Pneumonia

Is an Inflammation of the lung substance distal to the respiratory bronchioles

(alveolar ducts, alveoli & interstitium), and this inflammation could be:
Infectious
Non-infectious like organizing pneumonia and pneumonia secondary to
connective tissues disorder or interstitial lung diseases.
Pneumonia can be caused by microorganisms, irritants and unknown causes. but
infectious causes are the most common type.
The symptoms of infectious pneumonia are caused by the invasion of the lungs by
microorganisms and by the immune system's response to the infection. Although more
than one hundred strains of microorganism can cause pneumonia, only a few are
responsible for most cases. The most common causes of pneumonia are viruses and
bacteria. Less common causes of infectious pneumonia are fungi and parasites.
Some people say that the term of pneumonia related to infectious pneumonia and
Pneumonitis related to non infectious; but this is not true as the doctor said, because we
have varesella Pneumonitis which is an infectious pneumonia.

Pathologically by Harrison

Pneumonia is an infection of the alveoli, distal

airways, and interstitium of the lung manifested by:
Increased weight of the lungs
Replacement of the normal lung's sponginess by consolidation (increase tactile
vocal fremitus, increase dullness in percussion )
Alveoli filled with white blood cells, red blood cells, and fibrin. And this will
affect the gas exchange.

Clinically

Pneumonia is a constellation of symptoms and signs in combination

with at least one opacity on chest radiography chest infiltrate.

So the opacity is so important with the s&s to diagnose pneumonia, because some
pt. come with s&s of pneumonia but the chest x ray is clear so that this is not
pneumonia and it may be bronchitis or bronchopneumonia or upper respiratory
tract infection.

Symptoms and signs

Respiratory

cough, pleuritic chest pain, sputum production and sometimes heamoptosis

increased respiratory rate, dullness in percussion, bronchial breathing sound,

egophony, crackles, wheezes and pleural friction rub if the infiltration involving
the pleura
pneumonia dose not only has respiratory s&s but also may combined by systemic s&s
such as :

fever, chills, fatigue, myalgias, arthralgias

hyper- or hypothermia in extreme cases

skin rash esp. viral infection

The majority of the pt. come with Typical Clinical Manifestations (prominent
respiratory s&s)

Symptoms of pneumonia need immediate medical evaluation. Physical

examination by a health care provider may reveal fever or sometimes low body
temperature, an increased respiratory rate, low blood pressure, a high heart rate, or a low
oxygen saturation, which is the amount of oxygen in the blood as indicated by blood gas
analysis. People who are struggling to breathe, who are confused, or who have cyanosis
(blue-tinged skin) require immediate attention.
Physical examination of the lungs may be normal, but often shows decreased
expansion of the chest on the affected side, bronchial breathing on auscultation with a
stethoscope (harsher sounds from the larger airways transmitted through the inflamed and
consolidated lung), and crackles heard over the affected area during inspiration.
Percussion may be dulled over the affected lung, but increased rather than decreased
vocal resonance (which distinguishes it from a pleural effusion).

However, when your pt.

come with these s&s you
should consider the
differential diagnosis
look at the table.
We have many
respiratory diseases that
manifested by
combination of around 6
symptoms (cough, chest
pain, hemoptysis,
sputum, SOB) plus
constitutional symptoms
(fever, weight loss, rigor
and chills).
The same for lung
infiltrate not only
pneumonia cause lung
infiltrate, but also HF can
cause lunge infiltrate or
connective tissue disorder
or radiation pneumonitis.

Diagnosis
When the pt. come to the ER with s&s and you suspect that he has pneumonia;
you should go in further investigation to be more sure.
And the first thing you do and the most important is the chest X-ray to look for
lung infiltration or not.
If the pt. produce sputum, you ask for gram stain culture; although its
sensitivity is low but it is important to find out the MO, to radiate it.
So again:

X-ray PA and Lateral for:

Acute bronchitis > clear X ray as we said
illustrate lung abscesses, pleural effusions and masses
Lobar pneumonia vs. diffuse pneumonia

Gram Stain and Culture

Poor sensitivity and specificity
Important for etiology to prevent microbial resistance with antibiotic
treatment as we said

Other specific tests:

Fiberoptic bronchoscopy for lower respiratory section analysis and
Thoracocentesis with pleural fluid analysis:

Stain and culture

Glucose

LDH

Total protein

WBC count

pH

Classifications
1. Typical: when the pt. come with prominent respiratory s&s as we
said
2. Atypical: when the pt come with systemic s&s rather than respiratory,
like fever and arthralgias with mild or no cough; but when we do more
investigation we find that he has pneumonia

But these previous two terms are less commonly use recently.
Now the new classifications are:
3. Community-Acquired Pneumonias: CAP
4. Nosocomial pneumonias :
Hospital Acquired Pneumonia ( HAP )
Ventilator Associated Pneumonia ( VAP )
5. Aspiration pneumonia
6. Pneumonia in immune compromised pt.
Now the question is : why we use these new classifications?
The answer simply to
guide the treatment based
on the organisms,
because the agent that
cause CAP are deferent
from that cause
nosocomial pneumonia or
immunocopromised
pneumonia. Look at the
table
- From the table we can
notes that:
CAP is most
commonly caused by
G+ bacteria, other
atypical like
mycoplasma

or chlamydia and may be viral.

But in nosocomial mostly caused by G- enterobacteria and anaerobic bacteria;
but if the pt. has permanent catheter or line; we may think of G+ bacteria
rather than G-.
In immunocomromised there is more sever combination of G- and G+,
and a opportunistic infection.

Community-Acquired Pneumonia CAP

in the United States:

Each year 2 to 3 million cases of community-acquired pneumonia

10 million physician visits

500,000 hospitalizations

45,000 deaths

The doctor said that these number are absolutely change nowadays because we face a
pandemic disease swin flue.

Less than 1% among outpatients

Up to 30% for patients requiring hospitalization.

Definition of CAP:
Acute infection of the pulmonary parenchyma that is associated with symptoms of
lower respiratory tract disease

Accompanied by a new infiltrate on chest radiograph or auscultatory findings

consistent with pneumonia

And now :: if the pt. come to the hospital, and after that we discover that he has
pneumonia, how can we decide if this pneumonia is CAP or nosocomial?
Answer :: CAP is different from nosocomial in that:

Occur in pt. who is Not hospitalized or diagnosed within 48 hours of hospital

admission. Y3ni if the pt. enters the hospital for elective surgery for eg. Then in
the second day his temp. elevated and we diagnose that he has pneumonia (or he

has lung infiltrate). This pneumonia is CAP, because he does not have enough
time to acquire a nosocomial infection in 24 hours. But if we diagnose him after
48 hours, this pneumonia probably could be nosocomial ok
And who is not residing in a long-term-care facility nursing home for the 14
days before the onset of illness.

Predisposing factors:

Old age extreme ages

Previous pulmonary disease (COPD or other respiratory illnesses)

History of smoking

Socioeconomic class

Others Comorbid conditions

Prior antibiotic use
Alcohol abuse
Diabetes Mellitus
Chronic liver disease
Chronic renal insufficiency
Congestive Heart Failure

Etiologic agent:

Not found in 30-50% of case (are treated without knowing the MO)

In other cases Most common pathogen remains: Strep. Peumoniae

Other Pathogens:

In Patients with no comorbidities:

Mycoplasma Peumoniae

Chlamydia Peumoniae

Respiratory viruses

In Patients with comorbidities (look at the table below)V. imp

H. influenzae

Chlamydia Peumoniae

Respiratory viruses

Aerobic gram-negative bacilli

Staph aureus

Association of host factors with particular pathogens :

The dr didnt talk about these 2 tables :

dr didnt talk about this table as well :

Frequency of Most Common Pathogens
Causing Community-Acquired Pneumonia,
According to Severity of Illness

Severity of Pneumonia
1.

Ambulatory

2.

Treated on hospital
ward

3.

Treated in intensive care

unit

Rank Order of Pathogens

1. Streptococcus pneumoniae
2. Mycoplasma pneumoniae
3. Chlamydia pneumoniae
4. Haemophilus influenzae
5. Influenza viruses
6. Pneumocystis
1. S. pneumoniae
2. Mixed etiology
3. Viruses
4. H. influenzae
5. C. pneumoniae
6. Legionella spp.
7. M. pneumoniae
8. Staphylococcus aureus
9. Moraxella catarrhalis
10. Aerobic gram-negative bacilli
11. Mycobacterium tuberculosis
12. Pneumocystis
1. S. Pneumoniae
2. S. Aureus
3. Viruses
4. Mixed etiology
5. Aerobic gram-negative bacilli
6. Legionella spp.
7. M. pneumoniae 8.
Pneumocystis
9. H. influenzae

Assessment the Severity of Community-Acquired Pneumonia

1.The British thoracic society

concerned in 4 findings (CURB) look at
the table , and add to them (age over 65y
not included here, CURD-65).
These 4 findings are guideline
for determining the severity of CAP
(but it is not 100% accurate).
As the pt. has more than one of
these in combination the mortality rate
will increase.
Y3ny, if the pt come with
pneumonia and he has no any of these
findings so that the mortality rate
around 2.4%, but if he comes with
confusion for eg, the mortality rate
increase and become around 8%. And
if he comes with the combination of
these 4 findings, the mortality rate
becomes high around 83%... ok. (Look
at the table ).
As we said this is not 100%
accurate, but you should know it (keep
its name in your mind CURB).
The doctor said that one of the
disadvantage of this CURB, is they
dont mention the hypoxemia, in that
the pt may come with pneumonia
without any of these findings but he
has sever hypoxemia and anemia that will lead to death.

2. American Thoracic
Society Definition of
Severe Pneumonia: but
this is not recently use
(look at the table )

3. Pneumonia Patient
Outcomes Research Team
(PORT)
or Cohort Study Data or
pneumonia severity
index:
This is more accurate in
that it depends in many
data in the pt. to
determined the severity
(look at the table ), this
table is not to memorized
but you should know about
it as a doctor to evaluate
the pt..

So, the best method for

determined the severity of
CAP is by clinical
judgment, you take the
previous three methods as
a guidelines and then you
judge clinically if this
pneumonia sever or not .. ok

Admissions Criteria: (the doctor read the slid as it)

1. Inability to take oral medications
2. Multilobar involvement on chest radiograph
3. Severe vital sign abnormality (pulse >125/min, systolic blood pressure <90 mm
Hg, respiratory rate >30/min
4. Acute mental status changes
5. Arterial hypoxemia (room air oxygen tension <60 mm Hg)
6. Secondary suppurative infection (e.g., empyema, meningitis, endocarditis)
7. Severe acute electrolyte, hematologic, or metabolic abnormality (serum sodium
<130 mmol/L, hematocrit <30%, absolute neutrophil count <1000/mm3 , blood
urea nitrogen >50 mg/dl, creatinine >2.5 mg/dl)
8. Acute coexistent medical conditions (e.g., suspected acute myocardial infarction,
renal insufficiency, liver disease, malignancy)
9. Lack of support system

Treatment Guidelines:
You should always start empirical treatment based on the type of the
pneumonia
If the pt. comes with CAP you should treat him as based line treatment of CAP, and so
one for other pneumonia.(according to epidemiological features of the pt.)
In the emergency room, if the you suspected that the pt. has pneumonia you should
give the patient antibiotics directly , because the early institution of antibiotics
decreases the mortality rate.
so The initial approach to the patient with a clinical diagnosis of pneumonia should
be directed toward:
(1) Instituting empirical treatment. As we said
(2) assessing the severity of infection, and need for hospitalization or not
(3) Identifying the etiologic pathogen

Treatment:
This slid at the right is
the treatment baseline in the
past, we dont use it nowadays
as the doctor said.
Actually the treatment is
based on the population and the
antibiotic programs which we
have in the hospitals.
For example: in the past
we used a combination of 3ed
generation cephalosporin and
macrolides, in the past the
macrolides resistance was not
more than 15%, but now the
macrolide resistance approach
50%, so that the macrolides are
not much effective; so that you should look for the antibiotic program in the hospital
before give the antibiotics.
Some doctors agree in spite of present of CAP resistance MO, to continue treat
CAP by respiratory fluroquinolone or combination of macrolides with 3ed or 4th
generation of cephalosporin.
If the pt has any of comorbidities, you should considered the MO t at cause that
comorbiditi. For example: if the pt has a risk factor of G- bacteria you should give
antibiotic that cover the G-, or has a resk of pseudomonas you should give him
Antipseudomonal penicillin and so on . Look at the table below

Nosocomial pneumonia
Divided into:
1. Hospital Acquired Pneumonia ( HAP ) : health care associated pneumonia
Defined by the infection that develops 48 hrs after hospitalization.
More common outside ICU but patients requiring mechanical ventilation are at a
greater risk.
Early nosocomial infection: when there are a combination of weak hospital
acquired organism and community acquired organism.
Late nosocomial: when there are streak hospital acquired organism (G- and
anaerobes )
2. Ventilator Associated Pneumonia ( VAP ):
Subset of nosocomial pneumonia that occur within the first 2 days of
mechanical ventilation

Pathogenesis:

Aspiration of oropharyngeal secretions

Leading organisms
Gram negative bacilli: and the most common cause of the HAP in our ICU
is ACPC

Staph. Aureus : esp. in USA the most common cause of HAP is

Methecillin resistant staph.Aureus (MRSA)

Factors contributing to gram negative oropharyngeal colonization:

Severity of illness

Duration of hospitalization

Use of antibiotics

Age

Poor nutrition

Intubation

Major surgery

Aspiration pneumonia
Usually happens in who has changes in his mental status), due to:

Abnormal swallowing

Impaired gag reflex; this factor may contribute to have aspiration pneumonia in
normal person who has neurological disorders.

Altered consciousness

Delayed gastric emptying; such as in diabetic pt. this may cause micro
aspiration

Decreased gastric motility

The treatment of HAP is the same as the guidelines for treatment of CAP ok

things the dr didnt mention from slides:

Hospital acquired pneumonia :

4-7 per 1000 of hospitalized patients

25 % of all ICU patients
1% of mechanically ventilated patients develop VAP
Mortality rates in VAP:
Crude MR = 20-70%
Attributable MR = 27-33%

THE END
Especial thx for group A2s boys (I cant imagine life without u), and girls (gr8
sisters; GO ahead!!)
- And happy eid for all dof3at 2006 students, except mo3ad rabab3a (ya .)

Done by: KJB

www.shifa2006.com