Lectures 1-3 Flashcards
(282 cards)
1
Q
What is the pulmonary interstitium?
A
Network of tissue that extends throughout both lungs, including alveolar epithelium, basement membrane, pulmonary capillary endothelium
2
Q
What does the pulmonary interstitium proved support to?
A
The alveoli and capillary beds for gas exchange
3
Q
Can the pulmonary interstitium normally be seen on CXR or CT?
A
No, because it is so thin
4
Q
What happens to the alveoli in idiopathic pulmonary fibrosis?
A
There is fibrosis between alveoli which greatly decreases gas exchange
5
Q
What is restrictive lung disease?
A
Abnormalities along the interstitium
6
Q
What is a PFT or pulmonary function test?
A
Non-invasive tests that measure how well the lungs are expanding and contracting and how efficient the exchange of CO2 and oxygen are between the blood and air within the lungs
7
Q
What are some different types of PFTs?
A
Lung volumes, spirometry, spirometry before and after a bronchodilator, and diffusion capacity for carbon monoxide (DLCO)
8
Q
What is the lung volume?
A
A measure of air in L or mL
9
Q
What is the total lung capacity?
A
The volume of air in the lungs after maximal inspiration (includes residual volume)
10
Q
What is the lungs vital capacity mean?
A
The maximum volume of air that can be exhaled after a maximal inspiration
11
Q
What is the tidal volume?
A
The volume of air moved in and out during each breath
12
Q
What is the residual volume?
A
Volume of air remaining in the lungs after a maximal expiration
13
Q
“Measure of breath”
A
Spirometry
14
Q
Spirometer
A
An instrument for measuring the air capacity of lungs
15
Q
What is the most common type of PFT?
A
Spirometry
16
Q
Spirometry measure the volume of air exhaled (after max inhalation) at specific time points during a forceful and complete _____
A
Exhalation
17
Q
What are the three important variables generated by spirometry?
A
FVC, FEV1, and their ratio: FEV1/FVC
18
Q
The value found from spirometry are graded against what?
A
A predicted value
19
Q
What are the predicted values from spirometry pooled from?
A
Data on a large number of “normal” individuals: no hx of lung disease, no respiratory symptoms, normal CXR, normal EKG
20
Q
What can help diagnose and differentiate between obstructive lung disease and restrictive lung disease?
A
Spirometry
21
Q
Spirometry is an important tool is assessing what?
A
Asthma, COPD, cystic fibrosis, pulmonary fibrosis
22
Q
FVC is what?
A
Maximum amount of air exhaled after a maximal inhalation
23
Q
What if the FVC is low?
A
THe problem may be a restrictive disorder
24
Q
FEV1 is what?
A
The amount of air exhaled in the 1st second
25
What may a reduced FEV1 indicate?
Obstructed or narrowed airways
26
Most people are able to expel __% of their vital capacity in one second
70%
27
The FEV1/FVC ratio is used to identify what?
Airflow obstruction (if <70% of predicted)
28
What can flow volume loops be used for?
Strider or unexplained dyspnea
29
What does a flow volume loop consist of?
Forced inspiratory and expiratory maneuver
30
If the FEV1/FVC ratio is less than 70%, what can that indicate?
Obstructive pattern
31
What diseases are considered obstructive?
COPD, asthma
32
If the FEV1/FVC ratio is >70%, what does that mean?
Could be normal or restrictive disease
33
FEV1 over 70% predicted is (ATS criteria)
Mild obstruction
34
FEV1 60-70%
Moderate obstruction
35
FEV1 50-60%
Moderately severe obstruction
36
FEV1 35-50%
Severe obstruction
37
FEV1 <35% predicted
Very severe obstruction
38
If the DLCO is decreased, what type of obstructive disease can that signify?
Emphysema
39
If the DLCO is normal, which obstructive disease can it be?
Chronic bronchitis
40
If the DLCO is normal or increased, what type of obstructive disease can it be?
Asthma
41
If the DLCO is decreased, what type of restrictive disease can it be?
Parenchyma disease
42
If the DLCO if normal, what type of restrictive disease can it be?
Non-parenchymal (chest wall) restriction
43
the FEV1/FVS ratio will be decreased in which type of lung disease?
Obstructive lung disease
44
THe FVC will be decreased in what type of lung disease?
Restrictive lung disease
45
The DLCO measure what?
The overall function of the alveolar-capillary membrane
46
DLCO can be used to differentiate the etiology of what?
Restrictive lung disease
47
If the DLCO is low it could be due to what?
Interstitial lung disease
48
If the DLCO is normal, can be due to what?
Extrathoracic cause of restriction-obesity, chest wall disorder, neuromuscular disorder
49
Restrictive disease will show what results from a PFT?
FEV1/FVC ratio: normal
TLC: low
DLCO: Low
50
Obstructive disease will show what results from a PFT?
FEV1/FVC ratio: Low
FEV1: 46%
Pre vs Post BD: 12% increase
DCLO: Low
51
The inability to completely fill lungs with air
Restrictive pulmonary disease
52
What is restrictive pulmonary disease characterized by?
Reduced lung volumes
53
Unlike obstructive lung disease, restricted disease are associated with what?
A decreased total lung capacity
54
What are the two divisions of restrictive pulmonary disease?
Intrinsic and extrinsic
55
What are intrinsic restrictive pulmonary diseases?
Disease of the lung parenchyma, inflammation or scarring of lung tissue
56
What are some examples of intrinsic restrictive pulmonary disease?
Idiopathic fibrotic disease, pneumoconioses, and sarcoidosis
57
What are extrinsic restrictive pulmonary diseases?
Extra-pulmonary disease involving the chest wall, pleura, and respiratory muscles
58
What are some examples of extrinsic restrictive pulmonary disease?
Obesity, myasthenia gravis , ALS, kyphoscoliosis
59
What medications can induce interstitial lung disease?
Amiodarone, Methotrexate, and Nitrofurantoin
60
What is the most common diagnosis amount patients with interstitial lung disease?
Idiopathic fibrosing interstitial pneumonia
61
What is the overall prognosis for idiopathic fibrosing interstitial pneumonia?
Poor
62
Potential risk factors for idiopathic fibrosis interstitial pneumonia
Smoking, occupational exposure (stone, metal, wood, organic dusts), GERD (due to micro-aspiration)
63
Clinical features of idiopathic fibrosing interesting pneumonia
Insidious dry cough, extensional dyspnea, fatigue, tachypnea
64
What can be found on physical exam for idiopathic fibrosing interstitial pneumonia
Clubbing and inspiratory rales (crackles)
65
What other pulmonary disease is clubbing common in?
Cystic fibrosis, AV fistula, idiopathic pulmonary fibrosis, asbestosis, and malignancies of the lung and pleura
66
What GI diseases can clubbing be seen in?
Chron’s, cirrhosis, ulcerative colitis, and esophageal cancer
67
What will the PFTs show for idiopathic fibrosing interstitial pneumonia
Reduced FVC
Normal or elevated FEV1/FVC ratio
Reduced DLCO
Impaired 6 min walk
68
Radiographic findings for idiopathic fibrosing interistitial pneumonia
CXR: increased reticular markings (IPF, CHF)
CT: diffuse patchy fibrosis with pleural based honeycombing
69
The diagnosis for idiopathic fibrosing interstitial penumonia can be made based on what?
Basis of a characteristic presentation (symptomatology in combo with CT imaging)
70
What is a more definitive way to diagnose idiopathic fibrosing interstitial pneumonia?
Lung biopsy, can help rule out other possible causes as well
71
What types of supportive care can be given to someone with idiopathic fibrosing interstitial pneumonia?
Supplemental home oxygen, vaccinations (flu and pneumo), OP pulmonary rehab programs
72
What are some medication options for patients with idiopathic fibrosing interstitial pneumonia?
Nintedanib: a tyrosine kinase inhibitor
| Pirfenidone (Esbriet): an anti-fibrotic drug
73
What are some surgical options for pts with idiopathic fibrosing interstitial pneumonia?
Lung transplant
74
What are the qualifications for a lung transplant?
Age <65
Free of substance abuse (smoking, drugs)
Acceptable BMI range of 20-29
75
“Occupational lung disease”
Pneumoconioses
76
What is pneumoconioses?
Groups of interstitial lung diseases caused by the inhalation and deposition of inorganic particles and mineral dust with subsequent reaction of the lung
77
Clinically important pneumoconiosis include:
1. Coal worker’s pneumoconiosis
2. Silicosis
3. Asbestosis
78
“Black lung disease”
Coal workers pneumoconioses
79
What is the milder form of coal workers pneumoconioses?
Anthracosis
80
What is coal workers pneumoconioses caused by?
Prolonged exposure to coal dust, which is inert and cannot be removed by the body
81
Leads to inflammation, fibrosis, and sometimes necrosis
Coal worker’s pneumoconisoes
82
What are some symptoms for coal workers pneumoconioses?
Chronic cough, fever, and dyspnea on exertion usually develop 10-15 years after exposure
83
Radiographic findings for coal worker’s pneumoconioses
Small, rounded, modular opacities with a preference for the upper lobes
84
The nodular opacities in coal workers pneumoconioses tend to go where?
Upper lobes
85
What is coal workers pneumoconioses irreversible
When larger opacities with progressive massive fibrosis start to occur
86
What is silica?
Silicon dioxide (SiO2)
87
Silica is commonly found in nature as what?
Quartz
88
What are some uses for silica?
Glass, optical fibers porcelain, sand casting
89
Silicosis
Spectrum of pulmonary disease caused by inhalation of crystalline silica
90
What occupations are commonly effected by silicosis?
Mining, masonry, glass manufacturing, foundry work, and sandblasting
91
What are the various clinical stages of silicosis?
Acute chronic, and accelerated silicosis
92
What is the clinical presentation of silicosis?
Cough, dyspnea, sometimes fever or pleuritic chest pain
93
Evaluation of silicosis consists of what?
PFTs:
FEV1: decreased
DLCO: decreased
FEV1/FVC ratio: normal
94
Radiographic findings of acute silicosis
CXR/CT: bilateral, diffuse, ground glass opacities
95
Radiographic findings of chronic silicosis
CXR/CT: small, innumerable, rounded densities
96
The clinical diagnosis of silicosis is based on 3 key elements:
1. History of silica exposure
2. Chest imaging consisting with silicosis
3. Absence of any other diagnosis
97
What else can be done to diagnose silicosis?
Lung biopsy if the diagnosis cannot be made clinically
98
What are some treatment options for silicosis?
Avoid further exposure and supportive care, steroid therapy? Lung transplant
99
What are some associated complications with silicosis?
Mycobacterium infection, aspergillosis, lung cancer, chronic kidney disease
100
Asbestos
Group of naturally occurring fibrous composed of hydrated magnesium silicates used for variety of construction and insulating purposes
101
Asbestosis
Pneumoconiosis caused by inhalational asbestos fibers
102
What occupations can be effected by asbestosis?
Plumbers, construction, shipbuilding, railways, laborers, carpenters, electricians
103
Clinical presentation of asbestosis
Dyspnea on exertion, cough, weight loss
104
How long are you asymptomatic with asbestosis?
Atleast 20-30 years after initial exposure
105
What can be seen on physical exam for asbestosis?
Inspiratory crackles, clubbing
106
What will the PFTs show for asbestosis?
Vital capacity: reduced
Total lung capacity: reduced
DLCO: low
107
Radiographic findings of asbestosis
CXR: thickened pleural and calcified pleural plaques
CT: course honeycombing (in advanced disease), hazy ground glass appearance of peripheral pleural surface
108
What is needed to diagnose asbestosis?
Hx of exposure, chest imaging consistent with asbestosis, absence of any other diagnosis, bronchoalveolar lavage
109
What are some treatment options for asbestosis?
Avoid further exposure, supportive care, steroid therapy, smoking cessation
110
What is a complication of asbestosis?
Malignant mesothelioma
111
Sarcoidosis
Multisystem granulomatous disorder of unknown etiology
112
What systems are effected with sarcoidosis?
Lungs, lymph nodes, eyes, skin, liver, spleen, heart, nervous system, but approximately 90% of pts have lung involvement
113
What is the characterizing pathology of sarcoidosis?
Non-caseating granulomas
114
What population if sarcoidosis more common in?
Young black women and northern European whites
115
Clinical presentation of sarcoidosis
Cough, progressive worsening dyspnea, atypical chest discomfort, fever/night sweats, weight loss
116
Evaluation of sarcoidosis
Serum blood tests, ACE levels, ESR are non-diagnostic
117
Radiographic findings of sarcoidosis
CXR: bilateral hilar adenopathy
CT: right paratracheal lymphadenopathy along with bilateral diffuse reticular infiltrates
118
What is a term used to describe the radiographic findings of sarcoidosis?
Sarcoid galaxy sign
119
What is needed to diagnose sarcoidosis?
Endobronchial US guided biopsy (EBUS), cervical medastinoscopy, VATS lung biopsy
120
What type of lung disease has caseating granulomas?
TB
121
What are some treatment options for sarcoidosis?
Close observation for asymptomatic pts, 90% are responsive to a tapering course of oral corticosteroids over 4-6 weeks
122
Restrictive lung diseases are characterized by what?
Reduced lung volumes, low TLC, FVC and DLCO
123
Lung transplants may be a viable option for pts with what?
End stage IPF and sometimes silicosis
124
Treatment options are limited for restrictive lung disease except what?
Sarcoidosis
125
Inflammation of the large airways of the lungs
Acute bronchitis
126
Acute bronchitis is self limited to how long?
About 1-3 weeks
127
What microbes can cause acute bronchitis?
Influenza A&B, parainfluenza, RSV, coronavirus, rhinovirus, adenovirus
128
What are some clinical manifestations of acute bronchitis?
Persistent cough 1-3 weeks (w or w/out sputum), low grade fever, wheezing, mild dyspnea, rhonchi-clears with cough, chest pain
129
What are some reasonable indications to order a CXR on someone with acute bronchitis?
Tachycardia, tachypnea, fever, hypoxia, dementia, rales, egophony, tactile fremitus, MS changes in pts >75
130
When should a sputum sample be ordered?
Unlikely to help with acute bronchitis, unless suspicion for TB
131
PCT
Procalcitonin-in health individuals is below the level of detection
132
PCT for acute bronchitis
Rises in response to pro inflammatory stimulus especially of BACTERIAL origin
133
What can PCT be an indicator for?
Sepsis or pneumonia
134
If the PCT value is <0.25mcg/L
Discourage Abx use
135
If the PCT is >0.25mcg/L
Encourage Abx use
136
What are the possible treatment for acute bronchitis?
Pt education (no Abxs), antitussives, bronchodilators +/-
137
Who should albuterol be used for?
Acute bronchitis with wheezing or comorbidities
138
What OTC cough meds can be used for acute bronchitis?
Devtromethorphan (DM) and Guaifenesin
139
Dextromethorphan
Cough suppressant (Nyquil, Mucinex, Robitussin) in high doses produces similar effects to ketamine and PCP
140
Guaifenesin
Expectorant: DayQuil, Mucinex, Robitussin, Guiatuss
| Usually used with codeine, dextromethorphan, pseudoephedrine, acetaminophen
141
Rx cough meds used for acute bronchitis
Robissutin AC: Guaifenesin with Codein
| Tessalon pearles: benzonatate
142
What is a non-narcotic cough suppressant
Tessalon Pearles
143
What is a resp illness that affects upper and lower respiratory tracts?
Influenza
144
Influenza is accompanied by what?
Systemic signs and symptoms, sudden onset
145
Influenza is associated with what
Morbidity and mortality in certain high-risk populations
146
Who can get complications of influenza?
Pregnant women, children, >65, comborbidities
147
What microbes are responsible for influenza?
Orthomyxoviridae family, type A B and C
148
What are the further subtypes of influenza?
H surface hemagglutinin
| N neuraminidase antigens
149
Type A has how many H and Ns?
16 H subtypes and 9 N subtypes
150
What are the 3 major subtypes that affect humans?
H1, H2, H3, N1 and N2
151
What occur annually and result in outbreaks of variable extent and severity?
Antigenic drifts
152
What do antigenic drifts result from?
Point mutations in the RNA gene segments
153
Clinical manifestations of influenza
Sudden onset, HA, fever, myalgia, cough, sore throat
154
What is used to diagnose influenza
Rapid antigen tests, type A and B, nasopharyngeal swabs, immunofluorescence staining, respiratory swab
155
What test is the most sensitive and specific for influenza?
Nuclei acid tests- RT-PCR takes 4-6 hours, can differentiate types and subtypes
156
What neuraminidase inhibitors can be used to treat influenza?
Zanaminivir (Relenza) inhalation, Oseltamivir (Tamiflu), Peramivir (Rapivab) IV
157
What adamantane agents can be used to treat influenza?
Amantadine (Symmetrel) anti-Parkinson’s agent, no longer recommended
Rimantadine (Flumadine) not approved
158
Current influenza vaccines are what?
Trivalent or quadrivalent
159
Trivalent vaccine
Contains two influenza A virus antigens and one influenza B virus antigen
160
Quadrivalent influenza vaccine
Contains two influenza A antigens and tow influenza B antigens
161
Individuals >65 high dose of which vaccine is recommended?
Trivalent (FluZone)
162
Tuberculosis microbes
Mycobacterium tuberculosis, mycobacterium africanum and mycobacterium bovis
163
What are major contributors to resurgence of TB?
Drug resistance, poverty, HIV
164
What are some risk factors for TB?
Substance abuse, HIV, nutritional status, household contact, community setting, low SE status, minority
165
How is TB transmitted?
Person-to-person via inhalation of droplet nuclei (airborne particles 1-5 microns in diameter)
166
What are some factors associated with the risk to TB transmission
Presence of active untreated pulmonary or laryngeal disease, presence of cavitary disease, presence of sputum + for m.tuberculosis AFB
167
What are some risky procedures that can cause transmission
Endotracheal intubation, bronchoscope, sputum induction, chest PT, administration or aerosolized rugs, irrigation of TB abscess, autopsy on cadaver
168
What are the 4 things that can happen once you inhale the droplets of m.tuberculosis
1. Immediate clearance of organism
2. Primary diseasE: immediate onset of active disease
3. Latent infection
4. Reactivation disease: onset of active disease many years following a period of latent infection
169
The greatest risk for progression to active disease happens when?
In the first 2 years after infection
170
What are the clinical manifestations of primary disease (TB)
Fever-most common, fatigue, arthralgias, cough 2-3 weeks, pharyngitis
171
Latent disease (TB)
Asymptomatic, mild symptoms
172
Reactivation of TB clinical manifestations
Weight loss, night sweats, anorexia, pleuritic or retro sternal chest pain
173
What are some screening tools for TB?
TST, PPD, + supports diagnosis, but cannot be used to establish diagnoses
174
What can interfere with TB screening?
BCG
175
PPD reading will be positive if its >5mm for these people
HIV infected, recent contacts of TB case, persons with fibrotic changes on CXR consistent with healed TB, pts with organ transplants, immunosuppressed
176
PPD reading will be positive if its >10mm for these people
Recent arrival to US from high prevalence countries, IVDAs, residents and employees of high-risk congregate settings, mycobacteriology lab personnel, kids under 5,
177
PPD reading will be positive if its >15mm with who?
Everyone else
178
What else can be used to diagnose TB?
Sputum-either spontaneous or induced, acid-fast bacilli stain, mycobacterium culture, nuclei acid amplification (NAA)
179
What are the 2 major types of interferon gamma release assays available to diagnose TB?
QuantiFeron-TB Gold and T-SPOT TB
180
What are the interferon gamma release assays (IGRAs) testing?
Immune response to M.tuberculosis, preferred for pts with hx of BCG vaccine
181
What are the goals fo TB treatment?
Eradication, prevent transmission, prevent relapse, prevent development of drug resistance
182
What is used to treat TB?
Isoniazid, Rifampin, Pyrazinamide, Ethambutol, +/- Streptomycin
183
What is the intensive phase of TB management?
4 drugs: Isoniazid, Rifampin, Pyrazinamide, Ethambutol used for 2 mos, taken on empty stomach, need baseline LFTs
184
What type of follow-up care is needed for someone during the intensive phase of TB treatment?
Repeat CXR and AFB smear and CX, then monthly after that to asses clinical response
185
What 2 drugs are used in the continuation phase of TB?
Isoniazid and Rifampin for 4 additional months
186
When can the continuation phase of TB management be stopped?
Until 2 consecutive negative cultures
187
What is the treatment for latent TB?
Isoniazid QD 9 mos
| Rifampin QD 4 mos
188
MDR-TB
Multi drug resistant TB-resistant to atleast isoniazid and rifampin and possibly other chemotherapeutic agents
189
XDR-TB
Extensively drug-resistant TB resistant to atleast isoniazid, rifampin and atleast 1 of 3 injectable 2nd line drugs capreomycin, kanamycin, or amikacin
190
Definition of pneumonia
Inflammatory condition off the lung affecting predominantly the alveoli
191
What is the pathophys behind pneumonia?
1. Micro-aspiration of organism
2. Defect in host defense system
3. Virulence of the organism
192
What is the most common cause of community acquired pneumonia? (CAP)
Bacterial pneumonia
193
What are the 5 classifications of pneumonia
1. CAP
2. Healthcare Associated Pneumonia (HCAP)
3. Hospital Acquired Pneumonia (HAP)
4. Ventilator Acquired Pneumonia (VAP)
5. Aspiration Pneumonia
194
What is community acquired pneumonia? (CAP)
Non-hospitalized patient without extensive health care contact
195
What is healthcare associated Pneumonia (HCAP)?
Non-hospitalized pt with extensive healthcare contact
Hospitalized in an acute care setting >48 hours last 90 days
Resides in NH or LTC
IV therapy, chemotherapy or wound care <30 days
196
What is hospital acquired pneumonia (HAP)- nosocomial?
Pneumonia acquired while hospitalized after >48hours
| Early onset <5 days vs late onset >5 days
197
What is ventilator Acquired Pneumonia? (VAP)
48-72 hours after endotracheal intubation
198
What is aspiration pneumonia?
Relatively large amount of material from the stomach or mouth entering the lungs
199
Hospitalized in an acute care setting >48 hours last 90 days
Healthcare associated pneumonia (HCAP)
200
IV therapy, chemo, or wound care <30 days
Healthcare associated pneumonia (HCAP)
201
Early onset <5 days vs late onset >5 days
Hospital acquired pneumonia (HAP)
202
48-72 hours after endotracheal intubation
Ventilator acquired pneumonia
203
What are the most common etiologies of pneumonia?
Bacterial* and viral
204
Which types of microbes can effect the immunocompromised? (Pneumonia)
Fungus- cryptococcus, histoplasmosis, coccidiodes, aspergillus, pneumocystis jirovecii
Parasites-toxoplasmosis
205
What typical organisms cause bacterial CAP?
Strep pneumoniae #1
| H.influenzae
206
What atypical organisms cause bacterial CAP?
M.pneumoniae #2
| C.pneumoniae
207
What are the most common viral pathogens causing CAP?
Influenza*** RSV, adenovirus, rhinovirus, parainfluenza, coronavirus, severe acute respiratory syndrome (SARS), middle eastern respiratory syndrome (MeRs)
208
What are some risk factors for CAP
Tobacco use, ETOH abuse, altered LOC, age, pulmonary disease, congenital heart disease, malnutrition, immunosuppression diseases and agents, sick cell disease
209
Symptoms of pneumonia
Fever, productive or non productive cough, chills, pleuritic pain, hemoptysis, +/- HA, myalgia, body aches, nausea
Infants: poor feeding, restless
210
What are some PE findings for pneumonia
Fever, rales/crackles, tachypnea, decreased breath sounds, asymmetric breath sounds, expiratory wheezing, hypoxemia, tachycardia, hypotension
211
What are some typical manifestations for a legionella pneumoniae infection?
Diarrhea, abdominal pain, sore throat, congestion, cough, hyponatremia
212
What are the patient characteristics for a klebsiella pneumoniae infection?
Alcoholics
213
What is a great diagnostic tool for pneumonia?
CXR PA/Lateral
214
Why is the clinical evaluation of pneumonia difficult?
No constellation of symptoms or signs that accurately predict CAP >50%; sensitivity and specificity of clinical evaluation for pneumonia is <50%
215
What PE findings can be seen for pneumonia caused by influenza?
URI or flu-like symptoms rapid onset
216
What PE findings can be seen for pneumonia caused by other viruses?
URI symptoms slow in onset (except flu); diffuse change in breath sounds
217
What PE findings can be seen for pneumonia caused by M.pneumoniae?
Abrupt onset, myalgia, abdominal pain, OM, rash, conjunctivitis, sore throat
218
What PE findings can be seen for pneumonia caused by legionella?
Abdominal pain, diarrhea, confusion, high fevers, recent travel
219
What PE findings can be seen for pneumonia caused by bacteria?
Abrupt onset
220
Sputum type for s.pneumoniae
Rust color
221
Sputum type for atypical organisms
Non-productive, scant or watery
222
Sputum type of Klebsiella
Hemoptysis of currant jelly
223
What is the gold standard for diagnosis of pneumonia?
CXR
224
What is the criteria for chest XRay of pneumonia?
>1 of the following:
Temp >100, >100BPM, >20 RR
>2 of the following:
Decrease breath sounds, crackles, absence of asthma
225
What is a common CXR finding with strep pneumoniae?
Lobar: single lobe or segment/pattern
226
Interstitial and peribronchial CXR findings for what?
Viral pneumoniae; PCP
227
Necrotizing Pneumonia CXR findings for what?
Aspiration pneumonia, strep pneumoniae, GAS, S.aureus
228
Caseating granuloma
TB
229
What else can be used to diagnose pneumonia?
CT scan of the chest, sputum induction
230
CT scan for pneumonia
High sensitivity, expensive, high radiation exposure, utilize if will change treatment plan
231
What has limited utility due to technical and patient issues?
Sputum induction
232
Expectorated sputum specimens are recommended for hospitalized pts with any of the following criteria:
Admitted to ICU, Abx failure, cavitary lesion on CXR, active ETOH abuse, severe COPD or lung disease, immunocompromised host, epidemic pneumonia, pathogen of clinical interest
233
What is a sterile technique obtained form 2-3 different sites using a straight stick?
Blood cultures
234
Do all pts get blood cultures with pneumonia?
No
235
What is the criteria for when to obtain blood cultures? (Pneumonia)
ICU admission/severe CAP, leukopenia, ETOH abuse, chronic severe liver disease, cavitary lesion on X-ray, pleural effusion, asplenia, positive pneumococcal urine antigen test (UAT)
236
What organisms can the urine antigen test (UAT) pick up?
S. Pneumoniae, legionella
237
What are the pros to the urine antigen test (UAT)?
Simplicity; good sensitivity; ability to detect after Abx administrations may stay + for weeks
238
What are some cons for the UAT?
Cost; inability to perform susceptibility testing; detects only Legionella type 1; unsure if will change Abx management
239
What organisms can the influenza antigen test for?
Influenza A and B
240
What are some pros to the influenza antigen test?
Decrease Abx agents; identify for epidemiological purposes; high specificity
241
What are some cons to the influenza antigen test?
Cost; high rate of false -; low sensitivity; not superior to physician judgement
242
What organisms can the multiplex PCR test for?
M. Pneumoniae, C. Pneumoniae, B, Pertussis; 14 viruses (Influenza, RSV)
243
What are the pros to the multiplex PCR?
Rapid quick detection
244
What are the cons to the multiplex PCR?
Requires lab; high rate of false +; expense and availability
245
What organisms can the serology test for?
C. Pneumoniae, M. Pneumoniae, Legionella
246
What are the pros to the serology test?
Standard for diagnosis
247
What are the cons for serology?
Not practical; must compare an acute phase vs convalescent serology; + serology may confer present or past infection
248
What are some additional labs to check for pneumonia?
CBCD, BMP or CMP, lactic acid, CRP, pro-calcitonin
249
What is needed to diagnose pneumonia OP?
Clinical, CXR, organism testing only if will impact Abx management
250
What is needed to diagnose pneumonia as IP?
CXR, CBCD, BMP or CMP, +/- CRP, Sed rate or Lactic acid
251
What is needed to diagnose pneumonia in ICU?
CXR, blood cultures, UAT Legionella and pneumococcal, sputum, CBCD, BMP, CMP, Lactic acid, +/-CRP or sed rate
252
Macrolide are NOT used for what?
Blood, urine, or soft tissue infections
253
What is the OP treatment for someone with pneumonia who was previously healthy and has had no use of antimicrobials within past 3 mos
Azithromycin; Clarithromycin; OR Doxycycline
254
What is the OP treatment for pts with pneumonia with comorbidities; immunosuppression; or use of antimicrobials within past 3 mos
```
Respiratory fluoroquinolone (Moxifloxacin or Levofloxacin) OR
Beta-lactam (Amoxicillin, Augmentin, Cefpodoxime, Cefuroxime) PLUS Macrolide/Doxycycline
```
255
What is the inpatient, Non-ICU treatment for pneumonia?
Moxifloxacin, Levofloxacin IV +/- Glucocorticoids OR
| Ceftriaxone, Unasyn IV PLUS Macrolide/Doxycycline +/- Glucocorticoids
256
When can you transition form IV to oral Abx therapy for pneumonia?
Clinical improvement and afebrile after 48 hours, transition to similar class and complete treatment total 5-7 days
257
When should the fever improve after start of meds for pneumonia?
Should improve within 72 hours
258
Is the persistence of symptoms an indication to extend course of Abx?
No
259
Routine follow up for pneumonia
CXR not indicated if improved clinically, if needed 7-12 weeks out
260
Prevention of pneumonia
Smoking cessation, screen fo Influenza vaccine status, screen for pneumococcal vaccine status, at risk population: >65 YO, comorbidities or smoking
261
What is the treatment for HAP/VAP early onset <5 days
Ceftriaxone OR Levofloxacin OR Unasyn
262
What is the treatment for HAP/VAP late onset >5days and HCAP?
Cefepime OR Ceftazidime OR Meropenem OR Levofloxacin OR Zosyn PLUS
Vanco or Linezolid
263
What are some risks for multip-drug resistant pathogens
Antimicrobials therapy in preceding 9 0-days, current hospitalization >5days, High requests of Abx resistance in community or specific hospital unit
264
Definition of aspiration pneumonia
Relatively large amounts of material from the stomach or mouth entering the lungs
265
Risk factors for aspiration pneumonia
Altered LOC, dysphagia, neurological disorder, mechanical disruption, protracted vomiting, general debility, gastroparesis, ileus
266
What is the treatment for aspiration pneumonia?
Supportive IVF +/- ventilator support, +/0 glucocorticoids
267
What is the treatment for aspiration pneumonia if it develops into an infection?
Clindamycin IV or Flagyl + Amoxicillin
268
Opportunistic pneumonia microbes
TB, MAC, pneumocystis jirovecii, cryptococcus, cytomegalovirus, influenza, kaposi sarcoma, toxoplasmosis
269
What is the most common opportunistic infection associated with AIDS/HIV
PCP pneumonia (pneumocystis jirovecii)
270
PCP pneumonia
Dramatic decrease since onset of ART therapy and prophylactic therapy
271
What are some risk factors for PCP pneumonia
Advanced immunosuppression, previous PCP, oral thrush, recurrent pneumonia, high plasma RNA
272
Symptoms of PCP pneumonia
Gradual in onset days to weeks, fever, cough, dyspnea, fatigue, weight loss
273
What are some signs for PC pneumonia?
Fever, tachypnea, crack les, Rhonchi, thrush, hypoxemia
274
What labs can be used to diagnose PC pneumonia?
CD4 count, ABG, LDH, 1-3-beta-d-glucagon levees, induced sputum
275
What imaging can be used for PCP pneumonia?
CXR- diffuse bilaterally interstitial alveolar infiltrates, CT, Gallium citrate scanning, DLCO
276
What will the CXR how for PCP pneumonia?
Diffuse bilateral interstitial or alveolar infiltrates
277
What will the CT scan show for PCP pneumonia?
Ground glass appearance
278
What is the treatment for mild PCP pneumonia?
TMP-SMX
279
What is the treatment for moderate PCP pneumonia?
TMP-SMX PLUS Prednisone
280
What is the treatment for severe PCP pneumonia?
TMP-SMX PLUS Methylprednisolone
281
What are some indications for antimicrobial prophylaxis of PCP?
CD4 count <200, oropharyngeal candidiasis, CD4 count % <14
282
What are the prophylaxis options for PCP?
TMP-SMX, Dapsone, Atovaquone
