L20 Pneumonia

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Author:
jknell
ID:
200665
Filename:
L20 Pneumonia
Updated:
2013-02-15 00:00:46
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Pulmonary II
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pneumonia
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  1. Upper Respiratory Infection (URI)
    • Syndrome characterized by nasal congestion, +/- pharyngitis, +/- cough
    • "common cold"
  2. Laryngitis
    Inflammation of the larynx, leading to a change in the speaking voice
  3. Bronchitis
    Inflammation of the bronchi, characterized by excessive mucous production

    *can be difficult to tell apart from pneumonia (?)
  4. Bronchiolitis
    Inflammation of the bronchioles, often leading to airway obstruction
  5. Bronchiectasis
    Dialtion of the bronchi and terminal bronchioles, often due to a combination of obstruction and infection (inflammation)

    classically seen in CF

  6. Pneumonia
    Definition, epidemiology
    • -Infection of the lung parenchyma
    • -Infection may primarily involve the air spaces themselves (alveolar pattern) or the interstitium of the lung (interstitial pattern)

    • Epidemiology:
    • -2 million cases per year in US; 40-70K deaths (6th leading cause of death, most lethal nosocomical infection)
    • -developing countries: third leading cause of death
  7. Pleurisy
    Inflammation of the pleura leading to chest pain on inspiration
  8. Empyema
    Infection of the pleural space
  9. Defense mechanisms
    • Upper airway filters
    • Gag reflex
    • Cough
    • Tracheobronchial clearance
    • Alveolar macrophages
  10. Risk factors for developing pneumonia
    • Depressed cough
    • Depressed gag/disorders of swallowing
    • Injury to mucocilliary apparatus
    • Interference with phagocytic function of Alveolar macrophages
    • Pulmonary congestion
    • Accumulation of secretions
  11. Classifying Pneumonias
    • Organism
    • -Bacterial
    • -Mycobacterial
    • -Fungal
    • -Viral

    • Organism (specific) ... most common
    • -Pneumococcal
    • -Mycoplasma
    • -Legionella

    • Presentation:
    • -Community Acquired (CAP) vs. Nosocomial
    • -Classical vs Atypical
    • -Acute vs Chronic
    • -Normal host vs Immunocompromised
  12. Microbiological profile of Pneumonia
    most common in CAP
    • Stretococcus pneumoniae 20-60%
    • H. influenza 3-10%
    • S. aureus 3-5%
    • Miscellaneous 3-5%
    • Atypical agents 10-20%
    • Legionella 2-8%
    • Mycoplasma pneumoniae 1-6%
    • Chlamydia pneumoniae 4-6%
    • Viruses 2-15%
    • Aspiration 6-10%
  13. Diagnosis
    • Sputum gram stain
    • - Rapid
    • - Reliable
    • - Inexpensive
    • - Noninvasive

    • Adequate: lots of poly's with predominantly one but (most of the time); no epithelial cells

    • Inadequate: epithelial cells; no polys (spit)
  14. Classic bacterial pneumonias
    • Pneumococcal pneumonia (S. pneumoniae)
    • Staphylococcal pneumonia
    • Klebsiella pneumonia (prototypical GN)
    • Streptococcal pneumonia (beta hemolytic strep)
  15. Pneumococcal pneumonia
    • Epidemiology
    • -most common bacterial pneumonia
    • -Disease of elderly
    • -Usually follows URI

    • Presentation:
    • -Abrupt onset fever, shaking, chills, purulent sputum
    • -Leukocytosis/hypoxia
    • -Lobar pneumonia on X-ray
    • -bacteremia in 20-40%

    • Dx: sputum gram stain, culture
    • Rx: PCN/3rd gen cephalosporin
  16. Staphylococcal pneumonia
    • Epidemiology:
    • -Rare cause of CAP except in influenza outbreaks
    • -Frequent cause of nosocomial pneumonia
    • -Transmission: inhalation and hematogenous spread

    • Presentation:
    • -Acute presentation, pt appears ill, purulent sputum
    • -Causes parenchymal necrosis
    • -Leukocytosis
    • -X-ray picture varies

    • Dx: Sputum grain stain, culture, blood cultures
    • Rx: Vancomycin (if MRSA), semisythetic PCN
  17. Klebsiella pneumonia
    • Epidemiology:
    • -CAP in alcoholics, diabetics, those with underlying lung disease

    • Presentation:
    • -Acute presentation, severe illness
    • -"current jelly sputum"
    • -Leukopenia with left shift (increased immature leukocytes, primarily neutrophil  - aka "bands")

    • CxR: Bulging fissure/lobar consolidation with parenchymal necrosis (fissure line is lower than it should)

    • Dx: Sputum gram stain, culture, blood culture

    Rx: cephalosporins/quinolones
  18. Streptococcal pneumonia
    • Epidemiology:
    • -Caused by β hemolytic streptococci
    • -Rare cause of CAP but outbreaks still occur

    • Presentation:
    • -Acute presentation with shaking, chills, fever, cough, and chest pain
    • -Pleural effusions common in early infection
    • -Empyema common in those with WBC >20,000

    • Dx: Sputum, culture, blood culture, ASO titer (antistreptinolysin O antibody)

    Rx: PCN/clindamycin
  19. Hemophilus pneumonia
    • Epidemiology:
    • -Often in patients with COPD
    • -Usually NOT type B (for which we have vaccine)
    • -Sometimes difficult to distinguish from chronic bronchitis**

    • Sx: increase...
    • -SOB, fever, cough, sputum, mild leukocytosis

    • Dx: Sputum, culture - if no other pathogen is present...

    Rx: ampicillin/cephalosporin
  20. Atypical Pneumonia
    • -Mycoplasma pneumonia
    • -Chlamydia pneumonia
    • -Legionella pneumonia
    • -Viral pneumonia

    *Atypical does NOT mean uncommon; 10-20% of pneumonias are atypical; refers to presentation
  21. Mycoplasma pneumonia
    • Epidemiology:
    • -Second most common cause of CAP (5-25% of cases)

    • Pathophysiology:
    • -anaerobic and aerobic growth
    • -Slow growing in culture
    • -no peptidoglycan
    • -Attaches to respiratory epithelium (TLR-2)

    • Sx:
    • -HA, malaise, low grade fever, intractable non-productive cough, ear pain with bullous myringitis
    • Extrapulmonary manifestations:
    • -Rash (Stevens-Johnson syndrome)
    • -Hemolysis (IgM Abs to RBCs)
    • -CNS disease

    • Natural history:

    • Dx: cultural possible, but not commonly done
    • -PCR of secretion
    • -Antigen detection by EIA
    • -Bedside: cold-agglutinin (Ab to RBC cause agglutination of blood in cold temperature
    • -Antibody detection by EIA

    Rx: Tetracyclines, macrolides, quinolones

    • aka Bronchopneumonia (CxR shows patchy infiltrates in multiple lobes)
  22. Chlamydia Pneumonia
    • -Chlamydia are small prokaryotes - like mycoplasma (no peptidoglycan)
    • -Obligate intracellular organism
    • -Complex life cycle: biphasic

    • Species:
    • -chlamydophila pneumonia
    • -chlamydophila psittaci - (zoonosis)

    • Presentation:
    • -Elderly, and ages 18-30
    • -Gradual onset of sx: pharyngitis, hoarseness, sinusitis

    Dx: serology, DFA, PCR, culture but not usually done

    Rx: TCN or macrolides
  23. Legionella Pneumonia
    • Epidemiology:
    • -Smokers with COPD, transplant patients, those receiving steroids, CMI deficiency
    • -2-9% of CAP
    • -found in water (Air Con)

    • Pathogen...:
    • -Attachment via pili/ also have flagella
    • -Multiply intracellularly and prevent phagosomes - lysosomal fusion
    • -Mip, DOT & ICM virulence factors
    • -more than 70 serogroups: Legionella pneumophila causes 80% of disease
    • -Serotype 1, 4, and 6 are most common
    • -Aerobic, GN; require buffered charcoal yeast extract media for growth


    • Presentation:
    • -Can cause acute, self limited, febrile illness (Pontiac Fever)
    • -(normally) gradual onset of sx: nonproductive, F/B productive cough, GI complaints, high fever, relative bradychardia, hyponatremia, hematuria, proteinuria, mild leukocytosis

    • CxR: Patchy, nodular infiltrates, ill defined borders, pleural or perihilar based
    • 1. pleural based infiltrates; hilar enlargement:
    • 2. Perihilar infiltrates:

    Dx: Culture (3-5d), urinary antigen, serology

    Rx: quinolones or macrolides
  24. Aspiration pneumonia
    Aspiration of oral flora

    Predispositions: bad teeth, alcoholics, altered consciousness

    Presentation: indolent infection, low grade fever, putrid foul smelling sputum

    • CxR: Cavitary lesions in dependent lung segment

    • Dx: Sputum gram stain, transtracheal, aspirate, clinical
    • -Looks like mouth sample: lots of types of bacteria, but down in the lungs (no epithelial cells)

    Rx: aerobic and anaerobic coverage
  25. Poor prognostic factors in pts with CAP
    • Age >65 years
    • Coexisting conditions: DM, renal failure, chronic lung disease, chronic alcoholism...
    • Clinical findings: RR>30/min, SBP<90
    • Lab: WBC<4000 or >30,000; PO2 <60mmHg on RA; Hct<30%
    • CxR: multiple lobe involvement, rapid spread, or pleural effusion
    • Microbial pathogens: S. pneumonia, legionella, S. aureus
  26. Pneumonia Severity Index
    Predicts prognosis based on various characteristics about the patient, comorbid diseases, physical exam, and labs

    • Low risk:
    • -Class I (mortality is 0.1%)
    • -Class II (mortality is 0.6%)
    • -Class III (mortality is 0.9%)

    • Medium and high risk: hospitalization recommended
    • -Class IV (mortality is 9.5%)
    • -Class V (mortality is 26.7%)
  27. Nosocomial pneumonia
    • Risk factors:
    • -altered mental status
    • -mechanical ventilation
    • -H2 blockers (loss of acid)
    • -NG tubes
    • -thoracic or abdominal surgery
    • -obesity

    • Microbio:
    • -S. aureus
    • -Pseudomonas
    • -Enteric GNRs

    Dx: Change in status

    Rx: based on organism

    • Complications:
    • -Empyema
    • -ARDS
    • -Immunologic phenomena (i.e. hemolytic anemia)
    • -Meningitis, septic arthritis, abscesses, osteomyelitis

    • Prevention: 
    • -Pneumovax (>65years)
    • -Influenza vaccination
    • -Aspiration precautions
  28. Other causes of pneumonia
    • Mycobacterium hominis 
    • Pathogenic fungi
    • Viruses

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