1. Pneumonia

2. Definition
Acute respiratory illness associated with
recently developed radiological pulmonary
shadowing which may be segmental, lobar or
multi-lobar.
 It is usually characterized by consolidation, in
which the alveoli are filled with a mixture of
exudates, bacteria and leukocytes.


4. Epidemiology
Occurs throughout the year
 Results from different etiological agents
varying with the seasons
 Can occur in all ages
 Clinical manifestations severe in very young,
elderly and in chronically ill patients


5. Clinical features
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Fever
Rigors
Shivering
Vomiting
Loss of appetite
Pulmonary symptoms include:
 Cough [short, painful, dry, later accompanied with
mucopurulent sputum]
 Hemoptysis [in patients with Streptococcus
pneumonie]
 Pleuretic chest pain, referred to shoulder or anterior
abdomen
 Upper abdominal tenderness

6. Classification
Type 1
 Lobar pneumonia
 Bronchopneumonia
Type 2
 Community acquired
 Hospital acquired
 Suppurative and aspirational
 Immunocompromised hosts

7. Lobar pneumonia
Radiological and pathological term applied to
homogenous consolidation of one or more
lung lobes
 Associated with pleural inflammation


9. Bronchopneumonia

Patchy alveolar consolidation

Associated with bronchial and bronchiolar
inflammation often affecting both lower lobes

11. Community acquired pneumonia
(CAP)
Spread by droplet infection
 Occurs in previously healthy patients
 Once the organism settles in alveoli an
inflammatory response is stimulated
 Classical pathological response:
1. Congestion
2. Red and then grey hepatisation
3. Resolution with little or no scarring


12. Predisposing factors
Old age
 Cigarette smoking
 Upper respiratory tract infection
 Recent influenza infection
 Pre existing lung disease
 Corticosteroid therapy
 Alcohol


13. Related organisms
Majority of CAP are due to S. pneumonie
Young adults
 Mycoplasma pneumoniae
 Chlamydia pneumoniae
Elderly
 Haemophilus influenza
Foreign travels
 Legionella
 Staph aureus

15. Investigations
Radiological examination
Chest x-ray helps in differentiating between lobar and broncho
Spotting complications such as intrapleural abscess, empyema


Microbiological investigations
Assessment of gas exchange
Measures SaO2, assists in monitoring response to oxygen
therapy.
Arterial blood gas sampled for SaO2 <92% or with
severe pneumonia to assess for ventilatory failure

General blood tests
A very high WBC count is seen in severe pneumonia. Urea,
electrolytes and LFTs. C-reactive protein is raised


16. CURB-65 score

17. Management
Oxygen
Administered to patients with tachypnea, hypoxemia,
hypotension or acidosis. Maintain PaO2 >8kPa or SaO2 >92%.
Humidified high concentratiom for patients without hypercapnia.

Fluid balance
Oral intake of fluids, IV for severe cases. Inotropic support for
patients with shock

Treatment of pleuretic pain
Analgesics such as paracetamol


Physiotherapy

19. Complications
Para pneumonic effusion
 Empyema
 Retention of sputum causing lobar collapse
 Development of thromboembolic disease
 Pneumothroax
 Lung abscess
 ARDS
 Hepatitis, pericarditis, myocarditis
 Pyrexia due to drug hypersensitivity


20. Prevention

Influenza vaccination reduce the risk of
influenza and death in elderly

Polysacchride pneumococcal vaccines do
not appear to reduce the incidence of
pneumonia or death but may reduce the
incidence of invasive pneumoccocal disease

21. Hospital acquired pneumonia

Refers to new episode of pneumonia
occurring 2days after admission

Post operation

Aspiration pneumonia

Bronchopneumonia developing in patients
with lung disease

22. Predisposing factors
Reduced immune defences
 Reduced cough reflex
 Disordered mucociliary clearance
 Bulbar or vocal cord palsy
 Aspiration of gastric secretions
 Bacteria introduced into lower respiratory
tract (ET tube, tracheostomy, infected
ventilators, nebulisers)
 Bacteraemia (abdominal sepsis, IV
cannula infection, infected emboli)


23. Related organisms
Gram negative bacteria
 Escherichia, pseudomonas and klebsiella
 Staph aureus

24. Management
Adequate gram negative coverage
 3rd gen cephalosporins (eg cefotaxime) plus
an aminoglycoside (eg gentamicin)
 Meropenem
 Monocyclic β-lactam (eg aztreonam) plus
flucloxacillin
Aspiration pneumonia can be treated with coamoxiclav 8hourly plus metronidazole 500mg
8hourly
Physiotherapy

25. Suppurative and aspirational
pneumonia
Consolidation in which there is destruction of
lung parenchyma by inflammatory process
 Micro abscess formation with pus that may
rupture and escape into bronchus
 Caused by staph aureus, klebsiella
pneumoniae, strep pyogenes, h. influenza
 After aspiration of septic material during
operation on nose, mouth or throat under
GA. Vomitus during anesthesia or coma


26. Clinical features
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Productive cough
Pleural pain
Sudden expectoration of copious sputum
High pyrexia
Profound systemic upset
Pleural rub
Signs of consolidation
On chest x-ray homogenous lobar or segmental
opacity consistent with consolidation or collapse
A large dense opacity which may cavitate and show
fluid level, shows in lung abscess

27. Management

Oral amoxicillin 500mg 6hourly

For anaerobic bacteria, oral metronidazole
400mg 8hourly

For lung abscess prolonged treatment for 46weeks

28. Pneumonia in
immunocompromised patients

Patients receiving immunosupressive drugs
and those with diseases causing defects of
cellular or humoral immune mechanisms

Gram negative bacteria; pseudomonas
aeruginosa

29. Clinical features
Fever
 Cough
 Breathlessness

Infiltrations on chest x-ray

30. Management

Broad spectrum antibiotic (eg 3rd gen
cephalosporin or quinolone plus
antistaphylococcal antibiotic or
antipseudomonal penicillin)

31. Thank you
Reference
 Davidson’s principles and practice of
medicine 20th edition