pneumonia Flashcards
what does the URT consist of?
nasal passages, pharynx, larynx
what are the common causes of URTI?
Usually from the virus groups:-– Rhinovirus,
what conditions affect the URT?
- Common cold
- Laryngitis
- Pharyngitis
- Laryngotracheobronchitis (Croup)
- Epiglottitis
- Sinusitis
- Tonsillitis
- Ear - Otitis externa, media, interna
what is sinusitis?
- Inflammation of the paranasal sinuses
- Symptoms - Nasal discharge/blockage, facial pain, headache, anosmia
when would sinusitis need hospital referal?
– Orbital involvement
– Intracranial involvement
how do you manage sinusitis that does not need referal?
- Provide information regarding condition
- Advise on self management of symptoms
- Advise on over the counter symptom relief including: – Paracetamol, ibuprofen, decongestants.
- Advise a clinical review if the condition worsens or becomes prolonged.
who needs to be referred for sinusitis?
- Otherwise well but symptoms lasting longer than 10 days or more with little or no improvement.
OR - Very young, elderly and frail, immunocompromised,
complicating co-morbidities (e.g. significant heart, lung, kidney disease), persisting fever, chest pain,
neurological changes. - Severe symptoms.
- Caution in those with diabetes and asthma
what is the antibiotic interventions that should be given for sinusitis?
first choice phenoxymethylpenicillin- less chance of leading to resistance as it has a narrow spectrum of activity than amoxicillin
Co-amoxiclav reserved for more severe cases, this is active against active against beta-lactamase-producing bacteria
what should you give for sinusitis if there is a penicillin allergy?
doxycycline
clarithromycin
erythromycin (in pregnancy)
how does acute oitis media present?
- Presenting with earache.
- Common in children.
- Bacterial or viral cause.
- Often following ‘common cold’ symptoms.
- Referral often needed for examination with an
otoscope
for patients who do not require admission for AOM what advice should be given?
Reassure, antibiotics are not often needed.
– Without antibiotic treatment, symptoms will improve within 24 hours in 60% of children and 80% will recover within 3 days (but it can be up to a week).
– Long term complications are rare.
* Advise on self management of symptoms
– OTC symptom relief with paracetamol or an NSAID,
with appropriate age and weight advice.
+ safety net
how should you manage AOM with antibiotics?
- If an antibiotic is required:
- First line, amoxicillin for 5-7 days - see age based dosing advice.
- Second line (worsening symptoms despite 2 to 3 days of standard antibacterial treatment): co-amoxiclav.
- For people who are allergic to penicillin, a 5-7 day course of erythromycin or clarithromycin.
define pneumonia
- Infection in the lungs
- Tissue inflammation
- Alveoli filled with pus
- Clinical symptoms of respiratory infection
- Confirmed with new shadowing on chest X-ray
what can cause pneumonia?
- Commonly - Inhalation or aspiration
- Bacterial, viral or fungal microorganisms
- Failure of defence mechanisms
- Subsequent infection
- Inflammation of the lung parenchyma :- characterised by consolidation of the affected part, the alveolar air spaces being filled with exudate, inflammatory cells, and fibrin
what are the different classifications of pneumonia?
- Community acquired pneumonia (CAP)
- Hospital acquired pneumonia (HAP)
- Healthcare associated pneumonia (HCAP)
- Aspiration pneumonia
- Ventilator associated pneumonia
how do you diagnose pneumonia?
- COUGH - Symptoms similar to other LRTI
- Need examination or chest x-ray to distinguish
who are at risk of developing pneuomia?
- Smokers
- Chronic lung disease
- Immunocompromised
- Elderly / frail
- Diabetes
what are red flag symptoms for pneuomonia?
- Dyspnoea - difficulty in breathing or wheezing
- No improvement in condition after two or three weeks
- Persistent cough for longer than three weeks
- Recurrent cough
- Dry night-time cough in children
- Haemoptysis
- Chest pain
- Unexplained weight loss
- General malaise, systemically unwell, sweats or fever
- Painful or swollen, inflamed calf
what is the most common cause of CAP?
Streptococcus pneumoniae
who does Haemophilus influenzae most affect?
Typically affects patients with COPD and other chronic chest conditions.
* Sensitive to most antibiotics used commonly. Resistance developing
what is special about Mycoplasma pneumonia?
- Mollicute lacks a cell wall.
- No cell wall with peptidoglycan
means resistance to beta-lactam
antibiotics.
who does Mycoplasma pneumonia affect ?
- Affects young people
how do you assess the severity of pneumonia?
- Peripheral Oxygen
Saturation levels - Blood pressure
- Respiratory rate
- Urea and electrolytes
- C-reactive protein
- Full blood count
- Liver function tests
- Sputum culture and
sensitivity - May need blood cultures.
- The CURB-65 score
when should you treat pneumonia?
- consider home-based care for patients with a
CURB65 score of 0 - consider hospital assessment for all other patients, particularly those with a CURB65 score of 2 or more
what should you not routinely offer to patients with low severity cap ?
microbial tests
what should you do for patients with moderate- high sverity CAP?
- take blood and sputum cultures and
- consider pneumococcal and legionella urinary
antigen tests.
when would you use urinary antigen tests?
- NICE suggests for moderate or high severity CAP
– pneumococcal and legionella urinary antigen tests
how do you manage CAP with antibiotics? low severity
- Low-severity community-acquired pneumonia (CURB - 0)
- 5 days treatment
- Amoxicillin 500mg TDS
- Penicillin Allergic
- Macrolide - clarithromycin 500 mg twice a day for 5 days
- Tetracycline - doxycycline 200 mg on the first day
then 100 mg once a day for 4 days (total course of 5 days) - Inform patient - no improvement at day 3 or deterioration -seek further advice
- Prescriber may then extend the course or change therapy.
how do you manage moderate-high severity CAP?
- Moderate and high severity community-acquired pneumonia
- 7-10 days treatment
- Moderate severity- dual therapy with amoxicillin and a macrolide
- Severe - beta-lactamase stable beta-lactam and a macrolide.
- IV administration may be required
if a patient is admitted to hospital with CAP what should be done?
- Process to include rapid definitive diagnosis
- Chest x-ray
- Blood tests (CRP, WCC, FBC etc.)
- Early administration of antibiotics
- Within 4 hours of admission.
what monitoring should you do in hospital for CAP?
As a minimum (in hospital) measure a baseline
C-reactive protein concentration in patients with community-acquired pneumonia on admission to hospital, and repeat the test if clinical progress is uncertain after 48 to 72 hours.
what do you have to consider when switching from IV to oral?
- Resolution of fever > 24hrs
- Pulse rate <100bpm
- Resolution of tachyapnoea
- Well hydrated and taking oral fluids
- Absence of hypoxia
- Improving WCC
- Non-bacteraemic infection
- No evidence of legionella, staphylococcal or gram negative
enteric bacilli infection. - No concerns over G/I absorption.
what other treatment are there for pneuomnia?
- Oxygen
- Bronchodilators
- Steroids (depends on underlying conditions)
- Asses risk of venous thromboembolism - prophylaxis.
- Pain management
- Hypotension - fluid depletion/requirements
- Nutritional needs.
when is a patient with pneuomnia safe to discharge from hospital?
- They are not ready yet if in the past 24 hours they have
had 2 or more of the following findings:
– temperature higher than 37.5°C
– respiratory rate 24 breaths per minute or more
– heart rate over 100 beats per minute
– systolic blood pressure 90 mmHg or less
– oxygen saturation under 90% on room air
– abnormal mental status
– inability to eat without assistance.
How should you council a patient on their long term recovery from pneuomnia?
- 1 week: fever should have resolved
- 4 weeks: chest pain and sputum production should have substantially reduced
- 6 weeks: cough and breathlessness should have substantially reduced
- 3 months: most symptoms should have resolved but fatigue may still be present
- 6 months: most people will feel back to normal.
