Pneumonia Flashcards
What is pneumonia?
Acute respiratory illness associated with recently developed radiological pulmonary shadowing that can be segmental, lobar or multilobar
Classification of pneumonia is
Community acquired
hospital acquired
Immuno compromised pneumonia
What is lobar pneumonia?
Homogeneous consolidation of one or more lung lobes, often with associated pleural information
What is bronchopneumonia?
Patchy, alveolar consolidation associated with bronchial and bronchiolar inflammation
Open effect both lower lobes
Incidence of community acquired pneumonia
5 to 11 in 1000 adults
Percentage of community acquired pneumonia from all lower respiratory tract infection
5 to 12%
Age more at risk of community acquired pneumonia
Even though all ages are affected extreme of age are more at risk
Mode of transmission of community acquired pneumonia
Droplets
Most common infecting agents in community acquired pneumonia
Streptococcus pneumoniae
Type of bacteria, causing community acquired pneumonia
Streptococcus pneumonia
Mycoplasma pneumoniae
Legionella pneumophila
Chlamydia, pneumonia
Haemophilus influenza
Staphylococcus aureus
Chlamydia psittaci
Coxiella burnetii
Klebsiella pneumoniae
Viruses causing community acquired
Influenza
para influenza
Measles
Herpes Simplex
Varicella
Adenovirus
Cytomegalovirus
Coronaviruses (SARS cov, and mers cov)
Clinical features of community acquired pneumonia
Systemic - Fever, Rigors , Shivering, Malaise , Delirium
Respiratory - cough short painful
and dry, mucopurulent sputum, hemoptysis sometimes , pleuritic chest pain with referral to the shoulder or anterior abdominal wall, upper abdominal tenderness if lower lobe pneumonia or associated hepatitis
People more at risk of mycoplasma pneumonia infection . (CAP)
Young people, rare in the elderly
Demographic more at risk of Haemophilus influenza infection . (CAP)
Elderly
If a patient had influenza which type of bacteria would you suspect in the pneumonia? . (CAP)
Staph aureus
Bacteria associated with alcohol abuse, and in pneumonia. Presents with severe bacteremic llness. (CAP)
Klebsiella pneumoniae
Findings in clinical exam in community acquired pneumonia
Signs depend on stage of pneumonia
Dull to percussion if consolidated
Bronchial breathing
whispering pectoriquoly
Crackles
State of nutrition
Herpes labiales or rusty sputum if streptococcal infection
Differential diagnosis of pneumonia
Pulmonary-Infarction
Pulmonary/ pleural tuberculosis
Pulmonary edema
Pulmonary eosinophilia
Malignancy, broncho alveolar cell carcinoma
Cryptogenic organizing pneumonia
Investigation in community acquired pneumonia
Full blood counts - high wbc, neutrophil leukocytosis if bacterial , hemolytic anemia if mycoplasma
Urea and electrolytes marker of severity, - high urea, hyponatremia
Liver function test - hypoalbuminemia for severity
ESR Crp - not specifically elevated
Blood cultures for bacteremia
Cold agglutins- positive if mycoplasma
Arterial blood gases for ventilatory failure or acidosis
Sputum for culture
Oropharynx swab for PCR
You’re in for pneumococcus and legionella
Chest x-ray
Pleural fluid
Findings on chest x-ray in lobar pneumonia
Patchy opacification evolving into homogenous consolidation of affected lobe
Air bronchogram present
Management of community acquired pneumonia
Oxygen therapy, if tachypnea hypoxemia, hypotension or acidosis
Fluid balance with iV
Antibiotic, depending on clinical context usually five day
Analgesia with paracetamol, Co-Codamol or NSAID for pleural pain
Antibiotic of choice in uncomplicated CAP
Amoxicillin 500mg three times daily
Antibiotic given in staph infection
Flucloxacillin and clarithromycin
Complications of pneumonia
• Para-pneumonic effusion - common
• Empyema
• Retention of sputum causing lobar collapse
• Deep vein thrombosis and pulmonary embolism
• Pneumothorax, particularly with Staphylococcus aureus
• Suppurative pneumonia/lung abscess
• ARDS, renal failure, multi-organ failure (p. 198)
• Ectopic abscess formation (Staph. aureus)
• Hepatitis, pericarditis, myocarditis, meningoencephalitis
• Arrhythmias (e.g. atrial fibrillation)
• Pyrexia due to drug hypersensitivity
What is hospital acquired pneumonia
New episode of pneumonia at least two days after admission to the hospital
Second, most common hospital acquired infection
Hospital acquired pneumonia
People more at risk of hospital acquired pneumonia
Old
Patient in intensive care units, especially on mechanical ventilation
What is healthcare associated pneumonia?
Development of pneumonia in people who spent at least two days in hospital or attended hemorialysis you need or received IV antibiotics or stayed in a nursing home or long-term care facility
Clinical features/ investigations of hospital acquired pneumonia
Hospitalized
Purulent sputum
new radiological infiltrates
Unexplained increase in oxygen requirements
fever
leukocytosis or leukopenia
Hospital acquired pneumonia differentials
Pulmonary embolism
ARDS
Pulmonary Oedema
Pulmonary haemorrhage
Drug toxicity
In which form of pneumonia is microbiological confirmation more important , CAP or HAP
HAP
Factors predisposing to HAP
Reduced immune defences (e.g. glucocorticoid treatment, diabetes, malignancy)
Reduced cough reflex (e.g. post-operative)
Disordered mucociliary clearance (e.g. anaesthetic agents)
Bulbar or vocal cord palsy
Aspiration of nasopharyngeal or gastric secretions
Immobility or reduced conscious level
Vomiting, dysphagia (N.B. stroke disease), achalasia or severe reflux
Nasogastric intubation
Bacteria introduced into lower respiratory tract
Endotracheal intubation/tracheostomy
Infected ventilators/nebulisers/bronchoscopes
Dental or sinus infection
Bacteraemia
Abdominal sepsis
Intravenous cannula infection
Infected emboli
Management of HAP
Oxygenation
Fluid balance
ATBs
Which pulmonary dx overlaps with suppurative pneumonia
Pulmonary abscess
Risk factor for suppurative pneumonia
Inhalations of septic material during operation on nose, mouth, throat or vomitus
Bulbar / vocal palsy
Achalasia
Esophageal reflux
Clinical features sir suppurative pneumonia
Cough with large amounts of sputum, sometimes fetid and blood-stained
Pleural pain-common
Sudden expectoration of copious amounts of foul sputum if abscess ruptures into a bronchus
High remittent pyrexia
Profound systemic upset
Digital clubbing may develop quickly (10-14 days)
Consolidation on chest examination signs of cavitation rarely found
Pleural rub common
Rapid deterioration in general health, with marked weight loss if not adequately treated
Investigations in suppurative pneumonia
Homogenous lobar or segmental opacity for consolidation or collapse
Cavitation and fluid level if abscess
Management of suppurative pneumonia
Amoxicillin /metronidazole
Pneumonia in immunocompromised clinical features
fever
cough
breathlessness
