ITE ReviewMust Know PulmAngela Pugliese MDDepartment of Emergency MedicineHenry Ford Hospital

Resources

HFH outlines

Rosh Review• First quiz assigned• in tutor mode, complete by end of month

• Quizzes to be given prior to each topic• will be in test mode• attempt completion prior to topic

• Mock ITE assigned beginning of January• replaces In-class exam

Study Plans

• We’re here to help

• <90% of passing ABEM board will meet with Pugliese or Slezak to create personalized study plan

• All others welcomed to meetings, contact via email

Overview• Pneumonia• Legionnare’s/PCP• Tuberculosis• Effusions• Other infections• Hemoptysis• Pneumothorax• Asthma/COPD• Drowning• ARDS

Pneumonia

Pneumonia• Most common cause of pneumonia is children??

• Strep pneumo• Viral• Staph• Hemophilus• Mycoplasma

Pneumonia• Pneumococcal pneumonia

• Most common cause of CAP• Still most common cause of pneumonia in HIV

• Gram positive lancet-shape• Most common cause of lobar pneumonia• Tx –

• Still sensitive to PCN and drug of choice• Mcrolides or doxy• Ceftriaxone (90% sensitivity) tx for inpatient

Pneumonia

• Hemophilus

• Gram negative pleomorphic rod (encapsulated and unencapsulated)• 2nd most common cause of CAP• Classic patient is elderly and debilitated• Tx- zithromax, augmentin, ceftriaxone

Pneumonia

• Klebsiella

• Plump encapsulated gram negative bacilli in pairs• THINK ETOH• Current jelly sputum• Upper lobe bulging fissure or abscess• Tx – IV cephalosporin + aminoglycoside

Pneumonia• Staph

• Gram positive cocci in pairs or clusters• THINK IVDA, SNF, INFLUENZA• Empyema common• Tx – nafcillin or vanc

Atypical Pneumonia

• Mycoplasma• Most common atypical, ‘walking pneumonia’• Cold agglutinin titers elevated 60%• tx - erythromycin

• Chlamydial• Staccato cough• Tx – 3 week doxy or erythromycin

• Psittacosis• PET BIRD or PET SHOP• Hyperexia, hemoptysis• Tx – 3 week tetracycline

Pneumonia

• The Viruses

• RSV – most common etiology in children <6, winter• Parainfluenza – 2nd most common in kids (causes croup

too)• Varicella-Zoster- bad in pregnancy, IV acyclovir and

admit• Influenza – most common etiology in adults, Nov-April,

tamiflu• CMV – transplant and AIDS, ganciclovir• Hantavirus – RODENT, southwest US, severe

respiratory distress, IV ribavirin

Legionnaire’s Disease

• Gram negative facultative intracellular bacillus• WATER SYSTEMS• Inhalation of contaminated aqueous aerosols• GI SYMPTOMS – watery diarrhea• Hyponatremia• Dx – urinary antigen test• Tx – macrolides, cipro for transplant pts

PCP

• Unicellular fungi, opportunistic• Most common opportunistic infection in HIV and leading

cause of death• CD4 < 200• CXR – normal, bilateral diffuse infiltrate ‘bat wing’• LDH increased• Tx – Bactrim and pentamidine• Alternative clindamycin and primaquine• Steroids paO2 < 70

Tuberculosis

• Think SNF, HIV, prisons, shelters and immigration

• AIDS defining illness

• Weakly gram positive obligate aerobe = acid fast

• Aerosolized droplet transmission

TB• Clinical presentation• Inactive pulmonary – 90% asymptomatic, + PPD• Reactivation – most common clinical form• Fever, night sweats, malaise, weight loss, productive cough• 80 % pulmonary involvement, apical lungs

• Active pulmonary foci – insidious• Chronic cough with hemoptysis

• Extrapulmonary - any organ• Disseminated ( miliary)• Meningitis – CSF increased protein• Pleural – effusion is exudative• GU - hematuria

TB• Diagnostic Studies• TB skin test – detects infection no active disease

• Don’t forget some people are anergic (HIV/AIDS)

• CXR –• Primary : Ghon complex, hilar adenopathy hallmark for kids• Reactivation : upper lobes• Miliary : small nodules scattered throughout both lung fields

• Micro –• Sputum test for AFB : ziehl-neelson or fluorescent, spec 98%• Confirm with culture which is gold standard

TB• Treatment• ISOLATE – mask on patient, put in negative pressure

• 4 drugs – Isoniazid, rifampin, pyrazinamide and streptomycin or ethambutol

• Side effects –• INH : hepatitis, peripheral neuropathy, intractable sz• Pyridoxine (vitamin B6)

• Rifampin : orange color secretions• Pyrazinamide :hyperuricemia, arthralgias• Ethambutol : optic neuritis• Streptomycin : nephrotoxicity

Effusions

Transudative

• CHF, nephrotic, cirrhosis• CHF most common cause

of effusions overall• Little protein

Exudative• Infection, CA, PE• Lots of protein• Pleural/serum protein >

0.5• Pleural LDH > 200• pH < 7.3 think infection• < 7 think empyema

Other Infections

Aspiration Pneumonia• Severity from specific substance • pH and volume are the big factors

• Risk factors – depressed cough or gag• FB aspiration – incomplete obstruction = cough, wheeze• CXR hyperinflation of affect side• Think new wheeze in kid

• Treatment• Supportive (ie intubate if hypoxic/airway concern)• Bronch to remove FB• Signs of infection or elderly/chronically ill

• Antibiotics, remember cover anaerobes

Lung Abscess

• Polymicrobial• Complication of aspiration• Halitosis, poor dentitia• CXR – cavitation with air fluid level, most

common RUL• Tx – clindamycin 6-8 week course

Empyema

• TB, staph, pseudomonas

• Treatment –• Must drain, ie chest tube required• Consult CT surgery• High dose broad spectrum antibiotics

SARS• Highly infectious coronavirus, transmitted in resp. droplets

• Presentation• 2-10 day incubation then…• Fever with cough and hypoxia• URI symptoms uncommon

• Thrombocytopenia and lymphocytopenia

• Treatment - supportive

Hemoptysis

Hemoptysis• Massive – single expectoration of > 50 mL• Or 600 mL in 24 hrs

• Etiology : infection• Massive - Bronchiectasis, TB, abscess or neoplasm

• Treatment• Trendelenburg with affected lung down• Consult pulmonary and CT surgery

Pneumothorax• Primary (idiopathic)• Young healthy smoker (skinny male)

• CXR confirms diagnosis (don’t forget US)

• Treatment – • O2 for all patients• Observation vs. CASP vs. Chest Tube

• Tension – needle, NO XRAY

Asthma/COPD

Asthma• Chronic, non progressive with reversible airway obstruction

• Etiology – triggers URI/virus, NSAID, ASA, beta-blocker

• Diagnostic testing – peak flow, ABG• Treatment – beta agonists, anticholinergic agents, steroids• Mag, hydration, heliox, BIPAP, epi• Intubation increases morbidity/mortality

• Pregnant patients• Incidence rises in pregnancy• Treatment same, terb over epi

COPD

• Most important risk factor smoking

• Progressive – • Can lead to right heart strain and even cor pulmonale

• Treatment – • O2 most important• Don’t forget about hypoxic drive

Drowning• 3rd most common cause of accidental death• Immersion syndrome• Sudden death with submersion in very cold water• Vagally mediated asystole or vfib

• Near drowning• Think metabolic acidosis from hypoxemia• Cerebral edema

• Treatment• Resuscitate• Don’t forget c-spine• rewarm

• Dispo – home if asymptomatic for 6 hours, O2 normal, CXR normal

ARDS• Mortality 40-70 %, sepsis most common cause• Etiology – GRAM NEG bacteremia, acute neuro crisis, tox• Pathophysiology• Permeability pulm edema, severe hypoxemia unresponsive to O2• Ireversable if inciting event not controlled

• Diagnosis• Decreased PaO2 (PaO2:FiO2 < 200)• High airway resistance• CXR – pulmonary edema with small heart

• Treatment• Fix inciting event• Oxygenate = PEEP

THE END

Announcements• Up Next Renal/GU

• ROSH!! Don’t forget Peer VIII• All outlines via email today, use for quick review