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Respiratory > Pneumonia, Empyema & Lung abscess > Flashcards

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  • an outdated term referring to pneumonia caused by atypical organisms that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

How do you follow up after pneumonia resolves

A

CXR at 6 weeks hereafter underlying pathology should be
considered.

26
Q

Who gets pneumococcal vaccine [4]

A

> 65
Chronic heart / liver / lung
DM
Immunosuppression

27
Q

CURB 65 vs CRB 65
Function
Components [5]

A

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
Q

What are complications of pneumonia? [9]

A 
Pleural effusion
Pneumothorax, empyema, abscess
Atelactasis, Fibrosis
Bronchiectasis
Type 1 resp failure, ARDS

AKI

AF

Sepsis
Haemolytic anaemia

29
Q

When would infection not clear [2]

A

COPD

Bronchiectasis

30
Q

What is abscess common in

A

Klebsiella

31
Q

When can haemolytic anaemia occur in context of pneumonia

A

Mycoplasma pneumoniae - Blood film: ‘rouleux’ formation or stacking of RBC can be suggestive of mycoplasma pneumonia due
to the production of cold agglutinins.

32
Q

How does pneumonia progress: 1 week, 4 week, 6 week, 3m, 6m

A 
1 week fever resolves
4 week chest pain and sputum stop
6 week cough and Sob reduced
3 months = fatigue
6 months = normal
33
Q

Differential [5]

A 
TB
Lung cancer - CXR
PE 
CF
Pulmonary vasculitis
34
Q

How do you treat respiratory failure [3]

A

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

35
Q

What is empyema

A

Pus in pleural space

May see pleural effusion on CXR

36
Q

When do you suspect empyema [3]

clinical vs pleural fluid

A
  • Pneumonia resolving but fever persisting. Frankly/cloudy purulent pleural fluid.
  • When aspirate yellow, ph <7.2, decreased glucose, increased LDH
37
Q

How do you treat empyema?

A

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
Q

AF as complication of pneumonia: management [3]

A

Elderly
Improves with Rx
Can use BB or digoxin to slow

39
Q

What are rare complications of pneumonia [4]

A

Myocarditis
Pericarditis
Meningitis
Jaundice 2 to Ax or sepsis

40
Q

Klebsiella pneumonia clinical features [2]

CXR findings

A

Form abscess and empyema
Red current jelly sputum

CXR shows cavitating upper lobe pneumonia

41
Q

Who is Klebsiella common in [3]

Abx

A

Alcoholic
DM
Elderly

Abx: CEFOTAXIME or MEROPENUM

42
Q

Who is pseudomonas common in [3]

Abx [3]

A

Bronchiectasis
CF
ITU or post-op

Abx: TICARICILLIN or CEFTAZIDIME and GENTAMICIN

43
Q

How does mycoplasma present [4]

A

Flu like prodrome > dry cough
Erythema multiform rash
Neuro Sx in young patient
Autoimmune hemolytic anaemia

44
Q

How do you Dx mycoplasma [3]

A

CXR - patchy consolidation over 1 lower lobe, reticular nodular shadowing
Mycoplasma serology

45
Q

How do you Rx mycoplasma [2]

Complications [3]

A

Macrolide - clarithromycin

Complication:

  • SJS
  • Meningoencephalitis
  • Myelitis, GBS
46
Q

Symptoms of legionella [4]

Results of blood investigations [8]

A

Flu like prodrome > dry cough and SOB
Anorexia
D+V
Confusion, coma

Bradycardia
Lymphopenia
Hyponatremia
Abnormal LFT
Renal failure - urinalysis (hematuria)
47
Q

Causes and associations of legionella [2]

CXR findings

A

After holiday to Spain
Colonises in water tanks <60 deg

CXR: bi-basal consolidation

48
Q

How do you Dx legionella

Abx

A

Urinary antigen in urine sample

Abx: fluoroquinolone

49
Q

Chlamydia psittacosis
Aetiology
Symptoms [4]

A 
Ax: infected birds (parrots)
Symptoms: 
- Fever, flu
- Conjunctivitis
- Dry cough
- Severe headache
- Arthralgia
50
Q

Chlamydia psittacosis
Dx
Abx

A

Dx: chlamydophilia serology

Doxycycline

51
Q

Complications of chlamydia psittacosis [4]

A 
Meningoencephalitis
IE
Hepatitis 
Nephritis
Splenomegaly
52
Q

How does chlamydia pneumonia present [5]

A 
Bi-phasic illness
Pharyngitis
Hoarse
Otits media 
Then pneumonia
53
Q

Chlamydia pneumonia
Dx [1]
Abx [2]

A

Chlamydophilia complement fixation test

Doxycline or clarithromyin

54
Q

What are the components of CURB 65 score

A

Confusion
Urea >7 - don’t use in community
RR >30
BP <90 or <60
Age 65

55
Q

Complications of pneumonia

A
  • Parapneumonic effusions should be assessed at an early stage by diagnostic (± therapeutic) pleural aspiration, ideally under ultrasound guidance.
56
Q

What can cause an abscess to develop in the lung [5]

A

Aspiration (alcoholism)
Pneumonia (inadequately treated, empyema direct extension)
Bronchial obstruction (ca, fb)
Septic embolism (sepsis, endocarditis, IVDU)

57
Q

What are common organisms [4]

What are 3 signs of lung abscess?

A

S.Aureus
Pseduomona
Klebsiella
Anerobes

Signs:

  • Finger clubbing
  • Anaemia
  • Crackles
  • Dull percussion, bronchial breathing
58
Q

What are the symptoms of lung abscess [5]

A
  • 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
Q

CXR findings [3]

Management of lung abscess [3]

A

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
Q

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

A

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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