pneumonia

• Pneumonia is an inflammation of the parenchyma of the lung.

- Most cases of pneunomin are caused by microorganism.- non infectious causes include aspiration of food or gastric acid foreign bodies hydrocarbons and lipoid.substances hypersensitivity reaction and drug or radiation induced pneumonitis.

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• Classification .

1 : Anatomical classification.A – lobar pneumonia .

The consolidalion involves all or part of lobe

B – Bronchopneumoniathe consolidation involves scattered lobules

C - Interstitial pneumonia .As in viral pneumonia where inflammatory .

Infiltrate involve mainly interstitial tissue between alveli.

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2 : Etiological classfication.

the cause of pneumonia in patient is often difficult to determine because direct culture of lung tissue invasive and rarely performed.- culture obtained from upper respiratory tract or sputum genenally not accurately.

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• Causes of infectious pneumonia.Bacterial.Common.- streptococcus pneumoniaeGroup B streptococciGroup A streptococci .- Mycoplasma pneumoniae- chlamydia pneumoniae Adolescent.

- chlamydia trachomatis infant.-Mixed anaerobes Aspiration pneumonia- Gram-negative enteric.

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Uncommon.

- Haemphilus influenza Unimmunized.

- Staphylococcus aureus

- Moraxella catarrhalis

- Neisseria meningitides

- Francisella tularensis animal fly contact

- Nocardia species Immunosuppressed person.

- Chlamydia psittaci Bird contact.

- Yersinia pestis Plague

- Legionella species Exposure to contamianted water.

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PNEUMONIA -Viral

-CommonRespiratory syncytial virusParainflueza type 1 – 3 Influeza A . B

AdenovirusMetapneumovirus

-Un CommonRhinovirusEnterovirus NeonatesHerpes simplex NeontesCytomegalovirus Immunosuppressed person. MeaslesVaricellaHantavirus

Sars agent.

-Fungal.

Histoplasma capsulatum Bird bat contactCryptococcus neoformans Bird contact.Aspergillus species Immunosuppressed.Mucomycosis ImmunosuppressedCoccidioides immitisBlastomyces dermatitides

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-Rickettsial

Coxiella burnetii Goat sheep cattle exposureRickettsia rickettsiae

PNEUMONIA• Mycobacterial

Nycobacterium Tuberculosis Developed countries Nycobacterium avium-inteacellulare Immunosuppressed.

•ParasiticPneumocystis Carini Immunosuppressed. Steroid.Eosinophilic Ascaris .Loeffler syndrom

•Non infectious causes-Aspiration Of food.-Gastric acid.-foreign body.-Hydrocarbon Kerosen-Lipoid substances- Aspiration of amniotic fluid.

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Age groupFrequent PathogensNeonate <1moGroup B straptococcus – E coli

streptococcus Pneumoniae – H influeza.

1-3 mo febrile Pneu

Rsv . Influenza viruses para fluenza viruses – adenovirus S. pneumoniae . H . influenza

Afebrile PneuChlamydia trachomatis Mycoplasma hominis cytomegalovirus.

3 – 12 moR.S.V Influenza viruses para fluenza viruses adenovirus S. pneumoniae H . Influenza Chlamydia trachomatis Mycoplasma pneumoniae Group A straptococcus

2 – 5 yrInfluenza viruses para fluenza viruses adenovirus S. pneumoniae H . Influenza Mycoplasma pneumoniae Chlamydia pneumoniae

Group A straptococcus S . Aureus.

5 – 18 yrMycoplasma pneumoniae S. pneumoniae Chlamydia pneumoniae H . Influenza Influenza viruses adenovirus

> 18 yrMycoplasma pneumoniae S. pneumoniae Chlamydia pneumoniae H . Influenza Influenza viruses adenovirus.

PNEUMONIA• Hospitalization of children with pneumonia

-Age < 6 month- Sickle cell anemia with acute chest syndrom.- Multiple lobe involvement.

-Immunocompromised-Toxic appearance .

-Sever respiratory distress-Requirement for supplemental oxygen.

-Dehydration -Vomiting.

-No response to oral antibiotic. -Non compliant parent.

PNEUMONIA• Recurrent pneumonia

-Hereditary disorderCystic fibrosisSickle cell disease

-Disorders of immunityAidsBruton agammaglobulemiaSelective IgG subclass deficienciesCommon variable immunodeficiency syndromSever combined immunodeficiency syndrom-Disorders of leukocytes

�ٍChronic granulomatous diseaseHyperimmunoglobulin E syndrome

Leukocyte adhesion defect

PNEUMONIA- Disorders of ciliaImmotile cilia syndromKartagener syndrom

-Anatomic disorderSequestration Lobar emphysemaEsophageal refluxForeign bodyTracheo esophageal fistula ( H type )Gastroesophageal refluxBronchietasisAspiration ( oro pharyngeal in coordination )

PNEUMONIA• PathogenesisThe lower respiratory tract is normally sterile by-Physiologic defense mechanisms including-Mucociliary clearance-ProPerties of normal secretion such as secretory immunoglobulin A IgA- Clearing of air way by coughingImmunologic defense mechanism of lung limit invasion by pathogenic organismsIncludes macrophages are present in alveoli and bronchioles secretory IgAand others immunoglobulins

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PNEUMONIA•Viral pneumonia usually result from spread of infection along the air way. Accompanied by direct injury of respiratory epithelium resulting in air way obstruction from swelling abnormal secretion and cellular debris small calibar of air way in young infant makes them particularly susceptible to sever infection.Viral infection predispose to secondary bacterial infection by disturbing normal host defense mechanism altering secretion and modifying bacterial flora.

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•Bacterial infectionIn bacterial infection pathologic process varies according to the invading organism M . Pneumoniae attaches to the respiratory epithelium inhibit ciliary action and Lead to cellular destruction and an inflammatory response in the submucosaas the infection progresses sloughed cellular debris inflammatory cell and mucusCause airway obstruction with spread of infection occuriang along the bronchialTree as in viral pneumoia.

- S . PneumoniaeProduce local edema that aids in the proliferation of organism and their spreadInto adjacent portion of lung often resulting in the characteristic focal lobar Involvement

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-Grop A . Streptococcus pathology Includes necrosis of tracheobronchial mucosa formation -of large amount of exudate edema and local hemorrhage with extension into the Interalveolar septa and involvement of lymphatic vessel and pleura.

-S – aureus pneumoniaproduces Toxin and enzymes as hemolysin coagulase and

-staphylo kinaseIt causes broncho pneumonia often unilateral characterized by

prensence ofHemorrhagic necrosis and irregular areas of cavitation of

lung parenchymaResulting in pneumatoceles empyema or broncho pulmonary fistulaPyopneumothorax.

PNEUMONIAFollowing changes stages:1- congestion alveoli are failed with edema fluid and organism.2- red hepatization alveoli contain polymorph RBCs fibrin edema and organism.3-grey hepatization deposition of fibrin over the pleural surface phagocytosis starts inside the alveoli which are now filled with polymorph and fibrin.4-resolution: neutrophil degenerate fibrin thread and remaining bacteria and digested and removed by phagocyte

Clinical Manifestation Viral & bacterial pneumonia are often preceded by several day of symptomsof URTI typically rhinitis and cough.In viral pneumonia:fever is usually present lower than in bacteria.Tachypnea increased work of breathing accompanied by intercostal, subcostaland suprasternal retraction nasal flaring and use of accessory muscle.Severe infection accompanied by cyanosis and respiratory fatigue in infant.Auscultation of chest wheezing and crackle

PNEUMONIAIn bacterial pneumonia:Sudden shaking chill followed high fever, cough, grunting, chest pain, drowsiness, rapid respiration, dry cough, anxiety circumoaral cyanosis.

Physical finding:Depends on the stage of pneumonia diminished breath sound scattered crackels and rhonchi over affected lung.Increasing consolidation or complication.As effusion empyema or pyopneumothorax dullness on percussion and breathSound.Diminished abdominal distension because of gastric dilation from swallowed air or ileus. Abdominal pain in lower lobe pneumonia Liver may seem enlarged because downward of diaphragm secondary to hyper inflation of lungNeck rigidity without meningitis in right upper lobe.

PNEUMONIADiagnosis:Chest X-ray diagnosis of pneumonia may indicate complication pleural effusion or empyema.Viral pneumonia X-ray hyper inflation with bilateral interstitial infiltrate pneumococcal pneumonia lobar consolifation repeat chest x-ray are not required for proof of cure for ratient with uncomplicated pneumonia.- WBC can differentiating viral from bacterial in virtual WBC normal or elevated but usually not highert han 20,000/mm3 with lymphocyte predominanceBacterial 15,000- 40,000 predominance granulocyte.-Pleural effusion – lobar consolidation and high fever at onset of illness suggestive of bacterial.-Atypical pneumonia due to C.pneumoniae or M.pneumoniae is difficult to distinguish from pneumococal pneumonia by X-ray and other lab.-pneumococcal pneumonia higher in WBC count ESR-CRP.- Isolation of organism from blood-pleural fluid or lung culture of sputum blood culture.positive PCR in viruses

PNEUMONIATreatment:Treatment based on cause and clinical appearance of child.Children do not require hospitalization.-Amoxicillin ( 80-90mg/kg/24 hrs )- cefuroxime = Zinnat or Amoxicillinclavulante = ogmin.- For school age children with M-pneumonia.-C.pneumonia (atypical pneumonia)mcrolide antibiotic such as azilhromjcin Bacterial pneumonia in hostpitalized child cefuroxime (150 mg/kg/24 hrs) = Zinnat cefotaxime = claforan cefftriaxone = Rocephin - If staphylococcal pneumatotocele empyema Vancomycin or clindamycin Viral pneumonia no respiratory distress with hold antibiotic therapy - Up to 30% of patient wih known viral infection may have coexisting bacterial pathogen.

PNEUMONIADeterioration in clinical status antibiotic therapy should be initiated

Response to treatment:Patient with uncomplicated bacterial pneumonia respond to therapy with improvement in clinical symptom (fever, cough, tachypnea, chest pain) within 48-96 hrs.Slowly resolving pneumonia 1- complication as empyema.2- bacterial resistance.3- non bacterial etiology as viruses and aspiration of foreign bodies or food.4- bronchial obstruction from endobronchial lesion foreign body or mucus plug.5- pre-existing diseases such as immunodeficiencies- ciliary dyskinesia- cysticfibrosis pulmonary sequestration cystic adenomatoid malformation.6- non infectious causes: - bronchoilitis obliterans. - hypersensitivity pneumonitis - eosinophils pneumonia - aspiration - wegener granulomatosis

PNEUMONIAComplication:Usually result of direct spread of bacterial infection within thoracic cavity.(pleural effusion- empyema- pericarditis) or bacteremia and hematologic spread meningitis suppurative arthritis osteomyelitis

X-RAYS

Viral pneumonia x-ray

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Lobar pneumonia x-ray (RUL)

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bronchopneumonia x-ray

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Staph pneumonia x-ray

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