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Respiratory > Lecture 14- Lower respiratory tract infections and pneumonia > Flashcards

Lecture 14- Lower respiratory tract infections and pneumonia Flashcards

1
Q

Lower respiratory tract infections (LRTI) are a leading cause of death in the

A

elderly

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2
Q

Course of typical infection

A
  1. Alveolar macrophages fails to stop pathogen
  2. Cytokines to recruit more macrophages
  3. Inflammation= increased permeability
  4. More WBC/proteins
    1. Neutrophils
    2. Lymphocytes
    3. Antibodies to aid macrophage
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3
Q

course of typical infection outside the lungs

A
  • Inflammatory mediators (cytokines) into systemic circulation
  • Physiological- activates bone marrow/more CO and raised body temp
  • Dysregulation/ pathological inflammation– signs of tissue injury/ organ injury (multi-organ failure- low BP due to vasodilation of blood vessels in response to inflammation e.g. liver and kidney failure due to low BP
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4
Q

Inflammation=

A

increases blood supply and increases WBC to the site of infection via the release of cytokines

  • Damages lung tissue
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5
Q

common microbiota of the resp tract

A
  • Viridians streptococci
  • Neisseria sp
  • Anaerobes candida sp
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6
Q

Less common microbiota of respiratory tract

A
  • Streptococcus’s pneumoniae
  • Streptococcus pyrogens
  • Haemophilus influenzae

Others

  • Pseudomonas
  • E.coli
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7
Q

Upper resp tract=

A

nasal cavity to the larynx

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8
Q

lower resp tract

A

trachea –> lungs

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9
Q

lungs are not

A

sterile

  • normal alveolar microbiota
  • aspiration
  • blood stream spread
  • direct spread
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10
Q

Defences of resp tract

A
  • Muco-ciliary clearance mechanisms nasal hairs, ciliated columnar epithelium of the resp tract
  • Cough and sneezing
  • Respiratory mucosal immune system
    • Lymphoid follicles of the pharynx and tonsils, alveolar macrophages, secretary IgA and IgG
  • Alveolar microbiota
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11
Q

what causes dyrefulation of inflammation

A
  • the pathogens virulence factors
  • host factors
  • drugs
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12
Q

pathogen virulence factors

A
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13
Q

What causes dysregulation of inflammation: host factors

A
  • Over 75
  • Lifestyle
    • Smoking (abnormal ciliary function)
    • Alcohol/drugs
  • Chronic lung disease e.g. bronchiectasis, CF
  • Aspiration
    • Change in level of consciousness
    • Dysphagia
    • Wearing dentures whilese sleeping
  • Immunocompromised
    • DM
    • HIV
  • Metabolic
    • Malnutrition
    • Hypoxaemia
    • Acidosis
    • Uraemia
  • Co-infection with viruses (abnormal ciliary function)
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14
Q

What causes dysregulation of inflammation: drugs

A
  • Antacids
  • Antipsychotics
  • ACE inhibitors
  • Glucocorticoids
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15
Q
  • Antacids
A
  • PPI- increases risk for pneumonia
  • H2 antagonist- myelosuppression (rare, long term)
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16
Q
  • ACE inhibitors-
A

associated reduced risk but only seen in observational studies with reporting bias

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17
Q
  • Glucocorticoids-
A

use of inhaled corticosterois

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18
Q

types of URTI

A
  • Rhinitis
  • Pharyngitis
  • Epiglottis
  • Laryngitis
  • Tracheitis
  • Sinusitis
  • Otitis media
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19
Q

URTI are most commonly caused by

A

viruses

  • Rhinovirus
  • Coronavirus
  • Influenza/parainfluenza
  • Respiratory syncytial virus (RSV)
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20
Q

Bacterial superinfection (after viral infection)

*

A
  • Common with
    • Sinusitis and otitis media–> can lead to mastoiditis, meningitis, brain abscess
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21
Q

Lower respiratory tract infections

A
  • bronchitis
  • pneumonia
  • bronchiolitis
  • empyema
  • bronchiectasis
  • lung abscess
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22
Q
  • Bronchitis =
A

infection of the bronchi

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23
Q
  • Pneumonia=
A

infection of the lung parenchyma

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24
Q

LRTI definittions (inflammation of the lungalveoli)

A
  • community acquired pneumonia (CAP)
  • hospital acquired pneumonia (HAP)
  • venitalted acquired pneumonia (VAP)
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25
community acquired pneumonia (CAP)
outside healthcare setting
26
HAP
48 hours post admission
27
VAP (ventilator)
48h post intubation
28
acute bronchitis
* Inflammation (infection \*chronic bronchitis is just inflammation not infection\*) of medium sized airways * Mainly in smokers
29
symptoms of acute bronchitis
* Symptoms * Cough * Fever * Increase SoB * Increased sputum
30
investigations for acute nronchitis
* Investigations- CXR normal (don’t expect changes – in pneumonia we do)
31
organisms that cause acute bronchitis
* Organisms * S.pneumoniae * H.influenzae * M. Cararrhalis
32
treatment of acute bronchitis
* Bronchodilation (symptomatic) * Remove secretions with physiotherapy * If bacterial antibiotics
33
**Chronic bronchitis**
NOT primarily infection * Exacerbations have been associated with many organisms, but the role of infections remain controversial
34
what is penumonia
* Inflammation of the lung alveoli * Alveoli become full of fluid and neutrophils and macrophages (fluid in lungs-dull sound and crackles on stethoscope)
35
pathology is the same for all types of pneumonia
1. Acute inflammatory response 2. Exudation of fibrin-rich fluid 3. Neutrophil infiltration 4. Macrophage infiltration
36
Lobar pneumonia--\>
pneumonia involving 1 lobe
37
Bronchopneumonia--\>
patchy
38
**Symptoms of pneumonia**
* Shortness of breath * Coughing * Difficulty breathing
39
**Signs of pneumonia**
ABG- hypoxic
40
**_Community acquired pneumonia causative organisms_** *
* No microbiological ID made in most cases * True prevalence difficult to establish due to use of indirect methods /mixed infections * Typical and atypical organisms
41
typical causative (85%) organisms for CAP
- Strep pneumonia is commonoist - haemophilis influenzae if COPD
42
atypical organisms (15%)
mycoplasma commonest legionella- contaminated water sources
43
**Diagnosing CAP**
Clinical symptoms +imaging finding * Clinical * Cough (with/without sputum) * Dyspnoea * Pleurisy * Fever * Tachycardia * Organ dysfunction (e.g. hypotension/mental status change) * Crackles * Bronchial breathing * Imaging * Consolidation/infiltrate/cavitation’s * When to admit? Use CURB-65
44
**Assessing severity of CAP** *
* CURB-65 score * Confusion * Urea \>7mmol/l * Respiratory rate\>30 * Blood pressure \<90 systolic \<60 diastolic * Over 65
45
CURB- 65 score 2
admit
46
* Score 2-5=
manage as severe
47
CAP investigations
**Investigations** * FBC * U &E * CRP * ABG * Chest Xray * Microbiological * Sputum * Blood culture * Bronchoalveolar lavage fluid (BAL) * Nose and throat swabs or NPAs (viruses) * Urine (antigen test for legionella, pneumococcus) * Serum (antibody test) acute and convalescent sera (usually collected at presentation and 10-14 days
48
management of CAP
Management * Mild CAP- treat empirically * Moderate CAP * Blood culture/sputum culture * Urinary streptococcal antigen * Legionella +PCR * Viral screen * Serve CAP * Same as moderate management + bronchoscopic specimens
49
**Differential diagnoses for CAP** *
* Heart failure and pulmonary oedema * Pulmonary embolism * Atelectasis * Aspiration/ chemical pneumonitis * Drug reactions * Lung cancer * Vasculitis acute exacerbation of bronchiectasis * Interstitial lung disease
50
**Treatment of CAP** *
* Abx treatment * Empirical regimes can differ in hospitals/ allergy status/ comorbidities *
51
how many days of Abx for mild CAP
5-7 days
52
how many days of Abx for severe CAP
7-10 days
53
which type of Abx for mild-moderate CAP
* amoxicillin * or doxycyclin or erythromycin
54
which type of Abx for moderate-severe CAP
needing hospital admission - co-amoxiclav and clarithromycin
55
give amoxicillin because
commonest cause is S.pneumoniae
56
**Complications of CAP** *
* Initial infection progression * Empyema- infection of pleural cavity * Lung abscess * Bacteraemia * Non- resolving CAP * Delayed clinical response * Closed space infections * Bronchial obstruction e.g. a tumour * Subacute chronic CAP (TB/Fungal) * Incorrect initial diagnosis
57
causative organisms of hospital acquired pneumonia
* S.aureus * MRSA * enterobacteriaciae (E.coli and klebsiella spp\_ * Pseudomonas spp * Fungi (candida)
58
**Management of HAP**
* Cover S.aureus and gram negative enteric bacilli (e.g. klebsiella) + typical/atypical pathogens * **Co-amoxiclav** * Pseudomonas risk * Antipseudomonal beta lactam or anti-pseudomonal fluoroquinolone (ciprofloxacin) * MRSA risk- vancomycin/linezolid
59
first line treatment for HAP
co-amoxiclav
60
second line treatment of HAP
piperacillin or meropenem
61
**Aspiration pneumonia** *
Aspiration of exogenous material or endogenous secretions into the resp tract
62
Aspiration pneumonia most common in
* Common in pts with neurological dysphagia * Strokes * Epilepsy * Alcoholics * Drowning * At risk groups * Nursing home residents and drug overdose
63
what sort of infections can aspiration pneumonias be
* Mixed infection e.g. viridians streptococci and anaerobes
64
* Moderate to severe aspiration pneumonia treated with
Co-amoxiclav (broad spectrum)
65
**Immunosuppression and LRTI**
* HIV * Pneumocystis jirovecci * TB * Atypical mycobacteria * Neutropenia * Fungi e.g. aspergillus spp * Bone marrow transplant: cytomegaly virus * Splenectomy: encapsulated organism e.g. Pneumonia, H. influenzae, malaria
66
prevention of pneumonia
* immunisation * chemoprophylaxis * smoking advice
67
* **Immunisation**
* **Flu vaccine- given to high risk pts** * **Pneumococcal vaccine- every 5 years**
68
chemoprophylaxis e.g.

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