What is pneumonia?
A disease of the lungs that is characterized by inflammation of the parenchyma of the lung (alveoli) and accumulation of abnormal alveolar filling with fluid of lung tissue. Most commonly caused by infection
True or False: Lower airways of the lungs usually remain organism-free due to pulmonary host defense mechanisms
What is the most common way that material and microbes enter the lower respiratory tract?
What are the 6 mechanisms of infections pneumonia?
- Inhalation of infections particles
- Inhalation of oropharyngeal or gastric contents
- Hematogenous spread (blood stream infection e.g. endocarditis)
- Infections from adjacent or contiguous structures
- Direct inoculation
What are the bugs in "typical" pneumonia? (7)
Group A Streptococci
Aerobic Gram-negative Bacteria
What are the bugs in atypical pneumonia? (4)
What are some clinical history factors that can change a person's immune response and their ability to manage infections?
HIV, immunosuppression, alcohol/drug abuse.
These change your differntial for which bacteria may be involved
Why is age important when assessing for pneumonia?
Elderly patients have less of a classic presentation and findings may be subtle. They also go from relatively healthy to critically ill much faster
How can mineral oil usage be a concern for pneumonia?
Patients that use a lot of mineral oil or vasaline can inhale particles and develop pneumonia.
How is occupational history/allergic history important when looking for pneumonia?
It is important to consider these things to decide what else is on your differential. These are important to think about particularly if you're treating someone for pneumonia and they aren't getting better.
What underlying cardiopulmonary diseases are important to keep in mind when assessing for pneumonia?
COPD and congenital or acquired pulmonary diseases.
Chronic infections (e.g. patients with CF), can develop bronchiectasis which can change the kind of microbes that can end up in the lower lung tract. This will change how you treat the infection
What are co-morbidities for pneumonia? (4)
- Aspiration risk (alcohol, oral hygiene, dysphagia, GETA)
- IV Drug use
- Pregnancy (later trimesters, women have decreased esophageal junction tone and are more likely to aspirate)
- Diseases associated with immunosuppression
What drug clinical history should you watch out for when assessing a patient for pneumonia?
- Allergy drugs
- IV drug abuse
- Drug induced lung diseases
- immunosuppressive agents
When assessing for pneumonia, it is important to think about healthcare risk factors. What are these? (3)
- Nursing Home
- Recent Hospital discharge
community acquired vs healthcare associated will help you determine treatment
What are systemic symptoms of pneumonia?
High fever and chills
What are skin symptoms of pneumonia?
Clamminess and blueness
What are lung symptoms of infections pneumonia? (4)
Cough with sputum or phlegm
Shortness of breath
Pleuritic chest pain
What are musculoskeletal symptoms of infectious pneumonia?
Fatigue and aches, joint pain
What are gastric symptoms of infections pneumonia?
Nausea and vomiting
What are central symptoms of infectious pneumonia?
Headaches, loss of appetite, mood swings
What are the cardiovascular symptoms for infectious pneumonia?
Low blood pressure and high heart rate
How might elderly patients present with pneumonia?
What kind of physical examination findings do you find with pneumonia?
Fever (80%, may be absent in elderly)
Evidence of consolidation (bronchial breath sounds, egophany, dullness to percussion)
How does pneumonia show on CBC?
Leukocytosis (increased WBC)
or if a patient is very sick Leukopenia (decreased WBC) - poor prognosis
What do you look for in a basic chemistry panel for pneumonia?
You want to check renal function and electrolytes to get a sense of if the problem is just in the lungs or if there is systemic involvement.
How are blood and sputum cultures used for assessing for pneumonia?
While blood and sputum cultures test positive infrequently (in less than 20% of patient for blood and 10% for sputum), it can help in treating healthcare related pneumonia and identifying resistant strains.
How is respiratory PCR used in diagnosing pneumonia?
This is a newer development that is helping to identify the infectious organism. Before, these results took days but new technologies are reducing the time to hours so we can use this to help in treatment.
Urine tests can be used to identify which two pneumonia organisms?
S. pneumonia and legionella
True or False: Radiographic features alone can differentiate etiology of pneumonia
What is better for imaging pneumonia--CXR or CT?
CXR is a good starting point but CT can see more.
What is an empyema?
An empyema is a collection or gathering of pus within a naturally existing anatomical cavity
Is this lobar or multifocal pattern of pneumonia?
Is this lobar or multifocal distribution of pneumonia?
Infiltrate is bilateral in multiple lobes. The curved line on the right lung is a clear depiction of the fissure between the right middle and right upper lobes.
What is seen here?
This is an example of cavitation. You can see a horizontal line that depicts the air-fluid level. There is a big abcess and you can see the fluid leveling out.
What pattern of distribution is this? What should you be concerned about?
Miliary distribution. This should make you think about hematogenous disease (presence of bacteria in the blood). It looks like seeds spread around.
What's the pattern of pneumonia here? What should you think about?
Interstitial pneumonia. Lines follow bronchovascular bundles. This makes you think about scarring and idiopathic interstitial pneumonia.
Miliary pattern of disease makes you think of what 2 things?
Hematogenous disease (presence of bacteria in the blood) and tuberculosis
What's the mnemonic for remembering alveolar filling processes?
Poor funny boy can't piss for crap
Pus, fluid, blood, cells/cancer, protein, fat, calcium
This will help you build your differential
What is community acquired pneumonia?
Pneumonia begins outside of the hospital and is diagnosed in less than 48 hours after hospital admission. The patient is not a resident in a long-term facility for more than 14 days before the onset of symptoms.
Which organisms are most common for causing community acquired pneumonia?
Streptococcus pneumonia (30-60% CAP), atypical organisms (10-20% of CAP)
What is outpatient treatment for community acquired pneumonia?
Macrolides (azithromycin, clarithromycin, erythromycin, etc) or Doxycycline
Respiratory Fluoroquinolone (levofloxacin)
What is inpatient treatment for community acquired pneumonia?
Respiratory fluoroquinolone (levofloxacin) or
Beta-lactam and Macrolide (ceftriaxone + azithromycin)
Beta-lactam and Macrolide (ceftriaxone + azithromycin) or
Beta-lactam and respiratory fluoroquinolone
Consider Anti-MRSA Therapy (vancomycin) (if you see cavitary pneumonia or if the patient had just gotten over the flu--anything that would make you wonder if it's a staph infection)
What is hospital (nosocomial) acquired pneumonia?
Pneumonia that occurs more than 48 hours after hospital admission
What is ventilatory associated pneumonia?
Pneumonia that happens more than 48-72 hours after an endotracheal tube intubation
What is healthcare associated pneumonia?
Pneumonia in a non-hospitalized patient with extensive healthcare contact
-IV therapy, wound care, IV chemotherapy within the last 30 days
- Resident of a nursing home or Long-term acute care facility
- Hospitalized in acute care hospital for more than 2 days within the prior 90 days
- Attendance at hospital or hemodialysis clinic within the past 30 days
True or False: Pneumonia infections can be polymicrobial, especially with healthcare and hospital associated pneumonia
True or False: Hospital and healthcare associated pneumonia infections are more likely to be multi-drug resistant.
True. (e.g. Pseudomonas aeruginosa)
Name 5 gram-negative multi-drug resistant pathogens and 1 gram-positive multi-drug resistant pathogen
Gram-negative MDR pathogens
2. Pseudomonas aeruginosa (more common)
5. Enterobacter or Escherichia Coli
Gram-positive MDR pathogens
1. Methicillin-Resistant Staphylococcus Aureus (MRSA)
How do you treat hospital/healthcare/ventilator associated pneumonia?
When treating hospital/ventilator/healthcare associated pneumonia, why is it important to de-escalate therapy based on culture data and clinical response in 48-72 hours?
You're using a lot of broad spectrum antibiotics which can generate resistence and put people at risk for C. Diff.
What is the duration of therapy for the different kinds of pneumonia?
Outpatient community acquired pneumonia - 5 days
Inpatient community acquired pneumonia - 7 days
Health care associated pneumonia - 7 days
Ventilator associated pneumonia - 8 days
Longer duration therapy for pseudomonas and MRSA (about 14 days)
When do influenza outbreaks typically occur, how long does it last, and about how much of the population is affected?
Winter, 2-3 months, 10-20% of general population
Influenza viruses undergo periodic changes in the antigenic characteristics of their _____. Name them.
Envelope glycoproteins. Hemagglutinin (H#) and Neurominidase (N#)
Major changes in influenza envelope glycoproteins are called _____ ______ while minor changes in the glycoprotines are called _____ ______.
antigenic shifts, antigenic drifts
What are symptoms of respiratory virus infections?
Symptoms can be variable in severity and presentation but generally these are the symptoms:
Fever, runny nose, sore throat, lethargy, loss of appetite, diarrhea, coughing, wheezing, nausea, vomiting.
Influenza mortality is associated typically with which age groups?
Elderly or young
What are complications of influenza infection? (4)
Primary influenza pneumonia
Secondary bacterial pneumonia
Myositis and rhabdomyolysis
Which lab tests can diagnoze influenza?
Rapid antigen tests
Viral culture - 48 hour culture
What are two treatments for influenza? What does treatment do?
Neuraminidase Inhibitors (active against influenza A and B)
- Oseltamivir and Zanamivir are most common
Adamantanes - Active only against influenza A (rarely, if ever used)
- Amantadine and Rimantidine
Treatment can shorten the duration and severity of symptoms. Greatest benefit is if the treatment is given within the first 24-30 hours.