Pneumonia, Empyema & Lung abscess Flashcards
Pneumonia pathophysiology [3]
An inflammatory response of the lung to infection with usually bacterial micro-organisms.
* Inflammatory cell infiltration of the lung parenchyma results in accumulation of fluid and micro-organisms, and production of purulent sputum.
* Development of consolidation impairs gas exchange and is usually associated with a fever, rise in inflammatory markers and the evolution of a systemic inflammatory response, which if untreated, leads to sepsis, cardiovascular compromise and multi-organ failure.
When is it pneumonia rather than LRTI?
If consolidation seen on CXR
What is bronchopneumonia [2]
Pneumonia affects lungs and bronchi
Patchy inflammation
What is lobar pneumonia [2]
Pneumonia fills entire lobe
More invasive organism
How can pneumonia be classified? [3]
Anatomical - lobar or broncho
Aetiological
Microbiological - type of organism
What are etiological [7]
Community acquired Hospital acquired Immunocompromised/neutropenic Atypical Aspiration Hydrostatic Cardiac failure
What are common community acquired pneumonia? [4]
S.pneumonia = 80%
H. influenza
Mycoplasma pneumoniae
M. catarrhalis - immunocompromised / chronic lung
What is common following influenza?
S.aureus pneumonia
What is HAP?
Pneumonia > 48 hours after admission to hospital
are associated with unusual and often resistant organisms, e.g. Pseudomonas aeruginosa, MRSA or Gram-negative bacteria, which can be difficult to treat and is associated with high mortality.
What are atypical causes of pneumonia (don’t respond to standard guidelines)? [4]
- an outdated term referring to pneumonia caused by atypical organisms that
do not respond to ‘typical’ antibiotics. - These organisms often use intracellular replication and therefore are usually not beta lactam sensitive.
Mycoplasma pneumoniae
Legionella pneumophilia
Chlaymdia pneumoniae, psittaci
Coxiella burnetti
What causes recurrent pneumonia [6]
Local obstruction - tumour
Previous damage - bronchiectasis
CF
COPD
Immunocompromised
In those with high alcohol consumption there is an increased risk of aspiration pneumonia. Alcohol
intake may also influence responsible organisms and disease course by relative immunosuppression.
What are the symptoms of pneumonia [4]
Productive cough, Haemoptysis
Pleuritic chest pain suggests pleurisy, pleural effusion or empyema.
SOB
Fever / rigors, Malaise
What is green / yellow suggestive of?
What are the systemic signs of pneumonia [2]
Pneumococcal
Signs:
Signs of sepsis
Hypothermia, confusion (elderly)
What are chest signs [5]
Crackles - focal, inspiratory, coarse or focal crepitations
Dullness on percussion
Increased vocal resonance
Decreased expansion
Pleural rub
When do you get bronchial breathing
Consolidation
Who are at risk of aspiration pneumonia [5]
- poor dental hygiene
- swallowing difficulties
- prolonged hospitalisation or surgical procedures
- impaired consciousness
- impaired muco-ciliary clearance
How do you investigate pneumonia? [7]
Bloods
ABG (if severe or sats low)
CXR
Sputum (MC&S, legionella antigen)
Urine (legionella & pneumococcal ag)
Pleural fluid aspiration (if pleural effusion)
BAL or bronchoscopy (if ITU or immunocompromised)
CXR signs of pneumonia [4]
Describe 2 signs
- 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
- Silhouette sign - diaphragm loses contrast in LL or heart loses contrast in ML
What do you do for higher risk of atypical patients / complications [3]
Blood / sputum culture
Pneumococcal antigen
Urinary legionella antigen
Immediate management of pneumonia [9]
Oxygen if hypoxic
Analgesia if pleurisy
IV Fluids (if dehydration, anorexia, shock)
CPAP
Neb - SABA / SAMA to open up
Suction if needed
Anti pyretic
Antibiotic
Chest physio
What is standard Abx [2]
B lactam
Macrolide
Mx [2]
Abx CURB 0-1 [3]
0: Low risk and treat in community
1: do O2 sats + CXR
If sats low or CXR shows bilateral shadows = admit to hospital
Use beta-lactam
Amoxicillin OR
Clarithromycin / doxycycline if allergic
Mx CURB 2 [2]
Amoxicillin (beta-lactam) +
Clarithromycin / levofloxacin (macrolide)
Mx CURB 3-5 [5]
- If staph suspected [2]
- If MRSA suspected [2]
Admit to ITU
Coamoxiclav / Ceftriaxone / Tazobactam
+
Clarithromycin
Staph - Flucloxicillin +/- rifampicin
MRSA - vancomycin or teicoplanin
How do you follow up after pneumonia resolves
CXR at 6 weeks hereafter underlying pathology should be
considered.
Who gets pneumococcal vaccine [4]
> 65
Chronic heart / liver / lung
DM
Immunosuppression
CURB 65 vs CRB 65
Function
Components [5]
Used in community to decide need for admission
Note that in hospital, once blood tests are available the CURB65, rather than the CRB65, can be used. This adds an extra criterion of urea > 7 mmol/L:
What are complications of pneumonia? [9]
Pleural effusion Pneumothorax, empyema, abscess Atelactasis, Fibrosis Bronchiectasis Type 1 resp failure, ARDS
AKI
AF
Sepsis
Haemolytic anaemia
When would infection not clear [2]
COPD
Bronchiectasis
What is abscess common in
Klebsiella
When can haemolytic anaemia occur in context of pneumonia
Mycoplasma pneumoniae - Blood film: ‘rouleux’ formation or stacking of RBC can be suggestive of mycoplasma pneumonia due
to the production of cold agglutinins.
How does pneumonia progress: 1 week, 4 week, 6 week, 3m, 6m
1 week fever resolves 4 week chest pain and sputum stop 6 week cough and Sob reduced 3 months = fatigue 6 months = normal
Differential [5]
TB Lung cancer - CXR PE CF Pulmonary vasculitis
How do you treat respiratory failure [3]
High flow O2
Transfer to ITU if CO2 rises or hypoxia doesn’t improve
Aim sats 94-98%
What is empyema
Pus in pleural space
May see pleural effusion on CXR
When do you suspect empyema [3]
clinical vs pleural fluid
- Pneumonia resolving but fever persisting. Frankly/cloudy purulent pleural fluid.
- When aspirate yellow, ph <7.2, decreased glucose, increased LDH
How do you treat empyema?
Chest drain. Empyema requires surgery in up to 40% of cases (mortality up to 20%) and, therefore, early
discussion with thoracic surgeons should ensue.
AF as complication of pneumonia: management [3]
Elderly
Improves with Rx
Can use BB or digoxin to slow
What are rare complications of pneumonia [4]
Myocarditis
Pericarditis
Meningitis
Jaundice 2 to Ax or sepsis
Klebsiella pneumonia clinical features [2]
CXR findings
Form abscess and empyema
Red current jelly sputum
CXR shows cavitating upper lobe pneumonia
Who is Klebsiella common in [3]
Abx
Alcoholic
DM
Elderly
Abx: CEFOTAXIME or MEROPENUM
Who is pseudomonas common in [3]
Abx [3]
Bronchiectasis
CF
ITU or post-op
Abx: TICARICILLIN or CEFTAZIDIME and GENTAMICIN
How does mycoplasma present [4]
Flu like prodrome > dry cough
Erythema multiform rash
Neuro Sx in young patient
Autoimmune hemolytic anaemia
How do you Dx mycoplasma [3]
CXR - patchy consolidation over 1 lower lobe, reticular nodular shadowing
Mycoplasma serology
How do you Rx mycoplasma [2]
Complications [3]
Macrolide - clarithromycin
Complication:
- SJS
- Meningoencephalitis
- Myelitis, GBS
Symptoms of legionella [4]
Results of blood investigations [8]
Flu like prodrome > dry cough and SOB
Anorexia
D+V
Confusion, coma
Bradycardia Lymphopenia Hyponatremia Abnormal LFT Renal failure - urinalysis (hematuria)
Causes and associations of legionella [2]
CXR findings
After holiday to Spain
Colonises in water tanks <60 deg
CXR: bi-basal consolidation
How do you Dx legionella
Abx
Urinary antigen in urine sample
Abx: fluoroquinolone
Chlamydia psittacosis
Aetiology
Symptoms [4]
Ax: infected birds (parrots) Symptoms: - Fever, flu - Conjunctivitis - Dry cough - Severe headache - Arthralgia
Chlamydia psittacosis
Dx
Abx
Dx: chlamydophilia serology
Doxycycline
Complications of chlamydia psittacosis [4]
Meningoencephalitis IE Hepatitis Nephritis Splenomegaly
How does chlamydia pneumonia present [5]
Bi-phasic illness Pharyngitis Hoarse Otits media Then pneumonia
Chlamydia pneumonia
Dx [1]
Abx [2]
Chlamydophilia complement fixation test
Doxycline or clarithromyin
What are the components of CURB 65 score
Confusion
Urea >7 - don’t use in community
RR >30
BP <90 or <60
Age 65
Complications of pneumonia
- Parapneumonic effusions should be assessed at an early stage by diagnostic (± therapeutic) pleural aspiration, ideally under ultrasound guidance.
What can cause an abscess to develop in the lung [5]
Aspiration (alcoholism)
Pneumonia (inadequately treated, empyema direct extension)
Bronchial obstruction (ca, fb)
Septic embolism (sepsis, endocarditis, IVDU)
What are common organisms [4]
What are 3 signs of lung abscess?
S.Aureus
Pseduomona
Klebsiella
Anerobes
Signs:
- Finger clubbing
- Anaemia
- Crackles
- Dull percussion, bronchial breathing
What are the symptoms of lung abscess [5]
- Cough
- Purulent and foul smelling sputum, Haemoptysis
- Swinging fever
- Pleuritic chest pain
- Systemic features: Lethargy, Weight loss
- similar features to pneumonia but generally runs a more subacute presentation, where symptoms develop over weeks
CXR findings [3]
Management of lung abscess [3]
CXR:
- fluid-filled space within an area of consolidation
- Walled cavity
- Often with air-fluid level
- Empyema also in 20-30%
Mx:
- Drainage of pus through physiotherapy
- 6 week Abx (according to sensitivities)
- Surgical resection or percutaneous drainage
Middle East Respiratory Virus syndrome
Middle East respiratory syndrome (MERS) is an acute viral respiratory tract infection caused by the betacoronavirus MERS-CoV.
Incubation period
Source or host
Transmission
Clinical presentation
Incubation period: 2-14 days
Source or host: camels
Transmission: droplets
Clinical presentation varies just like covid, can be very mild or progress to life-threatening multi organ failure.
