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- Pulmonary hypertension
- Low pressure pulmonary edema
Pulmonary EdemaCauses: CHF, diastolic dysfunction (with arrhythmias or HTN), ARDS, volume overload, others not yet listed CXR clues: perihilar hazing, peribronchial cuffing, sub-pulmonic effusions (cannot see vessels overlying diaphragm), increased size of cardiac silhouette Treatment: oxygen, furosemide, morphine (reduce pain/anxiety and arterial/venodilation), nitroglycerine/nitroprusside, intubation/positive pressure ventilation (CPAP), HD/CVVH if renal failure Flash pulmonary edema from super-high HTN or restrictive pericarditis Pulmonary hypertensionCauses: left-sided heart failure, idiopathic, restrictive lung disease (sarcoidosis, ILD, scleroderma), chronic PE, high-altitude, kyphoscoliosis Treatment: correction of underlying cause can sometimes reverse HTN, decrease RVH O2 to minimize ongoing hypoxemia vasoconstriction more pulmonary HTN correct acid-base problems high-dose Ca channel blockers (25% response) IV epoprostenol (Flolan) can help in very select group of patients consider lifelong anticoagulation +/- IVC if chronic PE cardiopulmonary or pulmonary transplantation careful diuresis to relieve symptoms of right sided failure Primary pulmonary hypertension (PPHT) Causes: mitral stenosis, recurrent PE, sickle cell, collagen vascular diseases, congenital cardiac problems, cor triatriatum Low pressure pulmonary edemaUremia causes release of fluid into airspace / butterfly wing distribution on CXR Pneumonia [pediatric pneumonia] [see cavitary lung lesions] [age breakdown] 2 million per year / 40-70K deaths/yr / 6th leading cause of death overall / most common fatal nosocomial infection Presentation: cough, fever, sputum, pleurisy / elderly report fewer symptoms (even though they are there) Findings: tachypnea, crackles, bronchial breath sounds Types: lobar pneumonia, segmental pneumonia, bronchopneumonia, interstitial pneumonia, pneumonitis Organisms: Typical: S. Pneumo (1st), H. influenza, S. aureus, Moraxella Atypical: Mycoplasma, Klebsiella, Legionella, Chlamydia, Coxiella Virus: RSV, parainfluenza, influenza A/B, VZV Other: Tuberculosis, Pseudomonas, fungus (Cocci, Histo, etc), Nocardia, Actinomyces, PCP, parasites, Tularemia, Yersinia, RMSF, U. urealyticum (neonates), Prevotela (aspiration), Fusobacterium (aspiration), S. agalactiae Note: Enterobacter, Citrobacter and Flavobacterium almost never cause pneumonia, even on ventilator)
Diagnosis: 30-50% with no identified pathogen and bacterial picture CXR (60% with parapneumonic effusion; 5-10% develop empyema) Thoracentesis (if pleural effusion > 10mm on lateral decubitus film, loculated, evidence of pleural thickening on CT) Sputum: helpful if minimally contaminated (>25 PMN, <10 epithelials/LPF) Blood cultures: positive in 30-40% S. pneumo Serology: useful for Legionella, Mycoplasma, Chlamydia Ddx: aspiration pneumonitis, sarcoidosis, lymphoma, many other non-infectious lung diseases Labs: elevated ALT/AST: Q fever, psittacosis, Legionella (these are the only ones that do this) / elevated total bilirubin suggests S. pneumo or Legionella Treatment respiratory supportive care / PORT study addresses whether to hospitalize or not (based on demographics and exam findings) antibiotics: 3rd generation cephalosporin + macrolides or quinolone (Levaquin, Tequin) consider need for vancomycin (staph), cefepime +/- AG (pseudomonas), clindamycin (anaerobes), anti-fungal, more Course: pneumonia severity index or PSI (age, gender, comorbid disease, exam findings—O2 sat, lab data—BUN, Na) gives prognosis and helps determine if patient should be admitted Radiographic resolution: directly correlated with patient age / 80% of pts < 40 yrs have complete resolution by 6 wks / 20% of pts > 80 yrs / CXR resolution: may take several weeks / lack of at least partial radiographic resolution by 6 weeks (even asymptomatic) consider alternative causes (e.g., obstructing lesions/noninfectious causes) / bronchoscopy with BAL and TBBs (minimal morbidity, preferred initial invasive procedure) Tidbits: diffuse interstitial infiltrates: PCP, viral pleural effusions almost never in PCP cavitations & abscess necrotizing (staph, Tb, klebsiella, fungus) bronchopneumonia - low virulence organisms GI symptoms suggest Legionella relative bradycardia: subtract one from last digit of fever, multiple by 10 and add to 100 (105 degrees predicts HR of 140, anything less, even 120 is relative bradycardia) / seen in Legionella, Q fever, psittacosis, Salmonella (CAD only in HIV), others COPD/smoking ↑ H. influenza 80% of childhood pneumonia is viral Bacterial Pneumonia (More) U. urealyticum neonatal pneumonia Prevotela aspiration pneumonia Fusobacterium aspiration pneumonia Actinomyces chronic pneumonia MAI most common AFB MTb AFB rhodococcus equi AFB echinococcus S. agalactiae Klebsiella Legionella 2nd-3rd most common Francisella tularemia Yersinia pestis Pseudomonas aeruginosa AIDS / nosocomial AIDS
PCP look in exudate for cysts with central dot Kaposi’s sarcoma most common neoplasm Mucormycosis underlying disease Download 3.95 Mb. Share with your friends:
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