Th4 Finley Pulm Infections 08 2


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Th4 Finley Pulm Infections 08 2

  1. 1. Pulmonary Infections C. Richard Finley, Ed.D, PA-C Associate Professor Physician Assistant Department College of Allied Health & Nursing Nova Southeastern University
  2. 2. Objectives <ul><li>Having access to lecture notes the attendee should be able to: </li></ul><ul><ul><li>Recall the basic pathophysiology involved with lower respiratory tract infections </li></ul></ul><ul><ul><li>Recall the presenting signs and symptoms of lower respiratory tract infections </li></ul></ul><ul><ul><li>Recall the essentials of diagnosis and treatment of lower respiratory tract infections </li></ul></ul>
  3. 3. <ul><li>Pneumonia </li></ul><ul><li>Tuberculosis (TB) </li></ul><ul><li>Influenza (Flu) </li></ul><ul><li>Acute Bronchitis </li></ul>
  4. 4. A 44-year-old male presents to your office complaining of a “bad cough” for the past 3-4 weeks. Over the past several days he has developed a low-grade fever, chills, and night sweats. Physical exam is notable for cachexia, hypoxia, and bilateral rales with scant hemoptysis. Which of the following is the most likely diagnosis? <ul><li>Community-acquired pneumonia </li></ul><ul><li>Tuberculosis </li></ul><ul><li>Acute bronchitis </li></ul><ul><li>Influenza </li></ul><ul><li>Lung abscess </li></ul>
  5. 5. Epidemiology <ul><li>Pneumonia is the fourth leading cause of death among the elderly </li></ul><ul><ul><li>especially when it develops in connection with a long-term illness </li></ul></ul><ul><li>Cases of Tuberculosis in the U.S. have declined since 1992 </li></ul><ul><ul><li>now is being found more often among foreign-born people age 45 and older </li></ul></ul>
  6. 6. <ul><li>The Flu also can hit the elderly hardest </li></ul><ul><ul><li>50% of influenza-caused hospitalizations </li></ul></ul><ul><ul><li>80% of flu deaths involve elderly </li></ul></ul><ul><li>Acute Bronchitis is one of the most common problems seen in clinical practice </li></ul><ul><ul><li>frequently follows viral infection </li></ul></ul>
  7. 7. Mechanics of Pulmonary Infections <ul><li>In as many as half of P neumonia cases, pathogen remains unknown </li></ul><ul><li>Tuberculosis is caused by a bacterium called tubercle bacilli, which can enter the body and remain dormant </li></ul><ul><ul><li>sometimes for years - until the body’s immune system weakens for some reason </li></ul></ul>
  8. 8. <ul><li>The Flu is a virus that’s spread “from one lung to another”—by coughing or sneezing </li></ul><ul><li>Smokers are at higher risk of getting acute Bronchitis </li></ul>
  9. 9. Symptoms of Pulmonary Infections
  10. 10. Which of the following is a hallmark symptom of bronchitis? <ul><li>Wheezing </li></ul><ul><li>Chills </li></ul><ul><li>Night sweats </li></ul><ul><li>Hemoptysis </li></ul><ul><li>Cough </li></ul>
  11. 11. Pneumonia <ul><li>Fever </li></ul><ul><li>Cough </li></ul><ul><li>Congestion </li></ul><ul><li>In older patients </li></ul><ul><ul><li>fever might not be present </li></ul></ul><ul><ul><ul><li>confused or delirious </li></ul></ul></ul><ul><ul><ul><li>lose control of basic functions </li></ul></ul></ul>
  12. 12. Tuberculosis <ul><li>Fever </li></ul><ul><li>Cough </li></ul><ul><li>Congestion </li></ul><ul><li>Night sweats </li></ul><ul><li>Weight loss </li></ul><ul><li>Fatigue </li></ul>
  13. 13. Influenza <ul><li>Fever </li></ul><ul><li>Chills </li></ul><ul><li>Headache </li></ul><ul><li>Muscle aches </li></ul><ul><li>Sore throat </li></ul><ul><li>Runny nose </li></ul><ul><li>Hot, moist skin </li></ul><ul><li>Fatigue </li></ul><ul><li>Dry cough </li></ul>
  14. 14. Acute Bronchitis <ul><li>Cough is the chief complaint </li></ul><ul><li>SOB </li></ul><ul><li>Wheezing </li></ul>
  15. 15. Causes of Pulmonary Infections
  16. 16. Pneumonia <ul><li>Serious illness </li></ul><ul><li>Smoking </li></ul><ul><li>Malnutrition </li></ul><ul><li>Surgery </li></ul><ul><li>Repeated antibiotic therapy </li></ul><ul><li>Aspiration due to reduced cough reflex (food “down the wrong pipe”) </li></ul><ul><li>The flu </li></ul>
  17. 17. Tuberculosis <ul><li>Poor nutrition </li></ul><ul><li>Alcoholism or drug addiction </li></ul><ul><li>Immune dysfunction </li></ul><ul><ul><li>disease, drugs, or aging </li></ul></ul><ul><li>Homelessness or imprisonment </li></ul><ul><li>Diabetes, malignancies, chronic renal failure </li></ul>
  18. 18. Influenza <ul><li>A variety of chronic medical illnesses </li></ul><ul><li>Seasonal local outbreaks or epidemics </li></ul>
  19. 19. Acute Bronchitis <ul><li>Often attributed to a respiratory tract virus </li></ul><ul><li>When purulent sputum is present </li></ul><ul><ul><li>the bacteria that cause community-acquired pneumonias </li></ul></ul>
  20. 20. A 35-year-old male presents to the clinic with complaints of a sore throat and a “harsh cough with chest congestion” over the past 3-5 days. He relates slight yellowish sputum production. Which of the following would confirm your suspicions? <ul><li>Throat culture </li></ul><ul><li>Nasal swab </li></ul><ul><li>Sputum culture </li></ul><ul><li>Chest x-ray </li></ul><ul><li>Lung biopsy </li></ul>
  21. 21. Diagnosing Pulmonary Infections
  22. 22. Pneumonia <ul><li>Chest x-ray </li></ul><ul><li>Blood test </li></ul>
  23. 23. Tuberculosis <ul><li>Sputum </li></ul><ul><li>Skin test to determine the presence of “viable organisms” </li></ul><ul><li>Chest x-ray </li></ul><ul><li>Biopsy and examination of lung tissue </li></ul><ul><li>Urine sample </li></ul><ul><ul><li>three consecutive days </li></ul></ul>
  24. 24. Influenza <ul><li>Confirmation of an outbreak </li></ul><ul><li>Nasal or throat swab </li></ul><ul><li>Nasal wash </li></ul><ul><li>Sputum exam </li></ul>
  25. 25. Acute Bronchitis <ul><li>History </li></ul><ul><li>Chest x-ray </li></ul>
  26. 26. Treating Pulmonary Infections
  27. 27. Your 30-year-old male patient is a household member of a patient being treated for active TB. Which of the following is an acceptable treatment regimen? <ul><li>Increased fluids and bedrest for 2 weeks </li></ul><ul><li>Amantadine (Symmetrel), once daily for 2 months </li></ul><ul><li>High-dose amoxicillin-clavulanate, 2 g p.o. BID for 1 week </li></ul><ul><li>Isoniazid (INH), once daily for 6 months </li></ul><ul><li>Observation, with monthly chest x-rays for 3 months </li></ul>
  28. 28. Pneumonia <ul><li>Antimicrobials </li></ul><ul><li>Respiratory care </li></ul><ul><li>Drainage of fluid from the lungs and chest cavity </li></ul>
  29. 29. Tuberculosis <ul><li>Isoniazid (INH) for six to 12 months </li></ul><ul><li>Fully developed disease </li></ul><ul><ul><li>A regimen of INH and 3 other for two months </li></ul></ul><ul><ul><ul><li>Rifampin (Rifadin) </li></ul></ul></ul><ul><ul><ul><li>Ethambutol (Myambutol) </li></ul></ul></ul><ul><ul><ul><li>Pyrazinamide </li></ul></ul></ul><ul><ul><li>Selected antituberculosis drugs (depending on test results) for four more months </li></ul></ul>
  30. 30. Influenza <ul><li>Bedrest – aspirin – chicken soup (fluids) </li></ul><ul><li>Oseltamivir (Tamiflu) and zanamivir (Relenza), given within 48 hrs of symptoms </li></ul><ul><ul><li>Types A & B </li></ul></ul><ul><li>Amantadine (Symmetrel) and rimantadine (Flumadine) </li></ul><ul><ul><li>Type A </li></ul></ul><ul><ul><li>CDC recommendations - resistance </li></ul></ul>
  31. 31. Acute Bronchitis <ul><li>70% to 90% of patients are treated with antibiotics </li></ul><ul><ul><li>trials demonstrate little clinical benefit </li></ul></ul><ul><li>High fever, chills, respiratory distress, underlying pulmonary or immunosuppressive disorders, or signs of parenchymal infection </li></ul><ul><ul><li>should be evaluated for pneumonia </li></ul></ul><ul><ul><li>treated according to the guidelines for community-acquired pneumonia </li></ul></ul>
  32. 32. A b-lactam 7 ; vancomycin plus a respiratory fluoroquinolone 1 ; or an advanced macrolide 3 An antipseudomonal agent 10 plus ciprofloxacin; an antipseudomonal agent 8 plus a respiratory fluoroquinolone 1 ; or an advanced macrolide 3 ICU therapy      Pseudomonas not an issue      Pseudomonas a concern A respiratory fluoroquinolone, 1 or an advanced macrolide 3 plus a b-lactam 7 A respiratory fluoroquinolone, 1 or an advanced macrolide 3 plus a b-lactam 7 Inpatient therapy      No recent antibiotics       Antibiotic therapy within 3 mo Amoxicillin-clavulanate 8 or clindamycin 9 A b-lactam 7 or a respiratory fluoroquinolone 1 Suspected aspiration pneumonia       Influenza with suspected bacterial superinfection A respiratory fluoroquinolone 1 or an advanced macrolide 3 A respiratory fluoroquinolone, 1 or an advanced macrolide 3 plus a b-lactam 7 Comorbidities 6      No recent antibiotics       Antibiotic therapy within 3 mo A respiratory fluoroquinolone, 1 a macrolide, 2 or doxycycline A respiratory fluoroquinolone 1 alone; an advanced macrolide 3 plus high-dose amoxicillin 4 ; or high-dose amoxicillin-clavulanate 5 Outpatient therapy      Previously healthy      Antibiotic therapy within 3 mo Preferred Treatment Options Clinical Variables/Settings
  33. 33. Which of the following does not significantly increase an individual’s risk for developing tuberculosis? <ul><li>Immunodeficiency </li></ul><ul><li>History of COPD </li></ul><ul><li>Malnutrition </li></ul><ul><li>Alcoholism and drug abuse </li></ul><ul><li>Renal failure </li></ul><ul><li>Diabetes </li></ul>
  34. 34. Note: all superscript numbers in table refer to footnotes below: <ul><li>Respiratory fluoroquinolones: levofloxacin, moxifloxacin, or gemfloxacin. </li></ul><ul><li>Macrolides: erythromycin, clarithromycin, azithromycin. </li></ul><ul><li>Advanced macrolides: clarithromycin, azithromycin. </li></ul><ul><li>High-dose amoxicillin, 1 g p.o. three times a day. </li></ul><ul><li>High-dose amoxicillin-clavulanate, 2 g p.o. two times a day. </li></ul><ul><li>Comorbidities: chronic obstructive pulmonary disease, congestive heart failure, diabetes, renal insufficiency, malignancy. </li></ul><ul><li>b-Lactam antibiotics: high-dose amoxicillin or amoxicillin-clavulanate, cefpodoxime, cefprozil, or cefuroxime. </li></ul><ul><li>Amoxicillin-clavulanate, 500 mg p.o., q. 8 hr. </li></ul><ul><li>Clindamycin, 150–300 mg p.o., q. 6 hr. </li></ul><ul><li>Antipseudomonal agents: piperacillin-tazobactam, imipenem, meropenem, ceftazidime, cefepime, or aztreonam (should be chosen for b-lactam-allergic patients). </li></ul>