Pneumonia

Pneumonia defined as syndrome caused by an

acute inflammation of the lung parenchyma
caused by infection usually bacterial infection
characterized by clinical and radiological sign of
consolidation of a part or parts of one or both
lungs.

Pneumonitis: acute inflammation of the lung

resulting from non infectious cause i.e. chemical or
radiation injury
Classification of pneumonia

Microbiological classification

•Infectious
žBacterial.
žNon Bacterial. (Viral, Fungal, …)
•Non Infectious
žToxins
žChemical
žRadiation &Aspiration
Anatomical classification

•Lobar.
•Bronchopneumonia
•Interstitial.

Clinical classification
•Primary / secondary.
•Typical / Atypical
•CAP (community aquired) / HAP (hospital
aquired), VAP (ventilator aquired)
Pathological stages of Pneumonia
•Stage of congestion is the earliest stage characterized
by extensive serous exudation mainly neutrophils,
vasodilatation & congestion (vascular engorgement),

•Stage of red hepatization, reflecting the liver like

appearance of the consolidated lung: Airspaces are filled
with PNL, vascular congestion occurs, and extravasation of
RBCs causes a reddish discoloration on gross
examination→ RUSTY SPUTUM.
•Stage of gray hepatization, accumulation of fibrin is
associated with inflammatory WBCs and RBCs in various stages
of disintegration, and alveolar spaces are blocked with an
inflammatory exudate . The alveolar structure is still maintained,
which is why a pneumonia often resolves with minimal residual
destruction or damage to the lung.

•Stage of resolution, characterized by resorption of the

exudate. If resolution is incomplete, the fibrinous exudate
organizes so that alveoli become filled with fibroblasts that may
result in permanent scaring
ORGANIZING PNEUMONIA, There is transformation of
intraalveolar exudate into intraalveolar fibro-myxoid nodular
masses containing firoblast and chronic inflammatory cells.
Definition of CAP

Infection of the lung parenchyma in a person

who is not hospitalized. This pneumonia
develops in the outpatient setting or within
.48 hours of admission to a hospital
CAP – The Two Types of Presentations
Typical
•Sudden onset of CAP
•High fever, shaking chills
•Pleuritic chest pain, SOB
•Productive cough
•Rusty sputum, blood tinge
•Poor general condition
•High mortality up to 20%
in patients with bacteremia
•S.pneumoniae causative
Atypical
•Gradual & insidious onset
•Low grade fever
•Dry cough, No blood tinge
•Low mortality 1-2%;
except in cases of
Legionellosis
•Mycoplasma, Chlamydiae,
Legionella, Ricketessiae,
Viruses are causative
Indications for admitting CAP patients to ICU (1
major or 3 minor)
Major Criteria
Acute respiratory failure( mechanical ventilation) •
Severe sepsis or septic shock( need of vasopressors) •

Minor Criteria (ICU admission recommended if ≥3)

Respiration rate ≥ 30/min • Multi lobar involvement •
PaO2:FiO2 ≤250 +/-SaO2 <90% with 6 L O2 •
Confusion/ disorientation • Uremia BUN ≥20 mg/dl •
Leukopenia WBC < 4 x 109/L •
Thrombocytopenia Tc < 100.000 / mm3 •
Hypothermia core temp< 36° •
Hypotension requiring aggressive fluid resuscitation •
:Diagnostic testing
Outpatient setting: Routine diagnostic tests to identify
an etiologic diagnosis are optional for outpatients
.with CAP. Microbiological tests are not recommended

Inpatient setting: Routine diagnostic tests to identify

an etiologic diagnosis are required in critically ill CAP
and when specific pathogens are suspected (e.g. TB)
that would likely change individual antibiotic
management
Radiology
:Switching from IV to Oral
Patients treated initially with parenteral antibiotics
should be transferred to an oral regimen if:
§ Hemodynamically stable,
§ Improved clinically,
§ Able to ingest oral medication,
§ Have a normal functioning gastrointestinal tract

Duration of Treatment:
Adults should be treated for a minimum of 7 days (14
ds in IC), should be afebrile for 3 days and have no
signs of clinical instability before discontinuing
therapy.
Definition of HAP - VAP

• Pneumonia that develop 48 hours

after hospitalization (HAP) or
endotracheal intubation (VAP)
Pathogenesis of HAP/VAP
Pathogenesis of VAP

Endogenous and Exogenous Sources

 Clinical criteria

Pneumonia : new and persistent

radiographical infiltrate(s) plus two of the
following:
1) body temperature 38 C or ,36 C;
2) white blood cells .11,000 or ,4,000 mm
3) macroscopically purulent tracheal
aspirate
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