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Light Pulmo Cap Hcap DR Lee
Light Pulmo Cap Hcap DR Lee
PNEUMONIA
PREDISPOSING FACTOR
Inflammation of the lung parenchyma, the portion distal to the
What are the different predisposing factors, let’s say even when you have
terminal bronchioles and comprising the respiratory bronchioles,
alveolar ducts, alveolar sacs, and alveoli. colonizations of your oropharyngeal area by your Chlamydia, that does not
mean that you have Pneumonia already. There are some factors that
Bronchitis – inflammation of the larger airways
increase the development of Pneumonia.
Bronchiolitis - <2um
Risk factors to the development of pneumonia:
ROUTES OF MICROORGANISM
Before infection can take place, the microorganism should be able to Altered level of consciousness – can promote aspiration and every
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6. Esophageal abnormality → Anatomical abnormalities like achalasia difficulty in the entry of air into the alveoli leading to the feeling of difficulty
(causes regurgitation and esophageal fistula, do bronchoscopy) & of breathing or your dyspnea.
esophageal malignancies Decrease in lung compliances, poor responses to
7. Recurrent altered mental status → Chronic alcoholics & epileptics - vasoconstriction – capillary leak
LOC Hypoxemia
Stroke – affect muscle of deglutition Increased respiratory drive
**AIDS – Acquired immune defects – impaired T cell function Increased secretion
Inflammation related bronchospasm
HOST INFLAMMATORY REPONSE So these manifestations have reasons or explanation for it.
Patients who have Pneumonia usually have clinical manifestation that’s (+) peripheral chemoreceptors – aortic/ carotid bodies → pulmonary
why we would be able to take note of the possibility that the patients have shunting → severe hypoxemia → not responsive to supplemental oxygen
Pneumonia, and these clinical manifestations are usually the host response → severe → death
to infection. If the patient does not respond to infection, usually they will not
have these clinical manifestations that generally you will recognize to Epithelial cells
patients who have Pneumonia. Because when we talk about Pneumonia, Barrier to dissemination of microorganism
*X-RAY & CT SCAN OF LOBAR PNEUMONIA* In very some patients, who are severely ill, and you have already given a
This would be an example of patients who have an X-ray who have Lobar lot of antimicrobials, and yet the patient is not responding, then we have to
Pneumonia. Why do we say this is a Lobar Pneumonia and not a mass? This use a more invasive procedure to collect a specimen from the LRT like by
is because of the air bronchogram that you see. That’s why the alveoli are doing the Bronchopscopy, Protected Brush, Collection of Lung specimen or
filled up with secretions, debris, but the airway are patent so it will cast a transbronchial biopsy of the lungs in order to obtain the specific specimen.
black shadow on chest x-ray. So within the consolidation, within the white
shadow, you will see lines of black – that is your air bronchogram. This is Blood culture is really actually the GOLD STANDARD for us to determine
because if you do a CT scan, you will see the alveoli are all filled up with where the specific microbes.
secretions causing whiteness and the airways are patent that’s why you
have lines of lucency. So that is your air bronchogram. The sputum cultures is NOT specific. It is ONLY PROBABLE or HIGHLY POSSIBLE.
But your blood culture, if you are able to culture the microbes then this is
*CT SCAN OF BRONCHOPNEUMONIA* the SPECIFIC microbes.
This is what we call your Bronchopneumonia. It’s more in the airways,
demarcations, inflammations around the bronchi. Serologic Testing is also helpful in including the antigen determination. This
would also be specific because this is specific for a particular
*CT SCAN OF MILIARY PNEUMONIA* microorganism.
If you have your CT scan, you will have your spread, This also looks like
lymphangitic spread of malignancy when you have your cancer and you History & PE → most important
have lymphangitic spread it will also look like that. Sensitivity (58%) and specificity (67%)
Radiologic examination (diagnosis of choice) – needed – efficient
So you also have to correlate your anxillary findings to your clinical o Chest X-ray (definitive)
manifestations of your patient. o CT-scan →If chest x-ray in the 1st stage of pneumonia is
normal
Sputum examination – gram stain → etiology
Bronchoscopy – invasive
o Brush (protected)
o Transbronchial biopsy
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Lung biopsy – tissue Dictionary 2009), this is suggestive that the patient has Mycoplasma
Blood culture serologic studies and antigen detection pneumoniae.
o Blood culture – wait for days; specific, seldom (+) – 30%,
etiology If the patient has alterations in the level of consciousness or the lack of gag
o Serological studies – specific – see increase in titer – only reflex that means they tend to aspirate – Anaerobic & Polymicrobial
used in research microorganism causing the lung infection.
o Ag detection – acute phase only
If the patient has Pneumonia and manifestations suggestive of Encephalitis,
Diseases that may mimic pneumonia so there is alterations in the level of consciousness, then this is highly
o Bronchitis suggestive of atypical microorganism causing the infection such as your
o Patient with history of radiation Mycoplasma, Chlamydia, C. burmetti.
o Patient with congestion
o Pulmonary emboli The patients have Pneumonia and manifestations of cerebral Ataxia, then
you think of Mycoplasma pneumonia & Legionella pneumophilia.
PATHOLOGIC CHANGES IN THE LUNGS WHEREIN YOU WOULD HAVE
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Exposure to birds Chlamydophila psittaci
or bird flu
Exposure to rabbits Francisella tularensis
Exposure to cats – pregnant cat, Coxiella burnetti
goat or sheep
HIV (early) – CD 4 count is S. pneumonia
relatively good, around 200. H. influenza
M. tuberculosis
HIV (late) – CD4 is less than 200. S. pneumonia
Think of atypical microorganisms H. influenza
such as M. tuberculosis
P. jiroveci
Cryptococcus
Aspergillus
M. kansai
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If the patient has 1 point, the patient’s risk of mortality is low so the If yes, then check whether the patient has hypoxemia or
patient can be treated at an outpatient basis. hypoperfusion that means either of the 2, the patient
2 points means the patient has to have close monitoring, a few days belongs to HIGH RISK GROUP. The patient has to be
in the hospital and then you can send the patient home. hospitalized in the ICU.
If the patient has 3 points or more, it means the patient has Severe - If not, that means the patient has MODERATE RISK
Pneumonia, the patient has to be hospitalized. PNUEMONIA. The patient still has to be hospitalized, NOT in
If the patient has 4 or 5 points, that means the patient has to be the ICU, but in the GENERAL WARD.
taken care for at the ICU.
0 0.7% No hospitalization
1 3.2 % Hospital (OPD)
2 13 % Hospital (assessment supervised)
3 17. 5 % Severe
4 41.5 % CAP
5 57 % Urgent Admission
So CURB-65 need a laboratory result. So if you are practicing for
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For the EMPIRICAL TREATMENT recommended by the American Thoracic Or the patient may fail to improve because the pathogen or culprit is not
Society together with the Infectious Disease Society of the America: correct that’s why we gave the wrong antibiotics. We can give the correct
antibiotics with correct dosage if we have the correct microorganism. Or
the patient has already a superimposed nosocomial infection so the
patient may have Pneumonia because of Strep. pneumo because of the
hospital stay they acquired another microbe that causes Pneumonia. This
time it may be Pseudomonas, so we may be treating the patient who has
superinfection that we do not know about.
Sometimes patients who have CAP, may have clinical complications such
as: respiratory failure, mechanical ventilator, or they may develop septic
shock. So if the patient has severe infection, they may develop septic
shock, multiorgan failure. This can also cause problem with coagulability
and of course any illness can cause exacerbation of comorbid conditions
like heart failure, renal failure, liver failure. This may also lead to Strep
infection to other parts of the body, as well as typical lung abscess or
complicated bipleural effusion which we call as your PARAPNEUMO
EFFUSION.
So what are the risk factors for the development of HCAP or at risk of
getting health-care related Pneumonia. These are patients who have
short hospital stay, hospitalized for more than 2 days in the last 3 months,
Out Patient those who have been taken care of in nursing home extended-care
o 5-7 days → antimicrobial facility residence, antibiotic therapy for the last 3 months, chronic dialysis,
Other treatment patient’s who have renal failure or diabetic foot, patients who have home
o Hydration – very important infusion therapy – let’s say they have problem with nutrition at home or
o Oxygen/mechanical ventilation – if patient is hypoxemic, has to be given antibiotics at home, they are at risk for HCAP or family
give supplemental O2. If the patient needs to be member with MDR infection.
connected to a mechanical ventilator, try to tie the patient Table 251-1 Clinical Conditions Associated with and likely pathogesn
over the in-sole to the lung, then we need to connect the in Health-Care Associated Pneumonia
patient to the mechanical ventilator. Condition Pathogen
o Adrenal sufficiency – glucocorticoids MRSA Pseudo Acine MDR
Sometimes they recommend giving Immunomodulin-lowering therapy monas aeru Tobac Entero-
such as your **** but we don’t get this here so this is recommended to ginosa ter spp. bacter
patient who have persistent septic shock, severely ill patients. iaceae
Failure to improve Hospitalization for X X X X
If we give the correct medicine or the medicine we give is effective, then 48 hrs
we expect the patient to be afebrile within 2-3 days. Generally, 3 days and Hospitalization for X X X X
the WBC count would also drop within this period of time. Clinically, the 2 days in prior 3
patient will improve, but do not expect the CXR to improve. There is always months
a radiologic lag just like sometimes we suspect Pneumonia, but when we Nursing home or X X X X
get the CXR and it would be normal. After 24 hours, you repeat the CXR, it extended-care
would already show Pneumonia. There would always be radiographic lag. facility residence
In the resolution, there would also be a radiologic lag, but if you take the Antibiotic therapy X X
CXR one month after the bout of Pneumonia and there is still infiltrates then in preceding 3
there is very big question to the radiographic lag already. Usually, in 1 months
month time the infiltrates should have resolved already so there may be Chronic dialysis X
another problem to consider. Like if your patient is not improving despite Home infusion X
the medications, you may have the wrong diagnosis because the patient therapy
may have the following: Home wound X
o Pulmonary edema care
o Pulmonary embolism
Family member X X
o Lung CA
with MDR
o Radiation and hypersensitivity pneumonitis
infection
o Tissues disorders molding the lungs
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Note: MDR, multidrug-resistant; MRSA – methicillin-resistant have Pneumonia much earlier that means it would be easier to treat, but
Staphylococcus aureus the problem is sometimes you have already treated the Pneumonia and
after a few days then the patient is still mechanically ventilated because of
What are the pathogens we have to look out for? The most common other problem then the patient may have another bout of Pneumonia. So
would be your Methicillin-Resistant Staph. aureus (MRSA), followed by your that the patient will now be a late onset VAP. Then, we have to think of the
Pseudomonas aeruginosa, and your multi drug resistance MDR pathogen already as the microorganism causing the Pneumonia and
Enterobacteriacaea, and then lastly would be your Acinetobacter. this would be quite severe.
PATHOGENESIS
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movement of the G.I.T so that means you build up the secretion within the
will be able to empty the stomach faster. oropharyngeal area.
And if the stomach is emptied, there Secretions pooled above It will lessen the building up of secretions in
would be no refraction. So there is a endotracheal tube the oropharyngeal area and one way is to
purpose. So postpyloric enteric bleeding. elevate head of patient. Head of bed
Where is your pylorus so you have the elevated**; and use a special
stomach, the body of the stomach, then endotracheal tube with suction tip just
you have the pylorus, and then you have above the balloon of the ET tube so that
the duodenum. So you give the feeding, you will be able to suction out the
you insert the tube into the pyrlorus secretions in this area which is a common
through the pyloric ring into the source of microaspiration. When you
duodenum. Then the stomach would be aspirate this, then the risk for
emptied. So this could also lessen the microaspiration would also lessen. And of
reflux. If you lessen the reflux, then there course, if you would be able to wean the
would be decreased risk of Pneumonia. patient from the mechanical ventilator
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So what are our differential diagnosis because all of these manifestation is Bands > 50% 1 (additional)
not only because of Pneumonia, we have to figure our the possibility that Oxygenation (mmHg)
the patient may have PaO2/FiO2 <250 & no 2
- Atypical pulmonary edema ARDS
- Pulmonary Contusions Chest Radiograph
- Alveolar hemorrhage Localized infiltrate 2
- Hypersensitivity Pneumonitis Patchy or diffuse 1
- Pulmonary Emboli infiltrate
- ARDS; but usually ARDS is associated or seen more among
Progression of infiltrate 2
patients who have Pneumonia or sepsis.
(no ARDS or CHF)
Sometimes patient may have
Tracheal Aspirate
Fever and Leukocytosis – and not have Pneumonia. This may be
Moderate or heavy 1
because of Sinusitis, URTI because the patient may have a catheter
growth
on and this may also increase the risk of infection.
Same morphology on 1 (additional)
Antibiotic associated diarrhea
Gram stain
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