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Respiratory > Pneumonia + Abscess + Empyema > Flashcards

Pneumonia + Abscess + Empyema Flashcards

1
Q

What is pneumonia

A

Inflammation of gas exchange region of the lung - usually due to infection

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2
Q

When is it pneumonia rather than LRTI

A

If consolidation seen on CXR

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3
Q

What is bronchopneumonia

A

Pneumonia affects lungs and bronchi

Patchy inflammation

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4
Q

What is lobar pneumonia

A

Pneumonia fills entire lobe

More invasive organism

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5
Q

How can pneumonia be classified

A

Anatomical - lobar or broncho
Aetiological
Microbiological - type of organism

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6
Q

What are etiological

A 
Community acquired
Hospital acquired 
Immunocompromised
Atypical
Aspiration - gram -ve 
Hydrostatic
Cardiac failure
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7
Q

What are common community acquired pneumonia

A

S.pneumonia = 80%
H. influenza
M. catarrhalis - immunocompromised / chronic lung

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8
Q

What are other causes

A 
Kliebsella
Mycoplasma
Chlamydia
Legionella
Pseudomona - CF / bronchiectasis 
S.Aureus - CF
Anorobes
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9
Q

What is common following influenza and Rx

A

S.aureus pneumonia
- Also common if IVDU as skin contaminant
- Tends to be bibasal
Rx = flucloxacillin

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10
Q

What is HAP and Rx

A

Pneumonia 48 hours after admission to hospital

Rx = Co-amox if within 5 days or pipicellin and tazobactum if >5 days (cephalosporin / ciprofloxacin as well)

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11
Q

What are organisms causing HAP

A 
Gram -ve
S.Aureus
Pseudomonas 
Klebsiella
Fungi
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12
Q

What are atypical causes of pneumonia (don’t respond to standard guidelines)

What are common organism in HIV +ve patient

A

Mycoplasma
Legionella
Chlaymdia pssitaci
Coxiella - think if farmer with flu

HIV

  • CMV
  • Cryptococcus
  • PJP
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13
Q

What causes recurrent pneumonia

A 
Local obstruction - tumour
Damage - bronchiectasis
CF
COPD
Immunocompromised
Immune deficiency
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14
Q

What are the symptoms of pneumonia

A 
Rapid onset
Cough 
Sputum
Pleuritic chest pain
SOB
Haemoptysis
Fever / rigors
Malaise
Anorexia
Headache
Confusion
Signs 
Tachycardia 
Tachypnoea
Cyanosis
Reduced sats 
Hypotension
CAN CAUSE SEPSIS
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15
Q

What is green / yellow suggestive of

A

Pneumococcal

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16
Q

What does rigors suggest

A

Septicaemia

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17
Q

What are chest signs

A 
Crackles - focal, inspiratory, coarse 
Dullness on percussion
Bronchial breathing (consolidation)
Increased vocal resonance
Decreased expansion
Pleural rub
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18
Q

When do you get bronchial breathing

A

Consolidation

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19
Q

Who are at risk of atypical

A

Immunocompromised
Aspiration - gram -ve
Chronic lung - COPD / CF
Travel Hx

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20
Q

What do atypical organism tend to be

A

Amoxicillin resistant

Rx = clarithromycin / co-trimoxazole

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21
Q

How do you investigate pneumonia

A

O2 sats
FBC, U+E, LFT, CRP - dehydration / atypical / high WCC
WBC tend to respond faster than CRP which can be delayed
VBG for lactate
ABG if sats low to look for acidosis
CXR

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22
Q

When does CXR show

A

Areas of consolidation due to inflammatory cells
Patchy white opacity
Usually LL
Focal
Not well defined unless whole lobe affected
Air bronchogram sign - can see bronchi
Silouhette sign - diaphragm loses contrast in LL or heart loses contrast in ML

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23
Q

What do you do for higher risk of atypical patients / complications

A

Blood / sputum culture
Pneumococcal antigen
Urinary legionella antigen

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24
Q

What are other tests and when do you do them

A

Atypical serology / viral PCR / fungal culture / throat swab
CT bronchogram if ITU / immunocompromised
Pleural fluid aspiration

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25
Q

What do fine crackles suggest

A

Fibrosis

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26
Q

What do coarse crackles suggest

A

Oedema

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27
Q

How do you treat pneumonia

A 
Oxygen if hypoxic
Analgesia if pleurisy
Fluid balance
CPAP
Neb - SABA / SAMA to open up
Suction if needed
Anti pyretic
Antibiotic
Chest physio
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28
Q

What is standard Ax

A

B lactam

Macrolide

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29
Q

When would you not discharge from hospital

A 
If in 24 hours 
37.5
RR >24
HR >100
Systolic <90
Sats <90
Abnormal mental
Inability to eat
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30
Q

How do you follow up after pneumonia

A

CXR at 6 weeks

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31
Q

Who gets pneumococcal vaccine

A

> 65
Chronic heart / liver / lung
DM
Immunosuppression

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32
Q

What does CURB 65 take in

A 
Used in community to decide need for admission
Confusion - AMTS <8 
Urea >7 - don't use in community 
RR >30
BP <90 or <60 
Age 65
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33
Q

What is a score of 0

A 
Low risk
Treat in community
Amoxicillin 500mg TDS or 
If allergic 
Clarithromycin 500mg or 
Doxycycline 100mg BD with 200mg loading
34
Q

What is a score of 1

A

Do O2 sats + CXR
If sats low or CXR shows bilateral shadows = admit to hospital
Same as above

35
Q

Score of 2

A

Hospital Rx
Amoxicillin +
Clarithromycin / levofloxacin

36
Q

Score of 3+

A

Consider ITU
Coamoxiclav 1g TDS Ceftriaxone 1.5g TDS Tazobactam
+
Clarithromycin + levofloxacin

37
Q

What are complications of pneumonia

A 
Sepsis 
AKI 
Pleural effusion
Pneumothorax
Atelactasis
Fibrosis if doesn't clear
Empyema
Lung Abscess 
ARDS
Type 1 resp failure 
AF
Bronchiectasis
38
Q

When would infection not clear

A

COPD

Bronchiectasis

39
Q

What is abscess common in

A

Klebsiella

Staph if Hx of influenza

40
Q

What is haemolytic anaemia common in

A

Mycoplasma

41
Q

How does pneumonia progress

A 
1 week fever resolves
4 week chest pain and sputum stop
6 week cough and Sob reduced - follow up CXR 
3 months = fatigue
6 months = normal
42
Q

Differential

A 
TB
Lung cancer - CXR
PE 
CF
Pulmonary vasculitis
43
Q

How do you treat respiratory failure

A

High flow O2
Transfer to ITU if CO2 rises or hypoxia doesn’t improve
Aim sats 94-98%

44
Q

What causes hypotension

A

Dehydration

Vasodilation due to sepsis

45
Q

How do you treat

A

If systolic <90 = fluid challenge
250ml of crystalloid over 15 minutes
Central line + IV to maintain
Inotropic support in ITU

46
Q

What is empyema and what causes

A 
Pus in pleural space 
May see pleural effusion on CXR
- Pneumonia 
- Abscess
- Post-op / trauma
- OM
47
Q

When do you suspect empyema

A 
Pneumonia resolving but fever persisting
Chest pain
Fever
SOB
No cough
48
Q

How do you Dx + treat

What is seen on aspirate

A 
Pleural aspiration
- Yellow
- pH <7.2
- Decreased glucose 
- Increased LDH
CXR = pleural effusion 
Bronchoscopy

Rx

  • IV Ax
  • Chest drain
  • Surgical excision
49
Q

What is a lung abscess and what are common organisms

A 
Cavitating area of local infection caused by 
Pneumonia
Aspiration
Lung cancer 
Obstruction
Infarction
PE 
Septic emboli - IVDA

S.aures post influenza
Pseudomona
Klebsiella

50
Q

What are features of abscess

A 
Swinging fever
Cough
Purulent sputum
Pleuritic pain if discharge into pleural space 
Haemoptysis
Lethargy 
Weight loss
Clubbing 
Anaemia
Crepitations
51
Q

How do you Dx abscess

A

FBC, CRP, culture
Sputum microscopy and culture and cytology
CXR
CT to exclude obstruction

52
Q

How do you treat abscess

A 
Ax until healed (minimum 6 weeks) 
Postural drainage
Percutaenous drainage 
Repeated aspiration
Surgical excision 
Intrapleural tPA/DNase to break down adhesions
53
Q

When is AF common

A

Elderly
Improves with Rx
Can use BB or digoxin to slow

54
Q

What are rare complications of pneumonia

A

Myocarditis
Pericarditis
Meningitis
Jaundice 2 to Ax or sepsis

55
Q

What do atypicals tend to do

A

Don’t respond to cephalosporin / penicillin
Affect upper lobe
Associated LN and deranged LFT

56
Q

Klebsiella pneumonia

A

Form abscess and empyema

Red current jelly sputum

57
Q

Who is Klebsiella common in

A

Alcohol
DM
Elderly

58
Q

Who is pseudomonas common in

A 
Bronchiectasis
CF
ITU 
HAI
As resistant to Ax which these people are on
59
Q

How does PJP (fungal) present

A 
Dry cough no sputum 
SOB on exertion 
Fever
Night sweats 
Exercise induced desaturations
Absent chest signs 
Pneumothorax 
Bilateral infiltrates
60
Q

How do you Dx

A

CXR = bilateral consolidation

BAL as sputum doesn’t pick up with silver stain - often needed

61
Q

How do you treat PJP

A

IV pentandimine
Co-trimoxazole
Prophylaxis if severely low CD4
Steroid if severe hypoxia

62
Q

How does mycoplasma present

A 
Flu like
Dry cough
Erythema multiform rash 
Neuro Sx in young patient  
Atypical CXR - bilateral 
Bilateral consolidatin
63
Q

How do you Dx mycoplasma

A

Viral throat swab
PCR sputum
Cold agglutinins IGM

64
Q

How do you Rx mycoplasma

A

Macrolide - clarithromycin or doxycycline

65
Q

What are complications of mycoplasma

A 
Erythema multiform / nodosum
Deranged LFT
Haemolytic anaemia
ITP
Encephalitis
Myocarditis
GBS - weakness / loss of reflexes 
Hepatitis
Pancreatitis
Acute GN
66
Q

How does legionella present

A 
Flu like
Dry cough
Brady
Confusion
Hyponatrameia
Abnormal LFT
D+V
Lymphopenia
PLeural effusion
Renal failure
Haemolytic anaemia
Can get hepatitis
67
Q

When do you think of Legionella

A

After holiday to Spain

Contact with infected water etc

68
Q

How do you Dx

A

Urinary antigen in urine sample

69
Q

How do you Rx

A

Erythromycin

70
Q

How does psittacosis present

A 
Fever
FLu
Conjunctivitis
Dry cough
Hx of bird contact 
Severe headache
No response to penicillin
71
Q

How do you treat

A

Tetracycline

Macrolide 2nd line

72
Q

Complications of psittacosis

A 
Meningoencephalitis
IE
Hepatitis 
Nephritis
Splenomegaly
73
Q

How does chlamydia pneumonia present

A

Pharyngitis
Hoarse
Otits media
Pneumonia

74
Q

How do you treat

A

Doxycline or clarithromyin

75
Q

What does ezithromycin give you

A

Very sick stomach

76
Q

What puts you at risk of aspiration pneumonia

A 
Neurological - poor swallow
Stroke
MS
Spinal cord injury 
Alcohol intoxication
Poor dental hygiene
Prolonged hospital
Achalasia
Reflux
Intubation
Impaired consciousness
Impaired mucociliary clearance
77
Q

What is common organism

A

Klebsiella - red current jelly
S.Pneumonia
S.Aureus
H.influenza

78
Q

What suggest aspiration

A

R lower lobe

Absence of fever

79
Q

How do you monitor response to Rx

80
Q

What do you give to break down adhesions caused by empyema / abscess

A

Intrapleural tPA/DNase

81
Q

why does post-op pain increase risk of pneumonia

A

Shallow breathing

Respiratory (23 decks)

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