MEDICINA INTERNA NEUMOLOGÍA
Dr.. Christ Dr Christiam iam Oc Ochoa hoa
INFECC INFECCIÓN IÓN AGUDA AGUDA DEL PARENQU ARENQUIMA IMA PULMON PULMONAR AR (ASOCI (ASOCIAD ADA A A UN INFIL INFILTRA TRADO DO NUEVO NUEVO EN LA RAD RADIOG IOGRAF RAFÍA ÍA DE TÓRAX TÓRAX..
VÍA DE INFECCION MICROASPIRACION: MICROASPIRACION : mas fc sanos. Neumococo, pyogenes, algunos stafilococos, neisseria, corynebacterium, Haemofiilus, Moraxella, Mycoplasma. INHALACION: INHALACION: mycoplasma, clamidophila, C. pssitaci, Coxiella burnetti, virus, TBC, TBC, legionella, aspergillus. HEMATOGENA: HEMATOGENA: stafilococo aureus.
FACTORES DE RIESGO ADULTO MAYORMAYOR- DM – EPOC - BRONQUIECTASIA ALCOHOLISMO – VIH - ADVP
ETIOLOGÍA
BATERIA TIPICAS (60-70%): Neumococo Neumococo 20-60% - Haemophylus pneu. pneu. 3-10% - Sf. Sf. aureus aureus 3-5% Enterobacteriaceae Enterobacteriaceae 3-5% ATIPICOS (10-20): M. Pneumo Pneumoniae niae C. pneumo pneumoniae niae - L. pneumo pneumoniae niae VIRUS (5-10%): Influenza – Para Parainf influe luenz nzaa - Rsv Rsv
Clínica típica: Tos, Expe Expect ctor orac ació ión, n, Fieb Fiebre re,, Dolor pleurítico, Disnea. En ancianos hipo hipore rexi xia, a, conf confus usió ión n y deshidratación. En el examen físico: roncante roncantess o crepitan crepitantes tes
CLINICA Clinica atipica: febricula, febricula, tos seca seca,, artr artrom omia ialg lgia ia,, confu confusi sion, on, hema hematu turi ria, a, mielitis trans ansversa, miringitis miringitis bulosa, bulosa, anemia anemia hemolitica, etc
Table 257-3 Epidemiologic Factors Suggesting Possible Causes of Community-Acquired Pneumonia
Factor
Possible Pathogen(s)
Alcoholism
Streptococcus pneumoniae, oral anaerobes, Klebsiella pneumoniae, Acinetobacter spp., Mycobacterium tuberculosis
COPD and/or smoking
Haemophilus influenzae, Pseudomonas aeruginosa, Legionella spp., S. pneumoniae, Moraxella catarrhalis, Chlamydia pneumoniae
Structural lung disease
P. aeruginosa, Burkholderia cepacia, Staphylococcus aureus
Dementia, stroke, decreased level of consciousness
Oral anaerobes, gram-negative enteric bacteria
Lung abscess
CA-MRSA, oral anaerobes, endemic fungi, M. tuberculosis, atypical mycobacteria
Travel to Ohio or St. Lawrence river valleys
Histoplasma capsulatum
Travel to southwestern United States
Hantavirus, Coccidioides spp.
Travel to Southeast Asia
Burkholderia pseudomallei, avian influenza virus
Stay in hotel or on cruise ship in previous 2 weeks
Legionella spp.
Local influenza activity
Influenza virus, S. pneumoniae, S. aureus
Exposure to bats or birds
H. capsulatum
Exposure to birds
Chlamydia psittaci
Exposure to rabbits
Francisella tularensis
Exposure to sheep, goats, parturient cats
Coxiella burnetii
Outpatient treatment 1. Previously healthy and no use of antimicrobials within the previous 3 months: A macrolide (azithromycin, clarithromycin, or erythromycin) OR Doxycyline* 2. Presence of comorbidities such as chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs; or use of antimicrobials within the previous 3 months (in which case an alternative from a different class should be selected): A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) OR A beta-lactam (first-line agents: high-dose amoxicillin, amoxicillinclavulanate; alternative agents: ceftriaxone, cefpodoxime, or cefuroxime) PLUS a macrolide (azithromycin, clarithromycin, or erythromycin)* 3. In regions with a high rate (>25 percent) of infection with high-level (MIC ≥16 µg/mL) macrolide-resistant Streptococcus pneumoniae, consider use of alternative agents listed in (2) above. Inpatients, non-ICU treatment A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) OR An antipneumococcal beta-lactam (preferred agents: cefotaxime, ceftriaxone, or ampicillin-sulbactam; or ertapenem for selected patients)• PLUS a macrolide (azithromycin, clarithromycin, or erythromycin)*Δ Inpatients, ICU treatment An antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS azithromycin OR An antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) OR For penicillin-allergic patients, a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) PLUS aztreonam Special concerns If Pseudomonas is a consideration: An antipneumococcal, antipseudomonal beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) PLUS either ciprofloxacin or levofloxacin (750 mg) OR The above beta-lactam PLUS an aminoglycoside PLUS azithromycin OR The above beta-lactam PLUS an aminoglycoside PLUS a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]); for penicillin-allergic patients, substitute aztreonam for above beta-lactam If CA-MRSA is a consideration: Add vancomycin or linezolid
DEFINICION FACTORES DE RIESGO •TABAQUISMO -
ALCOHOLISMO • ADULTO MAYOR • USO PREVIO A ATB UREMIA • INTUBACIÓN ENDOTRAQUEAL • USO DE SNG - COMA • CIRUGÍA MAYOR • DESNUTRICIÓN • FALLA MULTIORGÁNICA • NEUTROPENIA • USO DE ANTI H2/IBP
ETIOLOGÍA • MRSA. • PSEUDOMONA • OTROS SF. • KLEBSIELLA PNEUMONIAE • ENTEROBACTER • E. COLI • ACINETOBACTER
Table 257-6 Pathogenic Mechanisms and Corresponding Prevention Strategies for Ventilator-Associated Pneumonia Pathogenic Mechanism Prevention Strategy Oropharyngeal colonization with pathogenic bacteria Elimination of normal flora
Avoidance of prolonged antibiotic courses
Gastroesophageal reflux
Postpyloric enteral feedingb; avoidance of high gastric residuals, prokinetic agents
Bacterial overgrowth of stomach
Prophylactic agents that raise gastric pHb; selective decontamination of digestive tract with nonabsorbable antibioticsb
Cross-infection from other colonized patients
Hand washing, especially with alcohol-based hand rub; intensive infection control educationa; isolation; proper cleaning of reusable equipment
Large-volume aspiration
Endotracheal intubation; avoidance of sedation; decompression of small-bowel obstruction
Microaspiration around endotracheal tube Endotracheal intubation
Noninvasive ventilationa
Abnormal swallowing function
Early percutaneous tracheostomya
Secretions pooled above endotracheal tube
Head of bed elevateda; continuous aspiration of subglottic secretions with specialized endotracheal tubea; avoidance of reintubation; minimization of sedation and patient transport
Altered lower respiratory host defenses
Tight glycemic controlb; lowering of hemoglobin transfusion threshold; specialized enteral feeding formula
Pneumonia types ●Hospital-acquired (or nosocomial) pneumonia (HAP) 48H.. ●Ventilator-associated pneumonia (VAP) 48 to 72 hours. ●Healthcare-associated pneumonia (HCAP) is defined as pneumonia that occurs in a nonhospitalized patient with extensive healthcare contact, as defined by one or more of the following: •Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days •Residence in a nursing home or other long-term care facility •Hospitalization in an acute care hospital for two or more days within the prior 90 days •Attendance at a hospital or hemodialysis clinic within the prior 30 days
Temperature ≥36.5 or ≤38.4 = 0 point - ≥38.5 or ≤38.9 = 1 point - ≥39 or <36.5 = 2 points
Blood leukocytes, microL ≥4000 or ≤11,000 = 0 points - <4000 or >11,000 = 1 point - Band forms ≥50 percent = add 1 point Tracheal secretions Absence of tracheal secretions = 0 point Presence of non-purulent tracheal secretions = 1 point Presence of purulent tracheal secretions = 2 points Oxygenation PaO2/FIO2, mmHg >240 or ARDS (defined as PaO2/FIO2 ≤200, PAWP ≤18 mmHg and acute bilateral infiltrates) = 0 points PaO2/FIO2 ≤240 and no ARDS = 2 points
Pulmonary radiography No infiltrate = 0 point Diffuse (patchy) infiltrate = 1 point Localized infiltrate = 2 points Progression of pulmonary infiltrate No radiographic progression = 0 point Radiographic progression (after HF and ARDS excluded) = 2 points Culture of tracheal aspirate Pathogenic bacteria cultured in rare or few quantities or no growth = 0 point Pathogenic bacteria cultured in moderate or heavy quantity = 1 point
TERAPIA EMPIRICA ATB: GUIA ATS
Table 257-8 Empirical Antibiotic Treatment of Health Care –Associated Pneumonia Patients without Risk Factors for MDR Pathogens Ceftriaxone (2 g IV q24h) or Moxifloxacin (400 mg IV q24h), ciprofloxacin (400 mg IV q8h), or levofloxacin (750 mg IV q24h) or Ampicillin/sulbactam (3 g IV q6h) or Ertapenem (1 g IV q24h)
Patients with Risk Factors for MDR Pathogens 1. A -lactam: Ceftazidime (2 g IV q8h)or cefepime(2 g IV q8 –12h) or Piperacillin/tazobactam (4.5 g IV q6h), imipenem (500 mg IV q6h or 1 g IV q8h), or meropenem (1 g IV q8h) plus The serum gentamicin or tobramycin concentration should be obtained six hours (or up to 14 hours) after the initial dose of 7 mg/kg and plotted on the above nomogram. The interval for drug administration of subsequent doses of 7 mg/kg is then determined based on the interval specified on the graph. * Application of the nomogram for amikacin requires the measured concentration be divided by two. The new value should be plotted on the nomogram in order
2. A second agent active against gram-negative bacterial pathogens: Gentamicin or tobramycin (7 mg/kg IV q24h) or amikacin (20 mg/kg IV q24h) or Ciprofloxacin (400 mg IV q8h) or levofloxacin (750 mg IV q24h) plus 3. An agent active against gram-positive bacterial pathogens: Linezolid (600 mg IV q12h) or Vancomycin (15 mg/kg up to 1 g IV q12h)
NEUMONIA NOSOCOMIAL
ASMA
EPIDEMIOLOGÍA
DEFINICIÓN INFLAMACIÓN CRONICA VIA AEREA HIPERREACTIVIDAD BRONQUIAL BRONCOESPASMO REVERSIBLE - RECURRENTE
FACTORES GENÉTICOS
FACTORES DESENCADENANTES
FISIOPATOGENIA
DIAGNÓSTICO CLÍNICA
ESPIROMETRÍA
CLASIFICACIÓN DE LA SEVERIDAD
CLASIFICACIÓN NIVELES DE CONTROL
CLASIFICACIÓN DE LA CRISIS
PREVENCIÓN
TRATAMIENTO
TRATAMIENTO B2 ACCION
CORTA BROMURO IPRATROPIO CORTICOIDES SISTEM. CORTICOIDES INH. ANTAGONISTAS LCT CROMOGLICATOS B2 ACCION LARGA
PREVENCION
EPOC DEFINICIÓN
FACTORES DE RIESGO
FISIOPATOGENIA
FISIOPATOGENIA
DIAGNÓSTICO CLÍNICA
ESPIROMETRÍA
CLASIFICACIÓN FISIOPATOLÓGICA CARACT.
TIPO A
TIPO B
Tipología
Asténico sop.rosado
Picnico, cian. abot.
Disnea
grave
Leve
Tos
Mínima
Leve
Esputo
No
Si
Infecciones
Raro
Frecuente
Rx tórax
Hiperinsuflado
Trama BV
Hipoxemia
Leve
Grave
>CO2, HbR y poliglobulia No
Si
HTP y Cor
No
Moderada intensa
CPT
Aumentado
Normal
VR
Aumentado
Poco aumentado
Difusión
Disminuido
Normal o poco.
CLASIFICACIÓN SEVERIDAD
CLASIFICACIÓN FUNCIONAL
TRATAMIENTO
TRATAMIENTO OXIGENOTERAPIA
CIRUGÍA
