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Pneumonia, Empyema & Lung abscess Flashcards

1
Q

Pneumonia pathophysiology [3]

A

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.

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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 [2]

A

Pneumonia affects lungs and bronchi

Patchy inflammation

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4
Q

What is lobar pneumonia [2]

A

Pneumonia fills entire lobe

More invasive organism

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5
Q

How can pneumonia be classified? [3]

A

Anatomical - lobar or broncho
Aetiological
Microbiological - type of organism

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6
Q

What are etiological [7]

A 
Community acquired
Hospital acquired 
Immunocompromised/neutropenic
Atypical
Aspiration
Hydrostatic
Cardiac failure
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7
Q

What are common community acquired pneumonia? [4]

A

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

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8
Q

What is common following influenza?

A

S.aureus pneumonia

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9
Q

What is HAP?

A

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.

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10
Q

What are atypical causes of pneumonia (don’t respond to standard guidelines)? [4]

A
  • an outdated term referring to pneumonia caused by atypical organisms that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

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11
Q

What causes recurrent pneumonia [6]

A

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.

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12
Q

What are the symptoms of pneumonia [4]

A

Productive cough, Haemoptysis
Pleuritic chest pain suggests pleurisy, pleural effusion or empyema.
SOB
Fever / rigors, Malaise

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13
Q

What is green / yellow suggestive of?

What are the systemic signs of pneumonia [2]

A

Pneumococcal

Signs:
Signs of sepsis
Hypothermia, confusion (elderly)

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14
Q

What are chest signs [5]

A

Crackles - focal, inspiratory, coarse or focal crepitations
Dullness on percussion
Increased vocal resonance
Decreased expansion
Pleural rub

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15
Q

When do you get bronchial breathing

A

Consolidation

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16
Q

Who are at risk of aspiration pneumonia [5]

A
  • poor dental hygiene
  • swallowing difficulties
  • prolonged hospitalisation or surgical procedures
  • impaired consciousness
  • impaired muco-ciliary clearance
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17
Q

How do you investigate pneumonia? [7]

A

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)

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18
Q

CXR signs of pneumonia [4]

Describe 2 signs

A
  • Areas of consolidation due to inflammatory cells
  • Patchy white opacity
  • Usually LL, focal
  • Not well defined unless whole lobe affected
  1. Air bronchogram sign - can see bronchi
  2. Silhouette sign - diaphragm loses contrast in LL or heart loses contrast in ML
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19
Q

What do you do for higher risk of atypical patients / complications [3]

A

Blood / sputum culture
Pneumococcal antigen
Urinary legionella antigen

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20
Q

Immediate management of pneumonia [9]

A

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

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21
Q

What is standard Abx [2]

A

B lactam

Macrolide

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22
Q

Mx [2]

Abx CURB 0-1 [3]

A

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

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23
Q

Mx CURB 2 [2]

A

Amoxicillin (beta-lactam) +

Clarithromycin / levofloxacin (macrolide)

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24
Q

Mx CURB 3-5 [5]

  • If staph suspected [2]
  • If MRSA suspected [2]
A

Admit to ITU

Coamoxiclav / Ceftriaxone / Tazobactam
+
Clarithromycin

Staph - Flucloxicillin +/- rifampicin
MRSA - vancomycin or teicoplanin

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25
How do you follow up after pneumonia resolves
CXR at 6 weeks hereafter underlying pathology should be considered.
26
Who gets pneumococcal vaccine [4]
>65 Chronic heart / liver / lung DM Immunosuppression
27
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:
28
What are complications of pneumonia? [9]
``` Pleural effusion Pneumothorax, empyema, abscess Atelactasis, Fibrosis Bronchiectasis Type 1 resp failure, ARDS ``` AKI AF Sepsis Haemolytic anaemia
29
When would infection not clear [2]
COPD | Bronchiectasis
30
What is abscess common in
Klebsiella
31
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.
32
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 ```
33
Differential [5]
``` TB Lung cancer - CXR PE CF Pulmonary vasculitis ```
34
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%
35
What is empyema
Pus in pleural space | May see pleural effusion on CXR
36
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
37
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.
38
AF as complication of pneumonia: management [3]
Elderly Improves with Rx Can use BB or digoxin to slow
39
What are rare complications of pneumonia [4]
Myocarditis Pericarditis Meningitis Jaundice 2 to Ax or sepsis
40
Klebsiella pneumonia clinical features [2] CXR findings
Form abscess and empyema Red current jelly sputum CXR shows cavitating upper lobe pneumonia
41
Who is Klebsiella common in [3] Abx
Alcoholic DM Elderly Abx: CEFOTAXIME or MEROPENUM
42
Who is pseudomonas common in [3] Abx [3]
Bronchiectasis CF ITU or post-op Abx: TICARICILLIN or CEFTAZIDIME and GENTAMICIN
43
How does mycoplasma present [4]
Flu like prodrome > dry cough Erythema multiform rash Neuro Sx in young patient Autoimmune hemolytic anaemia
44
How do you Dx mycoplasma [3]
CXR - patchy consolidation over 1 lower lobe, reticular nodular shadowing Mycoplasma serology
45
How do you Rx mycoplasma [2] | Complications [3]
Macrolide - clarithromycin Complication: - SJS - Meningoencephalitis - Myelitis, GBS
46
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) ```
47
Causes and associations of legionella [2] CXR findings
After holiday to Spain Colonises in water tanks <60 deg CXR: bi-basal consolidation
48
How do you Dx legionella | Abx
Urinary antigen in urine sample | Abx: fluoroquinolone
49
Chlamydia psittacosis Aetiology Symptoms [4]
``` Ax: infected birds (parrots) Symptoms: - Fever, flu - Conjunctivitis - Dry cough - Severe headache - Arthralgia ```
50
Chlamydia psittacosis Dx Abx
Dx: chlamydophilia serology | Doxycycline
51
Complications of chlamydia psittacosis [4]
``` Meningoencephalitis IE Hepatitis Nephritis Splenomegaly ```
52
How does chlamydia pneumonia present [5]
``` Bi-phasic illness Pharyngitis Hoarse Otits media Then pneumonia ```
53
Chlamydia pneumonia Dx [1] Abx [2]
Chlamydophilia complement fixation test | Doxycline or clarithromyin
54
What are the components of CURB 65 score
Confusion Urea >7 - don't use in community RR >30 BP <90 or <60 Age 65
55
Complications of pneumonia
* Parapneumonic effusions should be assessed at an early stage by diagnostic (± therapeutic) pleural aspiration, ideally under ultrasound guidance.
56
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)
57
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
58
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
59
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
60
# 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.

Respiratory (14 decks)

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