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1
Q

What are the three types of pneumonia?

A

HAP
CAP
Aspiration

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2
Q

What is the definition of a HAP?

A

> 48 hours after admission

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3
Q

Name 5 signs of septic shock secondary to pneumonia.

A 
• Tachypnoea (raised respiratory rate)
• Tachycardia (raised heart rate)
• Hypoxia (low oxygen)
• Hypotension (shock)
• Fever
ConfusioN
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4
Q

Name 3 chest signs of pneumonia.

A
  1. Bronchial breath sounds - consolidation of surrounding lung tissue (inspiration and expiration)
  2. Focal coarse crackles - air passing through sputum (like a straw through a drink)
    Dullness to percussion - due to collapse or consolidation
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5
Q

Which bacteria most commonly cause CAP?

A

Streptococcus pneumoniae

Haemophilus influenzae

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6
Q

Which bacteria cause pneumonia in immunocompromised patients?

A

Moraxella catarrhalis

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7
Q

Which bacteria cause pneumonia in patients with cystic fibrosis?

A

Pseudomonas aeruginosa

Staphylococcus aureus

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8
Q

Which investigations should be ordered for pneumonia?

A

CXR
FBC (WCC)
U&Es (for urea)
CRP

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9
Q

When is a rise in CRP expected in pnuemonia?

A

Delayed response, 2-3 days after.
WCC is more accurate of current infection.
Patients who are immunocompromised may not see a rise in CRP.

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10
Q

What scoring system is used to assess the severity of pneumonia? What are each of the parameters?

A

• C – Confusion (new disorientation in person, place or time)
• U – Urea > 7
• R – Respiratory rate ≥ 30
• B – Blood pressure < 90 systolic or ≤ 60 diastolic.
65 – Age ≥ 65

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11
Q

How should you interpret the CURB65 score?

A

• Score 0/1: Consider treatment at home
• Score ≥ 2: Consider hospital admission
Score ≥ 3: Consider intensive care assessment

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12
Q

What are the complications of pneumonia?

A 
Sepsis
Pleural effusions
Empyema
Lung abscess
Death
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13
Q

What is the definition of an atypical pneumonia?

A

Cannot be cultured in the normal way OR detected using a gram stain.

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14
Q

How can you remember the 5 causes of atypical pneumonia?

A 
Legionella pneumophila
Psittaci
Mycoplasma pneumoniae
Chlamydia pneumoniae
Coxiella burnetii (Q fever)
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15
Q

What electrolyte imbalance is seen in legionnaires disease? How is it caused?

A

Hyponatraemia

SIADH

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16
Q

Which bacteria causes pneumonia and erythema multiforme?

A

Mycoplasma pneumoniae

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17
Q

Which bacteria is associated with farming/animals?

A

Coxiella burnetii (Q fever)

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18
Q

Which bacteria is associated with infected birds?

A

Chlamydia psittaci

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19
Q

Which organism causes fungal pneumonia? Which patients are most likely to be infected?

A

Pneumocystis jiroveci (causes PCP in patients with HIV)

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20
Q

What antibiotics can be used to treat atypical pneumonias?

A

macrolides (e.g. clarithromycin)
fluoroquinolones (e.g. levofloxacin)
tetracyclines (e.g. doxycycline)

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21
Q

Which antibiotic is used to treat PCP?

A

Septrin

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22
Q

Which organisms is more common in patients who have recently had influenza?

A

Staphylococcus aureus

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23
Q

What are the two types of lung disease that can be distinguished using lung function tests?

A

Obstructive

Restrictive

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24
Q

What is FEV1?

A

Forced expiratory volume in 1 second

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25
What is FVC?
Forced vital capacity
26
What is a reversibility test?
Use a bronchodilator e.g. salbutamol and repeat the test.
27
Describe the pattern seen in obstructive disease? Name two causes.
FEV1:FVC ratio is <75% | FEV1 <80%.
28
Describe the pattern in restrictive disease? Name 4 causes.
FEV1:FVC ratio >75%
29
How can you distinguish between COPD and asthma on spirometry?
Asthma is reversible (FEV1 improves after bronchodilator).
30
What is peak flow? What is it used for?
Measure of the fastest expiratory flow (measures how much obstruction to air flow there is).
31
How should you counsel a patient on doing a peak flow test?
Stand up Take a deep breath in Form a tight seal around the mouth piece Blow as fast and hard as possible into the device Take three attempts and record the best result
32
How are the results of a peak flow interpreted?
Compared to predicted value (%) based on height, age, and sex.
33
What is the biggest risk factor for lung cancer?
Smoking - 80% preventable if non-smoker
34
What is the most common cancer in non-smokers?
Adenocarcinoma
35
Which type of cancer is most common in smokers?
Squamous cell carcinomas
36
What are the three main types of cancer?
NSCLC: 1. Adenocarcinoma 2. Squamous cell carcinoma SCLC (neurosecretory)
37
Which type of lung cancer carries a worse prognosis?
Small cell lung cancer
38
How does lung cancer present? Name some red flag symptoms.
* Shortness of breath * Cough ``` RED FLAGS • Haemoptysis (coughing up blood) • Finger clubbing • Recurrent pneumonia • Weight loss Lymphadenopathy – often supraclavicular nodes are the first to be found on examination ```
39
Which nodes are most commonly infiltrated by lung cancer?
Supraclavicular nodes
40
Name 6 paraneoplastic syndromes.
1. Nerve palsies - phrenic & laryngeal 2. SVC obstruction - Pemberton's sign (medical emergency) 3. Exogenous hormone secretion - SIADH, Cushing's & hyperparathyroidism 4. Limbic encephalitis 5. LEMS 6. Horner's syndrome
41
Name two nerves that can be affected in paraneoplastic syndromes.
Recurrent laryngeal nerve palsy - hoarse voice | Phrenic nerve - diaphragm weakness (SOB)
42
Which vessel might become obstructed by a lung tumour? How does this present?
SVC obstruction - facial swelling, distended veins in the neck and upper chest
43
What is Pemberton's sign?
Raising the hands about the head causes facial swelling and cyanosis - medical emergency
44
Which two hormones can be exogenously excreted by SCLCs?
ADH --> SIADH | ATCH --> Cushing's
45
Which hormone is exogenously excreted by squamous cell carcinomas of the lung?
Parathyroid hormone - secreted by squamous cell
46
What is limbic encephalitis?
Limbic encephalitis - SCLC causes immune system to make antibodies to the tissues in the brain. Short-term memory loss Hallucinations Seizures Anti-hu antibodies
47
What is LEMS?
Lambert-Eaton myasthenic syndrome (LEMS): antibodies again SCLC cells. Also target voltage gated calcium channels on the pre-synaptic terminals of motor neurones.
48
What are the causes of post-operative pyrexia?
``` Post operative pyrexia (5 W's) Day 1 - wind: Atelectasis Day 3 - water: UTI Day 5 - Wound: site infection Day 7 - Walking: DVT/PE Anytime - Wonder drugs: Adverse drug reaction ```
49
What are the causes of upper zone fibrosis?
CHARTS Coal workers’ pneumoconiosis Histiocytosis Ankylosing spondylitis/Allergic bronchopulmonary aspergillosis Radiation Tuberculosis Silicosis (progressive massive fibrosis), sarcoidosis
50
Which bacteria commonly causes aspiration pneumonia?
Klebsiella pneumoniae
51
Which bacteria can cause red-current jelly sputum?
Klebsiella pneumoniae Common in alcoholics and T2DM
52
What are the causes of a white out on CXR?
``` consolidation pleural effusion collapse pneumonectomy specific lesions e.g. tumours fluid e.g. pulmonary oedema ```
53
What are the symptoms of COPD?
Chronic cough --> sputum SOBOE Wheeze Recurrent RTIs (esp in winter)
54
How is breathlessness graded?
MRC Dyspnoea Council: ``` Grade 1 = SOBOE (strenuous) Grade 2 = SOB walking uphill Grade 3 = SOB slows walking Grade 4 = must stop to catch breath after 100m Grade 5 = cannot leave the house ```
55
How is COPD diagnosed?
Clinical presentation | Spirometry
56
What investigations should be done in COPD?
1. Spirometry (diagnose obstructive disease and assess severity) 2. CXR. - RO Lung ca 3. FBC - polycythaemia (secondary to chronic hypoxia) 4. Sputum sample - RO pnuemonia 5. Serum alpha-1 antitrypsin (esp if early onset) 6. BMI baseline (weight loss = lung ca, weight gain = steroids) 7. TLCO - reduced (raised in asthma)
57
How is the severity of COPD measured?
``` FEV1: Stage 1 = <80% Stage 2= 50-79% Stage 3= 30-49% Stage 4= <30% ```
58
What is the single most important factor in the management of COPD?
STOP SMOKING
59
What smoking cessation advice can be offered in COPD?
Nicotine therapy Vareniciline Bupropion
60
What is the first-line medical management of COPD?
SABA (salbutamol) or SAMA (ipratiotropium)
61
What are the steps in the medical management of COPD without asthmatic features?
1. SABA or SAMA 2. [SABA] + combined LABA & LAMA 3. Oral theophylline (short courses) 4. Oral azathioprine (prophylaxis in stable patients) 5. Mucolytics
62
What are the steps in the medical management of COPD in a patient with asthmatic features/response to steroids?
1. SABA or SAMA 2. [SABA] + combined [LABA + ICS] 3. [SABA] + combined [LABA + LAMA + ICS] 4. Oral theophylline 5. Oral azithromycin 6. Mucolytics
63
What should be done before starting a patient on prophylactic azithromycin for COPD?
1. CT thorax - RO bronchiectasis 2. Sputum culture - RO TB or atypical pneumonia 3. LFTs/ECG (azithromycin causes QT prolongation)
64
What can improve survival in COPD patients?
Smoking cessation LTOT Lung volume reduction surgery
65
Which vaccinations should COPD patients receive?
Annual influenza | One-off pneumococcal
66
Name a cardiac complication of COPD. How is it managed?
Cor pulmonale - ^JVP, peripheral oedema, parasternal heave, loud P2 ``` Loop diuretics (oedema) LTOT ```
67
How should you manage an acute exacerbation of COPD?
O SHIT: 1. O2 2. Salbutamol 2.5-5mg NEB B2B 3. Hydrocortisone 100mg IV 4. Ipratropium 500mg NEB 5. Theophylline: aminophylline infusion +Antibiotics +Chest physio +NIV --> intubation
68
How do you assess a patient for LTOT therapy?
2xABG, 3 weeks apart: pH <7.3 OR PaO2 7.3-8 + polycythaemia, peripheral oedema, pulmonary hypertension
69
When can patients not be offered LTOT?
Continued smoking

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