Lower respiratory tract infection in adults

Question 1

What are the possible lower respiratory tract infections ?

Answer 1

Acute bronchitis
Exacerbation of COPD
Pneumonia
Empyema
Lung abscess
Bronchiectasis

Question 2

What is acute bronchitis ?

Answer 2

Temporary inflammation of the bronchi

Question 3

How long does acute bronchitis last for ?

Answer 3

<3 weeks

Question 4

What are the signs of acute bronchitis ?

Answer 4

Cough

Sputum

Question 5

What is usually the cause of acute bronchitis ?

Answer 5

Viral

Question 6

What is COPD exacerbation ?

Answer 6

Worsening of symptoms
Change in colour of sputum
Increased SOB, wheeze, cough

Question 7

What is a likely caustitive agent of AECOPD ?

Answer 7

Strep pneumoniae
H.Influenzae
Moraxella catarrhalis
Viral

Question 8

What is the treatment of COPD exacerbation ?

Answer 8

Steroids
Antibiotics
    - amoxycillin
    - doxycycline
    - co-trimoxazole
    - clarithromycin

Question 9

What is pneumonia ?

Answer 9

Inflammation of the lung parenchyma

Question 10

How many cases of acute bronchitis develop into pneumonia ?

Answer 10

1 in 10

Question 11

What is consolidation ?

Answer 11

Solidification due to cellular exudate in alveoli leads to impaired gas exchange

Question 12

What are risk factors for pneumonia ?

Answer 12

Smoking, alcohol
Extremes of age
Preceding viral illness
Pre-existing lung disease
Chronic illness
Immunocompromised
Hospitalisation
IDVU

Question 13

What are the symptoms of pneumonia ?

Answer 13

Malaise
Fever
Chest pain (pleuritic)
Cough
Purulent sputum
Dyspnoea
Haemoptysis

Question 14

What is rusty sputum usually associated with ?

Answer 14

Strep pneumoniae

Pneumococcal pneumonia

Question 15

What are the signs of pneumonia ?

Answer 15

Pyrexia
Tachycardia 
Tachypnoea
Central cyanosis
Dullness of percussion of affected lobes
Bronchial breath sounds
Inspiratory crepitations
Increased vocal resonance

Question 16

What are the investigations for pneumonia in community ?

Answer 16

Maybe none

CXR if in doubt

Question 17

What are the investigations of pneumonia in hospital ?

Answer 17

Bloods- serum biochemistry, FBC, CRP
Blood cultures
CXR
Sputum culture
Viral throat swab
Legionella urinary antigen

Question 18

What are the most likely causes of pneumonia ?

Answer 18

Strep pneumonia
H.Influenzae

Legionella
Staph aureus 
Moraxella catarrhalis
Mycoplasma pneumoniae
Chlamydophilia pneumoniae 
Chlamydophilia psittaci 
Coxiella burnetti
All viruses

Question 19

What are the differential diagnosis of pneumonia ?

Answer 19

TB
Lung cancer 
Pulmonary embolism
Pulmonary oedema
Pulmonary vasculitis (wegners granulomatosis)

Question 20

What are typical community acquired microorganisms ?

Answer 20

Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae

Question 21

What are atypical community acquired microorganisms ?

Answer 21

Legionella pneumophilia
Chlamydia pneumoniae
Chlamydia psittaci
Coxiella burnetti
Moraxella catarrhalis
Viruses

Question 22

What is nosocomial infection ?

Answer 22

healthcare-associated infections (HAI)

Infections acquired during the process of receiving health care that was not present during the time of admission

Question 23

When does nosocomial (HAI) occur ?

Answer 23

> 48hrs after admission

Question 24

What are nosocomial microorganisms ?

Answer 24

Enterobacteria
Staphylococcus aureus
Pseudomonas aeruginosa
Klebsiella pneumoniae

Question 25

How is the severity of pneumoia scored ?

Answer 25

CURB65

Question 26

What does CURB65 mean ?

Answer 26

``` C- confusion U- blood urea >7mmol/L R- RR >/= 30/min B- systolic BP <90mmHg, diastolic BP <60mmHG 65- age >/= 65 ```

Question 27

What does a CURB score of 0-1 mean ?

Answer 27

Low risk- could be treated in community

Question 28

What does a CURB score of 2 mean ?

Answer 28

Moderate risk- hospital treatment usually required

Question 29

What does a CURB score of 3-5 mean ?

Answer 29

High risk of death and need for ITU

Question 30

What is the treatment for a CURB score of 0-1 ?

Answer 30

Amoxycillin Clarithromycin/ doxycycline (if penicillin allergy) for 5 days

Question 31

What is the treatment for a CURB score of 2 ?

Answer 31

Amoxycillin + clarithromycin Levofloxacin (if penicillin allergy) 5-7 days

Question 32

What is the treatment for a CURB score of 3-5 ?

Answer 32

Co-amoxiclav + clarithromycin Levofloxacin or co-trimoxazole (if penicillin allergy) 7-10 days

Question 33

What other treatment besides antibiotics is advisable ?

Answer 33

Oxygen IV fluids Continuous positive airway pressure Intubation and ventilation

Question 34

What are the complications of pneumonia ?

Answer 34

``` Sepsis Acute kidney injury Adult resp distress syndrome Parapneumonic effusion Empyema Lung abscess Disseminated infection ```

Question 35

Why can pulmonary embolism look like pneumonia on a scan ?

Answer 35

Because of the pulmonary infarcts they cause

Question 36

What are the most common causes of empyema ?

Answer 36

Streptococcus Staph aureus Anaerobes

Question 37

What are the signs/symptoms of empyema ?

Answer 37

Chest pain Absence of cough High fever

Question 38

How do you investigate empyema ?

Answer 38

CT and ultrasound

Question 39

How do you diagnose empyema ?

Answer 39

pH is less than 7.2 after pleural aspiration

Question 40

What is the treatment of empyema ?

Answer 40

Chest drain and intravenous antibiotics (prolonged - 6 weeks) Intrapleural tissue plasminogen activator and DNase sometimes required (these break down adhesions in pleural space and allow tissue to flow out) Surgery for patients who do not improve with the above management

Question 41

What can lung abscesses follow from ?

Answer 41

Pneumonia

Question 42

What are the symptoms of a lung abscess ?

Answer 42

Non-specific Lethargy Weight loss High Swinging fever

Question 43

What are the relevant investigations for lung abscess ?

Answer 43

CT thorax Sputum culture TB microscopy and culture as TB can be cavitating

Question 44

Which bacteria are more likely to cause lung cavitation ?

Answer 44

Staph. Aureus | Pseudomonas

Question 45

What is treatment for lung abscess ?

Answer 45

Prolonged antibiotics | Drainage via the bronchial tree or percutaneous

Question 46

What are the risk factors for recurrent pneumonia ?

Answer 46

Immunocompromised Underlying structural lung disease Aspiration

Question 47

What is bronchiectasis defined as ?

Answer 47

Abnormal widening of the bronchi or their branches, causing a risk of infection

Question 48

What are the causes of bronchiectasis ?

Answer 48

``` Idiopathic Childhood infection CF Ciliary dyskinesia Hypogammaglobulinemia Allergic bronchi-pulmonary aspergillosis (ABPA) ```

Question 49

What is hypogammaglobulinemia ?

Answer 49

Body does not produce immunoglobulin G

Question 50

What is allergic bronchopulmonary aspergillosis ?

Answer 50

Presents like asthma (wheezing and cough) | Allergy to aspergillus

Question 51

What are the symptoms of bronchiectasis ?

Answer 51

``` Chronic productive cough Daily sputum production Breathlessness Recurrent LRTI Haemoptysis ```

Question 52

What are the signs of bronchiectasis ?

Answer 52

Finger clubbing Coarse creps Wheeze Obstructive spirometry

Question 53

How do you describe the flitting chest pains in bronchiectasis ?

Answer 53

Short lived, vary between the left and the right hand side

Question 54

What are the relevant investigations for bronchiectasis ?

Answer 54

HRCT thorax Sputum culture - will typically include haemophilus influenzae which can be resistant to amoxicillin Serum immunoglobulins (searching for Hypogammaglobulinemia) Total IgE aspergillus precipitations CF genotyping

Question 55

What is the treatment of bronchiectasis ?

Answer 55

Chest physiotherapy since massive sputum production High dose antibiotics Mucolytics Inhaled therapy (corticosteroids and beta 2 agonists) Vaccinations