MEDICINA INTERNA

NEUMOLOGÍA

Dr. Christiam Ochoa

UNMSM
 NEUMONIA ADQUIRIDA EN LA COMUNIDAD
INFECCIÓN AGUDA DEL PARENQUIMA PULMONAR (ASOCIADA A UN INFILTRADO NUEVO EN LA RADIOGRAFÍA DE TÓRAX.

ETIOLOGÍA BATERIA TIPICAS (60-70%):

VÍA DE INFECCION Neumococo 20-60% - Haemophylus Clínica típica: Tos, CLINICA
pneu. 3-10% - Sf. aureus 3-5% - Expectoración, Fiebre,
MICROASPIRACION: mas fc
sanos. Neumococo, pyogenes,
Enterobacteriaceae 3-5% Dolor pleurítico, Clinica atipica: febricula,
algunos stafilococos, ATIPICOS (10-20): M. Pneumoniae - Disnea. En ancianos tos seca, artromialgia,
neisseria, corynebacterium, C. pneumoniae - L. pneumoniae hiporexia, confusión y confusion, hematuria,
Haemofiilus, Moraxella, VIRUS (5-10%): Influenza – deshidratación. En el mielitis transversa,
Mycoplasma. Parainfluenza - Rsv examen físico: miringitis bulosa, anemia
INHALACION: mycoplasma, roncantes o crepitantes hemolitica, etc
clamidophila, C. pssitaci,
Coxiella burnetti, virus, TBC,
legionella, aspergillus.
HEMATOGENA: stafilococo
aureus.

FACTORES DE RIESGO
ADULTO MAYOR- DM – EPOC
- BRONQUIECTASIA -
ALCOHOLISMO – VIH - ADVP

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 NEUMONIA ADQUIRIDA EN LA COMUNIDAD
Table 257-3 Epidemiologic Factors Suggesting Possible Causes of Community-Acquired Pneumonia
Factor
Alcoholism
COPD and/or smoking
Structural lung disease
Dementia, stroke, decreased level of consciousness
Lung abscess
Travel to Ohio or St. Lawrence river valleys
Travel to southwestern United States
Travel to Southeast Asia
Stay in hotel or on cruise ship in previous 2 weeks
Local influenza activity
Exposure to bats or birds
Exposure to birds
Exposure to rabbits
Exposure to sheep, goats, parturient cats
Possible Pathogen(s)
Streptococcus pneumoniae, oral anaerobes, Klebsiella pneumoniae, Acinetobacter
spp., Mycobacterium tuberculosis
Haemophilus influenzae, Pseudomonas aeruginosa, Legionella spp.,
S. pneumoniae, Moraxella catarrhalis, Chlamydia pneumoniae
P. aeruginosa, Burkholderia cepacia, Staphylococcus aureus
Oral anaerobes, gram-negative enteric bacteria
CA-MRSA, oral anaerobes, endemic fungi, M. tuberculosis, atypical mycobacteria
Histoplasma capsulatum
Hantavirus, Coccidioides spp.
Burkholderia pseudomallei, avian influenza virus
Legionella spp.
Influenza virus, S. pneumoniae, S. aureus
H. capsulatum
Chlamydia psittaci
Francisella tularensis
Coxiella burnetii

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 NEUMONIA ADQUIRIDA EN LA COMUNIDAD
Outpatient treatment
1. Previously healthy and no use of antimicrobials within the previous 3 months:
A macrolide (azithromycin, clarithromycin, or erythromycin) OR Doxycyline*
2. Presence of comorbidities such as chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing
conditions or use of immunosuppressing drugs; or use of antimicrobials within the previous 3 months (in which case an alternative from a different class
should be selected):
A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) OR A beta-lactam (first-line agents: high-dose amoxicillin, amoxicillin-
clavulanate; alternative agents: ceftriaxone, cefpodoxime, or cefuroxime) PLUS a macrolide (azithromycin, clarithromycin, or erythromycin)*
3. In regions with a high rate (>25 percent) of infection with high-level (MIC ≥16 µg/mL) macrolide-resistant Streptococcus pneumoniae, consider use of
alternative agents listed in (2) above.
Inpatients, non-ICU treatment
A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) OR
An antipneumococcal beta-lactam (preferred agents: cefotaxime, ceftriaxone, or ampicillin-sulbactam; or ertapenem for selected patients)• PLUS a macrolide
(azithromycin, clarithromycin, or erythromycin)*Δ
Inpatients, ICU treatment
An antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS azithromycin OR An antipneumococcal beta-lactam (cefotaxime,
ceftriaxone, or ampicillin-sulbactam) PLUS a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) OR For penicillin-allergic
patients, a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) PLUS aztreonam
Special concerns
If Pseudomonas is a consideration:
An antipneumococcal, antipseudomonal beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) PLUS either ciprofloxacin or levofloxacin
(750 mg) OR The above beta-lactam PLUS an aminoglycoside PLUS azithromycin OR The above beta-lactam PLUS an aminoglycoside PLUS a respiratory
fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]); for penicillin-allergic patients, substitute aztreonam for above beta-lactam
If CA-MRSA is a consideration:
Add vancomycin or linezolid

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 NEUMONIA INTRAHOSPITALARIA DEFINICION
Table 257-6 Pathogenic Mechanisms and Corresponding Prevention Strategies for Pneumonia types
Ventilator-Associated Pneumonia
●Hospital-acquired (or nosocomial)
FACTORES DE RIESGO Pathogenic Mechanism Prevention Strategy
pneumonia (HAP) 48H..
•TABAQUISMO - Oropharyngeal colonization with pathogenic bacteria ●Ventilator-associated pneumonia
ALCOHOLISMO Elimination of normal flora Avoidance of prolonged antibiotic courses (VAP) 48 to 72 hours.
• ADULTO MAYOR ●Healthcare-associated
Postpyloric enteral feedingb; avoidance of high gastric
• USO PREVIO A ATB - Gastroesophageal reflux
residuals, prokinetic agents pneumonia (HCAP) is defined as
UREMIA
• INTUBACIÓN Prophylactic agents that raise gastric pHb; selective pneumonia that occurs in a
Bacterial overgrowth of
ENDOTRAQUEAL decontamination of digestive tract with nonabsorbable nonhospitalized patient with
stomach
• USO DE SNG - COMA antibioticsb extensive healthcare contact, as
• CIRUGÍA MAYOR Hand washing, especially with alcohol-based hand rub; defined by one or more of the
Cross-infection from other
• DESNUTRICIÓN intensive infection control educationa; isolation; proper following:
colonized patients
• FALLA MULTIORGÁNICA cleaning of reusable equipment •Intravenous therapy, wound
• NEUTROPENIA Endotracheal intubation; avoidance of sedation; care, or intravenous
• USO DE ANTI H2/IBP Large-volume aspiration
decompression of small-bowel obstruction chemotherapy within the prior
ETIOLOGÍA Microaspiration around endotracheal tube 30 days
Endotracheal intubation Noninvasive ventilationa •Residence in a nursing home
• MRSA.
• PSEUDOMONA Abnormal swallowing or other long-term care facility
Early percutaneous tracheostomya
• OTROS SF. function •Hospitalization in an acute
• KLEBSIELLA Head of bed elevateda; continuous aspiration of subglottic care hospital for two or more
Secretions pooled above
PNEUMONIAE secretions with specialized endotracheal tubea; avoidance of days within the prior 90 days
endotracheal tube
• ENTEROBACTER reintubation; minimization of sedation and patient transport •Attendance at a hospital or
• E. COLI Altered lower respiratory Tight glycemic controlb; lowering of hemoglobin transfusion hemodialysis clinic within the
• ACINETOBACTER host defenses threshold; specialized enteral feeding formula prior 30 days
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 NEUMONIA INTRAHOSPITALARIA
Temperature
≥36.5 or ≤38.4 = 0 point - ≥38.5 or ≤38.9 = 1 point - ≥39 or <36.5 = 2 points
Blood leukocytes, microL
≥4000 or ≤11,000 = 0 points - <4000 or >11,000 = 1 point - Band forms ≥50 percent = add
1 point
Tracheal secretions
Absence of tracheal secretions = 0 point
Presence of non-purulent tracheal secretions = 1 point
Presence of purulent tracheal secretions = 2 points
Oxygenation
PaO2/FIO2, mmHg >240 or ARDS (defined as PaO2/FIO2 ≤200, PAWP ≤18 mmHg and
acute bilateral infiltrates) = 0 points
PaO2/FIO2 ≤240 and no ARDS = 2 points
Pulmonary radiography
No infiltrate = 0 point
Diffuse (patchy) infiltrate = 1 point
Localized infiltrate = 2 points
Progression of pulmonary infiltrate
No radiographic progression = 0 point
Radiographic progression (after HF and ARDS excluded) = 2 points
Culture of tracheal aspirate
Pathogenic bacteria cultured in rare or few quantities or no growth = 0 point
Pathogenic bacteria cultured in moderate or heavy quantity = 1 point
Same pathogenic bacteria seen on Gram's stain, add 1 point
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 NEUMONIA INTRAHOSPITALARIA
TERAPIA EMPIRICA Table 257-8 Empirical Antibiotic Treatment of Health Care–Associated
ATB: GUIA ATS Pneumonia
Patients without Risk Factors for MDR Pathogens
Ceftriaxone (2 g IV q24h) or
Moxifloxacin (400 mg IV q24h), ciprofloxacin (400 mg IV q8h), or levofloxacin (750 mg IV q24h) or
Ampicillin/sulbactam (3 g IV q6h) or
Ertapenem (1 g IV q24h)
Patients with Risk Factors for MDR Pathogens
1. A -lactam:
Ceftazidime (2 g IV q8h) or cefepime (2 g IV q8–12h) or
Piperacillin/tazobactam (4.5 g IV q6h), imipenem (500 mg IV q6h or 1 g IV q8h), or meropenem
(1 g IV q8h) plus

2. A second agent active against gram-negative bacterial pathogens:

The serum gentamicin or tobramycin concentration
should be obtained six hours (or up to 14 hours) after Gentamicin or tobramycin (7 mg/kg IV q24h) or amikacin (20 mg/kg IV q24h) or
the initial dose of 7 mg/kg and plotted on the above
nomogram. The interval for drug administration of Ciprofloxacin (400 mg IV q8h) or levofloxacin (750 mg IV q24h) plus
subsequent doses of 7 mg/kg is then determined based
on the interval specified on the graph. 3. An agent active against gram-positive bacterial pathogens:
* Application of the nomogram for amikacin requires
the measured concentration be divided by two. The Linezolid (600 mg IV q12h) or
new value should be plotted on the nomogram in order
to obtain the appropriate dosing interval. Vancomycin (15 mg/kg, up to 1 g IV, q12h)

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 ASMA EPIDEMIOLOGÍA

DEFINICIÓN
INFLAMACIÓN CRONICA VIA AEREA
HIPERREACTIVIDAD BRONQUIAL
BRONCOESPASMO REVERSIBLE - RECURRENTE

FACTORES GENÉTICOS FACTORES

DESENCADENANTES

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 FISIOPATOGENIA

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CLÍNICA ESPIROMETRÍA

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 CLASIFICACIÓN DE LA SEVERIDAD

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DE LA CRISIS

TRATAMIENTO

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TRATAMIENTO
RESCATE

B2 ACCION CORTA

BROMURO IPRATROPIO
CORTICOIDES SISTEM.

CONTROL

CORTICOIDES INH.
ANTAGONISTAS LCT
CROMOGLICATOS
B2 ACCION LARGA

PREVENCION

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 EPOC
DEFINICIÓN

FACTORES DE RIESGO

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 FISIOPATOGENIA

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 CLASIFICACIÓN FISIOPATOLÓGICA
CARACT. TIPO A TIPO B
Tipología Asténico sop.rosado Picnico, cian. abot.
Disnea grave Leve
Tos Mínima Leve
Esputo No Si
Infecciones Raro Frecuente
Rx tórax Hiperinsuflado Trama BV
Hipoxemia Leve Grave
>CO2, HbR y poliglobulia No Si
HTP y Cor No Moderada intensa
CPT Aumentado Normal
VR Aumentado Poco aumentado
Difusión Disminuido Normal o poco.
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CLASIFICACIÓN FUNCIONAL
SEVERIDAD

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OXIGENOTERAPIA CIRUGÍA

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