Respiratory: Pneumonia Flashcards by Isabelle Schiff

What is pneumonia?

1) Inflammatory condition of the lungs caused by infection
2) This leads to fluid and blood cells leaking into the alveoli
3) The infection spreads across the alveoli and eventually the lung tissue becomes consolidated, impairing the gas exchange due to reduced ventilation

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What is the most common cause of (community-acquired) pneumonia?

Streptococcus pneumoniae

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What are the three most common causes of (community-acquired) pneumonia?

1) Streptococcus pneumoniae
2) Haemophilus influenzae
3) Mycoplasma pneumoniae

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What are the symptoms of pneumonia?

1) Fever
2) Malaise
3) Rigors
4) Cough
5) Purulent sputum
6) Pleuritic chest pain
7) Haemoptysis

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What are the signs of pneumonia?

1) Tachypnoea
2) Tachycardia
3) Hypotension
4) Cyanosis
5) Pyrexia
6) Pleural rub

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What would you find on respiratory examination in pneuomonia?

1) Dull percussion
2) Increased vocal resonance/tactile vocal fremitus
3) Bronchial breathing
4) Pleural rub

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What is bronchial breathing?

1) Higher pitch, inspiration and expiration are equal
2) There is an audible pause between inspiration and expiration

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What is pleural rub?

1) Audible sound heard in patients with pleurisy
2) Caused by the layers of pleura rubbing against each other

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What is the definition of hospital-acquired pneumonia?

LRTI that develops > 48h after hospital admission

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What are the three most common causes of hospital-acquired pneumonia?

1) Pseudomonas aeruginosa
2) Staph aureus (gram positive cocci found in clusters)
3) Enterobacteria (gram negative) - e.g. Klebsiella, enterobacter, E coli

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What causes aspiration pneumonia?

An unsafe swallow

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What are risk factors for aspiration pneumonia?

1) Stroke
2) Myasthenia gravis
3) Bulbar palsy
4) Alcoholism
5) Achalasia

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Which lung is more commonly affected by aspiration pneumonia and why?

Right lung - right bronchus is wider and more vertical than the left bronchus, making it more likely to facilitate the passage of aspirate

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What type of pneumonia does staph aureus cause?

Bilateral cavitating pneumonia (hospital acquired)

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Which patients are more susceptible to staphylococcal pneumonia?

1) IV drug users
2) Elderly
3) Patients with influenza infection

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What type of bacterial pneumonia can develop on top of influenza infection?

Staphylococcal (staph aureus)

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What type of pneumonia does Klebsiella cause?

Cavitating pneumonia primarily affecting the upper lobes

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What is the key presenting symptom in Klebsiella pneumonia?

Redcurrant sputum

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Which type of pathogen causes redcurrant sputum in pneumonia?

Klebsiella

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What type of bacteria is Klebsiella?

Gram-negative anaerobic rod (bacillus)

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Which complications are patients with Klebsiella pneumonia at higher risk of developing?

1) Empyema
2) Lung abscesses
3) Pleural adhesions

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Which patients are at risk of Klebsiella pneumonia?

Those with weakened immune systems:
1) Elderly
2) Alcoholics
3) Diabetics
AND
4) Patients with malignancy
5) COPD
6) Long term steroid use
7) Renal failure

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What are the key presenting symptoms of mycoplasma pneumonia?

Flu-like symptoms:
1) Flu
2) Arthralgia
3) Myalgia
4) Dry cough
5) Headache
AND
6) Autoimmune haemolytic anaemia - autoimmune manifestation due to cold agglutinins
7) Erythema multiforme rash

Which patients are primarily affected by mycoplasma pneumonia?

Younger patients

Which pneumonia are younger patients particularly at risk of?

Mycoplasma pneumonia

Which pneumonia is associated with autoimmune haemolytic anaemia?

Mycoplasma pneumonia

What are the potential complications of mycoplasma pneumonia?

1) Erythema multiforme 2) Stevens-Johnson syndrome (toxic epidermal necrolysis/erythema multiforme major) 3) Guillain-Barre syndrome 4) Meningoencephalitis

Which type of pneumonia is associated with Guillain-Barre syndrome?

Mycoplasma pneumonia

How does legionella pneumonia typically present?

1) Fever 2) Myalgia 3) Malaise followed by 4) Dyspnoea 5) Dry cough

What disease is legionella pneumonia associated with?

Legionnaire's disease

Which patients are vulnerable to Legionella pneumonia?

Patients who have been exposed to poor hotel air conditioning

What might you see on blood tests in legionella pneumonia?

Hyponatraemia + deranged LFTs

What might you see in the urine in legionella pneumonia?

Legionella antigen

Which pneumonia would you suspect with hyponatraemia and deranged LFTs?

Legionella pneumonia

What is chlamydophila psittaci?

Intracellular bacteria that results in psittacosis (infectious disease of birds)

What causes infection with chlamydophila psittaci pneumonia?

Acquired from contact with infected birds e.g. parrots, cattle, horse and sheep

What are the key presenting features of chlamydophila psittaci pneumonia?

1) Lethargy 2) Arthralgia 3) Headache 4) Anorexia 5) Dry cough 6) Fever

What are additional features seen in Chlamydophila psittaci infection?

1) Hepatitis 2) Splenomegaly 3) Nephritis 4) Infective endocarditis 5) Meningoencephalitis 6) Rash

What is the causative organism in PCP (pneumocystis pneumonia)?

Pneumocystis jiroveci

What type of organism is Pneumocystis jiroveci?

Fungus

Which patients are affected by Pneumocystis pneumonia?

1) HIV positive 2) Immunosuppressed - malignancy or chemotherapy

In patients who are HIV-positive, when does the risk of PCP increase?

When the CD4 count < 200

What are the key symptoms in PCP pneumonia?

1) Exertional dyspnoea 2) Dry cough 3) Fever

What investigations do you do acutely for pneumonia?

1) ABG 2) Bloods - FBC, U&E, LFT, ESR, CRP 3) Blood culture 4) Sputum for microscopy + culture 5) CXR

Which investigations do you do in pneumonia to look for specific causative agents?

1) PCR - for mycoplasma pneumoniae 2) Urine antigen - for legionella and pneumococcal pneumonia 3) Sputum for microscopy and culture 4) Blood culture

What are you looking for on CXR in pneumonia?

1) Lobar 2) Multi-lobar 3) Cavitation 4) Pleural effusion

What test do you use to diagnose mycoplasma pneumonia?

PCR

What test do you use to diagnose legionella or pneumococcal pneumonia?

Urine antigen

What is CURB-65 used for?

To score community-acquired pneumonia - allows clinicians to classify the severity of a pneumonia and treat or escalate management accordingly The score also indicates the risk of mortality for a patient with pneumonia (0.7%-57%)

What are the components of CURB-65?

Score 1 point for each: 1) C – confusion (abbreviated mental test ≤ 8) 2) U – urea: >7mmol/L 3) R - RR ≥ 30/ min 4) B - BP < 90 systolic and/ or < 60mmHg diastolic 6) 65 - age: > 65 year old

How do you use CURB-65 to decide management for a patient with pneumonia?

1) 0-1 = home treatment 2) 2 = consideration for hospital treatment 3) 3-5 = hospital admission and consideration for ITU referral

How do you manage pneumonia?

1) Oxygen - keep sats > 94% 2) Fluid management 3) Analgesia if pleuritic chest pain - paracetamol 4) Antibiotics - oral only if not NBM and in community - for severe pneumonia IV required 5) Follow up in 6 weeks - CXR can be repeated if there are complications or symptoms have not been resolved

When would you repeat a CXR in pneumonia?

At 6 weeks if there are complications or symptoms have not resolved

Which vaccination protects against Streptococcus pneumoniae?

Pneumococcal vaccine - polysaccharide more commonly used over conjugate vaccine

Who is eligible for the pneumococcal vaccine?

1) Pneumococcal vaccine is routinely offered as three injections at the age of 2 months, 4 months and 12-13 months 2) People aged 65 years and older and those in at-risk groups should be offered the pneumococcal vaccine 3) At-risk groups include chronic heart, liver or renal conditions. These include liver cirrhosis, nephrotic syndrome, post-transplant and renal failure. Additionally, patients who are immuno-suppressed due to AIDS or chemotherapy; or have decreased spleen function due to splenectomy, asplenia or sickle cell disease qualify for this group. Furthermore, patients with chronic lung conditions such as COPD or bronchiectasis would be applicable. 4) Some patients within the at-risk group require a vaccination every 5 years. These include patients with decreased splenic function and nephrotic syndrome