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Core Conditions - Respiratory > Lobar Pneumonia > Flashcards

Lobar Pneumonia Flashcards

1
Q

What is pneumonia?

What usually causes it?

A

it is a common lower respiratory tract infection, characterised by inflammation of lung tissue

it is almost always an acute infection and almost always caused by bacteria

diagnosis is typically confirmed by chest X-ray

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2
Q

For what age group is pneumonia particularly dangerous?

A

it is responsible for many deaths of patients over the age of 80

deaths amongst younger populations have dramatically decreased after introduction of antibiotics

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3
Q

What is the incidence of pneumonia?

Amongst which particular group is the incidence of bacterial pneumonia higher?

A

incidence is 1 - 3 per 1,000

(0.1 - 0.3% of people have pneumonia at any one time)

incidence of bacterial pneumonia is higher amongst those with HIV , particularly IV drug users with HIV

the causatory organisms remain the same

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4
Q

What % of pneumonia cases are viral?

A

most cases are caused by bacteria

around 15% are viral

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5
Q

How can pneumonia be classified by anatomical location?

A

Localised pneumonia:

  • affects just one particular lobe

Bronchopneumonia:

  • this is a more diffuse pneumonia that affects the lobules and bronchioles
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6
Q

How can pneumonia be classified by aetiology?

A

Pneumococcal pneumonia:

  • accounts for 75% of cases

Atypical pneumonia:

  • accounts for 20% of cases
  • caused by atypical organisms such as Chlamydia, legionella or coxiella burnetti
  • the infection itself tends to have similar symptoms
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7
Q

If 75% of cases are pneumococcal and 20% are atypical, what are the other 5% of cases caused by?

A
  • aspiration of vomit
  • radiotherapy
  • allergic mechanisms
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8
Q

What is the most useful way to classify pneumonia?

A

the most useful distinction is between community acquired and hospital acquired pneumonia

the difference between the two is in the causatory organism

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9
Q

What is the definition of hospital acquired pneumonia?

A

pneumonia that develops within 48 hours of hospital admission

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10
Q

What is the prognosis like for community and hospital acquired pneumonia?

A

Community acquired:

  • prognosis generally good for younger patients
  • S. pneumoniae and viral pneumonias are still fatal in older patients

Hospital acquired:

  • prognosis generally poor due to co-morbidities, older age range of patients and resistance of organisms
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11
Q

What are common organisms that cause community acquired and hospital acquired pneumonia?

A

Community acquired:

  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • anaerobes are rare

Hospital acquired:

  • Gram negative bacilli
  • Staphylococcus aureus
  • Drug resistant organisms are more common and more dangerous
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12
Q

What rare organisms can cause community acquired pneumonia?

A
  • Chlamydia pneumoniae
    • ​common in institutions e.g. colleges, military camps
  • Mycoplasma pneumoniae
  • Legionella
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13
Q

What does a strep pneumoniae infection often follow on from?

A

strep pneumoniae infection often follows viral infection with influenza or parainfluenza

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14
Q

What are the precipitating factors for pneumonia?

A
  • Strep pneumoniae infection follows on from influenza or parainfluenza
  • hospital admission
    • hospital acquired infection is associated with Gram-negative organisms
  • cigarette smoking
    • ​this is the most important risk factor in pneumococcal disease
  • alcohol excess
  • bronchiectasis (e.g. in CF)
  • bronchial obstruction (e.g. carcinoma)
  • immunosuppression
  • IV drug use
  • dysphagia (leads to aspiration)
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15
Q

How are symptoms of pneumonia different in hospital acquired and community acquired cases?

A

symptoms are typically the same

increased secretions are noticeable in ventilated hospital acquired cases

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16
Q

What symptoms does pneumonia usually present with?

A
  • shortness of breath
  • cough
  • fever
  • rigors
  • vomiting
  • headache
  • loss of appetite
  • pleuritic chest pain
  • dyspnoea
  • tachypnoea
  • tachycardia
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17
Q

What type of cough does pneumonia typically present with?

A

the cough tends to be productive in adolescents and adults and may produce purulent sputum

it tends to be dry in infants and the elderly

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18
Q

What is pleuritic chest pain?

Where can it radiate to?

A

a sharp shooting or stabbing pain, usually in the side

it is most painful on inspiration, but can also be felt on expiration or even whilst talking

it can radiate to the shoulder (if diaphragm is involved) or to the anterior abdominal wall

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19
Q

What symptom may be present in patients with lower lobe pneumonia?

A

upper abdominal tenderness

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20
Q

What respiratory symptom is rarely present in pneumonia?

A

haemoptysis is very rarely present

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21
Q

What signs are present in pneumonia?

A

there will be signs of consolidation on examination and CXR

  • ipsilateral reduced chest expansion
  • dull to percussion
  • reduced breath sounds due to reduced air entry into that region of the lung
  • coarse crackles
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22
Q

What signs may be present in pneumonia caused by strep pneumoniae?

A
  • rapid shallow breathing
  • pleural friction rub
    • squeaking / grating sound of the pleural linings rubbing together
    • sounds like treading on fresh snow
    • occurs when pleural layers are inflamed and have lost their lubrication
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23
Q

What sign of pneumonia may be present in elderly patients?

A

sometimes confusion is the only sign present in elderly patients

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24
Q

When should we be concerned about oxygen saturation?

A

<92% is worrying

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25
Q

What is performed following clinical suspicion of pneumonia and what should it show?

A

a CXR is performed to confirm the diangosis

this shows the evidence of infiltrate in the form of consolidation

it can also show the spread of any infection by distribution of the infiltrate

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26
Q

When can consolidation be visible on a pneumonia CXR?

A

changes may not appear on CXR for up to 48 hours after symptoms

after effective treatment, consolidation may still be visible on X-ray for up to 6 weeks

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27
Q

How often should CXR be repeated for pneumonia patients and why?

A
  • CXR should be repeated at least weekly for inpatients
  • they should then be repeated every 6 weeks as an outpatient
  • any signs still present indicate the need for a further X-ray
  • persistent X-ray changes may suggest underlying carcinoma with secondary pneumonia
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28
Q

Why may blood cultures be taken?

A

blood cultures are taken to assess for bacteraemia

it is not routine practice to identify the causatory organism in community acquired infection

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29
Q

What would a full blood count for pneumonia show?

A
  • raised WCC
  • raised ESR (>100 mm/h) and raised CRP
  • possible anaemia (sign of abscess)
  • blood cultures are taken in ill patients to assess for septicaemia
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30
Q

When might urine samples be taken in pneumonia?

A

in severe cases of pneumonia, where legionella is suspected

urine testing for legionella antigen may be performed

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31
Q

When might pleural fluid aspiration be performed in pneumonia?

A

to assess for organisms

transthoracic aspiration may be performed (often with CT guidance) to identify lesions (e.g. empyema abscess) and to gain samples

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32
Q

What is used to assess the severity of community-acquired pneumonia?

A

CURB-65 score

this predicts the risk of mortality

(CURB score 0 = <1% risk - CURB score 5 = 60% risk)

each factor of the score is worth 1 point

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33
Q

How is the CURB-65 score measured?

A

C - CONFUSION:

  • use the abbreviated mental test (score = 8)

U - UREA:

  • > 7mmol/L

R - RESPIRATORY RATE:

  • >/= 30 / min

B - BLOOD PRESSURE:

  • < 90 systolic or <60 diastolic

65 - AGE:

  • age > 65 years

a score of 3 or more is severe pneumonia

a score of 2 or more requires hospitalisation

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34
Q

What are the differential diagnoses of pneumonia?

A
  • pulmonary oedema
  • tuberculosis
  • pulmonary embolism
    • patient is not usually systemically unwell
    • SOB more likely to be sudden onset
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35
Q

When are antibiotics given to treat pneumonia?

A
  • oral antibiotics are given if patient is NOT vomiting and CURB65 score = 2
  • IV antibiotics are given if patient is vomiting and/or CURB65 score is >/= 3
36
Q

What other treatments should be in place for pneumonia?

A
  • oxygen therapy is required to keep O2 sats > 92%
  • IV fluids are given to prevent dehydration and shock
  • progress is monitored via repeat CXRs
    • all patients should receive a 6-week follow up including repeat CXR
37
Q

How and when should complications of pneumonia be assessed for?

A

in any patient who is not responding to treatment appropriately, CXR and FBC should be repeated to assess for complications

CRP is of particular importance

38
Q

What are the 3 immediate complications of pneumonia?

A

these are present at presentation or within a few days

  • respiratory failure (most common)
  • hypotension
  • atrial fibrillation
39
Q

How is respiratory failure measured and treated?

What should sats be?

A

respiratory failure is present when PaO2 < 8 kPa

it is relatively easy to treat with 60% (high flow) oxygen

sats are aimed to be kept between 90 - 94%

40
Q

When should someone with respiratory failure be transferred to ICU?

In what patients should extra caution be taken?

A

if PaCO2 rises to >6 kPa or hypoxia does not resolve with oxygen therapy, then transfer to ICU

be careful using O2 in COPD patients as it can reduce hypoxic drive

regular ABG testing should be performed and intubation considered if situation is not improving

41
Q

Why does hypotension occur as a complication of pneumonia?

How is it treated?

A

it is the result of dehydration and vasodilation due to sepsis

it should be treated when systolic blood pressure drops below 90 mmHg

it is treated with 250ml of crystalline infusion over 15mins

42
Q

When does atrial fibrillation tend to occur as a complication of pneumonia?

How is it treated?

A

it is a common complication in the elderly

it usually resolves with the treatment of pneumonia, but digoxin can be given to reduce the HR as a short-term therapy

43
Q

What are the 5 different medium term complications associated with pneumonia?

A

these occur within days of initial presentation

  • pleural effusion
  • empyema
  • lobar collapse
  • thromboembolism
  • pneumothorax
44
Q

How can pleural effusion result from pneumonia?

How is it treated?

A

the pleura may become inflamed, which can result in excess fluid production, causing a pleural effusion

it often does not require treatment

in some individuals, it may require drainage

45
Q

When are clinical signs present for a pleural effusion?

A

clinical signs are not usually present until the volume of fluid is >500ml

rarely, the fluid can become infected, resulting in empyema

46
Q

When does empyema tend to affect a pneumonia patient?

How does it present?

A

typically presents in a patient who has partially recovered, but then develops a spike in temperature

signs of pleural effusion may be present:

  • decreased chest expansion
  • dullness to percussion
  • reduced breath sounds
  • pleural rub
  • all on the affected side
47
Q

What does the fluid look like following fluid aspiration in empyema?

How are samples obtained and what type of bacteria are usually present?

A

fluid is usually yellow, with a pH <7.2 and low levels of glucose

samples are obtained via aspiration, bronchoscopy or transthoracic aspiration using USS/CT guidance

70% of cases of empyema consist purely of anaerobes

30% of cases of empyema have both aerobic and anaerobic bacteria present

48
Q

What is the primary treatment method for empyema?

A

treatment is with the insertion of a chest drain, usually with radiological guidance

49
Q

What antibiotic therapy is given for the treatment of empyema?

A
  • antibiotics are given for 4 - 6 weeks
  • it needs to be something that is effective against both aerobic and anaerobic bacteria
  • typically IV cefuroxime and co-amoxiclav for 5 days followed by 3-5 weeks of metronidazole alone
50
Q

Why can lobar collapse occur as a complication of pneumonia?

A

this is most commonly the result of sputum retention

51
Q

When does pneumothorax tend to occur as a complication of pneumonia?

A

it is particularly associated with Staphylococcus aureus as a causative organism

52
Q

What are the 5 main categories of late complications of pneumonia?

A

these occur within days to weeks of initial presentation

  • lung abscess
  • septicaemia
  • ARDS / renal failure / multi-organ failure
  • ectopic abscess
  • hepatitis, pericarditis, myocarditis & meningitis
53
Q

What is a lung abscess?

What can it commonly result from?

A

it is a cavitating lesion containing pus, within the lung

it commonly results from aspiration (e.g. alcoholism, inhaled foreign body, oesophageal blockage, bulbar palsy)

it also occurs in bronchial obstruction (e.g. carcinoma)

it is most likely to occur if pneumonia is not adequately treated

54
Q

What organisms are more likely to cause a lung abscess?

A

some organisms are more likely to cause an abscess than others

such as Staphyloccocus aureus and Klebsiella pneumoniae

sometimes, septic emboli, particularly in the case of staphylococci, can result in multiple lung abscesses

55
Q

What else can more rarely lead to lung abscess formation?

A

pulmonary infarction can cavitate, may become infected, and result in abscess formation

56
Q

How would a lung abscess as a complication of pneumonia typically present?

A
  • a pneumonia that worsens despite treatment
  • production of purulent sputum, as a result of the growth of anaerobic organisms
  • likely to be fever, malaise, anaemia and weight loss
  • clubbing can occur if the abscess has been present for long enough
57
Q

What are the investigations for lung abscess?

A
  • CXR - shows a walled cavity, usually with a fluid level
  • Bloods - FBC for anaemia & neutrophilia
  • ESR & CRP will be raised
  • sputum sample - to identify organism
  • bronchoscopy is sometimes performed to obtain samples
58
Q

What are the treatments for lung abscess?

A
  • treat as per antibiotic sensitivities for 4-6 weeks
  • consider postural drainage to remove excess sputum
  • in severe cases, antibioitc instillation / aspiration and sometimes surgical excision may be required
59
Q

When can septicaemia occur as a complication of pneumonia?

What can it result in?

A

can occur if the bacteria enter the bloodstream

can result in infective endocarditis and meningitis

60
Q

What is the treatment for septicaemia following pneumonia?

A

the patient will be very systemically unwell and will need IV antibiotics once blood cultures have been performed to identify the causative organism

61
Q

When are hepatitis, pericarditis, myocarditis and meningitis typically seen as complications of pneumonia?

A

most commonly seen in mycoplasma pneumoniae infection, which is most prevalent in young adults

62
Q

In someone with streptococcus pneumoniae infection, how does the pneumonia tend to progress over time?

A
  • very commonly preceded by viral infection
  • patient rapidly becomes febrile, with a temperature of up to 39.5C, along with pleuritic pain and cough
  • the cough becomes productive over the coming days and produces rust coloured sputum
  • breathing may become rapid and shallow with decreased chest expansion on the affected side
  • pleural rub may be present
63
Q

What causes of pneumonia are more common in young people and older people?

A
  • Mycoplasma pneumoniae and Chlamydia pneumoniae are common in the young, but rare in the elderly
  • Haemophilus influenzae is common in elderly people, but rare in the young
  • viral infections are very common in children
64
Q

In what group of people is legionella infection more common?

A

it is more common in those with recent foreign travel

65
Q

How does acute coryza (the common cold) tend to present itself?

What symptoms are present?

A
  • rapid onset
  • burning / tickling sensation in the nose
  • sneezing
  • sore throat
  • blocked nose with watery discharge
  • discharge turns green / yellow after 24-48 hours
66
Q

What are the complications of acute coryza?

A
  • sinusitis
  • lower respiratory tract infection (bronchitis / pneumonia)
  • hearing impairment / otitis media due to blockage of eustachian tubes
67
Q

What is the treatment for acute coryza?

A
  • most do not require treatment
  • paracetamol 0.5-1g every 4-6 hourly for relief of systemic symptoms
  • nasal decongestants may be used
  • antibiotics are NOT necessary in uncomplicated coryza
68
Q

What is acute laryngitis often a complication of?

How does this present?

A
  • often a complication of acute coryza
  • dry sore throat with hoarse voice or loss of voice
  • attempts to speak cause pain
  • initially there is a painful and unproductive cough
69
Q

What symptom may be present in children with acute laryngitis and why?

A

stridor in children (croup) due to inflammatory oedema leading to partial obstruction of a small larynx

70
Q

What are the potential complications of acute laryngitis?

A
  • complications are rare
  • chronic laryngitis
  • downward spread of infection may cause tracheitis, bronchitis or pneumonia
71
Q
A
72
Q

What are the treatments for acute laryngitis?

A
  • rest the voice
  • paracetamol 0.5-1g every 4-6 hourly for relief of discomfort and pyrexia
  • steam inhalations
  • antibiotics are NOT necessary for acute laryngitis
73
Q

What is croup?

A

a childhood viral infection that causes swelling around the larynx (vocal cords), trachea and bronchi

the breathing is obstructed, causing a characteristic barking cough

74
Q

What are the symptoms of acute laryngo-tracheobronchitis (croup)?

A
  • initial symptoms are like the common cold
  • sudden paroxysms of cough accompanied by stridor and breathlessness
  • contraction of accessory muscles and indrawing of intercostal spaces
75
Q

What can happen to small children with croup if appropriate treatment is not given?

A

cyanosis and asphyxia (suffocation)

76
Q

What are the potential complications of acute laryngo-tracheobronchitis (croup)?

A
  • asphyxia and death
  • superinfection with bacteria, especially Streptococcus pneumoniae and Staphylococcus aureus
  • viscid secretions that may occlude the bronchi
77
Q

What are the treatments for acute laryngo-tracheobronchitis?

A
  • inhalations of steam and humidified air / high concentrations of oxygen
  • endotracheal intubation or tracheostomy to relieve laryngeal obstruction and allow clearing of bronchial secretions
  • IV antibiotics (co-amoxiclav or erythromycin)
  • maintain adequate hydration
78
Q

How does acute epiglottitis present?

A

fever and sore throat, rapidly leading to stridor because of swelling of the epiglottis and surrounding structures

stridor and cough in absence of much hoarseness can distinguish acute epiglottitis from other causes of stridor

79
Q

What organism is usually responsible for swelling of the epiglottis in acute epiglottitis?

A

Haemophilus influenzae

80
Q

What are the complications associated with acute epiglottitis?

What should be avoided and why?

A
  • death from asphyxia which may be precipitated by attempts to examine the throat
  • avoid using tongue depressor / any instrument unless facilities for endotracheal intubation or tracheostomy are immediately available
81
Q

What are the treatments for acute epiglottitis?

A
  • IV antibiotics - co-amoxiclav or chloramphenicol
  • other measures are the same as for acute laryngo-tracheobronchitis
82
Q

What does acute bronchitis & tracheitis often follow on from?

What are the initial symptoms?

A
  • often follows acute coryza
  • initially presents with irritating unproductive cough accompanied by retrosternal discomfort of tracheitis
  • when bronchi become involved, there is chest tightness, wheeze and breathlessness
  • tracheitis causes pain on coughing
83
Q

How does the sputum change in acute bronchitis & tracheitis?

A
  • initially sputum is scanty or mucoid
  • after about 1 day, sputum becomes mucopurulent and more copious
  • in tracheitis, sputum becomes blood-stained often
84
Q

What is acute bronchial infection associated with?

How long does it take to recover?

A
  • associated with pyrexia of 38 - 39C and a neutrophil leucocytosis
  • spontaneous recovery occurs over a few days
85
Q

What are the potential complications of acute bronchitis and tracheitis?

A
  • bronchopneumonia
  • exacerbation of chronic bronchitis, which often results in type II respiratory failure in patients with severe COPD
  • acute exacerbation of bronchial asthma
86
Q

What treatment is given to ease the cough in acute bronchitis & tracheitis?

A

Pholcodine

5 - 10 mg every 6-8 hourly

87
Q
A

Core Conditions - Respiratory (10 decks)

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