Pneumonia + Pneumo Thorax Flashcards
PNEUMONIA
• Inflammation of the Lung Parenchyma usually due to Bacteria but can also be due to Viruses
and Fungi; Presents as acute illness with Cough, Purulent Sputum, SOB and fever with
examination signs or radiology compatible with Lung Consolidation
• Can present with more subtle symptoms particularly in the elder
• 50% of Pneumonia is due to S pneumoniae; Other causes called Atypical Pneumonia
• Also classified either as Community Acquired, Hospital Acquired or as a result of
immunodeficiency secondary to other disease (e.g. HIV)
Community Acquired Pneumonia
• Increasing incidence attributed to changes in clinical practice and ageing population
• Pneumococcus more common cause, but 30-50% of cases have no organism identified and
20% have more than one organism present
• Can present as either Lobar (One or more lobes affected) or Diffuse when Lobules of the lung
are affected, especially if infection is centred on Bronchi/Bronchioles (Bronchopneumonia)
• Infection is spread by respiratory droplets; Clinical presentation varies with age and effective
of host immune response
• Other causes of Pneumonitis include Aspiration, Radiotherapy or Allergic mechanisms
Clinical Presentation of Community Acquired Pneumonia
• Cough – Dry or Productive; Haemoptysis can occur; Rust coloured with Pneumococcal
• SOB – Due to pus and debris filling Alveoli impairing gas exchange; Coarse Crackles due to
consolidation, Bronchial breath sounds over consolidated lung
• Fever – Can be high (39.5-40oC); Swinging fever often indicates Emphysema
• Chest Pain – Pleuritic; Pleural rub might be
heard early on in illness
• Extrapulmonary Features – Haemolysis (Due
to cold agglutinins; 50% of cases of
Mycoplasma Pneumonia),
Thrombocytopaenia is relatively common
• CAP can present as confusion or non-specific
symptoms (e.g. Recurrent falls) in Elderly
• When symptoms have been present for
several weeks or fail to respond to standard
antibiotics, possibility of TB
Investigation of Community Acquired Pneumonia
• Mild Infection – Diagnostic microbiology not
required; Treated at home with Antibiotics
(e.g. Amoxicillin or Clarithromycin if Penicillin
Allergic); CXR not recommended unless fail to
improve after 48-72hrs; Severity assessed by
C(U)RB65 score for likely risk of fatal outcome
• All patients admitted should have CXR, Blood
and Microbiological Tests
o CXR – Repeated 6 weeks after discharge unless complications occur; TRO Bronchial
malignancy causing obstruction predisposing to Pneumonia
o S pneumo – Consolidation with Air Bronchograms, Effusions and Collapse due to
retention of Secretions; Radiological abnormalities lag behind clinical signs; Normal
CXRs repeated in 2-3 days
▪ WBC >15×109
(Mostly Polymorphonuclear); CRP >100mg/L
▪ Gram Positive Diplococcus on Culture
o Mycoplasma – Usually one lobe affected but infection can be bilateral and extensive
▪ WBC might be normal; Haemolysis ruled
out (DAT and Cold Agglutinins)
o Legionella – Lobar progresses to Multilobar
shadowing; Small Pleural Effusion; Cavitation is rare;
Lymphopaenia without marked Leukocytosis;
Hyponatraemia, Hypoalbuminaemia and ↑LFTs
• Blood culture for all moderate-severe CAP; Pulse Oximetry
and ABG if SpO2 <94%
• HIV testing – Offered to all patients with Pneumonia
Management of Community Acquired Pneumonia
• Supplementary Oxygen – Administered to maintain saturation 94-98% if not COPD; 88-92% by
Venturi mask for COPD patients
• IV Fluids – For patients with hypotension showing evidence of fluid depletion
• Antibiotics – First dose should be within 4hrs to admission; Oral switch if temperature has
settled for period of 24hrs; Microbiology if initial treatment fails (e.g. S aureus, MRSA)
• Antibiotic regimen adjusted once MCS available; Increased incidence of C diff Associated
Diarrhoea with some antibiotics e.g. Cephalosporins
• Thromboprophylaxis – If admission >12hrs; LMWH and TED unless contraindicated
• Physio if sputum retention is an issue, Nutrition in severe disease
• Analgesia – Paracetamol, NSAID for pleuritic pain, reduce restricted breathing
• Prevention of future episodes – Smoking cessation and support, Vaccination against
influenza; Pneumococcus vaccination for all patients 65+
Complications of Pneumonia:Parapneumonic Effusion
1/3 of CAP; Majority are simple
exudative by Empyema might also develop; Early
indications of Empyema include Fever, rising/persistently
elevated CRP despite Antibiotics; Ultrasound-guided
Thoracentesis for Diagnosis
o Gram staining, Culture, Fluid proteins Glucose and
LDH in comparison with Serum; Light’s criteria to
differentiate Exudate from Transudate
o Exudate with Pleural pH <7.2 strongly suggestive of Empyema; Pathogens often
detectable and can be cultured to determine sensitivity
o Fluid should be urgently drained to prevent thick pleural rind
Complications of Pneumonia: Lung Abscess
Severe localised suppuration visible on CXR or CT often with fluid level;
Persisting or worsening pneumonia associated with large amounts of sputum often foul
smelling due to Anaerobes; Swinging fever, Malaise and Weight Loss; Clubbing in chronic
suppuration; Anaemia of Chronic Disease and ↑CRP
o Tuberculosis, Staph aureus or Klebsiella pneumonia
o Septic Emboli with Staphylococcus – IVDU; Investigate for IE (Especially Tricuspid)
o Bronchial obstruction by Endoluminal cancer, Foreign body inhalation
o Rarely Aspiration Pneumonia, Transdiaphragmatic spread of Amoebic Lung Abscesses
Hospital Acquired Pneumonia
• New onset Cough with Purulent Suppuration with CXR consolidation 2 days beyond initial
admission or have been in healthcare setting within last 3 months
• Second most common nosocomial infection behind UTI; Significant mortality in the elderly
• Different causative organisms than in CAP; Aerobic Gram-negative Organisms (Pseudomonas,
E coli, Klebsiella, Acinetobacter) commonly involved
• S aureus especially MRSA increasingly recognised – More common in Diabetics, Head Trauma,
and ICU patients; Empirical therapy should include anti-staphylococcals (e.g. Flucloxacillin)
• Piperacillin-Tazobactam (Tazocin) used for severe pneumonia for Pseudomonas cover
Aspiration Pneumonia
• Acute aspiration of gastric contents into lungs; Damage due to gastric acid
• Complicates delivery of Anaesthesia (Mendelson’s syndrome), especially in Pregnancy
• Aspirated material typically ends up on RML and Apical/Posterior segments of RLL; Persistent
Pneumonia due to Anaerobes which may progress to Abscess formation and Bronchiectasis
• Co-Amoxiclav for Mild/Moderate disease, Treatment escalated if lack of response or severe
Pneumocystis jirovecii Pneumonia
• =Pneumocystis Pneumonia (PCP) one of the most common opportunistic infections; Patients
on Immunosuppressants (e.g. Corticosteroids, Anti-TNF therapy, Methotrexate, Antirejection
medications) as well as patients with HIV (especially if CD4 <200/mm3
)
• Pneumocystis Jirovecii found in air; Pneumonia arises from reinfection rather than
reactivation of persisting organisms from childhood
• Presents as high fever, SOB, dry cough; Rapid saturation on exercise/exertion; Typically,
radiological appearance of diffuse bilateral Alveolar and Interstitial shadowing in Perihilar
regions, spreads out in butterfly pattern
• CXR also shows Localised Infiltration, Nodules, Cavitation or Pneumothorax
• Empirical treatment in very sick high-risk patients; Diagnosis by BAL or induced sputum
• First line treatment is Co-Trimoxazole/Septrin (Trimethoprim and Sulfamethoxazole)
PNEUMOTHORAX
• Air in the Pleural Space; Can be Spontaneous or occur as a result of Trauma; Spontaneous
Pneumothorax most common in young males (6:1)
o Primary Pneumothorax typically due to rupture of Pleural Bleb (usually Apical); Blebs
due to congenital defects of connective tissue of Alveolar walls
o Both Lungs affected with equal frequency; Patients usually tall and thin
o For patients >40; COPD more common cause; Rarer causes include Bronchial Asthma,
Carcinoma, Lung Abscess breaking down causing Bronchopleural Fistula, and Severe
Pulmonary Fibrosis with Cyst Formation
• Pneumothorax can become localised if Visceral Pleura previously adherent to Parietal Pleura,
or Generalised if there are no Pleural Adhesions
• Once air leak is closed, air is reabsorbed at rate of 1.25% of hemithorax per day (e.g. 50%
collapse requires 40 days to resorb)
• Pneumothoraces present with sudden onset unilateral pleuritic pain or progressively
increasing SOB; May develop Pallor and Tachycardia; Few physical signs if small
• Third of patients will have recurrence; Chemical Pleurodesis with Talc used for patients if
surgery contraindicated; Bleb resection and Pleurodesis can be done by VATS or open
Tension Pneumothorax
• Valvar mechanism develops where air is sucked into Pleural Space during inspiration but not
expelled during expiration
o Results in consistently positive intrapleural pressure; On further breathing Lung
deflates further, mediastinum shifts, venous return to heart decreases
• Rare except in patients on positive pressure ventilation
• Presents with Tachycardia, Hypotension, Distended neck veins and Tracheal deviation away
from affected side, in addition to simple Pneumothorax symptoms
• Insertion of a large bore needle and syringe partially filled with Saline or Venflon catheter,
inserted into 2nd intercostal space in the Mid-clavicular line
• CXR should only be taken after emergency chest decompression; Chest drain with water seal
inserted for long term management after patient is stable
Management of Primary Spontaneous Pneumothorax
• Active Intervention if significant breathlessness associated with any size of PTX
• Chest Drain if tension or bilateral with hospital admission; Observation is treatment of choice
if small PSP without significant SOB
o If large PSP without SOB may be managed with observation with patient selection
o Observation should be followed by early outpatient review; Written advice regarding
return if worsening breathlessness
• Needle Aspiration (14 – 16G) as effective as Large-bore Chest Drains; Needle aspiration
should not be repeated; If aspiration failed, Small-bore Chest Drains (<14Fr) instead
• Suction should not be routinely employed due to risk of Re-expansion Pulmonary Oedema
• Discharge and Follow Up – Safety netting, Follow-up with Respiratory medicine and
Avoidance of Air Travel until full resolution, permanently avoid Diving unless Bilateral Surgical
Pleurectomy and has normal Lung Function and CT Chest post-op
PRINCIPLES OF CHEST TRAUMA IN ATLS
• CAC-BCDE Approach as per ATLS
• Recognition of ‘Killer Conditions’ during Primary Survey – ATOM-FC = Airway Obstruction,
Tension PTX, Open PTX, Massive Haemothorax, Flail Chest, Cardiac Tamponade
o Also consider damage to Aorta, Tracheo-Bronchus, Oesophagus, Diaphragmatic
Injury, Cardiac or Pulmonary Injuries
• A – Deformity, Haematoma, Crepitus (Laryngeal Fracture), Surgical Emphysema (‘Bubble
Wrap’), Hoarse Voice, Gurgling (? Laryngeal Nerves), Airway Obstruction, Cyanosis
• B – Hyper-resonance and Decreased Breath Sounds, Tracheal Deviation, Respiratory Distress
• C – Signs of Shock, Beck’s Triad, Pulses Paradoxus
Haemothorax
• Collection of blood in pleural space, that can happen with Blunt or Penetrating Trauma; Most
are resulting from Rib Fractures, Lung Parenchymal Injuries and Minor Venous bleeders
o Less commonly due to arterial injury, requiring surgical repair
• Most minor-moderate HTx not detectable O/E; CXR, FAST or CT Chest
o Erect film CXR – 400 – 500mls of blood to obliterate costophrenic angle
o Supine CXR – No fluid level visible; Diffuse opacification with visible lung markings;
Might lead to false recognition of pneumothorax on contralateral side by contrast
• Chest Drain – Majority at presentation already stopped bleeding; Simple drainage only
o Minimum 32F for adults (preferably 36F) to prevent clotting
• Thoracotomy considered if haemodynamically unstable, large HTx; Patients with continuing
drainage with no signs of reduction in tube output; threshold quoted at around 1000 –
1500mls from hemithorax, or 200 – 250ml/hr output
