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Y3M - Respiratory > Pneumonia > Flashcards

Pneumonia Flashcards

1
Q

Definition of pneumonia.

A

Inflammation of the substance of the lung.

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2
Q

Classifications of pneumonia.

A

CAP

HAP

Aspiration pneumonia

Pneumonia in the immunocompromised host

Ventilator-acquired pneumonia

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3
Q

Risk factors of CAP.

A

<16 yo and >65 yo

Co-morbidities such as HIV, DM, CKD, Malnutrition and recent viral resp infection

CF, Bronchiectasis, COPD, obstructing lesion

Smoking, alcohol, IV drug use

Immunosuppressant therapy

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4
Q

What is lobar pneumonia?

A

When the whole of one or more lobes is affected.

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5
Q

What is diffuse pneumonia?

A

When the lobules of the lung are mainly affected

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6
Q

What is bronchopneumonia?

A

When the infection is centred on the bronchi and bronchioles.

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7
Q

Clinical features of CAP.

A

Dry or productive cough, sometimes haemoptysis

Dyspnoea

Fever

Chest pain (usually pleuritic)

Extrapulmonary features

Non-specific such as recurrent falls.

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8
Q

CXR features of pneumonia.

A

Airspace opacification

Filling of the alveoli with infectious material and pus

Initially patchy

Becomes confluent as infection develops

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9
Q

Examination findings of pneumonia.

A

Dullness on percussion

Decreased breath sounds

Bronchial breath sounds

Rhonchi

Crackles, Rales

Increased vocal fremitus

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10
Q

Causative organisms of CAP.

A

S. pneumoniae

H. influenzae

Moraxella catarrhalis

Atypicals such as…

Mycoplasma pneumoniae

S. aureus

Legionella pneumophila

Chlamydophila psittaci

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11
Q

What are extrapulmonary features of CAP?

A

Myalgia, arthralgia and malaise

Myocarditis and pericarditis

Headache

Abdo pain, diarrhoea and vomiting

Hepatitis

Labial herpes simplex reactivation

Erythema multiforme

Erythema nodosum

Stevens-Johnson syndrome

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12
Q

In which particular causative organisms are extrapulmonary features more common?

A

Legionella pneumophila

Mycoplasma pneumoniae

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13
Q

What causative organisms is associated with the following;

Myalgia, arthralgia and malaise

Myocarditis and pericarditis

Erythema nodosum and multiforme.

A

Mycoplasma pneumoniae

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14
Q

What causative organisms is associated with the following;

Myalgia, arthralgia and malaise

Headache

Meningoencephalitis

Hepatitis

A

Legionella pneumophila

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15
Q

Which organism is associated with labial herpes simplex reactivation?

A

Pneumococcal pneumonia

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16
Q

What is the initial assessment of CAP?

A

Assessing the severity of the pneumonia.

Chest examination

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17
Q

How is the severity of pneumonia assessed?

A

CURB-65

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18
Q

Explain CURB-65

A

Confusion (< 8/10 score)

Urea level (> 7 mmol/l)

Resp rate (> 30 b/min)

Blood pressure (systolic < 90 mmHg, diastolic < 60 mmHg)

Age > 65

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19
Q

What is a mild pneumonia infection?

A

CURB-65 of 0-1

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20
Q

How should a mild pneumonia be treated?

A

Send back home

No need for microbiological diagnostic tests or further investigations.

Give oral amoxicillin 500mg TD

or

ora clarithromycin 500mg BD

or doxycycline 100 mg OD

for 5 days

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21
Q

When should a patient with pneumonia be referred to hospital?

A

If scoring above 1.

At the score of 1 it can still be a clinical judgment, especially if urea levels are normal.

Usually urea levels are only measured if referral to hospital.

This means that a CURB65 score of 1 might be 2.

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22
Q

What other markers can assess the severity of pneumonia?

A

CXR (more than one lobe involved)

PaO2 ( < 8kPa)

Low albumin ( < 35 g/L)

WCC ( < 4 x 10^9/L or > 20 x 10^9/L)

Positive blood culture

Co-morbidities

Absence of fever in elderly

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23
Q

What investigations should be done on patients requiring hospital admission?

A

CXR

Blood tests

Microbiological tests.

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24
Q

A CXR might come back normal, why should it be repeated after 2-3 days?

A

Because the radiological abnormalities might lag behind the clinical signs.

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25
Should the CXR be repeated again after this? Why/Why not?
After 6 weeks it should be repeated to rule out underlying bronchial malignancy.
26
What blood tests should be done in CAP?
FBC Serum creatinine Electrolytes Biochemistry CRP
27
Abnormal bloods in S. pneumoniae.
WCC \> 15 x 5^9/L Inflammatory markers significantly elevated; ESR \> 100 mm/h CRP \> 100mg/L
28
Abnormal bloods in mycoplasma.
WCC usually normal If there is anaemia haemolysis needs to be ruled out via Coombs test and measurement of cold agglutinins.
29
Blood tests of Legionella.
Lymphopenia without marked leucocytosis. **Hyponatraemia** Hypoalbuminaemia High serum levels of liver aminotransferases (hepatitis)
30
What other tests might be done in CAP?
Sputum culture and blood cultures ABGs if sats less than 94% HIV test
31
When should sputum cultures and blood cultures be done in CAP?
In moderate to severe CAP
32
Management of pneumonia CURB65 1. (Patient has been referred to hospital due to **CRB-65** score of 1)
Maybe suitable for short stay or ambulatory care. No microbiological diagnostic testing necessary if not suspecting Mycoplasma epidemic. Give: Oral amoxicillin 500 mg TD or Oral clarithromycin 500 mg BD or Doxycycline 100 mg OD
33
Management of CAP CURB-65 = 2.
Blood cultures done Sputum Pneumococcal antigen if suspected clinically. Serology or PCR if there is an epidemic. Amoxicillin 500-1000 mg TD **and** clarithromycin 500 mg BD orally. or Doxycycline 100 mg OD or Levofloxacin 500 mg BD or Moxifloxacin 400 mg OD
34
Management of CRB-65 scoring 3-4 outside of hospital.
Urgent referral to hospital for assessment and admission.
35
Management of CURB-65 = 3-5.
Antibiotics as soon as possible. Co-amoxiclav 1.2g TD IV and clarithromycin BD IV. Give fluoroquinolone if legionnaire's. Alternatively IV cephalosporin like ceftriaxone 2g OD and clarithromycin 500 mg BD. IV benzylpenicillin 1.2g QD and fluoroquinolone. **ALSO** Do blood cultures, sputum, pneumococcal antigen, legionelly antigen serology and viral PCR. Tailor treatment to results later on.
36
What other managements might be used in CAP?
Oxygen if desaturated IV fluids if hypotensive Thrombophylaxis Physiotherapy (only if sputum retention) Nutritional supplementation Analgesia
37
When is thrombophylaxis done in CAP?
If admitted \> 12h LMW heparin and thromboembolus stockings.
38
Why does analgesia help a lot in CAP?
If there is pleuritic pain the patient might avoid coughing up sputum. This can lead to sputum retention, atelectasis or secondary infection.
39
Prevention of pneumonia.
Stop smoking Vaccination against influenza for risk-groups. Over 65 and admitted with CAP should have pneumococcal vaccine before discharge from hospital.
40
Complications of pneumonia.
Resp failure Sepsis Pleural effusion Empyema Lung abscess Organising pneumonia
41
How common is pleural effusion in CAP?
Around one-third to one-half of cases. The majority of them are **simple exudative effusions**.
42
What is empyema?
Purulent fluid in the pleural space. A fate worse than pleural effusion.
43
What are early indications of empyema?
Ongoing fever and rising or persistently elevated inflammatory markers despite antibiotics.
44
Investigations in pleural effusion.
Pleural aspiration under ultrasound guidance to make a diagnosis and fluid sent for gram stain, culture, fluid protein, glucose and LDH.
45
What can be used in order to differentiate between transudate and exudate?
Light's criteria.
46
What specific criteria suggests an empyema?
Exudative effusion with pleural fluid of \< 7.2 pH.
47
Management of empyema.
Fluid should be urgently drained to prevent further complications.
48
Complications of empyema.
Development of a thick pleural rind or prolonged hospital admission. Increased mortality risk. Increased duration of abx treatment.
49
What might have to be done in severe cases of empyema?
Thoracic surgical intervention.
50
How can a lung abscess be detected?
Severe localised suppuration with cavity formation visible on CXR or CT.
51
Clinical features of lung abscess.
Production of large quantities of sputum which is often foul-smelling owing the growth of **anaerobic** bacteria. **Swinging fever**, malaise and weight loss. Usually few clinical signs, clubbing might be present if chronic.
52
Markers of lung abscess.
Normocytic anaemia and raised ESR/CRP.
53
Investigation and treatment of lung abscess.
CT Bronchoscopy to obtain samples or remove foreign bodies. Tx guided by culture results or clinical judgment. Surgical drainage might be necessary.
54
Causes of lung abscess.
Aspiration pneumonia TB S. aureus and K. pneumoniae Septic emboli Inadequately treated CAP Spread from amoebic liver abscess. Foreign body
55
Definition of HAP.
New onset of cough with purulent sputum along with a compatible CXR demonstrating consolidation, in patients who are **beyond 2 days** of their initial admission or who have been in a healthcare setting within the last 3 months.
56
Causative organisms of HAP.
G- bacteria such as Pseudomonas, Escherichia spp, Klebsiella spp. Anaerobic bacteria like Enterobacter spp. S. aureus and MRSA Acinetobacter spp.
57
Treatment of legionella pneumophila pneumonia.
Fluoroquinolone with clarithromycin or rifampicin if severe.
58
Treatment of Chlamydophila species.
Tetracycline
59
Treatment of HAP pneumonia such as g- bacilli, pseudomonas and anaerobes.
Aminoglycoside IV + antipseudomonal penicillin IV or 3rd generation cephalosporin IV.
60
Causative organisms of ventilator-associated pneumonia.
Multidrug resistant gram negative organisms such as Acinetobacter baumanii.
61
Explain why aspiration pneumonia might occur.
Any motor neuron disease or if swallowing is impaired (CN IX and particularly CN X). Increases the risk of food getting down into the airways instead of oesophagus. GORD can also cause aspiration of acid droplets, as can vomiting.
62
Why is vomiting very noxious in aspiration pneumonia?
It can be very severe and even fatal as there is intense destructiveness of the lung parenchyma due to gastric acid. This can especially complicate anaesthesia.
63
What is Mendelson's syndrome?
Acute chemical pneumonitis caused by aspiration of stomach contents especially in pregnancy.
64
What are the most common places where aspirated objects get lodged?
Right middle lobe The apical or posterior segments of the right lower lobe.
65
What is persistent pneumonia commonly due to?
Anaerobes leading to lung abscess or even bronchiectasis.
66
Treatment of aspiration pneumonia.
Should be guided by positive cultures. If not then co-amoxiclav.
67
Treatment of aspiration pneumonia in case of S. pneumoniae or anaerobe positive.
Cephalosporin and metronidazole IV.
68
Causative organisms of pneumonia in the immunocompromised patient.
S. pneumoniae H. influenzae S. aureus M. catarrhalis M. pneumoniae G- bacilli **Pneumocystis jirovecii** **Fungi** **Viruses like CMV and HSV**
69
Give examples of which patients might be susceptible to Pneumocystis jirovecii.
Long term corticosteroids Monoclonal antibodies Methotrexate Anti-rejection medication HIV (particular at CD4 \< 200/mm3
70
Where is Pneumocystis jirovecii found?
In the air.
71
Clinical features of Pneumocystis jirovecii pneumonia.
High fever Dypsnoea Dry cough Rapid desaturation on exercise and exertion
72
CXR features of Pneumocystis jirovecii.
Diffuse **bilateral alveolar** and **interstitial shadowing beginning** at the **perihilar regions** and then making its way out spreading like a **butterfly**. Localised infiltration Nodules Caviation Pneumothorax
73
Treatment of Pneumocystis jirovecii pneumonia.
Empirical treatment only if very severe in high-risk patients. However diagnosis should be done first by indirect immunofluorescence on induced sputum or bronchoalveolar lavage fluid. **High-dose co-trimoxazole**
74
Special features of Klebsiella pneumonia.
Causes a cavitating pneumonia particularly of the upper lobes.
75
Cavitating pneumonias.
S. pneumoniae can cause cavitation in children. Mycoplasma tuberculosis Aspergillus S. aureus Legionella

Y3M - Respiratory (21 decks)

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