APPROACH TO COMMON

RESPIRATORY DISEASE
1. PNEUMONIA
2. PNEUMOTHORAX
3. PLEURAL EFFUSION

MO SUPERVISOR : DR DANTE GAN

SPECIALIST : DR HO TH
PNEUMONIA

by Kimberly Lim
INTRODUCTION

• Pneumonia is an infection in one or both of your lungs

• Characterised primarily by inflammation of the alveoli in the lungs
TYPES OF PNEUMONIA
• BASED ON THE AREAS INVOLVED:
• Lobar pneumonia: affects a lobe (section) of the lung
• Bronchopneumonia: affects patches throughout both lungs
BASED ON

•Community acquired pneumonia:

• is the most common type of pneumonia.
• The causal organism are those that is found in the community.
• Bacteria organisms are such as Streptococcus pneumoniae, Haemophilus influenza Staphylococcus
aureus and atypical organisms such as Moxiella catarrhalis, Chlamydia pneumonia and Legionella
penumophilia and Mycoplasma pneumoniae.
• In Malaysia, Mybacoteruim tuberculosis which causes tuberculosis is one of the most commonest
cause of pneumonia in the community.
• Generally, Streptococcus pneumonia is the commonest cause of pneumonia worldwide.
• Viruses that causes pneumonia are influenza virus, respiratory syncitial virus, adenovirus,
parainfluenza virus and the H1N1 viruses.
• Apart from bacteria and viruses, other organisms that can cause pneumonia are parasites
such Toxoplasma gondii, Strongyloides stercoralis dan Ascaris. These organism entres the body via
the skin or feco-orally and reaches the lung via the blood stream. Parasites can cause an immune
reaction which is called “eosniophilic pnuemonitis”.
Hospital Acquired Pneumonia:
• Also know as nosocomial pneumonia.
• This type of pneumonia occurs after 72 in hospital or after 72 or discharge from hospital due to other conditions.
• Causal organisms are Klebsiella, Pseudomonas, Enterobacter, Serratia and Methicillin Resistant
Staphylococcus Aureus (MRSA). 
• Hospital acquired pneumonia is more serious compared to community acquired pneumonia.
• Factors which predisposes to hospital acquired pneumonia are prolonged malnutrition, cardiac and lung
diseases, and low gastric acid.
• All these factors reduces the immune system to overcome an infection.
• Pneumonia associated with ventilation (Ventilator-associated-pneumonia) is a subset of nosocomial
pneumonia when it occurs 48 hours after invasive ventilation.
Healthcare associated Pneumonia (HCAP)

• pneumonia that affects residents of health facilities such as nursing homes.

Pneumonia in the immunocompromised/Immunosuppressed

• These are group of patients such as people living with the human immunodeficiency virus (PLHIV) or
those with acquired human immunodeficiency syndrome (HIV), patients receiving chemotherapy or
steroids, chronic renal failure patients and cancer patients.
• Organisms involved are similar the ones above, however they can also be infected by germs which do not
cause harm to normal individuals
• These are the cytomegaloviruses, Pneumocystis jiroveci, Penumocystis carini, Cryptococcus neoformas,
Coccidioides immitis and Histoplasma capsulatum, Mycobacterium avium-intercellulare and ‘invasive

aspergillosis or ‘invasive candidiasis’.
Others

• Chemical Pneumonitis: caused by inhaling pesticides

• Aspiration pneumonia:This occurs when materials from the mouth or gastric contents
are aspirated into the lungs. Apart from aspirating toxic agents anaerobic organisms
can also be aspirated. This type of pneumonia is one of the main cause of pneumonia
among patients with poor gag reflex for example those who are comatose.

• Interstitial pneumonia: involves the space between one alveolus and another, usually
caused by viruses or atypical bacteria
SIGNS AND SYPMTOMS
• High grade fever with or without chills and rigor
• Cough with productive sputum
• Shortness of breath
• Tachycardia
• Chest pain during dee breathing/ cough
• Fatigue, myalgia, arthralgia
• Nausea, Vomitting, Diarrhoea
• Cyanosis
• Streptococcus pneumonia:Rusty colored sputum
• Pseudomonas, Haemophilus and pneumococcal species: may produce greenish sputum
• Klebsiella species: Foul smelling sputum
Etiology

Streptococcus pneumonia,Mycoplasma pneumonia, Legionella

pneumophilia, Chlamydia pneumonia, Staphylococcus aureus,
Moraxella catarrhalis, Streptococcus pyogenes, Neisseria
Bacteria
meningitidis, Klebsiella Pneumoniae , Hemophillus influenzae,
Pneumocystis jirovecii,Chlamydia psittaci,Coxiella burnetii (Q
fever), Actinomyces israelii

Coronavirus, Influenza virus,Parainfluenza, Adenovirus,

Viruses
Rhinovirus,Measles, Herpes simplex, varicella,cytomegalovirus,

Fungi Pneumocystis carini

Stages of pneumonia
Risk factors

• Extremes of age
• Cigarrete smoking
• Recent viral respiratory infection(eg influenza)
• U/L stroke, dementia, Parkinsons (those with dysphagia or impaired consciousness)
• Chronic lung disease: COAD, bronchiectasis , cystic fibrosis
• Heart disease
• Long hospital stay
• corticosteroid therapy, HIV
• Indoor air pollution
COMPLICATIONS
• Parapneumonic effusion - common
• Bacteremia and sepsis
• Retention of sputum causing lobar collapse
• Lung abcess/ Empyema
• Pleural effusion
• Pneumothoras - particularly with staph aureus
• Shock
• Respiratory failure
• DVT, PE
• Endocarditis, hepatitis, myocarditis
Differential diagnosis

• Pulmonary infarction
• Pulmonary/Pleural TB
• Pulmonary oedema
• Pulmonary eosinophillia
• Malignancy: Bronchoalveolar cell carcinoma
• Rare disorders: cryptogenic organising pneumonia/ bronchiolitis obliterans organising
pneumonia (COP/BOOP)
Investigations

• FBC
• RP (urea, hyponatremia)
• LFT
• CRP/ESR
• Blood c&s
• Sputum c&s
• Sputum for TB C&S, sputum AFBx3
• COVID 19 PCR
• CXR, ABG
Treatment
• Uncomplicated CAP
Amoxicillin 500mg TDS fot 1 week

CLarithromycin 500mg BD (if allergic to penicillin)

• If staphylococcus is cultured/suspected
IV Flucloxacillin 1-2g QID + IV Clarithromycin 500mg BD

• If Mycoplasma or Legionella suspected

IV Clarithromycin 500mg BD or IV Erythromycin 500mg QID

plus IV Rifampicin 600mg BD (in severe cases)

SEVERE CAP

• IV Clarithromycin 500mg BD or IV Erythromycin 500mg QID plus

• IV Coamoxiclav 1.2g TDS or IV Ceftriaxone 1-2g OD or IV Cefuroxime 1.5g TDS or
• IV Amoxicillin 1g QID plus IV Flucloxacillin 2g QID
HAP

• early onset HAP:

no previous abx: co amoxiclav or cefuroxime

received abx: Piperacillin+tazobactam/ thrid generation cephalosporin+aminoglycoside

• MRSA:Vancomycin/linezolid
• A.Baumanii: Carbapenem
• *Physiotherapy
VACCINATION

• Pneumococcal conjugate vaccine (Prevnar): for children less than 2 years old with
underlying heart or respiratory disease

• Pneumococcal polysaccharide vaccine (Pneumovax): for elderly, smokers, diabetics,

asplenia, underlying respiratory ,kidney or heart diease which are high risk of
developing pneumococcal pneumonia. Given every 5 years.
PLEURAL EFFUSION

Nur Haziqah Suraya Abdul Haris

DEFINITION

• Pleural effusion is defined as an abnormal collection of fluid in the pleural

space due to excessive fluid production or decreased lymphatic absorption

• It can be detected on X-ray when 300 mL or more of fluid is present and

clinically when 500 mL or more is present
PATHOPHYSIOLOGY
• Pleural fluid serves as the lubricant to facilitate the normal physiologic sliding motion of both
pleural surfaces against each other during inspiration and expiration

• Balance of osmotic and hydrostatic pressure in parietal & visceral pleural capillary, resulting in
fluid movement into pleural space and promote reabsorption of this fluid

• Excessive hydrostatic pressure/ decrease oncotic pressure Transudative pleural effusion

• Increased permeability of capillaries protein-rich fluid to leak in pleural space

Exudative pleural effusion
CLASSIFICATION
TRANSUDATE
o Protein content is < 30 g/L
o Lactic dehydrogenase is < 200 IU/L
o And/or the fluid to serum LDH ratio is
< 0.6
• Increase venous pressure
(heart failure , fluid overload,
constrictive pericarditis)
• Hypoproteinaemia (cirrhosis,
nephrotic syndrome)
• Hypothyroidism
• Ovarian tumours producing
right-sided pleural effusion –
Meigs’ syndrome.
EXUDATE
o Protein content is > 30 g/L
o Lactic dehydrogenase is > 200 IU/L
o And/or the fluid to serum LDH ratio is
>0.6
Infection/inflammation/malignancy
• pneumonia
• tuberculosis
• carcinoma of the bronchus and pulmonary infarction –
fluid may be blood-stained
• connective tissue disease
• post-myocardial infarction syndrome
• acute pancreatitis (high amylase content)
• mesothelioma
• sarcoidosis
• yellow-nail syndrome (effusion due to lymphoedema)
CLINICAL FEATURES
• Can be asymptomatic
• Progressive dyspnoea
• Cough
• Pleuritic chest pain

• Physical sign:
- Reduced chest wall expansion

- Stony dullness to percussion

- Absent/reduced breath sounds

- Reduced tactile fremitus and vocal resonance

 INVESTIGATION

• Chest xray
• Blunting of costophrenic angle
(meniscus sign)

• Larger pleural effusion may cause

mediastinal shift
• Ultrasound

• nearly 100% sensitivity for

effusions > 100ml

• As guidance for pleural fluid

diagnostic or therapeutic aspiration,
reduces complications (risk of organ
puncture & pneumothorax)
• Pleural fluid aspiration & pleural fluid analysis

• Diagnostic pleural fluid sample should be aspirated with a fine-

bore (21G) needle and a 50 ml syringe

• Test:
o Biochemistry (cell count, pH, protein, glucose, lactate
dehydrogenase)

o Gram stain
o Cytology
o Microbiological culture (including AFB)
• Appearance
• Light’s Criteria
Diagnosis Based on Pleural Fluid Analysis
APPROACH TO DIAGNOSIS OF PLEURAL
EFFUSION
MANAGEMENT

• Treat the underlying cause

• Drainage : If effusion is symptomatic, drain it, repeatedly if necessary
• Pleurodesis with talc may be helpful for recurrent effusions
• Surgery : persistent collections and increasing pleural thickness (on
ultrasound)
References
• Kumar & Clark's Clinical Medicine (7th Edition)
• Harrison's Principles of Internal Medicine
• Professional Guide to Pathophysiology 3rd Edition, Lippincott Williams & Wilkins
• Pleural Effusion, Medscape
PNEUMOTHORAX

BY: RAJHMUNIRAN KANDASAMY

REFERENCE :
BRITISH MEDICAL JOURNAL
Best Practice
-last updated Nov 25 2021 -
CONTENT
1. DEFINITION
2. RISK FACTORS
3. PATHOPHYSIOLOGY
4. CLASSIFICATION
5. DIAGNOSIS
6. DIFFERENTIALS
7. MANAGEMENT
8. PREVENTION
9. FOLLOW UP
10. PROGNOSIS
DEFINITION

• Pneumothorax occurs when air gains access to, and accumulates in, the pleural space
RISK FACTORS

STRONG WEAK
1.Cigarette smoking
2.Family history of pneumothorax
1.Marfan syndrome
3.Tall and slender body
4.Age < 40 years
2.Homocystinuria
5.Recent invasive medical procedure
6.Chest trauma
3.Primary lung cancer
7.Acute severe asthma and metastatic
8.COPD cancer to the lungs
9.Tuberculosis
PATHOPHYSIOLOGY
PNEUMOTHORAX
• Normally, the alveolar pressure is greater than the
intrapleural pressure, while the intrapleural
pressure is less than atmospheric pressure.
AlvP>Pp<AtP
• Therefore, if a communication develops between an
alveolus and the pleural space, or between the
atmosphere and the pleural space, gases will follow
the pressure gradient and flow into the pleural space.
• flow will continue until there is NO pressure gradient
or the abnormal communication has been sealed
• the thoracic cavity enlarges and the lung becomes
smaller when a pneumothorax develops.
TENSION PNEUMOTHORAX
• medical emergency
• Occurs when intrapleural pressure exceeds atmospheric
pressure, especially during expiration
• results from a ball valve mechanism (ONE WAY
VALVE )that promotes inspiratory accumulation of pleural
gases.(AIR ENTERS BUT CANT LEAVE THE LUNG)
• The build-up of pressure within the pleural space eventually
results in hypoxaemia and respiratory failure from
compression of the lung and other neighbouring structure .
• Develops in patients with positive-pressure ventilation
(with mechanical ventilation or particularly during
resuscitation) and also results of untreated spontaneous
pneumothorax.
CLASSIFICATION –CLINICAL
SPONTANEOUS PNEUMOTHORAX
• occurs without preceding trauma or
precipitating event.
• Primary pneumothorax: occurs without •
clinically apparent pulmonary disease
• Secondary pneumothorax: occurs as a
complication of an underlying
pulmonary disease,including COPD,
asthma, and thoracic endometriosis
(catamenial pneumothorax).
TRAUMATIC ,TENSION,
IATROGENIC PNEUMOTHORAX
• Traumatic results from either penetrating or
blunt injury to the chest. These may be the
result of accidental or non-accidental injury.
Iatrogenic pneumothorax is a form of
accidental traumatic pneumothorax, and
occurs as a result of complications related to
medical interventions.
• Tension occurs when the intrapleural pressure
exceeds atmospheric pressure throughout
expiration and often during inspiration. It
DIAGNOSIS –SYMPTOMS

TENSION PNEUMOTHORAX NON TENSION PNEUMOTHORAX

• Cardiopulmonary deterioration • stable patient
- Hypotension; this suggests imminent cardiac arrest • who has sudden onset of chest
-Respiratory distress pain,dyspnoea (SSP), or cough,
-Low oxygen saturations especially if they have risk factors such
-Tachycardia as smoking or underlying lung disease.
-Shock
- Loss of consciousness
• Symptoms tend to be more severe in
SSP and may be minimal or absent in
• Severe chest pain
PSP
• Sweating
Ventilated patients, Following trauma (especially penetrating chest wounds) or
cardiopulmonary resuscitation, Lung disease, especially acute presentations of asthma and • Chest pain is usually pleuritic. PSP may
experience shoulder tip pain instead
bullous COPD, or long-standing lung disease such as cystic fibrosis, bronchiectasis, fibrotic
lung disease, or lung cancer,Blocked chest drain, Patients receiving non-invasive ventilation
(NIV) Other (e.g., hyperbaric oxygen treatment
DIAGNOSIS – EXAMINATION
TENSION PNEUMOTHORAX
• ipsilateral reduced breath sounds,
reduced chest expansion, hyper-
resonance on percussion,
• and tracheal shift to the contralateral
side.
• Put out an immediate cardiac arrest call
and give high-flow ox ygen. Perform
emergency needle decompression; do not
wait for imaging to confirm the diagnosis
NON TENSION PNEUMOTHORAX
• Ipsilateral reduced breath sounds
• Ipsilateral hyperinflation of the
hemithorax with hyper-resonance on
percussion
• Hypoxia; this is generally a late sign
• Evidence of penetrating trauma or rib
fractures in a traumatic pneumothorax.
DIAGNOSIS – INVESTIGATIONS
1. Chest X Ray – stable patients (erect PA, in inspiration)
- visible rim between the lung margin and the chest wall or surgical emphysema

- Absence of lung markings between the lung margin and chest wall
If pneumothorax is confirmed on imaging, measure the visible rim between the lung margin and
the chest wall at the level of the hilum. This can be done using chest x-ray but is most accurately
measured using CT
• Large pneumothorax: visible rim >2 cm
• Small pneumothorax: visible rim ≤2 cm
DIAGNOSIS – OTHER INVESTIGATIONS

2. Blood test – FBC and clotting factor (Aim INR>1.5, PLT >50) , ABG

3. Chest USG – if patient is immobilized post trauma

4. CT chest –gold standard (if CXR uncertain / stable pt with trauma)

WHY – ( size, pt with u/l lung disease –SSP, for ddx bullous lung dx)
DIFFERENTIALS
MANAGEMENT – SPONTANEOUS PNEUMOTHORAX
MANAGEMENT – TENSION PNEUMOTHORAX

• Put an immediate cardiac arrest call

• Put pt on high-flow oxygen.
• Immediate decompression is required;
do not wait for confirmation of the
tension pneumothorax on imaging.

• If the tension pneumothorax is not

secondary to trauma, insert a large-
bore cannula into the pleural space
through the 2nd ICS in the MCL line or
the 4TH/5TH intercostal space in the
MAL. A ‘hiss’ of air confirms the
diagnosis Use a standard safety
cannula.

• Insert a chest drain immediately

after needle decompression.
MANAGEMENT
TRAUMATIC PNEUMOTHORAX /TENSION PENUMOTHORAX SECONDARY TO TRAUMA

• Managed by a thoracic surgeon

• management will depend on the size of the pneumothorax and the clinical status of the patient.
• This may include a chest drain or thoracotomy.
• Never leave a patient with a penetrating chest wound or open pneumothorax unattended as tension pneumothorax
may develop.

• Cover the wound with a simple occlusive dressing and observe closely
• Give a dose of prophylactic antibiotics if a chest drain is being inserted to decrease the risk of empyema and
pneumonia.
PREVENTION
Primary Prevention
• Cigarette smoking cessation is the
single most important preventative
measure for both primary and
secondary spontaneous
pneumothoraces.
Secondary Prevention
• Early recognition and treatment of respiratory
infections, such as tuberculosis and Pneumocystis
jiroveciirespiratory infection in AIDS, are important
measures in the prevention of pneumothoraces.
• Adherence to prescribed therapy may curb the risk of
a secondary spontaneous pneumothorax in those
patients.
• Smoking cessation is the single most important step to
reduce the risk of a pneumothorax recurrence.
• Surgery may be indicated for some patients to prevent
recurrence. Options include open thoracotomy or
video-assisted thoracoscopic surgery (VATS)
FOLLOW UP

MONITORING COMPLICATIONS
• There is no established guideline for 1.Monitor for complications of chest drain insertion. Visceral
injury is the most serious complication, but other more
monitoring patients following a common complications include:
spontaneous pneumothorax.
- Pain

• Patient education is, therefore, an - Intrapleural or wound infection

important aspect in the treatment of
spontaneous pneumothoraces. -Drain dislodgement or blockage

- Surgical emphysema.
• Organise a follow-up chest x-ray
after 2 to 4 weeks to monitor 2. Re-expansion pulmonary edema
resolution of the pneumothorax for
-if the pneumothorax is large and present> 72 h
all patients who were managed with
observation alone or by needle - Normally occur in contralateral lung
PROGNOSIS
PRIMARY SPONTANEOUS
• Patients with primary spontaneous
pneumothoraces are at risk for recurrent
pneumothoraces. – WHY ?
• Between 30%and 50% of patients will have
an ipsilateral recurrent pneumothorax.
• Unless an intervention is undertaken in a
patient with a first recurrence, a third and
fourth event can be expected in 62% and 83%
of patients,respectively. These patients are
also at risk of a contralateral primary
spontaneous pneumothorax.
SECONDARY SPONTANEOUS
• Patients with secondary spontaneous
pneumothoraces are at greater risk of
recurrences.
• Because many lung diseases occur
bilaterally, these patients are typically at risk
for contralateral secondary
spontaneouspneumothoraces.
• The intervention taken for a persistent air
leak or a recurrent ipsilateral pneumothorax
may depend on available resources.