Respiratory: Acute Bronchitis, Pneumonia & Pneumothorax

Question 1

What is acute bronchitis?

Answer 1

LRTI which is usually self-limiting in nature.

It is a result of inflammation of the trachea and major bronchi.

Question 2

Clinical features of acute bronchitis?

Answer 2

• cough (may or may not be productive)
• sore throat
• rhinorrhoea
• wheeze

may have:
- low grade fever
- wheeze

Question 3

How is acute bronchitis usually diagnosed?

Answer 3

Clinical diagnosis

Question 4

What test can be done to guide whether antibiotic therapy is indicated in acute bronchitis?

Answer 4

CRP testing

Question 5

How can acute bronchitis be differentiated from pneumonia?

Answer 5

• Sputum, wheeze, breathlessness –> may be absent in acute bronchitis whereas at least one tends to be present in pneumonia.
• Focal chest signs (e.g. dullness to percussion, crepitations, bronchial breathing) –> typically absent in acute bronchitis, present in pneumonia.
• Systemic symptoms (e.g. malaise, myalgia, and fever) –> may be absent in acute bronchitis, whereas they tend to be present in pneumonia.

Question 6

Management of acute bronchitis?

Answer 6

Mainly supportive:
- analgesia
- good fluid intake

Question 7

When should Abx therapy be considered in acute bronchitis?

Answer 7

• systemically very unwell
• have pre-existing co-morbidities
• have a CRP of 20-100mg/L (offer delayed prescription) or a CRP >100mg/L (offer antibiotics immediately)

Question 8

What Abx is 1st line in acute bronchitis?

Answer 8

Doxycycline

Question 9

Prognosis of acute bronchitis?

Answer 9

The disease course usually resolves before 3 weeks, however, 25% of patients will still have a cough beyond this time.

Question 10

What age children are at risk of pneumonia?

Answer 10

<5

Question 11

What are the 5 ‘typical’ causes of bacterial pneumonia?

Answer 11

1) Strep. pneumoniae

2) H. influenzae

3) Staph. aureus

4) Klebsiella pneumoniae

5) Pseudomonas aeruginosa

Question 12

Which organism typically causes pneumonia in COPD patients?

Answer 12

H. influenzae

Question 13

Which organism typically causes pneumonia post-influenza?

Answer 13

Staph. aureus

Question 14

Which organism typically causes pneumonia in alcoholics & those with impaired swallowing?

Answer 14

Klebsiella pneumoniae

Question 15

Which organism typically causes pneumonia in patients with CF or immunocompromised states?

Answer 15

Pseudomonas aeruginosa:

Question 16

What are the 4 ‘atypical’ pneumonia?

Answer 16

1) Mycoplasma pneumoniae

2) Chlamydophila psittaci

3) Legionella pneumophila

4) Coxiella burnetii (causes Q fever)

Question 17

Which pneumonia is seen following exposure to birds?

Answer 17

Chlamydophila pneumoniae

Question 18

Which pneumonia is seen in IVDU?

Answer 18

Staph. aureus

Question 19

Which pneumonia is associated with contaminated water sources?

Answer 19

Legionella pneumophila

Question 20

What is the most common viral cause of pneumonia?

Answer 20

Influenza virus

Question 21

Define ventilator-associated pneumonia (VAP)

Answer 21

pneumonia that develops ≥48 hours after endotracheal intubation

Question 22

How is CURB-65 score used to determine hospital admission?

Answer 22

Home-based care for patients with a CRB65 score of 0 or 1

Consider hospital-based care for patients with a CURB65 score of 2 or more

Question 23

What investigation is recommended in pneumonia to help guide Abx use?

Answer 23

CRP test:

• CRP < 20 mg/L - do not routinely offer antibiotic therapy
• CRP 20 - 100 mg/L - consider a delayed antibiotic prescription
• CRP > 100 mg/L - offer antibiotic therapy

Question 24

Investigations in pneumonia?

Answer 24

1) CXR

2) blood and sputum cultures, pneumococcal and legionella urinary antigen tests (in intermediate or high-risk patient)

3) CRP monitoring

Question 25

What 2 atypical pneumonia are tested for using urine antigen tests?

Answer 25

1) pneumococcal
2) legionella

Question 26

What Abx is 1st line for low-severity community acquired pneumonia?

Answer 26

Amoxicillin (5 day course)

If penicillin allergic –> a macrolide or tetracycline

Question 27

1st line Abx for moderate and high-severity CAP?

Answer 27

Dual antibiotic therapy –> amoxicillin and a macrolide (7-10 day course).

Question 28

Pneumothorax can be classified into spontaneous, traumatic or iatrogenic.

What can spontaneous be further categorised into?

Answer 28

1ary –> no underlying pulmonary disease

2ary –> underlying disease e.g. COPD, CF

Question 29

What investigation is diagnostic for a pneumothorax?

Answer 29

CXR –> visceral pleural lines or absence of lung markings peripherally.

Question 30

What type of patients do 1ary spontaneous pneumothoraces typically occur in?

Answer 30

Tall, lean males.

Question 31

What are 1ary spontaneous pneumothoraces typically linked to?

Answer 31

Subpleural bleb rupture (this is an anatomical lung defect).

Question 32

What are some pre-existing lung diseases that can predispose to pneumothorax? (5)

Answer 32

1) COPD

2) Asthma

3) CF

4) Lung cancer

5) PCP

Question 33

What are 2 connective tissue diseases that can predispose to pneumothorax?

Answer 33

1) Marfan’s

2) RA

Question 34

Give some risk factors for pneumothorax

Answer 34

1) tall, lean males

2) pre-existing lung disease

3) connective tissue disease

4) ventilation, including non-invasive ventilation

Question 35

What is catamenial pneumothorax?

Answer 35

Recurrent spontaneous pneumothorax occurrig within 72 hours before or after onset of menstruation.

It is thought to be caused by endometriosis within the thorax.

Question 36

What is a tension pneumothorax?

Answer 36

If the entry point of air becomes a one-way valve (air enters but does not exit the pleural space).

The accumulating air compresses the mediastinum, impairing venous return to the heart, leading to a decreased cardiac output and potential circulatory collapse.

Question 37

Pathophysiology of a pneumothorax?

Answer 37

Normally the pleural space has a slightly negative pressure relative to atmospheric pressure –> ensures the lungs remain inflated against the chest wall.

1) Breach in integrity of lung or chest wall –> air enters pleural space –> disrupts the normal pressure gradient

2) Air accumulates –> intrapleural pressure becomes progressively more positive relative to the lung’s intrinsic pressure.

3) Affected lung starts to collapse due to its natural elastic recoil –> reduction in the lung volume on the affected side.

Question 38

What is a key mechanism of injury in a traumatic pneumothorax?

Answer 38

Penetrating or blunt chest trauma.

Question 39

What are some causes of iatrogenic pneumothorax?

Answer 39

Complication of medical procedures e.g:
- thoracentesis
- central venous catheter placement
- ventilation (including non-invasive ventilation)
- lung biopsy

Question 40

Clinical features of a pneumothorax?

Answer 40

1) Sudden onset pleuritic chest pain

2) SOB

3) Exam findings:
- diminished breath sounds
- hyper resonance on percussion
- decreased chest wall movement on affected side

4) Severe –> hypoxia, tachypnea, tachycardia, and hypotension.

Question 41

Clinical features of a tension pneumothorax?

Answer 41

1) severe respiratory distress

2) tracheal deviation

3) jugular venous distension

4) haemodynamic instability

Question 42

In cases of pneumothorax where the diagnosis is uncertain or the CXR is inconclusive, what investigation can be done?

Answer 42

CT scan of chest

Question 43

What does mx of a 1ary pneumothorax depend on?

Answer 43

Size

Question 44

Mx options of a 1ary pneumothorax?

Answer 44

1) If rim of air is <2cm AND patient is not short of breath –> consider discharge

2) Otherwise –> attempt aspiration

3) If this fails (> 2cm or still short of breath) –> chest drain

Question 45

Mx of 2ary pneumothorax if rim of air is >2cm?

Answer 45

If patient is >50 y/o and rim of air is >2cm and/or patient is short of breath –> chest drain

Question 46

Mx of 2ary pneumothorax if rim of air is 1-2cm?

Answer 46

1) Aspiration should be attempted.

2) If aspiration fails (ie. pneumothorax is still >1cm) –> chest drain

All patients should be admitted for 24 hours.

Question 47

Mx of 2ary pneumothorax is <1cm?

Answer 47

Give O2 and admit for 24 hours

Question 48

If a patient has a persistent air leak or insufficient lung re-expansion despite chest drain insertion, what can be considered?

Answer 48

Video-assisted thoracoscopic surgery (VATS) –> to allow for mechanical/chemical pleurodesis +/- bullectomy.

Question 49

If a patient has recurrent pneumothoraces, what can be considered?

Answer 49

VATS –> to allow for mechanical/chemical pleurodesis +/- bullectomy.

Question 50

Smoking advice regarding pneumothorax?

Answer 50

Patients should be advised to avoid smoking to reduce the risk of further episodes.

Question 51

Fitness to fly following a pneumothorax?

Answer 51

Absolute contraindication.

Patients may travel 2 weeks after successful drainage if there is no residual air.

Can travel by air 1 week post check x-ray.

Question 52

Scuba diving following a pneumothorax?

Answer 52

Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.