5. LRTI

Question 1

Discuss the pathophysiology of pneumonia

Answer 1

Acute resp symptoms with consolidation on the CXR

Infection of the alveolar space

Thickening of the basal membranes

Leaking of vessels

Question 2

What are the symptoms and signs of pneumonia?

Answer 2

Fever

Anorexia

Dyspnoea

Cough

Purulent sputum

Haemoptysis

Pleuritic pain

Tachypnoea

Hypotension

Signs of consolidation = diminished expansion, dull percussion, bronchial breathing

Crepitations

Increased vocal resonance

Question 3

What investigations should be performed for suspected pneumonia?

Answer 3

CURB 65 (dont use in chest infection, COPD, dementia)

o Confusion (AMT ≤ 8)

o Urea (> 7)

o Respiratory Rate (> 30)

o BP (SBP < 90; DBP < 60)

o Age (≥ 65)

CXR = consolidation, air bronchogram

Bloods = FBC, U+Es, LFTs, CRP, cultures

Sputum = microscopy and culture

Pleural fluid aspiration = C+S Immunocompromised or ITU = bronchoscopy or bronchoalveolar lavage

Question 4

How is pneumonia managed?

Answer 4

>2 CURB score = admit

CURB 1 = amoxicillin 5 days, doxy is pen-allergic

CURB 2 = amoxicillin + doxyclycline

CURB 3 = - co-amoxiclav + doxyclycline

Oxygen = sats >94%

IV fluids

Analgesia if pleurisy – paracetamol 1g/6h

Chest physiotherapy = if unable to clear secretions (prevent lobe collapse)

Follow up CXR at 6 weeks

Question 5

What complications can arise from pneumonia?

Answer 5

Early

• T1 resp failure
• Sepsis

Late

• Pleural effusion
• Empyema
• Lung abscess
• Bronchiectasis
• Bronchopleural fistula

Question 6

What is the aetiology of pneumonia?

Answer 6

CAP = strep pneumonia, H. influenza. Staph aureus

HAP = >48h after admission, Enterobacter, staph aureus

Aspiration = stroke, myasthenia, reduced consciousness

VAP = ventilator acquired (loss of cough, defence mechanism)

Question 7

What are the common causes of cough that should be investigated further?

Answer 7

Infection

Asthma

COPD

GORD

Bronchiectasis

Question 8

How do the antibiotic treatments differ for community acquired pneumonia and hospital-acquired pneumonia?

Answer 8

CAP = oral amoxicillin and clarithromycin

HA = IV aminoglycoside and IV penicillin

Question 9

What are the causes of a viral wheeze?

Answer 9

• non-atpoic disorder
• respiratory syncytial virus
• haemophilus
• rhinovirus
• coronaviruses
• human metapneumovirus
• human bocovirus

Question 10

How should a suspected viral wheeze be Ix?

Answer 10

• sweat test to rule out CF (especially if failure to thrive)
• nasal samples virology
• chronic: rule out TB, spriometry to rule out asthma

Question 11

Outline the Mx of a viral wheeze

Answer 11

• exclude inhaled foreign object
• avoid passive smoking (spead recovery)
• some need no Tx
• beta2-agonists via spacer (salbutamol )
• +/- inhaled steroids
• O2 needed/feeding diff = admit