Summary Respiratory notes for 4th year - core conditions

Pneumonia
Sunday, 27 November 2022
21:48
Acute lower respiratory tract infection associated with fever, symptoms and
signs in the chest and abnormalities on the chest x-ray (consolidation/opacity)

Classification and causes:
 Community-acquired pneumonia (CAP)
o Typical organisms
 Streptococcus pneumoniae (commonest)
 Haemophilus influenzae
 Moraxella catarrhalis
o Atypical organisms
 Mycoplasma pneumoniae
 Staphylococcus aureus (MSSA,MRSA)
 Legionella
 Chlamydia

 Hospital-acquired pneumonia (HAP)
o >48h after hospital admission
o Commonly Gram-ve enterobacteria or Staphylococcus aureus
o Also Pseudomonas, Klebsiella, Bacteroides and Clostridia

 Aspiration pneumonia

 Immunocompromised patient
o Streptococcus pneumoniae
o Haemophilus influenzae
o Staphylococcus aureus
o Moraxella catarrhalis
o Mycoplasma pneumoniae
o Gram -ve bacilli
o Pneumocystis jirovecii

Symptoms:
 Fever
 Rigors
 Malaise
 Anorexia
 Dyspnoea
 Cough
 Purulent sputum
 Haemoptysis
 Pleuritic pain

Signs:
 Pyrexia
 Cyanosis
 Confusion
 Tachypnoea
 Tachycardia
 Hypotension

,  Signs of consolidation (reduced expansion, dull percussion, increased
tactile vocal fremitus/vocal resonance, bronchial breathing)
 Pleural rub

Tests:
 Oxygenation
o Sats
o ABG if SaO2 <92% or severe pneumonia
o BP
 CXR
o Lobar infiltrates
o Cavitation
o Pleural effusion
 Sputum - MC+S
 Urine - Legionella, pneumococcal urinary antigens

Severity: CURB-65
Confusion (AMT <9)
Urea >=7mmol/L
Respiratory rate >= 30/min
BP <90 systolic and or <60
diastolic
Age >= 65
0-1=PO antibiotic/home treatment
2 = hospital therapy
>=3 = severe pneumonia -> ITU

Treatment:
 Antibiotics - see below
o CURB 1-2 - PO
o CURB >=3 - IV
 Oxygen
o PaO2 - >8.0 and/or sats >=94%
 IV fluids
o Anorexia, dehydration, shock
 VTE prophylaxis
 Analgesia
o Pleurisy
 Pneumococcal vaccine every 5 years
o Who?
 All >=65 yrs old
 Chronic heart, liver, renal or lung conditions
 Diabetes mellitus not controlled by diet
 Immunosuppression e.g. hyposplenism, AIDS, chemotherapy
or prednisolone, cochlear implant, occupation risk

PNEUMONIA ANTIBIOTICS
>Community-acquired
Clinical setting Organisms Antibiotic
 Mild  Streptoc  Oral
not occus amoxicillin/clarithromyci

, prev pneumo n/doxycycline for 5 days
iousl niae
y  Haemop
treat hilus
ed influenz
 CUR ae
B 0-
1
 Mod  Streptoc  Oral amoxicillin +
erat occus clarithromycin/doxycycli
e pneumo ne
 CUR niae  If IV required -
B2  Haemop amoxicillin +
hilus clarithromycin for 7 days
influenz
ae
 Mycopla
sma
pneumo
niae
 Sev As above  Co-amoxiclav/
ere cefuroxime IV +
 CUR clarithromycin for 7 days
B  Add flucloxacillin if Staph
>3 suspected
 Add vancomycin or
teicoplanin if MRSA
suspected
Atypical  Legionel  Fluoroquinolone
la +clarithromycin/rifampici
pneumo n
philia  Tetracycline
 Chlamy  High-dose co-trimoxazole
dophila
 Pneumo
cystis
jirovecii


>Hospital-acquired
 Gram -ve  IV gentamicin + antipseudomonal
bacilli penicillin IV/ cefuroxime IV
 Pseudomo
nas
 Anaerobes


>Aspiration
 Gram -ve  Cefuroxime IV +
bacilli metronidazole IV
 Pseudomo
nas

,  Anaerobes

>Neutropenic patients
Gram -ve  Gentamicin IV + antipseudomonal
cocci penicillin IV/Cefuroxime IV
Gram -ve  Consider antifungals after 48h
bacilli
Fungi

COMPLICATIONS OF PENUMONIA
 Respiratory failure
o T1RF common
o Treatment:
 High flow oxygen @ 60% aiming for 94-98%, PaO2 >=8kPa
 Hypotension
o If systolic <90mmHg - IV fluid challenge f 250ml colloid/crystalloid
over 15 mins
 Atrial fibrillation
o Usually self resolving but may require short term beta-blocker or
digoxin
 Pleural effusion
o Inflammation of the pleura by adjacent pneumonia -> fluid
exudation into pleural space
o If large, symptomatic, or infective (empyema) -> drainage
 Empyema
o Pus in the pleural space
o Clinical features:
 CXR - pleural effusion
 Pleural fluid is yellow, turbid, and has a pH <7.2, low glucose
and high LDH
o Treatment:
 Drainage using a chest drain
 Lung abscess
o Cavitating area of localised infection within the lung
o Causes:
 Poorly treated pneumonia
 Aspiration
 Bronchial obstruction
 Pulmonary infarction
 Septic emboli
o Clinical features
 Swinging fever
 Cough
 Purulent foul smelling sputum
 Pleuritic chest pain
 Haemoptysis
 Malaise
 Weight loss
 Clubbing
 Anaemia
 Crepitations
o Tests:
 Blood: