Pneumonia

Question 1

Define pneumonia

Answer 1

Infection of distal lung parenchyma

Bronchopneumonia: patchy consolidation in diff lobes

Lobar pneumonia: fibrosuppurrative consolidation of a lobe

Question 2

Explain the aetiology/ risk factors of pneumonia

Answer 2

CAP:

• Strep pneumoniae (70%)
• H. Influenza
• Moraxella catarrhalis (COPD)
• Chlamydia pneumoniae and psittaci (psittacosis -birds)
• Coxiella burnetii (Q fever - cattle, sheep, goats)
• Staph aureus
• TB
• Legionella

HAP:

• anaerobes, gram- Pseudomonas, Klebsiella

Aspiration:

• stroke, bulbar palsy, GCS, GORD, achalasia

Immunocompromised:

• usual suspects + PCP, TB, fungi, CMV/HSV

Risk factors:

• Age
• Smoking, ETOH
• Lung disease
• Immunodeficient
• Neuro diseases
• Contact with infected px

Question 3

Summarise the epidemiology of pneumonia

Answer 3

COMMON

0.5-1.1%

CAP is responsible for >60k deaths/y UK

Elderly and children and immunocompromised

Question 4

Recognise the presenting symptoms of typical pneumonia

Answer 4

Fever

Rigors

Sweating

Malaise

Cough

Sputum

SOB

Pleuritic CP

Confusion in elderly

Question 5

Recognise the presenting symptoms in atypical pneumonia

Answer 5

Headache

Malaise

Myalgia

Diarrhoea/ Abdo pain

DRY cough

Question 6

Recognise the presenting signs of pneumonia

Answer 6

HTN

Tachypnoea, tachycardia

Pyrexial

Cyanosis, respiratory distress

±clubbing in chronic suppurative disease (empyema, abscess)

Examination:

• increased VF
• bronchial breathing
• reduced expansion
• pleuritic rub
• decreased BS
• dull percussion
• coarse creps

Question 7

Identify appropriate investigations for pneumonia

Answer 7

Bloods: FBC, UEs, LFTs, CRP, ABG, culture, blood film for Mycoplasma RBC agglutination

Urine: pneumoccocal/legionella antigens

CXR: infiltrates, consolidation (lobar/patchy), effusion, cavities, abscesses

Sputum/pleural fluid: MCS

Atypical viral/bacterial serology: chlamydia, coxiella…

Immunofluorescence: PCP pneumonia in I/C

Bronchoscopy + BAL: if pneumocystis carinii pneumonia suspected

Question 8

Supportive management plan for pneumonia

Answer 8

Supportive:

• O2 - PaO2 >8, SpO2 94-98%
• Fluids
• Analgesia
• Chest physio
• Surgical drainage of abscess/empyema
• CPAP, BiPAP for resp failure
• Consider ITU if shock, sepsis, hypercapnoea, hypoxia
• F/U as 6 weeks with CXR
• rule out cancer

Question 9

What antibiotics are given for pneumonia?

Answer 9

Question 10

How do you assess severity of pneumonia?

Answer 10

Confusion <8 AMTS

Urea >7mM

Respiratory rate >30/min

BP systolic «90mmHg or diastolic «60mmHg

>65

Question 11

How do you prevent pneumonia?

Answer 11

Pneumovax

• 23 valent
• »65
• Chronic HLKP failure or conditions
• DM
• Immunocompromised - chemo, HIV, splenectomy
• CI: P, B, fever
• every 10 years

H.influenza type B vaccine

Question 12

When do you discharge patients?

Answer 12

CURB65:

• 0-1 home rx
• 2 - hospital rx
• >>3 consider ITU

DO NOT discharge when two or more signs of instability: pyrexial, tachy, tachypn, hTN, low sats

Question 13

Identify possible complications of pneumonia

Answer 13

Respiratory failure

hTN

AF

Pleural effusion

Empyema

Lung abscess

Sepsis

Pericarditis

Jaundice from AB

Question 14

Summarise prognosis of pneumonia

Answer 14

Most resolve between 1-3 weeks with tx

Severe pneumonia has high mortality