PNEUMONIA

Broadly defined as any infection of the lung parenchyma. Classification: (1)Community Acquired Pneumonia(CAP) (2)Health Care Associated Pneumonia(HCAP) -Hospital Acquired Pneumonia(HAP) -Ventilator Associated Pneumonia(VAP) *The above classification is required as the organisms causing the pneumonia are different in respective settings.

PATHOPHYSIOLOGY
Bacteria enters the lung by: -Small volume aspiration -Inhalation of contaminated droplets -Contiguous spread from infected pleural or mediastinal infection(rare) -Hematogenous spread eg.Tricuspid valve endocarditis(rare) Dysfunction of barriers: -Hair and turbinates of nose -Gag/cough reflex -Normal flora adhering to mucosa of nasopharynx.

 Organism ingested by alveolar macrophage upon entering alveolus. When infection exceeds macrophage capacity :Clinical pneumonia results. Various host inflammatory mediators are released such as IL-1,TNF-alpha,IL-8,G-CSF which are responsible for the clinical features of pneumonia.

 Pathological stages: (1)Stage of congestion (2)Stage of red hepatization:RBCs(and also neutrophils) extravasate into lung parenchyma from blood vessels. (3)Stage of gray hepatization:Neutrophil debris. (4)Stage of resolution.

Community Acquired Pneumonia

Definition: Pneumonia diagnosed in ambulatory patients who are not residents of nursing homes and other long-term care facilities and also if pneumonia develops in a previously ambulatory patient within 48 hrs. of admission to the hospital.

COMMUNITY ACQUIRED PNEUMONIA

 Risk factors for CAP: -Alcoholism -Asthma -Immunosuppression -Institutionilization -Age 70 years. -Dementia -Tobacco smoking. -COPD -HIV infection.

 C/F: Typical pneumonia: Symptoms -Fever -Cough with expectoration(usually purulent)-Expectoration may be absent in atypical pneumonia. -Chest pain(pleuritic type) -GI symptoms:nausea,vomitting,diarrhea -Fatigue,myalgia,arthralgia-usually in atypical pneumonia. In elderly individuals:All of the above may be absent-May present with delirium,non specific symptoms

Signs -Respiratory rate increased -Use of accessory muscles of respiration -Increased Tactile Vocal Fremitus -Auscultation: Fine crepts. during stage of Congestion,Bronchial breath sounds of tubular type during stages of red and grey hepatization,Coarse crepts during stage of resolution. Other signs:Increased Vocal Resonance,Whispering Pectoriloquy,Bronchophony.

 Typical pneumonia: Etiology:Strep.pneumoniae,H.Influenzae,K.pneumonia e,S.aureus. Atypical pneumonia: Usually subacute onset of symptoms with a nonproductive cough,headache myalgia and joint pains. Non-pulmonary symptoms are common and there is usually a disparity between the clinical examination of the chest and the CXR. Etiology:M.pneumoniae,C.pneumoniae,L.pneumophila ,Coxiella burnetti,Viruses.

 Complications: Pulmonary: -Extension into other lobes -Pleural effusion,Empyema. -Lung abscess. -Pneumothorax-eg. Staph. Pneumonia. Systemic: -Sepsis,ARDS. -Infective endocarditis -Meningitis,Meningism.

INVESTIGATIONS
TC,DC,ESR In typical pneumonia:Rise in WBC count(predominantly neutrophils) In atypical pneumonia:WBC count may be normal. Urea/Creatine,S/E:in cases of sepsis to r/o renal failure/electrolyte disturbances.Legionella pneumonia-hyponatremia. Sputum for Grams stain,AFB,other specific stains if suspected Sputum for C/S CXR PA view. ABG:Hypoxemia,Respiratory acidosis. CT-Thorax:When foreign body/tumor suspected. Blood C/S:Only in selected cases (eg.neutropenia,immunodeficient states,vascular prosthesis etc) Antigen testing:Pnemococcus,Legionella,Chlamydia(not routinely done) PCR(mainly experimental purposes)

Non-homogenous opacity in R upper and middle zone

TREATMENT
(1)O2 inhalation if hypoxemia present. (2)Expectorants,Bronchodialtors. (3)Antibiotic therapy depending on clinical features and/if specific organism isolated. (4)Oral/IV fluids to maintain hydration. (5)Assisted ventilation if necessary.

Treatment