Pneumonia aspect for nurses
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Pneumonia aspect for nurses

..


  • 1 < 5

  • 8-10%


  • pneumonia

      • Terminal, respiratory bronchiole

      • Alveoli

      • Interstitium

  • Community acquired pneumonia

    • .. 4-14

  • Typical

  • Atypical

    • Gradual onset


  • : , ,

    • Direct contact with respiratory droplet

    • Physical transfer of respiratory secretion

    • Aspiration of upper airway flora

    • Hematogenous


  • 25-75% bacteria virus

impair defense mechanism


ciliated epithelium

Mononuclear cell submucosa

debris

PMN

debrismucous

atelectasis

air trapping

normal flora nasopharynx


S.aureus, K. pneumoniae

necrosis of intra alveolar septa

destruction

abscess




Protective defense mechanism

  • nose, nasopharynx : filtration by nasal hair, sneezing

  • epipharynx : coughing

  • vocal cord : expiration

  • larynx : coughing( cough reflex)


mucous blanket

1 mm/min in peripheral airways

2 cm/min in the trachea

pharynx

swallowed

mucociliary system


alveolar macrophage

macrophage

phagocytose FB

mucociliary escalator

leave the lung by lymphatics or blood


bacteria

IgA in the mucous

kill by macrophage


Host defense disorders leading to pneumonia


Host defense disorders leading to pneumonia


..3

(1)

Cystic fibrosis


infection

bronchospasm

retained secretion

chronic lung disease

increased work of breathing

diaphragm fatigue

hypoxemia

hypercapnia


    • :


  • (1)

    • <2 >60 2-12 >50

    • 1-5 >40 5-16 >28

  • (dyspnea)

    • crackles


    • Vocal fremitus

    • Breath sound

    • Bronchial breath sound (consolidation)

    • Fine crackles(), rhonchi

  • pleura

    • Refer pain: ( meningism)


  • Consolidation

      • chest expansion

      • tactile vocal

        fremitus

      • Localized dullness

      • air entry - localized crackles

      • Bronchial breath sound - Pleural rub


  • Hypoxemia

    • hyperventilation

    • :

    • : ,

    • ,

    • pulmonary hypertension

  • Hypercapnia


      • Pulse oximetry

    • Poor peripheral perfusion, mottling, shock


flaring of alae nasi

suprasternal notch retraction


subcostal retraction


intercostal retraction


coryza

, wheezing


CXR: alveolar( consolidation)

Infected mucous

acinus

Alveolar wall injury

hematogenous

Edema fluid leak

Rapid spread from pore of Kohn

bronchiole

Terminal airspace

  • Spare: bronchial wall

    • Interstitial

Adjacent lobules


CXR: alveolar( consolidation)

Homogenous opacity fluffy margin except fissure


CXR: interstitial(viral)


Bronchovascular bundle

Interlobular septa

Increase bronchovascular marking


interstitial+ hyperaeration

Virus, aspiration


  • Bacterial: Alveolar infiltration: consolidation

    • Lobar, segmental

    • Air bronchogram

    • Diffuse bilateral bronchopneumonia


  • Virus, Mycoplasma: Interstitial infiltration

    • Bronchovascular marking

    • Peribronchial cuffing

    • Hyperaeration

    • Linear, nodule, honeycomb

    • Patchy consolidation from atelectasis

    • Bronchopneumonia ()


consolidation

interstitial


    • Pneumatocele: S. aureus

    • Reticulonodular : M.pneumonia

    • Round pneumonia:

    • :


    • 3-25

    • S.aureus

      • 33: primary 89: disseminated

    • .. 2-5

  • bronchoalveolar lavage

    • normal flora: TB


  • ESR, CRP:

  • antidiuretic hormone

    • 10

      • >25 PMN/high power field

      • <10 squamous cell

    • Hypertonic saline


  • ET tube aspiration

    • 1

      • Flora upper airway

      • Inflammatory response ET tube

    • Capsular polysaccharide antigen

    • nasopharynx effusion

    • Nasopharynx: PCR

    • Culture

    • Serology:IgG, IgM

  • M.pneumoniae: cold agglutinin,IgM,IgG, PCR


lymphocyte

bilateral diffuse interstitial


  • pleural effusion

  • empyema


S.pneumoniae

  • Pleural effusion 20, empyema

  • CXR

    • Lobar

    • Bulging if fissure (inflammatory exudate )

      • Klebsiella pneumoniae


H. influenzae

  • Unilateral consolidation bilateral

  • Pneumatocele

  • Pleural effusion: 26-76%

  • type b


S.aureus

  • 4.3+/- 2.5 , 32%:

  • Primary:

    • Unilateral lobar

  • Secondary:

    • Diffuse bilateral

  • Effusion:15% - 75%-

  • Pneumatocele 45-68%

  • Empyema ,Pneumothorax


S.aureus

  • 1986-1995

    • 27 primary

    • 92.6% < 2 (1-14)

    • Lobar consolidation 96.3% Multiple lobe 40.7%

    • 11.1%

    • 24.6% 14.8% 33.3%

    • WBC

      • 20,344 +/- 10,266 cell/mm3

      • < 15,000: 33.3%

      • PMN< 50% : 22.2%


Aspiration pneumonia

  • : ,

  • Wheezing: edema,mucous

    • Anaerobe

  • CXR

    • 2 ..

    • Lower lobe, diffuse bilateral

    • Perihilar: recurrent microaspiration


posterior

Superior segment

Basilar segment


Nasopharyngeal aspiration


TE fistula


  • RSV

    • URI

    • Wheezing, rales

    • bronchiolitis

  • Influenza

    • 2-3

    • :

  • Adenovirus

    • bronchiolitis obliteran


Chlamydia trachomatis

  • genitalia

  • Conjuntivitis 10

  • 3-6; staccato cough

  • Wheezing

  • CXR: perihilar infiltration

  • eosinophilia> 300 cell/mm3


M. pneumoniae

  • Wheezing

  • CXR:

    • interstitial,

    • One lower lobe 50% bilateral 10-40%

    • 34%

    • Effusion<10%


Immunodefiency


Immunodeficiency



:antibody

  • Recurrent+ severe URI/LRI

  • Encapsulated bacteria

    • X-linked agammaglobulinemia

      • 9-18antibody

      • IgG

    • Common variable immunodeficiency(CVID)

      • 10-30

      • IgA CD4/CD8 ratio


:antibody

  • IgGsubclass deficiency

    • IgG2 deficiency total IgG

    • IgG4 ,IgA deficiency

    • Atopic disease: asthma, allergic rhinitis


:T cell

  • SCID:severe combined immunodeficiency

    • X-linked, AR()

    • 4-6

    • Lymphopenia

    • CD3 T cell

    • Immunoglobulin


  • Monitoring: HR, SpO2

  • hypoxemia

  • ??


..

  • < 6 : diaphramatic fatigue

  • hypoxemia

  • : empyema


  • Collateral channels of ventilation

Paediatr Respir Rev 2004;5 Suppl A:S77-9.


: wheezing

Paediatr Respir Rev 2004;5 Suppl A:S77-9.


-horizontal insertion of diaphram

- fatigue-resistant muscles

Paediatr Respir Rev 2004;5 Suppl A:S77-9.


cannula


Oxygen hood


Endtidal CO2


positioning

  • Unilateral lung lesion (children and adult)

    • Lie down on an unaffected side (normal lung)

      • Better ventilation on the dependent lung matching with more perfusion also on the dependent lung (less ventilation- perfusion mismatch)

      • Secretion drainage by gravitation

      • Easy to do chest PT

      • Always monitoring

Prasad SA, Hussey J. Chest physiotherapy techniques and adjuncts to chest physiotherapy. In: Prasad SA, Hussey J, Campling J, editors. Pediatric respiratory care: a guide for physiotherapists and health professionals. London: Hapman & Hall; 1995. p. 67-97.


  • PaO2 < 60 mmHg FiO2 > = 0.6

  • PaCO2 > 50 60 mmHg CO2 ,PH < 7.3

  • (negative inspiratory pressure < -20 cmH2O vital capacity < 12-15 ./.)

  • protective airway reflex , gag reflex

  • shock


  • hyperventitation



Erythromycin(10-14)

Clarithromycin (10-14)

Azithromycin 10MKD then 5MKD(4)

Cloxacillin or cefazolin, Clindamycin (allergic)

Vancomycin( resistant)


PenicillinG

3rd cephalosporin(DRSP)

Clindamycin

PenicillinG, clindamycin

Erythromycin,ClarithromycinAzithromycin


:Penicillin, clindamycin, amoxcicillin-clavulanate

: Nosocomial- aminoglycoside, 3rd cephalosporin


    • : 5-7-10

    • : 10-14 3

    • S. aureus, , gr.A streptococcus: 2-3-4

    • S. aureus: 10-14

    • S.pneumoniae

      • 24-48

      • Empyema: 7

    • gr.A streptococcus :


  • H. influenzae/S.pneumiae/ S. aureus

    • 2nd, 3rd cephalosporin +cloxacillin

    • ampicillin with clavulanate+cloxacillin

  • S.pneumiae/M. pneumoniae

    • 2nd, 3rd cephalosporin+erythromycin


Chest physiotherapy


Incentive spirometry


Positive end expiratory pressure


EzPAP


  • Hib vaccine

    • 2-4-6

  • Pneumococal vaccine

    • Conjugate: 2-4-6-15


2

> 6

< 9 : 21 1

surface glycoprotein(hemagglutinin+ neuraminidase)

Antigenic variation



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