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Definition
Pneumonia is an acute
infection of the
parenchyma of the
lung, caused by
bacteria, virus, parasite
etc.
Pneumonia may also be
caused by other factors
including X-ray,
chemical, allergen
Epidemiology
Classification by acquired
environment
Community
acquired pneumoniaCAP
Hospital acquired pneumoniaHAP NP
Nursing home acquired pneumonia,NHAP
Immunocompromised host pneumonia,(ICAP)
CAP
Community Acquired
Pneumonia
Epidemiology:
Adeel A. Butt, MD
EPIDEMIOLOGY
EPIDEMIOLOGY
ICHP
Community Acquired
Pneumonia
Epidemiology: (contd)
fewest cases in 18-24 yr group
probably highest incidence in <5 and >65
yrs
mortality disproportionately high in >65 yrs
Adeel A. Butt, MD
Incidence
1400
1171 1207
1200
1000
# in
1000s
1071
898
800
684
600
# of cases
400
200
83
0
<5
Adeel A. Butt, MD
74.9
70
60
50
# in 40
1000s 30
# of deaths
20
10
5.7
0
<4
5 to 14 15-24
25-44
45-64
>65
Adeel A. Butt, MD
Community Acquired
Pneumonia
age
alcoholism
smoking
asthma
immunosuppression
institutionalization
COPD
PVD
dementia
ID Clinics 1998;12:723.
Am J Med 1994;96:313
Adeel A. Butt, MD
Etiology
pathogenesis
Pneumococci usually
reach the lungs by
inhalation or
aspiration. They lodge
in the bronchioles,
proliferation and
initiate an
inflammatory process.
Source
Route
colonization
aspiration
Air
Non-pulmonary
infection
Contiguous
infection
inhalation
blood
stream
direct
extention
Response
lung
defenses
Outcome
pneu.
PATHOGENESIS
Aspiration :Microaspiration of
contaminated oropharyngeal secretions
seems to be the most important of these
factors, as it is the most common cause of
HAP.
Inhalation
Contamination
Classification
Classification of anatomy
Classification of pathogen
Classification of acquired environment
.Classification by pathogen
Pathogen classification is the most useful
to treat the patients by choosing effective
antimicrobial agents
Risk Factors
Reduced consciousness
Pharyngeal anesthesia
Protracted vomiting
Large volume tube
feedings
Feeding gastrostomy
Recumbent position
Bacterial pneumonia
(1) Aerobic Gram-positive bacteria,such
as streptococcus pneumoniae, staphylococcus aureus, Group A hemolytic
streptococci
(2) Aerobic Gram-negative bacteria, such
as klebsiella pneumoniae, Hemophilus
influenzae, Escherichia coli
(3) Anaerobic bacteria
Atypical pneumonia
Including Legionnaies pneumonia ,
Mycoplasmal pneumonia ,chlamydia pneumonia.
Fungal pneumonia
Fungal pneumonia is commonly caused by
candida and aspergilosis.
pneumocystis jiroveci
Viral pneumonia
Viral pneumonia may be caused by
adenoviruses, respiratory syncytial
virus, influenza, cytomegalovirus,
herpes simplex
Pneumonia caused by
other pathogen
Rickettsias (a fever rickettsia),
parasites
protozoa
.Classification by anatomy
1. Lobar: Involvement of an entire lobe
2. Lobular: Involvement of parts of the lobe only,
segmental or of alveoli contiguous to bronchi
(bronchopneumonia).
3. Interstitial
Pneumonia Lobaris
Pneumonia Interstitial
Lobar pneumonia
Interstitial pneumonia
Lobular pneumonia
Diagnosis
Diagnosis
Clinical diagnosis
Pathogen diagnosis
Evaluate the severity degree of pneumonia
Diagnosis
History
and physical
examination(5W)
X-ray examination
Pathogen identification
Pathogen identification
Clinical manifestation
signs
Consolidation signs
Moist rales
Respiratory rate or heart rate
Laboratory examination
WBC
X-ray features
Pathology
Congestion
red hepatization
grey hepatization
resolution
Pathology
Red hepatilization
Abstraction
Pneumococcal
pneumonia is produced
by
streptococcal
pneumoniae
It is the most commonly
occurring bacterial
pneumonia
Clinical manifestations
Signs 1
The acutely ill patient is tachypneic, and
may be observed to use accessory muscles
for respiration, and even to exhibit nasal
flaring
Fever and tachycardia are present, frank
shock is unusual, except in the later stages
of infection or DIC
Signs 2
Auscultation of the chest reveals
bronchovesicular or tubular breath
sounds and wet rales over the
involved lung
A consolidation occurs, vocal and
tactile fremitus are increased
Laboratory examinations
X-ray examination
Chest radiographs is more sensitive than
physical examination
PA and lateral chest radiographs are
invaluable to detect pneumonia
X-ray examination
Usually lobar or
segmental
consolidation
suggests a bacterial
cause for pneumonia
If blunting of the
costophrenic angle is
noted, pleural
effusion may be exist.
The features of CT
Air-bronchogram sign
Complications
sepsis
lung abscess or
empyema
pleural effusion
pleuritis
ARDS
ARF
pneumothorax
Extrapulmonary infections
Pleural Effusion
GenMed 3
Differential diagnosis
pulmonary tuberculosis
Other microbial pneumonias:
klebsiella pneumonia,
staphylococal pneumonia,
pneumonias due to G (-) bacilli,
viral and mycoplasmal
Acute lung abscess
Bronchogenic carcinoma
Pulmonary infarction
Treatments
Antibiotics
Support therapy
Therapy of complications
Select antibiotics
According to guideline
Therapy
Antibiotic therapy
Treatment with any effective agent
should be given for at least 5 to 7 day or
after the patients have been afebrile for
2-3 days
Outpatient<60 years
old and no comorbid
diseases
Common pathogens:
S pneumoniaes,
M pneumoniae,
C pneumoniae,
H influenzae and
viruses
A new generation
macrolide
A beta-lactam: the first
generation
cephlosporin
A fluoroquinolone
Supportive measure
Treatment of complications
Empyema develops in appoximately 5% of patients
with pneumococcal pneumonia, although pleural
effusion commonly develop in 10%- 20% patients
Chest X-ray with lateral decubitus films are often
useful in the early recognition of pleural effusion,
pleural fluid that is removed should be subjected to
routing examination
If pneumococcal bacteremia occurs, extra pulmonary
complications such as arthritis, endocarditis must be
excluded, because the therapy requires higher dosages
Treatment of infections shock
Prognosis
Prognosis is much better
Any of the following factors makes the prognosis
less favorable and convalescence more prolonged
elderly:
involvement of 2 or more lobes
underlying chronic diseases (heart lung
kidney) normal temperature and WBC
count <5000
immunodeficiency with severe complication
Prevention
Release aspiration
Washing hands
vaccination
Prevention
The most important
preventive tool available
is using a poly valent
pneumococcal vaccine
in those with chronic
lung diseases, chronic
liver diseases,
splenectomy, diabetes
mellitus
and aged