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PRESENTED BY:

AMBREEN MALIK UTTRA ROLL# 55 UMME-HABIBA HASSAN ROLL# 40

HISTORY:

Pneumonia has been a common disease throughout human history. The symptoms were described by Hippocrates (460 BC 370 BC) Hippocrates referred to pneumonia as a disease "named by the ancients. Maimonides(11351204 AD) observed "The basic symptoms that occur in pneumonia and that are never lacking are as follows: acute fever, sticking pleuritic pain in the side, short rapid breaths, serrated pulse and cough. Bacteria were first seen in the airways of individuals who died from pneumonia by Edwin Klebs in 1875.

Initial work identifying the two common bacterial causes Streptococcus pneumoniae and Klebsiella pneumoniae was performed by Carl Friedlander and Albert Frnkel in 1882 and 1884, respectively.

Sir William Osler, known as "the father of modern medicine," appreciated the death and disability cause by pneumonia, describing it as the "captain of the men of death" in 1918, as it had overtaken tuberculosis as one of the leading causes of death in this time. Osler also described pneumonia as "the old man's friend as death was often quick and painless when there were many slower more painful ways to die.

EPIDEMIOLOGY:

Pneumonia is a common illness affecting approximately 450 million people a year and occurring in all parts of the world. It is a major cause of death among all age groups resulting in 4 million deaths (7% of the world's yearly total). Rates are greatest in children less than five, and adults older than 75 years of age. It occurs about five times more frequently in the developing world versus the developed world.

DEFINITION OF PNEUMONIA: It is defined as inflammation of lung parenchyma i.e. of alveoli rather than bronchi or bronchioles, of infective origin and characterized by consolidation. Consolidation is a pathological process in which the alveoli are filled with a mixture of inflammatory exudates, bacteria and WBC that on chest X-ray appears as an opaque shadow in normally clear lungs.

Pneumonia is an inflammatory condition of the lung especially affecting the microscopic air sacs (alveoli) associated with fever, chest symptoms, and a lack of air space (consolidation) on a chest X-ray. Pneumonia is typically caused by an infection but there are a number of other causes.
Infectious agents include: bacteria, viruses, fungi, and parasites.

Typical symptoms include cough, chest pain, fever, and difficulty breathing.

Pneumonia is typically diagnosed based on a combination of physical signs and a chest X-ray The World Health Organization has defined pneumonia in children clinically based on either a cough or difficulty breathing and a rapid respiratory rate, chest indrawing, or a decreased level of consciousness. A rapid respiratory rate is defined as greater than 60 breaths per minute in children under 2 months old, 50 breaths per minute in children two months to one year old, or greater than 40 breaths per minute in children one to five years old.

In adults, investigations are in general not needed in mild cases as if all vital signs and auscultation are normal the risk of pneumonia is very low. In those requiring admission to a hospital, pulse, chest radiography, and blood tests including a complete blood count, serum electrolytes, C-reactive protein, and possibly liver function tests are recommended. The diagnosis of influenza-like illness can be made based on the presenting signs and symptoms however verification of an influenza infection requires testing. Thus treatment is frequently based on the presence of influenza in the community or a rapid influenza test.

Vaccination is effective for preventing certain bacterial and viral pneumonias in both children and adults.

Influenza vaccines are modestly effective against influenza A and B. The Center for Disease Control and Prevention (CDC) recommends that everyone 6 months and older get yearly vaccination. When an influenza outbreak is occurring, medications such as amantadine, rimantadine, zanamivir, and oseltamivir can help prevent influenza.

Treatment depends on the underlying cause. Presumed bacterial pneumonia is treated with antibiotics.

Vaccinations against Haemophilus influenzae and Streptococcus pneumoniae have good evidence to support their use. Vaccinating children against Streptococcus pneumoniae has also led to a decreased incidence of these infections in adults, because many adults acquire infections from children. A vaccine against Streptococcus pneumoniae is also available for adults, and has been found to decrease the risk of invasive pneumococcal disease.

CLASSIFICATION OF PNEUMONIA:

Community acquired pneumonia

Hospital acquired pneumonia

Aspiration pneumonia

DEFINITION:
Pneumonia that begins outside of the hospital or is diagnosed within 48 hrs after the admission to the hospital in a patient who has not resided in long term care facility for 14 days or more before the onset of symptoms.

PATHOPHYSIOLOGY:

Pulmonary defense mechanisms (cough reflex, mucociliary clearance system, immune responses) normally prevent the development of LRTI following aspiration of oropharyngeal secretions containing bacteria or inhalation of infected aerosols. Aspiration pneumonia occurs when there is defect in or more of normal host defense mechanisms or when a very large infections inoculums or a highly virulent pathogen overwhelms the host.

Risks Factors :

Age Co morbidities: Pulmonary disease Cardiac disease Liver disease Renal disease Preceding influenza Alcohol abuse Tobacco abuse Immunosuppression HIV/AIDS Chronic corticosteroid use

ETIOLOGY: S.pneumoniae is the most common cause followed by H.influenzae and Mycoplasma pneumoniae.S.aureus, Legionella species, Moraxella and Chlamydia accounts for most of the remainder. Viruses accounts for up to 15 percent. CLINICAL FEATURES: SIGNS AND SYMPTOMS: I-PNEUMOCOCCAL LOBAR PNEUMONIA a-Cough initially dry and then may be blood stained, rust colored b- Fever c- Dyspnea d- WBC count is raised e- Chest x-ray shows consolidation confined to one or more lobes of lungs

II- BRONCHOPNEUMONIA
a- Productive cough b- Breathlessness c- Patchy consolidation on chest x-ray usually in the bases of both lungs

III.ATYPICAL PNEUMONIA
a- Fever b- Dry cough c- Widespread consolidation in the bases of both lungs d- Abnormalities in liver enzymes

DIAGNOSIS:
1. Sputum culture: Test to detect & identify bacteria and fungi that infect lungs/ breathing passages. 2. Bronchoscopy and bronchoalveolar lavage: Bronchoscope is passed through mouth/nose in to lungs & fluid is squirted into a small part of lung & then recollected for examination. It is performed to diagnose lung disease.

3-Blood culture: It is a microbiological culture of blood to detect infection in blood stream (bacterimia, septicemia).This is possible because blood stream is sterile environment.

TREATMENT:
MILD: Amoxicillin 500mg-1gq 8hr (PO) + Erythromycin 500mg q6hr (PO). or Fluoroquinolone i-e Levofloxacin 500mg OD(PO). or Moxifloxacin 400mg OD (PO). SEVERE: Co amoxiclave I/V or cephalosporin I/V (e.g. Cefuroxime 1.5g q 8hr I/V) and Erythromycin 1g q 6hr I/V.

DURATION OF THERAPY:

Therapy is continued until pt. is afebrile for atleast 72 hr for pneumonia due to S.pneumoniae and a minimum of 2 week of therapy is appropriate for pneumonia due to S.aureus, M.pneumoniae.

PREVENTION:

Polyvalent pneumococcal vaccine e.g. 23-valent Pneumovax II, 0.5 ml S/C is used

Brand Names: Pneumovax 23, Pnu-Imune 23, Prevnar

INDICATIONS FOR VACCINATION:


Age

> 65 Any chronic illness that increase the risk of CAP e.g. Chronic heart, renal or lung disease Diabetes mellitus Immunosuppression e.g. decreased spleen function

Revaccinate after 6 yrs.

Influenza Vaccine
The intramuscular vaccine consists of purified surface protein antigens from killed virus. Influenza vaccination has been demonstrated to not only reduce the incidence of clinical and serologically-confirmed influenza, but also reduces the risk for CAP, and for CAPrelated mortality.

Smoking cessation
People who smoke cigarettes should also receive the vaccine.

Treat comorbities

DEFINITION: Pneumonia developing more than 48 hrs after admission to hospital

PATHOPHYSIOLOGY:

Colonization of pharynx and possibly the stomach with bacteria is the most important step in the pathogenesis of nosocomial pneumonia. Impaired cellular and mechanical defense mechanism in the lungs of hospitalized pts raise the risk of infection.

Tracheal intubation increase the risk of lower RTI by mechanical obstruction of trachea, impairment of mucociliary clearance and interference with coughing

RISK FACTORS :

Mechanical ventilation ICU admission Aspiration risks: Swallowing dysfunction Supine positioning Tracheal intubation Tracheostomy Oropharyngeal microbial colonization Elevated gastric pH Immunosuppression Hyperglycemia/Poor glycemic control

ETIOLOGY:
Most common causes are Gram ve Bacilli (Enterobacteriaceae, Pseudomonas spp.) S.aureus

And

CLINICAL FEATURES: SIGNS AND SYMPTOMS:


These are usually non specific however one or more clinical findings are present in some patients. Fever Leucocytosis Purulent sputum Nosocomial pneumonia accounts for 10-15% of all hospital acquired infections usually presenting with sepsis and respiratory failure.

DIAGNOSIS:

Sputum culture Bronchoalveolar lavage Blood culture may be +v

TREATMENT:
a- Cefuroxime 750mg-1.5g q 8hr I/V + Gentamicin 5.1mg/kg I/V (OD) b- Piperacillin 4.5g q 8hr I/V + Gentamicin 5.1mg/kg I/V (OD) Therapy should be continued for 14 21 days

PREVENTION :

Avoid invasive mechanical ventilation Infection control measures Elevate head of bed Subglottic suctioning Oral / pharyngeal decontamination Maintain gastric acidity

DEFINITION:
Pneumonia caused by inhalation of stomach contents contaminated by bacteria from mouth.

It is a condition which may be seen either in community acquired pneumonia or hospital acquired pneumonia.

PATHOPHYSIOLOGY :

Aspiration of infected pharyngeal or gastric secretions deliver bacteria directly to lower airways

Pneumonia fills the lung's alveoli with fluid, hindering oxygenation. The alveolus on the left is normal, whereas the one on the right is full of fluid from pneumonia

RISK FACTORS:

1- Loss of protective air way reflexes ( swallowing & cough ) caused by :


a- Altered state of consciousness. b- Alcohol or drug overdose. c- During resuscitation procedures. d- Seriously ill or debilitated patients. e- Abnormalities of gag and swallowing reflexes. f- NG tube feeding.

2-Effects of aspiration depends on volume and character of aspirated material

a- Particulate matter aspiration - results in mechanical blockage


of airways and secondary infection. b- Anaerobic bacterial aspiration from oropharyngeal secretions. c- Gastric juice aspiration destructive to alveoli, capillaries and results in outpouring of protein rich fluid in to interstitial and intra alveolar spaces(impairs the exchange of CO2, O2 thus producing hypoxemia and respiratory failure).

ETIOLOGY:
Causative agents include S.pneumonia, Anaerobes

Clinical Features : Signs and symptoms :


a- Tachycardia, fever. b- Dyspnea, cough, tacypnea. c- Cyanosis. d- Crackles, wheezing. e- Pink, frothy sputum.

Diagnosis :
Chest X- ray may be normal initially but with the time shows consolidation.

The following tests may also help diagnose this condition:

Arterial blood gas Blood culture Bronchoscopy Chest x-ray Complete blood count (CBC) CT scan of the chest Sputum culture
CT of the chest demonstrating right sided pneumonia

TREATMENT:
Cefuroxime 1.5g q 8hr I/V + Metronidazole 500mg q 8hr I/V

MANAGEMENT OF PNEUMONIA:

Clear the obstructed air way a- If foreign body is visible it may be removed manually. b- If patient has aspirated solid particles, place the patient in tilted head-down on right side. Laryngoscopy or bronchoscopy. Fluid volume replacement for correction of hypotension. Antimicrobial therapy if there is evidence of super imposed bacterial infection. Correction of acidosis. Oxygen therapy and assisted ventilation.

The CURB-65 score is useful for determining the need for admission in adults. If the score is 0 or 1 people can typically be managed at home,
If it is 2 a short hospital stay or close follow up is needed, If it is 35 hospitalization is recommended.
CURB-65

Symptom
Confusion Urea>7 millimol/L Respiratory rate>30 SBP<90 mmHg , DBP<60 mmHg Age> 65

Points
1 1 1 1 1

CURB-65 Score
Clinical Features: Confusion: absent Blood Urea Nitrogen: less than/equal to 7 millimol per L) Respiratory rate: less than 30 breaths per minute Blood pressure: systolic greater than/equal to 90 and diastolic greater than 60 Age: less than 65 CURB-65 = 0: Low risk; consider home treatment

In children those with respiratory distress or oxygen saturations of less than 90% should be hospitalized.

The utility of chest physiotherapy in pneumonia has not yet been determined.

Over-the-counter cough medicine has not been found to be effective

WHO GUIDELINES FOR TREATING PNEUMONIA:


Following are some recommendations included in the guidelines

Because infants 6 months and younger cannot get the flu shot or nasal spray, their parents and caregivers should be sure to get the vaccine.

When antibiotics are necessary, amoxicillin should be first-line therapy for bacterial pneumonia, because it is safe and effective. Many doctors prescribe more powerful antibiotics, which are unnecessary and can kill off good bacteria in the body.
Although pneumonia from methicillin-resistant Staphylococcus aureus (MRSA) is uncommon, it can cause severe illness, so physicians need to consider it if a child doesn't improve after first-line antibiotic therapy.

HOME TREATMENT OF PNEUMONIA:


Home treatment is important for recovery from pneumonia. The following measures can help you recover and avoid complications:

Get plenty of rest. Drink plenty of fluids to prevent dehydration.

Take care of your cough if it is making it hard for you to rest. A cough is one way your body gets rid of the infection. And you should not try to stop your coughing unless it is severe enough to make breathing difficult, cause vomiting, or prevent rest.

Consider taking acetaminophen (such as Tylenol) or aspirin to help reduce fever and make you feel more comfortable. Do not give aspirin to anyone younger than 20 because of the risk of Reye syndrome.

REFERENCES:
1- Current medical diagnosis and treatment by Mc phee,Papadalris 2- Oxford handbook of clinical medicine by Congmore,Wilkinson,Turmezei and Kay Chemung 3- Clinical pharmacology and therapeutics by Roger walker and Cate whittle sea.

4- www.google.com