PNEUMONIAS

Ekwere, M
 LEARNING OBJECTIVES
• Be able to define pneumonia and
differentiate it from other forms of respiratory
tract infections
• Be able to classify pneumonias
• Understand the aetiology and
pathophysiology
• Diagnose and treat
 DEFINITION
• Pneumonia is a condition caused by microbial
infection within the lung parenchyma.
• This infection, together with the associated
host inflammatory response, impairs normal
alveolar function(i.e. gas exchange)
 CLASSIFICATION
• Community acquired pneumonia
• Hospital acquired pneumonia(nosocomial)
• Pneumonia in the immunocompromised
• Aspiration pneumonia
 EPIDEMIOLOGY
• CAP occurs between 1 and 10% per 1000 of the
adult population each year.
• More common in children aged <5 years and
progressively increases from age 40 years with a
peak in the very elderly.
• It is more common in those with co-morbidities:
COPD, bronchiectasis, chronic cardiac and renal
disease
• Occurs throughout the year with a peak during
winter months
 EPIDEMIOLOGY
• NP( nosocomial pneumonia) can occur in anyone
resident in a hospital for ≥ 7 days
• Common in ICU after endotracheal
intubation(ventilator-associated pneumonia(VAP)
• Immune dysfunction eg humoral(immunoglobin
deficiency), cancer chemotherapy, solid organ
transplantation, bone marrow transplantation
• Aspiration in those with swallowing difficulties
 RISK FACTORS
• Cigarette smoking
• Alcoholism
• Diabetes
• Oral steroids/immunosuppresion
• COPD
• Nursing home residents
 Aetiology of CAP
• Commonest infectious cause of death and the 6th leading
cause of death in the UK and USA
• Streptococcus pneunonia (the most frequently identified
organism)
• Legionella pneumophilia
• Staphylococcus aureus
• Influenza
• Mycoplasma pneumonia
• Clamydia pneumonia
• Clamydia psittaci
• Coxiella burnetti
 Zoonotic microbes and CAP
• Avian influenza(birds, animals)
• Cryptococcus neoformans(birds)
• Fransiscella tularensis(rabbits,rodents,cats)
• Histoplasma capsulatum(birds,bats)
• Bruscellosis(animals)
• Yersinia pestis(pneumonic plague,
rodents,cats)
Aetiology of Aspiration pneumonia
Pneumonia that follows aspiration of exogenous
material or endogenous secretions into the
lower respiratory tract
• Peptostreptococcus
• Fusiform nucleatum
• Prevotella
• Bacteroides
• Mixed infection is common
 Risk factors for aspiration
• Reduced consciousness level(alcohol, drug
overdose, post seizure, post general
anaesthesia, massive CVA)
• Dysphagia(motor neurone disease, stroke)
• Upper GIT disease( stomach/oesophagial
surgery, procedures impairing glottic closure-
tracheostomy, NG tube feeding)
• Increased reflux
 PATHOPHYSIOLOGY
• The lung and tracheobronchial tree are usually
sterile below the larynx, so an infecting agent
must reach this site via a breach in host defenses.
(microaspiration,hematogenous spread, direct
spread,inhalation. 4 MAIN STAGES:
• Congestion
• Red hepatization
• Gray hepatization
• Resolution
 CONGESTION
• Neutrophils engulf organisms and release
cytokines which cause an inflammatory
reaction
• The lungs become hyperemic and the
capillaries become highly permeable causing
fluid from the intravascular spaces to move
into the lung tissue and alveoli. There’s
impairment of gas exchange as a result of this
fluid movement.
 RED HEPATIZATION
• The lung appears red and hard lie the liver; its
characterized by massive confluent exudation
with RBCs, neutrophils and fibrin filling the
alveolar space. This occurs on the 2nd and 3rd
day
 GRAY HEPATIZATION
• Hyperemia subsides but the lung remains
hard, this is due to progressive disintegration
of RBCs and persistence of fibrin suppurative
exudates giving the lung a grayish appearance,
this is achieved by reduced blood to the lung,
and leukocyte and fibrin consolidation
 RESOLUTION
• Restoration of the lung structure. The
consolidated exudates within the lung
undergo progressive enzymatic digestion and
most debris is ingested by macrophages and
coughed out.
 CLINICAL FEATURES
Constitutional and chest specific
• Abrupt onset of fever, may be slower
• Cough
• Sputum production(purulent or blood stained)
• Breathlessness
• Muscle aches
• Headaches
• Anorexia
• Nausea and diarrhoea less common
• CNS dysfunction(confusion,incontinence,falls)
 Clinical features
• Features of lung consolidation(dull percussion,
bronchial breathing, increased vocal
resonance)
• Crackles
• Tachypnoea
• Tachycardia
• Hypotension in severe cases
• Altered sensorium in severe cases
 INVESTIGATIONS
Particularly necessary in those admitted to aid precise diagnosis, assess illness severity
and identify microbial cause.
• FBC(raised WBCs)
• Raised C-reactive proteins
• EUCr
• LFT
• Measures of gas exchange( oxygen saturation, ABG)
• Sputum mcs (+ve in 15% of CAP cases)
• Blood culture(in very ill patients)
• Urine for pneumococcal and legionella antigen
• PCR based tests for atypical organisms
• Bronchoscopic specimens in the immunocompromised
• Tracheal aspirates/ bronchoscopic samples in NP
• CXRAY(NEW LUNG SHADOWING/INFILTRATES-patchy,lobar,multilobar,bilateral.
Cavitation,effusion,pneumothorax
 SEVERITY ASSESSMENT
• CURB 65
• C-confusion
• U-blood urea >7mmol/l
• R -resp rate >30 cycles/minute
• B - systolic BP <90
• 65- Age >65 years
• PSI
 POOR PROGNOSTIC FACTORS
• Age > 65yrs
• Coexisting disease
• Respiratory rate ≥ 30 /minute
• Hypoxemia-respiratory failure with PaO2<8kPA
• Urea ≥ 7 mmol/l
• WBC >20 or <4
• Radiology- bilateral or multilobar involvement
• MCB- positive blood culture whatever the
pathogen
 TREATMENT
• Correction of gas exchange and fluid balance
abnormalities
• Antibiotics ( 7 days in uncomplicated cases)
• CPAP or assisted ventilation where indicated
 Antibiotics-CAP
• Community Rx- amoxicillin preferred,
macrolide alternative
• Hospital Rx- mild cases (oral amoxicillin +
macrolide), alternative macrolide or resp
fluoroquinolone
 DIFFERENTIAL DIAGNOSIS
• Acute bronchitis
• COPD exacerbation
• Left ventricular failure
• Pulmonary embolism
• Exacerbation of pulmonary fibrosis
 Prevention
• Stop smoking
• In those with co-morbid disease
vaccination(influenza and pneumococcal