25%, and Nocardia 3% Antibiotic coverage is primarily with Zosyn (Piperacillin + Tazobactum), alternatives are Clindamycin, and Ceftriaxone + Metformin. |
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Pneumonias in Cystic Fibrosis, microorganism, TX
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Common agents early in disease is
Staphylococcus aureus, and haemophilus influenza. Pseudomonas aeruginosa is more common later in the disease. Sputum for culture is usually abundant. Treatment involves coverage with two drugs that cover pseudomonas if pseudomonas is the culprit. Staph can be covered oxacillin or nafcillin for MSSA- Methicillin-sensitive Staphylococcus aureus- or vancomycin for MRSA. |
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Pneumonias in HIV patients,
most common pathogen and TX |
Most common pathogen is Pneumocystis carinii. Patients generally present with progressive shortness of breath and diffuse infiltrate.
Drug of choice for PCP is TMP-SMX (Bactrim) Other agents include Mycobacterium tuberculosis, diverse fungi. Pateints may also have Kaposi’s Sarcoma or lymphoma. Induced sputum or bronchial wash may guide therapy. |
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PE with pneumonia
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General evaluation of the patient, (very ill, respiratory distress)
Vitals; tachycardia, tachypnia, hypotension, fever, hypoxia Respiratory; rales or crackles in area of infiltrate, decreased breath sounds, Osteopathic; facilitation in T1-T6, AGRs, evaluate rib mechanics and vertebral dysfunctions. |
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Treatment for pneumonia, general considerations
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Primary goal is to normalize the patient’s mechanics.
Treat the sequence of areas of greatest restriction. Do your best to normalize the patient’s thoracic region. A somatic dysfunction in the rib cage could cause restrictive pulmonary mechanics. Normalizing the mechanics could significantly reduce the patients distress and potential save the patient’s life. The treatments may need to be modified to treat the patient as they are lying flat. |
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What is incentive spirometry?
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Incentive spirometry is a great tool to help the patient get better. The amount of exudate and secretions in the parenchyma alter diffusion and increase surface tension in the alveolus. Surfactant is a natural liquid covering in the alveolus to keep the alveolus open and distended.
The excess exudate and bi-products overwhelm the surfactant and collapses the alveolus. The collapsed alveolus becomes a pocket of infection almost like an abscess. It also reduces O2 and CO2 diffusion. The small popping open of the alveolus during respiration makes the audible rales during auscultation. Incentive spirometry encourages patient to take an excessive amount of air into the lungs and pop open the alveoli. A correct technique almost always produces a cough and some sputum production. The more compliant the patient the sooner they become free from need of supplemental oxygen. |
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What is the most common Lower respiratory tract infections?
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pneumonia
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The most common acute illness seen in primary care
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common cold
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Most of the URI infections are viral or bacterial in etiology?
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viral
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Which URI virus is most common in the spring and summer?
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rhinoviruses
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How can you tell by pt's symptomes if it is viral or bacterial in nature?
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if more than 1 system is affected, than viral
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What disease?
Sneezing Rhinnorrhea Nasal congestion Hyposmia/Anosmia Facial Pressure Post nasal drip Sore throat cough Ear fullness Fever Myalgia |
common cold
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How do URI's microorganisms transfered?
Who are at risk? |
URIs are transmitted by hand contact with infected persons, breathing small particles that linger in the air, and by breathing large particles directly from an infected person.
Those at risk those with underlying chronic disease, congenital immunodeficiency disorders, malnutrition, and those that smoke cigarettes. |
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Somatic dysfunction of the upper thoracic spine may result...
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result in vasospasm and thick secretions. The parasympathetic innervation results in thin watery secretions. Inhibition or excitation of this process can alter the body’s natural defenses.
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TX of URI
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at symptomatic relief and the normalization of the host that will allow the patient’s natural defenses and help the patient get better.
Osteopathic treatments should be focused at normalizing the structures of head with cranial lympahtics neck tissues thoracic inlet thoracic/lymphatic pump autonomic flow Some procedures or treatment types are Suboccipital myofascial release Trigeminal nerve procedures Anterior neck soft tissue procedures Thoracic lymphatic pump |
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What disease?
Hyposmia Nasal congestion/drainage Postnasal drip Fever Cough Fatigue Dental pain Ear fullness/pressure |
Sinusitis
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Ear fullness/pressure
with sinusitis associated with what somatic dysfunction? |
C1
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what disease?
facial pain/pressure nasal obstruction nasal discharge hyposmia/anosmia fever HA halitosis fatigue dental pain cough ear pain |
Acute rhinositis- fever
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what disease?
facial pain/pressure nasal obstruction nasal discharge hyposmia/anosmia no fever HA halitosis fatigue dental pain cough ear pain |
chronic rhynositis- no fever
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pathophys of sinusitis
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Obstruction of sinus drainage pathways that prevents normal drainage and causes hypoxia within sinus causes ciliary dysfunction and alterations in mucous production.
Ciliary impairment which is unable to move waste and infectious bi-products out of sinuses. Mucous quantity/quality |
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Major and minor sympthomes with rhinosinusitis
When is it qualify to sinusitis? |
2 or more major signs or
1 major and 2 or more minor or nasal purulence on exam Major: facial pain/pressure nasal obstruction nasal discharge hyposmia/anosmia fever (in acute) Minor: HA fatigue halitosis fever (in acute) dental pain cough ear pain/pressure |
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Acute vs Chronis vs Subacute vs Recurrent rhinosinusitis: time vs sympthomes
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Acute: up to 4 weeks with fever
Chronic: no fever, 12 weeks or more Subacute: 4-12 weeks, complete resolution after medica; theraphy Recurrent: 4 or more episodes in a year, with each episode at least 7 days in duration. |
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Sinusitis Treatment
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Often is Amoxicillin first line. Alternatives to amoxicillin are Bactrim or TMP/SMX, and erythromycin. If there is poor response or of the patient has chronic sinusitis the better antibiotic choice may be Amoxicillin plus clavulanate (Augmentin), or one of the 3rd generation cephalosporins or one of the respiratory flouroquinolones.
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When can't you give Bactrim to patient with sinusitis?
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Sulfur allergy
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What is the diagnosis?
Inflammation of the nasal mucosa. It is often just a presenting symptom of the common cold |
Rhinitis
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What disease?
nasal mucosa is pale and boggy instead of red and swollen with an infection. |
allergic rhinitis
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What disease?
primarily rhinorrhea, sneezing and pruritis and congestion. The patient may also have facial pressure or pain with altered sense of smell and post nasal drainage. The patient can also have a sore throat, tearing and burning of eyes, malaise, and cough. |
rhinitis
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Causes for Viral Pharyngitis and TX
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Rhinoviruses
Coronaviruses Adenoviruses Herpes Simplex (HSV) Parainfluenza Influenza EBV HIV TX; self limiting |
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Causes of Bacterial Pharyngitis
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Group A Strep (Streptococcus pyogenes)
Group C Strep Neisseria gonnorrhea Corynebacterium diphtheriae Mycoplasma pneumoniae Chlamydophila pneumoniae Archanobacterium haemolyticum Fusobacterium necrophorum |
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What disease?
Tonsillar edema and erythema Tonsillar exudates Anterior cervical lymphadenopathy Fever or history of fever Absence of cough |
of Bacterial Pharyngitis
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TX for bacterial pharyngitis
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Antibiotic management should be narrow spectrum and broad spectrum antibiotics should be avoided if possible.
Penicillin G and VK Amoxicillin For Penicillin allergies Clindamycin Azithromycin (Broad) |
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What included in the strep value diagram?
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fever
absence of cough tender anterior cervical nodes tonsillar exudates age<15 (age 15-45 is a 0) (age>45 is -1) treat 2-3 + |
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Complications from strep
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Acute Rheumatic Fever
Necrotizing Fascitis PANDAS Scarlet Fever Strep TSS Acute Glomerulonephritis Otitis Media Peritonsilar abscess |
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What disease?
fatigue malaise loss of apetite photophobia swollen tonsils white pathches in mouth and on tonsils lymph node swelling enlargement of spleen abdominal pain chills fever aches throat soreness and redness cough |
Infectious mononucleosis
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Lab eval for mononucleosis
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1. Rapid Mono Spot (react with horse blood will be hetero +) If hetero - it is due to CMV
2. Complete Blood Count CBC 3. Epstein-Barr titers |
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Most common cause of mononucleosis
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Epstein-Barr virus (hetro +)
CMV can cause it also it will be hetero -. |
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Eptein Barr Titers
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incubation period: 1st months-IgM
acute illness IgM and mainly IgG after 1st month-2 months Convalescence IgG EA-R/D and EBNA 2-6 months |
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Causes of viral parotitis
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Mumps
HIV EBV CMV Coxsackie A |
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What disease?
Fever Malaise Headache Anorexia |
viral parotitis
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What disease?
High fevers Chills Toxic apperance Dyspahgia Trismus |
Bacterial Parotitis
Trismus: Spasm of the jaw muscles, causing the mouth to remain tightly closed, typically as a symptom of tetanus |
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causes of horseness
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Acute laryngitis, which is self-limited and related to acute respiratory illness or acute voice misuse
Chronic laryngitis, which is related to irritants, reflux, chronic infection (such as fungal), or habitual vocal misuse Benign vocal fold lesions Malignancy Neurologic dysfunction Non-organic ("functional") issues Systemic conditions and rare causes more than 2 weeks of horseness needs a complete otolaryngolic eval |
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Causes of Epiglotitis and features? Age, and Tx
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mainly-Haemophilus influenzae type b
Penicillin-resistant Streptococcus pneumoniae Beta-hemolytic streptococci Staphylococcus aureus, including community-acquired methicillin-resistant S. aureus (MRSA) strains Airway management (Indications) Young age, particularly those <4 to 6 years old Severe respiratory distress Epiglottic abscess. Rapid onset and progression of symptoms. >50 percent obstruction of laryngeal lumen. Comorbid diabetes or immune deficiency (Indications) Antibiotics (3rd generation cephalosporin, and MRSA coverage like Vancomycin or Clindamycin) Other (Racemic Epinephrine) |
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What disease?
Cough Dyspnea (Shortness of Breath) Sputum (often Mucopurulent) Fever Pleuritic chest Pain Nausea Vomiting Diarrhea Mental Status Changes |
CAP: occur in any age group
Cough Dyspnea (Shortness of Breath) Sputum (often Mucopurulent) Fever Pleuritic chest Pain GI (nausea, vomiting, and Diarrhea) Mental Status Changes Tachypnea Tachycardia Respiratory distress Rales Crackles Decreased breath sounds Dullness to percussion Chest X ray infiltrate |
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Symptoms of CAP?
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Cough
Dyspnea (Shortness of Breath) Sputum (often Mucopurulent) Fever Pleuritic chest Pain GI (nausea, vomiting, and Diarrhea) Mental Status Changes Tachypnea Tachycardia Respiratory distress Rales Crackles Decreased breath sounds Dullness to percussion Chest X ray infiltrate |
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What is the typical representation of CAP on CXR?
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“lobar consolidation” is considered the typical manifestation of a CAP.
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What are the 2 diff types of pneumonias by classification?
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The two classes are
bronchopneumonias or lobar pneumonias. |
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What is widespread consolidation of large
areas and whole lobes of the lungs? |
lobar pneumonia
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what is small loci of
consolidated areas about 3 to 4 cm in diameter? |
bronchopneumonia
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What are the stages of Inflammation in Lobar Pneumonia
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Initial phase; composed of proteinaceous exudate and bacteria.
Red Hepatization; exudate with the addition of erythrocytes and neutrophils with the occasional bacteria Gray Hepatization; predominantly neutrophils and fibrin. The erythrocytes have been lysed and the bacteria are usually absent. Resolution; macrophages are the predominant cell type with an absence of bacteria and other inflammatory products. |
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The management of Community acquired pneumonias
is divided into what? |
into inpatient versus outpatient
management. There is often a dilemma in the determination of what the constitutes the requirements of admission to the hospital. If a patient is requiring supplemental oxygen then they should be admitted to receive it. |
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Most common causing organism of CAP?
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Streptococcus pneumonae
others: Haemophilus influenzae •Moraxella catarrhalis •Staphylococcus aureus •Legionella pneumophila •Enterobacteriaceae (Klebsiella pneumoniae) •Pseudomonas spp. |
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TX of CAP with
1. Outpatient Antibiotic Treatment without recent antibiotic use or co-morbid conditions for CAP. 2. Outpatient Antibiotic Treatment with recent exposure to antibiotics like beta-lactams, or macrolides for CAP 3. Inpatient Antibiotic Treatment for CAP |
1. Azithromycin (500 mg on day one followed by four days of 250 mg a day
Clarithromycin XL (two 500 mg tablets once daily) for five days Doxycycline (100 mg twice a day) for seven to 10 days 2. A respiratory fluoroquinolone like levofloxacin 750 mg daily, or moxifloxacin!400 mg daily) for a minimum of five days. 3. Combination therapy with ceftriaxone (1 to 2 g IV daily) or cefotaxime (1 to 2 g IV every 8 hours) plus azithromycin (500 mg IV or orally daily).Monotherapy with a respiratory fluoroquinolone given either IV or orally |
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Prevention of respiratory infections,
vaccination criteria |
PPV23 vaccine
Persons Aged greater than or equal to 65 Years • Persons Aged 2-64 Years Who Have Chronic Illness(e.g., congestive heart failure {CHF} or cardiomyopathies, COPD or emphysema, but not asthma, diabetes mellitus, alcoholism, chronic liver disease (cirrhosis), or CSF leaks.) • Persons Aged 2-64 Years Who Have Functional or Anatomic Asplenia • Persons Aged 2-64 Years Who Are Living in Special Environments or Social Settings • Immunocompromised Persons The recommendations for the influenza vaccine have changed to include everyone 6 months or older that are immunocompetent and have no direct contraindications to taking the influenza vaccine itself |
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How did the influenza vaccine remonnendation changed?
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to include everyone 6 months or older that
are immunocompetent and have no direct contraindications to taking the influenza vaccine itself |
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What is the 2010-2011 flu vaccine protect against?
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an H3N2 virus,
an influenza B virus and the H1N1 virus that caused so much illness last season. |
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What causes thick secretions in affected patients?
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Respiratory syncytial virus (RSV)
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HOw can you prevent RSV?
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monoclonal antibody called Palivizumab that is used to prevent infections. Palivizumab is only
recommended for the prevention, not treatment of RSV disease in the following populations: Infants and children younger than 2 years of age with chronic lung disease (CLD) who have required medical therapy (supplemental oxygen, bronchodilator, diuretic or corticosteroid therapy) for CLD within 6 months before the anticipated start of the RSV!season.! • Infants born at 32 weeks’ gestation or earlier—may benefit even if they do not have!CLD.! • Some infants between 32 and 35 weeks’ gestation may benefit when 2 or more of the following risk factors are present: child care attendance, school-aged siblings, exposure to environmental air pollutants, congenital abnormalities of the airways, or severe neuromuscular disease.! • Children who are 24 months or younger with hemodynamically significant congenital heart disease!(CHD).! • Other groups for which RSV prevention is sometimes considered are: ◦ Children with severe immunodeficiencies, such as severe combined immunodeficiency or severe acquired immunodeficiency!syndrome.! ◦ Children with cystic fibrosis. |
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Neonatal pnemonia types;
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Early and late onset
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define Early onset neonatal pnemonia:
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present with in 3 days of birth. It can occur by transplacental
transmission or by intrauterine aspiration. |
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define Late onset neonatal pnemonia:
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pneumonia that occurs after 3 days or after the infant has been taken home. It can be
caused by aspiration of amniotic fluid during or after birth. It can also be transmitted by exposure to pathogens. |
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Early onset neonatal pnemonia: transplacental
transmission or by intrauterine aspiration bugs |
Transplacental:
•Rubella •Cytomegalovirus •Herpes simplex virus •Adenovirus •Mumps virus •Toxoplasma gondii •Mycobacterium tuberculosis •Treponema pallidum •Listeria monocytogenes Intrauterine Aspiration of amniotic fluid: •Cytomegalovirus •Herpes simplex virus •Enteroviruses •Genital mycoplasma •Listeria monocytogenes •Chlamydia trachomatis •Mycobacterium tuberculosis •Group B streptococci •Escherichia coli •Haemophilus influenzae (nontypable) •Ureaplasma urealyticum |
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Late onset neonatal pnemonia:nosocomial vs apiration at delivery bugs
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Nosocomial:
•Staphylococcus aureus •Staphylococcus epidermidis •Group B streptococci •Klebsiella sp •Enterobacter •Pseudomonas •Bacillus cereus •Citrobacter diversus •Influenza virus •Respiratory synctial virus •Enteroviruses •Herpes virus •Candida sp •Aspergillus sp Aspiration: •Group B streptococci •Escherichia coli •Staphylococcus aureus •Klebsiella sp •Other streptococci •Haemophilus influenzae (nontypable) •Candida sp •Chlamydia tachomatis •Ureaplasma urealyticum |
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The most common cause of pneumonia in infants ...
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are viruses.
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afebrile pneumonia in infants can be caused by
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Chlamydia trachomatis, CMV, and Mycoplasma.
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most common cause of pneumonia is <5 yr
viral, bacterial- examples |
Viruses
The most common viruses are first RSV and then others like influenza and parainfluenza. Common bacterial agents that cause pneumonias in this age range are those like Streptococcus pneumoniae, Staphylococcus aureus, and Streptococcus pyogenes. |
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most common cause of pneumonia is >5 yr
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Strep pneumoniae. Mycoplasma pneuoniae, and Chlamydophila pneumoniae are also common causes
They have more of predisposition to have an atypical pneumonia. |
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Fever-high
•Headache •Tiredness (can be extreme) •Cough (usually dry in nature) •Sore throat •Runny or stuffy nose •Body aches •Diarrhea and vomiting |
influenza
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what is the incubation period for influenza?
When do you start to shed the virus? How long infection lasts in adults and in children? |
1-4 days
1 day before sympts starts adults: 5-10 days kids: 10 days |
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diagnosis of influenza
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made by combining the clinical picture with a rapid antigen test. Other
confirmatory tests are immunofluorescence (IF) assays, enzyme immunoassays (EIA), and reverse transcriptase-polymerase chain reaction (RT-PCR)-based testing. |
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The major cause of pandemic is
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influenza A virus contains hemagglutinin protein
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The major cause of epidemic
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oubreak of influenza A or B occurring in annual cycles
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Influenza A viruses infect
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humans, pigs, horses and birds.
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Antigenic drift
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Mutation of the hemagglutinin and neuraminidase in Influenza A causing yearly
seasonal flu. |
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Antigenic shift
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Recombination of RNA segments with those of animal viruses casuing
pandemics. |
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This influenza do not show antigenic shift of drift and infect mostly children who develop
antibodies preventing re-infection |
Influenza B and C
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Influenza viral pneumonia characterized by
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interstitial edema and inflammatory infiltrates,
diffuse alveolar damage with hyaline membranes, intra-alveolar edema and/or hemorrhage, capillary and small vessel thromboses. |
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Later stages of influenza show what?
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diffuse alveolar damage, fibrosis, epithelial regeneration and
squamous metaplasia. |
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The first line Treatment of Influenza and other Viral Pneumonias
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The first line treatment is one of the neuraminidase inhibitors zanamivir and oseltamivir. Both of these
medications work on type A and type B but only indicated for infections that started less than 48 hours at presentation The adamantanes, which are amantadine and rimantadine, are only active against influenza type A and are not recommended for use in the United States secondary to building resistance against these medications. Other viral infections are generally treated as bacterial pneumonias secondary to the fact that we are often not able to distinguish from viral or bacterial especially in the early phases |
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The spectrum of viral respiratory infections includes
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upper respiratory infections,
laryngotracheobronchitis, bronchiolitis, and pneumonia. |
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In viral URI’s
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the mucosa is swollen and red
with secretions infiltrates of lymphomonocytic and plasmacytic cells are present in the LOWER RESPIRATORY INFECTIONS LMU-DCOM Lower Respiratory Infections, Page 17 submucosa with excessive mucus production. |
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What disease?
vocal cord swelling, increased mucus production, impaired bronchociliary function (increasing risk of secondary bacterial infection), submucosal inflammatory cells. |
Laryngotracheobronchitis
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What disease?
plugging of airways with inflammatory exudate, fibrin , cellular debris. |
Bronchiolits
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The most common organism causing primary atypical pneumonia
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Mycoplasma pneumonia.
Other atypical bacteria such as Chlamydia pneumoniae and Coxiella brunetii (Q fever) in addition to numerous viruses may cause an interstitial pneumonia |
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What disease?
patchy lung involvement or lobar, bilateral or unilateral with the affected areas appearing blue-red and congested The alveolar septa are widened with edema and inflammatory cells consisting of lymphocytes, macrophages, plasma cells and sometimes neutrophils in acute cases. Sometimes there is a intraalveolar proteinaceous material and a cellular exudate. |
an atypical or interstitial pneumonia
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Risk Factors for Hospital Associated Pneumonia
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Hospital acquired pneumonia is a pneumonia that occurs 48 hours after admission to the hospital.
Age >70 years • Chronic lung disease • Depressed consciousness • Aspiration • Chest surgery • The presence of an intracranial pressure monitor or nasogastric tube • H2 blocker or antacid therapy • Transport from the ICU for diagnostic or therapeutic procedures • Previous antibiotic exposure, like 3rd generation cephalosporins • Reintubation or prolonged intubation • Hospitalization during the fall or winter season • Mechanical ventilation for acute respiratory distress syndrome • Frequent ventilator circuit changes • Paralytic agents • Underlying illness |
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The most significant risk factor for HAP
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intubation
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What drugs can increase the incidence of HAP and even CAP?
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acid reducing drugs like H2 blockers and PPIs
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What increase the risks for numerous vitamin deficiencies and increase different types of pneumonias.
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stress ulcer
prophylaxis |
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What is “double coverage” means?
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Pseudomonas
requires what is often called “double coverage” which is two drugs that work synergistically Antipseudomonal cephalosporin-(cefepime, ceftazidime) or Antipseudomonal carbepenem-(imipenem or meropenem) or beta-Lactam/beta-lactamase inhibitor-(piperacillin–tazobactam) + Antipseudomonal fluoroquinolone- (ciprofloxacin or levofloxacin) or Aminoglycoside (amikacin, gentamicin, or tobramycin) |
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Clinical presentation of Lung Abscesses
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•fatigue
•loss of appetite •sweating •fever •cough •foul smelling sputum often described as putrid •possible chest pain with inspiration |
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What disease?
•fatigue •loss of appetite •sweating •fever •cough •foul smelling sputum often described as putrid •possible chest pain with inspiration |
Clinical presentation of Lung Abscesses
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Common microbiology of lung abscesses are:
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Common causative organisms are S. aureus,
gm - Bacteroides species Fusobacterium species Proteus species Aerobacter species Escherichia coli gm+ Peptostreptococcus species Microaerophilic streptococcus Clostridium species Staphylococcus species Actinomyces species Opportunistic" Candida species Legionella species Mycobacterium species |
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Complications of lung abscesses
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include hemorrhage,
extension into the pleural space, septic emboli and secondary amyloidosis, a reactive systemic amyloidosis from chronic inflammatory conditions(rare). |
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Tx for lung abcess
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Anaerobic:
Clindamycin is usually the first line agent. Alternative - Penicillin Oral therapy - Clindamycin, metronidazole (Flagyl), amoxicillin (Amoxil) Gram-negative organisms First choices - Cephalosporins, aminoglycosides, quinolones Alternatives - Penicillins and cephalexin (Biocef) Oral therapy - Trimethoprim/sulfamethoxazole (Septra) Pseudomonal organisms: First choices include aminoglycosides, quinolones, and cephalosporin. Gram-positive organisms First choices - Oxacillin (Bactocill), clindamycin, cephalexin, nafcillin (Nafcil), and amoxicillin Alternatives - Cefuroxime (Ceftin) and clindamycin Oral therapy - Vancomycin (Lyphocin) Nocardial organisms: First choices include trimethoprim/sulfamethoxazole and tetracycline (Sumycin). |
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TX for Pneumocystis jirovecii (PCP)
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HIV patients
TMP-SMX (bactrim) |
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Infectious organism associated with CD4+ counts.
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CD4+ >200
! Bacterial and tuberculosis CD4+<200 ! Pneumocystis pneumonia (most common opportunistic infection in HIV) CD4+<50 ! Cytomegalovirus (CMV) ! Mycobacterium avium complex |
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Pneumonias in patients with CF are caused primarily by
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Pseudomonas.
Other agents that can cause respiratory infections in pateints with CF are Haemophilus influenzae, Staphylococcus aureus, and rare Mycobacterial species |
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What disease?
Sneezing •Rhinnorrhea •Nasal congestion •Hyposmia/Anosmia •Facial Pressure •Post nasal drip •Sore throat •cough •Ear fullness •Fever •Myalgia |
URTI
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The most common agents that cause of infection of the upper
respiratory system |
is viruses
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URIs are transmitted by
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hand contact with infected persons, breathing small particles that linger in the air, and by
breathing large particles directly from an infected person |
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The role of somatic dysfunction alters the body’s normal defense mechanisms by numerous ways.
List the main 2: |
deep tissue restriction decreasing lymphatic drainage and viscero-somatic reflexes altering
autonomic flow. |
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Somatic dysfunction of the upper thoracic spine may result in
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vasospasm and thick secretions.
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PNS in UTI result in?
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thin watery secretions.
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The cause of infection/bugs in the uncomplicated upper respiratory tract infection
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•Rhinoviruses
•Coronaviruses •Influenza A and B •Parainfluenza •Respiratory syncytial viruses •Adenoviruses •Enteroviruses |
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UTI TX
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Treatment should be focused at symptomatic relief and the normalization of the host that will allow the patient’s
natural defenses and help the patient get better. + OMM |
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OMM in UTI TX should focus on what?
TYpes? |
Osteopathic treatments should be focused at normalizing the structures
of the head with cranial. The next area of focused should be lymphatics and the tissues of the neck including the thoracic inlet with the thoracic/lymphatic pump should be normalized. The next area of focus would be autonomic flow. Some procedures or treatment types are •Suboccipital myofascial release •Trigeminal nerve procedures •Anterior neck soft tissue procedures •Thoracic lymphatic pump |
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what is primary cilliary
dyskinesia (PCD)? |
Kartagener’s syndrome
In PCD the cilia are immotile or dysfunctional. These individuals often have chronic cough, otitis, chronic sinus infections, and salpingitis. Nasal polyps are common in these individuals. People who have chronic respiratory infections with sinusitis, and otitis are suspects for having PCD. |
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What is Kartagener’s syndrome?
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primary cilliary
dyskinesia (PCD) In PCD the cilia are immotile or dysfunctional. These individuals often have chronic cough, otitis, chronic sinus infections, and salpingitis. Nasal polyps are common in these individuals. People who have chronic respiratory infections with sinusitis, and otitis are suspects for having PCD. |
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chronic cough, otitis, chronic sinus infections, and
salpingitis. Nasal polyps are common |
Kartagener’s syndrome is also called primary cilliary
dyskinesia (PCD). |
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What is rhinitis?
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Inflammation of the nasal mucosa. It is often just a presenting
symptom of the common cold. Rhinitis can be seen in a patient with what is commonly called seasonal allergies and it is called Allergic rhinitis. |
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rhinorrhea, sneezing and
pruritis and congestion. The patient may also have facial pressure or pain with altered sense of smell and post nasal drainage. The patient can also have a sore throat, tearing and burning of eyes, malaise, and cough. |
rhinitis
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What is the most common predisposing factor for sinusitis?
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viral infection
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What disease?
Hyposmia • Nasal congestion/drainage • Postnasal drip • Fever • Cough • Fatigue • Dental pain • Ear fullness/pressure |
sinusitis/bacterial
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Pathophys of sinusitis:
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1. Obstruction of sinus drainage pathways that prevents normal drainage and causes hypoxia within sinus causes
ciliary dysfunction and alterations in mucous production. 2. Ciliary impairment which is unable to move waste and infectious bi-products out of sinuses. 3. Mucous quantity/quality |
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Diagnosis of sinusitis
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Diagnosis depends on the symptoms of the patient, duration of the symptoms and or
response to treatment. |
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Tx for sinusitis
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Amoxicillin first line
Bactrim or TMP/SMX, and erythromycin |
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What bug causes pharyngitis?
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Pharyngitis is simply the inflammation of the mucosa of the pharynx. It is most commonly caused by viruses. It is
rarely of bacterial etiology. The most concerning bacterial etiology that causes pharyngitis is group A strep. |
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What is the main concern with pharyngitis?
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RF
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What disease?
Tonsillar edema and erythema • Tonsillar exudates • Anterior cervical lymphadenopathy • Fever or history of fever • Absence of cough |
pharyngitis
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What disease?
Fever • Malaise/fatigue • Bodyaches • Sore throat/Swollen Tonsils • Tonsillar Exudate • Prominent Cervical Lymphadenopathy |
Infectious mono
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TX for bacterial pharyngitis
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Pen G and VK
Amoxicillin Pt with Pen allergies: Clindamycin-Azithromycin Bacterial infections that are not group A strep do not require antibiotics |
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Bacterial pharyngitis caused by what organism?
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Group A Strep (Streptococcus pyogenes)
• Group C Strep • Neisseria gonnorrhea • Corynebacterium diphtheriae • Mycoplasma pneumoniae • Chlamydophila pneumoniae • Archanobacterium haemolyticum • Fusobacterium necrophorum |
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McIssac scale used for what?
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Streptococcus pyogenes or Group A beta hemolytic
strep (GAS) estimating the likely hood of GAS |
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Streptococcus pyogenes or Group A beta hemolytic
strep (GAS) TX |
•Penicillin G and VK
•Amoxicillin For Penicillin allergies •Clindamycin •Azithromycin (Broad and possibly avoided) |
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Complications of Group A Strep Infections
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ARF
Necrotizing Fascitis Pediatric autoimmune neuropsychiatric disorder (PANDAS) Scarlet Fever Streptococcal Toxic Shock Syndrome Acute Glomerular Nephritis Otitis Media Peritonsillar Abscess |
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What disease?
sandpaper rash that blanches, circumoral pallor, and a strawberry tongue |
Scarlet fever from GAS infection
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What is “hot potato voice.”
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Peritonsillar Abscess complication from GAS infection
A peritonsillar abscess is often the result of a multi-organism infection. Patients often present with the “hot potato voice.” Diagnostically, the exam often reveals a large swollen tonsillar pillar and more diagnostic is a deviated uvula with the enlarged tonsil. Often surgical I & D is the treatment of choice. Patients should be hospitalized and treated with IV antibiotics. Clindamycin is a good initial TX |
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What disease?
Dysphagia •Drooling •Distress •Tripod position •Studies to evaluate laryngeal disorders |
epiglottitis
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What disease?
Soft tissue radiographs -for thumb sign |
epiglottitis
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Tx for epiglottitis
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Airway management (Indications)
! Young age, particularly those <4 to 6 years old ! Severe respiratory distress ! Epiglottic abscess. Glucocorticoids ! Not recommended for the acute treatment of a patient. Antibiotics ! (3rd generation cephalosporin, and MRSA coverage like Vancomycin or Clindamycin |
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what disease?
Low raspy voice • Dry sensation, sore throat • Coughing, which can be a symptom of, or a factor in causing it• Difficulty swallowing • Sensation of swelling in the neck • Swollen lymph nodes in the face, chest or throat |
Acute Laryngitis
All most exclusively viral infections. There have been some bacteria like Moraxella catarrhalis, Hemophilus influenza, and Streptococcus pneumoniae |
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Tx for Acute Laryngitis
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Most commonly the treatment is symptomatic
control and stop the facilitation that is exacerbating the symptoms |
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What are thinking about if it is unresolved cough and pneumonia don't respond to medication?
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parasitic infection
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