PNEUMONIA AND
PLEURAL
EFFUSION
DEFINITION
Is 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
ETIOLOGY
Normally airway distal to larynx is sterile
because of protective defense mechanism
These includes
Filtration
of air
,macropha
ges
Epiglottis
closure
over
trachea
Warming ,
humidification
inspired air
Cough
reflex ,
IgA
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
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
drugs
Bed rest ,
prolonged
immobility
Feeding via NG
tubes
Head injury
seizures , drug
overdose
Tracheal
intubation
Chronic
dx
ACQUISITION OF ORGANISMS
Aspiration
Inhalation
Hematogenous
CLASSIFICATION
Typical
Oppur
tunistic
Atypical
Anaerobic
VAP/HAP
Opport
unistic
CATEGORY
Aspiration
CAP
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
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
lobar
Broncho
pneumonia
forms
TREATMENT
Cefotaxime /
ceftriazone
Antipseudomonal
fluroquinolones
Levofloxacin
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.
CONT……….
Sore throat , pleuritic pain
Ear ache
myalgia
Nasal congestion , pharyngitis
interstitial infiltrate = CXR
Doxycyclin , macrolides
fluroquinolones
Aseptic
meningitis
Meningo
encephalitis
Comp
lication
Transverse
myelitis
Peri ,
myocardits
Cranial nerve
plasty
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
LEGIONNAIRE DISEASE
High in smokers /
immunosuppressive therapy
Epidemic / sporadic
Lobar
consolidatio
n
Broncho
pneumonia
flu
Summerhigh
TREATED WITH…………..
• Erythromycin , Rifampin
• clarithromycin
• Macrolides
• fluroquinolones
CHLAMYDIAL PNEUMONIA
Single infiltrate on chest x-ray
Pleural effusion , upper respiratory tract infection
Tetracyclin , erythromycin
Complication include acute
respiratory failure
VIRAL
PNEUMONIA
Influenza 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
CONT..
Acute stage – within
ciliated cells
Infiltration of tracheo
bronchial trees
Extends into alveolar
area – edema ,
exudation
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
PNEUMONIA
PATIENT OUTCOMES
RESEARCH TEAM
SEVERITY INDEX
DRUG
THERAPY
HOSPITAL ACQUIRED , VENTILATOR
ASSOCIATED , HEALTH CARE ASSOCIATED
PNEUMONIA
HAP 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
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
PREDISPOSING FACTORS
Acute /
chronic illness
coma
Co
morbidities
supine
Hypo
tension
aspiration
Prolonged
hospitalization
malnutrition
INTERVENTION RELATED
FACTORS
Agents R/T CNS
depression
Impaired
secretions
removal
Thoraco Respiratory
therapy
abdominal devices ,
procedure equipments
COMMON ORGANISMS ARE…..
Entero bacter species
E- coli
H.Influenza
Proteus
Serratia
P.Aeruginosa
MRSA , S.pneumonia
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
STAP.AUREUS
Severe 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
KLEBSIELLA
Greater in elder / alcoholics
Mortality – 40 – 50%
Tissue necrosis , bronchopneumonia , lung
abscess , lobar consolidation
Cephalosporin , amino glycosides ,,
Antipseudomonal penicillin , monobactum ,
quinolones
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
ASPIRATION
Inert substance – barium
Mechanical airway obstruction
Toxics – gastric juices – chemical injury
48 – 72 hrs – chemical pneumonitis
Bacterial infection
Food , water , vomitus , toxics
OPPURTUNISTIC INFECTION
Severe PEM
Immuno
deficiency
Immuno
Suppression
Chemo
therapy
Radiation
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
CYTO MEGALO VIRUS
Particularly in transplant recipient , gives rise
to latent infection .
Reactivation with shedding of infectious virus
Ganciclovir is recommended
PATHOPHYSIOLOGY
Congestion
Red
hepatisation
Resolution
Grey
hepatisation
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
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
Physical examination reveals ………………..
increased tactile fremitus
crackles
ego phony
whispered pectoriloquy
dullness on percussion
bronchial breath sounds
DIAGNOSTIC STUDIES
History collection , physical examination
Chest X-Ray
lab
Microbiology
serology
ABG
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
COMPLICATIONS
Lung
abscess
Pleural
effusion
Atelectasis
Respiratory
failure
,shock
Peri ,
myocarditis
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
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
IT MAY BE COMPLICATION OF…..
heart failure
TB
Pneumonia
pulmonary infection / embolus
bronchogenic carcinoma
nephrotic syndrome
NORMAL PHYSIOLOGY
Fluid enters pleural space from capillary in parietal pleura
Removed by lymph situated in parietal pleura
Fluid also enter pleural space from interstial space of lung
Via visceral pleura / peritoneum via small holes in diaph
Lymph can absorb 20 times more fluid than is normally formed
So , either excess formation / impaired lymph absorption
EFFUSIONS CAN OCCUR DUE TO
heart failure
pulmonary embolisation
malignancy , TB
mesothelioma
hepatic hydrothorax , viral infection
parapneumonic effusion , AIDS
CHYLOTHORAX
Occurs 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
HEMOTHORAX
When 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
T YPES
TRANSUDATE
Primarily non inflammatory
conditions and is an
accumulation of protein
poor , cell poor fluid
EXUDATE
Accumulation of fluid in the area
of inflammation
Results from increased capillary
permeability
Occurs secondary to
Hydro thoraces caused by
Pulmonary malignancy
increased hydrostatic
pressure
Pulmonary infection , embolus
decreased oncotic
pressure
High protein content
Clear and pale yellow
Pancreatic disease
Dark amber / yellow
EMPYEMA
Is a pleural effusion which contain pus ,
caused by
TB
pneumonia
lung abscess
infections of chest
FIBROTHORAX
Complication of emphyema , in
which there is a fibrous fusion of
visceral and parietal pleura
EFFUSION MAY BE……….
clear
bloody
purulent
CLINICAL FEATURES
Progressive dyspnea
Decreased movement of chest wall on
affected side
Pleuritic pain
Dullness on percussion
Absent or decreased breath sounds
ASSESSMENT
THORA
CENTESIS
-
CHEMICAL
PLEURODESIS
SURGICAL TREATMENT
Pleurx
catheter
pleurectomy
Pleuro
peritoneal
shunt
EMPHYEMA
Accumulation of thick , purulent fluid
within pleural space often with fibrin
development and a loculated area where
infection is located
PATHOPHYSIOLOGY
Fluid is thin with
low leukocyte count
Fibro purulent
stage
Loculated
emphyema
MANAGEMENT
Needle aspiration
Tube thoracotomy
Open chest drainage via thoracotomy
decortications
NURSING
MANAGEMENT