Pneumonia and bronchiectasis
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Questions and Answers

What defines pneumonia?

  • A chronic infection of the upper respiratory tract
  • A mild inflammation of the bronchial tree
  • An infection limited to the pleural space
  • An acute infection that inflames the air sacs in the lungs (correct)

    • What is the primary difference between community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP)?

  • HCAP generally involves more resistant organisms than CAP (correct)
  • CAP occurs in hospitals, while HCAP occurs in the community
  • HCAP is caused only by viral pathogens
  • CAP leads to higher mortality than HCAP

    • What is the second most common cause of pneumonia according to the data from 2011-2013?

  • Klebsiella (correct)
  • E. coli
  • Chlamydia pneumoniae
  • Anaerobic bacteria

    • What type of pneumonia is primarily caused by anaerobic bacteria?

    <p>Aspiration pneumonia</p> Signup and view all the answers

    Which organism is the third most common cause of pneumonia from 2011 to 2013?

    <p>Pseudomonas aeruginosa</p> Signup and view all the answers

    Which of the following is NOT a clinical presentation of bacterial pneumonia?

    <p>Chronic cough</p> Signup and view all the answers

    The presence of pleural fluid in pneumonia warrants which of the following interventions?

    <p>Thoracentesis</p> Signup and view all the answers

    What complication of pneumonia involves accumulated pus in the pleural spaces?

    <p>Empyema</p> Signup and view all the answers

    What physical condition results from increased viscosity and resistance in the pulmonary system?

    <p>Cor-pulmonale</p> Signup and view all the answers

    Which symptom requires a doctor visit in the management of bronchiectasis?

    <p>Uncontrolled hemoptysis</p> Signup and view all the answers

    Which of the following organisms was the most frequently identified cause of pneumonia from 2011 to 2013?

    <p>E coli</p> Signup and view all the answers

    Name one anaerobic bacterium that is associated with pneumonia.

    <p>Any anaerobic bacteria (e.g., Bacteroides or Clostridium)</p> Signup and view all the answers

    The organism ____________ is the second most common cause of pneumonia according to the data from 2011-2013.

    <p>Klebsiella</p> Signup and view all the answers

    Identify one comorbidity that is a risk factor for pneumonia.

    <p>Congestive heart failure (CHF) or any other listed comorbidity</p> Signup and view all the answers

    Pleural effusion is a risk factor that can lead to pneumonia.

    <p>True</p> Signup and view all the answers

    What hematocrit level indicates polycythemia?

    <blockquote> <p>55%</p> </blockquote> Signup and view all the answers

    What is a common medication used as a mucolytic agent to loosen sputum?

    <p>N-acetylcysteine</p> Signup and view all the answers

    Chronic sinusitis can present with nasal _____ as a symptom.

    <p>polyps</p> Signup and view all the answers

    What test can help determine the specific bacterial pathogen involved in pneumonia?

    <p>Sputum culture and sensitivity test</p> Signup and view all the answers

    In viral pneumonia, the initial route of infection is through __________.

    <p>droplets</p> Signup and view all the answers

    Hypoxia or insufficient oxygen can lead to __________ in patients with pneumonia.

    <p>cyanosis</p> Signup and view all the answers

    What laboratory finding typically increases in pneumonia?

    <p>Increased CRP levels</p> Signup and view all the answers

    During which stage of bacterial pneumonia is the presence of abundant fibrin and a decrease in polymorphonuclear leukocytes observed?

    <p>Gray hepatization stage</p> Signup and view all the answers

    Name one clinical presentation of bacterial pneumonia.

    <p>Fever</p> Signup and view all the answers

    In bacterial pneumonia, the presence of ___ fluid may indicate the need for a thoracentesis.

    <p>pleural</p> Signup and view all the answers

    What type of cough is commonly associated with bacterial pneumonia?

    <p>Cough with purulent sputum</p> Signup and view all the answers

    The ___ stage of bacterial pneumonia involves the resolution of exudate and presence of macrophages.

    <p>Resolution</p> Signup and view all the answers

    Which symptom is commonly assessed through auscultation in pneumonia patients?

    <p>Presence of crackles</p> Signup and view all the answers

    Which of the following is a major risk factor for nosocomial pneumonia?

    <p>Improper handling by healthcare professionals</p> Signup and view all the answers

    Ventilator Associated Pneumonia (VAP) can occur within 48 hours after intubation.

    <p>True</p> Signup and view all the answers

    What is one method to improve personal hygiene to prevent pneumonia?

    <p>Washing hands</p> Signup and view all the answers

    The head of the bed should be elevated to __________ degrees to help prevent VAP.

    <p>30-45</p> Signup and view all the answers

    Match the following aspects of VAP prevention with their descriptions:

    <p>Daily oral care = Prevention of biofilm formation Sedative interruption = Readiness assessment for extubation Maintaining airway pressure = Minimize mechanical ventilation complications Early mobilization = Promotes lung function and circulation</p> Signup and view all the answers

    Which of the following is NOT a component of the VAP prevention bundle?

    <p>Routine suctioning of all patients</p> Signup and view all the answers

    Aspiration through microchannels to the lung is a significant part of VAP pathogenesis.

    <p>True</p> Signup and view all the answers

    What does the acronym ATS stand for in relation to pneumonia definitions?

    <p>American Thoracic Society</p> Signup and view all the answers

    Improvement in __________ is essential to prevent pneumonia.

    <p>body resistance</p> Signup and view all the answers

    Which of these might enhance colonization of the oropharynx in patients at risk for VAP?

    <p>Mechanical intubation</p> Signup and view all the answers

    Explain how the immune response contributes to the pathophysiology of pneumonia.

    <p>The immune response involves macrophages recognizing pathogens, leading to the release of inflammatory cytokines and the accumulation of white blood cells and edema in the alveoli.</p> Signup and view all the answers

    What are common vital sign abnormalities indicative of sepsis in pneumonia patients?

    <p>Common abnormalities include low blood pressure, increased respiratory rate, and elevated heart rate.</p> Signup and view all the answers

    Discuss the role of sputum culture and sensitivity tests in the diagnosis of pneumonia.

    <p>Sputum culture identifies the specific pathogen causing pneumonia, while sensitivity tests determine the most effective antibiotics for treatment.</p> Signup and view all the answers

    Describe how viral pneumonia leads to secondary bacterial infections.

    <p>Viral pneumonia causes damage to ciliated cells, impairing the mucociliary clearance, which makes the lungs susceptible to superimposed bacterial infections.</p> Signup and view all the answers

    What is the significance of the consolidation stage in bacterial pneumonia?

    <p>Consolidation refers to the filling of alveoli with fluid, white blood cells, and debris, which impairs gas exchange and contributes to symptoms like dyspnea.</p> Signup and view all the answers

    What lifestyle habit is identified as a risk factor for pneumonia alongside smoking?

    <p>Alcoholism</p> Signup and view all the answers

    Name a comorbidity associated with an increased risk of pneumonia related to lung health.

    <p>COPD</p> Signup and view all the answers

    According to the data from 2011-2013, which organism is listed as the second leading cause of pneumonia?

    <p>Klebsiella</p> Signup and view all the answers

    Identify one type of bacterial pneumonia caused by an organism that requires anaerobic conditions.

    <p>Aspiration pneumonia</p> Signup and view all the answers

    List a factor related to health care that can increase the risk of pneumonia in hospitalized patients.

    <p>Surgery</p> Signup and view all the answers

    What is a significant risk factor related to living conditions that can contribute to pneumonia?

    <p>Residence in a nursing home</p> Signup and view all the answers

    What role does prolonged wound care play in the development of pneumonia in patients?

    <p>It can lead to increased exposure to pathogens.</p> Signup and view all the answers

    Name another infectious agent, besides bacteria, that is mentioned as a cause of pneumonia.

    <p>Fungi</p> Signup and view all the answers

    What factors can improve body resistance against pneumonia?

    <p>A balanced diet, regular exercise, and adequate sleep can improve body resistance.</p> Signup and view all the answers

    Describe the significance of VAP in mechanically ventilated patients.

    <p>VAP is significant because it is the second most common infection in ICU patients and increases ICU stay duration.</p> Signup and view all the answers

    What role does health care professional handling play in nosocomial pneumonia risk?

    <p>Improper handling by healthcare professionals is a major risk factor for nosocomial pneumonia.</p> Signup and view all the answers

    What are two components of the VAP prevention bundle?

    <p>Elevation of the head of the bed and daily oral care with chlorhexidine are two components.</p> Signup and view all the answers

    How can aspiration contribute to the pathogenesis of VAP?

    <p>Aspiration allows secretions to reach the lungs through microchannels, leading to infection.</p> Signup and view all the answers

    What daily assessment is crucial for ventilated patients to prevent VAP?

    <p>Daily assessment of readiness to extubate helps ensure appropriate sedation management.</p> Signup and view all the answers

    Identify a risk factor related to supine positioning that can enhance pneumonia risk.

    <p>Supine positioning favors aspiration into the respiratory tract, increasing the risk of pneumonia.</p> Signup and view all the answers

    What is the recommended angle for head elevation in VAP prevention?

    <p>The head of the bed should be elevated at an angle of 30°-45°.</p> Signup and view all the answers

    What adaptive response occurs in the lungs due to hypoxia?

    <p>Pulmonary vasoconstriction and blood redistribution to well-ventilated segments.</p> Signup and view all the answers

    At what hematocrit level is polycythemia indicated in patients?

    <p>A hematocrit level greater than 55%.</p> Signup and view all the answers

    What are two potential complications of chronic hypoxemia?

    <p>Cor pulmonale and respiratory failure.</p> Signup and view all the answers

    Name one medication used to manage sputum in patients with bronchiectasis.

    <p>N-acetylcysteine (NAC).</p> Signup and view all the answers

    What symptom indicates the need for increased home chest physiotherapy frequency?

    <p>Acute exacerbation of respiratory symptoms.</p> Signup and view all the answers

    What physical condition results primarily from increased viscosity and resistance in the pulmonary system?

    <p>Cor pulmonale.</p> Signup and view all the answers

    Explain the role of bronchial artery embolization in the management of massive hemoptysis.

    <p>It helps control bleeding by occluding the blood supply to the affected area.</p> Signup and view all the answers

    What is one key patient education topic for those managing bronchiectasis?

    <p>Recognizing when to seek medical attention for uncontrolled hemoptysis.</p> Signup and view all the answers

    How do crackles relate to the clinical presentation of bacterial pneumonia?

    <p>Crackles are abnormal lung sounds that commonly indicate fluid in the airways or alveoli, often associated with bacterial pneumonia.</p> Signup and view all the answers

    What is the primary medical management approach for a patient with bacterial pneumonia?

    <p>The primary medical management includes administering antibiotics, ensuring high fluid intake, and providing rest.</p> Signup and view all the answers

    What occurs during the red hepatization stage of bacterial pneumonia?

    <p>During the red hepatization stage, alveoli become filled with polymorphonuclear leukocytes, fibrin, and red blood cells.</p> Signup and view all the answers

    What is the significance of thoracentesis in the context of pneumonia?

    <p>Thoracentesis is performed to drain pleural fluid that may be present, which can indicate complications such as empyema.</p> Signup and view all the answers

    How does the resolution stage of bacterial pneumonia differ from previous stages?

    <p>In the resolution stage, areas of consolidation begin to resolve as macrophages digest the exudate and lung function improves.</p> Signup and view all the answers

    Identify one complication linked to bacterial pneumonia.

    <p>One complication of bacterial pneumonia is septicaemia, which can lead to systemic infection.</p> Signup and view all the answers

    What role does physiotherapy play in the management of pneumonia?

    <p>Physiotherapy aims to promote lung expansion and improve mucociliary clearance, aiding in recovery.</p> Signup and view all the answers

    How is hypoxemia diagnosed in patients with pneumonia?

    <p>Hypoxemia is diagnosed through assessment of arterial blood gases or pulse oximetry readings.</p> Signup and view all the answers

    What differentiating feature is assessed through auscultation to distinguish pneumonia from lung fibrosis?

    <p>Characteristically, pneumonia often presents with crackles or decreased breath sounds on auscultation.</p> Signup and view all the answers

    How can vaccination contribute to the prevention of bacterial pneumonia?

    <p>Vaccination helps to boost the immune response against specific bacterial pathogens, reducing incidence of pneumonia.</p> Signup and view all the answers

    Study Notes

    Pneumonia

    • Acute infection of air sacs in one or both lungs
    • Caused by: bacteria, viruses, fungi, parasites, or non-infectious causes (idiopathic interstitial pneumonia)
    • Air sacs contain fluid and pus
    • Trend: Decreasing cases but increasing deaths, with a higher death rate in men than women

    Types of Pneumonia

    • Community-acquired pneumonia (CAP): Develops outside of healthcare settings
    • Healthcare-associated pneumonia (HCAP): Develops in long-term care facilities
    • Healthcare-acquired pneumonia (HAP): Develops during or after a hospital stay
    • Ventilator-associated pneumonia (VAP): Develops after being on a ventilator
    • Aspiration pneumonia: Caused by aspiration of food, saliva, or gastric contents into the airways

    CAP vs HAP (Causative Organisms)

    • CAP: Most commonly caused by Streptococcus pneumoniae, Haemophilus influenzae, and Mycoplasma pneumoniae
    • HAP: Most commonly caused by Methicillin-resistant Staphylococcus aureus (MRSA), Enteric gram-negative bacteria (e.g., E coli, Proteus, Enterobacter, Klebsiella, Serratia spp.), Chlamydia pneumoniae, Pseudomonas aeruginosa, and Anaerobic bacteria

    CAP vs HAP (Risk Factors)

    • CAP: Smoking, alcoholism, COPD, congestive heart failure (CHF), immunocompromise, seizures, dementia
    • HAP: Hospitalization longer than 5 days, previous infection with resistant organisms, surgery, pleural effusion, chemotherapy, dialysis, prolonged wound care, and residence in a nursing home

    Types of Pneumonia (Based on Affected Sites)

    • Crackles: CXR may show minor infiltrates to severe bilateral involvement, less frequent consolidations, and pleural effusion. Often secondary to bacterial infections, leading to productive cough

    Bacterial Pneumonia

    • Timeline:

      • Engorgement stage: First few days of infection, vascular engorgement, serious exudation, bacterial colonization
      • Red hepatisation stage: 2-4 days, Diapedesis of RBC, alveoli fill with polymorphonuclear leukocytes, fibrin, and RBC. Fluid exudate and organisms continue to multiply
      • Gray hepatisation stage: 4-8 days, Abundant fibrin, decreased polymorphonuclear leukocytes, and dead bacteria. Consolidation continues
      • Resolution stage: After 8 days, Consolidation resolves. Macrophages and enzymatic digestion of exudate occur

    • Clinical presentation: Fever, dyspnoea, tachypnea and tachycardia, hypoxemia, cough with purulent sputum, pleuritic chest pain, decreased chest expansion, muscle splinting, decreased/ absent breath sounds, wheezing, crackles

    • CXR: Atelectasis, infiltrates and consolidation

    Causes of Atelectasis

    • Airway obstruction: Compressed by a tumor, abnormal tissues, or a foreign body.
    • Hypoventilation: Usually occurs post-operatively
    • Fibrosis and chronic inflammation: Chronic pneumonia

    Pneumonia Medical Management

    • Antibiotics (tablet or IV)
    • Medications to reduce fever and inflammation
    • Increased fluid intake
    • Ultrasonic nebulization (for improved breathing)
    • Supplementary oxygen (for severe cases)

    Physiotherapy Management Goals (Pneumonia)

    • Reversing alveolar hypoventilation
    • Increasing ventilation/perfusion matching
    • Minimizing effects of impaired mucociliary transport
    • Augmenting mucociliary clearance
    • Minimizing effects of increased mucous production
    • Reducing sputum retention
    • Optimizing lymphatic drainage of the lungs
    • Promoting lung expansion

    CXR Image

    • RUL: Right upper lobe
    • LtUL & Lingula: Left upper lobe and lingula

    Complications of Pneumonia

    • Lung fibrosis
    • Cavitary lesion with lung abscess (postural drainage may be required)
    • Pleural effusion
    • Empyema (pus in the pleural spaces)
    • Septicemia
    • Respiratory failure (needing mechanical ventilation)

    Differentiating Pneumonia and Lung Fibrosis

    • Pneumonia: Inspiratory crackles that can be altered by coughing
    • Lung Fibrosis: Inspiratory crackles that are not altered by coughing

    Pneumonia Prevention

    • Improve body resistance
    • Improve personal hygiene
    • Avoid crowded areas
    • Wear masks if suffering from respiratory symptoms
    • Wash hands

    VAP (Ventilator Associated Pneumonia)

    • Definition: Pneumonia that occurs at the time of intubation and ventilation or within 48 hours.
    • Importance: Common in mechanically ventilated patients, second most common infection in ICUs, and increases length of stay in ICU
    • Preventable:

    Risk Factors For Nosocomial Pneumonia

    • Major: Improper handling by healthcare professionals, enhancing colonization of the oropharynx or stomach.
    • Contributing factors:
      • Mechanical intubation
      • Administration of antibiotics
      • Underlying chronic lung disease
      • Supine position
      • Nasogastric tube placement
      • Immobilisation
      • Surgery of the head, neck, thorax, or upper abdomen
      • *Coma

    Pathogenesis of VAP

    • Pooling of secretions through microchannels to the lung under suction (ETT)
    • Aspiration through microchannels to the lung
    • Biofilm formation
    • Intubation procedures
    • Contaminated respiratory equipment

    VAP Prevention Bundle

    • Elevation of Head of Bed (30-45 degrees)
    • Daily sedative interruption and assessment of readiness to extubate
    • Daily oral care with chlorhexidine
    • Maintain airway pressure (PEEP, minimize MHI, avoid routine suction)
    • Peptic ulcer disease and deep venous thrombosis prophylaxis
    • Promote early mobilization

    Bronchiectasis

    • Dilated and damaged airways, leading to chronic inflammation and recurrent infections

    Causes and Risk Factors

    • Common causes: Cystic fibrosis, primary ciliary dyskinesia, immunodeficiency, chronic lung diseases, pneumonia.
    • Other risk factors: Smoking, air pollution, genetic predisposition

    Clinical Manifestations

    • Respiratory symptoms: Chronic productive cough, dyspnoea, hemoptysis (coughing up blood), recurrent chest infections
    • Physical examination: Digital clubbing, cyanosis, plethora (increased red blood cells), weight loss, nasal polyps, signs of cor-pulmonale (right heart failure)
    • Radiographic findings: Bronchiectasis is visible on CXR, CT is better at identifying the extent and nature of the disease

    Consequences of Bronchiectasis

    • Recurrent chest infections
    • Pneumonia
    • Lung abscess
    • Empyema
    • Septicemia
    • Chronic hypoxemia
    • Cor-pulmonale
    • Respiratory failure

    Management of Bronchiectasis

    • Antibiotics: Long-term antibiotics are often necessary to prevent and treat infections, e.g., Azithromycin.
    • Mucolytics: To thin the sputum and improve airway clearance, e.g., N-acetylcysteine (NAC), ambroxol, sobrerol, carbocysteine
    • Trasmine: To control active bleeding
    • Bronchial artery embolization: For massive hemoptysis
    • Oxygen therapy: For hypoxemia
    • Chest physiotherapy: Airway clearance techniques (including postural drainage, percussion), breathing retraining, dyspnea management, and physical reconditioning
    • Patient education: Self-management skills (medication, chest physiotherapy), recognizing signs of exacerbations, when to seek medical attention

    Pneumonia

    • Common causative organisms: E. coli, Klebsiella, Pseudomonas aeruginosa, Mycoplasma pneumoniae, Chlamydia pneumoniae, Proteus, Enterobacter, Serratia spp.

    • Risk Factors:

      • Habits: Smoking, Alcoholism
      • Hospitalisation: More than 5 days, previous infection with resistant organisms, surgery, pleural effusion, chemotherapy, dialysis, prolonged wound care, residence in a nursing home
      • Other Comorbidities: COPD, Congestive Heart Failure (CHF), Immunocompromise, Seizures, Dementia

    Types of Pneumonia

    • Cyanosis: Caused by hypoxia

    Pathophysiology of Pneumonia

    • Multiplication of Pathogen: Bacterial pathogen escapes respiratory defenses and multiplies within the alveoli and airways
    • Intense Immune and Inflammatory Response: Macrophages in the lower airways and alveoli recognize pathogens
    • Consolidation: Inflammatory cytokines, white blood cells, and edema flood the alveoli and bronchi
    • Hypoxia: V/Q mismatch
    • Spreading: Infection may spread to the bloodstream (bacteremia and sepsis), pleura (empyema), or other organs (e.g., meningitis)

    Diagnosis

    • Physical Signs: Abnormal chest X-ray, fever, tachycardia, low blood pressure, desaturation, increased respiratory rate
      • Low blood pressure and increased respiratory rate may indicate sepsis
    • Laboratory Tests:
      • Increased white blood cell count in complete blood count (CBC)
      • Increased C-reactive protein (CRP) (normal: 0.25 ng/mL) indicates infection
      • Sputum culture and sensitivity test (C/ST)
    • Imaging:
      • CT thorax - to rule out pulmonary embolism and other respiratory conditions
      • Well's Score - to rule out deep vein thrombosis (DVT)
      • Bronchoscopy and Bronchoalveolar Lavage (BAL) for aspiration and testing

    Viral Pneumonia

    • Route of Infection: Droplet
    • Frequent Site of Infection: Ciliated cells of the respiratory tract

    Pathophysiology of Viral Pneumonia

    • Ciliated cells become paralyzed and degenerate leading to:
      • Necrosis and desquamation
      • A thin layer of non-ciliated basal replacement cells in the mucociliary blanket
      • Inflammatory responses leading to exudation of fluid and erythrocytes in both the alveolar space and airways
      • Formation of intra-alveolar hyaline membrane leading to congestion (alveoli filled with blood) and edema
      • Involved lung is susceptible to superimposed bacterial infections

    Clinical Presentation of Viral Pneumonia

    • Fever
    • Dyspnea
    • Persistent, non-productive cough
    • Auscultation: Scattered inspiratory crackles
    • Chest X-ray: Minor infiltrates to severe bilateral involvement, less frequent consolidations, and pleural effusion
    • Secondary bacterial infections often lead to productive cough

    Medical Management of Viral Pneumonia

    • Rest and sleep
    • High fluid intake and good nutrition
    • Reduced stress
    • Prevention: Receive vaccine

    Bacterial Pneumonia

    • Types:

      • Primary Infection: Pneumococcal origin
      • Secondary Infection: When the patient's defense system is ineffective

    • Presence of Pleural Fluid: Thoracentesis may be required

    Stages of Bacterial Infection of Lung Tissues

    • Engorgement Stage (First Few Days): Vascular engorgement, serious exudation, bacterial colonization
    • Red Hepatization Stage (Within 2-4 Days): Diapedesis of RBC, alveoli full of polymorphonuclear leukocytes, fibrin and RBC, fluid exudate and organisms continue to multiply, areas of consolidation become evident
    • Gray Hepatization Stage (Within 4-8 Days): Abundant fibrin, decreased polymorphonuclear leukocytes and dead bacteria, consolidation continues
    • Resolution Stage (After 8 Days): The area of consolidation begins to resolve, macrophages and enzymatic digestion of exudate are present, affected tissue with a large amount of grayish-red fluid within the alveoli, chest physiotherapy for removal of secretion, continues for 2-3 weeks, lung returns to a more normal appearance

    Clinical Presentation of Bacterial Pneumonia

    • Fever
    • Dyspnea
    • Tachypnea (increased respiratory rate) and tachycardia (increased heart rate)
    • Hypoxemia (low blood oxygen)
    • Cough with purulent sputum (containing pus)
    • Pleuritic chest pain over the affected lung field
    • Physical examination: Decreased chest expansion over the affected area and muscle splinting
    • Auscultation: Decreased/absent breath sounds, wheeze, or crackles
    • Chest X-ray: Atelectasis, infiltrates, and consolidation

    Causes of Atelectasis

    • Airway obstruction (absorption atelectasis): Compressed by tumor, abnormal tissues, foreign body, or secretion
    • Hypoventilation, usually post-operative
    • Fibrosis and chronic inflammation (chronic pneumonia)

    Medical Management of Bacterial Pneumonia

    • Antibiotics (tablet/IV)
    • Medication
    • Increased fluid intake
    • Ultrasonic nebulization: Helps to breathe better
    • Supplementary oxygen if symptoms are severe

    Physiotherapy Management of Pneumonia (Goals)

    • Reversing alveolar hypoventilation
    • Increasing ventilation/perfusion matching
    • Minimizing the effects of impaired mucociliary transport
    • Augmenting mucociliary clearance
    • Minimizing the effects of increased mucus production
    • Reducing sputum retention
    • Optimizing lymphatic drainage of the lungs
    • Promoting lung expansion

    Chest X-ray

    • Right Upper Lobe (RUL)
    • Left Upper Lobe (LtUL) & Lingula

    Complications of Pneumonia

    • Lung fibrosis
    • Cavitary lesion with lung abscess (requires postural drainage)
    • Pleural effusion
    • Empyema: Pus (infection) in the pleural spaces
    • Septicemia (blood poisoning)
    • Respiratory failure - May require mechanical ventilation

    Differentiating Pneumonia and Lung Fibrosis by Auscultation

    Pneumonia Lung Fibrosis
    Inspiratory crackles Inspiratory crackles
    Quality can be altered by cough Quality X be altered by cough

    Prevention of Pneumonia

    • Improve body resistance
    • Improve personal hygiene
    • Avoid crowded areas
    • Wear masks if suffering from respiratory symptoms
    • Wash hands

    Ventilator-Associated Pneumonia (VAP)

    • Definition:

      • CDC: Pneumonia occurring in intubated and ventilated patients or within 48 hours of intubation
      • ATS (American Thoracic Society) and IDSA (Infectious Diseases Society of America): Arise > 48-72 hours after intubation

    • Importance: Common in mechanically ventilated patients, second most common infection in the ICU, increases length of stay in the ICU, preventable

    Risk factors for Nosocomial (Hospital-Acquired) Pneumonia

    • Major:
      • Improper handling by healthcare professionals
      • Enhancing colonization of the oropharynx or stomach
        • Mechanical intubation
        • Administration of antibiotics
        • Underlying chronic lung disease
    • Favoring Aspiration into the Respiratory Tract/Reflux from the GI Tract:
      • Supine position
      • Nasogastric tube placement
      • Immobilisation
      • Surgery of the head, neck, thorax, or upper abdomen
      • Coma

    Pathogenesis of VAP

    • Pooling of secretion: Through microchannels to the lung, often under suction
      • Endotracheal tube (ETT)
      • Tracheostomy
    • Aspiration: Through microchannels to the lung
    • Biofilm formation
    • Intubation procedures
    • Contaminated respiratory equipment

    VAP Prevention Bundle

    1. Elevation of the Head of the Bed 30°-45°: Avoid supine positioning
    2. Daily Sedative Interruption and Daily Assessment of Readiness to Extubate
    3. Daily Oral Care with Chlorhexidine
    4. Maintain Airway Pressure:
      • Maintenance of Positive End-Expiratory Pressure (PEEP) and minimize manual lung hyperinflation (MHI)
      • Avoid routine suctioning and keep suction pressure and duration to a minimum.
    5. Peptic Ulcer Disease and Deep Venous Thrombosis Prophylaxis
    6. Promote Early Mobilization
    • Digital clubbing (in advanced pulmonary cases)
    • Cyanosis and plethora with polycythemia (increased red blood cell mass) from chronic hypoxia
      • Hypoxemia: Pulmonary vasoconstriction + redistribution of blood to optimally ventilated lung segments (an adaptive vasomotor response).
      • Polycythemia: Check hematocrit (ratio of RBC to total blood volume) >55% and hemoglobin level (F: >16.5g/dL and M: >18.5g/dL
    • Wasting and weight loss
    • Nasal polyps and signs of chronic sinusitis
    • Physical stigmata of cor-pulmonale (right heart failure) in advanced disease:
      • Increased viscosity (polycythemia) and increased resistance (hypoxia) leads to extra work for the heart to pump blood through the lungs. This causes the right ventricle of the heart to work harder, leading to increased pressure, dilation, and bulging.

    CT Findings

    • Bronchiectasis: Abnormal, widened airways caused by inflammation and infection.
    • Consequences of Bronchiectasis:
      • Recurrent chest infections
      • Pneumonia
      • Lung abscess
      • Empyema
      • Septicemia
      • Chronic hypoxemia leading to cor-pulmonale
      • Respiratory failure

    Management of Bronchiectasis

    • Antibiotics: e.g., azithromycin
    • Mucolytic agents: To loosen sputum, e.g., N-acetylcysteine (NAC), ambroxol, sobrerol, and carbocysteine
    • Tranexamic acid: For cases with active bleeding
    • Bronchial artery embolization: For massive hemorrhage
    • Hypoxemia: Oxygen therapy
    • Chest Physiotherapy:
      • Airway clearance techniques + home management (home postural drainage and percussion)
      • Prescription of adjuncts, e.g., flutter, acapella for self-management
      • Breathing retraining
      • Dyspnea management
      • Oxygen therapy
      • Physical reconditioning
    • Patient Education:
      • Self-management skills
      • When to take tranexamic acid/antibiotics for prophylaxis
      • When to increase the frequency of home chest physiotherapy
      • When to visit a doctor: Acute exacerbation and uncontrolled hemoptysis
      • Appropriate physical training

    Pneumonia

    • Causes: Bacterial (e.g., E. coli, Klebsiella, Pseudomonas aeruginosa), viral, fungal, and anaerobic bacteria
    • Risk factors: Smoking, alcoholism, COPD, CHF, immunocompromise, previous infections with resistant organisms, hospitalization for more than 5 days, surgery, pleural effusion, chemotherapy, dialysis, prolonged wound care, residence in a nursing home
    • Pathophysiology:
      • Bacterial pathogens multiply in alveoli and airways.
      • Macrophages trigger an inflammatory response.
      • Consolidation occurs as inflammatory cytokines, white blood cells, and edema flood the alveoli and bronchi.
      • Hypoxia: V/Q mismatch.
      • Infection can spread to the bloodstream (bacteremia and sepsis), pleura (empyema), or other organs (e.g., meningitis).
    • Diagnosis:
      • Abnormal CXR, vital signs (fever, tachycardia, low BP, desaturation, and increased respiratory rate).
      • Elevated WBC count in CBP/CBC, elevated CRP.
      • Sputum culture and sensitivity test.
      • FOB fiberoptic bronchoscopy.
      • Rule out pulmonary embolism and other conditions with CT thorax.
      • Rule out DVT with Wells' score.
      • Aspiration and testing with bronchoscopy and BAL.

    Viral Pneumonia

    • Route of infection: Droplets
    • Frequent site of infection: Ciliated cells of the respiratory tract
    • Pathophysiology:
      • Ciliated cells become paralyzed and degenerate.
      • Necrosis and desquamation occur.
      • A thin layer of non-ciliated basal replacement cells form in the mucociliary blanket.
      • Inflammatory responses lead to fluid and erythrocyte exudation in the alveolar space and airways.
      • Intra-alveolar hyaline membrane forms, causing congestion and edema.
      • Susceptible to superimposed bacterial infections.
    • Clinical presentation:
      • Fever, dyspnea, persistent non-productive cough, scattered inspiratory crackles on auscultation.
      • CXR shows infiltrates, severe bilateral involvement, less frequent consolidations, and pleural effusion.
      • Secondary bacterial infections can lead to a productive cough.
    • Medical management: Rest, sleep, high fluid intake, good nutrition, reduced stress, and vaccination.

    Bacterial Pneumonia

    • Types: Primary (e.g., pneumococcal origin) and secondary (when the patient's defense system is ineffective).

    • Stages:

      • Engorgement stage: Vascular engorgement, serious exudation, bacterial colonization.
      • Red hepatization stage: Diapedesis of RBCs, alveoli full of polymorphonuclear leukocytes, fibrin, and RBCs. Fluid exudate and organisms continue to multiply. Areas of consolidation become evident.
      • Gray hepatization stage: Abundant fibrin, decreased polymorphonuclear leukocytes, and dead bacteria. Consolidation continues.
      • Resolution stage: Areas of consolidation begin to resolve. Macrophages and enzymatic digestion of exudate is present. Lung returns to a more normal appearance over 2-3 weeks.

    • Clinical presentation: Fever, dyspnea, tachypnea, tachycardia, hypoxemia, cough with purulent sputum, pleuritic chest pain, decreased chest expansion over the affected area and muscle splinting, decreased or absent breath sounds, wheezes or crackles on auscultation, CXR showing atelectasis, infiltrates, and consolidation.

    • Causes of atelectasis: Airway obstruction, hypoventilation, fibrosis, and chronic inflammation.

    • Medical management: Antibiotics (tablet/IV), medication, increased fluid intake, ultrasonic nebulization, supplementary oxygen.

    Physiotherapy Management (Pneumonia)

    • Goals: Reverse alveolar hypoventilation, increase ventilation/perfusion matching, minimize the effects of impaired mucociliary transport, augment mucociliary clearance, minimize the effects of increased mucus production, reduce sputum retention, optimize lymphatic drainage of the lungs, and promote lung expansion.
    • Interventions: Airway clearance techniques, chest physiotherapy, breathing retraining, dyspnea management, oxygen therapy, and physical reconditioning.

    Ventilator-Associated Pneumonia (VAP)

    • Definition: Pneumonia that occurs in intubated and ventilated patients within 48 hours (CDC) or 48-72 hours (ATS and IDSA).
    • Importance: Common in mechanically ventilated patients, second most common infection in the ICU, and increases length of stay in the ICU.
    • Risk factors:
      • Major: Improper handling by healthcare professionals, enhancing colonization of the oropharynx/stomach (mechanical intubation, administration of antibiotics, underlying chronic lung disease), favoring aspiration into the respiratory tract/reflux from the GI tract (supine position, nasogastric tube placement, immobilization, surgery of the head/neck/thorax/upper abdomen, coma).
    • Pathogenesis: Secretion pooling, aspiration, biofilm formation, intubation procedures, and contaminated respiratory equipment.
    • VAP prevention bundle: Elevation of the head of the bed (30-45 degrees), daily sedative interruption and assessment of readiness to extubate, daily oral care with chlorhexidine, maintenance of airway pressure (PEEP, minimize MHI, avoid routine suction, keep suction pressure low and duration short), peptic ulcer disease and deep venous thrombosis prophylaxis, and promote early mobilization.
    • Physiotherapy aspects to prevent VAP: Digital clubbing, cyanosis and plethora with polycythemia, wasting and weight loss, nasal polyps, signs of chronic sinusitis, physical stigmata of cor pulmonale.

    Bronchiectasis

    • Definition: Irreversible dilation of the bronchi, often associated with chronic lung infections.
    • Causes: Cystic fibrosis, primary ciliary dyskinesia, immunodeficiency, infections (e.g., tuberculosis, pertussis), aspiration, and autoimmune diseases.
    • Clinical presentation: Recurrent chest infections, dyspnea, cough (with copious sputum), hemoptysis, digital clubbing, cyanosis, weight loss.
    • CT findings: Dilated bronchi, bronchial wall thickening, mucus plugging, and atelectasis.
    • Consequences: Recurrent chest infections, pneumonia, lung abscess, empyema, septicemia, chronic hypoxemia (leading to cor pulmonale), and respiratory failure.
    • Management: Antibiotics, mucolytic agents, transamine, bronchial artery embolization, oxygen therapy, chest physiotherapy, breathing retraining, dyspnea management, physical reconditioning, and patient education.

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    Pneumonia Lecture Notes PDF

    Description

    This quiz covers the fundamentals of pneumonia, including its definition, causes, and the various types such as community-acquired and healthcare-associated pneumonia. It also contrasts the causative organisms for community-acquired pneumonia versus healthcare-acquired pneumonia, highlighting key statistics and trends regarding this condition.

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