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Definition
Pneumonia is an acuteinfection of the
parenchyma of thelung, caused by
bacteria, virus, parasiteetc.
Pneumonia may also be
caused by other factors
including X-ray,chemical, allergen
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Epidemiology
The morbidity and mortality of pneumonia
are high especially in old people.
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Classification by acquired
environmentCommunity acquired pneumoniaCAP
Hospital acquired pneumoniaHAPNP
Nursing home acquired pneumonia,NHAP
Immunocompromised host pneumonia,(ICAP)
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CAP
CAPrefers to pneumonia acquired outside of
hospitals or extended-care facilities .
Streptococcus pneumoniae remains the mostcommonly identified pathogen.
Other pathogens include Haemophilus influenzae,
mycoplasma pneumoniae, Chlamydophilia
pneumoniae, Moraxella catarrhalis and ects.
Drug resistance streptococcus pneumoniae(DRSP)
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Community Acquired
Pneumonia Epidemiology:
4-5 million cases annually
~500,000 hospitalizations
~45,000 deaths
Mortality 2-30%
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EPIDEMIOLOGY
HAP is the most common infection occurring inpatients requiring care in an intensive care unit(ICU), with incidence rates ranging from 6% up to
52%, much higher than the 0.5% to 2% incidencereported for hospitalized patients as a whole.
This increased incidence is due to the fact thatpatients located in an ICU often require
mechanical ventilation, and mechanicallyventilated patients are 6 to 21 times more likely todevelop HAP than are nonventilated patients.Mechanical ventilation is associated
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ICHP
Pneumonia in an immunocompromised host
describes a lung infection that occurs in
a person whose ability to fight infection is
greatly impaired.
(Non-HIV-ICH)
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Causes, incidence, and risk factors
Immunosuppression can be caused by HIV
infection, leukemia, organ transplantation, bone
marrow transplant, and medications to treat cancer. Microorganisms include all kinds of bacteria and
virus(CMV), candida and aspergilosis.
pneumocystis carinii
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Epidemiology: (contd)
fewest cases in 18-24 yr group probably highest incidence in 65
yrs
mortality disproportionately high in >65 yrs
Community Acquired
Pneumonia
Adeel A. Butt, MD
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Community Acquired Pneumonia
Adeel A. Butt, MD
898
1071
83
1171 1207
684
0
200
400
600
800
1000
1200
1400
65
# of cases
# in
1000s
Incidence
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Community Acquired Pneumonia
Adeel A. Butt, MD
25.7
74.9
0
10
20
30
40
50
60
70
80
65
# of deaths# in
1000s
Mortality
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Etiology
There are two factors
involved in the
formation ofpneumonia , including
pathogens and host
defenses.
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pathogenesis
Pneumococci usually
reach the lungs by
inhalation oraspiration. They lodge
in the bronchioles,
proliferation and
initiate aninflammatory process.
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Bacter ia are introduced into the
lungs by the four routes Source Route Response Outcome
colonization aspiration
Air inhalation
Non-pulmonary blood lung pneu.
infection stream defenses
Contiguous direct infection extention
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Legionnaires disease is acquriedby inhaling aerosolized watercontaining Legionellaorganisms or possibly bypulmonary aspiration ofcontaminated water.
The contaminated water arederived from humidifiers,shower heads, respiratorytherapy equipment, industrailcooling water.
Because of the frequently use ofair conditioner, Legionnaiespneumonia is also seen inCAP
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Classification
Classification of anatomy
Classification of pathogen
Classification of acquired environment
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.Classif ication by pathogen
Pathogen classification is the most useful
to treat the patients by choosing effective
antimicrobial agents
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Risk Factors Elderly (not agingper
sebut its associations)
Swallowing difficulty
Use of sedativemedications
Depressed cough reflex
Dementia
Reduced consciousness
Pharyngeal anesthesia
Protracted vomiting
Large volume tube
feedings
Feeding gastrostomy
Recumbent position
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Bacter ial pneumonia
(1) Aerobic Gram-positive bacteria,such
as streptococcus pneumoniae, staphy-
lococcus aureus, Group A hemolytic
streptococci
(2) Aerobic Gram-negative bacteria, such
as klebsiella pneumoniae, Hemophilus
influenzae, Escherichia coli
(3) Anaerobic bacteria
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Atypical pneumonia
Including Legionnaies pneumonia ,
Mycoplasmal pneumonia ,chlamydia pneumonia.
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Fungal pneumonia
Fungal pneumonia is commonly caused by
candida and aspergilosis.
pneumocystis jiroveci
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Legionellae are small,gram-negative,obligately aerobic baclli.
.
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Viral pneumonia
Viral pneumonia may be caused by
adenoviruses, respiratory syncytial
virus, influenza, cytomegalovirus,
herpes simplex
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Pneumonia caused byother pathogen
Rickettsias (a fever rickettsia),
parasites
protozoa
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.Classif ication by anatomy
1. Lobar: Involvement of an entire lobe
2. Lobular: Involvement of parts of the lobe only,
segmental or of alveoli contiguous to bronchi(bronchopneumonia).
3. Interstitial
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Pembagian Berdasarkan Lokasi
Pneumonia Lobaris
Pneumonia Interstitial
Pneumonia Lobularis (Bronkopneumonia)
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Lobar pneumonia
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Lobular pneumonia
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Diagnosis
Give a definite diagnosis of pneumonia
To evaluate the degree of the pneumonia
To definite the pathogen of the pneumonia
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Diagnosis
Clinical diagnosis
Pathogen diagnosis
Evaluate the severity degree of pneumonia
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Diagnosis
History and physical
examination(5W)
X-ray examination
Pathogen identification
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Pathogen identification
Sputum: More than 25 white blood cells
(WBCs) and less than 10 epithelial cells.
Nasotracheal suctioning
Blood culture or pleural effusion culture
Serologic testing (immunological testing)
Molecular Techniques
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The diagnostic standard of severe
pneumonia
Altered mental status
Pa02
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signs
Consolidation signs
Moist rales
Respiratory rate or heart rate
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Pathology
Red hepatilization
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Abstraction
Pneumococcal
pneumonia is produced
by
streptococcal
pneumoniae
It is the most commonly
occurring bacterial
pneumonia
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Clinical mani festations
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Clinical manifestations (1)
Many patients have had an upper respiratory
infection for several days before the onset of
pneumonia Onset usually is sudden, half cases with a
shaking chill
The temperature rises during the first few
hours to 39-40
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Clinical manifestations (2)
Typically, patients have the symptoms of
high fever , shaking chill, sharp chest
pain, cough, dyspnea and blood-fleckedsputum.
But in some cases, especially those at age
extremes symptoms may be moreinsidious.
Cli i l if i (3)
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The pulse accelerates
Sharp pain in the involved hemi thorax
The cough is initially dry with pinkish or
blood-flecked sputum
Gastrointestinal symptoms such as,
anorexia, nausea, vomiting abdominal
pain, diarrhea may be mistaken as acuteabdominal inflammation
Clinical manifestations (3)
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Signs 1
The acutely ill patient is tachypneic, and
may be observed to use accessory muscles
for respiration, and even to exhibit nasal
flaring
Fever and tachycardia are present, frank
shock is unusual, except in the later stages
of infection or DIC
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Signs 2
Auscultation of the chest reveals
bronchovesicular or tubular breath
sounds and wet rales over theinvolved lung
A consolidation occurs, vocal and
tactile fremitus are increased
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Laboratory examinations
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X-ray examination
Usually lobar or
segmental
consolidation
suggests a bacterial
cause for pneumonia
If blunting of the
costophrenic angle isnoted, pleural
effusion may be exist.
The features of CT
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The features of CT
Air-bronchogram sign
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Complications
sepsis
lung abscess or empyema
pleural effusionpleuritis
ARDS
ARF
pneumothorax
Extrapulmonary infections
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Pleural Effusion
GenMed 3
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Differential diagnosis
pulmonary tuberculosis
Other microbial pneumonias:
klebsiella pneumonia,
staphylococal pneumonia,
pneumonias due to G (-) bacilli,
viral and mycoplasmal
Acute lung abscess Bronchogenic carcinoma
Pulmonary infarction
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Treatments
Antibiotics
Support therapy
Therapy of complications
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Therapy
The therapy should always follow
confirmation of the diagnosis of pneumonia
and should always be accompanied by adiligent effort to identify an etiologic agent.
Empiric therapy,(4-8h)
Combined empiric therapy to target therapy
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Antibiotic therapy
Treatment with any effective agent
should be given for at least 5 to 7 day or
after the patients have been afebrile for2-3 days
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Empiric therapy (1)
Outpatient
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Supportive measure
Supportive measure are generally used in
the initial management of acute pneumo-
coccal pneumonia, such measures include
Bed rest
Monitoring vital signs and urine output
Administering an occasional analgesic to
relieve pleuritic pain
Replacing fluids, if the patient is dehydrated
Correcting electrolytes
Oxygen therapy
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Treatment of complications
Empyema develops in appoximately 5% of patients
with pneumococcal pneumonia, although pleural
effusion commonly develop in 10%- 20% patients
Chest X-ray with lateral decubitus films are often
useful in the early recognition of pleural effusion,
pleural fluid that is removed should be subjected to
routing examination
If pneumococcal bacteremia occurs, extra pulmonary
complications such as arthritis, endocarditis must beexcluded, because the therapy requires higher dosages
Treatment of infections shock
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Therapy to Infectious Shock
Treatment in intensive care units
cardiac rhythm, blood pressure, cardiac performance, oxygen
delivery, and metabolic derangements can be monitored
Adequate oxygenation and ventilatory support
(sometimes mechanical ventilation)
Effective antibiotic therapy
Maintain blood pressure, including maintaincirculation blood volume, use of dopamine
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Prognosis
Prognosis is much better
Any of the following factors makes the prognosis
less favorable and convalescence more prolonged
elderly: involvement of 2 or more lobes
underlying chronic diseases (heart lung
kidney) normal temperature and WBC
count
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Prevention
Release aspiration
Washing hands
vaccination
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Prevention
The most important
preventive tool available
is using a poly valent
pneumococcal vaccine
in those with chronic
lung diseases, chronic
liver diseases,
splenectomy, diabetes
mellitus
and aged