Pulmonary (Pneumonia, Influenza)

Front 1

Define: Pneumonia

Back 1

an infection of the lung parenchyma (periphery) caused by bacteria, viruses, fungi or aspiration.

May have a ‘classic’ appearance or present “atypically”.

Older adults and smokers tend to develop ‘classic’ presentations Strep pneumonia (30-50%) or viral (10- 15%)

Viral infections include CMV, adenoviruses, varicella

Viral infections may be ‘mixed with’ bacterial
infection

Adolescents and young adults tend to develop ‘atypical’
organisms as causative e.g.:
Chlamydia pneumonia; or
Mycoplasma pneumonia (which is sometimes called
‘walking pneumonia’ due to its insidious onset,
persistent presentation, infrequent clinical rales or
rhonchi, and CXR with multiple infiltrates which are
disproportionate to the presentation)


-Pneumonia is an infection of the lower respiratory tract cause by bacteria, viruses, fungi, protozoa, or parasites.
- It is the 6th leading cause of death in the US.

Common pathogens that lead to CAP:
=Steptococcus pneumoniae
=Mycoplasma pneumoniae
=Haemophilus influenzae
Smokers and those with live w smokers are typically
colonized with this, thus when treating these
patients ensure antibiotic coverage for H. Influenzae
=Oral anaerobic influenza virus
=Legionella pneumophila
=Chlamydia pneumoniae
=Moraxella catarrhalis

=In healthy people, pathogens that reach the lungs are typically expelled or kept in check by self defense mechanisms
=If the pathogen passes first line defenses (cough, mucociliary clearance) then the next line of defense if the airway epithelium. These cells recognize some pathogens directly (S. Aureus and P. aeruginosa).
=The guardian cells of the lower respiratory tract is the alveolar macrophages – they are phagocytes that recognize pathogens through pattern-recognition receptors which activate both innate and adaptive immune responses.

Front 2

Pneumonia: Primary Prevention

Back 2

– Smoking avoidance
– ALSO: immunizations!:
• pneumococcal,
• diptheria (q5-10y),
• varicella (if disease, or imms >13y x2), and
• annual influenza

Front 3

Pneumonia: Secondary Prevention

Back 3

No screening for pneumonia available.

Front 4

Pneumonia: Assessment findings: CXR

Back 4

 CXR will be positive for infiltrates
 initial CXR rules out many of the differentials or complications: e.g.
 Pneumothorax
 Empyema
 Abscesses

Front 5

Pneumonia: Diagnostics

Back 5

CXR

 WBC
 Gram stains
 Blood cultures
 Serology for HIV may be indicated
 ABGs

Front 6

Pneumonia: Assessment findings: Physical Exam

Back 6

– Fever (less common in older adults)
– Tachypnea
– Tachycardia
– Dull percussion
– Diminished Breath Sounds
– Rales or rhonchi
– Consolidated lung tissue will produce egophony
– CXR will be positive for infiltrates – initial CXR rules out many of the differentials or complications: e.g. pneumothorax, empyema, abscesses
– WBC, gram stains, blood cultures, serology for HIV, ABGs may be indicated

Front 7

****Pneumonia: Symtomotology: All presentations

Back 7

– Cough
– Sputum production (less common in older adults)
– Dyspnea

Front 8

****Pneumonia: Symptomotology: Classic presentation

Back 8

– Cough
– Sputum production (less common in older adults)
– Dyspnea

PLUS

Chills
N/V
Chest Discomfort

Front 9

*****Pneumonia: Symptomotology: Atypical Presentation

Back 9

– Cough
– Sputum production (less common in older adults)
– Dyspnea

PLUS

HA
Malaise
May have diarrhea, ST, sinusitis, earaches

Front 10

Pneumonia: differentials

Back 10

– Chronic bronchitis exacerbation
– PE
– Neoplasm
– Bronchiolitis
– Sarcoidosis
– Pulmonary edema
– TB
– Empyema or abscess

Front 11

Patients at risk for Strep Pneumonia

Back 11

Increased exposure to S. pneumonia
Prison
Miliatry Barracks
Day Care Centers
Shelters for the homeless

Decreased host defenses
Complement deficiency
Antibody deficiency
Functional or anatomic asplenia
Decreased numbers or function of phagocytes
Specific disease entities
Multiple Myeloma
Lymphoma
Chronic Lymphocytic Leukemia
HIV
Respiratory/pulmonary problems
COPD
Smoker
Allergies
Prior viral infection

Front 12

Pneumonia: Treatment: determined by ....

Back 12

determined by empiric judgment

Evaluate what is in your enviroment from of causative
organism: e.g. Vanco-intermediate Staph aureus

Front 13

CURB- 65 SCORE

Back 13

IF CONSOLIDATION ON CXRAY

ONE POINT EACH

1) CONFUSION (ACUTE ONSET)
2) UREA > 7 mmols
3) RESPIRATION RATE (GREATER THAN OR EQUAL TO 30)
4) BLOOD PRESSURE (SBP < 90 or DBP < 60)
5) AGE > 65

Front 14

COMMUNITY ACQUIRED PNEUMONIA AND CURB 65 SCORE = 0 or 1

Back 14

MAY BE SUITABLE FOR ORAL ANTIBIOTICS AND OUTPATIENT MANAGEMENT

Need to consider comorbidities, social support, and likelihood of compliance.

Advise outpatient to seek medical attention if their conditions deteriorate

TREAT WITH

AMOXICILLIN 1 GRAM EVERY 8 HOURS

PLUS EITHER

ROXITHROMYCIN 300 mg PO DAILY

OR

DOXYCYCLINE 200 mg PO X 1 then 100 mg daily

Front 15

COMMUNITY ACQUIRED PNEUMONIA AND CURB 65 SCORE = 2

Back 15

Likely to require hospitalization for IV antibiotics

Benzylpenicillin 1.2 g IV q 6 hours

OR

Amoxicillin 1 g IV q 6 hours

PLUS EITHER

ROXITHROMYCIN 300 mg PO DAILY

OR

DOXYCYCLINE 200 mg PO X 1 then 100 mg daily

ADD

GENTAMICIN 4-6 mg/kg IV daily (if significant gram negative bacilli are identified on blood cultures or sputum)

Front 16

COMMUNITY ACQUIRED PNEUMONIA AND CURB 65 SCORE = 3, 4, 5

Back 16

MANAGE AS SEVERE PNEUMONIA IN THE HOSPITAL

Consider for intensive monitoring especially if score is 4 or 5

Azithromycin 500 mg IV daily

OR

Erythromycin 500 mg IV q 6 hours

PLUS

Benzylpenicllin /amoxycillin
1.2 g IV q 4 hrs/ 2 g IV q 6 hours

AND

GENTAMICIN 4-6 mg/kg IV daily

Front 17

******EMPIRICAL ANTIBIOTIC SELECTION FOR ADULT PATIENTS WITH COMMUNITY ACQUIRED PNEUMONIA: Outpatient WITHOUT modifying factors

AMERICAN GUIDELINES FOR OUTPATIENT

Back 17

First choice- Macrolide (ZITHROMAX)

Second Choice- Doxycycline

Front 18

EMPIRICAL ANTIBIOTIC SELECTION FOR ADULT PATIENTS WITH COMMUNITY ACQUIRED PNEUMONIA: Outpatient WITH modifying factors: No recent antibiotic or PO steroids within the last 3 months

Back 18

First choice- Newer macrolide

Second choice- Doxycycline

Front 19

****EMPIRICAL ANTIBIOTIC SELECTION FOR ADULT PATIENTS WITH COMMUNITY ACQUIRED PNEUMONIA: Outpatient WITH modifying factors: recent antibiotic or PO steroids within the last 3 months- H influenza and enteric gram negative rods implicated

Back 19

First choice- Respiratory fluoroquinolone

Second choice- Amoxicilin/ Clavulanate + macrolide
or
2 gms cephalosporin + macrolide

Front 20

EMPIRICAL ANTIBIOTIC SELECTION FOR ADULT PATIENTS WITH COMMUNITY ACQUIRED PNEUMONIA: suspected macroaspiration: oral anaerobes

Back 20

First choice:

Amoxicilin/ Clavulanate +/- macrolide (AUGMENTIN)

Second choice
"Respiratory" fluroquinolone (e.g. Levaquin) + clindamycin or metronidazole

Front 21

EMPIRICAL ANTIBIOTIC SELECTION FOR ADULT PATIENTS WITH COMMUNITY ACQUIRED PNEUMONIA: Nursing home residents

Back 21

Step Pneumoniae, enteric gram negative rods, H influenza implicated

First line
"respiratory" fluroquinolone alone
or
amoxicillin/clav + macrolide

2nd line

2g cephalosporin + macrolide

Front 22

Severity of community – acquired pneumonia: MAJOR

Back 22

• Invasive mechanical ventilation
• Septic shock with the need for vasopressors

Front 23

Severity of community – acquired pneumonia: MINOR

Back 23

• Respiratory rateb >30 breaths/min
• PaO2/FiO2 ratiob <250
• Multilobar infiltrates
• Confusion/disorientation
• Uremia (BUN level, >20 mg/dL)
• Leukopeniac (WBC count, <4000 cells/mm3)
• Thrombocytopenia (platelet count, < 100,000 cells/mm3)
• Hypothermia (core temperature, <36 degrees C)
• Hypotension requiring aggressive fluid resuscitation

Front 24

Pneumonia: Criteria for admission to hospital

Back 24

– Patients with these presentations:
• Severe illness:
• hypotension
• marked tachycardia >125bpm
• altered mental status
• tachypnea >30bpm
• hypoxemia <90% on room air
• need for mechanical ventilation
– Impaired host defense: HIV, COPD, diabetes
– Virulent organism: S. aureus and gram negative bacilli

Front 25

When to follow up if patient with pneumonia is not hospitalized.

Back 25

• If not hospitalized, re-evaluate patient in 48-72 hrs to recheck status e.g. fever, other symptoms, as well as WBC

Front 26

Assume smokers have bronchi colonized with .....

Back 26

H flu – ensure adequate coverage

Front 27

Pneumonia: Who gets a follow-up CXR?

Back 27

 Follow-up CXR indications
 Elderly patients (>60)
 Smoking history
 Immunosuppression
 More virulent pathogen (e.g., gram negative)
 Underlying chronic disease
 Persistent symptoms > 8 weeks
 Initial unusual x-ray findings

Front 28

Pneumonia: Non-pharmacological & complimentary tx

Back 28

– Fluids
– Nutrition
– Rest
– Avoid exertion
– Tylenol for discomfort
– Cough suppression
– Smoking cessation
– Avoid smoke exposure
– Older adults should preferably have caregiver or visiting nurse to ensure nutrition and care

Front 29

Pneumonia: Case Management: Pt/family psychosocial considerations

Back 29

• May be exhausting for family to have someone coughing in home

• Worrisome with small children or other older
adult contacts

Front 30

Pneumonia: Case Management: Psychosocial/cultural considerations

Back 30

• Treatment plan must be culturally and socioeconomically feasible.

Front 31

Pneumonia: Case Management: Economic/ethical/legal considerations

Back 31

• Many newer therapies e.g. Macrolides and Fluoroquinalones are expensive

Front 32

Influenza: Definition

Back 32

an acute upper airway infection. Caused by influenza viruses A, B, or C. A is most common and deadly.


Influenza is a febrile infection that has an acute onset as if someone turned a light switch on, is usually self limiting.
The symptoms are marked by inflammation of the nasal mucosa, pharynx, eye and respiratory tract, along with an overwhelming feeling of fatigue and malaise. Outbreaks occur almost every winter with varying degrees of severity. It usually will affect patients who are compromised; such as this patient who is obese, diabetic and asthmatic. She is also in the public frequently, in large crowds and has a very hectic lifestyle and is run down frequently
Influenza A is the usual suspect with the more severe symptoms, than influenza B. The virus responsible is ORTHOMYXOVIRUS.

Front 33

What is the most common and deadly type of influenza

Back 33

Influenza A

Front 34

Influenza: Primary Prevention

Back 34

• Vaccination (no vaccine if allergic eggs)
– Household contacts of ill persons and
health care workers should consider annual
vaccine

– Influenza vaccine q year for those at risk
for complications

-Older adults (>65y)

-Chronically ill – this includes those with
metabolic and Cardiopulmonary illness

-Immunocompromised individuals

-Women can receive vaccine once past 14wks
pregnant if pregnant during flu season

-Travelers to warm climates where flu season
differs, may need vaccine
– Since spread is by droplet

• Avoid crowds during flu season (October to March)

• Wash hands frequently

• Avoid contact with EENT system

• Dispose of Kleenex carefully to avoid spread to others.

• Avoid coughing or sneezing on other individuals

– Chemoprophylaxis indicated for:

-Community outbreak Influenza
-For high risk pt for whom vaccine is
contraindicated
-When vaccine doesn’t cover strain infecting
community
- Additional protection to
immunocompromised, who are unlikely to
develop adequate immunity from vaccine,
yet are high risk for complications.

– Use: oseltamivir in persons aged 1 year or older, or zanamivir in persons aged 5 years or older.

Front 35

Influenza: Secondary Prevention

Back 35

None

Front 36

Influenza: Symptomatology: Pt appears ill with predominantly .....

Back 36

systemic symptoms

Front 37

Influenza: Symptoms start with

Back 37

– Cough
– Fatigue
– Malaise

incubation period is 3 days

These symptoms can last for 3 weeks

Front 38

Influenza: Symptoms progress rapidly

Back 38

– Fever to 104F
– Chills
– HA
– ST
– Nasal congestion
– Myalgia
– Weakness
– Non-productive cough

Can last 7-10 days. Worse on days 3-5

Front 39

Influenza: differential diagnosis

Back 39

• URI
• SARS (Severe Acute Respiratory Syndrome)
• Parainfluenza virus (Fifth’s Disease)
• Adenovirus
• Measles
• LTB
• Bronchiolitis
• croup
• Bacterial pneumonia
Mycoplasma
pneumococcus

Front 40

Influenza: Assessment findings: Refer complicated cases to Internist or Pulmonologist

Back 40

• Be alert for dyspneic appearance and pulmonary findings which are not typical of influenza and may indicate viral pneumonia (younger pts, pregnant women, those with Rheumatic hearts). This is important as serious and may become fatal if progresses to ARDS
• Secondary bacterial pneumonia may also occur demonstrating these symptoms (older adults, smokers, immunocompromised or chronically ill). More often sputum production.
• Status asthmaticus may occur in asthmatics.
• Disease is diagnosed clinically, but consider:
-CBC for elevated WBC
-Viral throat swab (expensive and takes 3-7 d for
results)
-Influenza immunoassay (IgM) (80-90%sensitive,
97% specific) results may help in deciding on
antiviral therapy

Front 41

Influenza: Management

Back 41

• Supportive pharmacological as needed:
-Antipyretics (no ASA in children or
adolescents due to association with Reyes
syndrome)
- Cough suppressants
-Analgesics.
• Only agents in US currently for antiviral treatment of Influenza viruses A and B because resistance is rare:
-Neuraminidase inhibitors
-Zanamivir via inhaler
- Oseltamivir po
-Note: 2007 from CDC: “Until evidence of
susceptibility to amantadine or rimantadine has
been reestablished for circulating influenza A
viruses, these agents should not be used in the US
to treat or prevent influenza.”

Front 42

Influenza: Non-pharmacological & complimentary tx

Back 42

Mainstay of treatment of influenza is supportive
 -Rest
 -Fluids to maintain hydration
 -Careful observation for symptoms indicating
complications

Front 43

Influenza: Case Management: Pt/family psychosocial considerations

Back 43

– Consider chemoprophylaxis if family member infected
– Consider immunization if family member at high
risk of complications from influenza

Front 44

Influenza: Case Management: Psychosocial/cultural considerations

Back 44

– Acute illness may necessitate rest for 3-5 days

Front 45

Influenza: Case Management: Economic/ethical/legal considerations

Back 45

– Few costs involved in illness
– Since only 10-15% of those who are <65 years who are high risk are immunized q year, what is liability of health care provider who does not recommend vaccine yearly e.g. for diabetic?

Front 46

INFLUENZA: RISK FACTORS

Back 46

-Certain environments such as nursing homes; hospitals; schools; prisons…. But not limited to those. -Crowded environments also pose a potential risk for contracting the disease such as large events as concerts, shopping malls; fundraisers and the like while the epidemic is taking place.
-Hand to mouth contact is always a risk, therefore good hand washing technique is always a benefit, as well as covering mouth and nose for droplet protection.

Front 47

Summary of Influenza Antiviral Treatment Recommendations

Back 47

Clinical trials and observational data show that early antiviral treatment can shorten the duration of fever and illness symptoms, and may reduce the risk of complications from influenza (e.g., otitis media in young children, pneumonia, respiratory failure) and death, and shorten the duration of hospitalization. Clinical benefit is greatest when antiviral treatment is administered early, especially within 48 hours of influenza illness onset.
Antiviral treatment is recommended as early as possible for any patient with confirmed or suspected influenza who -is hospitalized; has severe, complicated, or progressive illness; or is at higher risk for influenza complications.
Persons at higher risk for influenza complications recommended for antiviral treatment include: children aged younger than 2 years; adults aged 65 years and older; persons with chronic pulmonary (including asthma), cardiovascular (except hypertension alone), renal, hepatic, hematological (including sickle cell disease), metabolic disorders (including diabetes mellitus), or neurologic and neurodevelopment conditions (including disorders of the brain, spinal cord, peripheral nerve, and muscle such as cerebral palsy, epilepsy [seizure disorders], stroke, intellectual disability [mental retardation], moderate to severe developmental delay, muscular dystrophy, or spinal cord injury); persons with immunosuppressant, including that caused by medications or by HIV infection; women who are pregnant or postpartum (within 2 weeks after delivery); persons aged younger than 19 years who are receiving long-term aspirin therapy; American Indians/Alaska Natives; persons who are morbidly obese (i.e., body-mass index is equal to or greater than 40); and residents of nursing homes and other chronic-care facilities.
Clinical judgment, on the basis of the patient’s disease severity and progression, age, underlying medical conditions, likelihood of influenza, and time since onset of symptoms, is important when making antiviral treatment decisions for high-risk outpatients.

Front 48

When should antiviral treatment start for influenza

Back 48

When indicated, antiviral treatment should be started as soon as possible after illness onset, ideally within 48 hours of symptom onset. However, antiviral treatment might still be beneficial in patients with severe, complicated or progressive illness and in hospitalized patients when started after 48 hours of illness onset, as indicated by observational studies.

Front 49

Treating influenza based on laboratory tests

Back 49

Decisions about starting antiviral treatment should not wait for laboratory confirmation of influenza, if testing was done.

While influenza vaccination is the first and best way to prevent influenza, a history of influenza vaccination does not rule out the possibility of influenza virus infection in an ill patient with clinical signs and symptoms compatible with influenza.
Antiviral treatment also can be considered for any previously healthy, symptomatic outpatient not at high risk with confirmed or suspected influenza on the basis of clinical judgment, if treatment can be initiated within 48 hours of illness onset