Pneumonia
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Transcript of Pneumonia
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PNEUMONIA
Dr Muhammed AslamMBBS , MD Pulmonary Medicine
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KUHS Exam - Model Question Essay Question- 10 Marks (1+2+3+2+2=10)
60 yrs old male smoker with DM presented to OPD with high grade fever , right sided chest pain and cough with rusty sputum for 1 week ?
• Give your provisional diagnosis ?• How will you diagnose?• What are the causes and pathogenesis ?• How will you Manage?• What are the complications ?
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Outline• Introduction• Risk factors • Pathogenesis• Types• Etiology• Clinical features• Investigation• Treatment• Complication• Prevention
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Pneumonia Pneumonia is an infection
in one or both lungs.
Pneumonia causes inflammation in the alveoli.
The alveoli are filled with fluid or pus, making it difficult to breathe.
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DEFINITION• “inflammation and consolidation of lung
tissue due to an infectious agent”
• COSOLIDATION = ‘Inflammatory induration of a normally aerated lung due to the presence of cellular exudative in alveoli’
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How does Pneumonia develop?• Most of the time, the body filters organisms.
• This keeps the lungs from becoming infected.
• But organisms sometimes enter the lungs and cause infections.
This is more likely to occur when:immune system is weak.organism is very strong.body fails to filter the organisms.
•
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Factors that predispose to Pneumonia
Cigarette smoking Upper respiratory tract infections Alcohol Corticosteroid therapy Old age Recent influenza infection Pre-existing lung disease
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Factors that predispose to Pneumonia
Reduced host defences against bacteria • Reduced immune defences (e.g. corticosteroid treatment,
diabetes, malignancy) • Reduced cough reflex (e.g. post-operative) • Disordered mucociliary clearance (e.g. anaesthetic
agents) • Bulbar or vocal cord palsy
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Factors that predispose to Pneumonia
Aspiration of nasopharyngeal or gastric secretions• Immobility or reduced conscious level • Vomiting, dysphagia, achalasia or severe reflux • Nasogastric intubation
Bacteria introduced into lower respiratory tract • Endotracheal intubation/tracheostomy • Infected ventilators/nebulisers/bronchoscopes • Dental or sinus infection
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Factors that predispose to Pneumonia
BacteraemiaAbdominal sepsis Intravenous cannula infection Infected emboli
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How does Pneumonia develop?
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PATHOLOGY
Congestion
• Presence of a proteinaceous exudate—and often of bacteria—in the alveoli
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RED HEPATIZATION • Presence of erythrocytes in the
cellular intraalveolar exudate • Neutrophils are also present
• Bacteria are occasionally seen in cultures of alveolar specimens collected
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Normal Lung Red Hepatization
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GRAY HEPATIZATION• No new erythrocytes are extravasating, and
those already present have been lysed and degraded
• Neutrophil is the predominant cell• Fibrin deposition is abundant
• Bacteria have disappeared• Corresponds with successful containment of the
infection and improvement in gas exchange
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RESOLUTION
Macrophage is the dominant cell type in the alveolar space
Debris of neutrophils, bacteria, and fibrin has been cleared
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Types of Pneumonia
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ANATOMICAL CLASSIFICATION
1. Bronchopneumonia affects the lungs in patches around bronchi
2. Lobar pneumonia is an infection that only involves a single lobe, or section, of a lung.
3. Interstitial pneumonia involves the areas in between the alveoli
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CLINICAL CLASSIFICATION
1) Community Acquired - Typical/Atypical/Aspiration
2) Pneumonia in Elderly
3) Nosocomial- HAP,VAP,HCAP
4) Pneumonia in Immunocompromised host
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Community Acquired Pneumonia (CAP)
DEFINITION:
• An infection of the pulmonary parenchyma • Associated with symptoms of a/c infection• Presence of a/c infiltrates on CXR or auscultatory findings
consistent with Pneumonia
In a patient not hospitalized or residing in LTC facility for > 14 days prior•
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Hospital Acquired pneumonia - HAP
HAP is defined as pneumonia that occurs 48 hours or more after admission, which was not incubating at the time of admission.•
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Ventilator Associated Pneumonia- VAP
VAP refers to pneumonia that arises more than 48–72 hours after endotracheal intubation .•
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Health Care Associated Pneumonia HCAP
HCAP includes any patient
• Who was hospitalized in an acute care hospital for 2 or more days within 90 days of the infection
• Resided in a nursing home or long-term care facility
• Received recent i.v antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection
Attended a hospital or hemodialysis clinic•
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ATYPICAL PNEUMONIA - Why ‘Atypical’?
Clinically• Subacute onset • Fever less common or intense • Minimal sputum
MicrobiologicallySputum does not reveal a predominant microbial etiology on routine smears (Gram’s stain, Ziehl-Neelsen) or cultures •
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ATYPICAL PNEUMONIA - Why ‘Atypical’?
Radiologically• Patchy infiltrates or• Interstitial pattern
Haemogram• Peripheral leukocytosis are less common or intense
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Causes of Atypical Pneumonia
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Aspiration pneumonia
• Overt episode of aspiration or bronchial obstruction by a foreign body.
• Seen in - alcoholism, nocturnal esophageal reflux, a prolonged session in the dental chair, epilepsy
• Usually Anaerobes
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ELDERLY• Infection has a more gradual onset,
with less fever and cough
• often with a decline in mental status or confusion and generalized weakness
• often with less readily elicited signs of consolidation
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MICROBIOLOGY
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EtiologyBacterialViralmycobacterialFungalparasitic
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Etiology Microbiological diagnosis - 40-71% Streptococcus pneumoniae most common Viruses – 10-36% In India - Streptococci pneumonia (35.3%) Staphylococcus aureus (23.5%) Klebsiella pneumonia (20.5%) Haemophilus influenzae (8.8%) Mycoplasma pneumoniae Legionella pneumophila
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VAP Micro
Harrison's Principles of Internal Medicine
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GENERAL SYMPTOMS
• High grade fever
• Cough-productive
• Pleuritic chest pain
• Breathlessness
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Additional symptoms• Sharp or stabbing chest pain
Headache•
• Excessive sweating and clammy skin•
• Loss of appetite and fatigue•
• Confusion, especially in older people•
•
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General Signs• Febrile• Tachypnoea• Tachycardia• Cyanosis-central• Hypotension• Altered sensorium• Use of accessory muscles of respiration• Confusion- advanced cases
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SIGNS OF CONSOLIDATION• Percussion-dull
• Bronchial Breath sounds
Crackles•
• Increased VF & VR•
• Aegophony & Whispering Pectoriloquy•
• Pleural Rub
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INVESTIGATIONS
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SPUTUM
•Gram Staining•AFB•Giemsa or methenamine silver stain•KOH mount•Culture
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X RayHomogenous opacity with air bronchogram
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LOBAR PNEUMONIA• Peripheral airspace consolidation pneumonia
• Without prominent involvement of the bronchial tree
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RUL Consolidation
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RML Consolidation
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RLL Consolidation
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BRONCHOPNEUMONIA• Centrilobular and
Peribronchiolar opacity pneumonia
• Tends to be multifocal• Patchy in distribution
rather than localized to any one lung region
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INTERSTITIAL PNEUMONIA • Peribronchovascular
Infiltrate• Mycoplasma , viral
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CT THORAXSeldom used
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INVESTIGATIONS• Complete white blood count• Blood Sugar• Electrolytes• Creatinine• Blood culture• Screening for retro(ICTC)
• Oxygen saturation by pulse oximetry
• ABG• USG Chest • Mantaux
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INVASIVE• Bronchoscopy• Thoracoscopy• Percutaneous aspiration/biopsy• Open lung biopsy• Pleural aspiration
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OTHER TESTS
• Bacterial antigen in sputum and urine• Rapid viral antigen detection in respiratory secretion• Serological- mainly for atypical• Molecular study• C-reactive Protein, serum procalcitonin, and neopterin
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TREATMENT
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CURB 65
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Outpatients Treatment(empirical)
Previously healthy and no antibiotics in past 3 months• A macrolide (clarithromycin or azithromycin or
Doxycycline )Comorbidities or antibiotics in past 3 months:• Respiratory fluoroquinolone [moxifloxacin ,levofloxacin ] or
β-lactam ( high-dose amoxicillin or amoxicillin/clavulanate)
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Inpatients, non-ICU• A respiratory fluoroquinolone [moxifloxacin ,levofloxacin ] • β -lactam [cefotaxime ,ceftriaxone ,ampicillin] plus a
macrolide [oral clarithromycin or azithromycin)
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Inpatients, ICU • β -lactam plus Azithromycin or a fluoroquinolone
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Pseudomonas• An antipneumococcal, antipseudomonal β-lactam
[piperacillin/tazobactam, cefepime , imipenem , meropenem plus flouroquinolons
• Above β-lactams plus an aminoglycoside and azithromycin • Above β-lactams plus an aminoglycoside plus an
antipneumococcal fluoroquinolone
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Methicillin-resistant Staphylococcus aureus
If MRSA , add linezolid or vancomycin
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COMPLICATIONS • Lung abscess• Para-pneumonic effusions• Empyema• Sepsis• Metastatic infections (meningitis,endocarditis,arthritis)• ARDS , Respiratory failure• Circulatory failure• Renal failure• Multi-organ failure
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Pneumonia complicationsSLAP HER (please don’t)• S - Septicaemia• L - Lung abcess • A - ARDS• P - Para-pneumonic effusions• H - Hypotension• E - Empyema • R - Respiratory failure /renal failure
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Course Most healthy people recover from pneumonia in one to
three weeks, but pneumonia can be life-threatening.
The mortality rate associated with community-acquired pneumonia (CAP) is very low in most ambulatory patients and higher in patients requiring hospitalization, being as high as 37 percent in patients admitted to the intensive care unit (ICU).
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Prevention• Smoking cessation• Better Nutrition• Respiratory hygiene measures• Pneumococcal polysaccharide vaccine• Inactivated influenza vaccine• Live attenuated influenza vaccine
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Conclusion• The presence of an infiltrate on plain chest radiograph is considered
the "gold standard" for diagnosing pneumonia when clinical and microbiologic features are supportive
• Most initial treatment regimens for hospitalized patients with community-acquired pneumonia (CAP) are empiric
• The mortality rate associated with community-acquired pneumonia (CAP) is very low in most ambulatory patients and higher in patients requiring hospitalization
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