Lobar Pneumonia Flashcards
(87 cards)
1
Q
What is pneumonia?
What usually causes it?
A
it is a common lower respiratory tract infection, characterised by inflammation of lung tissue
it is almost always an acute infection and almost always caused by bacteria
diagnosis is typically confirmed by chest X-ray
2
Q
For what age group is pneumonia particularly dangerous?
A
it is responsible for many deaths of patients over the age of 80
deaths amongst younger populations have dramatically decreased after introduction of antibiotics
3
Q
What is the incidence of pneumonia?
Amongst which particular group is the incidence of bacterial pneumonia higher?
A
incidence is 1 - 3 per 1,000
(0.1 - 0.3% of people have pneumonia at any one time)
incidence of bacterial pneumonia is higher amongst those with HIV , particularly IV drug users with HIV
the causatory organisms remain the same
4
Q
What % of pneumonia cases are viral?
A
most cases are caused by bacteria
around 15% are viral
5
Q
How can pneumonia be classified by anatomical location?
A
Localised pneumonia:
- affects just one particular lobe
Bronchopneumonia:
- this is a more diffuse pneumonia that affects the lobules and bronchioles
6
Q
How can pneumonia be classified by aetiology?
A
Pneumococcal pneumonia:
- accounts for 75% of cases
Atypical pneumonia:
- accounts for 20% of cases
- caused by atypical organisms such as Chlamydia, legionella or coxiella burnetti
- the infection itself tends to have similar symptoms
7
Q
If 75% of cases are pneumococcal and 20% are atypical, what are the other 5% of cases caused by?
A
- aspiration of vomit
- radiotherapy
- allergic mechanisms
8
Q
What is the most useful way to classify pneumonia?
A
the most useful distinction is between community acquired and hospital acquired pneumonia
the difference between the two is in the causatory organism
9
Q
What is the definition of hospital acquired pneumonia?
A
pneumonia that develops within 48 hours of hospital admission
10
Q
What is the prognosis like for community and hospital acquired pneumonia?
A
Community acquired:
- prognosis generally good for younger patients
- S. pneumoniae and viral pneumonias are still fatal in older patients
Hospital acquired:
- prognosis generally poor due to co-morbidities, older age range of patients and resistance of organisms
11
Q
What are common organisms that cause community acquired and hospital acquired pneumonia?
A
Community acquired:
- Streptococcus pneumoniae
- Haemophilus influenzae
- anaerobes are rare
Hospital acquired:
- Gram negative bacilli
- Staphylococcus aureus
- Drug resistant organisms are more common and more dangerous
12
Q
What rare organisms can cause community acquired pneumonia?
A
-
Chlamydia pneumoniae
- common in institutions e.g. colleges, military camps
- Mycoplasma pneumoniae
- Legionella
13
Q
What does a strep pneumoniae infection often follow on from?
A
strep pneumoniae infection often follows viral infection with influenza or parainfluenza
14
Q
What are the precipitating factors for pneumonia?
A
- Strep pneumoniae infection follows on from influenza or parainfluenza
-
hospital admission
- hospital acquired infection is associated with Gram-negative organisms
-
cigarette smoking
- this is the most important risk factor in pneumococcal disease
- alcohol excess
- bronchiectasis (e.g. in CF)
- bronchial obstruction (e.g. carcinoma)
- immunosuppression
- IV drug use
- dysphagia (leads to aspiration)
15
Q
How are symptoms of pneumonia different in hospital acquired and community acquired cases?
A
symptoms are typically the same
increased secretions are noticeable in ventilated hospital acquired cases
16
Q
What symptoms does pneumonia usually present with?
A
- shortness of breath
- cough
- fever
- rigors
- vomiting
- headache
- loss of appetite
- pleuritic chest pain
- dyspnoea
- tachypnoea
- tachycardia
17
Q
What type of cough does pneumonia typically present with?
A
the cough tends to be productive in adolescents and adults and may produce purulent sputum
it tends to be dry in infants and the elderly
18
Q
What is pleuritic chest pain?
Where can it radiate to?
A
a sharp shooting or stabbing pain, usually in the side
it is most painful on inspiration, but can also be felt on expiration or even whilst talking
it can radiate to the shoulder (if diaphragm is involved) or to the anterior abdominal wall
19
Q
What symptom may be present in patients with lower lobe pneumonia?
A
upper abdominal tenderness
20
Q
What respiratory symptom is rarely present in pneumonia?
A
haemoptysis is very rarely present
21
Q
What signs are present in pneumonia?
A
there will be signs of consolidation on examination and CXR
- ipsilateral reduced chest expansion
- dull to percussion
- reduced breath sounds due to reduced air entry into that region of the lung
- coarse crackles
22
Q
What signs may be present in pneumonia caused by strep pneumoniae?
A
- rapid shallow breathing
-
pleural friction rub
- squeaking / grating sound of the pleural linings rubbing together
- sounds like treading on fresh snow
- occurs when pleural layers are inflamed and have lost their lubrication
23
Q
What sign of pneumonia may be present in elderly patients?
A
sometimes confusion is the only sign present in elderly patients
24
Q
When should we be concerned about oxygen saturation?
A
<92% is worrying
25
What is performed following clinical suspicion of pneumonia and what should it show?
a **_CXR_** is performed to confirm the diangosis
this shows the **evidence of infiltrate** in the form of **_consolidation_**
it can also show the **spread of any infection** by **_distribution of the infiltrate_**
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When can consolidation be visible on a pneumonia CXR?
changes may not appear on CXR for **_up to 48 hours_ after symptoms**
after effective treatment, consolidation may still be visible on X-ray for **_up to 6 weeks_**
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How often should CXR be repeated for pneumonia patients and why?
* CXR should be repeated **_at least weekly_ for inpatients**
* they should then be repeated **_every 6 weeks_** as an outpatient
* any signs still present indicate the need for a further X-ray
* **_persistent X-ray changes_** may suggest **_underlying carcinoma_ with secondary pneumonia**
28
Why may blood cultures be taken?
blood cultures are taken to assess for **_bacteraemia_**
it is not routine practice to identify the causatory organism in community acquired infection
29
What would a full blood count for pneumonia show?
* **raised WCC**
* **raised ESR** (\>100 mm/h) and **raised CRP**
* **possible anaemia** (sign of abscess)
* blood cultures are taken in ill patients to assess for septicaemia
30
When might urine samples be taken in pneumonia?
in **severe cases** of pneumonia, where ***_legionella_*** is suspected
urine testing for **legionella antigen** may be performed
31
When might pleural fluid aspiration be performed in pneumonia?
to assess for organisms
**_transthoracic aspiration_** may be performed (often with CT guidance) to **identify lesions** (e.g. empyema abscess) and to **gain samples**
32
What is used to assess the severity of community-acquired pneumonia?
**_CURB-65 score_**
this predicts the **risk of mortality**
(CURB score 0 = \<1% risk - CURB score 5 = 60% risk)
each factor of the score is worth 1 point
33
How is the CURB-65 score measured?
**_C - CONFUSION:_**
* use the abbreviated mental test (score = 8)
**_U - UREA:_**
* \> 7mmol/L
**_R - RESPIRATORY RATE:_**
* \>/= 30 / min
**_B - BLOOD PRESSURE:_**
* \< 90 systolic or \<60 diastolic
**_65 - AGE:_**
* age \> 65 years
a score of 3 or more is severe pneumonia
a score of 2 or more requires hospitalisation
34
What are the differential diagnoses of pneumonia?
* pulmonary oedema
* tuberculosis
* pulmonary embolism
* patient is not usually systemically unwell
* SOB more likely to be sudden onset
35
When are antibiotics given to treat pneumonia?
* **_oral antibiotics_** are given if patient is **NOT vomiting** and CURB65 score **= 2**
* **_IV antibiotics_** are given if patient is **vomiting** and/or CURB65 score is **\>/= 3**
36
What other treatments should be in place for pneumonia?
* **_oxygen therapy_** is required to keep O2 sats **\> 92%**
* **_IV fluids_** are given to **prevent dehydration and shock**
* progress is monitored via **_repeat CXRs_**
* all patients should receive a 6-week follow up including repeat CXR
37
How and when should complications of pneumonia be assessed for?
in any patient who is **not responding to treatment** appropriately, **CXR and FBC** should be repeated to assess for complications
**_CRP_** is of particular importance
38
What are the 3 immediate complications of pneumonia?
these are present **_at presentation_** or **_within a few days_**
* **respiratory failure** (most common)
* **hypotension**
* **atrial fibrillation**
39
How is respiratory failure measured and treated?
What should sats be?
respiratory failure is present when ***_PaO2 \< 8 kPa_***
it is relatively easy to treat with **_60% (high flow) oxygen_**
sats are aimed to be kept between **90 - 94%**
40
When should someone with respiratory failure be transferred to ICU?
In what patients should extra caution be taken?
if ***PaCO2*** **rises to _\>6 kPa_** or **hypoxia does not resolve** with oxygen therapy, then transfer to ICU
be careful using O2 in COPD patients as it can reduce hypoxic drive
**_regular ABG testing_** should be performed and **_intubation_** considered if situation is not improving
41
Why does hypotension occur as a complication of pneumonia?
How is it treated?
it is the result of **_dehydration_** and **_vasodilation_** due to **sepsis**
it should be treated when **systolic** blood pressure drops **_below 90 mmHg_**
it is treated with **_250ml of crystalline infusion over 15mins_**
42
When does atrial fibrillation tend to occur as a complication of pneumonia?
How is it treated?
it is a common complication in the **elderly**
it usually resolves with the **treatment of pneumonia**, but **_digoxin_** can be given to reduce the HR as a **_short-term therapy_**
43
What are the 5 different medium term complications associated with pneumonia?
these occur within days of initial presentation
* pleural effusion
* empyema
* lobar collapse
* thromboembolism
* pneumothorax
44
How can pleural effusion result from pneumonia?
How is it treated?
the pleura may become **_inflamed_**, which can result in **_excess fluid production_**, causing a pleural effusion
it often does not require treatment
in some individuals, it may require **drainage**
45
When are clinical signs present for a pleural effusion?
clinical signs are not usually present until the **_volume of fluid is \>500ml_**
rarely, the fluid can become infected, resulting in **empyema**
46
When does empyema tend to affect a pneumonia patient?
How does it present?
typically presents in a patient who has **partially recovered**, but then develops a **spike in temperature**
signs of pleural effusion may be present:
* **decreased chest expansion**
* **dullness** to percussion
* **reduced breath sounds**
* **pleural rub**
* all on the affected side
47
What does the fluid look like following fluid aspiration in empyema?
How are samples obtained and what type of bacteria are usually present?
fluid is usually **_yellow_**, with a **_pH \<7.2_** and **_low levels of glucose_**
samples are obtained via aspiration, bronchoscopy or transthoracic aspiration using USS/CT guidance
**70%** of cases of empyema consist **_purely of anaerobes_**
**30%** of cases of empyema have **_both aerobic and anaerobic bacteria_** present
48
What is the primary treatment method for empyema?
treatment is with the insertion of a **_chest drain_**, usually with radiological guidance
49
What antibiotic therapy is given for the treatment of empyema?
* antibiotics are given for **_4 - 6 weeks_**
* it needs to be something that is effective against **both aerobic and anaerobic bacteria**
* typically **_IV cefuroxime_** and **_co-amoxiclav_** for **5 days** followed by **3-5 weeks** of **_metronidazole_** alone
50
Why can lobar collapse occur as a complication of pneumonia?
this is most commonly the result of **_sputum retention_**
51
When does pneumothorax tend to occur as a complication of pneumonia?
it is particularly associated with ***Staphylococcus aureus*** as a causative organism
52
What are the 5 main categories of late complications of pneumonia?
these occur within **days to weeks** of initial presentation
* lung abscess
* septicaemia
* ARDS / renal failure / multi-organ failure
* ectopic abscess
* hepatitis, pericarditis, myocarditis & meningitis
53
What is a lung abscess?
What can it commonly result from?
it is a ***_cavitating lesion_ containing _pus_, within the lung***
it commonly results from **_aspiration_** (e.g. alcoholism, inhaled foreign body, oesophageal blockage, bulbar palsy)
it also occurs in **_bronchial obstruction_** (e.g. carcinoma)
it is most likely to occur if **pneumonia is not adequately treated**
54
What organisms are more likely to cause a lung abscess?
some organisms are more likely to cause an abscess than others
such as ***Staphyloccocus aureus*** and ***Klebsiella pneumoniae***
sometimes, **_septic emboli_**, particularly in the case of **_staphylococci_**, can result in **_multiple lung abscesses_**
55
What else can more rarely lead to lung abscess formation?
**_pulmonary infarction_** can cavitate, may become infected, and result in abscess formation
56
How would a lung abscess as a complication of pneumonia typically present?
* a pneumonia that **_worsens despite treatment_**
* production of **_purulent sputum_**, as a result of the growth of **_anaerobic_ organisms**
* likely to be **fever, malaise, anaemia** and **weight loss**
* **_clubbing_** can occur if the abscess has been present for long enough
57
What are the investigations for lung abscess?
* CXR - shows a **_walled cavity_**, usually with a **_fluid level_**
* Bloods - FBC for **anaemia & neutrophilia**
* **ESR & CRP will be raised**
* **sputum sample** - to identify organism
* bronchoscopy is sometimes performed to obtain samples
58
What are the treatments for lung abscess?
* treat as per antibiotic sensitivities for **4-6 weeks**
* consider **postural drainage** to remove excess sputum
* in severe cases, antibioitc instillation / aspiration and sometimes surgical excision may be required
59
When can septicaemia occur as a complication of pneumonia?
What can it result in?
can occur if the **bacteria enter the bloodstream**
can result in **_infective endocarditis_** and **_meningitis_**
60
What is the treatment for septicaemia following pneumonia?
the patient will be very systemically unwell and will need IV antibiotics once blood cultures have been performed to identify the causative organism
61
When are hepatitis, pericarditis, myocarditis and meningitis typically seen as complications of pneumonia?
most commonly seen in mycoplasma pneumoniae infection, which is most prevalent in young adults
62
In someone with streptococcus pneumoniae infection, how does the pneumonia tend to progress over time?
* very commonly **_preceded by viral infection_**
* patient rapidly becomes **_febrile_**, with a temperature of up to **39.5C**, along with **_pleuritic pain_** and **_cough_**
* the cough becomes **productive** over the coming days and produces **_rust coloured sputum_**
* breathing may become **rapid and shallow** with **_decreased chest expansion_** on the affected side
* **_pleural rub_** may be present
63
What causes of pneumonia are more common in young people and older people?
* ***Mycoplasma pneumoniae*** and ***Chlamydia pneumoniae*** are common in the **_young_**, but rare in the elderly
* ***Haemophilus influenzae*** is common in **_elderly_** people, but rare in the young
* **viral infections** are very common in **_children_**
64
In what group of people is legionella infection more common?
it is more common in those with recent foreign travel
65
How does acute coryza (the common cold) tend to present itself?
What symptoms are present?
* **rapid onset**
* **burning / tickling sensation** in the nose
* **sneezing**
* **sore throat**
* **blocked nose** with **watery discharge**
* discharge turns **green / yellow** after **24-48 hours**
66
What are the complications of acute coryza?
* **sinusitis**
* lower respiratory tract infection (**bronchitis / pneumonia**)
* **hearing impairment / otitis media** due to blockage of eustachian tubes
67
What is the treatment for acute coryza?
* most do not require treatment
* **paracetamol 0.5-1g every 4-6 hourly** for relief of systemic symptoms
* **nasal decongestants** may be used
* antibiotics are NOT necessary in uncomplicated coryza
68
What is acute laryngitis often a complication of?
How does this present?
* often a complication of **acute coryza**
* **_dry sore throat_** with **hoarse voice** or **loss of voice**
* attempts to speak cause pain
* initially there is a **_painful and unproductive cough_**
69
What symptom may be present in children with acute laryngitis and why?
**_stridor_** in children (croup) due to **inflammatory oedema** leading to **_partial obstruction_ of a small larynx**
70
What are the potential complications of acute laryngitis?
* complications are rare
* **chronic laryngitis**
* downward spread of infection may cause **tracheitis, bronchitis or pneumonia**
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What are the treatments for acute laryngitis?
* **rest the voice**
* **paracetamol 0.5-1g every 4-6 hourly** for relief of discomfort and pyrexia
* **steam inhalations**
* antibiotics are NOT necessary for acute laryngitis
73
What is croup?
a **childhood viral infection** that causes **_swelling_** around the **larynx** (vocal cords), **trachea** and **bronchi**
the **_breathing is obstructed_**, causing a characteristic **_barking cough_**
74
What are the symptoms of acute laryngo-tracheobronchitis (croup)?
* initial symptoms are like the **common cold**
* sudden paroxysms of **_cough_** accompanied by **_stridor and breathlessness_**
* **_contraction of accessory muscles_** and **indrawing of intercostal spaces**
75
What can happen to small children with croup if appropriate treatment is not given?
cyanosis and asphyxia (suffocation)
76
What are the potential complications of acute laryngo-tracheobronchitis (croup)?
* **asphyxia** and death
* **_superinfection_** with bacteria, especially ***Streptococcus pneumoniae*** and ***Staphylococcus aureus***
* viscid secretions that may occlude the bronchi
77
What are the treatments for acute laryngo-tracheobronchitis?
* **inhalations of steam** and **humidified air** / high concentrations of oxygen
* **_endotracheal intubation_** or **_tracheostomy_** to relieve laryngeal obstruction and allow clearing of bronchial secretions
* IV antibiotics (**_co-amoxiclav_** or **_erythromycin_**)
* maintain adequate hydration
78
How does acute epiglottitis present?
**_fever_** and **_sore throat_**, rapidly leading to **_stridor_** because of **swelling of the epiglottis** and surrounding structures
**stridor and cough** in **absence of much hoarseness** can distinguish acute epiglottitis from other causes of stridor
79
What organism is usually responsible for swelling of the epiglottis in acute epiglottitis?
***Haemophilus influenzae***
80
What are the complications associated with acute epiglottitis?
What should be avoided and why?
* **_death from asphyxia_** which may be precipitated by attempts to **examine the throat**
* **_avoid using tongue depressor_** / any instrument unless facilities for **endotracheal intubation or tracheostomy** are **immediately available**
81
What are the treatments for acute epiglottitis?
* IV antibiotics - **_co-amoxiclav_** or **_chloramphenicol_**
* other measures are the same as for acute laryngo-tracheobronchitis
82
What does acute bronchitis & tracheitis often follow on from?
What are the initial symptoms?
* often follows **acute coryza**
* initially presents with **_irritating unproductive cough_** accompanied by **_retrosternal discomfort_** of tracheitis
* when bronchi become involved, there is **_chest tightness_**, **_wheeze_** and **_breathlessness_**
* tracheitis causes **_pain on coughing_**
83
How does the sputum change in acute bronchitis & tracheitis?
* initially sputum is **scanty or mucoid**
* after about **1 day,** sputum becomes **_mucopurulent_** and **_more copious_**
* in tracheitis, sputum becomes **_blood-stained_** often
84
What is acute bronchial infection associated with?
How long does it take to recover?
* associated with **pyrexia of 38 - 39C** and a **neutrophil leucocytosis**
* spontaneous recovery occurs over a few days
85
What are the potential complications of acute bronchitis and tracheitis?
* **bronchopneumonia**
* **exacerbation of chronic bronchitis**, which often results in type II respiratory failure in patients with severe COPD
* **acute exacerbation of bronchial asthma**
86
What treatment is given to ease the cough in acute bronchitis & tracheitis?
**_Pholcodine_**
**5 - 10 mg every 6-8 hourly**
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