Pneumonia and Its Management

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Pneumonia is defined as infection of the lung parenchyma caused by a wide variety of micro-organisms characterized by clinical and radiographic signs of consolidation of a part or parts of a lung or of both lungs. The term 'Pneumonitis is used when inflammation of the lung has resulted from non-infectious cause such as chemical and radiation injury.

Classification of Pneumonia

Epidemiological Classification

Community Acquired Pneumonia

Hospital Acquired Pneumonia Or Nosocomial Pneumonia Which Manifest After 48 Hours of Hospitalization

Anatomical Classification

Lobar pneumonia
Segmental pneumonia
Sub-segmental pneumonia
Bronchopneumonia

Microbiological Classification

Variou bacterial species including mycoplasma, chlamydiae and rickettsiae
Viruses
Fungi
Parasites

Bacteria Causing Community Acquired Pneumonia

Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae
Staphylococcal aureus.
Chlamydia
Legionella
Others

Clinical Classification According to Severity

Mild pneumonia
Moderate pneumonia
Severe pneumonia

Symptoms of Pneumonia

Chest Symptoms

Cough, purulent or rusty sputum, pleuritic chest pain, shortness of breathor difficulty in breathing etc

Systemic symptoms like fever with or without rigor, headache, malaise, aches and pains all over the body, loss of appetite, sore throat ,skin rash etc

Signs of Pneumonia

These depend on the severity of pneumonia. In general the patient will look unwell. The elderly may become confused, delirious and irritable. There is fever with tachycardia, tachypnoea, difficulty in speaking in sentences and sometimes cyanosis.

Classical signs of consolidation like decreased chest movement on the affected side or site., increased vocal fremitus, dull percussion note, bronchial breath sounds increased vocal resonance and crepitations. Crepitations may be the only chest finding in pneumonia. In atypical pneumonias chest findings may be minimal and systemic symptoms more prominent as in mycoplasma and chlamydial infections.

Investigations

The purpose of investigation is to establish the diagnosis to find the aetiological agent, to assess the severity, to detect complications and monitor the response to treatment. Depending on the severity the investigations are requested. In a mild case a chest X-ray and cbc may be enough. In general the following investigations are done in a hospitalized patient.

Chest X-ray - Pa and Lateral View
CBC and ESR
Sputum for Gram Stain and Culture
Blood Culture
If Necessary ABG (Arterial Blood Gases)
Liver Function Test
Renal Function Test
Serum Electrolytes
Serological tests and tests to detect antigens of bacteria in urine, sputum and blood.
HRCT and bronchoscopy with bronchoalveolar lavage is done to diagnose difficult cases of pneumonia.

While managing a case of pneumonia we have to try to answer the following questions.

Q 1. Why the person has pneumonia? Is there any underlying lung disease, immuno suppressive state, history of loss of consciousness, drug abuse or any other predisposing condition?

Q 2. What could be the most likely causative micro-organism?

Q 3. How severe is the pneumonia? Does the patient require hoptilalization or can be treated at home? If hospitalized is it safe to keep in the ward or the patient needs close monitoring in ICU.

There are many points system to assess the severity of pneumonia, in general the following features indicate severity :-

Confusion,
Respiratory rate >30/min,
BP-<90/60 mm of hg,</li>
Urea >11 mmol/l
Oxygen saturation <90%,</li>
Bilateral or multilobar involvement,
Coexisting diseases,
Elderly patient.

Q 4. What should be the most appropriate antibiotic or combination of antibiotics?

Q 5. Is the patient responding to treatment as expected? If not why? The reasons should be explored.

Q 6. Is there any respiratory or systemic complications?

Respiratory Complication :

Pleural Effusion
Empyema
Lung Abscess
Multi-Lobar Involvement
Respiratory Failure

Systemic Complication :

Hypotension
Septicaemia
Pericarditis, Myocarditis, Meningitis, Hepatitis, Paralytic-Ileus
Atrial Fibrillation
DIC
Multi-organ failure.

Treatment of Pneumonia:

Treatment of pneumonia depends on the severity, type of organism and other comorbid conditions.

General measures :

Rest,
Analgesics and antipyretics,
Adequate fluid intake,
If needed oxygen supplement.

Antibiotics :

In mild cases-

The following antibiotics can be prescribed for a period of 7-10 days,

Amoxycillin,
Clarithromycin,
Levofloxacin,
Cefuroxime.

In moderate cases:

Combination of beta-lactam antibiotic plus macrolides.
Amoxicillin-azithromycin or clarithromycin
Cefuroxime-axetil plus clarithromycin

In moderately severe cases requiring hospitalization, parenteral antibiotics in combination should be started till result of microbiological investigation is available.

The following combination is usually given :

IV Amoxycillin Plus Clavulinic Acid And Clarithromycin
Cefuroxime or Ceftriaxone Puls Clarithromycin
If there is possibility of staphylococcal infection iv flucloxacillin or vancomycin may be added to the above regimen.
In aspiration pneumonia amoxycillin - clavulinic acid plus metronidazole. Alternatively ceftazidime plus clindamycin can be given.
Nosocomial or hospital acquired infection usually caused by S-aureus, enteric gram negative bacilli or pseudomonas aeruginosa-ceftazidime or ticarcillin plus aminoglycoside like amikacin can be given.

Prevention of Pneumonia :

General Advice :

Smoking should be stopped.
Exposure to rain or cold should be avoided.
Good nutrition and healthy lifestyle maintained.
Over crowding should be avoided.

Vaccines :

Pneumococcal Vaccination [PNEUMOVAX]-0.5ML S/C Every 5-Years to individuals who are at risk of recurrent penumonia.

Influenza Vaccine -0.5ML S/C OR I/M should be given in august or september every year.

Lack of vitamin D threatens to raise cancer risk

Populations that lack exposure to sunlight during winter months should take vitamin D supplements to reduce their risk of cancer, warns a letter published in British Medical Journal.

Professor Cedric Garland of the University of California challenges a previous editorial warning against the dangerous rays of the sun. He argues that staying out of the sun altogether could cause a severe deficiency of the vitamin, which has been linked in studies to protection against cancers of the colon, breast, prostate and others.

Sunlight is a major source of vitamin D and finding equivalent amounts in the diet is difficult for many north European populations.

Professor Garland writes: "People in the United Kingdom cannot synthesise vitamin D from November to the end of March, like residents of Boston. The half life of the storage form of vitamin D is about three weeks, so Britons become deficient by December."

Submitted By:
DR. MD. MAHFUZUR RAHMAN & DR.AZIZUL HASAN

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