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3. CP - Diseases of the Respiratory System > (18) Lower respiratory tract infections > Flashcards

(18) Lower respiratory tract infections Flashcards

1
Q

What are the board types of LRTI?

A
  • tracheitis (trachea)
  • bronchitis (bronchus)
  • bronchiolitis (bronchioles)
  • pneumonia (lung)
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2
Q

What are the 2 different categories of bronchitis?

A
  • acute

- chronic (acute exacerbations)

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3
Q

What are the 4 different types of pneumonia?

A
  • community acquired (CAP)
  • hospital acquired (HAP)
  • ventilator acquired (VAP)
  • aspiration
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4
Q

What are the predisposing factors to LRTI?

A
  • loss or suppression of cough reflex/swallow
  • ciliary defects
  • mucous disorders
  • pulmonary oedema
  • immunodeficiency (congenital or acquired)
  • macrophage function inhibition
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5
Q

Loss or suppression of cough reflex/swallow is a predisposing factor to LRTI. What may this occur in?

A
  • stroke
  • coma
  • ventilation
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6
Q

A predisposing factor to LRTI is ciliary defects eg. PCD. What is PCD?

A

Primary ciliary dyskinesia

Autosomal recessive genetic disorder that causes defects in the action of cilia lining the respiratory tract

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7
Q

Mucous disorders are a predisposing factor to LRTI. Give an example

A

Cystic fibrosis

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8
Q

Macrophage function inhibition is a predisposing factor to LRTI. What may it be caused by?

A

Smoking

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9
Q

Which bacteria cause LRTIs?

A
  • strep. pneumoniae
  • haemophilus influenzae
  • staph. aureus
  • klebsiella pneumonia
  • mycoplasma pneumoniae
  • chlamydophila pneumoniae
  • legionella pneumophila
  • mycobacterium tuberculosis
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10
Q

Which viruses cause LRTIs?

A
  • influenza
  • parainfluenza
  • respiratory syncytial virus
  • adenovirus
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11
Q

Which fungi cause LRTIs?

A
  • aspergillus sp
  • candida sp
  • pneumocystitis jiroveci
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12
Q

What is acute bronchitis?

A

Inflammation and oedema of the trachea and bronchi

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13
Q

What are the symptoms of acute bronchitis?

A
  • cough (typically dry)
  • dyspnoae
  • tachypnoea

Cough may be associated with retrosternal pain

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14
Q

When and who is acute bronchitis common in?

A
  • most frequent in winter

- most common in children under 5

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15
Q

What organisms cause acute bronchitis?

A

Viruses are the usual cause

  • rhinovirus
  • coronavirus
  • adenovirus
  • influenza

Bacterial causes are less common

  • H. influenzae
  • M. pneumoniae
  • B. pertussis
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16
Q

How would you diagnose acute bronchitis?

A
  • diagnostic tests not indicated in mild presentations

- vaccination history and previous exposure (eg. influenza, B. pertussis) history may exclude some organisms

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17
Q

What may be helpful in acute bronchitis diagnosis if looking for a specific causes?

A

If needed, cultures of respiratory secretions may be helpful if looking for a specific cause eg. B. pertussis

But this is not routine

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18
Q

What treatment would you give for acute bronchitis?

A
  • supportive treatment for healthy patients

- those with severe disease of co-morbidity may require oxygen therapy or respiratory support

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19
Q

Should antibiotics be given for acute bronchitis?

A

Usually viral

Antibiotics only if bacterial cause is suspected or found

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20
Q

What is the definition of chronic bronchitis?

A

Cough productive of sputum on most days during at least 3 months of 2 successive years (which cannot be attributed to an alternative cause)

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21
Q

How common is chronic bronchitis?

A

Affects 10-25% of the population

  • most common in men and >40 years old
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22
Q

What is chronic bronchitis associated with?

A
  • smoking
  • pollution
  • allergens
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23
Q

If somebody with chronic bronchitis has airflow obstruction present on spirometry, what is this diagnosed as?

A

COPD

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24
Q

In chronic bronchitis, what is inflammation and oedema of the airways mediated by?

A

Exogenous irritants (rather than infective agents)

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25
Q

Can patients with chronic bronchitis have acute exacerbations?

A

Yes, patients have acute exacerbations mediated by the same infective pathogens as acute bronchitis

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26
Q

What is bronchiolitis?

A

Inflammation and oedema of the bronchioles

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27
Q

Who is bronchiolitis common in and when does it peak?

A

Primarily paediatrics

Infants 2-10 months

Peaks in winter and early spring

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28
Q

What are the signs and symptoms of bronchiolitis?

A
  • acute onset wheeze
  • nasal discharge
  • respiratory distress (grunting, retractions, nasal flaring)
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29
Q

What organisms cause bronchiolitis?

A

Most commonly caused by RSV (75% of cases) - 80% of children have evidence of previous RSV infection by 2 years old

Also caused by

  • parainfluenza
  • adenovirus
  • influenza
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30
Q

How would you diagnose bronchiolitis?

A
  • chest x-ray
  • full blood count
  • microbiological diagnosis:
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31
Q

How would you carry out a microbiological diagnosis of bronchiolitis?

A

Usually nasopharyngeal aspirate of respiratory secretions sent for viral PCR

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32
Q

How would you treat bronchiolitis?

A
  • supportive - oxygen, feeding assistance
  • no clear evidence to support steroids, bronchodilators, ribavirin
  • antibiotics only if complicated by bacterial infection
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33
Q

What is pneumonia?

A

Infection affecting the most distal airways and alveoli - formation of inflammatory exudate

34
Q

What are the two anatomical patterns of acute bacterial pneumonia?

A
  1. bronchopneumonia

2. lobar pneumonia

35
Q

Bronchopneumonia is one of the two anatomical patterns of pneumonia. What is it?

A

Characteristic patchy distribution centred on inflamed bronchioles and bronchi then subsequent spread to surrounding alveoli

36
Q

Lobar pneumonia is one of the two anatomical patterns of pneumonia. What is it?

A

Affects a large part, or the entirety of a lobe. 90% due to S. pneumoniae

37
Q

What is the definition of hospital acquired pneumonia (HAP)?

A
  • pneumonia developing >48 hours after hospital admission

- different causative organisms to CAP, especially if >5 days after admission: enterobacteriaceae and pseudomonas sp

38
Q

What is the definition of ventilator acquired pneumonia (VAP)?

A
  • subgroup of HAP

- pneumonia devleoping >48 hours after ET intubation and ventilation

39
Q

What is the definition of aspiration pneumonia?

A
  • subgroup of HAP
  • pneumonia resulting from the abnormal entry of fluids e.g. food, drinks, stomach contents etc. into the lower respiratory tract
  • patient usually has impaired swallow mechanism
40
Q

Describe the epidemiology of CAP?

A
  • 1 per 100 people per year
  • 20-40% cases require hospital admission
  • peak age = 50-70
  • peak onset = midwinter to early spring
41
Q

How are organisms acquired in CAP?

A
  • person-person or from a person’s existing commensals
  • from the environment
  • from animals
42
Q

In CAP, which organisms may be spread person-person?

A

S. pneumoniae

H. influenzae

43
Q

In CAP, which organisms may be a acquired from the environment?

A

L. pneumophilia

44
Q

In CAP, which organisms may be acquired from animals?

A

C. psittaci

45
Q

Bacterial causes of CAP are often divided into which two categories?

A
  • typical

- atypical

46
Q

What was ‘atypical pneumonia’ traditionally described as?

A

Cases which failed to respond to penicillin or sulpha drugs and no organism could be identified

(now this is recognised to be caused by ‘atypical’ organisms)

47
Q

When are the ‘typical’ organisms associated with CAP?

A
  • streptococcus pneumoniae
  • haemophilus influenzae
  • moraxella catarrhalis
  • staphylococcus aureus
  • klebsiella pneumoniae
48
Q

What are the ‘atypical’ organisms associated with CAP?

A
  • mycoplasma pneumoniae
  • legionella pneumophila
  • chlamydophila pneumoniae
  • chlamydophila psittaci
  • coxiella burnetii
49
Q

What are the clinical symptoms of bacterial CAP?

A
  • usually rapid onset
  • fever/chills
  • productive cough
  • mucopurulent sputum
  • pleuritic chest pain
  • general malaise: fatigue, anorexia
50
Q

What are clinical signs of bacterial CAP? (typical)

A
  • tachypnoea
  • tachycardia
  • hypotension
  • examination findings consistent with consolidation (dull to percuss, reduced air entry, bronchial breathing)
51
Q

What is the epidemiology of atypical pneumonia caused by mycoplasma pneumoniae?

A
  • autumn epidemics every 4-8 years

- commonest in children and young adults

52
Q

Guillain-Barre syndrome can occur as a complication of atypical pneumonia caused by mycoplasma pneumoniae. What is it?

A

Rapid-onset muscle weakness as a result of damage to the peripheral nervous system (auto-immune)

53
Q

What is the main symptom of atypical pneumonia caused by mycoplasma pneumoniae?

A

Cough

54
Q

How would you diagnose atypical pneumonia caused by mycoplasma pneumoniae?

A

Serology (difficult to culture)

55
Q

What are some rare complications associated with atypical pneumonia caused by mycoplasma pneumoniae?

A
  • pericarditis
  • arthritis
  • Guillain-Barre syndrome (peripheral neuropathy)
56
Q

What are outbreaks of atypical pneumonia caused by legionella pneumophilia associated with?

A

Colonises water piping systems

Outbreaks associated with showers, air conditioning units, humidifiers

57
Q

What are the signs and symptoms of atypical pneumonia caused by legionella pneumophila?

A
  • high fevers
  • rigors
  • cough (dry initially becoming productive)
  • dyspnoea
  • vomiting
  • diarrhoea
  • confusion
58
Q

What would you see on a blood test with atypical pneumonia caused by legionella pneumophila?

A
  • deranged LFTs

- SIADH (low sodium)

59
Q

Which atypical bacteria causes 3-10% of CAP cases in adults?

A

Chlamydophila pneumoniae

60
Q

What does chlamydophila pneumonia cause?

A

Atypical bacteria

Causes mild pneumonia or bronchitis in adolescents and young adults

Incidence highest in the elderly - may experience more severe disease

61
Q

The atypical pneumonia bacteria, chlamydophila psittaci, is associated with exposure to what?

A

Birds

62
Q

Which bacteria should you consider in patients with pneumonia, splenomegaly and bird exposure?

A

Chlamydophila psittaci

63
Q

In atypical pneumonia caused by chlamydophila psittaci, the patient may also have what?

A
  • rash
  • hepatitis
  • haemolytic anaemia
  • reactive arthritis
64
Q

Influenza virus usually produces uncomplicated disease but may also cause primary viral pneumonia. What are the symptoms of uncomplicated disease caused by influenza?

A
  • fever
  • headache
  • myalgia
  • dry cough
  • sore throat

(convalescence takes 2-3 weeks)

65
Q

Who does primary viral pneumonia occur more commonly in?

A

Patients with pre-existing cardiac and lung disorders

66
Q

What are the symptoms of primary viral pneumonia caused by influenza?

A
  • cough
  • breathlessness
  • cyanosis
67
Q

What may develop after initial period of improvement after primary viral pneumonia?

A

Secondary bacterial pneumonia

S. pneumoniae
H. influenzae
S. aureus

68
Q

How would you diagnose viral pneumonia?

A

Viral antigen detection in respiratory samples using PCR

69
Q

What are the non-microbiological investigations into CAP?

A
  • routine observations (BP, pulse, oximetry)
  • bloods: FBC, U&E, CRP, LFTs
  • chest X-ray
70
Q

When are microbiological investigations recommended for CAP?

A

Recommended for all moderate-severe CAP based on CURB65 score >2 (BTS guideline 2009)

71
Q

Give some examples of microbiological investigations for CAP

A
  • sputum gram stain and culture
  • blood culture
  • pneumococcal urinary antigen
  • legionella urinary antigen
  • PCR or serology
72
Q

What would you do PCR/serology for in CAP?

A
  • viral pathogens eg. influenza (PCR of respiratory samples)
  • mycoplasma pneumoniae (PCR of respiratory samples preferable, complement fixation: interpret with caution)
  • chlamydophila sp (complement fixation test most widely available)
73
Q

Why should be bother establishing a diagnosis for LRTI/CAP?

A
  • optimise antibiotic selection
  • limit the use of broad spectrum agents
  • identify organisms of epidemiological significance
  • identify antibiotic resistance and monitor trends
  • identify new or emerging pathogens
74
Q

How do you assess disease severity in CAP?

A 
C onfusion
U rea > 7mmol/l 
R espiratory rate > 30
B lood pressure 
 65 years

(give score of 1 for each feature present)

75
Q

What do CURB-65 scores indicate?

A

score = 0 = low severity = treat at home

score = 1 = low severity = home

score = 2 = moderate = treat in hospital

score = 3-5 = high = treat in hospital: assess for ITU admission

(This must be use in conjunction with clinical judgement)

76
Q

You would do ABC management for CAP as well as with any unwell or septic patient. What does A involve?

A

Airway

Ensure an open, patent and maintained airway

77
Q

You would do ABC management for CAP as well as with any unwell or septic patient. What does B involve?

A

Breathing

Asses respiratory rate and saturations

Provide supplemental oxygen to reach prescribed target

78
Q

You would do ABC management for CAP as well as with any unwell or septic patient. What does C involve?

A

Circulation

Assess blood pressure and heart rate

Gain IV access to give IV fluids if haemodynamically unstable

79
Q

What should you do after ABC when managing a CAP patient?

A

Prompt empirical antibiotic therapy

80
Q

Give some presentative methods against LRTIs?

A
  • pneumococcal vaccination (S. pneumoniae)

- influenza vaccination for vulnerable groups (annually)

81
Q

Who would you give a pneumococcal vaccination to?

A
  • patients with chronic heart, lung and kidney disease
  • patients with splenectomy
  • may repeat after 5 years in certain populations
82
Q

Who would you give an influenza vaccination to?

A
  • over 65s

- chronic disease, multiply co-morbidities

3. CP - Diseases of the Respiratory System (4 decks)

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