Pneumonia Ppt

PNEUMONIABY:

NABILAH BINTI MOHD KAMARUZAMAN

0501000839

SITI FATIMAH BINTI ABDUL AZIZ

050100849

DEFINITION Inflammation of lung parencymal

ETIOLOGY

Infective causes: Bacterial:

Gram +ve: Strep pneumoniae, Staph aureus Gram –ve: H. influenzae, Klebsiella, Legionella Anaerobes

Viral: Varicella virus, Influenza virus Fungal: Candida, Aspergillus Atypical: Mycoplasma, Chlamydia Helminths: Filariasis

Non infective causes: Physical agents Allergic diseases Collagenic diseases

PATHOGENESIS Main mechanisms by which bacteria

reaches lung: Inhalation: organisms bypass normal

respiratory defense mechanisms or patient inhales aerobic organisms that colonize the upper respiratory tract or respiratory support equipment

Aspiration: occurs when patient aspirates colonized upper respiratory tract secretions

Hematogenous: originate form a distant source and reach the lungs via blood stream

Congestion stage :

•The lung is a dark red and frothy due to the presence of inflammatory exudate and air in the alveolar lumen.

•The alveolar capillaries are engorged with increased numbers of neutrophils and bacteria.

•Fine “indux” crepitations without bronchial breathing on auscultation.

Red hepatization stage :

•The lung is firm red, liver-like and the pleural surface shows serofibrinous inflammation.

•The alveolar capillaries are dilated and congested with marked fibrinous exudate, neutrophils and increased bacteria.

•Medium-sized crepitations, bronchial breathing.

Gray hepatization stage :

•The lung is more solid and the pleural surface covered by a confluent fibrinous exudate.

•The alveolar exudate is increased in amount, dense fibrin strands and very numerous neutrophils, the congestion of capillaries is reduced.

•Coarse non-consonating “redux” crepitations on ausculation.

Resolution stage :

•The lung returns to normal, the fibrinous adhesions between the visceral and parietal pleura are liquified by proteolytic enzymes.

•The liquid products together with neutrophils are coughed up and macrophages invade the alveoli.

•Pleural rub may be present in this stage on auscultation.

CLASSIFICATIONS Site of infection:

LobarBronchopneumonia

Origin of infction:Community acquired pneumoniaNosocomial pneumonia ( hospital acqiures

pneumonia): occur 48 hours after admission which was not incubating at the time of admission

Aspiration pneumonia: occur when aspirate foreign matter into lungs

Immunocompromised pneumonia

Based on etiology:BacterialViralFungalAtypicalAspiration

DIAGNOSIS History taking: suggestive signs and

symptoms Physical examination Investigation Chest X-ray or other imaging techniques

SYMPTOMS AND SIGNS General symptoms:

Fever - MalaiseChills and rigors - Nausea and

vomitingLoss of appetiteMyalgia

Respiratory symptoms:Productive coughSputum +/- hemoptysisShortness of breathPleuritic chest pain

Specific symptoms:Abdominal pain

Advanced symptoms:CyanosisAlteration of mental status

PHYSICAL EXAMINATION Inspection: use of accessory muscles Palpation: decreased chest expansion,

increased tactile fremitus Percussion: maybe dullness on affected

lung, increased vocal resonance Auscultation: bronchial breathing,

crepitations

INVESTIGATION Basic:

Full Blood Count Blood Urea and Serum Electrolytes (BUSE) Creatinine Arterial Blood Gases (ABG) Chest X-Ray

Specific: Sputum FEME, C&S, AFB Blood C&S Pleural aspiration Bronchoscopy Serology (Mycoplasma, Chlamydia,Legionella) Immunoflourosence or Giemsa stain for PCP

CLINICAL DIAGNOSTIC: CXR Demonstrable infiltare by CXR or other

imaging technique:Establish diagnosis and presence of

complications (pleural effusion, etc)May not be possible in some outpatient

settingsCXR: classically thought of as the gold

standard

INFILTRATE PATTERNSPATTERN POSSIBLE DIAGNOSIS

Lobar Strep pneumoniae, Klebsiella, H. influenzae

Patchy Atypical, Viral, Legionella

Interstitial Viral, PCP, Legionella

Cavitary Anaerobes, Klebsiella, TB, Staph aureus, Fungal

Large effusion Staph, Anaerobes, Klebsiella

MANAGEMENT General considerations:

Monitor vital signs and SpO2 4 hourlyKeep SpO2 > 92%Oxygen therapyAdequate hydrationAssisted ventilation when necessary

Symptomatic: Analgesics, Mucolytic agents

Antibiotics

EMPIRICAL ANTIBIOTIC TREATMENT Community Acquired pneumonia

IV beta-lactam antibiotic plus IV/ oral macrolides or flouroquinolones

Nosocomial pneumoniaCephalosporin 2nd generation,

aminoglycosides Atypical pneumonia

Macrolides

Aspiration pneumonia:Cephalosporin 2nd generation plus

metronidazole Pneumocystic carinii pneumonia:

Co-trimoxazoleClindamycin

SWITCH TO ORAL THERAPY Four criteria:

Improvement in cough and dyspneaAfebrile on two occasions 8 hourly apartWBC decreasingFunctioning GI tract with adequate oral

intake If overall clinical picture is otherwise

favorable, can switch to oral therapy while still febrile

MANAGEMENT OF POOR RESPONDERS Consider non-infectious illnesses Consider less common pathogens Consider serologic testing Broaden antibiotic therapy Consider bronchoscopy

COMPLICATIONS Respiratory failure Bacteremia Exacerbation of comorbid illnesses Metastatic infections: brain abscess,

endocarditis Lung abscess Pleural effusion

PREVENTION Smoking cessation Vaccination recommendations:

Influenza Inactivated vaccine for people > 50 yo, those at

risk for influenza complications, household contacts of high-risk persons and healthcares workers

Intranasal live, attenuated vaccines for 5-49 yo without chronic underlying disease

Pneumococcal Immunocompromised > 65 yo chronic illness

and immunocompromised < 64 yo

CASE REPORT

ANAMNESIS Date of Admission : 24th January 2010 ,

Sunday Time of Admission : 6.00 pm

PERSONAL IDENTIFICATION Name : Rokiah binti Hanafi Age : 67 years old Race : Malay Address : Arau, Perlis Occupation : Farmer ( paddy-field)

CHIEF COMPLAINT

Fever 5/7, cough and lethargy

HISTORY OF PRESENTING ILLNESS

Previously patient is well until fever is started 5days ago, which was low grade,on and off. It was associated with chills and rigors and usually worsen at night. Patient took Paracetamol tablet but fever temporarily resolved.

Patient also developed cough during fever. It was non productive cough (dry cough). She had no vomiting and did not coughing out blood. She also had occasional shortness of breath and pleuritic pain when coughing. The pleuritic pain is dull in nature. She prefers to lie down as it can relieve the pain. Otherwise, no orthopnea, no wheezing and no night sweats.

She also had poor appetite but she can tolerating well. On day 5 of her illness, patient’s condition became worse and she also complained of lethargy. Patient went to emergency department yesterday and temperature was documented at 37.5⁰ C. Patient was then warded to ward 5.

PAST MEDICAL HISTORY

This is the patient’s 3rd admission. First admission was due to tonsil operation when she was 16 years old. Second was due to eye procedure 10 years ago.

Patient is a known case of hypertension (HPT) , diagnosed for more than 10 years. She is now under treatment and follow up at Klinik Kesihatan Arau. She is compliance to her medication.

She has no previous history of IHD or CVA. No history of Diabetes Mellitus or asthma.

Allergies : The patient has no allergy to any food or drugs.

PAST SURGICAL HISTORY Cataract operation Tonsil operation No complications occur pre or post operations.

FAMILY HISTORY

The patient is the 2nd child out of 7 siblings.The parents and her 3rd and youngest brother died of nature causes. There are no history of atopy, asthma and TB in the family.

SOCIAL HISTORY

She is married with 3 children. Her husband just passed away and

currently she is staying home alone. She is a non- smoker, non alcoholic

drinker She has cats in her house

PHYSICAL EXAMINATION1. GENERAL EXAMINATION:

The patient is alert and conscious, well oriented to time, place and people. She is lying comfortably in supine position. She is not in pain and respiratory distress.She is mildly dehydrated.

Blood pressure: 128/ 70 mmHg Pulse rate: 90 beats/minute. Good volume

and regular rhythm Respiratory rate: 22 breaths /minute Temperature: 37.0˚C SpO2: 97 % Pallor : no conjunctival pallor noted Cyanosis : no peripheral or central cyanosis

not Jaundice : no jaundice noted Clubbing : no clubbing noted Oedema : no pitting oedema

Head / neck : normocephalic Neck : The jugular venous pressure is not

raised and no lymph nodes enlargement detected. No neck stiffness

Eyes : not sunken, arcus angle Oral cavity : Oral hygiene is poor Ears : no discharge, normal shape Throats : not injected, tonsil bilaterally not

enlarged Abdomen : no scar, abdomen is soft and non-

tender Hands: There are no muscle wasting and no

gross deformity.(-) clubbing ,no palmar erythema, not pallor

CVS : Ejection systolc murmur,grade 3/6 and radiates to right aortic on auscultation.

RESPIRATORY SYSTEMSign observed Interpretation

Inspection Chest structure

Chest movement

Symmetry

Symmetrical & abdomino-thoracal respiratory

Palpation Chest expansionTactile vocal fremitus

SymmetricalIncreased at lower zone of right side

Percusion Lung sounds Dullness at lower lobe of right lung

Auscultation Breath sound

Additional sounds

Vocal resonance

Bronchial breathing on both sideFine crepitations > right side, no ronchiNot done

SUMMARY Rokiah bt hanafi, 67 years old,malay

came with chieft complaint of fever for 5 days, cough and lethargy. She is known case pf HPT for more than 10 years. No family hx of asthma and Tb. On chest examination revealed increase of vocal fremitus, dullnes on percussion and fine crepitation on auscultation on lower lobe of right lung.

DIAGNOSIS1. DIFFERRENTIAL DIAGNOSIS :

- PNEUMONIA- BRONCHIECTASIS- TB

2. WORKING DIAGNOSIS :- Pneumonia

INVESTIGATION

BASIC :• Full Blood Count• Blood Urea and• Serum Electrolytes (BUSE)• Creatinine • Arterial Blood Gases (ABG)• Chest X-Ray

SPECIFIC :

• Sputum FEME, C&S, AFB• Blood C&S• Pleural aspiration• Bronchoscopy • Serology (Mycoplasma,• Chlamydia,Legionella)• Immunoflourosence or Giemsa stain for PCP 

PLAN Monitor vital signs and SpO2 4 hourly Paracetamol tablet 1000 mg 8 hourly Tepid sponging prn Nasal Prong O2 3L prn Syrup Benadyl 15 ml TDS Septic management if fever more than

38⁰C IV Augmetin 1.2 g TDS To review all investigations results

FOLLOW UP24th january 2010,day 1

1. CXR

INTERPRETATION

PA view, erect position Trachea : centrally located Clavicle : symmetrical in position , no

fracture Bone : normal Homogenic opacity at right side of lung Honey-comb appearance on lower zone

of right lung Diaphragm : dome shape Impression : pneumonia

2. Result of Vital sign monitoring 4 hourly

24/01/2010 Pulse

(x/minute)

Blood

Pressure

(mmHg)

Temperature

(oC)

6.00 pm 97 138 / 71 37.5

10.00 pm 83 121 / 63 37.0

4.00 am 84 128/ 70 37.0

8.00 am 72 128/ 70 37.0

Vital signs are in normal range

2. FBC (Day 1)

Result Normal range

White Blood Cell 17 ( ) 4- 11

Red blood cell 4.9 ( ) 3.8-4.8

Hemoglobin 11.7 ( ) 12-15

Hematocrite 35.4 ( ) 36-46

MCV 72.8 ( ) 83-101

MCH 24.1 ( ) 27-32

Platelet 203 150-450

Neutrophil 14.62 ( ) 2-10

Lymphocyte 1.36 1-3

Monocyte 1.02 ( ) 0.2-1.0

Eosinophils 0 ( ) 0.02-0.5

Basophils 0 ( ) 0.02-0.1

Impression of FBC result

Leukocytosis: WBC increased, neutrophil predominates

suggestive of bacterial infection Plan: broad spectrum antibotics unitl blood C&S

result came back

3. Renal profile( day 1), 7.28 pm

Result Normal range

(mmol)

Sodium 138 135-145

Potassium 2.9 ( ) 3.3 – 5.3

Urea 18.5 ( ) 1.7-8.3

Creatinine 174 ( ) < 97

Impression of renal profile:

Hypokalemia: Potassium was 2.9 mmol Correction by adding 1g KCl IV

High urea: Urea level was 18.5, correlates with mild dehydration Plan: IVD normal saline in 24 hours

4. ECHO, ( day 2 ), 8am

Chambers : LV,RV,RA,LA are all normal Mild calcified of aortic valve ECHO was indicated as ejection systolic

murmur can be heard on auscultation.

DISCUSSION Patient is 67 years old, malay old woman came with chieft complaint of fever

for 5 days, cough and lethargy. pati On chest examination revealed increase of vocal fremitus, dullnes on percussion and fine crepitation on auscultation. Chest X-ray revealed the patchy infiltration at lower lobe of right lung. Patient is diagnosed to have Community-acquired pneumonia. Empirical antibiotic of IV amoxicillin with clavulanic acid ( beta-lactam antibiotic) is chose to treat the pneumonia.

To exclude bronchiectasis because : no history of obstructive lung disease, along with bronchitis and cystic

fibrosis. No history of frequent respiratory infections or chronic lung disease No CT scan was done to establish diagnosis and localize the bronchiectasis

To exclude TB because: Negative AFB No history of weight loss No night sweats

Thank you