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SPM- Respiratory > Pneumonia > Flashcards

Pneumonia Flashcards

1
Q

How can pneumonias be sub-classified?

A

Community acquired

Hospital acquired

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2
Q

What is the definition of pneumonia in community practice?

A

Symptoms of a lower respiratory tract infection (cough and one other), new focal signs on examination, and signs of systemic illness, pyrexia, sweating, rigors

+ No other more likely cause

(Signs and symptoms suggestive of pneumonia with no other more likely cause)

Note- Unlike in a hospital setting radiological evidence is not required to diagnose pneumonia in the community

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3
Q

What is the definition of pneumonia in hospital practice?

A

Signs and symptoms suggestive of pneumonia

Radiological evidence of pneumonia on a CXR- radiographic shadowing for which there is no other explanation

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4
Q

What is the definition of a hospital acquired pneumonia?

A

Acquired more than 48 hours after hospital admission. Includes ventilator and healthcare acquired pneumonia

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5
Q

What is the most common causative organism of CAP and HAP?

A

Streptococcus pneumoniae

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6
Q

What are the two most common causes of pneumonia in ITU?

A

Streptococcus pneumoniae

Legionella

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7
Q

What are the symptoms of pneumonia?

A 
Cough
Sputum production
Fever, Fatigue, Malaise
Pleuritic chest pain
Dyspnoea
Rigors
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8
Q

What are the clinical signs of pneumonia? (includes signs seen on examination)

A 
Tachycardia
Tachypnoea
Reduced chest wall expansion
Dullness to percussion
Crepitations on auscultation
Reduced oxygen saturations
Sputum pot
Bronchial breathing
Pyrexia
Confusion, Drowsiness, Coma
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9
Q

What respiratory failure might be seen in pneumonia?

A

Type 1 due to V/Q mismatch

Results in hypoxia without carbon dioxide retention but this may be seen later on or in patients with pre-existing COPD

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10
Q

What immediate investigations should be done if presenting at hospital?

A

Oxygen saturations

CXR

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11
Q

What blood tests should be done for someone presenting with pneumonia to hospital?

A 
FBC
U+Es
LFTs
CRP
ESR
Culture
HIV screen?

ABG if SPO2 less than 92%

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12
Q

When should an ABG be carried out for someone presenting with pneumonia?

A

If suspecting respiratory failure and SPO2 less than 92%

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13
Q

Should a sputum culture be done for all patients with pnuemonia?

A

Community- Not routinely, if not responding to ABx therapy consider

Hospital- Do for all hospital admissions for pneumonia or HAP. MC&S and AFB/ZN staining if considering TB

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14
Q

Should a sputum culture be done for patients in the community presenting with pneumonia?

A

Sputum culture should not be done routinely for all patients presenting with pneumonia in the community.

Should be considered if not responding to ABx treatment

If moderate or severe (CRB-65 of 2 or more) will require admission to hospital and a sputum culture should be done there

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15
Q

What might test might be done on the urine of a patient with severe CAP?

A

Legionella antigen

Common causative organism of ITU pneumonias

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16
Q

For a patient presenting at hospital with a CAP what investigations should be done?

A

CXR
Oxygen saturations
ABG if O2 Sats less than 92%
Bloods- FBC, U&E, ESR, CRP, LFT, Culture
Sputum culture- MC&S, Consider AFB/ZN Staining
Urine testing for legionella antigen (if severe)

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17
Q

How can CRP be used to guide ABX prescribing in the community?

A

CRP can be used to guide ABx prescribing for LRTI
0-20= No ABx
20-100= Delayed ABX
>100= Immediate ABx

18
Q

What are the criteria for CURB-65?

A 
Confusion= 1 point
Urea> 7 = 1 Point
Respiratory Rate> 30 = 1 Point
Blood Pressure- DBP <60 or SBP<90 = 1 Point
Aged 65 or more= 1 point
19
Q

In the community what CRB-65 score indicates admission to hospital?

A

2 or more

But use clinical judgement

20
Q

In the hospital what does the CURB-65 scores indicate?

A 
0-1 = Low Risk
2= Moderate Risk
3-5= High Risk

(Of death)

If 4 or 5 refer to critical care team

21
Q

Describe the supportive, definitive and preventative management for patients presenting with pneumonia at hospital

A

Supportive- IV Fluids, Oxygen Therapy, Monitoring
Definitive- ABx
Preventative- LMWH for VTE prophylaxis if appropriate

22
Q

How soon should investigations and treatment be carried out for a CAP at hospital?

A

All within 4 hours

Offer ABx as soon as possible after diagnosis

23
Q

How should a low severity CAP be treated? CRB- less than 2

What should you advise patients?

A

Oral ABx mono-therapy
Amoxicillin 500mg TDS 5 day course

Or doxycycline or clarithromycin if penicillin allergic

If no improvement or worsened symptoms after 3 days seek further medical help.

24
Q

How should a moderate severity CAP be treated? CURB- 65 of 2-3

A

Oral ABx- Dual Therapy
Amoxicillin with a macrolide (clarithromycin or erythromycin)

7-10 days worth

Use IV prep if CI

25
Q

How should a severe CAP be treated? CURB-65 of 3 or more

A

Parenteral dual antibiotic therapy with a beta-lactamase stable beta lactam ABx and a macrolide

Piperacillin and Tazobactam- Tazocin
Amoxicillin and clavulanic acid- Co-Amoxiclav

26
Q

When is it safe to stop IV ABx therapy and switch to oral?

A

Patient afebrile for more than 24 hours

Oral treatment not CI- e.g. vomiting

27
Q

If deemed severe in primary care, before admission, what should the GP give?

A

IV/IM Penicillin G/ Benzylpenicillin

PO Amoxicillin 1g

28
Q

What ABx should be given for a hospital acquired pneumonia?

A

Follow trust guidelines/policy
Give within 4 hours
5-10 days course

29
Q

What features would indicate that it is not safe to discharge someone?

A 
Temperature higher than 37.5
RR of 24 or more
HR>100
Systolic BP of 90 or less
Oxygen Sats less than 90% of air
Abnormal mental status
Inability to eat without assistance

2 or more of the above don’t discharge (unless already present at baseline- e.g. altered mental status and dementia)

30
Q

When should a follow-up appointment be done after pneumonia?

A

6/52

31
Q

When would you consider doing a repeat CXR for patients with pneumonia at follow up?

A

If there is a higher risk of malignancy that may have been a pre-disposing risk of developing the pneumonia (due to reduced ventilation)

32
Q

Outline that progress that should be made by patients after ABx treatment for pneumonia

A

1 week- Fever should’ve resolved
4 weeks- Chest pain and sputum production should have substantially reduced
6 Weeks- Cough and breathlessness should have substantially reduced
3 months- Most symptoms should have resolved but fatigue may still be present
6 Months- Most people will feel back to normal

33
Q

What type of pneumonia is common in the immunosuppressed?

What is seen on a CXR?

A

Pneumocystitis jirovecii pneumonia (PJP) is a causative organism in the immunosuppressed (e.g. HIV)

Presents with a dry cough, exertional dyspnoea, low PaO2, fever, bilateral crepitations

CXR may be normal or show bilateral peri-hilar interstitial shadowing

34
Q

How do you diagnose PJP? (common pneumonia in immunosuppressed)

A

Visualisation of the organism on induced sputum (nebulised salbutamol)
Bronchoalveolar Lavage
Lung biopsy

35
Q

What is the treatment for PJP?

A

High dose co-trimoxazole or pentamidine by slow IVI for 2-3 weeks
Steroids beneficial if sever hypoxaemia

36
Q

What is the most common cause of viral pneumonia?

A

Influenza virus

37
Q

What are some complications of pneumonia?

A

Respiratory Failure (Type 1 Most Common)
Hypotension- Infective process, give fluid challenge of 250ml over 15 minutes if SBP <90
Pleural Effusion
Empyema- Pus in pleural space, suspect is fever remains after pneumonia resolved
Lun abscess
Septicaemia

38
Q

When draining a pleural effusion what features indicate it is an empyema?

A 
Empyema= pus in the pleural space
Yellow fluid
pH<7.2
Low glucose
High amylase
39
Q

What are some causes of lung abscess?

A

Inadequately treated pneumonia
Aspiration- alcoholism, oesophageal obstruction, bulbar palsy, MS, GBS
Bronchial obstruction- tumour, foreign body
Pulmonary infarction
Septic Emboli- septicaemia, right heart endocarditis, IVDU
Sub-phenic or hepatic abscess

40
Q

What does a lung abscess look like on a CXR?

A

Cavitating lesion with an air fluid level

41
Q

What are some symptoms of a pulmonary abscess?

A 
Swinging fever
Cough
Foul smelling sputum
Pleuritic chest pain
Malaise
Weight loss
Empyema develops in 20-30%
42
Q

What is the treatment for lung abscess?

A

Antibiotics for 4-6 weeks
Aspiration
Antibiotic instillation
Surgical excision

SPM- Respiratory (17 decks)

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