Pneumonia
Surg Lt Cdr Shrinath V
CT Respiratory Medicine
Pneumonia is the presence of lung inflammation of sufficient extent to lead to symptoms, signs or
radiological features of an opacity
Community acquired Hospital acquired Ventilator acquired
pneumonia pneumonia pneumonia
• Infection acquired • Infection acquired
from community from hospital • Onset of symptoms,
signs after 48hrs of
• Onset of symptoms, • Onset of symptoms, initiation of
signs before signs after 48hrs of mechanical
admission of within hospital admission ventilation
48hrs of admission
Pathophysiolog
y of pneumonia
Stages of pneumonia
Classification of pneumonia
Lobar pneumonia
(air-space pneumonia)
• Characterized by the initial peripheral opacity that rapidly
evolves into confluent, homogenous consolidation often
conforming to anatomic boundaries such as interlobar
fissures.
• Lobar pneumonia uncommonly affects the entire lobe
• Is non-segmental (easily crosses pulmonary segments)
• Can cause expansion of a lobe (bulging fissure sign)
- Klebsiella pneumoniae
- Pneumococcal pneumonia
Bronchopneumonia
• Begins with infection of airway mucosa and subsequently
extends into adjacent alveoli.
• Multiple air space nodules or reticulonodular opacities that
are initially confined to one or more pulmonary segments
but it then progress to multifocal often bilateral
consolidation (asymmetric, lower lobe predominant)
• Airspace nodules : 5 – 10 mm nodules represent infection of
terminal and respiratory bronchiole with peribronchiolar
consolidation.
• Due to prominent airway involvement there can be volume
loss
• Mostly seen with Staph aureus or gram negative organism.
Interstitial pneumonia
• Caused by viruses, Mycoplasma pneumonia,
Pneumocystis jirovecii
• Inflammation limited to pulmonary interstitium
• bilateral symmetrical linear or reticular opacities
• Can also produce Ground glass opacities
•
• If untreated can evolve into consolidation
Causative agents
Based on causative organism
Typical pneumonia Atypical pneumonia
Caused by Caused by
- Strep pneumoniae - Legionella
- H. influenza - Chlamydia
- K. pneumoniae - C. burnetii
- viruses
Respiratory symptoms predominate
Systemic symptoms predominate
Increased WBC, Neutrophilia
Non-productive cough
Lobar consolidation
Relatively normal WBC
Clinico-radiological dissociation
Severe Pneumonia and non severe pneumonia
Severe pneumonia: One major criteria or three or more minor criteria
Major criteria Minor criteria
• Septic shock with Respiratory rate > 30 breaths/min
need for vasopressors PaO2/FIO2 <250
Multilobar infiltrates
• Respiratory failure Confusion/disorientation
requiring mechanical Uremia (blood urea nitrogen level > 20 mg/dl)
ventilation Leukopenia(white blood cell count , 4,000 cells/ml)
Thrombocytopenia (platelet count , 100,000/ml)
Hypothermia (core temperature , 368 C)
Hypotension requiring aggressive fluid resuscitation
ATS guidelines 2019
Clinical features
Symptoms
General Respiratory Symptoms in Classic organism specific
symptoms symptoms elderly symptoms
Fever Cough Generalized weakness Pneumococci: sudden onset
rigors followed by pleuritic
Malaise Sputum production Decreased appetite chest pain, rusty sputum
Pleuritic chest pain Altered mental status
Legionella: diarrhea, myalgia,
Dyspnea Incontinence headache, confusion
Hemoptysis Decompensation of Mycoplasma: meningitis,
underlying disease encephalitis, uveitis, iritis,
myocarditis
Clinical features
Signs
Inspection Palpation Percussion Auscultation
Fever Decreased movement Dullness on Bronchial breath
of affected percussion sounds
Tachypnea Tachycardia hemithorax
Stony dull if there is Absent breath sounds
Accessory muscles Tactile vocal fremitus effusion in case of effusion
recruited positive
Decreased movement of
affected hemithorax
Radiology
Air space consolidation : radiographic finding due to replacement of alveolar air by pus, fluid, blood or other
substances. Radiographic finding in consolidation include
Homogenous opacity Air bronchogram ill defined or fluffy opacities
obscuring blood vessels
Radiology
Air alveologram Acinar or air space nodules
5 -10 mm round opacities centrilobular or
peribronchiolar in distribution. Shows
consolidation in respiratory bronchiole
CT chest
• Should not be performed routinely
• Should be done in
- non resolving pneumonia
- to assess complication of pneumonia
Investigation
In all pneumonia patients In severe pneumonia
Complete blood count Complete blood count Sputum stain and culture
Routine serum biochemistry Routine serum biochemistry Blood culture
Chest X ray Chest X ray Urine legionella and
streptococcal antigen test
Procalcitonin
Importance of blood test in pneumonia
• In atypical pneumonia TLC rarely exceeds 15,000
• Procalcitonin
- a raised procalcitonin shows a bacterial pneumonia
- can be used to de-escalate antibiotics (<0.5 ng/ml)
• CRP
- non specific marker of systemic inflammation
Helps to look for sepsis
- multiorgan disfunction in the setting of pneumonia
Biofire panel
Highly sensitive
Results in few hours
Helps to find resistance
Whether to admit or not to admit
Out-patient treatment of CAP
ATS guidelines 2019 Duration of antibiotics: 5 – 7 days
In-patient treatment of CAP: empirical
antibiotics
• ATS guidelines 2019
In-patient treatment of CAP: culture guided
antibiotics
• Once culture results are obtained shift to culture sensitive antibiotics
• Duration
- 5 – 7 days
- 14 days in case of bacteremia
• 4 weeks in case of
- necrotizing pneumonia
- lung abscess
- empyema
Duration of antibiotics
• 5 – 7 days
• 14 days in case of bacteremia
• 4 weeks in case of
- necrotizing pneumonia
- lung abscess
- empyema
Other medications
• Supplemental oxygen if hypoxemic
• Prophylactic anticoagulants in patients admitted to ICU
• Invasive mechanical ventilation in patients with ARDS
• Corticosteroids in septic shock refractory to fluid therapy
Nursing care
• Remember you are dealing with an infectious disease
• Use personal protection
• Handwash and avoid inter person contamination
• Use spittoon with 5% phenol for sputum collection
• Remember ICU is home to extensively drug resistant organisms
• Chest physiotherapy
Prevention of hospital acquired pneumonia
Prevention of hospital acquired pneumonia
Thank you
