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Respiratory Physiology, Medicine and Critical Care > Lower Respiratory tract infection > Flashcards

Lower Respiratory tract infection Flashcards

1
Q

What are the main host defence mechanisms against Respiratory tract infection?

A
  • Alveolar macrophages
  • Mucociliary escalator
  • Cough reflex
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2
Q

What are the different classifcations of pneumonia by cause?

A
  • Community acquired
  • Hospital acquired
  • Atypical pneumonia
  • Aspiration pneumonia
  • Recurrent pneumonia
  • Pneumonia in the immunocompromised
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3
Q

What is pneumonia?

A

https://www.youtube.com/watch?v=X-CnwZDXr9g

Pneumonia is an acute exudative inflammatory condition of the lung affecting the alveoli. It is usually caused by infection with viruses or bacteria and less commonly other microorganisms, certain drugs and other conditions such as autoimmune diseases.

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4
Q

What is bronchopneumonia?

A

Characterised by patchy distribution, centred on inflamed bronchioles and bronchi with subsequent spread to alveoli. Areas affected are often the bases, and it can be bilateral.

Pus and consolidation occur at multiple foci centred around a bronchiole. This causes the alveoli connected to the bronchioles to become filled with neutrophils and pus. Inflammatory focal points are separated by healthy functioning parenchyma.

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5
Q

What is segmental/lobar pneumonia?

A

Pneumonia that affects anatomically delineated segments, or entire lobes of the lung. This results in an entire lobe becoming consolidated.

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6
Q

What are the stages of lobar pneumonia development?

A
  1. Congestion - first 24 hours - large inflammatory response to invading organism, which causes exudate to pour out into the alveolar sacs, which washes the bugs throughout the lung. Vascular engorgement also occurs.
  2. Consolidation (red hepatisation) - few days - Massive accumulation in the alveolar space of polymorphs, lymphocytes and macrophages. RBCs extravasated from the distended capillaries. The lung becomes red, solid and airless.
  3. Grey Hepatisation - few days - More fibrin accumulates, and white cells and red cells are destroyed.
  4. Resolution - occurs day 8-10 - resorption of exudate and enzymatic digestion of inflammatory debris, with preservation of alveolar architecture.
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7
Q

What is the most common cause of lobar pneumonia?

A

Strep. pneumoniae

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8
Q

What is pleurisy?

A

Pleuritis

Is inflammation of the membranes (pleurae) that surround the lungs and line the chest cavity.

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9
Q

What is empyema?

A

Collection of pus in the pleural cavity resulting from bacteria entering the pleural cavity. There are three stages:

  • Exudative - increase in pleural fluid with or without the presence of pus
  • Fibrinopurulent - fibrous septa form localized pus pockets
  • Organising stage - scarring of the pleura membranes with possible inability of the lung to expand
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10
Q

What is a lung abscess?

A

A localised area of lung suppuration leading to necrosis of the pulmonary parenchyma, with or without cavity formation. Particular organisms include:

  • Staph aureus
  • Pneumococci
  • Klebsiella.
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11
Q

What is crytogenic organising pneumonia?

A

Bronchiolitis obliterans organizing pneumonia (BOOP)

A form of non-infectious pneumonia; more specifically, BOOP is an inflammation of the bronchioles (bronchiolitis) and surrounding tissue in the lungs

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12
Q

Which is the most common area of the lung to be affected by aspiration pneumonia?

A

Apical segmental bronchus of right lower lobe

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13
Q

What is community acquired pneumonia?

A

Syndrome of infection acquired from the community that is usually bacterial, with symptoms and signs of consolidation of parts of the lung parenchyma.

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14
Q

What are the main organisms which cause CAP?

A
  1. S. Pneumonia (36%)
  2. All viruses (13.1%)
  3. H. Influenzae (10.2%)
  4. Myco. Pneumoniae (1.3%)
  5. Chlamydia psittaci (1.3%)
  6. S. aureus (0.8%)
  7. L. pneumophila (0.4%)
  8. Moraxella catarrhalis
  9. Coxiella burnetti
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15
Q

What are risk factors for CAP?

A
  • Aspiration
  • Alcoholism
  • Diabetes
  • Immunosuppression
  • Smoking
  • COPD
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16
Q

What are symptoms of pneumonia?

A
  • Malaise
  • Cough/Purulent Sputum/Haemoptysis
  • Dyspnoea
  • Fever
  • Chest pain
  • Extrapulmonary features
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17
Q

What colour of sputum can pneumococcal pneumonia produce?

A

Rusty coloured sputum

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18
Q

On examination, what signs may you see in someone with pneumonia?

A
  • Pyrexia
  • Tachypneoa
  • Reduced chest expansion
  • Accessory muscle use
  • Crackles (rales)
  • Central Cyanosis
  • Dullness on percussion of affected lobe
  • Bronchial breath sounds
  • Inspiratory crepitations
  • Increased vocal resonance/tactile vocal fremitus
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19
Q

Why can asymmetrical chest expansion occur in pneumonia?

A

If pneumonia (consolidation of the airways) and/or pleural effusions (fluid in the pleural space) are present, the normal compliance of the lung is reduced.

When inspiration occurs, the affected lung will have decreased expansion compared to normal.

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20
Q

What is the mechanism behind hearing bronchial breathing on ausculation in someone with pneumonia?

A

https://studentconsult.inkling.com/read/dennis-mechanisms-clinical-signs-2nd/chapter-2/bronchial-breath-sounds

Bronchial breath sounds are not normally heard over the lung fields, as the chest wall and alveoli muffle higher-frequency sounds. In the presence of consolidation, however, the alveolar ‘filter’ is replaced by a medium (such as pus) that transmits sound (and higher frequencies), better allowing bronchial breath sounds to be heard.

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21
Q

On examination, if a patient with a cough and fever had the following sound over the midzone of the right lung field, what might you suspect?

A

Pneumonia - bronchial breathing heard

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22
Q

How are crackles (rales) generated in someone with pneumonia?

A

Pneumonia may present with crackles in two ways:

  • Acutely – owing to infiltration of inflammatory cells, pus and oedema which fill or narrow the airways. Inspiration may abruptly open these blocked airways and generate sound.
  • Later – in the resolving stage of illness it is thought that oedema decreases but inflammatory cells are still present. The lung becomes drier, leading to reduced compliance in some parts, causing segmental airway collapse.
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23
Q

How may crackles in someone with acute pneumonia sound?

A

Mid inspiratory, coarse, similar to bronchiectasis in acute period

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24
Q

How may crackles in someone who is recovering from pnemonia sound?

A

During recovery, end inspiratory and short, similar to pulmonary fibrosis

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25
Q

How can haemoptysis occur in someone with pneumonia or bronchitis?

A

Inflammation of lung tissue can disrupt arterial and venous structures. Repetitive cough may damage the pulmonary vasculature, leading to haemoptysis.

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26
Q

What are the three distinctive sounds that can be heard when percussing?

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27
Q

Why would someone with pneumonia have dullness to percussion over the affected area?

A

https://studentconsult.inkling.com/read/dennis-mechanisms-clinical-signs-2nd/chapter-2/dull-percussion

Pleural fluid or consolidation dampens the normal resonance of the lung fields, creating the characteristic ‘stony’ dullness.

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28
Q

Why might you get a pleural rub in someone with pneumonia?

A

The common pathway is inflammation of the pleura and loss of normal pleural lubrication which has resulted from pneumonia.

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29
Q

How does vocal resonance and tactile vocal fremitus change in someone with pneumonia?

A

Consolidated lungs transmit low and higher frequencies effectively and so a patient’s voice is heard clearly and easily over a consolidated area. This is also true for fremitus, with sounds being felt more easily over affected areas.

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30
Q

What are signs of a pleural effusion?

A
  • Decreased chest expansion
  • Stony dull precussion
  • Diminished breath sounds
  • Decreased vocal resonance/fremitus
  • Bronchial breathing above effusion
  • Tracheal deviation
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31
Q

Why would you get bronchial breathing above a pleural effusion when examining someone?

A

The lung becomes crushed - similar to consolidation - can conduct more sound

32
Q

What is the diagnosis of CAP based on?

A
  • Symptoms and signs of an acute LRTI
  • New focal chest signs
  • New radiographic features
  • At least one systemic feature - sweating, fevers, ache, pains
33
Q

What investigations would you do if you suspected pneumonia?

A

Confirm diagnosis, identify the pathogen and assess severity

  • Observations
  • CXR
  • Bloods - FBC, U+E’s, LFT’s, CRP
  • Blood cultures
  • Sputum - microscopy and culture
  • Throat swab - micro, culture
  • Legionella - Sputum/Urinary antigen
  • Serology - severe CAP unresponsive to B-lactams
34
Q

Why would you do FBC as part of your investigations of pneumonia?

A

Look at WCC - WCC> 15x109 indicates bacterial infection

35
Q

Why would you look at U+E’s when investigating someone with pneumonia?

A
  • Look for deranged renal function
  • Look for dehydration
36
Q

Why would you look at CRP in someone with pneumonia?

A

May be useful in management, with high levels being more sensitive marker of infection than WCC. Serial measures may also be useful in treatment.

37
Q

When should someone have ABG’s if they present with symptoms of pneumonia?

A

SpO2 <92%, or signs of severe pneumonia

38
Q

How would you assess severity of pneumonia?

A

Confusion - AMTS <8

Urea >7mmol/L

Respiratory rate >30/min

Blood pressure (systolic) <90 mmHg

65 years old

39
Q

If someone had a parapneumonic pleural effusion/suspected empyema on CXR, what might you do to investigate?

A

Pleural fluid tap - micro, culture, serology and pH

40
Q

Why does hypoxia occur in pneumonia?

A

V/Q mismatch - shunting

41
Q

How would you tailor your management of pneumonia using CURB65 score?

A

0-1 = Home treatment possible

1-2 = hospital therapy

>3 = consider ITU - SEVERE PNEUMONIA

42
Q

What antibiotics would you use if someone had pneumonia with a CURB65 score of 0-1?

A
  • Oral Amoxicillin, or
  • Oral Clarithromycin/doxycycline - if penicillin allergy
43
Q

What antibiotics would you give someone with pneumonia with a CURB65 score of 2?

A

Oral/IV amoxicillin AND Clarythromycin

If intolerant - doxycycline or levofloxacin

44
Q

What antibiotics would you use in someone who had a CURB65 score of >/=3?

A
  1. Co-amoxiclav + Clarythromycin (IV), then
  2. Co-amoxiclav + clarythromycin (oral)
45
Q

What antibiotics would you use if someone was penicillin allergic and the had a CURB65 score of >/=3?

A
  1. Levofloxacin or Co-trimoxazole (IV), then switch to
  2. Doxycycline or Co-trimoxazole (oral)
46
Q

If you found someone to have staphylococcal pneumonia, what antibiotics would you use?

A

Add Flucloxacillin for 14-21 days

or

Add linezolid for 14 days

47
Q

What antibiotics would you use in someone with suspected aspiration pneumonia?

A
  1. Benzylpenicillin (IV) + Metranidazole (IV), then switch to
  2. Amoxicillin (Oral) + Metranidazole (Oral)

If penicillin allergic - Clarythromycin + Metranidazole

48
Q

How would you determine how to treat someone with Hospital acquired pneumonia?

A

< 5 days after admission - treat as for CAP

>/=5 days of admission - treat as for HAI

49
Q

If someone had suspected HAP, and it was classified as non-severe, what antibiotics would you use?

A

Oral amoxicillin, or Doxycycline/Co-trimoxazole (if penicillin allergy)

50
Q

If someone had suspected HAP, and it was classified as moderate or severe, what antibiotics would you use?

A

Co-amoxiclav (IV) + Gentamicin (IV), or

Levofloxacin if penicillin allergy

51
Q

If someone had suspected HAP, and it was found to be MRSA, what antibiotics would you use?

A

Add vancomycin to moderate severe treatment (co-amoxiclav + gentamicin)

52
Q

What bacteria can cause HAP?

A
  • Gram negative enterobacteria
  • S. aureus
  • P. aeruginosa
  • Klebsiella
  • Bacteriodes
  • Clostridia
53
Q

How would you manage someone with penumonia?

A
  • O2 therapy - Aim for 94-98% sats, unles COPD (aim 88-92%)
  • Fluids - Oral if possible, or IV if not and volume depleted
  • Analgesia - paracetamol/ibuprofen
  • Physiotherapy - chest physio
  • Nutritional supplementation
  • DVT prophylaxis
  • CPAP/NIV/Intubation
54
Q

How would you monitor someone with pneumonia?

A

Observations

  • RR
  • HR
  • BP
  • Mental status
  • Temp
  • SpO2
55
Q

What are causes of recurrent pneumonia?

A
  • Cystic Fibrosis
  • COPD
  • Asthma
  • Immunological compromise
  • Immotile cilia syndrome
  • B-cell dysfuntion
  • WBC anomalies
56
Q

If, when treating someone for pneumonia, the CRP does not fall by 50% within 3-4 days, what does this indicate?

A

Treatment failure or development of complication (lung abscess, empyema etc.)

57
Q

What are complications of pneumonia?

A

PEARL BASH

  • Pleurisy/Pleural effusion/Pericarditis/myocarditis
  • Empyema
  • AKI
  • Respiratory failure
  • Lung abscess
  • Bronchiectasis
  • ARDS
  • Septicaemia
  • Hypotension
58
Q

What are risk factors for the developement of HAP?

A
  • >70
  • Chronic lung disease
  • Reduced consciousness/CVA
  • Chest/abdo surgery
  • Mechanical ventilation
  • NG feeding
59
Q

What risk factors predispose to aspiration pneumonia?

A
  • Reduced consicousness
  • Dysphagea
  • Upper GI tract disease
  • Increased reflux
  • Nursing home resident
60
Q

What are the 3 pulmonary syndromes that can result from aspiration?

A
  • Chemical pneumonitis
  • Bacterial infection
  • Mechanical obstruction
61
Q

What features would indicate a chemical pneumonitis?

A
  • Rapid onset of symptoms
  • Low-grade fever
  • Severe hypoaemia
  • Diffuse lung infiltrates in affected areas
  • CXR changes within 2 hrs
62
Q

What is the pathophysiology of a lung abscess?

A

Bacterial inoculum reaches the lung parenchyma, which causes pneumonitis followed by necrosis. Cavitation occurs hen parenchymal necrosis leads to communication with the bronchus, with entry of air and expectoration of necrotic material leading to the formation of an air fluid level.

63
Q

How does a lung abscess tend to present?

A
  • Productive cough (foul sputum)
  • Haemoptysis
  • Breathlessness
  • Swinging Fevers/Night sweats
  • Chest pain
  • Systemic features - Anaemia, Weight loss
64
Q

How would you investigate someone with a suspected lung abscess?

A
  • Bloods - FBC, ESR, CRP, Blood cultures
  • Sputum - microscopy, culture
  • CXR/CT
65
Q

What might you see on CXR in someone with a lung abscess?

A
  • Walled cavity with air-fluid level.
  • Round - appear similarly in both frontal and lateral projections.
66
Q

What can be seen on the following x-ray, in someone with swinging fevers and foul smelling sputum?

A

Lung abscess

67
Q

How would you treat a lung abscess?

A
  • Antibiotics - as per sensitivities - infections usually mixed
  • Postural Drainage and phsyiotherapy
  • Surgical excision
68
Q

What are the indications for surgical excision of an abscess?

A
  • >6cm
  • Resistant organism
  • Haemorrhage
  • Recurrent disease
69
Q

What can be a complication of a lung abscess?

A

Major lung haemorrhage

70
Q

How does a simple parapneumonic effusion progress to an empyema?

A
  • Exudative stage - sterile fluid accumulates in the pleural space secondary to inflammation
  • Fibrinopurulent stage - bacterial invasion characterised by the fibrin deposition and the formation of fibrinous septae, loculations, and adhesions.
  • Empyema - Pus in the pleural space. May be free flowing or multiloculated
  • Organization - formation of thick, non-elastic pleural peel and dense fibrinous septations that inhibits lung expansion
71
Q

What are the clinical features of empyema?

A
  • Ongoing Fever
  • Sputum
  • Chest pain
  • Breathlessness
72
Q

How would you investigate suspected empyema?

A
  • Pleural tap
  • CXR/Contrast CT
73
Q

If someone had empyema, what would findings would you see on plleural tap?

A
  • Turbid/purulent fluid
  • Organisms of gram stain
  • pH<7.2
  • Decreased glucose
  • Increased LDH
74
Q

How would you manage someone with empyema?

A
  • Antibiotics
  • Chest tube drainage
75
Q

What are the indications for pleural chest drain insertion in empyema?

A
  • Purulent pleural fluid
  • Organisms in pleural fluid
  • Pleural fluid pH <7.2
76
Q

What may be the causative organism of a pneumonia which also presented with erythema multiforme?

A

Mycoplasma pneumoniae

Respiratory Physiology, Medicine and Critical Care (42 decks)

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