Daniel Eiven

Resp 163
Pulmonary Infections Assignment 1

1. State the incidence of pneumonia in the United States and its economic impact.
In the United States it is estimated that 4 million cases of pneumonia occur annually. Of these 4
million about 600,000 require hospitalization and costs about 20 billion dollars a year.
2. Discuss the current classification scheme for pneumonia and be able to define hospital-acquired
pneumonia, health care-associated pneumonia, and ventilator-associated pneumonia.
Pneumonia can be classified based on the clinical setting in which it occurred. The five classifications
include; Community-acquired pneumonia: acute, Community-acquired pneumonia: Chronic, Health
care-associated pneumonia, immuno-compromised host pneumonia, and nosocomial pneumonia.
Hospital-acquired pneumonia is defined as lower respiratory tract infection that develops in
hospitalized patients more than 48 hours after admission and excludes community-acquired infections
that are incubating at the time of admission. Health care-associated pneumonia is defined as pneumonia
occurring in any patient hospitalized for 2 or more days in the past 90 days in a n acute care setting or
who, in the past 30 days, has resided in a long-term care or nursing facility, attended a hospital or
hemodialysis clinic, or received intravenous antibiotics, chemotherapy or wound care. Ventilator-
associated pneumonia is defined as lower respiratory tract infection that develops more than 48 to 72
hours after endotracheal intubation.
3. Identify the pathophysiology and common causes of lower respiratory tract infections in specific clinical
settings.
Six pathodenetic mechanisms may contribute to the development of pneumonia. These mechanisms
are; inhalation of aerosolized infectious particles, aspiration of organisms colonizing the oropharynx,
direct inoculation of organisms into the lower airway, spread of infection to the lungs from adjacent
structures, spread of infection to the lung through the blood, and reactivation of latent infection usually
resulting from immuno-suppression.
4. List the common micro-biologic organisms responsible for community-acquired and nosocomial
pneumonias.
Common micro-biologic organisms for Community-acquired pneumonia, both acute and chronic:
Streptococcus pneumonia, Haemophilus influenzae, Moraxella catarrhalis, S. aureus, Leginella
pneumophila, Chlamydophila pneumoniae, Mycoplasma pneumoniae, Viruses, Coxiella burnetii,
Mycobacterium tuberculosis, Histoplasma capsulatum, Blastomyces dermatidis, and Coccidioides
immitis.
Common micro-biologic organisms for Nosocomial pneumonia: Mixed aerobes and anaerobes, Gram-
negative bacilli, S. aureus, Pseudomonas aeruginosa, Acinetobacter sp., Enterobacter sp., Klebsiella sp.,
and Stenotophomonas maltaphilia.
5. Describe the clinical findings seen in patients with pneumonia.
Clinical manifestations of pneumonia include fever and respiratory symptoms such as cough, sputum
production, pleuritic chest pain and dyspnea. Other problems such as hoarseness, sore throat, headache,
and diarrhea may accompany certain pathogens.
6. State the radiographic findings seen in patients with pneumonia; state why some patients with
pneumonia may have a normal chest radiograph.
Diagnosis of community-acquired pneumonia is established by the presence of a new pulmonary
infiltrate on the chest radiograph. Radiographic patterns produced by pathogens in community-acquired
pneumonia include lobar consolidation, bronchopneumonia, pleural effusion, interstitial infiltrates,
cavities, mediastinal widening without infiltrates, and rapidly progressive multilobar patterns. A normal
chest x-ray film does not exclude the diagnosis of pneumonia. The chest radiograph may be normal in
patients with early infection, dehydration, or P. jiroveci infection.
7. Describe the risk factors associated with increased morbidity and mortality in patients with
pneumonia.
Eleven variables are associated with increased morbidity and mortality in patients with pneumonia.
These variables are male sex, the absence of pleuritic chest pain, hypothermia, systolic hypotension,
tachypnea, diabetes mellitus, cancer, neurologic disease, bacteremia, leukopenia, and mutlilobar
infiltrates on chest radiograph.
8. State the criteria used to identify an adequate sputum sample for Gram stain and culture.
A satisfactory specimen contains more than 25 leucocytes and less than 10 squamous epithelial cells
per high power field
9. Describe the techniques used to identify the organism responsible for a nosocomial pneumonia.
There are many techniques for diagnosing nosocomial pneumonia. Clinical diagnoses is defined as the
development of a new infiltrate on chest radiograph, in the setting of fever, purulent tracheal secretions,
and leukocytosis in hospitalized patients. Clinical diagnosis lacks specificity because many other
causes of pulmonary infiltrates exist in hospitalized patients. Direct visualization by bronchoscopy of
the lower airway in ventilated patients is sometimes helpful in supporting the diagnosis of VAP.
Quantitative cultures of endotracheal aspirates have been used, but sensitivities have been only 68-82
% with specificities of 84-96 %. Bronchoalveolar lavage, in which a lung segment is lavaged with
sterile saline through the bronchoscope and recovered fluid is quantitatively cultured, has been studied
extensively as a tool for diagnosing nosocomial pneumonia. Some studies have supported the
usefulness of this technique, whereas others have questioned its specificity because of upper airway
contamination. BAL has been useful for obtaining alveolar cells for microscopic analysis, and several
studies have suggested that the presence of intracellular bacteria in 3-5 % of BAL cells distinguishes
those patients with nosocomial pneumonia from those without it. Mini-BAL performed by RTs has
been advocated for diagnosing VAP. Some centers use this technique as the primary method of
sampling respiratory secretions in suspected nosocomial pneumonia. Trans-thoracic ultra-thin needle
aspiration of the lung in non-ventilated patients with nosocomial pneumonia also has been studied
recently, and in one report was found to have a sensitivity of 60%, a specificity of 100%, and a positive
predictive value of 100%
10. Discuss strategies that can be used to prevent pneumonia.
Preventative strategies for community-acquired pneumonia have focused on immunization of
high-risk individuals against influenza and S. pneumoniae including individuals older than the
age of 60 years, and for individuals with chronic lung or heart disease or for whom the
morbidity of influenza may be substantial. Health care workers should also be immunized
annually to prevent transmission of influenza to patients. Strategies that can be used to prevent
nosocomial pneumonia include hand washing, which is extremely important and effective but
frequently neglected, isolation of patients with resistant organisms, infection control and
surveillance, enteral feeding rather than TPN, semi-erect positioning of patients, sucralfate for
bleeding prophylaxis, careful handling of respiratory therapy equipment, subglottic secretion
aspiration, selective digestive decontamination, and topical tracheobronchial antibiotics.