SECONDARY LOBULE

Normal lung histology Normal lung histology Inflammatory Cells lsPneumonia Inflammatory Cells lsPneumonia

WHAT IS PNEUMONIA ?

Pneumonia: Definition Syndrome Syndrome caused by acute infection, usually bacterial (may be non bacterial) caused by acute infection, usually bacterial (may be non bacterial) Involving lung parenchyma distal to terminal bronchioles Involving lung parenchyma distal to terminal bronchioles Characterized by clinical and/or radiographic signs of consolidation of a part or parts of one or both lungs. Characterized by clinical and/or radiographic signs of consolidation of a part or parts of one or both lungs.

What are symptoms of Pneumonia ?

Symptoms in Pneumonia Symptoms in Pneumonia Cough Cough Fever Fever Shortness of Breath Shortness of Breath Rapid Breathing Rapid Breathing Confusion Confusion Restlessness Restlessness

What are signs of Pneumonia General Inspection General Inspection Respiratory Inspection Respiratory Inspection Palpation Palpation Percussion Percussion Auscultation Auscultation

Clinical Signs in Pneumonia Fever Fever Tachycardia Tachycardia Rapid Respiratory Rapid Respiratory Cyanosis in Severe cases Cyanosis in Severe cases Signs of consolidation Signs of consolidation Reduced movement Reduced movement Dull Percussion sound Dull Percussion sound Bronchial Breathing and Crackles Bronchial Breathing and Crackles My be signs of Pleurisy/ Pleural Effusion My be signs of Pleurisy/ Pleural Effusion

Radiological Signs of Pneumonia What is the Hall Mark ?

Radiological Signs of Pneumonia What is the Hall Mark ? CONSOLIDATION AIRBRONCHOGRAM

What is this ?

Pneumonia of RUL

Classification of Pneumonias ??????

Classification of Pneumonia According to Etiology According to Etiology According to anatomical site According to anatomical site According to Clinical Settings According to Clinical Settings

Classification of Pneumonia According to Etiological agent According to Etiological agent

Classification of Pneumonia According to Aetiological agent According to Aetiological agent Bacterial Pneumonia Bacterial Pneumonia Viral Pneumonia Viral Pneumonia Bacteria like & Ricketsial Pneumonia Bacteria like & Ricketsial Pneumonia Fungal Pneumonias Fungal Pneumonias Parasitic Pneumonia Parasitic Pneumonia Chemical Pneumonia (lipoid pneumonia) Chemical Pneumonia (lipoid pneumonia) Physical Pneumonia (ionizing radiation) Physical Pneumonia (ionizing radiation)

Classification of Pneumonia According to anatomical site According to anatomical site Lobar Lobar Segmental Segmental Sub-segmental Sub-segmental Lobular/ Bronchopneumonia/ Diffuse Pneumonia Lobular/ Bronchopneumonia/ Diffuse Pneumonia

Lobar Pneumonia of RUL

Segmental Pneumonia Right Upper lobe

Bronchopneumonia/ Diffuse Pneumonia

Classification of Pneumonia According to Clinical Setting According to Clinical Setting Community acquired Pneumonia ( CAP) Community acquired Pneumonia ( CAP) Hospital acquired/Health care associated Pneumonia Hospital acquired/Health care associated Pneumonia Ventilator Associated Pneumonia (VAP) Ventilator Associated Pneumonia (VAP) Aspiration Pneumonia Aspiration Pneumonia Hypostatic Pneumonia Hypostatic Pneumonia Pneumonia in immunocompromised host Pneumonia in immunocompromised host

“Community Acquired Pneumonia” Can U define ?

Community Acquired Pneumonia (CAP) Pneumonia that begins outside hospital or is diagnosed within 48 hours of admission in hospital in a patient who has not been hospitalized or residing in a long- term care facility for 14 days or more before the onset of symptoms

AETIOLOGY No cause found in 40-60% of cases No cause found in 40-60% of cases In more than 20% cases, more than one organism In more than 20% cases, more than one organism Bacteria are more commonly identified than viruses Bacteria are more commonly identified than viruses Commonest Organisms Commonest Organisms Strept pneumonaie Strept pneumonaie Mycoplasma Mycoplasma H influenza H influenza Chlamydophilla pneumonaie Chlamydophilla pneumonaie MRSA MRSA Respiratory Viruses Respiratory Viruses

Which lobe is involved Which lobe is involved What is the organism What is the organism

60 years old woman is brought to hospital in confusional state. She is febrile and short of breath. On auscultation there are few crackles in the mid zone bilaterally. 60 years old woman is brought to hospital in confusional state. She is febrile and short of breath. On auscultation there are few crackles in the mid zone bilaterally. She is anaemic. WBC count is 6X10 9. She is anaemic. WBC count is 6X10 9. Her chest x-ray is : Her chest x-ray is :

What is the diagnosis ?

Mycoplasma Pneumonia)

Legionella Pneumonia

RISK FACTORS FOR PNEUMONIA

COPD COPD Pulmonary Oedema Pulmonary Oedema Altered consciousness Altered consciousness Recent Viral respiratory tract infection Recent Viral respiratory tract infection Cigarette smoking Cigarette smoking Alcohol Alcohol Bronchiectasis Bronchiectasis Bronchial obstruction Bronchial obstruction Immunosupression Immunosupression Intravenous drug abuse Intravenous drug abuse

How the organism reaches Lung ? Inhalation of micro-organism Inhalation of micro-organism Aspiration of gastric content Aspiration of gastric content Spread from contagious site Spread from contagious site Hematological spread from distant site Hematological spread from distant site

Aspiration

What investigations will you carry out ?

INVESTIGATIONS Blood Complete picture Blood Complete picture Chest X Ray Chest X Ray Sputum Gram stain ? Sputum Gram stain ? Sputum Culture Sputum Culture Blood cultures Blood cultures Urea, creatinine, electrolytes Urea, creatinine, electrolytes Serological studies Serological studies Arterial blood gases (ABGs) in severe cases Arterial blood gases (ABGs) in severe cases Thoracocentesis if effusion is present Thoracocentesis if effusion is present

Serological tests Pneumococcal antigen Pneumococcal antigen Latex test on urine, sputum & serum Latex test on urine, sputum & serum Mycoplasma antibodies (IgM & IgG) Mycoplasma antibodies (IgM & IgG) Cold agglutinin in 50% cases Cold agglutinin in 50% cases Legionella antibodies Legionella antibodies Immunoflorescence test Immunoflorescence test

MANAGEMENT OF PNEUMONIA Doctor should assess severity of the Pneumonia and should decide whether patient can be treated at home or in hospital

When to admit ? Age > 65 y Age > 65 y Comorbid condition Comorbid condition Abnormal vital signs Abnormal vital signs RR >30 RR >30 BP < 90/60 BP < 90/60 Temp > 101 Temp > 101 Altered mental status Altered mental status Sepsis/ multiorgan dysfunction Sepsis/ multiorgan dysfunction Abnormal Lab findings Abnormal Lab findings TLC TLC Po2,60 PCO2 > 50 Po2,60 PCO2 > 50 Multi-lobe involvement or pleural effusion Multi-lobe involvement or pleural effusion

Confusion Urea level (>19 mmol/L) Respiratory rate (>30 b/m) Blood Pressure SBP<90 mmHg or DBP <60 mmHg Age >65 yrs Excellent indicator for mortality

General Measures Care of mouth and skin Care of mouth and skin Fluids Fluids Cough Suppressants Cough Suppressants Analgesics for pain Analgesics for pain Antipyretics for fever Antipyretics for fever Oxygen Oxygen

DURATION OF TREATMENT Influnced by severity of illness, the agent, responsible, and other medical problems Influnced by severity of illness, the agent, responsible, and other medical problems For Strept Pneumonia: treat for 72 hours after the patient is afebrile For Strept Pneumonia: treat for 72 hours after the patient is afebrile For S aureus and Psudomonas, klebsiella, anaerobes, mycoplasma, legionella: two weeks at least For S aureus and Psudomonas, klebsiella, anaerobes, mycoplasma, legionella: two weeks at least

Lung Abcess Empyema

COMPLICATIONS OF PNEUMONIA Parapneumonic effusion Parapneumonic effusion Empyema Empyema Sepsis Sepsis ARDS ARDS Lung abcess Lung abcess Focal Bronchiectasis Focal Bronchiectasis

PREVENTION OF PNEUMONIA Polyvalent pneumococcal vaccine Influenza vaccine Smoking Cessation Alcohol cassation

Thanks

AETIOLOGY BACTERIAL Streptococcus Pneumoniae 2/3 rd of case > 30% Haemophilus influenzae Klebsiella Pneumoniae Staphylococcus aureus Moraxella catarrhalis Atypical Bacterial Mycoplasma pneumoniae (9%) Chlamydia pneumoniae (10%) Legionella Pneumoniae Coxeilla burneti

AETIOLOGY Viral Viral Influenza A & B Adenovirus Varicella Respiratry syncytial virus Measles Parainfluenza Virus CMV Corona Virus Coxsackie virus Rhino virus BACTERIAL BACTERIAL Streptococcus Pneumoniae Streptococcus Pneumoniae 2/3 rd of case 2/3 rd of case Haemophilus influenzae Haemophilus influenzae Klebsiella Pneumoniae Klebsiella Pneumoniae Staphylococcus aureus Staphylococcus aureus Moraxella catarhalis Moraxella catarhalis Atypical Bacterial Atypical Bacterial Mycoplasma pneumoniae Mycoplasma pneumoniae Chlamydia pneumoniae Chlamydia pneumoniae Legionella Pneumoniae Legionella Pneumoniae Coxeilla burneti Coxeilla burneti

Hospital Acquired Pneumonia Two days after hospital admission Two days after hospital admission Etiology Etiology Gram negative bacteria Gram negative bacteria Staphylococcal aureus Staphylococcal aureus Anaerobic organisms Anaerobic organisms Lobar pneumonia causing organisms Lobar pneumonia causing organisms

Staphylococcal

 Aetiological agents Pneumocystis carinii Pseudomonas aeroginosa Aspergillus fumigatus Cytomegalovirus Herpesviruses Mycobacterium tuberculosis Pneumonia in immunocompromised host