1. Copyright © 2006 by Mosby, Inc. Slide 1 PART III Infectious Pulmonary Diseases

2. Copyright © 2006 by Mosby, Inc. Slide 2 Chapter 15 Figure 15-1. Cross-sectional view of alveolar consolidation in pneumonia. TI, Type I cell; TII, type II cell; M, macrophage; AC, alveolar consolidation; L, leukocyte; RBC, red blood cell. Chapter 15 Pneumonia

3. Copyright © 2006 by Mosby, Inc. Slide 3 Anatomic Alterations of the Lungs  Inflammation of the alveoli  Alveolar consolidation  Atelectasis

4. Copyright © 2006 by Mosby, Inc. Slide 4 Etiology Bacterial Causes  Gram-positive organisms  Streptococcus  Staphylococcus

5. Copyright © 2006 by Mosby, Inc. Slide 5 Figure 15-2. The Streptococcus organism is a gram-positive, nonmotile coccus that is found singly, in pairs, and in short chains.

6. Copyright © 2006 by Mosby, Inc. Slide 6 Figure 15-3. The Staphylococcus organism is a gram-positive, nonmotile coccus that is found singly, in pairs, and in irregular clusters.

7. Copyright © 2006 by Mosby, Inc. Slide 7 Etiology Gram-negative organisms  Haemophilus influenzae  Klebsiella  Pseudomonas aeruginosa  Moraxella catarrhalis  Escherichia coli  Serratia species  Enterobacter species

8. Copyright © 2006 by Mosby, Inc. Slide 8 Figure 15-4. The bacilli are rod-shaped microorganisms and are the major gram-negative organisms responsible for pneumonia.

9. Copyright © 2006 by Mosby, Inc. Slide 9 Etiology Atypical organisms  Mycoplasma pneumoniae  Legionella pneumophila  Chlamydia psittaci  Chlamydia pneumoniae

10. Copyright © 2006 by Mosby, Inc. Slide 10 Etiology Anaerobic bacterial infections  Peptostreptococcus species  Bacteroides melaninogenicus  Fusobacterium necrophorum  Bacteroides asaccharolyticus  Porphyromonas endodontalis  Porphyromonas gingivalis

11. Copyright © 2006 by Mosby, Inc. Slide 11 Etiology Viral causes  Influenzavirus  Respiratory syncytial virus  Parainfluenza virus  Adenovirus  Coronavirus (SARS)

12. Copyright © 2006 by Mosby, Inc. Slide 12 Etiology Other causes  Rickettsial infections  Varicella  Rubella  Aspiration pneumonitis  Lipoid pneumonitis  Pneumocystis carinii  Cytomegalovirus  Tuberculosis  Fungal infections

13. Copyright © 2006 by Mosby, Inc. Slide 13 Etiology Acquired pneumonia classification  Community-acquired pneumonia (CAP)  Nursing home–acquired pneumonia  Hospital-acquired pneumonia  Ventilator-associated pneumonia

14. Copyright © 2006 by Mosby, Inc. Slide 14 Overview of the Cardiopulmonary Clinical Manifestations Associated with PNEUMONIA The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Alveolar Consolidation (see Figure 9-8), Increased Alveolar-Capillary Membrane Thickness (see Figure 9-9), and Atelectasis (see Figure 9-7)—the major anatomic alterations of the lungs associated with pneumonia (see Figure 15-1). During the resolution stage of pneumonia, Excessive Bronchial Secretions (see Figure 9-11) also may play a part in the clinical presentation.

15. Copyright © 2006 by Mosby, Inc. Slide 15 Figure 9-8. Alveolar consolidation clinical scenario.

16. Copyright © 2006 by Mosby, Inc. Slide 16 Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.

17. Copyright © 2006 by Mosby, Inc. Slide 17 Figure 9-7. Atelectasis clinical scenario.

18. Copyright © 2006 by Mosby, Inc. Slide 18 Figure 9-11. Excessive bronchial secretions clinical scenario.

19. Copyright © 2006 by Mosby, Inc. Slide 19 Clinical Data Obtained at the Patient’s Bedside Clinical Data Obtained at the Patient’s Bedside Vital signs  Increased respiratory rate  Increased heart rate, cardiac output, blood pressure

20. Copyright © 2006 by Mosby, Inc. Slide 20 Clinical Data Obtained at the Patient’s Bedside Clinical Data Obtained at the Patient’s Bedside  Chest pain/decreased chest expansion  Cyanosis  Cough, sputum production, and hemoptysis  Chest assessment findings  Increased tactile and vocal fremitus  Dull percussion note  Bronchial breath sounds  Crackles and rhonchi  Pleural friction rub  Whispered pectoriloquy

21. Copyright © 2006 by Mosby, Inc. Slide 21 Figure 2-11. A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation.

22. Copyright © 2006 by Mosby, Inc. Slide 22 Figure 2-16. Auscultation of bronchial breath sounds over a consolidated lung unit.

23. Copyright © 2006 by Mosby, Inc. Slide 23 Figure 2-19. Whispered voice sounds auscultated over a normal lung are usually faint and unintelligible.

24. Copyright © 2006 by Mosby, Inc. Slide 24 Clinical Data Obtained from Laboratory Tests and Special Procedures

25. Copyright © 2006 by Mosby, Inc. Slide 25 Pulmonary Function Study: Expiratory Maneuver Findings FVC FEV T FEF 25%-75% FEF 200-1200 FVC FEV T FEF 25%-75% FEF 200-1200  N or  N or  N  N or  N or  N PEFR MVV FEF 50% FEV 1% PEFR MVV FEF 50% FEV 1% N N or  N N or N N or  N N or  FVC FEV T FEF 25%-75% FEF 200-1200 FVC FEV T FEF 25%-75% FEF 200-1200  N or  N or  N  N or  N or  N PEFR MVV FEF 50% FEV 1% PEFR MVV FEF 50% FEV 1% N N or  N N or N N or  N N or 

26. Copyright © 2006 by Mosby, Inc. Slide 26 Pulmonary Function Study Lung Volume and Capacity Findings V T RV FRC TLC N or     VC IC ERV RV/TLC%    N V T RV FRC TLC N or     VC IC ERV RV/TLC%    N

27. Copyright © 2006 by Mosby, Inc. Slide 27 Arterial Blood Gases Mild to Moderate Pneumonia  Acute alveolar hyperventilation with hypoxemia pH PaCO 2 HCO 3 - PaO 2    (Slightly) 

28. Copyright © 2006 by Mosby, Inc. Slide 28 Time and Progression of Disease 100 50 30 80 0 0 Pa CO 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa O 2 Disease Onset Pa O 2 or Pa CO 2 Figure 4-2. Pa O 2 and Pa CO 2 trends during acute alveolar hyperventilation.

29. Copyright © 2006 by Mosby, Inc. Slide 29 Arterial Blood Gases Severe Pneumonia  Acute ventilatory failure with hypoxemia pH PaCO 2 HCO 3 - PaO 2    (Slightly) 

30. Copyright © 2006 by Mosby, Inc. Slide 30 Time and Progression of Disease 100 50 30 80 0 Pa O 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa CO 2 Acute Ventilatory Failure Disease Onset Point at which disease becomes severe and patient begins to become fatigued Pa 0 2 or Pa C0 2 Figure 4-7. PaO 2 and PaCO 2 trends during acute ventilatory failure.

31. Copyright © 2006 by Mosby, Inc. Slide 31 Oxygenation Indices Q S /Q T D O 2 V O 2 C(a-v) O 2   NormalNormal O 2 ERSv O 2  Q S /Q T D O 2 V O 2 C(a-v) O 2   NormalNormal O 2 ERSv O 2 

32. Copyright © 2006 by Mosby, Inc. Slide 32 Time and Progression of Disease 100 50 30 80 0 Pa O 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa CO 2 Acute Ventilatory Failure Disease Onset Point at which disease becomes severe and patient begins to become fatigued Pa 0 2 or Pa C0 2 Figure 4-7. PaO 2 and PaCO 2 trends during acute or Acute ventilatory failure.

33. Copyright © 2006 by Mosby, Inc. Slide 33 Abnormal Laboratory Tests and Procedures Sputum examination  Gram-positive organisms  Streptococcus  Staphylococcus  Gram-negative organisms  Klebsiella  Pseudomonas aeruginosa  Haemophilus influenzae  Legionella pneumophila

34. Copyright © 2006 by Mosby, Inc. Slide 34 Radiologic Findings Chest radiograph  Increased density  Air bronchograms  Pleural effusions CT scan  Consolidation and bronchograms may be seen

35. Copyright © 2006 by Mosby, Inc. Slide 35 Figure 15-5. Chest X-ray film of a 20-year-old woman with severe pneumonia of the left lung.

36. Copyright © 2006 by Mosby, Inc. Slide 36 Figure 15-6. Air bronchogram. The branching linear lucencies within the consolidation in the right lower lobe are particularly well demonstrated in this example of staphylococcal pneumonia. (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)

37. Copyright © 2006 by Mosby, Inc. Slide 37 Figure 15-7. Air bronchogram shown by CT in a patient with pneumonia. (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)

38. Copyright © 2006 by Mosby, Inc. Slide 38 General Management of Pneumonia Respiratory care treatment protocols  Oxygen therapy protocol  Bronchopulmonary hygiene therapy protocol

39. Copyright © 2006 by Mosby, Inc. Slide 39 General Management of Pneumonia Medications and procedures commonly prescribed by the physician  Antibiotics  Analgesic agents  Ribavirin aerosol  Aerosolized pentamidine  Thoracentesis

40. Copyright © 2006 by Mosby, Inc. Slide 40 Classroom Discussion Case Study: Pneumonia