محاضرة مبسطة للفرقة الخامسة

1. Alaa metwally
assistant proffesor
chest departmrnt
Pneumonia

2.  Pneumonia is: an inflammation of the gas exchanging part
of the lung (parenchyma of the lung). Most cases of
pneunomia are caused by microorganism.
 Pneumonitis is: an inflammation of the gas exchanging
part of the lung due to non infectious causes including
aspiration of food or gastric acid foreign bodies, chemicals
and lipoid substances. Hypersensitivity reaction and drug or
radiation induced pneumonitis.
PNEUMONIA, Definition

3. 1 : Anatomical classification.
A – Lobar pneumonia .Where the consolidation involves all or part
of the lobe.
B – Bronchopneumonia: The consolidation involves scattered
lobules
C - Interstitial pneumonia: Inflammatory infiltrate involve mainly
interstitial tissue between alveoli as in viral pneumonia.
.
PNEUMONIA, Classification

4. PNEUMONIA, Classification
•Community acquired pneumonia (CAP):
•Pneumonia which occurred in the community , ambulant
patient
•Hospital acquired and health care acquired pneumonia (HAP):
•Pneumonia occurred after 48 hours of hospital admission, or
frequent visits of health care facilities (e.g. hemodialysis
patients).
•Ventilator associated pneumonia (VAP):
•Pneumonia occurred after 48 hours of intubation and/ or
mechanical ventilation.

5. 2 : Etiological classfication.The cause of pneumonia is
often difficult to determine because culture of lung
secretions is invasive and rarely performed.
• Culture obtained from upper respiratory tract or sputum
generally not accurate and usually reflect contamination
rather than true pathological organism.
PNEUMONIA, Classification

6. PNEUMONIA
Bacterial.Common.
• Streptococcus pneumoniae, Group B streptococci, Group A
streptococci .
• Mycoplasma pneumoniae.
• Chlamydia pneumoniae  Adolescent.
• Chlamydia trachomatis  Infant.
• Mixed anaerobes  Aspiration pneumonia.
• Gram-negative enteric bacilli.  E coli,
PNEUMONIA, Classification

7. Uncommon.
- Haemphilus influenza  post viral.
- Staphylococcus aureus
- Moraxella catarrhalis
- Neisseria meningitides
- Francisella tularensis  animal contact
- Nocardia species  Immunocompromized Pts.
- Chlamydia psittaci  Bird contact.
- Yersinia pestis  Plague
- Legionella species  Exposure to contamianted
water.
PNEUMONIAPNEUMONIA, Classification

8. • Viral, Common
Respiratory syncytial virus
Parainflueza type 1 – 3
Influeza A . B
Adenovirus
Metapneumovirus
Un Common
Rhinovirus
Enterovirus Neonates
Herpes simplex Neontes
Cytomegalovirus Immunosuppressed person.
Measles
Varicella
Hantavirus
SARS.
PNEUMONIA, Classification

9. • Fungal.
Histoplasma capsulatum  Bird bat contact
Cryptococcus neoformans  Bird contact.
Aspergillus species  Immunosuppressed.
Mucomycosis  Immunosuppressed
Coccidioides immitis
Blastomyces dermatitides
•Rickettsial
Coxiella burnetii  Goat sheep cattle exposure
Rickettsia rickettsiae
PNEUMONIA, Classification

10. • Mycobacterial
Mycobacterium Tuberculosis  Developed countries
Nycobacterium avium-inteacellulare  Immunosuppressed.
•Parasitic
Pneumocystis Carini  Immunosuppressed. Steroid.
Eosinophilic  Ascaris .
Loeffler syndrom
•Non infectious causes
-Aspiration Of food.
-Gastric acid.
-foreign body.
-Hydrocarbon  Kerosen
-Lipoid substances
- Aspiration of amniotic fluid.
PNEUMONIA, Classification

11. PNEUMONIA, Predisposing factors
Item Example
Age Extremes of age (neonates, old age)
Diseases DM, renal, hepatic, cardiac, immunocompromised
Bad ventilation Poor housing , over crowded places
Drugs Long term corticosteroid, immunosuppressive drugs
Weather
changes
Very cold or very hot weather
Poor hygene Dental cares, bad oral hygene
Local defense
abnormality
Impaired consciousness, sedative drugs , epilepsy

12. PNEUMONIA,
• Recurrent pneumonia
-Hereditary disorder
•Cystic fibrosis
•Sickle cell disease
-Disorders of immunity
•Aqured immunodeficincy syndrome (AIDS)
•Bruton agammaglobulemia
•Selective IgG subclass deficiencies
•Common variable immunodeficiency syndrom
•Sever combined immunodeficiency syndrom
-Disorders of leukocytes
•Chronic granulomatous disease.
•Hyperimmunoglobulin E syndrome.
•Leukocyte adhesion defect

13. PNEUMONIA, etiology
Disorders of cilia
• Immotile cilia syndrom
• Kartagener syndrom
Anatomic disorder
•Sequestration
•Lobar emphysema
•Esophageal reflux
•Foreign body
•Tracheo esophageal fistula ( H type )
•Gastroesophageal reflux
•Bronchietasis
•Aspiration ( oro pharyngeal in coordination )

14. PNEUMONIA
• Pathogenesis, The lower respiratory tract is normally sterile by
•Physiologic defense mechanisms including
•Mucociliary clearance
•Normal secretion such as secretory immunoglobulin A
 IgA
•Clearing of air way by coughing
•Immunologic defense mechanism of lung limit invasion
by pathogenic organisms, including macrophages are
present in alveoli and bronchioles secretory IgA
and others immunoglobulins

15. PNEUMONIA, pathology
Viral pneumonia :
Usually result from spread of infection along the airway.
Accompanied by direct injury of respiratory epithelium resulting in air way
obstruction from swelling abnormal secretion and cellular debris small calibar
of air way in young infant makes them particularly susceptible to sever
infection.
Viral infection predispose to secondary bacterial infection by disturbing
normal host defense mechanism altering secretion and modifying bacterial
flora.

16. PNEUMONIA
•Bacterial infection
In bacterial infection pathologic process varies according
to the invading organism :
M . Pneumoniae attaches to the respiratory epithelium inhibit ciliary action and
Lead to cellular destruction and an inflammatory response in the submucosa
as the infection progresses sloughed cellular debris inflammatory cell and mucus
cause airway obstruction with spread of infection occuriang along the bronchial
Tree as in viral pneumoia.
- S . Pneumoniae
Produce local edema that aids in the proliferation of organism and their spread
Into adjacent portion of lung often resulting in the characteristic focal lobar
Involvement

17. PNEUMONIA
-Grop A . Streptococcus
pathology Includes necrosis of tracheobronchial mucosa formation
-of large
amount of exudate edema and local hemorrhage with extension into the
Interalveolar septa and involvement of lymphatic vessel and pleura.
-S – aureus pneumonia
produces Toxin and enzymes as hemolysin coagulase and
-staphylo kinase. It causes broncho pneumonia often unilateral characterized by
prensence of hemorrhagic necrosis and irregular areas of cavitation of
,lung parenchyma
•Resulting in pneumatoceles empyema or broncho pulmonary fistula
Pyopneumothorax.

18. PNEUMONIA
Following changes stages:
1- congestion alveoli are failed with edema fluid and organism.
2- red hepatization alveoli contain polymorph RBCs fibrin edema and organism.
3-grey hepatization deposition of fibrin over the pleural surface phagocytosis
starts inside the alveoli which are now filled with polymorph and fibrin.
4-resolution: neutrophil degenerate fibrin thread and remaining bacteria and
digested and removed by phagocyte
Clinical Manifestation
Viral & bacterial pneumonia are often preceded by several day of symptoms
of URTI typically rhinitis and cough.
In viral pneumonia:
fever is usually present lower than in bacteria.
Tachypnea increased work of breathing accompanied by intercostal, subcostal
and suprasternal retraction nasal flaring and use of accessory muscle.
Severe infection accompanied by cyanosis and respiratory fatigue in infant.
Auscultation of chest wheezing and crackle

19. PNEUMONIA, Diagnosis,
Signs and symptoms

20. PNEUMONIA
In bacterial pneumonia:
Sudden shaking chill followed high fever, cough, grunting, chest pain,
drowsiness, rapid respiration, dry cough, anxiety circumoaral cyanosis.
Physical finding:
Depends on the stage of pneumonia diminished breath sound scattered crackels
and rhonchi over affected lung.
Increasing consolidation or complication.
As effusion empyema or pyopneumothorax dullness on percussion and breath
Sound.
Diminished abdominal distension because of gastric dilation from swallowed
air or ileus. Abdominal pain in lower lobe pneumonia
Liver may seem enlarged because downward of diaphragm secondary to hyper
inflation of lung
Neck rigidity without meningitis in right upper lobe.

21. PNEUMONIA, Diagnosis:
Chest X-ray
•Diagnosis of pneumonia may indicate complication pleural
effusion or empyema.
•Viral pneumonia X-ray  hyper inflation with bilateral interstitial infiltrate.
•Pneumococcal pneumonia lobar consolifation
repeat chest x-ray are not required for proof of cure for patient with
uncomplicated pneumonia.
WBC can differentiating viral from bacterial (normal in viral
pneumonia or elevated in bacterial pneumonia)
-Atypical pneumonia due to C.pneumoniae or M.pneumoniae is difficult to
distinguish from pneumococal pneumonia by X-ray and other lab.
Sputum cultur and sensitivity, for guidance of antibiotic
treatment.
CT and fibrooptic bronchoscope may be required in certain
cases

22. PNEUMONIA
• Hospitalization of children with pneumonia
-Age < 6 month
- Sickle cell anemia with acute chest syndrome.
- Multiple lobe involvement.
-Immunocompromised
-Toxic appearance.
-Sever respiratory distress
-Requirement for supplemental oxygen.
-Dehydration
-Vomiting.
-No response to oral antibiotic.
-Non compliant parent.

23. PNEUMONIA, Treatment:
Treatment based on the cause and site of occurrence.
CAP without comorbidity
-Amoxicillin clavulente ( 80-90mg/kg/24 hrs ) OR
- Cefuroxime.(2nd
generation cephalosporin) OR
-Macrolide antibiotic such as azilhromjcin .
 HAP with other comorbidity
ceftriaxone plus
Macrolide antibiotic such as azilhromjcin
Fluroquinolone ( levofloxacin, moxifloxacin, gemifloxacin)
HAP
ceftriaxone plus
Macrolide antibiotic such as azilhromjcin
Fluroquinolone ( levofloxacin, moxifloxacin, gemifloxacin).
VAP, consider anti-pseudomonal , anti-staph
Piperacillin, Ciprofloxacin, Vancomycin or clindamycin
.

24. PNEUMONIA
Deterioration in clinical status antibiotic therapy should be initiated
Response to treatment:
Patient with uncomplicated bacterial pneumonia respond to therapy with improvement
in clinical symptom (fever, cough, tachypnea, chest pain) within 48-96 hrs.
Slowly resolving pneumonia
1- complication as empyema.
2- bacterial resistance.
3- non bacterial etiology as viruses and aspiration of foreign bodies or food.
4- bronchial obstruction from endobronchial lesion foreign body or mucus plug.
5- pre-existing diseases such as immunodeficiencies- ciliary dyskinesia- cysticfibrosis
pulmonary sequestration cystic adenomatoid malformation.
6- non infectious causes:
- bronchoilitis obliterans.
- hypersensitivity pneumonitis
- eosinophils pneumonia
- aspiration
- wegener granulomatosis

25. PNEUMONIA
Complication:
•Usually result of direct spread of bacterial infection within thoracic cavity.
(pleural effusion- empyema- pericarditis) .
•Bacteremia and hematologic spread meningitis suppurative arthritis osteomyelitis.
•
•Respiratory failure.
•Lung abcess.
•Bronchiactasis
•

26. X-RAYS
Viral pneumonia x-ray

27. X-RAYS
Lobar pneumonia x-ray (RUL)

28. X-RAYS
bronchopneumonia x-ray

29. X-RAYS
Staph pneumonia x-ray

30. THANKS ALOT