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Cardiorespiratory > 5-pneumonia > Flashcards

5-pneumonia Flashcards

1
Q

what are the main forms of pneumonia classification?

A

Main clinical classification:
• Community acquired pneumonia (CAP)
versus
• Hospital (Healthcare) acquired pneumonia (HAP)

Other forms to be considered:
• Aspiration pneumonia
• Atypical pneumonia
• Pneumonia in the immunocompromised host

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2
Q

list other forms of pulmonary/ thoracic infection

A
  • Empyema

* Lung abscess

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3
Q

what are the signs and symptoms of CAP?

A 
•	Fever ± chills and rigors
•	Cough productive of purulent sputum
•	Pleuritic chest pain
•	Shortness of breath (Dyspnoea)
Duration of symptoms – hours to a few days.
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4
Q

what are the atypical Symptoms of community-acquired pneumonia:

A 
•	Dry cough
•	Shortness of breath
•	Diarrhea, abdominal pain
•	Ear pain (bullous myringitis)
•	Myalgia 
•	Arthralgia
Duration of symptoms – may be up to 2-3 weeks
(atypical pneumonia)
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5
Q

what are the vital sign abnormalities in CAP?

A
  • Tachypnoea, tachycardia, hypotension, pyrexia

* ± Cyanosis (Hypoxaemia)

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6
Q

what are the focal chest signs in CAP?

A
  • ± Decreased chest expansion
  • Increased tactile fremitus
  • Dullness to percussion
  • Increased vocal resonance
  • Bronchial breath sounds
  • Coarse crepitations ***** (Strongest and most consistent finding)
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7
Q

what is bronchial breathing?

A

Loud and high pitched, through part of inspiration and all of the expiration
Heard over the sternum (normally)

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8
Q

what is the strongest and most consistent focal finding in CAP?

A

Coarse crepitations

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9
Q

what are the crepitations (crackles)

A

A pathologic breath sound on auscultation characterized by discontinuous, intermittent rattling. Etiologies include pneumonia, atelectasis, pulmonary fibrosis, bronchiectasis, interstitial lung disease, and pulmonary edema.
Fine: Soft, high pitches caused by the sudden opening of small airways, classically described as velcro being separated, typically heard mid-to-late inspiration, uninfluenced by cough, gravity, or body position
Coarse: loud, low pitched produced by pockets of air passing through airways as they open and close intermittently. Tend to occur early during inspiration and throughout expiration with popping quality

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10
Q

what are the causes of fine crackles?

A

normal, asbestosis, sarcoidosis (ILD)

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11
Q

what are the causes of coarse crackles?

A

COPD, pulmonary edema

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12
Q

what are the differential diagnoses of CAP?

A
  • Pulmonary Embolism – acute history, SOB, pleuritic pain, absence of auscultation findings, absence of febrile symptoms
  • Congestive cardiac failure – acute or chronic, bibasal crepitations, signs of right heart failure
  • Pulmonary vasculitis – haemoptysis, failure to respond to antibiotics
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13
Q

what are the complications of CAP?

A 
•	Respiratory Failure
–	Adult Respiratory Distress Syndrome (ARDS)/ Acute lung injury (ALI)
•	Sepsis/Multiorgan failure
•	Delirium/acute confusional state
•	Exacerbation of underlying co-morbidity (e.g Atrial fibrillation)
•	Parapneumonic effusion , empyema
•	Lung abscess
•	Tachyarrhythymias
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14
Q

what are the common causative agents of pneumonia?

A

• Standard pathogens:
– Streptococcus pneumoniae (30-35% of cases)
– Haemophilus influenzae
– Staphyloccus aureus

•	Atypical pneumonia features:
–	Mycoplasma pneumoniae
–	Chlamydia pneumoniae
–	Legionella pneumophilia
–	Viral (influenzae)
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15
Q

what are the usual diagnostic tests that are performed in CAP?

A 
1.	Blood tests:
•	FBC, U&E, LFT’S, CRP, Glucose
2.	Microbiology tests:
•	Blood cultures
•	Urinary antigen for Legionella and Pneumococcus
•	Sputum culture? Serology testing?
3.	Radiology:
•	CXR
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16
Q

what lab tests should be performed in a patient with suspected CAP?

A 
1.	Blood tests:
•	CBC, UA and Electrolytes, LFT’S, CRP, Glucose
2.	Microbiology tests:
•	Blood cultures
•	Urinary antigen for Legionella and Pneumococcus
•	Sputum culture
•	Serology testing
3.	Radiology:
•	CXR
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17
Q

what is the CURB 65 scoring?

A

A score used to decide whether patients with pneumonia require hospitalization. Confusion, blood urea > 7 mmol/L (20 mg/dL), respiratory rate ≥ 30/min, systolic blood pressure ≤ 90 mm Hg or diastolic BP ≤ 60 mm Hg, and age ≥ 65 years are each assigned 1 point. If the CURB-65 score is ≥ 2, hospitalization is indicated.

18
Q

do negative sputum cultures out-rule infection/ pneumonia?

A

no

19
Q

what are the CXR findings in CAP?

A
  • Heterogenous/ patchy infiltrate(s) – corresponding to a lobe(s)
  • Lobar/ multi-lobar – corresponds with severity (not organisms)
  • Pleural effusion – parapneumonic effusions vs empyema
  • Resolution of radiology findings lags behind clinical improvement
20
Q

what is the interpretation of CURB-?

A

CURB-65 score ≤ 1: The patient may be treated as an outpatient.
CURB-65 score ≥ 2: Hospitalization is indicated.
CURB-65 score ≥ 3: ICU-care should be considered.

21
Q

except for CURB- scoring, what are the additional adverse prognostic features?

A

SaO<92%, PaO2<8

CXR: bilateral/multilobar shadowing

22
Q

what are the pre-existing adverse prognostic features of CAP?

A

age >50

any other coexisting chronic illness (DM)

23
Q

what are the treatment options for a patient with CAP depending on location of the patient?

A

Outpatient
• Co-amoxyclav p.o.

Inpatient
• Co-amoxyclav i.v. + Clarithromycin p.o.

Intensive care (severe CAP)
•	Piperacillin-tazobactami.v. + Clarithromycin i.v.
24
Q

what is the pneumonia severity index (PSI)?

A

The pneumonia severity index (PSI) or PORT Score is a clinical prediction rule that medical practitioners can use to calculate the probability of morbidity and mortality among patients with community acquired pneumonia. The PSI/PORT score is often used to predict the need for hospitalization in people with pneumonia.

25
Q

what are the parameters used in PSI?

A

1) Sex
- -M (0 points)
- -F (-10 points)
2) Demographic factors
- -Age (1 point for each year)
- -Nursing home resident (10 points)
3) Comorbid illnesses
- -Neoplastic disease (30 points)
- -Liver disease (20 points)
- -Congestive heart failure (10 points)
- -Cerebrovascular disease (10 points)
- -Renal disease (10 points)
4) Physical examination findings
- -Altered mental status (20 points)
- -Respiratory rate ≥30/minute (20 points)
- -Systolic blood pressure <90 mmHg (20 points)
- -Temperature <35 degrees C or ≥40 degrees C (15 points)
- -Pulse ≥125/minute (10 points)
5) Laboratory and radiographic findings
- -Arterial pH <7.35 (30 points)
- -Blood urea nitrogen ≥30 mg/dL (11 mmol/L) (20 points)
- -Sodium <130 mEq/L (20 points)
- -Glucose ≥250 mg/dL (14 mmol/L) (10 points)
- -Hematocrit <30 percent (10 points)
- -Partial pressure of arterial oxygen <60 mmHg or oxygen saturation <90% (10 points)
- -Pleural effusion (10 points)

26
Q

what is the management of CAP inpatient?

A
  • Maintain oxygenation: nasal prongs, venturi face mask, high flow non-rebreathable face mask, CPAP (continous positive pressure ventilation, intubation & ventilation)
  • Maintain BP: iv fluids, inotropes (noradrenaline)
  • Consider steroids if obstructive lung disease
27
Q

what are the recommendations for influenza vaccination?

•

A

Inactivated influenza vaccine, rather than live attenuated, is recommended in adults
• The vaccine should be given to persons at increased risk for complications due to influenza
• Yearly vaccinations are recommended since this is safe and does not lead to a decreased immune
• In health care personnel yearly vaccination is recommended, especially in settings where elderly persons or other high-risk groups are treated response

28
Q

what are the at-risk patients for severe CAP?

A
  • age > 65 years
  • institutionalisation
  • chronic cardiac diseases
  • chronic pulmonary diseases
  • unstable diabetes mellitus
  • chronic renal diseases
  • immunocompromised persons
  • hemoglobinopathies
  • women who will be in the second or third trimester of pregnancy during the influenza season
29
Q

what are the recommendations for Pneumococcal vaccination?

A
  • Individuals with chronic/ structural lung disease – bronchiectasis, severe COPD
  • Previouspneumonia
  • Post – splenectomy
30
Q

what is the empyema?

A
  • Sequelae of pneumonia
  • Usually occurs 7-10 days after initial pneumonia
  • Duration of symptoms – may be weeks before presentation
  • Pleural fluid: exudate, ¯pH (acidic), ¯glucose, ­ WCC (neutrophilia)
  • ­­CRP, ¯SerumAlbumin
  • Organisms: similar to lung access pathogens
31
Q

what is the treatment of empyema?

A

Appropriate systemic antibiotic treatment
Chest tube (thoracostomy) to remove empyema fluid
Intrapleural administration of fibrinolytic agents (to improve chest tube drainage of empyema fluid)
Thoracoscopic debridement (removal of pus and pleural fibrosis) if empyema does not resolve after chest tube drainage

32
Q

in empyema, pleural fluid analysis shows transudative effusion.True/False

A

False

  • -Exudative effusion
  • -Low glucose (< 60 mg/dL) and pH < 7.3
  • -Positive bacterial culture
33
Q

what are the pathogens commonly involved in empyema?

A
  • -Most commonly: mixed infections caused by anaerobic bacteria that colonize the oral cavity (e.g., Peptostreptococcus, Prevotella, Bacteroides, Fusobacterium spp.)
  • -Less commonly: monomicrobial lung abscess caused by S. aureus, Klebsiella pneumoniae, Streptococcus pyogenes, Streptococcus anginosus
34
Q

what is the incidence of HAP?

A
  • 15% of all intra-hospital infections
  • 2nd most frequent nosocomial infection
  • Average incidence of 6.3 per 1000 hospital discharges
35
Q

what is the HAP?

A 
HAP
–	> 48 hours after admission
–	Early onset – within 4 days
–	Late onset – after 5 days
VAP
–	48 – 72 hours after endotracheal intubation

Similar pathogens for HAP and VAP
Almost always bacterial (in the immunocompetent host)
­Polymicrobial in VAP (especially in ARDS)

36
Q

what is the VAP?

A

A hospital-acquired infection that develops 48 hours after the initiation of mechanical ventilation via either tracheostomy or intubation. Approx. 5–10% of patients on mechanical ventilation develop VAP.

37
Q

how HAP is clinically diagnosed?

A 
•	New or progressive infiltrate on CXR
\+ (two out of three)
•	Fever > 380C
•	Leukocytosis or leukopenia
•	Purulent sputum/ secretions
38
Q

early vs late-onset HAP

A

late-onset HAP (≥5 days after admission) is more likely to be associated with difficult-to-treat pathogens, such as MDR microorganisms, which are formed in early-onset HAP (occurring within the first 4 days of a hospital- isation).

39
Q

what are the risk factors of HAP?

A

Among the factors contributing to contracting HAP are mechanical ventilation (ventilator-associated pneumonia), old age, decreased filtration of inspired air, intrinsic respiratory, neurologic, or other disease states that result in respiratory tract obstruction, trauma, (abdominal) surgery, medications, diminished lung volumes, or decreased clearance of secretions may diminish the defenses of the lung. Also, poor hand-washing and inadequate disinfection of respiratory devices cause cross-infection and are important factors

40
Q

what is the treatment of HAP?

A

A third generation cephalosporin (ceftazidime) + carbapenems (imipenem) + beta lactam & beta lactamase inhibitors (piperacillin/tazobactam)

Cardiorespiratory (24 decks)

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