5. Lower Respiratory Tract Infections

Question 1

Sx of CAP

Answer 1

Cough and breathlessnnes, pleuritic pain , new sputum production (54%), haemoptysis(15%)

Confusion, abd pain, GI upset, myalgia and headache

Question 2

Signs of CAP

Answer 2

Pyrexia, rigors, tachyc, hypoT, tachypneoa
COARSE inspiratory crackles, reduced expansion, bronchial breathing, pleural rub on pneum side, abd tenderness

Question 3

Def of CAP

Answer 3

Sx and signs consistent with LRTI, new CXR shadowing (eg. may have loss of definition of heart border), and no other explanation

Question 4

How to differentiate between Middle and Lower lobe pneumonia

Answer 4

If lower lobe, hemidiaphragm will not be clear

Question 5

What bacteria can cause lung abscess commonly

Answer 5

Staph aureus

Question 6

Are blood cultures needed for low risk pts for CAP

Answer 6

NO

Question 6

What can cause ARDS and how to treat

Answer 6

Influenza A, treat with oseltamivir

Question 7

How to assess pneumonia severity

Answer 7

CURB65
Confusion
Urea>7
SBP <90 or DBP<60
Age >65
1 or less is low severity

Question 8

If CURB =2, how to treat

Answer 8

Usually only oral antibiotics

Question 9

Ix for Moderate vs severe pneumonia

Answer 9

Blood cultures and sputum, pneumococcal urine antigen test for both (consider ONLY for moderate )

Ix for legionella only is suspected in mod pneumonia ( urine antigen and sputum ) vs Ix for legionella and atypical and viral pathogens for severe

Question 11

Common source of mild CAP and how to treat

Answer 11

Strep pneumoniae, just treat with oral amox

Question 12

Most common infectious agents in pneumonia

Answer 12

Streptococcus pneumoniae (accounts for around 80% of cases)
Haemophilus influenzae
Staphylococcus aureus: commonly after influenza infection
atypical pneumonias (e.g. Due to Mycoplasma pneumoniae)
viruses

Question 13

Strep p and H I gram +ve or -ve

Answer 13

+ve and -ve respectively!

Question 14

Common fx of pneumococcal pneumonia

Answer 14

rapid onset
high fever
pleuritic chest pain
herpes labialis (cold sores)

Question 15

Mod severity CAP Tx

Answer 15

Oral amox + clarithromycin

(IV benzyl may be fiven instead of amox if oral not possible)

Question 16

What is the use of clarithromycin in CAP

Answer 16

For atypical organisms

Question 17

High severity CAP Tx

Answer 17

IV co amox + clarithro, add levofloxacin if legionella

Question 18

How to treat parapneumonic effusion

Answer 18

With abx

Question 19

What is empyema

Answer 19

Infxn and pockets in pleural space

Question 20

When would chest drain be considered for Empyema

Answer 20

Pleural fluid acidosis
+ve bacteriology from pleural space
frank pus

Question 21

Empyema charcteristics

Answer 21

High protein (>30) and LDH (>1000),usually have loculations, high neurophil, low glucose (<2.2) and ph <7.2

Question 22

Org in pri vs sec empyema

Answer 22

Strep, anaerobes, staph aureus, gram -ve aerobes
vs
MRSA, Gram -ve aerobes like e coli, pseudomonas, kleb more common, s aureus and anaerobes

Question 23

Mx of empyema

Answer 23

Fluids, LMWH, ICD if meets criteria, Abx mainly coamox, but may use metro and cephs.

If failure to respond then decorticate and put abx, or if too frail then rib resection + permanent ICD

Question 24

If flu like Sx and then CAP, what org is likely

Answer 24

Staph aureus

Question 25

What is PCP assoc with

Answer 25

Immunocompromised

Question 26

What is legionella assoc with and what are the sx

Answer 26

Water, travel overseas Sx include malaise, diarrhoea, headache, confusion, hypokalaemia, deranged LFTs, AKI

Question 27

What is bronchiectasis

Answer 27

Permanently dilated airways-- chronic cough and sputum production, recurrent chest infections

Question 28

Sx of bronchiectasis

Answer 28

Fatigue, chest pain, cough, haemoptysis

Question 29

Most common causes (2) of bronchiectasis

Answer 29

No cause, then past infection

Question 30

Possible causes of bronchiectasis that should be investigated

Answer 30

Allergic bronchopulmonary aspergillosis, common variable immunodefeciency and CF

Question 31

Most common pathogen in bronchiectasis and what other causes

Answer 31

H influenzae, then pseudomonas

Question 32

Ix for bronchiectasis and observation on imaging

Answer 32

Chest CT Sputum culture, once a year and at exac start Dense opacification of lung fields due to chronic bronchietastic change on CXR

Question 33

what does signnet ring sign suuggest

Answer 33

Bronchiectasis- bronchus bigger than vessel

Question 34

What variables are considered in bronchiectasis severity index scoring

Answer 34

Age, low BMI (< 18.5), >3 lobes involved or cystic bronchiectasis, FEV1

Question 35

What is bronchiectasis a risk factor for

Answer 35

Coronary heart disease and stroke, independent of past smoking

Question 36

Tx for bronchiectasis exacerbation, and what the requirements for tx

Answer 36

Abx - - acute detioration, worsening local sx, and or systemic upset

Question 37

Non-medical treatment for bronchiectasis

Answer 37

physiotherapy

Question 38

What disease is DNAse used for

Answer 38

CF

Question 39

long term treatment for bronchiectasis

Answer 39

SAB2 agonist if airways obstruction , anti cholinergic also possible LABA if significant breathlessness and response to SA similar to COPD

Question 40

Macrolides side effect and when is it used

Answer 40

GI, CV, hearing impairment To reduce exac in high risk pts

Question 41

What are the high risk groups to target abx

Answer 41

BSI or >= 3 Exac per year

Question 42

Target froup for LT inhaled ABXs and which Abx are these

Answer 42

Chrminic PA or R, intolerance or lack of effect with macrolides Gent or colomycin

Question 43

What resp condition is a risk factor for TB

Answer 43

Silicosis

Question 44

Sx of TB

Answer 44

Progressive Sx ( weeks/ months) Weigh loss + night sweats Cough Possibly productive + haemoptysis Anorexia General malaise

Question 45

Which lobe predominance does TB have

Answer 45

Upper Lobe

Question 46

Features of active TB on chest radiograph

Answer 46

Soft nodular shadowing, consolidation, infiltration, cavitation, miliary nodules, pleural effusion, tuberculoma

Question 47

First Ix for LATENT TB

Answer 47

Tuberculin skin test (mantoux)

Question 48

Imaging for active TB

Answer 48

CXR- upper lobe cavitation in reactivated TB UNILATERAL hilar lymphadeonpathy more common but bilat may also be seen

Question 49

What are the TB specific antigens, are they present in BCH

Answer 49

ESAT 6 and CFP 10.

Question 50

When should INFg assay be performed

Answer 50

If Mantoux is +ve

Question 51

What samples should be done for pulmonary Tb and what test are done, what stain is used

Answer 51

Sputum x 3 is gold standard : smear with Ziehl neelsen stain used, culture (TB+ routine)and histopatholgy Induced sputum x3 BAL +- TBB

Question 52

should pulm tb pts be isolated in -ve pressure room

Answer 52

yes

Question 53

tx for TB and when shpuld it be extended

Answer 53

Rifampicin (R) 6mo Isoniazaid (H) 6mo + pyridoxine Pyrazinamide 2mo ethambutol 2mo extend if TB meningitis, extensive TB, miliary TB

Question 54

when should oral steroids be used in TB

Answer 54

extensive tb, meningitis, pericarditis, ureteric, and Pleural effusion

Question 55

Treatment for latent TB

Answer 55

6mo R/H or 3mo R+H

Question 56

Contact tracing for TB and precautions

Answer 56

Household and close contacts >8h Should screen all close contacts- TST, CXR, med assessment of concerns

Question 57

What is considered HAP

Answer 57

Over 48 hrs in hospital

Question 58

What are the common causes of HAP and how should HAP be treated

Answer 58

Pseudomonas and MRS Use coamox

Question 59

Should Gram-ve or Gram+ve be done for HAP first

Answer 59

Gram -ve then Gram +ve

Question 60

Pleural effusion in pneumonia- is it transudative or exudative

Answer 60

exudative pleural fluid protein divided by serum protein >0.5 pleural fluid LDH divided by serum LDH >0.6 pleural fluid LDH more than two-thirds the upper limits of normal serum LDH

Question 61

how to manage effusion in pneumonia

Answer 61

CXR, may use US for pleural aspiration, sne dfluid for pH, protein, LDH, cytologoy and microbio

Question 62

Bronchiolitis most likely cause and when

Answer 62

Respiratory syncytial virus (RSV) is the pathogen in 75-80% of cases Usually in <1yo Higher incidence in winter

Question 63

Fx of bronchiolitis

Answer 63

coryzal symptoms (including mild fever) precede: dry cough increasing breathlessness wheezing, fine inspiratory crackles (not always present) feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission

Question 64

Mx of bronchiolitis

Answer 64

Largely supportive humidified oxygen is given via a head box and is typically recommended if the oxygen saturations are persistently < 92% nasogastric feeding may be needed if children cannot take enough fluid/feed by mouth suction is sometimes used for excessive upper airway secretions

Question 65

When should induced sputum be done for pneumonia

Answer 65

If investigating TB or pneumocystis

Question 67

Most common HAP Pathogens

Answer 67

E coli, p aeruginosa, e cloacae, k oxytoca and S aureus- only Gram +ve in this group

Question 68

Aspiration lobar pneumonia in alcoholics, organism?

Answer 68

Klebsiella

Question 69

Which lobes are more commonly affected in aspiration pneumonia

Answer 69

Right middle and lower lobes