Respiratory: Cough and Pneumonia

Question 1

Discuss the pathophysiology of pneumonia

Answer 1

Acute resp symptoms with consolidation on the CXR

Infection of the alveolar space

Thickening of the basal membranes

Leaking of vessels

Question 2

What are the symptoms and signs of pneumonia?

Answer 2

Fever

Anorexia

Dyspnoea

Cough

Purulent sputum

Haemoptysis

Pleuritic pain

Tachypnoea

Hypotension

Signs of consolidation = diminished expansion, dull percussion, bronchial breathing

Crepitations

Increased vocal resonance

Question 3

What investigations should be performed for suspected pneumonia?

Answer 3

CURB 65 (dont use in chest infection, COPD, dementia)

o Confusion (AMT ≤ 8)

o Urea (> 7)

o Respiratory Rate (> 30)

o BP (SBP < 90; DBP < 60)

o Age (≥ 65)

CXR = consolidation, air bronchogram

Bloods = FBC, U+Es, LFTs, CRP, cultures

Sputum = microscopy and culture

Pleural fluid aspiration = C+S Immunocompromised or ITU = bronchoscopy or bronchoalveolar lavage

Question 4

How is pneumonia managed?

Answer 4

>2 CURB score = admit

CURB 1 = amoxicillin 5 days, doxy is pen-allergic

CURB 2 = amoxicillin + doxyclycline

CURB 3 = - co-amoxiclav + doxyclycline

Oxygen = sats >94%

IV fluids

Analgesia if pleurisy – paracetamol 1g/6h

Chest physiotherapy = if unable to clear secretions (prevent lobe collapse)

Follow up CXR at 6 weeks

Question 5

What complications can arise from pneumonia?

Answer 5

Early

• T1 resp failure
• Sepsis

Late

• Pleural effusion
• Empyema
• Lung abscess
• Bronchiectasis
• Bronchopleural fistula

Question 6

What is the aetiology of pneumonia?

Answer 6

CAP = strep pneumonia, H. influenza. Staph aureus

HAP = >48h after admission, Enterobacter, staph aureus

Aspiration = stroke, myasthenia, reduced consciousness

VAP = ventilator acquired (loss of cough, defence mechanism)

Question 7

What are the common causes of cough that should be investigated further?

Answer 7

Infection

Asthma

COPD

GORD

Bronchiectasis

Question 8

What drugs can cause cough as a side effect?

Answer 8

ACEi - lisinopril

Statin - simvastatin

Fluticasone nasal spray - relieves sneezing

Carvediol - anti HTN

Actonel - bisphosphonate

Keppa - anti epileptic

Question 9

What is idiopathic cough and when can this diagnosis be made?

Answer 9

A cough with no determined cause

Diagnosis can be made when all other possibilities can be rules out

Question 10

List some of the potential systemic complications of community-acquired pneumonia?

Answer 10

Hypotension

Sepsis

Jaundice

Mild anaemia

Arthritis

Question 11

What features may help differentiate a case of community acquired pneumonia from pulmonary tuberculosis?

Answer 11

Culture

CXR = TB cavitation, pneumonia consolidation

TST = +ve TB

Question 12

How do the antibiotic treatments differ for community acquired pneumonia and hospital-acquired pneumonia?

Answer 12

CAP = oral amoxicillin and clarithromycin

HA = IV aminoglycoside and IV penicillin

Question 13

What follow up arrangements should be made for a patient with pneumonia?

Answer 13

Follow up in 6 weeks

Plus CXR

Question 14

How does pneumonia appear on CXR?

Answer 14

Consolidation, air bronchogram

Complications = abscesses, pleural effusions, enlarged LNs