Management of pneumonia

1. Pneumonia
Dr Omer Surchi
MBCHB,DM,FICMS,FRCP
Assistant Professor/Consultant Internist
College of Medicine
Erbil-Iraq

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3. Pneumonia
• Pneumonia is as an acute respiratory illness associated with
recently developed radiological pulmonary shadowing that
may be segmental, lobar or multilobar.

5. pneumonias are usually classified as
• Community acquired pneumonia
• hospital-acquired pneumonia
• Pneumonia in immunocompromised patients .

6. Anatomical classification of
pneumonia
• Lobar pneumonia’ is a radiological and pathological
term referring to homogeneous consolidation of
one or more lung lobes, often with associated
pleural inflammation.
• bronchopneumonia refers to more patchy alveolar
consolidation associated with bronchial and
bronchiolar inflammation, often affecting both
lower lobes.

7. Pathology of pneumonia
It has 4 stages
1-edema
2-red hepatisation’.
the alveolar units are flooded by a
and by neutrophils and red blood cells, and numerous pneumococci
may be observed. As fibrin forms on the cut surface of the affected lobe,
it resembles liver and so this stage is known as ‘red hepatisation’
3-grey hepatisation
As congestion resolves, the lung tissue becomes grey (‘grey
hepatisation’), and ultimately, clearance and repair mechanisms restore
the normal architecture of the lung
4-resolution
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8. Community-acquired pneumonia
(CAP)
• In UK, an estimated 5–11/1000 adults suffer from
community-acquired pneumonia (CAP) each year,
accounting for around 5–12% of all lower
respiratory tract infections.

9. • CAP may affect all age groups but is particularly
common at the extremes of age I.e children and old
age groups .
• Pneumonia is the old man friend.

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Clinical features of pneumonia
Systemic symptoms
• Onset is acute.
• fever, rigors, shivering and
• malaise predominate and
• delirium may be present.
• The appetite is lost and
• headache frequently reported.

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Pulmonary symptoms
• cough, painful and dry,
• but later mucopurulent sputum,
occasionally haemoptysis.
• Rust-coloured sputum may be seen in
patients with Strep. pneumoniae.
• Pleuritic chest pain may be a presenting
feature and.

14. Specific features
Mycoplasma pneumoniae is more common in young people and rare in the
elderly.
Haemophilus influenzae is more common in the elderly, particularly if underlying
lung disease is present.
Legionella pneumophila occurs in local outbreaks by contaminated cooling
towers in hotels, hospitals and other industries.
Staph. aureus is more common following an episode of influenza.
Klebsiella pneumonia has a specific association with alcohol abuse and often
presents with a particularly severe bacteraemic illness.
Recent foreign travel raises the possibility of infections that may otherwise be
unusual e.g. MERS-coronavirus (Middle East), melioidosis caused by Burkholderia
pseudomallei (South-east Asia and northern Australia) and endemic fungal
infection (North, Central or South America).
Certain occupations may be associated with exposure to specific bacteria

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On examination
temperature is raised
Tachycardia
Tachypnea
BP may be low,
mental state may reveal delirium.
Cyanosis and respiratory distress may
happen.

16. Lung examination
• dull to percussion
• auscultation reveals bronchial breathing and
whispering pectoriloquy
• Crepitation

20. Investigations

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26. Treatment of Pneumonia
1-oxygen
2-Fluid therapy
3-antibiotics

28. Oxygen
Oxygen should be given to all patients with:
• tachypnoea,
• hypoxaemia,
• hypotension or
• acidosis
with the aim of maintaining the PaO 2 ≥ 8 kPa (60 mmHg) or
SaO 2 ≥ 92%.
High concentrations (≥ 35%), preferably humidified, should be
used in all patients who do not have hypercapnia associated
with COPD.
Continuous positive airway pressure (CPAP) should be
considered in those who remain hypoxic despite high-
concentration oxygen therapy.

29. Fluid
• Fluid balance:
Intravenous fluids should be considered in those with
severe illness, in older patients and those with
vomiting. Otherwise, an adequate oral intake of fluid
should be encouraged.

33. Prognosis
• Most patients respond promptly to antibiotic therapy.
Fever may persist for several days, however, and the
chest X-ray often takes several weeks or even months
to resolve, especially in old age.
• Delayed recovery suggests either that a complication
has occurred or that the diagnosis is incorrect .
• Alternatively, the pneumonia may be secondary to a
proximal bronchial obstruction or recurrent aspiration.
• The mortality rate of adults with non-severe
pneumonia is very low (< 1%);
• hospital death rates are typically between 5% and 10%
but may be as high as 50% in severe illness.

34. Prevention of CAP
• smokers should be advised to stop.
• Influenza and pneumococcal vaccination should be
considered in patients at highest risk of pneumonia
(e.g. those over 65 or with chronic lung, heart, liver
or kidney disease, diabetes or
immunosuppression).

35. Hospital-acquired pneumonia (HAP)

36. Hospital-acquired pneumonia (HAP)
• Hospital-acquired pneumonia (HAP) or nosocomial
pneumonia refers to a new episode of pneumonia
occurring at least 2 days after admission to
hospital. It is the second most common hospital-
acquired infection (HAI) and the leading cause of
HAI-associated death.
• Despite appropriate management, the mortality
from HAP is high (approximately 30%),

37. HAP
• The elderly are particularly at risk, as are patients in
intensive care units, especially when mechanically
ventilated.
• the term ventilator-associated pneumonia (VAP) is
applied.
• Health-care-associated pneumonia (HCAP) refers to
the development of pneumonia in a person who
has spent at least 2 days in hospital within the last
90 days, or has attended a haemodialysis unit, or
received intravenous antibiotics, or been resident
in a nursing home or other long-term care facility.

38. Predisposing factors of HAP

39. Treatment of HAP
• adequate oxygenation,
• appropriate fluid balance and
• antibiotics

40. • The organisms implicated in early-onset HAP
(occurring within 4–5 days of admission) are similar
to those involved in CAP. In patients who have
received no previous antibiotics, co-amoxiclav or
cefuroxime represents a sensible choice.
• If the patient has received a course of recent
antibiotics, then piperacillin/tazobactam or a third-
generation cephalosporin should be considered.
Treatment of HAP

41. • Late-onset HAP is more often attributable to Gram-
negative bacteria (e.g. Escherichia coli , Pseudomonas
aeruginosa , Klebsiella spp. and Acinetobacter
baumannii), Staph. aureus (including meticillin-resistant
Staph. aureus (MRSA)) and anaerobes, and the choice
of antibiotics ought to cover these possibilities.
• Antipseudomonal cover may be provided by a
carbapenem (meropenem), an anti-pseudomonal
cephalosporin or piperacillin–tazobactam.
• MRSA cover may be provided by glycopeptides such as
vancomycin or linezolid.
• A. baumannii is usually sensitive to carbapenems but
resistant cases may require nebulised and/or
intravenous colistin.
Treatment of HAP

42. Prevention of HAP
• Despite appropriate management, the mortality from
HAP is high (approximately 30%).
prevention:
• Good hygiene is important , particularly with regard to
hand-washing and any equipment used.
• Steps should be taken to minimise the chances of
aspiration and
• to limit the use of stress ulcer prophylaxis with proton
pump inhibitors.
• Oral antiseptic (chlorhexidine 2%) may be used to
decontaminate the mouth and upper airway.

43. Suppurative pneumonia, aspiration
pneumonia and pulmonary abscess
• Suppurative pneumonia
characterised by destruction of the lung
parenchyma by the inflammatory process. As well
as microabscess formation .

44. • Suppurative pneumonia and pulmonary abscess
often develop after:
1-the inhalation of septic material during operations
on the nose, mouth or throat, under general
anaesthesia, or of vomitus during anaesthesia or
coma, particularly if oral hygiene is poor.
2-Additional risk factors for aspiration pneumonia
include bulbar or vocal cord palsy, achalasia or
esophageal reflux, and alcoholism.

46. Management of aspiration p.
• Aspiration pneumonia can usually be treated with
amoxicillin and metronidazole.
• CA-MRSA is usually susceptible to a variety of oral
non-β-lactam antibiotics, such as
trimethoprim/sulfamethoxazole, clindamycin,
tetracyclines and linezolid. Parenteral therapy with
vancomycin or linezolid can also be considered.
• Prolonged treatment for 4–6 weeks may be
required in some patients with lung abscess.

47. • pulmonary actinomycosis needs 6–12 months
treatment with IV or oral penicillin, or with a
tetracycline in penicillin-allergic patients.

48. • Physiotherapy is of great value, especially when
suppuration is present in the lower lobes or when a
large abscess cavity has formed.

49. Pneumonia in the
immunocompromised patient
Patients immunocompromised by
• drugs or
• disease (particularly human immunodeficiency
virus (HIV) infection)
They are at increased risk of pneumonia

50. Clinical features
• include fever, cough and breathlessness but are
influenced by the degree of immunosuppression. in
those with a bacterial infection, the onset is rapid.
but more gradual in patients with opportunistic
organisms such as Pneumocystis jirovecii and
mycobacterial infections.
• In P. jirovecii pneumonia, symptoms of cough and
breathlessness can be present several days or
weeks before the onset of systemic symptoms or
the appearance of radiographic abnormality.

51. • broad-spectrum antibiotic therapy should be started
immediately,
• e.g. a third-generation cephalosporin, or a quinolone,
• plus an antistaphylococcal antibiotic, or
• an antipseudomonal penicillin plus an aminoglycoside.
• Thereafter, treatment may be tailored according to the
results of investigations and the clinical response.
Treatment of Pneumonia in the
immunocompromised patient

52. Thank you so much