Pneumonia

Question 1

Definition and classification

Answer 1

Is a chronic Inflammation in the lung parenchyma which is lower respiratory tract caused by bacteria virus fungi characterized by alveolar and interstitial tissue with exudation

CLASSIFICATION OF PNEUMONIA

1Community-acquired pneumonia
Nosocomial pneumonia – when patient was hospitalized with any another diagnosis, and after 48 hours in the hospital (not earlier!) pneumonia was diagnosed, or pneumonia after artificial lung ventilation
•Pneumonia due to aspiration. It results from the aspiration of gastric contents in addition to aspiration of upper respiratory flora in secretions.
2•Pneumonia in immunocompromised host – patients with AIDS or immunodeficit of other origin. Causes of pneumonia – viruses, fungi of saprofites (E.coli etc.)

III. Localization (side, lobe, segment)
IV. Stages of severity:
•Mild stage –conciousness is clear, t less than 38, heart rate less than 90, BP normal, dyspnea mild in case of physical activity, CXR – small infiltration
•Moderate – conciousness is clear, sweating, general weakness, t 38-39, heart rate 90-100, moderate dccreased BP, dyspnea, large size of infiltration
•Severe – t 39-40, conciousness is not clear, heart rate more than 100, low BP, severe dyspnea, cyanosis, large size of infiltration and presence of complications

Types of pneumonia
Lobar pneumonia
Interstitial pneumonia
Bronchopneumonia

Question 2

Diagnosis, symptoms and treatment

Answer 2

Pathogenesis 
Route of entry
 - Inhalation
 - Aspiration
 - Bloodborne
•Host/ organism dynamics tipped by
 - Defect in host defences
 - Virulent organism
 - Overwhelming inoculum

Diagnostic criteria of pneumonia

•Predisposition – CHF, diabetes, alcoholism, COPD
A. History of dyspnea, fever, productive cough.
B. Clinical syndrome – fever, pleuritic chest pain, productive cough with mucopurulent sputum.
C. Focal pulmonary findings (rales, crepitation or signs of consolidation)
D. General blood analysis – increased ESR, leucocytosis with left shift, elevated C-reactive proteins.
E. Sputum analysis – isolation of causative microorganism.
F. Chest X-Ray with infiltrates or consolidation

TREATMENT OF PNEUMONIA 
Community acquired pneumonia treatment 
•Macrolide
 Claritromycin (Clacid) 0,5 g 2-3 t/day,
 Azitromycin (Sumamed) 0,5 g 1t/d
 Roxitromycin (Rulid) 0, 15 g 2t/d

Nosocomial pneumonia treatment
Clindamicini i/m, i/v every 6 hours, total - 1 g/day
•Aztreonam (Azactam) – i/v, i/m every 8 hours, average – 3-6 g/day
•Vancomycini – i/v every 8-12 hrs, average – 30 mg/kg/d, max – 3 g/d

Aspirated pneumonia
Aminoglycozyde (tobramycin, sizomycin)+ Metronidazol
•Cephalosporini III-IV generation+Metronidazole

Pneumonia in immunocompromised host
•Cephalosporine III-IV generation
•Aminoglycozyde (tobramycin, sizomycin)

Question 3

Pleurisy: definition and classification

Answer 3

Definition
Inflammation of the pleura usually producing an exudative plural effusion and stabbing chest pain worsened by respiration and cough

Etiology
Could be from an underlying lung process
(Pneumonia,infarction,irritation from substance).

Classification.
Dry pleurisy (pleuritis sicca)
Wet pleurisy (pleuritis exudativa)

Inflammatory effusion may be serous, serofibrinous, purulent, hemorrhagic

Question 4

Symptoms, diagnosis and treatment

Answer 4

Dry pleurisy
Clinical picture
•pain in the chest (a characteristic symptom )which becomes stronger during breathing and coughing.
•cough (is usually dry)
•general indisposition;
•subfebrile temperature
• Respiration is superficial (deep breathing intensifies friction of the pleural membranes to cause pain). Lying on the affected side lessens the pain. Inspection of the patient can reveal unilateral thoracic lagging during respiration. Percussion fails to detect any changes except decreased mobility of the lung border on the affected side. Auscultation determines pleural friction sound over the inflamed site.

Wet pleurisy
Clinical picture
-Complains: fever, pain or the feeling of heaviness in the side, dyspnea (which develops due to respiratory insufficiency caused by com­pression of the lung). Cough is usually mild (or absent in some cases).
-Objective examination: The patient’s general condition is grave, especially in purulent pleurisy, which is attended by high temperature with pronounced circadian fluctuations, chills, and signs of general toxicosis.
-Inspection of the patient reveals asymmetry of the chest due to enlargement of the side where the effusion accumulated; the affected side of the chest usually lags behind respiratory movements.
-Vocal fremitus is not transmitted at the area fluid accumulation.

Symptoms
Pleuritic pain with stabbing sensation aggravated by breathing or coughing
Respiration is usually rapid breathing sounds may be diminished
Crackles harsh lethering sounds synchronous with respiration heart on inspiration and expiration
Tactile fremitus is absent
Percussion (dullness)

DIAGNOSTIC CRITERIA FOR PLEURISY
A. Chest pain which becomes severe, sharp, and knife-like on inspiration
B. Intercostal tenderness on palpation
C. Pleural friction rub granting or leathery sounds heard in both phases of respiration
D. Evidence of infection such as fever malaise, leucocytosis.
E. Pleural thickening on Chest x-Ray
F. Isolation of causative organism on sputum examination.
G. Pleural biopsy that rules out other conditions.

Treatment.

• Treatment of the underlying disease is essential.
• Chest pain may be relieved by wrapping the entire chest with two or three 6-in-wide nonadhesive elastic bandages, which must be reapplied once or twice daily. -Acetaminophen0.65 g qid or an NSAID is often effective.

-Oral narcotics may be necessary, but cough suppression may be not desired.
-Adequate bronchial drainage must be provided to prevent pneumonia. A patient
receiving narcotics should be urged to breathe deeply and cough when pain relief from the drug is maximal.
-Antibiotics (amoxicilin) and bronchodilators(salbutamol) should be considered for treatment of associated bronchitis.

Question 5

Pleural effusion

Answer 5

It is excessive fluid that accumulates in the plural cavity 
Examples 
Hemothorax
Hydrothorax
Pneumothorax 
Urinothorax
Chylothorax
Pyothorax

Classification
Transudate plural effusion: formed when fluid leaks from blood vessel into plural space
Examples of transudate pleural effusions include:
Congestive heart failure
Liver failure or cirrhosis
Kidney failure or nephritic syndrome
Peritoneal dialysis

Exudate plural effusion: are caused by inflammation of pleura itself and often due to diseases of the lungs 
Examples of exudate causes include:
 Lung or breast cancer
Lymphoma
Pneumonia
Tuberculosis
Post pericardotomy syndrome
Systemic lupus erythematosus
Uremia or kidney failure
Meigs syndrome
Pancreatic pseudocyst

DIAGNOSTIC CRITERIA FOR PLEURAL EFFUSION :
A. History of abdominal surgical procedures, alcohol abuse or pancreatic disease, exposure to asbestos, chest trauma, cardiac surgery , chronic hemodialysis.
B. Symptoms of dyspnea, cough, pleuritic chest pain.
C. Notable dullness to percussion, decreased or absent tactile fremitus, decreased breath sounds.
D. Posteroanterior and lateral chest radiograph that confirm presence of free pleural fluid that blunt the Costophrenic angle, form a meniscus laterally, or hide in a subpulmonic location causing elevated hemidiaphragm.
E. Thoracentesis and analysis of pleural fluid that confirms transudative or exudative effusion based on biochemical characteristics.
Fluid is exudative if:
1. The ratio of pleural fluid protein to serum protein is greater than 0.5
2. The pleural fluid LDH to serum LDH is greater than 0.6
3. Pleural fluid LDH is greater than two-thirds of the upper limit of normal for serum LDH.

Treatment

1. Tube tracheostomy
2. Bed rest
3. Treatment of underlying lung disease
4. NSAIDs ( indomethacin 25mg)
5. Aspiration of pleural fluid

Question 6

Purulent lung diseases

Answer 6

Definition-these are disorders characterized by pus formation in the lungs

a) According to different types of purulent lung diseases
- Bronchiectasis-destruction of epithelial, elastic, and muscular elements of bronchi, resulting in their irreversible dilatation.

• Lung abscess-presence of limited lung necrosis with one or more cavities (more than 0,5 cm) of destruction, filled with pus and surrounded by perifocal infiltration
• Gangrene of the lungs-purulent and putrid tissue necrosis of large areas of the lung or the entire lung collapse and tissue rejection with no tendency to limitation of viable parenchyma (no signs of demarcation), which has a tendency to proliferation
• Gangrenous abscess-purulent and putrid tissue necrosis of large areas of the lung or the entire lung collapse and tissue rejection with no tendency to limitation of viable parenchyma (no signs of demarcation), which has a tendency to proliferation
• Empyema-formation of pus
  b) According to location

1. Lung parenchyma - lung abscess, gangrene.
2. Bronchi - bronchiectasis.
3. Pleura - empyema.

Diagnostic criteria for Purulent disease of the lung;

The clinical manifestations of acute purulent destruction of lungs depend on the size of the focus and character of destruction, reactivity of the organism and stage of the disease, peculiarities of the drainage of purulent cavities and complications.
- general weakness, headache, malaise, suppressed appetite, moderate chest pain, dyspnea, subfebrile temperature.
-The sputum is foul-smelling.
- state of the patients is worsened. The fever rises to as high as 39-40°С and has a hectic character. At the same time the chest pain increases, which associates with a troubling cough and dyspnea, amount of sputum is small, with a rusty tone, possible hemoptysis. The sputum is foul-smelling.
- Further in favourable cases there is a considerable improvement of state of the patients. The body temperature falls, the signs of intoxication reduce and the appetite increases.
⁃ By palpation – weakened vocal fremitus.
⁃ At percussion – a blunted sound over the site of the purulent focus and perifocal infiltration (at subpleural location of the abscess).
⁃ By auscultation – tubular sound with a moist rales in the zone of purulent focus, moist rales on the background of amphoric respiration.
⁃ At X-ray of the chest at the stage of necrotic pneumonia is found out a rounded lesion with irregular contour

Treatment of purulent lung disease

Antibiotic therapy
-Antibiotics which can be used in patients with bronchiectasis are : amoxycillin, clarithromycin

ANTIBIOTICS IN LUNG ABSCESS
· First choice - Clindamycin

· Alternative - Penicillin

· Oral therapy - Clindamycin, metronidazole (Flagyl), amoxicillin (Amoxil)

*Gram-negative organisms

· First choices - Cephalosporins
aminoglycosides, quinolones

· Alternatives - Penicillins and cephalexin (Biocef)

· Oral therapy - Trimethoprim/sulfamethoxazole (Septra)