1. ITE Review Must Know Pulm Angela Pugliese MD Department of Emergency Medicine Henry Ford Hospital

2. Resources HFH outlines

3. Rosh Review First quiz assigned in tutor mode, complete by end of month Quizzes to be given prior to each topic will be in test mode attempt completion prior to topic Mock ITE assigned beginning of January replaces In-class exam

4. Study Plans We’re here to help <90% of passing ABEM board will meet with Pugliese or Slezak to create personalized study plan All others welcomed to meetings, contact via email

5. Overview Pneumonia Legionnare’s/PCP Tuberculosis Effusions Other infections Hemoptysis Pneumothorax Asthma/COPD Drowning ARDS

6. Pneumonia

7. Most common cause of pneumonia is children?? Strep pneumo Viral Staph Hemophilus Mycoplasma

8. Pneumonia Pneumococcal pneumonia Most common cause of CAP Still most common cause of pneumonia in HIV Gram positive lancet-shape Most common cause of lobar pneumonia Tx – Still sensitive to PCN and drug of choice Mcrolides or doxy Ceftriaxone (90% sensitivity) tx for inpatient

9. Pneumonia Hemophilus Gram negative pleomorphic rod (encapsulated and unencapsulated) 2 nd most common cause of CAP Classic patient is elderly and debilitated Tx- zithromax, augmentin, ceftriaxone

10. Pneumonia Klebsiella Plump encapsulated gram negative bacilli in pairs THINK ETOH Current jelly sputum Upper lobe bulging fissure or abscess Tx – IV cephalosporin + aminoglycoside

11. Pneumonia Staph Gram positive cocci in pairs or clusters THINK IVDA, SNF, INFLUENZA Empyema common Tx – nafcillin or vanc

12. Atypical Pneumonia

13. Mycoplasma Most common atypical, ‘walking pneumonia’ Cold agglutinin titers elevated 60% tx - erythromycin Chlamydial Staccato cough Tx – 3 week doxy or erythromycin Psittacosis PET BIRD or PET SHOP Hyperexia, hemoptysis Tx – 3 week tetracycline

14. Pneumonia The Viruses RSV – most common etiology in children <6, winter Parainfluenza – 2 nd most common in kids (causes croup too) Varicella-Zoster- bad in pregnancy, IV acyclovir and admit Influenza – most common etiology in adults, Nov-April, tamiflu CMV – transplant and AIDS, ganciclovir Hantavirus – RODENT, southwest US, severe respiratory distress, IV ribavirin

15. Legionnaire’s Disease Gram negative facultative intracellular bacillus WATER SYSTEMS Inhalation of contaminated aqueous aerosols GI SYMPTOMS – watery diarrhea Hyponatremia Dx – urinary antigen test Tx – macrolides, cipro for transplant pts

16. PCP Unicellular fungi, opportunistic Most common opportunistic infection in HIV and leading cause of death CD4 < 200 CXR – normal, bilateral diffuse infiltrate ‘bat wing’ LDH increased Tx – Bactrim and pentamidine Alternative clindamycin and primaquine Steroids paO2 < 70

17. Tuberculosis Think SNF, HIV, prisons, shelters and immigration AIDS defining illness Weakly gram positive obligate aerobe = acid fast Aerosolized droplet transmission

18. TB Clinical presentation Inactive pulmonary – 90% asymptomatic, + PPD Reactivation – most common clinical form Fever, night sweats, malaise, weight loss, productive cough 80 % pulmonary involvement, apical lungs Active pulmonary foci – insidious Chronic cough with hemoptysis Extrapulmonary - any organ Disseminated ( miliary) Meningitis – CSF increased protein Pleural – effusion is exudative GU - hematuria

19. TB Diagnostic Studies TB skin test – detects infection no active disease Don’t forget some people are anergic (HIV/AIDS) CXR – Primary : Ghon complex, hilar adenopathy hallmark for kids Reactivation : upper lobes Miliary : small nodules scattered throughout both lung fields Micro – Sputum test for AFB : ziehl-neelson or fluorescent, spec 98% Confirm with culture which is gold standard

20. TB Treatment ISOLATE – mask on patient, put in negative pressure 4 drugs – Isoniazid, rifampin, pyrazinamide and streptomycin or ethambutol Side effects – INH : hepatitis, peripheral neuropathy, intractable sz Pyridoxine (vitamin B6) Rifampin : orange color secretions Pyrazinamide :hyperuricemia, arthralgias Ethambutol : optic neuritis Streptomycin : nephrotoxicity

21. Effusions

22. Transudative CHF, nephrotic, cirrhosis CHF most common cause of effusions overall Little protein Exudative Infection, CA, PE Lots of protein Pleural/serum protein > 0.5 Pleural LDH > 200 pH < 7.3 think infection < 7 think empyema

23. Other Infections

24. Aspiration Pneumonia Severity from specific substance pH and volume are the big factors Risk factors – depressed cough or gag FB aspiration – incomplete obstruction = cough, wheeze CXR hyperinflation of affect side Think new wheeze in kid Treatment Supportive (ie intubate if hypoxic/airway concern) Bronch to remove FB Signs of infection or elderly/chronically ill Antibiotics, remember cover anaerobes

25. Lung Abscess Polymicrobial Complication of aspiration Halitosis, poor dentitia CXR – cavitation with air fluid level, most common RUL Tx – clindamycin 6-8 week course

26. Empyema TB, staph, pseudomonas Treatment – Must drain, ie chest tube required Consult CT surgery High dose broad spectrum antibiotics

27. SARS Highly infectious coronavirus, transmitted in resp. droplets Presentation 2-10 day incubation then… Fever with cough and hypoxia URI symptoms uncommon Thrombocytopenia and lymphocytopenia Treatment - supportive

28. Hemoptysis

29. Massive – single expectoration of > 50 mL Or 600 mL in 24 hrs Etiology : infection Massive - Bronchiectasis, TB, abscess or neoplasm Treatment Trendelenburg with affected lung down Consult pulmonary and CT surgery

30. Pneumothorax Primary (idiopathic) Young healthy smoker (skinny male) CXR confirms diagnosis (don’t forget US) Treatment – O2 for all patients Observation vs. CASP vs. Chest Tube Tension – needle, NO XRAY

31. Asthma/COPD

32. Asthma Chronic, non progressive with reversible airway obstruction Etiology – triggers URI/virus, NSAID, ASA, beta-blocker Diagnostic testing – peak flow, ABG Treatment – beta agonists, anticholinergic agents, steroids Mag, hydration, heliox, BIPAP, epi Intubation increases morbidity/mortality Pregnant patients Incidence rises in pregnancy Treatment same, terb over epi

33. COPD Most important risk factor smoking Progressive – Can lead to right heart strain and even cor pulmonale Treatment – O2 most important Don’t forget about hypoxic drive

34. Drowning 3 rd most common cause of accidental death Immersion syndrome Sudden death with submersion in very cold water Vagally mediated asystole or vfib Near drowning Think metabolic acidosis from hypoxemia Cerebral edema Treatment Resuscitate Don’t forget c-spine rewarm Dispo – home if asymptomatic for 6 hours, O2 normal, CXR normal

35. ARDS Mortality 40-70 %, sepsis most common cause Etiology – GRAM NEG bacteremia, acute neuro crisis, tox Pathophysiology Permeability pulm edema, severe hypoxemia unresponsive to O2 Ireversable if inciting event not controlled Diagnosis Decreased PaO2 (PaO2:FiO2 < 200) High airway resistance CXR – pulmonary edema with small heart Treatment Fix inciting event Oxygenate = PEEP

36. THE END

37. Announcements Up Next Renal/GU ROSH!! Don’t forget Peer VIII All outlines via email today, use for quick review