Pulmonology Flashcards
1
Q
ventilator-associated pneumonia (VAP) vs Hospital-acquire pneumonia
A
- Ventilator associated:
- more than 48hrs following intubation and mech vent
- MC pathogens: acinetobacter, strenotrophomonas maltophiia
- endotracheal aspiration cx (use sterile suction catheter and fiberoptic bronchoscopy with BAL)
- Hospital acquired:
- occurs more than 48h after admission to hospital or other health care facility and excludes any infxn present at time of admission
- MC pathogen: S. aureus, pseudomonas, GNR
2
Q
PNA tx: hospitalized or ICU pts
A
- Duration: 5d minimum or until pt afebrile x48-72h
- ICU: S pneumo, Legionella, H flu, Enterobact, S aureus, Pseudomonas
- Previously healthy: Azithro or resp FQ (moxi or levo) plus cefotaxime, ceftriaxone, or UNASYN
- if B lactam allergy: FQ plus Aztreonam
- pts at risk for drug resistance: Antipneumococcal and antipseudomonal B lactam: Zosyn, cefepime, imipenem or meropenem PLUS:
- cipro or levo, OR, antipneumo B-lactam (cefotaxime, ceftriaxone, UNASYN) PLUS Aminoglyc (gent, tobra, amikacin) PLUS Azithro or resp FQ
- If at risk for MRSA: add vanco or linezolid
3
Q
PNA tx: nosocomial PNA
A
- previously healthy: ceftriaxone, moxi, levo, cipro, UNASYN, Zosyn, or ertapenem
- at risk for drug resistance: one agent from each:
- Antipseudomonal
- Cefepime, Impenem, Zosyn, or aztreonam (if PCN allergy)
- Second antipseudomonal
- Levo, cipro, gent, tobra, or amikacin
- MRSA coverage
- vanco or linezolid
- Antipseudomonal
4
Q
When to admit for PNA
A
- CURB-65 Score
- confusion
- uremia
- resp rate
- blood pressure
- age >65
- <1 = no hosp
- 1-2 = hosp (maybe ICU)
- 3+ = definite ICU admit
5
Q
Postoperative pneumonia etiology and sxs
A
- MC complication leading to mortality after surgery
- Highest RF: peritoneal infxn, prolonged vent support
- RF: atelectasis, aspiration, copious secretions
- cause: gram neg bacilli - E. coli, pseudomonas, klebsiella
- sxs: acute or subacute onset of fever, gradual onset cough with or without sputum production, SOB on exertion,
- sweats, chills, rigors, chest discomfort, pleurisy, hemoptysis, fatigue, myalgias, anorexia, HA, abd pain
- signs: fever or hypotherm, tachypnea, tachycardia, O2 desat, insp crackes and bronchial breath sounds, dullness to percussion
6
Q
postop pneumonia dx
A
- dx: CXR - patchy airspace opacities to lobar consolidation with air bronchograms to diffuse alveolar or interstitial opacities (not necessary in outpt bc empiric tx is effective, recommended if unusual presentation, hx, or inpt, clearing of opacities can take 6wk or longer)
- CT = more sensitive and specific
- labs: sputum gram stain and sens, urinary ag test for s. pneumo and legionella, rapid ag test for flu, preantibiotic sputum and blood cxs, CBC, CMP, LFTs, bili, ABG in hypoxemic pts, HIV testing in at-risk pts, procalcitonin
7
Q
prophylaxis for postop PNA
A
- pneumovax 23, prevnar 13 (ind age 65+ and immunocomp give both, or any chronic illness with inc risk of CAP; immunocomp pts at high-risk should get single revax of 23 6y after first; immunocompetent and 65+ get second dose of 23 if first received vax 6+ y ago), influenza
8
Q
pulmonary neoplasm
A
- Risk factors: cigarette smoking (>85%) increased risk with increasing pack yrs
- Adenocarcinoma = lowest association of smoking
- Asbestos
- Radon
- COPD
- Metastatic dz: brain, bone, adrenal glands, liver
9
Q
Small cell lung cancer
A
- 25%
- Sxs: recurrent PNA, anorexia, weight loss, weakness, cough
- Associated sxs: superior vena cava syndrome (facial fullness, edema, dilated veins over ant chest, arms, face, JVD, phrenic nerve palsy, recurrent laryngeal nerve palsy (hoarseness), Horner syndrome (unilateral facial anihdrosis, ptosis, miosis), malignant pleural effusion, Eaton-Lambert syndrome (similar to myasthenia gravis)
- Dx: CXR (not for screening), CT chest (staging), bx (histologic type), cytologic exam of sputum (central tumors), fiberoptic bronchoscope (central dz), PET scan, transthoracic bx (peripheral dz), mediastinoscopy (advanced dz)
- Tx: chemo and radiation
- if dz is extensive, chemo only and then radiation if it is responsive to chemo
- Prognosis:
- Limited: 10-13% 5y survival
- Exstensive: 1-3% 5y survival
- Staging: limited = confined to CHEST and supraclavicular nodes (not cervical or axillary); extensive = outside chest and supraclavicular nodes
10
Q
non-small cell lung cancer
A
- Etiology: SCC, adeno, large cell, bronchoalveolar cell
- sxs: cough, hemoptysis, obstruction, wheezing, pancoast syndrome (superior sulcus tumor - shoulder pain, radiates down arm, pain and upper extremity weakness dt brachial plexus invasion, horner syndrome)
- associated sxs: paraneoplastic syndromes (SIADH, ectopic ACTH, PTH-like secretion, hypertrophic pulm osteoarthropathy)
- dx: CXR (pleural effusion) - always perform bx for intrathoracic lymphadenopathy
- tx: surgery = best option (if met outside chest, not candidate; may recur after surgery)
- Radiation: important adjunct, chemotherapy has an uncertain benefit
- staging: primary TNM staging
11
Q
tuberculosis
A
- can present as acute or latent infxn
- only active TB is contagious (cough, sneezing), PRIMARY TB IS NOT CONTAGIOUS
- difficult to dx in HIV, PPD will be neg, atypical CXR findings, sputum likely neg, granuloma may not be present
- RF: HIV, immigrants, prisoners, health care workers, close contact, alcoholics, DM, steroids, blood malig, IVDU
- MC: mycobacterium tuberculosis, slow growing
- Transmission: inhalation of aerosolized droplets
- sxs: fatigue, weight loss, fever, night sweats, productive cough
- dx: sputum stain (acid fast bacilli), sputume culture + for M. tuberculosis, PPD, CXR (caseating granuloma formation (pulm opacitis, most often atypical)
- tx: RIPE tx, dc tx if transaminases >3-5x ULN, can spread to vertebral column
12
Q
Primary, Secondary, and Extrapulmonary TB
A
- Primary: bacilli inhaled and deposited into lung - ingested by alveolar macrophages
- surviving orgs multiply and disseminate via lymphatics and blood
- granulomas form and “wall off” mycobacteria - remains dormant
- insults on immune syst reactivates (5-10%)
- Asymptomatic: pleural effusion, can be progressive with pulm and constitutional sxs, usually clinically and radiographically silent
- Secondary: Host’s immunity weakened (HIV, malignancy, steroids, substance abuse, poor nutrition), gastrectomy, silicosis, DM)
- most oxygenated parts of lung: apical/posterior segments
-
Symptomatic: fever, night sweats, weight loss, malaise, chronic cough, progressive (dry to purulent, blood streaked)
- signs: chronically ill appearing, malnourished, posttussive apical rales
- Extrapulmonary TB: impaired immunity cannot contain bacteria - disseminates (HIV)
- any organ
- Miliary TB: hematogenous spread - can be due to reactivation or new infxn, HIV pts, organomegaly, reticulonodular infiltrates, choroidal tubercles in eye
13
Q
TB diagnostics
A
- high index of suspicion depending on RF and presentation
-
CXR - unilateral apical infiltrates with cavitations, hilar and paratracheal lymph node enlargement, pleural effusions, Ghon complex, Ranke complex
- HIV may show lower lung zone, diffuse, or miliary infiltrates
- Sputum studies: definitive dx by sputum culture, obtain 3 morning sputum speciments, takes 4-8wks, PCR can detect specifics
-
PPD (Mantoux test): screening to detect previous TB exposure, not for active TB dx; if + use CXR to r/o active TB
- if sxatic or abnl CXR, order AFB
- >15mm if no risk factors; >10 if high risk (homeless, imigrants, health care workers, DM); >5 if very high risk (HIV, organ transplant, contact with active TB)
- Interferon gamma release assay: measures interferon gamma release in response to MTB antigens, helps exclude false + TST
- blood cultures
- NAAT-R
14
Q
signs of healed primary TB
A
- Ghon complex: calcified focus with associated lymph node
- Ranke complex: Ghon complex undergoes fibrosis and calcification
- CXR: fibrocavitary apical dz, discrete nodules, pneumonic infiltrates usually in apical or posterior segments of upper lobes or in superior segments of lower lobes
15
Q
TB treatment: active TB, pregnant women, latent TB, immunocompetent, HIV pos
A
- Active TB: droplet precautions; isolation until sputum neg for AFB
- 2 months of tx with 4 drug RIPE, then 4 months with INH and Rifampin
- once isolate determined to be isoniazid sensitive, ethambutold can be DCed; if susceptible to isoniazid and rif, may continue on 2-drug regimens
- tx >/= 3 mos past neg cxs for MTB
- Pregnant: DONT TAKE PYRAZINAMIDE: RIE x 2mo, then isoniazid and rif for 7 mo; B6 (pyridoxine) daily to prevent periph neuropathy; breastfeeding NOT contraindicated
- Latent (+ PPD): 9mo INH AFTER active TB excluded via CXR, sputum, or both; NOT infxous, no active dz
- Immunocompetent: INH x9mo; adverse effect = drug induced hepatitis
- HIV pos: 9mo INH OR 2mo rif and pyrazinamide OR rif x 4mo
- Other: 9 mo tx when miliary, meninegal or bone/jnt dz; surgical drainage and debridement of necrotic bone in skeletal dz; steroid tx to prevent constrictive pericarditis and neuro complications
