Pneumonia

1. ‫مهربان‬ ‫خداوند‬ ‫بنام‬

2. Acute tracheobronchitis
• Causes : influenza virus A and B, para
influenza and syncytial virus , rhinivirus
• ‫کننده‬ ‫مساعد‬ ‫های‬ ‫فکتور‬
:
‫ګازات‬ ، ‫غبار‬ ، ‫ګرد‬ ، ‫دود‬
‫رینیت‬ ، ‫سینوزیت‬ ‫و‬ ‫کیمیاوی‬

3. ‫اعراض‬
۱
:
‫اول‬ ‫روز‬
، ‫سرفه‬ ، ‫قص‬ ‫خلف‬ ‫ناراحتی‬ ، ‫ګلو‬ ‫ګرفتګی‬
‫وتعرق‬ ‫دار‬ ‫صدا‬ ‫تنفس‬
.
۲
:
‫چهارم‬ ‫تا‬ ‫سوم‬ ‫روز‬
‫دارد‬ ‫امکان‬ ‫تب‬ ، ‫قیحی‬ ‫مخاطی‬ ‫تقشع‬
‫دار‬ ‫خون‬ ‫تقشع‬ ‫و‬ ‫تنفس‬ ‫عسرت‬ ، ‫نباشد‬ ‫یا‬ ‫باشد‬ ‫موجود‬

4. ‫فزیکی‬ ‫معاینات‬
• No abnormal finding in inspection , palpation
and percussion
• Auscultation : Ronchi , wheezing , crepitation
• Leukocytosis , rised ESR, sputum culture
pneumococ I and H infleunza
• Normal chest x-ray

5. ‫تداوی‬
۱
:
‫میباشد‬ ‫عرضی‬ ‫مریضان‬ ‫این‬ ‫تداوی‬
۲
:
‫های‬ ‫برونکودیالتور‬ ‫ویزینګ‬ ‫و‬ ‫صدر‬ ‫ناراحتی‬ ‫درصورت‬
‫انشاقی‬
(
‫سالبوتامول‬
)
‫بعد‬ ‫ساعت‬ ‫چهار‬ ‫هر‬ ‫پف‬ ‫دو‬
۳
:
‫مص‬ ‫یا‬ ‫دارد‬ ‫قیحی‬ ‫تقشع‬ ‫مریضانیکه‬ ‫برای‬ ‫بیوتیک‬ ‫انتی‬
‫اب‬
‫میګردد‬ ‫توصیه‬ ‫باشد‬
.
• Amoxicillin 500mg TID
• Ampicillin , erythromycin , tetracyclin 250-
500mg qid
• Co –trimoxazol bid

6. ‫سیر‬
• ‫از‬ ‫بعد‬ ‫بهبودی‬
۲-۳
‫هفته‬
• Bronchopneumonia
• COPD

7. COPD
COPD is consist of :
• Chronic bronchitis
• Emphysema
• Small airways disease
‫تخریب‬ ‫اسناخ‬ ‫های‬ ‫جدار‬ ‫که‬ ‫میباشد‬ ‫حالت‬ ‫از‬ ‫عبارت‬ ‫امفزیما‬
‫میشود‬ ‫ها‬ ‫بول‬ ‫تشکل‬ ‫به‬ ‫ومنجر‬ ‫شده‬
.

8. ‫مزمن‬ ‫برانشیت‬
‫تعریف‬
:
‫سال‬ ‫دو‬ ‫مدت‬ ‫به‬ ‫اقل‬ ‫حد‬ ‫مریض‬ ‫یک‬ ‫صورتیکه‬ ‫در‬
‫داشته‬ ‫تقشع‬ ‫و‬ ‫سرفه‬ ‫ان‬ ‫از‬ ‫بیشتر‬ ‫یا‬ ‫ماه‬ ‫سه‬ ‫سال‬ ‫هر‬ ‫ودر‬
‫حالت‬ ‫این‬ ، ‫ګردد‬ ‫رد‬ ‫تقشع‬ ‫و‬ ‫سرفه‬ ‫اسباب‬ ‫وسایر‬ ‫باشد‬
‫میشود‬ ‫نامیده‬ ‫مزمن‬ ‫برانشیت‬
.

9. ‫کننده‬ ‫مساعد‬ ‫های‬ ‫فکتور‬
• Active smoking
• Passive smoking
• Air pollution
• Occupational factors
• Respiratory tracts infection
• Genetic predisposation

10. ‫اعراض‬
۱
:
‫تنګی‬ ‫نفس‬
(
‫استراحت‬ ‫در‬ ‫حتی‬ ‫بعد‬ ‫فزیکی‬ ‫فعالیت‬ ‫در‬ ‫ابتدا‬
)
۲
:
‫سرفه‬
۳
:
‫تقشع‬
(
‫میباشد‬ ‫قیحی‬ ‫تالی‬ ‫انتان‬ ‫مداخله‬ ‫ودر‬ ‫مخاطی‬ ‫میتواند‬
)
‫مراحل‬ ‫ودر‬ ‫بوده‬ ‫موجود‬ ‫سرد‬ ‫موسم‬ ‫در‬ ‫ابتدا‬ ‫عرض‬ ‫دو‬ ‫این‬
‫میباشد‬ ‫موجود‬ ‫سال‬ ‫طول‬ ‫تمام‬ ‫در‬ ‫پیشرفته‬
۴
:
‫صدر‬ ‫در‬ ‫ګرفتګی‬
۵
:
‫سردردی‬
۶
:
‫سفلی‬ ‫اطراف‬ ‫اذیمای‬

11. ‫عالیم‬
• Inspection ( hover sign)
• Palpation normal
• Percussion ( hyperresonance in emphysema)
• Auscultation ( coarse crepitation , ronchi )
• Lower limb edema
• Cyanosis

12. Chest x-ray

13. ‫تفریقی‬ ‫تشخیص‬
• Asthma
• Emphysema
• TB
• Bronchectasis
• Cyctic fibrosis

14. ‫سراپا‬ ‫مریضان‬ ‫تداوی‬
• Oxygen therapy( 18 or 14 hours in 24 hours)
• Postural drinage and chest percussion
• Bronchodilators
1: anticholenergic ( ipratropium bromide or
tiotropium via inhalation)
2: beta2 adrenergic agonists( salbutamol ,
salmetrol….)
3:theophyllin

15. Con…
• Corticosteriodes ( oral prednisolon trial 30mg
per day for 2-4weeks ) if COPD is steriode
responsive , then inhalation of steriode is
given .
• Anti biotics ( acute exacerbation , acute
bronchitis , prevention of exacerbation)
1:amoxicillin , amoxicillin –clavulanic acid
2:macroloides( azithromycin…)
3: fluroquinolones (levofloxacin…)
4:doxycyclin 100mg BID.

16. ‫بستر‬ ‫داخل‬ ‫مریضان‬ ‫تداوی‬

17. ‫فصد‬

18. ‫نمونیا‬
‫میباشد‬ ‫ریه‬ ‫پرانشیم‬ ‫حاد‬ ‫التهاب‬ ‫از‬ ‫عبارت‬ ‫نمونیا‬
.

19. ‫تصنیف‬
• Community acquired
• hospital acquired pneumonia .
• Aspiration pneumonia: stroke, myasthenia,
bulbar palsies, consciousness (eg postictal or
drunk), oesophageal disease (achalasia, refl
ux), or with poor dental hygiene risk aspirating
oropharyngeal anaerobes

20. • Lobar
• segmental
• bronchopneumonia
• interstitial pneumonia.

21. Community acquired
pneumonia)CAP)

22. Risk factors for CAP
• Asthma
• Immunosuppression
• Age older than 70 years
• alcoholism

23. Risk factors for pneumococcal
pneumonia
• Dementia
• Convulsion
• Heart failure
• Cerebrovascular diseases
• Smoking (the strongest ).
• Alcoholism
• COPD
• HIV (40 fold more common).

24. Cont..
• Risk factor for Legionnaire
– Male, Smoking, Diabetes, blood cancer & other cancers,
Renal failure & HIV.
• Risk factors for Gram- bacteria (pseudomonase)
– Aspiration
– Hospitalization
– Recent antibiotic therapy
– Bronchiectasis
– Alcoholism
– Heavy drinkers (predisposed to gram(-) pneumonia,
severely symptomatic , need prolonged antibiotic therapy)

25. Cont…
• ALPS:
– Alchollism, Leukopenia, Pneumococcal Sepsis with
80% morbidity

26. ‫اسباب‬
• 100 cases including bacteria , viruses ,fngi ,
parasites .
• Common causes Staph aureus , pneumococ,H
influenza, mycoplasma,moraxilla C ,chlamydia
P ,legionella , influenza viruses ,adenoviruses

27. Clinical presentation
• Fever
• Chills
• Cough initially dry , later productive with
purulent or rusty sputum
• S.O.B
• Pleuretic chest pain .
• Others headech , musculoskletal pain , back
pain ,nausia , vomiting
• Altered consciousness.

28. ‫فزیکی‬ ‫معاینات‬
• General : fever , warm and dry skin ,
tachycardia and tachypnea(RR more than 30),
use of ARM
• Inspection : decreased chest movements
• Palpation : decreased chest movements ,
increased vocal fremitus .
• Percussion : dullness
• Auscultation : fine crepitation , pleural rub ,
whispering pectoriloquy ,egophony .

29. Specific types of pneumonia
• Pneumococcal pneumonia is the commonest
bacterial pneumonia
• Risk factors mentioned
• Clinical features: fever, pleurisy, herpes labialis.
• CXR shows lobar consolidation

32. • Staphylococcal pneumonia may complicate
influenza infection , intravenous drug users,
or patients with underlying disease, eg
leukaemia, lymphoma, cystic fibrosis (CF).
• It causes a bilateral cavitating
bronchopneumonia.

35. • Klebsiella pneumonia is rare.
• Occurs in elderly, diabetics and alcoholics.
• cavitating pneumonia, particularly of the
upper lobes, often drug resistant.
• Treatment: cefotaxime or imipenem.

36. • Pseudomonas
• Common in bronchiectasis and CF.
• It also causes hospital-acquired infections,
particularly on ITU or after surgery.
• Treatment: antipseudomonal penicillin,
ceftazidime, meropenem, or ciprofloxacin +
aminoglycoside.
• Consider dual therapy to minimize resistance.

37. Cont…
• Pneumocystis jiroveci pneumonia (PCP) causes pneumonia in the
immunosuppressed (HIV).
• It presents with a dry cough, exertional dyspnoea, PaO2, fever, bilateral
crepitations.
• Exertional oxygen desaturation
• Pneumothorax
• CXR may be normal or show bilateral perihilar interstitial shadowing.
• Diagnosis: visualization of the organism in induced sputum,
bronchoalveolar lavage, or in a lung biopsy specimen.
• Drugs: high-dose co-trimoxazole or pentamidine by slow IVI for 2–3 weeks.
• Steroids are benefi cial if severe hypoxaemia.
• Prophyl axis is indicated if the CD4 count is <200≈106/L or after the 1st
attack.

39. Mycoplasma pneumonia
• Respiratory symptoms
• CNS: GBS, meningoencephalitis
• Blood: ITP, autoimmune hemolytic anemia
• heart: pericarditis , myocarditis
• GIS: hepatitis, pancreatitis
• Renal: glomerulonephritis
• Ear: bullous myrengitis
• skin rash (erythema multiforme Stevens–
Johnson syndrome

41. Cout..
• Chest radiography in all patients whose Tem
higher than 38,5 C or have pleuretic chest
pain.
• RR more than 30cycle/min.

42. CURB 65
• C : confusion.
• U : BUN more than 7mmol/L
• R: respiratory rate ≥30 cycle /min
• B : blood SBP ˂90 , DBP ˂60
• age ≥65

43. Cont….
• 0–1 home possible
• 2 hospital therapy
• ≥3 severe pneumonia indicates consider ITU.

44. Criteria for the severity of
pneumonia by USA
• Major mechanical ventilation
Vasopressor for > 4 hour
• Minor Systolic Bp less than 90mmHg
Pao2/F1o2 < 250
infected several lobs

45. Complications
• Pleural effusion
• Empyema
• lung abscess
• respiratory failure
• Septicaemia, shock
• brain abscess
• pericarditis, myocarditis
• Atrial fibrillation

46. Mortality
• 8%
• Cause of death:
– Respiratory failure, Heart disease & Infection
– Death more occur in first week
– independent death cause in pneumonia:
• Dementia, Immunosuppression, Systolic hypotension,
cancer, male and several lobes infiltration.

47. diagnosis
• Symptoms
• Signs
• Chest x-ray
• CT scan
• Diagnosis of causative bacteria by culture

50. • Chest-X-Ray
• CT-Scan
• If pneumonia is suspected clinically and first x-ray is
normal, radiography should be repeated after 24-48
hours or CT should be done.
• The Dx is difficult when Heart failure or Pulmonary
fibrosis is present.
• Causative Dx: Culture 6-20%
• Common bacteria:
– Strep. Pneumonia 60%, Staph.aureus & E.coli

51. Consolidation with cavitation

52. ‫بستر‬ ‫از‬ ‫خارج‬ ‫مریضان‬ ‫تداوی‬
• Pencillines
• Doxycyclin
• Macroloides( azithromycin, clarithromycin)
• Fluroquinolones ( levofloxacin , moxifloxacin,
gatifloxacin ..)

53. Cont…
• Healthy persons not taking antibiotics in last
3 months :
1: macrolids ( azithromycin or clarithromycin)or
2: doxycyclin
• Patients with comorbidities like heart ,lung
and renal diseases, malignancy , DM,
splenectomy :
1:floroquinolones ( moxifloxacin,
levofloxacin…)or

55. Con…
2: a macrolids plus a beta-lactam ( amoxicillin ,
augmentin ..)

56. Duration of treatment
• Pneumococci :continue therapy until the
patient is afebril for 72 hours .
– Staph.aureus, Pseudomonas aeruginosa, Klebsiella,
Anaerobes, Mycoplasma pneumonia, Chlamydiae
pnuemonia & Legionella:
• At least 2 week of treatment

57. Inpatient treatment regims
• Not in ICU:
1: a floroquinolone( levofloxacin ,moxifloxacin
gemifloxacin) oral or IV or
2: a Macrolide( azithromycin, clarithromycin)
Plus a beta –lactam ( ampicillin ,ceftriaxon
,cefotaxim)

58. Cion..
• In ICU
1: a macrolide (azithromycin ) or a
fluoroquinolone plus an antipneumococal
beta-lactam ( ampicillin-sulbactam , ceftriaxon
, cefotaxim)

59. Con…
• A fluroquinolone with or without clindamycin
, metronidazol for Aspiration pneumonia.
• Cystic fibrosis ( high risk for Pseudomonas
aeruginosa) an antipsedomonal antibiotics (
cefepime , Imipenem 0,5-1gr iv tid qid , or
meropenem1gr iv tid) plus A fluroquinolone (
high dose ciprofloxacin)

60. Duration of therapy
• For pneumococal pneumonia 72 hours after
discountuation of fever .
• Two weeks for Stap aureus , klebsiella ,
Pseudomonas aeruginosa, anaerobes.

61. Pneumococal pneumonia
‫ست‬ ‫ذریعه‬ ‫که‬ ‫میباشد‬ ‫ریه‬ ‫پرانشیم‬ ‫حاد‬ ‫التهاب‬ ‫از‬ ‫عبارت‬
‫رین‬
‫مختلفه‬ ‫های‬
Pneumococ
‫میاید‬ ‫بوجود‬
.
•
type3
Pneumococal pneumonia
‫خراب‬ ‫انذار‬
‫ضعیف‬ ‫امراض‬ ‫انهایکه‬ ‫و‬ ‫مسن‬ ‫مریضان‬ ‫در‬ ‫چون‬ ‫دارد‬
‫میاید‬ ‫بوجود‬ ‫دارند‬ ‫کننده‬
.
•
‫بنام‬ ‫نمونیا‬ ‫این‬
acute lobar pneumonia
‫میشود‬ ‫یاد‬ ‫نیز‬

62. pathology
1:Congestion:(12hours -3days)
• Vascular dilation and congestion in alveolar walls.
↓
• Increased Vascular permiability.
↓
• Exudation of fibrin –riched fluid into the alveoli
causes edema of the affected lobe and the air of
alveoli is replaced by the fluid .

63. Cot..
2: red hepatization:(1-3days)
• ↑ RBCs in alveoli , ↑ plasma proteins and
fibrinogen in alveoli , ↓ WBCs in alveoli .
• Liver-like(red) appearance in gross view .

64. 3: gray hepatization(2-6days)
• ↑ WBCs in alveoli.
• So , lung appears gray .
• Pus drained if the lung is pressed .

65. 4: resolution(after 6 day)
• Alveolar exudates ( WBCs,fibrin , pneumococci
) are enzymatically digested ( proteolytic
,otolytic) causing liquification of the exudate
which is either expectorated by coughing or
resorbed .

69. Symptoms
1: specific symptoms
• Fever(39-40C)
• Chills( single except those taking anti-pyretics)
• Cough( initially dry , later productive)
• Sputum (pinkish rusty)
• S.O.B
• Pleuretic chest pain(sometimes shoulder or
abdominal pain ) .

70. Con..
2:

71. Physical examination
• General : fever , warm and dry skin , tachycardia,
hypotension , tachypnia(RR 30-40), use of ARM ,
rapid and shallow respiration , cyanosis.
• Inspection : decreased chest movements,
deviation of trachea in case of empyemia and
pleural effusion.
• Palpation : decreased chest movements ,
increaesd vocal fremitus(↓in first day) .
• Percussion : dullness
• Auscultation : fine crepitation ,bronchophony,
whispering pectoriloquy ,tubular sounds

72. Changes in physical findings
• Atelactasis .
• If consolidation is not extensive .
• If pleural effusion occurs.

73. Lab examinations
• Blood exam( neutrophilic leukocytosis, ↑ESR)
• Blood culture( 20-25%)
• Gram stain and culture of sputum
• Pleural fluid exam
• Blood gas analysis
• Electrolytes ( decreased level of Na,Cl)

74. con
• Chest x-ray shows lobar or segmental
consolidation 12-18 hours after the onset of
pneumonia.

75. Cont…

76. defervescence
• If not treated
1: crisis . Fever falls suddenly after 5 or 10 days
2: lysis. Fever falls gradually .
• With treatment crisis occurs within 24 hours.

77. complications
• Pulmonary complications
1: spread to other lobes
2: late resolution ( old age, chronic bronchitis)
• Pleural complications
1: sterile pleural effusion
2: empyema

78. Con..
• Cardiovascular complications
1:circulatory collapse.
2:pneumococal pericarditis
3:pneumococal endocarditis .
4:DVT and pulmonary emboli.

79. Cont..
• Neurological complication
1: meningitis
2:meningismus
• Rare and specific complications :
1. Peritonitis.
2. Pyogenic arthritis.
3. Methastatic cutaneous abscess.

80. diagnosis
• Symptoms(fever , single chills)
• Signs of consolidation
• Neutrophilic leukocytosis
• Isolation of pneumococ from sputum
• Lobar or segmental consolidation

81. Differential diagnosis
• All kinds of pneumonia
• Lung infarction ( no fever , no response to
antibiotics )
• TB ( chronic disease, chest x- ray , BK+)
• Atelactasis (↓ breathing sounds , trachea
pulled toward the collapsed lung , x-ray)
• Acute bronchitis .
• TB pleurisy +effusion(no cough and sputum, signs of
effusion ,no leukocytosis , no response to antibiotics)

82. • Subdiaphragmatic inflammatory conditions
(appendicitis , cholecystitis , perforation of
peptic ulcer , peritonitis).
 Abdominal tenderness in these conditions.
 Tachypnia and fever in pneumonia.

83. treatment
• Uncomplicated Pneumococal pneumonia
(Pao2 more than 60mmHg, no other diseases,
one lobe involvement ) caused by pincillin
sensitive strains treated as OPD patients by
the following antibiotics .
1: amoxicillin 750mg bid.
2: macrolides( azithromycin , clarithromycin
500mg bid for 10 days )

84. Cont…
3: doxycyclin( 100mg bid for 10 days)
4: levofloxacin 750mg OD for 5 days .
• Inpatients regims (IV):
1: pencillinG 2MU every 4hourly IV.
2:ceftriaxon 1gr IV BID.
3: vancomycin 1gr IV Bid in case pincillin allergy
or pincillin resistant pneumococ.

85. Treatment of complications
• Sterile pleural effusion : no need for
thoracentesis .
• If pneumococ is isolated from the pleural fluid (
first aspiration , then chest tube drainage)
• Pericardial effusion is evaluated by echo .
• Pneumococal endocarditis is treated by pincillin
G (3-4 MU every 4 hourly) ,ceftriaxon 2gr IV OD,
or vancomycin 15mg /kg bid for 4 weeks.

86. Cont…
• Pincillin resistant pneumococ(MIC more than
0,1mcg/ml) are treated as follow
1: ceftriaxon 1gr iv bid
2: vancomycin 1gr iv bid
3: amoxicillin –clavulanat (650-1000mg bid ) for
CAP for 7-10 days .
4: fluroquinolone( levofloxacin , moxifloxacin ) is
oral alternative.

87. Nosocomial pneumonia
• HAP occurs more than 48 hours after admission to
the hospital .
• Health care-associated pneumonia occurs in
community members whose extensive contact with
healthcare has changed their risk for virulent and
drug-resistant organisms.
• Ventilator associated pneumonia .

88. Hospital acquired pneumonia
‫تعریف‬
:
‫که‬ ‫است‬ ‫نمونیا‬ ‫از‬ ‫عبارت‬
۴۸
‫بستر‬ ‫از‬ ‫بعد‬ ‫ساعت‬
‫موجود‬ ‫شدن‬ ‫بستر‬ ‫وقت‬ ‫در‬ ‫و‬ ‫اید‬ ‫بوجود‬ ‫شفاخانه‬ ‫در‬ ‫شدن‬
‫نباشد‬
(
‫و‬ ‫رادیوګرافیک‬ ‫های‬ ‫دریافت‬ ، ‫کلینیکی‬ ‫تظاهرات‬
‫مونونوکلیرها‬ ‫افزایش‬
.)

89. ‫فکتور‬ ‫سه‬
HAP
‫از‬ ‫را‬
CAP
‫میسازد‬ ‫متفاوت‬
:
.1
‫بودن‬ ‫متفاوت‬
‫سببی‬ ‫انتانات‬
.
.2
‫بودن‬ ‫متفاوت‬
‫ها‬ ‫بیوتیک‬ ‫انتی‬ ‫برابر‬ ‫در‬ ‫حساسیت‬
‫ه‬ ‫بیوتیک‬ ‫انتی‬ ‫برابر‬ ‫در‬ ‫مقاومت‬ ‫افزایش‬ ‫مخصوصا‬
‫ا‬
.
.3
‫خراب‬ ‫صحی‬ ‫حالت‬
‫معرض‬ ‫در‬ ‫را‬ ‫انها‬ ‫که‬ ‫مریضان‬ ‫این‬
‫میدهد‬ ‫قرار‬ ‫شدید‬ ‫انتانات‬ ‫خطر‬
.

90. • Uncommon in obstetric and psychiatric wards.
• 5-10% in internal medicine and surgical wards.
• HAP associated with high rate of mortality and
morbidity.
• Prolongation of hospitalization.
• Ventilator associated pneumonia .
• 50% cases of VAP at day four .
• HAP is 6-20 times higher in ventilated patients .

91. • Mortality rate in HAP is 30-70% and are more
common in:
 Bacteremic patients.
 Dangerious infections (pseudomonase).
 ICU patients.

92. • Risk factors of mortality in ICU patients:
 Shock.
 Associated diseases.
 Coma.
 SIRS.
 Bilateral pulmonary infiltrates in radiography.
 ARDS.
 Respiratory failure.

93. • Post-operative predisposing factors for HAP:
Age over 80.
History of weight loss.
Alcohol consumption.

94. Pathogenesis
• Risk factors of CAP.
• Independent risk factors.
• Factors disturbing defense of upper airways and
predispose to aspiration and microaspiration :
 Intubation.
 NG tube.
 Endotrachial tube.
 Feeding tube through stomach

95. • Eendotrachial tube predisposes pneumonia :
Acts as a conduit for the passage of bacteria .
Impairs cough .
Damages trachial epithlium and causes
accumulation of oropharyngeal secretion.

96. • Bacteria proliferate on the surface of endotrachial
tube and form a biofilm that can be disintegrated
and enters to the lower respiratory tract.
• Nasotrachial and nasogastric tube predispose to
nosocomial sinusitis.
• Antacid , H2-antagonists (alkalinize the stomach PH)
and NG tube feeding cause proliferation of bacteria
in stomach and may aspirate to respiratory tract.

97. • Risks of aspiration in ICU patients :
Supine .
NG tube.
Overdistention of stomach.

98. ‫اسباب‬
• Streptococcus pneumonia
• Stap aureus both MSSA and MRSA
• Gram negative rods like klebsiella , E coli,
serratia and proteous .
• Pseudomonas aeruginosa
• acinetobacter

99. • Staph aureus are common in :
Coma.
Head trauma.
DM.
Renal failure.

100. • The more resistant organisms:
MRSA.
Acinoacter.
Calcoacaticus-baummani.
Enterobacteriaceae.

101. ‫کلینیکی‬ ‫تظاهرات‬
‫تب‬
،
‫لوکوسایتوزس‬
،
‫ریوی‬ ‫جدید‬ ‫وارتشاح‬ ‫قیحی‬ ‫تقشع‬
‫در‬
‫میباشد‬ ‫موجود‬ ‫مریضان‬ ‫اکثر‬
.
‫وصفی‬ ‫نمونیاغیر‬ ‫این‬ ‫عالیم‬ ‫و‬ ‫اعراض‬ ‫اکثریت‬ ‫اما‬
‫و‬ ‫بوده‬
‫به‬ ‫مشابه‬
CAP
‫میباشد‬
.

102. ‫ادامه‬
..
‫کلینیکی‬ ‫های‬ ‫یافته‬ ‫دو‬ ‫از‬ ‫بیشتر‬ ‫یا‬ ‫دو‬
(
‫تب‬
.
‫لوکوس‬
‫و‬ ‫ایتوزس‬
‫قیحی‬ ‫تقشع‬
)
‫با‬
‫ریوی‬ ‫جدید‬ ‫ارتشاحات‬ ‫موجودیت‬
‫در‬
‫تشخیص‬ ‫برای‬ ‫مطالعه‬ ‫یک‬ ‫در‬ ‫صدر‬ ‫رادیوگرافی‬
VAP
‫به‬
‫اندازه‬
70% sensitive
‫و‬
75% specific
‫است‬ ‫بوده‬
.

103. DDx
• CHF.
• Atelactasis.
• Aspiration.
• ARDS.
• Pulmonary thromboembolism.
• Pulmonary hemorrage.
• Drugs reactions.

104. ‫تداوی‬
۱
:
‫باشد‬ ‫کم‬ ‫ادویه‬ ‫چند‬ ‫دربرابر‬ ‫مقاوم‬ ‫های‬ ‫پاتوجن‬ ‫خطر‬ ‫اګر‬
‫کنید‬ ‫ده‬ ‫استفا‬ ‫را‬ ‫ذیل‬ ‫های‬ ‫ادویه‬ ‫از‬ ‫یکی‬ ،
:
• Ceftriaxone 1-2gr every 12-24 hr
• Gemifloxacin 320mg OD, moxifloxacin400mg
OD, levofloxacin 750mg oral or IV.
• Pipracillin-tazobactam 3,375-4,5gr QID.

105. Con…
‫باشد‬ ‫زیاد‬ ‫ادویه‬ ‫چند‬ ‫دربرابر‬ ‫مقاوم‬ ‫های‬ ‫پاتوجن‬ ‫خطر‬ ‫اګر‬
،
‫کنید‬ ‫استفاده‬ ‫را‬ ‫دوا‬ ‫یک‬ ‫ذیل‬ ‫کتګوری‬ ‫هر‬ ‫از‬
:
۱: antipseudomonal coverage
• Cefipime 1-2gr iv bid or ceftazidime 1-2gr iv
tid
• Imipenem 0,5-1gr iv tid qid , or
meropenem1gr iv tid
• Pipracillin-tazobactam 3,375-4,5gr QID

106. Con…
2: coverage for MRSA
• Vancomycin IV .
• Linezolid 600mg iv bid

108. bronchectasis
‫تعریف‬
:
‫قابل‬ ‫غیر‬ ‫و‬ ‫دایمی‬ ‫تخریب‬ ‫و‬ ‫توسع‬ ‫از‬ ‫عبارت‬
‫در‬ ‫تخریبی‬ ‫تغییرات‬ ‫باعث‬ ‫ار‬ ‫که‬ ‫میباشد‬ ‫قصبات‬ ‫برګشت‬
‫میاید‬ ‫بوجود‬ ‫قصبات‬ ‫وعضلی‬ ‫االستیکی‬ ‫طبقات‬
.

110. ‫پتالوژی‬

111. ‫اسباب‬
1: acquired causes
• Tuberculosis
• Supporative pneumonia, aspiration
pneumonia
• Lung abscess, AIDS, RA, bronchial tumors
2 : acquired causes (children)
Whooping cough, pneumonia ,measle , primary
TB , foreign bodies.

112. Con…
3: congenital causes
• Cystic fibrosis ( thick mucus obstructing
bronchial lumen).
• Primary hypogammaglobinemia.
• Ciliary dysfunction syndrome.
One example is Kartagener syndrome
(bronchiectasis , sinusitis , infertility and
transposition of aorta)

113. ‫اعراض‬
۱
:
‫سرفه‬
.
‫افرازات‬ ‫تجمع‬ ‫باعث‬ ‫از‬
(
‫قیح‬
)
‫متوسع‬ ‫قصبات‬ ‫در‬
‫میاید‬ ‫بوجود‬ ‫مزمن‬ ‫سرفه‬
.
‫باتغییر‬ ‫و‬ ‫صبح‬ ‫هنګام‬ ‫سرفه‬
‫میګردد‬ ‫تشدید‬ ‫وضعیت‬
۲
:
‫تقشع‬
.
‫میباشد‬ ‫قیحی‬ ‫و‬ ‫زیاد‬
۳
:
‫تب‬
.
‫در‬ ‫اورد‬ ‫بوجود‬ ‫را‬ ‫نمونیا‬ ‫و‬ ‫ګردد‬ ‫منتشر‬ ‫انتان‬ ‫وقتیکه‬
‫میاید‬ ‫بوجود‬ ‫تب‬ ‫حالت‬ ‫این‬
.
۴
:
‫الدم‬ ‫نفث‬
.
‫باشد‬ ‫شدید‬ ‫یا‬ ‫خفیف‬ ‫میتواند‬
.
۵
:
‫عمومی‬ ‫اعراض‬
:
‫کلبنګ‬ ، ‫وزن‬ ‫ضیاع‬ ، ‫اشتهایی‬ ‫بی‬
‫انګشتان‬

114. ‫ادامه‬
۵
:
‫فنګ‬ ‫ودیګر‬ ‫اسپاراژیلوس‬ ‫مداخله‬ ، ‫ویزینګ‬ ، ‫تنګی‬ ‫نفس‬
‫س‬
‫میګردد‬ ‫اسما‬ ‫حمالت‬ ‫تشدید‬ ‫سبب‬ ‫ها‬
.

115. ‫عالیم‬
• Inspection. No
• Palpition. No
• Percussion. Dullness
• Auscultation. Wheezing , coarse crepitation,
amphoric sound in cystic form
• Cyanosis , clubbing

116. ‫رادیولوژی‬
• Mild cases . Normal chest x ray and CT scan
is required.
• Cystic form is visible in plane x-ray

119. DDx
• TB
• Chronic bronchitis
• Bronchial stenosis
• Bollus emphysemia
• Cystic fibrosis

120. complications
• Amyloidosis
• Emphysema
• Pneumonia
• Lung and brain absess

121. management
1: postural drainage and chest percussion. To
empty secretions from the dilated bronchi.
2: antibiotics .based on the culture results .
Empirical therapy includes the following
• Amoxiillin or augmentin , ampicillin or
tetracyclin in mild cases
• intravenous augmetin plus ciprofloxain or
ceftazidim (iv) for 5-10 days .

122. Con…
• Staph aureus : penillinase resistant pencillin
like naficillin , oxacillin plus a cephalosporin
like cefazolin .
• P aeruginosa : antipseudomonal pencillin plus
ceftazidime
3 :bronchodilators : in case of bronhospasm .
4 : prednison : in case of bronchial allergy due to
aspergilosis.