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PART III Infectious Pulmonary Diseases Slide 1 Copyright © 2006 by Mosby, Inc. Chapter 15 Pneumonia Chapter 15 Figure 15-1. Cross-sectional view of alveolar consolidation in pneumonia. TI, Type I cell; TII, type II cell; M, macrophage; AC, alveolar consolidation; L, leukocyte; RBC, red blood cell. Slide 2 Copyright © 2006 by Mosby, Inc. Anatomic Alterations of the Lungs Slide 3 Inflammation of the alveoli Alveolar consolidation Atelectasis Copyright © 2006 by Mosby, Inc. Etiology Bacterial Causes Slide 4 Gram-positive organisms Streptococcus Staphylococcus Copyright © 2006 by Mosby, Inc. Figure 15-2. The Streptococcus organism is a gram-positive, nonmotile coccus that is found singly, in pairs, and in short chains. Slide 5 Copyright © 2006 by Mosby, Inc. Figure 15-3. The Staphylococcus organism is a gram-positive, nonmotile coccus that is found singly, in pairs, and in irregular clusters. Slide 6 Copyright © 2006 by Mosby, Inc. Etiology Gram-negative organisms Slide 7 Haemophilus influenzae Klebsiella Pseudomonas aeruginosa Moraxella catarrhalis Escherichia coli Serratia species Enterobacter species Copyright © 2006 by Mosby, Inc. Figure 15-4. The bacilli are rod-shaped microorganisms and are the major gram-negative organisms responsible for pneumonia. Slide 8 Copyright © 2006 by Mosby, Inc. Etiology Atypical organisms Slide 9 Mycoplasma pneumoniae Legionella pneumophila Chlamydia psittaci Chlamydia pneumoniae Copyright © 2006 by Mosby, Inc. Etiology Anaerobic bacterial infections Slide 10 Peptostreptococcus species Bacteroides melaninogenicus Fusobacterium necrophorum Bacteroides asaccharolyticus Porphyromonas endodontalis Porphyromonas gingivalis Copyright © 2006 by Mosby, Inc. Etiology Viral causes Slide 11 Influenzavirus Respiratory syncytial virus Parainfluenza virus Adenovirus Coronavirus (SARS) Copyright © 2006 by Mosby, Inc. Etiology Other causes Rickettsial infections Varicella Rubella Aspiration pneumonitis Lipoid pneumonitis Pneumocystis carinii Cytomegalovirus Tuberculosis Fungal infections Slide 12 Copyright © 2006 by Mosby, Inc. Etiology Acquired pneumonia classification Slide 13 Community-acquired pneumonia (CAP) Nursing home–acquired pneumonia Hospital-acquired pneumonia Ventilator-associated pneumonia Copyright © 2006 by Mosby, Inc. Overview of the Cardiopulmonary Clinical Manifestations Associated with PNEUMONIA The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Alveolar Consolidation (see Figure 9-8), Increased Alveolar-Capillary Membrane Thickness (see Figure 9-9), and Atelectasis (see Figure 9-7)—the major anatomic alterations of the lungs associated with pneumonia (see Figure 15-1). During the resolution stage of pneumonia, Excessive Bronchial Secretions (see Figure 9-11) also may play a part in the clinical presentation. Slide 14 Copyright © 2006 by Mosby, Inc. Figure 9-8. Alveolar consolidation clinical scenario. Slide 15 Copyright © 2006 by Mosby, Inc. Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario. Slide 16 Copyright © 2006 by Mosby, Inc. Figure 9-7. Atelectasis clinical scenario. Slide 17 Copyright © 2006 by Mosby, Inc. Figure 9-11. Excessive bronchial secretions clinical scenario. Slide 18 Copyright © 2006 by Mosby, Inc. Clinical Data Obtained at the Patient’s Bedside Vital signs Slide 19 Increased respiratory rate Increased heart rate, cardiac output, blood pressure Copyright © 2006 by Mosby, Inc. Clinical Data Obtained at the Patient’s Bedside Chest pain/decreased chest expansion Cyanosis Cough, sputum production, and hemoptysis Chest assessment findings Increased tactile and vocal fremitus Dull percussion note Bronchial breath sounds Crackles and rhonchi Pleural friction rub Whispered pectoriloquy Slide 20 Copyright © 2006 by Mosby, Inc. Figure 2-11. A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation. Slide 21 Copyright © 2006 by Mosby, Inc. Figure 2-16. Auscultation of bronchial breath sounds over a consolidated lung unit. Slide 22 Copyright © 2006 by Mosby, Inc. Figure 2-19. Whispered voice sounds auscultated over a normal lung are usually faint and unintelligible. Slide 23 Copyright © 2006 by Mosby, Inc. Clinical Data Obtained from Laboratory Tests and Special Procedures Slide 24 Copyright © 2006 by Mosby, Inc. Pulmonary Function Study: Expiratory Maneuver Findings FVC FEVT N or FEF25%-75% N or FEF200-1200 N PEFR MVV FEF50% FEV1% N Slide 25 N or N N or Copyright © 2006 by Mosby, Inc. Pulmonary Function Study Lung Volume and Capacity Findings Slide 26 VT RV FRC TLC N or VC IC ERV RV/TLC% N Copyright © 2006 by Mosby, Inc. Arterial Blood Gases Mild to Moderate Pneumonia pH Slide 27 Acute alveolar hyperventilation with hypoxemia PaCO2 HCO3 (Slightly) PaO2 Copyright © 2006 by Mosby, Inc. Time and Progression of Disease Disease Onset Alveolar Hyperventilation 100 90 PaO2 or PaCO2 80 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors 70 60 PaO2 50 40 30 20 10 0 Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation. Slide 28 Copyright © 2006 by Mosby, Inc. Arterial Blood Gases Severe Pneumonia Acute ventilatory failure with hypoxemia pH Slide 29 PaCO2 HCO3 (Slightly) PaO2 Copyright © 2006 by Mosby, Inc. Time and Progression of Disease Disease Onset Alveolar Hyperventilation Acute Ventilatory Failure 100 90 Pa02 or PaC02 80 70 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors Point at which disease becomes severe and patient begins to become fatigued 60 50 40 30 20 10 0 Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure. Slide 30 Copyright © 2006 by Mosby, Inc. Oxygenation Indices Slide 31 QS/QT DO2 VO2 C(a-v)O2 Normal Normal O2ER SvO2 Copyright © 2006 by Mosby, Inc. Time and Progression of Disease Disease Onset Alveolar Hyperventilation Acute Ventilatory Failure 100 90 Pa02 or PaC02 80 70 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors Point at which disease becomes severe and patient begins to become fatigued 60 50 40 30 20 10 0 Figure 4-7. PaO2 and PaCO2 trends during acute or Acute ventilatory failure. Slide 32 Copyright © 2006 by Mosby, Inc. Abnormal Laboratory Tests and Procedures Sputum examination Slide 33 Gram-positive organisms Streptococcus Staphylococcus Gram-negative organisms Klebsiella Pseudomonas aeruginosa Haemophilus influenzae Legionella pneumophila Copyright © 2006 by Mosby, Inc. Radiologic Findings Chest radiograph Increased density Air bronchograms Pleural effusions CT scan Slide 34 Consolidation and bronchograms may be seen Copyright © 2006 by Mosby, Inc. Figure 15-5. Chest X-ray film of a 20-year-old woman with severe pneumonia of the left lung. Slide 35 Copyright © 2006 by Mosby, Inc. Figure 15-6. Air bronchogram. The branching linear lucencies within the consolidation in the right lower lobe are particularly well demonstrated in this example of staphylococcal pneumonia. (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.) Slide 36 Copyright © 2006 by Mosby, Inc. Figure 15-7. Air bronchogram shown by CT in a patient with pneumonia. (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.) Slide 37 Copyright © 2006 by Mosby, Inc. General Management of Pneumonia Respiratory care treatment protocols Slide 38 Oxygen therapy protocol Bronchopulmonary hygiene therapy protocol Copyright © 2006 by Mosby, Inc. General Management of Pneumonia Medications and procedures commonly prescribed by the physician Slide 39 Antibiotics Analgesic agents Ribavirin aerosol Aerosolized pentamidine Thoracentesis Copyright © 2006 by Mosby, Inc. Classroom Discussion Case Study: Pneumonia Slide 40 Copyright © 2006 by Mosby, Inc.