Pneumonia and CXR revision

Leigh-Anne Hill

Top Tips
Exam focused revision Work in groups of 3 for OSCE (one examiner, one student, one patient) Dont shy away from topics you are unfamiliar with/fear Make up your own mark sheets Practice

Objectives
Pneumonia
Hospital and community acquired

CXR revision

Pneumonia - Symptoms
Fever Cough (+/- sputum production) Breathlessness Pleuritic chest pain Off legs elderly

Community Acquired Pneumonia

Symptoms & signs of a LRTI New focal chest signs New consolidation on CXR At least one systemic feature (e.g. sweating, fever, aches, pains)

CAP- risk factors

Smoking
Strongest independent risk factor for invasive pneumococcal disease in the immunocompetent

COPD
Esp. bacterial pneumonia Increased incidence of M catarrhalis and H Influenzae

Diabetes
Increased risk of associated bacteraemia (with Pneumococcal pneumonia)

Immunosupression (e.g. steroids, azathioprine)

?Increased risk of Legionella

Nursing Home resident

45 year old female: Jane

Presents to MAU: cold 1 week ago Cough productive of brown sputum Fever 38.5C Breathlessness Aching all over Cold sore Previously well with no PMHx Stopped smoking 10 years ago 5 pack yr Hx

Organisms causing CAP

Organism Community Incidence (%) S.Pneumoniae 36 10 0.4 0.8 1.3 13 8 45 Hospital Incidence (%) 39 5 3.6 2 11 13 11 31 ICU Incidence (%) 22 4 18 9 3 10 5 32

H.Influenzae
Legionella S.Aureus

Mycoplasma
All viruses Influenza

None detected

Streptococcus pneumoniae
Most common pathogen (60-70% of bacterial pneumonias) Pleurisy, fever >39, ICU admission all positively associated with this Rusty sputum, cold sores (Herpes Simplex) Associated with increasing age, co-morbidities

Joe, 18 year-old male

Fever 38.4C Dry cough Lab report cold agglutinins in FBC sample Deranged LFTs Several friends unwell

Mycoplasma pneumonia
Younger age Occurs in 4-yearly epidemics May be associated with cold agglutanins, hepatitis and skin problems

Extra-pulmonary manifestations of Mycoplasma pneumonia

Arthralgia and arthritis Autoimmune haemolytic anaemia Neurological manifestations Pericarditis and myocarditis Hepatitis, glomerulonephritis Erythema multi-forme and Stevens-Johnson syndrome DIC

Staph Aureus pneumonia

Associated with influenza infection in 39% cases Winter months Diffuse bilateral infiltrates High incidence of ICU admission (especially if coincident influenza infection)

SEM Image of Staph aureus clusters of grapes (Ref: Wikipedia)

Archie, 72 year-old male

Smoker 80 pack years Cough Fever Confusion hyponatraemia Just returned from holiday in Med

Legionella pneumonia
Males, over 65, smokers Associated with cooling towers, large central air conditioning units May present with encephalopathy, GI & liver disturbance

Severity Assessment
CURB65 score Other poor prognostic indicators: WCC <4 or >20 Hypoxia : PaO2 <8kPA Multilobe involvement Positive blood cultures

CURB 65 score
Rigorously tested severity score:1. 2. 3. 4. New Confusion (AMT 8) Urea 7 Respiratory rate 30 Blood pressure mmHg: systolic 90 or diastolic 60 5. Age ( 65)

CURB 65 Mortality
4-5: Mortality 40% (consider ITU Mx) 3: Mortality 15% 2: Mortality 9% 1: Mortality <3% (0-1: May be suitable for home Rx)
Must be used in context of clinical judgement E.g. CURB65 1 but RR>40 must still be considered high risk

Investigations
Pulse oximetry (&ABGs) Sputum culture CXR FBC U&E CRP- as baseline & for monitroing LFTs

Microbacterial/serological tests
Often not necessary for low-severity (CURB 01) pneumonia Blood cultures if febrile Urine specific antigen for legionella if CURB 3+ Atypical serology (Mycoplasma) if in epidemic year / high risk

Management
Oxygen
Aim SpO2 96+ or 88-92 if COPD

Fluids Nutrition supplements Nicotine replacement patch (& support) Physiotherapy unproven benefit Steroids for COPD but no evidence for their use otherwise

Antibiotic Management
Early 1st dose of antibiotics is associated with improved outcome N.B. Broad spectrum antibiotics are associated with increased incidence of MRSA % c.diff
Therefore IV broad spectrum abx may be appropriate on admission but should be reviewed as soon as good clinical response has be achieved & afebrile x 24 hrs (or microbiological evidence guides narrow-spectrum Rx)

Follow-up
CXR required at 6 weeks for all smokers & over 50s
(83% will show complete resolution)

Prevention & Vaccination

All patients >65 years or at risk (DM, IHD, asplenic)
Annual influenza vaccination (C) Pneumococcal vaccination (23-valent) (C)

Smoking cessation (B)

Hospital Acquired Pneumonia (HAP)

Definition
Pneumonia occurring after 48 hours of admission

What are the possible organisms?.......

S. pneumoniae / H.Influenzae
Assoc with trauma

S. aureus (including MRSA)

Assoc. with head trauma (+/- ventilation)

Pseudomonas aeroginosa
Assoc with COPD, prolonged abx, intubation >8 days

Anaerobic bacteria
Assoc with abdominal surgery & aspiration

Risk factors

antibiotics surgery chronic lung disease advanced age immunosuppression tracheal intubation mechanical ventilation

Why hospital acquired?

1. 2. 3. 4. Ventilator Associated Pneumonia Aspiration Pneumonia Pneumonia in the immunocompromised Environmental source (Legionella pneumophila) 5. Spread of communicable disease (TB, influenza)

Ventilator assisted pneumonia

2/3 of patients ventilated over 48 hours will get VAP Mortality 15-50% Caused by breach of usual defences with ETT
Allows aspiration of oropharngeal secretions

Aspiration Pneumonia
Commonest cause of death in dysphagic patients due to neurological conditions 10% admitted with drug overdose will aspirate

Chemical pneumonitis
Around 25mls of gastric contents are required to cause chemical pneumonitis This then develops rapidly (within 3 mins)
Atelectasis Pulmonary haemorrhage Pulmonary oedema CXR changes (dependent segments) within 2 hours

Rx - support, suction (or bronchoscopy), prophylactic abx

Management
Oxygen
Aim SpO2 96+ or 88-92 if COPD

Fluids Nutrition supplements Nicotine replacement patch (& support) Physiotherapy unproven benefit Steroids for COPD but no evidence for their use otherwise

Complications of Pneumonia
Septicaemia Lung abcess Empyema ARDS Multiorgan failure Haemolytic syndrome Death

 Whats the difference between a Lung abscess and an Empyema ?? An empyema is a collection of pus in a naturally formed cavity (such as the pleura) An abscess is necrosis of pulmonary tissue which forms new cavities, containing debris or fluid from a microbial infection

HAP- prevention
Pre-op : smoking cessation Post-op : early mobilisation, clean respiratory equipment Hand hygiene of staff and patients

How to read a chest X-ray

Name Date Projection
Erect PA/AP Supine/lateral

Orientation Quality
Penetration, rotation and degree of inspiration

Heart Mediastinum Hila Lungs Pleura Diaphragm Ribs, clavicles, spine Soft tissues

Good inspiration? The diaphragms should lie at the level of the sixth ribs anteriorly. The right hemidiaphragm is usually higher than the left because the liver pushes it up. Is the patient rotated? The spinous processes of the thoracic vertebrae should be midway between the medial ends of the clavicles.

Good penetration? You should just be able to see the lower thoracic vertebral bodies through the heart.

 First look at the mediastinal contoursrun your eye down the left side of the patient and then up the right. The trachea should be central. The aortic arch is the first structure on the left, followed by the left pulmonary artery; notice how you can trace the pulmonary artery branches fanning out through the lung.

Two thirds of the heart lies on the left side of the chest. The heart should take up no more than half of the thoracic cavity. The left border of the heart is made up by the LA and LV. The right border is made up by the RA alone (RV sits anteriorly, therefore does not have a border on the PA. Above the right heart border lies the edge of the SVC. The pulmonary arteries and main bronchi arise at the left and right hila.

 Apart from the pulmonary vessels (arteries and veins), lungs should be black (air). Scan both lungs, starting at the apices and working down, comparing left with right at the same level. The lungs extend behind the heart, so look here too. Force your eye to look at the periphery of the lungsyou should not see many lung markings here; if you do then there may be disease of the air spaces or interstitium. Make sure you can see the surface of the hemidiaphragms curving downwards, and that the costophrenic and cardiophrenic angles are not blunted (effusion).

Finally look at the soft tissues and bones. Are both breast shadows present? Is there a rib fracture? This would make you look harder for a pneumothorax. Are the bones destroyed or sclerotic?

Collapse V Consolidation

Collapse (atelectasis)
Caused by a blockage of the air passages (bronchus or bronchioles) or by pressure on the outside of the lung. When the lobe is not aerated it will lose much of its volume and collapse to a predictable location depending on whether it is an upper, middle, or lower lobe.

Risk factors for developing atelectasis

Anaesthesia Foreign object (most common in children) Lung diseases Mucus that plugs the airway Pressure on the lung caused by build-up of fluid between the ribs and the lungs Prolonged bed rest with few changes in position Shallow breathing Tumours that obstruct the airway

Consolidation
Air in the lungs appears black on X-ray. Consolidation appears as areas of opacification sometimes conforming to the outline of a lobe or segment of lung in which the air has been replaced by an inflammatory exudate (e.g. pneumonia), fluid (e.g. pulmonary oedema), blood (e.g. pulmonary haemorrhage) or tumour (e.g. alveolar cell carcinoma). Bronchi containing air passing through the consolidated lung are sometimes clearly visible as black tubes of air against the white background of the consolidated lung: air bronchograms.

There are 4 main causes of white out

There are four main causes of confluent opacification of a hemithorax Consolidation (material within the air-spaces) Pleural effusion i.e. material within the pleural space, which could be serous fluid, blood, or pus. Complete collapse of one lung with the mediastinum shifting over the abnormal side can also cause a white out on the abnormal side. Finally, after a pneumonectomy the mediastinum shifts to the empty hemithorax and the residual pleural space fills with fluid and fibrotic material leaving the patient with a complete white out on the side that has been operated on

Left lower lobe consolidation: There is opacification of the left lower zone with loss of the hemidiaphragm, indicating the consolidation abuts the diaphragm i.e. is within the lower lobe. A key feature is that there is no loss of volume. There is no mediastinal shift and no fluid level

Right pleural effusion:

There is opacification of the lower right hemithorax with a fluid level, and the mediastinum is pushed to the left side

 Interpret this CXR

Interpret this CXR

Interpret this CXR

References
Dr A Blackburn, Pneumonia and Bronchiectasis seminar, UEA Module 5 Respiratory, October 2009 Stephen J. Bourke, Graham P. Burns. Lecture Notes: Respiratory Medicine 7th Ed Chest X-rays Made Easy STUDENTBMJ VOLUME 8 SEPTEMBER 2000 C., Jonathan. Chest X-ray Made Easy (2009) Churchill-Livingstone http://www.aic.cuhk.edu.hk/web8/Very%20BASI C%20CXR%20lungs.htm