Pneumonia

Presented by: Dr. Walker

Medical Centre 041 NAF Base Shasha

 Case Discussion
• 65-year-old male with fever, productive cough,
pleuritic chest pain
• CXR: Right lower lobe consolidation
• Rx: Admitted, started on ceftriaxone +
azithromycin
• Recovered after 5 days of therapy
 Outline
• Introduction
• Anatomy
• Epidemiology
• Risk Factors
• Aetiology
• Pathophysiology
• Classification
• Clinical Presentation
• Differential Diagnosis
• Investigations
• Treatment
• Complications
• Prevention
• Prognosis
• Conclusion
 Introduction
• Pneumonia is essentially an inflammation of the lung
parenchyma, the functional tissue of the lung, including the
alveoli and bronchioles. This inflammation is typically caused
by an infectious agent, but can also arise from non-infectious
causes.
• These air sacs (alveoli) may fill with fluid or pus, causing cough
with phlegm, fever, chills, and difficulty breathing.
• Severity can range from mild to life-threatening, especially in
vulnerable populations.
• It is a major cause of morbidity and mortality globally
• High-risk groups include: the elderly, immunocompromised,
and infants.
Brief Lung Anatomy for Pneumonia
• Two Lungs: Right (3 lobes) and left (2 lobes).
• * Airways: Trachea → Main Bronchi → Smaller Bronchi → Bronchioles → Alveoli (site of gas
exchange).
• * Pneumonia Target: Inflammation and fluid buildup in alveoli and interstitial space impair gas
exchange.

• Vascular Supply:
• * Pulmonary Arteries: Carry deoxygenated blood from the right ventricle to the lungs for
oxygenation, closely associated with the airways and alveoli.
• * Pulmonary Veins: Carry oxygenated blood from the lungs back to the left atrium of the heart.

• Nerve Supply:
• * Autonomic Nervous System:
• * Parasympathetic (Vagus Nerve): Causes bronchoconstriction (narrowing of airways), increased
mucus secretion, and vasodilation of pulmonary vessels.
• * Sympathetic (Thoracic Spinal Nerves): Causes bronchodilation (widening of airways) and
vasoconstriction of pulmonary vessels.
• * Sensory Nerves: Involved in cough reflex and pain perception.
Anatomy
Anatomy
 Anatomy
• Venous Drainage:
• * Pulmonary Veins: As mentioned above, these drain oxygenated blood
directly into the left atrium.
• * Bronchial Veins: Drain deoxygenated blood from the larger airways and
visceral pleura. They drain into the azygos and hemiazygos veins (systemic
circulation).

• Key Relevance to Pneumonia:

• * Inflammation in pneumonia affects the alveoli and surrounding
capillaries, disrupting the close relationship needed for efficient gas
exchange between the air and the pulmonary blood supply.
• * Nerve supply contributes to symptoms like cough and chest pain.
• * Understanding the vascular supply is important for considering potential
complications and the systemic effects of pneumonia.
 Epidemiology
• Leading cause of infectious death worldwide, especially in
young children and the elderly.
• Significant morbidity and mortality across all age groups.
• Highest incidence in children under 5 years and adults
over 65 years (due to immature/declining immune
systems).
• Higher prevalence in developing countries due to factors
like malnutrition, poor sanitation, and limited access to
healthcare.
• Seasonal patterns in some regions (e.g., increased viral
pneumonia during winter).
 Risk Factors
• Age: Very young children (under 2 years) and older adults (over 65 years)

• Weakened Immune System:

• - HIV/AIDS
• - Organ transplant recipients
• - Individuals on chemotherapy or long-term corticosteroids

• Chronic Diseases:
• - Asthma
• - Chronic obstructive pulmonary disease (COPD)
• - Cystic fibrosis
• - Heart disease
• - Diabetes
• - Sickle cell disease
 Risk Factors
• Smoking: Damages the airways and impairs
immune defenses.
• Difficulty Coughing or Swallowing: Increased
risk of aspiration.
• Exposure to Certain Environments: Hospitals,
nursing homes, crowded living conditions.
 Aetiology
• Infectious Agents (Most Common):

• Bacterial:
• - Streptococcus pneumoniae (most common community-acquired
pneumonia, CAP pathogen)
• - Haemophilus influenzae,
• - Mycoplasma pneumoniae (atypical pneumonia - "walking
pneumonia")
• - Chlamydophila pneumoniae (atypical pneumonia)
• - Legionella pneumophila (Legionnaires' disease)
• - Staphylococcus aureus (can be severe, especially after
influenza)
 Aetiology
• Viral:
• - Influenza virus (flu)
• - Respiratory syncytial virus (RSV) (common in young children)
• - Rhinovirus (common cold)
• - Adenovirus
• - Coronavirus (including SARS-CoV-2)

• Fungal (More common in immunocompromised hosts):

• - Pneumocystis jirovecii (PCP)
• - Aspergillus
• - Cryptococcus
 Aetiology
• Other Microorganisms:
• - Mycobacterium tuberculosis (can cause pneumonia-like
illness)

• Non-Infectious Causes (Less Common):

• - Aspiration pneumonia (due to inhaling food, liquid, or
vomit)
• - Chemical pneumonia (due to inhaling toxic fumes or
substances)
• - Hypersensitivity pneumonitis (allergic reaction to inhaled
organic dusts)
 Pathophysiology
• Pathogen Entry: Infectious agents (bacteria, viruses, fungi) typically
enter the lower respiratory tract via inhalation or aspiration,
overcoming local defenses.
• Inflammatory Cascade: The pathogen triggers a robust inflammatory
response involving:
• - Immune Cell Activation: Macrophages and other immune cells
recognize the invader.
• - Mediator Release: Pro-inflammatory cytokines and chemokines
are released.
• - Vascular Changes: Vasodilation and increased capillary
permeability occur.
• Alveolar Filling (Consolidation): Exudate (fluid, inflammatory cells,
debris) accumulates in the alveoli, replacing air.
Pathophysiology
 Pathophysiology
• Impaired Gas Exchange: Consolidation and potential alveolar
collapse (atelectasis) lead to:
• - V/Q Mismatch: Blood flows through poorly ventilated areas.
• - Hypoxemia: Reduced arterial oxygen levels.
• - Possible Hypercapnia: In severe cases, impaired CO2 removal.
• Resolution: In uncomplicated cases, the immune system clears
the infection and inflammation, with macrophages removing
exudate and tissue repair occurring.

• In summary: Pneumonia's pathophysiology centers on an

inflammatory response in the alveoli that leads to fluid and
cellular accumulation, ultimately disrupting normal gas exchange.
Pathophysiology
 Classification
• By Acquisition:
• Community-Acquired Pneumonia (CAP)
• Hospital-Acquired Pneumonia (HAP)
• Ventilator-Associated Pneumonia (VAP)

• By Anatomical Distribution:
• Lobar pneumonia
• Bronchopneumonia
• Interstitial pneumonia
 Classification
• I. By Acquisition: This classification is crucial for guiding initial
antibiotic selection and understanding likely pathogens.

• Community-Acquired Pneumonia (CAP): Pneumonia that develops in a

person who is not hospitalized or residing in a long-term care facility
for ≥14 days prior to the onset of symptoms.
• Common Pathogens: Streptococcus pneumoniae (pneumococcus) is
the most common bacterial cause. Others include Haemophilus
influenzae, Mycoplasma pneumoniae, Chlamydophila pneumoniae,
respiratory viruses (influenza, RSV, adenovirus), and less commonly
Legionella pneumophila and Moraxella catarrhalis.
• Clinical Context: Often seen in otherwise healthy individuals or those
with common comorbidities.
 Classification
• Hospital-Acquired Pneumonia (HAP):
• Pneumonia that develops in a patient ≥48 hours after
admission to a hospital and was not incubating at the time of
admission.
• Common Pathogens: Often involves more resistant bacteria
compared to CAP. Common culprits include Staphylococcus
aureus (including MRSA), Pseudomonas aeruginosa, Klebsiella
pneumoniae, Escherichia coli, and other Gram-negative bacilli.
• Clinical Context: Patients are often more ill, have underlying
medical conditions, and may have been exposed to various
hospital procedures and antibiotics, increasing the risk of
multidrug-resistant organisms.
 Classification
• Ventilator-Associated Pneumonia (VAP):
• A subtype of HAP that develops in patients who have been
intubated and mechanically ventilated for ≥48 hours.
• Common Pathogens: Similar to HAP, with a high risk of
multidrug-resistant organisms such as Pseudomonas
aeruginosa, Acinetobacter baumannii, Staphylococcus
aureus (MRSA), and Gram-negative enteric bacteria.
• Clinical Context: Critically ill patients with compromised
defenses due to intubation, mechanical ventilation, and
underlying conditions. VAP is associated with significant
morbidity and mortality.
 Classification
• II. By Anatomical Distribution: This classification
describes the pattern of lung involvement seen on
imaging (e.g., chest X-ray or CT scan).
• Lobar Pneumonia: found more in adults. Involves a
large and continuous portion of a single lobe (or
sometimes an entire lobe) of the lung.
• Typical Pathogen: Historically most associated with
Streptococcus pneumoniae.
• Imaging Findings: Dense consolidation of the affected
lobe with well-defined borders.
 Classification
• Bronchopneumonia: found more in children
• Characterized by patchy, multifocal areas of
consolidation centered around the bronchioles. It
typically involves multiple lobes.
• Common Pathogens: Often caused by bacteria like
Staphylococcus aureus, Streptococcus pneumoniae,
Haemophilus influenzae, and Gram-negative bacilli. Can
also be seen with some viruses.
• Imaging Findings: Scattered, ill-defined opacities
throughout the lungs, often more prominent in the lower
lobes.
 Classification
• Interstitial Pneumonia:
• Primarily involves the interstitial space (the tissue between the
alveoli), including the alveolar walls and connective tissue. There is
often less prominent alveolar filling with exudate compared to
lobar or bronchopneumonia in the early stages.
• Common Pathogens: Frequently caused by viruses (e.g., influenza,
RSV), atypical bacteria (Mycoplasma pneumoniae, Chlamydophila
pneumoniae), and some fungi or Pneumocystis jirovecii. Can also
be associated with non-infectious causes (e.g., drug reactions,
autoimmune diseases).
• Imaging Findings: Often presents with a reticular (net-like) or
reticulonodular pattern, ground-glass opacities, and may involve
both lungs diffusely.
 Clinical Presentation
• Symptoms:
• Cough (may be productive with phlegm - mucoid, purulent, blood-tinged)
• Fever (may be high, with chills and rigors)
• Shortness of breath (dyspnea)
• Chest pain (often pleuritic - sharp, worse with breathing or coughing)
• Fatigue and malaise

• Less Common Symptoms:

• Headache
• Muscle aches (myalgia)
• Joint pain (arthralgia)
• Nausea, vomiting, diarrhea (more common in atypical or viral pneumonia)
• Abdominal pain (especially in lower lobe pneumonia in children)
 Clinical Presentation
• Signs on Physical Examination:
• Tachypnea (increased respiratory rate)
• Tachycardia (increased heart rate)
• Fever
• Use of accessory muscles of respiration
• Nasal flaring (in children)
• Dullness to percussion over the affected lung area
• Increased tactile fremitus
• Increased vocal fremitus
• Crackles (rales) or bronchial breath sounds on auscultation
• Possible pleural rub (in cases with pleuritis)
 Clinical presentation
• Atypical Pneumonia Presentation:
• Often more insidious onset with less
prominent fever and cough.
• More likely to have extrapulmonary
symptoms (e.g., headache, myalgia).
• "Walking pneumonia" (Mycoplasma
pneumoniae).
 Classification presentation
• Presentation in Specific Populations:
• Infants and young children: May present with
irritability, poor feeding, lethargy, and
abdominal distension.
• Elderly: May have atypical presentations like
confusion, falls, or functional decline with
minimal respiratory symptoms.
 Differential Diagnosis
Infectious Diseases such as:

• Bronchitis
• Acute Bronchiolitis
• Influenza and Other Viral Respiratory Infections
• Tuberculosis (TB)
• Fungal Lung Infections
• Lung Abscess
• Empyema
• COVID-19
 Differential Diagnosis
• Non-Infectious Diseases:

• Pulmonary Embolism (PE)

• Acute Respiratory Distress Syndrome (ARDS)
• Heart Failure (Pulmonary Edema)
• Aspiration Pneumonitis
• Pulmonary Infarction
• Lung Cancer
• Interstitial Lung Diseases (ILDs)
• Drug-Induced Lung Disease
• Radiation Pneumonitis
• Connective Tissue Diseases with Lung Involvement
• Bronchiectasis
• Pulmonary Hemorrhage
 Management
• Clinical Assessment:
• Thorough history taking (onset, duration,
nature of symptoms, risk factors).
• Complete physical examination
 Investigations
• Chest X-ray (CXR): Gold standard for diagnosis. Look
for infiltrates (consolidation, opacities) in one or
both lung fields. Can help differentiate lobar,
bronchopneumonia, and interstitial patterns.
• CT Scan of the Chest: More sensitive and specific
than CXR, especially for complex cases, identifying
complications (e.g., empyema, abscess), or in
immunocompromised individuals. Often reserved
for cases with unclear diagnosis or suspected
complications.
Investigations
Investigations
Investigations
 Investigations
• Complete Blood Count (CBC): May show leukocytosis (increased white blood cell
count), but can be normal or low in some cases (e.g., viral, overwhelming infection,
immunocompromised).
• Inflammatory Markers: Elevated C-reactive protein (CRP) and erythrocyte
sedimentation rate (ESR) can support the diagnosis of infection.
• Blood Cultures: To identify the causative bacterial organism, especially in
hospitalized patients or those with severe illness.
• Arterial Blood Gas (ABG): To assess oxygenation and ventilation status in patients
with respiratory distress.
• Procalcitonin: Can help differentiate bacterial from viral infections.Procalcitonin
helps differentiate bacterial from viral pneumonia by typically showing significantly
higher levels in bacterial infections due to the systemic inflammatory response,
while remaining low or only mildly elevated in viral infections due to the inhibitory
effect of interferon-gamma. In viral infections, interferon-gamma (IFN-γ) is primarily
produced by various immune cells as part of the host's defense mechanism.
 Investigations
• Sputum Gram Stain and Culture: To identify the bacterial
pathogen and guide antibiotic selection.
• Pulse Oximetry: Non-invasive monitoring of oxygen
saturation.
• Molecular Tests (e.g., PCR) using Sputum, Bronchoalveolar
Lavage (BAL), Endotracheal Aspirate (ETA) or
Nasopharyngeal/Throat Swabs: For rapid detection of
specific bacterial or viral pathogens (e.g., influenza, RSV,
Mycoplasma).
• Urine Antigen Tests: For rapid detection of Streptococcus
pneumoniae and Legionella pneumophila antigens.
 Investigations
• Bronchoscopy with Bronchoalveolar Lavage
(BAL): To obtain lower respiratory tract
samples for diagnosis in complex or non-
resolving cases, especially in
immunocompromised patients.
• Thoracentesis: If pleural effusion is present, to
analyze the fluid (cell count, protein, glucose,
LDH, Gram stain, culture, pH).
Hospitalization criteria (CURB-65 score)
• CURB-65 is a simple, validated clinical
prediction rule used to assess the severity of
Community-Acquired Pneumonia (CAP) and
estimate the risk of mortality. It helps guide
decisions regarding the need for
hospitalization and the intensity of treatment.
• The Criteria: One point is assigned for each of
the following five risk factors present at the
time of initial assessment:
 CURB 65
• Confusion: New onset of confusion
(disorientation to person, place, or time).
• Urea: Blood urea nitrogen (BUN) level > 7
mmol/L (or > 19 mg/dL).
• Respiratory rate: ≥ 30 breaths per minute.
• Blood pressure: Systolic blood pressure < 90
mmHg or diastolic blood pressure ≤ 60 mmHg.
• Age: ≥ 65 years.
 CURB 65
• Interpretation and Management: The total score correlates with the risk
of mortality and helps in determining the appropriate site of care:
• 0-1 point: Low risk. Consider outpatient treatment.
• 2 points: Moderate risk. Consider a short inpatient stay or close
outpatient monitoring.
• 3-5 points: High risk. Requires hospitalization, with consideration for
intensive care unit (ICU) admission for scores of 3 or higher.
• Why it's important: CURB-65 is easy to use at the bedside and provides a
standardized approach to risk stratification in CAP, aiding in clinical
decision-making and resource allocation.
• In summary, CURB-65 is a practical tool for quickly assessing the severity
of community-acquired pneumonia based on five easily obtainable
clinical parameters, helping to guide treatment location and predict
mortality risk.
 Treatment
• General Principles:
• Supportive care: Oxygen therapy for
hypoxemia, intravenous fluids for dehydration,
antipyretics for fever, analgesics for pain.
• Prompt initiation of appropriate antimicrobial
therapy for infectious pneumonia.
• Monitoring of clinical status and response to
treatment.
 Treatment
• Antibiotics (for bacterial pneumonia):
• Community-Acquired Pneumonia (CAP):
• - Outpatient: Amoxicillin, doxycycline, macrolides
(azithromycin, clarithromycin) depending on local
resistance patterns and patient factors.
• - Inpatient (non-ICU): Beta-lactam (e.g., ceftriaxone,
cefotaxime) plus macrolide or doxycycline; or
fluoroquinolone (moxifloxacin, levofloxacin).
• - Inpatient (ICU): Beta-lactam (e.g., ceftriaxone,
cefepime) plus azithromycin or fluoroquinolone. Consider
anti-MRSA coverage if risk factors present.
 Treatment
• Hospital-Acquired Pneumonia (HAP) / Ventilator-
Associated Pneumonia (VAP): Broad-spectrum
antibiotics covering Pseudomonas aeruginosa and
other multidrug-resistant organisms (e.g.,
piperacillin-tazobactam, cefepime, ceftazidime,
carbapenems, vancomycin, linezolid) based on
local antibiograms and risk factors for specific
pathogens.
• Atypical Pneumonia: Macrolides (azithromycin,
clarithromycin), doxycycline, or fluoroquinolones.
 Treatment
• Antivirals (for viral pneumonia):
• - Influenza: Oseltamivir, zanamivir (especially if started early).
• - RSV: Ribavirin (in severe cases, especially in
immunocompromised individuals or infants).
• - COVID-19: Specific antivirals (e.g., remdesivir) may be used
depending on severity and guidelines

• Antifungals (for fungal pneumonia):

• - Specific antifungals (e.g., fluconazole, itraconazole,
voriconazole, amphotericin B) depending on the identified
fungal pathogen and patient's immune status
 Treatment
• Other Therapies:
• Bronchodilators (for underlying obstructive lung disease).
• Corticosteroids (in specific situations like Pneumocystis
jirovecii pneumonia with severe hypoxemia or severe
inflammatory response).
• Chest physiotherapy (to help clear secretions in some cases).
• Mechanical ventilation (in cases of severe respiratory
failure).
• Duration of Treatment: Varies depending on the causative
organism and clinical response (typically 5-10 days for
bacterial CAP, longer for HAP/VAP or atypical pathogens).
 Complications
• Parapneumonic effusion
• Empyema
• Lung abscess
• Acute respiratory distress syndrome (ARDS)
• Pleural effusion
• Respiratory failure
• Sepsis
 Prevention
• Vaccination:
• Pneumococcal Vaccines:
• - Pneumococcal conjugate vaccine (PCV13, PCV15, PCV20) for children
and adults.
• - Pneumococcal polysaccharide vaccine (PPSV23) for older adults and
those at high risk.
• - Influenza Vaccine: Annual vaccination recommended for all individuals
6 months and older.
• - Haemophilus influenzae type b (Hib) vaccine: Routine childhood
vaccination.
• - Varicella (chickenpox) and Measles vaccines: Can prevent pneumonia as
a complication of these viral infections.
• - COVID-19 vaccines: Help prevent severe pneumonia due to SARS-CoV-2.
 Prevention
• Good Hygiene Practices:
• - Frequent handwashing with soap and water or
using alcohol-based hand sanitizer.
• - Covering coughs and sneezes with a tissue or elbow.
• - Infection control in hospitals/ healthcare settings eg
• - Avoiding close contact with sick individuals.
• Healthy Lifestyle: maintaining a healthy diet, getting
regular exercise, adequate sleep and avoiding smoking.
 Prevention
• Management of Underlying Conditions:
optimal management of chronic diseases (e.g.,
diabetes, COPD, heart failure).
• Preventing Aspiration: proper positioning
during feeding, especially for infants and
individuals with swallowing difficulties.
• Careful management of conditions that
increase the risk of aspiration (e.g., stroke,
neurological disorders).
 Prevention
• Infection Control Measures in Healthcare
Settings:
• - Strict adherence to hand hygiene protocols.
• - Appropriate use of personal protective
equipment (PPE).
• - Environmental cleaning and disinfection.
• - the use of quarantine, adequate bed
spacing, cross ventilation, etc
 Prognosis
• Influenced by age
• Comorbidities
• Pathogen virulence/type of pathogen
• Early antibiotic initiation improves outcomes
• ICU admission may be required in severe cases
 Key Takeaways
• Pneumonia is a significant respiratory illness with diverse
causes and varying severity.
• It is a clinical diagnosis supported by imaging
• Accurate risk stratification guides treatment
• Early diagnosis through clinical assessment and imaging is
crucial.
• Prompt and appropriate treatment, primarily with
antimicrobials for infectious causes, is essential for
managing pneumonia and preventing complications.
• Prevention through vaccination and good hygiene is vital in
reducing the burden of disease.
 References
• WHO, CDC guidelines
• Harrison’s Principles of Internal Medicine
• IDSA/ATS Pneumonia Guidelines
• UpToDate, 2024 edition
• Thank you