SLIDES PNEUMONIA.pptx by Simon peter kayiwa

Pneumonia

1. PNEUMONIA DR DAVID MAYANI

2. OUT LINE Introduction Epidemiology Defense mechanism Pathophysiology Risk factors of Pneumonia Classification CAP: typical , atypical PJP Complication of Pneumonia Aspiration Pneumonia References

3. INTRODUCTION Pneumonia can be generally defined as an infection of the lung parenchyma, in which consolidation of the affected part and a filling of the alveolar air spaces with exudate, inflammatory cells, and fibrin is characteristic (medscape,2020) CONSOLIDATION = ‘Inflammatory induration of a normally aerated lung due to the presence of cellular exudative in alveoli’

4. EPIDEMIOLOGY Pneumonia remains common cause of Death Globally Pneumonia ranked 6 th leading cause of death CAP is most common cause of Severe Sepsis Pneumonia  accounts for 10 percent of under five deaths in  Uganda ( Unicef Uganda,2020 ).

5. Various defense mechanisms of lung from infection Hairs and turbinates in the nares Cough reflexes and gag reflex Tracheobronchial braching architecture Mucociliary clearance and local antebacterial factors Normal flora Cell & humoral mediated immunity Dual phagocytic system alveolar -macrophages & neutrophils

6. PATHOPHYSIOLOGY

7. PATHOLOGY

8. PATHOLOGY

9. Risk Factors Disruption of mucociliary clearance: Disruption of intact epithelial barrier: Increasing “inoculation” events:

10. Risk Factors Old age and immobility of any cause  Chronic diseases-Preexisting cardiopulmonary conditions; (e.g., bronchial asthma , heart failure) Immunosuppression

11. Risk Factors Impaired airway protection Smoking  Alteration in consciousness (e.g., due to stroke, seizure anesthesia,  drugs, alcohol) Dysphagia

12. Risk Factors Environmental factors Crowded living conditions (e.g., prisons, homeless shelters) Toxins (e.g., solvents, gasoline) Chronic inflammatory disorders (e.g., rheumatoid arthritis)

13. CLASSIFICATION Anatomically: Lobar pneumonia if one or more lobe is involved Broncho -pneumonia (Lobular) More patchy alveolar consolidation associated with bronchial and bronchiolar inflammation often affecting both lower lobes

14. … The pneumonic process has originated in one or more bronchi and extends to the surrounding lung tissue Interstitial pneumonia involves the areas in between the alveoli

15. CLASSIFICATION Etiologically: Bacterial Viral pneumonia Fungal pneumonia Aspiration pneumonia & Chemical pneumonia

16. CLASSIFICATION clinically: Community-acquired pneumonia: (Typical/Atypical ) Hospital-acquired Pneumonia(HAP/nosocomial ) Aspiration pneumonia Pneumonia in immunocompromised patient

17. 1.Community-acquired pneumonia (CAP) is a syndrome in which acute infection of the lungs develops in persons who have not been hospitalized recently and have not had regular exposure to the health care system Organisms causing CAP: Streptococcus pneumoniae (most common bacterial cause ) Staphylococcus aureus (esp. postinfluenza ,glucocorticoids ) Mycoplasma pneumoniae , chlamydophila pneumoniae (esp. in young & healthy)

18. 1.Community-acquired pneumonia Haemophilus influenzae, Moraxella catarrhalis (esp. in COPD ) Legionella pneumophila (esp. in elderly, smokers, ↓ immunity) Klebsiella pneumoniae & other GNR (esp. in alcoholics & aspiration) P. aeruginosa and other gram negative bacilli ( COPD or bronchiectasis, especially in those taking glucocorticoids)

19. … Viruses: Influenza (Influenza outbreaks) RSV Rhinovirus Parainfluenza virus Coronavirus Human metapneumovirus Adenovirus

20. … Nontuberculous mycobacteria Fungi : Histoplasma and coccidioides species (in endemic areas) Coxiella burnetii may cause acute pneumonia with cough, high fever, severe headache, and elevated aminotransferase levels

21. TYPICAL Streptococcus pneumoniae (20% to 60% of CAP cases) Haemophilus influenzae (3% to 10% of CAP cases) Klebsiella , Pseudomonas, Escherichia coli, Staphylococcus aureus (3% to 5% of CAP cases )

22. ATYPICAL Atypical organisms such as M. pneumoniae , C. pneumoniae , and L. pneumophila implicated in up to 40% of cases of CAP

23. ATYPICAL PNEUMONIA - Why ‘Atypical’? Clinically: Subacute onset Fever less common or intense Minimal sputum Microbiologically: sputum does not reveal a predominant microbial etiology on routine smears (Gram’s stain, Ziehl-Neelsen ) or cultures

24. ATYPICAL PNEUMONIA - Why ‘Atypical’? Radiologically : Patchy infiltrates or Interstitial pattern Hemogram : Peripheral leukocytosis are less common or intense

25. Typical CAP presentation History Previously healthy with sudden onset of fever and shortness of breath Physical signs and symptoms Fever,tachycardia,tachypnea,productive cough with purulent sputum and possible hemoptysis

26. pallor and cyanosis localized: dullness to percussion decreased breath sounds crackles , ronchi , egophony (“E” -to-”A” change) Investigations CXR showing lobar consolidation CBC showing leukocytosis w/ left shift Sputum sample contains neutrophils, RBCs; Gram stain may be positive depending on organism

27. CAP can be defined both on clinical and radiographic findings. In the absence of chest radiograph, CAP is defined as: Symptoms of an acute lower respiratory tract illness (cough with or without expectoration, shortness of breath, pleuritic chest pain) for less than 1 week. At least one systemic feature (temperature >37.7°C, chills, and rigors, and/or severe malaise) New focal chest signs on examination (bronchial breath sounds and/or crackles). No other explanation for the illness.

28. … When a chest radiograph is available, CAP is defined as: symptoms and signs as above with new radiographic shadowing for which there is no other explanation (not due to pulmonary edema or infarction).

29. Risk factors for CAP Aspiration Alcoholism and diabetes Oral steroids/Immunosuppression (legionella) Cigarette smoking COPD (H. influenza and Moraxella catarrhalis ) Nursing home residents (H. influenza)

30. DIAGNOSTIC STUDIES-DETERMINE CAUSE Gram staining and culture -Sputum (AFB, Giemsa or methenamine silver stain, Culture) Blood cultures (before antibiotics!)- 20-25% + ve inpatients with pneumococcal pneumonia,nearly always + ve stap.aureus Multiplex PCR- Myc.pneumoniae , Chl.pneumoniae , Respiratory viruses

31. ELISA- Urinary antigen- Legionella pneumophilla serotype 1 antigen (+ ve 74%), severe disesase and pneumococcal cell wall polysaccharides antigen (+ ve 77%-88%)- bacteremic pneumococcal pneumonia

32. DIAGNOSTIC STUDIES Complete blood count RFT and electrolytes, LFT ABG

33. CXR: Lobar pneumonia  Patchy opacification evolves into homogeneous consolidation of affected lobe Air bronchogram (air-filled bronchi appear lucent against consolidated lung tissue) may be present. Bronchopneumonia: Typically patchy and segmental shadowing Complications: Para-pneumonic effusion, intrapulmonary abscess or empyema

34. … Staph. aureus : Suggested by multilobar shadowing, cavitation, pneumatocoeles and abscesses

35. … RUL Consolidation: 36 RML Consolidation RLL Consolidation

36. Bronchopneumonia: Centrilobular and Peribronchiolar opacity pneumonia Tends to be multifocal Patchy in distribution rather than localized to any lung region

37. Interstitial pneumonia: Peribronchovascular Infiltrate Mycoplasma , viral

38. Factors associated with poor prognosis: Increased CURB-65 score Co-morbidity such as renal disease Hypoxemia (spo2 <8kPa) WBC count <4x10 9 /l or > 20x10 9 /l Multilobar involvement on CXR Temperature <35 °C or >40°C Thrombocytosis Blood urea more than 7 Positive blood cultures

39. Pneumocystis Jirovecii Pneumonia (PCP) Pneumocystis jirovecii is an unicellular eukaryote, generally classified as fungus but some authorities consider is a protozoa . PJP is common opportunistic infection in AIDS PCP is unlikely if in patients with CD4 count above 200cell/mm3 . Immunosuppressed patients, particularly after organ transplantation

40. Pathophysiology: The organism is confined to the alveolar space of the lung and produces debris and cysts in the alveolar space with interstitial infiltration of lymphocytes and plasma cells. As a result, it causes profound disturbance of oxygen exchange and fatal hypoxemia if left untreated The morphological appearance of pneumocystis jirovecii infection in the lungs => an interstitial pneumonitis with foamy intra-alveolar exudate

41. Features: Dyspnea Dry cough Fever Chest auscultation (normal findings) Extrapulmonary manifestations are rare Hepatosplenomegaly Lymphadenopathy Pneumothorax is a common complication of PJP

42. Investigation: Bronchoalveolar lavage (BAL) often needed to demonstrate PJP (silver stain shows characteristic cysts)- Definitive diagnosis. Lactate dehydrogenase (raised) Exercise induced desaturation. Lymphopenia is very suggestive of PJP in AIDS. CXR: Typically shows bilateral interstitial pulmonary infiltrates (usually diffuse ground glass appearance) Lobar consolidation It can show normal finding

43. Management of PJP: Co- trimoxazole (120mg/kg) daily IV pentamidine in severe cases Clindamycin with primaquine or Dapsone if allergic to co- trimoxazole Steroids have been shown to reduce mortality and prevent lung damage in people with moderate to severe PJP.

44. Severe PJP is defined by room air arterial oxygen pressure (pO2) of less than 9kPa If pO2 <9.3kPa then steroids reduce risk of respiratory failure by 50% and death While its true that long term steroid use is immunosuppressive, a 21-day tapering course has been shown to be safe and effective. Prophylaxis: All patients with CD4 count <200cell/mm should receive PJP prophylaxis-=- Co- trimoxazole

45. COMPLICATION OF PNEUMONIA SLAP HER (please don’t)- Mnemonic S - Septicemia L - Lung abscess A - ARDS P - Para-pneumonic effusions H - Hypotension E - Empyema R - Respiratory failure /renal failure Chronic complications Bronchiectasis

46. Noninfectious Complications Myocardial infarction New major arrhythmias (most commonly, atrial fibrillation) 7 to 10% of patients who were admitted for CAP Worsening of heart failure occurred in nearly 20% One or more of these complications occurred in 25% of patients.

47. Prevention Smoking cessation Better Nutrition Respiratory hygiene measures Pneumococcal polysaccharide vaccine Inactivated influenza vaccine (selected patients) Live attenuated influenza vaccine (selected patients)

48. Aspiration pneumonia Definition: Pneumonia that follows the aspiration of exogenous material or endogenous secretions in to the lower respiratory tract.

49. Epidemiology: Is the commonest cause of death in patients with dysphagia due to neurological disorders. Cause pneumonia in nursing home residents (20%). Occurs patients admitted to hospital due to drug overdose (10%)

50. Risk factors: Suppressed level of consciousness Alcohol Drug overdose Post seizure Post anesthesia Massive CVA Dysphagia Motor neuron disease

51. Risk factors Upper GI tract disease Surgery to stomach or esophagus Mechanical impairment of glottic or cardiac sphincter Increased reflux Large-volume vomiting Large-volume NG feeding Recumbent position

52. Pathophysiology of aspiration pneumonia Micro-aspiration is common in health individuals, but for an aspiration pneumonia to occur, there must be compromise of the normal defence protecting the lower airways (i.e. glottic closure, cough reflex), With inoculation of lower respiratory tract of significant amount of material Most pneumonias are a result of aspiration of micro-organisms from the oral cavity or nasopharyns .

53. Which lung? Due to angle of bronchi , the right lung is more commonly affected by aspiration than left lung which lobe? Depending on the patients position during aspiration: Patients who aspirates while recumbent (lying down): Posterior segment of the upper lobes or Apical segment of the right lower lobes Patient who aspirates while sitting upright The basal segment of the lower lobes are commonly affected

54. Organisms: Anaerobes and gram negative organisms are the usual organisms in abscesses following aspiration . Sputum or tracheal gram stain reveal mixed flora Complications: Lung abscess Empyema

55. Clinical features of aspiration pneumonia Three Pulmonary syndromes result from aspiration Chemical pneumonitis: This is aspiration of substances toxic to the lower airways, in the absence of bacterial infection. This causes chemical burns of the tracheobronchial tree causing an intense parenchymal inflammatory reaction , with release of inflammatory mediators that may lead to ARDS.

56. Feature: rapid onset of symptoms , breathlessness, low grade fever, severe hypoxemia, CXR changes with in 2 hours. RX: suction and bronchoscopy to clear the aspirated secretions or food. Steroids(controversial), antibiotics (for secondary bacterial infection).

57. 2. Bacterial infection: Aspiration of bacteria normally resident in the upper airways or stomach Features: cough, fever, purulent sputum, breathlessness. The process may involve over weeks or months rather than hours Involvement of dependent pulmonary lobes May present with later manifestations e.g. empyema, lung abscess Organisms: peptostreptococcus , fusobacterium nucleatum RX: cover anaerobes e.g. metronidazole, clindamycin

58. 3. Mechanical obstruction: Aspiration of matter that’s not directly toxic to the lung may lead damage by causing airway obstruction or reflex airway closure . Causative agents: saline, barium, most ingested fluids e.g. water, gastric contents with PH>2.5, inhalation of object . RX: Tracheal suction, Remove obstructing object if necessary No further treatment is needed if no CXR infiltrates

59. REFERENCE Jain, S., Self, W. H., Wunderink , R. G., Fakhran , S., Balk, R., Bramley , A. M., Reed, C., Grijalva , C. G., Anderson, E. J., Courtney, D. M., Chappell, J. D., Qi, C., Hart, E. M., Carroll, F., Trabue , C., Donnelly, H. K., Williams, D. J., Zhu, Y., Arnold, S. R., … Finelli , L. (2015). Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults. Http://Dx.Doi.Org/10.1056/NEJMoa1500245 , 373 (5), 415–427. https://doi.org/10.1056/NEJMOA1500245 Longo, D. L., Musher, D. M., & Thorner , A. R. (2014). Community-Acquired Pneumonia. N Engl j Med , 17 , 1619–1647. https://doi.org/10.1056/NEJMra1312885