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Respiriatory: Airway Disease > Chronic pulmonary Infection > Flashcards

Chronic pulmonary Infection Flashcards

1
Q

What are the possible diagnoses for a patient with the following symptoms:

  • Shadow on CXR
  • Weight loss
  • Persistent sputum production
  • Chest pain
  • Increasing shortness of breath
A
  • Lung Cancer
  • Intrapulmonary abscess
  • Empyema
  • Bronchiectasis
  • Cystic Fibrosis
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2
Q

What are risk factors for developing chronic pulmonary infection?

A

Abnormal host response

  • Immunodeficiency (congenital, acquired)
  • Immunosuppression (drugs, malignancy)
  • Abnormal innate host defence (damaged bronchial mucosa, abnormal cillia, abnormal secretions)
  • Repeated insult (aspiration, indwelling material)
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3
Q

What can cause immunodeficiency?

A
  • Immunoglobulin deficiency
  • Hypo-splenism
  • Immune paresis
  • HIV
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4
Q

What are different types of immunoglobulin deficiency?

A
  • IgA Deficiency: common, increased risk of acute infections, rarely chronic infections
  • Hypogammaglobulinaemia: rarer, increased risk of acute, and chronic infections
  • CVID: commonest cause of immunodeficiency, recurrent infections
  • Specific Polysaccharide Antibody Deficiency
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5
Q

How can smoking cause immunosuppression?

A

Abnormal cilia beat

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6
Q

What can causes aspiration?

A

NG tube down trachea rather than oesophagus

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7
Q

What is Specific Polysaccharide Antibody Deficiency (SPAD)?

A

Inability to develop antibodies against polysaccharide, so cannot resist certain bacteria

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8
Q

Why is hypo-splenism dangerous?

A

If no spleen, cannot produce polysaccharide antibodies

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9
Q

What is immune paresis?

A

Immune system goes into paretic state due to things like myeloma, lymphoma and metazoic malignancies

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10
Q

Why is immunosuppression common?

A

Due to increased use of immunosuppressant drugs

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11
Q

What are examples of immunosuppressant drugs?

A
  • Steroids
  • Azathioprine
  • Methotrexate
  • Cyclophosphamide
  • Monoclonal antibodies (Infliximab, etanercept: TNFa, Rituximab: CD20, Leflunamide)
  • Chemotherapy
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12
Q

What factors can damage bronchial mucosa?

A
  • Smoking
  • Recent pneumonia, or viral infection (‘Flu)
  • Malignancy
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13
Q

What conditions can lead to abnormal cillia?

A
  • Kartenager’s Syndrome

* Youngs Syndrome

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14
Q

What conditions cause abnormal secretions?

A
  • Cystic fibrosis

* Channelopathies

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15
Q

What are causes of recurrent aspiration?

A
  • NG feeding
  • Poor swallow
  • Pharyngeal pouch (collects food, etc)
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16
Q

What are causes of indwelling material?

A
  • NG tube in the wrong place
  • Chest drain
  • Inhaled foreign body (peanut, chicken bone, piece of coal, etc)
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17
Q

What are forms of chronic respiratory infection?

A
  • Intrapulmonary abscess
  • Empyema
  • Chronic Bronchial Sepsis
  • Bronchiectasis
  • Cystic Fibrosis and other oddities
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18
Q

What are clinical features of intrapulmonary abscesses?

A
  • Indolent presentation (no pain)
  • Weight loss common
  • Lethargy, tiredness, weakness
  • Cough
  • Possible sputum
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19
Q

Why is treatment for intrapulmonary abscesses vital?

A

High mortality if not treated

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20
Q

What are causes of intrapulmonary abscesses?

A

Usually a preceding illness of some sort

  • Pneumonic infection
  • Post viral
  • Foreign body
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21
Q

What are preceding illnesses of intrapulmonary abscesses?

A 
Pneumonia
(Remember ‘Flu -> Staph Pneumonia ->  Cavitating Pneumonia -> Abscess)
Aspiration pneumonia
* Vomiting
* Lowered conscious level
* Pharyngeal pouch
Poor host immune response
* Hypogammaglobulinaemia
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22
Q

What pathogens cause abscesses (stemming form pneumonia)?

A

Bacteria

  • Streptococcus
  • Staphylococcus (Particularly post ‘flu)
  • E-Coli – normally in bowel but can present in chest to cause pneumonia
  • Gram Negatives

Fungi
* Aspergillus

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23
Q

What can multiple abscesses on a CXR be indicative of?

A

Bacteraemia - bloot infection

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24
Q

What are causes of septic emboli?

A
  • Right sided endocarditis
  • Infected DVT – once infected travel to lungs
  • Septicaemia
  • Intravenous drug users
25
Q

Why are intravenous drug users at risk of septic emboli and abscesses?

A
  • Inject into groin – blood clot due to repeated trauma to the vien
  • Leads to DVT
  • Then Infection
  • Then PE + Abscesses
26
Q

Why are abscesses caused by PE’s so dangerous?

A
  • Very high mortality - 75%

* Abscesses sit close to pulmonary vessels – if abscess erodes into pulmonary artery, loss of blood (exsanguination)

27
Q

What is empyema?

A

Pus in the pleural space

28
Q

What are causes of empyema?

A
  • 57 % of all patients with pneumonia develop empyema (commonest cause)
  • Remainder are “Primary Empyema”, often iatrogenic, many idiopathic
29
Q

What is the mortality of empyema?

A
  • High mortality
  • As high as severe pneumonia
  • > 20 % of all patients with empyema die
30
Q

What is the appearance of an empyema on a CT?

A

Looks like a banana - dark with lighter areas

31
Q

What are the features of simple parapneumonic effusion?

A

Simple Parapneumonic Effusion

  • Clear fluid
  • pH > 7.2
  • LDH < 1000
  • Glucose > 2.2
32
Q

What are the features of complicated parapneumonic effusion?

A
  • pH < 7.2
  • LDH > 1000
  • Glucose < 2.2
  • Requires chest tube drainage
33
Q

What are the features of empyema?

A

Presence of pus

34
Q

What is the bacteriology of empyema?

A

Aerobic organisms most frequently

  • Gram Positive (strep Milleri, Staph Aureus)
  • Gram Negatives (E-Coli, Pseudomonas, Haemophilus Influenza, Kelbsiellae)
  • Anaerobes in 13 % of cases (usually in severe pneumonia, or poor dental hygiene)
35
Q

Why is it mostly aerobic organisms found in empyema?

A

Very high PO2 (anaerobes only found in severe pneumonia or poor dental hygiene)

36
Q

How is empyema diagnosed?

A

CXR

  • Loculations visible
  • D-sign

USS (ultrasound scan)

  • The preferred investigation
  • Simple, bedside test
  • Targetted sampling

CT
* Differentiation between Empyema and Abscess (empyema C-shaped)

37
Q

How is the drain site positioned?

A

Using USS or CT

38
Q

What are treatments (other than a chest drain) for empyema?

A 
IV antibiotics
Broad spectrum
Amoxicillin and Metronidazole initially
Oral antibiotics
Directed towards cultured bacteria
At least 14 days
39
Q

What are treatments (other than a chest drain) for empyema?

A

IV antibiotics

  • Broad spectrum
  • Amoxicillin and Metronidazole initially

Oral antibiotics

  • Directed towards cultured bacteria
  • At least 14 days
40
Q

What kind of pleural effusion is more likely to lead to empyema?

A

Complicated pleural effusion - requires sampling go the effusion

41
Q

What is bronchiectasis?

A

Localised, irreversible dilation of the bronchial tree

42
Q

What are the characteristics of the bronchi in bronchiectasis?

A

Involved bronchi are dilated, inflamed and easily collapsible

43
Q

What are the effects of bronchiectasis?

A
  • Airflow obstruction

* Impaired clearance of secretions

44
Q

What are the clinical features of bronchiectasis?

A
  • Recurrent “chest infections” (LRTIs)
  • Recurrent antibiotic prescriptions
  • No response to antibiotics or short lived response to antibiotics
  • Persistent sputum production
  • Possible chest pain
45
Q

What are radiological signs of bronchiectasis?

A

High resolution CT

  • Bronchus is larger in diameter than adjacent pulmonary artery
  • signet ring
46
Q

What is the pathophysiology of bronchiectasis?

A
  • Bronchial obstruction
  • Cystic Fibrosis
  • Young’s Syndrome
  • Kartanager’s Syndrome
  • ABPA
  • Immunodeficiency
  • Rheumatoid Arthritis
  • Bronchopulmonary sequestration
  • Mounier-Khun Syndrome
  • Yellow Nail Syndrome
  • Traction bronchiectasis associated with pulmonary fibrosis
  • Alpha1 Antitrypsin deficiency
47
Q

What are over 50% of bronchiectasis cases caused by?

A

Idiopathic > 50 %

48
Q

What is chronic bronchial sepsis?

A

All the hallmarks of bronchiectasis (including positive sputum result) but no bronchiectasis on HRCT scan

49
Q

What individuals are infected with chronic bronchial sepsis?

A
  • Often younger patients, mainly women, often involved in childcare
  • Others are older, usually with COPD, or airways disease
50
Q

What is a condition associated with chronic bronchial sepsis?

A

Chronic sinusitis - Infection with bacteria/viruses that are chronically in the sinuses

51
Q

What are the treatment options for chronic bronchial sepsis/bronchiectasis?

A
  • Stop smoking
  • ‘Flu vaccine
  • Pneumococcal vaccine
  • Reactive antibiotics - send sputum sample and give antibiotics appropriate to most recent positive culture (e.g. amoxicillin resistant culture, don’t give amoxicillin)
52
Q

What is the treatment for chronic bronchial sepsis/bronchiectasis when colonised with persistent bacteria?

A
  • Prophylactic antibiotics
  • Nebulised gentamicin, colomycin
  • Pulsed IV abx
  • Alternating oral antibiotics
53
Q

What is anti-inflammatory treatment for bronchiectasis?

A

Low dose macrolide antibiotics have been shown to reduce exacerbation rates in bronchiectasis

  • Clarithromycin 250 mg OD
  • Azithromycin 250mg Three Times a Week (particularly effective in pseudomonas colonised individuals)
54
Q

What is the prognosis for bronchiectasis?

A
  • Recurrent infection
  • Frequent Abscesses and empyema
  • Colonisation (treatment is often aggressivetotry and prevent colonisation)
55
Q

What is used to measure the severity of bronchiectasis?

A

Bronchiectasis severity index (BSI)

56
Q

In general examination, what is a sign of bronchiectasis?

A

Finger clubbing

57
Q

What is the incidence of cystic fibrosis?

A
  • Carrier rate of 1 in 25

* Incidence of 1 in 2,500 live births

58
Q

What are complications of cystic fibrosis?

A
  • Bronchiectasis (cystic and saccular)
  • Tenacious sputum
  • Biliary obstruction, and obstructive hepatitis
  • Pancreatic dysfunction (endocrine - CFRDM, exocrine - steatorrhoea)
  • Infertility for males
  • Psychology issues for all
59
Q

What is the mortality for abscesses and empyema?

A

Abscess - 10%

Empyema - 20%

Respiriatory: Airway Disease (10 decks)

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