PNEUMOMIA – Dr.
Constatntino PULMONOLOGY 2014
PNEUMONIA - No new erythrocytes are extravasating
Infection of the pulmonary parenchyma and those already present have been
lysed and degraded
Classification - The neutrophil is predominant, fibrin
CAP deposition is abundant and bacteria
HCAP – widespread use of potent antibiotics have disappeared
HAP 4. Resolution
VAP – early discharge from acute hospital setting - Macrophage is predominant in the
alveolar space, and debris of
Typical – gram (+) or (-) bacteria Neutrophils, bacteria, and fibrin has
Atypical – secondary to viral infection; been cleared
PATHOPHYSIOLOGY Patterns
- Results from microbial proliferation at the Bronchopneumonia – nosocomial infection
alveolar level and the subsequent response of Lobar – bacterial CAP
host to pathogens. Interstitial – viral or atypical
-
ACCESS TO LRT COMMUNITY ACQUIRED PNEUMONIA
Aspiration from oropharynx – most common
ETIOLOGY
Inhalation
Hematogenous spread - rare
S. pneumonia
Contiguous extension from infected pleural or
Most common
mediastinal spread
Typical organisms
HOST DEFENSE
S. pneumonia
Mechanical
H. influenzae
Hairs & turbinates
S. aureus
Branching acini
Gram negative: K. pneumoniae, P. aeruginosa
Gag reflex & Cough mechanism –
protection from aspiration
Normal flora in oropharynx – prevent Atypical organisms
pathogenic bacteria from binding, thereby Mycoplasma
decreasing the risk of pneumonia Chlamydophila
Cellular Legionella
Alveolar macrophage clear and kill
pathogens
Assisted by local proteins (surfactant
protein A & D) when capacity is exceeded
macrophages clinical pneumonia become
manifest
Inflammatory response
IL1 & TNFα fever
IL8 & GCSF release of Neutrophils &
migration to lung tissue peripheral
leukocytosis and increased purulent secretions
PATHOLOGY
Phases
1. Edema
- Presence of proteinaceous exudates,
and often of bacteria, in the alveoli
2. Red hepatization
*RISK STRATIFICATION (see attached table)
- Presence of erythrocytes in the cellular
1. Low risk
intraalveolar exudates
2. Moderate risk
3. Gray hepatization
3. High risk
Page 1 of 4
PNEUMOMIA – Dr. Constatntino PULMONOLOGY 2014
EPIDEMIOLOGY - Sometimes suggest an etiologic diagnosis
Etiologic Diagnosis
- Gram stain
- Culture & Sensitivity
- Antigen test
- PCR
- Serology
TREATMENT
*see attached table
HOSPITAL ACQUIRED PNEUMONIA/ VENTILATOR
ACQUIRED PNEUMONIA
HAP- acquired 72h after hospitalization
VAP – acquired after 48-72h after MV
Clinical manifestation
1. Fever
2. leukocytosis
3. ↑ respiratory secretions
4. Pulmonary Consolidation
DDx
1. Pulmonary edema
CLINICAL MANIFESTATION 2. Pulmonary contusion
1. Cough – nonproductive or productive of mucoid, 3. Alveolar hemorrhage
purulent, or blood-tinged sputum 4. ARDS
2. Fever with tachycardia 5. Pulmonary Embolism –
3. Chills - Varying radiologic findings
4. Pleuritic chest pain - ± pneumonia-like infiltrates
5. Extrapulmonary – Nausea/vomiting or diarrhea - Congestion, cephalization
6. Others: HA, fatigue, myalgia, arthralgia - Three classic signs: abrupt onset of pleuritic
chest pain, shortness of breath, and hypoxia (di
ko sure, pakitama na lang po if mali )
Physical Exam
Consolidation
Pathogenic Mechanism
Effusion
↑ RR and use of accessory muscles of respiration
Decreased tactile fremitus, dull to flat upon percussion
Elderly/ immunocompromised – confusion,
tachypnea, DOB
DIAGNOSIS
Clinical
DDx:
acute bronchitis
acute exacerbation of Chronic bronchitis
heart failure
Pulmonary embolism
Radiation pneumonitis
Radiographic findings
- Pneumatocele – infection with S. aureus, PTB- upper
lobe infiltrates
- Serves as baseline
Page 2 of 4
PNEUMOMIA – Dr. Constatntino PULMONOLOGY 2014
Clinical Pulmonary Infection Score - Aminoglycosides OR
- Clinical criteria for the diagnosis of VAP - Fluoroquinolones PLUS
Agent against gram (+)
- Vancomycin
COMPLICATIONS
1. Death
2. Prolongation of MechVent prolong hospital stay
in ICU
3. Necrotizing pneumonia
4. Catabolic state – muscle wasting
Microbiologic causes
TREATMENT
1. Patients without risk for MDR
Ceftriaxone OR
Moxifloxacin, ciprofloxacin OR
Ampicillin+sulbactam OR
Carbapinem
2. Patients with risk for MDR
Β- Lactam
- ceftazidime, cefipime, OR
- Piperacillin+tazobactam,
imipinem or meropenem PLUS
Second agent against gram (-)
Page 3 of 4
PNEUMOMIA – Dr. Constatntino PULMONOLOGY 2014
RISK DIAGNOSTI POSSIBLE TREATMENT dialysis,
STRATIFICATI C WORK-UP PATHOLOGY uncompensate
ON d COPD,
LOW RISK CAP Streptococcu Previously decompensate
Chest X-ray s healthy d
Stable vital Sputum pneumoniae Amoxicillin liver disease
signs: GS/CS Haemophiius Chest X-ray:
-RR < 30 (optional & influenzae OR - multilobar
breaths/min when Chlamydophi infiltrates
PR < 125 available) la Extended - (+) pleurai
beats/min pneumoniae macrolides3 effusion or
SBP>90mmHg Mycoplasma (suspected abscess
- DBP > 60 pneumoniae atypical Chest X-ray Streptococcu No risk for P.
mmHg Moraxella pathogen) HIGH RISK Blood CS s aeruginosa:
Temp > 36°C catarrhalis CAP Sputum pneumoniae IV non-
or <40°C Enteric With stable GS/CS Haemophiius antipseudomon
Gram- comorbid Any of the ABG influenzae al fi-lactam
No altered negative illness: clinical When Mycoplasma (BLIC.
mental state bacilli β-lactam/β- feature of available: pneumoniae cephalosporin
of acute onset (among lactamase Moderate risk - Urine Ag Chlamydophi or
No suspected those inhibitor CAP plus any test for L. la carbapenem)*
aspiration with co- combination of the pneumophil pneumoniae +
No or stable morbid (BLIC)b or 2nd following: a Moraxella IV Extended
co-morbid illness) generation oral Severe Sepsis - DFA test catarrhalis macrolide or IV
conditions cephalosporinsc and Septic for L. Enteric Respiratory
Chest X-ray: +/- Extended Shock pneumophil Gram- fluroquinolone
- localized macrolides OR a negative
infiltrates Alternative: 3rd Need for bacilli With risk for P.
- no evidence generation oral mechanical Legionella aeruginosa:
of pleurai cephalosporin3 ventilation pneumophila IV
effusion nor +/- Extended Anaerobes antipneumococ
abscess macrolide Staphylococc cal
Chest X-ray Streptococcu IV non- us aureus antipseudomon
MODERATE Blood CS s antipseudomon Pseudomona al U-lactam
RISK CAP Sputum pneumoniae al li-lactam s aeruginosa (BLIC,
GS/CS Haemophiius (BLIC, cephalosporin
Unstable vital When influenzae cephalosporin or
signs: available: Chlamydophi or carbapenem)9
- RR > 30 - Urine Ag la carbapenem)6 + IV Extended
breaths/min test for L. pneumoniae + macrolide +
PR >125 pneumophil Mycoplasma Extended aminoglycoside
beats/min a pneumoniae macrolide h
SBP < 90 - Direct Moraxella
mmHg - DBP < Fluorescent catarrhalis OR OR
60 mmHg Ab (DFA) Enteric IV
Temperature test for Gram- IV non- antipneumococ
< 36°C or > Lpneumophi negative antipseudomon cal
40°C la bacilli al (β-lactam antipseudomon
Legionella (BLIC, al (i-lactam
Altered pneumophila cephalosporin (BLIC,
mental state Anaerobes or cephalosporin
of acute onset (among carbapenem)6 or
Suspected those with + carbapenem)9
aspiration risk of Respiratory + IV
Unstable / aspiration) fluoroquinolone Ciprofloxacin or
Decompensat s' (FQ) Levofloxacin
ed comorbid (high dose)
condition
-uncontrolled
diabetes
mellitus,
active
malignancies,
neurologic
disease in
evolution,
congestive
heart failure
(CHF) Class II-
IV,
unstable
coronary
artery disease,
renal failure
on
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