Ward 5 (pneumonia)

Question 1

Most common chief complaints in A/E

Answer 1

• Trauma/ musculoskeletal but this group only made up 11% of the attendances resulting in an admission
• The most common reason for attendances resulting in an admission was Airway/ breathing and
  Gastrointestinal and General / minor/ admin
• The most common specific reasons for treat-and-release ED visits were abdominal pain, acute upper respiratory infection, and nonspecific chest pain

Question 2

What is CAP?

Answer 2

Any pneumonia acquired outside of a hospital in a community setting

Question 3

What his HAP?

Answer 3

Any pneumonia acquired 48 hours after being admitted in an inpatient setting such as a hospital and not incubating at the time of admission is considered as HAP

Question 4

What is VAP?

Answer 4

Any pneumonia acquired 48 hours after endotracheal intubation is considered as VAP

Question 5

Pneumonia classification based on pattern of involvement

Answer 5

• Focal non-segmental or lobar pneumonia: involvement of a single lobe of the lung.
• Multifocal bronchopneumonia or lobular pneumonia
• Focal or diffuse interstitial pneumonia

Question 6

What is pneumonia?

Answer 6

Infection of the lung

Question 7

Age group with highest pneumonia related death

Answer 7

More than half of pneumonia-related
deaths occur in people older than 84 years

Question 8

Chief complaints of a patient with pneumonia

Answer 8

• the chief complaints in case of pneumonia include systemic signs like fever with chills, malaise, loss of appetite, cough, anorexia, and myalgias
• Pulmonary findings include cough with or without sputum production
• There may be an associated pleuritic chest pain with the concomitant involvement of the pleura.
• Dyspnea, diffuse heaviness of the chest, hemoptysis are also seen occasionally

Question 9

Sputum in viral vs bacterial pneumonia

Answer 9

• Bacterial pneumonia is associated with purulent or rarely blood-tinged sputum
• Viral pneumonia is associated with watery or occasionally mucopurulent sputum production.

Question 10

Common findings on physical examination of a patient with pneumonia

Answer 10

• Tachypnea
• Tachycardia
• Fever with or without chills
• Pallor/Cyanosis
• Hypotension
• Signs of consolidation (solidification e.g fluids, scarring)(reduced expansion, dull percussion,
  tactile vocal fremitus/vocal resonance, bronchial breathing)
• Decreased or bronchial breath sounds
• Egophony and tactile fremitus, both suggestive of a consolidative process
• Crackles on auscultation of the affected regions of the lung
• Confusion (may be the only sign in the elderly, may also be hypothermic)

Question 11

What is fremitus and types

Answer 11

• Fremitus is a vibration transmitted through the body.
• In common medical usage, it usually refers to assessment of the lungs by either the vibration intensity felt on the chest wall (tactile fremitus) and/or heard by a stethoscope on the chest wall with certain spoken words (vocal fremitus)

Question 12

What is egophony?

Answer 12

Egophony is a medical term that describes an increase in voice resonance when listening to the lungs with a stethoscope. It’s a type of bronchophony that occurs when abnormal lung tissue distorts vowel sounds, making them more nasal and similar to a goat’s bleat. For example, when a patient says the letter “e”, it may sound like the letter “a”, which is known as an “E to A change

Question 13

What does increased or decreased vocal resonance suggest?

Answer 13

Increased vocal resonance suggests increased density, while reduced vocal resonance suggests an increase in the amount of air present

Question 14

Steps in evaluating pneumonia

Answer 14

• Clinical evaluation
• Radiological evaluation
• Laboratory evaluation

Question 15

Clinical evaluation of pneumonia

Answer 15

• Involves performing a thorough history and physical examination indicative of pneumonia
• The “CURB-65” scoring system should be used for risk stratification
• Assess oxygenation: oxygen saturation ((ABGs if SaO2 <92% or severe
  pneumonia)
  -

Question 16

Radiological evaluation of pneumonia

Answer 16

A demonstratable infiltrate by chest x-ray is necessary and is considered the best method (with supportive clinical findings) for the diagnosis of pneumonia (CT if X ray is inconclusive)

Question 17

Pneumonia chest x ray findings

Question 18

Laboratory evaluation of pneumonia

Answer 18

• These include a series of tests like blood culture, sputum culture and microscopy, routine blood counts, U and E, LFT, and lymphocyte count
• Two tests, procalcitonin and C-reactive protein help differentiate viral from bacterial causes when clinical and radiological findings may not be obvious.
• Evaluation of VAP, on the other hand, is a bit different from that of CAP. It requires radiological and microbiological evidence prior to initiation of antimicrobial therapy.

Question 19

Additional tests in VAP

Answer 19

Invasive sampling techniques like mini broncho-alveolar lavage (BAL) or bronchoscopic BAL or even protected specimen brush (PSB) to identify causal organisms

Question 20

Treatment and management of CAP patients

Answer 20

• Initial risk stratification to decide whether to manage outpatient or inpatient (CURB-65)
• Start ASAP Broad spectrum antibiotics (Oral if CURB 1-2 and IV if more than 2) until causative organism is found (if found)
• Oxygen and symptomatic relief if needed
• Oxygen: keep PaO2 ≥ 8.0 and/or saturation ≥94%.
• IV fluids (anorexia, dehydration, shock) and VTE prophylaxis. Analgesia if
  pleurisy.
• Consider ITU if shock, hypercapnia, or remains hypoxic.
• Follow-up: at 6 weeks (±CXR).

Question 21

Differential diagnosis of pneumonia

Answer 21

• Includes asthma, chronic obstructive pulmonary disease (COPD), pulmonary edema, malignancies, non-infective consolidative processes of the lung, pleuritis, pulmonary embolism, aspiration of a foreign body, bronchiectasis, bronchiolitis, and others just to name a few
• In case a differentiation becomes difficult, parameters like C-reactive protein, erythrocyte sedimentation rate, procalcitonin levels, leucocyte count, and temperature may be used to establish a diagnosis

Question 22

Complications of pneumonia

Answer 22

Complications of untreated or undertreated pneumonia include respiratory failure (type 1), sepsis, metastatic infections, empyema, lung abscess, pericarditis, myocarditis, brain abcess, cholestatic jaundice, and multi-organ dysfunction

Question 23

Most common organism of CAP

Answer 23

Streptococcus pneumoniae (commonest)

Question 24

How common is viral CAP

Answer 24

Viruses account for up to 15% of cases

Question 25

Most common organisms of HAP

Answer 25

Most commonly Gram-negative enterobacteria or Staph. aureus.

Question 26

What is CURB 65 and how is it scored

Answer 26

Pneumonia severity scoring system. 1 point for each of:
- Confusion (abbreviated mental test ≤8)
- Urea >7mmol/L
- Respiratory rate ≥30/min
- BP <90 systolic and/or 60mmHg diastolic)
- Age ≥65

Question 27

How is CURB 65 interpretted?

Answer 27

• 0–1, PO antibiotic/home treatment
• 2, hospital therapy
• ≥3, severe pneumonia indicates
  mortality 15–40%—consider ITU.
• It may ‘underscore’ the young—use clinical judgement.
• Other features increasing the risk of death are: comorbidity; bilateral/multilobar; PaO2
  <8kPa.

Question 28

What is considered type 1 resp fail?

Answer 28

PaO2 <8kPa

Question 29

When should pneumonia patient be transferred to ITU based on oxygenation?

Answer 29

Transfer the patient to ITU if
hypoxia does not improve with O2 therapy or PaCO2 rises to >6kPa

Question 30

What to watch out for when administering oxygen in patients with pneumonia?

Answer 30

Be careful with O2 in COPD patients; check ABGS frequently, and consider elective ventilation if rising
PaCO2 or worsening acidosis.

Question 31

Treatment of hypotension

Answer 31

If systolic BP is <90mmHg, give an intravenous fl uid challenge of 250mL
colloid/crystalloid over 15min. If BP does not rise, consider a central line and give IV fluids to maintain the systolic BP >90mmHg.
- If systolic BP remains <90mmHg despite fluid therapy, request ITU assessment for inotropic support

Question 32

Clinical features of lung abscess

Answer 32

Swinging fever; cough; purulent, foul-smelling sputum; pleuritic chest pain; haemoptysis; malaise; weight loss.
-Look for: finger clubbing; anaemia;
crepitations. Empyema (An empyema is a collection or gathering of pus within a naturally existing anatomical cavity. The term is most commonly used to refer to pleural empyema, which is empyema of the pleural cavity. It must be differentiated from an abscess, which is a collection of pus in a newly formed cavity.) develops in 20–30%.

Question 33

Tests to be ordered if suspecting lung abcess

Answer 33

• Tests: Blood: FBC (anaemia, neutrophilia), ESR, CRP, blood cultures. Sputum microscopy, culture, and cytology.
• X-ray
• Consider CT scan to exclude obstruction, and bronchoscopy to obtain diagnostic specimens

Question 34

Antibiotic therapy in pneumonia for low severity

Answer 34

First-choice oral antibiotic if low severity (based on clinical judgement and guided by a CRB65 score 0 or a CURB65
score 0 or 1 when these scores can be calculated) –> Amoxicillin
Alternative for low sevirity, penicillin allergy, or amoxicillin unsuitable (for example, if atypical pathogens
suspected) –> Doxycycline, clarithromycin, or erythromycin (in pregnancy), levofloxacin

Question 35

Antibiotic therapy in pneumonia for moderate severity

Answer 35

First-choice oral antibiotics if moderate severity (based on clinical judgement and guided by a CRB65 score 1 or 2, or a
CURB65 score 2 when these scores can be calculated; guided
by microbiological results when available) –> Co-amoxiclav (oral) with (if atypical pathogens suspected)–> clarithromycin (oral)
Or Erythromycin (oral) (in pregnancy)

Alternative oral antibiotics if moderate severity, for penicillin allergy (guided by microbiological results when available) –> Doxycycline or clarithromycin

Question 36

Antibiotic therapy in pneumonia for severe patients

Answer 36

First-choice antibiotics if high severity (based on clinical judgement and guided by a CRB65 score 3 or 4, or a CURB65
score 3 to 5 when these scores can be calculated; guided by microbiological results when available) –> Co-amoxiclav IV with clarithromycin (oral or IV) or erythromycin oral (in pregnancy)
Alternative antibiotic if high severity, for penicillin allergy (guided by microbiological results when available; consult a local microbiologist if fluoroquinolone not appropriate) –>
Levofloxacin (IV or oral) (consider safety issues)

Question 37

Fluoroquinolone safety

Answer 37

• For fluoroquinolone antibiotics, see Medicines and Healthcare products Regulatory Agency
  (MHRA) advice for restrictions and precautions because of very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and
  nervous systems.
• Warnings include: stopping treatment at first signs of a serious adverse
  reaction (such as tendonitis), prescribing with special caution for people over 60 years and avoiding coadministration with a corticosteroid

Question 38

Alternative to CURB 65 and interpretation

Answer 38

CRB65: confusion, respiratory rate 30/minute or more, blood pressure (systolic less than 90 mmHg or diastolic 60 mmHg or less), age 65 or more
- 0 outpatiant treatment
- 1-2 admission required
- 3-4 Admission with intensive medical care recommended

Question 39

Mortality rate based on CURB65

Answer 39

30 mortality
0- 0.6%
1- 2.7%
2- up to 10%
3> 15-40%

Question 40

X ray findings pneumonia

Answer 40

Findings may vary from lobar or multilobar infiltrate to interstitial infiltrate, to occasionally cavitary lesions with air-fluid levels suggestive of a more severe disease process. Pleural effusion may be seen
- airspace opacification:
filling of the alveoli with infectious material and pus
initially patchy
becomes confluent as infection develops
- air bronchograms:
air-filled bronchi running through pus-filled alveoli
- complications:
pleural collection
cavitation

Question 41

What is opafication

Answer 41

any area that appears white on a chest radiograph when it should be darker, indicating higher density (since air has relatively lower density)