Respiratory - Pneumonia Flashcards
A 45 year old male professor presents with a fever and shortness of breath associated with confusion. On examination there is decreased expansion on the left side & the patient has a respiratory rate of 35/min.
A. Urinary Tract Infection
B. Pneumonia
C. Pulmonary Embolism
D. Pneumothorax
E. Pleural Effusion
B. Pneumonia
Fever, confusion, SOB, decreased expansion, increased RR
Incidence and mortality of pneumonia?
Incidence 5-11/1000 of adults (0.5-1%) -> 30% are >65yo.
1-3/1000 require hospitalisation
Mortality - 14% (1/5 in hospital)
Pneumonia SYMPTOMS?
Fever + chest symptoms:
Fever (+ malaise, anorexia, rigors) Dyspnoea, Cough, purulent sputum (rusty), haemoptysis, pleuritic pain
Pneumonia SIGNS?
Pyrexia
Cyanosis,
Tachypnoea
Tachycardia
Hypotension
On Examination = signs of consolidation
Confusion!!
Organisms causing ATYPICAL pneumonia?
Legionella
Chlamydia
Mycoplasma pneumoniae
+ Pseudomonas Aeruginosa
+ Staphylococcus Aureus
Aspiration pneumonia risk factors?
COMPROMISED SWALLOW -> oropharyngeal anaerobes
Neuro: Stroke, myasthenia gravis, bulbar palsies decreased consciousness (e.g. drunk or post-ictal)
GIT: Oesophageal disease (e.g. achalasia, reflux)
Pneumonia investigations?
Oxygenation: SpO2, ABGs if <92%
Bloods: FBC, U&E, CRP (LFT), Blood culture (pyrexial)
Sputum MC&S
Chest X-ray
Pleural fluid aspirate
Urine Antigen Tests – S. pneumoniae, Legionella
Pneumonia CXR findings?
Chest X-ray: ALVEOLAR OPACIFICATION +/- Air bronchograms (air-filled bronchi (dark) being made visible by the opacification of surrounding alveoli (grey/white))
(extra: What to think about: Lobar vs Multilobar? Cavitating? Pleural effusions? “Fluffy”? Check the nature of the whiteness and its border:
Uniform with well-demarcated border – collapse or effusion
Non-uniform, not well-demarcated – consolidation, fibrosis or other infiltrative condition)
How do you measure the prognosis of a patient with pneumonia?
CURB65 - 1 point for each (MAX 5)
Confusion ≤ 8 AMT
Urea > 7mmol/L
RR ≥ 30/min
BP < 90 Systolic and/or 60 Diastolic
Age ≥ 65
Score 0-1: home treatment if possible 2: hospital therapy ≥ 3 = SEVERE, consider ITU
(Additional Risk Factors for ICU: Hypoxaemia (PaO2 <8kPa/SaO2 < 92%) Co-existing disease Bilateral/Multilobar involvement)
What are the complications of pneumonia?
LUNG: T1 Respiratory Failure
Pleural Effusion
Empyema (pus in the pleural space –> recurrent fever; CXR –> effusion; aspirate yellow and turbid)
Lung Abscess (‘cavitating area of localized, suppurative infection’ -> Inadequately treated pneumonia, aspiration, bronchial obstruction, pulmonary infarction, Swinging fever, purulent foul-smelling sputum, pleurisy, haemoptysis, finger-clubbing)
HEART: Atrial Fibrilation, Pericarditis, Myocarditis
OTHER: Septicaemia, Hypotension, Cholestatic jaundice, Brain abscess, Renal failure
How to manage pneumonia?
ABC Approach
- Treat Hypoxia (SaO2 < 88%) with O2
- Treat Hypotension/Shock with IV Fluids
- Assess Dehydration
No improvement:
Consider CPAP
If hypercapnic will require non-invasive or invasive ventilation
Antibiotics:
Mild – Oral Amoxicillin
Moderate – Oral or IV Amoxicillin + Clarithromycin (IV if vomiting)
Severe – IV Co-Amoxiclav + Clarithromycin, Seek URGENT help
Oxygen: if hypoxia Keep PaO2 > 8 and SaO2 > 94%
Fluids: if dehydrated or in SHOCK
Analgesia: if pleuritic pain (paracetamol)
ITU: if High CURB65, hypoxic, hypercapnic, SHOCK
Follow up: At 6 weeks
Features of atypical pneumonias?
Generally younger patients
Prolonged symptoms of general malaise, headache before a dry cough
Muscle pains, abdo pain, N&V
MAY HAVE no signs on chest examination OR signs not in keeping with X-ray
A plumber renovating old properties presented to casualty with fever & loss of consciousness. On examination he had bilateral consolidation. Plasma sodium was low. The doctor sent for urinary antigen & serology. On the results he was treated with azithromycin & ciprofloxacin and improved.
LEGIONELLA PNEUMOPHILIA
Legionella infecting the lungs is Legionnaires’ disease or Legionella pneumonia Gram negative rod Bacteria is found in aqueous environments such as lakes and almost all cases are from contaminated water systems, air conditioned hotels (conferences) Flu-like symptoms (myalgia, fever, malaise) preceding dry cough + SOB. 2-10 days incubation period. It can cause confusion (and coma) as well as hyponatraemia, abdominal pain, diarrhoea, hepatitis, renal failure and bradycardia. Diagnosis - urine antigen detection, serology or culture on special media. CXR – bi-basal consolidation, Bloods – hyponatraemia, lymphopenia, deranged LFTS Treatment is with Fluoroquinolones (e.g. Ciprofloxacin) + macrolide (e.g. Clarithromycin, Azithromycin)
A 20 year old previously healthy woman presents with general malaise and a headache, severe cough & breathlessness which has not improved with a 7 day course of amoxicillin. There is nothing significant to find on examination, chest is clear on auscultation. The x-ray shows patchy shadowing throughout the lung fields. The blood film shows clumping of red cells with suggestion of cold agglutinins.
MYCOPLASMA PNEUMONIA
Insidious onset– flu-like symptoms (headache, myalgia, arthralgia), dry cough often does not resolve, prolonged symptoms and a low-grade fever CXR – often lower lobes, reticulonodular shadowing Young people who ‘live together’ are commonly affected. Complications – Transverse myelitis The cold agglutinins = give away! - Mycoplasma is associated with with a cold AIHA and cold type agglutinins. Diagnosis – PCR sputum or serology Treated with Macrolides (e.g. Erythromycin and Clarithromycin)
A 44 year old man presents with a headache and general malaise. On taking a history he admits to increasing SOBOE as well as some Diarrhoea. He as not been abroad recently, and his chest examination is unremarkable. Whilst taking him to the ward, he asks if he can ring his daughter to feed his parrots this evening.
CHLAMYDOPHILA PSITTACI
C. psittaci – psittacosis Acquired from birds (typically parrots) Symptoms – headache, fever, dry cough, lethargy, arthralgia, anorexia, D&V Diagnosis Chlamydophila serology TREATMENT = Doxyclycline OR Clarithromycin
What are the 3 most popular organisms causing atypical pneumonia?
Mycoplasma, Chlamydophila and Legionella
How to recognise mycoplasma pneumonia (in SBA)?
Mycoplasma is associated with a cold type AIHA.
How to recognise chlamydophila pneumonia?
Chlamydophila pneumoniae is associated with otitis, pharyngitis and hoarseness prior to respiratory symptoms and psittaci is associated with birds as vectors.
