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KURSK STATE MEDICAL

UNIVERSITY
DEPARTMENT OF
PROPAEDEUTIC OF INNER
DISEASES

PNEUMONIA
LUNG ABSCESS

Acute pneumonia
Definition
Pneumonia is an acute inflammatory
process of infectious origin affecting the
pulmonary parenchyma.

Types of pneumonia
1.
2.

3.
4.

Community-acquired pneumonia
Hospital-acquired (nosocomial)
pneumonia
Aspiration pneumonia
Pneumonia in the
immunocompromised host
(including AIDS)

Types of pneumonia

Typical pneumonia
(usually lobar, pleuropneumonia)
Atypical pneumonia
(usually bronchopneumonia)
Primary pneumonia
Secondary pneumonia

In the diagnosis must be note about


location of consolidation (side, lobe, segment)

Morphologic variants of
pneumonia
Variant
Lobar

Bronchopneumon
ia

Causative
organism
Most frequently
Pneumococcus

Characteristics

Many organisms
(Staph. Aureus,
Haemophilus
influenza,
Klebsiella, Strep.
pyogenes)

Acute
inflammatory
infiltrates
extending from
bronchioles into
adjacent alveoli
Patchy distribution
involving one or
more lobes.

Predominantly
intra-alveolar
exudate resulting
in consolidation.
May involve entire
lobe.

Community acquired
pneumonia

This form is
responsible for over
1000 000
admissions per
year.

Mortality: 6-20%
Increasingly common
with age

Community acquired
pneumonia.
Etiology
Common organisms:
Str. Pneumoniae
70% (50-80%)

Chlamidia pneum.
10%

Mycoplasma pneum.
9%

Legionella pneum.
5%
Uncommon organisms:

Haemophilus influenzae
3%

Staphyl. Aureus
<1%

Chlamidia psittaci
<1%

Klebsiella pneum.
<1%
Primary viral pneumonia:
Influenza, parainfluenza, measles

Community acquired
pneumonia.
Transmission

Aspiration of organisms that


colonize the oropharynx.
Inhalation of infectious aerosols
from ambient air.
Hematogenous dissemination.
Direct inoculation from contiguosly
infected sites.

Transmission

Aspiration is the major route of acquisition


for most forms of pneumonia, but very few
individuals who do aspirate contaminated
oropharyngeal secretion develop
pneumonia.

45% of normal people and 70% of


obtunded patients aspirate oral secretion,
respiratory tract defenses prevent majority
from becoming ill.

Hospital acquired
pneumonia (nosocomial)
Refers to a new episode of
pneumonia occurring at least 2
days after admission to the
hospital.
The term includes post-operative
and certain forms of aspiration
pneumonia.

Hospital acquired
pneumonia
Predisposing factors

1. Reduced host defences against


bacteria:
Reduced immune defences
(corticosteroid treatment, diabetes,
malignancy).
Reduced cough reflex (post-operative).
Disordered mucociliary clearance
(anaesthetic agents).
Bulbar or vocal cord palsy.

Hospital acquired
pneumonia
Predisposing factors

2. Aspiration of nasopharyngeal or
gastric secretion:
Immobility or reduced conscious
level.
Vomiting, dysphagia, achalasia or
severe reflux.
Nasogastric intubation.

Hospital acquired
pneumonia
Predisposing
factors
3. Bacteria introduced into lower

respiratory tract:
Endotracheal intubation / tracheostomy.
Infected ventilators / nebulisers /
bronchoscopes.
Dental or sinus infection.
4. Bacteraemia:
Abdominal sepsis.
Intravenous cannula infection.
Infected emboli.

Hospital acquired
pneumonia
Etiology

The majority of hospital


acquired infections are caused by
Gram negative bacteria
(Escherichia, Pseudomonas,
Klebsiella).

Pneumonia in the
immunocompromised
patient

Pulmonary infection is common in


patients receiving
immunosuppressive drugs and in
those with diseases causing
defects of cellular or humoral
immune mechanisms (Ex.: AIDS).

Lobar pneumonia
Homogeneous consolidation of one ore more
lobes, associated with pleural inflammation.

Lobar

Most frequently Predominantl


Pneumococcus y intraalveolar
exudate
resulting in
consolidation
. May involve
entire lobe.

Lobar pneumonia
Main syndromes
1.
2.
3.
4.
5.
6.
7.

Inflammation of the lung tissue.


Consolidation of the lung tissue.
Intoxication.
General inflammation.
Acute respiratory insufficiency.
Heart failure.
Affection of the other organs.

Lobar pneumonia
Morphology
4 stages:
1. Congestion
2. Red hepatization
3. Grey hepatization
4. Resolution

Lobar pneumonia
Morphology

Lobar pneumonia
Morphology
CONGESTION
1) Hyperemia of the lung tissue.
2) Exudation.
3) Obstruction of capillary patency.
4) Stasis of the blood.

It lasts from 12 hours to 3 days

Lobar pneumonia
Morphology
RED HEPATIZATION
1) Massive confluent
exudation with red cells
and neutrophils and
fibrin filling the alveolar
spaces.
2) The lobe now appears
distinctly red, firm, and
airless with a liver like
consistency.
Continues from 1 to 3
days.

Lobar pneumonia
Morphology
GRAY HEPATIZATION
1) Progressive disintegration
of red cells.
2) The alveoli (containing
fibrin) become filled with
leucocytes
3) Persistence of
fibrosuppurative
exudates, giving the gross
appearance of a grayish
brown, dry surface.

Lasts from 2 to 6 days.

Lobar pneumonia
Morphology
RESOLUTION
The consolidated exudate within
the alveolar spaces undergoes
progressive enzymic digestion to
produce a granular, semifluid
debris that is resorbed, ingested
by macrophages, or coughed up.

Lobar pneumonia
Clinical stages
1.
2.

Onset of the disease (1st

morphological stage)

Height of the disease


(2nd and 3rd morphological stages )

3.

Resolution (4th morphological stage)

Clinical symptoms
I stage (onset of the
disease)
Shaking chills
(persist for 1-3 hours) or rigor
Complaints:

(imply bacteraemia).
Fever (39- 400C)
Pleuritic pain in the chest (on the affected side)
in lower lobe pneumonia can simulate acute
appendicitis, hepatic colics.

Dyspnoea.
Cough is first dry (in 1-2 days rusty sputum is

expectorated in the beginning of red hepatization


stage).

Severe headache (in atypical pneumonia).


Pain in the body & limbs.

Clinical symptoms
I stage
General inspection:

General condition is grave .


Confusion (hallucinations &
delirium, especially in alcoholic patients).
Convulsions (may be in children)

Facies pneumonica:
Hyperemia of the cheeks, more
pronounced on the affected
side, participation of the nostrils
in breathing, herpes nasalis &
labialis.
General cyanosis

Clinical symptoms
I stage

Respiratory system
examination

Lagging of the affected


side.
Dyspnoea.
Vocal fremitus is
increased.
Dulled-tympanic
percussion sound.
Auscultation diminished
vesicular breathing,
crepitation indux,
increased bronchophony

Clinical symptoms

II stage (height of the disease)

General inspection data the same as in I


stage.
Lagging of the affected side
Tachypnoea (30-40 per min).
Vocal fremitus increased.
Dull percussion sound.
Bronchial breathing, pleural friction rub.
Bronchophony increased, egophony (ee as
ay), whispered pectoriloquy.
Cardiovascular symptoms: tachycardia, may
be vascular collapse (vascular failure, BP drop
due to toxicosis).

Clinical symptoms

III stage (resolution)

Cough with mucopurulent sputum.


Dyspnoea decreases.
Vocal fremitus increased.
Dullness decreases. Dulled
tympanic sound.
Bronchial breathing gradually
disappears. Crepitation redux.
Moist rales.

Investigations
Blood test

A high neutrophil leucocytosis


(bacterial pneumonia).
Marginally raised or normal white
cell count (atypical agents).
A marked leucopenia in viral
etiology.
Increased ESR.

Investigations
Blood test

Blood gases to determine oxygen


therapy.
Blood culture.
Biochemical test:
Hyponatraemia (typical for Legionella).
Liver function test (often abnormal in
atypical
pneumonia).
Serum urea >7 mmol/L (predictive of
high mortality).

Investigations
Sputum

1st stage (congestion): may be present small

amount - tenacious; slightly crimson, contains


much protein, a small number of leucocytes,
erythrocytes, alveolar cells and macrophages.
2nd stage (red hepatization): scant and rusty; it
contains fibrin and higher number of formed
elements.
3rd stage (gray hepatization): leukocyte count
increases significantly; mucopurulent sputum.
4th stage (resolution): leukocytes are converted
into detritus

Microbiological
investigations
Sputum:

Direct smear by
Gram.
Culture.
Antimicrobial
sensitivity test.

Microbiological
investigations
Serology:
Acute and convalescent titers (Mycoplasma,
Chlamidia, Legionella and viral infections).
Pneumococcal Ag in sputum, serum & urine.
Direct fluorescent Ab stain in Legionella.
Legionella Ag in urine.
Cold agglutinins positive in 50% of
patients with Mycoplasma.

Investigations
X-ray

Homogeneous
opacity
localized to the
affected lobe

Complications:

1. pulmonary
2.
extrapulmonary

Para- or metapneumonic effusion


Empyema
Retention of sputum causing lobar collapse
Pneumothorax (particularly with Staph.
aureus)
Lung abscess
Septicaemia
Cirrhosis of the affected lung (carnification)
Renal failure, multi-organ failure
Adult respiratory distress syndrome
Ectopic abscess formation
Hepatitis, nephritis, pericarditis, myocarditis,
meningoencephalitis

Bronchopneumonia
(focal pneumonia)

More patchy alveolar consolidation


associated with bronchial and
bronchiolar inflammation

It occurs most commonly in infancy,


in aged patients especially with longstanding and severe diseases
(cancer, uremia, stroke)

Main syndromes in
bronchopneumonia
1.
2.
3.

Focal consolidation.
Respiratory insufficiency.
Intoxication.

Bronchopneumonia
Clinical symptoms

The onset is usually overlooked


because it often develops against the
background of bronchitis or catarrh
of the upper airways (secondary).
The findings of physical examination
at the onset are the same as in acute
bronchitis.

Bronchopneumonia
Clinical symptoms

Cough
Fever different: remittent, irregular
(usually subfebrile). Temperature may be
normal at aged patients.
Dyspnoea
Pain in the chest (only in involvement
of the pleura in peripheral located
inflammatory focus)

Bronchopneumonia
Clinical symptoms

Moderate hyperemia of the face; cyanosis


of the lips.
Tachypnoea (25-30 per min).
Palpation, percussion and auscultation
may be not effective (if the foci are small
and deeply located).

Bronchopneumonia
Clinical symptoms
In presence of large focus,
if it is located peripherally
(over the limited part of the
chest):

vocal fremitus increased


dull percussion sound
vesiculobronchial or
bronchial breathing,
dry / consonating moist
rales,
crepitation

Bronchopneumonia
Investigations

Blood test: mild leucocytosis,


moderately increased ESR.
Sputum: mucopurulent; great
number of leucocytes, macrophages
and columnar epithelium. Bacterial
flora is varied.
X-ray: focal consolidations at least 12 cm in diameter

Treatment of pneumonia

Food should be rich in vitamins and


easily assimilable.
Antibiotics.
Sulpha drugs.
Oxygen therapy.
Expectorants.

Criteria for hospitalization


of patients with pneumonia:
the PORT score (Pneumonia
Patient Outcomes Research Team )

Risk class

No. of points

Recommendatio
ns for site of
care

No predictors Outpatient

II

< 70

Outpatient

III

71 90

Inpatient

IV

91 130

Inpatient

>130

Inpatient

Criteria for hospitalization


of patients with pneumonia
Demographic factor

Characteristic

Points

Men

Age (years)

Women

Age (years) - 10

Nursing home
resident

+ 10

Criteria for hospitalization


of patients with pneumonia
Coexisting illnesses

Characteristic

Points

Neoplastic disease

+30

Liver disease

+30

Heart failure

+10

Cerebrovascular disease

+10

Renal disease

+10

Criteria for hospitalization


of patients with pneumonia
Physical examination findings

Characteristic

Points

Altered mental status +20


Resp. rate >30/min

+20

SBP<90 mm Hg

+20

Temp. <350 or>400C

+15

Pulse > 125/min

+10

Criteria for hospitalization


of patients with pneumonia
Laboratory & radiographic
findings

Characteristic

Points

Arterial pH < 7,35

+30

Blood urea nitrogen > 30 mg/dL

+20

Sodium < 130 mmol/L

+20

Glucose > 250 mg/dL (14 mmol/L) +10


Hematocrit < 30%

+10

O2 saturation < 90%

+10

Pleural effusion

+10

Pulmonary abscess
Is a purulent melting of the lung
tissue circumscribed by an
inflammatory swelling
It develops mostly as an outcome of
pneumonia or complicated
bronchoiectasis.

Pulmonary abscess
Etiology

Streptococci
Staphylococci
Pneumococci

Pulmonary abscess
Clinical symptoms
2 periods are distinguished:
1st before opening an abscess
(formation of abscess; it continues
10-12 days)
2nd after opening an abscess (begins
with the opening of the purulent
abscess into the bronchus)

Pulmonary abscess
I period
Complaints:
Weakness
Chills
Cough with meager sputum
Pain in the chest (in pleura
involvement)
Dyspnoea
Fever (remittent or hectic)

Pulmonary abscess
I period
In peripheral location of abscess

Palpation of the chest: pain (when the


costal pleura is involved)
Unilateral thoracic lagging
Vocal fremitus increased
Percussion: dull sound
Auscultation: diminished vesicular or
bronchial
breathing, smt. harsh with dry rales
In deep abscess (or small size) results of
objective examination are not changed

Pulmonary abscess
I period
Investigations

Blood test: neutrophylic leucocytosis; shift to


the left,
to the myelocytes; ESR increased significantly
Sputum: not specific
X-ray: does not differ from pneumonia or
tuberculosis infiltration: a large focus of
increased density with rough and indistinct
margins

Pulmonary abscess
II period
Complaints:
Severe cough with sudden release of
ample offensive purulent sputum (full
mouth):
on standing separates into three layers:
mucous, serous and purulent
(from 200 ml to 1-2 L/day)
Dyspnoea
Pain in the chest

Pulmonary abscess
II period

Clinical symptoms

Unilateral thoracic
lagging
Vocal fremitus
increased
Percussion: tympanic /
metallic sound;
crackled - pot sound
Auscultation: bronchial
(amphoric / cavernous)
breathing;
resonant moist rales;
gutta cadens (falling
drop sound)

Pulmonary abscess
II period

Investigations:
Blood test:
Neutrophylic leucocytosis.
Shift to the left,
to the myelocytes.
ESR increased significantly.
Sputum:
On standing separates into
three layers: mucous, serous
and purulent.
Elastic fibers.
Leucocytes and
erythrocytes.
Dittrichs plugs (resemble
the lenticular formations
with offensive odour on
pressing )

Pulmonary abscess
II period
X-ray:
cavity with liquid
level

Pulmonary abscess
Treatment

Hospitalization
Adequate draining
Antibiotics
Desintoxication