Pneumonia is an infection of the lungs that causes inflammation in the air sacs (alveoli) and makes breathing difficult. It has many potential causes including bacteria, viruses, and other pathogens. The presentation involves symptoms like cough, fever, and chest pain. Diagnosis involves chest x-ray and testing of sputum samples. Treatment depends on severity but generally involves antibiotics, oxygen, fluids and rest. Complications can include lung abscesses, sepsis and respiratory failure. Prevention focuses on vaccination, smoking cessation, and respiratory hygiene.

1. PNEUMONIA
M2 LECTURE NOTES.
DR OBETEN EKPO. MBBCH, FWACP.
CONSULTANT RESPIRATORY PHYSICIAN

2. Outline
•Introduction
•Risk factors
•Pathogenesis
•Types
•Etiology
•Clinical features
•Investigation
•Treatment
•Complication
•Prevention

3. Introduction
• Pneumonia: Pneumonia is an infection in one or both lungs.
Pneumonia causes inflammation in the alveoli.
• The alveoli are filled with fluid or pus, making it difficult to breathe.
• DEFINITION •“inflammation and consolidation of lung tissue due to
an infectious agent” • CONSOLIDATION = ‘Inflammatory induration of
a normally aerated lung due to the presence of cellular exudative in
alveoli’

4. Introduction
• Pneumonia was regarded by William Osler in the 19th century as "the
captain of the men of death“.
• The advent of antibiotic therapy and vaccines in the 20th century
have seen radical improvements in survival outcomes for patients.
• Nevertheless, in the third world, among the very old, the very young
and the chronically ill, pneumonia remains a leading cause of death.
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5. • True incidence of CAP is uncertain
• 20-50% of patients require hospitalization
• Estimates of CAP range from 2- 15 cases/1000 persons/yr
• Substantially higher rates in elderly
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6. • Second most common and most fatal nosocomial infections
• Adequate diagnosis and management is complicated by growing
proportion of -
• aged, comorbid, debilitated, institutionalized immunocompromised
individuals
• increasing diverse array of microorganisms, and by evolving antimicrobial
resistance
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7. • Pneumonia is a common illness affecting approximately 450 million
people/ year worldwide.
• It is a major cause of death among all age groups resulting in 4 million
deaths (7% of the worlds yearly total)
• Rates are greatest in children less than five and adults older than 75 years
of age.
• It occurs about five times more frequently in the developing world versus
the developed world.
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8. • CAP accounted for 2.5% of all medical admissions in a study in Nigeria
• Hospital mortality rate ranges from was 11.9%-15%.
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9. • The global health community has declared November 12 to be World
Pneumonia Day
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10. Introduction
How does Pneumonia develop?
• Most of the time, the body filters organisms.
• This keeps the lungs from becoming infected.
• But organisms sometimes enter the lungs and cause infections.
• This is more likely to occur when:
• immune system is weak – immunosuppression
• organism is very strong.- very virulent organism
• body fails to filter the organisms. – loss of body defenses

11. Factors that predispose to Pneumonia
• Cigarette smoking
• Upper respiratory tract infections
• Alcohol
• Corticosteroid therapy
• Old age
• Recent influenza infection
• Pre-existing lung disease

12. Factors that predispose to Pneumonia
• Reduced host defenses against bacteria
• Reduced immune defenses (e.g. corticosteroid treatment, diabetes,
malignancy)
• Reduced cough reflex (e.g. post-operative)
• Disordered mucociliary clearance (e.g. anesthetic agents)
• Bulbar or vocal cord palsy
• Aspiration of nasopharyngeal or gastric secretions
• Immobility or reduced conscious level •Vomiting, dysphagia,
achalasia or severe reflux •Nasogastric intubation Bacteria introduced
into lower respiratory tract •Endotracheal

13. Factors that predispose to Pneumonia
• Intubation/tracheostomy
• Infected ventilators/nebulisers/bronchoscopes
• Dental or sinus infection
• Bacteraemia
• Abdominal sepsis
• Intravenous cannula infection
• Infected emboli.

14. PATHOLOGY
• Congestion •Presence of a proteinaceous exudate—and often of bacteria—
in the alveoli
• RED HEPATIZATION •Presence of erythrocytes in the cellular intraalveolar
exudate •Neutrophils are also present •Bacteria are occasionally seen in
cultures of alveolar specimens collected
• GRAY HEPATIZATION •No new erythrocytes are extravasating, and those
already present have been lysed and degraded •Neutrophil is the
predominant cell •Fibrin deposition is abundant •Bacteria have
disappeared •Corresponds with successful containment of the infection
and improvement in gas exchange
• RESOLUTION Macrophage is the dominant cell type in the alveolar space
Debris of neutrophils, bacteria, and fibrin has been cleared

16. Classification of Pneumonia
• ANATOMICAL CLASSIFICATION
• 1.Bronchopneumonia affects the lungs in patches around bronchi
• 2.Lobar pneumonia is an infection that only involves a single lobe, or
section, of a lung.
• 3.Interstitial pneumonia involves the areas in between the alveoli
that’s the lung interstitium

17. Classification of Pneumonia
• CLINICAL CLASSIFICATION
• Community Acquired - Typical/Atypical/Aspiration
• Pneumonia in Elderly
• Nosocomial- HAP,VAP,HCAP
• Pneumonia in Immunocompromised host

18. Classification of pneumonia
• Community Acquired Pneumonia (CAP) DEFINITION: An infection of
the pulmonary parenchyma ,Associated with symptoms of acute
infection ,Presence of acute infiltrates on CXR or auscultatory findings
consistent with Pneumonia ,In a patient not hospitalized or residing in
LTC facility for > 14 days prior •
• Hospital Acquired pneumonia - HAP •HAP is defined as pneumonia
that occurs 48 hours or more after admission, which was not
incubating at the time of admission. •
• Ventilator Associated Pneumonia- VAP •VAP refers to pneumonia that
arises more than 48–72 hours after endotracheal intubation . •

19. • Health Care Associated Pneumonia HCAP HCAP includes any patient
Who was hospitalized in an acute care hospital for 2 or more days
within 90 days of the infection ,Resided in a nursing home or long-
term care facility ,Received recent i.v antibiotic therapy,
chemotherapy, or wound care within the past 30 days of the current
infection •Attended a hospital or hemodialysis clinic •
• ATYPICAL PNEUMONIA - Why ‘Atypical’? Clinically •Subacute onset
•Fever less common or intense •Minimal sputum Microbiologically
•Sputum does not reveal a predominant microbial etiology on routine
smears (Gram’s stain, Ziehl-Neelsen) or cultures •

20. Classification of pneumonia
• ATYPICAL PNEUMONIA - Why ‘Atypical’? Radiologically •Patchy infiltrates
or •Interstitial pattern Haemogram •Peripheral leukocytosis are less
common or intense
• Causes of Atypical Pneumonia
• Aspiration pneumonia •Overt episode of aspiration or bronchial
obstruction by a foreign body. •Seen in - alcoholism, nocturnal esophageal
reflux, a prolonged session in the dental chair, epilepsy •Usually Anaerobes
• ELDERLY •Infection has a more gradual in onset, with less fever and cough
•often with a decline in mental status or confusion and generalized
weakness •often with less readily elicited signs of consolidation

21. Typical/Atypical Pneumonias
Characteristics Typical Atypical
Onset Abrupt Progressive
Fever with chills
Productive Cough
Focal clinical chest
sign
Extrapulmonary
symptoms
Leucocytosis
CAUSATIVE
ORGANISMS
Present
Usually
Yes
May occur
Elevated
Extracellular
organisms
No chills
Not productive
Usually diffuse
Very profound
Modest
Intracellular
bacteria/viruses
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22. MICROBIOLOGY
• Etiology: Bacterial , Viral, mycobacterial, Fungal, parasitic
• Etiology Microbiological diagnosis - 40-71% Streptococcus
pneumoniae most common.
• Viruses – 10-36%
• In India - Streptococci pneumonia (35.3%) Staphylococcus aureus
(23.5%) Klebsiella pneumonia (20.5%) Haemophilus influenzae (8.8%)
Mycoplasma pneumoniae, Legionella pneumophila

23. The Organisms
Typical
• Strep. Pneumoniae c.60%
• Haemophilus influenzae
c.5%
• Staph. Aureus c.2%
Atypical
• Mycoplasma c.8%
• Legionella
pneumophilia.4%
• Chlamydophila
pneumoniae c.10%
• Coxiella burnetti
• Viruses, fungi
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24. Clinical features
• GENERAL SYMPTOMS •High grade fever •Cough-productive •Pleuritic
chest pain •Breathlessness
• Additional symptoms •Sharp or stabbing chest pain •Headache •
•Excessive sweating and clammy skin •Loss of appetite and fatigue
•Confusion, especially in older people •
• General Signs •Febrile •Tachypnoea •Tachycardia •Cyanosis-central
•Hypotension •Altered sensorium •Use of accessory muscles of
respiration •Confusion- advanced cases
• SIGNS OF CONSOLIDATION •Percussion-dull •Bronchial Breath
sounds •Crackles • •Aegophony & Whispering Pectoriloquy •Pleural
Rub

25. Differential Diagnosis
Pulmonary oedema
Pulmonary infarction
Acute respiratory distress Syndrome
Pulmonary Haemorrhage
Lung Cancer or metastatic cancer
Atelectasis
Radiation pneumonitis
Pulmonary Vasculitis
Drugs reactions involving the lung
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26. INVESTIGATIONS
• INVESTIGATIONS
• SPUTUM •Gram Staining •AFB •Giemsa or methenamine silver stain
•KOH mount •Culture
• X-Ray Homogenous opacity with air bronchogram
• LOBAR PNEUMONIA •Peripheral airspace consolidation pneumonia
•Without prominent involvement of the bronchial tree

27. • Chest X-Ray: BRONCHOPNEUMONIA •Centrilobular and
Peribronchiolar opacity pneumonia •Tends to be multifocal •Patchy in
distribution rather than localized to any one lung region
• INTERSTITIAL PNEUMONIA •Peribronchovascular Infiltrate
•Mycoplasma , viral
• CT THORAX Seldom used

28. Other Investigations
• Complete blood count •Blood Sugar •Electrolytes •Creatinine •Blood
culture •Oxygen saturation by pulse oximetry •ABG •USS Chest
•Mantaux
• INVASIVE •Bronchoscopy •Thoracoscopy •Percutaneous
aspiration/biopsy •Open lung biopsy •Pleural aspiration
• OTHER TESTS •Bacterial antigen in sputum and urine •Rapid viral
antigen detection in respiratory secretion •Serological- mainly for
atypical •Molecular study •C-reactive Protein, serum procalcitonin,
and neopterin

29. Management of CAP
• Depends on severity and co-morbidity
• Supportive treatment
– IV fluids
– oxygen
– analgesia
• Formally assess severity
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30. TREATMENT.
• The CURB-65 criteria include five variables:
• Confusion (C);
• Urea >7 mmol/L (U);
• Respiratory rate 30/min (R);
• Blood pressure, systolic 90 mmHg or diastolic 60 mmHg (B); and
• Age 65 years (65).
• Patients with a score of 0, among whom the 30-day mortality rate is 1.5%, can be
treated outside the hospital.
• With a score of 2, the 30-day mortality rate is 9.2%, and patients should be
admitted to the hospital.
• Among patients with scores of 3, mortality rates are 22% overall; these patients
may require admission to an ICU.

31. CURB-65
Lim WS et. al. Thorax 2003; 58: 377-382
CURB- 65 SCORE RISK GROUP 30-DAY MORTALITY MANAGEMENT
0-1 I 1.5% HOME
2 II 9.2% LIKELY ADMISSION
3-5 III 22% ADMIT, MANAGE AS
SEVERE
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32. Treatment
• Outpatients Treatment(empirical) Previously healthy and no antibiotics in past 3 months
•A macrolide (clarithromycin or azithromycin or Doxycycline ) Comorbidities or
antibiotics in past 3 months: •Respiratory fluoroquinolone [moxifloxacin ,levofloxacin ] or
β- lactam ( high-dose amoxicillin or amoxicillin/clavulanate)
• Inpatients, non-ICU •A respiratory fluoroquinolone [moxifloxacin ,levofloxacin ] •β -
lactam [cefotaxime ,ceftriaxone ,ampicillin] plus a macrolide [oral clarithromycin or
azithromycin)
• Inpatients, ICU •β -lactam plus Azithromycin or a fluoroquinolone
• Pseudomonas •An antipneumococcal, antipseudomonal β-lactam
[piperacillin/tazobactam, cefepime , imipenem , meropenem plus flouroquinolons
•Above β-lactams plus an aminoglycoside and azithromycin •Above β-lactams plus an
aminoglycoside plus an antipneumococcal fluoroquinolone
• Methicillin-resistant Staphylococcus aureus If MRSA , add linezolid or vancomycin

33. Duration of antibiotic therapy
• 7 days for non-severe CAP
• 10 days for severe
• at least 14 days for legionella, staph or gram negative severe
pneumonias
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34. COMPLICATIONS
• Lung abscess
• Para-pneumonic effusions
• Empyema
• Sepsis
• Metastatic infections (meningitis,endocarditis,arthritis)
• ARDS , Respiratory failure
• Circulatory failure
• Renal failure
• Multi-organ failure
• Pneumonia complications SLAP HER (please don’t) •S - Septicaemia •L - Lung abcess •A - ARDS •P - Para-
pneumonic effusions •H - Hypotension •E - Empyema •R - Respiratory failure /renal failure
• Course Most healthy people recover from pneumonia in one to three weeks, but pneumonia can be life-
threatening. The mortality rate associated with community-acquired pneumonia (CAP) is very low in most
ambulatory patients and higher in patients requiring hospitalization, being as high as 37 percent in patients
admitted to the intensive care unit (ICU).

35. Prevention
• Smoking cessation
• Better Nutrition
• Respiratory hygiene measures
• Pneumococcal polysaccharide vaccine
• Inactivated influenza vaccine
• Live attenuated influenza vaccine

36. Conclusion
• The presence of an infiltrate on plain chest radiograph is considered
the "gold standard" for diagnosing pneumonia when clinical and
microbiologic features are supportive
• Most initial treatment regimens for hospitalized patients with
community-acquired pneumonia (CAP) are empiric
• The mortality rate associated with community-acquired pneumonia
(CAP) is very low in most ambulatory patients and higher in patients
requiring hospitalization