LRTI

Question 1

what is acute bronchitis

Answer 1

• viral infection
• inflammation of the - trachea or bronchi
  presents with a fever, acute cough 1-4 weeks

Question 2

pneumonia: hospitalisation and mortality

Answer 2

pneumonia often results in hospitalisation and the chance of mortality in hospital is quite significant.
- Mortality depends on pre-morbid state or the severity of pneumonia

Question 3

pneumonia: symptoms? early vs late?

Answer 3

early stages of pneumonia are quite non-specific

malaise 
myalgia- muscle pain
fever
chest pain
cough- initially dry
purulent sputum
dyspnoea - if condition is bad enough

Question 4

pneumonia: investigations

Answer 4

serum biochemistry and full blood count
CXR - may give diagnosis
blood cultures
throat swab
urinary legionella antigen
HIV test
sputum microscopy and culture- often not useful

Question 5

what are blood cultures used for in pneumonia investigations

Answer 5

try to isolate organisms but it’s only positive in 25 % of patients

Question 6

why is legionella a significant bacterium

Answer 6

it causes pneumonia or similar disease called Legionnaires’ disease

Question 7

why is sputum microscopy and culture often not useful

Answer 7

because it’s often negative but if it does come back positive the results take a while to come back and in the meantime the patient has been treated with antibiotics

Question 8

define the term ‘consolidation’ in the lung

Answer 8

lung tissue that has filled with liquid instead of air.

it is a radiologic term

Question 9

what investigation is not carried out often for pneumonia

Answer 9

CT scan however you may come across it in a CT scan whilst looking for something else

Question 10

common organisms that cause pneumonia infection

Answer 10

strep pneumoniae 39%
H.influenzae 5.2%
Legionella 3.4 %
staph aureus 0.8%

Question 11

what is the most common scoring system to determine the severity of pneumonia

Answer 11

CURB 65

Question 12

explain CURB 65

Answer 12

C confusion
U blood urea >7
R respiratory rate >30
B diastolic blood 
    pressure <60
65 age> 65

score of 1 for each
score out of 5 overall
3-5 high risk of death and need for (ITU intensive treatment unit)

Question 13

what treatment is used for those with a CURB score 0-1

Answer 13

amoxycillin or clarithromycin/ doxycycline

Question 14

what treatment is used for those with a CURB score 2

Answer 14

amoxycillin and clarithromycin or levofloxacin

Question 15

what treatment is used for those with a CURB score 3-5

Answer 15

co-amoxiclav and clarithromycin or levofloxacin (if allergic to penicillin)

Question 16

if pneumonia is more severe, what treatment options are available (4)

Answer 16

oxygen - if hypoxic
IV fluids - dehydration due to liver damage
CPAP
intubation and ventilation - very severe cases - tracheal tube inserted

Question 17

what complications can come with pneumonia ie other conditions (9)

Answer 17

Resp failure - type 1 quite common

septicaemia - sepsis and shock

acute kidney injury

empyema- infection in the pleural space

lung abscess- collection of pus within cavity of lung

metastatic infection- organisms in the blood spread through body

Acute Respiratory Distress Syndrome (ARDS) - inflammatory complication

Atrial fibrillation -common in elderly usually resolves with treatment. Beta blocker or digoxin may be required to slow heart rate in short term

hypotension - due to dehydration/vasodilation due to sepsis

Question 18

how is empyema investigated, diagnosed and treated

Answer 18

investigate using CT thorax and pleural ultrasound

diagnosed by sampling fluid in the pleural space
pH should be less than 7.2

treatment includes chest drain, IV antibiotics or surgery for patients not improving with this management

Question 19

Empyema and pneumonia

Answer 19

may or may not follow documented episode of pneumonia

mostly caused by streptococcus and anaerobes

chest pain without cough

high swinging fever due to pus

Question 20

lung abscess and pneumonia

Answer 20

may or may not follow pneumonia

symptoms are non specific - lethargy, weight loss, swinging fever

Question 21

investigations and treatment for lung abscess

Answer 21

CT thorax and sputum culture including TB microscopy and culture

prolonged antibiotics
drainage is via bronchial tree but occasionally drainage through chest wall

Question 22

What is bronchiectasis and what happens to the airways due to this condition?

Answer 22

Abnormal permanently dilated airways due to bronchial wall inflammation, thickening and irreversible damage

this causes a build-up of excess mucus that can make the lungs more vulnerable to infection as it can trap more bacteria

If an infection does develop, the bronchi may be damaged again, so even more mucus gathers in them and the risk of infection increases further.

airway walls thicken and the airways dilate even out at the periphery of the lung

Question 23

causes of bronchiectasis

Answer 23

Idiopathic

Immotile Cilia Syndrome – cilia stop working - not common cause

Cystic fibrosis – commonest autosomal recessive condition

Childhood infections such as measles or whooping cough

Hypogammaglobulinaemia – don’t produce sufficient amount of antibodies to fight infection. Can be acquired or inherited

asthma

Question 24

aspiration pneumonia

Answer 24

inhale own vomit

- leads to lung injury and resultant bacterial infection.

Question 25

how does influenza cause complications with pneumonia

Answer 25

higher freq of staphylococcal pneumonia

Question 26

staphylococcal pneumonia including PVL toxin

Answer 26

PVL toxin is rare - certain strains of staph aureus produce this toxin and this can cause quite a severe pneumonia

Question 27

Haematological malignancy/neutropenia

complication with pneumonia

Answer 27

if you’ve had lymphoma or leukemia you will be immunosuppressed - don’t fight off infection so well- different spectrum of organisms- need to use broad spectrum antibiotics- also have to consider anti-fungal drugs

Question 28

what is pneumococcal pneumonia?

what is used to treat it?

Answer 28

a type of pneumonia
commonest bacterial pneumonia

affects all ages but more common in elderly, alcoholics, post splenectomy, immunosuppressed and patients with chronic heart failure or pre-existing lung disease

amoxicillin
benzylpenicillin
cephalosporin

Question 29

describe a bit about staphylococcal pneumonia

what is used to treat it?

Answer 29

may complicate influenza infection or occur in the young, elderly IV drug users or patients with underlying disease e.g leukaemia, lymphoma, CF

causes bilateral cavitating bronchopneumonia

flucloxacillin +/- rifampicin

MRSA - contact lab; maybe consider vancomycin

Question 30

describe a bit about mycoplasma pneumoniae

How is it diagnosed? what is used to treat it?

Answer 30

occurs in epidemics

insidiously with flu-like symptoms followed by a dry cough

CXR reticular-nodular shadowing or patchy consolidation often of one lower lobe

diagnose:- PCR sputum or serology

treatment:- clarithromycin
doxygycline
fluroquinolone

Question 31

legionella pneumophila

what is it?
diagnosis
treatment
mortality

Answer 31

flu like symptoms precede a dry cough and dyspnoea

anorexia
renal failure
confusion
coma

CXR shows bi basal consolidation

urinalysis may show haematuria

diagnosis: urine antigen/culture

treatment: fluoroquinolone
clarithromycin

10% mortality

Question 32

viral pneumonia

Answer 32

influenze commonest

swine flu is now considere seasonal and covered by the annual flu vaccine

others: measles + varicella zoster

Question 33

pneumocystis pneumonia

Answer 33

pnuemonia in immunosuppressed (HIV)

dry cough, exertional dyspnoea, decrease in partial pressure of arterial O2, fever

CXR may be normal or show bilateral peri-hilar interstitial shadowing

diagnosis: lung biopsy, sputum sample or bronchioalveolar lavage

treatment - high dose co-trimoxazole
pentamidine
steroid if severe hypoxaemia

Question 34

Pneumonia in genera:
definition
signs
symptoms
diagnosis/innvestigation
management

Answer 34

inflammation of the substance of the lungs usually due to bacterial infection

signs: pyrexia (fever), tachypnoea, central cyanosis, dullness of percussion of affected lobe (fluid), bronchial breath sounds (hollow), inspiratory crepitations (crackles), increased vocal resonance (denser or inflamed lung tissue)
symptoms: malaise, fever, pleuritic chest pain, cough, purulent sputum, dyspnoea

diagnosis/investigation: FBC and serum biochemistry
CXR
blood cultrues
throat swab
urinary legionella antigen 
sputum microscopy and culture

management: CURB 65

O2, CPAP, iv fluids
intubation/ventilation if any required

Question 35

what is hypersensitivity pneumonitis?

definition
signs 
symptoms
diagnosis/investigation 
management

Answer 35

inflammatory reaction in small airways and alveoli due to inhalation of different antigens. Non- infectious

signs: abnormal CXR, tachypnoea, coarse end inspiratory crackles on auscultation, cyanosis.
If chronic - severe weight loss, idiopathic pulmonary fibrosis

symptoms- malaise, fever, cough, SOB

diagnosis/investigation:-
CXR - fluffy nodular shadowing
CT - reticular and nodular changes
PFT - ie spirometry - restrictive defect
Blood tests - IgG (Main one in blood)
precipitating antibodies present in serum

management - avoid allergen if possible, alter working practice if possible, manage symptoms with corticosteroids

Question 36

define what the interstitium of the lung is

Answer 36

space between alveolar sacs and pulmonary arterioles

Question 37

what 2 classes of antibiotics should be used to treat a patient with left lower lobe pnuemonia before a bacteriological diagnosis is reached?

Answer 37

Macrolides - Azithromycin, Clarithromycin

Beta - lactams