PANCE Blueprint Pulmonary (10%)

Infectious Pulmonary Disorders (PEARLS)

The NCCPA™ PANCE  Pulmonary Content Blueprint covers nine topics under the label infectious disorders including four types of pneumonia.

Acute bronchiolitis (ReelDx) Most often caused by RSV, diagnosed by nasal washing

Presentation:

  • Infants, young children
  • Tachypnea, respiratory distress, wheezing

Treatment:

  • RSV- admit if O2 sat < 95% and/or retractions. give IV ribavirin
  • Not RSV- supportive, suction
Acute bronchitis (ReelDx) Cough which persists for more than five days, 95% are viral

  • Organisms:
    • Most common: Viral
    • Chronic lung patients: H. influenzae, S. pneumoniae, M. catarrhalis
  • Presentation:
    • Cough, fever, constitutional symptoms
    • Typically less severe than pneumonia, normal vital signs, no rales, no egophony
  • Chest radiograph: Normal
  • Treatment: If O2 is less than 96% on room air the patient should be hospitalized
    • Treatment is supportive with Humidified 02, antipyretics
    • Beta-agonists, nebulized racemic epinephrine, corticosteroids if h/o underlying reactive airway disease - all are commonly used but do not have proof of efficacy
    • Ribavirin if severe lung or heart disease and in immunocompromised patients
Acute epiglottitis Caused by Hib, unvaccinated child, Thumbprint sign on X-Ray

3 D’s of epiglottitis:

  1. Dysphagia
  2. Drooling
  3. Respiratory Distress
Croup (ReelDx) Etiology: Parainfluenza virus

Presentation:

  • Winter months, patients < 3 years old
  • Barking cough, stridor at night
  • AP radiograph: “Steeple sign”

Treatment:

  • Supportive (air humidifier)
  • Severe: IV fluids and racemic epinephrine
Influenza (ReelDx) Presentation: Fevers, chills, coryza, myalgia

  • Rapid antigen test can be performed in the clinic

Treatment:

  • Supportive therapy
  • Zanamivir and Oseltamivir (Tamiflu) both treat influenza A and B must be given within 48 hours
  • Amantadine and Rimantadine treat only influenza A

Annual vaccine for everyone 6 months and older unless contraindicated

Pertussis (Whooping Cough) Organism: Bordetella pertussis (gram negative capsule)

Presentation:

  • Patients < 2 years old
  • Catarrhal stage: Cold-like symptoms, poor feeding, and sleeping
  • Paroxysmal stage: high-pitched "inspiratory whoop"
  • Convalescent stage: residual cough (100 days)

Diagnostic studies:

  • diagnose by nasopharyngeal swab
  • Lymphocytosis

Treatment: Macrolide

Vaccine: Tdap booster at 11-12 y/o, DTaP

Pneumonias (PEARLS) Presentation: Tachycardia, tachypnea, dyspnea, febrile, age 65+

Physical exam: Egophony, fremitus, rales

Chest radiograph: Infiltrates and or consolidation

Treatment:

Community-Acquired

  • Adult:
    • Healthy patients:
      • First line: Macrolide
      • Second line: Doxycycline
    • Comorbidities:
      • First line: Fluoroquinolone
      • Second line: Beta-lactam + Macrolide
    • Child:
      • First line: Amoxicillin
      • Second line: 2nd or 3rd generation Cephalosporin, Clindamycin or Macrolide

Hospital Acquired (HAC): Vancomycin + Piperacillin/Tazobactam

AIDs patients receive Bactrim prophylaxis against PCP pneumonia

  • Dapsone is second line

Admission criteria: CURB65

  • Confusion, Urea >7, RR >30, BP <90/<60, age >65
Pathogen Demographics Presentation
Streptococcus pneumoniae Most common, post splenectomy Rust colored sputum, single rigor. Lobar infiltrate
Mycoplasma pneumoniae College student, dorms Walking pneumonia: low temp, bullous myringitis
Klebsiella pneumoniae Alcohol abuse, chronic illness Currant jelly sputum
Legionella pneumophila Air conditioning, aerosolized water
Chlamydia pneumoniae College kids Long prodrome, sore throat
Pseudomonas spp. Cystic fibrosis *HAC: Ventilator associated
Haemophilus influenzae COPD, smokers, postsplenectomy
Pneumocystis jiroveci HIV CD4 <200, immunosuppressed Slow onset, increased LDH, interstitial infiltrates, bilateral
Staphylococcus spp. After influenza/viral infection *HAC (MRSA)  S. Aureus - salmon colored/lobar
Fungus Leukemia, lymphoma, immunosuppressed, AIDs

  • Histoplasma capsulatum caused by bat droppings -looks like sarcoidosis on CXR
  • Cryptococcus causes meningitis
  • Coccidioides (valley fever) in dry states
Viral
  • Influenza pneumonia: Most common in adults, characterized by a more precipitous onset and fulminant course
  • Adenovirus: Tends to cause symptoms fast, will present with GI symptoms and lasts about 1 week. May differentiate from bacterial mycoplasma pneumonia as mycoplasma is slow and insidious.
  • RSVChildren <1-year-old
  • Parainfluenza: Children 2-5 years old
Respiratory syncytial virus infection (ReelDX) Infants, young children, tachypnea, respiratory distress, wheezing.

  • Diagnosed with nasal washing

Supportive measures include albuterol via nebulizer, antipyretics and humidified oxygen admit if O2 sat < 95% and/or retractions

See Bronchiolitis

Tuberculosis (ReelDx) Organism: Mycobacterium tuberculosis (acid-fast bacilli)

Presentation: fatigue, productive cough, night sweats, weight loss, post-tussive rales

  • RF: endemic area, immunocompromised (HIV), recent immigrants (<5 y), prisoners, healthcare workers
  • Transmission: inhalation of aerosolized droplets
  • CXR: cavitary lesions, infiltrates, ghon complexes in the apex of lungs
  • Three sputum specimens for acid-fast bacilli staining (AFB smears) and Mycobacterium tuberculosis cultures
    • Sputum stain: acid-fast bacilli on smear
    • Sputum culture (+) for M. tuberculosis PPD
  • Biopsy: Caseating granulomas
  • Can spread to the vertebral column: Pott disease

Mantoux Test: Test is positive if induration

  • > 5 mm in immunosuppressed patients
  • > 10 mm in patients age < 4 or has risk factors
  • > 15 mm if there are no risk factors

Treatment:

  • Latent treatment: Isoniazid for 9 months
  • Active quad therapy (RIPE): Isoniazid, Rifampin, Ethambutol, Pyrazinamide for 8 weeks
    • Rifampin- Red orange urine, hepatitis
    • Isoniazid- peripheral neuropathy (give with B6)
    • Pyrazinamide- hyperuricemia
    • Ethambutol- Optic neuritis (eye changes), red-green blindness

Patients with active TB will need two negative AFB smears and cultures in a row negative for therapy cessation

  • Prophylaxis for household members: Isoniazid for 1 year
  • D/C therapy if transaminases > 3-5 × ULN
  • Pt's on INH should take supplemental Vitamin B6 (Pyridoxine) daily to prevent neuropathy
Emphysema (Prev Lesson)
(Next Lesson) Brian Wallace PA-C Podcast: Pulmonary Infections
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