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BRONCHO PNEUMONIA PRESESNTATION.pptx
- 1. BRONCHO PNEUMONIA BY MR. EGUYUJOHN MBCHB III
- 2. DEFINATION Pneumonia is aninfection of the pulmonary parenchyma . bronchopneumonia refers to more patchy alveolar consolidation associated with bronchial and bronchiolar inflammation, often affecting both lower lobes.
- 3. CLASSIFICATION Pneumonia hasusually been classified as community-acquired (CAP) hospital-acquired (HAP), or ventilator-associated (VAP)
- 4. EPIDEMEOLOGY In UK,an estimated 5–11/1000 adults suffer from community-acquired pneumonia (CAP) each year This accounts for around 5–12% of all lower respiratory tract infections. CAP may affect all age groups but is particularly common at the extremes of age; for example, worldwide, CAP continues to kill more children than any other illness and the propensity to ease the passing of the debilitated and the elderly led to designation of pneumonia as the ‘old man’s friend’
- 5. pathophysiology Mechanical defensesof the airway hairs and turbinates of the nares branching tracheobronchial tree mucociliary clearance gag and cough reflexes all play a role in host defense but are insufficient to effectively block bacterial access to the lower airways.
- 6. Cont.. In the absenceof a sufficient barrier, microorganisms may reach the lower respiratory tract by a variety of pathways, including inhalation microaspiration direct mucosal dispersion
- 7. Cont.. Lung microbiota isdetermined by three factors: Microbial entry into the lungs Microbial elimination regional growth conditions for bacteria, such as pH, oxygen tension, and temperature
- 8. Cont. An inflammatoryevent resulting in epithelial and or endothelial injury results in the release of cytokines, chemokines, and catecholamines, some of which may selectively promote the growth of certain bacteria, such as Streptococcus pneumoniae and P. aeruginosa This cycle of inflammation, enhanced nutrient availability, and release of potential bacterial growth factors may result in a positive feedback loop that further accelerates inflammation and the growth of particular bacteria, which may then become dominant.
- 9. Cont.. In casesof CAP and HAP, the trigger may be a viral infection compounded by microaspiration of oropharyngeal organisms In cases of true aspiration pneumonia, the trigger may simply be the macroaspiration event itself
- 12. Clinical features CAP usually presentsas an acute illness. Systemic features include fever, rigors, shivering malaise Delirium may be present. The appetite is invariably lost headache frequently reported
- 13. Pulmonary symptoms include cough, which at first is characteristically short, painful and dry, Later is accompanied by the expectoration of mucopurulent sputum. Rust-colored sputum may be produced by patients with Strep. Pneumonia infection and the occasional patient may report haemoptysis Pleuritic chest pain may be a presenting feature and on occasion may be referred to the shoulder or anterior abdominal wall. Upper abdominal tenderness is sometimes apparent in patients with lower lobe pneumonia or those with associated hepatitis.
- 14. DDX OF CAP Pulmonary infarction Pulmonary/pleural tuberculosis Pulmonary oedema (can be unilateral) Pulmonary eosinophilia Malignancy: Broncho alveolar cell carcinoma Cryptogenic organizing pneumonia/bronchiolitis obliterans organizing pneumonia (COP/BOOP)
- 15. Hospital acquired pneumonia 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 The elderly are particularly at risk, as are patients in intensive care units, especially when mechanically ventilated
- 16. Cont.. 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
- 17. Clinical features andinvestigation The diagnosis should be considered in any hospitalised or ventilated patient who develops purulent sputum (or endotracheal secretions) new radiological infiltrates an otherwise unexplained increase in oxygen requirement A core temperature >38.3°C, and a leucocytosis or leucopenia.
- 18. DDX OF HAP The clinical features and radiographic signs are variable and non-specific, however, raising a broad differential diagnosis that includes pulmonary embolism, ARDS, pulmonary oedema, pulmonary hemorrhage drug toxicity.
- 19. Therefore, incontrast to CAP, microbiological confirmation should be sought whenever possible. Adequate sputum samples may be difficult to obtain in the frail elderly person Physiotherapy should be considered to aid expectoration. In patients who are mechanically ventilated, bronchoscopy- directed protected brush specimens, Broncho alveolar lavage (BAL) Endotracheal aspirates may be obtained
- 20. Investigations Full bloodcount Very high (>20×109/L) or low (<4×109/L) white cell countt: marker of severity Neutrophil leucocytosis >15×109/L: suggests bacterial aetiology Haemolytic anaemia: occasional complication of Mycoplasma Urea and electrolytes Urea >7 mmol/L (~20 mg/dL): marker of severity Hyponatraemia: marker of severity
- 21. Cont.. Liver functiontests Abnormal if basal pneumonia inflames liver Hypoalbuminaemia: marker of severity Erythrocyte sedimentation rate/C-reactive protein Non-specifically elevated Blood culture Bacteraemia: marker of severity
- 22. Cont.. Cold agglutinins Positive in 50% of patients with Mycoplasma Arterial blood gases Measure when SaO2 <93% or when clinical features are severe, to assess ventilatory failure or acidosis Sputum samples Gram stain , culture and antimicrobial sensitivity testing
- 23. Cont.. Polymerase chainreaction for Mycoplasma pneumoniae and other atypical pathogens Pneumococcal and/or Legionella antigen test Air bronchogram (air-filled bronchi appear lucent against consolidated lung tissue) may be present Bronchopneumonia Typically patchy and segmental shadowing Complications • Para-pneumonic effusion, intrapulmonary abscess or empyema Staphylococcus aureus
- 24. Cont.. Suggested bymultilobar shadowing, cavitation, pneumatoceles and abscesses Laboratory samples used Sputum Oropharynx swab Pleural fluid
- 25. X-RAY Pneumonia ofthe right middle lobe. Posteroanterior view: consolidation in the right middle lobe with characteristic opacification beneath the horizontal fissure and loss of normal contrast between the right heart border and lung
- 26. Cont.. Lateral view: consolidationconfined to the anteriorly situated middle lobe
- 27. Factors predisposing tohospital acquired pneumonia • Reduced immune defences (e.g. glucocorticoid treatment, diabetes, malignancy) • Reduced cough reflex (e.g. post-operative) • Disordered mucociliary clearance (e.g. anesthetic agents) • Bulbar or vocal cord palsy • Immobility or reduced conscious level • Vomiting, dysphagia (N.B. stroke disease), achalasia or severe reflux • Nasogastric intubation
- 28. Cont.. Endotracheal intubation/tracheostomy Infected ventilators/nebulisers/bronchoscopes Dental or sinus infection Abdominal sepsis Intravenous cannula infection Infected emboli Reduced host defenses against bacteria Aspiration of nasopharyngeal or gastric secretions Bacteria introduced into lower respiratory tract Bacteremia.
- 29. Pneumonia in immunocompromised Patients immunocompromised by drugs or disease particularly human immunodeficiency virus (HIV) infection; are at increased risk of pulmonary infection and pneumonia is the most common cause of death in this group majority of infections are caused by the same pathogens that cause pneumonia in immunocompetent individuals
- 30. Cont.. They aresusceptible to opportunistic’ pathogens like Gram-negative bacteria, especially P. aeruginosa, viruses, Fungi mycobacteria, less common organisms such as Nocardia spp. Infection is often due to more than one organism
- 31. Clinical features Thesetypically include fever, cough and breathlessness but are influenced by the degree of immunosuppression, and the presentation may be less specific in the more profoundly immunosuppressed. The onset of symptoms tends to be swift in those with a bacterial infection but more gradual in patients with opportunistic organisms such as Pneumocystis jirovecii and mycobacterial infections
- 32. Cont.. 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
- 33. investigations HRCT canbe helpful: • focal unilateral airspace opacification favours bacterial infection, mycobacteria or Nocardia • bilateral opacification favours P. jirovecii pneumonia, fungi, viruses and unusual bacteria, e.g. Nocardia • cavitation may be seen with N. asteroides, mycobacteria and fungi
- 34. Cont.. the presenceof a ‘halo sign’ (a zone of intermediate attenuation between the nodule and the lung parenchyma) may suggest aspergillosis pleural effusions suggest pyogenic bacterial infections and are uncommon in P. jirovecii pneumonia
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- 37. Management The most importantaspects of management include oxygenation fluid balance and antibiotic therapy. In severe or prolonged illness, nutritional support may be required
- 38. Oxygen Oxygen should beadministered to all patients with tachypnoea, hypoxaemia, hypotension or acidosis with the aim of maintaining the PaO2 ≥8 kPa (60 mmHg) or SaO2 ≥92%
- 39. Fluid balance Intravenousfluids should be considered in those with severe illness, in older patients and those with vomiting. It may be appropriate to discontinue hypertensive agents temporarily Otherwise, an adequate oral intake of fluid should be encouraged Inotropic support may be required in patients with shock
- 40. Treatment of pleuralpain It is important to relieve pleural pain in order to allow the patient to breathe normally and cough efficiently. For the majority, simple analgesia with paracetamol, co-codamol or NSAIDs is sufficient In some patients, opiates may be required but must be used with extreme caution in individuals with poor respiratory function
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- 42. Complications of pneumonia Para-pneumonic effusion – common Empyema Retention of sputum causing lobar collapse Deep vein thrombosis and pulmonary embolism Pneumothorax, particularly with Staphylococcus aureus
- 43. Cont.. Suppurative pneumonia/lungabscess ARDS, renal failure, multi-organ failure Ectopic abscess formation (Staph. aureus) Hepatitis, pericarditis, myocarditis, meningoencephalitis Arrhythmias (e.g. atrial fibrillation) Pyrexia due to drug hypersensitivity
- 44. prognosis Most patientsrespond 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
- 45. references Davidson's principlesand practice of medicine. 24st ed. E.L.B.S. and Churchill Livingstone, London. Harrison's principles of internal medicine. 21st ed. New York :McGraw-Hill, Health Professions Division
- 46. Sir Robert Hutchison’sprayer. From the inability to let well alone; From too much zeal for the new and contempt for what is old; From putting knowledge before wisdom, science before art, and cleverness before common sense; From treating patients as cases; And from making the cure of disease more grievous than the endurance of the same; Good Lord, deliver us.”