PNEUMONIA
PNEUMONIA
CAUSES:
The causes of pneumonia are classified into, Hospital and Non-hospital causes.
Hospital Causes include:
- Pseudomonas aeruginosa,
- Klebsiella,
- Escherichia coli,
- Proteus,
- Others
Non-Hospital Causes include:
- Pneumococcus,
- Mycoplasma,
- Haemophilus Influenzae,
- Legionella,
- Others
Pneumonia results from the proliferation of microbial pathogens at the alveolar level and the host’s response to those pathogens. The most common is aspiration from the oropharynx. Many pathogens are inhaled as contaminated droplets. Rarely, pneumonia occurs via hematogenous spread (e.g., from tricuspid endocarditis) or by contiguous extension from an infected pleural or mediastinal space.
RISK FACTORS:
- Weak immune system
- HIV infection
- Cigarette Smoking
- Cold
- Air Pollution
- Chronic Diseases
- Prolonged Hospitalization
CLASSIFICATION:
Pneumonia can be classified into, Community-Acquired Pneumonia (CAP), and Hospital-Acquired Pneumonia.
COMMUNITY-ACQUIRED PNEUMONIA:
Community-acquired pneumonia (CAP) is pneumonia that develops outside the hospital or within the first 48 hours after hospitalization.
In contrast, nosocomial pneumonia occurs in patients who have recently visited a hospital or live in long-term care settings.
Community-acquired pneumonia is common, affecting people of all ages, and its symptoms result from fluid filling the oxygen-absorbing areas of the lungs (alveoli). It suppresses lung function, causing shortness of breath, fever, chest pain, and coughing.
Its causes include bacteria, viruses, fungi, and parasites. The diagnosis of community-acquired pneumonia is made by symptom assessment, physical examination, x-rays, or sputum examination.
Patients with CAP sometimes require hospitalization. Treatment is mainly with antibiotics, antipyretics, and cough suppressants. Some forms of CAP can be prevented by vaccination and smoking cessation.
HOSPITAL-ACQUIRED PNEUMONIA:
Nosocomial (nosocomial, hospital) pneumonia is a hospital-acquired infection of the lower respiratory tract, the signs of which develop no earlier than 48 hours after the patient is admitted to a hospital. Nosocomial pneumonia is one of the three most common nosocomial infections, second only in prevalence to wound infections and urinary tract infections. Nosocomial pneumonia develops in 0.5-1% of patients undergoing treatment in hospitals, and in patients in intensive care and intensive care units it occurs 5-10 times more often. Mortality in nosocomial pneumonia is extremely high - from 10-20% to 70-80% (depending on the type of pathogen and the severity of the patient's background condition).
SYMPTOMS:
The presenting symptoms include:
1) Febrile temperature (>37.5°C) with tachycardia.
2) Cough, which can be productive or non-productive
3) Depending on the severity, the patient may experience dyspnea.
4) The localization of the inflammatory process is indicated by pleuritic pain.
5) Some patients ( ~ 20% ) may experience gastrointestinal symptoms including, nausea, vomiting, diarrhea.
6) Other symptoms include arthralgia, myalgia, headache, and fatigue.
DIAGNOSIS:
PHYSICAL EXAMINATION:
Physical exam shows an increase in breathing rate, use of accessory muscles of respiration. Increased or decreased tactile fremitus is noted upon palpation. The percussion sound is dull. Upon auscultation, crackles, pleural friction sound, and bronchial breathing are noted.
CLINICAL BLOOD ANALYSIS:
Blood with pneumonia can be characterized by the following indicators:
leukocytes with pneumonia are increased, leukocytosis occurs. Normally, the content of white blood cells in the blood of a healthy adult varies from 4 to 9 g / l. However, with pneumonia, this indicator can increase to 40-60 G / l, since the body's resistance to infection begins;
erythrocytes are within normal limits or are slightly reduced. A significant reduction in the number of erythrocytes can only be under the condition of a severe course of the disease as a result of dehydration;
a decrease in the number of leukocytes (leukopenia) - characteristic of viral pneumonia;
if the leukocyte formula shows a reduced number of lymphocytes and an increased number of neutrophils, this in most cases means the presence of viral pneumonia;
a decrease in the percentage of monocytes, basophils, and eosinophils;
ESR with pneumonia (or sedimentation reaction, ROE) exceeds normal values. The ESR norm for women is 2-15 mm / h, for men 1-8 mm / h, while with pneumonia, this indicator in both sexes can exceed 30 mm / h;
platelets are usually within the normal range.
CHEST X-RAY (CXR)
What pneumonia looks like on an X-ray picture depends on the stage of the disease and its nature. However, in any case, the signs of pneumonia on x-rays are visible as violations of the structure of the lung. Doctors pay attention to the features of the pulmonary pattern, the roots of the lung, pleura, and the location of infiltrative foci. Light areas in the image are interpreted as airless.
Croupous
Croupous pneumonia on X-ray is characterized by an increase in the pulmonary pattern and thickening of the root, slight compaction of the pleura, and also reduced airiness of the lung. The decrease in airiness directly depends on the stage of the disease. This disease looks like an average shading intensity. Croupous pneumonia is one of the most dangerous.
Focal
As with croupous pneumonia, with focal x-ray, an increase in the pulmonary pattern and thickening of the root, as well as pleural compaction, are visible. Such pneumonia is characterized by focal shadows of various sizes with indistinct contours. There is also a deformation of the pulmonary pattern, which is very clearly visible on the x-ray. Symptoms of focal pneumonia on x-rays are difficult to identify, so only an experienced doctor can diagnose this disease.
Viral
Atypical pneumonia is referred to as viral pneumonia. With the strengthening of the pulmonary pattern and the compaction of the pleura, in this case, the roots of the lungs do not change. The appearance on the X-ray of focal shadows in the lower and middle parts of the lungs with bilateral viral pneumonia confirms the diagnosis. The whole world is aware of the rapid development and danger of this form of the disease, and this is another argument in favor of examining the signs of pneumonia on x-rays.
DETERMINING THE SEVERITY OF PNEUMONIA:
There are currently two sets of criteria: the Pneumonia Severity Index (PSI), a prognostic model used to identify patients at low risk of dying; and the CURB-65 criteria, a severity-of-illness score.
PSI is a good criterion considering 20 variables including age, comorbidities, findings on physical and laboratory exams, but it is impractical to be considered in emergency situations.
CURB-65 is a simple criterion and considers the following factors:
C - Confusion
U - Urea ( >7mmol/l)
R - Respiratory Rate (>30/min)
B - Blood Pressure (< 60/90 mmHg )
65 - Age > 65 years
Patients with a score of 0, can be treated outside the hospital.
With a score of 2, patients should be admitted to the hospital.
Patients with scores of ≥3, may require ICU admission.
TREATMENT :
In the treatment of pneumonia, antimicrobial drug (AMP) is chosen first after diagnosis. At the initial stage of the disease, the use of etiotropic therapy is impossible. Based on the patient's age and complaints, medical history, the severity of inflammation, the presence of complications, concomitant pathologies, the doctor chooses one of the recommended regimens (according to clinical protocols).
Antimicrobial drugs for pneumonia:
β-lactam antibiotics
• Unprotected amoxicillin
• Protected amoxicillin
• Cefuroxime acetyl
Macrolides
• Clarithromycin
• Roxithromycin
• Azithromycin
Fluoroquinolones (for pulmonary pathology)
• Levofloxacin
• Moxifloxacin
• Gemifloxacin
PREVENTION:
Immunization against Hib, pneumococcus, measles, and whooping cough (pertussis) is the most effective way to prevent pneumonia.
Adequate nutrition is key to improving children's natural defenses, starting with exclusive breastfeeding for the first 6 months of life. In addition to being effective in preventing pneumonia, it also helps to reduce the length of the illness if a child does become ill.
Addressing environmental factors such as indoor air pollution (by providing affordable clean indoor stoves, for example) and encouraging good hygiene in crowded homes also reduces the number of children who fall ill with pneumonia.
In children infected with HIV, the antibiotic cotrimoxazole is given daily to decrease the risk of contracting pneumonia.
COMPLICATIONS:
- Respiratory Failure
- Shock
- Multiorgan failure
- Coagulopathy
- Exacerbation of comorbid illness
- Metastatic Infection
- Lung Abscess
- Complicated Pleural Effusion
- Pulmonary Hemorrhage (in case of necrotizing pneumonia)
- Death
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2) Pneumonia. (2021, November 11). WHO.INT. https://www.who.int/news-room/fact-sheets/detail/pneumonia
3) Pneumonia. (n.d.). [Photograph]. https://miro.medium.com/max/1050/1*t2d0oXxbRZgY8l1JJXIRGg.jpeg
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5) Causes of pneumonia. (2018). [Photograph]. https://www.verywellhealth.com/thmb/3Qs-uDcM6DcfoxPk8HNNOMmkqBg=/614x0/filters:no_upscale():max_bytes(150000):strip_icc():format(webp)/pneumonia-causes-5b0d70dea474be00375ae127.png
6) Signs of pneumonia. (n.d.). [Photograph]. https://www.mountelizabeth.com.sg/images/default-source/default-album/pneumonia-symptoms.jpg?sfvrsn=73f7c811_6
7) Diagnosis of pneumonia. (n.d.). [Photograph]. https://www.ankitparakh.com/wp-content/uploads/2020/04/PNEUMONIA-DIAGNOSIS-WEB-768x768.jpg
8) Prevention of pneumonia. (n.d.). [Photograph]. https://pbs.twimg.com/media/CTpPgqyUkAEPnHN?format=jpg&name=900x900
9) Complications of pneumonia. (n.d.). [Photograph]. https://i.pinimg.com/564x/1e/a1/26/1ea12660ee51d3fe879f42b2c4baf933.jpg
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