Ass-prof. N. Bilkevych

1. Topic of the lecture:Pneumonias. Pleural syndrome. Ethiology. Clinical pattern. Daignostics. Complications. Principles of treatment Ass-prof. N. Bilkevych

2. Acute inflammation of lung parenchyma with obvious involvement of alveoli. Usually is caused by bacteria or viruses Pneumonia(pneumonia)

3. Alveoli and lung cells that produce surfactant

4. In up to 30% of patients no organism is identified, usually because of prior antibiotic administration. In many patients there is a preceding history of an upper respiratory virus infection. Most community acquired pneumonias can be managed at home, and have a low mortality; studies of such patients admitted to hospital have shown a mortality of 6—24% depending on the population studied and the presence or absence of such risk factors as old age and underlying disease.

5. Ethiology: • Not specific pathogenic or obligate-pathogenic microbes

6. Pathogenesis: • Infection spread into the organism through respiratory airways. Microbes appears and multiple on bronchial mucosa of upper airways and than spread down to bronchi and lung tissue

7. Acquired and congenital defects of bronchial clearance • disordered function of ciliated epitheliumsurfactant system defects • infufficiency of alveolar makrophages • Deranged bronchial patency

8. disordered function of diaphragm and chest excursions • changes of local and systemin immunitydepressed coughing reflex

13. Pathogenetic difference • Betveen croupous and focal pneumonia depends o the reaction of macroorganism on infectious agent • In croupous pneumonia this reaction is hyperergic, in focal one – normo- or hypoergic

14. Classification • Community-acquiredpneumonia. • Nosocomial(intrahospital) pneumonia – acute infection of lower airways confirmed with X-ray, has being developed in 48 hrs after appearance of the patient in hospotal environment. • Aspirationpneumonia. • Pneumoniain immunocompromizwd patients

15. Community acquired Streptococcus pneumoniae Mycoplasma pneumoniae Influenza virus A Haemophilus influenzae Legionella pneumophila Staphylococcus aureus Coxiella burneti Chlamydia psittaci Hospital acquired Gram-negative bacilli Staphylococcus aureus Streptococcus pneumoniae Legionella pneumophila Haemophilus influenzae Pseudomonas spp Immunocompromised patients Pneumocystis carinii Cytomegalovirus Mycobacterium avium-intracellulare Mycobacterium tuberculosis Streptococcus pneumoniae Haemophilus influenzae Legionella pneumophila Actinomyces israelii Aspergillus fumigatus Nocardia asteroides Pneumonia: infecting organisms in approximate descending order of frequency

16. Course Mild RR – less than 25 per min, РS – less than 90 per min, t – less than380C signs of hypoxia and circulatory insufficiency are absent, volume of infiltrate – 1-2 segments unilaterally

17. Moderate: RR – less than30per min, РS – less than100 per min, t – less than390C mild hypoxia, circulatory insufficiency is absent, volume of infiltrate – 1-2 segments bilaterally or entire lobe

18. Severe: RR – till40per min, РS – more than than100 per min, t – till400C • signs of hypoxia and circulatory insufficiency are present, volume of infiltrate – severalsegments or more than 1 lobe

19. Very severe RR – more than40per min, РS – more than 100 per min, t – more than400C • Marked signs of hypoxia and circulatory insufficiency, extensive damage

21. Croupous pneumonia • Acute inflammation of lungs, which in most cases spreads on all pulmonary lobe. That is why it is called lobar pneumonia (pneumonia lobaris), but can be limited to the affection of segment or a few segments. • Synonimsfibrinous pneumonia, pleuropneumonia

23. The usual clinical presentation in pneumonia caused by Streptococcus pneumoniae is acute, with the abrupt onset of malaise, fever, rigors, cough, pleuritic pain, tachycardia and tachypnoea, often accompanied by confusion, especially in the elderly. The signs in­clude a high temperature, consolidation and pleural rubs, and herpetic lesions may appear on the lips. There may also be signs of pre-existing disease, especially chronic bronchitis and emphysema or heart failure in the elderly. The sputum becomes rust-coloured over the following 24 hours. The diagnosis is made on clinical grounds and confirmed by chest X-ray.

24. Pneumococci

25. пневмокок

26. Pneumococci are typically asociated with pneumonia

27. Patalogoanatomical stages: • inflow (12 hrs - 3 days) • red hepatisation (1 hr - 3 days) • greyhepatisation ( 2 - 6 days) • resolution

28. Clinical stages: • initial • clinical manifestation (corresponds to red and greyhepatisation • resolution

29. Lobar pneumonia: stage of onset • Morphology. Congestion stage — extensive serous exudation, vascular engorgement, rapid bacterial pro­liferation. • Inspection. An increased respiratory rate is usually evident. Pain is a frequent accompaniment, and with it the involved side shows a lag of respiratory motion. • Palpation. Palpation confirms the findings on in­spection. Tactile fremitus is normal or even slightly decreased, and a pleural friction rub may be present. • Percussion. Impaired resonance may be elici­ted with light percussion. This finding is extremely important. • Auscultation. Although the breath sounds may be diminished, expiration is prolonged and crepitation (crepitus indux) is heard. With pleural involvement, a pleural friction sound is determined.

31. Lobar pneumonia: stage of consolidation • Morphology. Red hepatization stage — airspaces are filled with PMN cells, vascular congestion, extravasa­tion of RBC. Grey hepatization stage — accumulation of fibrin, inflammatory WBCs and RBCs in various stages of disintegration, alveolar spaces filled with in­flammatory exudate. • Complaints. Coughing may be associated with i sharp pain in the affected side. Mucoid sputum be comes rusty brown (prune juice color).

32. General inspection. Cyanosis of the lips and fin gers. When the fever is high, the face may be flushed The patient's nostrils dilate on inspiration, and expi ration is often grunting. • Inspection. Dyspnea is invariably present. Respi ratory movements are generally decreased on the af fected side. • Palpation. Diminished respiratory excursions, i pleural friction rub may be felt. Tactile fremitus is in creased. • Percussion. Dullness. • Auscultation. Bronchial breathing, bronchophony, pectoriloquy and whispered bronchophony are evident with consolidation provided the bronchus to the in volved area is open. Rales are less numerous and dis tinct than in the stages of engorgement or resolution,

35. Forced position

41. Lobar pneumonia: stage of resolution • Morphology. Resolution stage — resorption of the exudate. • Inspection. The patient looks more comfortable and the cyanosis disappears. The dyspnea disappears and the affected lung begins to expand again. • Palpation. The previously increased tactile fremitus becomes less marked and gradually findings beco­me normal.

42. Percussion. The dullness gradually disappears and normal resonance returns. • Auscultation. The bronchial breathing is gradually replaced by bronchovesicular breathing and later by normal vesicular breathing. Crepitation reappears (crepitus redux). Small and large moist rales are heard in increasing numbers.

43. Laboratory tests • The white cell count and ESR are usually elevated. Blood should be sent for culture before antibiotic ther­apy is given and a baseline blood sample taken for se-rology. Sputum should be sent for culture. Direct Gram-staining of a fresh sputum sample may show the organism. Pneumococcal antigen can be identified in sputum, urine or serum. Antibiotic therapy should not be delayed while awaiting sputum culture results.

45. The symptoms usually resolve rapidly over 7—10 days and the signs over a slightly longer period. Radio­logical resolution should be complete by 12 weeks. Per­sistence of changes in the X-ray after this, or recur­rence of pneumonia, suggests some other pathological process and should trigger a search for underlying car­cinoma. Careful examination should be made at pre­sentation for clinical features of AIDS.

46. Complications • Lung abscess or gangroene • Pleurisy • Toxic shock • Myocarditis • Acute respiratory insufficiency • Pneumosclerosis • Atelectasis • Sepsis • Meningitis, encefalitis