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Pathophysiology of ill-health > Pneumonia > Flashcards

Pneumonia Flashcards

1
Q

Relevance

A

0.5-1% of adults in UK affected each year

16% of all deaths in children under 5, 808,694 in 2017 (WHO)

USA - most common cause of hosp admission except birth

**Common cause of sepsis and septic chock, causing 50% OF EPISODES

Pregnant women at risk - leading cause of death in maternity settings

Adult literature relevant to MH

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2
Q

Hospital Acquired Pneumonia - relevance

A

Increases hospital stay by 7-9 days per patient

Second most common hospital acquired infection other than UTI’s - significant mortality association

LD - respiratory conditions are major contributor to death amongst cohort

Chronic health conditions - MH population high, pneumonia risk is significant

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3
Q

Causes

A

Genetics, underlying medical and lifestyle conditions, determine pneumonia susceptibility

  • babies and young children
  • people over 65 - poor immune system - less cilia
  • people who smoke - fewer cilia
  • people with otehr health conditions such as asthma, cystic fibrosis, kidney, liver, HIV, anything which affects immune system - malnourished, post surgery,
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4
Q

Definition / Classification

A

No definition - too many types

Bacterial, Viral, Fungal - organism

Part of lung affected - lobar, bronchial

Location - Community-acquired or Hospital-acquired pneumonia

Mycoplasma pneumonia - ‘walking pneumonia’

Aspiration pneumonia - esp if laying- acid in lungs

Atypical pneumonia

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5
Q

Most common causes

A

Streptococcus pneumoniae - especially children

Hameophilus influenzae

Respiratry syncytial virus

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6
Q

Describe

A

Air sacs fill with puss and may become solid. Inflammation may affect one lung or both (double v single)

Inflammatory process

Purulent respiratory secretions, pyrexia and chest x-ray changes associated with the area of infection

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7
Q

Characteristics - describe

A

Inflammation and infection in the terminal bronchioles and alveoli, leading to engorgement of the capillaries and subsequently stasis of blood and also causing conslidation

21% oxygen in

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8
Q

Consolidation

A

Region of normally compressible lung tissue that has filled with liquid(fluid/exudate) instead of air

Shadowing on chest x-ray - can be detected on auscultation

Heavy fluid - pressure on the alveoli - can cause atelectasis (airway collapse)

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9
Q

Consolidation

A

Region of normally compressible lung tissue that has filled with liqui(fluid/exidate) instead of air

Shadowing on chest x-ray - can be detected on auscultation

Heavy fluid - pressure on the alveoli - can cause atelectasis (airway collapse)

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10
Q

Air journey - respiratory system

A

Oxygen in 21% in to down trachea, to bification of tracea (charina) - divide into right and left bronchiole tree, travels down via brionchioles, terminal brionchiles, alveoli - capillary interface, into circulation

Prevented at capillary interface

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11
Q

Respiratory Auscultation - what do you find?

A

Wheezing

Rales (upper airways) - popping crackling

Rhonchi - fluid - assoc. with heart failure and pneumonia - deep sea sounds

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12
Q

Atelectasis

A

airway collapse due to fluid in alveoli

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13
Q

Diagnosing pneumonia

A

Clinical symptoms - malaise, lethargy, fever, persistent cough, pleuritic pain

Dyspnoea - difficult / laboured breathing

Cough - sputum yellow green, rusty

Accompanied by pyrexia, chest x-ray changes and leucocytosis - elevated WBC count

Auscultation - rales, rhonchi

Send off lab sample - streptococcus pneumoniae?

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14
Q

Leucocytosis

A

Elevated WBC count

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15
Q

Dyspnoea

A

Shortness of breath - difficulty breathing

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16
Q

Classic diagnostic?

A

Start with chest x-ray

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17
Q

Inflammation

A

Th2 cells - white cells involved in inflammatory response

Th2 cells are activated by virus, bacteria, fungus

Release of cytokines

Get inflammatory response - symptoms (consolidation)

Helper type Th2 cell is a distinct type of T cell that secretes IL-4,5,9,11,13,17,25 (inflammatory mediators / cytokines)

Other cytokines produced by Th2 cells stimulate eosinophil activation and survival (IL-5) or promote mast cell activation (IL-9)

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18
Q

Inflammatory response:

A
  1. VASODILATION, INCREASED PERMEABILITY of blood vessels
  2. Emigration of phagocytes from the blood into the area of injury
  3. Tissue repair
  4. In pneumonia this presents as consolidation
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19
Q

Symptoms

A 
Muscular aches
Respiratory system
Fever, 
Low BP
Fast HR
Nausea vomiting

Can hear it with stethoscope

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20
Q

Lobes of lungs

A

3 lobes on Right side (superior, middle, inferior)

2 on Left side (superior, lower)

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21
Q

Most common for pneumonia?

A

Right bronchus - as higher, more vertical, bigger

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22
Q

Cell walls - humans?

A

NO - bacteria, plants

Humans have cell membranes

Virus’ don’t have cell walls

23
Q

Laboratory sample

A

streptococcus comes back green

24
Q

Clinical presentation - ‘way in’ logical thinking

A

‘Advanced investigations’

Systemic - high fever, chills

Temperature 36.0-37,5

AIRWAY:

Respiratory rate depth and pattern - 12-20 breaths per minute normal depth

Oxygen - not delivered, cells respire anaerobically, make lactic acid, pH starts to fall, chemoreceptor, medulla olongata, phrenic nerve, increased resp

Cyanosis - lungs full of fluid - can’t get oxygen from respiratory to circulatory system

Pulse and BP

Pyrexia mega principle

25
Q

Pyrexia in pneumonia

A

Pyrexia inhibits bacterial growth, mobilises immune defences, damage membranes of body and bacteria cells

Any human cell that’s damaged releases PYROGENS

More damage, more pyrogens

Pyrogens travel to HYPOTHALAMUS, act directly or via prostoglandins, change the set point of thypothalamus, body then perceived to be too cold, activate nervous system, start to shiver which brings your temperature up

26
Q

Examples of pyrogen

A

IL-1 - acts directly on hypothalamus (pyrogen and cyctokine)

Tumour Necrosis Factor - the principle cytokine that mediates acute inflammation

TNF - acts directly on hypothalamus AND stimulates other white cells to release IL-6, IL-8 (more cytokines)

More cytokines, more neutrophils

27
Q

TNF Tumour Necrosis Factor stimulates production of?

A

Interleukin 6 = proinflammatory cytokine, stimulates liver to produce acute phase proteins, STIMULATES THE PRODUCTION OF NEUTROPHILS

Interleukin 8 = PRODUCED BY MACROPHAGES IN THE ALVEOLI AND ATTRACTS NEUTROPHILS TO THE SITE OF INFLAMMATION

28
Q

What are the products of cellular aerobic respiration?

A

Carbon dioxide, heat, ATP, water

29
Q

What causes increase in heat?

A

Increase muscle use
heart beating faster
liver working hard fighting infection -

IL-1 and TNF on hypothalamus

TNF - IL1 &

Aerobic resp - metabolic rate goes up

30
Q

Excessive high temperatures:

A

Swell mitochondria

Change cell permeability

31
Q

Temperature leads to….

A

Sweating

Leads to dehydration - lost a lot? circulatory volume is reduce, BP can fall

32
Q

Why does HR go up if BP falls?

A

If BP falls (e.g. due to sweating)

Baroreceptors in neck - measure BP

Connected to Medulla Oblongata

Connected to heart via vagus nerve

Break taken off vagus nerve, HR speeds up

BUT - also stress - adrenaline

33
Q

Why sputum green?

A

neutrophils have ‘respiratory burst’ - they produce free radicals

enzymes in the white cells, made of iron, cause change in colour

Live neutrophils stain yellow - eosinophils

Iron enzymes + sputum = green

34
Q

Raised white blood cell count?

A

Leukocytosis

neutrophils - tend to rise with bacterial infections

lymphocytes - viral infection

monocytes - chronic cancer

eosinophiles - parasitic infections

basophils - anaphalyxis

35
Q

End point - impact on funtioning

A

Lungs - oxygen in co2 out

requires - large surface area, thin membrane for gaseous exchange, good blood supply, concentration gradient, adaptable

consolidation impedes process

o2 cant move down bronchiole tree into circulatory system

…becoming…HYPOXIC

(asthma, pneumonia - can both cause)

reduction of available oxygen systemically for cells, tissues and organs

less oxygen in arteriole blood

36
Q

Tissue Hypoxia

A

Starved of oxygen for 4 minutes - brain, kidney, heart

Tissue becomes necrotic

Clot - anything downstream is starved of oxygen

37
Q

Alveoli filled with fluid =

A

Oxygen can’t reach the bloodstream

38
Q

Normal pH of blood

Normal lactate

Normal carbon dioxide

Normal oxygen

A

blood: 7.35 - 7.45
lactate: 0.5 - 1

carbon dioxide: 4-6.5 kilapascals

oxygen: 11-14 killapascals

low oxygen - hypoxia

39
Q

Types of hypoxia

A

5 x types

Anaemic hypoxia - decreased haemoglobin
Hypoxic hypoxia - asthma, choke and pneumonia
Ischaemic hypoxia - arteriolar obstruction or vasoconstriction
Oxygen affinity hypoxia - e.g carbon monoxide poisoning
Stagnant hypoxia - very low blood pressure

40
Q

Types of hypoxia

A

5 x types

Anaemic hypoxia - decreased haemoglobin
Hypoxic hypoxia - asthma, choke and pneumonia
Ischaemic hypoxia - arteriolar obstruction or vasoconstriction
Oxygen affinity hypoxia - e.g carbon monoxide poisoning
Stagnant hypoxia - very low blood pressure

41
Q

What happens if deprived of oxygen?

A

Switch from aerobic to anaerobic respiration

in 21%, out 16.5% oxygen - I use 25% of oxygen breathed in

binds to haemoglobin - oxyhaemoglobin,

42
Q

Oxygen journey

Respiration

A 
Nasophayryx, orapharynx, lyn
trachea
bhronchos
bhroncioles
diffuses axcross thin membrane to bloodstream binds to haemoglobin forms oxyhaemoglobin, then pumped to tissues

when red cells arrive in capillary bed, xygen diffuses through capillary wall, through interstitial space that surrounds cell, through membrane and into the cytoplasm

oxygen is combined with glucose

  1. Glycolysis
  2. Krebs cycle
  3. Electron transport phosphorylation - make 36 ATP’s
43
Q

Unable to get oxygen? what happens?

A

Switch to Anaerobic respiration

Glycolysis - Glucose -> 2 x ATP & Pyruvic Acid

-> Lactic Acid & Lactate

lactate levels start to climb, ph starts to fall

Become more acidic - 7.35 -> 6.8= death

44
Q

Consequences of anaerobic respiration?

A

Reduced ATP, disrupted sodium potassium pump

Decrease in pH
Increase in lactate
Compromised cell membrane and cell organelle activity

45
Q

Cell membrane disruption pathway 1

A

ATP dependent sodium potassium pump relies on ionic gradient

Sodium accumulates in cell, oedema
Calcium accumulates
Potassium leaks out of cell (always leaks from acidotic cells)

Leads to fluid and electrolyte imbalance

Oedema and alectroltye imbalance disrupt the function of key cell organelles leading to irreverible damage and death

46
Q

Cell membrane disruption pathway 2

A

Lysosome - An organelle involved in breaking down proteins & carbohydrates

Thick organelle cell wall full of digestive enzymes

Due to lack of ATP, cell membrane eaten away by enzymes inside lysosome

Once cell walls become permeable, lysosomal enzymes self digest resulting in cell death

47
Q

2 x major reasons for cell death

A
  1. water movement, ph imbalance, electrolyte disturbance
  2. Lysosomal enzyme activation

caused by lack of oxygen, ph imbalance and failure of sodium potassium pump

ACID

48
Q

Assessment of pneumonia

Resuscitation council recommend…

A

Assess area for safety, think about an early call for help, PPE, privacy and dignity

Try to illicit response

A - If responding, airway open. Look listen and feel
B - look listen and feel
C - 
D - consciousness, blood glucose
E -
49
Q

Airway

A

Chest and abdominal movements, accessory muscle use, presence o

Green (iron) or yellow (wbc live) sputum

Cyanosis - purple/blue, grey assoc. with sat <85% changes between 3-5 g / decilitre

50
Q

Breathing

A

Look Listen Feel

Respiratory distress
Fast respiratory rate*
Using accessory muscles*
Speech interrupted due to strained breathing
Rales, rhonchi with stethoscope
Hypoxia
51
Q

Circulation

A

Temperature up -> dehydration
Dehydration can cause low BP, increased HR
BP falls - baroreceptors in neck, medulla oblongata, vagus nerve, heat beats faster

Delayed capillary refill, over 2 sec
Perfusion to kidney low, urine output reduced
Perfusion to stomach low, feel sick or vomit

52
Q

Disability

A 
Altered level of consciousness due to lack of oxygen to brain - hypoxic confusion
A
C
V
P
U

Blood sugar - elevated due to stress response

53
Q

Exposure

A

Maintain privacy and dignity
Minimise heat loss
Check for rashes fractures and breathing

hot to the touch expected in pneumonia
Baseline observations need to be considered

Asthma, pneumonia - ABCDE
Outside of ABCDE…

Pneumonia - changes in chest x-ray, white cell count

54
Q

Assessment tools for pneumonia

A

British Thoracic society - CURB 65

C - new mental confusion due to hypoxia
U - urea due to dehydration
R - fast respiratory rate
B - blood pressure systolic <90, diastolic <60
65 - 65 years or older?

Critique - 12-20 is norm (RCUK)

BTS - above 30 is a worry

RCUK - say 25 is a worry

Pathophysiology of ill-health (16 decks)

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