Transcript Document 7244722

Topic of the lecture:
Pneumonias. Pleural syndrome.
Ethiology. Clinical pattern.
Daignostics. Complications.
Principles of treatment
Ass-prof. N. Bilkevych
Pneumonia (pneumonia)
Acute inflammation of lung
parenchyma with obvious
involvement of alveoli.
Usually is caused by bacteria or
viruses
Alveoli and lung cells that produce
surfactant
• In up to 30% of patients no organism is
identified, usually because of prior antibiotic
administration. In many patients there is a
preceding history of an upper respiratory virus
infection. Most community acquired pneumonias
can be managed at home, and have a low
mortality; studies of such patients admitted to
hospital have shown a mortality of 6—24%
depending on the population studied and the
presence or absence of such risk factors as old
age and underlying disease.
Ethiology:
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Not specific pathogenic
or
obligate-pathogenic
microbes
Pathogenesis:
• Infection spread into the
organism through respiratory
airways. Microbes appears and
multiple on bronchial mucosa of
upper airways and than spread
down to bronchi and lung tissue
Acquired and congenital defects
of bronchial clearance
disordered function of ciliated
epithelium
surfactant system defects
• infufficiency of alveolar
makrophages
• Deranged bronchial patency
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• disordered function of diaphragm and
chest excursions
• changes of local and systemin
immunity
depressed coughing reflex
Pathogenetic difference
• Betveen croupous and focal
pneumonia depends o the reaction
of macroorganism on infectious
agent
• In croupous pneumonia this
reaction is hyperergic, in focal one
– normo- or hypoergic
Classification
• Community-acquired pneumonia.
• Nosocomial (intrahospital) pneumonia – acute
infection of lower airways confirmed with Xray, has being developed in 48 hrs after
appearance of the patient in hospotal
environment.
• Aspiration pneumonia.
• Pneumonia in immunocompromizwd patients
Pneumonia: infecting organisms in
approximate descending order of frequency
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Community acquired
Streptococcus pneumoniae
Mycoplasma pneumoniae
Influenza virus A
Haemophilus influenzae
Legionella pneumophila
Staphylococcus aureus
Coxiella burneti
Chlamydia psittaci
Hospital acquired
Gram-negative bacilli
Staphylococcus aureus
Streptococcus pneumoniae
Legionella pneumophila
Haemophilus influenzae
Pseudomonas spp
• Immunocompromised
patients
• Pneumocystis carinii
• Cytomegalovirus
• Mycobacterium aviumintracellulare
• Mycobacterium tuberculosis
• Streptococcus pneumoniae
• Haemophilus influenzae
• Legionella pneumophila
• Actinomyces israelii
• Aspergillus fumigatus
• Nocardia asteroides
Course
Mild
RR – less than 25 per min, РS – less
than 90 per min, t – less than 380C
signs of hypoxia and circulatory
insufficiency are absent, volume of
infiltrate – 1-2 segments
unilaterally
Moderate:
RR – less than 30 per min, РS –
less than 100 per min, t – less
than 390C
mild hypoxia, circulatory
insufficiency is absent,
volume of infiltrate – 1-2
segments bilaterally or
entire lobe
Severe:
RR – till 40 per min, РS – more
than than 100 per min, t – till
400C
• signs of hypoxia and
circulatory insufficiency are
present, volume of infiltrate
– several segments or more
than 1 lobe
Very severe
RR – more than 40 per min, РS –
more than 100 per min, t – more
than 400C
• Marked signs of hypoxia and
circulatory insufficiency, extensive
damage
Croupous pneumonia
• Acute inflammation of lungs, which in
most cases spreads on all pulmonary
lobe. That is why it is called lobar
pneumonia (pneumonia lobaris), but
can be limited to the affection of
segment or a few segments.
• Synonims
fibrinous
pleuropneumonia
pneumonia,
• The usual clinical presentation in pneumonia caused by
Streptococcus pneumoniae is acute, with the abrupt
onset of malaise, fever, rigors, cough, pleuritic pain,
tachycardia and tachypnoea, often accompanied by
confusion, especially in the elderly. The signs include a
high temperature, consolidation and pleural rubs, and
herpetic lesions may appear on the lips. There may also
be signs of pre-existing disease, especially chronic
bronchitis and emphysema or heart failure in the elderly.
The sputum becomes rust-coloured over the following 24
hours. The diagnosis is made on clinical grounds and
confirmed by chest X-ray.
Pneumococci
пневмокок
Pneumococci are typically
asociated with pneumonia
Patalogoanatomical
stages:
• inflow (12 hrs - 3 days)
• red hepatisation (1 hr - 3 days)
• grey hepatisation ( 2 - 6 days)
• resolution
Clinical stages:
• initial
• clinical
(corresponds
hepatisation
• resolution
to
manifestation
red and grey
Lobar pneumonia: stage of
onset
• Morphology. Congestion stage — extensive serous
exudation, vascular engorgement, rapid bacterial proliferation.
• Inspection. An increased respiratory rate is usually
evident. Pain is a frequent accompaniment, and with it
the involved side shows a lag of respiratory motion.
• Palpation. Palpation confirms the findings on inspection.
Tactile fremitus is normal or even slightly decreased, and
a pleural friction rub may be present.
• Percussion. Impaired resonance may be elicited with
light percussion. This finding is extremely important.
• Auscultation. Although the breath sounds may be
diminished, expiration is prolonged and crepitation
(crepitus indux) is heard. With pleural involvement, a
pleural friction sound is determined.
Lobar pneumonia: stage of
consolidation
• Morphology. Red hepatization stage — airspaces are filled
with PMN cells, vascular congestion, extravasation of
RBC. Grey hepatization stage — accumulation of fibrin,
inflammatory WBCs and RBCs in various stages of
disintegration, alveolar spaces filled with inflammatory
exudate.
• Complaints. Coughing may be associated with i sharp pain
in the affected side. Mucoid sputum be comes rusty brown
(prune juice color).
• General inspection. Cyanosis of the lips and fin gers.
When the fever is high, the face may be flushed The
patient's nostrils dilate on inspiration, and expi ration is
often grunting.
• Inspection. Dyspnea is invariably present. Respi ratory
movements are generally decreased on the af fected
side.
• Palpation. Diminished respiratory excursions, i pleural
friction rub may be felt. Tactile fremitus is in creased.
• Percussion. Dullness.
• Auscultation. Bronchial breathing, bronchophony,
pectoriloquy and whispered bronchophony are evident
with consolidation provided the bronchus to the in volved
area is open. Rales are less numerous and dis tinct than
in the stages of engorgement or resolution,
Forced position
Lobar pneumonia: stage of
resolution
• Morphology. Resolution stage — resorption of the
exudate.
• Inspection. The patient looks more comfortable and the
cyanosis disappears. The dyspnea disappears and the
affected lung begins to expand again.
• Palpation. The previously increased tactile fremitus
becomes less marked and gradually findings become
normal.
• Percussion. The dullness gradually
disappears and normal resonance returns.
• Auscultation. The bronchial breathing is
gradually replaced by bronchovesicular
breathing and later by normal vesicular
breathing. Crepitation reappears (crepitus
redux). Small and large moist rales are
heard in increasing numbers.
Laboratory tests
• The white cell count and ESR are usually elevated.
Blood should be sent for culture before antibiotic therapy
is given and a baseline blood sample taken for se-rology.
Sputum should be sent for culture. Direct Gram-staining
of a fresh sputum sample may show the organism.
Pneumococcal antigen can be identified in sputum, urine
or serum. Antibiotic therapy should not be delayed while
awaiting sputum culture results.
• The symptoms usually resolve rapidly over 7—
10 days and the signs over a slightly longer
period. Radiological resolution should be
complete by 12 weeks. Persistence of changes
in the X-ray after this, or recurrence of
pneumonia, suggests some other pathological
process and should trigger a search for
underlying carcinoma. Careful examination
should be made at presentation for clinical
features of AIDS.
Complications
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Lung abscess or gangroene
Pleurisy
Toxic shock
Myocarditis
Acute respiratory insufficiency
Pneumosclerosis
Atelectasis
Sepsis
Meningitis, encefalitis
Pleurisy
Pleurisy with effusion: 1—
Damoiseau's curve; 2—
Garland's triangle;
3—Rauchfuss-Grocco triangle.
Lung abscess
Lung abscess
Focal pneumonia
Focal pneumonia
Focal pneumonia
• The feature of these pneumonias is
an involvement of separate lobules
or groups of lobules in the
inflammatory process. Therefore it is
named also lobular (pneumonia
lobularis)
Synonim: bronchopneumonia
• Mycoplasma pneumoniae is the most common
cause of the «atypical» pneumonias. Infection
usually occurs in older children and young
adults, who present with pharyngitis and
bronchitis; pneumonia occurs in mi-nority and is
rarely severe. Psittacosis is acquired from birds
and Q-fever from animals, commonly farm livestock; they also cause «atypical pneumonia»,
although the Q-fever organism, Coxiella burnetti,
may also cause endocarditis. The diagnosis of
the atypical pneumonia is usually made by
serology.
• Staphylococcal pneumonia typically occurs as a
complication of influenza, especially in the
elderly and, although uncommon, is important
because of the attendant high mortality. It is a
destructive pneumonia, which frequently leads
to the formation of cavities within the lung. Such
cavitating pneumonia was most frequently
caused by tuberculosis in the past but now
Staphylococci, Klebsiella and anaerobic
organisms are the most common causes.
• Legionnaires' disease is pneumonia caused by
Le-gionella pneumophila. Infection is most
common in debilitated or immunocompromised
patients. Most cases are sporadic, but outbreaks
occur from contaminated water droplet sources.
Patients may present with a wide spectrum of
additional symptoms, such as headache,
cerebellar ataxia, renal failure or hepatic involvement. Special medium is necessary for the
culture of the organism and the diagnosis is
usually made by serology.
• Aspiration pneumonia results from the
aspiration of gastric contents into the lung
and is associated with impaired
consciousness {e.g. anaesthesia; epilepsy,
alcoholism) or dysphagia. Multiple
organisms may be isolated.
• Nosocomial pneumonia occurs when infection takes
place in hospital; patients may be debilitated,
immunocompromised or have just undergone a major
operation. The causative organism(s) are often Gramnegative or Gram-positive coccus, Staphylococcus aureus. The high mortality is usually related to the severity
of the underlying disease. Lung abscess or empye-ma (a
collection of pus within the thoracic cavity), or both, may
be caused by specific organisms or may complicate any
aspiration pneumonia. Septic pulmonary emboti can lead
to multiple lung abscesses, pulmonary infarcts may
become infected cavities and abscesses can develop
distal to lesions obstructing a bronchus.
• Treatment of all pneumonias should be
started immediately and the antibiotic chosen
should be the «best guess» (decided on by
the origin of the pneumonia and its clinical
severity). If community-acquired, then
semisynthetic penicillins (or macrolids) will
usually be effective, in severe cases –
cefalosporines. The reserve drugs are
pthorchynolones. Combinations such as
macrolids with cephalosporin may be used.
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• If legionnaires'disease is suspected on
epidemiological grounds, rifampicin should be
given with erythromycin. In hospital-acquired
pneumonia, combination therapy is required to
cover the range of possible pathogenic organisms (especially Gram-negative bacilli).
• In aspiration pneumonia, in which anaerobes
may be present, metronidasole should be added
to these combinations. Supportive measures
should include oxygen, intravenous fluids,
inotropic agents when necessary, bronchial
suction and assisted ventilation.
• Physiotherapy and bronchod-ilators are of value
in pneumonia complicating chronic bronchitis
and emphysema.
Infection in the
immunocompromised host
• There has been a steady increase in the number of
patients whose immune system has been damaged by
malignancy, organ failure, drugs or the HIV virus. In such
immunocompromised patients, infections of the lung are
common and may be caused by organisms that are not
usually pathogenic in the normal host. Invasive fungal
infections tend to occur in neutropenic patients, whereas
T-cell defects often lead to infection with viruses,
mycobacteria and protozoa such as Pneumocystis
carinii. The tempo of infection in the
immunocompromised patients can be extremely rapid; it
is important to take steps to identify the pathogen and to
start therapy as soon as possible.
• Pneumocystis carinii is the most important cause
of fatal pneumonia in immunosuppressed
patients. It is believed that the infection is
acquired in early childhood, and that reactivation
occurs when immune system becomes
damaged. The incubation period is approximately 1-2 months before the insidious
appearance of a low-grade progressive
pneumonia, which manifest itself as severe
dyspnoea with, at first, only minimal chest signs
and X-ray changes.
• In Pneumocystis carinii pneumonia the changes on X-ray
may be very minor, but the patient is markedly hypoxic
and a transbronchial biopsy usually reveals P. carinii.
Unless the infection is treated promptly, most severe
pneumonic changes follow.
• The pneumonia progresses rapidly, and within a few
days obvious pneumonic changes may be seen on the
chest X-ray. Diagnosis depends on demonstrating the
organism in sputum, bronchial lavage or lung tissue,
which may require a lung biopsy. Treatment is with
cotrimoxazole or pentamidine; both of these may be
used in prophylaxis. Mortality remains high despite
treatment.
Principles of treatment
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Antibiotics
Expectorants
Desintoxication
Oxygen
Antigistamine agents
Symptomatic therapy
Сorrect regimen
Bed mode
Care of patients:
• proper lighting and ventilation
(fresh air improve patient’s sleep and
bronchial clearance)
• Care of oral cavity
Diet
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about 2,5-3 litres of loquid per day
(water with lemon juice, mineral or
boiled water
Fruit juices
chicken clear soups
food should be easly assimilable
in some days – diet № 10 or 15.
Diet enriched with vitamins
Climatotherapy Кліматотерапія
mild dry warm
climat
ПРИМОРСЬКІ КУРОРТИ З НИЗЬКИМ РІВНЕМ
ВОЛОГОСТІ
Symptomatic means
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antitussives
antipyretics
Pain killers
antiinflammmatory
(nonsteroidal in pleural pain)
• cardiotonics