Pneumonia Flashcards
Define pneumonia
Lower respiratory tract infection, Esp during winter months Can imvolve trachea, (tracheitis) bronchi, (bronchitis) CAP, nosocomial Or those occuring in immunosupressed.
Inflammation of substance of lung. Classified by site- lobar, diffuse, bronchopneumonia. Or by ateliology. Bacterial, fungal, aspirations…
Or radiotherapy, allergic agents. Or ventilator associated( multiple organisms- Pseudomonas, Klebsiella, Acinetobacter.
Legionella- infected water tanks, air conditioning..
Whats the epidemiology of pneumonia?
CAP: 5-11 per 1000,
GP- 10-12 annually
22-42 CAP admitted to hosp, 5-10% require intensive therapy.
CAP mortality
Whats the pathogenesis of pneumonia?
Streptococcus pneumoniae commones CAP
Mycoplasma pneumoniae 2nd
Legionella spp. Ass with water systems in modern buildings
Staphylococcus Aureus- pneumonia- caused by influenza epidemics and has high mortality
Chem causes- aspiration pneumonia
What are the CFs of pneumonia?
CAP: acute illness, preceeded by symptoms of upper resp tract infc. Breathless, + cough, sputum production, rusty coloured in pneumococcoal pts. (Pus- neutrophils) assc wt leuritic chest pain.
Pneumonia caused by chlamydia + mycoplasma
More general: malaise, sweating, myalgia, arthralgia, + headaches.
Haemoptysis! ❌ in pneumonia, malignancy!!??
O/E of pneumonia?
Signs of lung consolidation:
Dullness to percussion, bronchial breathing, localaised inspiratory crackles.
Severe pneumonia- septicaemia, comfusion, hypotension. Rapid REsp rate.
How would you investigate pneumonia?
🔹bedside: Sputum: Gram stain(rapid indication) & culture
🔹Bloods:FBC, WCC, CRP, U+Es,
Blood cultures - done in hospital, before giving antibiotics.
🔹CXR- consolidations or pleural effusion (parapneumonic effusion)
Pleural fluid is aspirated, examined & cultured, and sent for cytology. -straw colour( parapneumonic)
🔸Urinalysis for sugar (diabetic?)
Blood for viral Serology and Legionella/Mycoplasma
Serology for pneumoccocoal antigen (blood, sputum and urine)
Rapid urine test available for Legionella.
Whats parapneumonic pneumonia?
1st stage- exudative state- low LDH, low WCC. Sterile pleural fluid rapidly accumulates in the pleural space. The pleural fluid originates in the interstitial spaces of the lung and in the capillaries of the viscera pleura due to increased permeability.
These effusions resolve with antibiotic therapy and chest tube insertion is not required. 2-5 days of the onsent of pneunonia. pH normal
Then bacterial invasion of pleural space–> accumulation of leukocytes, bacteria & cellular debris. Tendency towrds loculation + septations, pH inelastic membrane called pleural peel. Pleural fluid is thick–>untreated, will drain into the thoracic wall. Empyema thoracis necessitas
What happens in empyema thoracis?
May not be associated with pneumonic process
Eosophagela perforation, trauma, septicaemia, surgical procedure in pleura.
Last stage- 2-3 weeks to develop.
(Viscus pus with intense inflammatory rind; are enlarges through osmosis)
How do you asses pneumonia severity?
How ill is the pt?
CURB -65- 1 pt for each (5) assc wt ⬆️ risk of death
🔹Confusion: new disorientation in place, person and time
🔹Urea >7mmol/l –> multiorgan F & septicaemia.
🔹RR > 30/min: stromgly assc wt hypoxia & ⬆️ mortality
🔹BP: systolic 65
Score 0-1 treat as outpatients
2- admit
3+- often require ICU care.
Other markers for severe pneumonia:
CXR >1 lobe involved
PaO2 20x10.9/L)
Blood culture-+ve
Use of CURB-65
Score.
0-1: suitable for home treatment- chillin. (2% Low mortality)
2 : consider Nosocomial admission- intemediate (9%)
>~3 : Manage as severe pneumonia; asses for admission to ICU esp if 4-5. SHIT. High risk of death (22%)
How do we manage pneumonia?
Rest Fluids intake ⬆️ Not smoke Patacetamol for pleuritic pain Continuous O2 if saturation
How is non severe pneumonia treated at home?
Oral antibiotics: amoxicillin for 7 days or clarithromycin or levofloxacin for penicillin allergy.
hospital-treated severe pneumonia
I.V antibiotics coamoxiclav + clarithromycin + asses need for high- dependancy or intensive care.
What are some complications of pneumonia?
Fail to improve- alternative diagnosis?
LC or Poedema?
Uncomplicated parapneumonic effusions pH >7.2
Do not require drainage.
Complicated pleural eff (pleural fluid pH
How could we prevent pneumonia?
Annual influenza vaccine those at high risk from influenza & pneumonia (chronic lung, heart, liver diseases, DM, immunosupression or >65. )
Pneumococcoal polysaccharide at 2Y or older + >65Y.
When should a pneumococcoal vaccination be repeated?
NOT REPEATED within 3 Y.
So 4
When should you do a CXR?
At diagnosis and after 6-8 w repeat to see improvement.
If less apetite, sweaty at nights… Come back.
RFs:
Smoke x10
Passive smoking eg working in night clubs in Mediteranean where its allowed.
Arsenic
Asbestos - ⬆️ x9
Smokimg and asbestos- 90x more chances
33 year old non smoker admitted to medical ass, 2 day hx of fever, sweating, cough, productive yellow, lightly blood stained sputum.
Had pleuritic pain in L axilla. Herpes labiallis present.
Dx?
Typical CAP pneumonia hx.
Signs: Fever, ⬆️RR, dullness to percussion L lung base: consolidation.
Bronchial breathing: left lung base: consolidation.
What are the likely imfecting organisms?
Strep pneumoniae- most liekly: 35-80% Haemophilus influenzae- esp in smokers with COPD Mycoplasma (4 yearly epidemics) Legionella Staph aureus Viral: influenza Chlamydophilia psittaci
73 year old man brought to A+ E. Had winter bronchitis for last 5 years and is a current smoker. 1 week ago had the flu and this morning increasingly brathless, sweaty, pale and confused. Angina 2 years ago dx.
O/E:
Confused, RR>30, BP 110/40, dehydrated, pre-existing COPD, pre-existing angina.
CXR- diffuse opacities and ring opacities ( absecss formation)
Redydration: IV fluids.
IV antibiotics- severe CAP
Pulse oximetry- give O2 to maintain sats >90%.
Watch for resp F- IPPV might be needed.
Physiotherapy if diff coughing up sputum.
What are some indications for intanive care monitoring and assisted respiration?
PaO2 6.4
Patient exhausted, drowsy or unconscious
Shock
Hypotension or circulatory failure.
Antibiotic choices for CAP
Uncomplicated mild CAP
Treat 5 days with oral unless pt not swallowing or not absorbing.
Oral amoxicillin 500mg x3 day + erythromycin 500mg x4 daily (or clarithro cz diarrhoea)
In Pen allergic with underlying lung disease: H. Influenzae suspected.
Clarithromycin 500mg x2 daily.
SEVERE CAP
IV antibiotics until sign improvement.
Co-amoxiclav 1.2g IV x 3 daily + clarithromycin 500mg IV x2 daily.
Antiviotics for up to 10days,
Staphylococcal pneumonia
Treat for 10-14 days.
Flucloxacillin 2g x4 daily IV + fusidic acid oral 0.5-1g x 3 OR
Gentamycin 3-5mg/kg IV daily as a single dose (check gentamycin levels before 2nd dose).
