ITE Review
Must Know Pulm
Angela Pugliese MD
Department of Emergency Medicine
Henry 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
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Pneumonia
Legionnare’s/PCP
Tuberculosis
Effusions
Other infections
Hemoptysis
Pneumothorax
Asthma/COPD
Drowning
ARDS
Pneumonia
Pneumonia
• Most common cause of pneumonia is children??
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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
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Plump encapsulated gram negative bacilli in pairs
THINK ETOH
Current jelly sputum
Upper lobe bulging fissure or abscess
Tx – IV cephalosporin + aminoglycoside
Pneumonia
• Staph
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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)
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Rifampin : orange color secretions
Pyrazinamide :hyperuricemia, arthralgias
Ethambutol : optic neuritis
Streptomycin : nephrotoxicity
Effusions
Transudative
Exudative
• CHF, nephrotic, cirrhosis
• CHF most common cause
of effusions overall
• Little protein
• 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