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Stage 2: Supporting Life > Pneumonia - Features + Treatment > Flashcards

Pneumonia - Features + Treatment Flashcards

1
Q

Who does pneumonia primarily affect?

A

Young children, elderly and immunocompromised

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2
Q

What is the most common (bacterial cause) of pneumonia?

A

Streptococcus pneumoniae (30%)

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3
Q

What are the leading respiratory virus causes of pneumonia?

A

RSV, rhinovirus, influenza (30%)

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4
Q

What are 4 other bacterial causes of pneumonia?

A
  • Haemophilius influenzae
  • Staphylococcus aureus
  • Klebsiella pneumoniae
  • Pneumocystis jirovecii
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5
Q

Describe the aetiology (spread) of pneumonia?

A
  • Nasopharyngeal aspiration → normal ecological niche = nasopharynx
  • Droplet spread
  • Inhalation of airborne microorganisms → spore format e.g. aspergillus
  • Haematogenous spread
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6
Q

Describe the action of cells in the respiratory immune system

A

1) Mucociliary clearance → entrapment in mucus, ciliary escalator
2) Alveolar macrophages → phagocytosis, inflammation
3) Neutrophils → phagocytosis (but can reach phagocytosis capacity)
4) Complement and antibodies → opsonisation, agglutination
5) Lymphocytes → inflammation, activation of other immune cells

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7
Q

What is the pathophysiology of pneumonia?

A

1) Alveoli fill with pus (can see on x ray or CT)
2) Impaired gas exchange → by pathogen and infiltrates from blood
3) SIRS → systemic inflammatory response, sepsis
4) Bacteraemia

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8
Q

What causes congestion?

A

Vascular engorgement, intra-alveolar fluid

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9
Q

What is red hepatisation?

A

When there is exudation of red cells, neutrophils and fibrin in the alveoli (precedes grey hepatisation)

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10
Q

What is grey hepatisation?

A

Disintegration of RBCs, persisting inflammatory cells leaving a fibrinosuppurative exudate in the alveoli

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11
Q

Do lungs normally scar due to pneumonia?

A

No

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12
Q

What are the (non-specific) symptoms of the infection?

A
  • Dyspnoea
  • Cough
  • Sputum ± purulence (inflammatory infiltrate)
  • Fever (cytokines)
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13
Q

Why is there not much pain in pneumonia?

A

Bc there is not much nerve supply to the lung itself

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14
Q

What are the signs of infection?

A
  • Tachypnoea
  • Tachycardia
  • Hypotension
  • Pyrexia (fever)
  • Crackles
  • Whispering pectoriloquy
  • Increased tactile fremitus
  • Increased vocal resonance
  • Central cyanosis
  • Altered mental status
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15
Q

What investigations would you do to determine pneumonia?

A
  • ABG (if hypoxic bc checking for type 2 respiratory failure)
  • CXR
  • FBC
  • U&E, CRP, LFT
  • Blood and sputum cultures
  • Viral PCR
  • Atypical serology
  • Urine Ag for legionella and S. Pneumoniae (useful if positive)
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16
Q

What is whispering pectoriloquy?

A

When as the consolidated lung has better sound transfer, what sounds like upper respiratory sounds might be at the bottom

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17
Q

What is atypical serology useful for?

A

Tells us what has caused the pneumonia (more useful for epidemiology than acutely)

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18
Q

What are the urine Ag for legionella and S. Pneumoniae useful for?

A

To find out the bacteria to be able to narrow down the spectrum of antibody (initially given broad spectrum)

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19
Q

What does consolidation of the (right) middle lobe normally obscure?

A

The heart

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20
Q

What does consolidation of the (right) lower lobe usually obscure?

A

The diaphragm

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21
Q

Where is right upper lobe consolidation located?

A

Above the horizontal fissure

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22
Q

What does left lingula consolidation obscure?

A

The left heart border

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23
Q

Which consolidation can be difficult to see with a CXR and why? (But can see with CT)

A

(Left) lower lobe as it is behind the diaphragm

24
Q

Why might you want to follow up after consolidation CXR?

A

To check it’s not lung cancer

25
Q

What is patchy consolidation called?

A

Diffuse bronchocentric consolidation

26
Q

What is the scoring system used for CAP?

A

CURB65

27
Q

What does CURB65 tell us?

A

It predicts mortality and tells us which patients need to be in hospital/ICU/GP/home

28
Q

What are the 5 parts of the CURB65 score?

A

1) Confusion → AMTS ≤ 8
2) Serum urea > 7mmol/L
3) RR ≥ 30
4) Systolic BP < 90 or diastolic BP ≤ 60mmHg (evidence of sepsis?)
5) Age ≥ 65

29
Q

How does the CURB65 scoring system work?

A

1 point for each feature

30
Q

What would you do with a CURB65 score of 0?

A

Oral antibiotics at home → however, if patient has hypoxia and low sats, don’t send home (just a guideline)

31
Q

What would you do with a CURB65 score of 1?

A

Consider hospital admission

32
Q

What would you do with a CURB65 score of 2?

A

Consider IV antibiotics

33
Q

What would you do with a CURB65 score of 3?

A

Consider ICU admission

34
Q

How do you manage pneumonia (ABCDE)?

A

A - ensure patent airway
B - oxygen to maintain desired saturation (94-98%) or mechanical ventilation (in patient with COPD or other factors)
C - IV fluids if required → inotropes, haemofiltration (kidney support - ICU)
D - GCS (confusion)
E - analgesia, antipyretics
ANTIBIOTICS

35
Q

Describe antibiotic treatment in pneumonia

A
  • Within 4 hours
  • Empirical (and broad spectrum in pt unwell) at initiation, then narrow if specific organism cultured
  • OP → penicillin derivative bc cover strep pneumo and others
  • IP moderate severity → penicillin derivative + macrolide (some are resistant)
  • IP severe → IV beta-lactamase resistant antibiotics (co-amoxiclav or cephalosporin) + macrolide
36
Q

How would you diagnose viral pneumonia?

A
  • Cytology → intranuclear or cytoplasmic inclusion bodies
  • Viral cultures
  • PCR → for nasopharyngeal aspirates
  • Rapid Ag detection
  • Serology
37
Q

How do you management viral pneumonia?

A

Largely supportive, not v much evidence for anti-virals but give them for some viruses

38
Q

What medications are used to treat viral pneumonia linked to influenza?

A
  • Amantadine → slightly reduces URT symptoms and myalgia
  • Oseltamivir → to prevent spread of flu rather than to treat patient
  • Zanamivir
39
Q

What medications are used to treat viral pneumonia linked to RSV?

A

Ribavarin

40
Q

What medications are used to treat viral pneumonia linked to HSV or VSV?

A

Aciclovir (v effective)

41
Q

What are 5 examples of immunosuppressed patients?

A

1) Malignancy
2) Steroids
3) Asplenia
4) Diabetes
5) CKD

42
Q

What are 4 differential diagnoses for pneumonia?

A

1) Malignancy
2) Vasculitides
3) Infarcted lung, PE
4) Pulmonary oedema

43
Q

What are the complications of pneumonia (can appear even if treat if treatment is late) and describe them/their treatment?

A

1) Septic shock → hypotension, fever
2) Adult respiratory distress syndrome → supportive care, low pressure ventilation, ECMO
3) Parapneumonic effusion and empyema → pus or fluid pH < 7.2, intercostal drain, VATS
4) Cavitation and abscess → prolonged antibiotics (4-6 weeks response), resection
5) MI → double the rate of MI after pneumonia

44
Q

What is adult respiratory distress syndrome?

A

Lung inflammation syndrome after systemic infection, most common = pneumonia

45
Q

When should you drain fluid?

A

If lots of fluid, pus or acidic

46
Q

What does ARDS look like on CXR?

A

Large white space covering almost all of one lung

47
Q

What does empyema look like on a CXR?

A

Loculated abscess → white blob

48
Q

How do you treat an abscess?

A

Co-amoxiclav

49
Q

Describe the follow-up after pneumonia

A

1) Clinical review at 6 weeks (might still feel tired) → mainly want to check that CXR is better (not cancer)
2) CXR if smoker, <50, still symptomatic

50
Q

How do you prevent pneumonia?

A

1) Vaccination

2) Prophylactic antibiotics

51
Q

Describe vaccination to prevent pneumonia

A

1) Pneumovax → against strep pneumo, >65s are vaccinated
2) Prevenar → has an adjuvant. esp. for children <2, responsible for reduction in pneumococcal states and probably general reduction
3) Influenza vaccine

52
Q

When are prophylactic antibiotics given and which ones?

A

1) Splenectomy → should be on penicillin life-long

2) After transplant → septrin, aciclovir and penicillin

53
Q

When would you not want to identify the species causing the pneumonia?

A

If patient has CURB65 score of 0 → no benefit if patient will get better on their own anyway

54
Q

Which antibiotic is usually used for gram negative bacteria?

A

Gentamicin

55
Q

Which antibiotic gives a risk of C.difficile?

A

Ciprofloxacin

56
Q

What is prodrome?

A

Early symptoms indicating the onset of a disease or illness

57
Q

What does a prodrome in pneumonia indicate?

A

More likely to be flu and strep pneumo

Stage 2: Supporting Life (30 decks)

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