Pneumonia
DEFINITION
+ pneumonia ,an Infection of lung
parenchyma ,is classified as community
acquired (CAP),Hospital –acquired
(HAP),ventilator- associated(VAP),or health
care –associated(HCAP).
TYPES
Clasification 1
Community acquired pneumonia
Hospital acquired (nosocomial) pneumonia
Pneumonia occuring in immuno-compromised patient and patient
with underlying lung disease
Aspiration pneumonia
Clasification 2
Lobar pneumonia
bronchopneumonia
PATHOPHYSIOLOGY:
1. Microorganisms gain acess to the lower respiratory tract via
microaspiration from oropharynx (the most common
route),hematogenous spread or contiguous extension from
an infected pleural or mediastinal space.
2.Many CAP pathogen are component of normal alveolar
microbiota ,which is similar to the oropharyngeal microbiota.
This observation suggests that alteration in host defenses(e.g
alveolar macrophage activity,surfactant protein A and D,
mucociliary elevator function) allow overgrowth of one or more
Component of the normal bacterial microbiota.
The two most likely sources of an altered
alveolar microbiota are viral upper respiratory
tract infection for CAP and antibiotic therapy for
HAP/VAP.
PATHOGENE
SIS
PULMONARY
CONSTANT
HOST
EXPOSURE TO
DEFENSES
PARTICULATE &
(NONSPECIFIC
MICROORGANIS
& SPECIFIC)
MS
1. MICROASPIRATION
2. LOCAL INFLAMMATORY RESPONSES
3. SYSTEMIC INFLAMMATORY RESPONSE
4. DYSREGULATED INFLAMMATORY
RESPONSE
5. VIRULENCE FACTORS
6. PREDISPOSING HOST CONDITIONS…….
OLDER AGE
CHRONIC LUNG DISEASES LIFESTYLE FACTORS
• COPD • Smoking tobacco
• Cystic fibrosis • Alcohol consumption
• Bronchiectasis • Opioid use
• Heart failure • Toxic inhalations
• Bronchial obstruction • Overcrowding
• Lung cancer • homelessness
• Previous pneumonia
• Immotile cilia
CONDITIONS WITH INCREASED RISK METABOLIC FACTORS
OF MICROASPIRATION • Malnutrition
• Any alteration in sensorium • Uraemia
• Dysphagia • acidosis
• Wearing dentures while sleeping
IMMUNOCOMPROMISED INSTRUMENTATION OF
• Diabetes mellitus RESPIRATORY TRACT
• HIV infection
• Solid organ/HSC transplantation
• Immunosuppressive treatment
VIRAL RTI
DRUGS &
PNEUMONIA
ACID REDUCING AGENTS • Increased risk of CAP
• Both PPI & HRB
ANTIPSYCHOTIC DRUGS • 50-60% increase in risk
• Especially among elderly
• Atypical > typical
• Even fatal pneumonias
GLUCOCORTICOIDS • Even inhaled glucocorticoids
• Oral and iv are also
SEDATIVES • Increased risk of aspiration
• Aspiration pneumonia
CLINICAL
PULMONARY FEATURES PRESENTATION
• Cough (with/without expectoration) SYSTEMIC & OTHER
• Dyspnea FEATURES
• Pleuritic chest pain
• Fever
• Tachypnea • Chills, fatigue, malaise
• Increased work of breathing • Anorexia
• Bronchial breathing
• Nausea, vomiting
• Tactile fremitus
• Egophony & bronchophony
• Diarrhea
• Dullness on percussion • Signs of sepsis
• Crackles & ronchi
MAKING A DIAGNOSIS
OF CAP
CLINICALLY COMPATIBLE SYNDROME (FEVER,
DYSPNEA, COUGH AND SPUTUM
EXPECTORATION)
INFILTRATE ON CHEST
IMAGING
COMPUTED
CHEST TOMOGRAPHY
XRAY OF CHEST
DEFINING THE
SEVERITY
PSI – CURB -
PNEUMONIA 65
SEVERITY SCORIN
INDEX G
AMBULATORY HOSPITAL ICU
CARE ADMISSION ADMISSION
• Otherwise • SpO2 < 92 @room • Respiratory
healthy air failure requiring
• Normal vital mechanical
signs • PSI scores ≥ III ventilation.
• No concern for
complication • CURB score ≥ 1 • Sepsis requiring
• PSI scores of I vasopressor
& II support
• Curb score 0
MILD MODERAT SEVERE
PNEUMO E PNEUMONIA
NIA PNEUMO
NIA
PATHOLOGY
Congestion(1-2 days)
•Presence of a proteinaceous
exudate—and often of bacteria—in
the alveoli
RED HEPATIZATION(3-4days)
•Presence of erythrocytes in the cellular
intraalveolar exudate
Neutrophils are also present
•
Bacteria are occasionally seen in
•
cultures of alveolar specimens collected
Normal Lung Red Hepatization
GRAY HEPATIZATION (5-7days)
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 (8+days)
Macrophage is the dominant cell type in the alveolar space
Debris of neutrophils, bacteria, and fibrin has been cleared
Types of Pneumonia
ANATOMICAL CLASSIFICATION
Bronchopneumonia affects the lungs in
1.
patches around bronchi
Lobar pneumonia is an infection that
2.
only involves a single lobe, or section, of
a lung.
Interstitial pneumonia involves the
3.
areas in between the alveoli
CLINICAL CLASSIFICATION
1) Community Acquired - Typical/Atypical/Aspiration
2) Pneumonia in Elderly
3) Nosocomial- HAP,VAP,HCAP
4) Pneumonia in Immunocompromised host
CLINICAL CLASSIFICATION
1) Community Acquired - Typical/Atypical/Aspiration
2) Pneumonia in Elderly
3) Nosocomial- HAP,VAP,HCAP
4) Pneumonia in Immunocompromised host
Community Acquired Pneumonia (CAP)
DEFINITION:
•An infection of the pulmonary parenchyma
•Associated with symptoms of a/c infection
•Presence of a/c infiltrates on CXR or auscultatory findings
consistent with Pneumonia
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 .
it occurs in 10% of patients
•
undergoing ventilation.
•Mechanical ventilation increases the
risk of pneumonia 6-fold to 21-fold.
•
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
•
ATYPICAL PNEUMONIA - Why ‘Atypical’?
Radiologically
•Patchy infiltrates or
•Interstitial pattern
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 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
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
VAP Micro
Harrison's Principles of Internal Medicine
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
•Alteredsensorium
•Use of accessory muscles of respiration
•Confusion- advanced cases
SIGNS OF CONSOLIDATION
• Percussion-dull
• Bronchial Breath sounds
Crackles
•
• Aegophony & Whispering Pectoriloquy
•
• Pleural Rub
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
•
RUL Consolidation
RML Consolidation
RLL Consolidation
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
INVESTIGATIONS
•Complete white blood count •Oxygen saturation by pulse
•Blood Sugar oximetry
•Electrolytes •ABG
•Creatinine •USG Chest
•Blood culture •Mantaux
•Screening for retro(ICTC)
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
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
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).
Prevention
•Smoking cessation
•Better Nutrition
•Respiratory hygiene measures
•Pneumococcal polysaccharide vaccine
•Inactivated influenza vaccine
•Live attenuated influenza vaccine
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
