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TCD 12 Pneumonia Zainab Ajaj Classification Presentation Causes What we will Investigations cover today Management Complications Practicequestions OSCEsClassification Pneumoniaisacommonlowerrespiratorytractinfection causinginflammationofthelungtissue.It’salmostalways anacuteinfectionandmainlycausedbybacteria ● Communityacquiredpneumonia(CAP):develops outsidethehospital ● Hospital acquiredpneumonia(HAP):develops48 hoursafterhospitaladmission-drugresistant organismsmorecommon(worseprognosis) Aspirationpneumonia:developsasaresultofaspiration (inhalingforeignmateriale.g.food)-neuromuscular problems(stroke,myastheniagravis).Commonlyaffects rightlowerlobe.Presentation Symptoms: Signs: ● SOB ● Tachypnoea ● Cough-productive ● Tachycardia ● Fever ● Hypoxia ● Pleuriticchestpain ● Fever ● Hypotension(shock) ● Haemoptysis ● Confusion Chestsignsspecifictopneumonia: ● Bronchialbreathsounds(↑BS) ● Focalcoarsecrackles Differentials? PE, pulmonary oedema, acute asthma, ● Dullnesstopercussion COPD, ACS. ● Increasedvocalresonance(↑VR) Pneumoniaisnoisy(↑BS,↑VR)Common causes ● StreptococcusPneumoniae(50%):lobarpneumonia,rustysputum ● HaemophilusInfluenzae(20%):commoninCOPDpatients ● MoraxellaCatarrhalis:commoninimmunocompromisedpatients& COPD ● PseudomonasAeruginosa:commoninpatientswithcysticfibrosisor bronchiectasis ● StaphylococcusAureus:patientswithcysticfibrosisAtypical pneumonia Pneumoniacausedbyorganismsthatcannotbeculturedinthenormalwayordetected usingagramstain.Don’trespondtopenicillins. “LegionsofpsittaciMCQs” ● Legionellapneumophila:usuallycausedbyinfectedwatersuppliesorair conditioningunits.Diarrhea+vomiting.CancauseSIADHresultingin hyponatraemia(lowsodium). ● Chlamydiapsittaci:contactwithinfectedbird(parrotowner). ● Mycoplasmapneumoniae:milderpneumoniacancauseerythemamultiforme(target lesions-pinkringswithpalecentres)andhaemolyticanaemia. ● Chlamydophilapneumoniae:gradualonset,initialpharyngitis/URTIsymptoms. ● Qfever-Coxiellaburnetii:acquiredfromsheep&otherfarmanimals.PartofQ fever:flu-likesymptoms,hepatitis&endocarditis.Fungal pneumonia Pneumocystisjiroveci(PCP)pneumonia: ● Patientwhoareimmunocompromised- poorlycontrolledornewHIV withlowCD4count ● Presentswithdrycough(nosputum),bilateralpneumonia, SOBon exertionandnightsweats ● High-resolutionCTmayshowgroundglassopacities ● Treatedwithco-trimaxazole.MAybegivenprophylacticallytopatients withlowCD4counts.Assessing severity of pneumonia WeusethescoringsystemCURB-65toassesstheseverityofpneumonia: ● Confusion(newdisorientation,abbreviatedmentalscore≤8) ● Urea>7.Incommunityyoudon;tcounturea(CRB-65) ● Respiratoryrate≥30 ● Bloodpressure:SBP<90orDBP≤60 ● 65-Age≥65 Ithelpsustopredictsmortalitysocanhelpguideyouwhethertoadmitthe patienttohospital: ● Score0/1:Considertreatmentathome ● Score≥2:Considerhospitaladmission ● Score≥3:ConsiderintensivecareassessmentInvestigations Inpatienttests: ● ChestX-ray:consolidation(shouldbe repeatedweekly) ● Bloods:FBC(raisedWCC),U&Es (urea),CRP(raised),ESR(raised)and bloodculture ● Sputumculture ● O2sats-ABGif<92%orseverely unwell ● Legionellaandpneumococcalurinary antigensTreatment ● Antibiotics-followlocalareaguidelines ● Mildtomoderate:oralamoxicillin(clarithromycinordoxycyclineif allergicoratypicalsuspected)-5daycourse. ● Moderatetosevereorsepticpatientsareusually startedwithIV antibiotics(e.g.amoxicillinandmacrolide).Useoxygentherapyas required,IVfluidstopreventdehydration&shock. 7-10daycourse.Follow-up Recovery: ● Fevershouldresolvewithin1week ● Cough&SOBmaytakeupto6weekstoresolve ● Fatiguemaypersistupto3months Allpatientsshouldreceivea6weekfollowupincludingrepeatCXR(to checkifclearandruleoutunderlyinglungdisease).Complications ● Sepsis ● Pleuraleffusion ● Empyema ● Lungabscess ● DeathSepsis Conditionwherethebodyproducesanextremeimmune responsetoaninfectionleadingtosystemicinflammation thataffectstheorgansofthebody. Management: Riskstratifypatientsintolow,mediumandhighriskbased onpresentation.Withhighriskpatientsneedingurgent managementandattention.Butlow/moderateriskmay bemanagedinthecommunity(safety-net). Sepsis6(take3,give3): ● Threetests:Bloodlactate,cultureandurineoutput ● Threetreatments:Oxygen,antibioticsandIVfluidsPleural effusion Collectionoffluidinthepleuralcavity.Canbeexudative(eggsarehighin protein)witha highproteincount>30g/L ortransudativewithalowprotein count<30g/L). ● Exudativecauses(inflammation-usuallyunilateral):Pneumonia,TB, lungcancer,PE,Rheumatoidarthritis ● Transudativecauses(usuallybilateral):CCF,cirrhosis(hypoalbuminaemia), rarely-hypothyroidism,meigssyndrome(RSpleuraleffusion+ovarian cancer) Symptoms:SOB,coughandpleuriticchestpain Signs:Dullnesstopercussion,↓breathsounds,trachealdeviationawayfromeffusionif massiveInvestigations: ● 1stline-CXR(opacificationwithfluidlevel,bluntingofcostophrenicangle,fluidin lungfissure,largeeffusionmayhavemeniscusandmediastinaldeviation. ● Pleuralaspiration:Toanalyseitforproteincount,cellcount,pH,glucose,LDH andmicrobiologytesting ● Light’scriteriafor 25-35g/Lproteincounttodetermineiftransudativeor exudative. - Fluid:serumproteinratio:transudative<0.5<exudative - Fluid:serumLDHratio:transudative<0.6<exudative Management:Treatunderlyingcause,mayrequirepleuralaspirationorchestdrain. Chestdrainshouldbeplacedifsignsofpleuralinfection:cloudyfluidorpH<7.2 Empyema:infectedpleuraleffusion.Suspectinpatientswhohasimprovingpneumonia butnew/ongoingfever.Pleuralaspirationshowspus,pH<7.2,lowglucoseandhigh LDH.Treatedwithantibioticsandchestdraintoremovepus.Practise questions1.An85-year-oldladyisadmittedwithaurinarytractinfectionunderthegeriatricmedicalteam. After3daysoftreatmentwithantibiotics,sheisfoundtomoredrowsythanusual,spiking temperatures,andappearsshortofbreath.Onauscultation,shehasleftbasalcrepitations.Achest X-rayshowsleftlowerlobeshadowing. Whatisthemostlikelydiagnosis? A. Pulmonaryembolism B. Empyema C. Hospital-acquiredpneumonia D. Community-acquiredpneumonia E. Pneumothorax1.An85-year-oldladyisadmittedwithaurinarytractinfectionunderthegeriatricmedicalteam. After3daysoftreatmentwithantibiotics,sheisfoundtomoredrowsythanusual,spiking temperatures,andappearsshortofbreath.Onauscultation,shehasleftbasalcrepitations.Achest X-rayshowsleftlowerlobeshadowing. Whatisthemostlikelydiagnosis? A. Pulmonaryembolism B. Empyema C. Hospital-acquiredpneumonia D. Community-acquiredpneumonia E. Pneumothorax2.A27-year-oldmanpresentstotheemergencydepartmentwitha2dayhistory ofheadaches,myalgiaandadrycough. Onexaminationhelooksunwell,witharespiratoryrateof20,heartrateof65and temperatureof38.5degreescelsius. Bloodresultsshowaraisedcreatinine,ureaandlowsodium. Whichofthefollowingorganismsismostlikelyresponsibleforhispresentation? A. Legionellapneumophila B. Pneumocystisjiroveci C. Mycoplasmapneumoniae D. Chlamydophilapsittaci E. Klebsiellapneumoniae2.A27-year-oldmanpresentstotheemergencydepartmentwitha2dayhistory ofheadaches,myalgiaandadrycough. Onexaminationhelooksunwell,witharespiratoryrateof20,heartrateof65and temperatureof38.5degreescelsius. Bloodresultsshowaraisedcreatinine,ureaandlowsodium. Whichofthefollowingorganismsismostlikelyresponsibleforhispresentation? A. Legionellapneumophila B. Pneumocystisjiroveci C. Mycoplasmapneumoniae D. Chlamydophilapsittaci E. Klebsiellapneumoniae3.A64-year-oldwomanpresentstotheemergencydepartmentwithafeverandcoughproductiveof rusty-colouredsputum. Onexamination,therearecoarsecracklesintheleftlowerzone.Vitalsignsrevealaheartrateof90,blood pressureof100/55andrespiratoryrateof22.Anabbreviatedmentaltestscore(AMTS)isconductedand shescores9/10. Abloodtestshowsahaemoglobinof130,whitecellcountof17,creatinineof100andureaof8.9. WhichofthefollowingisthecorrectCURB-65scoreforthispatient? A. 2 B. 1 C. 5 D. 4 E. 33.A64-year-oldwomanpresentstotheemergencydepartmentwithafeverandcoughproductiveof rusty-colouredsputum. Onexamination,therearecoarsecracklesintheleftlowerzone.Vitalsignsrevealaheartrateof90,blood pressureof100/55andrespiratoryrateof22.Anabbreviatedmentaltestscore(AMTS)isconductedand shescores9/10. Abloodtestshowsahaemoglobinof130,whitecellcountof17,creatinineof100andureaof8.9. WhichofthefollowingisthecorrectCURB-65scoreforthispatient? A. 2 B. 1 C. 5 D. 4 E. 34.A45yearoldHumanImmunodeficiencyVirus(HIV)positivemanpresentstotheirGPanddescribesfeelingoutofbreath. Hehasadrycoughandreportsadecreaseinhisexercisetolerancefrombeingpreviouslyveryactivetonowonlyableto walk50metersbeforeneedingtorest.Auscultationofthechestisunremarkable.Hisobservationsareasfollows: Heartrate(HR):75 Respiratoryrate(RR):20 Oxygensaturations(SATS):98%atrest,90%aftera20meterwalkdownthecorridor Bloodpressure(BP):128/79 Temperature:38' Whatisthemostlikelycauseofthesesymptoms? A. *Legionellapneumophilia*pneumonia B. *Streptococcuspneumoniae*pneumonia C. *Mycoplasmapneumoniae*pneumonia D. Aviralpneumonia E. *Pneumocystisjirovecii*pneumonia4.A45yearoldHumanImmunodeficiencyVirus(HIV)positivemanpresentstotheirGPanddescribesfeelingoutofbreath. Hehasadrycoughandreportsadecreaseinhisexercisetolerancefrombeingpreviouslyveryactivetonowonlyableto walk50metersbeforeneedingtorest.Auscultationofthechestisunremarkable.Hisobservationsareasfollows: Heartrate(HR):75 Respiratoryrate(RR):20 Oxygensaturations(SATS):98%atrest,90%aftera20meterwalkdownthecorridor Bloodpressure(BP):128/79 Temperature:38' Whatisthemostlikelycauseofthesesymptoms? A. *Legionellapneumophilia*pneumonia B. *Streptococcuspneumoniae*pneumonia C. *Mycoplasmapneumoniae*pneumonia D. Aviralpneumonia E. *Pneumocystisjirovecii*pneumonia5.A65yearoldmalepatientpresentstothegeneralpractitionerwitha2monthhistoryof worseningshortnessofbreathand3episodesofhaemoptysis.Healsonotesa3kgweightloss.He hassmoked20cigarettesperdayfor50years. Onphysicalexaminationthereisreducedchestexpansionontherightsideanddullnessto percussionattherightbaseandassociatedabsentbreathsounds. Whichofthefollowingfindingsismostlikelytobepresentinthepleuralfluid? A. LDH<2/3upperreferencelimitofserumLDH B. Proteingradientbetweenserumandpleuralfluid>3.1g/dL C. Protein<25g/L D. LDH<0.5relativetoserum E. Protein>35g/L5.A65yearoldmalepatientpresentstothegeneralpractitionerwitha2monthhistoryof worseningshortnessofbreathand3episodesofhaemoptysis.Healsonotesa3kgweightloss.He hassmoked20cigarettesperdayfor50years. Onphysicalexaminationthereisreducedchestexpansionontherightsideanddullnessto percussionattherightbaseandassociatedabsentbreathsounds. Whichofthefollowingfindingsismostlikelytobepresentinthepleuralfluid? A. LDH<2/3upperreferencelimitofserumLDH B. Proteingradientbetweenserumandpleuralfluid>3.1g/dL C. Protein<25g/L D. LDH<0.5relativetoserum E. Protein>35g/LOSCEs ● RespiratoryHistory:AcuteSOB,coughwithsputum,fever,chestpain (pleuritic),recenttravelorsurgery,(ruleoutPE),smoking(COPD,lung cancer),recentholiday(legionella),HIV(PCP) ● Focussedrespiratoryexamforpneumonia:Bronchialbreathsounds, focalcoarsecrackles,dullnesstopercussion,↑VR. ● Datainterpretation:practiseCXR(consolidation),bloods-hyponatremia (legionella),pleuralaspiration(transudativeorexudative) ● Management:ABCDEapproach,tests(ECG,CXR,bloods,cultures, urinaryantigen)Resources ● https://zerotofinals.com/medicine/respiratory/pneumonia/ ● https://zerotofinals.com/medicine/respiratory/pleuraleffusi on/ ● https://zerotofinals.com/medicine/infectiousdisease/sepsis/ ● Oxfordclinicalhandbookofmedicine ● QuesmedThank you :) Any questions?