Pneumonia

Question 1

Explain pneumonia to patients

Answer 1

Pneumonia is an infection of the alveoli sac in the lung. Pneumonia replaces the areas normally filled with air, with inflammatory cells, fluids and neutrophils.
The cause of pneumonia is usually either viral or bacteria, but can also be more complicated.

Pneumonia causes symptoms of a productive cough, blood when coughing, a temperature, chest pain, no appetite.

Pneumonia is treated with antibiotics if the source is bacterial.

Question 2

What are the symptoms and signs of pneumonia?

Answer 2

Symptoms:
Cough
Purulent sputum
Haemoptysis
Fever/Rigor
Chest pain
Anorexia/lack of appetite

Less frequent symptoms (usually in elderly): incontinence, confusion falls, abdominal pain shortness of breath

Signs of pneumonia

• Tachypnoea
• Pyrexia
• Clear lungs, focal crackles, bronchial breathing
• Dull percussion

Question 3

How is Pneumonia managed?

Answer 3

1. Diagnose
2. Assess type of pneumonia
3. Assess severity (CURB 65)
4. Test for cause
5. Treat

Question 4

How is pneumonia diagnosed?

Answer 4

Full blood count

• Increased WCC = Infection
• Neutrophillia = Bacterial infection
• Neutropenia = Viral Infection
• Lymphopenia = Severe infection
• Low Hb = Anaemia (complicates pneumonia)
• Thrombocytopenia/thrombophillia = Infection

U+ E
- Indicate Acute kidney injury

LFT’s
- Deranged if septic as liver perfusion is reduced

CRP

• Acute phase protein produced by liver in response to infection/ trauma
• > 100 = Bacterial infection
• Low levles = inflammatory condition/malignancy

Lactate
- increased in sepsis and shock (product of anaerobic respiration)

CXR
- Area of consolidation

CT scan
- ? suspected abscess / emphysema

USS

• Pleural effusion
• Chest drain insertion if needed

Blood cultures
- Identify infecting organism (best if taken at time of fever)

Sputum culture
- culture + sensitivity

Urinary sample
- ? pneumococcus/legionella

HIV test

• Offered t those under 60
• common presentation of HIV in an undiagnosed individual

Question 5

What are the various types of pneumonia and what are their causes?

Answer 5

1. Community acquired pneumonia (CAP)
   
   • Gram positive bacteria e.g STREP PNEUMONIAE
   • Influenza
   • Mycoplasma
2. Hospital acquired pneumonia (HAP)
   [In-patient/pneumonia within 10 days of discharge]
   
   • Gram negative bacteria e.g. H. INFLUENZA,
     PSEUDOMONAS AEURGINOSA
   • Staphylococcus (MRSA)
3. Immunocompromised pneumonia
   [Recent transplant, chemotherapy, HIV infection]
   
   • Unusual organisms. e.g. Tuberculosis
   • Fungi e.g. Pneumocystis jirovecii, aspergillos, candida, cryptococcus neoformans
     -Viral: HSV, CMV, VZV
4. Aspiration pneumonia
   [Swallowing difficulties, reduced consciousness]
   
   • Chemical pneumonitis
   • Anaerobic bacteria
5. Terminal event pneumonia

Question 6

How do you assess the severity of Pneumonia?

Answer 6

CURB-65 score
C = Confusion
U = Urea (>7mmol/L) 
R = Respiratory rate (>30/min)
B = Blood pressure  (SBP <90mmHg, DBP <60mmHg)

65 = Aged >65

Question 7

How does severity affect the management of pneumonia?

Answer 7

Scores:
0-1 = 1-2% mortality = Managed at home
2 = 9% mortality = Hospital admission
3+ = 22% mortality = ICU admission

Question 8

How is pneumonia treated? (according to severity)

Answer 8

Oxygen
Fluids
Antibiotics (according to CURB 65 score)

CURB 65 score:
0-1 = Amoxicillin
2 = Amoxicillin + Clarithromycin
3-5 = Amoxicillin (IV) + Clarithromycin (IV)

Question 9

How does pneumonia cause consolidation of the lung?

Answer 9

The lung developed areas that are solidified and appear ‘liver-like. This is known as HEPATISATION.
These areas do not get ventilated and therefore don’t contribute to gas exchange.

Question 10

How can pneumonia become complicated?

Answer 10

• Simple para-pneumonic effusion
• Emphysema
• Metastatic infection (joints, brain)
• Pulmonary venous thromboembolism
• Antibiotics side effects