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Pneumonia by Dr. Sookun Rajeev Kumar
- 1. PNEUMONIA Dr. Sookun RajeevK (MD) Dept of General Medicine Anna Medical College
- 2. Definition: • Pneumonia isan infection of the pulmonary parenchyma (that is; the functional lung tissue) commonly caused by infectious agents.
- 3. MODE OF TRANSMISSION Waysyou can get pneumonia include: Bacteria and viruses living in the nose, sinuses, or mouth may spread to the lungs. One may breathe some of these germs directly into your lungs (droplets infection). Inhalation of food, liquids, vomit, or fluids from the mouth into the lungs (aspiration pneumonia).
- 4. RISK FACTORS FORPNEUMONIA 1. Immuno-suppressed patients 2. Cigarette smoking 3. Difficulty in swallowing ( due to stroke,dementia,parkinson’s diseases,other neurological conditions) 4. Impaired consciousness (loss of brain function due to dementia,stroke,etc…)
- 5. RISK FACTORS FORPNEUMONIA 5. Chronic Lung Diseases (COPD, Bronchiectasis). 6. Frequent suction 7. Medical comorbidities such as Heart disease, Liver cirrhosis, and Diabetes 8.Recent cold, Laryngitis or flu.
- 6. CLASSIFICATION OF PNEUMONIA Accordingto Area involved: 1. Lobar pneumonia; if one or more lobe is involved 2. Broncho-pneumonia; the pneumonic process has originated in one or more bronchi and extends to the surrounding lung tissue.
- 7. CLASSIFICATION OF PNEUMONIA Accordingto Area involved:
- 8. CLASSIFICATION OF PNEUMONIA Accordingto Causes: 1. Bacterial (the most common cause of pneumonia) 2. Viral pneumonia 3. Fungal pneumonia 4. Chemical pneumonia (ingestion of kerosene or inhalation of irritating substance) 5. Inhalation pneumonia (aspiration pneumonia)
- 9. CLASSIFICATION OF PNEUMONIA Accordingto Etiology: 1. Community Acquired Pneumonia (CAP) 2. Atypical Pneumonia 3. Hospital Acquired Pneumonia (Nosocomial Pneumonia) 4. Aspiration Pneumonia 5. Opportunistic Pneumonia
- 10. COMMUNITY ACQUIRED PNEUMONIA •This occurs out of hospital or within 48 h of admission and may be primary or secondary to existing disease.
- 11. COMMUNITY ACQUIRED PNEUMONIA Causesinclude: Streptococcus pneumoniae (most common), Haemophilus influenzae and Staphylococcus aureus. Viruses are implicated in approximately 10% of cases. In pre-existing lung disease (e.g. COPD/bronchiectasis), organisms such as Pseudomonas aeruginosa and Moraxella catarrhalis are more common.
- 12. ATYPICAL PNEUMONIA They canbe acquired in the community or in institutions. This is caused by organisms such as Mycoplasma, Legionella and Chlamydia species.
- 13. HOSPITAL ACQUIRED PNEUMONIA Thisis new-onset pneumonia occurring at or more than 48 h after admission to hospital. Gram-negative organisms such as Pseudomonas and Klebsiella are much more common causes.
- 14. ASPIRATION PNEUMONIA This occursas a result of the aspiration of gastrointestinal contents because of an inability to protect the airway such as after a cerebral vascular event or with a decreased consciousness level. Anaerobic organisms may be implicated. Stroke patients are at particular risk of aspiration pneumonia.
- 15. OPPORTUNISTIC PNEUMONIA • Individualswith cystic fibrosis are at increased risk of Pseudomonas pneumonia due to changes in the composition of airway surface mucus. • Patients with impaired immune system (e.g. HIV+) are at increased risk of fungal (e.g. Aspergillus), Pneumocystis jiroveci or viral (e.g. CMV, HSV) pneumonia. • Patients on respiratory support (e.g. ventilated in intensive care) are at increased risk of ventilator- associated pneumonia (VAP) commonly caused by Pseudomonas or Klebsiella.
- 16. CLINICAL FEATURES OFPNEUMONIA The ‘typical’ symptoms of pneumonia are: Fever (rapidly rising 39.5 – 40.5) Shaking chills Tachypnoea Dyspnoea Productive cough of purulent sputum Pleuritic chest pain (aggravated by respiration and coughing)
- 17. CLINICAL FEATURES OFPNEUMONIA The ‘typical’ symptoms of pneumonia are: Tachypnea – nasal flaring Pt is very ill and lies on the affected side to reduce pain Use of accessory muscles of respiration Flushed cheeks Loss of appetite, lethargy and fatigue Cyanosed lips and nail beds
- 18. CLINICAL FEATURES OFPNEUMONIA The ‘typical’ symptoms of pneumonia are: Signs of pulmonary consolidation (dullness, increased vocal resonance, bronchial breath sounds and coarse crepitations) may be found on physical examination and coincide with abnormalities on the CXR.
- 19. CLINICAL FEATURES OFPNEUMONIA The ‘atypical’ symptoms of pneumonia are: ‘Atypical’ pneumonia has a more gradual onset Dry cough Extrapulmonary symptoms (headache, muscle aching, fatigue, sore throat, nausea, vomiting and diarrhoea).
- 20. DIAGNOSTICS • History Taking •Physical Examination • Instrumental Diagnostics
- 21. PHYSICAL EXAMINATION Examination mayreveal coarse inspiratory crepitations. Bronchial breathing with a dull percussion note is present in <25%.
- 22. DIAGNOSTICS 1. Chest X-Ray Confirm the presence of the diffuse or lobar pulmonary infiltrates and assess the extent of infection. Air bronchograms may be seen within the areas of consolidation. Other features that may be present include pleural effusions, pulmonary cavitation or hilar lymphadenopathy. Cavitating lesions may be caused by oral anaerobic bacteria, enteric Gram-negative bacilli, S. aureus, Pseudomonas, Legionella, TB and fungi.
- 23. DIAGNOSTICS 1. Chest X-Ray(Lobar) • Consolidation confined to one or more lobes of the lungs
- 24. DIAGNOSTICS 1. Chest X-Ray(Lobar)
- 25. DIAGNOSTICS 1. Chest X-Ray(Bronchopneumonia) • Patchy consolidation usually in the bases of the lungs
- 26. DIAGNOSTICS 2. Blood tests 1.Full blood count may show a neutrophilia. 2. ABG: assess oxygenation, hypercapnia and pH. 3. U&Es: raised urea is indicative of dehydration and is part of the CURB65 score (see later) which assesses severity. 4. Oximetry : Oxygen saturation
- 27. DIAGNOSTICS 2. Blood tests 1.C-reactive protein: may be raised and can help in assessing response to treatment. 2. Blood cultures if pyrexic (and prior to commencing antibiotic therapy, but should not delay antibiotics). 3. Serology for atypical organisms should be taken if clinical suspicion is present and then repeated in 10-14 days
- 28. DIAGNOSTICS 3. Sputum Microscopyand Culture Sputum microscopy and culture is important in severe bacterial pneumonia and those with chronic lung disease.
- 29. DIAGNOSTICS 4. Pleural tap Forpleural effusion, if present and thought to be parapneumonic, should be aspirated to assess for infection or empyema and drained if needed. Microscopy, culture and sensitivity should be performed. If there is any suggestion there may be a more sinister cause for the effusion a sample should be sent for cytology.
- 30. DIAGNOSTICS 5.Urine The urine canbe tested for streptococcal and Legionella urinary antigen. These can remain positive even after antibiotics have been commenced.
- 31. DIAGNOSTICS 6. Bronchoscopy Fibreoptic bronchoscopyis rarely performed for pneumonia but has become the standard invasive procedure used to obtain lower respiratory tract secretions from seriously ill or immunocompromised patients.
- 32. DIAGNOSTICS 6. Bronchoscopy Samples arecollected with a protected double sheathed brush, by bronchoalveolar lavage or by transbronchial biopsy at the site of the pulmonary consolidation. It may be indicated too if there is ev- idence of collapse due to airway obstruction/ tumour or mucous plug.
- 33. ASSESSMENT OF SEVERITY Themanagement of community acquired pneumonia is guided by the severity. The CURB65 score is a validated tool to assess severity. Each component (confusion, urea, respiratory rate, systolic blood pressure and age) scores 1 point.
- 34. ASSESSMENT OF SEVERITY Ascore of 0 or 1 means home treatment is possible. A score of 2 warrants hospital treatment A score of 3 or above indicates severe pneumonia requiring admission and aggressive management.
- 35. ASSESSMENT OF SEVERITY Increasingscore is associated with increasing mortality. Confusion: new confusion, abbreviated mental test score <8. Urea >7 mmol/L. Respiratory rate >30 per min. Systolic blood pressure <90 mmHg and/or Diastolic Blood pressure <60 mmHg. Age >65.
- 36. TREATMENT Mainstay treatment forpneumonia is: 1. Antibiotics 2. O2 (aiming for saturations of 94- 98%) 3. Adequate hydration 4. Analgesia for potential pleuritic pain 5. Chest physiotherapy
- 37. TREATMENT Community Acquire Pneumonia (uncomplicated) •Broad-spectrum penicillin, e.g. amoxicillin. Macrolide, e.g. clarithromycin if penicillin-allergic or if atypical organism suspected Flucloxacillin if S. aureus suspected
- 38. TREATMENT Community Acquire Pneumonia(severe) • Third-generation cephalosporin, e.g. cefuroxime or co-amoxiclav IV and macrolide for atypical organisms Flucloxacillin if S. aureus suspected
- 39. TREATMENT Atypical Pneumonia • Erythromycinor other macrolide Tetracycline for Chlamydia or Mycoplasma Give for 10–14 days
- 40. TREATMENT Hospital Acquired Pneumonia •Broad-spectrum cephalosporin or co-amoxiclav plus increased Gram-negative cover, e.g. aminoglycoside, ciprofloxacin Vancomycin or teicoplanin if MRSA pneumonia
- 41. TREATMENT Aspiration Pneumonia • Coverfor anaerobic organisms Cephalosporin plus metronidazole Co-amoxiclav often sufficient
- 42. PROGNOSIS With treatment, mostpatients will improve within 2 weeks Elderly or very sick patients may need longer treatment
- 43. COMPLICATIONS Acute Respiratory Distress Syndrome PleuralEffusion Lung Abscess Respiratory Failure (Requires mechanical ventilator) Sepsis, which may lead to organ failure