Pneumonia

Question 1

Define Pneumonia?

Answer 1

Infection of distal lung parenchyma

Question 2

What are the different ways Pneumonia can be categoried?

Answer 2

Community-acquired 
Hospital-acquired/nosocomial
Aspiration Pneumonia 
Pneumonia in the immunocompromised
Typical
Atypical (Mycoplasma, Chlamydia, Legionella)

Question 3

What is the aetiology of Community-Acquired Pneumonia?

Answer 3

Streptococcus pneumoniae (70%)
Haemophilus influenzae 
Moraxella catarrhalis (occurs in COPD patients)
Chlamydia pneumonia 
Chlamydia psittaci (causes psittacosis)
Mycoplasma pneumonia 
Legionella (can occur anywhere with air conditioning)
Staphylococus aureus 
Coxiella burnetii (causes Q fever)
TB

Question 4

What is the aetiology of Hospital-Acquired Pneumonia?

Answer 4

Gram-negative enterobacteria (Pseudomonas, Klebsiella)

Anaerobes (due to aspiration pneumonia)

Question 5

What are the risk factors for Pneumonia?

Answer 5

Age 
Smoking 
Alcohol
Pre-existing lung disease (e.g. COPD)
Immunodeficiency 
Contact with patients with pneumonia

Question 6

What is the epidemiology of Pneumonia?

Answer 6

5-11/1000

Community-acquired pneumonia is responsible for > 60,000 deaths per year in the UK

Question 7

What are the presenting symptoms of Pneumonia?

Answer 7

Fever 
Rigors 
Sweating 
Malaise 
Cough 
Sputum 
Breathlessness 
Pleuritic Chest Pain 
Confusion (in severe cases or in the elderly)

Question 8

What are the Atypical Pneumonia symptoms?

Answer 8

Headache
Myalgia
Diarrhoea/abdominal pain
Dry cough

Question 9

What are the signs of Pneumonia on physical examination?

Answer 9

Pyrexia 
Respiratory distress
Tachypnoea 
Tachycardia
Hypotension
Cyanosis 
Decreased Chest expansion
Dull to percuss over affected area 
Increased tactile vocal fremitus over affected area 
Bronchial breathing over affected area 
Coarse crepitations on affected side 
Chronic suppurative lung disease (empyema, abscess) leads to clubbing

Question 10

What investigations do we do for Pneumonia?

Answer 10

Bloods 
CXR 
Sputum/Pleural fluid 
Urine 
Atypical Viral Serology
Bronchoscopy and Bronchoalveolar Lavage

Question 11

What bloods do we do for Pneumonia and what might we see?

Answer 11

FBC- Raised WCC
U&Es 
LFT
Blood cultures 
ABG (assess pulmonary function)
Blood film - Mycoplasma causes red cell agglutination

Question 12

What do we see on a CXR for Pneumonia?

Answer 12

Lobar or patchy shadowing
Pleural effusion
Klebsiella often affects upper lobes
May detect complications (e.g. lung abscess)

Question 13

Why do we check sputum/ pleural fluid for Pneumonia?

Answer 13

MC&S

Question 14

What do we look for in the Urine for Pneumonia?

Answer 14

Pneumococcus and Legionella antigens

Question 15

When do we do Bronchoscopy and Bronchoalveolar Lavage for Pneumonia?

Answer 15

If pneumocystis carinii pneumonia is suspected, or if pnenomia fails to resolve

Question 16

How do we assess the severity of Pneumonia?

Answer 16

British Thoracic Society Guidelines

Question 17

What is the first line of treatment for Pneumonia?

Answer 17

Start empiral antibiotics

Question 18

What is the order of antibiotics we give for Pneumonia?

Answer 18

Oral Amoxicillin (0 markers)
Oral or IV Amoxicillin + Erythromycin (1 marker)
IV cefuroxine/Cefotaxime/Co-amoxiclav + Erythromycin (> 1 marker)
Add metronidazole if required
Switch to appropriate antibiotic based on sensitivity

Question 19

When do we add Metronidazole for Pneumonia?

Answer 19

If there is:
Aspiration
Lung Abscess
Empyema

Question 20

What is the Supportive treatment for Pneumonia?

Answer 20

Oxygen
IV fluids
CPAP, BiPAP or ITU care for resp failure
Surgical drainage may be needed for lung abscesses and empyemea

Question 21

Wha is the Discharge planning for Pneumonia?

Answer 21

If TWO OR MORE features of clinical instability are present there is a high risk of re-admission and mortality
Consider other causes if Pneumonia isn’t resolving

Question 22

What are some examples of the features of clinical instability in Pneumonia?

Answer 22

High temperature 
Tachycardia
Tachypnoea 
Hypotension
Low oxygen sats

Question 23

What is the prevention of Pneumonia?

Answer 23

Pneumococcal vaccine
Haemophilus Influenzae type B vaccine
These are only usually given to high risk groups (e.g. elderly, splenectomy)

Question 24

What are the possible complications of Pneumonia?

Answer 24

Pleural effusion
Empyema 
Localised suppuration (e.g. abscess)
Septic shock
ARDS 
Acute renal failure 
Extra complications of Mycoplasma pneumonia

Question 25

What are the symptoms of Abscesses that might also be present as a complication of Pneumonia?

Answer 25

Swinging fever
Persistent Pneumonia
Copious/foul-smelling sputum

Question 26

What are some of the extra complications of Mycoplasma Pneumonia?

Answer 26

Erythema multiforme 
Myocarditis 
Haemolytic anaemia 
Meninogoencephalitis 
Transverse myelitis 
Guillain-Barre syndrome

Question 27

What is the prognosis for patients with Pneumonia?

Answer 27

Most resolve within treatment within 1-3 weeks

Severe pneumonia has a high mortality

Question 28

What is used to assess the severity of Pneumonia with regards to prognosis?

Answer 28

CURB-65 score

Question 29

What is the CURB-65 score?

Answer 29

Confusion < 8 AMTS
Urea > 7 mmol/L
Respiratory rate > 30/min 
BP: systolic < 90 mm Hg or diastolic < 60 mm Hg 
Age > 65 yrs