LRTIs in Adults

Question 1

What is acute bronchitis?

Answer 1

Inflammation of bronchi.
Temporary (<3 weeks).
Cough and sputum - usually viral.
Supportive management.

5% of acute bronchitis cases lead to pneumonia.

Question 2

When should you see a GP for a review of acute bronchitis?

Answer 2

Cough - severe, >3 weeks.
Temperature - high, >3 days (flu / pneumonia).
Sputum - blood.
Underlying heart or lung conditions.
SOB - worsening.
Repeated episodes of bronchitis.

Question 3

What is COPD exacerbation?

Answer 3

Change in colour of sputum.
Fever.
Increased SOB.
Wheeze.
Cough.

Caused by S. Pneumoniae, H. Influenzae, M. Catarrhalis, or a viral infection.
Treat with steroids, antibiotics, or nebulisers.

Question 4

What can cause bronchiectasis?

Answer 4

Idiopathic.
Childhood infection.
CF.
Ciliary dyskinesia.
Hypogammaglobulinaemia.
Allergic bronchopulmonary aspergillosis (ABPA).

Question 5

What are the symptoms of bronchiectasis?

Answer 5

Chronic productive cough.
SOB.
Recurrent LRTIs.
Haemoptysis.
Finger clubbing.
Creps (coarse).
Wheeze.
Obstructive spirometry.

Question 6

What can cause infective exacerbations in bronchiectasis?

Answer 6

S. Aureus.
H. Influenzae.
Pseudomonas spp.

Question 7

What are the tests and treatments for bronchiectasis?

Answer 7

Sputum Cx (essential) - has AAFBs.
Chest physiotherapy.
Mucolytics.
Prolonged abx (~2 weeks).
Consider prophylactics.
Vaccinations.

Question 8

What are the risk factors for pneumonia?

Answer 8

Smoking and alcohol.
Extremes of age.
Viral illness.
Pre-existing lung disease.
Chronic illness.
Immunocompromised.
Hospitalisation.
IVDU.

Question 9

What are the symptoms of pneumonia?

Answer 9

Fever, rigors, myalgia.
Cough and sputum.
(S. Pneumoniae causes rusty brown sputum).
Chest pain - pleuritic.
Dyspnoea.
Haemoptysis.

Question 10

What are the signs of pneumonia?

Answer 10

Tachypnoea and tachycardia.
Reduced expansion.
Dull percussion.
Bronchial breathing.
Creps.
Increased vocal resonance.
Inflammation of lung parenchyma.

Consolidation - solidification due to cellular exudate in alveoli, impairs gas exchange.

Question 11

What are the investigations of pneumonia?

Answer 11

CXR - if diagnosis doubt, or not improving.
Bloods - cultures, serum biochemistry, FBC, CRP.
Sputum cultures, viral throat swabs.
Legionella urinary antigen.

Question 12

What are the differential diagnoses of pneumonia?

Answer 12

Tuberculosis.
Lung cancer.
Pulmonary embolism / oedema / vasculitis.

Question 13

What are examples of typical community-acquired pneumonia?

Answer 13

S. Pneumoniae.
H. Influenzae.
M. Pneumoniae (5 year cycles, extrapulmonary complications).

Question 14

What are examples of atypical community-acquired pneumonia?

Answer 14

L. Pneumophilia (from water / air abroad).
C. Pneumoniae (CAD).
C. Psittaci (birds).
C. Burnetti (farm animals).
M. Catarrhalis (COPD).
Viruses (influenza, RSV, SARS).

Question 15

What are examples of nosocomial pneumonia?

Answer 15

Enterobacteria and clostridia spp.
S. Aureus (IVDU).
P. Aerigunosa (green sputum).
K. Pneumoniae and TB (cavitations).
Anaerobes.

Question 16

How is severity scored in pneumonia?

Answer 16

CURB 65.
Confusion.
Urea > 7mmol/L.
RR > 30/min.
BP < 90mmHg (diastolic < 60mmHg).
65 < age.

Consider young people, the hypoxic, and multi-lobar consolidation.

Question 17

What does a CURB 65 score of 0-1 in pneumonia represent?

Answer 17

Low risk of death (<3%). Treat in community.
Amoxicillin (clarithromycin or doxycycline if allergic to penicillin) for 5 days.

Question 18

What does a CURB 65 score of 2 in pneumonia represent?

Answer 18

Moderate risk of death (9%).
Hospital treatment is usually required.
Amoxicillin (with clarithromycin for atypical; levofloxacin if allergic to penicillin) for 5-7 days.

Question 19

What does a CURB 65 score of 5 in pneumonia represent?

Answer 19

High risk of death (25%). ITU needed.
Co-amoxiclav (with clarithromycin for atypical; levofloxacin or co-trimoxazole if allergic to penicillin) for 7-10 days.

Question 20

What should be considered when managing pneumonia?

Answer 20

Route - IV or oral.
Supportive management - oxygen, fluids, antipyretics, NSAIDs, intubation, ventilation.

Question 21

What are special circumstances with pneumonia?

Answer 21

Influenza - S. Aureus as a secondary infection.
Immunocompromised - caused by fungi, viruses, haematological malignancy, neutropenia, HIV, and PJP (treat PJP with co-trimoxazole).
MRSA - treat with vancomycin.

Question 22

Describe recovery from pneumonia and recurrent pneumonia.

Answer 22

Takes weeks.
CXR is repeated after 6 weeks in >50yr old smokers (smoking cessation is encouraged).

Consider immunocompromised, underlying structural lung disease, or aspiration in recurrent pneumonia.

Question 23

What is aspiration pneumonia?

Answer 23

Likely caused by anaerobes.
Caused by stroke, MS, myasthenia, sedation, or oesophageal disease.
Treat with amoxicillin and metronidazole.

Question 24

What are the complications of pneumonia?

Answer 24

Sepsis.
AKI.
Adult Respiratory Distress Syndrome.
Parapneumonic effusion or empyema.
Lung abscess.
Disseminated infection.

Question 25

How are empyema and lung abscesses treated?

Answer 25

Empyema:
Thoracic ultrasound +/- aspiration.
Simple - pH > 7.2.
Complicated - pH < 7.2.
Pus or positive culture.
May require drainage and prolonged abx.

Lung abscess:
Likely from S. Aureus or Pseudomonas spp.
Purulent sputum and haemoptysis.
Screen for TB.
CT scan +/- bronchoscopy.
Prolonged abx.