Lower Respiratory tract infections: Pathology etc - pneumonia and all those ones

Question 1

What are the main LRTIs seen clinically?

Answer 1

ACUTE bronchitis

Exacerbation of COPD

Pneumonia

Empyema

Lung abscess

Bronchiectasis

Question 2

What is the incidence rate of pneumonia in the UK?

Answer 2

5-11 people per 1000 adult population

Question 3

What is the mortality rate of hospitalised patients with pneumonia?

Answer 3

5.7 - 12%

Question 4

What are the symptoms of pneumonia?

Answer 4

Malaise 
Myalgia 
Fever 
Pleuritic (chest) pain
Cough 
Purulent sputum 
Dyspnoea

Question 5

What is myalgia?

Answer 5

Pain in a (group of) muscle(s)

Question 6

What is malaise?

Answer 6

General feeling of illness or discomfort

Question 7

What is Dyspnoea?

Answer 7

Difficulty breathing

Question 8

What is the appearance of ‘purulent’ sputum with someone with pneumonia?

Answer 8

Off-white to rusty to green colour

Question 9

What are the main signs of pneumonia on examination?

Answer 9

Pyrexia

Tachpnoea

Central cyanosis

Dullness on percussion of affected lobes

Bronchial breath sounds

Inspiratory crepitations

Increased vocal resonance

Question 10

What are the main investigations for pneumonia?

Answer 10

Serum biochemistry, CRP and full blood count

CXR

Blood cultures

Throat swab (for atypical pathogens)

Urinary legionella antigen test

Sputum microscopy and culture

HIV test

Question 11

Where is pneumonia typically located in the lung(s) and why?

Answer 11

Lower lobes

Gravity innit

Question 12

Pneumonia caused by inhalation of something normally affects which lung?

Why?

Answer 12

Right lung

Primary bronchus of RL is more vertical than LL’s so stuff goes down there easier

Question 13

Which microorganism most commonly causes pneumonia?

How prevalent?

Answer 13

Strep pneumoniae

39%

Question 14

What are the most common causes of pneumonia? >5.2%

microorganisms
(in order)

Answer 14

Strep. pneumoniae - 39%

Chlamydophila. pneumoniae - 13.1%

All viruses - 13.1%

Mycoplasma. pneumoniae - 10.8%

H. influenzae - 5.2%

Question 15

What is the common clinical name given to Strep. pneumoniae?

Answer 15

Pneumococcus

Question 16

What is the appearance of pneumococcus under a microscope?

Answer 16

Chains of oval-ee shaped bacteria

gram positive so they’d stain purple

Question 17

What is the scoring method for severity of pneumonia?

Answer 17

CURB 65

Question 18

What are the parameters for CURB 65 scoring?

Answer 18

C - confusion?

U - Blood urea >7?

R - Respiratory rate >30?

B - diastolic blood pressure >60?

65 - Age>65?

Question 19

What are the different score bands for CURB65?

Answer 19

0 = They’re chillybeans

1-2 = Hospital treatment usually required

3-5 = high risk of death and need for ITU

Question 20

Treatment for CURB 0-1?

Answer 20

Amoxycillin or clarithromycin / doxycycline

+ ‘other treatments’

Question 21

Treatment for CURB 2?

Answer 21

Amoxycillin and clarithromycin or levofloxacin

+ ‘other treatments’

Question 22

Treatment for CURB 3-5?

Answer 22

Co-amoxyclav and clarithromycin or levofloxacin

+ ‘other treatments’

Question 23

Why would levofloxacin be used instead of amoxycillin etc?

Answer 23

If the patient is allergic to penicillins

Question 24

What is the situation and treatment for aspiration pneumonia?

Answer 24

Amoxycillin and metronidazole

Metronidazole needed because aspiration pneumonia often has anaerobes

Question 25

Treatment for haematological malignancy / neutropenia?

Answer 25

Broad spectrum antibiotics Consider anti-fungals

Question 26

Aside from normal treatment, what should be considered when a patient has legionnaires disease?

Answer 26

Consider involving public health

Question 27

If a patient has influenza What would be expected to be seen on their bacterial culture?

Answer 27

High frequency of pneumococcus

Question 28

Some patients with pneumonia have been infected by MRSA How is this treated?

Answer 28

Vancomycin or linezolid

Question 29

If someone has HIV, what is the most likely type of pneumonia they will have?

Answer 29

PJP (aka PCP) (Pneumocystis jiroveci Pneumonia)

Question 30

Aside from pure throwing drugs at them What are the 'other treatments' for patients with pneumonia?

Answer 30

Oxygen IV fluids CPAP (ventilator) Intubation + ventilation

Question 31

What are the main complications seen with pneumonia?

Answer 31

``` Septicaemia Acute kidney injury Empyema Lung abscess Metastatic infection ARDS ```

Question 32

What is septicaemia?

Answer 32

Infection of blood

Question 33

What is empyema?

Answer 33

Collection of pus in the pleural cavity

Question 34

What is ARDS?

Answer 34

Acute resp. distress syndrome Basically a rapid onset/spread of infection through the lungs

Question 35

Many patients presenting with respiratory problems show similar symptoms but for different diseases/conditions What are important differential diagnoses to check?

Answer 35

Tuberculosis Lung cancer Pulm. embolism Pulm. oedema Pulm. vasculitis (Wegners granulomatosis)

Question 36

Both pneumonia and pulm. oedema involve fluid in the lungs... How is pulmonary oedema different from pneumonia?

Answer 36

Causes: Pneumonia is infection based whereas PO is linked to heart failure PO doesn't really involve any microorganisms or infection so the lungs are still sterile

Question 37

How does empyema look on a CXR?

Answer 37

Large area of cloudy-ness across whole of the pleural cavity/lung

Question 38

What are the main causes of empyema?

Answer 38

Bacterial infection by: - Streptococcus 52% - Staph. aureus 11% - Anaerobes 20% or Secondary to pneumonia infection

Question 39

What are the main symptoms/signs of empyema?

Answer 39

Pleuritic (chest) pain High swinging fever ABSENCE of cough

Question 40

What is the investigative/diagnostic route for empyema?

Answer 40

CT thorax & Pleural ultrasound Diagnosed by Pleural aspiration (ph <7.2)

Question 41

How is empyema treated?

Answer 41

Chest drain IV antibiotics (may be prolonged >6 weeks) Intrapleural t-PA / DNase sometimes required Surgery for patients not improving with above management.

Question 42

What organisms are most likely to be found in a lung abscess?

Answer 42

Staph. aureus Pseudomonas Anaerobes

Question 43

Why are lung abscesses sometimes hard to predict from patient's presenting complaints?

Answer 43

Non-specific symptoms Usually things like lethargy, weight loss, high swinging fever + normal resp disease symptoms

Question 44

What is the investigative route for lung abscess?

Answer 44

CT thorax Sputum culture (including TB culture/microscopy)

Question 45

What is the treatment route for a lung abscess?

Answer 45

Prolonged antibiotics Drainage via bronchial tree, but occasionally percutaneous drainage may be necessary

Question 46

What is bronchiectasis?

Answer 46

airways of the lungs become abnormally widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection

Question 47

What are the causes of bronchiectasis?

Answer 47

Idiopathic Immotile Cilia Syndrome Cystic fibrosis Childhood infections such as measles Hypogammaglobulinaemia Allergic Bronchopulmonary Aspergillosis (ABPA)

Question 48

What are the symptoms of bronchiectasis?

Answer 48

Chronic cough Daily sputum production (often shite tons) Sometimes, - Wheeze - Dyspnoea - Tiredness - Flitting chest pains - Haemoptysis

Question 49

What are the main signs of bronchiectasis?

Answer 49

Finger clubbing Course inspiratory crepitations (auscultation)

Question 50

How should bronchiectasis be investigated?

Answer 50

High resolution CT thorax Sputum culture Serum immunoglobulins Total IgE and Aspergillus precipitins CF genotyping

Question 51

What microorganisms are typical to bronchiectasis?

Answer 51

Haemophilus influenzae Staph aureus Pseudomonas aeruginosa

Question 52

How is bronchiectasis treated?

Answer 52

Appropriate antibiotics May require inhaled beta2 agonist and inhaled corticosteroid Chest physiotherapy