Respiratory: Pneumonia Flashcards
What is pneumonia? And how is it characterised?
- Inflammation of the lung parenchyma of infective origin (lower respiratory tract)
- Characterised by consolidation (radiographic x ray shadowing)
What is the pathophysiology of pneumonia alveoli compared to a normal one?
Infected: (lower lobe of left lung)
- Inflammation of alveolar wall
- Fluid and pus filled air space containing bacteria/blood cells
Normal: (upper left lung)
- Bronchiole (tiny air ways)
- Healthy Alveoli (airspaces)
What is primary pneumonia? What pathogens cause it?
- Patient without risk factors (infection occurs as bacteria like growing in mucus)
- Pathogens: bacteria (gram postitive) and viruses
What is secondary pneumonia? What pathogens cause it?
- Patient has risk factors that predispose for pneumonia
- Risk factors: COPD, HIV (compromised immune system), aspiration of gastric acid
- Pathogens: Herpes virus, fungi and anaerobial bacteria
What different sections can pneumonia localise itself in the lung?
- Bronchioles
- Lobar: lower long
- Interstitial: between alveoli
What are the three clinical ways pneumonia is classified?
- Community acquired pneumonia:
- Infection occurs during normal life from nursing homes etc - Hospital acquired pneumonia:
- Infection acquired within hospital 48 hours or more after admission - Aspiration pneumonia:
- Caused by inhalation of stomach content
Who are mainly at risk from community acquired pneumonia?
- Infants 2 years and younger or patients 65 and older (weak immune system)
- Living and working in nursing home or in contact with children
- Smoking (passive included)
- Pre-existing pathological conditions (COPD, stroke). Less movement leads to build up of mucus.
- Influenza
- Hospitalisation in previous 5 years
What is the main cause of pneumonia?
Streptococcus Pneumoniae
What are the typical symptoms of community acquired pneumonia?
- Temperature is higher than 38 degrees
- Cough
- Purlent/ blood stained/ rusty coloured sputum
- Malaise
Sometimes:
1. Pleural pain
- Night sweats
- Dyspnea (laboured breathing)
What are the four stages of pneumonia?
- Consolidation (shadow in x ray picture)
- Red hepatization
- Grey hepatization
- Resolution
How do you diagnose pneumonia?
- Acute illness in 21 days or more
- Cough
- Least one symptom of respiratory tract infection:
- Fever
- Sputum production
- Breathlessness
- Wheeze
- Chest discomfort or pain
- acute bronchitis or COPD exacerbation
How do you assess the severity of a patient to see where they are in terms of developing pneumonia?
- Severity Assessment test that scores for mortality in primary care
- 0= low risk
- 1-2 = intermediate risk
- 3-4 High risk
What questions can be asked to see if a patient is confused or not?
- Age
- Date Birth
- Time (nearest hour)
- year
- Hospital name
- Recognition of two people (nurse and doctor)
- Address
- Date of significant event
- Name of monarch
- Count backwards
8 or less points = mid confusion
How do you confirm the diagnosis of community acquired pneumonia?
- Chest X ray
- Oxygen saturations
- Severity test score
- C reactive protein at hospitalisation
- Microbiology test: blood and sputum test
- Full blood count and liver function tests
What do each of the letters mean in CURB65 for the severity index and mortality assessment?
C: confusion
U: Urea more or equal to 7mmol/l
R: Respiratory rate more or equal to 30/min
B: Blood pressure more than or equal to 90mmHg/60mmHg
65: Age 65 or more?
What does a 0 to 1 CURB65 value, severity and treatment site mean?
- Low risk of death
2. No hospitalisation required for clinical reasons
What does a 2 CURB65 value severity and treatment site mean?
- Moderate severity
- Increased risk of death
- Hospitalisation and assessment should be considered
What does a 3 to 5 CURB65 value of severity and treatment site mean?
- High severity
- High risk of death
- Urgent hospital and admission required
How do you treat pneumonia? Give examples of some antibiotics used?
- Empiric treatment with antibiotics
- Examples:
- Betalactams: Amoxicillin
- Macrolides: Erythromycin
- Tetracyclins: Doxycyclin
- Cephalosporins
How do you treat patients with low severity community associated pneumonia?
- 5 day course of single antibiotic
- Amoxicillin: first line of treatment
Macrolide: second line of treatment
Tetracyclin: second line of treatment - Improvement in 3 days
if not: seek more medical advice and extend treatment for 2/5 days
How do you treat patients with moderate and high severity community associated pneumonia?
- 7 to 10 day course of dual antibiotic therapy
- Moderate: Amoxicillin and Macrolide
- High: beta lactams, beta lactamase and macrolide:
Amoxiclav, cefotaixime and clarithyromycin - Improvement in 1 week, symptoms should steadily improve
How do you monitor the efficacy of therapy and discharge the patient?
- Improvement of clinical presentation seen in 48 to 72 hours
Discharge:
2. Temperature: 37.5 degrees
- Heart rate: 100 beats/min
- Systolic blood pressure: 90mmHg or more
- Oxygen saturation: 90% or more
- Normal mental status
- Eat without assistance
- Need at least 2 of the above criteria
What’s the indication for therapeutic failure?
- Increase of lung infiltration
2. Looking at wrong possible dose, wrong diagnosis
When should you use parenteral and oral treatment for pneumonia?
- Parenteral treatment: severe pneumonina and impaired conciousness
- Oral therapy: not as severe
What are the other pharmacological and non pharmacological treatments for pneumonia?
- NSAIDS to relieve pain
- Fever reducing agents
- Cough suppressant
- Salbutamol
- Fluids
- Oxygen therapy
What are the risk factors of hospital acquired pneumonia, diagnosis and causes?
- Risk factors:
- Stroke
- Chronic Lung Disease
- Mechanical ventilation
- Recent surgery
- Previous antibiotic treatment - Diagnosis: Chest X ray
- Causes: bacteria and virus
Describe the aetiology (causes of a disease) of hospital acquired pneumonia
Aerobic gram negative bacilli
Describe the treatment options available for hospital acquired pneumonia? And the advantages and disadvantages?
- Empiric antibiotic therapy: as soon as possible within 4 hours.
- 5 to 10 day course of therapy - Pros:
Mortality lower if treatment is effective - Cons:
- Unnecessary use of extended spectrum anti-biotics
- Anti-biotic treatment may have to be changed
How do you prevent hospital acquired pneumonia?
- Hand hygiene
- Personal protective equipment
- Sterilisation or disinfection of equipment and maintenance of instruments
- Patient procedures
- Anti-microbials
- Selective decontamination of digestive tract tropical
- Parenteral agents with activity against gram negative bacilli - Modalitites:
- Chest physiotherapy
How is aspiration pneumonia caused and the factors that may enhance it? (ventilator associated)
- Caused by aspiration of gastric contents
- Pneumonitis
- Infection by bacteria in oropharyngeal secretions - Predisposing factors:
- Decreased consciousness
- Hepatic failure
- Protracted vomiting
- Neuromuscular disorders e.g. multiple sclerosis, parkinsons
- Alcohol and drug abuse
Explain the important infection pathway in hospital associated pneumonia?
- Lung tissue necrosis
- Secondary infection
- Gram positive and Gram negative pathogens
- Pneumonia
