Lower Respiratory Tract Infections

Question 1

Definitions

Answer 1

Acute bronchitis, exacerbation of COPD, pneumonia

Question 2

Acute bronchitis

Answer 2

Inflammation of the bronchi, lasts less than 3 weeks. Gives cough and sputum and is usually viral, only supportive management

Question 3

COPD exacerbation

Answer 3

Changes in sputum colour, fever, increased breathlessness and cough, wheeze. Can be caused by strep. Pneumoniae, haemophilus influenzae, viruses, moraxella catarrhalis and are treated with steroids and antibiotics and possibly nebulisers

Question 4

Pneumonia pathophysiology

Answer 4

Inflammation of the lung parenchyma. Can be bronchopneumonia, lobar pneumonia or interstitial. Has risk factors eg extremes of age and smoking. Causes consolidation of alveoli due to increased cellular exudate, this leads to impaired gas exchange and shows on an CXR

Question 5

Clinical signs and symptoms of pneumonia

Answer 5

Signs- tachypnoea, tachycardia, reduced expansion, dull percussion, crepitations, increased vocal resonance

Symptoms- Fever, cough and sputum(rusty brown for strep.pneu, pleuritic chest pain, dyspnoea(SOB),

Question 6

Investigations for pneumonia

Answer 6

In community perhaps a CXR if not improving

In hospital bloods, blood cultures, CXR, sputum culture, legionella urinary antigen

Question 7

What bacteria usually cause pneumonia

Answer 7

Strep pneumoniae, chlamydia pneumoniae, mycoplasma pneumoniae, viruses, haemophilus influenzae

Question 8

Typical organisms that cause community acquired pneumonia

Answer 8

Pneumococcal pneumonia, haemophilus influenzae, mycoplasma pneumoniae

Question 9

Atypical organisms that cause pneumonia in the community

Answer 9

Legionella pneumophilia (water)
Chlamydia pneumoniae 
Chlamydia psittaci (birds)
Coxiella burnetti (farm animals) 
Moraxella catarrhalis (COPD patients)
Viruses eg flu, RSV, SARS

Question 10

Organisms that cause pneumonia in nosocomial settings

Answer 10

Enterobacteria
Staphylococcus aureus
Pseudonomas aerigunosa (horrible sputum)
Klebisella pneumoniae

Question 11

How do we score severity of pneumonia

Answer 11

C - confusion 
U - urea in blood >7mmol/L
R - respiratory rate ≥ 30/min
B - BP less than 90/60
65 - age over 65

Score 2-5 usually hospital

3-5 death risk is 15-40%

Question 12

CURB 0-1 pneumonia treatment

Answer 12

Amoxicillin or clarythromicin/doxycycline for 5 days

Question 13

CURB 2 pneumonia treatment

Answer 13

Amoxicillin and clarythromicin, levofloxacin if allergy for 5-7 days

Question 14

CURB 3-5 pneumonia treatment

Answer 14

Co-amoxiclav and clarythromicin for 7-10 days

Question 15

Special circumstances in pneumonia

Answer 15

Aspiration pneumonia eg stroke, MS, heavy drinking - anaerobes likely

Immunocompromised eg aspergillus fumigatus candida

MRSA - use vancomycin

Question 16

Complications of pneumonia

Answer 16

Sepsis, kidney injury, ARDS, parapneumonic effusion (do CXR and aspirate, may need drain), abscess (staph aureus, Pseudonomas, anaerobes with purulent sputum), empyema

Question 17

Bronchiectasis

Answer 17

Dilatation of bronchi with lots of mucus, can be idiopathic, childhood infection, cystic fibrosis. Causes chronic productive cough, breathlessness, recurrent LRTI, haemoptysis, finger clubbing, crepitations, wheeze and obstructive spirometry

Question 18

Common LRTI presentation in children

Answer 18

Cough, wheeze, fast breathing

Question 19

Laryngotracheobronchitis (croup) presentation in kids

Answer 19

Very common, viral narrowing of large airways. Inspiratory stridor, hoarseness, preceding cough and fever. Worse at night, 6m-6y

Question 20

Management of croup

Answer 20

Supportive with reassurance and safety netting. One off dose of dexamethasone (steroid)

Question 21

Bacterial tracheitis in kids

Answer 21

Uncommon, croup that doesn’t get better, strep or staph, give co-amoxiclav

Question 22

Bacterial epiglottis in kids

Answer 22

Rare, high fever toxic child, drooling and leaning forward with sore throat

Question 23

Bronchiolitis (RSV)

Answer 23

Respiratory Syncytial Virus

Very common esp winter, inflammation, congestion, mucus, cold symptoms then cough, crackles and perhaps wheeze. Managed same as croup but admitted if worse symptoms for oxygen, no CXR or bloods needed

Question 24

Whooping cough (bordatella pertussis)

Answer 24

Common as vaccine only reduces risk and severity. Cold like then coughing fits with red face and vomit, inspiratory whooping sound. Is a bacterial notifiable disease and treat with macrolides

Question 25

Bronchitis in kids

Answer 25

Very common, endobronchials. Loose rattly cough with URTI, normal chest, can vomit. Caused by haemophilus/pneumococcus and disturbed mucociliary clearance

Question 26

Pneumonia in kids

Answer 26

Fever >39 persistent and chest recession, raised RR

Question 27

Pneumonia in neonates

Answer 27

Grunting, poor feeding, irritable, lethargic, tachypnoea

Question 28

Pneumonia in infants

Answer 28

Cough, tachypnoea, grunting, rd, not feeding, irritable with preceding URTI

Question 29

When to admit for kids pneumonia

Answer 29

O2<95%, RR>70 or 50 in older, tachycardia, Crt> 2s, RD, younger than 6m, failure of 48hrs Abx, pleuritic pain

Question 30

Management of pneumonia in community

Answer 30

No CXR, do amoxicillin or macrolides if needed

Question 31

Empyema in kids

Answer 31

Better prognosis than in adults, give Abx and maybe drain, complication of pneumonia

Question 32

Viral induced wheeze

Answer 32

6m-5y, could be infective exacerbation of asthma. Give bronchodilators