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Flashcards in Pneumonia Deck (22)
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What is the pathological classification of pneumonia?

lobar vs bronchopneumonia

    • widespread patchy inflammation centred on airways
    • often bilateral
    • patchy areas of consolidation 
    • bronchi containing acute inflammatory exudate
    • also upper lobe emphysema
    • diffuse inflammation affecting an entire lobe/lobes
    • photo - entire lobe, paler than other
    • consolidation due to accum of acute inflammatory exudate within alveoli
    • abrupt demarcation at interlobar fissure

This classification largely was based on macroscopic exam of lungs at autopsy in pts w/ florid pneumonias in a pre-antibiotic era. Problem - difficult to apply in most cases as patterns overlap + classical picture is extremely blurred by modern day abx therapy. 


What does consolidation refer to?

  • on CXR - refers to replacement of air in alveoli by fluid or other material, with preservation of underlying alveolar architecture
  • in case of pneumonia, air is replaced by acute inflammatory exudate
  • there is no destruction of underlying architecture


What are the typical organisms that cause community-acquired pneumonia?

  1. streptococcus pneumonia (pneumococcus) - most common bacterial cause, affects all ages particularly elderly. Also presents w/ herpes labialis + rusty sputum. Most common (60-75%). Lobar consolidation on CXR.
  2. haemophilus infulenzae - common cause of pneumonia in pre-existing lung disease: COPD. Can be diffuse or confined to one lobe. 


The remainder of organisms causing CAP are a mixed bag termed 'atypicals' (an unhelpful term). 

What are the 'atypical' organisms that cause CAP?


What organisms are responsible for hospital-acquired pneumonia (HAP)?

  • E.coli (gram-negative)
  • staphlococcus aureus
  • pseudomonas
  • klebsiella
  • bacteroides
  • clostridia


What organisms are responsible for pneumonia in the immunocompromised patient?

  • bacteria: strep pneumoniae, staph aureus, pseudomonas 
  • fungi: pneumocystitis, candida albicans, aspergillus
  • virus: influenza A virus, adenovirus, CMV, HSV, SARS, varicella


What are risk factors for pneumonia?

  • underlying lung disease (COPD, bronchiectasis, obstruction)
  • age (v young + v old)
  • smoking
  • alcohol xs
  • winter months
  • hospitalisation
  • immunocompression
  • IV drug use
  • inhalation from oeseophageal obstruction


What are the symptoms of pneumonia?

  • fever + rigors
  • malaise
  • anorexia
  • dyspnoea
  • cough + purulent sputum
  • haemoptysis
  • pleuritic chest pain


What are the signs of pneumonia?

  • tachypnoea
  • reduced chest expansion over affected area
  • inc vocal resonance/tactile fremitus
  • dull percussion note
  • bronchial breathing
  • coarse inspiratory crackles
  • confusion
  • cyanosis
  • tachycardia
  • hypotension


The severity of CAP is assessed based on the CURB-65 criteria.

What is the criteria?

  • Confusion of new onset (AMT ≤8)
  • Urea >7mmol/L
  • Resp rate ≥30
  • BP <90 systolic or ≤60 diastolic
  • 65 years or

0-1 = home tx, 2 = hosp therapy, >3 = severe pneumonia (ITU)



What are clinical features that suggest an atypical organism is responsible?

  • headache + flu-like symptoms
  • dry cough
  • extra-thoracic, systemic symptoms:
    • abdo pain + diarrhoea (legionella)
    • night sweats + weight loss (pneumocystitis or tb)
  • discordance between chest signs and illness of pt
  • NO leukocytosis
  • sometimes no consolidation


What are the investigations for pneumonia?

  • Bloods - FBC, U+E, LFT, CRP, cultures
  • Urine (-> strep pneumoniae + legionella ag)
  • Sputum
  • CXR
  • Oxygen saturation 
  • ABG
  • Pleural fluid
  • Bronchoscopy + bronchoalveolar lavage 


What might a CXR show for pneumonia?

  • lobar or multilobar consolidation
  • cavitation
  • pleural effusion



What is the management of CAP?

  • NON-SEVERE (CURB65 0-1)
    • oral amoxicillin or clarithromycin or doxycycline
  • SEVERE (CURB65 2-5)
    • benzylpenicillin IV
    • clarithromycin IV

Oral switch to doxycycline or amoxicillin (+/- carithromycin PO)


What antibiotic should be used for legionella?

fluoroquinolone combined w/ clarithromycin or rifampicin


What antibiotic is used for pneumocystitis jirovecii?



What is the management of HAP?

  • mobile pt, reduce sedation, pain control
  • physiotherapy
  • oral co-amoxiclav
  • IV penicillin and gentamycin


What is the management of aspiration pneumonia?

  • cephalosporin IV + metronidazole IV


Who is the pneumococcal vaccine indicated for?

  • over 65s
  • chronic heart, liver, renal or lung conditions
  • diabetes mellitus
  • immunosuppression (decreased spleen fxn, aids, chemo, steroids)

Re-vaccination is necessary after 6yrs


Who is the influenza vaccine indicated for?

  • over 65yrs old
  • chronic heart, liver, renal, lung conditions
  • diabetes mellitus
  • COPD, asthma
  • immunosuppression
  • pregnancy, lactation
  • children from 6months - 2yrs
  • healthcare workers
  • ppl living in large institutions

vaccination recommended once a year


Who is the BCG vaccine indicated for?

  • infants under 1yr living in areas of UK w/ high rate of TB
  • infants under 1yr whose parents have lived in high-risk areas
  • children (under 16yrs) who have migrated from high-risk areas
  • adults under 35yrs who have come from high-risk areas
  • health-workers, prison staff, those intending to stay in areas with high rate of TB + those w/ contact to people with active TB

Lifetime immunity is acquired through vaccination


What are potential complications of pneumonia?

  • para-pneumonic pleural effusion
  • epyema
  • lung abscess
  • resp failure
  • septicaemia
  • pericarditis
  • myocarditis