Pneumonia and Cor-pulmonale

 

MAIN TOPIC :

RESPIRATORY DISEASE

SUB TOPIC : PNEUMONIA

DEFINITION :

Pneumonia is an infection that inflames the air sacs in one or both lungs. The air sacs may fill with Fluid or pus (purulent material), causing cough with phlegm or pus, Fever, chills, and difficulty breathing. A variety of organisms, including bacteria, viruses and fungi, can cause Pneumonia.

Pneumonia can range in seriousness from mild to life-threatening It is most serious for infants and young children, people older than age 65, and people with health problems or weakened immune systems.

CAUSES :

           Streptococcus pneumoniae

           Haemophilus influenzae

           Mycoplasma pneumoniae

           Chlamydia pneumoniae

           Legionella pneumoniae

           Staphylococcus aureus

          Klebsiella pneumoniae

          Actiomyces israelii

          Primary viral pneumonia :

                         - Influenza

                         - Para influenza

                         - Measles

CLASSIFICATION :

1) On the basis of Biological :

a) Bacterial Pneumonia

- Pneumococcus

- H. influenza

- Staphylococcus

- Mycoplasma

- Legionella

b) Viral Pneumonia ;

Eg; Corona, Rhino,Measles,Eco,mumps 

c) Fungal Pneumonia;

Eg; Aspergillosis

2) On the basis of Clinical features :

a) Typical ;

- Shortness of breath

- Fever

b) Atypical ; ( caused by mycoplasma )

- Diarrhoea

- Vomiting

3) On the basis of Morphology :

a) Lobular ; single lobe

b) Bronchopneumonia ; More than two lobe

4) On the basis of Exposure :

a) CAB ( Community Acquired Pneumonia )

b) HAB ( Hospital Acquired Pneumonia )

- > 48 hour, after admission of hospital

c) Aspiration Pneumonia

 CLINICAL FEATURES OF PNEUMONIA

 SYMPTOMS ;

- Fever

- Cough

- Sputum

- Chest pain

- Anorexia

- Headache

- Malaise

 SIGNS ;

I. Inspection

- High Respiratory Rate

- High Temperature

- Low Chest Movement

II. Palpation

- Law Chest Movement

- High Vocal Fremitus

III. Percussion

- Resonant

IV. Auscultation

- Bronchial Breath Sound

 INVESTIGATION :

Chest X-ray. This helps to diagnose Pneumonia and determine the extent and location of the infection. However, it can't tell doctor what kind of germ is causing the Pneumonia.

Blood tests. Blood tests are used to confirm infection and to try to identify the type of organism causing the infection. However, precise identification isn't always possible.

Pulse oximetry. This measures the oxygen level in blood. Pneumonia can prevent patient lungs from moving enough oxygen into our bloodstream.

Sputum test. A sample of Fluid from patient lungs (sputum) is taken after a deep cough and analyzed to help pinpoint the cause of the infection.

Pleural Fluid culture. A Fluid sample is taken by putting a needle between patient ribs from the pleural area and analyzed to help determine the type of infection.

CT scan. If patient Pneumonia isn't clearing as quickly as expected, doctor may recommend a chest CT scan to obtain a more detailed image of patient lungs.

RISK FACTORS

Pneumonia can affect anyone. But the two age groups at highest risk are:

Children who are 2 years old or younger developing

People who are age 65 or older

Other risk factors include:

Chronic disease. Patient are more likely to get Pneumonia if patient have Asthma, chronic obstructive pulmonary disease or Heart disease.

Weakened or suppressed immune system. People who have HIV/AIDS, who've had an organ transplant, or who receive chemotherapy or long-term steroids are at risk.

Smoking. Smoking damages our body's natural defenses against the bacteria and viruses that cause Pneumonia.

Being hospitalized. Patient are at greater risk of Pneumonia if patient are in a hospital intensive care unit, especially if patient are on a machine that helps you breathe (a ventilator).

 DIFFERENTIAL DIAGNOSIS

• Pulmonary infarction

• Pulmonary oedema

• Pulmonary tuberculosis

• Pulmonary eosinophilia

TREATMENT 

Nausea and vomiting prevent you from keeping down oral antibiotics Eg. Amoxicillin 500mg or Cepodoxim 500mg should be given.

​ Blood pressure drops

​Breathing is rarapid

​Needbreathing assistance

​Temperature is below normal

​Heart rate is below 50 or higher than 100

Patient may be admitted to the intensive care unit if patient need to be placed on a breathing machine (ventilator) or if your symptoms are severe.

Children may be hospitalized if they:

Are younger than age 2 months

Are excessively sleepy

Have trouble breathing

Have low blood oxygen levels

Appear dehydrated

Have a lower than normal temperature

SUB TOPIC :

COR- PULMONALE

DEFINITION

Cor-pulmonale can be defined as an alteration in the structure (e.g., hypertrophy or dilatation) and function of the right ventricle (RV) of the heart caused by a primary disorder of the respiratory system resulting in pulmonary hypertension.

PATHOPHYSIOLOGY

Cor- pulmonale right ventricular dilation and hypertrophy-- develops following pulmonary hypertension caused by diseases of the lung or pulmonary vasculature. Changes in the pulmonary arteries and arterioles are usually present.

CAUSES

   a) Lung parenchymal diseases:

   Asthma                    

   COPD

   Bronchiectasis

  Pulmonary fibrosis

b) Pulmonary vascular diseases:

Pulmonary hypertension

​Pulmonary embolism

​Pulmonary vasculitis

c) Thoracic cage abnormality:

​Kyphosis

​Scoliosis

​Thoracoplasty

d) Others:

​Myasthenia gravis

​Poliomyelitis

CLINICAL FEATURES

✓ Symptoms

  Insidious onset

​Breathlessness, wheeze

​Palpitation

​Features of right heart failure

                   - High JVP

                   - Tender hepatomegaly

                   - Oedema (pedal)

✓Signs

General Examinations:

​Stopping forward position

​Face is dusky and bloated

​Central cyanosis

​Enlarged neck veins

Dependent ooedema

2. Chest Examinations:

​Barrel shaped chest

​Diminished chest movement

​Hyperresonance on percussion

​Pushed down liver dullness

Diminished breath sounds

​Added sounds may be heard

Systolic murmur on tricuspid area

INVESTIGATION

a) Chest x- Ray:

                - Features of emphysema

                - Cardiomegaly with prominent

                - Bronchovascular markings

b) ECG:   

            - P- pulmonale

            - Right axis deviation

            - Right ventricular hypertrophy

c) ABG: 

         - Hypoxia with or without hypercapnia

d) Blood: 

     - Hematocrit raised

e) Lung function test:

                - FEV1/VC markedly reduced.

f) Echocardiography:

               - Right ventricular enlargement

               - Tricuspid regurgitation

RISK FACTOR

Most cases of pulmonary hypertension are secondary to lung disease. Almost any chronic lung disease can cause it. COPD (eg emphysema, chronic bronchitis) in the chronic setting.

COMPLICATIONS

​Syncope

​Hypoxia

​Pedal edema

​ Passive hepatic congestion

​ Death

TREATMENT

a) Rest in propped up position

b) Intermittent O2 inhalation

c) Bronchodilator

           - Beta2 agonist

           - Aminophylline

           - Theophyllines

d) Treat respiratory tract infection with antibiotics

e) Treat heart failure:

                - Fluid restriction

                - Diuretics

                - Digoxin

f) Venesection if haematocrit >55%

g) Treat underlying causes 

h) To prevent cor-pulmonale: Appropriate treatment of COPD with O2 inhalation.

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