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MBBS 3: Internal Medicine > Pneumonia > Flashcards

Pneumonia Flashcards

1
Q

What patterns can be seen on a chest X-ray?

A
  1. consolidation
  2. interstitial
  3. nodule or mass
  4. atelectasis
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2
Q

Whats a consolidation?

A

any pathologic process that fills the alveoli with fluid, pus, blood, cell (including tumor cells) or other substances resulting in lobar, diffuse or multifocal ill-defined opacities

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3
Q

What is an interstitial pattern?

A

involvement of the supporting tissue of the lung parenchyma resulting in fine or coarse reticular opacities or small nodules

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4
Q

What is a nodule or mass pattern on a chest x-ray?

A

any space occupying lesion either solitary or multiple

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5
Q

What is atelectasis?

A

the collapse of a part of the lung due to a decrease in the amount of air in the alveoli resulting in volume loss and increased density

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6
Q

What is pneumonia?

A

acute inflammatory process of the pulmonary parenchyma

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7
Q

Types of pneumonia?

A
  1. nosocomial pneumonia
  2. community acquired penumonia
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8
Q

Types of nosocomial pneumonia?

A
  1. hopital acquired pneumonia
  2. ventilator associated pneumonia
  3. healthcare associated pneumonia
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9
Q

Causes of community acquired pneumonia according to pathogens?

A
  1. bacterial
  2. viral
  3. fungal
  4. parasitic
  5. eosinophilic
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10
Q

Types of community acquired pneumonia according to part of lung affected?

A
  1. lobar pneumonia
  2. bronchopneumonia
  3. interstitial pneumonia
  4. diffuse pneumonia
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11
Q

How long does it take for you to acquire hospital acquired pneumonia?

A

in hospital for >48 hours

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12
Q

How long does it take to get ventilator acquired pneumonia?

A

on ventilator for >48 hours

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13
Q

Bacterial pathogens - typical?

A
  1. streptoccocus pneumoniae - 20-60%
  2. haemophilus influenza - 3-10%
  3. s. aureus
  4. gram negatives - 80% of nosocomial infections
  5. mycobacteria tuberculosis
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14
Q

Causes of nosocomial infections?

A

gram negatives
1. E. coli
2. klebsiella
3. pseudomonas
4. acinetobacter

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15
Q

Bacterial causes of pneumonia - atypical?

A

have no cell wall
1. mycoplasma pneumoniae
2. chlamydophila pneumoniae
3. legionella pneumophila

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16
Q

Viral causes of pneumonia?

A
  1. respiratory syncytial virus - RSV
  2. SARS-COV-2
  3. rhinovirus
  4. adenovirus
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17
Q

Fungal causes of pneumonia?

A
  1. histoplasma capsulatum
  2. cryptococcus neuformans
  3. aspergillus
  4. PCP
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18
Q

What questions to ask in background medical history for pneumonia?

What can make you susceptible to acquiring pneumonia?

A
  1. HIV/malignancy/immunosuppressant drugs?
  2. Structural lung diseases/cystic fibrosis
  3. High aspiration risk?—GNRs, anaerobes if poor dentition
  4. Recent hospitalization or on a ventilator
  5. End stage renal disease(ESRD)/ Intravenous drug use - staph aureus
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19
Q

Questions to ask on occupational hsitory?

A
  1. Animal exposures
  2. Recent hotel stay or cruise ship trip/ long haul flights - legionella from air conditioners
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20
Q

The purpose of investigations?

A
  1. establish diagnosis
  2. identify the pathogen
  3. assess the severity
21
Q

Routine blood investigations?

A
  1. CBC - with differential
  2. BUN/Cr
  3. electrolytes
  4. glucose
  5. liver enzymes
  6. blood culture
22
Q

Microbiological tests?

A
  1. sputum gram stain
  2. sputum for culture
  3. sputum for Ziehl Heelsen stain
  4. sputum cytology
  5. sputum for gene xpert MTB/RIF
23
Q

Imaging studies?

A
  1. x-ray chest P/A and lateral view
  2. compute tomography
24
Q

Serological tests?

A
  1. pneumococcal antigen test
  2. legionella antigen test
25
Q

Oxygen tests?

A
  1. pulse oximetry
  2. arterial oxygen saturation
26
Q

Miscellaneous tests?

A
  1. HIV test
  2. nasopharyngeal/oral swab
27
Q

What is the CURB 65 score used for?

A

scoring system used as guidance on the likely risk of fatal outcomes for community acquired pneumonia

28
Q

What is CURB 65 score criteria?

A

C - confusion
U - urea level in plasma > 7mmol/L (19mg/dl)
R - respiratory rate > or = 30/min
B - blood pressure (systolic < 90mmHg, diastolic < 60mmHg)
65 - age > 65

29
Q

What is the CURB 65 scoring system?

A

0-1 : treat as outpatient
2 : admit into hospital
3 and above : indication of severe pneumonia (often require ICU care)

30
Q

Pathogenesis of pnemonia?

A
  1. aspiration of secretions from the mouth and nasopharynx into the lungs - most common route of entry
  2. direct inhalation
  3. hematogenous route
  4. contiguous extension
31
Q

Pathophysiology of pneumonia?

A
  1. bacteria enter the lungs - from the throat, nose, airborne droplets or blood
  2. bacteria may invade the spaces between cells and between alveoli
  3. the macrophages and neutrophils inactivate the bacteria and the neutrophils also release cytokines
  4. this cause general activation of the immune system
  5. leading to the fever, chills and fatigue
  6. the neutrophils, bacteria and fluid fill the alveoli
  7. resulting in the consolidation seen on the chest x-ray
32
Q

Pathological evolution of lobar pneumonia?

A
  1. oedema
  2. red hepatization
  3. grey hepatization
  4. resolution
33
Q

Describe oedema pathology?

A

1st - 2nd day = 2 days
1. onset is sudden with fever and rigors
2. the affected lung lobe experienced usual early changes of acute inflammation
- the alveolar capillaries are engorged and contain an increased number of polymorphs
3. the affected lung lobe appeared to be dark red, frothy and contained blood-stained fluid rich with causative bacteria

34
Q

Describe red heaptization?

A

2nd - 4th day = 3 days
1. there is pain upon breathing due to the pleural exudate and productive cough with brown sputum
2. the affected lung lobe is dry, solid, red, granular and contains no air
3. there are presence of massive confluent exudation with neutrophils, red cells and fibrin filling the alveolar spaces of the affected lung lobe
4. some fibrin is also found on the pleural surface

35
Q

Describe grey hepatization?

A

4th - 8th day = 5 days
- due to the development of antibodies towards the causative bacteria
- the affected lung lobe is even more solid and is dry, granular and has grayish white color appearance upon cut section
- gray color is due to the presence of increased amount of exudate within the alveolar of the affected lung lobe
- the alveolar exudate contained high concentration of neutrophils and dense fibrin
- the pleural surface is covered by a confluent fibrinous exudate

36
Q

Describe resolution?

A

8th - 9th = days
- the inflammatory process subsides due to the elimination of causative bacteria
- the consolidated exudate within the alveolar spaces undergoes progressive enzymatic digestion to produce granular, semi-fluid debris that will be resorbed, ingested by macrophages, expectorated or organized by fibroblasts growing into it
- this is enzymatic digestion is catalyzed by proteolytic enzymes possibly produced in part by the neutrophils

37
Q

Symptoms of pneumonia?

A
  1. pleuritic pain
  2. hemoptysis - coughing out blood or blood-stained sputum
  3. purulent sputum
  4. fever
  5. cough
  6. dyspnea
  7. anorexia
  8. malasie
  9. rigor
38
Q

Signs of pneumonia on physical exam?

A
  1. tachypnea
  2. tachycardia
  3. hypotension
  4. fever
  5. cyanosis
  6. signs of lung consolidation
  7. pleural rub
39
Q

What are the signs of lung consolidation?

A
  1. diminished lung expansion
  2. dull percussion note
  3. increased tactile vocal fremitus
  4. increased vocal resonance
  5. bronchial breathing
40
Q

Differential diagnosis of pneumonia?

A
  1. pulmonary TB
  2. pulmonary edema
  3. pulmonary infarction
  4. acute respiratory distress syndrome
  5. pulmonary hemorrhage
  6. lung cancer or metastatic cancer
  7. atelactasis
  8. radiation pneumonitis
  9. drug reactions involving the lung
  10. extrinsic allergic alveolitis
  11. pulmonary vasculitis
  12. pulmonary eosinophilia
  13. bronchiolitis obliterans and organizing penumonia
41
Q

General complications of pneumonia?

A
  1. respiratory failure
  2. sepsis - multisytem failure
  3. haemolytic anaemia
  4. cardiac dysfunction
42
Q

Local complications of pneumonia?

A
  1. pleural effusion/parapneumonic effusion
  2. empyema
  3. lung abscess
  4. DVT and pulmonary embolus
  5. pneumothorax
  6. adult respiratory distress syndrome
43
Q

What is empyema? Clinical signs and symptoms?

A

definition - collection of purulent fluid in the pleural space
signs + symptoms - ongoing fever, persistently elevated inflammatory markers despite appropriate antibiotic therapy

44
Q

Principles of management?

A
  1. oxygen supply
  2. intravenous fluid
  3. analgesia
  4. empirical antibiotic treatment for pneumonia
  5. management of complications
45
Q

Oxygen therapy?

A
  • Supplemental oxygen should be maintained at oxygen saturations between 94% - 98%
  • In COPD patient, the oxygen saturation should be maintained in between 88% - 92%.
46
Q

Intravenous fluid management?

When to give it?

A

Maybe required if the patient has
1. anorexia
2. dehydration
3. shock

47
Q

Analgesia management?

A

If there is presence of pleuritic pain / pleurisy,youcan use simple analgesia like:
1. paracetamol
2. non-steroidal anti-inflammatory drugs (NSAIDs)

48
Q

Benefits of treating the pain?

A
  1. reduces the risk of further complications
    e.g. sputum retention, atelectasis [incomplete expansion of lung / airlessness in a previously air-filled space]
  2. reduces risk of secondary infection
    - due to restricted breathing that is caused by pleuritic pain
49
Q

Treatment for pneumocystis jirovecii pneumonia?

A
  1. cotrimoxazole (sulphamethoxazole) 100mg/kg/day
  2. trimethoprim 20mg/kg/day)
    - for 21 days
  3. add prednisolone start 40 mg bd 5/7, 40mg od 5/7, then 20mg od x 11/7 days
    (If severe with hypoxia or respiratory distress)

MBBS 3: Internal Medicine (72 decks)

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