medical education

1. PNEUMONIA
DR.PRABHAKAR K
DEPARTMENT OF PULMONARY MEDICINE

2. Learning objectives
▶ Definition
▶ Risk factors
▶ Etiology
▶ Pathology
▶ Clinical features
▶ Investigations
▶ Treatment
▶ Prevention

3. Pneumonitis
Pneumonia
PNEUMONITIS: broad term for inflammation of the lung.
PNEUMONIA: used more specifically to indicate lung
inflammation which is:
• Caused by an infectious agent.
• Leads to formation of an inflammatory exudate inside the
alveoli.
• Leads to impaired gas exchange.
This is referred to as hepatization (pathology) or
consolidation (clinical).

4. Pneumonia
Community Acquired Pneumonia
(CAP)
Hospital Acquired Pneumonia
(HAP)
Pneumonia acquired outside the
hospital or extended care facility
without recent exposure to the
health care system.
Pneumonia that occurs > 48 h after
hospital admission.
Ventilator Associated Pneumonia
(VAP) arises > 48h after endotracheal
intubation.
Health Care Associated Pneumonia
(HCAP) arises in patients who were
hospitalized in the last 3 months or
attended out-patient clinic or HDU in
the last month.

5. ▶ CAP in the absence of chest radiograph is defined as:
(a) symptoms of an acute lower respiratory
tract illness (cough with or without
expectoration, shortness of breath, pleuritic
chest pain) for less than 1 week;
(b) at least one systemic feature (temperature
>37.7°C, chills, and rigors, and/or severe
malaise);
(c) new focal chest signs on examination (bronchial
breath sounds and/or crackles);
(d) no other explanation for the illness
Lung India • Supplement 2 • Jul - Sep 2012

6. CAP defined as
When a chest radiograph is available, CAP is defined as:
▶ symptoms and signs of CAP with new
radiographic shadowing for which there is no other
explanation (not due to pulmonary edema or infarction)
▶ Radiographic shadowing may be seen in the form
of a lobar or patchy consolidation, loss of a
normal diaphragmatic, cardiac or mediastinal
silhouette, interstitial infiltrates, or bilateral
perihilar opacities, with no other obvious cause.
Lung India • Supplement 2 • Jul - Sep 2012

7. Classification of pneumonia
According to causes
▶ Bacterial (the most common cause of pneumonia)
▶ Viral pneumonia
▶ Fungal pneumonia
▶ Inhalation pneumonia (aspiration pneumonia)
According to areas involved
o LOBAR PNEUMONIA : one or more lobes are involved
o BRONCHO PNEUMONIA: pneumonic process has been started in one or two bronchi
and may extend into surrounding lung tissue

9. Community Acquired Pneumonia (CAP)
Typical Pneumonia [85 %]
(Typical Organisms)
Atypical Pneumonia [15 %]
(Atypical Organisms)
• Strept pnemoniae
(Penicillin sensitive and resistant strains)
• Haemophilus influenzae
(Ampicillin sensitive and resistant strains)
• Moraxella catarrhalis
(All strains penicillin resistant)
• Mycoplasma pneumoniae
• Chlamydia pneumoniae
• Chlamydia psittaci
• Legionella pneumonia
(Legionnaires' disease)
• Fungal pneumonia
• Viral pneumonia
CAP is usually caused by a single organism, except aspiration pneumonia, which is
commonly polymicrobial.
Atypical organisms are not revealed on ordinary Gram stain and culture media.

10. Pathogens Involved

11. Routes of Infection
Inhalation Haematogenous
Direct
Extension
Predisposing Factors
Age > 65 Y Chronic
Comorbidities
Immune-
Compromised
Commonest route. From pleura or
subdiaphragmatic space
Constitute 30% of
cases of CAP, and
60% of pneumonia
hospitalization
heart, liver, kidney
disease, dm,copd
,asthma dementia
Aspiration
Use of
PPI, H2B
The decreased gastric acidity  risk of
bacterial colonization in the stomach.
This may be aspirated to the lungs.
Sucralfate does not  CAP risk.
Risk  in presence of stroke, seizures,
neuromuscular
disease

12. COPD, Smoking, Bronchiectasis, Cystic Fibrosis : Pseudomonas
Influenza /viral : Staph. aureus
Aspiration : - Gm –ve enteric bacteria
- Oral anaerobes
Lung Abscess : - Oral anaerobes
- Fungi
Exposure to Birds : Chlamydia psittaci (psittacosis)
HIV : - Pneumocystis jiroveci pneumonia
- Fungi
Risk Factors for Specific Pathogens

13. LOBAR PNEUMONIA
◦ PATHOLOGICAL STAGES
◦ Congestion
◦ Red Hepatization
◦ Grey Hepatization
◦ Resolution

14. Diagnosis of CAP
Clinical Radiologic Microbiologic
Required for
Diagnosis
• Onset: Acute (more common) or Subacute (suggestive of atypical pneumonia)
• General (Systemic) Manifestations: fever, myalgia
• Local (Pulmonary) Manifestations:
• Productive cough, dyspnoea, pleuritic chest pain.
• Bronchial breathing,  Vocal resonance
• Extra- Pulmonary Manifestations in Atypical Pneumonia:
• Erythema nodosum: in Psittacosis
• Erythema Multiforme: in Mycoplasma pnemonia
• Headache / mental confusion/Abdminal pain / diarrhoea.
• Relative bradycardia :legionella and chlamydia

15. ??????

16. ???

17. Investigations in CAP
OXYMETRY :should complement clinical exam. It may give a clue for presence of
pneumonia and/or hypoxaemia.
ABG :PaO2/FiO2 < 250 mmHg is a criterion of severe CAP
LABORATORY : -  ESR,  CRP,  WBCs,  procalcitonin
URINARY ANTIGEN TEST : legionella
SERUM ANTIGEN: pneumococcal
RTPCR AND RAPID ANTIGEN TESTS for influenza and covid 19.
DIRECT FLOURESCENCE ANTIBODY tests are available for influenza and RSV
ACUTE PHASE SEROLOGICAL TESTING Chlamydophila pneumoniae, Mycoplasma
pneumoniae, and Legionella species other than L. pneumophila, relies on acute- and
convalescent- phase serologic testing
PCR tests :legionella and chlamydia

18. CULTURE guides therapy if +ve, but not exclusive if –ve, which is usual.
Blood and respiratory cultures should be obtained.
Respiratory samples include: Sputum (spontaneous or induced),
endotracheal aspiration, bronchoalveolar lavage (BAL).
Cultures obtained lower down the respiratory tract are more representative
for bacteria actually invading the lungs and have higher predictive values.
S. pneumoniae and H. influenzae are frequently associated with positive
blood cultures.

19. TREATMENT

20. CURB 65 criteria used for admission

21. Clinical
• Tachypnoea > 30 breath/min
• Hypotension requiring aggressive IV fluid resuscitation
• Hypothermia < 36 OC
• Confusion / disorientation
Hypoxaemia
• PaO2 / FiO2 < 250 mmHg
• Need for non-invasive ventilation
Investigations
• BUN > 20 mg/dL
• WBCs < 4000 cells/mm3
• Platelets < 100,000 celss/mm3
• Pulmonary infiltrates (X-Ray)
•Invasive mechanical ventialtion
• Septic shock with need for vasopressors
•The one major criteria and three or more minor
criteria –severe pneumonia –icu
IDSA/ATS 2019

22. OUT PATIENT
•CURB65 - 0,1
IN PATIENT /
WARD
•CURB65 - 2
INPATIENT / ICU
•CURB65 - 3,4
BRIEFLY

24. COMMUNITY ACQUIRED PNEUMONIA
IDSA/ATS 2019

25. ▶ In the INDIAN setting FQ are not used as empirical therapy
▶ FQ may be used if tuberculosis is not a diagnostic consideration at admission
▶ Pts should undergo sputum for acid fast bacilli simultaneously if FQ are used
LUNG INDIA .supplement 2 . jul - sept 2012

26. CAP COMPLICATIONS
▪ Hypotension and septic shock
▪ 3-5% Pleural effusion;
▪ 1% Empyema thoracis
▪ Lung abscess – destruction of lung .
▪ Single (aspiration) anaerobes, Pseudomonas
▪ Multiple (metastatic) Staphylococcus aureus
▪ Septicemia – Brain abscess, Liver Abscess
▪ Multiple Pyemic Abscesses

27. Non-Responding Pneumonia
These criteria of clinical stability are achieved within 3 – 6 days in most patients. Absence
of clinical response or occurrence of deterioration after 3 – 6 days thus defines non-
responding pneumonia.
•Causes of Non-Responding Pneumonia:
• Resistant organism.
• Missed organism (TB / fungus).
• Nosocomial superinfection: another pneumonia, empyema, endocarditis
• Misdiagnosis (PE, CHF, vasculitis)
• Non- infectious complications: eg, Bronchiolitis Obliterans Organizing Pneumonia.
• Drug fever
•Comorbidities: DM, RF, HF
• Immunocompromised states
•

28. • Management of Non-Responding Pneumonia:
• Transfer to a higher level of care (eg, from ordinary ward to ICU)
• Further diagnostic testing.
• Escalation or change of treatment

29. This means persistence of pulmonary infiltrates > 30 days after initial presentation.
• Causes:
• Resistant organism.
• Missed organism (TB / fungus).
• Nosocomial superinfection: another pneumonia,
• empyema, endocarditis
Non-Resolving or Slowly Resolving Pneumonia
Bronchiloitis Obliterans Organizing Pneumonia (BOOP)
• Comorbidities: DM, RF, HF
• Immunocompromised states
Resolution of pneumonia requires resorption of the inflammatory exudate in the alveoli.
In BOOP, the inflammatory exudate persists in the alveoli and bronchioles and becomes
organized into fibrous tissue which further obliterates the air spaces.
X-Ray shows bilateral wide spread patches of fibrosis.
Diagnosis is confirmed by CT and bronchoscopic biopsy.
Most patients recover with steroid tharapy.

30. Antibiotics for Specific Pathogens
Doxycyclin 100 PO BID
Or Macrolide (Azithromycin or Clarithromycin)
Treatment for 10 days
Mycoplasma
pneumonia &
Chlamydia
pneumonia
Doxycyclin 100 mg PO BID for 14 days
Chlamydia psittaci
Fluoroquinolones for 14 days, starting IV then shifting to
oral.
Legionella
Trimethoprim / Sulphamethoxazole 15 mg TMP/Kg/day
IV Div q8h or 2 DS tablets (800 mg sulfamethoxazole and
160 mg trimethoprim) PO q8h for 21 days
PJP (Pneumcystis
Jiroveci
Pneumonia)
Itraconazole 200 mg PO or IV q24h
Or Amphotericin B 3 mg/kg q24h if severe
Duration of therapy: 1-12 months
Fungal Pneumonia
(Aspergillosos,
Histoplasmosis)

31. An N95 respirator is a
respiratory protective device
designed to achieve a very
close facial fit and very efficient
filtration of airborne particles.

32. Viral Pneumonia
Influenza
Types
Hosts
Type A Humans,
birds, pigs
and horses
Type B Humans
only
Type C Humans
only
H: Haemagglutinin
N: Neuraminidase

33. Oseltamivir (Tamiflu)
• Effective against both influenza A, B
• 75 mg PO BID for 5 days.
• Early treatment shortens the course and decreases risk of lower respiratory
complications.
• Patients should receive also antibiotics covering Strept. Pneumoniae and
Staph. aureus which are the most common causes of 2ry bacterial pneumonia
in patients with influenza.
• Can be used also for post- exposure prophylaxis:
75 mg od daily for 10 days.
Neuraminidase Inhibitors
Neuaminidase is an enzyme on surface of influenza virus that enables it to be
released from the host cell.

34. Covid 19 pneumonia
• Symptomatic management /home isolation ( mild )
• Oxygen support based on saturation levels.
(Moderate )
• ARDS : Niv / MV (severe )
• Steoids(dexamethasone, methyl prednisolone) in
oxygen dependent and icu. (Moderate and severe )
• Remdesvir antiviral.(moderate and severe)
• Plasma therapy early. No role
• Monoclonal antibodies early ,stable non oxygen
• Prone position / execises / Rehabilitation

35. Prevention
• Smoking cessation
• Quit alcohol consumption
• Vaccination (pneumococcal , influenza ).
• Respiratory hygiene
• Hand hygiene.