Community Aquired Pneumonia Aspiration Pneumonia Noninfectious Pulmonary Infiltrates

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Community Aquired PneumoniaAspiration
PneumoniaNoninfectious Pulmonary Infiltrates

• Tintinalli Chapter 68

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Epidemiology

• CAP 4 million cases, 1 million hospitalizations
• 6th leading COD
• Can present classically or with more subtle
  findings, particularly in elderly

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Pathophysiology

• Aspiration risk
• Bacteremia risk
• Debilitation
• Chronic diseases
• Pulmonary disorders

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Pathophys, contd

• Infection of alveolar portion of lung
• Bacterial intense inflammatory reaction
• Fail to ID specific pathogen 40-60 of time
• Pneumoccocus most common single agent
• Viruses and atypicals

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Clinical features

• Cough, fatigue, fever, dyspnea, sputum, pleuritic
  chest pain
• Headache and GI symptoms can also be present
• PE rales, rhonchi, dullness, decreased BS

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Pneumococcal Pneumonia

• Highest risk
• Rapid progression asplenia, immunosuppressives
• Slow progression chronic lung dis., elderly
• Classically sudden onset with fever, rigors,
  dyspnea, bloody sputum, chest pain, tachycardia,
  tachypnea
• Lab leukocytosis, ?bilirubin or liver enzymes,
  hyponatremia
• Tx penicillin, macrolide, or quinolone

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Other bacteria

• Staph aureas
• chronic lung dis, ca, IC, NH residents, s/p viral
  illness
• CXR extensive disease, mult infiltrates,
  effusion
• Klebsiella
• IC, alcoholics, elderly, chronic lung dis
• Pseudomonas
• Hospital acquired, structural lung disease, NH
  pts, high dose steroid use
• H influenza
• Moraxella

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Atypicals

• Legionella
• smokers, chronic dis, transplant patients, IC
• can affect multiple systems, GI tract
• CXR patchy infiltrate
• Chlamydia
• mild subacute illness
• CXR patchy segmental infiltrate
• Mycoplasma
• subacute
• retrosternal chest pain
• CXR patchy infiltrates, hilar adenopathy,
  pleural effusions

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Diagnosis

• Clinical signs/symptoms plus
• CXR for confirmation of diagnosis
• If hospitalized CBC, CMP, blood cx, ABGs,
  sputum cx
• ICU legionella antigen

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Special Populations
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Alcoholics

• Higher risk for many lung diseases, poor
  nutrition, aspiration, heavy tobacco use,
  cirrhosis and portal HTN, oral pharyngeal
  colonization with gram (-)
• Strep pneumo most common
• Klebsiella, H flu
• Higher incidence of pneumonia overall compared to
  nonalcoholics

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Diabetics

• 4x more likely to have pneumonia and influenza
• 2-3x more likely to die from pneumonia
• S.aureus, gram (-)s, Mucor, TB
• Strep pneumo, Legionella higher morbidity and
  mortality

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Pregnancy

• CAP one of most serious non-ob infections
  complicating pregnancy 3mortality
• Risk for preterm labor and low birth weight
• Varicella pneumonia 5x risk if smoker, 16x more
  likely if skin lesions present
• Acyclovir

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Elderly

• Pneumonia most common infection
• 5th leading cause of death
• 40 mortality rate
• Comorbids, dementia, diminished gag
• Legionella most common atypical
• Post influenza bacterial causes S. pneumo, S.
  aureus, H. flu
• May be afebrile with normal WBC count
• Atypical symptoms weakness, confusion, GI

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Nursing Home Patients

• Major cause of morbidity, mortality,
  hospitalization
• Significant independent predictors of HCAP
• ?HR, ?RR, Temp gt100.4, somnolence, AMS, crackles
  of PE, no wheezes, ?WBC
• Pathogens S. pneumo, gram (-) bacilli, H. flu
• Cover for MRSA as well

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HIV

• S. pneumo 1
• In those admitted for pneumonia
• Lower CD4 count
• Higher APACHE II score
• Longer length of stay
• Higher ICU likelihood
• Higher fatality
• Pseudomonas common
• PCP when CD4lt200
• Pleural effusions occur in 60 of bacterial
  pneumonia in AIDS pts

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Transplant

• Bacterial pneumonia common after liver, heart,
  lung transplant first 3 months post op
• Less common s/p renal transplant
• Gram (-) pseudomonas (ventilator assoc), Staph,
  Legionella predominate 1st 3 months
• 33 mortality in early onset nosocomial
• 6 months post-transplant less mortality and
  pathogens typical of CAP

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CAP Treatment

• Outpatient
• doxy, macrolide or fluoroquinolone
• Inpatient
• Fluoroquinolone or
• Ceph macrolide

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HCAP

• Antipseudomonal ceph, carbapenem, or B-lactamase
  inhibitor
• Plus
• Fluoroquinolone
• Plus
• Anti-MRSA

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Disposition

• Risk Stratification
• PORT score
• CURB-65
• www.mdcalc.com
• Outpatient vs inpatient vs level of inpatient care

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Aspiration pneumonia

• Alveolar space infection due to inhalation of
  pathogenic material from oropharynx
• Chemical injury (pneumonitis)
• Aspiration pneumonia
• Incidence
• 5-15 of CAP
• 20 of CAP in the elderly
• Majority of NH acquired
• Risk factors
• intoxicants, neurologic, poor oral hygiene, GERD,
  supine position, intubation, ? age

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Pathophysiology

• Aspirated volume of 20-30 mL with a pH of less
  than 2.5 is the general consensus
• Direct injury then inflammatory response
• Typical bacteria
• CAPStrep pneumo, staph aureas, h flu,
  enterobacter
• HCAPpseudomonas, gram negatives

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Clinical Presentation

• Fever, dyspnea, productive cough
• AMS, lethargy, nausea, vomiting
• Exam may reveal classic signs for pneumonia
• CXR unilateral focal or patchy infiltrates in
  dependent segments

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Treatment

• Witnessed
• suctioning, intubation, bronchodilators
• Prophalactic ATB, steroids not recommended
• Healthy patients
• observe and discharge
• Nursing home/chronically ill
• observe if stable, atb if not resolving

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Noninfectious Pulmonary Infiltrates

• Suspected by appearance of CXR and after ATB fail
  to resolve
• Intersitial fine, diffuse, linear density
• Alveolar small ill defined or reticular density
• Ground glass multiple finely granular densities

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Causes

• CHF
• PE
• Aspiration pneumonitis
• Allergic aspergillosis
• Eosinophilic lung disease
• Hypersensitivity pneumonitis
• ARDS
• Drug induced pneumonitis
• Sarcoidosis
• Wegener granulomatosis
• Goodpasture Syndrome
• Alveolar hemorrhage
• Leukemic infiltrate
• Fat emboli

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Treatment and Disposition

• Noninvasive mechanical respiratory assistance
• Intubation
• Stabilize
• Additional testing required for most
• Admission depends on severity of pts condition

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sources

• Tintinalli, Chapter 68