PNEUMONIA (Pulmonya

)
RHU Quezon Lecture Series # 2 January 30, 2011 Paolo Victor N. Medina MD Municipal Health Officer Quezon, Quezon

Mga Pinagkunang Sipi:
• Philippine Community Acquired Pneumonia (CAP) Guidelines 2010 • Integrated Management of Childhood Illness (IMCI) • Integrated Management of Childhood Illness (IMCI) Technical Update 2007

Mga Layunin
• Ipakilala sa RHU staff ang madalas na ginagamit na grading ng antas ng ebidensiya sa tinatawag na Evidence Based Medicine • Mabilisang pagbabalik-aral sa anatomiya ng Daanang Hangin (respiratory tract) ng katawan • Balikan ang depinisyon ng Pneumonia/Pulmonya
– Ano ang pulmonya? – Papaanong masasabing may pulmonya ang isang tao?

• Matutunan ang kahalagahan ng

Mga Layunin
• Matutunan ang basic na gamutan ng Pulmonya
– 2010 Clinical Practice Guidelines (para sa matatanda) – IMCI 2007 Technical Update (para sa mga bata)

• Matutunan ang tamang pagpapayo sa mga pasyenteng may pulmonya
– Pag-iwas sa pulmonya

• Mga paalala

Grading System for the Strength of the Recommendations and Quality ofDefinition Evidence Grade
Strength of Recommendation
A B C Good evidence to support a recommendation for or against use Moderate evidence to support a recommendation for or against use Poor evidence to support a recommendation for or against use

Quality of Evidence
Level I Level II Evidence from ≥ 1 randomized control trial Evidence from >1 well-designed clinical trial, without randomization; from cohort or case-control analytic studies (preferably from >1 center); from multiple time series; or from dramatic results of uncontrolled experiments Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports from expert committees

Level III

Ang Daanang Hangin ng Katawan

Ano ang Pulmonya/Pneumonia?
• Pinakasimple: Impeksyon ng lower respiratory tract (ibabang bahagi ng daanang hangin) – mula trachea hanggang alveoli • Sa ating pang araw-araw na karanasan, ang pinakamahalagang matutunan at maintindihan ay ang community acquired pneumonia (CAP)
– “community-acquired” dahil nakukuha

Ano ang Pulmonya/Pneumonia?
• Community Acquired Pneumonia (CAP)
– Impeksyong nakukuha sa community sa loob ng 24 na oras hanggang 2 linggo – Karaniwang sintomas (adult):
• • • • • Ubo (24 hours < 2 weeks) Tachypnea (RR > 20 breaths per minute) Tachycardia (HR > 100 beats per minute) Fever (T > 37.8 C) WITH at least one abnormal chest finding:
– – – – Decreased breath sounds Rhonchi Crackles Wheeze

Ano ang Pulmonya/Pneumonia?
• Community Acquired Pneumonia (CAP)
– Karaniwang sintomas (pediatric):
• Ubo (24 hours < 2 weeks) • Fever (T > 37.8 C) • Fast Breathing:
– RR > 50 per minute (2 to 12 months) – RR > 40 per minute (12 months to 5 years)

• SEVERE: chest indrawing or stridor in a calm child

– WITH at least one abnormal chest finding:
• • • • Decreased breath sounds Rhonchi Crackles Wheeze

Ano ang Pulmonya/Pneumonia?
• PERO kahit may mga nakitang sintomas at senyales gaya ng mga naunang nabanggit, hindi pa rin siguradong CAP ang diagnosis • Pero pwede pa ring gumawa ng presumptive diagnosis ng CAP na ang batayan ay history at P.E. (Grade B Evidence)

Ano ang Pulmonya/Pneumonia?
• Kung may history ng admission sa ospital o long-term health facility sa loob ng 2 linggo, hindi pwedeng maging CAP ang diagnosis • Dapat ding tandaan na kapag elderly ang pasyente, malaki ang posibilidad na wala sila ng mga tinatawag na “classical symptoms” gaya ng lagnat, ubo, dyspnea, etc.

Anong Diagnosic/Laboratory Procedure ang Mahalaga sa Diagnosis ng Pulmonya?

• Hangga’t maari, DAPAT may chest x-ray ang bawat pasyenteng pinaghihinalaang may pneumonia (Grade A Evidence) – CAP CPG 2010
– Matutukoy kung gaano kalala ang pulmonya – Masisiguro ang diagnosis ng pulmonya – Makikita kung may ibang sakit ang pasyente na maipapaliwanag ang kanyang mga sintomas

• Subalit para sa mga lugar o sitwasyong walang sapat na resources o mga pasilidad, pwede nang hindi gawin ang X-ray sa mga sumusunod na kundisyon:
– Mga relatively malusog na tao na may “stable co-morbid conditions” – Normal/Stable vital signs and assuring PE findings – AND nakakasisiguro tayo sa follow-up ng pasyente at pagsunod sa payo

Anong Diagnosic/Laboratory Procedure ang Mahalaga sa Diagnosis ng Pulmonya?

• Hindi na rin kailangan ang CXR kung susundin ang IMCI guidelines (para sa mga 0-5) • Kung magpapagawa ng CXR para sa pasyente, kung gumaganda naman ang

Kailan Dapat I-refer ang Pasyente sa Ospital (Adult)? pagbasehan ang mga • Kailangang

sumusunod sa pagdedesisyon kung sa ospital ba dapat gamutin ang pasyente o pwedeng outpatient (Grade A Evidence)
– Kondisyon ng pasyente sa oras ng pagkonsulta – Kung ang kanyang ibang sakit (comorbid condition) ay hindi stable – CXR Findings – Base sa mga ito, mayroong management-oriented risk

Kailan Dapat I-refer ang Pasyente sa Ospital (Adult)?

• Ang mga pasyenteng mapapabilang sa kategoryang Low-risk ang maaaring gamutin bilang outpatient (Grade A Evidence) • Kung ang pasyente ay nasa categoryang Moderate-risk o Highrisk kinakailangang ma-ospital ang pasyente para sa mas tutukang pagbabantay at gamot na padadaanin sa swero (Grade A

Clinical Features of Patients with CAP According to Risk Categories (CAP CPG 2010)
• LOW-RISK CAP
– Presence of:
• Stable vital signs: RR < 30 breaths/min, PR < 125 beats/min • Temp > 36 C or < 40 C • SBP ≥ 90mmHg, DBP > 60mmHg

– – – –

No altered mental state of acute onset No suspected aspiration No OR stable comorbid conditions CXR
• Localized infiltrates • No evidence of pleural effusion or abscess

Clinical Features of Patients with CAP According to Risk Categories (CAP CPG 2010) • MODERATE-RISK CAP
– ANY of the following:
• Unstable vital signs: RR ≥ 30 breaths/min, PR ≥ 125 beats/min • Temp ≥ 40 C or ≤ 36 C • SBP < 90, DBP ≤ 60 • Altered mental state of acute onset • Suspected aspiration • Decompensated co-morbid condition • CXR
– Multilobar infiltrates – Pleural effusion or abscess

Clinical Features of Patients with CAP According to Risk Categories (CAP CPG 2010) • HIGH-RISK CAP
– ANY of the criteria under moderate risk CAP category PLUS Severe Sepsis and Septic Shock – Need for mechanical ventilation

Kailan Dapat I-refer ang Pasyente sa Ospital (Pedia)?
• Based on IMCI Guidelines:
• • • •

– Presence of ANY Danger Signs
Hindi makasuso/dede o makainom Isinusuka ang lahat Ang bata ay nagkombulsyon Tingnan kung ang bata ay lethargic (sobrang tamlay) o walang malay

– (+) Chest Indrawing OR – (+) Stridor in a CALM child

Pediatric Risk Classification of Pneumonia (based on Pediatric Pneumonia CPG)
Variables PCAP A Minimal Risk
None Yes Possible None Able > 11 mos 50/min 40/min 30/min

PCAP B Low PCAP C Risk Moderate Risk
Present Yes Possible Mild Able > 11 mos >50/min >40/min >30/min Present No Not Possible Moderate Unable < 11 mos >60/min >50/min >35/min

PCAP D High Risk
Present No Not Possible Severe Unable < 11 mos >70/min >50/min >35/min

Co-morbid Illness Compliant Caregiver Ability to Follow-up Presence of Dehydration Ability to Feed Age Respiratory Rate 2-12 mos 1-5 years > 5 years

Pediatric Risk Classification of Pneumonia (based on Pediatric Pneumonia CPG)
Variables PCAP A Minimal Risk
None None None None None Awake

PCAP B Low Risk

PCAP C Moderate Risk

PCAP D High Risk

Signs of Respiratory Failure a. Retraction b. Head bobbing c. Cyanosis d. Grunting e. Apnea f. Sensorium

None None None None None Awake

Intercostal/Subcost Present al Present Present Present Present Present None Lethargic/Stupor None ous/Comatose Irritable Present Present

Supraclavicular/Int ercostal/Subcostal

Complication (effusion, pneumothorax) Action Plan

None

None

OPD Follow up at OPD Follow up the end of after 3 days treatment

Admit to regular ward

Admit to ICU (refer to specialist)

Ano ang Gamutan Para sa Pneumonia?
• ADULT:
– Low-risk CAP without comorbid illness, amoxicillin remains the standard drug of choice (Grade A).
• Amoxicillin 500mg TID x 7 days • 5 to 7 days for low risk uncomplicated pneumonia (Grade B)

– In our setting (dito sa Quezon RHU), we can still try using cotrimoxazole but IT IS NOT RECOMMENDED (dahil sa resistance sa gamot) – For Low-risk CAP with stable comorbid illness – REFER TO RHU MD =)
• Co-amoxiclav • Cefuroxime

Ano ang Gamutan Para sa Pneumonia?
• PEDIA:
– IMCI Technical Update 2007:
• Non-severe Pneumonia:
– 3 days Oral Amoxicillin or Cotrimoxazole – Where resistance to Cotrimoxazole is high, Amoxicillin IS preferred – DOSE: Amoxicillin 25mg/kg/dose BID x 3 days

• Severe Pneumonia:
– Ideally hospitalization – But if not feasible due to lack of resources/logistics, oral amoxicillin may be given

Ano ang Gamutan Para sa Pneumonia?
– Pediatric Pneumonia CPG:
• For a patient PCAP A or PCAP B:
– Oral Amoxicillin 40-50 mg/kg/day TID x 7 days

– Cotrimoxazole:
• 40 mg/kg sulfamethoxazole per day (BID) x 7 days • IMCI 4mg/kg trimethoprim per dose BID

Paano Masasabing Gumagaling ang Pasyenteng May Pneumonia? • ADULT:
– Assess: Temperature, RR, HR, BP, Sensorium, O2 Saturation, Inspired O2 concentration – Dapat gumaganda na ang lagay ng pasyente sa loob ng 24 hanggang 72 oras. (Average: 2 days). Kung hindi gumaganda ang lagay ng pasyente matapos ang 72 oras, dapat ulitin (o magpa) CXR (Grade A) – Kung hindi gumaganda ang lagay ng

Paano Masasabing Gumagaling ang Pasyenteng May • PEDIA: Pneumonia?
– Gumagandang lagay ng Pasyente (lalung-lalo na ang pagbagal ng “fast breathing”) sa loob ng 72 oras (ave. 2 days) matapos umpisahan ang antibiotic – Kung hindi gumaganda ang lagay ng pasyente, REFER!

Pag-iwas sa Pneumonia
• ADULT:
– Ang bakuna laban sa influenza ay inirerekomenda para sa pag-iwas sa Pulmonya (Grade A) – Ang bakunang tinatawag na pneumococcal vaccine ay inirerekomenda para maiwasan ang invasive pneumococcal disease (Grade A) – SMOKING CESSATION is recommended for all patients with CAP

Pag-iwas sa Pneumonia
• Recommendations for Pneumococcal Vaccination (one time vaccination):
– > 60 years old – Persons with chronic illnesses – Immunocompromised persons (mahina ang resistensiya, depensa ng katawan) – Mga nakatira sa nursing home o iba pang long term care facilities – Mga naninigarilyo o may hika edad 19 to 64

Pag-iwas sa Pneumonia
• • • • • ≥ 50 years old Chronic illness Immunosuppression (HIV, CA, etc) Buntis na nasa 2nd or 3rd trimester Mga nakatira sa nursing home o iba pang katulad na pasilidad • Health care personnel • Household contacts and caregivers of children < 5 years and adults ≥ 50 • Household contacts (including children) and caregivers of persons with medical conditions that put them at high risk for severe complications from influenza

THE END
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