It is the inflammation of tracheobronchial tree

It is the inflammation of tracheobronchial tree

• It is the inflammation of tracheobronchial tree

• Rhynovirus, Influensa virus are the most common causes

• Frequent in children and elderly

• Frequently follows upper airway infection

Cough

• Cough

• Sputum

• Substernal cough related pain (Tracheitis)

• Fever not so frequent

• Crackles that change or diminish after coughing can be detected on chest oscultation (A. Bronchitis)

• Ronchus can be detected (A. Bronchitis)

• Physical examination can be normal

• Chest x-ray is normal

Viral infections damage airway epitelium

• Viral infections damage airway epitelium

• Mucous hypersecretion

• Decreased mucosiliary clerance

• Activation of irritating cough receptors

• Airway hyperresponsiveness may occur

Symptomatic

• Symptomatic

• Rest
• Antipiretics
• Antitussives or expectorants
• Antibiotics if necessary
• İnhaler steroids if bronchial hyperresponsiveness occurs

Definition: Acute infectious inflammation of the distal lung paranchyme (Distal to terminal bronchioles) with clinical and radiological signs of consolidation

• Definition: Acute infectious inflammation of the distal lung paranchyme (Distal to terminal bronchioles) with clinical and radiological signs of consolidation

• Pneumonitis: Noninfectious inflammation

• Community Acquired
• Nosocomial (Hospital acquired)
• Pneumonia in immuncompromised host

The microorganism reaches the lungs by:

• The microorganism reaches the lungs by:

• Inhalation or aspiration
• Hematogenious way
• Direct invasion from the neighbouring tissues

• The amount of the organism inoculated, the virulance factors and the immunity of the host are important factors

Smoking, alcohol

• Smoking, alcohol

• Viral airway infections

• Age

• COPD

• Corticosteroids

• Immunosuppression and drugs

The symptoms of pneumonia are usually not specific but generaly include:

• The symptoms of pneumonia are usually not specific but generaly include:

• Fever (chills)
• Cough
• Sputum production (purulent)
• Thoracic pain
• Dyspnea

S. Pneumonia (50%)

• S. Pneumonia (50%)

• H. İnfluenzae

• Moraxella catarrhalis

• Mycoplasma pneumonia

• Chlamydia pneumonia

• Legionella pneumophilia

• Virus (10-20%)

Typical pneumonia is characterised by abrubt onset high fever, chills, productive cough, thoracic pain, focal clinical signs, lobar or segmental radiographic findings, leukocytosis

• Typical pneumonia is characterised by abrubt onset high fever, chills, productive cough, thoracic pain, focal clinical signs, lobar or segmental radiographic findings, leukocytosis

• Strep. Pneumonia
• H. influenzae

• Confusion, tachypnea, hypotermia can be the presenting symptom in old age groups

Atypical pneumonias are characterised by progressive onset, fever without chills, a cough without sputum, headache, myalgia, diffuse crackles, modest leukocytosis, interstitial infiltrates on chest radiographs.

• Atypical pneumonias are characterised by progressive onset, fever without chills, a cough without sputum, headache, myalgia, diffuse crackles, modest leukocytosis, interstitial infiltrates on chest radiographs.

• Mycoplasma pneumonia
• Legionella
• Clamydia

High fever, tachicardia, tachypnea, (hypotension, confusion, drowsiness, altered mental status)

• High fever, tachicardia, tachypnea, (hypotension, confusion, drowsiness, altered mental status)

• Respiratory system:

• Inspection:

• Normal
• Respiratory disstress
• Ortopnea
• Cyanosis

• Palpation

• İncreased Vibration thoracic (local)
• Decreased hemithoracal movement

Percution

• Percution

• Normal sonority
• Dullness (Matite)

• Oscultation

• End inspiratory fine crackles
• Local diminished breath sounds
• Bronchial voice

History and symptoms

• History and symptoms

• Physical examination

• PA Chest x-ray

• Microbiologic examination

• Routine laboratory tests

• Blood gas

Consolidation

• Consolidation

• Lobar or patchy (Bronchopneumonia) nonhomogenious infiltrations
• Air bronchogram
• Round opacity
• Fine reticular density

The causative pathogen can not be isolated in 30-50% of CAP

• The causative pathogen can not be isolated in 30-50% of CAP

• Sputum

• Gram Staining (more specific than culture but less sensitive)

• In microscopic examination sputum shoud show <10 epithelial cell , and >25 PNL

• Culture

• Blood culture (Hospitalised patients)

• Pleural fluid analysis (If present)

Serology (Urine, sputum or blood: pneumococcal antigen, urine: Legionella antigen, 4 fold increase in specific antibody titers (cold agglutinins) between acute and covalescent period

• Serology (Urine, sputum or blood: pneumococcal antigen, urine: Legionella antigen, 4 fold increase in specific antibody titers (cold agglutinins) between acute and covalescent period

• İnvasive techniques (FOB, BAL, Protected-brush, TBB, PCFNA)

CBC

• CBC

• ESR

• CRP

• Hepatic enzymes

• Renal functions

Is it an infection?

• Is it an infection?

• Pulmonary edema
• Pulmonary embolism
• Interstitial fibrosis
• Atelectasis
• Malignancy

• How severe is the illness? (Hospitalization?)

• Risk factors
• Severe condition

Age>65

• Age>65

• Comorbid illness

• Alcoholism

• Aspiration?

• Recurrent pneumonia <1year

• Mental problems

• Spleenectomy

• Malnutrition

• Social problems

Respiratory rate >30/min

• Respiratory rate >30/min

• BP <90/60 mmHg

• Fever>38,3 C

• Extrapulmonary disease (menegitis, artritis, myocarditis etc)

• WBC <4000 or >30000 / mm3

• Htc <30% or Hb<9 gr/dl

• ABG PaO2<60 mmHg

• PCO2>50 mmHg

• BUN >20 mg/dl

• Multilober infiltration, cavity, effusion, rapid progression

• Sepsis or multisystem disfunction

Major

• Major

• PaO2/FiO2 <200
• Septic Shock

Probable microorganism

• Probable microorganism

• S. pneumoniae
• M. pneumoniae
• Chlamydia pneumoniae
• H. influensa
• Virus
• Enteric gr (-) eg:Pseudomonas, klebsiella
• MRSA
• Other

Pneumococ Pneumonia

• Pneumococ Pneumonia

• Typical pneumonia
• Leucocytosis
• Lober infiltration
• Rast colored (pink) sputum
• Labial herpes lesions
• Penicilline or macrolide (10-14 days)

Frequent in alcoholic, diabetic, nursing home residents old age group

• Frequent in alcoholic, diabetic, nursing home residents old age group

• E coli, Klebsiella pneumonia

• Necrose, cavitation is frequent, upper lobe enlargement in klebsiella

• Pseudomonas

• chronic lung disease, (Bronchiectasis, C. Fibrozis)
• nebulisator, ventilator use,
• recent antibiotic use (>7 days in the previous month)
• Steroid (>10 mg/day)
• Malnutrition

Probability of aspiration (alcoholism, epileptic atack, gingivitis, esophageal obstruction

• Probability of aspiration (alcoholism, epileptic atack, gingivitis, esophageal obstruction

• Fusobacterium, bacteroides, peptostreptococcus, actinomyces

• Sputum with bad smell, fever, leucocytosis

• Multipl necrotic area on chest x ray, lung abscess, emphyema

• H. influenzae

• Smoking
• COPD

Legionella pneumonia

• Legionella pneumonia

• Fatigue, myalgia in the first 24 hours
• Abrubt high fever
• Patchy infiltrations
• Bradicardia
• Confusion
• Hyponatremia
• Ekstrapulmonary signs
• Contaminated water system (Air condition)

Follow a viral upper airway infection

• Follow a viral upper airway infection

• High complication and mortality

• Rapid progression to cavity, pneumatocell, emphyema (Changes in 24 hours)

• SA is found in upper airway flora; skin wounds; iv port

• Iv drug addicts! and nursing home residents are the risk group

Control of comorbidities

• Control of comorbidities

• Good Nutrition

• General hygene

• Quit smoking and alcohol abuse

• Influensa vaccine

• Pneumococ vaccine

A new pulmonary infiltrate and signs of pneumonia that occur after 48 hours of hospitalization or within 48 hours of discharge

• A new pulmonary infiltrate and signs of pneumonia that occur after 48 hours of hospitalization or within 48 hours of discharge

• VAP (ventilator associated pneumonia): A pneumona that occurs after 48 hours of entubation

• The second most common nosocomial infection after urinary tract infection (mortality %25-70)

Oropharyngeal or gastric aspiration (colonization)**

• Oropharyngeal or gastric aspiration (colonization)**

• Inhalation

• Hematogenious

• Contamination (orofecal or from the hands of the staff)

• Immunedisturbances of the patient

Risk Factors

• Risk Factors

• MV (>48 hours)increases the risk by 6-20 times.

• Invasive procedures (Catheters, intubation etc)

• Duration of hospitalization, antibiotic use, the severity of the underlying disease. (chronic respiratory or immunosuppressive)

• Increased gastric ph (antiacid drugs)

A new infiltration on chest x-ray that (was apsent before) can not be explained by an another pathology

• A new infiltration on chest x-ray that (was apsent before) can not be explained by an another pathology

• Fever >38,3 or <36 C,

• Leucocytosis or PNL>25 in sputum

• Purulent secretions

Group 1 (Early onset ≤ 4 days)

• Group 1 (Early onset ≤ 4 days)

• S. Pneumonia
• H. İnfluenzae
• M. Catarrhalis
• S. Aureus (meticilline sensitive)

Antibiotic use in the previous 3 months (90 days)

• Antibiotic use in the previous 3 months (90 days)

• ≥5 days of hospitalization

• High antibiotic resistance in the hospital or public

• Immunsuppressive treatment

• MV >7 days

• İntensive care >48 hours

• Emergency intubation

• Severe sepsis/septic shock

• PaO2/FiO2 <250mmHg

• Bilateral, multilober infiltration, cavitation, complication,rapid progression

S aureus

• S aureus

• Coma
• Head trauma
• D. Mellitus
• Renal failure
• Past influensa

• Legionella

• Corticosteroid use
• Kemotherapy
• Past antibiotic

Noninvasive

• Noninvasive

• Blood cultures (obligatory but low sensitivity)
• Qualitative culturing of sputum or endotracheal aspirates (high sensitivity but low specificity)

Empirically based parentheral antibiotics, can be changed according to the microbiologic culture results

• Empirically based parentheral antibiotics, can be changed according to the microbiologic culture results

• Specific risk factors should be considered

• Prevention

• Staff education (hand washing, gloves)
• Noninvasive approach when possible
• Sucralphate for gastric prophylaxis
• Enteral feeding as much as possible
• Avoid narcotics
• Early mobilization
• Early discharge from IC or hospital

Rare in people with normal immunity

• Rare in people with normal immunity

• Influensa A >50% B
• Parainfluensa
• RSV
• Herpes
• Mixed bacteriel infection

• İmmunocompromised person

• CMV
• Herpes
• Parainfluensae
• RSV
• Varicella
• 50% bacteria, fungus, protozoa (PCP) superinfection occurs

Endemic

• Endemic

• Histoplasmosis
• Blastomycosis
• Coccidiomycosis
• Paracoccidiomycosis
• Criptococcosis
• Sporotricosis

Aspergillus fumigatus

• Aspergillus fumigatus

• ABPA
• Asthma
• Eosinophylia (>1000 mm3)
• Central bronchiectasis
• High serum IgE
• Aspergillus specific IgE and IgG (+)
• Aspergilloma
• Chronic necrotising aspergillosis
• Invasive aspergillosis

Aspergilloma:

• Aspergilloma:

• Fungus ball in chronic cavity
• Cause massive hemopthysis

• Invasive aspergillosis

• Seen in immunsuppressive patients (neutropenia)
• Inhaled spores cause pneumonia with fever and cough
• X ray may be normal in the beginning, focal infiltrations can be seen later
• Pleuritic chest pain is common

Neutropenia

• Neutropenia

• Nonneutropenia

• Organ transplantation
• Corticosteroid

• AIDS

The classic symptoms and signs are commonly absent

• The classic symptoms and signs are commonly absent

• Infectious and noninfectious pathologies can be concomitant

• Mixed infection with multipl pathogens can be the cause

• The general condition of the patient may not allow the invasive diagnostic procedures (BAL, proBAL, TTFNAB)

Opportunistic infections are common with high mortality (45%)

• Opportunistic infections are common with high mortality (45%)

• Differential diagnosis of noninfectious pathologies is important

Infectious

• Infectious

• S. Aureus
• Gr (-) bacteria
• Legionella
• Nocardia
• CMV
• Herpes
• Adenovirus
• Varicella
• Aspergillus
• Criptococcus
• Candida
• Tbc
• PCP
• Toxoplasmosis

The type of infective agent differs according to the type of immune defect

• The type of infective agent differs according to the type of immune defect

• Physical examination can be nonspecific

• Radiologic changes can be late

Solid organ transplant

• Solid organ transplant

• CMV
• H. influensa, s. pneumonia
• Later: Nocardia, tbc and atipical mycobacteria

• Bone marrow transplantation (Stem cell)

• CMV, PCP (less common due to allogenic trans and prophylaxis)
• Later pneumococ pneumonia

CD4>500 bacterial pneumonia

• CD4>500 bacterial pneumonia

• CD4 200-499 recurrent bacterial pneumonia, tuberculosis

• CD4<200 PCP, disseminated tb

• CD4<100 CMV, MAC, toxoplasma, disseminated fungus

Live vaccines are contraindicated

• Live vaccines are contraindicated

• Influensa and pneumococ vaccines should be given

• Chemoprophylaxis (PCP, CMV)

• Donor seropositivity in transplantation

Recurrent pneumonia:

• Recurrent pneumonia:

• A second pneumonia that occurs after the complete healing of a first attack (>1 month). At least 2 times a year.

• Late resolution:

• A pneumonia that resolves <50% in 2 weeks or incomplete regression in 4 weeks

Age

• Age
• COPD
• Alcoholism
• Smoking
• D mellitus
• Malignancy
• Renal or cardiac failure
• CS use

Pleural effusion (parapneumonic)

• Pleural effusion (parapneumonic)

• Emphyema

• Bronchopleural fistule

• Mediastinitis, pericarditis, chest wall infection

• Necrosis, cavitation

• Pneumatocel

• Pneumothorax

• ARDS

• Fibrosis

• Bronchiectasis

• Late resolution or recurrens