Question 1

What organism is associated with the highest mortality rate for patients with pneumonia?

Accepted Answer

Mortality varies according to the infecting agent and was highest for P. aeruginosa (61.1%), Klebsiella species (35.7%), Escherichia coli (35.3%), and S. aureus (31.8%). Mortality rates for more common pathogens were lower but still substantial and included Legionella species (14.7%), S. pneumoniae (12.3%), C. pneumoniae (9.8%), and M. pneumoniae (1.4%).

Question 2

An intubated, mechanically ventilated patient is suspected of developing nosocomial pneumonia. The pulmonologist decides to perform a bronchoscopy. Which bronchoscopy findings would be consistent with pneumonia?
1) Alveolar collapse
2) Distal purulent secretions
3) Persistent secretions surging from distal bronchi during exhalation
4) P/F ratio less than 50

Accepted Answer

1) Alveolar collapse is not a specific finding for pneumonia and can be seen in a variety of conditions.
2) Distal purulent secretions are consistent with pneumonia as they suggest the presence of infected material in the lower respiratory tract.
3) Persistent secretions surging from distal bronchi during exhalation are also consistent with pneumonia, as they indicate the presence of infected material that is difficult to clear.
4) A P/F ratio less than 50 indicates severe hypoxemia, which may be seen with pneumonia.

Question 3

Which of the following would interfere with the collection of a good sputum sample for Gram stain?
1) Contamination of the sample with oral secretions
2) Lack of productive cough
3) Prior antibiotic therapy
4) Rinsing with mouthwash prior to sputum collection

Accepted Answer

1) Contamination with oral secretions can dilute the sputum with bacteria from the mouth, not the lungs. 2) A lack of productive cough may result in insufficient sputum for analysis. 3) Prior antibiotic therapy can alter the bacterial flora present in the sputum, potentially leading to misleading results. 4) Rinsing with mouthwash is not mentioned as interfering with sputum collection for Gram stain; it might even reduce oral contamination, though not specified in standard guidelines.

Question 4

Which of the following organisms have been found to colonize the oropharynx of healthy individuals?

Accepted Answer

In routine sputum culture, the isolation of bacteria, such as S. pneumoniae and H. influenzae, must be interpreted within the context of the Gram stain because these organisms can colonize the oropharynx, and their presence in culture may not signify true lower respiratory tract infection.

Question 5

What type of severe lung infection may result in the development of small lung cavities called pneumatoceles?

Accepted Answer

Patients with severe staphylococcal or gram-negative pneumonias may develop small cavities called pneumatoceles.

Question 6

What finding is usually used to confirm the diagnosis of pneumonia?

Accepted Answer

In patients with a compatible clinical syndrome, the diagnosis of community-acquired pneumonia is established by the presence of a new pulmonary infiltrate on the chest radiograph.

Question 7

What percent of patients with community-acquired pneumonia have a parapneumonic pleural effusion?

Accepted Answer

Parapneumonic pleural effusions are common and occur in 30% to 50% of cases of community-acquired pneumonia.

Question 8

What clinical finding should raise your suspicion that a patient has developed hospital-acquired pneumonia?

Accepted Answer

HCAP, HAP, and VAP usually present with a new onset of fever in hospitalized or institutionalized patients.

Question 9

Which of the following organisms that cause pneumonia is most likely to result in a positive blood culture?

Accepted Answer

Blood cultures should be obtained in hospitalized patients with community-acquired pneumonia and may be helpful in establishing the diagnosis in patients with typical bacterial pathogens. Blood cultures are positive in approximately 30% of patients with pneumococcal pneumonia and in up to 70% of those with H. influenzae pneumonia.

Question 10

What type of lung infection is most commonly associated with cavitating lesions on the chest radiograph?

Accepted Answer

Cavitary infiltrates are seen in reactivation pulmonary tuberculosis; fungal pneumonias, such as histoplasmosis and blastomycosis; nocardiosis; pyogenic lung abscess; and rarely, P. jiroveci pneumonia.

Question 11

In order to determine the presence of ventilator-associated pneumonia, what diagnostic procedure might be done by a respiratory therapist?

Accepted Answer

Recently, mini-BAL performed by RTs has been advocated for diagnosing VAP. In one study, results obtained using this technique were comparable with those obtained by bronchoscopy using PSB.

Question 12

Which of the following clinical conditions are often associated with a normal chest radiograph in the patient with pneumonia?
1) Dehydration
2) Early infection
3) Klebsiella pneumonia
4) Pneumocystis jiroveci infection

Accepted Answer

Dehydration can cause an elevation in the hematocrit and a relative decrease in lung markings on a chest radiograph, leading to a normal chest radiograph in the setting of pneumonia. Early stage pneumonia may not always be apparent on a chest radiograph, and Pneumocystis jiroveci infection can present with a normal chest radiograph in up to 20% of cases. Klebsiella pneumonia, on the other hand, typically presents with a visible lobar pneumonia on a chest radiograph. Therefore, options 2 and 4 are correct, while options 1 and 3 are incorrect.

Question 13

A 35-year-old man is admitted to the hospital and has been confirmed to have pneumococcal pneumonia. What test would it be wise to order at this time?

Accepted Answer

Because pneumococcal and H. influenzae pneumonia occur with higher frequency in patients with HIV than they do in the average population, an HIV test is recommended for patients with community-acquired pneumonia who are between the ages of 15 and 54 years. HIV testing is also recommended for other individuals who engage in behaviors that put them at risk for HIV.

Question 14

Which of the following would be associated with a fatal outcome in a patient with pneumonia who is mechanically ventilated?

Accepted Answer

In mechanically ventilated patients, factors associated with fatal outcome include the following:

Question 15

In the patient suspected of having tuberculosis, what finding on Gram stain would result in the initiation of antituberculosis medications?

Accepted Answer

In patients with suspected tuberculosis, the finding of acid-fact bacilli in stained specimens of sputum often prompts initiation of antituberculous therapy, because culture isolation of M. tuberculosis may take up to 6 weeks.

Question 16

Rapidly spreading multilobar consolidation is typical for what type of pneumonia?

Accepted Answer

Legionella pneumonia, caused by the Legionella pneumophila bacterium, can lead to rapidly spreading multilobar consolidation. This type of pneumonia is often severe and can spread quickly to multiple lobes of the lungs.

Question 17

Which of the following clinical findings is not associated with an increased risk of death in the patient with pneumonia?

Accepted Answer

Points are assigned for the presence of a number of variables, and cumulative point scores are used to stratify patients into one of five different risk groups with predictable mortality rates Of the above only respiratory alkalosis is NOT associated with increased risk of death.

Question 18

An elderly patient comes in with failure to thrive, shortness of breath, confusion, and worsening congestive heart failure. What is most likely the patient's primary problem?

Accepted Answer

The clinical presentation of community-acquired pneumonia in elderly patients deserves special mention because it may be subtle. Older individuals with pneumonia may not have a fever or cough and may simply present with shortness of breath, confusion, worsening congestive heart failure (CHF), or failure to thrive.

Question 19

What finding on the chest radiograph is typical for a viral pneumonia?

Accepted Answer

Interstitial infiltrates, especially if diffuse, suggest viral disease, P. jiroveci, or miliary tuberculosis in patients with community-acquired pneumonia.

Question 20

What would be important to perform in order to obtain a good sputum sample that is to be used to detect the pathogen causing community-acquired pneumonia?

Accepted Answer

The RT has an important role in the collection of an appropriate specimen of expectorated sputum. Patients should be advised to rid the mouth of contaminating saliva, either by rinsing with water or by spitting, and then to expectorate a specimen from deep within the tracheobronchial tree into a collection container. Prompt transportation to the laboratory is essential and improves the diagnostic yield from culture.

Quiz 24: Pulmonary Infections