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Respi > Pneumonia > Flashcards

Pneumonia Flashcards

1
Q

What is the definition of pneumonia?

A

Pneumonia = infection of the lung parenchyma by bacteria, fungi, viruses characterised by exudation into the alveoli.

Case Definition: Lower respiratory tract signs with radiological evidence of consolidation

If no radiological evidence of consolidation 🡪 this is diagnosed as LRTI instead

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2
Q

What are LRTI signs?

A
  • Cough
  • Fever
  • Breathless +/- Wheeze
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3
Q

How do you differentiate between bronchopneumonia vs lobar pneumonia?

A

Bronchopneumonia = Characterized by patchy foci of consolidation (pus in many alveoli and adjacent air passages) scattered in one or more lobes of one or both lungs

Lobar pneumonia = Characterized by an acute inflammation of the entire lobe or lung. Histologically, tissue changes are classified into four stages: congestion, red hepatization, grey hepatization and resolution

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4
Q

What are the 4 phases of progression of lobar pneumonia?

A

1) Congestion Day 1- 2
- Pulmonary vessels dilate, exudate enters alveoli
- Patient is febrile, develops dyspnoea and cough

2) Red hepatisation Day 2-4
- Alveoli fills with RBCs and fibrin strands 🡪 lobe of lung is solid
- No gas exchange 🡪 Patient is hypoxic, breathless; may cough up blood stained sputum (due to RBC that fills alveoli)

3) Grey hepatisation Day 4-8
- Alveoli full of neutrophils and dense fibrous strands 🡪 Lung remains solid
- Patient coughs up purulent sputum; remains breathless

4) Resolution Day 8-10
- Monocytes clear the inflammatory debris; normal lung architecture restored

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5
Q

How do you decide if a patient has pneumonia (IFLASH)?

A

Infiltrate* - consolidation on CXR: this is the single most definitive sign of pneumonia

Fever

Leucocytosis

Auscultatory findings

  • Coarse crepitation
  • Decreased air entry
  • Bronchial breath sounds

Sputum

  • Pneumonia usually p/w productive cough
  • Atypical pneumonia may be non-productive
  • Colour of sputum have no definite correlation

Hypoxemia

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6
Q

What are the symptoms of pneumonia?

A
  • Cough – painful, dry, productive, haemoptysis
  • Sputum and colour
  • Fever and rigors (shivers)
  • Dyspnoea
  • Fever – swinging fever suggests empyema
  • Pleuritic chest pain
  • Anorexia
  • Sudden onset malaise
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7
Q

What is the physical examination findings of pneumonia?

A
  • Vitals -> pyrexia, tachypnoea, tachycardia, hypotension, desaturation
  • Mental status -> confused
  • Respiratory
  • Consolidation -> decreased chest expansion, dullness to percussion, bronchial breath sounds, increased vocal resonance
  • Signs of respiratory distress, cyanosis (if severe)
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8
Q

When do you decide to admit a patient with pneumonia?

A

CURB 65

  • Confusion of new onset (AMTS ≤8 – abbreviated mental test score)
  • Urea ≥7
  • Respiratory rate ≥30/min
  • Blood pressure: systole ≤90mmHg and/or diastole ≤60mmHg
  • Age ≥65

Score 2= admit to ward
Score >2= admit to ward, may need ICU

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9
Q

What are the pathogens responsible for community acquired pneumonia?

A

Typicals: Strep Pneumo; Moraxella Cattarhalis, Haemophilus Influenzae

Atypicals (Walking Pneumonia): Legionella; Chlamydophila, Mycoplasma

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10
Q

What is hospital acquired pneumonia and what are the pathogens responsible for it?

A

Think: MRSA, Pseudomonas

Pneumonia that develops ≥48h after admission to hospital

CXR on admission must be clear

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11
Q

What is healthcare associated pneumonia?

A
  • Develops within 3 months of having been in a healthcare setting for which pt has been hospitalized for 2 or more days
  • Nursing home or long-term care facility (common)
  • Hospital or haemodialysis clinic
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12
Q

What is VAP and what are the pathogens responsible for it?

A

Think: MRSA, Pseudomonas

48-72 hours after endotracheal intubation

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13
Q

What is aspiration pneumonia normally caused by and what are the PMH associated with it?

A

Think: Klebsiella, anaerobes and gram negatives

Pts w/ stroke, myasthenia, bulbar palsies, ↓ consciousness, oesophageal disease etc

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14
Q

What are the pathogens more likely causing pneumonia in a patient post URTI?

A

Influenza, Staph Aureus (but rare)

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15
Q

What are the pathogens more likely causing pneumonia in a diabetic patient?

A

Melioidosis & Klebsiella

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16
Q

What is the pathogen most likely causing pneumonia in an immunocompromised patient with soil exposure patient? What are the antibiotics used to treat?

A

Melioidosis

Drug of choice – Ceftazidime

Empirical Abx – ABC: Azithromycin, (Benzyl) Penicillin, Ceftazidim

17
Q

What are the pathogens more likely causing pneumonia in a HIV patient?

A
  • CD4>200: S. pneumoniae, H. influenza, TB

- CD4<200: S. pneumoniae, H. influenza, TB, PCP, Cryptococcus, Histoplasma

18
Q

What pathogens cause cavitatory lesions on cxr?

A
  • Staph A, Klebsiella, TB
  • However, TB has less dyspnoea, more constitutional symptoms of weight loss, night sweats, fever + chronic cough >2 weeks
19
Q

What pathogen is likely to cause pneumonia in a patient with antibiotic exposure?

A

Pseudomonas

20
Q

What pathogen is likely to cause pneumonia in a patient with bats exposure?

A

histoplasma (spelunking)

21
Q

What pathogen is likely to cause pneumonia in a patient with birds exposure?

A

chlamyhophilia psittaci (psittacosis)

22
Q

What pathogen is likely to cause pneumonia in a patient with cats parturient exposure?

A

coxiella burnetti (Q fever)

23
Q

What pathogen is likely to cause pneumonia in a patient with rabbits exposure?

A

Fransicella Tularensis (Tularaemia)

24
Q

What are the CXR findings in a patient with pneumonia?

A

Classically: Looking for heterogenous opacification of the lung field w/ air bronchograms

  • Restricted to 1 lobe if lobar; or diffuse if atypical
  • However, requires adequate hydration for consolidation to appear on CXR

Other possible findings

  • Cavitatory lesions w/ air fluid level
  • Parapneumonic effusion w/ blunting of costophrenic angles
  • Lung Collapse
25
Q

What are the investigations (other than CXR) to conduct in a patient with pneumonia?

A

Sputum culture, Gram-stain, AFB Smear

Urine Antigen Test

  • Strep pneumoniae and Legionella (only possible thru urine Ag)
  • Advantages over culture: faster; not affected by antibiotics

Influenza nasopharyngeal swab PCR – if viral is suspected

Blood cultures – before starting antibiotics

FBC (check leucocytosis)

  • Typical pneumonia: WBC > 15 x 109/L, ESR >100mm/hr, CRP >10mg/L
  • No Leucocytosis in Atypical Pneumonia

CRP, ESR, Procalcitonin (sign of bacterial sepsis / severe bacterial infection)

ABG if SpO2 <92%
ECG – for QTc prolongation

Renal Panel (UECr)

  • To assess hydration levels and electrolyte derangement
  • ↑ Urea is a marker of severity (CURB-65)
  • Legionella: hyponatremia, renal failure

LFT

  • Baseline LFTs: antibiotics can cause cholestatic picture
  • Legionella: deranged LFTs, hepatitis

Bronchioalveolar lavage – if no sputum production and a Dx is mandatory (eg: ICU pt)

26
Q

What antibiotics to treat a patient with CAP (Home/ general ward setting)

A

Augmentin & Clarithromycin (Klacid)
- Augmentin to cover for typicals; Clarithromycin to cover to atypicals

If penicillin allergy 🡪 switch to quinolones (Levofloxacin, Moxifloxacin).

  • Ciprofloxacin has bad lung penetration.
  • Alternatively: Lincosamide

If QTc prolongation 🡪 switch to doxycycline

However, at primary care we tend to give single-agent – Augmentin or amoxicillin

27
Q

What antibiotics to treat a patient with severe Pneumonia (requiring ICU) + Signs of Melioidosis / with RFs?

A

Have to also cover melioidosis 🡪 esp for DM and Immunocompromised patients

Triple antibiotics (ABC) – Azithromycin + (Benzyl) penicillin + ceftazidime

Switch to Ceftazidime once Dx of Melioidosis is established

28
Q

What antibiotics to treat a patient with HCAP/ VAP?

A

Piperacillin- tazobactam (Piptazo) + Vancomycin

  • Vanco to cover MRSA; Piptazo to cover Pseudomonas
  • Note: Other Anti-Pseudomonal agents include Ceftazidime, Meropenem, Ciprofloxacin
29
Q

How long is the antibiotic treatment for pneumonia?

A

CAP (Home/General/ICU) – 5-7 days

Melioidosis/MRSA/Bacteremia – total duration 1 month

30
Q

Other than antibiotics, how else is pneumonia managed?

A

1) Oxygen – maintain SpO2 between 94% and 98% (in COPD maintain between 88% and 92%)
2) IV fluids – hypotensive patient with volume depletion
3) Thromboprophylaxis – if admitted >12h, give subcutaneous LMWH, TED stockings
4) Nutritional supplementation
5) Analgesia – paracetamol, NSAIDs
6) Pneumococcal vaccinations for >65 years and previously unvaccinated

31
Q

What is the parapneumonic effusion? What are the investigations done for it?

A

Parapneumonic effusion = pleural effusion that develops adjacent to bacterial pneumonia

CXR: to pick up parapneumonic effusion

Thoracocentesis: aspiration of pleural fluid under USS guidance

1) Indicated if
- >10mm on CXR (significant enough volume)
- Loculated
- Thickened parietal pleura (empyema)
2) Sample sent for Gram-stain, culture, fluid protein, glucose, LDH
3) Light’s criteria to assess if exudative or transudative
- pleural fluid/ serum protein ratio >0.5
- pleural fluid/ serum LDH ratio >0.5
- LDH > 2/3 ULN of normal serum LDH

USS – to assess for loculations, guides thoracocentesis

32
Q

What are the findings in uncomplicated parapneumonic effusion? How is it managed?

A
  • Exudative effusion w/ neutrophilic influx
  • -ve culture, pH >7.2, glucose >3.3, w exudative changes (LDH and protein)
  • Has no inherent infection / inflamm, will resolve if pneumonia

Management

  • Observation; No need to treat / drain as Abx treatment of pneumonia is sufficient
  • Serial chest X-ray or U/S to assess improvement
33
Q

What are the findings in complicated parapneumonic effusion? How is it managed?

A
  • Bacterial invasion of pleural space
  • Also Exudative effusion w/ neutrophilic influx
  • +ve culture, pH <7.2, glucose <3.3
  • In this stage, pleural fluid has been infected 🡪 triggers inflammation & fibrin deposition -> pleural becomes thickened and +/- loculated

Management

  • Empiric IV antibiotics (will be part of treatment of pneumonia); Coverage – anaerobes: e.g. co-amoxiclav
  • Tube thoracostomy -> drain effusion as it is unlikely to resolve spontaneously -> if no loculations
  • Consider VATS (video-assisted thoracoscopic surgery) with debridement if -> if Cx by multiple loculations, thickened pleura
  • If empyema, 4-6 weeks of antibiotics may be needed
34
Q

What are the findings in thoracic empyema? What are the causative agents>

A
  • Bacterial invasion of pleural space
  • +ve culture, pH <7.2, glucose <3.3
  • pus in the pleural space: yellow, cloudy, foul odour
  • Early indications of empyema: ongoing (Swinging) fevers, rising or persistently high inflammatory markers despite antibiotics

Commonly implicated micro-organisms

  • Streptococcus spp (50%) – most common cause of parapneumonic effusion
  • Anaerobes (20%)
  • S.aureus (10%)
  • Gram negative aerobes (10%)
35
Q

What are the causes of lung abscess?

A
  • Aspiration pneumonia: hx of excessive alcohol consumption, impaired swallowing
  • TB
  • Pneumonia caused by Staphylococcus aureus (post-URTI) or Klebsiella pneumonia
  • Septic emboli containing Staphylococci – multiple lung abscesses. If multiple lung abscesses in IVDA, investigate for infective endocarditis of tricuspid valves. Infarcted areas of lung can cavitate and become infected
  • Spread from amoebic liver abscess – usually right lower lobe following trans-diaphragmatic spread
  • Bronchial obstruction by endoluminal cancer
  • Foreign body inhalation
36
Q

What are the clinical feature of lung abscess?

A
  • Swinging fever
  • Cough
  • Purulent, foul-smelling sputum
  • Pleuritic chest pain
  • Haemoptysis
  • Malaise
  • Weight loss
  • Clubbing
37
Q

What are the complications of lung abscess?

A

Massive haemoptysis (especially when cavitation lies on pulmonary vessels)

38
Q

What is the management of lung abscess?

A
  • Surgical Treatment

- Long term Abx Therapy

Respi (13 decks)

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