p neumonia and pleural effusion. definition is an acute inflammation of lung parenchyma caused by...
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PNEUMONIA AND PLEURAL
EFFUSION
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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
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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
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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
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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
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drugsHead injury
seizures , drug overdose
Bed rest , prolonged immobility Tracheal
intubation
Feeding via NG tubes
Chronic dx
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ACQUISITION OF ORGANISMS
Aspiration
Inhalation
Hematogenous
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CLASSIFICATION
Typical
Atypical
Anaerobic
Oppurtunistic
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CATEGOR
Y
VAP/HAP
CAP
Aspiration
Opportunisti
c
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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
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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
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lobar Bronchopneumonia
forms
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TREATMENT
Cefotaxime / ceftriazone
Antipseudomonal fluroquinolones
Levofloxacin
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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.
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CONT……….
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Aseptic meningitis
Meningoencephalitis
Peri , myocardits
Transverse myelitis
Cranial nerve plasty
Complication
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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
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LEGIONNAIRE DISEASE
High in smokers / immunosuppressi
ve therapy
Epidemic / sporadicLobar
consolidation
Bronchopneumo
nia
flu
Summer- high
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TREATED WITH…………..
• Erythromycin , Rifampin
• clarithromycin• Macrolides
• fluroquinolones
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CHLAMYDIAL PNEUMONIA
Single infiltrate on chest x-ray
Pleural effusion , upper respiratory tract infection
Tetracyclin , erythromycin
Complication include acute respiratory failure
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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
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CONT..
Acute stage – within ciliated cells
Infiltration of tracheo bronchial trees
Extends into alveolar area – edema , exudation
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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
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PNEUMONIA PATIENT
OUTCOMES RESEARCH
TEAM SEVERITY
INDEX
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DRUG THERA
PY
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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
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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
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PREDISPOSING FACTORS
Acute / chronic illness
Comorbidities
supine
coma
Hypotension
aspiration
Prolonged hospitalization malnutrition
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INTERVENTION RELATED FACTORS
Agents R/T CNS depression
Impaired secretions removal
Thoracoabdominal procedure
Respiratory therapy devices , equipments
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COMMON ORGANISMS ARE…..Entero bacter species
E- coli
H.Influenza
Proteus
Serratia
P.Aeruginosa
MRSA , S.pneumonia
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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
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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
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KLEBSIELLA Greater in elder / alcoholics
Mortality – 40 – 50%
Tissue necrosis , bronchopneumonia , lung abscess , lobar consolidation
Cephalosporin , amino glycosides ,, Antipseudomonal penicillin , monobactum , quinolones
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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
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ASPIRATION
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OPPURTUNISTIC INFECTION
Severe PEM
Chemo therapy
Radiation
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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
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CYTO MEGALO VIRUS
Particularly in transplant recipient , gives rise to latent infection .
Reactivation with shedding of infectious virus
Ganciclovir is recommended
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PATHOPHYSIOLOGY
Congestion
Red hepatisat
ion
Resolution
Grey hepatisat
ion
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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
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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
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Physical examination reveals ………………..
increased tactile fremitus
crackles
ego phony
whispered pectoriloquy
dullness on percussion
bronchial breath sounds
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DIAGNOSTIC STUDIES
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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
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COMPLICATIONS
Lung abscessPleural
effusion
Atelectasis
Respiratory failure ,shock
Peri , myocarditis
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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
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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
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IT MAY BE COMPLICATION OF…..
heart failure
TB
Pneumonia
pulmonary infection / embolus
bronchogenic carcinoma
nephrotic syndrome
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NORMAL PHYSIOLOGY
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EFFUSIONS CAN OCCUR DUE TO
heart failure
pulmonary embolisation
malignancy , TB
mesothelioma
hepatic hydrothorax , viral infection
parapneumonic effusion , AIDS
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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
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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
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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
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EMPYEMAIs a pleural effusion which contain pus , caused by
TB
pneumonia
lung abscess
infections of chest
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FIBROTHORAX
Complication of emphyema , in
which there is a fibrous fusion of
visceral and parietal pleura
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EFFUSION MAY BE……….
purulent
bloody
clear
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CLINICAL FEATURESProgressive dyspnea
Decreased movement of chest wall on affected side
Pleuritic pain
Dullness on percussion
Absent or decreased breath sounds
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ASSESSMENT
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THORACENTESIS - CHEMICAL
PLEURODESIS
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SURGICAL TREATMENT
pleurectomy Pleurx catheter
Pleuroperitoneal shunt
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EMPHYEMA
Accumulation of thick , purulent fluid
within pleural space often with fibrin
development and a loculated area
where infection is located
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PATHOPHYSIOLOGYFluid is thin with low leukocyte count
Fibro purulent stage
Loculated emphyema
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MANAGEMENTNeedle aspiration
Tube thoracotomy
Open chest drainage via thoracotomy
decortications
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NURSING MANAGEMENT
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