Pneumonia + COPD Flashcards
explain Df ,Predisposing factors
-DF: Pneumonia is an acute infection of lung parenchyma including alveolar spaces and interstitial tissue.
-Predisposing factors for pneumonia include:
Preceding respiratory viral infections
Alcoholism
Cigarette smoking
Underlying diseases such as Heart failure, COPD
Age extremes
Immunosuppressive therapy and disorders
Decreased consciousness, comma , seizure etc
Surgery and aspiration of secretions
explain Microbial Pathogen that cause Pneumonia
-Microbial Pathogen that cause Pneumonia: depend on the setting in which pneumonia is acquired:
1. Community-acquired pneumonia
o Streptococcus pneumoniae ( pneumococcal pneumonia ) commonest cause
o Mycoplasma pneumoniae
o Chlamydia pneumoniae
o Haemophilus influenza
o Oral anaerobic bacteria
o Staphylococcus aureus
o Legionella pneumophila
o Mycobacterium tuberculosis
2. Aspiration pneumonia: This occurs when large amount of oropharyngeal or gastric
contents are aspirated into the lower respiratory tract. Aspiration occurs more frequently
in patients with:
Decreased level of consciousness (alcoholism, seizure, strokes or general anesthesia)
Neurologic dysfunction of oropharynx and swallowing disorders.
People with periodontal disease are affected more.
Common Etiologic agents of Aspiration pneumonia: It is often polymicrobial
o Anerobic organisms in the oral cavity
o Enterobateriacae
o S. pneumoniae
o S.aureus
3. Community acquired Pneumonia in Immunocompromised hosts: Immunocompromised hosts such as transplant recipients, HIV infected patients, and patients on Chemotherapy etc. are prone to develop pneumonia. The etiologic agents are;
o Common bacterial causes of CAP : St. Pnumoniae , H.influenzae,
Mycoplasma
o Gram negative organisms : enterobacteriaceae
o Funguses such as Pneumocystis carinii ( jerovecii ), C. neoformans , Histoplasmosis , Aspergillus
o Mycobaterium tuberculosis
o Viruses : HSV , CMV
4. Hospital-acquired pneumonia: a patient is said to have hospital acquired pneumonia if the symptoms begin 48 hours after hospital admission and not incubating at the time of admission. Common organisms that cause hospital-acquired pneumonia are:-
o Gram-negative bacilli including Pseudomonas aeroginosa, K.pneumoniae
o Staphylococcus aureus ( may ne drug resistant )
o Oral anaerobes.
explain The “typical” Community acquired pneumonia ,Clinical Presentation , symptoms ,Physical findings
-Clinical Presentation of community acquired pneumonia
Community acquired pneumonia can have typical or atypical presentations. This classification is less distinct but it may have diagnostic value. More commonly patients have “typical” presentation and it is mainly caused by S.Pneumonae. But other
organisms like H. influenza and oral flora can be causes.
Pneumonia is often preceded by a URTI.
-symptoms :
Sudden onset with a single shaking chill. This is followed by high grade fever (up to 40.50c )
Cough productive of purulent, blood streaked or rusty sputum
Pleurtic chest pain on the involved side worsened during inspiration and coughing
Daphnia ( shortness of Breath )
Headache , myalgia , arthralgia and fatigue
-Physical findings
The Patient will have tachycardia (pulse 100 to 140/min)and tachypnea (RR > 20/min).
There will be pulmonary signs of consolidation (lobar pneumonia), which are Increased tactile fremitus and vocal fremitus , dullness on percussion Bronchial breath sound, egophony, whispering pectoriloquy, crackles and pleural
friction rub.
explain The “atypical” pneumonia
–The “atypical” pneumonia present with:
Atypical” pneumonia is usually caused by M. pneumoniae, C.pneumoniae, oral anaerobes and P. carinii (usually in HIV patients), as well as S. Pneumoniae. Some viruses like influenza virus, Varicella zoster virus and cytomegalovirus may cause
“atypical” pneumonia. Tuberculosis could also present in this form.
More gradual onset of symptoms, dry cough, shortness of breath.
Prominence of systemic symptoms like headache, malign, fatigue, nausea, vomiting and diarrhea.
Chest findings on physical examination are minimal even though X-ray changes are marked.
Complications
-Complications:
Local: Parapneumonic effusion or pus in the pleural space (empyema).
Distant complications: include septic arthritis and meningitis. Pneumonia can progress to sepsis, sometimes with septic shock.
Laboratory findings
-Laboratory findings:
1) CBC: leucocytosis with increased neutrophils is seen in most cases.
2) Gram stains from sputum may show a predominant pathogen like Gram-positive diplococci.
3) Chest x-ray shows pulmonary infiltrates or homogeneous opacity indicating lobar pneumonia. Very early in the course, it may be normal.
Diagnosis , Prognosis
–Diagnosis:
Pneumonia should be suspected in patients with acute febrile illness, associated with chest pain, dyspnea and cough.
Presumptive diagnosis can be made from history, changes on chest x-ray, blood and sputum culture and sputum Gram stains. An absolute diagnosis requires demonstration
of S. pneumoniae or other etiologic agents in pleural fluid, blood, lung or transtracheal aspirate
–Prognosis: The overall mortality rate is low, if treated early. Factors that herald a poor
prognosis include the following:-
Extremes of age, especially < 1 yr or >60yrs,
Positive blood culture
Involvement of more than one lobe
Peripheral WBC < 5000/ml
Presence of associated diseases (e.g. cirrhosis, CHF, immunosuppression)
Development of extrapulmonary complications like meningitis and endocarditis.
Management Mild form of CAP
—-Mild form of CAP :
-Patients with uncomplicated “typical” pneumonia can be treated at OPD
Amoxicillin 500 mg PO TID or Ampicillin 500 mg PO QID for 7 to 10 days OR.
Procaine penicillin 600,000 IU IM every 12 hrs.
-If “atypical” pneumonia is suspected,
Erythromycin 500 mg PO QID for 7-10 days or Doxycycline100 mg PO BID
-Supportive Therapy: Patients should also get bed rest, adequate fluids and analgesics for pleuritic chest pain and fever.
-Response – In mildly ill patients who are treated early, fever subsides in 24 to 48 hrs. Others
may require 4 days to respond.
If Patients are allergic to penicillins, cephalosporins, erythromycin, and clindamycin can
be given. TTC are less predictable and should not be used in seriously ill patients.
If a patient does not improve, the following factors should be considered:
.Wrong etiologic diagnosis
.Adverse drug reaction
.Far advanced case or superinfection
.Inadequate host defenses due to associated condition
.Non-compliance to the drug regimen in outpatients
.Antibiotic resistance of the strain and
.Complications like empyema requiring drainage, or metastatic foci of infection requiring higher doses (e.g. meningitis, endocarditis or septic arthritis)
Management Severe forms of CAP
–Severe forms of CAP :If patients are seriously ill they should be admitted and treated as inpatient. Criteria for Hospitalization of patients with Pneumonia are:
1) Respiratory rate of >28/min ( Tachypnea ) tachycardia >140/min
2) Systolic blood pressure <90mm Hg (hypotension
3) Hypoxemia (arterial PO2 < 60mm Hg) while breathing room air or O2 saturation < 90 %
4) New onset of confusion or impaired level of consciousness .
5) Unstable /Significant co-morbidity (e.g. Heart faiure , uncontrolled diabetes, Chronic
Renal insufficiency ,alcoholism , immunosuppresion )
6) Multilobar pneumonia is Hypoxemia is present
7) Pleural effusion and with analysis showing characteristics of complication
Other conditions in which inpatient management may be advisable
Elderly patient >65 yrs of age
Leukopenia <5000 WBC/ml
Pneumonia caused by St. aureus or Gram negative bacilli
Suppurative complications e.g. empyema, arthritis, meningitis, endocarditis
Failure of Outpatient treatment
Inability to take oral medication or persistent vomiting
Management of CAP
–Supportive management
Ensure adequate oxygenation to patients with cyanosis, significant hypoxemia, sever dyspnea, circulatory disturbance or delirium.
Patients should be well hydrated
Fever and pain should be managed
–Antibiotic Therapy
Admitted patients should be started on antibiotics empirically
High dose of crystalline penicillin 3-4 million IU IV every 4-6 hours
Alternatives are Ceftriaxone 1gm IV daily or 2X /day or Ampicillin 500 mg IV QID Or Cefotaxime
In severely ill patients erythromycin or a flouroquinolone can be added.
Choice of Antibiotics may be modified based on culture and sensitivity results, if available.
If the patient improves, IV treatment can be changed to oral after 3-4 days to complete a 7-10 days course.
–Prevention
Cessation of smoking and alcoholism
Vaccines : Influenza an Pneumococcal vaccines ( available in developed countries )
explain Pneumonia in the Compromised Host ,Diagnosis Treatment
-DF :
Immunocompromised hosts include patients with AIDS, acute leukemia, cancer chemotherapy, diabetes, sickle cell disease, Hodgkin’s disease, and corticosteroid treatment.
The potential pathogens in compromised hosts are many, as it has been stated above.
Pathogens like Streptococcus pneumonia, which cause pneumonia in immunocompetent people, are still responsible for the majority of pneumonia in compromised patients
–Diagnosis:
Sputum examination and culture are used but they are not specific.
Transtracheal aspirate, bronchoscopy and biopsy have high accuracy; however these are done only in specialized hospitals.
High index of suspicion from clinical presentation is important to diagnose pneumonia in immunocompromised hosts.
-Treatment ;
Acutely ill patients who have suspected bacterial infections are often treated with antibiotics selected on the basis of probabilities and the findings with sputum gram stain and culture. Later treatment is adjusted on the basis of more definitive diagnostic evaluation.
In patients with HIV infection and “atypical” pneumonia, PCP should be considered and treated with high dose of co-trimoxazole ( 3 tablets every 6 hours for 3 weeks) if clinically considered
explain Hospital acquired Pneumonia (HAP)
-The definition of HAP includes the presence of a new or progressive infiltrates of Chest X-ray , plus at least two of the following
Fever >37.8 oC
Leukocytosis > 10,000/mm3
Production of purulent sputum
Other findings: dyspnea, hypoxemia and chest pain
-Treatment
Antibiotics: Should be initiated empirically which latter on may be modified based on culture and sensitivity result.
The selection of drugs should be guided by an understanding of local patterns of antibiotics resistance
..Antibiotics should cover at least gram negatives and S. aureus
Ceftriaxone 1gm IV daily or BID plus Cloxacillin or meticillin Or
Levofloxacin 500 mg IV /day When resistant organisms are suspected
Cefotaxime 750 mg IV TID plus Vancomycin 1gm IV BID
–Prevention
Strict hand washing protocols by health care providers
Extubate an entubated patient as soon as the patient is stable
Remove NG tubes when the patient is stable
Proper aseptic handling of IV lines
