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S3 Respiratory > LRTIs And Pneumonia > Flashcards

LRTIs And Pneumonia Flashcards

1
Q

Who do LRTIs affect and how bad are they?

A

95% of LRTIs are to those >65yrs

World wide biggest cause of death in the elderly

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2
Q

Which microbiota affect the respiratory tract?

A

Common - viridans streptococci, neisseria Spp (multiple species), anaerobes Candida Sp

Less common: Streptococcus pneumoniae, Haemophilus influenza

Other: pseudomonas, E.coli

Majority get through microaspirations in alveolar

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3
Q

Defences of the respiratory tract

A

NUCO-ciliary clearance

Cough & sneezing reflex

Respiratory mucosal immune system lymphoid follicles of the pharynx and tonsils, alveolar macrophages, secretory IgA and IgG

Alveolar microbiota - prevents organisms entering and establishing

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4
Q

Explain the course of a typical infection within the lungs

A
  1. Alveolar macrophage fails to stop pathogens
  2. Cytokines recruit more macrophages- systemic
  3. Inflammation = increased permeability (inc blood supply to region)
  4. More WBCs/ proteins
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5
Q

Course of a typical infection outside the lungs

A
  1. Inflammatory mediators (cytokines/ chemokines) systemic
  2. Activates bone marrow/ more CO/ raised body temp
  3. Dysregulation - signs of tissue/ organ injury -> multi-organ failure
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6
Q

What three things cause dysregulation?

A
  1. The pathogen
  2. Host factors
  3. Drugs
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7
Q

Give some examples of pathogen/ virulence factors

A

Chlamydia pneumoniae- ciliostatic factor

Mycoplasma pneumoniae- shear off cilia

Influenza virus - reduces mucus velocity (up to 12wk post infection)

Strep pneumoniae/ neisseria meningitides- split immunoglobulin (IgA)

Pneumococcus - capsule inhibits phagocytosis

Mycobacterium/ nocardia/ legionella - resistant to phagocytosis

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8
Q

Give some examples of host factors

A

> 65yrs

Smoking/ alcohol/ drugs

Chronic lung diseases (bronchiectasis/ cystic fibrosis)

Aspiration (change in consciousness/ dysphagia/ wearing denatures while sleeping)

Immunocompromised

Metabolic - malnutrition, hypoxaemia, acidosis, uraemia

Co-infection with viruses (abnormal ciliary function)

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9
Q

Give examples of drugs which cause dysregulation

A

Antacids
PPI - increases risk of pneumonia
H2 antagonist - myelosuppression (rare, long term)

Antipsychotics - unclear association
60% increase in risk older ppl, atypical antipsychotics associated fatal pneumonia

ACE inhibitors - associated reduced risk

Glucocorticosteroids - ICS increase risk

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10
Q

Give examples of URTIs and some causes

A

Most commonly caused viruses:
Rhinovirus, coronavirus, influenza, parainfluenza

Bacterial super- infection common with sinusitis and otitis media, can -> mastoiditis, meningitis, brain abscess

Rhinitis (common cold) 
Pharyngitis
Epiglottis
Laryngitis 
Tracheitis
Sinusitis
Otitis media
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11
Q

Give examples of LRTIs

A

Bronchi + alveolar

Bronchitis:
Bronchiolitis
Bronchiectasis

Pneumonia:
Empyema (pus filled pockets in pleural space)
Lung abscess

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12
Q

What is acute bronchitis? Symptoms, causes, treatment

A

Inflammation of medium sized airways
Mainly in smokers
Cough, fever, increased sputum, increased dyspnoea

CXR normal

Triggers: chemicals, pollen, pathogen

Organisms:
Viruses, S. Pneumoniae, H. Influenza, M. Catarrhalis

Bronchodilator, physiotherapy +/- antibiotics

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13
Q

What are the different types of pneumonia?

A

All LRTIs involving inflammation of the lung alveoli

Community acquire pneumonia - outside healthcare

Hospital acquired pneumonia - 48hrs post admission

Ventilated acquired pneumonia - 48hrs post intubation & ventilation

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14
Q

What’s the pathology of pneumonia, what’s the difference between lobar and bronchopneumonia?

A

Acute inflammatory response

Exudation of fibrin- rich fluid

Neutrophil & macrophage infiltration

Displaces air

Lobar pneumonia - affects one lobe

Bronchopneumonia - patchy areas, crackles on breathing and auscultations dull

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15
Q

What microorganisms cause community acquired pneumonia?

A

No microbiological ID made in most cases

Typical (85%):
Strep Pneumoniae
Haemophillus influenza (underlying chronic lung disease) 
Moraxella catarrhalis 
Staph aureus & MRSA
Viruses 
Atypical (15%):
Mycoplasma
Legionella (H20 sources)
Coxiella burnetii (farm animals)
Chlamydia pneumoniae 
Chlamydia Psittaci (birds)
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16
Q

Diagnosing CaP and assessing severity

A

Diagnosis:
Clinical syndrome + imaging finding
- cough, dyspnoea, pleurisy, fever, tachycardia, organ dysfunction (hypotension, mental status change), crackles, bronchial breathing

Imaging - consolidations/ infiltrates/ cavitation NEVER normal

Use CURB- 65 to asses when to admit:
Confusion, urea >7mmol/l, Rr >30, BP <90 syto & <60 diastolic, >65yrs

Score 2-5 manage as severe
<2 mild - managed in community

17
Q

Investigations for moderate -> severe CAP

A 
FBC
Urea and electrolytes
C reactive protein 
Arterial blood gases
CXR

Microbiological samples:
Sputum/ induced
Blood culture
Bronchoalveolar lavage fluid
Nose/ throat swabs or NPAs
Urine (antigen for legionella/ pneumococcus)
Serum (antibody) - usually collect presentation and 10-14 days later

18
Q

Managing LRTIs

A

Mild CaP: treat empirically

Moderate: blood cultures/ sputum culture/ urinary streptococcal antigen, legionella (+PCR)/ viral screen

Severe: moderate + bronchoscopic specimens

19
Q

Differential diagnosis for LRTIs

A

Heart failure + pulmonary oedema

Pulmonary embolism

Atelectasis (collapse lung tissue)

Aspiration/ chemical pneumonitis

Drug reactions

Lung cancer

Vasculitis

Acute exacerbation bronchiectasis

Interstitial lung disease

20
Q

Treatment of CAP

A

Antibiotics (empirical regimes can differ hospital/ allergy status/ comorbidities)

General approach 5-7 days mild CaP
7-10 severe

UHL antibiotics:
Mild- moderate - amoxicillin Or doxycycline OR erythromycin/ clarithromycin

Moderate- severe - hospital admission co-amoxiclav & clarithromycin/ doxycycline

21
Q

Complications of CaP

A

Initial infection progression - empyema, lung abscess, bacteraemia

Non resolving CAP: delayed clinical response/ closed space infections/ bronchial obstruction (e.g. tumour)/ subacute, chronic CAP (Tb/ fungal)

22
Q

Aetiology of hospital acquired pneumonia and management

A 
Staphylococcus aureus 
MRSA
Enterobacteriaciae
Pseudomonas SPP
Fungi (Candida sp)

Management:
Cover SA + gram negative enteric bacilli + typical/ atypical pathogens co-amoxiclav

Pseudomonas risk - anti pseudomonas beta lactam (piperacillin/ tazibactam/ ceftazidime) or anti-pseudomonal
Fluroquinolone

MRSA risk - vancomycin/ linezolid

UHL: first line co-amoxiclav, second line/ ITU piperacillin/ tazibactam OR meropenem

23
Q

What is aspiration pneumonia? Who’s at risk? Treatment

A

Aspiration of exogenous material or endogenous secretions into respiratory tract

Common in patients with neurological dysphagia (strokes), epilepsy, alcoholics, drowning

At risk groups - nursing home residents, drug overdose

Mixed infection - viridans streptococci and anaerobes

Moderate- severe: co-amoxiclav

24
Q

What are different types of immunosuppressed patients most at risk of in terms of microorganisms? HIV, neutropenia, bone marrow transplant, splenectomy

A

HIV - pneumocystitis jirovecci , TB, atypical mycobacteria

Neutropenia - fungi e.g. aspergillus spp

Bone marrow transplant - cytomegalovirus virus

Splenectomy - encapsulated organisms e.g. S pneumoniae, H influenza, malaria

25
Q

Prevention ofLRTIs

A

Immunisation - flu vaccine, pneumococcal every five years, 23 polyvalent polysaccharide vaccine dose given to patients with co-morbidities (risk pneumococcal disease)

Chemoprophylaxis - oral penicillin/ erythromycin to patients with higher risk of LRTIs (asplenia, dysfunctional spleen, immunodeficiency)

Smoking advice

S3 Respiratory (21 decks)

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