You are on page 1of 50

Pneumonia @ Acute

Dr. mohammad Kharraz
Courtesy of Up To Date



RLL Lingula
Acute inflammation of the tracheobronchial tree,
generally self-limited and with eventual complete
healing and return of function.
Though commonly mild,
bronchitis may be serious in debilitated patients and
those with chronic lung or heart disease.
Pneumonia is a critical complication
Acute infectious bronchitis
Acute irritative bronchitis
Cough-variant asthma
 It may develop after a common cold or other viral infection of the
nasopharynx, throat, or tracheobronchial tree, often with secondary
bacterial infection.
 Mycoplasma pneumoniae and Chlamydia also cause a. in. b., often in
young adults.
 Recurrent attacks often complicate chronic bronchopulmonary
diseases, which impair bronchial clearance mechanisms.
 Repeated infections may be associated with:
 chronic sinusitis
 bronchiectasis
 bronchopulmonary alergy
 in children – hypertrophied tonsils and adenoids.
 May be caused by various mineral and vegetable dusts; fumes
from strong acids, ammonia, certain volatile organic solvents,
chlorine, hydrogen sulfide, sulfur dioxide, or bromine; the
environmental irritants ozone and nitrogen dioxide; or tobacco or
other smoke.
 Asthma in which the degree of bronchoconstriction is not sufficient
to produce overt wheezing.
 It may be caused by allergen inhalation, or chronic exposure to an
airways irritant (airways hyperreactivity relatively mild)
 Hyperemia of the mucous membranes

 desquamation, edema leukocytic infiltration of the submucosa

 production of sticky or mucopurulent exudate
 The protective functions of bronchial cilia, phagocytes, and
lymphatics are disturbed

 bacteria may invade the bronchi

 accumulation of cellular debris and mucopurulent exudate
 Cough, though distressing, is essential to eliminate bronchial secretions

•edema of the bronchial

•retained secretions airways
•in same cases → spasm obstruction
of bronchial muscules
• Coryza
• Malaise
• Fever
• Chills
• Back and Muscle pain
• Sore throat
 Cough initially dry and nonproductive----
 small amount of viscid sputum are raised after a few hours or
 It may later become abundant and more mucoid or
 Frankly purulent sputum suggets superimposed bacterial
 Persistant fever suggests complicated pneumonia.
 Dyspnea may be notable secondary to airway obstruction.
• Scattered high-or-low-pitch rhonchi or
• Occasional crackling or
• Wheezes especially after cough.
• Persistant localized signs suggest bronchopneumonia.
• The most common causes of acute bronchitis are viruses.
• Influenza,Parainfluenza, RSV, rhinovirus andadenovirus, and corona
viruses are the main viral genera, but many people develop fairly
mild symptoms so often the viral genus is never determined.
• Bacteria are less common the causative agents of acute bronchitis
• Mycoplasma,
• Streptococcus,
• Bordetella,
• Moraxella,
• Haemophilus, and
• Chlamydia pneumoniae.
• In addition, other agents such as tobacco smoke, chemicals and air
pollution may irritate the bronchi and cause acute bronchitis.
• The majority of people with acute bronchitis are contagious if the
cause is an infectious agent such as a virus or bacterium.
• People are usually less likely to be contagious as the symptoms wane.
• However, acute bronchitis that is caused by exposure to pollutants,
tobacco smoke, or other environmental agents is not contagious.
history and physical exam.
If the diagnosis is not clear or the specific cause needs to be identified ,
such tests as
sputum cytology,
throat cultures,
influenza tests,
chest X-rays,
blood gas,
. In many people, the symptoms of acute bronchitis are mild to moderate
and symptoms like cough are treated for a few days before a more
extensive workup is begun
Pneumonia is an infection that inflames the air sacs in one or
both lungs. The air sacs may fill with fluid or pus, causing
cough with phlegm or pus, fever, chills and difficulty breathing.
A variety of organisms, including bacteria, viruses and fungi,
can cause pneumonia.
Pneumonia can range in seriousness from mild to life-
It is most serious for infants and young children,
people older than age 65, and people with underlying
health problems or weakened immune systems.
 Pneumonia results from the proliferation of microbial pathogens at the alveolar level and the host's
response to those pathogens
 Microorganisms gain access to the lower respiratory tract in several ways: »»»»»»»»»»»»»»»»»»
• The most common is by aspiration from the oropharynx
• Many pathogens are inhaled as contaminated droplets
• pneumonia occurs via hematogenous spread
• contiguous extension from an infected pleural or mediastinal space
 Mechanical factors are critically important in host defense: »»»»»»»»»»»»
 hairs and turbinates of the nares catch larger inhaled particles
 branching architecture of the tracheobronchial tree traps particles on the airway lining
 mucociliary clearance and local antibacterial factors either clear or kill the potential pathogen
 gag reflex and the cough mechanism
 normal flora adhering to mucosal cells of the oropharynx
 resident alveolar macrophages
• The host inflammatory response, rather than the proliferation of microorganisms, triggers the clinical syndrome of
The release of inflammatory mediators, such as IL-1 and TNF »»»»»»»»»»»» fever
Chemokines, such as IL-8 and GCSF, stimulate the release of neutrophils and their attraction to the lung »»»»»»»»»»»
peripheral leukocytosis and increased purulent secretions
• Even erythrocytes can cross the alveolar-capillary membrane, with consequent hemoptysis
• The capillary leak results in a radiographic infiltrate and rales detectable on auscultation
• hypoxemia results from alveolar filling
• some bacterial pathogens appear to interfere with the hypoxic vasoconstriction that would normally occur with fluid-filled
alveoli, and this interference can result in severe hypoxemia
• Increased respiratory drive in the SIRS leads to respiratory alkalosis
• Dyspnea due to :

Decreased compliance due to capillary leak Hypoxemia

increased respiratory drive increased secretions
infection-related bronchospasm
 - etiologic agents in CAP includes bacteria, fungi, viruses, and protozoa
 -Newly identified pathogens include hantaviruses, metapneumoviruses, the coronavirus (SARS), and community-
acquired strains of MRSA
 Most cases of CAP are caused by relatively few pathogens
-Streptococcus pneumoniae is most common
 other organisms must also be considered in light of the patient's risk factors and severity of illness
 it is most useful to think of the potential causes as either "typical" or "atypical" organisms
 -Typical bacterial pathogens includes : S. pneumoniae, Haemophilus influenzae, S. aureus , gram-negative bacilli
such as Klebsiella pneumoniae and Pseudomonas aeruginosa
 -Atypical organisms include : Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella spp, respiratory
viruses such as influenza viruses, adenoviruses, RSVs
-The atypical organisms cannot be cultured on standard media, nor can they be seen on Gram's stain-
are intrinsically resistant to all -lactam agents and must be treated with macrolide, fluoroquinolone, tetracycline
 Data suggest that a virus may be responsible in up to 18% of cases of CAP
 In the ~10–15% of CAP cases that are polymicrobial
• aInfluenza A and B viruses, adenoviruses, respiratory syncytial viruses,
parainfluenza viruses
•Anaerobes play a significant role only when an episode of aspiration has
occurred days to weeks before presentation for pneumonia.
• combination of an unprotected airway (alcohol or drug overdose or a seizure
disorder) and significant gingivitis constitutes the major risk factor.
•Anaerobic pneumonias are often complicated by abscess formation and
significant empyemas or parapneumonic effusions
•S. aureus pneumonia is well known to complicate influenza infection.
Table 251-2 Microbial Causes of Community-Acquired Pneumonia, by Site of Care

Hospitalized Patients
Outpatients Non-ICU ICU
Streptococcus pneumoniae S. pneumoniae S. pneumoniae
Mycoplasma pneumoniae M. pneumoniae Staphylococcus aureus
Haemophilus influenzae Chlamydophila pneumoniae Legionella spp.
C. pneumoniae H. influenzae Gram-negative bacilli
Respiratory virusesa Legionella spp. H. influenzae

Respiratory viruses
Table 251-3 Epidemiologic Factors Suggesting Possible Causes of Community-Acquired

Factor Possible Pathogen(s)

Alcoholism Streptococcus pneumoniae, oral anaerobes, Klebsiella
pneumoniae, Acinetobacter spp., Mycobacterium tuberculosis
COPD and/or smoking Haemophilus influenzae, Pseudomonas aeruginosa, Legionella
spp., S. pneumoniae, Moraxella catarrhalis, Chlamydophila
Structural lung disease (e.g., P. aeruginosa, Burkholderia cepacia, Staphylococcus aureus
Dementia, stroke, decreased Oral anaerobes, gram-negative enteric bacteria
level of consciousness
Lung abscess CA-MRSA, oral anaerobes, endemic fungi, M. tuberculosis,
atypical mycobacteria
Travel to Ohio or St. Histoplasma capsulatum
Lawrence river valleys
Travel to southwestern Hantavirus, Coccidioides spp.
United States
Travel to Southeast Asia Burkholderia pseudomallei, avian influenza virus
Stay in hotel or on cruise Legionella spp.
ship in previous 2 weeks
Local influenza activity Influenza virus, S. pneumoniae, S. aureus
Exposure to bats or birds H. capsulatum
Exposure to birds Chlamydophila psittaci
Exposure to rabbits Francisella tularensis
Exposure to sheep, goats, Coxiella burnetii
parturient cats
 In the US, ~80% of the 4 million CAP cases that occur annually are treated on an outpatient basis
 The incidence rates are highest at the extremes of age
RF for CAP: alcoholism, asthma, immunosuppress, institutionalization, age of
70Y versus 60–69 Y
 RF for pneumococ: dementia, seizure, heart failure, CVA, alcoholism,
smoking, COPD, HIV
 RF for CA-MRSA: homeless youths, men who have sex with men, prison
inmates, military recruits, children in day-care centers, and athletes such as
 RF for Enterobacteriaceae: recently hospitalization and/or antibiotic therapy,
comorbidities such as alcoholism, heart failure, renal failure
 RF for P. aeruginosa : as above, severe structural lung disease
 RF for Legionella: diabetes, hematologic malignancy, cancer, severe renal
disease, HIV infection, smoking, male gender, a recent hotel stay or ship
 CAP can vary from indolent to fulminant in presentation and from mild to fatal in severity
 constitutional findings and manifestations limited to the lung and its associated structures
 fever, tachycardia, chills and/or sweats
 cough that is either nonproductive or productive of mucoid, purulent, or blood-tinged sputum
 the patient may be able to speak in full sentences or may be very short of breath
 If the pleura is involved, the patient may experience pleuritic chest pain
 Up to 20% of patients may have GI symptoms such as nausea, vomiting, and/or diarrhea
 Other symptoms may include fatigue, headache, myalgias, and arthralgias
 An increased respiratory rate and use of accessory muscles of respiration are common
 Palpation may reveal increased or decreased tactile fremitus
 Percussion can vary from dull to flat, reflecting underlying consolidated lung and pleural fluid
 Crackles, bronchial breath sounds, and possibly a pleural friction rub may be heard
 Severely ill patients who have septic shock are hypotensive and may have evidence of organ
• a sputum sample must have >25 neut and <10 squamous epithelial cells per low-power field
• sensitivity / specificity of the sputum Gram's stain and culture are highly variable »»»»»»»»»
in cases of proven bacteremic pneumococc, the yield of positive cultures from sputum samples is 50%

• Some patients, particularly elderly individuals, may not be able to produce an appropriate
expectorated sputum sample.
• The inability to produce sputum can be a consequence of dehydration, and the correction of this
condition may result in increased sputum production and a more obvious infiltrate on radiography
• For patients admitted to the ICU and intubated, a deep-suction aspirate or BAL sample
1) The yield from blood cultures, even those obtained before antibiotic therapy, is disappointingly
 Only ~5–14% of cultures of blood from patients hospitalized with CAP are positive
 the most frequently isolated pathogen is S. Pneumoniae
2) Since recommended empirical regimens all provide pneumococcal coverage, a blood culture
positive for this pathogen has little effect on clinical outcome ************* susceptibility data
may allow a switch from a broader-spectrum regimen to penicillin in appropriate cases
 Because of 1) the low yield and 2) the lack of significant impact on outcome, blood cultures are no
longer considered de rigueur for all hospitalized CAP patients
should have blood cultured : 
 neutropenia secondary to pneumonia
 Asplenia
 complement deficiencies
 chronic liver disease
 severe CAP
 Two commercially available tests detect
a) pneumococcal
b) certain Legionella antigens in urine
 The test for Legionella pneumophila detects only serogroup 1, but this serogroup accounts for
most CAP cases of Legionnaires' disease
 The sensitivity and specificity of the Legionella urine antigen test are as high as 90% and 99%
 The pneumococcal urine antigen test is also quite sensitive and specific 80% and >90%
 false-positive results can be obtained with samples from colonized children,but the test is reliable
 Both tests can detect antigen even after the initiation of appropriate antibiotic therapy and after
weeks of illness
 Other antigen tests include a rapid test for influenza virus and direct fluorescent antibody tests
for influenza virus and RSV
 the test for RSV is only poorly sensitive
PCR tests are available for a number of pathogens, including :
• L. Pneumophila
• Mycobacteria

a multiplex PCR can detect the nucleic acid of

• Legionella spp.
• M. Pneumoniae
• C. pneumoniae
 Look at the diaphram:
for tenting
free air
abnormal elevation
 Margins should be sharp
(the right hemidiaphram is
usually slightly higher than
the left)
 Size,Shape
 Silhouette-margins should be sharp
 Diameter (>1/2 thoracic diameter is enlarged heart)
: AP views make heart appear larger than it actually is.
Cardiac Silhouette

1. R Atrium 4. Superior Vena Cava 7. Pulmonary Valve

2. R Ventricle 5. Inferior Vena Cava 8. Pulmonary Trunk
3. Apex of L Ventricle 6. Tricuspid Valve 9. R PA 10. L PA
Margins should
be sharp
Loss of Sharp Costophrenic Angles
• The hilar – the large blood vessels
going to and from the lung at the
root of each lung where it meets
the heart.
• Check for size and shape of aorta,
nodes,enlarged vessels
• Infiltrates
• Increased interstitial markings
• Masses
• Absence of normal margins
• Air bronchograms
• Increased vascularity