PNEUMONIA IS INFLAMMATION OF THE PARENCHYMA OF THE LUNGS. MOST CASES OF PNEUMONIA ARE CAUSED BY...
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Transcript of PNEUMONIA IS INFLAMMATION OF THE PARENCHYMA OF THE LUNGS. MOST CASES OF PNEUMONIA ARE CAUSED BY...
PNEUMONIA IS INFLAMMATION OF THE
PARENCHYMA OF THE LUNGS.
MOST CASES OF PNEUMONIA ARE CAUSED
BY MICROORGANISMS.
NONINFECTIOUS CAUSES of PNEUMONIAE
-ASPIRATION OF FOOD AND OR GASTRIC ASID
-FOREIGN BODIES
- HYDROCARBONS
-LIPOID SUBTANCES
-HYPERSENSITIVITY REACTIONS
-DRUG
- RADIATION MAY INDUCED PNEUMONIAE
PNEUMONIA HAS BEEN CLASSIFIED ON AN
ANOTOMIC BASIS AS A LOBAR, ALVEOLAR
OR LOBULAR, OR INTERSTITIAL PROCESS
1. LOBAR PNEUMONIA-ALVEOLAR1. LOBAR PNEUMONIA-ALVEOLAR
STREPTOCOCCUS PNEUMONIAE
2. LOBULAR-BRONCHOPNEUMONIAE2. LOBULAR-BRONCHOPNEUMONIAE
STREPTOCOCCUS PNEUMONIAE
HAEMOPHILUS INFLUENZAE
KLEBSIELLA SP.
GROUP B STREP
E.COLI
S.AUREUS
3. INTERSTITIAL PNEUMONIAE VIRAL3. INTERSTITIAL PNEUMONIAE VIRAL
PNEUMONIAE
RSV
CMV
ADENOVIRUS
INFLUENZA A.B
CLASSIFICATION OF PNEUMONIA WITHRESPECT TO AGE
NEW BORNNEW BORN
GROUP B STREPTOCOCCI
(SEROTYPES I, II)
L.MONOCYTOGENES
H.INFLUENZAE (NONTYPABLE)
GRAM-NEGATIVE ENTERIC BACILLI
NOSOCOMIAL NOSOCOMIAL
PNEUMONIAPNEUMONIA
P.AEROGINOSA
E.COLI
GRAM-NEGATIVE BACILLI
C.TRACHOMOTIS
1 MONTH-6 YEAR1 MONTH-6 YEAR
S.PNEUMONIA (1.3.6A.14.18C, 19F,
23F)
H.INFLUENZAE (HIB)
GROUP A STREPTOCOCCI
S.AUREUS
M.CATARHALIS
OVER 6 YEARS OF AGE AND OVER 6 YEARS OF AGE AND
ADOLESCENTSADOLESCENTS
S.PNEUMONIA
M.PNEUMONIA ATYPICAL PNEUMONIA
C. PNEUMONIA
IMMUNOCOMPETENT IMMUNOCOMPETENT IMMUNOCOMPROMISEDIMMUNOCOMPROMISED BACTERIALBACTERIAL S.PNEUMONIAE PSEUDOMONAS SP
H.INFLUENZA ENTEROBACTERIACEAE S.AUREUS L.PNEUMOPHILIA GROUP A STREP NOCARDIA SPP M.CATARHALIS RHODOCOCUS EQUI Y.PESTIS ACTINOMYCES BRUCELLA SP ANAEROBIC BACTERIA FRANCISELLA TULARENSIS ENTEROCOCCUS SP N.MENENGITIDIS SALMONELLA SPP
BACTERIA-BACTERIA-LIKE AGENTSLIKE AGENTS M.PNEUMONIAE
C.PNEUMONIAE C.TRACHOMATIS C.PSITTACI COXIELLA BURNETI RICKETTSIA RICKETTSII
PROTECTING MECHANISM OF THE LUNG
FILTRATION OF THE PARTICLES IN THE
NARES 5-20 Μm
1. PREVENTION OF ASPIRATION BY THE EPIGLOTTAL REFLEX
2. EXPULSION OF ASPIRATED MATERIAL BAY THE COUGH REFLEX
3. ENTRAPMENT AND EXPULSION OF ORGANISM BY MUCUS SECRETING AND CILIATED CELLS
PROTECTING MECHANISM OF THE LUNG
4. ENTRAPMENT AND EXPULSION OF ORGANISM BY MUCUS SECRETING AND CILIATED CELLS
5. INGESTION AND KILLING OF BACTERIA BY ALVEOLAR MACROPHAGES
6. NEUTROLIZATION OF BACTERIA BY LOCAL IMMUN SUBSTANCES. LACTOFERRIN, LYZOZIM, INTERFERON, IgG, IgA
7. TRANSPORT OF PARTICLES FROM THE LUNGS BY LYMPHATIC DRAINES
PATHOLOGY AND PATHOGENESIS
PATHOGENES REACH THE LRT
BY ASPIRATION
BY HEMATOGENEOUS
OR LOCAL SPREAD
RESPIRATORY PATHOGENES WHEN REACH THE
THERMINAL BRONCHIOLES AND BEYOND
↓
EDEMA FLUID INTO THE ALVEOLI
↓
LEUKOCYTES INFILTRATION
↓
LOBULAR, SEGMENTAL OR LOBAR INFLAMMATION
↓MACROPHAGES
(REMOVE CELLULER AND BACTERIAL DEBRIS)
IN S.AUREUS PNEUMONIA, PULMONARY
INVOLVEMENT FOLLOWS THE DISTRIBUTION OF
AFFECTED AREA. AS THE INFECTION PROGRESSES IT
DESTROYS THE WALL OF THE ALVEOLI WITH THE
FORMATION OF AIR FILLED CAVITES WHICH ARE
CALLED PNEUMATOCELES
PNEUMATOCELE↓
MAY RUPTURE↓
PYOPNEUMOTORAX
CLINICAL FEATURES
A) NONSPESIFIC SIGNS AND SYMPTOMS
FEVER VOMITING
CHILLS ABDOMNAL DISTANTION
HEAD ACHE DIARRHEA
IRRITABILITY ABDOMINAL PAIN
APPREHENSION
B) PULMONARY SIGNS
NASAL FLARING
TASYPNEA
DYSPNEA
APNEA
USE OF ACCESORY INTERCOSTAL MUSCLES AND ABDOMINAL MUSCLES
COUGH IS INITIALLY DRY, LATER PRODUCTIVE
OF PURULENT OR EVEN BLODDY SPUTUM
C) EXTRA PULMONARY SIGNS
ABSCESSES OF SKIN
ABSCESSES OF SOFT TISSUE
ROENTGENOGRAPHIC FINDINGS:
PATCHY INFILTRATES (IN INFANCY)
SEGMENTAL OR S. PNEUMONIAELOBAR CONSOLIDATION H.
INFLUENZAE
HILAR LYMPHNODUS H. INFLUENZAES.AUREUS
PNEUMOTOCELE S.AUREUSKLEBSIELLA
PLEVRAL EFFUSION S. AUREUSPNEUMOTORAX KLEBSIELLA
ROENTGENOGRAM CLEARS WITH IN 3-4
WEEKS 80 PERCENT OF CASES
IN S.AUREUS PNEUMONIA THIS DURATION
MUCH LONGER
LABORATORY FINDINGS:
THE BLOOD CELL↑ 15.000 – 40.000 CELLS/MM3
PMN↑
SPUTUM CULTURE (+)
BLOOD CULTURE (+) 10-15 PERCENT OF CASES
COUNTER
IMMUNOELECTROPHORESIS BACTERIAL
LATEX PATICLE ANTIGEN (+)
AGLUTINATION
PLEVRAL FLUID (EXUDATE)
PROTEIN> 3.0 GR/DL
↓ GLUCOSE BELOW 40 MG/L
LACTIC DEHYDROGENASE 1000 IU/L
Ph BELOW 7.20
PROGNOSIS
MORTALITY RATE IS VERY LOW
(LESS THEN 1 PERCENT) in LOBAR PNEUMONİAE
DEATH IS SEEN WITH AN UNDERLYING DISEASE
OR WITH A COMPLICATED COURSE S. AUREUS
PNEUMONIA
MORTALITY RANGES 10-30%
PHYSICAL EXAMINATION
FINE CRACKLING RALES
DIMINISHED OR TUBULAR BREATH SOUND
DULLNESS ON PERCUSSION (PLEVRAL EFFUSION )
LIVER MAY SEEM ENLARGED EMPYEMA
DIFFERENTIAL DIAGNOSIS
- FOREIGN BODY
- ALLERGIC ALVEOLITIS
- ATELECTASIS
- TBC PNEUMONIAE
- CYSTIC FIBROZIS
- ACUTE EXACERBATIONS OF BRONCHIECTASIS
- PULMONARY ABSCESS
- ACUTE ABDOMEN
COMPLICATIONS
EMPYEMA
PNEUMOTORAX
LUNG ABCESS
MIDDLE EAR INFECTIONS
PERICARDIAL EFFUSION
OSTEOMYELITIS
ABSCESSES OF SOFT TISSUE
TREATMENT
GROUP B STEP.
DURING THE FIRST 24-48 HOURS OF LIFE
AGGRESSIVE CARDIOVASCULAR AND
VENTILATORY SUPPORT IS REQUIRED
ANTIBIOTIC THERAPY:
AMPICILLINE or PEN. + GENTAMISIN
OR
AMPICILLINE or PEN + III. JEN. CEPHALOSPORIN
IF THE MINIMAL BACTERICIDAL CONCENTRATION FOR
PENICILLIN IS ADEQUATE GENTAMISIN CAN BE
DISCONTINUED
TREATMENT IS GIVEN FOR 10-14 DAYS
PNEUMOCOCCAL PNEUMONIA
IN OLDER CHILDREN
PROCAINE PENICILLIN 600.000 UNITS/DAY
OR ORAL PENICILLIN U 50-250 MG/KG/DAY
200.000 U = 125 MG EVERY 4-6 HOURS
OR ORAL ERYTHROMYCIN 30-50 MG/KG/DAY
EVERY 6 HOURS
IF PATIENTS APPEAR TOXIC OR IN INFANTS,
OR IN YOUNG CHILDREN
PENICILLIN G 200.000-400.000 U/KG/DAYEVERY 4-6
HOURS
IF S.PNEUMONIA IS REZISTANT TO PENICILLINE
CEFUROXIME 20-100 MG/KG
CEFTRIAXONE 25-50 MG/KG 2-3 DOSE
CEFOTAXIME 50-100 MG/KG
VANCOMYCIN 40 MG/KG 4X1
IF PATIENTS ALLERGIC TO PENICILLINE
ERYTHROMYCIN 30-40 MG/KG (10-14 DAYS)
TREATMENT IS GIVEN
PREVENTION:
CHILDREN IN HIGH RISK GROUPS
2 YEAR OR OLDER
0.5 ML 23 VALANT PNEUMOCOCCAL/VACCINE
HAEMOPHILUS INFLUENZAE (HIB)
TREATMENT:
AMPICILLIN 100 MG/KG/DOZ 4X1
+
CHLOROMPHENICAL 50-75 MG/KG/DOZ 4X1
MAX DOZ: 1,2 GR
OR CEFUROXIME
CEFTRIAXONE CEFOTAXIME
TREATMENT IS GIVEN 10-14 DAYS.
PREVENTION:
HIB CONJUGATED VACCINE
SINGLE DOSE
12-18 MONTHS OF AGE
IN HAUSEHOLD CANTACT 4 YEAR ↓
RIFAMPIN 20 MG/KG ONCE DAILY FOR 4 DAY
2-6 MONTHS 4-8 WEEK INTERVAL
IM OR SC 3 DOSES
1 YEAR LATER 1 DOSES
6-12 MONTHS4-8 WEEKS INTERVAL
2 DOSES
1 YEAR LATER 1 DOSES
1-5 YEARS 1 DOSES
S. AUREUS PNEUMONIA
ALL PATIENT IN ALL AGES SHOULD BE HOSPITALIZED
NAFCILLIN IV
OXACILLIN IV 100-150 MG/KG/DAY 4X1
METHICILLIN IV
OR
IV CEFAZOLIN 100 MG/KG/DAY 3X1 +IV GENTAMISIN 5 – 7 MG/KG/DAYORNEUTROMYCIN 40 MG/KG/DAY 4X1
IF S. AUREUS IS REZISTANT TO METHICILLINIV VANCOMYCIN 40 MG/KG/DAY 4X1
TREATMENT IS GIVEN 6-10 WEEKS
MYCOPLASMA PNEUMONIAE
ATYPICAL PNEUMONIAE
M. PNEUMONIAE WAS IDENTIFED AND
CHARACTERIZED AS THE ETIOLOGIC AGENT
IN 1963 BY CHANOCK (PRESUMABLY A VIRUS)
HIGHEST INCIDENCE OF PNEUMONIAE TO
BE IN SCHOOL AGE CHILDREN FROM AGE 6
TO 18 M.P ENTIRE RESPIRATORY TRACT BY
DROPLET
LARYNGITIS
TRACHEOBRONCHITIS URTI
PNEUMONIAE
RECURRENT M.PNEUMONIAE ARE QUITE
COMMON IN INFANCY AND CHILDHOOD
PATHOPHYSIOLOGY: SINCE HUMAN TISSUE IS RARELY
OBTAINABLE (IN
HAMSTER MODEL)
MYCOPLASMA PNEUMONIAE
ATTACH TO
RECEPTORS ON CLIATED RESPIRATORY
EPITHELIAL CELLS
DAMAGES AND SLOUGHED THE CELLS
ATELECTASIS
BOTH THE DURATION OF THE INFECTION
AND THE TIME REQUIRED TO REGENERATE
EPITHELIAL CELLS LEADS TO A PROLONGED
PERIOD OF DISORDORED MUCOSAL
CLEARANCE AS EVIDENCED BY THE CHRONIC
COUGH
CLINICAL PRESANTATION
INCUBATION PERIOD 2 TO 3 WEEKS
CORYZA
SORE THROAT
MALASIE
LOW-GRADE FEVER
PAROXYSMAL
PRODUCTIVE
SHORTNESS OF BREATH DURING THE SECOND WEEK OF ILLNESS
MILD CHEST PAIN
URTI
COUGH
PHYSICAL EXAMINATION
BRONCHIAL BREATH SOUND
RHONCHI
LOCALIZED CREAKLES
WHEEZING
FLEURAL PAIN
CHEST FILMS
• LOCALIZED INFILTRATES (BRONCHOPNEUMONIAE)
• LOBAR CONSOLIDATION
• BILATERAL DIFFUSE INFILTRATES
• SMALL PLEURAL EFFUSION
EXTRAPULMONARY MANIFESTATIONS
CEREBELLAR ATAXIA ENCEPHALOPATHY
PERIPHERAL NEUROPATHIES
CARDIOMYOPATHY
MYOSITIS
PANCREATITIS
HEMOLYTIC ANEMIA
E. MULTIFORME
STEVENS-JOHNSON SYNDROME
HEPATOSPLENOMEFALY
LABORATORY FINDINGS
WBC: N
COLD HEMAGGLUTININ ASSAY 1/64↑(+)
COMPLEMENT FIXATION ASSAY (+)
PCR (POLYMERASE CHAIN REACTION) TO
DETECT
ANTIGEN IN RESPIRATORY SECRETION
COURSE OF DISEASE
• UNTREATED M.P EVOLUES OVER A PERIOD OF 2 TO 4 WEEKS BUT ALMOST ALWAYS RESOLVES WITHOUT RECOGNIZABLE SEQUALAE
• APPROPRIATE ANTIBIOTICS ALTER THE COURSE OF DISEASE BUT NOT DRAMATICALLY
• PROPHYLACTIC ANTIBIOTIC TREATMENT HAS NO PLACE IN THE MANAGEMENT OF THESE INFECTIONS
TREATMENT
MACROLIDES ANTIBIOTICS IS
EFFECTIVE IN MP
AZITROMYCIN 250 mg 2-5 days
CLARITHROMYCIN 250 mg 2x1 7-10 days
ERYTHROMYCIN 200x3 7-10 days
PNEUMONIAS OF VIRAL ORIGIN
• RSV
• PARAINFLUENZACORONOVIRUSES
• ADENOVIRUSES HERPES VIRUSES
• INFLUENZAENTEROVIRUSES
• CMV
• RHINOVIRUSES
CLINICAL MANIFESTATIONS
RHINITISCOUGH
FEVERTACHYPNEAINTERCOSTALSUBCOSTALSUPRASTERNALNAZAL FLARINGUSE OF ACCESSORY MUSCLE
CYANOSISRESPIRATORY FATIQUE
URTI
RETRACTIONS
IN SEVERE CASES
AUSCULTATION: WIDE SPREAD RALES
AND WHEEZING
CHEST FILMS:DIFFUSE INFILTRATES IN CHEST
ROENTGENOGRAM
• SCATTERED INF (PI)
• HYPERINFLATION (RSV, AV)
• PERIHILAR AND PERIBRONCHIAL INFILTRATIONS (RSV)
• ATELECTASIS (PI, RSV)
• PNEUMONITIS (CMV)
LABORATORY
WHITE BLOOD CELL N OR SLIGHTLY
ELEVATED
<10.000 mm3
LYMPHOCYTES ↑
ESR
CRP
ISOLATION OF THE VIRUS FROM ISOLATION OF THE VIRUS FROM NASOPHARYNGIALNASOPHARYNGIAL
SECRETIONS (+)SECRETIONS (+)
N OR SLIGHTLY ELEVATED
PNÖMONİLERE AİT BÜTÜN AKCİĞER
GRAFİLERİ HASTA HAKLARI AÇISINDAN
DERS SLAYTLARINDAN ÇIKARILMIŞTIR.