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Medicine Part 2 > CBL4 Bronchiectasis and Pneumonia > Flashcards

CBL4 Bronchiectasis and Pneumonia Flashcards

1
Q

What’s bronchiectasis?

(in terms of simple pathology)

A

Bronchiectasis describes a permanent dilatation of the airways secondary to chronic infection or inflammation.

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2
Q

Causes of bronchiectasis

A

Causes

  • post-infective: tuberculosis, measles, pertussis, pneumonia
  • cystic fibrosis
  • bronchial obstruction e.g. lung cancer/foreign body
  • immune deficiency: selective IgA, hypogammaglobulinaemia
  • allergic bronchopulmonary aspergillosis (ABPA)
  • ciliary dyskinetic syndromes: Kartagener’s syndrome, Young’s syndrome
  • yellow nail syndrome
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3
Q

Physical signs of bronchiectasis

A
  1. Clubbing
  2. Coarse inspiratory creps
  3. Wheeze
  4. Purulent sputum
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4
Q

What characteristic features can be seen on that X-ray?

What’s the diagnosis?

A
  • Chest x-ray showing tramlines, most prominent in the left lower zone
  • Diagnosis: bronchiectasis
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5
Q
  • What can be seen on that X ray? (characteristic feature) (2)
  • What’s the diagnosis?
A
  • CT chest showing widespread tram-track and signet ring signs
  • diagnosis: bronchiectasis
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6
Q

Main organisms causing infections in bronchiectasis

A
  1. H. influenza
  2. Pneumococcus
  3. S.aureus
  4. Pseudomonas
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7
Q

4 main categories of causes of bronchiectasis

A
  1. Post infective
  2. Cystic fibrosis
  3. Ciliary dyskinetic syndrome
  4. . Bronchial obstruction - lung cancer
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8
Q

Investigations for Bronchiectasis

A
  1. Sputum
  2. Blood - test for IgG, Alpha 1 anti trypsin
  3. Chest X ray - tramlines and rings
  4. Spirometry - obstructive
  5. CT - dilated and thickened airways
  6. Cystic fibrosis sweat test
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9
Q

Differential diagnosis for bronchiectasis

A
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10
Q

Normal antibiotics used to treat bronchiectasis exacerbation?

A
  1. Amoxicillin / Clarithromycin
  2. Tazocin if IV
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11
Q

Symptoms of bronchiectasis

A
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12
Q

Characteristics of the cough in bronchiectasis

A
  • productive
  • worse in the morning
  • large volume
  • daily purulent sputum
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13
Q

Investigations in bronchiectasis (just in general)

A
  • spirometry
  • CXR
  • CT
  • sputum culture
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14
Q

What pattern of spirometry may be seen in bronchiectasis?

A

Obstructive or normal

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15
Q

Characteristic features of CXR in bronchiectasis

A
  • May be normal
  • Ring opacities, tram-tracks
  • Fluid-filled cysts or bronchocoeles
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16
Q

Characteristic features of CT in bronchiectasis

A
  • Signet ring sign and tram-tracks
  • Lack of tapering of airways - thickness is NOT reduced towards the end
  • Mucus impaction
  • Mosaicism (vessels of different size in different regions of the lungs - smaller where less perfused)
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17
Q

Investigations for Bronchiectasis

A

Sputum MCS

Blood: Se Ig, Aspergillus precipitins, RF, α1-AT level 

Test Ig response to pneumococcal vaccine 

CXR: thickened bronchial walls (tramlines and rings)

Spirometry: obstructive pattern 

HRCT chest - Dilated and thickened airways 

  • Saccular dilatations in clusters c¯ pools of mucus 

Bronchoscopy + mucosal biopsy

Focal obstruction  PCD

 CF sweat test (pilocarpine iontopheresis)

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18
Q

Management of bronchiectasis

A
  • physiotherapy (e.g. inspiratory muscle training) - has a good evidence base for patients with non-cystic fibrosis bronchiectasis
  • postural drainage (airway clearance)
  • antibiotics for exacerbations + long-term rotating antibiotics in severe cases
  • bronchodilators in selected cases
  • immunisations (influenza and bronchodilators)
  • surgery in selected cases (e.g. Localised disease)
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19
Q

3 major symptoms of bronchiectasis

A
  1. Persistent cough and purulent sputum
  2. Haemoptysis
  3. Fever, weight loss and malaise
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20
Q

Most common organisms isolated from patients with bronchiectasis (4)

A

Most common organisms isolated from patients with bronchiectasis:

  • Haemophilus influenzae (most common)
  • Pseudomonas aeruginosa
  • Klebsiella spp.
  • Streptococcus pneumoniae
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21
Q

M

A
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22
Q

Management of infective exacerbations in bronchiectasis (what to do in general)

A
  • Review previous sputum culture results & most recent course of antibiotics given
  • Send more sputum for culture
  • Choose antibiotic (in line with local guidance):

–amoxicillin/clarithromycin/doxycycline oral

–ciprofloxacin if Pseudomonas aeruginosa

–Tazocin/3rd generation cephalosporin IV

*Total course 10-14 days

*May need to consider outpatient IV antibiotics

•Chest physiotherapy

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23
Q

Antibiotics used in infective exacerbations of bronchiectasis

  • what oral antibiotics
  • what for Pseudomona aeurginosa
  • what IV antibiotic
  • how long for
A

* Choose antibiotic (in line with local guidance):

–amoxicillin/clarithromycin/doxycycline oral

–ciprofloxacin if Pseudomonas aeruginosa

–Tazocin/3rd generation cephalosporin IV

  • Total course 10-14 days
  • May need to consider outpatient IV antibiotics
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24
Q

How to treat pseudomonas aureginosa exacerbation of bronchiectasis?

A

Ciprofloxacin

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25
Q

Management of Pseudomonas Aeurginosa infection

  • oral
  • IV
  • nebulised
A

•can colonise abnormal lungs

  • also be associated with active infection
  • Only orally active antimicrobial is Ciprofloxacin (fluoroquinolone antibiotic)
  • IV: Tazocin (Piperacillin and Tazobactam), Ceftazidime (cephalosporin)
  • Nebulised: colomycin (polymyxin antibiotic) can be used to suppress Pseudomonas in the case of colonisation with frequent exacerbations
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26
Q

Azithromycin

  • class
  • use
  • usual dose
A

Azithromycin

Class: macrolide antibiotic

Antimicrobial and immuno-modulatory actions

Dose (usual):250mg three times a week

Use: aim of reducing exacerbation frequency

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27
Q

Side effects of Azithromycin

A

Key Side Effects:

–Prolonged QT and cardiac dysrhythmia

–Hearing loss (usually reversible)

–Hepatic dysfunction

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28
Q

Presenting symptoms of pneumonia

A
  • cough
  • sputum
  • dyspnoea
  • chest pain: may be pleuritic
  • fever
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29
Q

What is pneumonia? (in general)

What is the most common cause?

A

Any inflammatory condition affecting the alveoli of the lungs, but in the vast majority of patients this is secondary to a bacterial infection

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30
Q

What is the likely organism causing pneumonia in the following presentation?

  • Accounts for 80% of cases

Particularly associated with high fever, rapid onset

  • A vaccine to pneumococcus is available
A

Streptococcus pneumoniae (pneumococcus)

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31
Q

What is the likely organism causing pneumonia in the following presentation?

Particularly common in patients with COPD

A

Haemophilus Influenzae

32
Q

What is the likely organism causing pneumonia in the following presentation?

Often occurs in patient following influenza infection

A

Staphylococcus aureus

33
Q

What is the likely organism causing pneumonia in the following presentation?

  • One of the atypical pneumonias
  • often present a dry cough
  • atypical chest signs/x-ray findings
  • Autoimmune haemolytic anaemia and erythema multiforme may be seen
A

Mycoplasma pneumoniae

34
Q

What is the likely organism causing pneumonia in the following presentation?

  • Another one of the atypical pneumonias
  • Hyponatraemia and lymphopenia common
A

Legionella pneumophilia

35
Q

What is the likely organism causing pneumonia in the following presentation?

Classically seen in alcoholics

A

Klebsiella pneumoniae

36
Q

What is the likely organism causing pneumonia in the following presentation?

  • Typically seen in patients with HIV
  • Presents with a dry cough, exercise-induced desaturations and the absence of chest signs
A

Pneumocystis jiroveci

37
Q

Signs of pneumonia

A
  • signs of systemic inflammatory response: fever, tachycardia
  • reduced oxygen saturations
  • ausculatation: reduced breath sounds, bronchial breathing
38
Q

What does it show?

A
  • a classical signs of right upper lobe consolidation - abnormal opacity within the right upper lobe abutting the horizontal fissure.
  • note how the ‘position’ of the consolidation on the film (i.e. in the ‘middle’ of the lung) doesn’t necessarily correlate with the lobe affected
39
Q

What does it show?

A
  • consolidation is harder to spot
  • Look at the left heart border -> it is normally well dermaracted (borders are visible) with the lung
  • Here -> it is fuzzy = this is a classic sign of left lingula consolidation
40
Q

What types of investigations (in general) would you perform in pt presenting with Sx of pneumonia?

A
  • CXR
  • blood
  • blood cultures and sputum samples
  • ABG
41
Q

Differential diagnosis of pneumonia

A
42
Q

What bloods to perform in suspicion of pneumonia?

A

Bloods

  • FBC -> high or low WBCs
  • neutrophilia in bacterial infections
  • leucopenia in viral infections
  • U&Es -> check for dehydration (remember the ‘U’ for urea in CURB-65, see below) and also other changes seen with some atypical pneumonias, organ impairment in sepsis
  • LFTs -> organ impairment in sepsis, hepatitis with atypical pneumonia
  • CRP -> raised in response to infection
43
Q

When to send sputum culture in a patient with pneumonia?

A
  • CAP of moderate severity or high severity
  • all patients who fail to improve with standard therapy
  • for Legionella should always be attempted for patients who are legionella urine antigen positive
  • for AAFB & mycobacterial culture for those who fail to improve or whose clinical features suggest possible TB or NTM (non-tuberculosis mycobacterium/mycobacterial disease)
44
Q

What are possible (3) features of a chest Xray in pneumonia?

A

•Consolidation

–air bronchograms – pus in alveolar spaces around bronchi

–patchy

–may follow lobar contours

•Collapse

–tracheal deviation

–sail sign

•Pleural effusion

45
Q

What’s consolidation? What’s effusion?

A
  • Consolidation - fluid inside the lungs
    • Effusion - fluid in pleural space (between chest wall and lungs)
46
Q

What’s that?

A

Consolidation

47
Q

What’s that?

A

Collapse

48
Q

What’s that?

A

Pleural effusion

49
Q

General Mx of pneumonia (2)

A

Patients with pneumonia require the following:

  • antibiotics: to treat the underlying infection
  • supportive care:
  • oxygen therapy - if the patients is hypoxaemic
  • IV fluids - if the patient is hypotensive or shows signs of dehydration
50
Q

What determines the management of a patient with CAP?

A

CURB 65 score

51
Q

What are the components of CURB-65?

A
52
Q

Interpretation + management for the CURB-65 scores

(0-2)

A
  • 0 - management in the community
  • 1 - check sats (should be >92%) - to be safely managed in the community and a CXR performed. If the CXR shows bilateral/multilobar shadowing hospital admission is advised
  • 2 - severe CAP, hospital management

The CURB-65 score also correlates with an increased risk of mortality at 30 days with patients with a CURB-65 score of 4 approaching a 30% mortality rate at 30 days

53
Q

Range of pH on ABG

A

7.35-7.45

54
Q

Range of pCO<strong>2</strong> on ABG

A

pCO2: 4.7-6

55
Q

Range of PO2 on ABG

A

PO2: 11.3-14

56
Q

Ranges of HCO3 on ABG

A

22-26

57
Q

Range of BE on ABG

A

-2.3 - +2.3

58
Q

What’s type 1 Respiratory Failure?

A

Low O2

(the rest of ABG picture is normal)

59
Q

What are examples of causes of Type 1 respiratory failure?

A

pneumonia, PE, pulmonary oedema, pneumothorax

60
Q

What’s type 2 respiratory failure?

A

high CO2 and low O2

61
Q

Example of Type 2 resp failure causes (2)

A

COPD exacerbation, very severe pneumonia

62
Q

Picture of respiratory acidosis on ABG

A
63
Q

Possible causes of respiratory acidosis

A
64
Q

4 main categories of causes of bronchiectasis

A
  1. Post infective - TB/measles/pneumonia/pertussis
  2. Cystic Fibrosis
  3. Bronchial obstruction - lung cancer
  4. Ciliary dyskesia - Katagener’s syndrome
65
Q

Picture of respiratory alkalosis on ABG

A
66
Q

Possible causes of respiratory alkalosis

A
67
Q

Treatment for low severity CAP (detailed)

A

Low severity CAP

  • Single antibiotic, 5 days
  • Amoxicillin (macrolide or tetracycline if allergic)
68
Q

Treatment for moderate severity CAP (detailed)

A

Moderate severity

–Dual antibiotics, 7-10 days

–Amoxicillin + macrolide (unless allergy)

69
Q

Treatment for high severity CAP

A

High severity

–Dual antibiotics, 7-10 days

–beta‑lactamase stable beta‑lactam + macrolide

70
Q

Empyema vs pleural effusion on CXR

A

Empyema - pus filled pockets on the pleura

Effusion - fluid in the pleura

71
Q
A
72
Q

How to (in general) differentiate pleural effusion from consolidation?

A

Pleural effusion -> fluid inside the pleura, can shift depending on pt’s position and gravity (as pleura is an open space)

Consolidation -> fluid inside the lung, cannot shift

73
Q

How long is the antibiotic therapy in treating bronchiectasis exacerbation?

A

10 - 14 days

74
Q

What is high in respiratory acidosis?

A
  1. PCO2
  2. HCO3
  3. BE
75
Q

What is low in respiratory acidosis?

A

PH

76
Q

What is high in respiratory alkalosis?

A

PH

HCO3

77
Q

What is low in repsiratory alkalosis?

A

CO2

Medicine Part 2 (12 decks)

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