Medicine Marrow Pg 271-280 (Pulmonology)

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Questions and Answers

What is a primary cause of defective cell-mediated immunity leading to pneumonia?

Virus infection (correct)

Parasitic infection

Fungal infection

Bacterial infection

Cytokines such as IL-1 and IL-6 are involved in causing fever during pneumonia.

True

What is the definition of pneumonia?

Acute infection of lung parenchyma without necrosis

The easiest access to the lower respiratory tract is through the ______.

oropharynx Signup and view all the answers

Match the cytokines with their respective functions in pneumonia:

IL-1 = Fever IL-6 = Fever TNF α = Recruitment of neutrophils IL-8 = Capillary leak and exudate Signup and view all the answers

Which of the following is an indication for long-term oxygen therapy?

PaO₂ < 55 mm Hg Signup and view all the answers

Which of the following characteristics is true for Streptococcus pneumoniae?

It is bile soluble Signup and view all the answers

Lung volume reduction surgery is contraindicated if FEV₁ is greater than 20%.

False Signup and view all the answers

What does the BODE index assess in chronic obstructive pulmonary disease patients?

BMI, obstructive ventilatory defect, dyspnea, exercise capacity Signup and view all the answers

Streptococcus pneumoniae is highly invasive except for type 3.

False Signup and view all the answers

An exacerbation event in COPD is characterized by ___ and/or cough with sputum.

dyspnea Signup and view all the answers

What toxin produced by Streptococcus pneumoniae creates pores in cell membranes?

Pneumolysin Signup and view all the answers

A significant risk factor for community-acquired pneumonia (CAP) includes age greater than _____ years.

65 Signup and view all the answers

Match the following O₂ therapy durations with their correct usage:

O₂ concentrators = 15-16 hours/day Long-term oxygen therapy = Indicated for PaO₂ < 55 mm Hg Exacerbation event = Characterized by dyspnea and cough Lung volume reduction surgery = Contraindicated if FEV₁ < 20% Signup and view all the answers

Match the following risk factors with their effects on community-acquired pneumonia:

Diabetes = Deficient cell-mediated immunity Steroid consumption = Immunocompromised Chronic kidney disease = Deficient cell-mediated immunity Transplant = Immunocompromised Signup and view all the answers

Which organism is most commonly associated with upper lobe involvement and cavitation in pneumonia?

Klebsiella Signup and view all the answers

MRSA is typically associated with presentations of cystic fibrosis.

True Signup and view all the answers

What is the possible etiology associated with dementia and decreased level of consciousness?

Coxiella burnetii or Francisella tularensis Signup and view all the answers

The presence of _ is a possible etiology for lung abscesses.

MRSA or Klebsiella or Anaerobes Signup and view all the answers

Match the following factors with their possible etiologies:

Bacteremia/diabetes, H/o alcoholism = Streptococcus pneumoniae, Klebsiella Cystic fibrosis = MRSA, Anaerobes Exposure to bats = Histoplasma, Legionella Travel to Ohio & St. Lawrence river valley = Histoplasma capsulatum, Chlamydia pneumoniae Signup and view all the answers

What is the minimum blood eosinophil count required to initiate treatment with inhaled corticosteroids?

300 cells/µL Signup and view all the answers

Repeated pneumonia is a contraindication for inhaled corticosteroid usage.

True Signup and view all the answers

What combination of medications is typically administered for asthma treatment?

ICS + Formoterol Signup and view all the answers

Patients with _______ and blood eosinophils greater than 300 cells/µL would receive LAMA + LABA + ICS.

Group B Signup and view all the answers

What is the main indication for bronchodilator reversibility testing?

To confirm a diagnosis of asthma or COPD Signup and view all the answers

In emphysema, FEV values are usually normal.

False Signup and view all the answers

Match the treatment types with their indicated conditions:

LABA = Dyspnea LAMA = ≥2 moderate exacerbations ICS = Blood eosinophils ≥ 300 cells/µL Roflumilast = Chronic bronchitis with FEV₁ < 50% Signup and view all the answers

What is the significance of a FEV₁/FVC ratio less than 0.7?

It indicates airflow obstruction and may warrant bronchodilator reversibility testing. Signup and view all the answers

Chronic damage to the parenchyma leads to chronic __________, which can progress to pulmonary hypertension.

hypoxia Signup and view all the answers

Match the following GOLD grades with their corresponding FEV₁ values:

GOLD 1 = ≥80% GOLD 2 = 50%-79% GOLD 3 = 30%-49% GOLD 4 = <30% Signup and view all the answers

What is the most common causative organism of lobar pneumonia?

Streptococcus pneumoniae Signup and view all the answers

Atypical pneumonia is typically characterized by an abrupt onset.

False Signup and view all the answers

Identify one clinical feature of typical pneumonia.

Cough with sputum Signup and view all the answers

The most common virus associated with interstitial pneumonia is _____ .

not specified Signup and view all the answers

Match the following pneumonia types with their respective characteristics:

Typical Pneumonia = Extracellular organism, Abrupt onset Atypical Pneumonia = Intracellular organism, Insidious onset Signup and view all the answers

Which type of pneumonia occurs more than 48 hours after admission to the hospital?

Hospital acquired pneumonia Signup and view all the answers

Community acquired pneumonia can be classified as either typical or atypical based on the organism responsible.

True Signup and view all the answers

Which of the following organisms is commonly associated with outpatient community-acquired pneumonia?

Strep. pneumoniae Signup and view all the answers

Name one anatomical classification of pneumonia.

Lobar or Interstitial Signup and view all the answers

Ventilator-associated pneumonia occurs more than 48 hours after __________ intubation.

endotracheal Signup and view all the answers

Cavity formation and hemoptysis are indicators of community-acquired MRSA infection.

True Signup and view all the answers

Match the types of pneumonia to their definitions:

Lobar = Affects a large and continuous area of the lobe of a lung Interstitial = Affects the tissue and spaces around the alveoli Typical = Caused by common bacteria such as Streptococcus pneumoniae Atypical = Caused by less common organisms like Mycoplasma pneumoniae Signup and view all the answers

What type of hemolysis is exhibited by Streptococcus pneumoniae on blood agar?

Alpha hemolysis Signup and view all the answers

Patients with _____ heart failure are at an increased risk for MRSA and MDR negative infections.

congestive Signup and view all the answers

Match the following types of pneumonia infections with their corresponding risk factors:

Community-Acquired Pneumonia = Recent antibiotic use Inpatient Non-ICU Pneumonia = Respiratory viruses Inpatient ICU Pneumonia = High mortality risk Outpatient Pneumonia = Strep. pneumoniae Signup and view all the answers

Which clinical feature might be the only symptom of pneumonia in older patients?

Confusion Signup and view all the answers

Leukocytosis is typically normal in lobar pneumonia.

False Signup and view all the answers

What is the usual cause of lobar pneumonia?

Streptococcus pneumoniae Signup and view all the answers

The hallmark sign of interstitial pneumonia is bilateral, diffuse fine ______ opacity.

reticular Signup and view all the answers

Match the following types of pneumonia with their usual cause:

Lobar pneumonia = Streptococcus pneumoniae Bronchopneumonia = Staphylococcus aureus Interstitial pneumonia = Pneumocystis jiroveci Aspiration pneumonia = Stroke or Seizure Signup and view all the answers

Study Notes

Long Term Oxygen Therapy

Long-term oxygen therapy for COPD is indicated when PaO₂ is less than 55 mm Hg or between 55 and 60 mm Hg if polycythemia or right heart failure is present.
O₂ concentrators are usually prescribed for 15-16 hours per day.

Surgical Management

Lung volume reduction surgery is contraindicated if FEV₁ is less than 20%.

BODE Index

BODE index is used to assess the severity of COPD and includes factors like:
- Body mass index (BMI)
- Obstructive ventilatory defect
- Dyspnea
- Exercise capacity

Exacerbation Management

COPD exacerbations are characterized by dyspnea and/or cough with sputum.

Pneumonia Definition and Pathogenesis

Pneumonia is an acute infection of lung parenchyma without necrosis.
It affects structures like alveoli, alveolar interstitium, vascular interstitium, respiratory bronchioles, and alveolar ducts.
Necrotizing pneumonia, leading to lung abscess, involves destruction of lung parenchyma.
Defective cell-mediated immunity allows viruses to disrupt lung microbiota, leading to alveolar epithelial barrier disruption and bacterial entry through microaspiration.
Cytokine release contributes to inflammation and symptoms:
- IL-1 and IL-6 cause fever
- TNF α recruits neutrophils
- IL-8 causes capillary leak leading to alveolo-capillary exudate, impairing diffusion, causing hypoxia, and leading to dyspnea.
Protective mechanisms of the lungs include pulmonary alveolar macrophage, gag reflex, and mucociliary clearance.
The oropharynx is the easiest and most common access route to the lower respiratory tract through aspiration.

Streptococcus pneumoniae Characteristics

Bile soluble
Optochin susceptible
Ferments inulin

Toxins Produced by Streptococcus pneumoniae

Capsular polysaccharide
Pneumolysin (cytolytic toxin)
IgA1
Pneumococcal somatic C antigen
C-reactive protein

Risk Factors for Community-Acquired Pneumonia (CAP)

Deficient cell-mediated immunity:
- Diabetes
- Chronic kidney disease
- Hemodialysis
- COPD, bronchiectasis
- Cardiac failure
- Age > 65 years
Immunocompromised:
- Steroid or monoclonal antibody consumption
- Transplant
- Neutropenia

Diagnostic Investigations for Pneumonia

Sputum microscopy (mainly used in atypical pneumonia, low yield)
Sputum culture
Blood culture
Bronchoalveolar lavage (BAL)

Etiology of Various Pneumonia Presentations and Histories

Bacteremia/diabetes, history of alcoholism, upper lobe involvement, bulging fissure, cavitation, golden S sign: Streptococcus pneumoniae, Klebsiella
COPD/smoking, bronchiectasis: Pseudomonas, Burkholderia cepacia
Cystic fibrosis: MRSA, anaerobes
Lung abscess, cavity, pneumatocele: MRSA, Klebsiella, anaerobes
Dementia, decreased level of consciousness, exposure to sheep, cats, goats: Coxiella burnetii, Francisella tularensis
Exposure to rabbits, exposure to bats: Histoplasma, Legionella
Travel in cruise ship, travel to Ohio and St. Lawrence river valley: Histoplasma capsulatum, Chlamydia pneumoniae
Atherosclerosis: various causes

Community-Acquired Pneumonia

Hospital-acquired pneumonia occurs greater than 48 hours after admission.
Ventilator-associated pneumonia occurs greater than 48 hours after endotracheal intubation.

Anatomical Classification of Pneumonia

Lobar Pneumonia
Interstitial Pneumonia

Organism-Based Classification of Pneumonia

Typical Pneumonia
Atypical Pneumonia

Inhaled Corticosteroids (ICS)

Indications for ICS in COPD:
- Blood eosinophils ≥ 300 cells/µL
- ≥ 2 moderate exacerbations/year
- History of concomitant asthma
- History of hospitalization for asthma exacerbation
Contraindications for ICS in COPD:
- Repeated pneumonia
- Blood eosinophils < 100 cells/µL
- History of tuberculosis
The 2019 guidelines recommend reducing the use of steroids.
In asthma, ICS are usually prescribed with formoterol.

Medical Management of COPD

Initial treatment for COPD:
- ≥ 2 moderate exacerbations or ≥ 1 hospitalization: LABA + LAMA ± ICS (if blood eosinophils ≥ 300)
- 0–1 moderate exacerbation: LABA/LAMA (Group A)
- Blood eosinophils < 300: LABA/LAMA (Group B)
- Blood eosinophils > 300: LAMA + LABA + ICS (Group B)
LABA (Long acting β agonist): Formoterol, Indacaterol
LAMA (Long acting muscarinic agonist): Tiotropium
Follow-up treatment for COPD:
- Dyspnea: LABA/LAMA, LABA + LAMA
- Exacerbation: LABA/LAMA, LAMA + LABA + ICS (if blood eosinophils ≥ 300)
Roflumilast (phosphodiesterase-4 inhibitor) may be beneficial in patients with chronic bronchitis and FEV₁ < 50%.
For unresponsive cases, azithromycin may be considered, particularly for patients with history of smoking/emphysema.

Alveoli and Pulmonary Vasculature in COPD

Alveoli and the alveolocapillary unit are involved in COPD.
Parenchyma damage leads to chronic hypoxia (↓PaO₂, ↑ PaCO₂), which triggers pulmonary vasoconstriction.
This can lead to pulmonary hypertension, pulmonary cor pulmonale, edema, and eventually death.

Diagnosis of COPD

Pulmonary function test (PFT):
- Emphysema:
  - Reduced FEV₁
  - Normal FVC
  - Reduced FEV₁/FVC
If FEV₁/FVC < 0.7, bronchodilator reversibility testing is recommended.
DLCO:
- Chronic bronchitis: Normal
- Emphysema: Reduced
Bronchodilator reversibility testing:
- Positive: Asthma
- Negative: COPD
Gold ABE assessment tool:
- Spirometry confirms diagnosis.
- Assess airflow obstruction and symptoms/risks.

Causative Organisms in Pneumonia

Lobar Pneumonia:
- Site: Restricted to one lobe
- Bacteria: Streptococcus pneumoniae (most common), Staphylococcus aureus (MRSA sp), Klebsiella pneumonia, Hemophilus influenza, Moraxella catarrhalis
Interstitial Pneumonia (Atypical):
- Site: Not localized to one lobe
- Bacteria: Mycoplasma, Chlamydia, Legionella
- Fungi: Aspergillus, Pneumocystis jirovecii (HIV), Nocardia (immunocompromised)
- Virus: Various viruses (most common)

Typical vs Atypical Pneumonia

Typical Pneumonia:
- Organism: Extracellular
- Onset: Abrupt
- Pathology: Alveolar capillary exudates, neutrophilic
- Predominance: Fever
- Clinical features: Cough with sputum, pleuritic pain, hemoptysis, dyspnea
- Culture/gram stain: Can be detected
- Inflammatory parameters: ↑CRP, ↑procalcitonin, leucocytosis
- Radiological features: Large area of consolidation (lobar involvement)
Atypical Pneumonia:
- Organism: Intracellular
- Onset: Insidious
- Pathology: Interstitial infiltrates, lymphocytic
- Clinical features: Mild URI → Dry cough, dyspnea, ARDS, low-grade fever, scanty sputum, extrapulmonary involvement
- Culture/gram stain: Cannot be detected

Community-Acquired MRSA

Concurrent influenza infection may be present.
Cavity, hemoptysis, and pneumatocele may occur.

Outpatient vs. Inpatient Pneumonia Treatment

Outpatient: Streptococcus pneumoniae, viruses, Mycoplasma, Chlamydia, H. influenza
Inpatient (Non-ICU): Streptococcus pneumoniae, respiratory viruses, Legionella sp.
Inpatient (ICU): Streptococcus pneumoniae, MRSA, multidrug-resistant gram-negative (MDR)

Risk Factors for MRSA and MDR Negative Infection

Congestive heart failure
Hemodialysis
Antibiotic use within the last 3 months
Hospitalization
Structural lung disease

Pneumococci Morphology and Culture

Gram-positive diplococci in chains, often described as flame-shaped or lanceolate.
Alpha hemolytic (partial hemolysis in 5% blood agar) and produces a green color on blood agar.

Hemolysis Flowchart

Complete hemolysis → Streptococcus → Partial hemolysis → Streptococcus pneumoniae, Enterococci → Streptococcus viridans → No hemolysis

CXR Findings in Pneumonia

Lobar Pneumonia:
- Homogeneous consolidation
- Silhouette sign
- Air bronchogram
- Sharply marginated fissure
- Usual cause: Streptococcus pneumoniae
Bronchopneumonia:
- Poorly defined heterogeneous patchy infiltrates scattered throughout the lung
- Air bronchogram
- Usual cause: Staphylococcus aureus (multilobar + cavitation + pneumatocoeles + abscess)
Interstitial Pneumonia:
- Bilateral, diffuse fine reticular opacity
- Usual cause: Pneumocystis jirovecii pneumonia (PCP)
Aspiration:
- Airspace opacification in a lobar or segmental distribution
- Gravity-dependent predilection
- Usual cause: Stroke, seizure

Clinical Pattern of Pneumonia

Bacteria bind to type 2 alveolar epithelial cells.

Clinical Features of Lobar Pneumonia

High spiking fever
Pleuritic chest pain
Cough
Hemoptysis
Dyspnea
Abdominal symptoms (Diffuse abdominal pain, recurrent hiccups)
Confusion

Pneumonia Investigations

CXR/CT
Blood investigations:
- CBC: ↑Leucocytosis (lobar pneumonia), normal (interstitial bronchopneumonia)
- CRP: ↑ (lobar pneumonia), normal (interstitial bronchopneumonia)
- Procalcitonin: ↓ (lobar pneumonia), normal (interstitial bronchopneumonia)

Community-Acquired Pneumonia Clinical Pattern

Bacteria bind to type 2 alveolar epithelial cells.

Clinical Features of Lobar Pneumonia

High spiking fever
Pleuritic chest pain
Cough
Hemoptysis
Dyspnea
Abdominal symptoms (Diffuse abdominal pain, recurrent hiccups)
Confusion

Investigations for Pneumonia

CXR/CT:
- Lobar pneumonia: Homogeneous consolidation, silhouette sign, air bronchogram, sharply marginated fissure
- Bronchopneumonia: Poorly defined heterogeneous patchy infiltrates, air bronchogram
- Interstitial pneumonia: Bilateral, diffuse fine reticular opacity
- Aspiration: Airspace opacification in a lobar or segmental distribution, gravity-dependent predilection
Blood investigations:
- CBC: ↑Leucocytosis (lobar pneumonia), normal (interstitial bronchopneumonia)
- CRP: ↑ (lobar pneumonia), normal (interstitial bronchopneumonia)
- Procalcitonin: ↓ (lobar pneumonia), normal (interstitial bronchopneumonia)

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Description

Test your knowledge on long-term oxygen therapy, surgical management, and the BODE index related to COPD, along with an understanding of pneumonia and its pathogenesis. This quiz covers critical concepts essential for managing respiratory conditions effectively.