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Pneumonia
Slaiman Al-Momani
Malak & Hind
16 / 11 / 2009
1

U

Dear colleagues, unfortunately the Dr. refused to give us the
slides so we are sorry if there is any mistake but fortunately
the lec is easy so ENJOY
UPneumonia :

Inflammation of the lung substances, usually distal to the
respiratory bronchioles. This inflammation can be infectious or
non-infectious .

Types of pneumonia :

Organizing pneumonia .
Pneumonia secondary to connective tissue disorders ; SLE &
interstitial lung disease .
Pneumonitis : ( hypersensitivity , radiation ..etc ).

c Definition of Pneumonia according to ( Harrison ) : as the Doc.
said
It is an infection of the alveoli distal to the airways and the
interstetium of the lung, manifested by many changes due to
inflammation there will be:

- Production of inflammatory cells .
- Gross weight of the lung will increase .
- The normal spongy character of the lung is replaced by
compact solid structure , as increase CVF & increase
dullness .
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- The byproduct of the inflammation ( WBC , RBC ,fibrin )
will fill the alveoli , which will affect the gas exchange .



This pic is taken from wiki .

From clinical point of view pneumonia means a group
of signs and symptoms in the presence of chest radiographic
infiltrate.



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When a patient comes with signs and symptoms of
pneumonia but clear chest x-ray, this is not pneumonia but it
is bronchitis or bronchopneumonia or mistaken upper
respiratory tract infection.

Signs & symptoms :

O Cough.
O Chest pain .
O Fever.
O Rigor.
O Chills.
O SOB .
O Excessive sputum production.
O Sometimes hemopmtysis .

Physical findings :

O Tachypnea.
O Dullness of the area of inflammation .
O Bronchial breathing sound .
O Additional breathing sound ; crackles , crepitation etc
O Extreme cases there is pleural rub .

Systemic manifestation :

O Fever
O Rigor
O Chills
O Myalgia
O Arithritis
O General fatigue .
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O Elevated temperature.
O Extreme cases hypothermic .
O In certain infections it maybe associated with rash
especially viral infection .



Cl assi f i c at i on of pneumoni a :
Typical : prominent respiratory signs and symptoms with minor
systemic complains .
Atypical : extra pulmonary manifestation .


Investigation :

+ Chest x-ray; if there is an infiltrate we consider it as
pneumonia .


This pic is from KUMAR


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+ Grams stain and culture of the sputum, this test is
important although it has low sensitivity.
+ Blood gases
+ CBC
+ Kidney function .

Specific test for pneumonia
Fibreoptic bronchoscopy - samples of the lung tissue- ,
analysis of pleural effusion, culture of exudates .
:



Cl assi f i c at i on of pneumoni a ac c or di ng t o t he
or gani sms :
This classification is important to guide the treatment
according to the organism.
Community acquired pneumonia : streptococcus pneumponia
is the prevalent bacteria (gram positive bacteria ),
mycoplasma,.chlamydia & viral pneumonia .

C Nosocomial pneumonia : gram negatives , anaerobes , but
usually it depends on the risk factors like patient with
catheter the cause may be gram positive.

There is early and late nosocomial pneumonia :

* Early nosocomial : the organisms are combination of weak
hospital acquired organisms and communit acquired organisms .

* Late nosocomial : the organisms are strictly hospital
acquired organisms , gram negatives ,anaerobes and some gram
positives, they are more common in the ICU , patient who are
on invasive respiratory equipment ( ventilator ) .
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SO ,
Ventilator associated pneumonia
Most common organism causes hospital acquired pneumonia
in our hospital is ACPC ( gram negative bacilli ) ,but in the USA is
Methecillin resistant staph.Aureus MRSA .
is a subset of hospital
acquired pneumonia , it is a pneumonia which occurs after at
least 48 hrs of intubation and mechanical ventilation .



Risk factors for hospital acquired pneumonia :
1. Severity of the illness.
2. Nutrition.
3. Duration.
4. Age.
5. Antibiotics.
6. Major surgery .

C Immunocopromised patients : combination of gram ve &
gram +ve , but we consider the opportunistic infections .


Other types of pneumonia :
Aspiration pneumonia :
It happens in patient with impaired consciousness , or in
patient with loss of gagreflex because of neurological
disorders , bulbar palsy , encephalopathy and diabetics
patients who have gastropathy .





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Definition of community acquired pneumonia :
Signs and symptoms of pneumonia , lung infiltrate in a patient
who has not been hospitalized or diagnosed within 48 hrs of
admission .



^ If a patient admitted to the hospital for elective hernia
surgery , but next day he had fever with chest infiltrate , this is
a community acquired pneumonia not noscomial , coz it needs 48
to consider it as nosocomial pneumonia .

^ A patient who has always been in the long term health care
facility , and get out and start suffering of pneumonia , this
pneumonia it not a community acquired pneumonia unless he is out
for at least 2 weeks .

In year 2005 up to 2 to 3 million cases diagnosed of community
acquired pneumonia, but now this number will increase bcoz
of SWINE FLU

.(basma H.)
Predisposing factors of pneumonia :

O Extreme ages .
O Patients with COPD .
O Smoking .
O Heart failure
O Diabetes
O Chronic pneumothorax ( not sure )
* All these are also risk factors for H1N1, so we do PCR.
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OTaking antibiotics without prescription , decreases the
immunity of the lung causing pneumonia .

30-50 % of cases treated without finding the organism, but the
most common organism causes community acquired pneumonia is
Steptococcus pneumonia .


If patient has certain co morbidities he may predisposed to
certain organisms , like patient with COPD , he will be more prone
to Streptococcus Pneumonia , H.influenza and Moraxella
Catarrhalis , patient with alcoholism more prone to
streprococcus , staphylococcus and klebsiella, patient with
diabetes have staph and strep


How to asses the severity of pneumonia :

1. According to the CURB-65 criteria which is recommended by
the British Thoracic Society , which include these risk factors
and each risk factor scores 1 point( for a maximum score = 5 ) :

Confusion new disorientation in person place or time.
Urea > 7 mmol/L
Respiratory rate > or = 30 /min
Blood pressure
Systolic < 90 mmHg
Diastolic < or = 60 mmHg
Age > 65 yrs .



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*The risk of death increases as the score increases ( combination
of risk factors ) :

0 0.7 %
1 3.2 %
2 13 %
3 17 %
4 41.%
5 57 %

* It is used as a mean of deciding the action that is needed to be
taken for that patient , 0-1 treat as an outpatient , 2 consider as
a short stay in hospital or watch very closely as an outpatient , 3-
5 requires hospitalization with consideration as to whether they
need to be in intensive care unit .

* This assessment of severity it is not 100 % accurate , bcoz
patient may have severe hypoxemia which an important risk
factor but it is not included here .

2. Cohort criteria, pneumonia severity index, which is
recommended by national community of general medicine ,this
criteris depends on many factors :

1. Patient demographic. (Whether someone is older , and is male
or female )
2. Age.
3. Co existing diseases .
4. Physical examination findings .
5. Laboratory and radiology findings .

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Each factor has a point, the summation of these points give us
the risk group according to Cohort .but these groups are not for
memorizing .

3. Clinical judgment : the best method to asses the severity of
community acquired pneumonia , we took all the factors of CURB
& Cohort as guidelines then we judge clinically whether it is a
sever pneumonia or not .

Criteria to admit patients to the hospital

:
1. Patient clinical situation.
2. Social criteria
3. Hypoxemic
4. Multilobar infiltrate .
5. Co-existing illnesses .


Treatment of pneumonia :

1. We should always start empirical treatment based on the
type of pneumonia according to the epidemiologic features of
the patient.

In the emergency room we should

give the patient
antibiotics within 6-8 hrs , bcoz the early institution of
antibiotics decreases the mortality .
2. Asses the severity of the infection, whether we discharge
the patient or we admit him to the floor or to the ICU.

You are free to elect doing certain workup to identify the
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organism in the outpatients , but you should do these workup
to the inpatient .
These workup are : blood culture , sputum .

In simple pneumonia with no risk factors , no co morbidities ,
no features of severity we just give the patient oral
antibiotics and discharge him home without any investigation .

c Treatment in general depends on the population and the
antibiogram that we have in the hospitals .

For example
in our community we dont use Macrolides( azithromycin and
clarithromycin ) , bcoz people have developed resistance to
these drugs .
:

According to the prevalence of resistance for community
acquired pneumonia , we should use fluoroquinolones or
combination of macrolides and 3
rd
or 4
th
generation of
cephalosporins.

* If the patient has any co morbidities we should consider the
organism that should be covered , if he has risk factors for
gram negative we give him antibiotics for gram negative , if the
patient is diabetic we should give him antipseudomonas drugs .

Wi k i
Antibiotics for hospital acquired pneumonia include 3
rd
and
4
th
generation cephalosporins , carbpenams , fluroquinolones ,
aminoglycosides and vancomycin.
:

THE END
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DONE BY :
Malak Abu-Eishah & Hind Sarayrah.

Special thanx :
Barah Al- Rashdan we are glad to have a friend like
u , enshalla ndal sawa 3la tool .

Dana , Shorooq & Jwana the best ever ( alla la yfare2na
3n b3d )

Group A5 : wallahi the best group ever :

Barah Alrashdan , Reham Nawaf , Areej Salameen , Olga
khawaldeh , Hani 3ed , Laith 3nani , Mohammad Kurd , Suleiman
3neim , Ahmad Salem , Saif Al 3dwan , Samer Kuleib , Mahmoud
Bader , Baraa Al Dahleh , Raed Jaradat .

SAWA GROUP:
Rawan , Nour , Salsabeel , Raad , Bashar , Adnan, Rashed..

- Sahar , Reem , Hala , Ansam , Oraib , Lana , Alaa bawa3neh ,
Safaa , Rawan , Heba , Nour , Yazan , Husam hadad ,
Rasheed Janaideh , Firas








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Corrections for Lec.3 : ( correction in bold)
In page 4 : -will increase the possibility to develop asthma .
-Eosinophil cationic proteins
In page 6 : PERF : we look for improvement by 60 ml ( or 20 %) or diurnal
variation >20 % as in dr. slides whereas in kumar book look for 20%
change and at least 60 l/ min on the recorder .
In page 15 : in last point :- the frequency of nibulizing medication .