pneumonia
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Pneumonia.
Pneumonia (P) is one of the most wide-spread disease of human. In spite of
wide prevalence of P, knowledge of modern methods of diagnostics and treatment
of disease are not enough.
PNEUMONIA - is acute infectious disease, mainly bacterial etiology, which
causes the air sacs in the lungs (called the alveoli), and the smaller bronchial tubes
to become inflamed and fill with fluid. From data of official statistics in Ukraine in
2005, morbidity of adults of P. was 4,26 on 1000 population, and death rate – 13,5
% per 100 thousand persons, it means that about 3,2 % of all people who
developed pneumonia subsequently died from the infection.
Etiology.
Many different organisms can cause P, including bacteria (Str. Pneumoniae, Staf.
pyogenus, Staf. albus, Klebsiella pneumoniae is a pneumobacillus, Neisseria
cataralis, Proteus vulgaris, Haemophilus influenzae, Psevdomonas aeruginosa,
Legionella pneumophilia,, Micoplasma pneumoniae,, Bacteroides fragilis), the
viruses of Citomegalovirus, and fungi of Candida albicans. Pneumonia can range
from mild to severe. The severity depends on the type of organism causing
pneumonia, as well as your age and underlying health.
The basic patogenetic links of development of pneumonia are:
- penetration of infection in pulmonary tissue (by inhalation, bronchogenic
way, hematogenic way – at a sepsis, direct distribution of infection in lungs from
nearby organs, lymphogenic way).
- a change of the system of local bronchopulmonary protection -the state of
mucociliary transport, bronchopulmonary immune system, factors of unspecific
resistance (lysozyme , lactoferrin, IGA, interferon, system of surfactant),
- development of local inflammatory process and his distribution on
pulmonary tissue , that depends on the type of infection:
Str. Pneumoniae, Klebsiella pneumoniae, Haemophilus influenzae and E.
coli producing endotoxins and during persistence in air-cells they cause a serosal
edema. This serosal edema is their reproducing environment and helps them to
penetrate through the Kon’s pores to nearby air-cells. In such way segmentary
and croupous pneumonias are developed.
Streptococci, staphylococcuss producing exotoxins, which promote
limitation of inflammation by fibrin, and smaller bronchial tubes to become
inflamed and fill with fluid with formation of microatelectasis. In such way focal
pneumonia is developed.
Production by leucocytes and epithelial cells bioactive substances
(cytokines) plays important role in development of inflammation. Cytokines
influence on chemotaxis of macrophages, neutrophils and other cells, which are
taking part in local inflammatory reaction.
Classification
Select the followings types of pneumonias:
community-acquired pneumonia
nosocomial or hospital-acquired pneumonia
Aspiration pneumonia
Pneumonia in an immunocompromised host
Pneumonia that develops outside the hospital setting is considered
community-acquired pneumonia. Pneumonia developing 72 hours or more
after admission to the hospital is termed nosocomial or hospital-acquired
pneumonia. Pneumonia can be mild, moderate and severe.
Severe P. is the special form of disease of different etiology, which shows
up a heavy intoxication syndrome, haemodynamic changes, expressed respiratory
insufficiency and signs of septic shock.
Recommend to select the large and small criteria of severe pneumonia.
SMALL CRITERIA :
- breathing frequency 30 in 1 mins and more,
- unconsciousness, - pressure of oxygen below 60 ,
- a systole arterial blood pressure below 90
- bilateral or polifocal defeat, cavities of disintegration, pleura effusion.
LARGE CRITERIA:
- requirement of artificial ventilation of lungs,
- rapid progress of focal infiltration, infiltration more than on 50% during the
nearest 2 days,
- septic shock or necessity of introduction of vasopressor medicines
during 4 hours and more. We can say about severe P. if we have 2
small and 1 large criteria. In such cases must be immediate
hospitalization.
M. pneumoniae is a common cause of mild pneumonia that usually affects people
younger than 40. Various studies suggest that it causes 15-50% of all pneumonia in
adults and an even higher percentage of pneumonia in school-aged children.
People at highest risk for mycoplasma pneumonia include those living or working
in crowded areas such as schools and homeless shelters, although many people
who contract mycoplasma pneumonia have no identifiable risk factor.
The symptoms are generally mild and appear over a period of 1 to 3 weeks. They
may become more severe in some people.
Common symptoms include the following:
Headache, fever (may be high),Chills, excessive sweating, Cough (usually dry
and without phlegm or blood), chest pain, sore throat
Less frequently seen symptoms include:
Skin lesions or rash
Eye pain or soreness
Muscle aches and joint stiffness
Neck lump
Rapid breathing
Ear pain
A physical examination may reveal enlarged lymph nodes and inflammation of the
eardrum. An examination of the chest with a stethoscope (auscultation) reveals
crackles.
Legionella pneumophila.
Most infection occurs in middle-aged or older people, although it has been reported
in children. Typically, the disease is less severe in children. Symptoms tend to get
worse during the first 4 to 6 days. They typically improve in another 4 to 5 days.
Symptoms may include:
Muscle aches and stiffness
Joint pain
Loss of energy
General discomfort, uneasiness, or ill feeling (malaise)
Headache
Fever
Shaking chills
Nonproductive cough
Coughing of blood
Shortness of breath
Chest pain,
Diarrhea
Chlamydophila pneumonia occurs year round and accounts for 5-15% of all
pneumonias. It is usually mild with a low mortality rate.
Community acquired pneumonia
Community-acquired pneumonia develops in people with limited or no contact
with medical institutions or settings. The most commonly identified pathogens are
Streptococcus pneumoniae , Haemophilus influenzae , and atypical organisms (ie,
Chlamydia pneumoniae , Mycoplasma pneumoniae , Legionella sp). Symptoms
and signs are fever, cough, dyspnea, tachypnea, and tachycardia. Diagnosis is
based on clinical presentation and chest x-ray. Treatment is with empirically
chosen antibiotics. Prognosis is excellent for relatively young and/or healthy
patients, but many pneumonias, especially when caused by S. pneumoniae and
influenza virus, are fatal in older, sicker patients.
Symptoms and Signs
Symptoms include malaise, cough, dyspnea, and chest pain. Cough typically is
productive in older children and adults and dry in infants, young children, and the
elderly. Dyspnea usually is mild and exertional and is rarely present at rest. Chest
pain is pleuritic and is adjacent to the infected area. Pneumonia may manifest as
upper abdominal pain when lower lobe infection irritates the diaphragm.
Symptoms become variable at the extremes of age; infection in infants may
manifest as nonspecific irritability and restlessness; in the elderly, as confusion and
obtundation.
Symptoms and signs were previously thought to differ by type of pathogen, but
presentations overlap considerably. In addition, no single symptom or sign is
sensitive or specific enough to predict the organism. Symptoms are even similar
for noninfective lung diseases such as pulmonary embolism, pulmonary
malignancy, and other inflammatory lung diseases.
Diagnosis
The most important diagnostic tool for pneumonia is the stethoscope. Sounds in
the chest that may indicate pneumonia include:
- Rales, a bubbling or crackling sound. Rales on one side of the chest
or that are heard while the patient is lying down strongly suggest
pneumonia.
- Abnormal rumblings indicating that there is sputum in the large
airways.
- A dull thud. The physician will use a test called percussion, in which
the chest is tapped lightly. A dull thud, instead of a hollow drum-like
sound, indicates certain conditions that suggest pneumonia. These
conditions include consolidation (in which the lung becomes firm
and inelastic) and pleural effusion (fluid build-up in the space
between the lungs and the lining around it).
Diagnosis is suspected on the basis of clinical presentation and is confirmed by
chest x-ray .Chest x-ray almost always demonstrates some degree of infiltrate;
rarely, an infiltrate is absent in the first 24 to 48 h of illness. In general, no specific
findings distinguish one type of infection from another, though multilobar
infiltrates suggest S. pneumoniae or Legionella pneumophila infection, and
interstitial pneumonia suggests viral or mycoplasma etiology.In severe cases, a
doctor needs to use invasive diagnostic measures to identify the cause of the
infection. Standard lab tests used to help diagnose pneumonia include:
Sputum Tests. The color of the mucus (sputum) sample coughed up from the lungs
can reveal the severity of the disease. Only a sputum sample will reveal the
organism causing the infection.The patient coughs as deeply as possible to bring
up mucus from the lungs, since a shallow cough produces a sample that usually
only contains normal mouth bacteria. Some people may need to inhale a saline
spray to produce an adequate sample. In some cases, a tube will be inserted
through the nose into the lower respiratory tract to trigger a deeper cough.
The physician will check the sputum for:
- Blood, which means an infection is present.
- Color and consistency: If it is yellow, green, or brown, an infection
is likely.
The sputum sample is sent to the laboratory, where it is analyzed for the presence
of bacteria and to determine whether the bacteria are Gram-negative or Gram-
positive.
Blood Tests. The following blood tests may be performed:
- White blood cell count (WBC). High levels indicate infection.
- Blood cultures. Cultures are done to determine the specific organism
causing the pneumonia, but they usually cannot distinguish between
harmless and dangerous organisms. They are accurate in only 10 -
30% of cases. Their use is generally limited to severe cases.
- Detection of antibodies to S. pneumoniae. Antibodies are immune
factors that target specific foreign invaders. One type of
immunohistochemical test for S. pneumoniae is showing tremendous
promise. The presence of antibodies that are responding to
mycoplasma or chlamydia infection are not present early enough in
the course of pneumonia to allow for prompt diagnosis and
treatment.
Patients with CAP can be categorized into 1 of 4 groups based on information
collected at the time of the initial evaluation. The risk factors for stratification
include the need for hospitalization, the severity of illness, the presence of
coexisting disease, and the patient's age. The 4 major categories not only speculate
the microbial etiology but also predict ultimate prognosis and outcome. These
categories are
(1)CAP occurring in patients aged 60 years or younger who have no evidence
of comorbidity and who can be treated in an outpatient setting,
(2) CAP occurring in patients with evidence of comorbidity and/or who are
aged 60 years or older who can be treated in an outpatient setting,
(3)CAP requiring hospitalization but not admission to an intensive care units
(ICU),
(4) severe CAP requiring ICU care.
Treatment
Because organisms are difficult to identify, antibiotics are selected based on likely
pathogens and severity of illness
A/b for empiric treatment, divide into medicines of the first choice (medicines of 1
choice and alternative medicines) and second row.
EMPIRIC ANTIBAKTERIAL THERAPY
PATIENTS OF CAP IN AMBULATORY
Group of
patients
Possible exciter
Antibiotic
first row Antibiotic of the
second rowDrugs of
choice
Alternative
Drugs
1 group
(with the
unsevere
CAP,
without
concomitant
pathology
and other
modifying
factors
M. pneumoniae
S. рneumoniae
H. influenzae
Peroral
reception:
amoxycillin
or
macrolide
Peroral
reception:
fluoroquinolones
III-IV
generation
Peroral
reception:
1. Makrolide or
doxycycline at
uneffectiveness
of
aminopenicillin
2.
Aminopenicillin
or
fluoroquinolones
III-IV
generation at
uneffectiveness
of macrolide
11 group
With the
unsevere
CAP, with
the
presence of
concomitant
pathology
M. pneumoniae
S. рneumoniae
H. influenzae
S. aureus
M. catarrhalis
family
Enterobacteriaceae
A peroral
reception is
amoxycillin
or
cefuroxym
ethanol
Peroral
reception:
fluoroquinolones
III-IV
generation
Or
Ceftriakson
Peroral
reception:
To add to в-
lactam macrolide
or
monotherapy
Fluoroquinolones
III-IV generation
or other
modifying
factors
Note: * - parenterally introduction of Ceftriakson is appointed at
impossibility of peroral reception of preparations of choice.
Estimation of efficiency of antibacterial therapy is conducted in 48 hours
from the beginning of treatment.
Duration of antibacterial therapy:
For patients with the unsevere CAP antibacterial therapy can be completed
after achievement of normalization of temperature during 3-5 days. As a rule in
such cases treatment takes 7-10 days.
Criteria of efficiency of antibacterial therapy
- Temperature of body below 37,5
- absence of symptoms of intoxication,
- absence of signs of respiratory failure (breathing frequency below 20 in 1
mins),
- absence of festering sputum,
- there is a less than amount of leucocytes in blood, neutrocytes less than
80%, young forms –less 6%,
- absence of negative dynamics from data of roentgenologic research.
If patient saved high temperature of body, intoxication or symptomatology
makes progress, treatment is considered ineffective, and it is necessary to change
antibacterial therapy to the antibiotic of the second row . U should remember some
sings that are not necessary to change therapy.
Clinical signs and states which are not necessary to change therapy
or make its modifications
Clinical sign
temperature of body of 37,0-37,5оС In absence of other signs of bacteria
infection can be the sign of non-
bacterial inflammation, postinfectious
asthenia, medicinal fever
Maintainance of remaining changes on a
x-rays (infiltration, increasing of
pulmonary vasculature)
Can be saved during 1-2 months and
more after carried P
(a roentgenologic dynamics is carried
out more slowly, for 60% patients
regress in the first 4 weeks. and these
information can not be criteria for
determination of duration of à/b
therapy)
Dry cough Can be saved during 1-2 months.
Maintainance of wheezes during
auscultation
Dry wheezes can be saved during 3-4
weeks and more
Increase of erythrocyte sedimentation
rate, ESR
Heterospecific index, is not only the
sign of bacteria infection
Weakness, sweating Displays of postinfectious asthenia
It is necessary to conduct differential diagnosis with the empyema of pleura,
cancer of lungs, tuberculosis.
Empiric à/b therapy of patients of CAP in the hospital.
To the patients 1 and 2 groups which are hospitalized on social testimonies,
appoint the proper à/b therapy.
To the patients 3 groups must be appointed the combined à/b therapy with
the parenterally setting of preparations.
Antibacterial THERAPY OF PATIENTS with CAP IN HOSPITAL
Group of
patients
Possible exciter
Antibiotic
first row Antibiotic of the
second rowPreparation
choice
Alternative
preparation
3
group
(with the
unsevere
CAP)
S. рneumoniae
H. influenzae,
Atipichnye
exciters,
Gramnegativny
e
enterobacteria
Application of
intravenous
introduction or
intramuscular
introduction of:
protected
aminopenicillin +
macrolide (per
os)
or
cephalosporin II-
IIIgenerations +
macrolide (per
os)
Intravenous
application:
Fluoroquinolones
III-IV generation
Intravenous
application of
Fluoroquinolones
III-IV generation
or carbapenems
IV
group
with
severe CAP
S. рneumoniae
H. influenzae
S. aureus,
Legionella spp.,
Polimikrobnye
associations
intravenous
introduction of
protected
aminopenicillin +
macrolide
or
cephalosporin III
generations +
macrolide
Intravenous
application:
Fluoroquinolones
III-IV generation
+ в-lactam
Intravenous
application of
Fluoroquinolones
III-IV generation
+ carbapenems
Or
carbapenems
+
Macrolide
At suspicion on
P. aeruginosa
cephalosporin
III-IV +
aminoglycoside +
cyprofloxaciny
Intravenous
application:
cephalosporin
III-IV
generation +
aminoglycoside
+ Macrolide
Intravenous
application
Meropenem
+ aminoglycoside
+cyprofloxaciny
Estimation of efficiency – on those criteria in 48-72 hours from the
beginning of therapy.
Duration of à/b therapy – at treatment of patients with the severe CAP– 10
days. In this term mark disappearance of leukocytosis .
For patients with an early adequate clinical answer for à/b therapy it is
possible to change parenterally injection to taking antibiotics per os.. In default of
answer for treatment during the first 3 days it’s necessary make the correction of
treatment and additional inspection.
COMPLICATIONS OF NP
- pleura effusion,
- empyema of pleura,
- destruction / abscess of pulmonary tissue ,
- acute respiratory failure,
- infectious toxic shock,
- pericarditis, myocarditis..
Risk factors:
- age more 50 years
- concomitant diseases
- severe pneumonia,
-smoking.
Hospital-acquired pneumonia (HAP) or Nosocomial pneumonia
refers to any pneumonia contracted within 48-72 hours of being admitted in
hospital. In practice, hospital-acquired pneumonia is often suspected on the basis
of the appearance of a new infiltrate on a chest x-ray.
Classification
Select:
Early HAP – arises up during the first 5 days from the moment of hospitalization
and caused by infection which patient had before hospitalization -S. Rneumoniae,
H. Influenzae, methicillinsensetive S. aureus and other representatives of normal
microflora of cavity of mouth. More frequent these agents are sensible to antibiotic
drugs, and pneumonia has more favourable prognosis.
Late – develops not earlier 6 day of hospitalization and caused actually by hospital
microflora with more high risk of development of high-virulent and polyresistant
bacterias, such as P. Aeruginosa, Enterobacteriaceae, methicillinresistant culture
of S. aureus. Such HAP has a less favourable prognosis.
Risk factors:
Endotracheal intubation with mechanical ventilation poses the greatest overall
risk; ventilator-associated pneumonia constitutes > 85% of all cases, with
pneumonia occurring in 17 to 23% of ventilated patients. Endotracheal intubation
breaches airway defenses, impairs cough and mucociliary clearance, and facilitates
microaspiration of bacteria-laden secretions that pool above the inflated
endotracheal tube cuff. In addition, bacteria form a biofilm on and within the
endotracheal tube that protects them from antibiotics and host defenses.
In nonintubated patients, risk factors include previous antibiotic treatment, high
gastric pH (from stress ulcer prophylaxis therapy), and coexisting cardiac,
pulmonary, hepatic, and renal insufficiency. Major risk factors for postoperative
pneumonia are age > 70, abdominal or thoracic surgery, and dependent functional
status.
Пример клинического диагноза
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