Pneumonia

Question 1

Describe the typical presentation (signs and symptoms) of a patient with CAP or HAP?

Answer 1

Symptoms:
Productive cough
Fever
Pleuritic pain
Dysopnea 
Malaise

Signs:
Crackles
Tachypnoea
Dullness on percussion
Bronchial breath sounds (louder and coarser)

Question 2

Describe the CURB 65 score?

Answer 2

Confusion:
Urea: 7mmol
Resp rate: >30
BP: 90/60
Age: 65

Score guides treatment options as it correlates to morbidity.

Greater than curb 2 should be treated in hospital.

Question 3

List the common pathogens causing CAP and HAP.

Answer 3

CAP:
Typical:
Strep. Pneumoniae (often post viral inf.)
HIB
Viruses

Atypical:
Mycoplasma Pneumoniae
Chlamydophila Pneumoniae
Legionella

HAP:
Gram -ve bacteria (E.coli, klebsiella, pseudomonas)
S. Aureus

Question 4

What are the factors that predispose to pneumonia?

Answer 4

Hospitalised
Viral Infection

Bronchiectasis
COPD
Immunocompromised

Smoking
Alcoholics
IVDU

Note: Pneumonia is a LRTI with evidence of consolidation on CXR, it is a radiological finding.

Question 5

Describe the pathology of acute lobar pneumonia and bronchopneumonia?

Answer 5

Acute lobar pneumonia:

Can occur at any age.
Usually affects large areas or a whole lobe and progresses through the stages of acute inflammation:
Exudate (>30g of protein), hepatatisation, fibrin laid down, resolution (day 8-10).

Bronchopneumonia:
Occurs at the extremes of age, or in those with chronic conditions (bronchiectasis, COPD) or as a secondary infection following a viral infection.

Spreads from the bronchioles to the alveoli. Bronchioles become inflamed and ciliated epithelial are destroyed/damaged and the bronchioles become congested with pus.

May heal with fibrosis causing permanent damage or may fully resolve.

Question 6

Outline the investigations of a patient presenting with suspected CAP?

Answer 6

Bedside:
O2 sats

Bloods/lab:
FBC.
UE (urea for curb, hyponatraemia in leigonairres)
Blood cultures.
Sputum culture if possible.
Urinary antigen testing for strep pneumoniae and leigonairres if severe.

Imaging:
CXR

Question 7

Discuss the treatment supportive and medical for pneumonia?

Answer 7

CAP:
Mild: 500mg amoxiclav tds 7 days

Moderate: 500mg-1g amoxiclav tds 7days +/- clarithromycin 500mg bd 7 days

Severe: Co-amoxiclav IV 1.2g tds PLUS Clarithromycin IV 500mg bds 7 days (Critical care)

Lifestyle: Quit smoking, physiotherapy for bronchopneumonia, O2 if sats are low

HAP:
Broad spectrum abx per local guideline

6 week follow up CXR to confirm resolution.

Question 8

Describe the complications of pneumonia?

Answer 8

• Sepsis.
• Infection spreading to the blood aka septicaemia.
• Lung abscess formation associated with klebsiella and s.aureus (HAP).
• Empyema (the presence of pus in the pleural cavity)
• Pneumothaoraces (in severe infections)