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RESPIRATORY > PNEUMONIA > Flashcards

PNEUMONIA Flashcards

1
Q

What is pneumonia?

A

inflammation of the lung parenchyma with the normal air-filled lungs becoming filled with infective liquid (consolidation)

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2
Q

Whats the most common microorganism type to cause pneumonia?

A

Bacteria

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3
Q

How can bacteria reach the lungs to cause pneumonia?

A

Inhalation
Aspiration
Rare - Haematogenous e.g. staph aureus with IV drug users

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4
Q

Whats the most common causative pathogen of CAP?

A

Streptococcus pneumoniae (80% of cases)

Others - H.influenza, staph aureus, atypical pneumonias and viruses

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5
Q

What atypical bacteria cause CAP?

A

Chlamydia pneumoniae
Chlamydia psittaci (parrots!)
Legionella pneumophila
Mycoplasma pneumoniae
Coxiella Burnetti (Q fever)

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6
Q

What viruses cause CAP?

A

Influenza A and B
RSV
Adenovirus
Some coronaviruses

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7
Q

What are the 2 presentations of CAP?

A

Typical - classic symptoms
Atypical - insidious onset, subacute onset, pulmonary and extra pulmonary symptoms

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8
Q

What is HAP?

A

efined by NICE as a pneumonia contracted > 48 hrs after hospital admission that was not incubating at the time of admission.

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9
Q

What organisms are most likely to cause HAP?

A

Gram-negative bacilli (e.g. Pseudomonas aeruginosa)
Staphylococcus aureus
Legionella pneumophila

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10
Q

Which groups of pt are at risk of aspiration pneumonia?

A

Reduced conscious level
Neuromuscular disorders
Oesophageal conditions
Mechanical interventions such as endotracheal tubes.
Hospitalised pt on PPI

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11
Q

What organisms are most common with aspiration pneumonia?

A

Bacteria that usually reside in the oral cavity
Aerobic e.g. streptococcus pneumonia, staph aureus, H.influenza, pseudomonas aeruginosa, klebsiella (klebsiella - mostly in alcoholics)
Anaerobic - bactericides, prevotella, fusobacterium, peptostreptococcus

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12
Q

What is Mendelson’s syndrome?

A

a chemical pneumonitis caused by aspiration of acidic gastric contents

Most commonly associated with anaesthesia

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13
Q

What are likely causative organisms in immunocompromised patients?

A

Bacteria: Streptococcus pneumoniae, Haemophilus influenzae, Klebsiella pneumoniae, Pseudomonas aeruginosa, Legionella pneumophila, and Staphylococcus aureus.

Viruses: RSV, influenza virus, CMV, HSV, VZV.

Fungi: Candida albicans, Aspergillus fumigatus, Pneumocystis jirovecii, and Cryptococcus neoformans.

Parasites: Toxoplasma gondii and Strongyloides stercoralis.

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14
Q

What type of CAP does streptococcus typically cause?

A

Lobar pneumonia

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15
Q

What is idiopathic interstitial pneumonia?

A

a group of non-infective causes of pneumonia e.g. bronchiolitis that develops as a complication of RA

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16
Q

What is atypical pneumonia?

A

pneumonia caused by an organism that cannot be cultured in the normal way or detected using a gram stain. They don’t respond to penicillins

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17
Q

What are the significant features of strep pneumoniae?

A

Associated with high fever, rapid onset and reactivation of herpes labialis (cold sores)
Rust coloured sputum
Frequently causes significant leukocytosis and raised CRP

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18
Q

Who is pneumonia caused by haemophilus influenza most common in?

A

Pt with COPD

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19
Q

What are the significant features of staph aureus-caused pneumonia?

A

Often occurs in patient following influenza infection

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20
Q

What are the important features of pneumonia caused by mycoplasma pneumoniae?

A

It tends to affect a younger demographic and occurs in cyclical epidemics i.e. every 4 years.

It causes an atypical pneumonia with a prolonged, insidious onset and often presents with a dry cough. It may exhibit extrapulmonary features.

Extrapulmonary features include:
Erythema multiforme (target lesions)
Autoimmune haemolytic anaemia
Arthralgia
Neurological symptoms in young patients
Myocarditis, pericarditis

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21
Q

What are the important features of pneumonia caused by legionella pneumophilia?

A

Atypical pneumonia. Chest symptoms may be preceded by several days of myalgia, headache and fever
Hyponatraemia secondary to SIADH and lymphophenia are common. Can also cause hypophosphataemia and raised serum ferritin.
Classically seen secondary to infected air conditioning units, humidifiers and showers

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22
Q

Who typically gets pneumonia caused by klebsiella pneumoniae?

A

Alcoholics

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23
Q

Which microorganism causes a pneumonia with a sputum with red-current jelly appearance?

A

Klebsiella pneumoniae

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24
Q

What are the important features of pneumonia caused by pneumocystis jiroveci?

A

Typically seen in patients with HIV
Presents with a dry cough, exercise-induced desaturations and the absence of chest signs
Hypoxia and a raised LDH are also common findings.
It does not respond to antifungals and is instead treated with co-trimoxazole (trimethoprim-sulfamethoxazole).

25
Q

What are symptoms of pneumonia?

A

Cough
Sputum
Dyspnoea
Chest pain which may be pleuritic
Fever
Delirium
Sepsis

26
Q

What are signs of pneumonia?

A

Ssystemic - fever, tachycardia, hypotension
Reduced ox sats
Reduced breathe sounds and bronchial breathing, focal coarse crackles on auscultation
Dullness to percussion

27
Q

How do we determine the severity of CAP?

A

CRB-65

28
Q

How do we determine the severity of HAP?

A

CURB65

29
Q

Outline the CURB65 scoring scale?

A

C – Confusion (new disorientation in person, place or time)
U – Urea > 7
R – Respiratory rate ≥ 30
B – Blood pressure < 90 systolic or ≤ 60 diastolic.
65 – Age ≥ 65

30
Q

How do you interpret CURB65 score?

A

0-1 - consider home-based care- low risk (less than 5% 30 day mortality risk)

2 - consider hospital-based care - intermediate risk (less than 10% 30 day mortality risk)

3 or more - consider intensive care assessment - high risk (4 points 40% mortality risk)

31
Q

What is the most common cause of pneumonia in cystic fibrosis?

A

Pseudomonas aeruginosa

32
Q

What can you treat atypical pneumonia with?

A

Macrolides - first line
Fluoroquinolone
Tetracyclines

33
Q

Pt recently went on a cheap hotel holiday and returned with cough, SOB and hyponatraemia. Whats the causative organism?

A

Legionella pneumophila (they may have legionnaires disease)

34
Q

What is Q fever?

A

Bacterial infection caused by coxiella burnetii.
Zoonotic disease - cattle, sheep, goats most common
Can cause mild flu-like symptoms or pneumonia, hepatitis and endocarditis
Vaccines are available for high risk people e.g. those who work in the livestock industry

35
Q

What is psittacosis?

A

A respiratory tract infection caused by chlamydia psittaci
Usually spread through contact with infected birds and their droppings (parrots, cockatiels, budgerigars)
Symptoms are fever, chills, headache, muscle aches, cough, SOB and in severe cases, pneumonia

36
Q

What are some of the main differences between the presentations of the different types of microorganisms that cause pneumonia?

A

Bacterial - develops quickly causes high fever, cough with sputum, SOB and chest pain. It can lead to sepsis
Viral - develops more slowly than bacterial and causes milder symptoms e.g. dry cough, fever, fatigue. In severe cases it can cause acute respiratory distress syndrome
Fungal - develops slowly with fever, night sweats, dry cough and SOB. More common in immunocompromised
Parasitic - fever, cough, SOB and more common in people who travel to regions with high rates of parasitic infections

37
Q

How are pt with low CD4 counts protected against pneumocystis jiroveci?

A

Prophylactic oral co-trimoxazole

38
Q

How do you investigate pneumonia?

A

Bedside - obs, sputum sample for culture, urinary sample (pneumococcal and legionella urinary antigen test), ECG

Bloods - FBC, U&E, CRP, blood culture

Imaging - CXR,

39
Q

How do you interpret CRB65 score?

A

0: low risk (less than 1% mortality risk)
NICE recommend that treatment at home should be considered (alongside clinical judgement)

1 or 2: intermediate risk (1-10% mortality risk)
NICE recommend that ‘ hospital assessment should be considered (particularly for people with a score of 2)’

3 or 4: high risk (more than 10% mortality risk)
NICE recommend urgent admission to hospital

40
Q

What are CXR findings for pneumonia?

A

Consiolidation (initially may be patchy but becomes confluent as infection develops)
Air bronchograms
May also show complications e.g. parapneumonic effusion, pleural collections, abscess or cavitation

41
Q

How do you manage CAP in the community?

A

Low severity - amoxicillin 5 days
Moderate severity - dual antibiotic therapy with amoxicillin and a macrolide for 7-10 days (
High severity - beta-lactamase stable penicillin (e.g. co-amoxiclav) + macrolide for 7-10 days

42
Q

Outline the typical speed of improvement in CAP?

A

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 might still be present.
6 months — symptoms should have fully resolved

43
Q

How should you follow up a pt with CAP in primary care?

A

Reassess people with community-acquired pneumonia if symptoms and signs do not improve as expected or worsen rapidly or significantly.
Review choice of antibiotics according to microbiological testing results
Arrange a CXR after 6 weeks if symptoms/signs persist or if at higher risk of underlying maliganncy
Advise smoking cessation
Consider whether pneumococcal or influenza immunization is necessary after the person has recovered from the acute illness

44
Q

How should you manage pneumonia in hopsital?

A

Oxygen if needed
IV fluids
Analgesia
High severity CAP - IV beta-lactamase stable beta-lactam e.g. co-amoxiclav and a macrolide
HAP - mild - co-amoxiclav 625mg orally TDS
HAP - severe - Tazocin 4.5g IV TDS

45
Q

What are complications of pneumonia?

A

Sepsis
Pleural effusion
Empyema
Lung abscess
Death

46
Q

Who should have a follow up CXR following pneumonia and when?

A

6-8 weeks post-event
Anyone over 50 yo check for underlying lung cancers and to check consolidation has resolved
(11% of smokers over 50 who have pneumonia have lung cancer)

47
Q

What factors suggest you should delay discharge for a pt with pneumonia?

A

temperature >37.5°C
RR 24 BPM or more
HR >100 bpm
systolic bp 90 mmHg or less
ox sats <90% on room air
abnormal mental status
inability to eat without assistance.

48
Q

What are the stages of lobar pneumonia?

A

Congestion - 1-2 days - blood vessels and alveoli start filling with excess fluid

Red hepatization - 3-4 days - exudate, neutrophils and fibrin start filling airspaces and makes them more solid

Grey hepatization - 5-7 days - lungs still firm but colour has changed as RBCs in exudate start breaking down

Resolution - day 8 and continues for 3 weeks - the exudate gets digested by enzymes, ingested by macrophages, or coughed up.

49
Q

What are the types of pneumonia?

A

Lobar pneumonia
Bronchial pneumonia
Interstitial pneumonia

50
Q

What is lobar pneumonia?

A

pneumonia affecting one lobe of a lung
Multilobar pneumonia refers to the involvement of multiple lobes in a single lung or both lungs.
Panlobar pneumonia involves all the lobes of a single lung.

51
Q

What is bronchial pneumonia?

A

pneumonia affecting the tissue around the bronchi and/or bronchioles
Aka lobular pneumonia

52
Q

What is interstitial pneumonia?

A

pneumonia affecting the tissue between the alveoli

53
Q

How do you diagnose mycoplasma pneumoniae?

A

Serology

54
Q

How do you diagnose legionella pneumophila?

A

Urinary antigen test

55
Q

What can predispose you to staphylococcus aureus pneumonia?

A

Preceding influenza infection

56
Q

Which sites of the lungs is aspiration pneumonia most likely to occur and why?

A

Right middle and lower lung lobes - larger calibre and more vertical orintetaion of the right main bronchus

57
Q

Who should receive prophylaxis for pneumocystis jiroveci?

A

Patients with CD4 counts <200

58
Q

Whats a common complication of pneumocystis jiroveci?

A

Pneumothorax

RESPIRATORY (22 decks)

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