Kuliah pneumonia 25-5-12

8/10/2019 Kuliah pneumonia 25-5-12

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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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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



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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

Documents

Kuliah pneumonia 25-5-12