It is the inflammation of tracheobronchial tree



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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



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





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