outine about pneumonia,general aspects and treatment

1. Dr. Zohaib Altaf, PGT Medicine,
SKBZ/CMH MZD AJK

2. To Diagnose and treat the patients with
Pneumonia(CAP) and prevent
complications and reduce mortality
rate.
Pneumonia 2

3. 1. Introduction
2. Epidemiology
3. Essential of Diagnosis
4. Classification
5. Etiology
6. Predisposing Factors
7. Pathophysiology
8. Clinical Manifestation
9. Differential Diagnosis
10. Management
11. Complications
12. Prevention
Pneumonia 3

4.  Pneumonia is an inflammation of the lung parenchyma
of infective origin.
 It is an acute respiratory illness associated with
recently developed radiological pulmonary shadowing,
which may b segmental, lobar or multilobar.
4

5.  It is the most common infectious cause of death.
 It is usually characterized by signs of consolidation both
clinically and radiologically.
 Consolidation is a pathological process in which the alveoli
are filled with a mixture of inflammatory exudate, bacteria &
WBC.
5

6.  Community-acquired pneumonia (CAP) is a common
disorder, with approximately 4–5 million cases
diagnosed each year in the United States, 25% of which
require hospitalization.
 Mortality: in milder cases treated as outpatients is <
1%. Among patients hospitalized for CAP, in-hospital
mortality is approximately 10–12% and 1-year mortality
(in those over age 65) is > 40%.
CMDT, ED 2018, Vol 1 , Pag # 273
6

7. 1) Fever or hypothermia, tachypnea, cough with or
without sputum, Dyspnea, chest discomfort,
sweats or rigors (or both).
2) Bronchial breath sounds or inspiratory crackles
on chest auscultation.
3) Parenchymal opacity on chest radiograph.
7
CMDT, ED 2018, Vol 1 , Pag # 273

8. 1. Epidemiological Classification
2. Clinical Classification
3. Radiological Classification
Pneumonia 8

9. 1. Community Acquired Pneumonia
2. Nosocomial Pneumonia:
A. Hospital acquired HAP
B. Ventilator associated
3. Immunocompromised host
4. Aspiration pneumonia
Pneumonia 9
Ref: CMDT edition 2018, Vol 01 Page 272

10. Pneumonia which develops in an otherwise healthy
person outside of hospital or have been in hospital
for less than 48hrs.
Pneumonia 10

11. Hospital Acquired Pneumonia (HAP) is a new episode of
pneumonia occurring at least 2 days after admission to
hospital.
Pneumonia 11

12. 1:Segmental, Lobar or multilobar.
2: Brochopneumonia.
Pneumonia 12

13. Bronchopneumonia is infection of the terminal bronchioles
that extends into the surrounding alveoli resulting in patchy
consolidation of the lung.
Pneumonia 13

14. Lobar pneumonia is a radiological and pathological term referring
to homogeneous consolidation of one or more lung lobes often
associated wit pleural inflammation.
Pneumonia 14

15. Potential etiologic agents in CAP –
 Bacteria
 Viruses
 Fungi
Potential bacteriologic causes can be divided into
two types:
1. Typical bacterial pathogens
2. Atypical bacterial pathogens
Pneumonia 15

16. 16

17.  Cigarette smoking
 Upper respiratory tract infections
 Alcohol
 Corticosteroid therapy
 Old age
 Recent influenza infection (esp. staph aureus)
 Pre-existing lung disease
 HIV
 Indoor air pollution
Pneumonia 17

18. Microbial invasion of the normally sterile lower respiratory
Tract.
Three routes:
1. Inhaled as aerosolized particles.
2. Haematogenous spread from an extrapulmonary site
of infection.
3. Aspiration of oropharyngeal contents.
Pneumonia 18

19.  Invasion occurs as a result of
 Defect in host defense mechanism
 Overwhelming inoculums
Lung infection with viruses suppress the antibacterial
activity of the lung by impairing alveolar macrophage
function & mucocilliary clearance thus setting the
stage for secondary bacterial pneumonia.
Pneumonia 19

20.  It occurs in previously healthy individuals.
 Who are not residents of nursing homes or other long
term care facility .
 It may be diagnosed in a patient who develop sings
and symptoms within 48 hours after admission to
hospital.

21. 1) Indolent to fulminant in presentation(age factor)
2) Mild to fatal in severity
3) Typical symptoms –
I. Fever
II. Chills
III. Cough
IV. Mucopurulent sputum
V. Dyspnea ( shortness of breath)
VI. Pleuritic chest pain
4: signs: pyrexia ,cyanosis, confusion(can b only sign in
elderly)tachypnoea,tachycardia,hypotensin,
signs of consolidation: reduced expansion ,> vocal fremitus
/vocal resonance,bronchial breathing, pleural rub.
Pneumonia 21

22. 1. Insidious onset.
2. Degree of lung involvement don’t correlate with clinical
features.
3. Usually present with low-grade fever, dry cough and mild
dyspnea.
4. Extra pulmonary manifestations:
Head ache,myalgias ,arthralgia,nausea,vomiting and diarrhea
1. Caused by:legionella, mycoplasma, chlamydia and viral
etiology
Pneumonia 22

23. Likely hood of other organisms to b involved depends on the
age of the patient and the clinical context in which pneumonia
develops.
1. Strep pneumonae . Commonest.
2. Staph aureus: esp. post influenza.
3. Viral CAP in children
4. Klebsilla: esp in alcoholics
5. Mycoplasma, chlamydia : young and healthy people.
6. H. Influenzae: elderly e underlying lung disease(copd).
7. Legionella pneumophilia: outbreaks in hotles, hospitals with
contaminated cooling towers.
Pneumonia 23

24. Patients with CAP should be risk stratified.
It is performed in two steps:
1.The need for hospital admission
2.Followed by assessment of the site of admission
(non- ICU vs. ICU).
Initial assessment should be done with CURB-65
Pneumonia 24

25. Score one point for presence of each Clinical feature
(0 – 5)
 1.Confusion *
 2.Urea > 7 mmol/l (20mg/dl)
 3.Respiratory rate >30/min
 4.Blood pressure (SBP <90 or DBP <60mmHg)
 5.Age >65yrs
* Defined as mental test score of 8 or less, or new disorientation in person place and time.
Lim et al Thorax 2003;58:377-382/Davidsons ed 22 page 683
Pneumonia 25

26. Pneumonia 26

27. 27

28. 28
RESULTS: Overall 30-day mortality was 4.3% (0.6% in out-patients and
5.5% in hospitalized patients, p<0.0001). Overall, the CURB, CRB and
CRB-65 scores provided comparable predictions for death from CAP.

29. Major criteria
1. Septic shock with need for vasopressor support
2. Respiratory failure with need for mechanical ventilation
Minor criteria
1. Respiratory rate ≥ 30 breaths/min
2. Hypoxemia
3. Hypothermia, with core temperature < 36.0°C
4. Hypotension requiring aggressive intravenous fluid resuscitation
5. Confusion/disorientation
6. Multilobar pulmonary opacities
7. Leukopenia, due to infection, with white blood cell count < 4.0 × 109/L
8. Thrombocytopenia, with platelet count < 100 × 109/L
9. Uremia, with blood urea nitrogen level ≥ 7.1 mmol/L
10. Metabolic acidosis or elevated lactate level
Pneumonia 29
Patients meeting either major criterion or three or more minor
criteria generally require care in the intensive care unit.
ATS/IDSA, American Thoracic Society/Infectious Diseases Society
of America.

30. 1-BLOOD:
 Full blood count: TLC >15 x 10-9 suggest bacterial etiology.
> 20 or < 4 x 10-9 marker of severity.
 Urea and electrolyte: urea > 7mmol/l(20mg /dl) marker of severtiy.
 Liver function test: abnormal if basal pneumonia inflames liver .
Hypoalbumenemia : marker of severity.
 Esr/ c reactive protein: non specifically elevated
 Blood culture:(before antibiotics) bacteremia : marker of severtiy
 Arterial blood gases: measure when sao2 <93% to assess ventilatory failure
2- Chest x-ray:
Lobar or multilobar infiltrates,cavitation or pleural effusion
However pattern of radiographic abnormality is not specific to any particular cause of
pneumonia.
30

31. 3-Sputum:
 Gram stain and zeil Nelson stain
 Culture and sensitivity
4-Pleural fluid aspiration:
Always aspirate and culture when present in more than trivial amounts.
5-Special investigations:
 Serology: Legionella antigen in urine. Pneumococcal antigen in sputum and blood.
Immediate IgM for Mycoplasma
 Cold agglutinins: positive in 50% of patients with Mycoplasma
 Selected patients Throat/nasopharyngeal swabs: helpful in children or during
influenza epidemic.
 Broncoscopy: if immunocompromised ,critically ill, failing to respond or chronic
pneumonia, or if inadequate or negative sputum.
Pneumonia 31

32. Pneumonia 32
Lobar pneumonia
Consolidation confined
to one or more
lobes (or segments of
lobes) of lungs.

33. Pneumonia 33
Bronchopneumonia
Patchy consolidation
usually in the bases of
both lungs.

34. Goals of therapy
Eradication of the offending organism.
Selection of an appropriate antibiotic.
To minimize associated morbidity.
Pneumonia 34

35. The most important aspects of management :
1: oxygenation.
2:fluid balance and antibiotic therapy.
3:In severe or prolonged illness, nutritional support may be
required.
 Bronchodilators (albuterol)
 Chest physiotherapy with postural drainage
 Expectorants
 Chest pain- analgesics
Pneumonia 35

36. 1. CURB score 4-5 failing to respond rapidly to initial
management
2. Persisting hypoxia (PaO2 < 8 kPa (60 mmHg)) despite
high concentrations of oxygen
3. Progressive hypercapnia
4. Severe acidosis
5. Circulatory shock
6. Reduced conscious level
Davidson’s principal and practice of
Medicine 22nd edition.page 685 36

37.  The initial choice of antibiotic is guided by clinical context,
severity assessment, local knowledge of antibiotic resistance
patterns, and at times epidemiological information.
 In Uncomplicated pneumonia a 7-10-day course is adequate, longer
in patients with Legionella, staphylococcal or Klebsiella
pneumonia.
37

38. 38
CMDT, ED 2018, Vol 1 , Pag # 273

39. 1. For previously healthy patients Who have not
taken antibiotics within past 3 months :
A. A macrolide (CLARYTHROMYCIN, 500 mg p/ox B.D , AZITHROMYCIN 500 mg p/o loading dose then
250mg x od x4 days or 500mg p/o x odx 3days)
or
A. Doxycycline(100mg p/o x BD)
Pneumonia 39
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40. 2. For patients with comorbid medical conditions or use of
antibiotics within the previous 03 months:
A. A respiratory fluoroquinolone (orally or IV moxifloxacin, 400 mg daily;
Gamifloxacin 320mg p/o xod; levofloxacin, 750 mg daily) or
B. A macrolide plus a b-lactam (amoxicillin-clavulanate, 2 g orally twice a day
are preferred).
Pneumonia 40
CMDT, ED 2018, Vol 1 , Pag # 273

41. 1. A respiratory fluoroquinolone(oral or i/v)
For intravenous therapy:
Moxifloxacin, 400 mg daily;
Levofloxacin, 750 mg daily;
or
2. A macrolide plus a b-lactam.
For intravenous therapy:
Ampicillin, 1–2 g every 4–6 hours;
Cefotaxime, 1–2 g every 4–12 hours;
Ceftriaxone, 1–2 g every 12–24 hours.
Pneumonia 41
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42. Resp FQ +(3rd gen cephalosporin or ampicilin – salbactum)
2. For patients allergic to b-lactam antibiotics, a fluoroquinolone
plus aztreonam (1–2 g every 6–12 hours).
If Resp FQ are contraindicated .. Azithromycin cab be used
Pneumonia 42
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43. 3. For patients at risk for Pseudomonas infection:
 An antipneumococcal, antipseudomonal b-lactam (piperacillin-tazobactam,
3.375–4.5 g every 6 hours; cefepime, 1–2 g twice a day; imipenem, 0.5–1 g every
6–8 hours; meropenem, 1 g every 8 hours) or levofloxacin,
or
 The above b-lactam plus an aminoglycoside (gentamicin, tobramycin, amikacin,
plus azithromycin or a respiratory fluoroquinolone.
 . For patients at risk for methicillin-resistant Staphylococcus aureus infection, add
vancomycin or linezolid.
Pneumonia 43
CMDT, ED 2018, Vol 1 , Pag # 273

44.  Consider TMP/SMX if pcp suspected inmmuncompromised host.
 Steroids(pred 50mgx 7days or methyl pred 0.5mg/kg q12 h x 5
days) may speed clinical stabilization and decrease late resp
faliure,not widely embraced yet**
 Duration: CAP :5-7 days if stable and afebrile for 48to 72 hours.
**Lancet 2015: 385;1511, JAMA 2015:313;677
12/12/2011Pneumonia 44

45. 1. Para-pneumonic effusion-common
2. Empyema
3. Retention of sputum causing lobar collapse
4. DVT and pulmonary embolism
5. Pneumothorax, particularly with Staph. aureus
6. Suppurative pneumonia/lung abscess
7. ARDS, renal failure, multi-organ failure
8. Ectopic abscess formation (Staph. aureus)
9. Hepatitis, pericarditis, myocarditis, meningoencephalitis
10. Pyrexia due to drug hypersensitivity
Pneumonia 45

46. 1. Pulmonary infarction
2. Pulmonary/pleural TB
3. Pulmonary oedema (can be unilateral)
4. Pulmonary eosinophilia
5. Malignancy: bronchoalveolar cell carcinoma
6. Rare disorders: cryptogenic organising
pneumonia/bronchiolitis obliterans organising
pneumonia (COP/BOOP)
Pneumonia 46

47. The decision to discharge a patient depends on home
circumstances and the likelihood of complications
Follow up: Clinical review at 6 weeks.
chest X-ray obtained if there are persistent symptoms,
physical signs or reasons to suspect underlying malignancy
Pneumonia 47

48.  At risk groups:
1: all adults > 65 yrs old.
2: comorbids(chronic heart ,liver ,renal ,lung prob and DM)
3: immunosuppression (splenectomy, AIDS, or on chemo or
pred 20mg/day)
vacc done every 5 yrs.
12/12/2011Pneumonia 48

49. 1. The risk of further pneumonia is increased by smoking, so
current smokers should be advised to stop.
2. Because of the mode of spread , Legionella pneumophila
has important public health implications and usually
requires notification to the appropriate health authority.
3. In developing countries,tackling malnourishment and indoor
air pollution, and encouraging immunisation against
measles, pertussis and Haemophilus influenzae type b are
particularly important in children.
Pneumonia 49

50. Pneumonia 50

51. 1-Current Medical Diagnosis and Treatment
2018, Volume # 01, Page 272-273.
2-Davidsons principals and practice of
medicine ed 22nd , page 682
3-oxford hand book of clinical med ed 10 page
166
4-the massachustts general hospital hand book
of internal medicine ed 6th (pneumonia 6-1)
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