pneumonia

Question 1

define pneumonia?

Answer 1

infection of distal lung parenchyma

Question 2

How is pneumonia categorized?

Answer 2

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

Question 3

what organisms cause community-acquired pneumonia?

Answer 3

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

Question 4

what organisms cause hospital-acquired pneumonia?

Answer 4

o	Gram-negative enterobacteria (Pseudomonas,Klebsiella)
o	Anaerobes (due to aspiration pneumonia)

Question 5

what are risk factors for developing pneumonia?

Answer 5

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

Question 6

summarise the epidemiology of pneumonia?

Answer 6

o 5-11/1000

o 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 atypical pneumonia symptoms?

Answer 8

o	Headache
o	Myalgia
o	Diarrhoea/abdominal pain
o	DRYcough

Question 9

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 crepitation’s on affected side
• Chronic suppurative lung disease(empyema, abscess) –> clubbing

Question 10

appropriate bloods for pneumonia and what to look for?

Answer 10

o	FBC - raised WCC
o	U&Es
o	LFT
o	Blood cultures
o	ABG (assess pulmonary function)
o	Blood film -Mycoplasmacauses red cell agglutination

Question 11

what will be seen on a chest x-ray with pneumonia?

Answer 11

o Lobar or patchy shadowing
o Pleural effusion
o NOTE:Klebsiellaoften affects upper lobes
o May detect complications (e.g. lung abscess)

Question 12

other relevant investigations?

Answer 12

• Sputum/Pleural Fluid
• Urine-PneumococcusandLegionellaantigens
• Atypical Viral Serology
• Bronchoscopy and Bronchoalveolar Lavage- ifPneumocystis carinii pneumoniais suspected, or if pneumonia fails to resolve

Question 13

what is the antibiotic management plan for pneumonia?

Answer 13

Generate a management plan for pneumonia
• Assess severity using theBritish Thoracic Society Guidelines
1) 0 markers - oral amoxicillin
2) 1 marker - oral or IV Amoxicillin + Erythromycin
3) >1 marker - IV co-amoxiclav + Erythromycin
4) Add metronidazole if:
• Aspiration
• Lung abscess
• Empyema
o Switch to appropriate antibiotic based on the sensitivity

Question 14

what is an appropriate supportive therapy for pneumonia?

Answer 14

o Oxygen
o IV fluids
o CPAP, BiPAP or ITU care for respiratory failure
o Surgical drainage may be needed for lung abscesses and empyema

Question 15

How to assess whether to discharge a pneumonia patient?

Answer 15

o IfTWO OR MOREfeatures of clinical instability are present
- e.g. high temperature, tachycardia, tachypnoea, hypotension, low oxygen sats

then there is a high risk of re-admission and mortality

Question 16

How to prevent pneumonia?

Answer 16

o Pneumococcalvaccine
o Haemophilus influenzaetype B vaccine
o These are only usually given to high risk groups (e.g. elderly, splenectomy)

Question 17

what are the possible complications of pneumonia?

Answer 17

•	Pleural effusion
•	Empyema
•	Localised suppuration (e.g. abscess)
o	(Symptoms of abscesses) 
•Swinging fever
•Persistent pneumonia
•Copious/foul-smelling sputum
•	Septic shock
•	ARDS
•	Acute renal failure
•	Extra complications ofMycoplasma pneumonia
oErythema multiforme
oMyocarditis
oHaemolytic anaemia
oMeningoencephalitis
oTransverse myelitis
oGuillain-Barre syndrome

Question 18

how to assess the prognosis for patients with pneumonia?

Answer 18

• Most resolve within treatment within 1-3 weeks
• Severe pneumonia has ahigh mortality
• TheCURB-65score is used to assess the severity of pneumonia:
o Confusion < 8 AMTS
o Urea > 7 mmol/L
o Respiratory rate > 30/min
o Blood pressure: systolic < 90 mm Hg or diastolic < 60 mm Hg
o Age >65yrs