PNEUMONIA
Aspiration Pneumonia
DEFINITION
● Pneumonia is an infection in the lungs that can be
caused by a variety of different pathogens.
● Pneumonia is an acute infection of the lung
parenchyma distal to the terminal bronchiole, most
commonly bacterial, and associated with clinical
and/or radiological evidence of consolidation of part.
(Feldman et.al, 2007)
● Pneumonia is an infection that inflames the air sacs
in one or both lungs. The air sacs may fill with fluid or
pus (purulent material), causing cough with phlegm or
pus, fever, chills, and difficulty breathing.
● Pneumonia is the third leading cause of morbidity
(2001) and mortality (1998) in Filipinos based on the
Philippine Health Statistics. (Department of Health)
● Pneumonia is a second most common nosocomial
infection in the hospitals and is associated with
substantial morbidity and mortality. (Philippine Heart
Center, 2013)
PNEUMONIA CATEGORIES
Based on where the infection was acquired:
A. Community-Acquired Pneumonia (CAP)
~ an acute infection of the pulmonary parenchyma in
a patient who has acquired the infection in the
community within 24hrs or less than 2 weeks.
B. Hospital-Acquired Pneumonia (HAP)
~ “Nosocomial Pneumonia”
C. Ventilator-Associated Pneumonia (VAP)
~ pneumonia that arises more than 48 to 72 hours
after endotracheal intubation
D.
~pneumonia acquired by accidental/unwanted
inhalation of exogenous substances; food,
water, etc.
E. Healthcare-Acquired Pneumonia (HCAP)
~ pneumonia acquired in healthcare facilities
such as nursing homes, hemodialysis centers and
outpatient clinics or a hospitalization within the
past three months.
~ Patients with HCAP were thought to be at
higher risk for Multidrug-resistant (MDR)
organisms
Based on Site of Infection
I. Bronchopneumonia
II. Atypical/ Interstitial Pneumonia
III. Lobar Pneumonia
Stages:
❏ Congestion (Day 1 & 2)
❏ Blood vessels & alveoli fill with excess
fluid
❏ Red Hepatization (Day 3 & 4)
❏ Exudates (RBCs, neutrophils) fill the
airspaces making them more solid which
creates the liver-like appearance
❏ Gray Hepatization (Day 5 to 7)
❏ Color change due to breakdown of RBCs
❏ Resolution (Day 8 to 3 weeks)
❏ Exudates are digested by enzymes or
ingested by macrophages
EPIDEMIOLOGY
(Pneumonia in Children)
● The annual incidence of pneumonia is estimated
to be 33 per 10,000 in children < 5 years and 14.5
per 10,000 in children 0 to 16 years. (World
Health Organization)
● In 2009, Pneumonia is the leading cause of
mortality for children aged under 5 yrs. old.
● The Philippines is one of the 15 countries that
composes 75% of childhood pneumonia cases
worldwide.
●
(Community-Acquired Pneumonia)
● Overall rate of CAP in adults is approximately
5.16 to 6.11 cases per 1000 persons per year
● Rate of CAP is directly proportional to age and
higher for men than women and for black
compared to Caucasians
● Streptococcus pneumoniae is the most commonly
identified bacterial cause of CAP worldwide.
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ETIOLOGY
(Pneumonia-causing Microbes)
A. Virus
Influenza (flu)
Respiratory syncytial virus is the most common
viral cause of pneumonia
B. Bacteria
Streptococcus pneumoniae
Haemophilus influenzae type b (Hib) – the second
most common cause of bacterial pneumonia
Staphylococcus aureus
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumophila
C. Fungi (Rare)
Coccidioidomycosis, Histoplasmosis
Blastomycosis, Cryptococcus
Pneumocystis jiroveci - risk for
immunocompromised individuals
RISK FACTORS
❏ Age (ie. pediatric, geriatric)
● Pediatric - While most healthy children can fight
the infection with their natural defences, children
whose immune systems are compromised and
are inadequately fed are at higher risk of
developing pneumonia.
● Geriatric - organ function decline leading to
susceptibility to virulent pathogen; immune
system unable to completely protect the body.
❏ Environment (ie. toxic fumes, pollutant, chemicals)
❏ Lifestyle
(ie. cigarette smoking (strongest risk factor),
alcoholism
● suppresses inflammatory responses to infection
● decreases the ability of the host to eliminate
pathogen by inhibiting the lung immune cells to
kill bacteria
● disrupt the intricate interface of immune cells
❏ Medical Condition
~comorbid conditions including cardiovascular
disease; chronic respiratory disease such as
bronchitis, asthma; cerebrovascular disease, HIV,
COPD
❏ Medications
● PPI & H2 blockers - reduce the amount of
stomach acid but at higher doses could produce
an opposite effect which increases the
intragastric pH that allows specific bacterial
growth in the stomach leading to
microaspiration and lung colonization,
eventually pneumonia.
● Inhaled corticosteroid
(ie. fluticasone, budesonide) - decreases bacterial
adherence & increase macrophage production
necessary for antibacterial immunity. However, long
term use and inappropriate therapy leads to opposite
effect. ↑bacterial adherence; ↓ macrophage response;
↓ immunity. *Although the exact mechanisms by
which ICS increase the risk of pneumonia are not
fully understood, the immunosuppressive effects of
ICS on the respiratory epithelium and the disruption
of the lung microbiome are most likely to be
implicated. *additional
● Antipsychotics - block dopamine receptor
resulting to dyskinesia of oropharyngeal
musculature and dysphagia, eventually
aspiration. pneumonia
● Sedatives - cause swallowing problems and
difficulty coughing
● Immunosuppressants - ↓ resistance to
virulent pathogen
❏ Malnutrition (immunosuppression) - a child's
immune system may be weakened by
malnutrition or undernourishment, especially in
infants who are not exclusively breastfed.
❏ Oxygen and Inhalation Therapy - associated w/
VAP
❏ Low Albumin level - determines the severity of
inflammation; considered as a good prognostic
marker for infection
❏ Low cholesterol level - related to malnutrition
espec. in geriatric patients
*Considerations:
Severity of pneumonia and/or comorbidities
Specific pathogen
TRANSMISSION (Oral)
1. Breathing
2. Coughing
3. Sneezing
*Pneumonia can be spread in a number of ways. The
viruses and bacteria that are commonly found in a child's
nose or throat, can infect the lungs if they are inhaled.
They may also spread via air-born droplets from a cough
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or sneeze. In addition, pneumonia may spread through blood, ● Central cyanosis
especially during and shortly after birth. ● Altered mental status

DIAGNOSIS
CLINICAL PRESENTATION 1. Medical History
(Bacterial Pneumonia) - sudden onset and rapid illness ~Risk Factors
Symptoms ~Previous contact with those having
● Chest pain – due to inability of the lungs to condition
● Dyspnea ~having been hospitalized
● Hemoptyisis 2. Physical Examination
● Decreased exercise tolerance ~Physical Signs
● Abdominal pain from pleuritis 3. Diagnostic Tests
● Cough with productive sputum a. Chest X-ray
■ Rust colored ~ S. pneumoniae ~views the buildup of fluids in the
■ Green colored ~pseudomonas, lungs and site of infection
Haemophilus, pneumococcal b. Blood Test
■ Red currant jelly ~ Klebsiella ~biomarkers that indicate the
■ Foul smelling and taste ~ anaerobic presence of infection
● Fever c. Blood Culture
● Rigors (pneumococcal associated) ~identification of pathogen
● Non-specific: myalgias, headache, abdominal 4. Sputum Test – identify the pathogen
pain, nausea, vomiting, diarrhea, anorexia and 5. CT Scan – determine the affected areas in
weight loss, and altered sensorium. the lungs or if complications exist due to
● Pertussis with whooping sound and/or post- lung abscess and pleural effusions; gives a
tussive vomiting in children. greater view of the affected areas in the
● mental status changes or GI SYMPTOMS ~ usually lungs as compared to Chest X-ray
associated to LEGIONELLA pneumonia 6. Pleural Fluid Culture- identify pathogen by
● Pontiac fever and frank Legionella pneumonia using pleural fluid extracted by
~ Pomtiac fever characterized as virus thoracentesis
pneumonia-like condition; frank Legionaella 7. Pulse Oximetry
Pneumonia, a severe state of Legionella ~tests for the lungs capability to absorb
pneumonia oxygen
8. Bronchoscopy
~views the actual lungs by a bronchoscope
(Viral Pneumonia) 9. Tactile Vocal Fremitus
● fever ~done by holding the palm of the patient
● chills and having them repeat a phrase. Vibration
● nonproductive cough felt in the palms indicate build-up of fluids in
● rhinitis the lungs; it renders the lungs seem to be
● Myalgia consolidated/ seems like a solid
● headaches 10. Late Inspiratory Crackles
● fatigue ~done by hearing the late inhalation of a
● Virus specific symptoms patient using a stethoscope; Crackling sound
is heard due to the buildup of fluids
Physical Signs 11. Bronchophony
● Hyperthermia (fever, typically >38°C) or ~done by hearing the patient repeat a
hypothermia (< 35°C) phrase, while hearing them speak through a
● Tachypnea (>18 respirations/min) stethoscope placed by the chest;
● Use of accessory respiratory muscles bronchophony is present, when the phrase
● Tachycardia (>100 bpm) or bradycardia (< 60 repeated is heard clearly through the
bpm) stethoscope.
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12. Egophony
~done by having the patient say ‘ee’ as in ‘beet’. Egophony is present when the sound heard through a
stethoscope resembles an ‘a’ sound.

TREATMENT GUIDELINES
(Empiric Treatment of HAP in patients with Normal Renal Functions)

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TREATMENT GUIDELINES
(CAP: Determining the appropriate site of treatment for adults)

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PNEUMONIA SEVERITY INDEX (PSI)
❏ Preferred system because it is more ❏ PSI CLASSES:
accurate and validated than CURB-65
❏ Takes into account sex, age, co-morbid
conditions, physical exam findings, and
Arterial Blood Gas (ABG)

CURB – 65 Scoring System

❏ C – Confusion or change in mental status
❏ U – Uremia (BUN >20)
❏ R – Respiratory rate (>30 breaths)
❏ P – pressure (BP); Systolic 90mmHg or
less; Diastolic 60mmHg or less
❏ 65 – years old and above

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PATHOPHYSIOLOGY

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