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pneumonia pneumonia Presentation Transcript

  • Pneumonia
  • Definition Acute respiratory illness associated with recently developed radiological pulmonary shadowing which may be segmental, lobar or multi-lobar.  It is usually characterized by consolidation, in which the alveoli are filled with a mixture of exudates, bacteria and leukocytes. 
  • Epidemiology Occurs throughout the year  Results from different etiological agents varying with the seasons  Can occur in all ages  Clinical manifestations severe in very young, elderly and in chronically ill patients 
  • Clinical features      Fever Rigors Shivering Vomiting Loss of appetite Pulmonary symptoms include:  Cough [short, painful, dry, later accompanied with mucopurulent sputum]  Hemoptysis [in patients with Streptococcus pneumonie]  Pleuretic chest pain, referred to shoulder or anterior abdomen  Upper abdominal tenderness
  • Classification Type 1  Lobar pneumonia  Bronchopneumonia Type 2  Community acquired  Hospital acquired  Suppurative and aspirational  Immunocompromised hosts
  • Lobar pneumonia Radiological and pathological term applied to homogenous consolidation of one or more lung lobes  Associated with pleural inflammation 
  • Bronchopneumonia  Patchy alveolar consolidation  Associated with bronchial and bronchiolar inflammation often affecting both lower lobes
  • Community acquired pneumonia (CAP) Spread by droplet infection  Occurs in previously healthy patients  Once the organism settles in alveoli an inflammatory response is stimulated  Classical pathological response: 1. Congestion 2. Red and then grey hepatisation 3. Resolution with little or no scarring 
  • Predisposing factors Old age  Cigarette smoking  Upper respiratory tract infection  Recent influenza infection  Pre existing lung disease  Corticosteroid therapy  Alcohol 
  • Related organisms Majority of CAP are due to S. pneumonie Young adults  Mycoplasma pneumoniae  Chlamydia pneumoniae Elderly  Haemophilus influenza Foreign travels  Legionella  Staph aureus
  • Investigations Radiological examination Chest x-ray helps in differentiating between lobar and broncho Spotting complications such as intrapleural abscess, empyema   Microbiological investigations Assessment of gas exchange Measures SaO2, assists in monitoring response to oxygen therapy. Arterial blood gas sampled for SaO2 <92% or with severe pneumonia to assess for ventilatory failure  General blood tests A very high WBC count is seen in severe pneumonia. Urea, electrolytes and LFTs. C-reactive protein is raised 
  • CURB-65 score
  • Management Oxygen Administered to patients with tachypnea, hypoxemia, hypotension or acidosis. Maintain PaO2 >8kPa or SaO2 >92%. Humidified high concentratiom for patients without hypercapnia.  Fluid balance Oral intake of fluids, IV for severe cases. Inotropic support for patients with shock  Treatment of pleuretic pain Analgesics such as paracetamol   Physiotherapy
  • Complications Para pneumonic effusion  Empyema  Retention of sputum causing lobar collapse  Development of thromboembolic disease  Pneumothroax  Lung abscess  ARDS  Hepatitis, pericarditis, myocarditis  Pyrexia due to drug hypersensitivity 
  • Prevention  Influenza vaccination reduce the risk of influenza and death in elderly  Polysacchride pneumococcal vaccines do not appear to reduce the incidence of pneumonia or death but may reduce the incidence of invasive pneumoccocal disease
  • Hospital acquired pneumonia  Refers to new episode of pneumonia occurring 2days after admission  Post operation  Aspiration pneumonia  Bronchopneumonia developing in patients with lung disease
  • Predisposing factors Reduced immune defences  Reduced cough reflex  Disordered mucociliary clearance  Bulbar or vocal cord palsy  Aspiration of gastric secretions  Bacteria introduced into lower respiratory tract (ET tube, tracheostomy, infected ventilators, nebulisers)  Bacteraemia (abdominal sepsis, IV cannula infection, infected emboli) 
  • Related organisms Gram negative bacteria  Escherichia, pseudomonas and klebsiella  Staph aureus
  • Management Adequate gram negative coverage  3rd gen cephalosporins (eg cefotaxime) plus an aminoglycoside (eg gentamicin)  Meropenem  Monocyclic β-lactam (eg aztreonam) plus flucloxacillin Aspiration pneumonia can be treated with coamoxiclav 8hourly plus metronidazole 500mg 8hourly Physiotherapy
  • Suppurative and aspirational pneumonia Consolidation in which there is destruction of lung parenchyma by inflammatory process  Micro abscess formation with pus that may rupture and escape into bronchus  Caused by staph aureus, klebsiella pneumoniae, strep pyogenes, h. influenza  After aspiration of septic material during operation on nose, mouth or throat under GA. Vomitus during anesthesia or coma 
  • Clinical features        Productive cough Pleural pain Sudden expectoration of copious sputum High pyrexia Profound systemic upset Pleural rub Signs of consolidation On chest x-ray homogenous lobar or segmental opacity consistent with consolidation or collapse A large dense opacity which may cavitate and show fluid level, shows in lung abscess
  • Management  Oral amoxicillin 500mg 6hourly  For anaerobic bacteria, oral metronidazole 400mg 8hourly  For lung abscess prolonged treatment for 46weeks
  • Pneumonia in immunocompromised patients  Patients receiving immunosupressive drugs and those with diseases causing defects of cellular or humoral immune mechanisms  Gram negative bacteria; pseudomonas aeruginosa
  • Clinical features Fever  Cough  Breathlessness  Infiltrations on chest x-ray
  • Management  Broad spectrum antibiotic (eg 3rd gen cephalosporin or quinolone plus antistaphylococcal antibiotic or antipseudomonal penicillin)
  • Thank you Reference  Davidson’s principles and practice of medicine 20th edition