PNEUMONIA

Dr. Paulo Gurgel

Definition
Inflammatory processes are generally acute lung parenchyma.
Morbidity and mortality
• 5-11 cases per thousand people per year. • Increased frequency in young childr
en and elderly. • Lethality: 1% of cases (up to 50% among patients requiring ICU
admission).
Etiology
For chemical pneumonia For physical agents by biological agents (infectiou
s) Other Bacterial
Pneumonia (infectious)
Community-acquired pneumonia - CAP nosocomial pneumonia (NP) -------------------
-------------------- ---------------------- CAP affects patients outside the hos
pital or onset in the first 72 hours (CDC) after admission.
Pathways
• • • • • For inhalation by aspiration By focusing distance (Hematogenous) by co
ntiguity For local reactivation
Agent identification
• In 50% of cases at most. • In 60-80% of cases, when we include serological tec
hniques.
CAP
• S. pneumoniae - up to 43% of cases • M. pneumoniae (*) • C. pneumoniae (*) • H
. • influenzae Legionella sp (*) • Viruses • S. aureus • Others • • Mista M. tub
erculosis
PN
• P. • Other aeruginosa Gram-negative bacteria S.aureus • • polymicrobial
(*) Atypical: 1 / 3 of cases
Clinical
• RSV infection -------------------------- • Fever • Chills • Cough • Chest pain
• Sputum • Other
Physical examination
• Tachypnea: correlates with the severity of clinical signs of pulmonary consoli
dation •
- Cracking rales / Blow tube - FTV increased - dullness to percussion
1 / 3 of cases • Pleural effusion?
"Syndromic approach"
Typical (Pneumococcus) atypical (Mycoplasma)
Not an accurate predictor of microbiological cause. The clinical expression of d
isease is also determined by epidemiological and functional status of the patien
t.
Radiological diagnosis
It is essential to:
- Diagnosis - Evaluation of gravity - Identification of complications - Monitori
ng the progress and response to treatment
Pneumonia PD
Pneumonia with cavities
Pneumatoceles in staphylococcal pneumonia
Microbiological examination of sputum
collection, processing, techniques and interpretation
• Sample taken a deep cough, before antibiotics • Processing <2 hours after the
collection • Techniques
- Gram - Ziehl-Neelsen (AFB) - For fungi (selected cases)
• Direct examination (Gram)
- <10 epithelial cells and> 25 PMN field-100X
Serology and antigen detection
• Mycoplasma • cryoagglutinins for urinary antigen for Legionella pneumophila --
-------------------------------------- ------------------ • Need to show serocon
version, which delays the diagnosis
Other tests
• • • • • • • • Blood test Glucose Urea Electrolytes and creatinine Biochemistry
of liver pH and gases Blood samples for HIV serology
Invasive diagnostic methods
• • Bronchoscopy Thoracentesis
- Lavage (BAL) - Brushed - Biopsy
• • transtracheal aspirate aspiration biopsy • Surgeries
- Video-assisted (BPVA) - Mini-thoracotomy - the open sky
Risk classification
Class I II III IV V Mortality 0.1 0.6 2.8 8.2 29.2 Local treatment Outpatient Am
bulatory Brief Hospitalization Hospital (ICU)
Stratification by age, sex, area of residence, comorbidities, physical abnormali
ties, laboratory and radiological (Manual Pulmonology 2002, BTA).
Outpatient treatment
• fluoroquinolones • Macrolides (or elderly patients with associated comorbiditi
es) • Beta-lactams
Hospital treatment
Pseudomonas?
NO YES
Cipro + beta-lactam or aminoglycoside anti-P Beta-lactam anti-P + aminoglycoside
+ macrolide
Fluoroquinolone Cephalosporin 2nd, 3rd or 4th + macrolide
When suspicion of Pseudomonas aeruginosa
• structural lung disease (eg, bronchiectasis) • Recent use of antibiotics and /
or steroids • Malnutrition
Treatment - other situations
• Anaerobic
- Amoxicillin and clavulanate - Ampicillin with sulbactam - Clindamycin
• S. aureus
- Oxacillin - Vancomycin
• P. carinii
- Sulfamethoxazole with trimethoprim (add prednisone)
Some questions
• The duration of treatment: 7-21 days • Sequential treatment • Supplemental oxy
gen - SpO2 <90% - PaO2 <60mmHg • The therapeutic failure
Conduct in the pleural effusion (SD)
• Puncture
DP parapneumonic pleural empyema
• Drainage tube closed (water-sealed) open + • Drainage Therapy • Pulmonary De
cortication
Recommended Reading
• Manual Pulmonology 2002 - BTS • www.pneumoatual.com.br> Themes> • www.sbpt.org
CAP in adults.br> Publications> Guidelines for Community-acquired pneumonia in
immunocompetent adults
GRATEFUL FOR ATTENTION
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