RC 110 Chapter 16 Pneumonia

Diagnosis of pneumonia

1. Localized symptoms may include: cough, sputum, sweating, chest pain, dyspnea 2. Systemic manifestations of the infection include: general malaise, chills, fever

Treatments for Pneumonia

1. Oxygen Therapy Protocol 2. Lung Expansion Therapy 3. Aerosol Therapy 4. Thoracentesis

Chronic pneumonia (6 of 6)

Actinomyces: species are normally present in the gingival area and are common opportunistic pathogens of humans, particularly in the oral cavity (infections associated with dental procedures and oral abscesses)

Community-Acquired Atypical Pneumonia ( 8 of 9)

Adenovirus: serotypes 4, 7, 14 and 21 cause viral infections and pneumonia in all age groups. Serotype 7 has been related to fatal causes of pneumonia in children. Transmitted by aerosol. Occurs during the fall, winter and spring.

Chronic pneumonia ( 4 of 6)

C, neoformans proliferates in pigeon droppings, which have a high nitrogen content, and readily scatters into the air and dust

Community-Acquired Atypical Pneumonia ( 3 of 9)

Chlamydia spp. Pneumonia (chlamydia pneumonia, chlamydia psittaci, chlamydia trahomatis and coxiella burnetii): Chlamydia is a type of bacteria that may be found in the cervix, urethra, rectum, throat, and respiratory tract. Chlamydia is also found in the feces of variety of birds (parrots, parakeets, lorikeets, cockatoos, chickens, pigeons, ducks pheasants, turkey) clinical manifestations closely resemble M. pneumoniae.

What test to identify pneumonia?

Cultures of Sputum or tissues samples: gram staining, culture sensitivity testing and cytology

Aspiration Pneumonia ( 4 of 6)

Dysphagia: result of an abnormal swallow that can involve the oral, pharyngeal and esophageal phases.

Aspiration Pneumonia ( 6 of 6)

Dysphonia dysarthria: some patients with serve and bilateral sensory deficits develop aspiration pneumonia. Patients with tracheostomy are at high risk for silent aspiration. Perhaps 55% to 70% of intubation or tracheostomy patients aspirate.

Describe classifications of pneumonia Community-Acquired Pneumonia ( 6 of 7)

Enterobacteriaceae (Klebsiella pneumonia): Organisms have long been associated with lobar pneumonia, particularly in men older than 40 years and in chronic alcoholics of both ganders. Gram-negative bacillus that is found singly, in pairs and in chains of very lengths. Normal inhabitant of the human gastrointestinal tract. Transmitted directly by aerosol or indirectly by contact with freshly contaminated articles. Common nosocomial or hospital acquired disease. Typically transmitted by routes such as clothing, intravenous solutions, foods and the hands of health care workers. Mortality of patients is very high because septicemia is a frequent complication

Aspiration Pneumonia ( 3 of 6)

Gastroesophageal reflux disease (GERD): causes disruption in nerve-mediated reflexes in the distal esophagus, resulting in alternation of the primary and secondary peristaltic wave and reflux. GERD is three times more prevalent in patients with asthma than in other patients. GERD causes chronic cough in 10% to 20% of patients

Describe classifications of pneumonia Community-Acquired Pneumonia (4 of 7)

Haemophilus influenza: common inhabitant of human pharyngeal flora. One of the smallest gram-negative bacilli, six types (A to F), only type B is most common pathogenic. Type B is seen most often in children aged 1 month to 6 years. Type B is always the cause of acute epiglottis. The organism is transmitted via aerosol or contact with contaminated objects. It is sensitive to cold and does not survive long after expectoration. Cultured from the sputum of patients having an acute exacerbation of chronic bronchitis.

Community-Acquired Atypical Pneumonia ( 9 of 9)

Human metapneumovirus (hMPV): a negative single-stranded RNA virus associated with a family of viruses that also includes respiratory syncytial (RSV) viruses and parainfluenza viruses. Second most common cause of lower respiratory infection in young children. Occur in older children and is less serve. Mild symptoms include cough, runny nose or nasal congestion, sore throat and fever. More severe cases demonstrate wheezing, difficulty breathing. Hoarseness, cough and pneumonia

Pneumonia

Infection of the lower airway Pneumonia = Consolidation= dull percussion sound (gradient shunt) symptom: shortness of breath (Dysplasia)

Community-Acquired Atypical Pneumonia ( 7 of 9)

Influenza viruses A and B: most common causes of viral respiratory tract infections. A and B commonly occur in epidemics during the winter month. Children, young adults and older individuals are most at risk. Transmitted from person to person by aerosol droplets. Often the first sign of an epidemic is an increase in school absenteeism. Virus survives well in conditions of low temperatures and low humidity. Found in horses, swine, and birds. Incubation period of 1 to 3 days and usually cause upper respiratory tract infections.

Pneumonia in the immunocompromised host ( 4 of 5)

Invasive Aspergillosis: term used for a wide variety of infections caused by fungi of the genus Aspergillus. Most common forms are allergic bronchopulmonary aspergillosis, pulmonary aspergilloma and invasive aspergillosis.

Pneumonia in the immunocompromised host ( 5 of 5)

Invasive Candidiasis: yeast like fungus ( Candida albicans), in patients with HIV an AIDS, the fungi can invade tissue that normally would be resistant to infections thus producing an opportunistic infection. Candida infections can involve any part of the body

Describe classifications of pneumonia Community-Acquired Pneumonia (5 of 7)

Legionella pneumophila: Severe pneumonia like disease outbreak occurred at an American Legion convention in Philadelphia. Was found to be an unusual and fastidious gram-negative bacillus with atypical concentrations of certain branched-chain lipids. More than 20 different species. Species are free living in soil and water, where they act as decomposer organisms. Multiplies in standing water such as contaminated mud puddles, large air conditioning systems and water tanks. Transmitted from person to person. Organism can be detected in pleural fluid, sputum, or lung tissue by direct fluorescent antibody microscopy. Rarely found outside the lungs, the organism may be found in other tissues. Most common found in middle-aged men who smoke

Aspiration Pneumonia ( 2 of 6)

Mendelson's syndrome: usually confined to aspiration pneumonitis in pregnant women, classified: (1) toxic injury to the lung (such as that caused by gastric acid) (2) obstruction (by foreign body or fluids) (3) infection. Aspiration is the presumed cause of nearly all cases of anaerobic pulmonary infection. Aspiration of gastric contents causes initial hypoxemia regardless of the pH level of the aspirate. Consequently, oximetry is a good measurement if aspiration is suspected. If the pH of the aspirate is relatively high (greater than 5.9), the initial injury is rapidly reversible.

Pneumonia in the immunocompromised host ( 3 of 5)

Mycobacterium avium complex (MAC): serious opportunistic infection that is caused by the following two similar bacteria: Mycobacterium avium and Mycobacterium intercellulare. Found in the soil and dust particles and found in patients with AIDS. Mode of infection is usually inhalation or ingestion. Spread through the blood steam to infect lymph nodes, bone marrow, the liver, the spleen, spinal fluid, the lungs, and the intestinal tract. Symptoms of MAC include fever, night sweats, weight loss, fatigue, anemia, diarrhea and enlarged spleen

Community-Acquired Atypical Pneumonia (2 of 9)

Mycoplasma (primary atypical pneumonia)(walking pneumonia): organism is the most common cause of an acquired pneumonia. The mycoplasma are tiny, cell wall deficient organisms. They are smaller than bacteria but larger than viruses. Term atypical refers to (1) the organism escapes identification by standard bacteriologic tests (2) there is generally only a moderate amount of sputum (3) there is an absence of alveolar consolidation (4) there is only moderate elevation of white cell count (5) there is a lack of alveolar exudate. Symptoms: similar to both bacterial and viral pneumonia, although the symptoms develop more gradually and are often milder. Chills and fever are early symptoms. The patient typically presents with a mild fever, and patchy inflammatory changes in the lungs that are mostly confined to the alveolar septa and pulmonary interstitium. More symptom is a cough that tends to come in violent attacks, producing only a small amount of white mucus. Some patients experience nausea or vomiting. Also may experience profound weakness that lasts for a long time, commonly seen children and young adults. This type of pneumonia spreads easily in areas where people congregate like child care centers, schools, and homeless shelters. Known as walking pneumonia because of the mild condition and the patient is still ambulatory.

Chronic pneumonia ( 5 of 6)

Nocardia: gram -positive, rod-shaped bacteria that can be found worldwide in soils that are rich with organic matter. Opportunistic infection in patients with weak immune systems such as small children, the elderly and the immunocompromised (most common in patients with HIV)

Chronic pneumonia ( 3 of 6)

Opportunistic yeast pathogens: Candida albicans, Cryptococcus neoformans, and Aspergillus may also cause pneumonia in certain patients. A C. albicans infection of the mouth is called thrush; it is characterized by a white, adherent, patchy infection of the membranes of the mouth, gums, cheeks and throat

Community-Acquired Atypical Pneumonia ( 6 of 9)

Parainfluenza viruses: also members of the paramyxovirus group. 5 types of parainfluenza viruses: type 1, 2, 3 are the major causes of infections in humans. Type 1 is considered a croup type of viruses. Types 2 and 3 are associated with severe infections. Type 3 is seen in persons of all ages. Type 1 and 2 are seen most often in children between ages of 6 months and 5 years. Type 1 and 2 happen in fall whereas type 3 seen in late spring and summer. Transmitted by aerosol droplets and by direct person to person contact. The parainfluenza viruses are known for their ability to spread rapidly among members of the same family

Pneumonia in the immunocompromised host ( 2 of 5)

Pneumocystis jirovecii (pneumocystis carinii): opportunistic, often fatal, form of pneumonia seen in patients who are profoundly immunosuppressed. Can normally be found in the lungs of humans, but it does not cause disease in healthy hosts, only in individuals whose immune systems are critically impaired, (AIDS and HIV infections)

List the anatomic alternations of the lungs associated with pneumonia

Pneumonia or pneumonitis with consolidation is the result of an inflammatory process that primarily affects the gas exchange area of the lung, In response to the inflammation, (effusion) :fluid (serum) and some red blood cells (RBCs) from adjacent pulmonary capillaries pour into the alveoli. Polymorphonuclear leukocytes move into the infected area to engulf and kill invading bacteria on the alveolar walls called surface phagocytosis. If the infection is overwhelming, the alveoli become filled with fluid, RBCs polymorphonuclear leukocytes and macrophages called consolidated. Atelectasis is often associated with patients who have aspiration pneumonia.

Chronic pneumonia ( 2 of 6)

Primary fungal pathogens include Histoplasma capsulatum, Coccidioides immitis and Blastomyces dermatitidis. Because most fungi are aerobes, the lung is a prime site for fungal infections

Describe classifications of pneumonia Community-Acquired Pneumonia (7 of 7) *** Pseudomonas***

Pseudomonas aeruginosa: highly mobile, gram-negative bacillus. Found in the gastrointestinal tract burns, and catheterized urinary tract and is a contaminant in many aqueous solutions. Frequently cultured from the respiratory tract of patients who are chronically ill and tracheostomized and is a leading cause of hospital acquired pneumonia. Risk factors include neutropenia, HIV infection, preexisting lung disease, endotracheal intubation and previous antibiotic use. Pseudomonas organism thrives in dampness if is often cultured from contaminated respiratory therapy equipment. Transmitted by aerosol or by direct contact with freshly contaminated articles.

Community-Acquired Atypical Pneumonia ( 5 of 9) *** Common Cold****

Respiratory syncytial virus (RSV): member of the paramyxovirus group. Parainfluenza, mumps and rubella viruses also belong this group. RSV is most often seen in children less than 12 months of age and in older adults with underlying heart or pulmonary disease. The infection is rarely fatal infants, RSV vaccine have been unsuccessful. The virus is transmitted by aerosol and by direct contact with infected individuals. Most commonly seen in patients during the late fall, winter or early spring months

Severe Acute Respiratory Syndrome (SARS)

Severe Acute Respiratory Syndrome (SARS): SARS is a newly recognized virus strain called a coronavirus. Coronaviruses are a group of viruses that have a halo like or corona-like appearance when observed under an electron microscope. Cause common colds and upper respiratory tract infections. Highly contagious on close personal contact with infected individuals. Spread through droplet transmission by coughing and sneezing. Might be transmitted through the air or from objects that have become contaminated. Patient usually develops fever, followed by chills, headaches, general feeling of discomfort and body aches. Patient with SARS usually develops a dry, nonproductive cough, shortness of breath, and malaise. 10% to 20% of patients with SARS require mechanical ventilation. No specific treatment recommendations exist at this time.

Aspiration Pneumonia ( 5 of 6)

Silent aspiration: defined as aspiration that does not evoke clinically observable adverse symptoms such as overt coughing, choking and immediate respiratory distress.

Describe classifications of pneumonia Community-Acquired Pneumonia ( 3 of 7)

Staphylococcal pneumonia: (1) staphylococcus aureus: responsible for most "staph" infections in humans, commonly transmitted by aerosol from a cough or sneeze of an infected individual and indirectly via contact with contaminated floors, bedding, clothes, and the like. (2) Staphylococcus albus and Staphylococcus epidermidis: are part of the normal skin flora. Staphylococcal pneumonia often follows a predisposing virus infection and is seen most often in children and immunosuppressed adults. Staphylococci are a common cause of hospital-acquired pneumonia or nosocomial pneumonia and are becoming increasing antibiotic resistant (multiple drug resistant S. aureus (MDRSA)) organisms.

Describe classifications of pneumonia Community-Acquired Pneumonia (2 of 7)

Streptococcal pneumonia: (also known as pneumococcal pneumonia) accounts for more than 80% of all the bacterial pneumonia. The organism is a gram-positive, nonmotile coccus that is found singly in pairs (diplococci) and in short chains. Cocci are enclosed in a smooth, thick polysaccharide capsule that is essential for virulence. Serotype 3 organisms are the most virulent. Streptococci are generally transmitted by aerosol from a cough it sneeze of an infected individual. Most strains of S.pneumoniae are sensitive to penicillin and its derivatives. S. pneumoniae is also commonly cultured from the sputum of patients having an acute exacerbation of chronic bronchitis.

Individuals most risk for Pneumonia

The very young, the very old, the infirmed

Community-Acquired Atypical Pneumonia ( 4 of 9)

Virus: Account for about 50% of all pneumonias and several are associated with a community-acquired atypical pneumonia. Although most viruses attack the upper airways, some can produce pneumonia. Most pneumonias are not life threatening and last only a short time, Viral pneumonia tends to start with flue like signs and symptoms. The early symptoms are a dry (nonproductive) cough, headache, fever, muscle pain, and fatigue. As the disease progress the patient may become short of breath, cough and produce a small amount of clear or white sputum. Viral pneumonia always carries the risk of development of a secondary bacterial pneumonia. They are parasitic and depend on nutrients inside cells for their metabolic and reproductive needs. About 90% of acute upper respiratory tract infections are caused by viruses. Common in young children, peaking between the ages of 2 and 3 years

Pneumonia impaired pulmonary defense

altered protective effects of epiglottis & glottis, suppressed or ineffective cough, impaired consciousness, obstructive airway lesions, abnormal mucus, defective cellular immunity, recent viral infection

Describe causes of pneumonia

bacteria, viruses, fungi, protozoa, parasites, tuberculosis, anaerobic organisms, aspiration, and the inhalation of irritating chemicals such as chlorine. Pneumonia is an insidious disease because its symptoms vary greatly, depending on the patient's specific underlying condition and the type of organism causing the pneumonia. Pneumonia often mimics a common cold or the flu. Bronchopneumonia is limited to the segmental bronchi and surrounding lung parenchyma. Lobar pneumonia is a widespread or diffuse alveolar inflammation and consolidation. Lobar pneumonia is often the end result of severe bronchopneumonia in which the infection spreads from one lung segment to another until the entire lung lobe is involved. Interstitial pneumonia is usually diffuse and is commonly associated with infections with Mycoplasma pneumonia or viruses

Chronic bronchitis-Bronchiectasis-pneumonia

bronchi (chronic bronchitis)-bronchioles (bronchiectasis)-alveolar sacs (pneumonia)

Aspiration Pneumonia ( 1 of 6)

common pathogenic agents associated with aspiration pneumonia include anaerobic oral flora (Bacteroids, Prevotella, Fusobacterium, Peptostreptococcus) admixed with aerobic bacteria such as S. pneumonia, S. aureus, H. influenza and P. aeruginosa. Aspiration of gastric fluid with pH of 2.5 or less causes a serious and often fatal from of pneumonia. Aspiration of oropharyngeal secretions and gastric fluids are the major causes of anaerobic lung infections. Inflammatory reactions generally increases un severity for 12 to 26 hours and may progress to acute respiratory distress syndrome (ARDS) which includes interstitial and intraalveolar edema, intraalveolar hyaline membrane formation and atelectasis.

Pneumonia in the immunocompromised host ( 1 of 5)

cytomegalovirus (CMV): a member of the herpesvirus family, most common viral pulmonary complication of AIDS. CMV infection commonly coexist with Pneumocystis carinii infection

Major structural changes

inflammation of the alveoli, alveolar consolidation and atelectasis (aspiration pneumonia)

Hospital-Acquired Pneumonia (nosocomial pneumonia

is an infection whose development is caused by the hospital environment. Common causes of hospital-acquired pneumonias include Enterobacteriaceae (Klebisella spp., Serratia marcescens, Eschericha coli), Pseudomonas spp. ,and Staphylococcus aureus (usually methicillin-resistant

Describe classifications of pneumonia Community-Acquired Pneumonia (1 of 7)

refers to a pneumonia acquired from normal social contact (in community) as opposed to being acquired while in hospitals or extended-care facilities (nursing home)

Necrotizing Pneumonia and Lung abscess

refers to localized pus formation and necrosis within the pulmonary parenchyma, resulting in one or more large cavities. Necrotizing pneumonia often coexist with a lung abscess, making the distinction between the two difficult (1) anaerobic organisms, which entered the lungs via aspiration if infective material (2) aspiration of gastric contents (3) complications of necrotizing bacterial pneumonia (4) bronchial obstruction (5) septic embolism (6) anaerobic bacteria

Community-Acquired Atypical Pneumonia ( 1 of 9)

the patient typically presents with a variety of both pulmonary and extra pulmonary findings (respiratory symptoms such as cough plus headache, general fatigue or diarrhea)

Chronic pneumonia ( 1 of 6)

typically, a localized lesion in patients with a normal immune system, with or without regional lymph mode involvement. Patients with chronic pneumonia usually have granulomatous inflammation, which is often due to bacteria (M. tuberculosis) or fungi. Tuberculosis is by far the most important organism within the category of chronic pneumonia. Estimates that tuberculosis causes 6% of all deaths worldwide. Chronic pneumonias associated with granulomas include tuberculosis and fungal diseases of the lung. Predisposing factors of tuberculosis include homeless, drug abuse, and acquired immunodeficiency syndrome (AIDS)