Pneumonia & ITS Complications

PNEUMONIA & ITS IMPORTANT COMPLICATIONS.

1. PNEUMONIA
PROF.DR RIZWAN ZAFAR
PROF. OF MEDICINE
AKHTAR SAEED MEDICAL & DENTAL COLLEGE ,LAHORE

2. Learning objectives
•Organisms causing pneumonia
•Types of pneumonia
•Clinical features of pmeumonia
•Differential diagnosis
•Complications
•Investigations
•Treatment

3. Definition of pneumonia
•inflammation or
Infection of the lung
substance
•Causative agents
include bacteria,
viruses, fungi

4. Pleurisy
•Pleurisy is pain arising from any disease of the pleura.
The localized inflammation produces sharp localized
pain, which is worse on deep inspiration, coughing and
occasionally on twisting and bending movements.
Common causes are
•Pneumonia,
•pulmonary infarct and
•Carcinoma.
•Rarer causes include rheumatoid arthritis and systemic
lupus erythematosus.
•

5. Clinical presentations
•Clinically, it usually presents as an acute illness
with cough, purulent sputum, breathlessness
and fever, together with physical signs or
radiological changes compatible with
consolidation of the lung/
•However, it can present with more subtle
symptoms, particularly in the elderly

6. Classification of pneumonia
Accordingtocauses
•Bacterial(themostcommoncauseofpneumonia)
•Viralpneumonia
•Fungalpneumonia
•Chemicalpneumonia(ingestionofkeroseneor
inhalationofirritatingsubstance)

7. Bacteriology

8. Bacteriology
•Pneumococcusis the
most common cause
overall; cough with rusty
sputum
•30–50% of cases, no
organism is identifiable,
while in about
•20% of cases more than
one organism is present.

9. Classification of pneumonia
Accordingtoareas/siteinvolved
•Lobarpneumonia;ifoneormorelobeisinvolved
•Broncho-pneumonia;thepneumonicprocesshas
originatedinoneormorebronchiandextends
bilaterallytothesurroundinglungtissue,assmall,
multifocal,bilateralareasofair-spacedisease

10. Review of Lung Anatomy
RUL
RML
RLL
LUL
LLL
Lingula

11. BRONCHOPNEUMONIA
Bilateral
multifocal

12. •Community Acquired Pneumonia (CAP)
•Nosocomial Pneumonia
1..Hospital acquired pneumonia
2..Ventilator associated pneumonia ..(VAP)..Arises
>48-72 hours after endotracheal intubation
•Pneumonia in Immunocompromizedindividuals
•Atypical pneumonia
•Others, such as PCP, BOOP
Classification according to setting

13. Community Acquired Pneumonia (CAP)
•CAP ..Occurs outside of the hospital or within 48 hours
of hospital admission in a patient not residing in a
long-term care facility.
•Mortality rate =12% in-hospital; near 40% in ICU
patients

14. Risk factors for community-acquired
pneumonia
•Age<16and>65years
•Immuno-suppresedHIVpatients
•Cigarettesmoking.Alcohal,ivdrugabuse
•Difficultyinswallowing(duetostroke,dementia,parkinsons
disease,orotherneurologicalconditions)
•Impairedconsciousness
•Chroniclungdisease(COPD,bronchiactasis)
•Othercomorbidillnesssuchasheartdisease,livercirrhosis,
andDM
•chemical insult, such as in the aspiration of vomit
•radiotherapy
•allergic mechanisms .

15. Clinical features of community-acquired
pneumonia
•Cough: this may be dry or productive; haemoptysiscan
occur. In pneumococcal pneumonia, sputum is rust-coloured.
•Breathlessness: the alveoli become filled with pus and
debris, impairing gas exchange.
•Cracklesare heard on auscultation, due to consolidation of
the lung parenchyma.
•Bronchial breath soundsover areas of consolidated lung.
•Fever:this can be as high as 39.5–40°C. If swinging fevers
are present, this often indicates empyema .
•Chest pain:this is commonly pleuritic in nature and is due to
inflammation of the pleura. A pleural rub may be heard early
on in the illness.
•Extrapulmonaryfeatures: these are more common in
certain infections and are not universal

16. Signs
•Inspection..reducedchest wall movements
•Palpation..increasedvocal fremitus
•Percussion..mayhave dull notes
•Auscultation..bronchialbreathing
crepitations

18. Extrapulmonaryfeatures of community
acquired pneumonia
•Myalgia, arthralgia and malaiseare common, particularly
in Legionella and Mycoplasma
•Myocarditis and pericarditisin Mycoplasma pneumonia
•UncommonlyMeningoencephalitismay also occur
•Abdominal pain, diarrhoeaand vomiting, Hepatitis are
features of Legionella pneumonia
•Labial herpes simplex reactivation is relatively common
in pneumococcal pneumonia
•Other skin rashes, such as erythema multiformeand
erythema nodosum, are found in Mycoplasma
pneumonia.Stevens–Johnson syndromeisa rare and
potentially life-threatening complication of pneumonia

20. Extrapulmonaryfeatures of community
acquired pneumonia
Staphylococcus aureusnecrotizing cavitatingpneumonia
and bilateral infiltrates
Haemophilusinfluenza,Moraxellacatarrhalis
More common in pre-existing structural lung disease (cystic
fibrosis, bronchiectasis, COPD) and in the elderly
Chlamydophilapsittaci
Acquired from birds
Coxiellaburnetti(Q fever)
Recognized cause of endocarditis
Klebsiella pneumoniae
Alcohol,diabetes and other co-morbidities; of
Pseudomonas aeruginosa
Cavitation and abscess formation seen In cystic fibrosis,
bronchiectasis, COPD

21. Differential diagnosis
•Pulmonary TB
•Pulmonary fibrosis
•CCF
•Liver abscess( lower
lobe pneumonia)
•Pulmonary embolism
•CA Lung

22. Complications
•General
•• Respiratory failure
•• Sepsis –multisystem failure
•Local
•• Pleural effusion…Exudative
•• Empyema
•• Lung abscess
•• Organizing pneumonia

23. Causes of slow-resolving pneumonia
•Obstructing lesion
•Bronchoalveolarcell carcinoma
•Bronchiectasis
•Tuberculosis
•Pulmonary thromboembolic disease
•Cryptogenic organizing pneumonia
•Incorrect or incomplete antimicrobial treatment
•Complications of pneumonia .. Lung abscess,empyema

24. Severity of pneumonia
•1… CURB-65 or the CRB-65 score These give a guide
to the likely risk of fatal outcome but antibiotic choice
must always be tempered by clinical assessment and
judgement. The CRB-65 score is used in the community
where the serum urea level is not usually available.
•CURB -65 score
•C: confusion present
•U: (plasma) urea level>7 mmol/L
•R: respiratory rate >30 breaths/min
•B: systolic blood pressure <90 mmHg; diastolic <60
mmHg
•65: age >65

25. CURB-65 or the CRB-65 score
•1 point for each of the above:
•• Score 0–1: Treat as outpatient
•• Score 2: Admit to hospital
•• Score 3+: Often require care in the intensive
treatment unit
Mortality rates increase with increasing score.

26. Other markers of severe community-acquired
pneumonia
•Chest X-ray –more than one lobe involved
•• PaO2 –<8 kPa
•• Low albumin –<35 g/L
•• White cell count –<4 ×109/L or >20 ×109/L
•• Blood culture –positive
•• Other co-morbidities
•Absence of fever in the elderly

27. CAP –Investigations
•CXR… Radiological abnormalities can lag behind clinical
signs. …InMycoplasmaand Chlamydophilainfection the
shadowing is often more extensive than would
be expected from the clinical picture.
•Sputum Gram Stain and culture,Bloodculture
•Pulse oximetry
•Routine lab testing –CBC, LFTs,urea,creat,
•In Strep. pneumoniae. White cell count is usually >15
×109/L (90% polymorphonuclearleucocytosis),and ESR
>100

28. CAP –Investigations
•ABG necessary if oxygen satsare < 90%
•Serological tests..Urinarylegionella antigen test
•Low albumin and low Na in severe pneumonias
•Thoracentesisif pleural effusion present
•CT Chest in non resolving pneumonia

29. Case Summary…(Real life)
A 48 years old male, Smoker, presented with productive cough,
associated with wheez, and exertionalshortness of breath, on
going to washroom.. There was no hemoptysis, Fever was
intermittent, upto102, associated with chills…since 10 days.
He had oxygen saturation of 80% in ER, bilateral crackles and
bronchial breathing more on right side

32. Treatment of Pneumonia
•Oxygen therapy(maintain saturations between 94%-98%
•IV fluids if patient is dehydrated
•Antibiotics
•Thromboprophylaxisfor DVT if prolonged stay
•Vaccine if associated with COPD and high risk patients
•Nutritional supplementation. Need is assessed by a
dietician, particularly in severe disease.
•Analgesia. Simple analgesia, such as paracetamolor
NSAID, helps treat pleuritic pain,therebyreducing the risk
of further complications due to restricted breathing

33. Empiric antibiotics for community-acquired
pneumonia
•Outpatient management
•1. For previously healthy patients who have not taken
antibiotics within the past 3 months:
•a. A macrolide
Clarithromycin, 500 mg orally twice a day; OR
Azithromycin, 500 mg orally daily for 3 days,
OR
•b. Doxycycline, 100 mg orally twice a day.

34. Outpatient management
•For patients with comorbid medical conditions as chronic
heart, lung, liver, or renal disease; diabetes mellitus;
alcoholism; malignancy; asplenia,immunosuppressed
•a. A respiratory fluoroquinolone
moxifloxacin, 400 mg orally daily;
gemifloxacin, 320 mg orally daily;
levofloxacin, 750 mg orally daily) OR
•b. A macrolide (as above) plus a beta-lactam
amoxicillin, 1 g orally three times a day;
amoxicillin-clavulanate, 2 g orally twice a day

35. Inpatient management not requiring
intensive care
•1.A respiratory fluoroquinolone
IV moxifloxacin, 400 mg daily;
IV levofloxacin, 750 mg daily;
IV Ciprofloxacin, 400 mg every 8–12 hours OR
•2.A macrolide plus a beta-lactam
For intravenous therapy, ampicillin, 1–2 g every 4–6 hours;
Cefotaxime, 1–2 g every 4–12 hours;
Ceftriaxone, 1–2 g every 12–24 hours.

36. ICU management
•1..Azithromycin 500 mg daily for 3 days OR a respiratory
fluoroquinoloneplus an antipneumococcalbeta-lactam
(cefotaxime, ceftriaxone, or ampicillin-sulbactam, 1.5–3 g
every 6 hours).
•2. For patients allergic to beta-lactam antibiotics, a
fluoroquinoloneplus aztreonam1–2 g every 6–12 hours
•3. For patients at risk for Pseudomonas infection
•a. An antipneumococcal, antipseudomonalbeta-lactam
(piperacillin-tazobactam, 3.375–4.5 g every 6 hours;
cefepime, 1–2 g twice a day; imipenem, 0.5–1 g every 6–8
hours; meropenem, 1 g every 8 hours) plus ciprofloxacin
(400 mg every 8–12 hours) or levofloxacin, or

37. ICU management
•b. The above beta-lactam plus an
aminoglycoside gentamicin, tobramycin,
amikacin, plus azithromycin or a respiratory
fluoroquinolone.
•For methicillin-resistant Staphylococcus aureus
infectionAddvancomycinor linezolid (600 mg
twice a day).

38. CAP -Prevention
•Influenza Vaccine(influvac) Pneumococcal
Vaccine

39. Duration of Therapy
•5 -7 days -outpatients
•7-10 days –inpatients, S. pneumoniae
•10-14 days –Mycoplasma, Chlamydia,
Legionella

40. Other types of pneumonia
Hospital Acquired Pneumonia (HAP)
•(HAP) is defined as new onset of cough with purulent
sputum, along with a compatible X-ray demonstrating
consolidation, in patients who are beyond 2 days of their
initial admission to hospital or who have been in a
healthcare setting within the last 3 months
•P.aeruginosa, Escherichia coli, K. pneumoniaeand
Acinetobacterspecies Staph. Aureus,MRSAAnaerobic
bacteria (Enterobacterspp.)..similar bacteria between
HAP/VAP
•Piperacillin–tazobactamis commonly used in severe HAP.

41. Ventilator-associated pneumonia (VAP)
•Develops more than 48 hours following endotracheal
intubation and mechanical ventilation.
•fever, leukocytosis, »» New or progressive parenchymal
opacity on chest radiograph.
Aspiration pneumonia
•Acute aspiration of gastric contents into the lungs can
produce an extremely severe and sometimes fatal illness
owing to the intense destructiveness of gastric acid.
•This can complicate anaesthesia, particularly during
pregnancy (Mendelsonsyndrome). Because of the
•Right middle lobe and apical or posterior segments of
the right lower lobearecommonly involved

42. •The persistent pneumonia is often due to anaerobes and
progresses to lung abscess or even bronchiectasis
•Treatment should be directed specifically against
positive cultures
Pneumoniain immunocompromised patients
•Patients who are immunosuppressed (either
iatrogenicallyor due to a defect in host defences) are at
risk not only from all the usual organisms that can cause
pneumonia but also from opportunistic pathogens that
would not be expected to cause disease.
•The symptom pattern may resemble CAP or be more
non-specific.

43. PCP -Treatment
•TMP/SMX (trimethoprim/sulfamethoxazole)
–Drug of choice
–High incidence of side effects in HIV+ pts
•Dapsone + TMP
•Clindamycin + primaquine
•Atovaquone
•Pentamadine IV

45. •Predominant non
pulmonary symptoms
like fatique, diarrhea,
arthralgia
•Patchy, may be
diffuse, infiltrtrates

47. Atypical pneumonia..patchy,diffuse
infiltrate

48. Lung Abscess

49. Definition
•Infection of the lung parenchyma consisting of one or
more necrotic inflammatory cavities, containing
fibropurulentexudates andoften air fluid level
Anatomic Alterations of the Lungs in Lung abscess
•Alveolar consolidation,
•Tissue necrosis,
•Cavity formation
•Fibrosis of lung parenchyma

50. Lung Abscess
Cavity with
“Air-Fluid level”

51. Etiology of Lung Abscess
•Aspiration: seizure, coma, surgery, DM,
sedatives, alcohol, neurologic diseases
•Bronchial obstruction: malignancy, F.B.
•Septic emboli: SBE, catheters, prostheses,
pelvic thrombophlebitis
•Direct Spread:subphrenic, hepatic
•Pneumonia complication:S. aureus,
Klebsiella, pseudomonas, etc

52. Microorganisms
•Streptococcus milleri
•Staphylococcus aureus
•Klebsiella pneumoniae
•Gram-negative enteric bacilli
•Mycobacterium tuberculosis
•Anaerobic bacteria (post aspiration)
•Haemophilusinfluenzae

53. Clinical features of Lung Abscess
•Cough : 77%
•Sputum : 65%
•Fever and chills : 40%
•Chest pain : 24%
•Hemoptysis : 16%
•Dyspnea : 15%
•Anorexia : 4%
•Night sweats : 1 %
•Clubbing
•Coarse crackles

55. Lung abcess

56. Diagnosis
•X-ray : Cavity with “air-fluid level”
•CBC : leukocytosis, Anemia , etc
•Cultures : Sputum & Blood
•Chest CT
•Sputum cytology
•Sputum AFB
•Bronchoscopy or NAB to Rule out malignancy

57. Treatment
•Medical treatment is the mainstay..
•Choice depends upon C/S Penicillin,
Cephalosporin Clindamycin, Metronidazole
to cover for the Anarobes…
•DURATION 4-6 weeks
•Postural drainage
•Bronchoscopicdrainage

58. Indications for Surgery
•Massive hemoptysis
•Refractory to Medical treatment
•Large cavity with thick walls
•Empyema develops
•Chronicity, Recurrence

59. EMPYEMA

60. EMPYEMA
•Infected pleural effusion
•Pus in the pleural space
•Loculated(walled-off, immobile) pleural effusion
•Lens-shaped, homogeneous opacity abutting chest wall
•Early indications of empyema are ongoing fever, and
rising or persistently elevated inflammatory markers,
despite appropriate antibiotic therapy.
•An exudative effusion with pleural fluid pH <7.2 is
strongly suggestive of empyema.

61. RIGHT EMPYEMA

63. EMPYEMA…Treatment
•Chest tube drainage,
•Antibiotics +/-s
•Surgery

64. QUESTIONS
1..Which organisms cause community
acquired pneumonia
2..What are signs of pneumonia
3..Enlist complications of pneumonia
4.. What are causes of slow resolving
pneumonia
5.. How do you treat pneumonia in a patient
admitted in ward