pneumonia

Question 1

what does the URT consist of?

Answer 1

nasal passages, pharynx, larynx

Question 2

what are the common causes of URTI?

Answer 2

Usually from the virus groups:-– Rhinovirus,

Question 3

what conditions affect the URT?

Answer 3

• Common cold
• Laryngitis
• Pharyngitis
• Laryngotracheobronchitis (Croup)
• Epiglottitis
• Sinusitis
• Tonsillitis
• Ear - Otitis externa, media, interna

Question 4

what is sinusitis?

Answer 4

• Inflammation of the paranasal sinuses
• Symptoms - Nasal discharge/blockage, facial pain, headache, anosmia

Question 5

when would sinusitis need hospital referal?

Answer 5

– Orbital involvement
– Intracranial involvement

Question 6

how do you manage sinusitis that does not need referal?

Answer 6

• Provide information regarding condition
• Advise on self management of symptoms
• Advise on over the counter symptom relief including: – Paracetamol, ibuprofen, decongestants.
• Advise a clinical review if the condition worsens or becomes prolonged.

Question 7

who needs to be referred for sinusitis?

Answer 7

• Otherwise well but symptoms lasting longer than 10 days or more with little or no improvement.
  OR
• Very young, elderly and frail, immunocompromised,
  complicating co-morbidities (e.g. significant heart, lung, kidney disease), persisting fever, chest pain,
  neurological changes.
• Severe symptoms.
• Caution in those with diabetes and asthma

Question 8

what is the antibiotic interventions that should be given for sinusitis?

Answer 8

first choice phenoxymethylpenicillin- less chance of leading to resistance as it has a narrow spectrum of activity than amoxicillin

Co-amoxiclav reserved for more severe cases, this is active against active against beta-lactamase-producing bacteria

Question 9

what should you give for sinusitis if there is a penicillin allergy?

Answer 9

doxycycline
clarithromycin
erythromycin (in pregnancy)

Question 10

how does acute oitis media present?

Answer 10

• Presenting with earache.
• Common in children.
• Bacterial or viral cause.
• Often following ‘common cold’ symptoms.
• Referral often needed for examination with an
  otoscope

Question 11

for patients who do not require admission for AOM what advice should be given?

Answer 11

Reassure, antibiotics are not often needed.
– Without antibiotic treatment, symptoms will improve within 24 hours in 60% of children and 80% will recover within 3 days (but it can be up to a week).
– Long term complications are rare.
* Advise on self management of symptoms
– OTC symptom relief with paracetamol or an NSAID,
with appropriate age and weight advice.
+ safety net

Question 12

how should you manage AOM with antibiotics?

Answer 12

• If an antibiotic is required:
• First line, amoxicillin for 5-7 days - see age based dosing advice.
• Second line (worsening symptoms despite 2 to 3 days of standard antibacterial treatment): co-amoxiclav.
• For people who are allergic to penicillin, a 5-7 day course of erythromycin or clarithromycin.

Question 13

define pneumonia

Answer 13

• Infection in the lungs
• Tissue inflammation
• Alveoli filled with pus
• Clinical symptoms of respiratory infection
• Confirmed with new shadowing on chest X-ray

Question 14

what can cause pneumonia?

Answer 14

• Commonly - Inhalation or aspiration
• Bacterial, viral or fungal microorganisms
• Failure of defence mechanisms
• Subsequent infection
• Inflammation of the lung parenchyma :- characterised by consolidation of the affected part, the alveolar air spaces being filled with exudate, inflammatory cells, and fibrin

Question 15

what are the different classifications of pneumonia?

Answer 15

• Community acquired pneumonia (CAP)
• Hospital acquired pneumonia (HAP)
• Healthcare associated pneumonia (HCAP)
• Aspiration pneumonia
• Ventilator associated pneumonia

Question 16

how do you diagnose pneumonia?

Answer 16

• COUGH - Symptoms similar to other LRTI
• Need examination or chest x-ray to distinguish

Question 17

who are at risk of developing pneuomia?

Answer 17

• Smokers
• Chronic lung disease
• Immunocompromised
• Elderly / frail
• Diabetes

Question 18

what are red flag symptoms for pneuomonia?

Answer 18

• Dyspnoea - difficulty in breathing or wheezing
• No improvement in condition after two or three weeks
• Persistent cough for longer than three weeks
• Recurrent cough
• Dry night-time cough in children
• Haemoptysis
• Chest pain
• Unexplained weight loss
• General malaise, systemically unwell, sweats or fever
• Painful or swollen, inflamed calf

Question 19

what is the most common cause of CAP?

Answer 19

Streptococcus pneumoniae

Question 20

who does Haemophilus influenzae most affect?

Answer 20

Typically affects patients with COPD and other chronic chest conditions.
* Sensitive to most antibiotics used commonly. Resistance developing

Question 21

what is special about Mycoplasma pneumonia?

Answer 21

• Mollicute lacks a cell wall.
• No cell wall with peptidoglycan
  means resistance to beta-lactam
  antibiotics.

Question 22

who does Mycoplasma pneumonia affect ?

Answer 22

• Affects young people

Question 23

how do you assess the severity of pneumonia?

Answer 23

• Peripheral Oxygen
  Saturation levels
• Blood pressure
• Respiratory rate
• Urea and electrolytes
• C-reactive protein
• Full blood count
• Liver function tests
• Sputum culture and
  sensitivity
• May need blood cultures.
• The CURB-65 score

Question 24

when should you treat pneumonia?

Answer 24

• consider home-based care for patients with a
  CURB65 score of 0
• consider hospital assessment for all other patients, particularly those with a CURB65 score of 2 or more

Question 25

what should you not routinely offer to patients with low severity cap ?

Answer 25

microbial tests

Question 26

what should you do for patients with moderate- high sverity CAP?

Answer 26

* take blood and sputum cultures and * consider pneumococcal and legionella urinary antigen tests.

Question 27

when would you use urinary antigen tests?

Answer 27

* NICE suggests for moderate or high severity CAP – pneumococcal and legionella urinary antigen tests

Question 28

how do you manage CAP with antibiotics? low severity

Answer 28

* Low-severity community-acquired pneumonia (CURB - 0) * 5 days treatment * Amoxicillin 500mg TDS * Penicillin Allergic * Macrolide - clarithromycin 500 mg twice a day for 5 days * Tetracycline - doxycycline 200 mg on the first day then 100 mg once a day for 4 days (total course of 5 days) * Inform patient - no improvement at day 3 or deterioration -seek further advice * Prescriber may then extend the course or change therapy.

Question 29

how do you manage moderate-high severity CAP?

Answer 29

* Moderate and high severity community-acquired pneumonia * 7-10 days treatment * Moderate severity- dual therapy with amoxicillin and a macrolide * Severe - beta-lactamase stable beta-lactam and a macrolide. * IV administration may be required

Question 30

if a patient is admitted to hospital with CAP what should be done?

Answer 30

* Process to include rapid definitive diagnosis * Chest x-ray * Blood tests (CRP, WCC, FBC etc.) * Early administration of antibiotics * Within 4 hours of admission.

Question 31

what monitoring should you do in hospital for CAP?

Answer 31

As a minimum (in hospital) measure a baseline C-reactive protein concentration in patients with community-acquired pneumonia on admission to hospital, and repeat the test if clinical progress is uncertain after 48 to 72 hours.

Question 32

what do you have to consider when switching from IV to oral?

Answer 32

* Resolution of fever > 24hrs * Pulse rate <100bpm * Resolution of tachyapnoea * Well hydrated and taking oral fluids * Absence of hypoxia * Improving WCC * Non-bacteraemic infection * No evidence of legionella, staphylococcal or gram negative enteric bacilli infection. * No concerns over G/I absorption.

Question 33

what other treatment are there for pneuomnia?

Answer 33

* Oxygen * Bronchodilators * Steroids (depends on underlying conditions) * Asses risk of venous thromboembolism - prophylaxis. * Pain management * Hypotension - fluid depletion/requirements * Nutritional needs.

Question 34

when is a patient with pneuomnia safe to discharge from hospital?

Answer 34

* They are not ready yet if in the past 24 hours they have had 2 or more of the following findings: – temperature higher than 37.5°C – respiratory rate 24 breaths per minute or more – heart rate over 100 beats per minute – systolic blood pressure 90 mmHg or less – oxygen saturation under 90% on room air – abnormal mental status – inability to eat without assistance.

Question 35

How should you council a patient on their long term recovery from pneuomnia?

Answer 35

* 1 week: fever should have resolved * 4 weeks: chest pain and sputum production should have substantially reduced * 6 weeks: cough and breathlessness should have substantially reduced * 3 months: most symptoms should have resolved but fatigue may still be present * 6 months: most people will feel back to normal.