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Respiratory Medicine Made Simple : Pneumonia : Clinical Examination, Investigations and Management

 Pneumococcal pneumonia presents classically as lobar or segmental consolidation.

Multiple , non-contiguous and sometimes bilateral segments may be affected with multilobar involvement being a poor prognostic factor.

The absence of an air bronchogram within an area of consolidation suggests exudate or pus filling the conducting airways aside from Streptococcus pneumonia , organisms commonly responsible for this appearance include Staphylococcus and Gram negative organisms.

Early cavitation in an area of consolidation is typical ofstaphylococcal infection but consider Gram negative organism such as Klebsiella and donot forget Tuberculosis.

Also consider Aspiration pneumonia or proximal bronchial obstruction eg due to carcinoma or a foreign body.

A variety of Radiographic patterns are described in Mycoplasma pneumonia & in Lgionnaire”s disease.

The presence of pleural fluid is suggestive of bacterial aetiology and a diagnostic tap should be performed if this is anything more than trivial in size.

In pneumococcal pneumonia the radiograph maybe normal at presentation even in the presence of a classical history and signs of consolidation on examination only to become abnormal over the next few hours.

Routine blood tests :

Full blood count

Anemia will compound impared tissue oxygen delivery and white cell count is likely to be elevated.

However a patient with overwhelming sepsis may have a normal white cell count.

Electrolytes and Renal function

Uremia is a bad prognostic sign in pneumonia

Hyponatremia is another non-specific marker of severity of infection and is also a particular feature of Legionaires disease.

Liver function Tests :

Derangement of liver enzymes maybe seen in any severe sepsis but transient hepatitis is seen as a part of multisystem involvement in atypical infections such as Legionairres disease.

Also inflammatory markers such as CRP is a more sensitive marker of severity of pneumonia than an increased temperature or a white cell count.

Microbiological Tests :

Sputum microscopy and culture

If sputum is obtainable,it is important to send early in infection

And do a sputum for AFB test / Acid fast bacilli

Blood cultures

Urinary assays of specific antigens : pneumococcal antigen and Legionella antigen

Serological testing : Send acute and convalescent titres for atypical serology

Pleural fluid if there is significant effusion.

Management

General management and resuscitation if needed.

CURB -65 score

Assessment using CURB-65 is vital as a prognostic indicator

Confusion

Mini mental scale Examination < 8

Or new disorientation in person , place and time

Urea > 7 mmol/l

Respiratory rate > 30 / minute

BP systolic < 90 mm Hg or

Diastolic < 60 mmHg

Age > 65 yrs

Score 1 point for each feature present.

A score of 3 – 5 suggests severe pneumonia,

Antibiotics :

Antibiotics should be given without delay with the choice guarded by the BTS guidelines

And / or local knowledge of of the pathogens commonly implicated.

Always consult local prescribing policies in addition to obtaining microbiological advice as necessary.

CURB-65 score 1 or 2 in the moderately sick patient ,oral amoxicillin and a macrolide should be given.

In those patients allergic to penicillin, a fluoroquinolone should be given ie levofloxacin

CURB 65 score 3 or more

In the more severely ill patient , co-amoxiclav or a third generation cephalosporin should be given intravenously in conjunction with a macrolide.

In patients who are penicillin allergic, an intravenous fluoroquinolone in addition to a macrolide shoukd be considered.

If Legionaires disease is considered, then intravenous Erythromycin 1 Gram every 6 hours should be considered.

If there is any suggestion of preceding influenza , consider adding a specific antistaphylococcal antibiotic eg Fluclocloxacillin.

If Gram negative infection or aspiration is suspected , then a 3rd Generation Cephalosporin is the antibiotic of choice.

Respiratory Medicine Made Simple : Pneumonia : Definition , Causes and History

 

Pneumonia refers to infection &  inflammation of the lung tissue / parenchyma.

Pneumonia is an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty breathing.

A variety of organisms, including bacteria, viruses and fungi, can cause pneumonia.

 

Pneumonia can range in seriousness from mild to life-threatening.

It is most serious for infants and young children, people older than age 65, and people with health problems or weakened immune systems.

Symptoms

The signs and symptoms of pneumonia vary from mild to severe, depending on factors such as the type of germ causing the infection, and your age and overall health.

Mild signs and symptoms often are similar to those of a cold or flu, but they last longer.

 

Signs and symptoms of pneumonia may include:

Chest pain when you breathe or cough

Confusion or changes in mental awareness (in adults age 65 and older)

Cough, which may produce phlegm

Fatigue

Fever, sweating and shaking chills

Lower than normal body temperature (in adults older than age 65 and people with weak immune systems)

Nausea, vomiting or diarrhea

Shortness of breath

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Clinical features of pneumonia

Fever

Cough

Shortness of breath

Malaise

Breathlessness

Confusion

Fever : is usually high grade upto 38.5 C

Breathlessness is a characteristic feature of pneumonia.

It indicates a ventilation perfusion mis match as seen in pneumonic consolidation.

Cough :

Does the patient have a cough?

If yes,is it dry , productive or purulent?

Does the patient normally have a cough and produce sputum?

In a patient with Normal lungs, a dry cough is suggestive of pneumonia of any sort.

A purulent cough is suggestive of an underlying bacterial infection.

A brownish red / rusty colored cough is suggestive of pneumococcal infection.

Chest pain could be due to soreness from coughing or it may be pleuritic due to which is more common in bacterial than non-bacterial infection.

When did the illness start ?

Bacterial pneumonias have a small prodrome as compared to non-bacterial infections

Eg Mycoplasma will have a longer prodromal phase.

Presence of confusion indicates the pneumonia is severe.

But note that classic symptoms and signs of pneumonia are less likely in the elderly and hence confusion may be the main presenting symptoms and only diagnostic clue.

Are there any other likely Diagnosis ?

Other common causes of acute presentation with breathlessness include :

Pulmonary oedema

Pulmonary embolism

Are there any clinical features that suggest these as possible cause ?

Patients with atypical pneumonias may have GI symptoms.

Relevant Past Medical history

A detailed Past Medical history is required

But particular emphasis should be on the following ;

Ask if the patient has a previous history of

COPD / Chronic Obstructive Pulmonary Disease

Bronchiectasis or a long standing lung problem

Smoking history

Alcohol History

Alcoholism can lead to recurrent Aspiration Pneumonias as well as pneumococcal and Gram negative and atypical infections.

Also determine if the patient has suffered from Alcohol withdrawal  if admitted to the hospital.

Pets : are there any parrots or budgies at home of patient ?

Is the patient immunosuppressed ?

HYPONATREMIA : RISK FACTORS , CAUSES, INVESTIGATIONS ,COMPLICATIONS & MANAGEMENT

HYPONATREMIA : RISK FACTORS , CAUSES, INVESTIGATIONS ,COMPLICATIONS & MANAGEMENT

RISK FACTORS OF HYPONATREMIA

The following factors may increase your risk of hyponatremia:

Age. Older adults may have more contributing factors for hyponatremia, including age-related changes, taking certain medications and a greater likelihood of developing a chronic disease that alters the body's sodium balance.

Certain drugs. Medications that increase your risk of hyponatremia include thiazide diuretics as well as some antidepressants and pain medications. In addition, the recreational drug Ecstasy has been linked to fatal cases of hyponatremia.

Conditions that decrease your body's water excretion. Medical conditions that may increase your risk of hyponatremia include kidney disease, syndrome of inappropriate anti-diuretic hormone (SIADH) and heart failure, among others.

Intensive physical activities. People who drink too much water while taking part in marathons, ultramarathons, triathlons and other long-distance, high-intensity activities are at an increased risk of hyponatremia.

SIADH

SYNDROME OF INAPPROPRIATE ADH SECRETION

Syndrome of inappropriate antidiuretic hormone secretion occurs when excessive levels of antidiuretic hormones (hormones that help the kidneys, and body, conserve the correct amount of water) are produced. The syndrome causes the body to retain water and certain levels of electrolytes in the blood to fall (such as sodium).

CAUSES OF SIADH

SYNDROME OF INAPPROPRIATE ADH SECRETION

SIADH tends to occur in people with heart failure or people with a diseased hypothalamus (the part of the brain that works directly with the pituitary gland to produce hormones). In other cases, a certain cancer (elsewhere in the body) may produce the antidiuretic hormone, especially certain lung cancers. Other causes may include the following:

Meningitis (inflammation of the meninges, the membranes that cover the brain and spinal cord)

CAUSES OF SIADH

SYNDROME OF INAPPROPRIATE ADH SECRETION

Encephalitis (inflammation of the brain)

Brain tumors

Psychosis

Lung diseases

Head trauma

Guillain-Barré syndrome (a reversible condition that affects the nerves in the body. GBS can result in muscle weakness, pain, and even temporary paralysis of the facial, chest, and leg muscles. Paralysis of the chest muscles can lead to breathing problems.)

Certain medications

Damage to the hypothalamus or pituitary gland during surgery

Thyroid or parathyroid hormone deficiencies

HIV

Hereditary causes

INVESTIGATIONS FOR DETECTING CAUSE OF HYPONATREMIA

URINARY SODIUM CONCENTRATION is useful for disinguishing between renal and extrarenal hypovolemic hyponatremia and hypervolemic hyponatremia.

PAIRED URINE AND PLASMA OSMOLALITIES  should be sent to exclude possibilty of SIADH.

CT Head to exclude any sub dural haematoma / head injury to exclude SIADH as a cause of hyponatremia.

COMPLICATIONS OF HYPONATREMIA

In chronic hyponatremia, sodium levels drop gradually over 48 hours or longer — and symptoms and complications are typically more moderate.

In acute hyponatremia, sodium levels drop rapidly — resulting in potentially dangerous effects, such as rapid brain swelling, which can result in a coma and death.

Premenopausal women appear to be at the greatest risk of hyponatremia-related brain damage. This may be related to the effect of women's sex hormones on the body's ability to balance sodium levels.

PREVENTION OF HYPONATREMIA

Treat associated conditions. Getting treatment for conditions that contribute to hyponatremia, such as adrenal gland insufficiency, can help prevent low blood sodium.

Educate yourself. If you have a medical condition that increases your risk of hyponatremia or you take diuretic medications, be aware of the signs and symptoms of low blood sodium. Always talk with your doctor about the risks of a new medication.

Take precautions during high-intensity activities. Athletes should drink only as much fluid as they lose due to sweating during a race. Thirst is generally a good guide to how much water or other fluids you need.

MANAGEMENT OF HYPONATREMIA

Hyponatremia treatment is aimed at addressing the underlying cause, if possible.

If you have moderate, chronic hyponatremia due to your diet, diuretics or drinking too much water, your doctor may recommend temporarily cutting back on fluids. He or she may also suggest adjusting your diuretic use to increase the level of sodium in your blood.

If you have severe, acute hyponatremia, you'll need more-aggressive treatment. Options include:

TREATMENT OF HYPONATREMIA

Intravenous fluids. Your doctor may recommend IV sodium solution to slowly raise the sodium levels in your blood. This requires a stay in the hospital for frequent monitoring of sodium levels as too rapid of a correction is dangerous.

Medications. You may take medications to manage the signs and symptoms of hyponatremia, such as headaches, nausea and seizures.

1.8 % saline infused at rate of ( 1.7 * patients weight in Kg) ml/hr or 3% saline infused at rate of (1.0 * pts weight in Kg )/ml/hr will increase serum sodium concentration by 1 mmol/hour.

Aim in early phases is to increase serum sodium concentration by  1 mmol/hour  but no more than  15 – 20 mmol/hour over 48 hour.

TREATMENT OF SIADH

Specific treatment for SIADH will be determined by your doctor based on:

Your age, overall health, and medical history

Extent of the disease

Your tolerance for specific medications, procedures, or therapies

Expectations for the course of the disease

The most commonly prescribed treatment for SIADH is fluid and water restriction. If the condition is chronic, fluid restriction may need to be permanent. Treatment may also include:

Certain medications that inhibit the action of ADH (also called vasopressin)

Surgical removal of a tumor that is producing ADH

Other medicines to help regulate body fluid volume