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Pneumonia

Dr Putra Hendra SpPD


UNIBA

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

The morbidity and mortality of pneumonia


are high especially in old people.

Classification by acquired
environment
Community

acquired pneumoniaCAP
Hospital acquired pneumoniaHAP NP
Nursing home acquired pneumonia,NHAP
Immunocompromised host pneumonia,(ICAP)

CAP

CAP refers to pneumonia acquired outside of


hospitals or extended-care facilities .
Streptococcus pneumoniae remains the most
commonly identified pathogen.
Other pathogens include Haemophilus influenzae,
mycoplasma pneumoniae, Chlamydophilia
pneumoniae, Moraxella catarrhalis and ects.
Drug resistance streptococcus pneumoniae(DRSP)

Community Acquired
Pneumonia

Epidemiology:

4-5 million cases annually


~500,000 hospitalizations
~45,000 deaths
Mortality 2-30%
<1% for those not requiring hospitalization

Bartlett. CID 1998;26:811-38.

Adeel A. Butt, MD

EPIDEMIOLOGY

General risk factors for developing


HAP include age more than 70 years,
serious comorbidities, malnutrition,
impaired consciousness, prolonged
hospitalization, and chronic
obstructive pulmonary diseases.

EPIDEMIOLOGY

HAP is the most common infection occurring in


patients requiring care in an intensive care unit
(ICU), with incidence rates ranging from 6% up to
52%, much higher than the 0.5% to 2% incidence
reported for hospitalized patients as a whole.
This increased incidence is due to the fact that
patients located in an ICU often require
mechanical ventilation, and mechanically
ventilated patients are 6 to 21 times more likely to
develop HAP than are nonventilated patients.
Mechanical ventilation is associated

ICHP

Pneumonia in an immunocompromised host


describes a lung infection that occurs in
a person whose ability to fight infection is
greatly impaired.
(Non-HIV-ICH)

Causes, incidence, and risk factors

Immunosuppression can be caused by HIV


infection, leukemia, organ transplantation, bone
marrow transplant, and medications to treat cancer.
Microorganisms include all kinds of bacteria and
virus(CMV), candida and aspergilosis.
pneumocystis carinii

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

Community Acquired Pneumonia

Incidence
1400

1171 1207

1200
1000

# in
1000s

1071
898

800

684

600

# of cases

400
200

83

0
<5

5 to 18-24 25-44 45-64 >65


17

Adeel A. Butt, MD

Community Acquired Pneumonia


Mortality
80

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

Risk Factors for 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

There are two factors


involved in the
formation of
pneumonia , including
pathogens and host
defenses.

pathogenesis

Pneumococci usually
reach the lungs by
inhalation or
aspiration. They lodge
in the bronchioles,
proliferation and
initiate an
inflammatory process.

Bacteria are introduced into the


lungs by the four routes

Source

Route

colonization

aspiration

Air
Non-pulmonary
infection
Contiguous
infection

inhalation
blood
stream
direct
extention

Response

lung
defenses

Outcome

pneu.

Legionnaires disease is acquried


by inhaling aerosolized water
containing Legionella
organisms or possibly by
pulmonary aspiration of
contaminated water.
The contaminated water are
derived from humidifiers,
shower heads, respiratory
therapy equipment, industrail
cooling water.
Because of the frequently use of
air conditioner, Legionnaies
pneumonia is also seen in
CAP

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

Elderly (not aging per


se but its associations)
Swallowing difficulty
Use of sedative
medications
Depressed cough reflex
Dementia

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

Legionellae are small,


gram-negative,
obligately aerobic baclli.
.

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

Pembagian Berdasarkan Lokasi

Pneumonia Lobaris

Pneumonia Interstitial

Pneumonia Lobularis (Bronkopneumonia)

Lobar pneumonia

Interstitial pneumonia

Lobular pneumonia

Diagnosis

Give a definite diagnosis of pneumonia


To evaluate the degree of the pneumonia
To definite the pathogen of the pneumonia

Diagnosis

Clinical diagnosis
Pathogen diagnosis
Evaluate the severity degree of pneumonia

Diagnosis
History

and physical
examination(5W)
X-ray examination
Pathogen identification

Pathogen identification

Sputum: More than 25 white blood cells


(WBCs) and less than 10 epithelial cells.
Nasotracheal suctioning
Blood culture or pleural effusion culture
Serologic testing (immunological testing)
Molecular Techniques

It is important to evaluate the


severity degree of pneumonia

The critical management decision is


whether the patient will require hospital
admission. It is based on patient
characteristics, comorbid illness, physical
examinations, and basic laboratory findings.

The diagnostic standard of severe


pneumonia

Altered mental status


Pa02<60mmHg. PaO2/FiO2<300, needing MV
Respiratory rate>30/min
Blood pressure<90/60mmHg
Chest X-ray shows that bilateral infiltration,
multilobar infiltration and the infiltrations enlarge
more than 50% within 48h.
Renal function: U<20ml/h, and <80ml/4h

Clinical manifestation

The onset is accute


Respiratory symptoms
Extrapulmonary symptoms

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

Clinical manifestations (1)


Many patients have had an upper respiratory
infection for several days before the onset of
pneumonia
Onset usually is sudden, half cases with a
shaking chill
The temperature rises during the first few
hours to 39-40

Clinical manifestations (2)


Typically, patients have the symptoms of
high fever , shaking chill, sharp chest
pain, cough, dyspnea and blood-flecked
sputum.
But in some cases, especially those at age
extremes symptoms may be more
insidious.

Clinical manifestations (3)


The pulse accelerates
Sharp pain in the involved hemi thorax
The cough is initially dry with pinkish or
blood-flecked sputum
Gastrointestinal symptoms such as,
anorexia, nausea, vomiting abdominal
pain, diarrhea may be mistaken as acute
abdominal inflammation

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

Laboratory examinations (1)


The peripheral white blood cell (WBC) count
Before using antibiotic, the culture of blood and
of expectorated purulent sputum between 24-48
hours can be used to identify pneumococci
Colony counts of bacteria from bronchoalveolar
lavage washings obtained during endoscopy are
seldom available early in the course of illness
Use of the PCR may amplify pneumococcal
DNA and improve potential for detection

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

The principal of therapy

Select antibiotics
According to guideline

Therapy

The therapy should always follow


confirmation of the diagnosis of pneumonia
and should always be accompanied by a
diligent effort to identify an etiologic agent.
Empiric therapy,(4-8h)
Combined empiric therapy to target 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

Empiric therapy (1)

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

Supportive measure are generally used in


the initial management of acute pneumo coccal pneumonia, such measures include
Bed rest
Monitoring vital signs and urine output
Administering an occasional analgesic to
relieve pleuritic pain
Replacing fluids, if the patient is dehydrated
Correcting electrolytes
Oxygen therapy

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

Therapy to Infectious Shock

Treatment in intensive care units


cardiac rhythm, blood pressure, cardiac performance, oxygen
delivery, and metabolic derangements can be monitored

Adequate oxygenation and ventilatory support


(sometimes mechanical ventilation)
Effective antibiotic therapy
Maintain blood pressure, including maintain
circulation blood volume, use of dopamine

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