Pulmonary

acute bronchitis

infection of the lower respiratory tract associated with inflammation and/or bronchospasm

what are 90% of acute bronchitis cases caused by?

viral infection

what are the signs and symptoms of acute bronchitis?

cough, wheezing, SOB, chest tightness

what test can you order when you are trying to differentiate between acute bronchitis and pneumonia?

chest XR

treatment for acute bronchitis?

supportive

if wheezing: bronchodilator (SABA: albuterol)

cough medicine

steroids (prednisone) - inhaled, systemic

what are some possible complications of acute bronchitis?

post-bronchitic cough, pneumonia, chronic bronchitis, pneumothorax

how can you educate patients on prevention from acute bronchitis?

follow contagious precautions, wash hands, don’t share food

bronchiolitis

respiratory illness w/ inflamed bronchioles, mucus production, and possible airway obstruction

in what population is bronchiolitis most prevalent in?

peak in 2-6 months old; common in 2 year olds

what are the signs and symptoms of bronchiolitis?

- URI symptoms (fever, congestion/drainage)

- cough

- noisy/raspy breathing

- signs: SOB, wheezing, nasal flaring, retraction, irritability, hypoxia (severe case), apnea

what tests should be done when bronchiolitis is suspected?

pulse oximetry and CXR to rule out pneumonia

treatment for bronchiolitis?

supportive (fluids, Tylenol, Motrin)

O2 if hypoxic

how can you educate patients on prevention from bronchiolitis?

prophylactic palivizumab (for high-risk infants)

What is the etiology for Bronchiolitis?

• RSV

• metapneumovirus

• parainfuenza

• influenza

What are complications to Bronhiolitis?

• hypoxia

• apnea

• resp failure

treatment aimed at helping the patient feel better, minimize complications, and support optimal recovery

supportive care

what supportive care can be given to help treat a fever?

Tylenol, Motrin, fluids

what supportive care can be given to help treat bodyaches?

Tylenol or Motrin

what supportive care can be given to help treat wheezing?

SABA (short acting beta agonist)

• not for RSV

what supportive care can be given to help treat hypoxia?

O2

what supportive care can be given to help treat dehydration?

fluids

highly contagious viral infection transmitted by respiratory route

influenza

what are the pathogens that cause influenza?

orthomyxovirus (type A, B, C) through respiratory droplet

why do we have an annual epidemic with influenza?

due to antigen drift

what are the symptoms of influenza?

fever, chills, coryza, myalgias, congestion, non-productive cough, GI sxs

What are some differentials for influenza?

• URI

• pnemonia

• covid

• viral syndrome

• pertusis

• legionnaires dz

treatment for influenza?

when should you consider antiviral?

what antiviral can be given?

supportive

all acutely ill patients, especially high risk patients (very young/old, pregnant, comorbidities)

oral oseltamivir (Tamiflu) 75 mg BID x 5 days

Which tests can be given for Influenza?

• rapid flu test

What are complications to influenza?

• OM

• sinusitis

• pneumonia

• pneumonitis

• sepsis

• death

If fever persists longer than 4 days with patients with the flu and they have a productive cough, and WBC >10,000, what can be suspected?

secondary bacterial infection

What are the methods for influenza prevention?

• vaccination first

• Chemoprophylaxis is an option for the unvaccinated, those within 2 weeks of vaccination, or immune compromised

  • high risk pts get oseltamivir 75 mg QD x 7 days from last exposure

  • in long term care: oseltamivir 75 mg QD x 2 wks

When do we start to admit patients with influenza?

• pneumonia + flu

• hypoxia

• altered mental status

• consider admission if pregnant

severe acute respiratory syndrome spread via respiratory droplets

COVID-19

What is the etiology of Covid-19?

Coronavirus (SARS-CoV-2)

what are the symptoms of COVID-19?

cough, fever/chills, myalgias, dyspnea, fatigue, sore throat, loss of taste/smell, congestion, runny nose, diarrhea, n/v

what are the 3 tests that can be done for COVID-19?

1. molecular (PCR)

2. rapid antigen (do they have COVID?)

3. antibodies (have they had COVID in the past?)

What are some differentials for COVID?

• URI

• HA

• pharyngitis

• flu

• viral syndrome

• pneumonia

• Gastroenteritis

treatment for COVID-19?

outpatient?

inpatient?

• supportive

• outpt (for mild-moderate at risk for severe): supportive, Paxlovid PO x 5 days (start within 5 days of onset) or Remdesivir IV (start within 7 days of onset)

• inpt: Remdesivier (if not on O2)

  • add Dexamethasone (if on O2),

  • Dexamethasone + Baricitinib or Tocilizumab (if on high-flow or non-invasive ventilation)

  • anticoagulation

who should get admitted if they have COVID?

- respiratory complications

- hypoxia (<88% pulse ox)

- advanced age

- immunosuppression

- chronic disease

- thrombotic event

- multisystem involvement

What are complications to COVID?

• pneumonitis

• pneumonia

• ARDS

• resp failture

• pleural effusion

• myocardiitis

• DVT

• Pulmonary embolism

• AKI

• GI sx

• long covid - fatigue, muscle weakness

infection of one or both of the lungs

pneumonia

who is at the greatest risk of developing pneumonia?

<2 yrs, > 65 yrs, smokers, chronically ill

what prevention can be given for penumonia?

pneumococcal vaccine, influenza vaccine, COVID-19 vaccine, adequate HIV tx

who should the pneumococcal vaccine be given to?

adults 65 and older or high risk populations aged 19-64

any pneumonia that results from contagious infection outside of a hospital or clinic or within 48 hrs of admission

Community Acquired Pneumonia (CAP)

what are the risk factors for CAP?

- older age

- tobacco use

- excessive alcohol use

- comorbid conditions

what testing is required for CAP diagnosis?

what additional testing should be ordered if there are inpatient?

CXR or CT

sputum, blood cultures x2, CBC, CMP, influenza, COVID-19

what treatment should be given for CAP for a patient that is healthy and being treated outpatient?

Amoxicillin 1 g TID

OR

Doxycycline 100 mg BID

OR

macrolide (azithromycin or clarithromycin)

what treatment should be given for CAP for a patient that has comorbidities and being treated outpatient?

macrolide (azithro or clarithro) OR doxycycline AND beta-lactam (amoxicillin-clavunate or cephalosporin)

OR

fluoroquinolone (levofloxacin, moxifloxacin)

what treatment should be given for CAP for a patient that is being treated inpatient (no ICU)?

fluoroquinolone (levofloxacin, moxifloxacin)

OR

macrolide (azithro or clarithro) AND beta-lactam (amox-clavunate, ceftriaxone)

pneumonia that develops more than 48 hours after a hospital admission

Nosocomial pneumonia

nosocomial pneumonia occurring >48 hours after being admitted in the hospital

HAP (hospital acquired pneumonia)

pneumonia in patient on mechanical ventilator support for >48hrs

VAP (ventilator associated pneumonia)

what are the signs & symptoms of pneumonia?

productive cough, fever, SOB, increased HR + RR, hypoxia, crackles, egophony, dullness

treatment for nosocomial pneumonia?

1. empiric abx

2. narrow abx regimen (once culture results available)

+ supportive

group of lung diseases affecting the interstitium (tissue and space around the alveoli of the lungs), causing scarring

Interstitial Lung Disease (ILD)

how would subacute interstitial lung disease present?

progressive dyspnea for weeks/months

cough

fatigue

decreased diffusion capacity

restriction

the space between the airspaces and vascular structures is usually ______, but ILD makes this space _______

thinner; thicker

what is FEV1?

forced expiratory volume in 1 second

what is FVC?

forced vital capacity

how would a restrictive lung condition look for FEV1?

normal

how would a obstructive lung condition look for FEV1?

decreased

how would a restrictive lung condition look for FVC?

decreased

how would a obstructive lung condition look for FVC?

normal or decreased

how would a restrictive lung condition be for FEV1/FVC ratio?

normal to increased

if the FEV1/FVC ratio is above the lower limit of normal, it is indicative of what type of lung disease?

normal or restrictive

if the FEV1/FVC ratio is below the lower limit of normal, it is indicative of what type of lung disease?

obstructive

what are some late disease signs/symptoms of interstitial lung disease?

tachypnea, decreased lung volumes, digital clubbing, right sided heart failure

what would you see on a CXR/CT chest in a person with interstitial lung disease?

ground glass appearance, nodular, cystic, honeycomb, fibrotic changes

what diagnostics can be used for interstitial lung disease?

PFTs, serologies, lavage, biopsy

progressive, extensive remodeling and scarring of the lungs due to an unknown cause

Idiopathic Interstitial Pneumonias (idiopathic pulmonary fibrosis)

what are the classic findings of idiopathic interstitial pneumonia on CXR/CT?

ground glass, honeycombing, fibrotic changes, traction bronchiectasis (usual interstitial pneumonia (UIP))

what are the symptoms of idiopathic interstitial pneumonia?

gradual onset of dyspnea, cough, fatigue

diffuse crackles

how are ILD exacerbations often treated?

- high flow oxygen (if presenting with acute respiratory failure)

- rule out infectious etiology

- broad spectrum abx and corticosteroids (high dose)

treatment for idiopathic interstitial pneumonia?

limited therapeutic options

lung transplant only cure

anti-fibrotics: nintedanib or pirfenidone (may slow progression)

chronic multisystem inflammatory non-caseating granulomatous disease

sarcoidosis

what are the signs & symptoms of sarcoidosis?

50% asymptomatic

fever, malaise, dry cough, dyspnea, erythema nodosum, lymphadenopathy

what would you expect to see on the following labs in a person with suspected sarcoidosis?

ACE

calcium

ESR

increased in all

what imaging would you order for sarcoidosis and what would you expect to see on them?

CXR: b/l hilar adenopathy and fibrotic changes

CT: parenchymal abnormalities (that aren't seen on xray)

what is shown here?

Hilar adenopathy

what are the ways in which you can make a sarcoidosis diagnosis?

biopsy (would see noncaseating granulomas)

patients with sarcoidosis should also have a complete ______ exam

eye

treatment for sarcoidosis?

oral corticosteroids (prednisone)

immunosuppressants if steroids failed (methotrexate, azathioprine, infliximab)

referral

what monitoring should be done for patients with sarcoidosis?

ACE levels, yearly exams, PFTs, eye exams, CXR, EKG

what can cause lung inflammation that is indistinguishable from other ILDs?

clinical manifestations of these?

connective tissue disease (CTD)

dyspnea, cough, fever, weight loss, general malaise

a group of lung disorders where ILD is caused by a medication

drug induced ILD

what are the more common drugs that can cause drug induced ILD?

amiodorone and macrobid

damage to the lungs in which particles from a fire coat the alveoli and prevent the normal exchange of gases

smoke inhalation

treatment for smoke inhalation?

- 100% O2

- bronchodilators

- suctioning of secretions

- PEEP

- burn treatment

- hydroxycobalamin

what are the essentials for diagnosing e-cigarette/vaping associated lung injury?

1. Hx of vaping w/n 3 months

2. chest image findings

3. r/o infectious cause

what are the signs & symptoms of e-cigarette/vaping associated lung injury?

SOB, chest pain

GI sxs

tachycardia & tachypnea

hypoxia

treatment for e-cigarette/vaping associated lung injury?

supportive

corticosteroids

what would be seen on CXR in e-cigarette/vaping associated lung injury?

b/l pulmonary opacities

abnormal condition caused by dust in the lungs, with chronic inflammation, infection, and bronchitis

pneumoconiosis

lung disease from inhalation and deposition of coal dust particles

coal workers pneumoconiosis

what are the signs & symptoms of coal workers pneumoconiosis?

usually asymptomatic

dyspnea, cough, rales

Rheumatoid Arthritis /w Coal Worker's Pneumoconiosis

Caplan syndrome

what would be seen on imaging with coal workers pneumoconiosis?

biopsy?

nodules in upper lung and fibrosis

dust laden macrophages

disease due to silica or glass dust in the lungs; occurs in mining occupations

silicosis

what are the signs & symptoms of silicosis?

often asymptomatic

dyspnea, cough, crackles