Lower Respiratory Tract Infections

Question 1

What is pneumonia?

Answer 1

Strictly speaking it means any inflammatory condition affecting the alveoli of the lungs
But usually relates to a bacterial infection

Question 2

What is the commonest type of organism that causes pneumonia?

Answer 2

Bacterial

Question 3

What other types of organisms can cause pneumonia?

Answer 3

Viruses

Fungi

Question 4

What are symptoms of pneumonia?

Answer 4

Cough 
Sputum (purulent, rusty)
SoB
Chest pain (pleuritic)
Fever
Malaise

Question 5

What are signs of pneumonia?

Answer 5

Pyrexia, tachycardia
Tachypnoea
Reduced oxygen saturations
Dullness to percuss affected lobe
Bronchial breathing
Inspiratory creps
Increased vocal resonance

Question 6

What is the classical CXR finding in pneumonia?

Answer 6

Consolidation

Question 7

What bloods would you do for someone with pneumonia?

Answer 7

FBC - usually seen neutrophilia in bacterial infections
UE
CRP - raised in response to infections

May do ABG if low oxygen sats/pre-existing lung disease, e.g. COPD

Question 8

Aside from CXR/bloods, what other investigation might you do in pneumonia?

Answer 8

Sputum microscopy + culture
Blood culture
Urinary legionella anigen
Throat swab (for atypical pathogens)

Question 9

What organism most commonly causes pneumonia?

Answer 9

Strep pneumoniae

Question 10

What severity scoring system is used to determine best treatment course in pneumonia?

Answer 10

CURB 65
C = confusion 
U = urea >7
Resp rate >=30/min
B = BP, systolic <=90 +/or diastolic <=60mmHg

65 - aged >=65

Question 11

How is a CURB score of 0 managed?

Answer 11

In the community

Question 12

How is a CURB score of 1 managed?

Answer 12

Have SaO2 assessed if >92% –> do CXR and manage in community

If CXR shows bilateral/multinodal shadowing hospital admission advised

Question 13

How is a CURB score of 2+ managed?

Answer 13

In hospital (as it represents severe CAP)

Question 14

What does the CURB correlate with?

Answer 14

Risk of mortality at 30 days

Question 15

What are the basics of treating pneumonia?

Answer 15

Antibiotics

Supportive care - oxygen, IV fluids etc.

Question 16

What is idiopathic interstitial pneumonia?

Answer 16

A group of non-infective causes of pneumonia, e.g. COP

Question 17

What is COP a complication of?

Answer 17

RA or amiodarone therapy

Question 18

What scoring system for pneumonia should be used in the primary care setting?

Answer 18

CRB65
Confusion (abbreviated mental test score <=8/10)
Resp rate >=30/min
BP systolic <=90, diastolic <=60
Aged >=65

Question 19

How should a CRB65 score of 0 be managed?

Answer 19

At home

All other scores in hospital

Question 20

What other method may be used to decide if patients need antibiotics for pneumonia in primary care?

Answer 20

Point of care CRP testing
CRP <20 - do not give antibiotics
20-100 - consider delayed prescription
>100 - offer antibiotics

Question 21

For what CURB65 score should ITU be considered?

Answer 21

3+

Question 22

What investigations should be done for suspected pneumonia?

Answer 22

CXR
Intermediate/high risk patients - blood + sputum cultures, pneumococcal and legionella urinary antigen tests
CRP monitoring

Question 23

How is low-severity CAP managed?

Answer 23

1st line: amoxicillin (if allergic - tetracycline/macrolide) 5 day course

Question 24

How is moderate/high-severity CAP managed?

Answer 24

Dual antibiotic therapy - amoxicillin + macrolide 7-10 day course

Consider co-amoxiclav/ceftriaxone/piperacillin with tazobactam + macrolife in high severity CAP

Question 25

NICE recommend pneumonia patients are not routinely discharged in the last 24 hours if they have 2 or more of:

Answer 25

Temp >37.5C
RR >=24
HR >100bpm
Systolic BP 90mmHg or less
O2 <90% on air
Abnormal mental status
Inability to eat without assistance

Question 26

Describe how pneumonia gradually gets better

Answer 26

1 week - fever resolved
4 weeks - chest pain + sputum production substantially redued
6 weeks - cough and SoB should be substantially reduced
3 months - most symptoms resolved but fatigue may be present
6 months - should feel normal

Question 27

What are complications of pneumonia?

Answer 27

Septicaemia
AKI
Empyema 
Lung abscess
Haemolytic anaemia (mycoplasma)
ARDS

Question 28

What are differentials for pneumonia?

Answer 28

TB
Lung cancer
Cardiac failure
PE
Pulmonary vasculitis (e.g. Wegener's)

Question 29

What is an empyema?

Answer 29

Pus in the pleural space

Question 30

What is pleuritic chest pain?

Answer 30

Chest pain on inspiration due to inflammation of the parietal pleura

Question 31

What do the majority of empyemas follow?

Answer 31

A pneumonia

Question 32

What organism most commonly causes an empyema?

Answer 32

Strep

Question 33

What are symptoms/signs of an empyema?

Answer 33

Consitutional symptoms - malaise, anorexia etc.
Pyrexia, rigors
Dullness to percussion
Reduced breath sounds and reduced vocal resonance
Productive cough
Pleuritic chest pain
SoB

Question 34

What investigations should be ordered for suspected empyema?

Answer 34

Blood cultures
CRP 
WCC
CXR
Thoracentesis - pleural fluid appearance, odour, pH, total protein concentration etc. 

NB aspiration of frank pus is diagnostic (no futher Ix req)
Pleural fluid pH <7.2 also diagnostic

Question 35

How is empyema managed?

Answer 35

IV antibiotics
Chest tube drainage
Supportive care
Intrapleural fibrinolytics and surgery may be recommended for some patients

Question 36

What organisms are more likely to result in a cavitating pneumonia and hence predispose to lung abscess formation?

Answer 36

S. aureus
Pseudomonas
Anaerobes

Question 37

What are symptoms of lung abscesses?

Answer 37

Fever, productive cough, wt loss etc.

Question 38

What investigations are used to investigate a suspected lung abscess?

Answer 38

CXR

Sputum gram stain, culture

Question 39

How is lung abscess managed?

Answer 39

Antibiotics
Chest physio/postural drainage
May require drainage via bronchoscopy or percutaneous drainage