03. primera clase neumologia unmsm.pdf

MEDICINA INTERNA NEUMOLOGÍA PRIMERA CLASE TBC-NAC-NIH PLEURA-IRA-ASMA

Dr. Christiam Ochoa UNMSM

PATOGENIA • INFECCION: Por vía inhalatoria (M. tuberculosis). Raramente por ingestión de leche de vaca contaminada (M. bovis). Lo más frecuente es que se necesiten varios meses de convivencia con un enfermo bacilífero para que se produzca la transmisión. La primoinfección suele ser asintomática. 5% TBC primaria. • ENFERMEDAD TUBERCULOSA: Primaria (niños 6 was considered suggestive of pneumonia)

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

Large-volume oropharyngeal aspiration around time of intubation

Short course of prophylactic antibiotics for comatose patientsa

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

Prolonged duration of ventilation

Daily awakening from sedation,a weaning protocolsa

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

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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

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)

OBSTETRICIA

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PLEURA

•DOLOR PLEURITICO –TOS - FIEBRE •MATIDEZ A LA PERCUSION - ABOLICION DE MV – VV •RADIOGRAFÍA: PA –LATERAL - ECOGRAFÍA – TAC / menisco pleural o línea de Ellis-Damoiseau •TORACOCENTESIS - BIOPSIA PLEURAL

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Disease

Diagnostic pleural fluid tests

Empyema

Observation (pus, putrid odor); culture

Malignancy

Positive cytology

Lupus pleuritis

LE cells present; pleural fluid serum ANA >1.0

Tuberculous pleurisy Positive AFB stain, culture

•Severo • exudado • linfocitos • pseudoquilotorax • ph menor de 7.2 • glucosa menor de 50 mg/dl • ADA mayor de 45 UI/L

TBC

•varon • moderado • exudado • linfocitos • pseudoquilotorax • ph menor de 7.2 • glucosa menor de 15 mg/dl

AR

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Esophageal rupture

High salivary amylase, pleural fluid acidosis (often as low as 6.00)

Fungal pleurisy

Positive KOH stain, culture

Chylothorax

Triglycerides (>110 mg/dL); lipoprotein electrophoresis (chylomicrons)

Hemothorax

Hematocrit (pleural fluid/blood >0.5)

Urinothorax

Creatinine (pleural fluid/serum >1.0)

Peritoneal dialysis

Protein (1.0

Rheumatoid pleurisy Characteristic cytology

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Causes of transudative effusions

Comment

Processes that always cause a transudative effusion Atelectasis Caused by increased intrapleural negative pressure Cerebrospinal fluid leak into Thoracic spinal surgery or trauma and ventriculopleural shunts pleural space Heart failure Acute diuresis can result in borderline exudative features Hepatic hydrothorax Rare without clinical ascites Hypoalbuminemia Edema fluid rarely isolated to pleural space Misplaced intravenous catheter into the pleural space; post Fontan Iatrogenic procedure Nephrotic syndrome Usually subpulmonic and bilateral Peritoneal dialysis Acute massive effusion develops within 48 hours of initiating dialysis Urinothorax Caused by ipsilateral obstructive uropathy Processes that may cause a transudative effusion, but usually cause an exudative effusion Amyloidosis Often exudative due to disruption of pleural surfaces Constrictive pericarditis Bilateral effusions Hypothyroid pleural effusion From hypothyroid heart disease or hypothyroidism per se Usually exudative, but 3 to 10 percent transudative possibly due to Malignancy early lymphatic obstruction, obstructive atelectasis, or concomitant disease (eg, heart failure) Pulmonary embolism Most are exudative effusions Sarcoidosis Stage II and III disease May be due to acute systemic venous hypertension or acute blockage Superior vena caval obstruction of thoracic lymph flow Trapped lung A result of remote or chronic inflammation

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EMPIEMA •

• • • • • •

FIEBRE ALTA ESCALOFRIOS TORACOCENTESIS FRUSTRAS PROTEINAS > 3gr/dl LEUCOCITOS > 25 000 / mm3 Ph < 7.2 LDH > 1000 UI/L GLUCOSA < 40 mg/dl

Pleural space anatomy

Bacteriology

Minimal,