5-pneumonia

Question 1

what are the main forms of pneumonia classification?

Answer 1

Main clinical classification:
• Community acquired pneumonia (CAP)
versus
• Hospital (Healthcare) acquired pneumonia (HAP)

Other forms to be considered:
• Aspiration pneumonia
• Atypical pneumonia
• Pneumonia in the immunocompromised host

Question 2

list other forms of pulmonary/ thoracic infection

Answer 2

• Empyema

* Lung abscess

Question 3

what are the signs and symptoms of CAP?

Answer 3

•	Fever ± chills and rigors
•	Cough productive of purulent sputum
•	Pleuritic chest pain
•	Shortness of breath (Dyspnoea)
Duration of symptoms – hours to a few days.

Question 4

what are the atypical Symptoms of community-acquired pneumonia:

Answer 4

•	Dry cough
•	Shortness of breath
•	Diarrhea, abdominal pain
•	Ear pain (bullous myringitis)
•	Myalgia 
•	Arthralgia
Duration of symptoms – may be up to 2-3 weeks
(atypical pneumonia)

Question 5

what are the vital sign abnormalities in CAP?

Answer 5

• Tachypnoea, tachycardia, hypotension, pyrexia

* ± Cyanosis (Hypoxaemia)

Question 6

what are the focal chest signs in CAP?

Answer 6

• ± Decreased chest expansion
• Increased tactile fremitus
• Dullness to percussion
• Increased vocal resonance
• Bronchial breath sounds
• Coarse crepitations ***** (Strongest and most consistent finding)

Question 7

what is bronchial breathing?

Answer 7

Loud and high pitched, through part of inspiration and all of the expiration
Heard over the sternum (normally)

Question 8

what is the strongest and most consistent focal finding in CAP?

Answer 8

Coarse crepitations

Question 9

what are the crepitations (crackles)

Answer 9

A pathologic breath sound on auscultation characterized by discontinuous, intermittent rattling. Etiologies include pneumonia, atelectasis, pulmonary fibrosis, bronchiectasis, interstitial lung disease, and pulmonary edema.
Fine: Soft, high pitches caused by the sudden opening of small airways, classically described as velcro being separated, typically heard mid-to-late inspiration, uninfluenced by cough, gravity, or body position
Coarse: loud, low pitched produced by pockets of air passing through airways as they open and close intermittently. Tend to occur early during inspiration and throughout expiration with popping quality

Question 10

what are the causes of fine crackles?

Answer 10

normal, asbestosis, sarcoidosis (ILD)

Question 11

what are the causes of coarse crackles?

Answer 11

COPD, pulmonary edema

Question 12

what are the differential diagnoses of CAP?

Answer 12

• Pulmonary Embolism – acute history, SOB, pleuritic pain, absence of auscultation findings, absence of febrile symptoms
• Congestive cardiac failure – acute or chronic, bibasal crepitations, signs of right heart failure
• Pulmonary vasculitis – haemoptysis, failure to respond to antibiotics

Question 13

what are the complications of CAP?

Answer 13

•	Respiratory Failure
–	Adult Respiratory Distress Syndrome (ARDS)/ Acute lung injury (ALI)
•	Sepsis/Multiorgan failure
•	Delirium/acute confusional state
•	Exacerbation of underlying co-morbidity (e.g Atrial fibrillation)
•	Parapneumonic effusion , empyema
•	Lung abscess
•	Tachyarrhythymias

Question 14

what are the common causative agents of pneumonia?

Answer 14

• Standard pathogens:
– Streptococcus pneumoniae (30-35% of cases)
– Haemophilus influenzae
– Staphyloccus aureus

•	Atypical pneumonia features:
–	Mycoplasma pneumoniae
–	Chlamydia pneumoniae
–	Legionella pneumophilia
–	Viral (influenzae)

Question 15

what are the usual diagnostic tests that are performed in CAP?

Answer 15

1.	Blood tests:
•	FBC, U&E, LFT’S, CRP, Glucose
2.	Microbiology tests:
•	Blood cultures
•	Urinary antigen for Legionella and Pneumococcus
•	Sputum culture? Serology testing?
3.	Radiology:
•	CXR

Question 16

what lab tests should be performed in a patient with suspected CAP?

Answer 16

1.	Blood tests:
•	CBC, UA and Electrolytes, LFT’S, CRP, Glucose
2.	Microbiology tests:
•	Blood cultures
•	Urinary antigen for Legionella and Pneumococcus
•	Sputum culture
•	Serology testing
3.	Radiology:
•	CXR

Question 17

what is the CURB 65 scoring?

Answer 17

A score used to decide whether patients with pneumonia require hospitalization. Confusion, blood urea > 7 mmol/L (20 mg/dL), respiratory rate ≥ 30/min, systolic blood pressure ≤ 90 mm Hg or diastolic BP ≤ 60 mm Hg, and age ≥ 65 years are each assigned 1 point. If the CURB-65 score is ≥ 2, hospitalization is indicated.

Question 18

do negative sputum cultures out-rule infection/ pneumonia?

Answer 18

no

Question 19

what are the CXR findings in CAP?

Answer 19

• Heterogenous/ patchy infiltrate(s) – corresponding to a lobe(s)
• Lobar/ multi-lobar – corresponds with severity (not organisms)
• Pleural effusion – parapneumonic effusions vs empyema
• Resolution of radiology findings lags behind clinical improvement

Question 20

what is the interpretation of CURB-?

Answer 20

CURB-65 score ≤ 1: The patient may be treated as an outpatient.
CURB-65 score ≥ 2: Hospitalization is indicated.
CURB-65 score ≥ 3: ICU-care should be considered.

Question 21

except for CURB- scoring, what are the additional adverse prognostic features?

Answer 21

SaO<92%, PaO2<8

CXR: bilateral/multilobar shadowing

Question 22

what are the pre-existing adverse prognostic features of CAP?

Answer 22

age >50

any other coexisting chronic illness (DM)

Question 23

what are the treatment options for a patient with CAP depending on location of the patient?

Answer 23

Outpatient
• Co-amoxyclav p.o.

Inpatient
• Co-amoxyclav i.v. + Clarithromycin p.o.

Intensive care (severe CAP)
•	Piperacillin-tazobactami.v. + Clarithromycin i.v.

Question 24

what is the pneumonia severity index (PSI)?

Answer 24

The pneumonia severity index (PSI) or PORT Score is a clinical prediction rule that medical practitioners can use to calculate the probability of morbidity and mortality among patients with community acquired pneumonia. The PSI/PORT score is often used to predict the need for hospitalization in people with pneumonia.

Question 25

what are the parameters used in PSI?

Answer 25

1) Sex - -M (0 points) - -F (-10 points) 2) Demographic factors - -Age (1 point for each year) - -Nursing home resident (10 points) 3) Comorbid illnesses - -Neoplastic disease (30 points) - -Liver disease (20 points) - -Congestive heart failure (10 points) - -Cerebrovascular disease (10 points) - -Renal disease (10 points) 4) Physical examination findings - -Altered mental status (20 points) - -Respiratory rate ≥30/minute (20 points) - -Systolic blood pressure <90 mmHg (20 points) - -Temperature <35 degrees C or ≥40 degrees C (15 points) - -Pulse ≥125/minute (10 points) 5) Laboratory and radiographic findings - -Arterial pH <7.35 (30 points) - -Blood urea nitrogen ≥30 mg/dL (11 mmol/L) (20 points) - -Sodium <130 mEq/L (20 points) - -Glucose ≥250 mg/dL (14 mmol/L) (10 points) - -Hematocrit <30 percent (10 points) - -Partial pressure of arterial oxygen <60 mmHg or oxygen saturation <90% (10 points) - -Pleural effusion (10 points)

Question 26

what is the management of CAP inpatient?

Answer 26

* Maintain oxygenation: nasal prongs, venturi face mask, high flow non-rebreathable face mask, CPAP (continous positive pressure ventilation, intubation & ventilation) * Maintain BP: iv fluids, inotropes (noradrenaline) * Consider steroids if obstructive lung disease

Question 27

what are the recommendations for influenza vaccination? | •

Answer 27

Inactivated influenza vaccine, rather than live attenuated, is recommended in adults • The vaccine should be given to persons at increased risk for complications due to influenza • Yearly vaccinations are recommended since this is safe and does not lead to a decreased immune • In health care personnel yearly vaccination is recommended, especially in settings where elderly persons or other high-risk groups are treated response

Question 28

what are the at-risk patients for severe CAP?

Answer 28

* age > 65 years * institutionalisation * chronic cardiac diseases * chronic pulmonary diseases * unstable diabetes mellitus * chronic renal diseases * immunocompromised persons * hemoglobinopathies * women who will be in the second or third trimester of pregnancy during the influenza season

Question 29

what are the recommendations for Pneumococcal vaccination?

Answer 29

* Individuals with chronic/ structural lung disease – bronchiectasis, severe COPD * Previouspneumonia * Post – splenectomy

Question 30

what is the empyema?

Answer 30

* Sequelae of pneumonia * Usually occurs 7-10 days after initial pneumonia * Duration of symptoms – may be weeks before presentation * Pleural fluid: exudate, ¯pH (acidic), ¯glucose, ­ WCC (neutrophilia) * ­­CRP, ¯SerumAlbumin * Organisms: similar to lung access pathogens

Question 31

what is the treatment of empyema?

Answer 31

Appropriate systemic antibiotic treatment Chest tube (thoracostomy) to remove empyema fluid Intrapleural administration of fibrinolytic agents (to improve chest tube drainage of empyema fluid) Thoracoscopic debridement (removal of pus and pleural fibrosis) if empyema does not resolve after chest tube drainage

Question 32

in empyema, pleural fluid analysis shows transudative effusion.True/False

Answer 32

False - -Exudative effusion - -Low glucose (< 60 mg/dL) and pH < 7.3 - -Positive bacterial culture

Question 33

what are the pathogens commonly involved in empyema?

Answer 33

- -Most commonly: mixed infections caused by anaerobic bacteria that colonize the oral cavity (e.g., Peptostreptococcus, Prevotella, Bacteroides, Fusobacterium spp.) - -Less commonly: monomicrobial lung abscess caused by S. aureus, Klebsiella pneumoniae, Streptococcus pyogenes, Streptococcus anginosus

Question 34

what is the incidence of HAP?

Answer 34

* 15% of all intra-hospital infections * 2nd most frequent nosocomial infection * Average incidence of 6.3 per 1000 hospital discharges

Question 35

what is the HAP?

Answer 35

``` HAP – > 48 hours after admission – Early onset – within 4 days – Late onset – after 5 days VAP – 48 – 72 hours after endotracheal intubation ``` Similar pathogens for HAP and VAP Almost always bacterial (in the immunocompetent host) ­Polymicrobial in VAP (especially in ARDS)

Question 36

what is the VAP?

Answer 36

A hospital-acquired infection that develops 48 hours after the initiation of mechanical ventilation via either tracheostomy or intubation. Approx. 5–10% of patients on mechanical ventilation develop VAP.

Question 37

how HAP is clinically diagnosed?

Answer 37

``` • New or progressive infiltrate on CXR + (two out of three) • Fever > 380C • Leukocytosis or leukopenia • Purulent sputum/ secretions ```

Question 38

early vs late-onset HAP

Answer 38

late-onset HAP (≥5 days after admission) is more likely to be associated with difficult-to-treat pathogens, such as MDR microorganisms, which are formed in early-onset HAP (occurring within the first 4 days of a hospital- isation).

Question 39

what are the risk factors of HAP?

Answer 39

Among the factors contributing to contracting HAP are mechanical ventilation (ventilator-associated pneumonia), old age, decreased filtration of inspired air, intrinsic respiratory, neurologic, or other disease states that result in respiratory tract obstruction, trauma, (abdominal) surgery, medications, diminished lung volumes, or decreased clearance of secretions may diminish the defenses of the lung. Also, poor hand-washing and inadequate disinfection of respiratory devices cause cross-infection and are important factors

Question 40

what is the treatment of HAP?

Answer 40

A third generation cephalosporin (ceftazidime) + carbapenems (imipenem) + beta lactam & beta lactamase inhibitors (piperacillin/tazobactam)