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Questions and Answers
What is a primary cause of defective cell-mediated immunity leading to pneumonia?
What is a primary cause of defective cell-mediated immunity leading to pneumonia?
- Virus infection (correct)
- Parasitic infection
- Fungal infection
- Bacterial infection
Cytokines such as IL-1 and IL-6 are involved in causing fever during pneumonia.
Cytokines such as IL-1 and IL-6 are involved in causing fever during pneumonia.
True (A)
What is the definition of pneumonia?
What is the definition of pneumonia?
Acute infection of lung parenchyma without necrosis
The easiest access to the lower respiratory tract is through the ______.
The easiest access to the lower respiratory tract is through the ______.
Match the cytokines with their respective functions in pneumonia:
Match the cytokines with their respective functions in pneumonia:
Which of the following is an indication for long-term oxygen therapy?
Which of the following is an indication for long-term oxygen therapy?
Which of the following characteristics is true for Streptococcus pneumoniae?
Which of the following characteristics is true for Streptococcus pneumoniae?
Lung volume reduction surgery is contraindicated if FEV₁ is greater than 20%.
Lung volume reduction surgery is contraindicated if FEV₁ is greater than 20%.
What does the BODE index assess in chronic obstructive pulmonary disease patients?
What does the BODE index assess in chronic obstructive pulmonary disease patients?
Streptococcus pneumoniae is highly invasive except for type 3.
Streptococcus pneumoniae is highly invasive except for type 3.
An exacerbation event in COPD is characterized by ___ and/or cough with sputum.
An exacerbation event in COPD is characterized by ___ and/or cough with sputum.
What toxin produced by Streptococcus pneumoniae creates pores in cell membranes?
What toxin produced by Streptococcus pneumoniae creates pores in cell membranes?
A significant risk factor for community-acquired pneumonia (CAP) includes age greater than _____ years.
A significant risk factor for community-acquired pneumonia (CAP) includes age greater than _____ years.
Match the following O₂ therapy durations with their correct usage:
Match the following O₂ therapy durations with their correct usage:
Match the following risk factors with their effects on community-acquired pneumonia:
Match the following risk factors with their effects on community-acquired pneumonia:
Which organism is most commonly associated with upper lobe involvement and cavitation in pneumonia?
Which organism is most commonly associated with upper lobe involvement and cavitation in pneumonia?
MRSA is typically associated with presentations of cystic fibrosis.
MRSA is typically associated with presentations of cystic fibrosis.
What is the possible etiology associated with dementia and decreased level of consciousness?
What is the possible etiology associated with dementia and decreased level of consciousness?
The presence of _ is a possible etiology for lung abscesses.
The presence of _ is a possible etiology for lung abscesses.
Match the following factors with their possible etiologies:
Match the following factors with their possible etiologies:
What is the minimum blood eosinophil count required to initiate treatment with inhaled corticosteroids?
What is the minimum blood eosinophil count required to initiate treatment with inhaled corticosteroids?
Repeated pneumonia is a contraindication for inhaled corticosteroid usage.
Repeated pneumonia is a contraindication for inhaled corticosteroid usage.
What combination of medications is typically administered for asthma treatment?
What combination of medications is typically administered for asthma treatment?
Patients with _______ and blood eosinophils greater than 300 cells/µL would receive LAMA + LABA + ICS.
Patients with _______ and blood eosinophils greater than 300 cells/µL would receive LAMA + LABA + ICS.
What is the main indication for bronchodilator reversibility testing?
What is the main indication for bronchodilator reversibility testing?
In emphysema, FEV values are usually normal.
In emphysema, FEV values are usually normal.
Match the treatment types with their indicated conditions:
Match the treatment types with their indicated conditions:
What is the significance of a FEV₁/FVC ratio less than 0.7?
What is the significance of a FEV₁/FVC ratio less than 0.7?
Chronic damage to the parenchyma leads to chronic __________, which can progress to pulmonary hypertension.
Chronic damage to the parenchyma leads to chronic __________, which can progress to pulmonary hypertension.
Match the following GOLD grades with their corresponding FEV₁ values:
Match the following GOLD grades with their corresponding FEV₁ values:
What is the most common causative organism of lobar pneumonia?
What is the most common causative organism of lobar pneumonia?
Atypical pneumonia is typically characterized by an abrupt onset.
Atypical pneumonia is typically characterized by an abrupt onset.
Identify one clinical feature of typical pneumonia.
Identify one clinical feature of typical pneumonia.
The most common virus associated with interstitial pneumonia is _____ .
The most common virus associated with interstitial pneumonia is _____ .
Match the following pneumonia types with their respective characteristics:
Match the following pneumonia types with their respective characteristics:
Which type of pneumonia occurs more than 48 hours after admission to the hospital?
Which type of pneumonia occurs more than 48 hours after admission to the hospital?
Community acquired pneumonia can be classified as either typical or atypical based on the organism responsible.
Community acquired pneumonia can be classified as either typical or atypical based on the organism responsible.
Which of the following organisms is commonly associated with outpatient community-acquired pneumonia?
Which of the following organisms is commonly associated with outpatient community-acquired pneumonia?
Name one anatomical classification of pneumonia.
Name one anatomical classification of pneumonia.
Ventilator-associated pneumonia occurs more than 48 hours after __________ intubation.
Ventilator-associated pneumonia occurs more than 48 hours after __________ intubation.
Cavity formation and hemoptysis are indicators of community-acquired MRSA infection.
Cavity formation and hemoptysis are indicators of community-acquired MRSA infection.
Match the types of pneumonia to their definitions:
Match the types of pneumonia to their definitions:
What type of hemolysis is exhibited by Streptococcus pneumoniae on blood agar?
What type of hemolysis is exhibited by Streptococcus pneumoniae on blood agar?
Patients with _____ heart failure are at an increased risk for MRSA and MDR negative infections.
Patients with _____ heart failure are at an increased risk for MRSA and MDR negative infections.
Match the following types of pneumonia infections with their corresponding risk factors:
Match the following types of pneumonia infections with their corresponding risk factors:
Which clinical feature might be the only symptom of pneumonia in older patients?
Which clinical feature might be the only symptom of pneumonia in older patients?
Leukocytosis is typically normal in lobar pneumonia.
Leukocytosis is typically normal in lobar pneumonia.
What is the usual cause of lobar pneumonia?
What is the usual cause of lobar pneumonia?
The hallmark sign of interstitial pneumonia is bilateral, diffuse fine ______ opacity.
The hallmark sign of interstitial pneumonia is bilateral, diffuse fine ______ opacity.
Match the following types of pneumonia with their usual cause:
Match the following types of pneumonia with their usual cause:
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Study Notes
Long Term Oxygen Therapy
- Long-term oxygen therapy for COPD is indicated when PaO₂ is less than 55 mm Hg or between 55 and 60 mm Hg if polycythemia or right heart failure is present.
- O₂ concentrators are usually prescribed for 15-16 hours per day.
Surgical Management
- Lung volume reduction surgery is contraindicated if FEV₁ is less than 20%.
BODE Index
- BODE index is used to assess the severity of COPD and includes factors like:
- Body mass index (BMI)
- Obstructive ventilatory defect
- Dyspnea
- Exercise capacity
Exacerbation Management
- COPD exacerbations are characterized by dyspnea and/or cough with sputum.
Pneumonia Definition and Pathogenesis
- Pneumonia is an acute infection of lung parenchyma without necrosis.
- It affects structures like alveoli, alveolar interstitium, vascular interstitium, respiratory bronchioles, and alveolar ducts.
- Necrotizing pneumonia, leading to lung abscess, involves destruction of lung parenchyma.
- Defective cell-mediated immunity allows viruses to disrupt lung microbiota, leading to alveolar epithelial barrier disruption and bacterial entry through microaspiration.
- Cytokine release contributes to inflammation and symptoms:
- IL-1 and IL-6 cause fever
- TNF α recruits neutrophils
- IL-8 causes capillary leak leading to alveolo-capillary exudate, impairing diffusion, causing hypoxia, and leading to dyspnea.
- Protective mechanisms of the lungs include pulmonary alveolar macrophage, gag reflex, and mucociliary clearance.
- The oropharynx is the easiest and most common access route to the lower respiratory tract through aspiration.
Streptococcus pneumoniae Characteristics
- Bile soluble
- Optochin susceptible
- Ferments inulin
Toxins Produced by Streptococcus pneumoniae
- Capsular polysaccharide
- Pneumolysin (cytolytic toxin)
- IgA1
- Pneumococcal somatic C antigen
- C-reactive protein
Risk Factors for Community-Acquired Pneumonia (CAP)
- Deficient cell-mediated immunity:
- Diabetes
- Chronic kidney disease
- Hemodialysis
- COPD, bronchiectasis
- Cardiac failure
- Age > 65 years
- Immunocompromised:
- Steroid or monoclonal antibody consumption
- Transplant
- Neutropenia
Diagnostic Investigations for Pneumonia
- Sputum microscopy (mainly used in atypical pneumonia, low yield)
- Sputum culture
- Blood culture
- Bronchoalveolar lavage (BAL)
Etiology of Various Pneumonia Presentations and Histories
- Bacteremia/diabetes, history of alcoholism, upper lobe involvement, bulging fissure, cavitation, golden S sign: Streptococcus pneumoniae, Klebsiella
- COPD/smoking, bronchiectasis: Pseudomonas, Burkholderia cepacia
- Cystic fibrosis: MRSA, anaerobes
- Lung abscess, cavity, pneumatocele: MRSA, Klebsiella, anaerobes
- Dementia, decreased level of consciousness, exposure to sheep, cats, goats: Coxiella burnetii, Francisella tularensis
- Exposure to rabbits, exposure to bats: Histoplasma, Legionella
- Travel in cruise ship, travel to Ohio and St. Lawrence river valley: Histoplasma capsulatum, Chlamydia pneumoniae
- Atherosclerosis: various causes
Community-Acquired Pneumonia
- Hospital-acquired pneumonia occurs greater than 48 hours after admission.
- Ventilator-associated pneumonia occurs greater than 48 hours after endotracheal intubation.
Anatomical Classification of Pneumonia
- Lobar Pneumonia
- Interstitial Pneumonia
Organism-Based Classification of Pneumonia
- Typical Pneumonia
- Atypical Pneumonia
Inhaled Corticosteroids (ICS)
- Indications for ICS in COPD:
- Blood eosinophils ≥ 300 cells/µL
- ≥ 2 moderate exacerbations/year
- History of concomitant asthma
- History of hospitalization for asthma exacerbation
- Contraindications for ICS in COPD:
- Repeated pneumonia
- Blood eosinophils < 100 cells/µL
- History of tuberculosis
- The 2019 guidelines recommend reducing the use of steroids.
- In asthma, ICS are usually prescribed with formoterol.
Medical Management of COPD
- Initial treatment for COPD:
- ≥ 2 moderate exacerbations or ≥ 1 hospitalization: LABA + LAMA ± ICS (if blood eosinophils ≥ 300)
- 0–1 moderate exacerbation: LABA/LAMA (Group A)
- Blood eosinophils < 300: LABA/LAMA (Group B)
- Blood eosinophils > 300: LAMA + LABA + ICS (Group B)
- LABA (Long acting β agonist): Formoterol, Indacaterol
- LAMA (Long acting muscarinic agonist): Tiotropium
- Follow-up treatment for COPD:
- Dyspnea: LABA/LAMA, LABA + LAMA
- Exacerbation: LABA/LAMA, LAMA + LABA + ICS (if blood eosinophils ≥ 300)
- Roflumilast (phosphodiesterase-4 inhibitor) may be beneficial in patients with chronic bronchitis and FEV₁ < 50%.
- For unresponsive cases, azithromycin may be considered, particularly for patients with history of smoking/emphysema.
Alveoli and Pulmonary Vasculature in COPD
- Alveoli and the alveolocapillary unit are involved in COPD.
- Parenchyma damage leads to chronic hypoxia (↓PaO₂, ↑ PaCO₂), which triggers pulmonary vasoconstriction.
- This can lead to pulmonary hypertension, pulmonary cor pulmonale, edema, and eventually death.
Diagnosis of COPD
- Pulmonary function test (PFT):
- Emphysema:
- Reduced FEV₁
- Normal FVC
- Reduced FEV₁/FVC
- Emphysema:
- If FEV₁/FVC < 0.7, bronchodilator reversibility testing is recommended.
- DLCO:
- Chronic bronchitis: Normal
- Emphysema: Reduced
- Bronchodilator reversibility testing:
- Positive: Asthma
- Negative: COPD
- Gold ABE assessment tool:
- Spirometry confirms diagnosis.
- Assess airflow obstruction and symptoms/risks.
Causative Organisms in Pneumonia
- Lobar Pneumonia:
- Site: Restricted to one lobe
- Bacteria: Streptococcus pneumoniae (most common), Staphylococcus aureus (MRSA sp), Klebsiella pneumonia, Hemophilus influenza, Moraxella catarrhalis
- Interstitial Pneumonia (Atypical):
- Site: Not localized to one lobe
- Bacteria: Mycoplasma, Chlamydia, Legionella
- Fungi: Aspergillus, Pneumocystis jirovecii (HIV), Nocardia (immunocompromised)
- Virus: Various viruses (most common)
Typical vs Atypical Pneumonia
- Typical Pneumonia:
- Organism: Extracellular
- Onset: Abrupt
- Pathology: Alveolar capillary exudates, neutrophilic
- Predominance: Fever
- Clinical features: Cough with sputum, pleuritic pain, hemoptysis, dyspnea
- Culture/gram stain: Can be detected
- Inflammatory parameters: ↑CRP, ↑procalcitonin, leucocytosis
- Radiological features: Large area of consolidation (lobar involvement)
- Atypical Pneumonia:
- Organism: Intracellular
- Onset: Insidious
- Pathology: Interstitial infiltrates, lymphocytic
- Clinical features: Mild URI → Dry cough, dyspnea, ARDS, low-grade fever, scanty sputum, extrapulmonary involvement
- Culture/gram stain: Cannot be detected
Community-Acquired MRSA
- Concurrent influenza infection may be present.
- Cavity, hemoptysis, and pneumatocele may occur.
Outpatient vs. Inpatient Pneumonia Treatment
- Outpatient: Streptococcus pneumoniae, viruses, Mycoplasma, Chlamydia, H. influenza
- Inpatient (Non-ICU): Streptococcus pneumoniae, respiratory viruses, Legionella sp.
- Inpatient (ICU): Streptococcus pneumoniae, MRSA, multidrug-resistant gram-negative (MDR)
Risk Factors for MRSA and MDR Negative Infection
- Congestive heart failure
- Hemodialysis
- Antibiotic use within the last 3 months
- Hospitalization
- Structural lung disease
Pneumococci Morphology and Culture
- Gram-positive diplococci in chains, often described as flame-shaped or lanceolate.
- Alpha hemolytic (partial hemolysis in 5% blood agar) and produces a green color on blood agar.
Hemolysis Flowchart
- Complete hemolysis → Streptococcus → Partial hemolysis → Streptococcus pneumoniae, Enterococci → Streptococcus viridans → No hemolysis
CXR Findings in Pneumonia
- Lobar Pneumonia:
- Homogeneous consolidation
- Silhouette sign
- Air bronchogram
- Sharply marginated fissure
- Usual cause: Streptococcus pneumoniae
- Bronchopneumonia:
- Poorly defined heterogeneous patchy infiltrates scattered throughout the lung
- Air bronchogram
- Usual cause: Staphylococcus aureus (multilobar + cavitation + pneumatocoeles + abscess)
- Interstitial Pneumonia:
- Bilateral, diffuse fine reticular opacity
- Usual cause: Pneumocystis jirovecii pneumonia (PCP)
- Aspiration:
- Airspace opacification in a lobar or segmental distribution
- Gravity-dependent predilection
- Usual cause: Stroke, seizure
Clinical Pattern of Pneumonia
- Bacteria bind to type 2 alveolar epithelial cells.
Clinical Features of Lobar Pneumonia
- High spiking fever
- Pleuritic chest pain
- Cough
- Hemoptysis
- Dyspnea
- Abdominal symptoms (Diffuse abdominal pain, recurrent hiccups)
- Confusion
Pneumonia Investigations
- CXR/CT
- Blood investigations:
- CBC: ↑Leucocytosis (lobar pneumonia), normal (interstitial bronchopneumonia)
- CRP: ↑ (lobar pneumonia), normal (interstitial bronchopneumonia)
- Procalcitonin: ↓ (lobar pneumonia), normal (interstitial bronchopneumonia)
Community-Acquired Pneumonia Clinical Pattern
- Bacteria bind to type 2 alveolar epithelial cells.
Clinical Features of Lobar Pneumonia
- High spiking fever
- Pleuritic chest pain
- Cough
- Hemoptysis
- Dyspnea
- Abdominal symptoms (Diffuse abdominal pain, recurrent hiccups)
- Confusion
Investigations for Pneumonia
- CXR/CT:
- Lobar pneumonia: Homogeneous consolidation, silhouette sign, air bronchogram, sharply marginated fissure
- Bronchopneumonia: Poorly defined heterogeneous patchy infiltrates, air bronchogram
- Interstitial pneumonia: Bilateral, diffuse fine reticular opacity
- Aspiration: Airspace opacification in a lobar or segmental distribution, gravity-dependent predilection
- Blood investigations:
- CBC: ↑Leucocytosis (lobar pneumonia), normal (interstitial bronchopneumonia)
- CRP: ↑ (lobar pneumonia), normal (interstitial bronchopneumonia)
- Procalcitonin: ↓ (lobar pneumonia), normal (interstitial bronchopneumonia)
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