Chronic Pulmonary Infection

Question 1

How is chronic pulmonary infection diagnosed?

Answer 1

Shadow on CXR 
Weight loss 
Persistent sputum production 
Chest pain 
Increased SOB

Question 2

What can be the differential diagnosis if pulmonary infection is suspected?

Answer 2

Lung cancer 
Intrapulmonary abscess
Emypema 
Bronchiectasis 
CF

Question 3

What are the risk factors for developing chronic pulmonary infections?

Answer 3

Abnormal host response
Abnormal innate host defence
Repeated insult

Question 4

What is abnormal host response?

Answer 4

Immunnodeficiency: Congenital, acquired
Immunosuppression: Drugs, malignancy

Question 5

What is abnormal innate host defence?

Answer 5

Damaged bronchial mucosa
Abnormal cillia
Abnormal secretions

Question 6

What is repeated insult?

Answer 6

Aspiration

Indwelling material

Question 7

What is immunodeficiency?

Answer 7

Immunoglobulin deficiency
Hypo-splenism
Immune paresis
HIV

Question 8

What are the different types of immunoglobulin deficiency?

Answer 8

IgA deficiency: common, increased risk of acute infections, rarely chronic infections
Hypogammaglobulinaemia: rarer, increased risk of acute and chronic infections
CVID: commenest cause of immunodeficiency, recurrent infections
Specific Polysaccharide Antibody Deficiency SPAD

Question 9

What are the different types of immune paresis?

Answer 9

Myeloma
Lymphoma
Metastatic malignancy

Question 10

What can cause immunosuppression?

Answer 10

Steroids 
Azathioprine
Methotrexate
Cyclophosphamide 
Monoclonal antibodies: Infliximab
Rituximab 
Chemotherapy

Question 11

What can cause damaged bronchial mucosa?

Answer 11

Smoking
Recent pneumonia or viral infection
Malignancy

Question 12

What can cause abnormal cilia?

Answer 12

Kartenager’s Syndrome

Youngs Syndrome

Question 13

What can cause abnormal secretions?

Answer 13

CF

Channelopathies

Question 14

What can cause recurrent aspirations?

Answer 14

NG feeding
Poor swallow
Pahyngeal pouch

Question 15

What can cause indewlling of material?

Answer 15

NG tube in the wrong place
Chest drain
Inhaled foreign body (peanut, chicken bone ect)

Question 16

What are different forms of chronic infection?

Answer 16

Intrapulmonary abscess
Empyema 
Chronic Bronchial Sepsis
Bronchiectasis
CF or other oddities

Question 17

What are the signs and symptoms of intrapulmonary abscess?

Answer 17

Indolent presentation 
Weight loss common
Lethargy, tiredness, weakness
Cough - can be with or without sputum
High mortality if not treated 
Usually a preceding illness of some sort

Question 18

What can be the preceding illness that leads to intrapulmonary abscess?

Answer 18

Pneumonia: Flu - Staph pneumonia - cavitating pneumonia - abscess
Aspiration pneumonia: vomiting, lowered conscious level, pharyngel pouch
Poor host immune response: Hypogammaglobulinaemia

Question 19

What pathogens can cause intrapulmonary abseccess?

Answer 19

Bacteria: Streptococcus, Staphylococcus, E-coli, Gram negatives
Fungi: Aspergillus

Question 20

What can cause a septic emboli?

Answer 20

Right sided endocarditis
Infected DVT
Septicaemia
IV drug users (PWID) - inject into groin, DVT, infection, PE + abscesses

Question 21

What is an empyema?

Answer 21

Pus in the pleural space
57% of all patients with pneumonia develop pleural fluid
Remainder are primary empyema - often iatrogenic, many idiopathic
High mortality - 20% of all patients with empyema die

Question 22

What are the characteristics of a simple parapneumonic effusion?

Answer 22

Clear fluid
pH > 7.2
LDH < 1000
Glucose > 2.2

Question 23

What does LDH measure?

Answer 23

Tissue damage

Question 24

What are the characteristics of a complicated parapneumonic effusion?

Answer 24

pH <7.2
LDH >1000
Glucose <2.2
Requires chest tube drainage

Question 25

What are the characteristics of am empyema?

Answer 25

Frank pus

Question 26

What is the bacteriology of an empyema?

Answer 26

Aerobic organisms most frequently Gram positives: Strep milleri, staph aureus (usually post-operative or nosocmial in immunocompromised individuals) Gram negatives: E-coli, pseudomonas, haemophilus influenzae, kelbsiellae Anaerobes in 13% of cases - usually in severe pneumonia or poor dental hygiene

Question 27

How is an empyema diagnosed?

Answer 27

Clinical suspicion: slow to resolve pneumonia with lateral CXR CXR: persisting effusion USS: simple bedside test, targetted sampling CT: Differentiation between empyema and abscess

Question 28

What does a CXR look like in empyma?

Answer 28

Look for D sign | Better CXR increase sensitivity and specificity

Question 29

How can empyema's be treated?

Answer 29

USS guided drainage IV antibiotics - broad spectrum, amoxicillin and metrondioazole Oral antibiotics - directed towards cultured bacteria for at least 14 days

Question 30

What is bronchiectasis?

Answer 30

The localised, irreversible dilation of the bronchial tree Involved bronchi are dilated, inflamed and easily collapsed This causes airflow obstruction and impaired clearance of secretions

Question 31

What is the presentation of bronchiectasis?

Answer 31

Recurrent chest infections Recurrent antibiotics prescriptions but no response to antibiotics or a short lived response to antibiotics Persistent sputum production

Question 32

How is bronchiectasis diagnosed?

Answer 32

Clinical - cough production of sputum, chest pain, recurrent LRTIs Radiological - HRCT

Question 33

What can cause bronchiectasis?

Answer 33

``` Bronchial obstruction CF Young's syndrome Kartanger's syndrome ABPA Immunodeficiency Rheumatoid arthritis Bronchopulmonary sequestration Mounier-Khun syndrome Yellow nail syndrome Traction bronchiectasis associated with pulmonary fibrosis ```

Question 34

What is chronic bronchial sepsis?

Answer 34

Has all the hallmarks of bronchiectasis but no findings on the HRCT. Confirmed positive sputum results, often in younger patients, mainly women, often in involved in childcare Others are older, usually with COPD or airways disease Same work up as bronchiectasis The sinuses are resovoirs of infections

Question 35

What are treatment options for bronchiectasis?

Answer 35

Stop smoking Flu vaccine Pneumococcal vaccine Reactive antibiotics - send sputum sample, give antibiotics appropriate to most recent positive culture

Question 36

What is the treatment when the patient with bronchiectasis is colonised with bacteria?

Answer 36

Prophylactic antibiotics Nebulised gentamicin, colomycin Pulsed IV antibiotics Alternating oral antibiotics

Question 37

What is the prognosis for patients with bronchiectasis?

Answer 37

Recurrent infections Abscesses and empyema Colonisation

Question 38

What are some complications of CF?

Answer 38

``` Bronchiectasis - cystic saccular Tenacious sputum Biliary obstruction and obstructive hepatitis Pancreatic dysfunction Psychological issues for all ```