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Medicine 1 (Year 1) > Pathology Respiratory infection > Flashcards

Pathology Respiratory infection Flashcards

1
Q

Lung infections are the outcome of which opposing factors?

A

microorganism pathogenicity; Primary, facultative, opportunistic

capacity to resist infection: state of host defence mechanisms, age of the patient

population at risk

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2
Q

NAme some Upper Respiratory Tract infections

A

coryza - common cold

sore throat syndrome

acute laryngotracheobronchitis (croup)

laryngitis

sinusitis

acute eppiglottitis

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3
Q

Explain acute epiglottitis

A

Haemophilus influenza (type b - hib)

Group a beta-haemolytic streptococci

(rarely caused by parainfluenza virus type 5 but other viruses also responsible)

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4
Q

signs of epiglottitis

A

red cherry like swollen epiglottis

child has breathing difficulties

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5
Q

List some lower respiratory tract infections

A

Bronchitis

Bronchiolitis

pneumonia - infection within parenchyma alveoli of the lung

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6
Q

What are the respiratory tract defence mechanisms

A

macrophage-mucociliary escalator system

general immune system - humoral and cellular immunity

  • respiratory tract secretions (antimicrobial to an extent)
  • upper respiratory tract acts as a filter (breathe through the nose for the larger matter) also uRT act humidifier to deliver warm humid air.

failure of any of these systems increases the risk of RTI

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7
Q

what does the macrophage-mucociliary escalator system involve

A
  • alveolar macrophages

the mucociliary escalator itself

an intact and functioning cough reflex

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8
Q

What sort of environment is the normally lower respiratory tract

A

sterile

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9
Q

explain what alveolar macrophages do in the respiratory tract

A

travel around the large surface area eating (phagocytosis) foreign material and migrate the end product to the ciliated airways.

mucus conducts material out of the lung up ciliated areas on epithelium (like escalator) movement to back of throat

to top of the trachea and out

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10
Q

how is smaller material excreted out the respiratory system?

A

through the lymphatic system and out into the lymph nodes in the mediastinum.

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11
Q

What is required to keep the lower respiratory tract sterile?

A

intact ciliated respiratory epithelium

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12
Q

what is an important risk to note following a severe influenza infection

A

secondary bacterial infection

can cause morbidity and mortality during influenza pandemics

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13
Q

why is this secondary infection following influenza infection happening?

A

damage to the respiratory epithelium - failure of defence mechanisms = inhaled bacteria then cause secondary infection - very common scenario

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14
Q

explain bronchiolitis

A

cellular

lymphoid chronic inflammatory reaction

causes airway obstruction by inflammatory exudate - patient has small airways for short time while the cellular bronchitis is active

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15
Q

Explain the classifications of pneumonia

A

anatomical - radiology

aeitiological - (circumstance ) (useful)

microbiology (appropriate for treatment) what caused infection

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16
Q

list aetiological classifications for pneumonia

A
  • community aquired pneumonia - hospital aquired (nosocomial) pneumonia - pneumonia in the immunocompromised -atypical pneumonia - aspiration pneumonia - recurrent pneumonia
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17
Q

What is an important thing to note for nosocmial pneumonia?

A

Hospital-acquired - this type of pneumonia are very often drug resistance

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18
Q

what is atypical pneumonia

A

pneumonia caused by rare organisms or viruses or sub bacterial particles e.g. mycoplasma

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19
Q

What is aspiration pneumonia

A

aspiration into the lungs of food material for a variety of reasons that has then caused the infection

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20
Q

patterns of pneumonia

A
  • Bronchopneumonia - segmental - lobar
  • hypostatic - aspiration - obstructive
  • retention - endogenous - lipid
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21
Q

what is hypostatic pneumonia

A

the localisation of the infection or infectious process in the lower zones of both lung and relates to other diseases like cardiac failure or COPD where excess secretions or oedema accumulate in the lungs through gravity.

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22
Q

describe bronchopneumonia (with histology)

A

multifocal usually involves both lungs + more in lower zones

common in COPD - establish in small areas of bronchi + bronchioles and spills over into adjacent alveoli (see pus)

see neutrophils and polymorphs + inflammatory exudates relating to cause infection airspaces.

focal (cm-mm size areas of the lung)

spreads a little into centriacinar

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23
Q

confluent bronchopneumonia (severe)

A

spreads centriacinar focal patchy process - significant consolidation of lung - nut reaching the pleura

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24
Q

bronchopneumonia xray signs

A

patchy opaque nature of xray

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25
Q

xray signs lobar/segmental pneumonia

A

the infectious process involving the whole lobe or large chunk of one - or sometimes two lobes

pathological change when organism lands in the lung (completely solid section) white

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26
Q

outcome/complication of pneumonia

A

Outcome

  • most resolve (if not why not?)
  • *Complication**
  • Pleurisy (pleural inflammation), Pleural effusion and empyema (pus in pleural space)
  • Change of organisation -
    A mass lesion, COP (cryptogenic organising pneumonia - BOOP)
  • Lung abscess - Bronchiectasis - Pneumonia is still potentially fatal
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27
Q

what is pleural effusion

A

Pleural effusion sometimes referred to as “water on the lungs,” is the build-up of excess fluid between the layers of the pleura outside the lungs. The pleura are thin membranes that line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing.

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28
Q

what is pleurisy

A

Pleurisy is a condition in which the pleura — two large, thin layers of tissue that separate your lungs from your chest wall — becomes inflamed. Also called pleuritis, pleurisy causes sharp chest pain (pleuritic pain) that worsens during breathing.

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29
Q

what is empyema?

A

Empyema / purulent pleuritis. It’s a condition in which pus gathers in the area between the lungs and the inner surface of the chest wall (pleural space)

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30
Q

what is bronchiectasis

A

pathological dilation of bronchi (inappropriate for position in bronchial tree) due to:

severe infective episode recurrent infections (many causes)

proximal bronchial obstruction

lung parenchymal destruction

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31
Q

What are the signs of bronchiacstatis

A
  • 75% start in childhood
  • Cough, abundant, purulent, fouls sputum

haemoptysis coughing of blood from lung (signs of chronic infection)

coarse crackles clubbing

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32
Q

investigating for bronchiactesis

A

thin section CT (previously bronchography)

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33
Q

treating bronchiectasis

A

postural drainage

antibiotics

surgery

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34
Q

what is a big risk of bronchiectasis poses

A

severe bronchial haemorrhage which can be fatal

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35
Q

Recurrent Lung infections - what can cause them?

A
  • Localbronchial obstruction - Tumour/foreign body
  • Local pulmonary damage -bronchiectasis
  • Generalised lung disease - cystic fibrosis - COPD - Asthma
  • Non-respiratory disease: Immunocompromised

HIV - other

Aspiration

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36
Q

what may cause aspiration pneumonia

A
  • Vomiting - Oesophageal Lesion
  • Obstetric Anaesthesia - Neuromuscular disorder
  • Sedation

oesophageal disease (reflux)

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37
Q

opportunistic infections

A

increased chance of “ordinary” infections - sometimes ones not normally capable of causing infection: opportunistic pathogens

  • usually in immunocompromised pm steroidal therapy, chemotherapy
  • infection by organisms not normally capable of producing disease in patients with intact lung defences
  • low-grade bacterial pathogens CMV

pneumocystis jirovecil

other fungi and yeasts

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38
Q

the upper respiratory tract and infections:

A

nose, larynx, pharynx, epiglottis,

nose - rhinitis

ear -otitis media

pharynx - pharyngitis

Larynx - laryngitix

epiglottis - eppiglotitis

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39
Q

respiratory

infections invasions?

A

virus - repelled?

bacteria 1 pneumococcus, Haemophilus, staph, Moraxella

bacteria 2 invasion pertussis, mycoplasma

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40
Q

what is the fine line between colonisation and infection

A

epithelium

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41
Q

what are the side effects of antibiotics (child URTI)

A
  • diarrhoea
  • oral thrush
  • nappy thrush
  • allergic reaction
  • multi resistance
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42
Q

what percentage of admissions of all children to hospital are (child URTI AND LRTI)

A

roughly 1/3

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43
Q

(child URTI) facts

A

common

  • fever; antibiotic or not? prodrome to serious illness?
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44
Q

(child URTI) hint for management

A

give it time.

look hydration and nutrition

antipyretic (paracetmol)

sugary fluids and time.

can review in future.

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45
Q

what is rhinitis

A

very common

winter months occurs often

self-limiting condition

prodrome to other illness: pneumonia, bronchiolitis, meningitis, septicaemia

review If not sure

normal duration symptoms 11-16 days

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46
Q

what is otitis

A

infection of ear

the bulging eardrum can pop and pus comes out

common - self-limiting - very red -a primary viral infection

  • secondary infection with pneumococcus h’flu

spontaneous rupture of the ear drum

antibiotic treatment usually doesn’t help

3-7 days duration normal

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47
Q

treat otitis NICE

A

offer regular paracetamol or ibuprofen for pain

self-care

consider antibiotic

reassess if symptoms worsen or signs of more serious illness of condition

refer hospital if severe systemic infection or complication like mastoiditis

Mastoiditis is a serious infection in the mastoid process, (hard, the prominent bone just behind and under the ear). Ear infections that people fail to treat cause most cases of mastoiditis.

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48
Q

what is tonsilitis/pharyngitis (child URTI)

A

common infection

is it viral or bacterial?

take throat swab

treat with nothing or 10 pays penicillin Alternative first choices for penicillin allergy or intolerance are clarithromycin or erythromycin.

not amoxicillin - avoid if there is a possibility of glandular fever (Epstein Barr virus).

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49
Q

(CHILD URTI) - how to try differentiate bacterial or viral tonsillitis/pharyngitis

A

children who have strep throat often have scarlet fever - faint pink rash

classically pallor (an unhealthy pale appearance.) around the mouth and often not felt right/well for a week or two

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50
Q

(CHILD URTI) treat tonsilitis/pharyngitis

A

treat with nothing or 10 pays penicillin Alternative first choices for penicillin allergy or intolerance are clarithromycin or erythromycin.

not amoxicillin - avoid if there is a possibility of glandular fever (Epstein Barr virus).

normally lasts 2-3 days but can last over a week

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51
Q

(child URTI) croup/epiglottitis

A

croup (LTB) (larynx), windpipe (trachea) and bronchial tubes (bronchi). Human parainfluenza viruses

common

generally well

coryza (catarrhal inflammation of the mucous membrane in the nose, caused especially by a cold or by hay fever)

stridor, hoarse voice “bark” cough

treat oral dexamethasone

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52
Q

(child URTI) croup/epiglottitis

A

Haemophilus influenzae (H influenzae) type B

rare

toxic

symptoms: stridor, -drooling (partial obstruction oesophagus)

treatment - needs intubation and antibiotic.

usual duration 1 day.

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53
Q

(child LRTI) - conditions and what is LRT

A

trachea - bronchus -bronchioles - lungs - pleura

trachea - tracheitis; bronchus - bronchitis; bronchioles - bronchiolitis

lung - pneumonia; pleura - empyema

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54
Q

(child LRTI)

the typical definition of infection and when it is cleared

A

no infection in an otherwise sterile area

infection is the sterile area becomes occupied by an infective agent

infection is cleared when the agent is cleared and has left the area sterile again

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55
Q

two most common bacterial causes of infection (child URTI)

A

Haemophilus and pneumococcus

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56
Q

common bacterial causes of infection (child URTI)

A

bacterial; strep pneumonia, Haemophilus influenzae, Moraxella catarrhalis, mycoplasma pneumonia, chlamydia pneumonia

viral - RSV, parainfluenza 3, influenza A and B, adenovirus

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57
Q

principles of management (child LRTI)

A
  • make a diagnsis

assess the patient

oxygenation, hydration, nutrition

treat or not treat?

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58
Q

what is tracheitis (child LRTI)

A

swollen tracheal wall narrowed tracheal lumen luminal debris

uncommon “croup which does not get better) LBT

fever, sick child staph or strep invasive infection

give augmentin Amoxicillin/clavulanic acid, also known as co-amoxiclav

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59
Q

(child LRTI) bronchitis signs

A

common ++ endobronchial infection loose rattly cough with URTI

post-tussive vomit (glut) chest free of crepitations or wheeze

Haemophilus / pneumococcus cause

mostly self-limiting

child very well + parent worried

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60
Q

(child LRTI) bronchitis mechanisms/causes

A
  • disturbed mucociliary clearance (escalator cilia)

minor airway malacia (abnormal softening of biological tissue)

RSV/adenovirus

lack of social inhibition

  • bacterial infection/ overgrowth is secondary

can last 7-10 days can be 25 days.

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61
Q

what is natural history/pattern of bacterial bronchitis (child LRTI)

A

follows from URTI (rhinovirus) can last up to 4 weeks

60=80% cases respond to antibiotics (sometimes significant side effects)

morbidity: 1st winter children at nursery high symptoms

2nd winter lapse and but better

3rd winter fine

** any winter it’s usually pneumococcus and Haemophilus cold**

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62
Q

what is the best approach with persistence with bacterial bronchitis (child LRTI)

A

make diagnosis

reassure parents/family

do not treat with antibiotic

nutrition +hydration

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63
Q

what is the bronchiolitis (child LRTI)

A
  • LRTI of infants

affects 30-40% of all infants

  • usually RSV virus, others include paraflu 3, HMPV

nasal stuffiness, tachypnoea, poor feeding

crackles +/- wheeze

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64
Q

what is should you consider with bronchiolitis symptoms regarding days inoculated?(child LRTI)

A

day 1-2 child is well day 3-5 child worsens day 5-7 child stabilising day 7> recovery

if a child on day 3 is not feeding and o2 low with poor hydration, you would admit to the hospital as you know they will get worse

if a child on day 5 you know the child is stabilising and likely to not get worse

normal duration about 12 days some more than 16 days

Respiratory syncytial virus (RSV)

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65
Q

what is the natural history/pattern of bronchiolitis (child LRTI)

A

under 12 months old (infants)

one-off infection (not recurrent)

treat with maximum observation + minimal intervention

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66
Q

typical investigation for a clinical diagnosis of w bronchiolitis (child LRTI)

A

nasopharyngeal aspirate NPA - to identify what the virus is (nurse in the same ward)

test spo2 (severity)

no routine need for a chest x-ray, blood or bacterial culture

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67
Q

what medications don’t benefit bronchiolitis (child LRTI)

A
  • salbutamol

ipratropium bromide

adrenalin

steroid

antibiotic

nebulised hypertonic saline

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68
Q

(child LRTI) common symptoms

A

48 hour fever (>38.5); shortness of breath; cough; grunting

  • wheeze makes bacterial cause unlikely

reduced or bronchial breath sounds

often caused by infective agents (virus + commensal bacteria/bacterium) (usually does no harm but if given opportunity then can)

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69
Q

Pneumonia (child LRTI) when to call it pneumonia

A
  • word causes anxiety be careful

signs of pneumonia IF

-signs are focal i.e one whole area (left lower zone e.g)

you hear crepitations

they have a high fever

otherwise, call it a lower respiratory tract infection

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70
Q

(child LRTI) BTS guidelines for community-acquired pneumonia

A

investigate chest cray and inflammatory markers (not routine)

management

nothing if symptoms are mild (offer review if things get worse)

-Oral amoxicillin first line

oral macrolide second choice

only for Iv if vomiting

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71
Q

guideline for antibiotic prescribing in upper and lower RTI

A

bronchiolitis - not indicated (usually RSV, parainfluenza 1, adenovirus)

croup - not indicated (usually parainfluenza 3, also RSV, adenovirus)

acute lower respiratory tract infection - not often indicated - child <2 mild presentations rarely need and have pneumococcal vaccine however, first-line can be amoxicillin

otitis media - antibiotic not usually indicated - amoxicillin if under age 2 and signs of bilateral infection

pharyngitis/tonsillitis - not usually indicated - consider penicillin, not amoxicillin

72
Q

what is pertussis

A

whooping cough

73
Q

what helps avoid pertussis (child LRTI)

A

it’s common

vaccine reduces risk

vaccine reduces severity

symptoms - coughing fits - paroxysm of coughing convulsed

vomiting and colour change of skin

74
Q

what is empyema (child LRTI)

A
  • complication of pneumonia

extension of infection into pleural space

includes chest pain and feeling very unwell

  • give antibiotics +/- drainage
  • good prognosis in contract to adults
75
Q

what part of the pleura causes pain in empyema (child LTRI)

A

The parietal pleura is sensitive to pressure, pain, and temperature. It produces a well localised pain, and is innervated by the phrenic and intercostal nerves.

76
Q

treating (child LRTI) best treatment and what antibiotic

A

first sort out oxygenation, hydration and nutrition

antibiotic? which one?

tracheitis yes Augmentin

Bronchitis no

LRTI/pneumonia optional oral amoxicillin

bronchiolitis no

empyema yes iv antibiotics

77
Q

(adult LRTI) conditions

A
  • acute bronchitis - exacerbation of COPD -pneumonia
  • empyema - Lung abscess - bronchiectasis
78
Q

(adult LRTI) what is bronchitis

A
  • inflammation of bronchi
  • temporary <3 weeks
  • cough and sputum

usually viral

requires supportive management

79
Q

(adult LRTI)what is gp advice regarding acute bronchitis

A
  • if cough severe or last longer than 3 weeks

high temp for more than 3 days (sign of flu or more serious e.g. pneumonia)

cough mucus with blood

have underlying heart or lung condition e.g. asthma, heart failure or emphysema

becoming more breathless

have repeated episodes of bronchitis

80
Q

signs of COPD exacerbation (adult LRTI)

A
  • change the colour of sputum -fevers - increased breathlessness - wheeze - cough

caused often by streptococcus pneumonia Haemophilus influenza Moraxella catarrhalis viral

81
Q

treating COPD exacerbation (adult LRTI)

A
  • steroids

antibiotics - amoxicillin doxycycline co-trimoxazole clarithromycin

+/- nebulisers

82
Q

explain pneumonia (adult LRTI)

A

inflammation of lung parenchyma and consolidation - solidification due to cell exudate impairs gas exchange

1 in 20 bronchitis develop to pneumonia (due to damaged cilia unable to escalate products out of lung)

Risk factors: smoking; alcohol excess; extremes of age; pre-existing lung disease; chronic illness; immunocompromised; hospitalisation; IVDU; preceding viral illness

83
Q

pneumonia signs and symptoms (adult LRTI)

A

symptoms: fever; rigours; myalgia muscle pain; cough + sputum; chest pain (pleuritic) increase inspiring; dyspnoea; haemoptysis

rusty brown sputum typical streptococcus pneumonia

signs: tachypnoea (>RR); tachycardia; reduced expansion chest; dull percussion; bronchial breathing; crepitations; a vocal resonance

84
Q

community and hospital investigations for pneumonia (adult LRTI)

A

community - maybe none, chest x-ray if in doubt or not improving (rule out cancer)

Hospital - bloods (serum biochemistry, Full blood count, CRP, Blood cultures

Chest x-ray

sputum culture, viral throat swab legionella urinary antigen

85
Q

what are differential diagnoses for pneumonia (adult LRTI)

A
  • tuberculosis
  • lung cancer

pulmonary embolism

pulmonary oedema

pulmonary vasculitis (Wegener’s granulomatosis)

86
Q

pneumonia on chest-x-ray (adult LRTI)

A

right upper zone in pic - will see clear white exudate and consolidation

87
Q

what viruses often cause pneumonia (adult LRTI)

A

streptococcus pneumonia

h. influenzae

viruses

less common - legionella, staph aureus, mozzarella catharsis, mycoplasma pneumonia, chlamydia pneumonia, chlamydia psittaci, Coxiella burnetti

88
Q

clasiffication on pneumonia (adulte LRTI)

typical and atypical

A
  • *Community-acquired**
  • *typical** streptococcus pneumonia (gram neg) Haemophilus influenzae mycoplasma pneumonia
**atypical** (more systemic symptoms e.g. more dry cough less sputum)
legionella pneumophilia (fresh water a/c), chlamydia pneumonia, chlamydia psittaci, Coxiella burnetti, Moraxella catarrhalis, viruses
89
Q

clasiffication on pneumonia (adult LRTI)

nosociomial

A

nosocomial (>48 hours)

enterobacteria (aspiration); staphylcoccus aureus; pseudomonas aerigunosa; klebseilla pneumonia - chlostridia - anaerobes - TB

90
Q

Which type of infecions can cause cavitation?

A

staphylcoccus aureus;

klebseilla pneumonia

TB

91
Q

which type of infection shows a bright yellow foul smelling sputum? (adult LRTI)

A

pseudomonas aerigunosa;

92
Q

pneumonia severity scoring what is it for?

A

to determine whether or not somebody can be treated in the community or needs to come into hospital

CURB65

93
Q

What is the scoring for pneumonia severity scoring (adult LRTI)

A

c - confusion

u - blood urea >7mmol/l

R - respiratory rate >30 min

B - Systolic bp <90mmHg diastolic bp < 60mmHg

65 - age >65

A score of 0-1 low risk treat community: 2 - moderate risk - usually hospital treat: 3-5 high risk of death need for ITU

94
Q

what should clinicians be wary of scoring pneumonia? (adult LRTI)

A
  • young people they likely wont score on this but doesn’t mean they don’t have severe pneumonia. they tend to compensate physiologically until they get bad.
  • hypoxic patients
  • those with multilobular consolidation
95
Q

treating pneumonia (adult LRTI)

A

severity antibiotic penicillin allergy duration

CURB 0-1 AMOXICILLIN Clarythromycin or doxycycline 5 days

CURB 2 amoxicillin
+clarythromycin Levofloaxin 5-7 days
(atypicals)

CURB 3-5 Co-amoxiclav Levofluoxacin or
+clarithromycin co-trimoxazole 7-10 days
(atypicals)

** consider route iv vs oral

96
Q

apart from antibiotic, what other treatment should be considered for pneumonia (adult LRTI)

A

o2 therapy, fluids (iv or oral)

antipyretic (paracetamol), NSAIDS ibuprofen

intubation and ventilation

97
Q

when Is Iv antibiotic more appropriate for patients with pneumonia (adult LRTI)

A

if they cannot swallow, if they are septic or have signs of sepsis (high temp, tachy)

if vomiting

98
Q

circumstances of pneumonia (adult LRTI) influenza occurs from__

A

staphylococcus aureus secondary infection

99
Q

circumstances of pneumonia (adult LRTI) aspiration pneumonia often happens due to __

treat with __

A

stroke, MS, myasthenia, sedation, oesophageal disease (struggling to swallow)

anaerobes are likey (anaerobes are organisms that do not require energy oxygen for metabolism)

treat with - Amoxicillin and metronidazole

100
Q

circumstances of pneumonia (adult LRTI) pneumonia in immunocompromised

treat with __

A

haemoglobion malignancy, neutropenia, HIV

  • fungis usually - aspargillus fumigatus, candida

viruses usually - CMV, HSV, VZV

pneumocystis jiroveci pneumonia treat cotrimoxazole

MRSA treat vancomycin

101
Q

complications of pneumonia (adult LRTI)

A
  • Sepsis - AKI (acute kidney injury) - Adults respiratory distress syndrome
  • Parapneumonid effusion (fluid pleural space) - empyema - lung abscess
  • disseminated infection (bacteremia which can cause sceptic emboli in other organs)

signs of these: swinging fever, sweats, persistently high WBC count/CRP, weight loss, failure to improve

102
Q
  • Parapneumonic effusion (fluid pleural space) how to diagnose (adult LRTI)
A

thoracic ultrasound +/- aspirate

  • fluid parameter

simple ph >7.2

complicated <7.2

empyema pus/culture +ve

May need drain and prolonged antibiotic

surgery/intrapleural tPA + DNAse

Tissue plasminogen activator (tPA) is a protein involved in the breakdown of blood clots.

103
Q

Diagnosing lung abscess (adult LRTI)

A

more likely with staph aureus pseudomonas, anaerobes

  • purulent sputum, haemoptysis
  • screen for TB

CT scan +/- bronchoscopy

prolonged antibiotic

104
Q

what is normal recovery with pneumonia (adult LRTI)

A

recovery can take weeks

repeat chest x-ray 6 weeks if over 50 years old and smokers

recommend smoking cessation

recurrent pneumonia

? immunocompromised

underlying structural lung disease

?aspiration

105
Q

Bronchiactases adult LRTI

A

would give recurrent LRTI

havin dilated distal bronchi - tend to produce sputum in thickened/inflames airways. = airway becomes narrow due to inflammation regardless of dilated airway

= obstructive change on spirometry.

106
Q

chest x-ray of bronchiectasis (adult LRTI)

A
  • wider bronchi than corresponding blood vessels
  • signet ring sign - bronchi look like a ring
  • tree bud change in the structure
107
Q

causes of bronchiectasis (adult LRTI)

A
  • idiopathic - Childhood infection - pertussis,/whooping cough - Ciliary dyskinesia - Hypogammaglobulinaemia - Cistic Fibrosis
  • Allergic broncho-pulmonary aspergillosis (ABPA)
108
Q

signs and symptoms of bronchiectasis (adult LRTI)

A
  • Chronic productive cough - breathlessness - recurrent LRTI -Haemoptysis
  • Finger clubbing -crepitations (coarse) - Wheeze - Obstructive spirometry
109
Q

test and treatment for bronchiectasis (adult LRTI)

A

exacerbations: staph aureus ; h influenzae; pseudomonas aerigonsa
need: sputum, chest x-ray (including AAFB)
- seen by chest physio - mucolytics
- prolonged antibiotic course 10-14 days

vaccinations

consider prophylactic antibiotic

110
Q

define endemic

A

a constant presence and/or prevalence of a disease/infectious agent in a population within a geographical area

e,g, chickenpox UK: malaria Malawi

111
Q

define epidemic

A

increase, often sudden, in number of cases of a disease above what is normally expected in population in a certain area

112
Q

outbreak definition

A

carries the same definition of. epidemic (sudden increase number of cases of a disease above normal ina population area(s)

but it often used for a more limited geographical area

113
Q

Define pandemic

A

an epidemic that has spread over several countries or continents, usually effecting a large number of people

114
Q

virology viruses alpha beta gamme and delta

A

alpha and beta (most common for infection humans) source mainly bats

gamma - mainly comes from birds

Delta - comes porcine so pigs

115
Q

transmission factors for covid-19

A

Incubation period days - 1-14 days

median 5-55 days for symptoms

infectious peak 24 hours pre symptoms.

reproduction number - people acquiring infection from infected 2.2 - 3.3

1.4 Scotland

116
Q

Pathophysiology of COVID-19

A

1 viral entry+early infection:

2 host immune response - immune cells early macrophages + dendritic - late phase cytotoxic cells

  1. hyperinflammatory phase infects t cells and macrophages = more cytokine release that is infected

4 multiple organ dysfunction - lungs reduce the capacity of airways alveoli reduced capacity spreads to other organs and poor o2 shut down need ventilation - death

117
Q

common general symptoms of COVID-19

A
  • rhinorrhoea (runny nose) -general malaise (unwell pale) - headache - sore throat - cough fever
118
Q

respiratory symptoms of covid-19

A

covid can cause pneumonia and acute respiratory distress syndrome - lots of white patches

119
Q

extra pulmonary symptoms of COVID-19

A

brain headache dizziness, confusion, epilepsy. ataxia,ansomia, ageusia: systemic inflammation _ cerebral edemam pulmonary hypoxia, matebolic acidosis

heart elevated cardiac troponin elevated nt-probnp, bnp: myocarditis - stress-induced cardiomyopathy

kidney elevated serum creatinine, increase urea, proteinuria: direct infection, systemic inflammation

blood - increased: prothrombin time, d-dimer, fibrinogen, aPTT: SARS COV 2 MEDIATED ENDOTHELIAL DYSFUNCTION systemic inflammation (e.g. cytokine, complement pathway)

body increased: ferritin, c reactive protein, esr + lymphopenia, fever: systemic inflammation

120
Q

prevention for COVID-19

A

Handwashing

social distancing

mask wearing

isolation

vaccines

PPE

121
Q

Isolation with COVID-19

A

if you are well to stay at home - 10 days

if unwell (e.g. admitted to hospital) 14 days

if very unwell and needed ITU or immunocompromised - 21 days

122
Q

types of COVID-19 vaccines

A

pzifer/niontech moderna aztrazenca

vaccine type mRNA vaccine mRNA vaccine attenuated virus

efficacy 95% 94% 70%

Authorised dose doses 3 weeks 2 doses 4 weeks 2 doses 12 weeks
apart apart apart

123
Q

treatment for COVID-19

A

anti-pyretic (paracetamol)

steroids

supportive therapy

clinical trials

02 therapy

6mg dexamethasone once a day for 10 days for anyone who needs o2 therapy.

124
Q

o2 therapies for COVID-19

A

mild - nasal cannula 1-6L

moderate nasal cannula or simple facemask (sm) 5-10L

severe - simple facemask or reservoir mask 15L

very severe nasal high-flow o2 (up tp 70L) or Cpap (15L)

for airway maintenance - venturi mask suitable for resp type 2 failure 2-15L

non-invasive ventilation 0-15L

125
Q

vulnerable groups for TB in UK

A

those from high prevalence countries

  • 70% non-UK born most aged between 15 and 44

HIV positive or immunocompromised

elderly, neonates and diabetics

homeless, alcohol dependency, idvu, those with mental health problems and those in prisons approximately 1 in 10 cases

126
Q

mycobacteria - what are they?

A

numerous species - ubiquitous in the soil and water

few species responsible for human disease

tuberculosis )m.tuberculosis, m africanum, m bovis (bovine tb is bcg strain)

non-tuberculosis - mycobacteria NTM infection/atypical mycobacteria

leprosy (m leprae)

non-motile bacillus, slow-growing (disease slow but treatment is long)

aerobic (predilection for apices or lungs)

uniquely thick fatty cell wall - resistant to acids, alkalis and detergents

resistant to neutrophil and macrophage destruction

not all AAFB are tb (aafb= alcohol and acid fast bacilli)

127
Q

how does TB spread?

A

airborne (pulmonary and laryngeal tb)

someone with tb in lungs if they cough, sneeze, yell, sing

tb bacteria attaches to aerosol droplets

someone breathing these bacteria in through droplets - required prolonged close contact

outdoors - mycobacteria usually eliminated by UV radiation and dilution

not by shaking hands, sharing food, touching surfaces, sharing toothbrushes or kissing

exception to rule is mycobacterium bovis can be spread by consumption of unpasturised infected cows milk (uncommon in UK)

128
Q

An endemic is a sudden increase in cases of a disease, above what would normally be expected in a given population.

Select one:

True

False

A

False – this describes an epidemic. An endemic disease is maintained at a consistent and predictable level in a given population, for example chickenpox in the UK.

129
Q

Influenza can lead to secondary bacterial infection by impairing the body’s ability to make antibodies.

Select one:

True

False

A

False – secondary bacterial infection after flu is usually due to damage to the mucociliary escalator, which results in bacteria and mucus accumulating in the lower respiratory tract.

130
Q

Diarrhoea and vomiting are a feature of atypical pneumonia.

Select one:

True

False

A

True – pneumonia caused by atypical organisms classically presents slightly differently to typical pneumonia. Features include diarrhoea and vomiting, headache, myalgia (muscle ache) and dry cough.

131
Q

Lung consolidation results in a decrease in vocal resonance on examination.

Select one:

True

False

A

False – vocal resonance is used as part of clinical examination to detect areas of consolidation in the lung. Consolidated lung transmits sound more effectively than aerated lung, so the voice of the patient is heard more clearly over abnormal lung, i.e. vocal resonance is increased.

132
Q

A patient with hypoxia due to pneumonia will have a CURB 65 score of at least 2.

Select one:

True

False

A

False – not necessarily. CURB 65 does not account for hypoxia, and young patients with a good capacity to compensate physiologically may not have a high respiratory rate or low blood pressure until they are very unwell. Hypoxia is an important feature indicating severe illness regardless of CURB 65 score

133
Q

People with neuromuscular disorders are at higher risk of opportunistic infections.

Select one:

True

False

A

False – opportunistic infections generally occur in people with severely compromised immune systems, for example from untreated HIV. However, people with some neuromuscular disorders are at higher risk of aspiration pneumonia, through impaired swallowing mechanism.

134
Q

Croup is treated with oral steroid.

Select one:

True

False

A

True – Croup – or laryngotracheobronchitis – is a common childhood illness, most commonly caused by the Parainfluenza I virus. It causes a barking cough and stridor (sound caused by upper airway obstruction). Treatment, when required, is with dexamethasone (a steroid) to reduce inflammation.

135
Q

Recurrent lung infection is always concerning.

Select one:

True

False

A

True – if a person is recurrently developing lung infections, this indicates that one or more parts of their body’s defence mechanism are not working. Examples include diseases such as COPD, cystic fibrosis, or bronchiectasis; localized obstruction such as a tumour or a foreign body; or immunocompromise due to HIV or medications.

136
Q

A 72 year old with pneumonia who is alert, has a respiratory rate of 26, a blood pressure of 100/80mmHg and a blood urea of 4.5mmol/L has a CURB 65 score of 3.

Select one:

True

False

A

False – this patient would have a CURB 65 score of 1, for their age. Remember:

C = confusion

U = blood urea >7mmol/L

R = respiratory rate over 30

B = systolic BP <90mmHg, diastolic BP <60

and 65 = age over 65.

Each component scores 1 point. Patients with a CURB 65 score over 3 have a significant risk of death and require critical care input.

137
Q

Bacterial lower respiratory tract infections in children always requires antibiotics.

Select one:

True

False

A

False – if the child is eating and drinking well, and their oxygen levels are normal, it is reasonable to keep a close eye on them and do nothing.

138
Q

Patients being treated for TB with ethambutol should have their vision monitored as it can cause optic neuritis.

Select one:

True

False

A

True – this is a recognized side effect of ethambutol, so patients will routinely have their vision monitored during treatment.

139
Q

Amoxicillin will treat pneumonia caused by most typical and atypical organisms.

Select one:

True

False

A

False – Amoxicillin does not have much activity against atypical organisms. When pneumonia is severe or atypical infection is suspected, treatment should include a macrolide antibiotic like clarithromycin, or an alternative like doxycycline, levofloxacin or co-trimoxazole.

140
Q

A positive AAFB smear is diagnostic of pulmonary TB.

Select one:

True

False

A

False – while pulmonary TB will often give a positive Acid Alcohol Fast Bacilli smear, not all positive AAFB smears are TB, and a negative AAFB smear does not rule out TB.

141
Q

how TB bacteria ends up in alveoli

A

1 activates macrophages recognising TB - ingests bacteria - t helper cells activated and come from lymph nodes secreting cytokines - develop into epithelioid cells and Langhans giant cells

2 create granulomas for the immune system to fend off infection

3 causes ventral necrosis which may later calcify

142
Q

history of TB primary infection stage

A
  • no preceding exposure or immunity
  • mycobacteria spread via lymphatics to draining hilar lymph nodes

usually, no symptoms can have fever malaise (generally unwell pale) erythema nodosum (Erythema nodosum is swollen fat under the skin causing bumps and patches that look red or darker than surrounding skin.) rarely chest signs

for the majority, 85% of initial lesion +local lymph node (primary complex) health without scar may calcify

associated with the development of immunity to tubercoloprotein

143
Q

primary infection 3 outcomes usually

A

progressive disease

contained latent (in granulomas contained)

cleared/cured

144
Q

what happens when primary TB infection progresses

A

Tuberculosis bronchopneumonia

  • primary focus continues to enlarge (cavitation) - enlarge hilar lymph compress bronchi, lobar collapse, enlarge lymph node discharges into bronchus = poor prognosis
145
Q

what is miliary TB

A

(look like millet seeds on autopsy) develops with hematogenous spread of bacteria to multiple organs

fine mottling on x-ray widespread granulomata

CNS TB in 10-30%

146
Q

Post primary disease TB

A

only in humans. most animals succumb to primary TB and never develops to post-primary TB

two hypothesis

  1. tb bacteria entering a dormant stage with low or no replication over long periods of time
  2. balances state of replication and destruction by immune mechanisms
147
Q

clinical presentation of TB

A
  • cough
  • fever
  • sweats (mainly at night)
  • weight loss

crp normal in 15% esr normal in 21%

148
Q

Diagnosing active TB xray post-primary

A

tb likes oxygen - apices

soft fluffy/nodular upper zone

cavitation 10-30%

lymphadenopathy rare

149
Q

for assessing TB when would you consider a CT

A

if you have a normal chest x-ray but clinical suspicion

  • military TB

cavitation and nother differential

lymphadenopathy, alternative diagnosis

150
Q

How to diagnose active pulmonary TB in chest x-ray

A

Chest x-ray

mediastinal lymphadenopathy (mainly unilateral 15% bilateral)

pleural effusion

miliary (haematogenous spread 1-3%)

** if pt short history (few weeks) unwell and looks lobar pneumonia (usually pneumococcal cause) + large hilar lymph nodes think tb could be primary **

151
Q

if a patient has short history (few weeks) of feeling unwell and xray looks like lobar pneumonia and xray shows large hilar lymph nodes what should you also consider?

A

if a patient has a short history (few weeks) of feeling unwell and xray looks like lobar pneumonia and xray shows large hilar lymph nodes think tb as it could could be primary TB

152
Q

how to test for TB

A

get the bug - get 2 sputum samples 8-24 hour gap at least one early morning sample

  • induced sputum - saline to encourage cough - bronchoscopy with BAL (bronchial alveolar lavage)

endobronchial ultrasound (EBUS) with biopsy

  • lumbar puncture in CNS TB - urine in urogenital tb

aspirate/biopsy from tissue (lymph-node, bone, joint, brain, access

Mantoux or IGRA (interferon-gamma release assays) are NOT routinely used in diagnosing active TB (mainly dormant or latent TB)

153
Q

medications used for TB

A
  • isoniazid (h)

pryazinamide (z)

Riampicin (r)

ethambutol (e)

154
Q

rules for treating TB

A
  • multiple drug therapies essential - Therapy must continue for at least 6 months
  • single-agent treatment leads to drug resistance organisms within 14 days
  • TB therapy is a job for specialists only - legal requirement to notify all cases
  • test for HIV, Hep b and Hep C also
155
Q

Standard treatment regime for TB

A

4:2/2:4 = 4 drugs treat for 2 month / 2 drugs treat for 4 month = 6 months total

R/H/Z/E = Rafimpicin (R), Isoniazid (H), Pyrazinamide (Z), Ethambutol (E) 2 months

R/H = Rafimpicin (R), Isoniazid (H), 4 months

standard 70kg patient takes 12 tabs daily

give 2-9 month if monoresistance

12 months for cns tb, h monoresistance extensive disease

9-12 or 18-20 months for MDR, TT TB

156
Q

what other treatments do we give for patients undergoing TB treatment?

A

risk of isoniazid induced retinopathy - add vitamin b6 to reduce risk

steroids (sometimes)

vitamin - D substitution?

157
Q

what are the side effects of TB treatment?

A

rifampicin - orange ‘irn bru’ tears/urine/lenses. induces liver enzymes, prednisolone, anticonvulsants. all hormonal contraceptive ineffective, hepatitis

Isoniazid - hepatitis, peripheral neuropathy (pyridoxine b6)

pyrazinamide - hepatitis, gout

ethambutol - optic neuropathy (check visual activity)

+ all 4 drugs can cause rash

158
Q

what is screening methods for latent TB criteria

A

screen - contact of people aged <65 (hepatotoxicity increased with age)

  • new entrants from high endemic areas

pre-biologics (TNF alpha inhibitors) - are of outbreaks

asymptomatic with normal chest x-ray and examination and positive either Mantoux test or IGRA

159
Q

what is latent TB

A

where the immune system controls the TB infection and bacteria are still viable in the body but don’t cause disease.

160
Q

Treating latent TB

A

always rule out active TB

  • rifampicin + isoniazid for 3 months or isoniazid only for 6 month
  • *or_ Rifampicin only for 6 months _or** rifapentine and isoniazid once weekly for 12 weeks (underserved population)
161
Q

Rusty brown sputum is a symptom of Staphylococcal pneumonia.

Select one:

True

False

A

False – rusty brown sputum is classically seen with pneumonia caused by Streptococcus pneumonia.

162
Q

A pneumonia is labelled “hospital-acquired” if it occurs at least 24 hours after admission to hospital.

Select one:

True

False

A

False - the cut-off is at least 48 hours after admission to hospital.

163
Q

TB can be spread by physical contact, e.g. shaking hands or kissing.

Select one:

True

False

A

False – TB is an airborne pathogen, and is not spread by physical contact.

164
Q

Coxiella burnetti pneumonia is classically associated with exposure to birds.

Select one:

True

False

A

False – C. burnetti is classically associated with exposure to farm animals. Bird owners are classically prone to pneumonia from Chlamydia psittaci.

165
Q

Nasal high flow oxygen can deliver oxygen at 1-6L/min.

Select one:

True

False

A

False – high flow nasal oxygen can be delivered up to 70L/min! The oxygen is warmed and humidified, otherwise this would be prohibitively drying and uncomfortable. It is important to be aware that this is classed as an aerosol-generating procedure.

166
Q

Most patients with TB will present during their primary infection.

Select one:

True

False

A

False – the primary infection (i.e. the point at which the person becomes infected; the first exposure to TB) is often asymptomatic, and in the majority of people it will either be cleared completely or contained within a granuloma as latent TB. Most symptomatic presentations of TB result as a reactivation of latent TB.

167
Q

Acute epiglottitis is dangerous and can be fatal.

Select one:

True

False

A

True –Most upper respiratory tract infections are self-limiting. However, rarely, the epiglottis can become inflamed from a bacterial infection (such as Haemophilus influenzae) and this can lead to airway obstruction and even death. This used to be more common in children than it is now, but fortunately incidence is falling due to the Hib vaccine.

168
Q

Bronchiolitis is usually a bacterial infection.

Select one:

True

False

A

False – it is usually caused by a respiratory syncytiovirus, and is most common in babies.

169
Q

Latent TB does not require any treatment.

Select one:

True

False

A

False – latent TB (positive Mantoux or IGRA test in a person who has had contact with TB, but is asymptomatic and has a normal CXR) is treated to reduce the chance of developing active TB. The same antibiotics are used, for a slightly shorter course, usually 3 to 6 months.

170
Q

Influenza can lead to secondary bacterial infection by impairing the body’s ability to make antibodies.

Select one:

True

False

A

False – secondary bacterial infection after flu is usually due to damage to the mucociliary escalator, which results in bacteria and mucus accumulating in the lower respiratory tract.

171
Q

Pseudomonas aeruginosa pneumonia is typically associated with cystic fibrosis.

Select one:

True

False

A

True – pseudomonas infection is typically seen in cystic fibrosis and other bronchiectatic disease. It causes copious, green, foul-smelling sputum.

172
Q

A reservoir mask can provide oxygen up to 15L/min.

Select one:

True

False

A

True – a reservoir or “non-rebreathe” mask uses a bag to create a reservoir of oxygen and increase the concentration of oxygen being delivered to around 60-90%.

173
Q

Miliary TB is a rare complication of primary TB infection.

Select one:

True

False

A

True – this involves the wide dissemination through the bloodstream of TB granulomata, and commonly involves spread to the brain and meninges.

174
Q

Staphylococcus aureus pneumonia is associated with intravenous drug abuse.

Select one:

True

False

A

True – Intravenous drug users are at higher risk of S. aureus bacteraemia (as S. aureus is a common skin commensal) and S. aureus pneumonia. It is also classically seen following influenza infection.

175
Q

The respiratory tract is protected from infection by free-moving lymphocytes which clear pathogens and debris by phagocytosis.

Select one:

True

False

A

False – the key cells in the respiratory system’s innate defence mechanism are macrophages. They participate in the macrophage-mucociliary escalator, and clear debris from the lungs by phagocytosis.

Medicine 1 (Year 1) (15 decks)

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