Respiratory Medicine Made Simple : Pneumonia

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PNEUMONIA:

An acute lower respiratory tract illness associated with fever,symptoms and signs in the chest and abnormalities on Chest X ray.

An inflammation of lungs caused by acute infection and characterized by recently developing signs of consolidation both clinically and radiologically.

CLASSIFICATION AND CAUSES

COMMUNITY ACQUIRED PNEUMONIA:

May be primary or secondary to underlying disease.

Most common cause is Streptococcus pneomonia.

This is followed by Haemophilus Influenzae and Mycoplasma pneumoniae

Other organisms include : Staphylococcus aureus,Legionella species,Morexalla catarrhalis and Chlamydia.

Rarer causes include : Coxiella Burnetti and anaerobes.

Viruses account for 15 % of causes.

Flu may be complicated by community acquired MRSA pneumonia (CA-MRSA)

HOSPITAL ACQUIRED PNEUMONIA

Occurs more than 48 hours after hospital admission.

Most commonly cased by Gram negative enterobacteria or Staphylococcus aureus.

Other organisms include the following :

Pseudomonas Aeuroginosa

Klebsiella

Bacteroides

Clostridia

ASPIRATION PNEUMONIA

This occurs due to poor swallowing and unwell patients with low GCS.

Increased incidence occurs in the following patients:

Stroke

Septicemia.

Bulbar palsies

Myasthenia

Decreased consciousness (post ictal)

Oesophageal diseases (Achalasia and reflux)

PNEUMONIAS IN IMMUNOCOMPROMISED PATIENTS

These are caused by the following organsims:

Streptococcus pneumonia

H.Influenzae

Staphycoccus aureus

Mycoplasma oneumonia

Gram negative bacilli

Pneumocystic Jirovecii/carinii

Fungi

Mycobacteria

Viruses: CMV , HSV

CLINICAL FEATURES

SYMPTOMS:

Fever

Rigors

Malaise

Anorexia

Cough

Dyspnoea/shortness of breath.

Purulent sputum

Haemoptysis

Pleuritic chest pain

SIGNS

Fever

Cyanosis

Confusion

Tachypnoea

Tachycardia

Hypotension

Signs of consolidation :Diminished expansion,dull percussion note,increased tactile vocal fremitus and increased vocal resonance,bronchial breathing and  pleural rub

INVESTIGATIONS

Objective is to:

Establish diagnosis

Identify the pathogen

Assess severity

CXR:

Lobar or multilobar infiltrates,cavitation or pleural effusion.

Assess oxygen saturation

Arterial blood gases if SaO2 less than 92 %

BLOOD TESTS: FBC,CRP,U&Es,BLOOD CULTURES

SPUTUM FOR MICROSCOPY AND CULTURE

ATYPICAL RESPIRATORY SEROLGY IN SEVERE CASES:

VIRAL SEROLOGY/COMPLEMENT FIXATION TESTS

PNEUMOCOCCAL ANTIGEN IN URINE

LEGIONELLA : SPUTUM CULTURE AND URINE ANTIGEN

PLEURAL FLUID ASPIRATION FOR CULTURE

BRONCHOSCOPY AND BRONCHOALVEOLAR LAVAGE IF PATIENT IS IN ITU OR

IMMUNOCOMPROMISED

ASSESSMENT OF SEVERITY

CURB – 65 SCORE IS USED TO GUIDE SEVERITY

1 SCORE FOR EACH OF THE FOLLOWING BELOW :

CONFUSION : ABBREVIATED MENTAL TEST SCORE LESS THAN OR EQUAL TO 8.

UREA > 7 MMOL/L

RESPIRATORY RATE  MORE THAN OR EQUAL TO 30/MIN

SYSTOLIC BLOOD PRESSURE LESS THAN 90 MM HGOR DIASTOLIC LESS THAN 60 mmHg

AGE MORE THAN OR EQUAL TO 65

MANAGEMENT OF PNEUMONIAS:

ANTIBIOTICS:

These are given orally if not severe pneumonia,and intravenous in case of sec=vere pneumonia

COMMUNITY ACQUIRED PNEUMONIAS:

MILD:

STREPTOCOCCUS PNEUMONIAE/HAEMOPHILUS INFLUENZAE:

Oral Amoxicillin 500 – 1 Gm 8 hourly or

Clarithromycin 500 mg 12 hourly or Doxycycline 200 mg loading and 100 mg 12 hourly

MODERATE:

STREPTOCOCCUS PNEUMONIAE/HAEMOPHILUS INFLUENZAE/MYCOPLASMA PNEUMONIAE:

Oral amoxicillin 500 mg – 1 Gm 8 hourly or Doxycycline 200 mg loading then 100 mg 12  hourly.

COMMUNITY ACQUIRED PNEUMONIA

SEVERE

STREPTOCOCCUS PNEUMONIAE/HAEMOPHILUS INFLUENZAE/MYCOPLASMA PNEUMONIAE

Co-amoxiclav 1.2 Gm / 8 hourly IV  or

Cephalosporin IV eg Cefuroxime 1.5 Gm IV 8 hourly and

Clarithromycin 500 mg 12 horly IV

Add flucloxacillin if staphylococcus is suspected

ATYPICAL PNEUMONIAS:

LEGIONELLA PNEUMOPHILIA :

Consider adding Rifampicin,Treaat for 14 – 21 days

Chlamydophilia species : Tetracyclines

Pneumocystis Jiroveci : High dose co-trimoxazole

MANAGEMENT OF PNEUOMONIAS

HOSPITAL ACQUIRED PNEUMONIAS:

GRAM NEGATIVE BACILLI:/PSEUDOMONAS/ANAEROBES

AMINOGLYCOSIDE IV PLUS ANTIPSEUDOMONAL PENICILLIN IV OR 3RD GENERATION CEPHALOSPORIN IV

ASPIRATION PNEUMONIA:

CAUSED BY ANAEROBES AND STREPTOCOCCUS PNEUMONIAE : CEFUROXIME 1.5 GM/8HOURLY IV PLUS METRONIDAZOLE 500 MG 8 HOURLY IV

NEUTROPENIC PATIENTS :

GRAM POSITIVE COCCI AND GRAM NEGATIVE BACILLI :

AMINOGLYCOSIDE IV PLUS ANTIPEUDOMONAL PENICILLIN IV OR 3RD GEN CEPHALOSPORINS IV

CONSIDER ANTIFUNGALS FOR FUNGAL PNEUMONIAS IN NEUTROPENIC PATIENTS

MANAGEMENT OF PNEUMONIAS

OXYGEN:

To keep PaO2 > 8.0 Kpa and saturation > 94 %

IV FLUIDS:

In case of dehydration,anorexia,shock

ANALGESIA:

In case of pleurisy eg by paracdetamol 1 Gm PO 6 hourly.

ITU TREATMENT:

|In case of shock,hypercapnea or uncorrected Hypoxia.

Look for complications in case of failure to improve or persistent elevation of CRP.

FOLLOW UP:

In 6 weeks time with CXR.

COMPLICATIONS OF PNEUMONIA

PLEURAL EFFUSION

LUNG ABSCESS

EMPYEMA

RESPIRATORY FAILURE

BRAIN ABSCESS

SEPTICEMIA

MULTIPLE ORGAN FAILURE

PERICARDITIS

MYOCARDITIS

CHOLESTATIC JAUNDICE