KURSK STATE MEDICAL UNIVERSITY

DEPARTMENT OF PROPAEDEUTIC OF INNER DISEASES

PNEUMONIA LUNG ABSCESS

Acute pneumonia Definition

Pneumonia is an acute inflammatory process of infectious origin affecting the pulmonary parenchyma.

Types of pneumonia
1. 2.

3. 4.

Community-acquired pneumonia Hospital-acquired (nosocomial) pneumonia Aspiration pneumonia Pneumonia in the immunocompromised host (including AIDS)

Types of pneumonia

Typical pneumonia (usually lobar, pleuropneumonia) Atypical pneumonia (usually bronchopneumonia) Primary pneumonia Secondary pneumonia In the diagnosis must be note about location of consolidation (side, lobe, segment)

Morphologic variants of pneumonia

Variant Lobar Causative organism Most frequently Pneumococcus Characteristics
Predominantly intra-alveolar exudate resulting in consolidation. May involve entire lobe. Acute inflammatory infiltrates extending from bronchioles into adjacent alveoli Patchy distribution involving one or more lobes.

Bronchopneumon ia

Many organisms (Staph. Aureus, Haemophilus influenza, Klebsiella, Strep. pyogenes)

Community acquired pneumonia

This form is responsible for over 1000 000 admissions per year.
Mortality: 6-20% Increasingly common with age

Community acquired pneumonia. Etiology Common organisms:

Str. Pneumoniae 70% (5080%) Chlamidia pneum. 10% Mycoplasma pneum. 9% Legionella pneum. 5% Uncommon organisms: Haemophilus influenzae 3% Staphyl. Aureus <1% Chlamidia psittaci <1% Klebsiella pneum. <1% Primary viral pneumonia: Influenza, parainfluenza, measles

Aspiration of organisms that colonize the oropharynx. Inhalation of infectious aerosols from ambient air. Hematogenous dissemination. Direct inoculation from contiguosly infected sites.

Community acquired pneumonia. Transmission

Transmission

Aspiration is the major route of acquisition for most forms of pneumonia, but very few individuals who do aspirate contaminated oropharyngeal secretion develop pneumonia. 45% of normal people and 70% of obtunded patients aspirate oral secretion, respiratory tract defenses

Hospital acquired pneumonia (nosocomial)

Refers to a new episode of pneumonia occurring at least 2 days after admission to the hospital. The term includes post-operative and certain forms of aspiration pneumonia.

1. Reduced host defences against bacteria: Reduced immune defences (corticosteroid treatment, diabetes, malignancy). Reduced cough reflex (post-operative). Disordered mucociliary clearance (anaesthetic agents). Bulbar or vocal cord palsy.

Hospital acquired pneumonia Predisposing factors

2. Aspiration of nasopharyngeal or gastric secretion: Immobility or reduced conscious level. Vomiting, dysphagia, achalasia or severe reflux. Nasogastric intubation.

Hospital acquired pneumonia Predisposing factors

Hospital acquired pneumonia Predisposing factors 3. Bacteria introduced into lower

respiratory tract: Endotracheal intubation / tracheostomy. Infected ventilators / nebulisers / bronchoscopes. Dental or sinus infection. 4. Bacteraemia: Abdominal sepsis. Intravenous cannula infection.

Hospital acquired pneumonia Etiology

The majority of hospital acquired infections are caused by Gram negative bacteria (Escherichia, Pseudomonas, Klebsiella).

Pulmonary infection is common in patients receiving immunosuppressive drugs and in those with diseases causing defects of cellular or humoral immune mechanisms (Ex.: AIDS).

Pneumonia in the immunocompromised patient

Lobar pneumonia
Homogeneous consolidation of one ore more lobes, associated with pleural inflammation.

Lobar pneumonia Main syndromes

1. 2.

3. 4. 5. 6. 7.

Inflammation of the lung tissue. Consolidation of the lung tissue. Intoxication. General inflammation. Acute respiratory insufficiency. Heart failure. Affection of the other organs.

Lobar pneumonia Morphology

4 stages: 1. Congestion 2. Red hepatization 3. Grey hepatization 4. Resolution

Lobar pneumonia Morphology

Lobar pneumonia Morphology

CONGESTION 1) Hyperemia of the lung tissue. 2) Exudation. 3) Obstruction of capillary patency. 4) Stasis of the blood.

It lasts from 12 hours to 3 days

Lobar pneumonia Morphology

RED HEPATIZATION 1) Massive confluent exudation with red cells and neutrophils and fibrin filling the alveolar spaces. 2) The lobe now appears distinctly red, firm, and airless with a liver like consistency. Continues from 1 to 3

Lobar pneumonia Morphology

GRAY HEPATIZATION 1) Progressive disintegration of red cells. 2) The alveoli (containing fibrin) become filled with leucocytes 3) Persistence of fibrosuppurative exudates, giving the gross appearance of a grayish brown, dry surface.

Lobar pneumonia Morphology

RESOLUTION The consolidated exudate within the alveolar spaces undergoes progressive enzymic digestion to produce a granular, semifluid debris that is resorbed, ingested by macrophages, or coughed up.

Lobar pneumonia Clinical stages

1. Onset of the disease (1st
morphological stage)

2. Height of the disease

(2nd and 3rd morphological stages )

3. Resolution (4th morphological stage)

Clinical symptoms I stage (onset of the disease) Shaking chills (persist for 1-3 hours) or Complaints:

rigor (imply bacteraemia). Fever (39- 400C) Pleuritic pain in the chest (on the affected side) in lower lobe pneumonia can simulate
acute appendicitis, hepatic colics.

Dyspnoea. Cough is first dry (in 1-2 days rusty sputum is

expectorated in the beginning of red hepatization stage).

Severe headache (in atypical pneumonia). Pain in the body & limbs.

Clinical symptoms I stage General inspection:

General condition is grave . Confusion (hallucinations & delirium, especially in alcoholic

patients). Convulsions (may be in children)

Facies pneumonica: Hyperemia of the cheeks, more pronounced on the affected side, participation

Clinical symptoms I stage

Lagging of the affected side. Dyspnoea. Vocal fremitus is increased. Dulled-tympanic percussion sound. Auscultation diminished vesicular breathing,

Respiratory system examination

II stage (height of the disease)

Clinical symptoms

General inspection data the same as in I stage. Lagging of the affected side Tachypnoea (30-40 per min). Vocal fremitus increased. Dull percussion sound. Bronchial breathing, pleural friction rub. Bronchophony increased, egophony (ee as ay), whispered pectoriloquy. Cardiovascular symptoms: tachycardia, may be vascular collapse (vascular failure, BP drop due to toxicosis).

Clinical symptoms

III stage (resolution)

Cough with mucopurulent sputum. Dyspnoea decreases. Vocal fremitus increased. Dullness decreases. Dulled tympanic sound. Bronchial breathing gradually disappears. Crepitation redux. Moist rales.

Investigations Blood test

A high neutrophil leucocytosis (bacterial pneumonia). Marginally raised or normal white cell count (atypical agents). A marked leucopenia in viral etiology. Increased ESR.

Investigations Blood test

Blood gases to determine oxygen therapy. Blood culture. Biochemical test: Hyponatraemia (typical for Legionella). Liver function test (often abnormal in atypical pneumonia). Serum urea >7 mmol/L (predictive

Investigations Sputum

1st stage (congestion): may be present small

amount - tenacious; slightly crimson, contains much protein, a small number of leucocytes, erythrocytes, alveolar cells and macrophages. 2nd stage (red hepatization): scant and rusty; it contains fibrin and higher number of formed elements. 3rd stage (gray hepatization): leukocyte count increases significantly; mucopurulent sputum. 4th stage (resolution): leukocytes are

Microbiological investigations
Sputum:

Direct smear by Gram. Culture. Antimicrobial sensitivity test.

Microbiological investigations
Serology: Acute and convalescent titers (Mycoplasma, Chlamidia, Legionella and viral infections). Pneumococcal Ag in sputum, serum & urine. Direct fluorescent Ab stain in Legionella. Legionella Ag in urine.

Investigations X-ray

Homogeneous opacity localized to the affected lobe

Complications:

1. pulmonary 2. extrapulmonary Para- or metapneumonic effusion Empyema Retention of sputum causing lobar collapse Pneumothorax (particularly with Staph. aureus) Lung abscess Septicaemia Cirrhosis of the affected lung (carnification) Renal failure, multi-organ failure Adult respiratory distress syndrome Ectopic abscess formation Hepatitis, nephritis, pericarditis,

Bronchopneumonia (focal pneumonia)

More patchy alveolar consolidation associated with bronchial and bronchiolar inflammation It occurs most commonly in infancy, in aged patients especially with longstanding and severe diseases (cancer, uremia, stroke)

Main syndromes in bronchopneumonia

1. 2. 3.

Focal consolidation. Respiratory insufficiency. Intoxication.

Bronchopneumonia Clinical symptoms

The onset is usually overlooked because it often develops against the background of bronchitis or catarrh of the upper airways (secondary). The findings of physical examination at the onset are the same as in acute bronchitis.

Bronchopneumonia Clinical symptoms

Cough Fever different: remittent, irregular (usually subfebrile). Temperature may be normal at aged patients. Dyspnoea Pain in the chest (only in involvement of the pleura in peripheral located inflammatory focus)

Bronchopneumonia Clinical symptoms

Moderate hyperemia of the face; cyanosis of the lips. Tachypnoea (25-30 per min). Palpation, percussion and auscultation may be not effective (if the foci are small and deeply located).

Bronchopneumonia Clinical symptoms

In presence of large focus, if it is located peripherally
(over the limited part of the chest):

vocal fremitus increased dull percussion sound vesiculobronchial or bronchial breathing,

Bronchopneumonia Investigations

Blood test: mild leucocytosis, moderately increased ESR. Sputum: mucopurulent; great number of leucocytes, macrophages and columnar epithelium. Bacterial flora is varied. X-ray: focal consolidations at least 12 cm in diameter

Treatment of pneumonia

Food should be rich in vitamins and easily assimilable. Antibiotics. Sulpha drugs. Oxygen therapy. Expectorants.

Criteria for hospitalization of patients with pneumonia: the PORT score

Risk class

(Pneumonia Patient Outcomes Research Team )

No. of points

Recommendatio ns for site of care

I II III IV V

No predictors Outpatient < 70 71 90 91 130 >130 Outpatient Inpatient Inpatient Inpatient

Criteria for hospitalization of patients with pneumonia

Demographic factor
Points Age (years) Age (years) - 10 + 10 Characteristic Men Women Nursing home resident

Criteria for hospitalization of patients with pneumonia

Coexisting illnesses
Characteristic Neoplastic disease Liver disease Heart failure Cerebrovascular disease Renal disease Points +30 +30 +10 +10 +10

Criteria for hospitalization of patients with pneumonia

Physical examination findings
Points Characteristic

Altered mental status +20 Resp. rate >30/min SBP<90 mm Hg Temp. <350 or>400C Pulse > 125/min +20 +20 +15 +10

Criteria for hospitalization of patients with pneumonia

Characteristic

Laboratory & radiographic findings

Points +30 +20 +20 +10 +10 +10

Arterial pH < 7,35 Blood urea nitrogen > 30 mg/dL Sodium < 130 mmol/L Hematocrit < 30% O2 saturation < 90% Pleural effusion

Glucose > 250 mg/dL (14 mmol/L) +10

Pulmonary abscess
Is a purulent melting of the lung tissue circumscribed by an inflammatory swelling It develops mostly as an outcome of pneumonia or complicated bronchoiectasis.

Pulmonary abscess Etiology

Streptococci Staphylococci Pneumococci

Pulmonary abscess Clinical symptoms

2 periods are distinguished: 1st before opening an abscess (formation of abscess; it continues 10-12 days) 2nd after opening an abscess (begins with the opening of the purulent abscess into the bronchus)

Pulmonary abscess I period

Complaints: Weakness Chills Cough with meager sputum Pain in the chest (in pleura involvement) Dyspnoea Fever (remittent or hectic)

Pulmonary abscess I period

In peripheral location of abscess

Palpation of the chest: pain (when the costal pleura is involved) Unilateral thoracic lagging Vocal fremitus increased Percussion: dull sound Auscultation: diminished vesicular or bronchial breathing, smt. harsh with dry rales In deep abscess (or small size) results of objective examination are not changed

Pulmonary abscess I period

Investigations

Blood test: neutrophylic leucocytosis; shift to the left, to the myelocytes; ESR increased significantly Sputum: not specific X-ray: does not differ from pneumonia or tuberculosis infiltration: a large focus of increased density with rough and indistinct margins

Pulmonary abscess II period

Complaints: Severe cough with sudden release of ample offensive purulent sputum (full mouth): on standing separates into three layers: mucous, serous and purulent (from 200 ml to 1-2 L/day) Dyspnoea Pain in the chest

Pulmonary abscess II period

Unilateral thoracic lagging Vocal fremitus increased Percussion: tympanic / metallic sound; crackled - pot sound Auscultation: bronchial (amphoric / cavernous) breathing; resonant moist rales; gutta cadens (falling drop sound)

Clinical symptoms

Investigations: Blood test: Neutrophylic leucocytosis. Shift to the left, to the myelocytes. ESR increased significantly. Sputum: On standing separates into three layers: mucous, serous and purulent. Elastic fibers. Leucocytes and erythrocytes. Dittrichs plugs (resemble the lenticular formations

Pulmonary abscess II period

Pulmonary abscess II period

X-ray: cavity with liquid level

Pulmonary abscess Treatment

Hospitalization Adequate draining Antibiotics Desintoxication