Respiratory pt 2 Flashcards
Croup (all info)
- viral inflammation of the upper and lower respiratory tract causing respiratory distress
- Etiology: PAIR :: Parainfluenza virus type I (60% of cases), also types II-IV; Adenovirus; Influenza; RSV
- Age: typically occurs in children aged 6 mos to 3 yrs
- Sex: M:F ratio 2:1.
- Sx: prodrome–few days of mild URI with coryza, nasal congestion, sore throat, cough, low-grade fever
then developing: hoarse voice and harsh, brassy, seal bark-like cough
Respiratory stridor (often at night) - PE: distress: from minimal to severe respiratory failure due to airway obstruction
Mild cases: examination at rest usually is normal; may be mild expiratory wheezing
More severe cases: inspiratory stridor at rest with nasal flaring, suprasternal and
intercostals retractions. Lethargy or agitation from hypoxemia .Tachypnea, tachycardia out of proportion to fever, lethargy, pallor - Course: usually peaks over 3-5d, resolves in 4-7d.
- Laboratory: leukocytosis with left shift
- Diagnosis: A-P X-ray of the C-spine, “steeple sign”
- Prognosis: self-limited disease, but can very rarely result in death from complete airway obs
- DDx: other causes of SOB and stridor:
-epiglottitis- hot potato voice, high fever, drool (emergency, don’t try to visualize!)
-foreign body–no hx URI, no fever
-retropharyngeal abscess–swelling at back of throat, seen on lateral xray
-diphtheria- grayish membrane over pharynx/larynx
ACUTE BRONCHITIS
- Self-limited inflammation the bronchus—usually from viral infection
Influenza A and B, parainfluenza, coronaviris (types 1-3), rhinovires, RSV
Rare pathogens: H flu, Mycoplasma pneumoniae, Chlamydophila pneumoniae, Pertussis
- SX: Cough > 5 days with sputum production (often starting with URI sx)
Sputum may be purulent from sloughing tracheobronchial and inflammatory cells
- PE:
- Generally afebrile or low grade fever
- Wheezing suggests bronchospasm
- Rhonchi indicates mucus in upper airways, clear with cough
- Normal percussion, no changes in transmitted voice tests
- Lab: CBC usually not warranted. No to mild leukocytosis
- Imaging: CXR usually not warranted. Only if developing signs of pneumonia, >75 yo, abnormal vitals, presence of crackles
- DDX: chronic bronchitis (persists), pneumonia, post-nasal drip, GERD, asthma
PNEUMONIA SPUTUM TO CAUSE
- Bloody/rust colored
- Green
- Foul-smelling
- Currant jelly
- Bloody/rust colored: pneumococcus
- Green: Pseudomonas, Haemophilus, and pneumococcal spp
- Foul-smelling: anaerobic
- Currant jelly: Klebsiella
PNEUMONIA CLASSIFICATIONS
a. Community-acquired pneumonia:
- 5-6 cases/1000 persons per year, worse in winter months
- Higher rates in males and in African Americans; in US, 8th most common cz of death
- Pre-disposing host conditions: level of consciousness, smoking, alcohol consumption,underlying lung disease, malnutrition, advancing age, peds, immunocompromised
- Most common organisms:
PAIR :: parainfluenza virus, adenovirus, influenza viruses A or B, RSV
Bacterial: S pneumoniae, H flu, S aureus, Group A strep, M catarrhalis, Klebsiella pneumoniae (rare), Legionella spp., M pneumoniae, Chlamydophila pneumoniae, P. aeruginosa
b. i Hospital-acquired (nosocomial) pneumonia
Pneumonia onset in >48hrs of hospital admission
ii Ventilator-associated pneumonia
Pneumonia onset 48-72 hrs after endotrachial intubation
iii Healthcare-associated pneumonia
Pneumonia occurs after extensive healthcare contact (IV therapy, chemotherapy, dialysis, nursing home residence)
Common organisms for above: E coli, Klebsiella, enterobacter spp, P aeruginosa, MRSA, H flu
General sxs of pneumonia
bacterial
viral
mycobacterium
bacterial: cough with thick greenish or rust-colored mucus; SOB; rapid breathing; sharp pleuritic pain–worse with deep breaths (S pneumoniae esp); abdominal pain, and severe fatigue. May be profuse sweating and mental confusion.
viral: malaise/headache/myalgia (flu-ike presentation), chest pain, sore throat, cough with scant sputum, dyspnea
mycobacterium: often very benign, slow progression, looks like URI (sore throat, fever, headache, malaise) and resolves without any treatment. possible violent attacks of coughing with scant mucus, chills/fever; occ. N/ V…..dry cough can persist for as long as a month; some pts can have a protracted
illness/weakness lasting as long as 6 weeks.
PE of pneumonia
bacterial
viral
mycobacterium
bacterial: Patient looks sick (fever, pallor, tachycardia, bradycardia, altered mental state) and lung exams point to consolidation (bronchial breath sounds, positive egophony, dullness to percussion, increased tactile fremitis, wheezes/rhonchi/crackles)
viral: most just have mild fever; some may have respiratory/multi-organ failure (decreased breath sounds, pleurisy, wheezing/rhonchi/crackles, tachypnea, tachycardia, sternal or intercostal retractions)
mycobacterium: non-toxic looking, CTAB, possibly rash, mild cervical LA, erythematous TM, pharyngeal erythem w/no exudate
This fungus is a frequent cause of morbidity and mortality in persons who are immunocompromised, may be AIDS-defining diagnosis. Rare in general population
(also give sxs and complications)
Pneumocystis jirovecii pneumonia (formerly P carinii)
Sxs: usually insidious onset of malaise, weight loss, night sweats and low-grade fever associated with a dry cough (sputum is too viscous to expectorate)
may be more severe: dyspnea, cyanosis, respiratory distress, chest pain, productive cough
Complications: spontaneous pneumothorax and hypoxemia Can also affect the liver, spleen and kidney.
Coccidioidomycosis (San Joaquin Valley fever or desert rheumatism)
Etiology: Coccidioides immitis, a soil fungus particularly adapted to arid condition. Southwest US (Utah, Ariz.), Mexico, S. America ….. Spores become airborne with soil disruption: construction, farming, quakes
Sxs: self-limited respiratory tract infx, occurs 1-3 weeks after exposure. most cases subclinical, never reaching the attention of a physician
common complaints are nonspecific: fever, cough, chest pain, fatigue, dyspnea, headache, arthralgias, and/or myalgias
May disseminate to other body systems in those immunocompromised
PE: Pulmonary: findings are generally nonspecific: crackles, pleural rubs, wheezing, and decreased breath sounds from effusions
Disseminated disease:
· Dermatologic; erythema nodosum
· CNS: disseminated CI may lead to meningitis - fever, altered mental status.
· Cardiovascular: endocarditis (rare but serious if involved)
· Musculoskeletal: osteomyelitis, septic arthritis, and synovitis.
Work-up:
· CBC - leukocytosis with eosinophilia, lymphocytosis, or monocytosis.
· CXR: Infiltrates can range from segmental or lobar to diffuse reticulonodular
· Skin testing - delayed-type hypersensitivity reactions may become pos in 1-3 wks.
· Serology tube precipitin assays for IgM may detect acute infection.
· Sputum culture results are usually delayed (5- to 7-day incubation period)
Diagnosis: clinical suspicion and history of possible exposure or travel to an endemic area.
Prognosis: General good, but poor if the patient is immunocompromised
Allergic Bronchopulmonary Aspergillosis
Eosinophilic pneumonia: Type I and II allergic rx. to Aspergillosis nigra or fumigatus (Fungus found in soil, decaying vegetation, dust, water)
Typical patient already has asthma- then develops cough, wheezing, dyspnea worse than normal, low-grade fever
Sputum- extremely tenacious, forms plugs with brown flecks filled with aspergillosis (colonized in the mucus)
CBC- diff. 50+% eosinophils, increased IgE, pos RAST skin test to aspergillosis
CXR shows infiltrates (Alveoli packed with eosinophils)
Histoplasmosis “spelunker’s lung”
Etiology:Histoplasma capsulatum, a fungus found in soil enriched with bird or bat droppings (caves) In US: Ohio and Mississippi river valleys, and Southeast. Spores inhaled into alveolar spaces, budding yeast seen within cells. Infx varies in sxs and seriousness (short-term, treatable infection to a disseminated disease)
Sxs:
- Acute (short term, mild) - fatigue, fever, chills, chest pain, dry cough (~10 d post exp)
- Chronic (long term, serious) – persistent or relapsing
- Disseminated histoplasmosis leads to serious symptoms, multiple body organs
PE: related to the extent and duration of infection.
- Acute pulmonary histoplasmosis
- Lung auscultation: crackles or wheezes (rarely)
- Heart auscultation: may be pericardial friction rub (~5% of pts develop pericarditis)
- Skin: erythema multiforme or erythema nodosum(~5-6% of pts develop)
- Chronic pulmonary histoplasmosis:
- Lung auscultation: crackles, wheezes
- Chronic progressive disseminated histoplasmosis:
- Mouth: ulcers on the buccal mucosa, tongue, gingiva, and larynx.
- Eyes: May be vision loss
- Abdomen: hepatosplenomegaly is possible
Work-up: sputum culture for the organism; positive histoplasma skin test, useful only for outbreak investigations; PCR to identify DNA; CXR: calcified hilar lymph nodes, lung scarring seen in chronic forms
Prognosis: acute pulmonary histoplasmosis is associated with a good outcome; chronic progressive disseminated histoplasmosis has a protracted course, lasting up to years, with long asymptomatic periods. If untreated may result in death
Two forms of non-infectious pneumonia
Aspiration from: esophageal dz., seizures, chronic hiccups, while under general anesthesia, post-surgery, alcoholism, drug abuse, disturbances of consciousness, vomiting
-local structures having problems leading to liquid in the lungs; severe inflamx process ensues, potentially fatal
Lipoid aspiration (fat or oil)- e.g. mineral oil (elderly pt.), nasal ointments, nose drops, furniture polish into lungs
- Oil causes inflammation, secondary infection
SX: acute: fever, cough, oil droplets in sputum, chronic wt loss, night sweats
CXR reveals infiltrates throughout lung
LUNG ABSCESS
- Sequestration of anaerobic bacteria leading to necrosis of lung parynchema, typically as a complication of aspiration pneumonia, or severe bacterial pneumonia
- SX: history of unresolving pneumonia, fever, cough, sour-tasting sputum for > 2wks; night sweats, weight loss, hemoptysis, pleurisy
- Work-up: Seen as cavitation on CXR and CT
Considerations with unresolved bacterial pneumonia
- Comorbidities: alcoholism, COPD, CHF, CKD, Malignancy, DM, HIV
- Advancing age >65
- Aggressive organism: Klebsiella, Legionella, S Aureus
- Drug-resistant organism: eg S pneumoniae
- Non-bacterial agents: TB, fungi
- Underlying neoplastic dz
- Misdiagnosis of: connective tissue dz, sarcoidosis, pulmonary embolism, pulmonary edema, drug-induced lung dz
Complications include: lung abscess, pleural effusion, empyema
Important points about top five bacteria causing pneumonia
i) Streptococcus pneumoniae (Pneumococcus pneumonia) (60-80%)
- Prognosis: overall mortality 5%
- Complications: meningitis, endocarditis
- REFER if: BUN >70, WBC <5000, other underlying dz. (heart, COPD)
ii) Klebsiella pneumoniae
- gram negative bacilli causes aggressive necrotizing lobar pneumonia
- risk factors: alcoholism, malnutrition, DM, recent tx with antibiotic, COPD, >40yo, hospitalized individuals
- Prognosis: 40-60% if untreated
- Sx: Cough, fever, pleuritic chest pain, dyspnea; spreads quickly, “currant jelly” sputum, Relative bradycardia: pulse rate does not increase as much with fever (usually with every degree in temp rise is inc 10 in heart rate)
iii) Haemophilus influenzae
- most commonly arises in the winter and early spring
- risk factors: asthma, COPD, smoking, immunocompromised
iv) Staphylococcus aureus
* in IV drug abusers and other individuals with debilitations infx often spread hematogenously to the lungs from contaminated injection sites.
v) Legionella pneumophila (gram negative bacterium) “Legionnaire’s disease”
- outbreaks from aerosolized organisms from air conditioning system or contaminated shower heads, more often in hotels and hospitals
- associated GI symptoms >50% of the time: anorexia, nausea, vomiting, and diarrhea.
