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Project: Ghana Emergency Medicine Collaborative
Document Title: Pneumonia in the ED
Author(s): Phil Bossart (University of Utah), MD 2012
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Pneumonia in the EDPneumonia in the ED
Phil Bossart MDPhil Bossart MD
University of UtahUniversity of Utah
Salt Lake CitySalt Lake City
33
Types of PneumoniaTypes of Pneumonia
CAP community acquired CAP community acquired pneumoniapneumonia
HAP hospital acquired pneumoniaHAP hospital acquired pneumonia
HCAP health care associated HCAP health care associated pneumoniapneumonia
44
Community Acquired Community Acquired PneumoniaPneumonia
Indications for Admission to hospitalIndications for Admission to hospital
PSI Pneumonia Severity IndexPSI Pneumonia Severity Index
CURB 65 Confusion, Uremia (BUN > CURB 65 Confusion, Uremia (BUN > 20mg/dl or 7 mmol/L, RR >30, BP 20mg/dl or 7 mmol/L, RR >30, BP sys <90 or diastolic < 60, Age >65.sys <90 or diastolic < 60, Age >65.
55
CURB 65CURB 65
Some use CRB 65Some use CRB 650 – 1 home treatment0 – 1 home treatment1 Admit to hospital1 Admit to hospital>> 3 Admit to ICU 3 Admit to ICU
Prediction rules are Prediction rules are aids only aids only Many other issues ( co-morbidities, Many other issues ( co-morbidities,
social factors)social factors)
66
Causes of pneumoniaCauses of pneumonia PneumococcusPneumococcus Haemophilus influenzaeHaemophilus influenzae Atypical Bacteria (mycoplasma, Atypical Bacteria (mycoplasma,
chlamydia, legionella)chlamydia, legionella) Oropharyngeal aerobes and anaerobes Oropharyngeal aerobes and anaerobes
( asp)( asp) Resp VirusesResp Viruses StaphStaph Gram neg bacteriaGram neg bacteria TBTB
77
Diagnosis of PneumoniaDiagnosis of Pneumonia
Clinical cough, fever, chest painClinical cough, fever, chest pain Rales, hypoxiaRales, hypoxia Radiologic findings – chest x-ray is Radiologic findings – chest x-ray is
not 100% sensitivenot 100% sensitive
Clinical diagnosis – no single tests Clinical diagnosis – no single tests gives definitive answer.gives definitive answer.
88
Source undetermined
Source undetermined
99
These are PA and lateral films of RML pneumonia (arrows). Note the indistinct borders, air bronchograms, and silhouetting of the right heart border. Pneumococcal pneumonia
Source undetermined
Source undetermined
1010
· Aspiration, no matter what the type, usually occurs in the gravity dependent portions of the lung
§ Lower lobes, especially right-sided, including and especially the superior segments of the lower lobes
· Because of the larger caliber and straighter course of the right main bronchus
§ Posterior segments of the upper lobes
§ Aspiration which occurs while the person is prone may be seen in the right upper lobe and middle lobe or the lingula
Source undetermined
1212
Pneumocystis jiroveci (formerly carinii) pneumonia: chest X ray with bilateral, diffuse granular opacities
Emperic TreatmentEmperic Treatment
IDSA infectious disease society of IDSA infectious disease society of americaamerica
ATS american thoracic societyATS american thoracic society BTS british thoracic societyBTS british thoracic society
IDSA/ATS : in patient treatment: anti-IDSA/ATS : in patient treatment: anti-pneumococcal fluoroquinolone pneumococcal fluoroquinolone (levofloxicin) or (betalactam plus (levofloxicin) or (betalactam plus macrolide)macrolide)
1414
IDSA/ATS guidelinesIDSA/ATS guidelines
If suspect pseudomonas: add If suspect pseudomonas: add piperacillin-tazobactam or imipenempiperacillin-tazobactam or imipenem
If suspect MRSA: add vanc or linezolidIf suspect MRSA: add vanc or linezolid
1515
British Thoracic SocietyBritish Thoracic Society
Amoxicillin 500 tid or Doxycycline Amoxicillin 500 tid or Doxycycline 200mg load then 100mg q day.200mg load then 100mg q day.
Much cheaper Much cheaper
1616
Timing of Antibiotics in EDTiming of Antibiotics in ED
Retrospective studies suggested decrease Retrospective studies suggested decrease mortality if abx given within 4 horusmortality if abx given within 4 horus
Lead to Lead to ““standardstandard”” in U.S.A. ERs in U.S.A. ERs
Lead to overuse of abxLead to overuse of abx
Now rec 6 hoursNow rec 6 hours
1717
Out patient treatmentOut patient treatment
Zithro or doxycyclineZithro or doxycycline Levofloxacin if sicker patient or more Levofloxacin if sicker patient or more
complicatedcomplicated
1818
Aspiration PneumoniaAspiration Pneumonia
Most pneumonia is from Most pneumonia is from ““aspirationaspiration””
Larger amount of aspiration causing Larger amount of aspiration causing ““pneumonitispneumonitis””
Anaerobes are less virulent bacteriaAnaerobes are less virulent bacteria
1919
Aspiration PneumoniaAspiration Pneumonia
Reduced consciousnessReduced consciousness DysphagiaDysphagia GERDGERD NG feedingsNG feedings
Gastric acid suppression meds – assoc Gastric acid suppression meds – assoc with increased risk of pneumoniawith increased risk of pneumonia
2020
Chemical PneumonitisChemical Pneumonitis
Aspiration of substances toxic to Aspiration of substances toxic to lungs separate from bacterial lungs separate from bacterial infectioninfection
Diagnosis is presumptive based on Diagnosis is presumptive based on hx and chest Xrayhx and chest Xray
Supportive careSupportive care
Most do fine but risk of ARDS and Most do fine but risk of ARDS and pneumoniapneumonia
2121
Aspiration PneumoniaAspiration Pneumonia
Anaerobic bacteria from gingivaAnaerobic bacteria from gingiva More common with poor dentitionMore common with poor dentition Most commonly evolves slowlyMost commonly evolves slowly May present late with lung abscess, May present late with lung abscess,
empyema, pulmonary necrosisempyema, pulmonary necrosis Treatment: Clinda or Augmentin or Treatment: Clinda or Augmentin or
PCN + MetroPCN + Metro
2222
Pulmonary TBPulmonary TB
Eighth leading cause of death Eighth leading cause of death Effective medical therapy for over 50 Effective medical therapy for over 50
years yet: lack of access to dx and years yet: lack of access to dx and rx, coexistence with HIV, drug rx, coexistence with HIV, drug resistance.resistance.
TBI : inhalation, asymptomatic, TBI : inhalation, asymptomatic, noninfectious, called latent TB. Will noninfectious, called latent TB. Will have pos PPD or TST.have pos PPD or TST.
2323
EpidemiologyEpidemiology
About one third of population is About one third of population is infectedinfected
About 1.3 million deaths in 2007About 1.3 million deaths in 2007 Prevalence is decreasing but slowlyPrevalence is decreasing but slowly MDR –TB : resistant to INH or RIFMDR –TB : resistant to INH or RIF XDR – TB: resist to INH, RIF, XDR – TB: resist to INH, RIF,
Fluoroquinolones, and Fluoroquinolones, and aminoglycosides or Capreomycin.aminoglycosides or Capreomycin.
2424
Primary Pulmonary TuberculosisPrimary Pulmonary Tuberculosis
Symptoms occurring around time of Symptoms occurring around time of inoculation. inoculation.
Generally mild and usually feverGenerally mild and usually fever Most people are asymptomaticMost people are asymptomatic Hilar adenopathy or mid/lower lung Hilar adenopathy or mid/lower lung
infiltratesinfiltrates
2525
Reactive TBReactive TB
Chronic TB, post primary TB, Chronic TB, post primary TB, recrudescent TB, endogenous TBrecrudescent TB, endogenous TB
In USA this is 90% of TB in non HIV In USA this is 90% of TB in non HIV patientspatients
Typically insidious: fever, cough, Typically insidious: fever, cough, weight loss, fatigue, night sweats.weight loss, fatigue, night sweats.
2626
Reactive TBReactive TB
Chest X ray : apical infiltrates, may Chest X ray : apical infiltrates, may see cavities with air fluid levels. see cavities with air fluid levels.
5% may have normal Chest x-ray – 5% may have normal Chest x-ray – esp HIV patientsesp HIV patients
Endobronchial TB – may mimic Endobronchial TB – may mimic asthmaasthma
2727
Source undetermined
2828
25 year old Indian girl presented with cough and hemoptysis. CXR showed consolidation with cavitations in the right upper zone.
Source undetermined
2929
20 year-old female with history of chronic productive cough and weight loss. Pulmonary tuberculosis - Cavitary lesion
Source undetermined 3030
Pulmonary TuberculosisGhon ComplexSub pleural nodule with mediastinal adenopathy.
Source undetermined
3131
The Ghon complex is seen here at closer range. Primary tuberculosis is the pattern seen with initial infection with tuberculosis in children. Reactivation, or secondary tuberculosis, is more typically seen in adults.
Source undetermined 3232
Widespread hematogenous dissemination of Mycobacterium TuberculosisSo named because the nodules are the size of millet seeds (1-5mm with a mean of 2 mm) Miliary TB represents only 1-3% of all cases of TB
Extra-pulmonary TBExtra-pulmonary TB
Lymphadenitis: cervical, mediastinal, Lymphadenitis: cervical, mediastinal, axillary nodesaxillary nodes
Pleural TBPleural TB CNS TBCNS TB PeritonitisPeritonitis PericarditisPericarditis Skeletal: Thoracolumbar spine ( Potts Skeletal: Thoracolumbar spine ( Potts
disease)disease) Miliary TB: hematogenous spreadMiliary TB: hematogenous spread
3333
TB DiagnosisTB Diagnosis
TST, Mantoux test, PPDTST, Mantoux test, PPD Diameter of induration at 48-72 hrs.Diameter of induration at 48-72 hrs. Delayed type hypersensitivityDelayed type hypersensitivity Takes 2 – 12 weeks to turn positiveTakes 2 – 12 weeks to turn positive False positives: BCG vaccine, other False positives: BCG vaccine, other
mycobacteriummycobacterium False negatives: anery, advanced False negatives: anery, advanced
age, immune suppression, etc.age, immune suppression, etc.3434
TB DiagnosisTB Diagnosis
About 10 % of immunocompetent About 10 % of immunocompetent people with LTBI will develop TB in people with LTBI will develop TB in life time.life time.
Greatest risk ( 5%) in first 2 years.Greatest risk ( 5%) in first 2 years. Serum IGRAs - Interferon gamma Serum IGRAs - Interferon gamma
release assays – measures IFG release assays – measures IFG release after exposure to M release after exposure to M tuberculosis-specific antigens. tuberculosis-specific antigens.
3535
TB diagnosis TB diagnosis
Smear microscopySmear microscopy Most rapid and least expensiveMost rapid and least expensive AFB stainingAFB staining NNA nucleic acid amplification testNNA nucleic acid amplification test Culture: liquid 1 – 3 weeks, solid up Culture: liquid 1 – 3 weeks, solid up
to 6 weeksto 6 weeks
3636
TB treatmentTB treatment
Latent TB: INH for 9 monthsLatent TB: INH for 9 months Active TB : DOT (direct observation Active TB : DOT (direct observation
therapy)therapy)
Initial phase of 4 drugs Initial phase of 4 drugs for 2 months followed by 4 – 7 for 2 months followed by 4 – 7 months continuation phasemonths continuation phase
TB with HIV: Only a few differences. TB with HIV: Only a few differences. 3737