2. Definition: pulmonary inflammatory D ofDefinition: pulmonary inflammatory D of
terminal bronchioles, alveoli and interstitia.terminal bronchioles, alveoli and interstitia.
PathogensPathogens
Microbial, physiochemical, immunological,Microbial, physiochemical, immunological,
allergic or drugsallergic or drugs
Bacterial pneumonia is most commonBacterial pneumonia is most common
3. Prevalence and etiologyPrevalence and etiology
Almost most commonAlmost most common
Risk factorsRisk factors
1.1. Genetic variance and antigen driftGenetic variance and antigen drift
2.2. Increased poor population, and agingIncreased poor population, and aging
populationpopulation
3.3. SmokingSmoking
4.4. Increased nosocomial pneumoniaIncreased nosocomial pneumonia
5.5. Unsuitable use of antibioticsUnsuitable use of antibiotics →bacterial→bacterial
multiple-drug resistancemultiple-drug resistance
6.6. Complicated with severe systemic DComplicated with severe systemic D
7.7. Dysfunction of immune system: administrationDysfunction of immune system: administration
of immunosuppressive agents, tumor, DM,of immunosuppressive agents, tumor, DM,
Uremia, AIDS, etcUremia, AIDS, etc
7. In terms of environmentsIn terms of environments
Community acquired pneumoniaCommunity acquired pneumonia
(CAP)(CAP)
Infected out of the hospital, including thoseInfected out of the hospital, including those
onset in hospital, but infected out ofonset in hospital, but infected out of
hospital in terms of latent periodhospital in terms of latent period
Common pathogens: streptococcusCommon pathogens: streptococcus
pneumoniae, haemophilus influenza, etcpneumoniae, haemophilus influenza, etc
8. EvidenceEvidence
1.1. Recent occurrence of cough, sputum orRecent occurrence of cough, sputum or
aggravated on the basis of previousaggravated on the basis of previous
presentationspresentations
2.2. Fever, purulent sputum, chest painFever, purulent sputum, chest pain
3.3. Dullness and/or moist rales,Dullness and/or moist rales,
4.4. WBC>10X109/L or <4X109/L,WBC>10X109/L or <4X109/L,
hyposegmentationhyposegmentation
5.5. X-ray examine show laminar infiltrated shadowX-ray examine show laminar infiltrated shadow
or interstitial changes, with or without pleuralor interstitial changes, with or without pleural
effusioneffusion
Diagnosed by any one of items 1-4 + item 5Diagnosed by any one of items 1-4 + item 5
9. Hospital-acquired pneumoniaHospital-acquired pneumonia
(HAP)(HAP)
Not infected out of hospital or not in the latentNot infected out of hospital or not in the latent
period, but infected within 48 Hrs after admissionperiod, but infected within 48 Hrs after admission
to hospitalto hospital
Nosocomial infectionNosocomial infection
EvidenceEvidence
Similar with CAPSimilar with CAP
Common pathogens:Common pathogens: streptococcusstreptococcus
pneumoniae, haemophilus influenza, S. aureus,pneumoniae, haemophilus influenza, S. aureus,
enteric aerobic G- bacilli, klebsiella, etcenteric aerobic G- bacilli, klebsiella, etc
10. 1.1. Lobar pneumonia –Lobar pneumonia –termed as alveolar pneumoniatermed as alveolar pneumonia
2.2. Foliolar pneumonia –Foliolar pneumonia – termed as bronchialtermed as bronchial
pneumoniapneumonia
3.3. Interstitial pneumoniaInterstitial pneumonia
According to anatomyAccording to anatomy
11. Lobar pneumonia–Lobar pneumonia– termed as alveolartermed as alveolar
pneumoniapneumonia
1.1. Alveolar inflammation of one lobe orAlveolar inflammation of one lobe or
segment, parenchymal inflammation,segment, parenchymal inflammation,
bronchi is not involvedbronchi is not involved
2.2. Pathogens:Pathogens: streptococcus pneumoniae,streptococcus pneumoniae,
infiltrated via blood circulationinfiltrated via blood circulation
3.3. X-ray: dullness shadow in a lobe orX-ray: dullness shadow in a lobe or
segmentsegment
12. Foliolar pneumonia—bronchialFoliolar pneumonia—bronchial
pneumoniapneumonia
1.1. Inflammation ofInflammation of bronchiole, terminal bronchiole,bronchiole, terminal bronchiole,
respiratory bronchiole & alveolarrespiratory bronchiole & alveolar
2.2. Pathogens:Pathogens: streptococcus pneumoniae, S. aureus,streptococcus pneumoniae, S. aureus,
virus, mycoplasma, legionella, etc. infiltrated viavirus, mycoplasma, legionella, etc. infiltrated via
bronchibronchi
3.3. Often secondaryOften secondary to other D such as bronchitis,to other D such as bronchitis,
bronchiectasis, viral infection of upper R tractbronchiectasis, viral infection of upper R tract
4.4. Moist ralesMoist rales is audible, but no dullness signsis audible, but no dullness signs
5.5. X-ray: irregular lamellar shadowX-ray: irregular lamellar shadow distributed alongdistributed along
bronchi with foggy margin, no dullnessbronchi with foggy margin, no dullness
14. Interstitial pneumoniaInterstitial pneumonia
1.1. Interstitial inflammation: involve bronchial wallInterstitial inflammation: involve bronchial wall
& their peripheral tissue, hyperplasia of alveolar& their peripheral tissue, hyperplasia of alveolar
wall, edematous changes in interstitiawall, edematous changes in interstitia
2.2. Pathogens: bacteria, mycoplasma, viruses orPathogens: bacteria, mycoplasma, viruses or
cariniicarinii
3.3. Mild symptom, few abnormal signsMild symptom, few abnormal signs
4.4. X-ray: unilateral or bilateral irregular stripe orX-ray: unilateral or bilateral irregular stripe or
net-like shadow on inferior field, stretched fromnet-like shadow on inferior field, stretched from
hilus, accompanied with small piece ofhilus, accompanied with small piece of
atelectasisatelectasis
15. Clinical manifestationsClinical manifestations
Various with different pathogensVarious with different pathogens
Determined by the status both of host &Determined by the status both of host &
pathogenspathogens
Pay much attention to signs of dullnessPay much attention to signs of dullness
and signs of pleural effusionand signs of pleural effusion
16. Diagnosis & DifferentiationDiagnosis & Differentiation
DiagnosisDiagnosis
ProcedureProcedure
1.1. Make sure of diagnosis of pneumoniaMake sure of diagnosis of pneumonia
2.2. Esp. distinguish from upper R. infectionEsp. distinguish from upper R. infection
3.3. Distinguish from other D such as TB, LC,Distinguish from other D such as TB, LC,
acute lung abscess, lung thromboembolicacute lung abscess, lung thromboembolic
disease, or non-infectious lung infiltrationdisease, or non-infectious lung infiltration
X-ray film
CT, MRI
Scintigraphic Imaging
17. Severity evaluationSeverity evaluation
Which is determined by 3 factorsWhich is determined by 3 factors
1.1. local inflammationlocal inflammation
2.2. Generalized or notGeneralized or not
3.3. Inflammatory reaction as wholeInflammatory reaction as whole
18. Risk factorsRisk factors
Factors indicate:Factors indicate: ↑↑severity andseverity and
mortalitymortality
1.1. History:History: >age of 65, with severe diseases such>age of 65, with severe diseases such
as COPD, DM, chronic heart or kidney failureas COPD, DM, chronic heart or kidney failure
2.2. PE:PE: R>30 tpm, P>120tpm, T>40R>30 tpm, P>120tpm, T>40ººC, or <35C, or <35ººC,C,
BP<90/60mmHg, abnormal consciousness,BP<90/60mmHg, abnormal consciousness,
accompanied with infection in other organ oraccompanied with infection in other organ or
system such as meningitis, sepsis, etcsystem such as meningitis, sepsis, etc
3.3. Lab test & imaging:Lab test & imaging: WBC>20WBC>20×10×1099
/L/L<4<4×10×1099
/L,/L,
NN<1<1×10×1099
/L;/L;
PaO2<60mmHgPaO2<60mmHg ,, PaCO2>50mmHg;PaCO2>50mmHg;
Cr>106mol/LCr>106mol/L ,, BUN>7.1mmol/L; toxicBUN>7.1mmol/L; toxic
symptoms or evidence of DIC; X-ray: over 1symptoms or evidence of DIC; X-ray: over 1
lobe involved, cavity, dispersed quickly, orlobe involved, cavity, dispersed quickly, or
pleural effusionpleural effusion
19. Standard for severeStandard for severe
pneumoniapneumonia
In China, severe pneumonia is determined byIn China, severe pneumonia is determined by
series of indicatorsseries of indicators
1.1. Abnormal consciousnessAbnormal consciousness
2.2. R>30tpmR>30tpm
3.3. PaO2<60mmHg, PaOPaO2<60mmHg, PaO22/FiO/FiO22<300, mechanical<300, mechanical
ventilation requiredventilation required
4.4. BP<90/60mmHgBP<90/60mmHg
5.5. X-ray: bilateral or multiple lobes involved, orX-ray: bilateral or multiple lobes involved, or
pathological region dispersed rapidly>50% 48pathological region dispersed rapidly>50% 48
Hrs after admissionHrs after admission
6.6. Oligouria <20ml/h or <80ml/4hOligouria <20ml/h or <80ml/4h→ acute kidney→ acute kidney
failure when dialysis requiredfailure when dialysis required
20. Detection of pathogenDetection of pathogen
MethodsMethods
SamplingSampling
1.1. SputumSputum
2.2. Bronchoscopy-based techniques: airwayBronchoscopy-based techniques: airway
aspiration, brushing sample, alveolar lavageaspiration, brushing sample, alveolar lavage
3.3. Subcutaneous needle aspirationSubcutaneous needle aspiration
ExaminationExamination
1.1. Directly examinationDirectly examination
2.2. Culture + drug sensitivity test of sputum,Culture + drug sensitivity test of sputum,
Effusion or bloodEffusion or blood
21. TreatmentTreatment
AntibioticsAntibiotics —most important—most important
Experience is important—on the basis ofExperience is important—on the basis of
epidemiologic dataepidemiologic data
More reliable if selection is based resultsMore reliable if selection is based results
from culture + sensitivity testfrom culture + sensitivity test
22. Antibiotics selection on patients statusAntibiotics selection on patients status
1.1. The youth or patients without basicThe youth or patients without basic
diseases: macrolides, penicillin,diseases: macrolides, penicillin,
quinolones or 1quinolones or 1stst
generationgeneration
cephalosporin is selectablecephalosporin is selectable
2.2. The elder, or those with basic diseases:The elder, or those with basic diseases:
2nd or 3rd cephalosporins and/or2nd or 3rd cephalosporins and/or ββ--
lactamase inhibitors, quinolones, and/orlactamase inhibitors, quinolones, and/or
macrolidesmacrolides
23. Principles for severe pneumoniaPrinciples for severe pneumonia
1.1. Broad-spectrum, sufficiency &Broad-spectrum, sufficiency &
combination with 2 or morecombination with 2 or more
2.2. CAP: 3rd generation cephalosporin +CAP: 3rd generation cephalosporin +
macrolide +macrolide + ββ-lactamase inhibitors-lactamase inhibitors
3.3. If hypersensitive to penicillin: quinolone +If hypersensitive to penicillin: quinolone +
aminoglycosideaminoglycoside
4.4. Combining with norvancomycin ifCombining with norvancomycin if
necessarynecessary
24. Situations for changing antibioticsSituations for changing antibiotics
No improvement 72Hrs after useNo improvement 72Hrs after use
Possible reasonsPossible reasons
1.1. Pathogen is resistant or not overlappedPathogen is resistant or not overlapped
2.2. Special pathogen: TB, fungus, or virusSpecial pathogen: TB, fungus, or virus
3.3. Influenced by complication orInfluenced by complication or
immunosuppressive statusimmunosuppressive status
4.4. Diagnosis is wrong, e.g.Diagnosis is wrong, e.g. non-infected D, ornon-infected D, or
drug-induced feverdrug-induced fever
25. Family careFamily care
Enhance basic status by appropriateEnhance basic status by appropriate
exerciseexercise
Reduce risk factors such as smoking andReduce risk factors such as smoking and
alcohol abusealcohol abuse
Administration of vaccines to preventAdministration of vaccines to prevent
influenza and pneumonia, esp. for theinfluenza and pneumonia, esp. for the
elder, those with basic D or administrationelder, those with basic D or administration
of suppressive agentsof suppressive agents
27. Natural historyNatural history
Half of patients with CAPHalf of patients with CAP
Pathogen: S. pneumoniae—G+Pathogen: S. pneumoniae—G+
Capsular polysaccharide: main pathogenicCapsular polysaccharide: main pathogenic
factorfactor
Natural course:1—2 WeeksNatural course:1—2 Weeks 。。
TT 5—10 days later spontaneously5—10 days later spontaneously
T normalized by administration of effectiveT normalized by administration of effective
antibiotics within 1-3 daysantibiotics within 1-3 days
28. TriggersTriggers: coldness, drunkenness,: coldness, drunkenness,
fatigue, viral infectionfatigue, viral infection
Abrupt onset, characterized of highAbrupt onset, characterized of high
fever, rigor, cough with ferruginousfever, rigor, cough with ferruginous
sputum and chest painsputum and chest pain
Pleural involvement is commonPleural involvement is common
Clinical manifestationsClinical manifestations
29. StagingStaging
1.1. Congestion stage:Congestion stage: vascular engorgementvascular engorgement
and serous exudationand serous exudation
2.2. Red hepatization stage:Red hepatization stage: reflecting liverlikereflecting liverlike
appearance of consolidated lung—RBCappearance of consolidated lung—RBC
extravasationextravasation
3.3. Gray hepatization stage:Gray hepatization stage: accumulation ofaccumulation of
fibrins mixed with WBC and RBCfibrins mixed with WBC and RBC
4.4. Resolution stage:Resolution stage: absorption of exudationabsorption of exudation
30. PEPE
Acute feverish face, red cheeks, rapidAcute feverish face, red cheeks, rapid
respiration, dry skin, thirsty, herpes onrespiration, dry skin, thirsty, herpes on
mouth corner or around nosemouth corner or around nose
Cyanosis in some severe patientsCyanosis in some severe patients
Bleeding in skin & sclerotic jaundice inBleeding in skin & sclerotic jaundice in
those with toxic pneumoniathose with toxic pneumonia
Stiff neck + in those with meningitisStiff neck + in those with meningitis
31. Tachycardia or arrhythmiaTachycardia or arrhythmia
Abdominal tenderness & distentionAbdominal tenderness & distention
Shock, ARDS or abnormal consciousnessShock, ARDS or abnormal consciousness
32. Signs of LungSigns of Lung
No significant signs in early stageNo significant signs in early stage
Consolidation is the typical signs in redConsolidation is the typical signs in red
and grey hepatization stage: increasedand grey hepatization stage: increased
fremitus, dullness, bronchophony, pleuralfremitus, dullness, bronchophony, pleural
friction sound may be audiblefriction sound may be audible
Moist rales in resolution stageMoist rales in resolution stage
34. Laboratory testingLaboratory testing
WBC10--20x10WBC10--20x1099
/L, N>80%, hyposegmentation,/L, N>80%, hyposegmentation,
toxic granulestoxic granules
WBC may be lower than 4 x10WBC may be lower than 4 x1099
/L in the elder,/L in the elder,
drunk or those with immune deficiency, but ratiodrunk or those with immune deficiency, but ratio
of N/WBC is higherof N/WBC is higher
Pathogen examinationPathogen examination
Gram staining or capsule staining with sputumGram staining or capsule staining with sputum
precipitantprecipitant
CultureCulture
ELISA or PCR for detection of antigen or geneticELISA or PCR for detection of antigen or genetic
markersmarkers
35. X-rayX-ray
Typical changes: segmental or lobarTypical changes: segmental or lobar
consolidation shadowconsolidation shadow
44. TreatmentTreatment
AntibioticsAntibiotics
Primary: penicillin GPrimary: penicillin G
AdministrationAdministration
1.1. Adult mild: 2,400,000u/d, q8h im;Adult mild: 2,400,000u/d, q8h im;
2.2. Moderate: 2.4Moderate: 2.4~4.8 million~4.8 million u/d, ivgtt, q6h oru/d, ivgtt, q6h or
q8hq8h 。。
3.3. Severe or with meningitis: 10Severe or with meningitis: 10~~30million30million
u/du/d ,, ivgttivgtt ,, q6hq6h
45. Hypersensitive to penicillin, or infected by MDRHypersensitive to penicillin, or infected by MDR
strainsstrains
Selectable drugs: quinolones, cephalosporins, orSelectable drugs: quinolones, cephalosporins, or
even norvancomycineven norvancomycin
Standard course: 14d, or 3 days later after TStandard course: 14d, or 3 days later after T
normalizednormalized
In some cases, oral administration may persistIn some cases, oral administration may persist
for another 2 weeksfor another 2 weeks
46. Supportive treatmentSupportive treatment
Sufficient rest, balanced dietSufficient rest, balanced diet
In-time monitoring, prevention againstIn-time monitoring, prevention against
shockshock
Painkillers used for severe chest painPainkillers used for severe chest pain
48. General principlesGeneral principles
Pathogen: mycoplasma pneumoniae, whichPathogen: mycoplasma pneumoniae, which
exists among ciliary epithelial cellsexists among ciliary epithelial cells
Disseminated via respiratory tractDisseminated via respiratory tract
More common in childhood or youthMore common in childhood or youth
Pathology: inflammation of bronchi, bronchioles,Pathology: inflammation of bronchi, bronchioles,
alveolar or interstitiaalveolar or interstitia
Natural course is 4 weeks, self-limitedNatural course is 4 weeks, self-limited
49. Diagnostic EssentialsDiagnostic Essentials
2-3 weeks latency2-3 weeks latency
Stimulant cough, some with fatigue, sore throat,Stimulant cough, some with fatigue, sore throat,
headache, fever, dyspepsia, diarrhea, myalgiaheadache, fever, dyspepsia, diarrhea, myalgia
Extrapulmonary: dermatitisExtrapulmonary: dermatitis
Few signsFew signs
X-ray: segmental distributed polymorphicX-ray: segmental distributed polymorphic
infiltration shadow, mainly in inferior field,infiltration shadow, mainly in inferior field,
disappears spontaneously 3-4 weeks laterdisappears spontaneously 3-4 weeks later
50. Laboratory testing: WBC countingLaboratory testing: WBC counting
increase slightly, Nincrease slightly, N↑↑
2/3 patients with positive result of cold2/3 patients with positive result of cold
aggregation test (1:32), more meaningful ifaggregation test (1:32), more meaningful if
titertiter ↑↑ graduallygradually
Detection of Mycoplasma-specific IgMDetection of Mycoplasma-specific IgM
51. TreatmentTreatment
Administration of antibioticsAdministration of antibiotics
Course: 2 weeksCourse: 2 weeks
Primary: macrolides such as erythromycinPrimary: macrolides such as erythromycin
2g/D, roxithromycin 150mg po bid,2g/D, roxithromycin 150mg po bid,
azithromycin 0.5g, qdazithromycin 0.5g, qd
Selectable: quinolones or tetracyclinesSelectable: quinolones or tetracyclines
Ineffective: penicillin and cephalosporinsIneffective: penicillin and cephalosporins
52. Appendices 1 –antibioticsAppendices 1 –antibiotics
CephalosporinCephalosporin
44thth
generationgeneration
1.1. Wider spectrum, more effective on GWider spectrum, more effective on G ++
coccus, especially for penicillin-coccus, especially for penicillin-
resistant S. pneumoniaeresistant S. pneumoniae
2.2. Stronger activity on GStronger activity on G--
bacillibacilli
3.3. More stable to β- lactamaseMore stable to β- lactamase
54. CarbopenemCarbopenem
Representatives: tienam composed ofRepresentatives: tienam composed of
Imipenem and cilastatin sodiumImipenem and cilastatin sodium
Most effective in the worldMost effective in the world
Quite stable to β- lactamase because ofQuite stable to β- lactamase because of
trans structure formed by hydroxyl lateraltrans structure formed by hydroxyl lateral
chain and β-lactate loopchain and β-lactate loop
Cilastatin inhibit enzymes (degradeCilastatin inhibit enzymes (degrade
imipenem) in kidneyimipenem) in kidney
55. TienamTienam
1.1. Wide spectrum—aerobic or anaerobic GWide spectrum—aerobic or anaerobic G
++ coccus and G- bacilli, including thosecoccus and G- bacilli, including those
with super β-lactamase (ESBL), andwith super β-lactamase (ESBL), and
resistant against 3resistant against 3rdrd
-generation-generation
cephalosporincephalosporin
2.2. Imipenem combine with PBP-2 and PBP-Imipenem combine with PBP-2 and PBP-
2Ib2Ib →induce rapid resolution,→induce rapid resolution,
production of endotoxinproduction of endotoxin
56. QuinolonesQuinolones
Representative: levoflaxacin (Representative: levoflaxacin ( 左旋氧氟沙星来立左旋氧氟沙星来立
信信 ))
AdvantagesAdvantages
1.1. No need for cutaneous sensitivity testNo need for cutaneous sensitivity test
2.2. Oral administrationOral administration
3.3. Wide-spectrumWide-spectrum
4.4. Less side-effect on liver & kidneyLess side-effect on liver & kidney
5.5. Effective on intracellular pathogens such as legionellaEffective on intracellular pathogens such as legionella
and mycobacterium, mycoplasma, Chlamydia, etc.and mycobacterium, mycoplasma, Chlamydia, etc.
DisadvantagesDisadvantages
1.1. Weaker effective on GWeaker effective on G++
coccuscoccus
2.2. Toxic to long bones and article, not recommended toToxic to long bones and article, not recommended to
be used in youth (be used in youth (<< ageage of 16)of 16)
57. MacrolidesMacrolides
Representative: erythromycin, roxithromycin,Representative: erythromycin, roxithromycin,
clarithromycin, azithromycinclarithromycin, azithromycin
very effective on Gvery effective on G ++ coccuscoccus
Effective on atypical infectionsEffective on atypical infections
58. AminoglycosidesAminoglycosides
Representations: kanamycin, amikacin,Representations: kanamycin, amikacin,
netimicin, etimicin (netimicin, etimicin ( 爱大爱大 ))
G- bacilliG- bacilli
Toxin injury to Ear, auditory Nerve, kidneyToxin injury to Ear, auditory Nerve, kidney
Etimicin more effective than gentamicinEtimicin more effective than gentamicin
Netimicin, etimicin less side-effectNetimicin, etimicin less side-effect
59. Anti fungus drugsAnti fungus drugs
Representatives: Amphotericin B, ketoconazole,Representatives: Amphotericin B, ketoconazole,
fluconazolefluconazole
Candida, cryptococcus, aspergillusCandida, cryptococcus, aspergillus
Anti anaerobic bacteriaAnti anaerobic bacteria
Penicillin, metronidazole, tinidazole,Penicillin, metronidazole, tinidazole,
chloromycetin, clindamycin. Erythromycin ischloromycetin, clindamycin. Erythromycin is
only against anaerobic coccus, metronidazoleonly against anaerobic coccus, metronidazole
against all anaerobic bacteriaagainst all anaerobic bacteria
63. Extracurricular taskExtracurricular task
List the diagnostic essentials forList the diagnostic essentials for
1.1. Viral pneumoniaViral pneumonia
2.2. Fungal pneumoniaFungal pneumonia
3.3. Staphylococcual pneumoniaStaphylococcual pneumonia
4.4. Klebsiella pneumoniaKlebsiella pneumonia
5.5. Pneumonia caused by gramPneumonia caused by gram--
bacillibacilli
6.6. And pneumonia of legionnaires’ diseaseAnd pneumonia of legionnaires’ disease
64. Look for the primary antibiotics andLook for the primary antibiotics and
selectable ones against pneumonia listedselectable ones against pneumonia listed
above?above?
Try to make out the essentials forTry to make out the essentials for
diagnosis of pneumonia?diagnosis of pneumonia?