Successfully reported this slideshow.

More Related Content

Related Books

Free with a 14 day trial from Scribd

See all

Pneumonia

  1. 1. Pneumonia Sriloy Mohanty B.N.Y.S
  2. 2. Pneumonia – Definition An acute infection of the pulmonary parenchyma that is associated with at least some symptoms of acute infection, accompanied by some auscultatory findings consistent with pneumonia and radiological pulmonary shadowing
  3. 3. What happens ??? • Inflammatory condition where alveoli are filled with fluid and blood cells • Begins with infection of alveoli followed by inflamed pulmonary membrane and becomes highly porous • Whole lobe or sometimes whole lungs is consolidated
  4. 4. Pneumonia I. Reduction in the total available surface area of the respiratory membrane II. Decreased ventilation-perfusion ratio These two causes  Hypoxemia  hypercapnia
  5. 5. Pneumonia • The major cause of death in the world • The 6th most common cause of death in the U.S. • Annually in U.S.: 2-3 million cases, ~10 million physician visits, 500,000 hospitalizations, 45,000 deaths, with average mortality ~14% inpatient and <1% outpatient
  6. 6. Risk factors • Old age • Recent influenza infection • Pre-existing lung disease • Lowered immune system due to corticosteroid therapy, • Alcohol,smoking
  7. 7. Pneumonia - Symptoms • Cough (productive or non-productive) • Dyspnea • Pleuritic chest pain • Fever or hypothermia • Myalgias • Chills/Sweats • Fatigue • Headache • Diarrhea (Legionella) • Sinusitis • Loss of appitite
  8. 8. Findings on Exam • Physical:  Vitals: Fever or hypothermia  Pyrexia,techicardia,hypoxamia  Lung Exam: Crackles, rhonchi, dullness to percussion • Labs:  Elevated WBC  Hyponatremia – Legionella pneumonia  Positive Cold-Agglutinin – Mycoplasma pneumonia
  9. 9. Investigations • Chest X-ray ▫ Pulmonary shadow • Microbiological investigation ▫ Strep. pneumo urinary antigen ▫ Legionella urinary antigen ▫ < 10 Squamous Epithelial Cells • Arterial blood gas measurements ▫ PO2 • General blood test ▫ High neutrophil leucocytes
  10. 10. Investigation objectives • To obtain a radiological conformation of the diagnosis • To exclude other condition that may mimic pneumonia • To obtain microbiological diagnosis • To assess the severity of the pneumonia
  11. 11. Chest X-ray RUL RML RLL LUL Lingula LLL RUL RML RLL LUL Lingula LLL
  12. 12. Chest X-ray – Pneumonia
  13. 13. Chest X-ray - Pneumonia
  14. 14. Chest X-ray -- Pneumonia
  15. 15. Types of Pneumonia • Community-Acquired (CAP) • Hospital-Acquired Pneumonia (HAP) ▫ Pneumonia that develops after 5 days of hospitalization ▫ Includes:  Ventilator-Associated Pneumonia (VAP)  Aspiration Pneumonia
  16. 16. Common Bugs for Pneumonia Community-Acquired • Streptococcus pneumoniae • Mycoplasma pneumoniae • Chlamydophila psittaci or pneumoniae • Legionella pneumophila • Haemophilus influenzae • Moraxella catarrhalis • Staphylococcus aureus • Nocardia • Mycobacterium tuberculosis • Influenza • RSV • CMV • Histoplasma, Coccidioides, Blastomycosis HCAP or HAP • Pseudomonas aeruginosa • Staphylococcus aureus (Including MRSA) • Klebsiella pneumoniae • Serratia marcescens • Acinetobacter baumanii
  17. 17. Special Clues on Chest X-ray • Lobar pneumonia – Strep. Pneumonia • Diffuse interstitial infiltrates – Pneumocystis • RUL infiltrate – Tuberculosis • Diffuse interstitial infiltrates – Tuberculosis in HIV
  18. 18. PORT Score
  19. 19. PORT Score
  20. 20. Antibiotics treatment • Amoxillin 500mg 8-hourly orally • If patient allargic to penicilin ▫ Clarithromycin 500mg 12 hourly orally ▫ Erythromycin 500mg 6 hourly orally • If staphylococcus is cultured ▫ Flucoxamin 1-2g 6 hourly orally ▫ Clarithromycin 500mg 12 hourly orally
  21. 21. Severe CAP ▫ Clarithromycin 500mg 12 hourly orally ▫ Erythromycin 500mg 6 hourly orally ▫ Amoxillin 500mg 8-hourly orally ▫ Co-amoxiclav 1.2mg 8 hourly i.v
  22. 22. Treatment of HCAP, HAP, VAP • Antipseudomonal cephalosporin (Cefepime, Ceftazidime) + Vancomycin • Anti-pseudomonal Carbapenem (Imipenem, Meropenem) + Vancomycin • Beta-Lactamase/Beta-Lactamase Inhibitor (Pip-Tazo – Zosyn) + Pseudomonal Fluoroquinolone (Cipro) + Vancomycin • Aminoglycoside (Gentamycin, Amikacin) + Vancomycin
  23. 23. HAP – Failure of Therapy  Incorrect diagnosis – it is not pneumonia – Atelectasis, CHF, PE with infarction, lung contusion, chemical pneumonitis, ARDS, pulmonary hemorrhage  Pathogen resistance  Host factors that increase mortality – Age > 60, prior pneumonia, chronic lung disease – immunosuppression  Antibiotic resistance
  24. 24. HAP - Prevention  Hand washing  Vaccination – Influenza – Pneumococcus  Isolation of patients with resistant respiratory tract infections  Enteral nutrition  Choice of GI prophylaxis  Subglottoc secretion removal?
  25. 25. Special Cases! • HIV  Pneumocystis jirovecii  Mycobacterium tuberculosis  Cryptococcus  Histoplasmosis • Transplant Patients  Fungi (Aspergillosis, Cryptococcus, Histoplasmosis)  Nocardia  CMV • Neutropenic Patients  Fungi ( Aspergillosis)  Gram-negatives
  26. 26. More Special Cases • Smokers: S. pneumo, H. influenzae, M. catarrhalis • Alcoholics: S. pneumo, Klebsiella, anaerobes • IV Drug User: S. aureus, Pneumocystis, anaerobes • Splenectomy: encapsulated organisms (S. pneumo, H. influenzae) • Cystic fibrosis: Pseudomonas, S. aureus • Deer mouse exposure: Hantavirus • Bat exposure: Histoplasma capsulatum • Rat exposure: Yersinia pestis • Rabbit exposure: Francisella tularensis • Bird Exposure: C. psitacci, Cryptococcus neoformans • Bioterrorism: Bacillus anthracis, F. tularensis, Y. pestis
  27. 27. Pneumococcal Vaccine • What does it cover?  Protects against 23 serotypes of Strep. Pneumoniae (90% of invasive pneumonia infections) • Who should get it?  Anyone over age 65  Anyone with chronic medical problem such as cancer, diabetes, heart disease, lung disease, alcoholism, cirrhosis, sickle cell disease, kidney failure, HIV, damaged spleen or no spleen, CSF leaks  Anyone receiving cancer therapy, radiation, steroids  Alaskan natives and certain Native American populations • How often to get it?  Give second dose if >5 years from first dose if > 65, cancer, damaged spleen, kidney disease, HIV or any other condition lowering immune system function
  28. 28. Thank You

×