1.PNEUMONIAS medical for medical and.ppt
- 1. PNEUMONIAS
- 2. LECTURE OBJECTIVES • Define pneumonia. • Classify and define each of the type of pneumonia. • Describe the etiologic agents, risk factors for, clinical features, investigations, treatment, complications and preventive measures of the various types of pneumonias.
- 3. PNEUMONIA DEFINITION • Pneumonia is acute respiratory illness associated with recently developed radiological pulmonary shadowing which is either segmental or affects more than one lobe. • Pneumonia may be bacterial, viral, mycobacterial or fungal.
- 4. CLASSIFICATION 1) Community-acquired pneumonia. 2) Hospital-acquired pneumonia. 3) Aspiration pneumonia (including suppurative pneumonia). 4) Pneumonia in the immunocompromised host.
- 5. COMMUNITY-ACQUIRED PNEUMONIA (CAP) DEFINITION • Pneumonia acquired in the patient’s home or in the non-hospital environment such as a nursing home. • Mainly spread by inhalational.
- 6. CAP • Lobar pneumonia is a radiological and pathological term referring to homogeneous opacification (red hepatisation) of one or more lung lobes often associated with pleural inflammation. • Bronchopneumonia refers to more patchy alveolar consolidation associated with bronchial and bronchiolar inflammation affecting both lower lobes.
- 7. CAP ETIOLOGIC AGENTS (ORGANISMS) • Streptococcus pneumoniae 30% • Chlamydia pneumoniae 10% • Mycoplasma pneumoniae 9% • Legionella pneumophila 5% • Hemophilus influenza 3%
- 8. CAP ETIOLOGIC AGENTS (ORGANISMS • Others – Staphylococcus aureus, Chlamydia psittaci, Coxiella burnetti, Klebsiella pneumoniae, Actinomyces israeli all <1%. • Viruses – Influenza virus 7-8% of CAP - Parainfluenza - Measles - Respiratory syncytial virus (RSV) in infancy - Varicella (chicken pox)
- 9. RISK FACTORS • Cigarette smoking • Alcohol intake • Corticosteroid therapy • Old age • Recent influenza infection • Preexisting lung disease • Contact with sick birds (Chlamydia psittaci) • Farm environments (Coxiella burnetti)
- 10. CLINICAL FEATURES SYMPTOMS • Cough – productive of rust coloured sputum. • Fever • Malaise • Pleuritic chest pain • Headache • Confusion
- 11. CLINICAL FEATURES SIGNS • Fever • Tachycardia • Tachypnoea • Hypoxemia • Hypotension • Confusion • Pleural rub • Signs of consolidation – dull percussion note and bronchial breath sounds • Crepitations • Signs of a pleural effusion – stony dullness and absent or reduced breath sounds.
- 12. INVESTIGATIONS 1) Chest radiograph – may show a homogenous opacity localised to the affected lobe or segment. • Is useful in identifying pleural effusion, intrapulmonary abscess formation or when empyema is suspected. • Hilar lymphadenopathy is seen in Mycoplasma pneumonia.
- 13. INVESTIGATIONS 2)Microbiological Investigations - sputum microscopy, culture and sensitivity - aspiration of tracheal/ bronchial secretions during bronchoscopy for M/C/S - Blood cultures and sensitivity patterns. 3) Arterial blood gas measurement for assessment of disease severity
- 14. INVESTIGATIONS 4) Complete blood count - Neutrophil leucocytosis suggests bacterial pneumonia. - Leucopenia suggests viral etiology.
- 15. ASSESSMENT OF DISEASE SEVERITY Clinical parameters - Age of 60yrs or older - Respiratory rate >30/min - Diastolic blood pressure 60mmHg or less - Confusion - More than 1 lobe involved in CXR - Presence of underlying disease
- 16. ASSESSMENT OF DISEASE SEVERITY Laboratory parameters - Hypoxemia (PaO2 <8kPa) - Leucopenia (<4000x109 /L) - Leucocytosis (>20000x109 /L) - Raised serum urea ≥7mmol/L - Positive blood culture - Hypoalbuminemia
- 17. ASSESSMENT OF DISEASE SEVERITY • The 4 cardinal markers of severity are:- - RR ≥30/ min - Diastolic BP ≤60mmHg - Serum BUN of ≥7mmol/L - Presence of confusion • Patients with 2 or more of the 4 cardinal markers of severity have a 36-fold higher risk of dying compared with patients without these signs.
- 18. TREATMENT • Supportive and specific treatment. • Good response to antibiotic therapy. • When there is delayed recovery suspect:- - complications - wrong diagnosis - proximal bronchial obstruction - recurrent aspirate
- 19. SUPPORTIVE TREATMENT • Oxygen- for all hypoxemic patients. Use concentrations ≥35% in those without advanced COPD or hypercapnia. • IV fluids. • Physiotherapy • Pain relief with paracetamol or if severe then with pethidine or morphine.
- 20. SPECIFIC TREATMENT • Antibiotic therapy – given after specimens have been obtained for microbiological evaluation. • Strep. pneumoniae - benzyl penicillin. • Klebsiella pneumoniae - gentamicin and ceftazidime. • Chlamydia pneumoniae - erythromycin or tetracycline. • Chlamydia psittaci – tetracycline • Actinomycosis – benzyl penicillin • Varicella pneumonia – oral acyclovir.
- 21. COMPLICATIONS • Parapneumonic effusions • Empyema • Sputum retention • Pneumothorax
- 22. PREVENTION • Immunization with influenza A/B for all people >50yrs. • Immunization with 23 polyvalent pneumococcal and H. influenza type B vaccines for all susceptible people e.g. elderly>65yrs, patients with co morbidities like diabetes, immunocompromised, sickle cell disease or asplenia. • Treatment of water sources to prevent Legionella pneumophila.
- 23. HOSPITAL ACQUIRED PNEUMONIA (HAP) • Also known as nosocomial pneumonia. DEFINITION • A new episode of pneumonia occurring at least 2 days (48hrs) after admission to hospital. • Occurs in 2-5% of all hospital admissions. • Mortality is high ≈ 30%.
- 24. HAP ETIOLOGIC AGENTS (ORGANISMS) • Gram negative bacteria -Escherichia coli -Pseudomonas -Klebsiella species • Staph aureus including methicillin resistant staph aureus (MRSA) • Anaerobic organisms
- 25. RISK FACTORS 1 • Reduced host defences against bacteria - Reduced immune defences e.g. diabetes , malignancy. - Reduced cough reflex( Post-operative) - Disordered mucociliary clearance. - Bulbar or vocal chord palsy.
- 26. RISK FACTORS 2 • Aspiration of nasopharyngeal or gastric secretions - Immobility or reduced level of consciousness. - Vomiting, dysphagia, achalasia, severe reflux. - Nasogastric intubations
- 27. RISK FACTORS 3 • Bacteria introduced into the lower respiratory tract - Endotracheal intubation/ tracheostomy - Infected ventilators, nebulisers, bronchoscopes. - Dental or sinus infections • Bacteremia - Abdominal sepsis - Intravenous cannula infections - Infected emboli
- 28. CLINICAL FEATURES • Cough • Fever • Sputum purulence • Breathlessness • Central cyanosis • Crepitations
- 29. INVESTIGATIONS 1) Chest radiograph – mottled appearance in both lung fields in the lower zones. 2) Complete blood counts – neutrophil leucocytosis. 3) Tracheal aspirates. 4) Blood cultures.
- 30. TREATMENT Supportive treatment - Physiotherapy - Oxygen therapy - Fluid support and monitoring Specific therapy • IV antibiotics guided by culture results. • Gram negative coverage which includes -Third generation cephalosporin plus an aminoglycoside or - imipenem or - a monocyclic β-lactam plus flucloxacillin
- 31. PREVENTION • Improved pulmonary toilet in post-op patients through frequent suctioning, incentive spirometry and non-cough suppressant analgesia. • Handwashing. • Appropriate sterilization and handling of devices and respiratory equipment. • Proper placement of NG tubes. • Appropriate volume and rate of oral and enteral feeding. • Elevation of head of bed to 30 -450 .
- 32. ASPIRATION PNEUMONIA / SUPPURATIVE PNEUMONIA DEFINITION • Pneumonia resulting from introduction of foreign objects or substances into the lower respiratory tract. ETIOLOGIC AGENTS (ORGANISMS) - Enterobactericeae - Staphylococcus aureus - Streptococcus pneumoniae - Haemophilus influenza
- 33. MECHANISMS FOR ASPIRATION AND SUPPURATIVE PNEUMONIA 1) Primary bacterial pneumonias with pulmonary suppuration due to Staph. aureus and Klebsiella pneumoniae. 2) Inhalation of septic material during operations on the nose, mouth or throat under general anaesthesia. 3) Inhalation of vomitus 4) Bacterial infection of a pulmonary infarct or of a collapsed lobe.
- 34. RISK FACTORS • Gross oral sepsis. • Bulbar palsy • Vocal chord palsy • Achalasia • Oesophageal reflux disease • Alcoholics • IVDU – at risk of lung abscesses associated with endocarditis affecting the pulmonary and tricspid valves.
- 35. CLINICAL FEATURES SYMPTOMS • Cough – productive of large amounts of sputum, fetid and bloodstained. • Chest pain (pleuritic) • Sudden expectoration of copius amount of foul sputum occurs if abscess ruptures into a bronchus.
- 36. CLINICAL FEATURES SIGNS • High fever • Digital clubbing may develop quickly in 10- 14 days. • Signs of consolidation. • Pleural rub is common. • Weight loss.
- 37. INVESTIGATIONS 1)Chest radiograph • May reveal a homogenous lobar or segmental opacity consistent with consolidation or collapse. • Large, dense opacity which may later cavitate and show a fluid level is the characteristic finding when a frank lung abscess is present. • A preexisting emphysematous bulla may become infected and appears as a cavity containing an air-fluid level. 2) Sputum examination and culture
- 38. TREATMENT 1) Supportive treatment – Physiotherapy to assist in drainage of large cavities. 2) Specific treatment • Amoxicillin combined with metronidazole. • Modify treatment according to microbiology results. • Treat for 4-6 weeks. • Removal of any obstructing endobronchial lesion is essential. • Surgical intervention for abscesses that fail to resolve despite optimal medical therapy.
- 39. COMPLICATIONS • Fibrosis • Bronchiectasis PREVENTION • Good oral hygiene. • Assess patients at risk of aspiration and nurse them with head of bed elevated between 30 – 450 .
- 40. PNEUMONIA IN THE IMMUNOCOMPROMISED HOST DEFINITION • Pneumonia in patients receiving immunosuppressive drugs and in those with diseases causing defects in cellular or humoral immune mechanisms. ETIOLOGIC AGENTS( ORGANISMS) • Gram negative bacteria especially P. aeruginosa. • Unusual organisms normally considered to be of low virulence or non-pathogenic.
- 41. RISK FACTORS/ ETIOLOGIC AGENT • Neutropenia due to cytotoxic drugs, agranulocytosis or acute leukemia predisposes to pneumonia due to - Staph aureus - Gram negative bacteria - Candida albicans - Aspergillus fumigatus
- 42. RISK FACTORS/ ETIOLOGIC AGENT 2 • T-cell defects due to lymphoma, CLL, immunosuppressive drugs, bone marrow transplant or splenectomy predisposes to pneumonia due to - C. albicans - Mycobacteria tuberculosis - Pneumocystis carinii - Cytomegalovirus - Gram negative bacteria - Staph aureus - Strep pneumoniae - H.influenza
- 43. RISK FACTORS/ ETIOLOGIC AGENT 3 • Abnormalities in antibody production due CLL and myeloma predispose to pneumonia due to - Strep.pneumonia - H.influenza
- 44. CLINICAL FEATURES • Fever • Cough • Breathlessness
- 45. INVESTIGATIONS 1) Chest radiograph 2) Sputum microscopy, culture and sensitivity. May require sputum induction using hypertonic saline in patients with dry cough. 3) Bronchoscopy with broncho-alveolar lavage (BAL) for M/C/S. 4) Lung biopsy.
- 46. TREATMENT • Treatment based on an established etiological diagnosis. • Empirically use a broad spectrum antibiotic e.g. third generation cephalosporin or a quinolone plus an antipseudomonal penicillin plus an aminoglycoside. • If the cause is PCP treat with high dose septrin.
- 47. PREVENTION • Use of granulocyte colony stimulating factors eg filgrastim and sargramostim in patients with neutropenia.
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