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 - commonly in fall and winter months

  • Infants and young children
  • Tachypnea, respiratory distress, wheezing
  • Diagnosed by nasal washing for RSV culture and antigen assay; CXR = normal

Treatment:

  • Hospitalization if O2 saturation < 95-96%, age <3 months, RR > 70, nasal flaring, retractions, or atelectasis on CXR
  • Supportive ⇒ humidified O2, antipyretics, beta-agonist, nebulized racemic epinephrine, and steroids
  • The only treatment demonstrated to improve bronchiolitis is oxygen
  • Ribavirin is given if severe lung or heart disease and in immunocompromised patients

Palivizumab prophylaxis (once per month for five months beginning in November) for special populations (immunocompromised, premature infants, neuromuscular disorders)

Acute bronchitis (ReelDx) Acute bronchitis is defined by a cough >5 days; can last 1-3 weeks

Organisms:

  • Most common - viral (95%)
  • Common bacterial = M. catarrhalis
  • Chronic lung patients: H. influenzae, S. pneumoniae, M. catarrhalis

Presentation:

  • Cough, fever (unusual), constitutional symptoms
  • Typically less severe than pneumonia, normal vital signs, no rales, no egophony
  • Obtain CXR if the diagnosis is uncertain or symptoms persist despite conservative treatment

Treatment is symptomatic and supportive - hydration, expectorant, analgesic, B2 agonist, cough suppressant

  • Corticosteroids if a history of underlying reactive airway disease
  • Ribavirin if severe lung or heart disease and in immunocompromised patients
  • If O2 < 96% on room air the patient should be hospitalized
  • Antibiotics are indicated in elderly, underlying cardiopulmonary disease, cough >7-10 days, or immunocompromised
Acute epiglottitis Supraglottic inflammation and obstruction of airway due to infection with Haemophilus influenzae type B (Hib)

  • This is a medical emergency
  • Caused by Hib - usually unvaccinated children (Hib vaccine at 2, 4, 6, 12-15 mo)

Tripod positioning ⇒ 3 D's of epiglottitis:

  • Dysphagia
  • Drooling
  • Respiratory Distress

The classic finding is thumbprint sign on x-ray lateral neck film, secure airway then culture for H.flu

Treatment involves intubating if necessary, supportive care, ceftriaxone, may treat as an outpatient if stable

Croup (ReelDx) Croup refers to an infection of the upper airway, which obstructs breathing and causes a characteristic barking cough

  • Caused by the parainfluenza virus
  • Common in children 6 mo-3 yrs, fall and early winter months (same time of year as bronchiolitis)
  • Barking cough and stridor
  • Steeple sign on PA CXR (narrowing trachea in the subglottic region)

Treatment:

  • Supportive (air humidifier), antipyretics
  • Severe: IV fluids and nebulized racemic epinephrine, steroids
Influenza (ReelDx) Influenza is a viral respiratory infection caused by orthomyxovirus resulting in fever, coryza, cough, headache, and malaise

  • Three strains exist: A, B, and C

Everyone > 6 mo should receive an annual influenza vaccine

  • Avoid vaccination: severe egg allergy, previous reaction, Guillain-Barré syndrome (GBS) within 6 weeks of previous vaccination, GBS in the past 6 weeks, <6 mo old. Avoid FluMist in pt with asthma

Dx: rapid antigen test in the clinic, rapid serology test more accurate

Treatment is symptomatic (for most) or with antivirals ⇒ ideally< 48 hours – Tamiflu (oseltamivir), inhaled Relenza (zanamivir), IV Rapivab (peramivir), and oral baloxavir (Xofluza)

  • Zanamivir and Oseltamivir both treat influenza A and B ⇒ (think Dr. “OZ” treats the flu)
  • Indications for antiviral treatment: hospitalized, outpatient with severe/progressive illness, an outpatient at high risk for complications (immunocompromised, pt with chronic medical conditions, >65 yo, pregnant women / 2 weeks postpartum)
Pertussis (Whooping Cough) Whooping cough (pertussis) is a highly contagious respiratory tract infection marked by a severe hacking cough followed by a high-pitched intake of breath that sounds like a whoop.

Gram-negative bacteria Bordetella pertussis – high contagious

  • Consider in adults with cough >2 weeks, 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)

Diagnosed by a nasopharyngeal swab of nasopharyngeal secretions – culture

Tx: macrolide (clarithromycin/azithromycin); supportive care with steroids / beta2 agonists

  • Vaccination: 5 doses – 2, 4, 6, 15-18 mo, 4-6yrs (DTap)
  • 11-18 yo = 1 dose Tdap
  • Expectant mothers should get Tdap during each pregnancy, usually at 27-36 weeks
Pneumonia (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 PJP pneumonia

  • Dapsone is second line

CURB-65 Score for Pneumonia Severity
Estimates mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment.

  • confusion, urea >7, RR >30, Systolic BP < 90 mmHg or Diastolic BP ≤ 60 mmHg, age >65
    • 0-1 = low risk, consider home tx
    • 2 = probable admission vs close outpatient management
    • 3-5 admission, manage as severe

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, post-splenectomy
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) MC cause of lower respiratory tract infection in children worldwide – virtually all get it by age 3; the leading cause of pneumonia and bronchiolitis

  • Rhinorrhea, wheezing/coughing that persists for months, low-grade fever, nasal flaring/retractions, nail bed cyanosis
  • Diagnosed with nasal washing, RSV antigen test; CXR can show diffuse infiltrates

Tx: Indications for hospitalization ⇒ tachypnea with feeding difficulties, visible retractions, oxygen desaturation < 95-96%

  • Supportive measures include albuterol via nebulizer, antipyretics and humidified oxygen, steroids (controversial), resolves in 5-7 days
  • Vaccine for children with lung issues or born premature/immunocompromised at birth should get Synagis prophylaxis (palivizumab) = once per month for five months beginning in November

See Bronchiolitis

Tuberculosis (ReelDx) Tuberculosis (TB) is a disease caused by bacteria called 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/o), prisoners, healthcare workers
  • Transmission: inhalation of aerosolized droplets

Screening with tuberculin skin test (TST) or interferon-gamma release assays IGRAs

Mantoux Test Rules: Test is positive if induration

  • > 5 mm at high risk, fibrotic changes on CXR, immunocompromised HIV/drugs, steroids/TNF antagonists daily, or close contact with pt with infectious TB
  • > 10 mm in patients age < 4 or some risk factors = hospitals and other healthcare facilities, IVDU, recent immigrants from high prevalence area, renal insufficiency, prison, homeless shelter, diabetes, head/neck cancer, gastrectomy/jejunoileal bypass surgery
  • > 15 mm if there are no risk factors

Diagnosis with sputum for AFB smears and Mycobacterium tuberculosis cultures – have to be 3 AFB negative

  • NAAT helps diagnosis better and sooner
  • CXR: cavitary lesions, infiltrates, ghon complexes in the apex of lungs
  • Biopsy ⇒ caseating granulomas
  • Military TB = spread outside lungs  ⇒ vertebral column: Pott disease; scrofula (TB to cervical lymph nodes)

Treatment: start empiric treatment in those who likely have it

  • PPD positive + CXR negative: latent TBIsoniazid for 9 months (+ B6 to prevent neuropathy)
  • PPD positive + CXR positive: active TB  Quad therapy (RIPE): rifampin, isoniazid, pyrazinamide, ethambutol – all are hepatotoxic

Four drugs x 8 weeks (RIPE) then two drugs x 16 weeks (RI)

  • Rifampin- Red-orange urine, hepatitis
  • Isoniazid- peripheral neuropathy (B6 = pyridoxine 25-50mg/day)
  • Pyrazinamide- hyperuricemia (gout)
  • 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 25-50mg/day) to prevent neuropathy

Monitor serum creatinine; take meds on an empty stomach since food can reduce absorption, watch for hepatotoxicity, aware of drug interactions especially with HIV meds

Emphysema (Prev Lesson)
(Next Lesson) Brian Wallace PA-C Podcast: Pulmonary Infections
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