Pneumonia MDT 2018

Question 1

dullness on lung percussion suggests…

Answer 1

fluid inside the thoracic cavity: pneumonia, pleural effusion

Question 2

is bronchial breath sounds are physiological on lung auscultation?

Answer 2

anywhere except sternum is pathological

Question 3

what is the tactile fremitus (vocal resonance)?

Answer 3

• -Ask the patient to say “toy boat” and feel for vibrations transmitted throughout the chest wall.
• -Can be asymmetrically decreased in effusion, obstruction, or pneumothorax, among others
• -Can be asymmetrically increased in pneumonia

Question 4

what is the sepsis?

Answer 4

Life threatening organ dysfunction caused by dysregulated immune response to infection

Question 5

what are the SIRS criteria?

Answer 5

syndrome defined by meeting 2 or more of the following criteria: 1) temperature > 38ºC or < 36ºC; 2) heart rate > 90 beats/min; 3) respiratory rate > 20 breaths/min or PaCO2 < 32 mm Hg; and 4) white blood count > 12,000 cells/mm³, < 4,000 cells/mm³, or >1% band forms. These criteria are oudated; sepsis and septic shock are now evaluated based on Sequential Organ Failure Assessment (SOFA) scoring.

Question 6

what are the co-morbidities associated with increased mortality in sepsis?

Answer 6

• -COPD
• -DM
• -Chronic liver disease
• -cancer
• -CKD
• -immunosuppressant medications
• -age>75
• -HIV/AIDS

Question 7

3 to give and 3 to take at the first hour of sepsis?

Answer 7

1) 1. O2 (94-98% or 88-92%), IV antibiotics, IV fluids

2) Blood cultures & other appropriate cultures, CBC, lactate, urinary output

Question 8

in sepsis, organ dysfunction is determined by assessing the function of …

Answer 8

• -Respiration: PaO2/FiO2 (mmHg)
• -Coagulation: Platelets x 103/mm3
• -Liver: Bilirubin (mg/dL)
• -Cardiovascular system
• -Central nervous system: Glasgow Coma Scale
• -Renal system: Creatinine (mg/dL) or urine output (mL/d)

Question 9

what is the septic shock?

Answer 9

• -Sepsis +
• -Significant circulatory, metabolic, and cellular abnormalities +
• -Requiring vasopressor therapy to maintain a mean blood pressure of ≥ 65 mmHg and presence of increased lactate levels > 2 mmol/L (18 mg/dL) in the absence of hypovolemia
• -Septic shock occurs more frequently in pregnant women, neonates, and the elderly. The predicted mortality of patients with septic shock is > 40%.

Question 10

Definition of pneumonia?

Answer 10

1) Evidence of infection
- -Fever, chills, and leucocytosis
2) Clinical symptoms and signs localized to the respiratory tract
- -Cough, sputum production or increased sputum production, shortness of breath, chest pain
3) Infiltrate (new or changed) on CXR

Question 11

CAP vs HAP?

Answer 11

1) Community-Acquired Pneumonia (CAP)
- -pneumonia which develops in patients outside the hospital setting
2) Hospital-Acquired Pneumonia (HAP)
- -pneumonia that occurs 48 hours or more after admission, which was not incubating at the time of admission

Question 12

what are the Initial Laboratory Investigations in suspected pneumonia?

Answer 12

• -WCC
• -CBC
• -Urea
• -Creat
• -CRP
• -LFTs
• -Sputum cultures
• -Blood cultures
• -ABGs

Question 13

CURB-65 criteria?

Answer 13

• -Confusion
• -Urea > 7 mmol/L
• -Increased respiratory rate >30
• -Low blood pressure (SBP <90 or DBP <60)
• -Age >65 years

Question 14

Pneumonia Severity Index (PSI)?

Answer 14

demographics, the coexistence of co-morbid illnesses, findings on physical examination, vital signs and essential laboratory findings

Question 15

where should be treated the patient with CURB score 4-5?

Answer 15

in ICU

Question 16

how pneumonia is diagnosed?

Answer 16

All patients admitted to hospital with suspected CAP should have a chest radiograph performed as soon as possible to confirm the diagnosis

Question 17

does all patients with suspected CAP that will be treated outpatient need CXR?

Answer 17

For patient’s being managed in the community it is not necessary to perform a chest radiograph in patients with suspected CAP unless:

• -the diagnosis is in doubt
• -the patient is not responding to treatment
• -the patient is considered at risk of underlying lung pathology such as lung cancer

Question 18

If pneumonia does not resolve in weeks, you should consider the presence of an underlying…

Answer 18

obstructing lesion, such as a neoplasm, that is preventing adequate drainage from that portion of the lung.

Question 19

Pneumonia is more opaque than normal lung on CXR. T/F

Answer 19

True

Question 20

Radiology take-home points of pneumonia

Answer 20

• -Pneumonia is more opaque than normal lung
• -Margins may be fluffy and indistinct
• -Affected areas homogenous in density
• -May contain air-bronchograms

Question 21

which patients with pneumonia can be treated outpatient?

Answer 21

Patients with a CURB-65 score ≤ 1 and sufficient oxygen saturation (SaO2 ≥ 90%)

Question 22

What other questions might you ask when deciding on the antibiotic treatment?

Answer 22

• -Recent antibiotics / antibiotic failure?
• -Travel history
• -Vaccination history
• -Animal/bird exposure
• -Occupational history
• -Hobbies

Question 23

what s the treatment of CAP with CURB-65 score ≥ 3?

Answer 23

• -CO-AMOXICLAV 1.2g TDS IV plus CLARITHROMYCIN 500mg PO BD

- -Usually 7 DAYS (max. 10 DAYS) total including PO switch

Question 24

what samples need to be sent to the microbiology?

Answer 24

1) Sputum
- -Culture and sensitivity
2) Blood cultures
- -Culture and sensitivity
3) Throat swab
4) Influenza PCR
5) Urine
- -Legionella and pneumococcal antigens

Question 25

Paired acute & convalescent serology testing may be indicated in certain circumstances if …

Answer 25

atypical pneumonia is suspected; this should be discussed with the clinical microbiology team.

Question 26

how reliable is sputum analysis in yielding the cause of pneumonia?

Answer 26

–“For the microbiologic diagnosis of pneumonia, by definition, an infiltrate must be present on a chest x-ray.
–A deeply expectorated sputum sample will yield the causative organism from 20-80% of the time, depending on the study.
–Sputum specimens will be rejected by the laboratory if they have >10 epithelial cells per high power field.
The reason is that epithelial cells are usually from the upper airway, and have many adherent bacteria
–These bacteria constitute the normal flora of the upper airway, and confuse interpretation of the culture.”

Question 27

what is the most common cause of CAP?

Answer 27

Streptococcus pneumoniae remains the most commonly identified pathogen in community-acquired pneumonia. Other pathogens have been reported to cause pneumonia in the community, and their order of importance depends on the location and population studied. These include long-recognized pathogens such as Haemophilus influenzae, Mycoplasma pneumoniae, and influenza A, along with newer pathogens such as Legionella species and Chlamydophilia pneumoniae. Other common causes in the immunocompetent patient include Moraxella catarrhalis, Mycobacterium tuberculosis, and aspiration pneumonia. The causative agent of community-acquired pneumonia remains unidentified in 30% to 50% of cases

Question 28

Which of the following is a laboratory characteristic of Strep Pneumoniae?

• -Beta hemolysis on blood agar
• -Optochin sensitive
• -Gram negative bacilli
• -Gram positive bacilli
• -Obligate intracellular organism

Answer 28

optochin sensitive

It is cocci not bacilli and is extracellular and -hemolytic

Question 29

what are the microbiological characteristics of S. pneumoniae?

Answer 29

• -The pneumococcus is a Gram-positive diplococcus.
• -Like all streptococci, it will occasionally form head-to-tail chains of organisms.
• -Around some organisms in this field, there is a halo. This is indicative of capsule formation. The capsule provides a survival advantage to the pneumococcus, and is perhaps why it survives in the lung and causes lobar pneumonia following aspiration, whereas other mouth flora apparently does not.”

Question 30

What additional test(s) need to be conducted in a patient with CAP?

• -Antistreptolysin O test (ASOT)
• -Atypical pneumonia serology
• -Urine for streptococcal antigen
• -Urine for legionella antigen
• -Nasopharyngeal swab for influenza

Answer 30

Nasopharyngeal swab for influenza

as CAP commonly complicate influenza

Question 31

how can we prevent future readmissions with pneumonia?

Answer 31

1)Vaccinations
–23-valent polysaccharide pneumococcal vaccine (PPV-23)
–Single dose in adults > 65
–Repeated after 5 years in asplenic/hyposplenic patients and immunosuppresed patients i.e. HIV, nephrotic syndrome
And
2Influenza vaccine
–Yearly

Question 32

what are the CXR recommendations after the discharge of a patient with CAP?

Answer 32

• -CXR need not be repeated prior to hospital discharge in those who have made a satisfactory clinical recovery from CAP
• -CXR should be arranged after about 6 weeks for all those patients who have persistence of symptoms or physical signs or who are at higher risk of underlying malignancy (especially smokers and those aged >50 years) whether or not they have been admitted to hospital
• -If repeat CXR is abnormal further investigation CT/ Bronchoscopy will be required
• -It is the responsibility of the hospital team to arrange the follow-up plan with the patient and the general practitioner for those patients admitted to hospital

Question 33

Why not image prior to discharge?

Answer 33

–Radiological resolution often lags behind clinical improvement from CAP
particularly following legionella and bacteraemic pneumococcal infection.
–Pneumonia caused by atypical pathogens clears more quickly than pneumonia caused by bacterial infection.
–Radiological resolution is slower in elderly patients, smokers, inpatients>outpatients and where there is multilobar involvement.
–In one study, complete resolution of chest radiographic changes occurred at 2 weeks after initial presentation in 51% of cases, in 64% by 4 weeks and 73% at 6 weeks.