MGT OF PNEUMONIA

by
DR TASIE OBINNA
NATIONAL ASSEMBLY CLINIC, ABUJA.
7 SEPT 2015.

OVERVIEW

Introduction
Epidemiology
Classification
Causes
Pathophysiology
Symptoms and signs
Diagnosis
Investigation
Treatment
Complication
Differential diagnosis
Conclusion

INTRODUCTION
Inflammatory condition affecting the
lung
parenchyma due to acute
microbial infection with at least one
opacity on chest radiograph.
OR
Acute respiratory illness associated with
recently developed radiological pulmonary
shadowing which may be segmental, lobar
or multilobar.

EPIDEMIOLOGY
Common illness seen in general
outpatient clinic. Pneumonia is the
second major killer of Nigerian
children with 17% infant mortality
per year, yet our fathers and
mothers are ignorant of its causes
and prevention.
In a prospective cohort study in Ilorin, the
rate of pneumonia was 2 episodes per
child per year as compared with South
East Asia( 0.36 episodes/ child/ year),
European regions ( 0.06 episodes/ child

 In Bronchopneumonia, rates are

greatest in children less than 5yrs
and adults older than 65yrs, occuring
frequently in developing world than
in developed world.
Rudan et al calculated and published the
1st global estimate of incidence of clinical
pneumonia. More than half of the world
annual new pneumonia cases are
concentrated in just five countries: India,
China, Pakistan, Bangledesh and Nigeria.

CLASSIFICATION
SITE: lobar or bronchopneumonia
AETIOLOGY: infective , chemical, allergic,
PREVIOUS HEALTH: CAP, Nosocomial
pneumonia , immunocompromised.
CLINICAL PRESENTATION: typical or
atypical.

ATYPICAL PNEUMONIA
aka Interstitial pneumonitis.
Inflammation is in the alveolar septa
and interstitium, there is no exudate in
the alveolar space.
caused by viruses and mycoplasma
pneumonia in majority of cases.
Symptoms are milder and longer
lasting than typical pneumonia.
Histology: chronic inflammatory
cells in the alveolar wall and
interstituim with pink hyaline

COMMUNITY ACQUIRED
PNEUMONIA

Infectious lung disease involving the

alveoli, distal airways and the interstituim
of the lungs , contracted outside the
hospital setting.
Affects 4 million adults yearly.
Severity is determined by host factor , not
pathogen type and virulence.
Most gram negative bacteria that cause
CAP are enterobacteria [ S.pneumonia,
H.influenza] and enter the lungs via
inhalation of vomits.

HOSPITAL ACQUIRED PNEUMONIA

aka nosocomial infection.
Refers to new episode of pneumonia
occurring at least 2days after admission to
hospital and not incubating at the time of
admission.
Highest rates among ICU patients
undergoing mechanical ventilation.
The most important distinction between
hospital and community acquired pneumonia
is the difference in the spectrum of the
pathogenic organism.

CAUSES
1.BACTERIA eg : Strep pneumonia,
Chlamydia pneumonia, Mycoplasma
pneumonia, Legionella
pneumophilia, H. influenza, Staph
aureus, Klebsella etc.
2. VIRUSES eg : Rhinovirus, Coronavirus,
Adenovirus, Parainfluenza, Human
simplex virus. Human simplex virus
rarely causes pneumonia except in
groups such as newborn, person
with cancer, transplant recipients
and significant burns patients.

3. FUNGI eg Histoplasma capsalatum,

C.immitis, C.neoformans,
Aspergilloses, Candidiasis( rare),
Sporotrichosis.
4. PARASITIC causes
T.gondii, Ascaris lumbricoides, Hookworm
and S.stercoralis.

PREDISPOSING FACTORS
1. Smoking.
2. Chronic alcoholism.
3. Asthma.
4. Chronic obstructive airway disease.
5. Old age.
6. Recent cold or flu.
7. Immunodeficiency state.
8. Male gender.
9. Use of acid suppressing medications like
proton pump inhibitor/ H2 blocker, steroid
therapy

 10. Contaminated ventilator system or

equipments.
11. Aspiration of oropharyngeal contents
into the lower respiratory tract.
12. Sepsis

PATHOPHYSIOLOGY
Bacteria typically enter the lungs with
inhalation, though they can reach the
lung via the blood stream if other part of
the body are infected.
Often bacteria live in the upper
respiratory tract and are continually being
inhaled into the alveoli. Once inside the
alveoli, bacteria travel into the spaces
between the cells and also between
adjacent alveoli through connecting
pores.

BACTERIA AND FUNGI

Invasion of the lungs by bacteria and fungi

causes cellular death and triggering of the
immune system leading to phagocytosis of
the bacteria by neutrophils.
Cytokines released by neutrophils causes
exudation of fluid inside the alveoli.
The neutrophil, bacteria debris and the
exudates in the alveoli result in impaired
oxygen transportation.
Sepsis may occur from bacteremia.
Septic shock may occur and leads to
damage in multiple parts of the body.

PATHOPHYSIOLOGY
contd.

Viral infections occur when

contaminated airborne droplets are
inhaled through the mouth or nose.
Some viruses such as measles and
Human simplex virus may reach the
lung via the blood. The invasion of
the lungs may lead to varying
degrees of cell death. When the
immune system responds to the
infection , even more lung damage
may occur.

PARASITE
Enters the body through skin or
swallowing.
Migrates to the lungs most often through
the blood.
Both mechanism of cellular destruction
and immune response result in disruption
of oxygen transportation.
Immune response is mediated by
eosinophil.

STAGES
1. Congestion
The affected lung parenchyma is
partially consolidated and red purple.
Occurs on Day1/2. On microscopy, there
is vascular engorgement, few
neutrophils and bacteria in the alveoli.
2. Red hepatization seen on Day 3/4
The pulmonary lobe appears consolidate, red
brown, dry, firm with liver like consistency.
Microscopically, there is accumulation in the
alveolar space of exudate rich in fibrin mainly
with leucocytes, erythrocytes and bacteria.

contd of STAGES.
3. Gray hepatization occur on Day 5-7
The affected lungs have a liver like
consistency with uniform gray color. On cut
surface, you would see grayish purulent
liquid drains.
4. Resolution
begins on Day 8 and continues for 3weeks
while the exudates within the alveolar
spaces will be drained through lymphocytes
and airways.

SYMPTOMS/ SIGNS
1. Cough: productive or non
productive. sputum may be whitish ,
yellowish or greenish.
2. Fever: moderate/ high grade.
3. Fatigue.
4. Pleuritic chest pain: stabbing pain
aggravated or worse on deep
inspiration or coughing.
5. Difficulty in breathing.
6. Confusion.
7. Headache.

DIAGNOSIS
1) History
2) Physical Examination
a) Respiratory exam
Tachypnea i.e. respiratory rate> 18c/m
Decreased chest expansion on the
affected side.
Increased vocal resonance.
Dull percussion note.
Bronchial breath sounds.
Fine / coarse crepitation on the
affected side.

INVESTIGATION.
1. Chest Xray
. 38yr old patient with M.pneumonia chest
xray film showing vague ill defined opacity
in the left lower lobe.

XRAY FINDINGS IN
LEGIONELLA PNEUMONIA

LOBAR PNEUMONIA XRAY

FILM

 Legionella pneumonia is implicated in

2- 15% of Community acquired
pneumonia. Mild infection may manifest
with bilateral involvement but in severe
infection , lung agitation and bulging of the
fissure have been reported.

INVESTIGATIONS
2. Sputum M/C/S
3. Full blood count. increased WBC is
noted> 11,000 cells/ microliter.
4. Urine ELISA : legionella
5. Pleural fluid M/C/S: mycoplasma,
chlamydia, coxiella.
6. Blood culture.
7. Pulse oximetry: simple non invasive
method of measuring arterial oxygen
saturation, and assist in monitoring
oxygen therapy response.

Rare lab test

High resolution computed tomograghy
[ HRCT] can pick up opacities even if
chest xray is normal
PCR
Amplification of the DNA or RNA of micro
organism can be used to detect legionella,
mycoplasma, and chlamydia pneumonia.

OBJECTIVES
The main objectives of investigating patients
with a clinically based diagnosis of
pneumonia are:
1. Obtain radiological confirmation of
diagnosis.
2. Obtain a microbiological diagnosis.
3. Assess the severity
4. Identify the development of complications.

INDICATION FOR ADMISSION

CURB 65
C- confusion
U- blood urea nitrogen >7mmol/l
R- respiratory rate> 30cycles/min
B- diastolic blood pressure<60mmHg
systolic blood pressure< 90mmHg
Age > 65years.

TREATMENT
Antibiotics is the drug of choice for
treating pneumonia. They include :
PARENTERAL INFUSION.
IV Ceftriazone 1g daily
IV Erythromycin 500mg qds [ if
mycoplasma or legionella is suspected].
IV Augmentin 1.2g bd
IV Flucloxacillin 1g tds [ if staph is
implicated]

 IV antibiotics can be changed to oral

therapy when :
WBC is returning toward normal
There are two normal temperature
readings [<37.5C ] 16 hours apart
There is improvement in cough and
shortness of breath.

ORAL ANTIBIOTICS
Caps Ampiclox 500mg tds
Tabs Augmentin 625mg bd
Tabs Ciprofloxacin 500mg bd
Tabs Flagyl 400mg tds
Tabs Erythromycin 500mg bd
Tab cefuroxime 500mg bd
Caps Doxycycline 100mg bd [ has
activity against strep pneumonia and
atypical pathogens

ANTIBIOTICS RATIONALE
Collect blood and sputum samples before
initiating antibiotics.
Antibiotics of choice should penetrate both
tissue and alveoli fluid
Route of antibiotic should be Intravenous if
patient is unconscious , severely ill or
vomiting.
Treat for at least 5days and 2- 3 weeks if
staph pneumonia or legionella is
suspected.

HOME TREATMENT
Bed rest
Encourage patient to drink plenty
fluids to correct dehydration.
Give paracetamol to correct fever,
chest pain.
Warm drink of honey and lemon can help
relieve the discomfort caused by
coughing.

PREVENTION
1.Vaccination against H. influenza and strep.
pneumonia.
2. Smoking cessation
3. Decrease Indoor air pollution
4. Hand hygiene
5. Exclusive breast feeding
6. Treat any underlying illness.
7. In patient undergoing mechanical
ventilation, you need to extubate early and
careful periodic drainage of tubing
condensate.

DIFFERENTIAL DIAGNOSIS
1. Chronic obstructive airway disease
2. Asthma
3. Bronchiectasis
4. Lung cancer
5. Pulmonary emboli

6. Pulmonary oedema.
7. Pulmonary Tuberculosis

Differences btw Pneumonia and

Asthma.
Pneumonia
Viral or bacteria
origin
Rhonchi present

Asthma
Genetic or
environmental
Wheeze on
exhalation
Dry cough with no
Moist cough and
sputum production.
produce sputum ie
yellowish or
greenish.

COMPLICATIONS
1.
2.
3.
4.
5.
6.

Pleuritis with fibrinous exudates

Lung Abscess
Septicaemia
Pleural effusion
Pulmonary fibrosis
Deep vein thrombosis

CONCLUSION
Most patients will come to the hospital to
see a doctor and during their interaction,
they often say things like " I have
pneumonia" as a past medical history. That
is a misconception , pneumonia is not
usually persistent in human body like
Diabetes!, it usually clears after treatment.
As we look forward to November 12, we
implore all health professional and govt
should rise to the demands of improved
standard living , social services , healthy
environment and improved quality of life.