PNEUMONIA AND PLEURAL

EFFUSION

DEFINITIONIs an acute inflammation of lung parenchyma

caused by various micro organism

Pneumonitis is a general term that describe an inflammatory process in the lung tissue that may predispose or place the at risk for microbial invasion.

The discovery of sulfa drugs and penicillin was pivotal in treatment of it .Since that time , there has been remarkable progress in the development of antibiotics to treating pneumonia . However despite the new antimicrobial agents ,this is still common and is associated with significant morbidity and mortality

ETIOLOGYNormally airway distal to larynx is sterile because of protective defense mechanism

These includes

Filtration of

air ,macrophages

Warming , humidification

inspired air

Epiglottis closure

over trachea

Cough reflex ,

IgA

FACTORS THAT PREDISPOSE

When defense mechanism become incompetent or overwhelmed by virulence or quantity of inflammatory

agents

Pneumonia results

decrease consciousness depresses cough and epiglottal reflex

Aspiration

CONT…Tracheal intubation interferes with normal cough

reflex and muco ciliary escalator mechanism ; also bypasses upper airway

Muco ciliary mechanism is interfered with air pollution , cigarette , viral URI , aging . In case of mal nutrition functions of lymphocytes and PMN leucocytes are altered

Alcoholism , DM , Leukemia are associated with GNB in oropharynx

Altered oropharyngeal flora Secondary to antibiotic therapy

drugsHead injury

seizures , drug overdose

Bed rest , prolonged immobility Tracheal

intubation

Feeding via NG tubes

Chronic dx

ACQUISITION OF ORGANISMS

Aspiration

Inhalation

Hematogenous

CLASSIFICATION

Typical

Atypical

Anaerobic

Oppurtunistic

CATEGOR

Y

VAP/HAP

CAP

Aspiration

Opportunisti

c

COMMUNITY ACQUIRED

PNEUMONIA is defined as LRTI of lung parenchyma with onset in community / during first 2 days / 48 hrs after hospitalization

CAUSATIVE AGENTS ARE :

Strep.pneumoniae

Myco . pneumoniae

H.influenza

Respiratory virus

Clamydia pneumonia

legionella pnemophila

Oral anaerobes

Nocardia

M.tb , enteric GNB

Staph.aureus , fungi

STREPTOCOCCUS PNEUMONIAE

Commonest in age < 60 yrs without co morbidity and > 60yrs with co morbidity

Prevalent in winter and spring when URTI is frequent

Gram positive , capsulated non motile coccus resides naturally in URT

Organism colonizes URT and cause disseminated invasive infection , LRTI , URTI , otitis , sinusitis ,pneumonia

Bacteremia – 15% - 25 % cases

lobar Bronchopneumonia

forms

TREATMENT

Cefotaxime / ceftriazone

Antipseudomonal fluroquinolones

Levofloxacin

MYCOPLASMA PNEUMONIA

Most common in older children and young adult is spread

by infected respiratory droplets through person to person

contact .

Patient tested for Mycoplasma antibodies

Inflammatory infiltrate is primarily interstial rather

than alveolar

Mortality = < 0.1%

Spreads throughout entire tract including bronchioles

, has characteristic of bronchopneumonia.

CONT……….

Aseptic meningitis

Meningoencephalitis

Peri , myocardits

Transverse myelitis

Cranial nerve plasty

Complication

HEMOPHILUS INFLUENZA

Affects elderly and those with co morbid illness

Mortality = 30%

Associated with URTI = 2 – 6 wks before onset of illness

Fever , chills , productive cough usually involves one or more lobes , sub acute bacteremia

CXR = multilobar patchy bronchopneumonia / area of consolidation

Cephalosporin , macrolides , quinolones

LEGIONNAIRE DISEASE

High in smokers / immunosuppressi

ve therapy

Epidemic / sporadicLobar

consolidation

Bronchopneumo

nia

flu

Summer- high

TREATED WITH…………..

• Erythromycin , Rifampin

• clarithromycin• Macrolides

• fluroquinolones

CHLAMYDIAL PNEUMONIA

Single infiltrate on chest x-ray

Pleural effusion , upper respiratory tract infection

Tetracyclin , erythromycin

Complication include acute respiratory failure

VIRAL PNEUMONIAInfluenza A ,B , adeno virus , RSV

Parainfluenza , CMV , Corono virus

Winter months , epidemics occur 2 – 3yrs

Patchy infiltrate on CXR with effusion , URTI , bronchitis , pleurisy

TYPE A = AMANTIDINE , RIMANTIDINE

TYPE A / B = ZANAMIVIR ,OSELTAMIVIR

CONT..

Acute stage – within ciliated cells

Infiltration of tracheo bronchial trees

Extends into alveolar area – edema , exudation

IDSA , ATS – 3 STEP APPROACH

STEP 1 = assessment of ability to treat the patient at

home

STEP 2 = calculation of PORT PSI with

recommendation , for home care and clinical

judgment .this scale is produce by agency of

health care research and quality based on

multiple factors and scores indicates patient’s

risk class

STEP 3 = clinical judgment in final decision to treatment

, either as OP / IP

PNEUMONIA PATIENT

OUTCOMES RESEARCH

TEAM SEVERITY

INDEX

DRUG THERA

PY

HOSPITAL ACQUIRED , VENTILATOR

ASSOCIATED , HEALTH CARE ASSOCIATED

PNEUMONIAHAP occurring 48hrs / longer after hospital admission

and not incubating at time of hospitalization.

VAP refers to pneumonia that occurs 48 – 72 hrs after ETT intubation

HCAP INCLUDES ANY PATIENT WITH NEW

ONSET WHO

hospitalized in acute care hospital for 2 or more days with in 90 days of infection

resided in a long term care facility

received recent IV antibiotic , chemo / wound care with in past 30 days of current infection

CONT.. attended a hospital

HAP OCCURS WHEN AT LEAST ONE OF 3 CONDITIONS OCCUR;

host defenses are impaired

an inoculums of organism reaches the LRT an overwhelms the host defenses

highly virulent organism is present

PREDISPOSING FACTORS

Acute / chronic illness

Comorbidities

supine

coma

Hypotension

aspiration

Prolonged hospitalization malnutrition

INTERVENTION RELATED FACTORS

Agents R/T CNS depression

Impaired secretions removal

Thoracoabdominal procedure

Respiratory therapy devices , equipments

COMMON ORGANISMS ARE…..Entero bacter species

E- coli

H.Influenza

Proteus

Serratia

P.Aeruginosa

MRSA , S.pneumonia

P.AERUGINOSA

High in pre existing lung disease / cancer / homograft transplants , burns , tracheostomy , suctioning

Diffuse consolidation = chest x-ray

Toxic appearance , fever , productive cough , relative bradycardia , leucocytosis

Amino glycosides and Antipseudomonal agents – ticarcillin , piperacillin

Lung cavitations

STAP.AUREUSSevere hypoxemia , cyanosis , bacteremia necrotizing

infection

As a complication of epidemic influenza

Accounts for 10 – 30% of HAP

Mortality rate – 25 - 60%

Complications include effusion , pneumothorax , lung abscess , emphyema

Nafcillin , oxacillin , clindamycin , linezolid

KLEBSIELLA Greater in elder / alcoholics

Mortality – 40 – 50%

Tissue necrosis , bronchopneumonia , lung abscess , lobar consolidation

Cephalosporin , amino glycosides ,, Antipseudomonal penicillin , monobactum , quinolones

ASPIRATION PNEUMONIA Refers to sequlae occurring abnormal entry of secretion

or substances into lower airway .

it usually follows aspiration of material from mouth or stomach into trachea and subsequently to lungs

history of LOC , depressed gag or cough reflex , RT feeds

dependent portion of lung – superior segments of lower lobe , posterior segments of upper lobe

ASPIRATION

OPPURTUNISTIC INFECTION

Severe PEM

Chemo therapy

Radiation

PNEUMOCYSTITIS JIROVECI Fungal infection

pulmonary diffuse bilateral alveolar pattern of infiltration.

in wide spread infection lungs are massively consolidated

fever , tachycardia , tachypnea , hypoxemia , non productive cough

TMP – SMZ , dapsone to those intolerant to bacterim , aerosolized pentamident , primaquine ,clindamycin

CYTO MEGALO VIRUS

Particularly in transplant recipient , gives rise to latent infection .

Reactivation with shedding of infectious virus

Ganciclovir is recommended

PATHOPHYSIOLOGY

Congestion

Red hepatisat

ion

Resolution

Grey hepatisat

ion

CLINICAL FEATURES

Chills – sudden onset

Rapidly raising fever

Pleuritic chest pain – aggravated by deep breathing and coughing

Tachypnea – 45b/m , respiratory distress

Use of accessory muscles for respiration

Relative bradycardia

Purulent sputum , poor appetite

Rusty blood tinged sputum

Diaphoresis , myalgia , pharyngitis

Preferred to be in propped up / sitting position leaning forward

Mucoid or mucopurulent sputum

Hypoxemia , orthopnea

Central cyanosis

Physical examination reveals ………………..

increased tactile fremitus

crackles

ego phony

whispered pectoriloquy

dullness on percussion

bronchial breath sounds

DIAGNOSTIC STUDIES

COLLABERATIVE CARE

Amantidine , Rimantidine

Neuroaminase Inhibitors – Zanamivir , Oseltamivir

Inactivated Influenza Vaccine , Live Attenuated Virus Vaccine

LAIV– Flumist – Intranasal – 5- 49yrs

Inactivated - . 6 mths

Pneumococcal Vaccine

COMPLICATIONS

Lung abscessPleural

effusion

Atelectasis

Respiratory failure ,shock

Peri , myocarditis

RESTRICTIVE DISORDERS

These are characterized by restriction in

lung volume either caused by decreased

compliance of lungs or chest wall as

opposed to obstructive disorders are

characterized by increased resistance to

airflow

PLEURAL EFFUSION

Collection of fluid in a pleural space , rarely a

primary disease , usually secondary to other

disease

It is a sign of serious disease

Normally it contains 5 – 15 ml

IT MAY BE COMPLICATION OF…..

heart failure

TB

Pneumonia

pulmonary infection / embolus

bronchogenic carcinoma

nephrotic syndrome

NORMAL PHYSIOLOGY

EFFUSIONS CAN OCCUR DUE TO

heart failure

pulmonary embolisation

malignancy , TB

mesothelioma

hepatic hydrothorax , viral infection

parapneumonic effusion , AIDS

CHYLOTHORAXOccurs when the thoracic duct is

disrupted and chlye accumulates in pleural space

Most common cause – trauma

Dyspnea , large effusion

Milky fluid , TGL – exceeds 1.2mmol/l

Chest tube with octreotide

Pleuroperitoneal shunt

HEMOTHORAXWhen diagnostic thoracentesis –

bloody pleural effusion , a HCT – on fluid

If more than half of that in periperal blood – hemothorax

Trauma , tumor , rupture of vessels

thoracostomy

TYPES TRANSUDATE EXUDATE

Primarily non inflammatory conditions and is an accumulation of protein poor , cell poor fluid

Hydro thoraces caused by

increased hydrostatic pressure

decreased oncotic pressure

Clear and pale yellow

Accumulation of fluid in the area of inflammation

Results from increased capillary permeability

Occurs secondary to

Pulmonary malignancy

Pulmonary infection , embolus

Pancreatic disease

High protein content

Dark amber / yellow

EMPYEMAIs a pleural effusion which contain pus , caused by

TB

pneumonia

lung abscess

infections of chest

FIBROTHORAX

Complication of emphyema , in

which there is a fibrous fusion of

visceral and parietal pleura

EFFUSION MAY BE……….

purulent

bloody

clear

CLINICAL FEATURESProgressive dyspnea

Decreased movement of chest wall on affected side

Pleuritic pain

Dullness on percussion

Absent or decreased breath sounds

ASSESSMENT

THORACENTESIS - CHEMICAL

PLEURODESIS

SURGICAL TREATMENT

pleurectomy Pleurx catheter

Pleuroperitoneal shunt

EMPHYEMA

Accumulation of thick , purulent fluid

within pleural space often with fibrin

development and a loculated area

where infection is located

PATHOPHYSIOLOGYFluid is thin with low leukocyte count

Fibro purulent stage

Loculated emphyema

MANAGEMENTNeedle aspiration

Tube thoracotomy

Open chest drainage via thoracotomy

decortications

NURSING MANAGEMENT