[OS 213] LEC 15 Pneumonia (B)-1

OS 213: Human Disease Treatment 3 (Circulation and Respiration) LEC 15: PNE!ON"# ,i-% 2% #leoli in Pneumonia% ?"rma''&, a'e"'i are t$in-;a''e#. But $ere, t$ere is t$ic)ene# a'e"'ar 'ining ;it$ brin"us materia's, $ea&i'& 'a#en ;it$ %"'&m"r%$"nuc'ear ce''s an# %uru'ent materia'sKexu#ates.

*% Ris ,actors  $e n"rma' air;a& an# 'ungs are e8ui%%e# ;it$ mec$anisms t" %r"tect against in(ecti"ns. But t$ere ma& be eents t$at c"u'# 'ea# t" t$e im%airment "( t$ese #e(ense mec$anisms. Ris ,actors: o tructura' #isease "( "r"%$ra&nx o !m%aire# c"ug$ reexes i.e. a'c"$"'ics7 o !m%aire# muc"ci'iar& trans%"rt i.e. sm")ers7 o !mmun"c"m%r"mise# states Ot'er Ris +actors: o Age M 65 &rs "'# o A'c"$"'ism- ris) ("r as%irati"n, a'c"$"' is genera''& ba# ("r t$e immune s&stem o m")ing- #estr"&s t$e c"ug$ reex mec$anism o As%'enia- 'ac)s antib"#ies o a'nutriti"n o C0PD o Prei"us e%is"#e "( %neum"nia o C$r"nic br"nc$itisN o Br"nc$iectasisN o C&stic br"sisN o Diabetes o !mm"ti'e ci'ia s&n#r"meN o Anat"mic "bstructi"n "( br"nc$usN o A!D NAnat"mic c$anges in res%irat"r& s&stem- ;i'' accumu'ate secreti"ns an# ten# t" be #irecte# t";ar#s t$e e"'uti"n "( %neum"nia •

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C% Etiolo-0 Determining eti"'"g& is im%"rtant em%iric treatment

in

NAs %atient bec"mes m"re an# m"re immun"c"m%r"mise#, t$e %r"minence "( ram-negatie bacteria as eti"'"g& increases •

 $e seerit& "( t$e #isease an# t$ere("re, t$e site "(  care, see ab'e 27 ;"u'# be #ictate# b& t$e s%ecic "rganism t$at cause# t$e %neum"nia

Ta/le 2% !icro/ial Causes o+ Communit0;#c.uired Pneumonia6 /0 site o+ care (Hospitali4ed Patients) Outpatients Non;"C "C treptococcus . pneumoniae .  pneumoniae -. pneumoniae  pneumonia -ycoplasma #. pneumoniae e  pneumoniae &. in0uen1a . aureus &aemophilus /egionella spp. /egionella in0u1ena 2espiratory  spp. #hlamydia 3iruses 4ram5+  pneumoniae bacilli 2espiratory 3iruses &. in0uen1a Nc"nsi#er t$e c$aracteristics "( &"ur %atient an# t$e agent

D% Di o C$est %ain is because "( inammati"n t$at exten#s t" %'eura o L"ts "( brin"us secreti"ns t$at g" u% o PE: #ecrease# breat$ s"un#s, increase# "ca' (remitus, #u''ness "n %ercussi"n, crac)'esKra'es can $e'% '"ca'ie t$e area a+ecte#7, increase# ;$is%ere# %ect"ri'"8u&, #ecrease m"ement "n tacti'e (remitus Hospital;ac.uired Pneumonia o a)a ?"s"c"mia' %neum"nia o a)a 4ea't$care-ass"ciate# %neum"nia o cause# b& en#emic "ra "( t$e $"s%ita'@ usua''& ram -7 bacteria but #e%en#s "n t$e t&%e "(  $"s%ita' $"urs a(ter a#missi"n i( be("re a#missi"n: o OF c"mmunit&-ac8uire#, i( a(ter: $"s%ita'-ac8uire#7@ an# n"t incubating at t$e time "( a#missi"n ;$ic$ arises m"re t$an OF-92 o CAP-%neum"nia $"urs a(ter en#"trac$ea' incubati"n  is ("r enti'at"r&7 o 4CAP-%neum"nia ;it$in  #a&s a(ter receiing an& ("rm "( $ea't$ care o

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Ta/le 1% "mportant Pat'o-ens CausinPneumonia

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 ounadult

'ealt'0

Elderl0

treptococcus pneumoniae' -ycoplasma pneumoniae' irus,  B

. pneumoniae' !nuena

 B

De/ilitated

. pneumoniae' inuena, "ra' "ra, B, ram-negatie baci''i

Hospitali4ed

0ra' "ra, taphylococcus aureus' ram negatie baci''i

"mmunocompr omised

0ra' "ra, ram negatie baci''i

C'ronic =S #cute •

*o//ie6 Camille6 innie

Acute Pneum"nia

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OS 213: Human Disease Treatment 3 (Circulation and Respiration) LEC 15: PNE!ON"# •

C$r"nic Pneum"nia- i( M2 ;ee)s

T0pical =S #t0pical • •

 $ese are "'# terms Pneum"nia mig$t %resent in #i+erentKat&%ica' ;a&s

Ta/le 3% T0pical s% #t0pical Pneumonia $ very important table!+ T0pical #t0pical u##en "nset "( (eer ra#ua' "nset "(   s&m%t"ms, "(ten mi'# C"ug$ ;it$ %uru'ent Dr& c"ug$ s%utum- #"esnQt matter ;$at c"'"r $"rtness "( breat$ $"rtness "( breat$ P'euritic c$est %ain Extra%u'm"nar& s&m%t"ms: $ea#ac$e, m&'agia, (atigue, s"re t$r"at, nausea, "miting, #iarr$ea PE ;it$ c"ns"'i#ati"n &stemic res%"nse "(  #u''ness, increase# b"#& < n"t rea''& (remitus, eg"%$"n&, un#erst""# unti' n"; #ecrease# br"nc$ia' inima' signs "n PE breat$ s"un#s, ra'es7 >sua''& cause# b& >sua''& attribute# t": bacteria em"rie7: - -ycoplasma  pneumoniae - . pneumoniae - &. in0uen1a - #hlamydophila  pneumoniae - -ora,ella catarrhalis - /egionella  s%%. """% C$"N"C#$ PRESENT#T"ON O, PNE!ON"# #% Common (T0pical) Presentations o+ Pneumonia 1. Cou-': natura' reex t" tr& t" ex%e' secreti"ns 2. ,eer: %art "( t$e inammat"r& res%"nse o Cause# b& inter'eu)ins . C'ills: 6asabay po ba ng lagnat ay may panlalamig7 o >sua''& #en"tes bacteria' "r ira' eti"'"g& O. C'est Pain: cause# b& %'euritic %ain 5. Di?cult0 in *reat'ino ui#-''e# a'e"'ar sacs ineJcient ("r gas exc$ange o !n#icatie "( t$e seerit& "( %neum"nia o Can be measure# b& res%irat"r& rate 8% !alaise

#ccurac0 to Predict Pneumon ia

87-F=

Decrease# B Absence "(  ast$ma 6F=

96=

"=% D"#NOST"C TOO$S #% C'est Radio-rap' =alue o+ C'est Radio-rap' • • • •

*"r #iagn"stic certaint& Assess seerit& "( #isease an# %r"gn"sticati"n uggest %"ssib'e eti"'"g& "( %neum"nia 4e'% #i+erentiate %neum"nia (r"m "t$er c"n#iti"ns:

Correct CR •

 $e ("''";ing $ae t" be c"nsi#ere# t" a"i# misinter%retati"ns o Rotation- centere#K e8ui#istant base# "n trac$ea@ e8ua' #istance bet;een me#ia' en# "( c'aic'e an# mi#'ine "( t$e c$est /-ra& o Penetration < a+ecte# b& tec$ni8ue "( ra#i"'"g&@ resu'ts mig$t be mista)en ("r s"met$ing e'se o "nspirationE@piration o Remember &"ur anat"m&: R>L, RL, RLL, L>L, LLL7

,i-% 3% Normal C'est Radio-rap'% C'ear 'ung e'#s, n"rma' s$a#"; "( %u'm"nar& ascu'ar mar)ings an# car#iac si'$"uette Radio-rap'ic ,indin-s #ir *ronc'o-ram- %at$"gn"m"nic "( %neum"nia br"nc$ia' mar)ings ''e# ;it$ gases, usua''& seen o t" %enetrate #ense in'trates as seen in C/R7, "r c"ns"'i#ati"n ;$ic$ in#icates %neum"nic %r"cess as see in C7  in %neum"nia ;K" ui#, "n'& inammat"r& o res%"nse S (remitus is increase#, s"un#s are res"nant, ;K crac)'es !eniscus Si-n G$en n" air br"nc$"grams are seen, t$is suggests o t$at 'ung is ''e# ;it$ ui# ;$ic$ ("rms a c"nexit& Hilar mass lesion ?" "bi"us in'trates, but %resents ;it$ (eer an# o c"ug$ Can a'rea#& start treatment i( c'inica''& %resent o ;it$ %neum"nia >se C scan t" ru'e "ut ma'ignanc& o

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*% C'est E@amination Ear'& "n in #isease a ne cre%itant ra'es "er t$e in"'e# %"rti"n "( t$e 'ungs7 Pr"gressi"n t" '"bar c"ns"'i#ati"n resu'ts in: o Du''ness t" %ercussi"n < #ue t" secreti"ns an# ui# in a'e"'i ;it$in t$e s%ecic regi"n in t$e 'ungs being %ercusse# o "ca' (remitus o G$is%ere# %ect"ri'"8u& o Br"nc$ia' breat$ing

Ta/le 5% Diremia B>? 'ee' M 2 mgK#'7 o Leu)"%enia GBC c"unt T O, ce''sKmm7 o o  $r"mb"c&t"%enia %'ate'et c"unt T 1, ce''sKmm27 o 4&%"t$ermia c"re tem%erature T 6 C7 4&%"tensi"n re8uiring aggressie ui# o resuscitati"n !aor Criteria o !nasie mec$anica' enti'ati"n o e%tic s$"c) ;it$ t$e ne e# ("r as"%ressin

*o//ie6 Camille6 innie

&'o are at ris +or Pseudomonas (E#! KEST"ON) o 4ist"r& "( %r"'"nge# antibi"tic use M 9 #a&s7 Br"a#-s%ectrum antibi"tics M9 #a&s ;Kin 'ast m"nt$7 o C$r"nic 'ung #isease C0PD, br"nc$iecstasis, c&stic br"sis o a'nutriti"n o >se "( ster"i#s C"rtic"steri"# t$era%& M1 mg Pre#nis"ne #ai'&7 

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="% PRE=ENT"ON 1% Smoin- cessation 2% Pneumococcal accine o *"r M 6 &ears "'# in t$e P$i'i%%ines o 0nce eer& e &ears o  $"se ;it$ certain c$r"nic i''nesses Diabetes, C"ngestie 4eart *ai'ure, C$r"nic Lier Disease, C0PD, C$r"nic Rena' Disease, as%'enia re#ucti"n in antib"#ies7 o  $"se ;it$ immun"c"m%r"mise# states o Resi#ents "( nursing $"mes an# "t$er '"ng term (aci'ities o m")ers an# ast$matic %ers"ns 1-6O &ears "'# o  $e %neum"nia s$"t %r"tects against 2 ser"t&%es "( %neum"c"ccus t$ere are 1 ser"t&%e7 o ?"t 1= e+ectie in %reenti"n but #ecreases c$ances "( m"rta'it& 3% "nLuen4a accine o *"r M 5 &ears o  Hear'&, een i( n"t ira' %neum"nia, since %neum"nia can be su%erim%"se# "n u o  $"se ;it$ c$r"nic i''nesses an# immun"c"m%r"mise# states n#  an# r# trimester o Pregnant in 2 o Resi#ents "( nursing $"mes 

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OS 213: Human Disease Treatment 3 (Circulation and Respiration) LEC 15: PNE!ON"# 4ea't$care ;"r)ers o 4"use$"'# c"ntacts an# caregiers "( %ers"ns ;K me#ica' c"n#iti"ns an# c$i'#ren T5 &ears "r a#u'ts M5 &ears o Basica''&, EERH0?E 5% "n+ection Control < %reents transmissi"n "(  %neum"nia o 4an# $&gieneK$an#;as$ing o !s"'ati"n "( sic) %atients o Pr"%er sucti"ning o Gearing "( mas)s < m"re c"st e+ectie i( %atients ;i'' be t$e "nes t" ;ear mas)s o Res%irat"r& eti8uette o

=""% C#SES Case 1: 0o male6 S! emplo0ee6 non;smoer • • •

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C$ie( c"m%'aint: c"ug$ an# (eer PE: crac)'es at Rig$t base, #ecrease# breat$ s"un#s 2 #a& $ist"r& "( $ig$ (eer ;it$ c$i''s an# &e''"; %$'egm ita' signs: 12K9, .F, RR 6, 4R 11 Dia-nosis: $o to !oderate ris C#P rig$t mi##'e '"be7 anagement: A#mit t" ;ar#, ! ;it$ %enici''inase, 2 n# generati"n ce%$a'"s%"rinK ce(ur"xime

Case 2: 8G! • • •

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C$ie( c"m%'aint: (eer an# c"ug$ reenis$ %$'egm,  %ac)-&ears Dia-nosis: Hi-' Ris pneumonia  tre%, arice''a catarr$a'is, %seu#"m"nas7 Ex%ecte# PE: ra'es, cra)'es, ;$is%ere# %ect"ri'"8u&, 'ag tacti'e (remitus7, c"ns"'i#ati"n ;$ic$ ;"u'# increase (remitus7 "r i( 'i8ui#, #ecrease (remitus7, #i+use ;$eeing sm")er7 anagement: a#mit t" ard

Case 3: 57! unresponsie6 smells o+ mi@ed alco'ol and omitus •

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Dia-nosis: %"ssib'e as%irati"n, 'i-' ris C#P $em"#&namic c"m%r"mise7, Pseu#"m"nas anagement: intubateK "C !ntubate because mu'ti'"bar, a'm"st a'' 'ung e'#s

Case 5: 2G, pre-nant 32 ees #O6 re.uired intu/ation •

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Reticu'ar %atterns, #i+use# crac)'es, incessant c"ug$s ira' "t$er;ise &"ung7 Dia-nosis: 'i-' ris C#P anagement: !C>, Pseu#"m"nas antibi"tics, #=O"D usin- .uinolones (terato-enic) %utum K, nas"%$ar&ngea' s;ab  $is is a case ;$ere t$e %atient misse# $er inuena s$"t be("re t$e %regnanc&@ bacteria' %neum"nia ;as su%erim%"se# "n t"% "( inuena

Case F: 2G! • •

C$ie( c"m%'aint: (eer, s$"rtness "( breat$ Disc$arge#  ;ee)s ("r m"#erate CAP ;it$ Ce(ur"xime

*o//ie6 Camille6 innie

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PE: c'ear 'ungs, tac$&car#ic, c$est /Ra& n"rma', CBC n"rma' G$at tests t" "r#er an# t$eir resuts7 o %utum n"rma'7 o AB s'ig$t'& #ecrease#7 o But Pneum"c&stis ;as i#entie# Dia-nosis: PCP anagement: get AB: $&%"xemic %0 2: ?"rma'S F-17 !n PCP, %atients c"u'# be er& i'' &et ;it$ at&%ica' mani(estati"ns. ="""% "!PORT#NT $ECTRE PO"NTS Pneum"nia is a (re8uent'& seen i''ness an# a'' %$&sicians must be (ami'iar ;it$ its #iagn"sis an# management Diagn"sis b& g""# $ist"r& an# PE, c$est /-ra&, an# s%utum test Ris) straticati"n ;i'' gui#e management Preenti"n ("r t$"se at ris) Di+erent eti"'"gies #e%en#ing "n ris) straticati"n s" em%iric t$era%&K#rug "( c$"ice at %resentati"n a's" aries

Ta/le 17% Dru- o+ c'oice +or C#P t0pe Clinical situation Dru- o+ c'oice L"; ris) CAP Am"xici''in ?" c"m"rbi#ities L"; ris) CAP Exten#e# macr"'i#es us%ecting at&%ica' %at$"gens L"; ris) CAP Am"xici''in c'au'anic tab'e c"m"rbi#ities aci# ex. C"ntr"''e# D, Am"xici''in su'bactam ast$matic but ;it$ n" u'tamici''in attac) in t$e 'ast 1 &ears, Ce(ac'"r etc7 Ce(ur"xime WK- exten#e# macr"'i#e "#erate ris) CAP Beta-'actam Ce%$a'"s%"rin Erta%enem W macr"'i#e "r res%irat"r& 8uin"'"ne 4ig$ ris) CAP Ce(triax"ne "r ?" Pseu#"#"m"nas ris) Erta%enem W acr"'i#e "r Res%irat"r& 8uin"'"ne 4ig$ ris) CAP Pi%eraci''in-ta" Git$ Pseu#"m"nas ris) Ce(tai#ime Carba%enem END *o//ie: 4e''" i''ie an# innie 4e''" t" a'' B'"c) B %e"%'e  !Qm excite# ("r sembrea) An# C$ristmas Camille: ! '"e t$is ;ee) innie: De'i)a#" mag)a Y'"ng ;ee)en#U. ?AAAAAD. an""# )a&" ng 0nce >%"n A ime 4i$i. 4e''" ritiP;i#i a'iga&ang Bu;an ng Gi)a 4i i''ie an# B"bbie 4i P$i', 3ust because. :P 4e''" sa mga )a'ar" )"ng guess t$e m"ie 4a$a.

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OS 213: Human Disease Treatment 3 (Circulation and Respiration) LEC 15: PNE!ON"# •

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