Community acquired pneumonia

Question 1

Pathological definitino of pneumonia

Answer 1

inflammation of the lung parenchyma leading to consolidation

doesnt have to be infectious (e.g., cryptogenic causing inflammation) or bacterial (can be viruses or fungi) however usually is.

Question 2

Consolidation

Answer 2

when areas of the lung that are normally filled with air is replaced with something else

Appears as white on X-ray

The liquid can be pulmonary edema, inflammatory exudate, pus, inhaled water, or blood (from bronchial tree or hemorrhage from a pulmonary artery).

Question 4

Pneumonia has symptoms of a LRTi. They are:

Answer 4

pleuritic pain, cough, sputum, breathlessness

Question 5

What changes would you see on CXR compared to healthy lung

Answer 5

shows consolidation, areas of incresaed density so whiter

Question 6

What localised breathing sounds would you look out for?

Answer 6

respiratory crackles- reduced air entry into one section of the lung

Question 7

definition of community acquired pneumonia

Answer 7

acquired outside the hospital or healthcare facility (didnt acquire it within 48 hours of being discharged and it wasnt incubating)

Question 8

Hospital acquired pneumonia

Answer 8

Acquired <48 hrs into hospital admission that wasn’t incubating on admission.

Recently hospitalised patients can be treated as CAP unless additional risk factors for MDR’s/ HAP e.g. recent Ab (antibiotic) abuse

Question 9

Disproportionately affects which 2 groups of people?

Answer 9

old and socioeconomically less well off

Question 10

Typical bacterial pathogens that cause pneumonia

Answer 10

streptococcus pneumoniae

haemophilus influenza

staphylococcus aureus

Question 11

Symptoms of typical bacterial infection causing pneumonia

Answer 11

Sudden onset

malaise

fever

producrtive cough

on auscultation- crackles and bronchial breath soudns are audible

Opacity related to one lobe

Question 12

Bacterial pathogens associated with pneumonia

Answer 12

Atypical- DON’T RESPOND TO B-LACTAMS

Mycoplasma pneumonia

Chlamydia pneumoniae

Legionella pneumoniae

Question 13

Symptoms of atypical bacterial pneumonia infection

Answer 13

Gradual onset

Unproductive cough

Dyspnoea

Auscultation is unremarkable

X-ray shows diffuse opacity- almost subtle infiltrates

Question 14

Other bacteria that can cause pneumonia

Answer 14

Pseudomonas aeruginosa

Enterobacteriaceae

Group A steptococcus

Question 15

Viral pathogens that can cause pneumonia

Answer 15

Influenza A and B

Rhinoinfluenza

Corona virus–> COVID-19 and SARS

Question 16

Entry

Answer 16

Inhaled

Aspiration from oropharynx

Direst spread

Haematogenous spread

Question 17

Protective factors

Answer 17

Lung mucosal microbiome

Immunity (innate and adaptive)

Question 18

Risk factors for pneumonia

Answer 18

• Age >65 years
• Residence in a healthcare setting
• COPD
• HIX infection
• Cigarette smoke exposure
• Alcohol abuse
• Pharmaceuticals- PPI, inhaled corticosteroids, antidiabetic drugs

Question 19

Differential diagnosis

Answer 19

Left ventricular failure

Pulmonary embolus

Infective exacerbation COPD

Acute asthma

TB

Emphysema

Lung neoplasm

Question 20

When to consider atypical pathogens

Answer 20

Foreign travel

Prior antibiotics, hyponatraemia (mycoplasma)

Air conditioning exposure

Abnormal LFTs

Neurological exposure

Subacute presentation

Question 21

Clinical signs to look for on examination

Answer 21

Fever

cyanosis, tachypnoea, dyspnoea

Tachhycardia, hypotension (think sepsis)

localising signs- dullness to percussion, bronchial breathing, crackles

AVPU- rapidly grade a patient’s level of consciousness (Alert, Verbally responsive, pianfully responsive, Unresponsive)

Question 22

What measure would you use to assess the severity of pneumonia?

Answer 22

CURB-65

Confusion (AMTS < 8/10 Abbreviated mental test score

Urea (>7mmol/L)

Respiratory rate >/= 30 breaths/min

Blood pressure (SBP < 90mmHg), DBP =60)

Age> 65 years

a score of 0-1 is low severity 3-5 is high severity

Question 23

What is the pneumonia severity index

Answer 23

Index to assess the severity of pneumonia. Higher the score higher the MR.

The more factors you have, the higher your suspected mortality rate is. Helps determine whether a patient can be treat as an outpatient or needs to be in.

Split into 4 main categories:

Demographics: age, nursing home residency

Co-morbidities: neoplasia, liver disease, CHF, renal disease, cerebrovascular disease

Physical exam/ vital signs: mental confusion, repiratory rate, tachycardia

Laboratroy imaging: Arterial pH, sodium, glucose, haematocrit, pleural effusion, oxygenation

Question 24

Once your patient has been diagnosed whaty other investigations will you need?

Answer 24

Routine bloods: FBC, U and E, LFTs, CRP procalcitonin

ABG

Blood culture testing for Ab sensitivity

Sputum culture and screen

Pneumococcal/ legionella urinary antigen screening

Paired serology if they’re not responding to treatment

Question 25

Where would you treat someone with a low severity pneumonia?

Answer 25

At home

Question 26

Conraindication to outpatient therapy

Answer 26

Inability to maintain oral intake History of substance abuse Severe comorbid ilnesses Cognitive impairment Impaired functional status Availability of support at home

Question 27

Imaging options for pnuemonia

Answer 27

Lung ultrasound Chest CT

Question 28

Lung ultrasound for pneumonia

Answer 28

Quick Simple Cheap Reliable Assess plueral effusions Can miss diagnosis of diffuse diseas or interstitial pneumonias

Question 29

Chest CT

Answer 29

Provides the most information poor access and ionizing radiation

Question 30

Supportive treatment for all patients

Answer 30

Oxygen to keep SpO2 (oxygen sat) 94-\> 98% or 88-\>92% if T2RF Fluids if hypotensive VTE (venous thromboembolism) prophylaxis Nutritional support if prolonged illness Sitting up for at least 20 mins a day Chest physio review to remove sputum

Question 31

***_British Thoracic Society (BTS) Community Acquired Pneumonia Care Bundle_***

Answer 31

1. Perform CXR within 4 hours of admission 2. Assess oxygen saturation and prescribe oxygen according to appropriate target range 3. Calculate CURB-65 in all patients where CXR demonstrates pneumonia 4. Administer antibiotics within 4 hours of diagnosis appropriate to CURB 65 score

Question 33

What is the first line antibiotic used in suspected mild pneumonia?

Answer 33

Amoxicillin Alternatives: clarithromycin or doxycycline

Question 34

Amoxicillin

Answer 34

CLASS: semisynthetic penicillin derivative antibacterial CHEMSITRY: PHARMACOLOGY: Action: bacteriocydal. attaches to cell wall of susceptible bacteria and kills by inhibiting the cross-linkage of peptidoglycan polymer chains that make up the major component of the bacterial cell wall penicillin allergy beware Amoxicillin rash may also be an indicator of infectious mononucleosis in patients with EBV infection

Question 35

Doxycycline

Answer 35

Broad spectrum antibiotic Tetracycline Bacteriostatic- inhibits bacterial protein synthesis- **binds the 30S ribosomal subunit, prevents the binding of transfer RNA to messenger RNA at the ribosomal subunit** **Amino acids therefore cant be added to polypeptide chains** meaning that no new proteins can be made

Question 36

What medication should be given to severe pneumonia

Answer 36

co-amoxiclav (consider adding clarithromycin)

Question 37

If atypical pneumonia suspected add...?

Answer 37

clarithromycin

Question 38

If aspiration pneumonia treatment

Answer 38

Antibiotics not needed unless concerned about secondary infection (co-amoxiclav)

Question 39

Discahrge and follow up

Answer 39

Discharge when established on oral Ab's and the 'abnormal' vitals are normal Patient should have CXR 6 weeks after discharge Explain to patients/ carers that they should see the GP is symptoms do not begin to improve within 3/7 weeks of starting Ab's and return to ED if they worsen Pneumnonia patient information leaflet

Question 40

What to do if the patient isnt getting better

Answer 40

Consider differential diagnosis- empyema, lung abscess, lung cancer Differnt organism? reculture Bronchoscopy with lavage-- TB?

Question 41

Empyema

Answer 41

aka pyothorax Condition in which pus gathers in the pleural space

Question 42

Lung abscess

Answer 42

Death of lung tissue Collection within it is either air or fluid check for spiking temperature despite antibiotics

Question 43

How long does it take to feel better after pneumonia?

Answer 43

can take a few months to feel better rest and build up your strangth again