Int21 Pneumonia

7/28/2019 Int21 Pneumonia

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Pneumonia

Slaiman Al-Momani

Malak & Hind

16 / 11 / 2009


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U

Dear colleagues, unfortunately the Dr. refused to give us the

slides so we are sorry if there is any mistake but fortunately

the lec is easy so ENJOY

UPneumonia :Inflammation of the lung substances, usually distal to the

respiratory bronchioles. This inflammation can be infectious or

non-infectious .

Types of pneumonia :

Organizing pneumonia . Pneumonia secondary to connective tissue disorders ; SLE &

interstitial lung disease . Pneumonitis : ( hypersensitivity , radiation ..etc ). Definition of Pneumonia according to ( Harrison ) : as the Doc.said

It is an infection of the alveoli distal to the airways and the

interstetium of the lung, manifested by many changes due to

inflammation there will be:

Production of inflammatory cells . Gross weight of the lung will increase . The normal spongy character of the lung is replaced by

compact solid structure , as increase CVF & increase

dullness .


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The byproduct of the inflammation ( WBC , RBC ,fibrin )will fill the alveoli , which will affect the gas exchange .

This pic is taken from wiki .

From clinical point of view pneumonia means a group

of signs and symptoms in the presence of chest radiographic

infiltrate.


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When a patient comes with signs and symptoms ofpneumonia but clear chest x-ray, this is not pneumonia but it

is bronchitis or bronchopneumonia or mistaken upper

respiratory tract infection.

Signs & symptoms :

Cough.

Chest pain .

Fever.

Rigor.

Chills. SOB .

Excessive sputum production.

Sometimes hemopmtysis .

Physical findings :

Tachypnea.

Dullness of the area of inflammation .

Bronchial breathing sound .

Additional breathing sound ; crackles , crepitation etc

Extreme cases there is pleural rub .

Systemic manifestation :

Fever Rigor

Chills

Myalgia

Arithritis

General fatigue .


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Elevated temperature.

Extreme cases hypothermic .

In certain infections it maybe associated with rash

especially viral infection .

Classification of pneumonia :

Typical : prominent respiratory signs and symptoms with minorsystemic complains .

Atypical : extra pulmonary manifestation .

Investigation :

Chest x-ray; if there is an infiltrate we consider it aspneumonia .

This pic is from KUMAR


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Grams stain and culture of the sputum, this test isimportant although it has low sensitivity.

Blood gasesCBCKidney function .

Specific test for pneumoniaFibreoptic bronchoscopy - samples of the lung tissue- ,

analysis of pleural effusion, culture of exudates .

:

Classification of pneumonia according to theorganisms :

This classification is important to guide the treatment

according to the organism.

Community acquired pneumonia : streptococcus pneumponia

is the prevalent bacteria (gram positive bacteria ),

mycoplasma,.chlamydia & viral pneumonia .

Nosocomial pneumonia : gram negatives , anaerobes , butusually it depends on the risk factors like patient with

catheter the cause may be gram positive.

There is early and late nosocomial pneumonia : Early nosocomial : the organisms are combination of weak

hospital acquired organisms and communit acquired organisms .

Late nosocomial : the organisms are strictly hospital

acquired organisms , gram negatives ,anaerobes and some gram

positives, they are more common in the ICU , patient who are

on invasive respiratory equipment ( ventilator ) .


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SO ,Ventilator associated pneumonia

Most common organism causes hospital acquired pneumonia

in our hospital is ACPC ( gram negative bacilli ) ,but in the USA is

Methecillin resistant staph.Aureus MRSA .

is a subset of hospital

acquired pneumonia , it is a pneumonia which occurs after at

least 48 hrs of intubation and mechanical ventilation .

Risk factors for hospital acquired pneumonia :1. Severity of the illness.2.Nutrition.3.Duration.4.Age.5.Antibiotics.6.Major surgery . Immunocopromised patients : combination of gram ve &

gram +ve , but we consider the opportunistic infections .

Other types of pneumonia : Aspiration pneumonia :

It happens in patient with impaired consciousness , or in

patient with loss of gagreflex because of neurological

disorders , bulbar palsy , encephalopathy and diabetics

patients who have gastropathy .


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Definition of community acquired pneumonia :Signs and symptoms of pneumonia , lung infiltrate in a patient

who has not been hospitalized or diagnosed within 48 hrs of

admission .

If a patient admitted to the hospital for elective hernia

surgery , but next day he had fever with chest infiltrate , this is

a community acquired pneumonia not noscomial , coz it needs 48

to consider it as nosocomial pneumonia .

A patient who has always been in the long term health care

facility , and get out and start suffering of pneumonia , this

pneumonia it not a community acquired pneumonia unless he is out

for at least 2 weeks .

In year 2005 up to 2 to 3 million cases diagnosed of community

acquired pneumonia, but now this number will increase bcozof SWINE FLU

.(basma H.)

Predisposing factors of pneumonia :

Extreme ages .

Patients with COPD .

Smoking .

Heart failure Diabetes

Chronic pneumothorax ( not sure )

* All these are also risk factors for H1N1, so we do PCR.


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Taking antibiotics without prescription , decreases the

immunity of the lung causing pneumonia .

30-50 % of cases treated without finding the organism, but the

most common organism causes community acquired pneumonia is

Steptococcus pneumonia .

If patient has certain co morbidities he may predisposed to

certain organisms , like patient with COPD , he will be more prone

to Streptococcus Pneumonia, H.influenza and Moraxella

Catarrhalis , patient with alcoholism more prone tostreprococcus , staphylococcus and klebsiella, patient with

diabetes have staph and strep

How to asses the severity of pneumonia :

1. According to the CURB-65 criteria which is recommended by

the British Thoracic Society , which include these risk factors

and each risk factor scores 1 point( for a maximum score = 5 ) :

Confusion new disorientation in person place or time.

Urea > 7 mmol/L

Respiratory rate > or = 30 /min

Blood pressure

Systolic < 90 mmHg

Diastolic < or = 60 mmHg

Age > 65 yrs .


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*The risk of death increases as the score increases ( combination

of risk factors ) :

0 0.7 %

1 3.2 %

2 13 %

3 17 %

4 41.%

5 57 %

* It is used as a mean of deciding the action that is needed to be

taken for that patient , 0-1 treat as an outpatient , 2 consider asa short stay in hospital or watch very closely as an outpatient , 3-

5 requires hospitalization with consideration as to whether they

need to be in intensive care unit .

* This assessment of severity it is not 100 % accurate , bcoz

patient may have severe hypoxemia which an important risk

factor but it is not included here .

2. Cohort criteria, pneumonia severity index, which is

recommended by national community of general medicine ,this

criteris depends on many factors :

1. Patient demographic. (Whether someone is older , and is male

or female )

2. Age.

3. Co existing diseases .4. Physical examination findings .

5. Laboratory and radiology findings .


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Each factor has a point, the summation of these points give us

the risk group according to Cohort .but these groups are not for

memorizing .

3. Clinical judgment : the best method to asses the severity of

community acquired pneumonia , we took all the factors of CURB

& Cohort as guidelines then we judge clinically whether it is a

sever pneumonia or not .

Criteria to admit patients to the hospital

:

1.Patient clinical situation.2.Social criteria

3.Hypoxemic4.Multilobar infiltrate .5.Co-existing illnesses .

Treatment of pneumonia :

1. We should always start empirical treatment based on the

type of pneumonia according to the epidemiologic features of

the patient.

In the emergency room we should

give the patient

antibiotics within 6-8 hrs , bcoz the early institution of

antibiotics decreases the mortality .

2.Asses the severity of the infection, whether we dischargethe patient or we admit him to the floor or to the ICU.

You are free to elect doing certain workup to identify the


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organism in the outpatients , but you should do these workup

to the inpatient .

These workup are : blood culture , sputum .

In simple pneumonia with no risk factors , no co morbidities ,

no features of severity we just give the patient oral

antibiotics and discharge him home without any investigation .

Treatment in general depends on the population and the

antibiogram that we have in the hospitals .

For examplein our community we dont use Macrolides( azithromycin and

clarithromycin ) , bcoz people have developed resistance to

these drugs .

:

According to the prevalence of resistance for community

acquired pneumonia , we should use fluoroquinolones or

combination of macrolides and 3rd or 4th generation of

cephalosporins.

* If the patient has any co morbidities we should consider the

organism that should be covered , if he has risk factors for

gram negative we give him antibiotics for gram negative , if the

patient is diabetic we should give him antipseudomonasdrugs .

WikiAntibiotics for hospital acquired pneumonia include 3

rd

and4thgeneration cephalosporins , carbpenams, fluroquinolones ,

aminoglycosides and vancomycin.

:

THE END


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DONE BY :Malak Abu-Eishah & Hind Sarayrah.

Special thanx :

Barah Al- Rashdan we are glad to have a friend like

u , enshalla ndal sawa 3la tool .

Dana , Shorooq & Jwana the best ever ( alla la yfare2na

3n b3d )

Group A5 : wallahi the best group ever :

Barah Alrashdan , Reham Nawaf , Areej Salameen , Olga

khawaldeh , Hani 3ed , Laith 3nani , Mohammad Kurd , Suleiman

3neim , Ahmad Salem , Saif Al 3dwan , Samer Kuleib , Mahmoud

Bader , Baraa Al Dahleh , Raed Jaradat .

SAWA GROUP:Rawan , Nour , Salsabeel , Raad , Bashar , Adnan, Rashed..

- Sahar , Reem , Hala , Ansam , Oraib , Lana , Alaa bawa3neh ,Safaa , Rawan , Heba , Nour , Yazan , Husam hadad ,

Rasheed Janaideh , Firas

www.sawa2006.com


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Corrections for Lec.3 : ( correction in bold)

In page 4 : -will increase the possibility to develop asthma .-Eosinophil cationicproteins

In page 6 : PERF : we look for improvement by 60 ml ( or 20 %) or diurnalvariation > 20 % as in dr. slides whereas in kumar book look for 20%

change and at least 60 l/ min on the recorder .

In page 15 : in last point :- the frequency ofnibulizing medication .
http://www.google.jo/search?hl=ar&ei=OX8BS_KGHNWF4QaArNXwCw&sa=X&oi=spell&resnum=0&ct=result&cd=1&ved=0CAYQBSgA&q=eosinophil+cationic+proteins&spell=1http://www.google.jo/search?hl=ar&ei=OX8BS_KGHNWF4QaArNXwCw&sa=X&oi=spell&resnum=0&ct=result&cd=1&ved=0CAYQBSgA&q=eosinophil+cationic+proteins&spell=1http://www.google.jo/search?hl=ar&ei=OX8BS_KGHNWF4QaArNXwCw&sa=X&oi=spell&resnum=0&ct=result&cd=1&ved=0CAYQBSgA&q=eosinophil+cationic+proteins&spell=1http://www.google.jo/search?hl=ar&ei=OX8BS_KGHNWF4QaArNXwCw&sa=X&oi=spell&resnum=0&ct=result&cd=1&ved=0CAYQBSgA&q=eosinophil+cationic+proteins&spell=1http://www.google.jo/search?hl=ar&ei=OX8BS_KGHNWF4QaArNXwCw&sa=X&oi=spell&resnum=0&ct=result&cd=1&ved=0CAYQBSgA&q=eosinophil+cationic+proteins&spell=1

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