Pneumonia Flashcards
What is the basic definition of pneumonia
Infection in the lung
Also known as a respiratory tract infection
Lobar Pneumonia
Involvement of entire lung lobe
Typically is the end result of severe or chronic bronchopneumonia that has spread of one lung segment to another until the entire lung is involved
Double Pneumonia
Involvement of both lungs
Walking Pneumonia
Mild case of pneumonia where the patient remains ambulatory
Often caused by mycoplasma pneumoniae
What are the different causes of pneumonia
Bacteria
Viruses
Fungi,
Protozoa,
Parasites,
TB,
anaerobic organisms,
aspirations
Inhalation of irritating chemical like chlorine
Bronchopneumonia
Patchy pattern of infection limited to segmental bronchi and surrounding lung parenchyma
Usually involves both lungs
Seen more often in lower lobes
polymorphonuclear leukocytes
Will go into the alveoli with bacterial pneumonia in order to clear out the infection
Will not travel into the alveoli for interstitial pneumonia
Interstitial pneumonia
Diffuse and often bilateral inflammation that primarily involves the alveolar septa (separates adjacent alveoli) and the interstitial space
Mycoplasma pneumonia and other viruses cause interstitial pneumonias.
Most interstitial pneumonias cause only minor permanent alveolar damage and usually resolve without consequences.
CURB-65
CURB-65, is used to help predict mortality for CAP and guide where the patient shout be treated
C-Confusion
U-Blood urea >20 mg/dl
R-RR >30
B-Blood pressure with systolic <90 or diastolic <60
65-Is the patient greater than 65
If any of the above questions are answered yes, then it is considered to be one point
1 or 2 risk criteria-outpatients
2 criteria-wards
three or more risk factor should be treated in ICU
The risk factors for the development of HAP and VAP
- Factors that interfere with hosts immunity
- Underlying illness
- Certain interventions (intubation or trach)
- Meds such as sedative and corticosteroids
- Factors the encourage exposure to pathogenic micro-organisms
- Endotracheal or nasogastric tube
- Contaminated equipment
- Prior antibiotic therapy
- Neutralization of gastric pH
Non-ventilated patient mortality risk with pneumonia increased when there is
Bilateral infiltrates
Respiratory Failure
Infection with high risk organism
Ventilated patient mortality risk with pneumonia increased when there is
Infection with high-risk organisms such as P. aeruginosa, Acinetobacter species, and Stenotrophomonas maltophilia
Multisystem organ failure
Nonsurgical diagnosis
Therapy with antacids or histamine-2 (H2)-receptor antagonists
Transfer from another hospital or ward
Renal failure
Prolonged mechanical ventilation
Coma or shock
Inappropriate antibiotic therapy
Hospitalization in a noncardiac ICU
Empiric anti-microbial therapy and Pneumonia
Empiric anti-microbial therapy is used while a definitive microbiologic diagnosis is awaited
Empiric therapy is treatment that is initiated based on the most likely cause of infection when the specific cause is unknown
In ~50% of patient a microbiologic diagnosis has not been made which can be attributed to
Inability for patient to produce sputum
The sputum acquisition is done after antibiotics has been started
There is a failure to perform routine serologic studies in all patients
Many different organisms (viruses and anaerobic bacteria) are not routinely tested for
fomites
Objects capable of transmitting infection through physical contact with them
what is VAP
VAP stands for Ventilator-Associated Pneumonia and is basically pneumonia that develops 48 hours or longer after mechanical ventilation is initiated on a patient.
What are the three most common gram-negative organisms associated with VAP?
(1) Pseudomonas aeruginosa, (2) klebsiella pneumoniae, and (3) E. Coli
What is the most common gram-positive organism associated with VAP?
Methicillin-Resistant Staphylococcus Aureus
What kind of secretions typically does a diagnosed VAP patient have?
Strong smell (purulent)
What fungi can cause VAP in immunocompromised patients?
Aspergillus
What is pneumonia?
Pneumonia is an inflammatory condition of the lungs primarily affecting the alveoli which may fill with fluid and pus. It is an acute infection of the lung parenchyma.
What is the assessment of viral pneumonia?
Low-grade fever, non-productive cough, WBC normal to low elevation, less severe than bacterial.
What can be assessed on patients with bacterial pneumonia?
High fever, productive cough, WBC elevated, chest X-ray show infiltrates more severe.
What medication therapy can be used for pneumonia?
Antibiotics, bronchodilator, and corticosteroids.
What type of pneumonia is frequently undiagnosed?
Nonbacterial Pneumonia.
What are the three key signs of bacterial pneumonia?
Expectoration of yellow sputum, increased white blood cell count, and the presence of fever.
What type of anatomic alteration leads to aspiration pneumonia?
Alveolar consolidation – atelectasis – inflammation of the alveoli.
What term applies to the filling of alveolar spaces as a result of pneumonia?
Effusion.
The expression “walking pneumonia” is generally applied to patients with what type of pneumonia?
Mycoplasma pneumonia
What is the most commonly found bacterial cause of pneumonia?
Streptococcus pneumonia
What are some of the viruses that can cause pneumonia?
Influenza A or B, respiratory syncytial virus, rhinovirus, and coronavirus (SARS, MERSCoA).
What are some of the fungi that can cause pneumonia?
Cryptococcus, histoplasma, coccidioides, aspergillus and mucor.
What are some of the non-infectious etiologies of pneumonia?
Carcinomas, lymphomas, vasculitis, sarcoidosis, heart failure and pulmonary embolism.
What is the problem with pneumonia?
Even with antibiotics, patients with pneumonia have a high morbidity and mortality rates with the highest incidence in 1-4-year-olds or over 65.
What is hospital-acquired pneumonia?
This type of pneumonia is a ventilator associated and health care associated and happens at least 48 hours – 72 hours or more after admission to the hospital.
What is the pathophysiology of pneumonia?
- Trigger inflammatory response-Increase blood flow and vascular permeability
- Neutrophil activation
- Microorganism enter alveoli
- Extotxin produced by bacteria or cell lysis caused by viruses
- Increased vascular permeability
- Macrophage recruitment
What is the inflammatory response?
More neutrophils are activated (cascade effect) resulting to edema of the airways and fluid leaks from the capillaries to the alveoli. This affects normal oxygen transport.
What are the mechanical barriers from a bacterial infection?
Mechanical barriers include air filtration, epiglottis, cough reflex, and mucociliary response; reflex bronchoconstriction; and, secretion of immunoglobulins A and G and alveolar macrophages.
Why is antibiotic therapy beneficial for pneumonia?
Macrophages break down the bacteria and process the debris, lung tissue is allowed to recover and gas exchange returns to normal. They help to result in homeostasis and healing occurs if there are no other complications.
What type of pneumonia is more common in children and young adults?
Viral pneumonia.
What type of pneumonia is more common in adults and elderly?
Strep pneumonia.
What type of pneumonia is commonly found in people with HIV?
Pneumocystic jiroveci (FUNGAL).
What are the most common forms of pneumonia in neonates (0-1 month)?
Group B Strep and HSV.
What is the most common cause of pneumonia in infants (1-6 months)?
Bordetella pertussis and chlamydia trachomatis.
What is the most common cause of pneumonia in children (6 months – 5 years old)?
RSV and influenza.
What is the most common pathogen found on a young, healthy adult contracting pneumonia?
Mycoplasma.
What is the most common cause of pneumonia in older adults?
Strep pneumonia and H. flu.
What chest x-ray finding would indicate that the pneumonia will be difficult to treat and is life threatening?
Lung abscess (pus in the lung).
What are the atelectasis findings on a chest x-ray?
Collapse or incomplete expansion of the lung, loss of volume, Dyspnea or respiratory failure if severe and apex will usually be at the hilum.
What chest x-ray finding is usually associated with empyema (pus in the lung)?
Parapneumonic effusion.
What is a bronchogram on chest x-ray?
Air filled bronchi made visible by opacification of surrounding alveoli and peribronchial cuffing/thickening.
What will you usually see on a CBC with pneumonia?
Leukocytosis and L shift.
What should true sputum show when trying to find the cause of pneumonia?
An abundance of inflammatory cells, no squamous epithelial cells and large numbers of a single organism.
What pattern of pneumonia will have entire lobe consolidation and is commonly caused by Klebsiella?
Lobar. It can usually be seen in bronchograms too.
What pattern of pneumonia is multifocal and patchy and usually seen with staph, strep, and h. flu pneumonia?
Bronchopneumonia
What pattern of pneumonia is caused by viruses?
Interstitial that is characterized by a ground glass appearance.
What are the four most common symptoms of pneumonia?
Productive cough, shortness of breath, chest pain, fevers and chills.
What are the typical and atypical organisms associated with community-acquired pneumonia?
Typical involves S pneumoniae (pneumococcus), which is the most common cause requiring hospitalization, Haemophilus and Staphylococcus species. While atypical is caused by legionella, mycoplasma, chlamydia species and pneumocytis jiroveci (associated with HIV diagnosis).
What factors impair pulmonary clearance of pneumonia?
Viral upper respiratory tract infection, smoking, alcohol, uremia (raised levels of urea and other nitrogenous waste compounds in the blood), and bronchial obstruction.
What is the difference between typical (virulent) and atypical pneumonia?
Typical has an abrupt onset characterized productive cough with purulent sputum, pleuritic chest pain, impressive physical findings, leukocytosis with left shift or leukopenia, abdominal pain and high fever. This type responds to beta-lactams.
While atypical has a gradual onset that presents nonproductive/dry cough, sub-sternal chest pain, unimpressive physical exam, WBC count normal (no left shift), and nonspecific symptoms (headaches, malaise, nausea, vomiting, diarrhea, interstitial or patchy infiltrate). This type responds to macrolides and quinolones.
What indications are observed to determine the type of organism that caused the pneumonia infection?
Patients are observed by their chills, relative bradycardia and sputum.
For chills, a single chill suggests S. pneumoniaewhile multiple chills suggest S. aureus or K. pneumoniae. For relative bradycardia, association with viral infection, mycoplasma pneumonia, psittacosis, tularemia, and legionella spp.
Sputum is identified if rust-colored sputum or currant-jelly. Rust-colored sputum suggests association with infection by S. pneumoniae while currant-jelly sputum is associated with infection by Klebsiella species. Foul-smelling or bad-tasting sputum is often produced by anaerobic infections.
Pneumonia Definition
Pneumonia is the result of an inflammation process that primarily affects the gas exchange of the lungs
In response to inflammation fluid (serum) and RBC from adjacent pulmonary capillaries will pour into the alveoli (this fluid transfer is known as effusion)
8th leading cause of death
Consolidation in the Lungs
When an infection is overwhelming the alveoli will become filled with fluid , RBC, leukocytes, and macrophages
When this happens the lungs are considered to be consolidated
When this happens the alveolar structure will be maintained meaning that after the pneumonia has been resolved there will be minimal residual destruction to the parenchyma
Pneumonia as a Insidious Disease
Pneumonia is an insidious disease as symptons depend upon underlying condition and organism causing pneumonia
High Risk Groups for Pneumonia
Seen in the hospital with other co-morbidities, but anyone can get pneumonia
High-risk groups for pneumonia
- COPD
- HIV
- Altered LOC/dyspnea/dementia
- Patient undergoing chemotherapy
- Intubated
- Recent Surgery
- Paraplegic
- Pregnant
- Alcoholics
Anatomical Alterations of the Lungs
Inflammation of Alveoli
Alveolar Consolidation-Blocks alveoli
Atelectasis-E.g. Aspiration pneumonia
Increased Alveolar Capillary Membrane Thickness
Excessive Bronchial Secretions-During resolutions phase
Bronchopneumonia
Inflammation in the bronchi
Bilateral
Lobar Pneumonia
Involvement of entire lung lobe
Widespread in the alveoli
Double Pneumonia
Involvement of both lungs
Bilateral
Walking Pneumonia
Mild case of pneumonia
Typically mycoplasma pneumonia
Patient remains ambulatory
Gram-Negative Organism
- Haemophilus Influenzae
- Klebsiella
- Pseudomonas Aeruginosa
- 1st degree killer
- Primary killer in hospital pneumonia
*
- Primary killer in hospital pneumonia
- 1st degree killer
Gram-Positive Organism
Streptococcus-Most common community pneumonia
Staphylococcus-Most common hospital acquired (E.g. MRSA)
Bacterial Causes
Alveolar exudates will be mainly composed of neutrophils
It is important to promptly get a gram stain and culture analysis
Can be gram positive or gram negative
Atypical Organism
Organism escapes standard identification from bacterial test
Moderate sputum
Absence of alveolar consolidation
Only moderate WBC elevation
Lack of alveolar extubate
Atypical Organism Types
-
Myocoplasma Pneumoniae
- Most common acquired atypical pneumonia
- Walking pneumonia
-
Legionella Pneumonia
- Found in hot tubes
- Middle age smokers
-
Chamydia Osittaci
- School aged children
- Chlamydia Pneumoniae
Viral Causes
Viral cases account for 50% of pneumonia cases
Influenza A and BVirus
Respiratory Syncytial Virus (RSV)-Tends to affect children younger than one year, with a seasonal presentation
Parainfluenza Virus-Affects all ages and will spread quickly
Adenovirus-Affects all ages with a high morbidty in children
Coronavirus (SARS)
H1N1 (Swine Flu)
Other Causes of Pneumonia
Rickettsial Infections
Varicella
Rubella
Aspiration Pneumonitis
Lipoid Pneumonitis
Immuno-comprimised Patients
AIDs Patients
Tuberculosis
Fungal infections
Avian Influenza A
Cryptogenic Organizing Pneumonia (COP)
Unknown cause
No consolidation
Appear with history of dry cough
Inflammatory process
Treated with steroids
Rare and very severe
Can reoccur
Acquired Pneumonia Classifications
Community-Acquired Pneumonia (CAP)
Nursing home acquired pneumonia
Hospital-Acquired Pneumonia
Ventilator-Associated Pneumonia
Community Acquired Pneumonia-Typical Acute Forms
Streptococcus Pneumoniae
Haemophilus Influenza
Moraxella Catarrhalis
Staphylococcus Aureus
Community Acquired Pneumonia-Chronic Forms
Mycobacterium tuberculosis
Histoplasma capsulatum
Coccidiodes Immitis
Blastomyces Dermatiditis
Immuno-Comprimised Host
Pneumocystic Carinii
Cytomegalovirus
Aspergillus Species (Fungal)
Cryptococcus Neoformans (Yeast)
Re-Activation of Tuberculosis or Histoplasmosis
Aspiration
Not always nosocomial
Patients with GERD (asthma, pregnant) will be more acidic when they aspirate which also puts them at greater risk for ARDS
Trach patients will have difficultly swallowing which will put them at a higher risk for aspiration pneumonia (especially when the cough is inflated)
Mixed aerobic and anaerobic species
Enteric-Normal gram negative
Staph Aureus
Mendelson’s Syndrome
Clinical picture of aspiration pneumonitis in pregnant women
Include tachypnea, dyspnea, and cyanosis
Silent aspiration
Aspiration that does not evoke observable adverse symptoms
Ventilator Associated Pneumonia
Most common nosocomial infection
Pseudomonas Aeruginosa-1 Degree Killer
Acinetobacter Species
Enterobacter Species
Klebiella
Staphylococcus Aureus
Moraxella Catarrhalis
Typical Process of Pneumonia
- Begins with alveoli filled with exudate and pathogen (edema)
- Early consolidation RBC and neutrophils
- Severe consolidation, phagocytation by polymorpho-nuclear neutrophils, PMNS
- Resolution macrophages replace neutrophils, debris clean up
Lung Exudate
Exudate: A fluid rich in protein and cellular elements that oozes out of blood vessels due to inflammation and is deposited in nearby tissues.
Streptococcal Pneumonia Treatment
Most strains are sensitive to pencillin and its derivities
Streptococcal Pneumonia Onset
Will tend to begin in the upper airway (URT infection) and then move down
Will have an abrupt onset with a cough, shaking, and chills
Streptococcal Pneumonia
Gram positive
Accounts for over 80% of bacterial pneumonia
The bacteria is enclosed in a sugar jacket (polysaccharide) which accounts for their virulence (how fast and aggressive they spread)
Splinting (immobilization) causes a low tidal volme and tachypnea
Mixed red and grey hepatization
Fibrinous pleural exudate
Streptococcal Pneumonia Sputum
Rusty color sputum from hemorrhagic caps
Streptococcal Pneumonia Transmission
Aerosol
Cough, Sneeze
Streptococcal Pneumonia Breath Sounds
Fine crackles, pleural rub,
Staphylococcal Pneumonia Breath Sounds
Coarse and medium crackles
Staphylococcal Pneumonia Clinical Presentation
High fever
Hemoptysis
Pleuriti adhesions
Etiology has a definite respiratory componenet
Staphylococcal Pneumonia
Gram positive
The patient will often need to be intubated
Will often be nosocomial as it is the main hospital acquired pneumonia
Origin on normal flora of humans
Half the population are carrier, but it is rare to see this as a community acquired disease unless there is a influenze outbreak, as it often follows a predisposing viral infection (super infection after a viral insult)
Can cause emphysema, cavitation, abscess, potential pneumothorax on the lung and endocarditis and tri cuspid lesions and the heart
Often seen in children and immunosuppressant adults
There is a high mortality rate due to the complexity of the disease
Staphylococcal Pneumonia Types
Staphylococcal Aureus-Most virulent
Staphylococcus Epidermidis-In the normal flora of the skin
Staphylococcal Pneumonia Treatment
Methicillin-Susceptible Strains-Nafcillin
Methicillin-Resistant Strains-Vancomycin
This is very difficult to treat and often we need to conslt a specialist
Staphylococcal Pneumonia Transmission
Aerosol-Cough
On any surface after a viral infection
Klebseiella (Friedländer’s)
Gram Negative
Commonly seen in diabetics, the homeless, alchoholics, trach pt. and men over 40
Sudden onset
Hemptyosis
There is a significant mortality rate as it can lead to septicemia
Often nonsocomial
Can be misdiagnosed as TB due to abscess formation
1st or 2nd super infection pathogen
looks like currant jelly sputum
Klebseiella (Friedländer’s) Transmission
Can be aerosol but more likely is contact from food and unclean hands
Klebseiella (Friedländer’s) Origin
Fecal/oral route
Normal flora of GI tract
Aerosol
Klebseiella (Friedländer’s) Treatment
3rd or 4th Generation Cephalosporins (ceftazidime, ceftriaxone)
Aminoglycoside
Antipseudomonal
Penicillin
Monobactam (aztreonam)
Quinolone
Klebseiella (Friedländer’s) Resolution
Resolution
Will have a large number of organisms such as necrotizing and fibrin (scar) producing elements during the resolution
Pseudodomas Aeruginosa
Gram negative
Can be confused with flesh eating disease
Can be seen in ICU with pt. who are immuno comprimised
Pseudodomas Aeruginosa Tranmission
Aerosol or freshly contaminated surfaces
Often will be nosocomial and due to respiratory equipment (ex. Trachs)
Often cultured especially in aquesouns solution (loves dampness)
Pseudodomas Aeruginosa Origin
Normal GI flora
Meaning wash your hands after you use the bathroom
Pseudodomas Aeruginosa Treatment
Trobramycin
Pseudodomas Aeruginosa Sputum
Copious production
Greenish
Sweet smelling sputum
Pseudodomas Aeruginosa Clincal Presentation
Fever
Rigors
Abscesses
Pseudodomas Aeruginosa Mortality Rate
High Mortailty rate
Haemophilus Influenza
Smallest gram negtaive
often seen secondary to a viral infection
With a severe infection there is a 30% mortality rate
Haemophilus Influenza Transmission
Aerosol
Recently contaminated surfaces-It does not liek the cold and will not last long out side of the body (not easy to transmit)
The above are also the origin of the disease
Haemophilus Influenza Treatment
Ampicillin
Haemophilus Influenza Affected Populations
Commonly seen in small children where it can cause acute epiglottitis
Also seen in pt. with COPD, alchoholics,
Haemophilus Influenza Clinical Presentation
Low leve cough
Fever
Will grow to dyspnea-Not a fast acting disease
Purulent spurum
Patchy infiltrates on x-ray
Viruses
Non-living pathogens
Parasites that are dependent upon living cells for nutrition and replication
Have protein spikes on their surface which will match to receptor sites on specific cells (designation H and N)
These spikes can facilitate penetration of the usually intact cell membrane and allow viruses to either inject RNA or the entire viral packet into the cell
Once inside the cell the viral RNA will force copes of itself to be made
Viruses will often kill the host cell through using up all the cells nutrients and proteins and initiating over production of RNA packets which will lead to burst of the cell membrane
Influenza Viral Pneumonia
Severe parencyma congestion, hemorrhage, edema, consolidation, and emphysema
The A/C membrane will thicken by the edema, capillaries will engore, alveoli filled with type I and II cells leukocytes, and macrophages (fibrin producing)
Can be diagnosed though symptons and a rapid antigen test will can produce results in 15 min but is high in false negatives
Criteria for Severe Designation
- RR over 30 at rest
- PaO2 less than 60 on 30% or more O2
- Multiple lob involment
- Shocky;
- Low BP; systolic under 90 and diastolic under 60
- Low Urine Output-Less than 20 ml/hr
General Physical Examination
Vital signs-Tachycardia, tachypnea, increase blood pressure
Chest pain and decreased chest expansion-Moved to pleural space and painful
cyanosis
cough, sputum, hemoptysis
Confusion and mood change (may mean septic shock)
Nausea and vomitting
Chest Assessment
Incresed tactile and vocal fremitus
dull percussion
bronchial bretah sounds throughout
crackles and wheezes
pleural friction rub-if in pleural space
increased whispered pectoriloquy
Pulmonary Function Test
Restrictive
Arterial Blood Gases- Severe Stages
Acute Alveolar Ventilation with hypoxemia
Acute Respirtory Acidosis
Arterial Blood Gases- Mild to Moderate Stages
Acute Alveolar hyperventilation with hypoxemia
Acute Respirtory Alkaslosis
Oxygenation Indices
Pulmonary shunt (Qs/Qt)
Chest Radiograph
Increased density (from consolidation and atelectasis)
Air Bronchograms
Pleural Effusion
General Mangement of Pneumonia is Based Upon
Specific etiology of the Pneumonia-Bacteria, Virus, Aspiration
Severity of Symptons
Fungi-Causes
Aspergillus Species
Cryptococcus Neoformans
Cardida Species
Bacterial Causes- Types
Streptococcus Pneumonia
Staphylococcus Aureus
Hemophilius Influenza
Pseudomonas Aerginosa
Kledsiella Pneumonia
Legionella Species
Mycoplasma Pneumonia
Chalmydia Species
Types of Protozoa
Pneumocystis Carinii
