Project: Ghana Emergency Medicine Collaborative
Document Title: Pneumonia in the ED
Author(s): Phil Bossart (University of...
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Pneumonia in the ED
Phil Bossart MD
University of Utah
Salt Lake City
3
Types of Pneumonia
 

 

 

CAP community acquired
pneumonia
HAP

hospital acquired pneumonia

HCAP health care associa...
Community Acquired
Pneumonia
 

Indications for Admission to hospital

 

PSI Pneumonia Severity Index

 

CURB 65 Conf...
CURB 65
Some use CRB 65
0 – 1 home treatment
1 Admit to hospital
> 3 Admit to ICU
Prediction rules are aids only
Many othe...
Causes of pneumonia
 
 
 

 

 
 
 
 

Pneumococcus
Haemophilus influenzae
Atypical Bacteria (mycoplasma,
chlamydi...
Diagnosis of Pneumonia
 
 
 

 

Clinical cough, fever, chest pain
Rales, hypoxia
Radiologic findings – chest x-ray is...
Source undetermined

Source undetermined

These	
  are	
  	
  PA	
  and	
  lateral	
  films	
  of	
  RML	
  pneumonia	
  (a...
Source undetermined

Source undetermined

·∙	
  Aspira3on,	
  no	
  ma5er	
  what	
  
the	
  type,	
  usually	
  occurs	
 ...
PCP

11
Pneumocys*s	
  
jiroveci	
  (formerly	
  
carinii)	
  pneumonia:	
  
chest	
  X	
  ray	
  with	
  
bilateral,	
  diffuse	
 ...
Mycoplasma	
  pneumonia	
  

Source undetermined
13
Emperic Treatment
 

 
 

 

IDSA infectious disease society of
america
ATS american thoracic society
BTS british thor...
IDSA/ATS guidelines
If suspect pseudomonas: add
piperacillin-tazobactam or imipenem
If suspect MRSA: add vanc or linezolid...
British Thoracic Society
 

 

Amoxicillin 500 tid or Doxycycline
200mg load then 100mg q day.
Much cheaper

16
Timing of Antibiotics in ED
 

Retrospective studies suggested decrease
mortality if abx given within 4 horus

 

Lead t...
Out patient treatment
 
 

Zithro or doxycycline
Levofloxacin if sicker patient or more
complicated

18
Aspiration Pneumonia
 

 

 

Most pneumonia is from “aspiration”
Larger amount of aspiration causing
“pneumonitis”
Ana...
Aspiration Pneumonia
 
 
 
 

Reduced consciousness
Dysphagia
GERD
NG feedings

Gastric acid suppression meds – assoc
...
Chemical Pneumonitis
 

 

 

 

Aspiration of substances toxic to
lungs separate from bacterial
infection
Diagnosis i...
Aspiration Pneumonia
 
 
 
 

 

Anaerobic bacteria from gingiva
More common with poor dentition
Most commonly evolve...
Pulmonary TB
 
 

 

Eighth leading cause of death
Effective medical therapy for over 50
years yet: lack of access to d...
Epidemiology
 

 
 
 
 

About one third of population is
infected
About 1.3 million deaths in 2007
Prevalence is dec...
Primary Pulmonary Tuberculosis
 

 
 
 

Symptoms occurring around time of
inoculation.
Generally mild and usually fev...
Reactive TB
 

 

 

Chronic TB, post primary TB,
recrudescent TB, endogenous TB
In USA this is 90% of TB in non HIV
pa...
Reactive TB
 

 

 

Chest X ray : apical infiltrates, may
see cavities with air fluid levels.
5% may have normal Chest...
25	
  year	
  old	
  Indian	
  girl	
  
presented	
  with	
  cough	
  and	
  
hemoptysis.	
  CXR	
  showed	
  
consolida3o...
20	
  year-­‐old	
  female	
  
with	
  history	
  of	
  
chronic	
  produc3ve	
  
cough	
  and	
  weight	
  
loss.	
  Pulm...
Pulmonary	
  
Tuberculosis	
  
Ghon	
  Complex	
  
Sub	
  pleural	
  
nodule	
  with	
  
medias3nal	
  
adenopathy.	
  	
 ...
Source undetermined

The	
  Ghon	
  complex	
  is	
  seen	
  here	
  at	
  closer	
  range.	
  Primary	
  tuberculosis	
  ...
Widespread	
  
hematogenous	
  
dissemina3on	
  
of	
  Mycobacterium	
  
Tuberculosis	
  
So	
  named	
  because	
  the	
 ...
Extra-pulmonary TB
 

 
 
 
 
 

 

Lymphadenitis: cervical, mediastinal,
axillary nodes
Pleural TB
CNS TB
Peritoni...
TB Diagnosis
 
 
 
 
 

 

TST, Mantoux test, PPD
Diameter of induration at 48-72 hrs.
Delayed type hypersensitivity...
TB Diagnosis
 

 
 

About 10 % of immunocompetent
people with LTBI will develop TB in
life time.
Greatest risk ( 5%) i...
TB diagnosis
 
 
 
 
 

Smear microscopy
Most rapid and least expensive
AFB staining
NNA nucleic acid amplification t...
TB treatment
 
 

Latent TB: INH for 9 months
Active TB : DOT (direct observation
therapy)
Initial phase of 4 drugs
for ...
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GEMC: Pneumonia in the ED: Resident Training

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This is a lecture by Dr. Phil Bossart from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC: Pneumonia in the ED: Resident Training

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Pneumonia in the ED Author(s): Phil Bossart (University of Utah), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1  
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. 2   To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  3. 3. Pneumonia in the ED Phil Bossart MD University of Utah Salt Lake City 3
  4. 4. Types of Pneumonia       CAP community acquired pneumonia HAP hospital acquired pneumonia HCAP health care associated pneumonia 4
  5. 5. Community Acquired Pneumonia   Indications for Admission to hospital   PSI Pneumonia Severity Index   CURB 65 Confusion, Uremia (BUN > 20mg/dl or 7 mmol/L, RR >30, BP sys <90 or diastolic < 60, Age >65. 5
  6. 6. CURB 65 Some use CRB 65 0 – 1 home treatment 1 Admit to hospital > 3 Admit to ICU Prediction rules are aids only Many other issues ( co-morbidities, social factors) 6
  7. 7. Causes of pneumonia                 Pneumococcus Haemophilus influenzae Atypical Bacteria (mycoplasma, chlamydia, legionella) Oropharyngeal aerobes and anaerobes ( asp) Resp Viruses Staph Gram neg bacteria TB 7
  8. 8. Diagnosis of Pneumonia         Clinical cough, fever, chest pain Rales, hypoxia Radiologic findings – chest x-ray is not 100% sensitive Clinical diagnosis – no single tests gives definitive answer. 8
  9. 9. Source undetermined Source undetermined These  are    PA  and  lateral  films  of  RML  pneumonia  (arrows).     Note  the  indis=nct  borders,  air  bronchograms,  and  silhoueBng  of  the  right  heart  border.  9 Pneumococcal  pneumonia  
  10. 10. Source undetermined Source undetermined ·∙  Aspira3on,  no  ma5er  what   the  type,  usually  occurs  in   the  gravity  dependent   por3ons  of  the  lung     §  Lower   lobes,  especially  right-­‐sided,   including  and  especially  the   superior  segments  of  the   lower  lobes     ·∙  Because  of  the  larger   caliber  and  straighter  course   of  the  right  main  bronchus     §  Posterior  segments  of  the   upper  lobes     §  Aspira3on  which  occurs   while  the  person  is  prone   may  be  seen  in  the  right   upper  lobe  and  middle  lobe   10 or  the  lingula  
  11. 11. PCP 11
  12. 12. Pneumocys*s   jiroveci  (formerly   carinii)  pneumonia:   chest  X  ray  with   bilateral,  diffuse   granular  opaci=es   12 Source undetermined
  13. 13. Mycoplasma  pneumonia   Source undetermined 13
  14. 14. Emperic Treatment         IDSA infectious disease society of america ATS american thoracic society BTS british thoracic society IDSA/ATS : in patient treatment: anti-pneumococcal fluoroquinolone (levofloxicin) or (betalactam plus macrolide) 14
  15. 15. IDSA/ATS guidelines If suspect pseudomonas: add piperacillin-tazobactam or imipenem If suspect MRSA: add vanc or linezolid 15
  16. 16. British Thoracic Society     Amoxicillin 500 tid or Doxycycline 200mg load then 100mg q day. Much cheaper 16
  17. 17. Timing of Antibiotics in ED   Retrospective studies suggested decrease mortality if abx given within 4 horus   Lead to “standard” in U.S.A. ERs   Lead to overuse of abx   Now rec 6 hours 17
  18. 18. Out patient treatment     Zithro or doxycycline Levofloxacin if sicker patient or more complicated 18
  19. 19. Aspiration Pneumonia       Most pneumonia is from “aspiration” Larger amount of aspiration causing “pneumonitis” Anaerobes are less virulent bacteria 19
  20. 20. Aspiration Pneumonia         Reduced consciousness Dysphagia GERD NG feedings Gastric acid suppression meds – assoc with increased risk of pneumonia 20
  21. 21. Chemical Pneumonitis         Aspiration of substances toxic to lungs separate from bacterial infection Diagnosis is presumptive based on hx and chest Xray Supportive care Most do fine but risk of ARDS and pneumonia 21
  22. 22. Aspiration Pneumonia           Anaerobic bacteria from gingiva More common with poor dentition Most commonly evolves slowly May present late with lung abscess, empyema, pulmonary necrosis Treatment: Clinda or Augmentin or PCN + Metro 22
  23. 23. Pulmonary TB       Eighth leading cause of death Effective medical therapy for over 50 years yet: lack of access to dx and rx, coexistence with HIV, drug resistance. TBI : inhalation, asymptomatic, noninfectious, called latent TB. Will have pos PPD or TST. 23
  24. 24. Epidemiology           About one third of population is infected About 1.3 million deaths in 2007 Prevalence is decreasing but slowly MDR –TB : resistant to INH or RIF XDR – TB: resist to INH, RIF, Fluoroquinolones, and aminoglycosides or Capreomycin. 24
  25. 25. Primary Pulmonary Tuberculosis         Symptoms occurring around time of inoculation. Generally mild and usually fever Most people are asymptomatic Hilar adenopathy or mid/lower lung infiltrates 25
  26. 26. Reactive TB       Chronic TB, post primary TB, recrudescent TB, endogenous TB In USA this is 90% of TB in non HIV patients Typically insidious: fever, cough, weight loss, fatigue, night sweats. 26
  27. 27. Reactive TB       Chest X ray : apical infiltrates, may see cavities with air fluid levels. 5% may have normal Chest x-ray – esp HIV patients Endobronchial TB – may mimic asthma 27
  28. 28. 25  year  old  Indian  girl   presented  with  cough  and   hemoptysis.  CXR  showed   consolida3on  with   cavita3ons  in  the  right   upper  zone.   Source undetermined 28
  29. 29. 20  year-­‐old  female   with  history  of   chronic  produc3ve   cough  and  weight   loss.  Pulmonary   tuberculosis  -­‐   Cavitary  lesion   Source undetermined 29
  30. 30. Pulmonary   Tuberculosis   Ghon  Complex   Sub  pleural   nodule  with   medias3nal   adenopathy.     Source undetermined 30
  31. 31. Source undetermined The  Ghon  complex  is  seen  here  at  closer  range.  Primary  tuberculosis  is  the  pa5ern  seen  with   ini3al  infec3on  with  tuberculosis  in  children.  Reac3va3on,  or  secondary  tuberculosis,  is  more   31 typically  seen  in  adults.  
  32. 32. Widespread   hematogenous   dissemina3on   of  Mycobacterium   Tuberculosis   So  named  because  the   nodules  are  the  size   of  millet  seeds  (1-­‐5mm   with  a  mean  of  2  mm)       Miliary  TB  represents  only   1-­‐3%  of  all  cases  of  TB   Source undetermined 32
  33. 33. Extra-pulmonary TB               Lymphadenitis: cervical, mediastinal, axillary nodes Pleural TB CNS TB Peritonitis Pericarditis Skeletal: Thoracolumbar spine ( Potts disease) Miliary TB: hematogenous spread 33
  34. 34. TB Diagnosis             TST, Mantoux test, PPD Diameter of induration at 48-72 hrs. Delayed type hypersensitivity Takes 2 – 12 weeks to turn positive False positives: BCG vaccine, other mycobacterium False negatives: anery, advanced age, immune suppression, etc. 34
  35. 35. TB Diagnosis       About 10 % of immunocompetent people with LTBI will develop TB in life time. Greatest risk ( 5%) in first 2 years. Serum IGRAs - Interferon gamma release assays – measures IFG release after exposure to M tuberculosis-specific antigens. 35
  36. 36. TB diagnosis           Smear microscopy Most rapid and least expensive AFB staining NNA nucleic acid amplification test Culture: liquid 1 – 3 weeks, solid up to 6 weeks 36
  37. 37. TB treatment     Latent TB: INH for 9 months Active TB : DOT (direct observation therapy) Initial phase of 4 drugs for 2 months followed by 4 – 7 months continuation phase TB with HIV: Only a few differences. 37

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