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Flashcards in PNA and influenza Deck (43):
1

Define pneumonia

most common cause?

1) inflammation of parenchyma (alveoli)

2) accumulation of abnormal alveolar filling with fluid

caused by infection

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Why are lungs considered protective defenses?

1) lungs exposed to particulate matter and microbes in upper airway

2) lower airways organism free but NOT STERILE

3) MICROASPIRATION allows materials/microbes to enter lower resp tract

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Causes of infectious pneumonia (6)

1) inhalation of infectious particles ** (develops into CAP for Legionella/M tuberculosis)

2) inhalation of oropharngeal/gastric contents

3) hematogeneous spread (blood stream infectious)

4) infection from adjacent/contiguous structures

5) direct inoculation

6) reactiv

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Mechanism of pneumonia

1) decr host ability to fight against microbial pathogens

2) leads to impaired mechanical (cilia, mucous), humoral, and cellular host defenses

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Clinical presentation

Main symptoms of infectious pneumonia

1) infection = high fever, chills

2) skin = clammmy/blue = hypoxia/hypoxemia

3) pleuritic chest pain

4) Low blood pressure, high HR due to incr metabolims and incr vascular resistance due to fever

5) cough with sputum/phlegm

6) SOB

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Production of sputum vs. minimal sputum indicates what type of pneumonia

sputum = bacterial

minimal sputum = atypical vs viral

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Clinical history of pneumonia

1) elderly = atypical because may not have cough

2) atypical PNA = young patients (most common d/t fatigue)

3) Acute < 7 days, subacute 7-14, chronic > 14

 

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Risk factors for PNA

1) alcohol

2) HIV
3) welder/farmer/wood worker

4) mineral oil --> oil destroys cilia in airways

5) social factors

6) COPD

7) Drugs= IVDU (macrobid/nitrofurantoin/methotrexate)

 

 

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Vital signs of pneumonia

1) fever

2) tachypnea

3) tachycardia

4) hypoxia

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Pulmonary exam for pneumonia

1) crackles

2) rhonchi

3) bronchial breath sounds

4) egophony

5) dullness to percussion

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Tests to order for pneumonia

1) CXR

2) CBC

3) CMP

4) Blood gas/pulse ox

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Can radiographic features differentiate etiology of pneumonia?

RADIOGRAPHIC FEATURES ALONE CAN'T DIFFERENTIATE ETIOLOGY OF PNEUMONIA

 

NOT SUFFICIENT TO CONFIRM DIAGNOSIS

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What can fill alveoli?

Poor = pus

Funny = fluid

Boy = blood

Can't = cells/cancer

Piss = proteins

For = fat/lipid

Crap = calcium

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What are key features of pneumonia on CXR

1) lobar consolidation

2) interstitial infiltrates

3) cavitation

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DDx of Pneumonia Airways Diseases

1) crytogenic organizing pneumonia = rare interstitial lung disease

2) allergic bronchopulmonary aspergillosus

3) bronchiectasis = destruction of airway due to chronic infection and/or assoc with genetic abnormalities (cystic fibrosis)

4) bronchopulmonary sequestration

5) bronchocentric granulomatosis

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Pneumonia DDx Vascular Diseases

• Alveolar Hemorrhage Syndromes = destroy basement membrane of capillary bed

• Eosinophilic lung diseases = idiopathic or drug related
• Pulmonary infarction"
• Fat emboli = Fat to lungs is pro-inflamm; from trauma

• Vasculitis
• Collagen Vascular Diseases = scleroderma, lupus, RA
• Vascular tumors"
• Acute chest syndrome in sickle cell crisis

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If bronchiectasis is localized to right middle lobe and patient is aged (70’s, Caucasian descent)

= Lady-windermere syndrome  (non-tuberculosis mycobacterial disease)

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Pneumonia DDx of parenchymal diseases

1) hypersensitivity pneumonitis = type of ILD = allergic reaction due to birds

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Consolidation with air bronchograms

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Right upper lobe obstruction with alveolar filling spaces

Air fluid level (straight line) on left lung

Cavitation on right and pneumonia on left = bacteria

24

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Right sided pleurla effusion and every lung field is involved (reticular pattern = lacy like pattern = interstitial pattern = miliary pneumonia) = disseminated tuberculosis

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Dense consolidation of right upper lobe

Some consolidation in right lower lobe

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interstitial pneumonia

Reticular fine pattern

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mediastinal widening = hila on right and left (fluffiness of hila) à vascular pouch is widened

= inhalational anthrax

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normal CXR that can lead to S pneumonia PNA = filled with fluid and ARDS

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Initial management

 

1) is patient immunocompromised/severe disease

- sputum gram stain

- but still start antibiotic immediately within first 60 min to decr mortality

- urinary antigens

2) inpatient

- HIV

- thoracentesis = analysis of pleural effusion

- nasal swab for fluid or viral multiplex

- quantiferon for TB

3) deteriorating patient without cause

- bronchoscopy

- transthoracic apirate

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Treatment of PNA

pathogen directed vs. empiric therapy

1) broad spectrum empiric antibiotic therapy first

2) then after you figure out PNA etiology --> tailor antibiotics

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Types of pneumonia (4)

1) Community acquired pneumonia

2) Nosocomial acquired pneumonia/

3) ventilator assoc pneumonia

4) healthcare assoc pneumonia

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Community acquired pneumonia

1) how do you get it

outside the hospital

diagnosed < 48 hrs after hospital admission (cannot be in facility for >14 days)

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Community acquired pneumonia

most commonly caused by:

Bacteria most common

- strep pneumo (30-60%) and atypical organisms (10-20%)

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CAP treatment

outpatient

1) macrolide or doxycycline

2) respiratory fluoroquinolone

3) beta-lactam + macrolide

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CAP treatment

inpatient

1) Non ICU = respiratory fluoro or beta lactam + macrolide

2) ICU = beta lactam + macrolide, beta lactam + resp fluoro

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Nosocomial acquired pneumonia

how do you get?

PNA > 48 hrs after hospital admission

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Ventilator associated pneumonia

how do you get?

PNA > 48-72 hrs after endotracheal tube intubation

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Key features of HAP, VAP, HCAP organisms

1) polymicrobial, MDR organisms colonize oropharynx

2) enter lowe resp tract by micro/macro aspiration

 

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MDR pathogens

gram negatives

SPACE

1) serratia

2) pseudomonas

3) acinetobacter

4) citrobacter

5) enterobacter or e coli

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MDR

gram positive

MRSA

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How do you treat HAP, VAP, HCAP?

1) Antipseudomonal agent = cephalosporin or carbopenem

2) + 1 of either = anti-pseudomonal fluoroquinolone or anti-gram neg aminoglycoside

3) + 1 of either anti-MRSA = linezolid or vancomycin

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