Pneumonia

foreign what's up Ninja nerds in this video today we are going to be talking about pneumonia there's a lot to discuss we'll go over the pathophys we'll go over the different types of ways that we can kind of classify pneumonia based upon the microbes based upon how you acquire it based upon the location we'll talk a lot about that stuff then we'll go over some of the features and complications really tying things together we'll talk about Diagnostics and finish up with some treatment all right so we talk about first things first the kind of the pathophys behind pneumonia whenever patients develop pneumonia you have to think about the different mechanisms I wish they can develop pneumonia obviously pneumonia is an inflammation infection of the lung tissue itself due to a particular pathogen this could be bacterial this could be viral this could be fungal could be a lot of different entities right most common it's going to be bacterial though but the ways that the bacteria get into the respiratory tract is important now one of the ways that this can happen is usually aspiration right and so when I mean aspiration this usually means that some type of secretion whether this be like secretions within our oral pharynx so some of the salivary secretions and things from our oral cavity nasal cavity all of those things kind of draining down unfortunately into the airway so oropharyngeal aspiration is actually tends to be one of the most common ones I'm going to represent that with this orange arrow here where some of the secretions within this oral pharyngeal portion here instead of it going down into the esophagus which is this green tube it unfortunately goes right down into the blue tube right into the airway right and whenever these pathogens that are within these secretions get socked up down here into like a little bronchial or alveoli they have the ability to cause damage to the lung tissue inflammation of the lung tissue infect it and then lead to pneumonia now another mechanism besides oral pharyngeal secretion so let's actually put like a little one here so one is to represent the oral pharyngeal type of aspiration the second aspiration which is really nasty really scary is gastric right so someone has some type of situation here where some of their gastric secretions go right into their air tube this would be the second one so some type of gastric type of aspiration so if someone has gastric aspiration there could be a lot of different reasons for this particular problem but either way that's a way for the bacteria to be able to move from parts of our esophagus from our stomach some of the natural floor within this area naturally to get into the lung tissue cause injury inflammation infection and then you got pneumonia so my question for you is how would these particular pathogens that are coming from oral pharyngeal secretions or from a gastric secretions even get into the actual lung tissue how does it get into the airway that's the question right because we should naturally have protective reflexes there to prevent us right you try to go and stab like the back of the tonsils or the throat you're going to have a gag reflex or something kind of gets in the proximal Airway agitates the tissue there cough reflex or instead of oral pharyngeal secretions or things coming from our GI tract uh going upwards into the airway that should naturally go down into the GI tract so the normal swallowing process those should also all be intact but what if a patient doesn't have those intact so what if for some particular reason you have right for example here we have our central nervous system here's going to be like the the parts that control a lot of these particular reflexes let's say here's a lot of the different cranial nerves that are involved in some of the particular gag reflex particularly within the cough reflex or particularly within the swallowing reflex so now you have a disease process for what whatever particular reason it may be and what it's going to do is there's going to be some type of disease process or depression whatever it may be that's shutting down this cough gag and swallowing reflex so in these patients the primary reason by which they aspirate is the loss of the gag reflex or a decrease in the gag reflex a decrease in the cough reflex or a decrease within the swallowing reflex and that basically prevents us from being able to prevent things from going into the airway and also prevent us from naturally allowing things to go into the GI tract and then undesirably go right into the airway and create an opportunity for pneumonia now my question to you is what kind of things would actually cause this disease process where you inhibit this central nervous system diseases baby nothing crazy to think about it right so one would be if you have any kind of CNS disease think about this it's not too complicated you have a stroke you damage part of the brain seizures Parkinson's disease multiple sclerosis lots of different diseases which are going to lead to this inhibition of this pathway ALS right the other one is any kind of CNS depression and I think this is important also to be able to remember so it may not be a disease process but if you have patients who are on some type of opioids or they're also taking particularly maybe some type of benzodiazepine or they're being sedated or they're being paralyzed for because of the ventilator or they're having to be intubated whatever you're taking away the natural type of reflex from the central nervous system so any type of CNS depression would also be a big one the really big ones that I really want you to remember here especially is alcohol use as well so alcohol use is a big one here as well as any kind of sedation so I would remember sedation or neuromuscular blockade things of that nature but either way you're shutting down the cough gag swallowing reflex allowing for aspirated material now here's the thing this kind of things happen and then the microbe gets in what are some of the microbes that we should really be concerned with whenever a patients aspirate there's a lot of different bugs but the ones that I really really want you to be thinking about especially in patients with some type of underlying aspiration the particular bugs that I would actually be somewhat concerned with the microbes if you will that I would think about in this particular scenario is klebsiella so one would be klebsiella this is a really really nasty bug okay this is very common in patients who are an alcohol use or have some type of aspiration from a CNS disease other ones would be anaerobes so anaerobes are really really nasty when you want to know why anaerobes because this will come from the GI tract GI tract naturally is going to have a lot of anaerobic bacteria and the other one that I would also consider here is going to be staphylococcus Arius so the ones that I would actually be really really potentially considering and patients who have some type of aspiration would think about klebsiello anaerobic bacteria and potentially staphylococcus Arius due to aspiration loss of or decreasing gag cough swallowing reflex due to CNS disease or CNS depression of some particular etiology all right boom roasted next particular thing what will be another reason why someone actually has a pathogen get into the actual Airways cause inflammation infection and lead to pneumonia one is you inhale a really nasty kind of Hardy pathogen and what would that potential pathogens have to be what would be some of the risk factors that would be associated with it so let's say that you're in a population particularly in a particular environment where there's a high kind of volume population lots of close contact in situations where there's lots of this close contact lots of a highly populated individuals you're at risk for some particular types of pathogens that I think are worthy of remembering and the ones that I would really want you guys to potentially think about here in situations where there's lots of close contact a lot of people hoarded together within a very tight population is really be thinking about mycoplasma pneumonia this is a really big one mycoplasma I would also think about chlamydia and I would also think about influenza think about an influenza as well okay so these are really really big things to be able to consider in these particular patient populations again whenever you have a lot of close contact There's an opportunity for a lot of these particular pathogens to be passed on Via respiratory droplets inhaled move right into the airway and have the ability to cause a particular infection so think about influenza mycoplasma chlamydia sometimes Legionella as well but I would put a plus minus with Legionella because the real particular thing that you really want to remember here with Legionella is think about I'm just going to put here think about water sources I really want you to think about contaminated water sources but this could still be in highly populated types of areas hot tubs pools showers you know AC units within a lot of different hotels and things like that all right but we got aspiration we got inhalation particularly within close contact Airborne pathogens but here's another one maybe it's not like a person-to-person transmission via mycoplasma chlamydia influenza or Legionella maybe it's some type of like soil or dust exposure or like nasty droppings from particular animals that put these patients at high risk and it's dependent upon the geographic location which is very high yield so sometimes you can have a lot of fungal infections really really nasty fungal infections and the ones that I want you to remember that they may test you on the exams they may say there was a patient who had potentially has pneumonia and he was just hiking in southwestern United States near California whenever you hear Southwestern portion of the actual United States you want to think about something called coccidio mycosis so what I'm going to put coccidio here so think about coccidiomycosis whenever some people say they were you know doing a lot of spelunking they were looking at different birds and bats and stuff like that near the Mississippi or Ohio River Valley areas you want to think about histoplasmosis so look for that on the clinical vignette so histoplasmosis particularly think about that that kind of buzzword terms bird backdroppings Ohio Mississippi River Valley area or spelunking and the next one is if you think about broad-based yeast in the East right this is going to be particularly more on the western side I'm sorry the Eastern side of the United States so if you see kind of like the Southeastern northeastern part of the United States think about the broad-based yeast in the East this is going to be blastomycosis so think about blasto okay so these are the particular types of fungal infections that I would want you guys to be aware of and potentially Airborne inhalation so this would again be the particular microbes but again when we talk about these particular microbes we're really talking about a fungal type of infection so this would be a fungal type of population that I would want you guys to think about all right so these are the big big things that I really want you guys to be aware of for the potential etiologies first one aspiration second one inhalation now what if a patient let's say for whatever reason they don't have any particular problem with maybe an aspiration or an inhalation but they have something other kind of problem down here that has to do with their normal respiratory function because they have underlying types of diseases that are altering their natural immune system defenses such as mucociliary clearance let's talk about how that potentially could be another problem for patients that are developing pneumonia if a patient does have no problem where they didn't aspirate something right they didn't have any situation where they inhaled like a hearty pathogen like a fungal infection or a mycoplasma chlamydia Legionella or viruses then you want to be thinking about is there something wrong with the actual anatomy of the respiratory tract is there a defense system a little bit altered in a particular way and so one of the big kind of defense mechanisms that our actual respiratory tract has is what's called mucociliary clearance it's a really interesting concept so you have Celia right there beating beating beating they're usually beating things upwards so if you have something kind of stuck within the bronchi or the trachea generally these little guys will beep beep beep the bacteria mucus upwards so we can spit it out or swallow so it doesn't stay within a respiratory tract and sometimes we'll have little mucous globules that will trap the pathogen and again make it easy to be able to beat that bacteria up via the Cilia let's say that there's disease processes that either really chalk up the mucus where the Cilia now they can't handle all this mucus they're trying to beat against this thick thick mucus wall or there's damage to the Cilia now you don't have the ability to move that mucociliary clearance or escalator what are disease processes that would alter this and then lead to an opportunity for pathogens to kind of like get locked up in the lower Airways cause inflammation and infection leading to pneumonia one disease process that would really kind of increase this mucus production think about it guys it's not really hard what about cystic fibrosis so think about potentially someone who has what's called cystic fibrosis or they have the other disease maybe it's not due to cystic fibrosis but it's due to other particular things such as malignancies or such as primary cellular dyskinesia a lot of inflammation of the Airways and this could be something like what's called bronchiectasis bronchiectasis and so in these particular situations you know that this is going to increase a lot of the mucus if you increase the mucus so the Cilia going to be able to beat the bacteria and all that mucus upwards no because now the mucus is going to get so thick imagine that these like cilia they're trying to be able to push like 2 000 pounds versus like 10 pounds now they got this big thing that they got to try to move that's not going to allow for the bacteria to be easily cleared plus it's going to create an opportunity for bacteria to not get moved and so then what happens is some of these like nasty little pathogens they're supposed to get in cleared guess what they kind of just stay in these areas and then they move down to like the smaller bronchioles and alveoli and create an infection other situations is maybe it's not an increase in the mucus maybe the problem is that their cilia is all jacked up maybe we inhibit the potential cilia what if I damage the Cilia you know what kind of diseases would actually damage the Cilia what about COPD right or maybe they don't have underlying COPD but they are a smoker so sometimes patients who are like big big smokers we know that the tobacco also will cause destructive damage to the Cilia and elderly individuals so as you get older you kind of lose some of that natural function of the Cilia so elderly individuals will also have this high risk potentially here now we have an understanding of like these are the patient populations now what I want you to think about what kind of microbes would potentially be present here because if our cilia isn't beating or the mucus is getting too thick it creates an opportunity for the bacteria to not get mobilized they stick down here and they cause pasta form and then they lead to infection pneumonia the potential pathogens that I would want you guys to really be aware of potentially within this situation here is there's a lot of them okay one is I want you to be thinking about this very very specifically with your COPD patients so in these COPD patients and patients who have COPD they're at very high risk for something called haemophilus influenza and something called maraxella catarallis these are really really nasty types of bugs that actually can accumulate here and cause nasty nasty infection the other thing is that patients who are actually going to have cystic fibrosis and bronchiectasis you know what's really really bad with this one with cystic fibrosis and bronchiectasis these are at really high risk for a really nasty bug called pseudomonas so it's called pseudomonas originosa so I really really want you guys to be able to remember that one as well the next particular thing that I also LNG has to be thinking about is that patients who are elderly and who smoke so smokers and elderly individuals are at very high risk for another type of pathogen particularly this one that I would want you guys to be thinking about is Legionella remember we talked about that with the contaminated water sources so contaminated water source but also be thinking about this is an atypical pathogen and patients who are smokers and elderly so these are the big things that I really want you guys to be thinking about in this situation here all right so let's say that there's a problem where again patient aspirated they aspirated some of these particular pathogens into the airway because of the alteration in their natural central nervous system function or they inhale a really hearty nasty pathogen because of close contact or they were in a particular geographic location that put them at high risk for a fungus or they have some type of alteration within the normal normal defense system of the respiratory tract like impaired mucociliary clearance what if by some terrible situation we get a pathogen that gets into the bloodstream when it gets into the bloodstream it then spreads to the lungs oh that'd be a terrible situation but guess what patients who are IV drug abusers are very high risk from whenever they're using dirty needles you know on the skin you have a potential pathogen called staphylococcus Arius so in patients who are IV drug abusers they have this risk of taking this pathogen from Dirty needles getting into the bloodstream and spreading to the lung tissue where it can then cause inflammation and infection obviously didn't get endocarditis and things like that as well but this is a big one so because of that I really want you guys to be thinking about staphylococcus aureus impatients who are IV drug abusers the only other thing that I would potentially want you guys to think about was staphylococcus aureus is not just from IV drug abuse but sometimes add this into your memory don't forget this one is that sometimes in a patient population where they just had the influenza so they just got influenza after they have influenza their immune system is a little bit kind of like not as protective they're at high risk for Staphylococcus aureus so post-influenzafections infections these patients are high risk for Staphylococcus remember two things IV drug abuse and post-influenza for Staphylococcus Arius all right but that's another route that's another way that patients can develop pneumonia they can aspirate they can hail they lose their mucosiliary clearance or they get in the blood and it spreads to the lungs here's the other thing what if the patient gets it spread from the blood right so it comes from the blood hematogenously gets into the lungs or it's inhaled it's aspirated or there's an impaired mucosiliary clearance and it gets into one either way the same result is the the same kind of thing here we develop inflammation infection and then we develop pneumonia what if naturally our immune system is there's another altar there's another defense we have macrophages we have our immune system that will come and try to be able to clear and get rid of the pathogen and get rid of all that kind of infected material that's our natural kind of immune response but what if a patient doesn't have a good immune system what if for whatever reason whenever they come in exposure to that actual pathogen their macrophages aren't doing very well they try to recruit a lot of lymphocytes and neutrophils but all of this is particularly depressed and so their ability all of these immune system cells to be able to work and clear this infection is inhibited because their immune system is depressed they have a decreased function of their macrophages particularly decreased number of lymphocytes would be the big big one that I want you guys think about and again just decrease activity of the immune system in general what kind of patients would be really really high risk HIV so I want you guys to be thinking about patients particularly our immunocompromised such as HIV or what else maybe they have diabetes maybe they have CKD maybe they're alcoholics maybe they are status post transplant right or maybe they're on some type of immunosuppressant medication what are some types of immunosuppressants that you guys would really want to be aware of that they may present on the actual exam think about tnf Alpha Inhibitors think about um your D Mars any kind of things like that steroids would be a really big one so any of those dmards any of the actual types of steroids would be really really big things to think about so these are the things I really want you guys to be able to be aware of but now here's the thing microbes that patients are really high risk of when their immunocompromises is also really really important so if a patient is immunocompromised they are really really at high risk for a lot of different microbes and I think it's worthy of mentioning some of these one of them especially in these immunocompromised patients you want to be thinking about is pseudomonas pseudomonas is very high risk and these patients with underlying disease process as an immunosuppression other one that I would really want you guys to think about here especially in this patient population is Legionella legionelle is another really big one it's that atypical type of pathogen that we talked about with the contaminated water sources elderly and smokers other big thing here is something called PJP pneumocystic jerovichi pneumonia this is a fungus and the big big population that you need to be aware of when they present this on the exam is patients with HIV and I can't stress how important this is a CD4 count less than 200 if they present that on the exam they're trying to point you to this it's a PJP that's causing the pneumonia so a patient who's immunosuppressed with HIV CD4 count less than 200 think about that particular pathogen the next thing that I want you guys to be thinking about besides this one is also think about you know sometimes some of the viruses like CMV would also be another particular one to be thinking about and any type of really other underlying kind of nasty fungal infection would be a big one but the big ones I really think about is pseudomonas Legionella PJP CMV and there could be a lot of other like nasty ones as well potentially other fungal infections but for right now I'd say that these are the primary ones that I really want you guys to be able to remember so let's stick with these ones as the primary ones here okay all right so we have I think a pretty good understanding now of how patients can develop pneumonia it could be from an aspiration problem it could be from an inhalation problem it could be from an impaired mucous clearance problem it could because it spread via the blood to get to the lung tissue I have your drug abusers or it could be because they got it in from the blood or they got it inhaled aspirated impaired mucous area clearance any one of these mechanisms but their immune system wasn't competent enough to clear the infection okay the last thing I want to talk about here is whenever patients we talk about pneumonia we talked about it with respect to pathophysiology mechanisms we talked about with respect to microbes but we didn't talk about the acquisition of pneumonia so what I mean by this I want to briefly talk about it because we'll talk about later in the Diagnostics or something called community acquired pneumonia and Hospital acquired pneumonia it's really straightforward it's not hard community acquired pneumonia you acquired the infection the pathogen from the community which means it's a special type of bug streptococcus pneumonia is a really really important one that I can't let you guys forget so whenever you have a patient who has what's called community acquired pneumonia think about streptococcus pneumonia that's going to be one of the most common types usually you'll see that with the elderly patients as well so if you really wanted to add it into the list here for the elderly I would also add in here streptococcus pneumonia and this is going to be the most common cause of community acquired pneumonia in most patients okay but they acquired it within the community or they got admitted into the hospital and within less than two days in the hospital has to be key less than two days in the hospital or out in the community they acquired the infection from strep pneumo if it's Hospital acquired there's a usually a very specific definition so Hospital acquired pneumonia is they've been in the hospital for more than 48 hours more than two days and now the bug changes from strep pneumo to a very very nasty resistant bugs that you can encounter in the hospital and usually the most common type of hap or Hospital acquired pneumonia is a subtype called VAP ventilator-associated pneumonia these are patients who have an endotracheal tube within their Airway or some type of trach like they have a trach or they have an endotracheal tube and what happens is once they're in the hospital for greater than two days they now have nasty bugs that they can actually form and the two bugs that I really want you guys to remember here is going to be MRSA so methicillin resistance staphylococcus aureus and the other one is going to be pseudo monus now in patients who develop ventilator Associated pneumonia due to they have an endotracheal tube you obviously need that in more than two days to have the actual diagnosis so they haven't had an endotracheal tube in for greater than two days or 48 hours what are potential things that put these patients at risk I think that this is one that I would actually consider remembering for the exam okay they may ask you this because it's relatively high yield oftentimes when patients are in the ICU we give them particular drugs to suppress their gastric acid production to prevent them from getting like stress ulcers and so we may give them things like proton pump inhibitors we may give them things like h2ras like famotidine and what that does is that suppresses their gastric acid production so they don't get ulcers but you know what else it does it increase the gastric pH do you think bacteria survive better in a high pH or low ph they survive better on a high pH and if that's the case and for whatever reason they reflux some of this around the edges of the endotracheal tube and it gets into the lungs this can really cause a little nasty pneumonia so I really want you guys to remember that gastric acid suppression tends to be a very very big potential cause for ventilator Associated pneumonia the other one here is when patients are being sedated normally if you have pathogens there you cough and cough and cough and you'll clear those secretions or you'll get suctioned if patients aren't getting actively suctioned so there's decreased suctioning decreased suctioning of potential secretions that can build up form of film and then lead to an infection or if you're having a lot of increased sedation so when patients are on lots of sedation they don't have a lot of that cough reflex to clear a lot of those secretions or you know what else is really bad if they're paralyzed if your paralyzed can you cough no and so whenever you're either not suctioning out the secretions and getting them to cough or you're taking away their cough and their natural kind of like mechanisms to clear secretions such as an increased sedation or increased paralysis for whatever potential reason these potential things really increase the risk of ventilator Associated pneumonia but you need an endotracheal tube for two days and then think about these particular bugs for cap what I say less than two days in the community or in the hospital and strep pneumo all right let's move on to features and complications all right my friend so patient develops pneumonia right they have an infection of their lung tissue whenever they start having a misinfection of their lung tissue what are some of the features the complications when they present this on the vignette right they're gonna say oh this patient has pneumonia no they're going to say okay the patient's coming in and they're presenting with blah blah blah blah blah blah blah and then they may present some other underlying lung disease that maybe puts them at risk for aspiration they were in a very tight controlled crowds they were like hiking in Southwestern parts of the United States they have an immunosuppressive condition they are an IV drug abuser you get the point so it's important to be able to understand what are those features and complications that really point you towards pneumonia now remember I told you that I use the terms a little bit Loosely I didn't really mention them and discuss them in detail but there's a typical pneumonia and what I really mean by typical pneumonia is this is the pneumonia that most people think about that are like a very specific bacteria like subset so this is like your streptococcus pneumonia your klebcl your haemophilus influenza your staph aureus Etc all of those nasty bugs pseudomonas and so on and so forth when we talk about atypical pneumonia we're talking about a very specific subset okay so what I want to do is I want to write down here because I didn't mention them a ton but you talk about something called atypical pneumonia and when I talk about atypical pneumonia really what I'm saying is this is a very specific subset and I like to just break it down a little easy mycoplasma chlamydophilia and Legionella are the three atypical pathogens that I really want you to remember and so I'm not going to write all this down I'm going to abbreviate it to help you guys remember it as well I always remember atypical MCL mycoplasma chlamydia Legionella and then the other one to remember is your viruses remember I told you influenza para influenza CMV SARS cov2 and covid-19 so there's a lot of different viruses out there that could also fit within the atypical umbrella the key thing that you have to remember is that with atypical pneumonia due to mycoplasma due to chlamydia due to legionnil or due to viruses they won't present with a lot of the classic features that we're going to see with typical pneumonia oftentimes the key ways to differentiate this subset is they present with upper respiratory tract infection like symptoms so that's really what I want you guys to remember for the atypical types of pneumonias due to these pathogens think about upper respiratory tract infection type symptoms what does that include well it can cause headache so think about headaches think about some type of like nasal congestion or rhinorrhea you know what else is a really big one how about a sore throat so some type of sore throat sometimes here's the other big one that I would want you guys to remember earaches so I want to show you guys a potential picture here especially with mycoplasma pneumonia you know with mycoplasma it can cause a really nasty infection of the tympanic membrane and cause bullous meningitis they may present this on the actual exam so think about this when they say ear pain atypical features like upper respiratory tract infection symptoms go looking in that ear and this is what it would look like all right so that's some of the big things now sometimes upper respiratory tract infections they may have very low grade fevers and myalgias and arthralgias so you can also add those features in there as well so think about a low-grade fever okay but these would be the big things to think about upper respiratory tract infections are really going to be the key thing so headaches sore throat nasal congestion earaches with the bulls meningitis and then again some low-grade fevers myalgia's arthritis things like that here's the big big stuff with the typical now everything else we're going to talk about is typical pneumonia for the typical pneumonia you see a lot of classic features whenever you have let's say here's this area of infection so you have all of this part of the lung is all locked up with bacteria when it's all locked up with bacteria it's going to cause a massive inflammatory type of process which releases a lot of cytokines interleukin-1 interleukin-6 all these things that you probably don't really care about but what they do is they really kind of work on your central nervous system and particularly at the level of the hypothalamus and your hypothalamus says oh got to increase the body temperature so that the bacteria can't survive baby oh I may have to make these patients shake a little bit due to this type of problem so they may develop fever and rigors very common features in patients with atypical pneumonia and I'd be really important to remember here that it would be more of a high grade fever rather than a low-grade fever the other thing is as you lock up this kind of like alveoli now look at this look at this I'm going to lock up these poor little alveoli with pus and I'm going to even maybe hit some of the bronchials normally whenever we have a good measurement of oxygenation it's dependent upon the ventilation of the alveoli and the perfusion to the alveoli let's say in this situation the perfusion is normal so the ability to move blood through the pulmonary vessels and pick up oxins good but the ventilation in this situation is decreased because now I got to try to send oxygen into this locked up alveolar it's going to stop right there and I got to try to send oxygen down here and now the auction has to try to move across these all socked up and pus-filled alveoli imagine how little oxygen is going to move into these alveoli so what's the end result here because I have something called a low ventilation and a normal perfusion I get something a combined effect of these called a V Q mismatch do you guys remember this from our hypoxia MC respiratory failure lecture that whenever a VQ mismatch this can lead to hypoxemia due to this alveoli being filled with pus here's the next thing when a patient gets hypoxemic what are the potential reflexive reactions that they may present on the vital signs let's come down and talk briefly about that now here's another really interesting thing that they may present so they may say okay the patient's coming in they have high grade fevers they got rigors they have low O2 saturation on their pulse ox and then when they look at the vitals also maybe in the vignette they may also say something else and I want to just kind of explain why this usually happens because it's a pretty concept uh dependent type of thing so whenever you have this locked up area that causes that VQ mismatch right so decrease ventilation to this portion of the lung so whenever you mismatch that portion decrease ventilation good perfusion it leads to hypoxemia so low levels of oxygen within the blood so there's going to be poor oxygenation at this point here now we know that when that gets into the pulmonary circulation that'll go back to the left side of the heart rate we know pulmonary veins return to the left heart and whenever they return to the left heart you'll empty all that blood into the left ventricle from the left ventricle you'll take this blood and then send it outwards into your aorta and into the Carotid system now what you guys probably remember is that there's all these different chemoreceptors within the aorta and the Carotid uh bifurcation there that pick up the sensation of oxygen or pick up the concentration of oxygen and whenever the concentration of oxygen is low it really activates these chemoreceptors and they send sense this impulses into the central nervous system and the new medulla goes like haywire and it says oh geez the oxygen is low I got to increase the blood flow out of my heart to the lungs to increase perfusion and I need to increase the respiratory rate to increase my ventilation and so subsequently what happens is you'll notice that the patient may have an increase in their heart rate and they also may have an increase in their respiratory rate and depth so they may present to kipnic or dysnic and tachycardic hypoxemic fevers and rigors okay what else if you think about this locked up area here and let's say that some of this pneumonia is involving some of the actual bronchi and bronchioles and you got some of this pus that's kind of filling into the lungs here here's filling into the alveoli it's involving some of the bronchi bronchioles whenever you inflame the bronchon bronchioles they're really really heavily innervated by a lot of different types of noisy receptors and kind of like cough receptors and so when you stimulate this because of a lot of inflammation they're going to go Haywire send that information into your central nervous system and your central nervous system will say oh okay there's a lot of secretions and mucus within the Airways if I cough I may be able to clear some of those secretions up and so it produces this intense cough reflex but the cough should be what productive all right so that is going to be a big thing to think about here with these patients so look for a productive cough filled with a lot of muco purulent sputum high fevers rigors hypoxemia reflexive tachycardia tachypnea which maybe look like they're breathing hard and working hard to breathe the other thing here key types of basic Foundation stuff is whenever you have let's say inflammation of the lung parenchyma here and it gets close to involving the nearby pleura if you agitate or inflame the perlera guess what else there is near that pleura pain receptors agitation receptors that are going to be able to pick up that sensation of inflammation and send that to the central nervous system and these are somatic motor fibers that present with referred type of pain and so they'll have pain in their chest whenever they take a breath what is that called pleuritic chest pain very common and any type of pulmonary pathology to present with a pleuritic chest pain so look for polyritic chest pain productive cough hypoxemia reflexive tachypnea tachycardia high grade fevers and rigors with atypical you don't really get a lot of that stuff you know what I'm saying MCL viruses the other thing that I really want you guys to think about here is these are really high yield concept is your physical exam findings so you know when a patient gets a locked up portion of the lung let's say here's a big old consolidation in their lung when they have this consolidation you go and you try to do your physical exam there's big big things that they may ask you they may even ask you these questions they may present it in the clinical vignette where you have this area of consolidation so it's filled with fluid that's filled with pus that's filled with cells all of those things is a really kind of fluid consolidation here's the best big term I actually want you guys to get away so consolidative findings so consolidation is a big big thing that they sometimes will ask you on the exams so if you have a consolidation there is this concept that air right whenever sound is moving through particular substances if it moves through air and it moves through fluid so between the two which one would it actually move faster through and better through it moves better and faster through the fluid than it does the air and so it increased the intensity of a lot of physical exam findings so one of the things that would actually be very very important to consider here is you go to the chest and you percuss if you really do that you'll hear something called dullness to percussion so you'll have a lot of dullness to their percussion if you listen and you take the stethoscope and you put it over their chest and you have them perform some specialized types of activities where first thing you do is you have them say uh 99 and you're listening to their lungs or where the area of consolidation is when that sound is moving through the consolidation when they say 99 it's going to sound so dang clear and it shouldn't sound clear so because of the air usually that's filling that space so if they have what's called a able to hear the 99 clearly during auscultation that's called a positive bronchophony that's a really big one the other one is that sometimes you'll have the patient say e and when you say e or whenever the sound moves through that consolidation it really kind of amplifies it and changes to where it can sound like a so if it goes from e to a that's a consistent with a Consolidated finding so we call that positive e Golf and remember e and it go off in the E going to a e goffo knee okay the next thing here is that sometimes we can have them whisper and so when you're only having with me like one two three what that will do is you shouldn't be able to hear that really at all and a patient who has an all air filled lungs but they have a consolidation that sound's going to move really really easily and you're going to be able to hear it relatively well so if you can hear one two three when they whisper very very easily it's consistent with the consolidation so it's called whispered pactility I'm not going to spell that out because I'll probably butcher it the next thing that I also want you guys to consider here as if you do something called tactile fremitus you take the hypothen our imminences and you put it on the area of where the consolidation is normally vibration that's moving from the sound waves moving through their Airway through the pleura through the chest wall onto your hypothenar eminence is kind of dependent upon air right but also whatever the fluid that it actually is moving through or the substance that it's moving through when that sound waves move through a fluid consolidation the actual vibrations are intensified and so you'll feel that way more intensely in a patient who has a consolidation that knows with normal lungs and we call that increased tactile fremitus so they will have increased tactile fremitus all right my friends these are big big findings that I would really don't forget for your exam because they will probably ask you this as a Consolidated findings okay so we have these as the features of typical pneumonia and here's what's the scary thing with with pneumonia when patients develop pneumonia they can develop a couple Associated complications so let's say here we have a pneumonia in this left lower lobe left lower lobe is all locked up with bacterium pus well that's going to cause a localized inflammation so the capillaries are going to become leaky they're going to be invasive dilated and fluid is going to start leaking out into the pleural space if the fluid leaks into the pleural space around that area of a pneumonia what called a paranormic effusion sometimes though it can really get locked up and actually some of the bacteria so sometimes you know what can happen is you can have some of the fluid here but some of the bacteria actually kind of spreads contiguously into the space and makes it really loculated type of appearance and so you can get two potential complications one is you have a sterile inflammation around the pneumonia and one is you have a lot of inflammation with a lot of loculated bacteria and pus within the pleural cavity what are these called my friends this is called first one a paranormic effusion a Para mnemonic effusion we talked about this in the pleural disease lecture you guys remember that right and then the other one this one here where there's a loculated type of a pus infection within the pleural cavity spreading from a localized area of pneumonia this is called a empyema empyema these are scary complications from this disease okay so impaima here paranormic effusion here all right what else can happen here the other really big thing here is that sometimes if you get like a lot of anaerobes and staphylococcus or klebsiella remember told you that anaerobes club Cialis Catholic Stars aspiration in those situations what can happen is you can have like an infection here right but then the bacteria get really smart especially anaerobes and those anaerobes start kind of Walling off the bacteria and then you can have this infection here where you have this big big cavity filled with let's just kind of make it all nasty here all this pus and bacteria here what is this called when you have this cavitation in the lungs where there's actually the ability for the anaerobes or klebsal or staphylococcus to wall themselves off this is a lung abscess this is another potential complication here that you would want to remember with patients who have pneumonia the other thing obviously is that as you start causing inflammation and infection of multiple alveoli and bronchials let's say that you just continue to keep spreading this is very very common with like Broncho pneumonia but you start causing multiple alveol like diffuse alveolar damage to occur you can lead to ards so acute respiratory distress syndrome is another one where we talked about that before as well this is a pretty common etiology right here's the big one though and I think this is really important to remember this one because it leads into how we kind of like wrist stratified diagnose these patients and determine which one needs hospitalization which will probably test you on and which ones don't so sometimes let's say that you have a really really nasty pneumonia in this patient right here's their pneumonia and then what happens is some of the bacteria from this pneumonia seed into the circulation e that's not good and if they seed into the circulation now you have bacteremia bacteremia doesn't necessarily mean sepsis but if it seeds into the circulation and it starts causing potential organ failure oh then we might be getting into that kind of sepsis criteria especially if the patient is having like hypoxemia low blood pressure tachycardia tachypnea fevers you're getting to that range of sepsis now if you have a patient who has pneumonia that starts seeding into the actual circulatory system what happens is it causes vasodilation increased capillary permeability when these pathogens get out here and uh oh what do we get we get a low blood pressure low mean arterial pressure we stop perfusing organs my friends and as we stop perfusing organs such as the kidneys the liver the brain multiple other organs you can lead to multi-system organ failure and on top of that you start altering the normal coagulation system and decreasing the number of platelets that are important to form clots and then you start consuming them to make a bunch of different clots but then you have the chance of bleeding what is this called DIC so it's really really important to remember that patients who develop pneumonia have a very very high risk of sepsis okay especially going down the road of septic shock all right my friends let's now go into the Diagnostics of pneumonia all right my friend so we've already talked a little bit about this already with the kind of Diagnostics we talked about capped versus hap but I just want to kind of take a little quick second here because there was a couple things that I said and I didn't write down but I just want to kind of like again keep testing your knowledge right so a patient comes into the emergency department they come into your clinic whatever it may be they're presenting with cough shortness of breath fever they have low two stats they're a little to Kip Nick they're working a little bit hard to breathe they're short of breath they're complaining of that right their rest of their heart rate's a little bit up you hear evidence of consolidation on their physical exam they got a productive cough they have pleuritic chest pain or maybe they just have the atypical so they have low grade fevers of respiratory tract infections like headaches sore throat you know nasal congestion runny nose maybe they have a little bit of myalgia arthralgias Etc whenever a patient comes like that and you think about the risk of them having pneumonia such as the etiologies and pathophys the next thing is to determine is this a community quiet or a hospital acquired right so community acquired pneumonia there's a couple different things I want you to know so obviously it was acquired within the community community so we can say it was acquired within the community up to less than two days in hospital and the reason why this is important because this determines the risk of what types of bugs bacteria pathogens that the patient is most likely going to have and you can use that degree of Suspicion to say it's likely that it's cap and so I therefore can use this particular antibiotic regimen but if it's greater than two days in the hospital you can't say with confidence that this is the same bug it might be a different one so you have to change your antibiotic regimen that's why it's important so Community to less than two days in the hospital they developed this pneumonia if you will now when patients developed pneumonia within the community oftentimes it tends to be kind of this low bar pneumonia and there's a very specific pathogen I already told you that you see in patients greater than 65 years of age elderly most common in nursing home facilities it's the most common one streptococcus pneumonia so it's going to be most commonly streptococcus pneumonia a second line would be hemophilus influenza rexella caterels and your COPD patients okay the next thing that I want you guys to understand is Hospital acquirement so this would be cap all right community acquired pneumonia hap on the other hand is you have them greater than two days in the hospital and this could be in the hospital they got a tube down their Airway intubated okay VAP which is the most common subset of hap in this situation oftentimes this type of pneumonia is usually Bronco so it involves the bronchi the bronchioles and a little bit of the alveoli and it's a little bit more scattered in that sense we'll talk about this a little bit later when we get into the Imaging but oftentimes for these patients for hap the very specific types of pathogens that I want you guys to remember about for this one is oftentimes going to be generally when we think about hap what did I tell you before MRSA and we said pseudomonas these are the two bugs that's why it's really important to understand because when you're in the hospital you have multi-drug resistant pathogens nasty pathogens that you'll have in the hospital that you won't have in the community that's why it's important to know this definition now when you establish whether it's a hap or a cap based upon this type of discussion that can help you to determine your antibiotic regimen then you kind of say okay I think this patient I have a certain degree of confidence that they have pneumonia let me get some Labs let me get some Imaging maybe they ask you on the clinical vignette what's some of the labs that you would order for this patient or maybe they present you with labs and you have to kind of use the clinical context the clinical features and based upon it being cap or hap which types of labs are more suggestive or better for you oftentimes it's not really that many there's a lot of extra labs and I don't think they're super critical so one of the things that I would do consider right away is what if they are presenting with features of upper respiratory tract infections so if they have any features of upper respiratory tract infections I would just go right away and get a respiratory viral panel because this is going to be helpful to look for maybe influenza maybe it'll help me to rule out some type of SARS cov2 like in you know covid-19 RSV Etc so there there's so many that I can I can pick here but that's the first thing that I would do if do they have any of these features do they have the atypical presentation send that off first I would do that first the other thing here is oftentimes just get some basic blood work for the patient oftentimes if they have this pneumonia what did I tell you that it's going to activate their immune system right and if they activate their immune system it's going to cause an immune response it can release all those cytokines it'll activate their bone marrow have them amp up their white blood cell production so if I expect to see an increase in their white blood cells whether this be lymphocytes more enviral or neutrophils more in bacterial I would order a CBC not too bad right the other thing here is so if I think that that could be one potential thing the other thing here is that sometimes with these infections they can cause that multi-system organ failure right and if I'm concerned about multi-system organ failure I'm concerned about sepsis so sometimes what can happen is I'll actually check maybe a BMP okay and so if I check their BMP what I'm looking for is is there any evidence of an acute kidney injury increasing their bun is there any increase in the creatinine because this is telling me a little bit more about concern for organ failure so is the pneumonia causing sepsis it's not helpful in the diagnosis you see what I'm saying I'd say that in anything CBC would be better than the BMP in this situation what could be potentially helpful is that whenever you are really doing this for the exam the BMP may also show you low sodium if a patient presents with low sodium who is elderly smoker immunocompromised and has some type of exposure to contaminated water sources which one should you think about guys Legionella so think about lesionella all right the other thing here Sometimes some of these pathogens okay they can get into the bloodstream and then they can get filtered across the kidney and can get filtered into the urine specifically some of their antigens can be tested and so we can test the urinary antigens and so what I'll do is I'll test the urinary antigens specifically for strap pneumo and Legionella all right baby so these are some of the things that I would start off with a CBC to look for a leukocytosis that's probably the easiest one a BMP to look for any acute kidney injury or hyponatremia cute kidney injury be more concerning for early sepsis hyponatremia suggestive of lesionella and then consider the urinary antigens to look for strep pneumonia or Legionella the other thing here is that sometimes this inflammation can actually work on the liver and when it works on the liver you may have the liver increase the production of something called CRP I don't think that this is super helpful so I wouldn't really worry about this one the other thing is that sometimes some of these and some of these actual pathogens may get into the bloodstream and cause kind of injury to the liver and cause a bump in the lfts and one of the things I would consider here is in a patient who has hyponatremia nausea vomiting diarrhea elderly smoke or immunocompromised and some type of contaminated water source you bet it Legionella look for this hyponatremia increased lfts think about Legionella all right the last thing that I would also consider here is if you're concerned that the patient is developing sepsis I would get blood cultures so consider also testing the blood to make sure that the pathogen hasn't seeded into the circulatory system so checking blood cultures may also be a good thing and then if you really want to figure out what's the specific type of pathogen because oftentimes you'll start antibiotics empirically in really sick patients when you get the sputum cultures back it'll tell you oh this is the pathogen oh okay it's strep pneumon I don't need to have all these intense antibiotics I can get rid of these and then use the specific antibiotic for that pathogen so sputum cultures may also be helpful to take and really kind of run like a suction down there and what you can do is if you can get the suction down there and pull some of the sputum out or what usually it's in the proximal Airways you suck some of that sputum out you can suck some of that sputum out and then put it into a tube and then send that off to be tested for culture so you can do what's called a sputum culture and that's really just to help you kind of like narrow down the antibiotics once you get the bacteria back okay all right I hope that made sense with the labs the big ones that I would really be worthy of considering here is your CBC your blood cultures your sputum cultures and your respiratory viral panel and then potentially a BMP to be looking for and again hyponatremia with increased lfts thinking about lesion they like to ask that on the exam okay let's go through Imaging which is actually way more Superior and way more important I think the really really important thing to be able to elucidate here is the Imaging so not only knowing a couple two different things what the actual image would suggest off the chest x-ray if they present it to you is it a low bar is it an interstitial is it a Bronco so we'll talk about that briefly here in a second and we'll take a look at some images but also there's also other ways that we can Define pneumonia right so microbe acquisition and also location so when we think about the actual type of pneumonia based upon location we can Define them again here we have low bar and it's not too hard uh Bronco pneumonia because you know the nice thing about this is that they were very very generous when they came up with these names and had them actually like make sense and then last one is interstitial and I think there's two particular um things that I want you guys to take away from from this kind of like location description of pneumonia so low bar pneumonia it's straightforward it's a pneumonia that's occupying one of the lobes of the lung so if I had an ammonia here I could have a bunch of different types I could have a right upper lobe a right middle lobe right lower lobe left lower lobe left upper lower ammonia in this situation I'm just going to pick a right lower lobe pneumonia right that's that's all it is but the big pathogen that I want you guys to be thinking about because they may ask you this is already talked about up there strap pneumo strep pneumonia I'm gonna put strep pneumonia right there okay the next one is if you have a bronchial pneumonia it's not hard it's involving the bronchi and the bronchioles maybe some of the alveoli as well so it's going to have like patchy it's going to be very patchy and it's going to be extending kind of scattered throughout the lungs so it'll be kind of like very very patchy opacities that you'll see bilaterally this is bronchopneumonia and usually the microbes for this one if it's Hospital acquired yes it's MRSA it's pseudomonas but if it's community acquired that's a different situation so what I want you to remember is if it's community acquired ammonia I just do it like this because it helps me to remember it staphylococcus aureus streptococcus pneumonia homophilus influenza and klebsiella for the community acquired Bronco pneumonia for the hospital acquired pneumonia we already know MRSA and pseudomonas Originals I'm going to put PSA there okay so that's really what I want you guys to be thinking about okay so if we have a low bar pneumonia it's situating to one of the lobes if it's Bronco it's involving the bronchi bronchioles it's scattered bilaterally like these kind of like patches interstitial it's involving the interstitial spaces so the pathogen is kind of infecting not the lung parenchyma itself it's causing infection here and the interstitial space is and this my friends is very common with your atypical pneumonia what did I tell you is atypical in the morning the way that I wanted you guys to remember it MCL and viruses so MCL mycoplasma chlamydia Legionella which one would be these be the most common out of those three mycoplasma young children and college dormant like college or dorm rooms very close contact occupied spaces they're young healthy and usually that's going to be one of the most common types of atypicals don't forget that one if it's like um young kids in a very close contacts like like generally like dorms are the best examples that they'll present this in or like you know uh boot camps and things like that but the other one would be viruses all right I think that gives us a pretty good idea of the types of pneumonia that we have on Imaging now let's take a look at a bunch of Imaging all right my friend so I think one of the big things to think about is okay we get Imaging well what kind of Imaging do we get do we get a chest x-ray do we get a CD oftentimes a chest x-ray should be the initial test whenever patient's coming in with like shortness of breath this nampleretic chest pain they got purling cough any kind of thing like that it's not a bad idea to just start off with a quick initial chest x-ray it's ease of access and it's going to be a quick one that you can get done so I would do that one first the only time I really do a CT is if you don't really know what's going on off their chest x-ray their chest x-ray is inconclusive you are treating them for pneumonia and they're not getting better and then the only third reason I would say is if they're immunocompromised so I'd say three reasons why you get a CT chest x-ray is inconclusive but you still have a high degree suspicion that's pneumonia you're treating them for pneumonia they're not getting better and then third is their their immunocompromise and you think that they may have some type of weird pneumonia that was worthy of taking a better look at okay so first one here is Broncho pneumonia how can I tell it's not situated to like a particular lobe I can see that there's like patchy you see how there's like patchy consolidation here patchy here it's kind of a patchy over here so it's this patchy kind of bilateral consolidations in both lungs that's Broncho pneumonia think about this in outpatients what with that staphylococcus streptococcus hemophilus and klebsiella if it's Hospital acquired think about MRSA and then pseudomonas okay let's take a look at another chest x-ray all right my friends here's another chest x-ray for a patient who came in they had headaches they had uh kind of like some nasal congestion rhinorrhea sore throat ear aches with bullous meningitis they had some low-grade fevers my allergies arthralgias they're young they're they're living in a dormitory and boom you think about mycoplasma right or chlamydia that'd be another one or and if I said contaminated water sources in an elderly young individual who smokes are immunosuppressed and Etc you think about Legionella or viruses but this right here when you see this kind of like fine like threading like it almost looks like a ground glass type of appearance it just looks really really odd kind of like someone who's like out in the winter and you're blowing on like the the glass when it's really cold and it kind of looks like that it has that kind of ground glass opacities but it's very very fine reticular their markings that are moving from the hilum outwards towards the pleura this is very very classic of your interstitial pneumonia okay so this would be on your differential for mycoplasma chlamydia lesionella and viruses all right my friends so we're taking a look here what's called a PA and lateral chest x-ray that's that deserves another question which type of X-ray do I put into the thing like if they ask me like what kind of x-rays are the best if they asked me the best would be a PA and lateral chest x-ray APS can sometimes distort the anatomy and kind of not provide the best clinical picture Pas are going to be really really good pictures that will really kind of enhance the you know the the chest wall and show pathology and lateral x-rays are really good because sometimes you can't see those lower lobes on a PA view and so if you put them in a lateral x-ray you can get that lower lobe view which is really nice so I'd say PA and lateral chest x-ray are going to be the best test that you can do if you had to pick between the chest x-rays PA ladder because PA will give you the upper lobes and like maybe a little bit of like the right middle lobe but the lower lobe sometimes can be hidden and then you can get that better on that lower that lateral chest x-ray so here we can see right upper lobes look good left upper lobe looks good right middle lobe looks good can't really see the right lower lobe left lower lobe I'm seeing some opacity here because it's kind of like obscuring the edge of the heart like that left heart border but I might be missing some of the lower parts going down into the behind this diaphragm portion so I put a lateral in there and look at that I can see here in this like left lower lobe really Consolidated area here they got a left lower lobe pneumonia so that's what you'd be looking for and thinking about strep pneumo is a big one here okay let's take a look at another x-ray all right my friends here's another Axwell x-ray look at that right upper lobe looks clean right lower low clean I'm able to kind of pick up my right heart border left heart border here I can kind of make it out so I definitely don't see any opacity of the left lower lobe but I'm kind of obscuring over here near the left kind of portion of the mediastinum near the aorta and the pulmonary knob I'm kind of obscuring my left upper lobe it looks hazy it looks so pacified that's a left upper lobe of pneumonia okay that's a low bar pneumonia let's take a look at another one all right my friend so here I can see here my right upper low Bliss clean my left upper lobe looks clean I can see pretty well my left heart border so left lower lobe looks relatively good but look at that my right border I can't actually make out completely and there's a little opacity or hazy consolidation here on that right middle lobe portion that's our right middle lobe pneumonia my friends all right let's do a look at another x-ray all right so here's another one I look at my left upper a little bit it's clean look at my left lower lobes clean I can see the nice left heart border right heart borders nice and clear so I don't have a right middle of pneumonia if I had a lateral view I'd be able to be able to get a better view of my right lower lobe and my left lower lobe a little bit better but I don't have that here but what I do see that pops out like a sore thumb is this kind of right upper low opacity and I can even kind of see it because he said no here's the fissure so if you're horizontal and you're oblique fissure that would come down here I can already see my horizontal fissure here so there's kind of like that little fissure that's bulging there and then again I know that I have like this opacity that's involving my right upper lobe so think about that one as well okay all right let's take a look at another type of image all right my friend so this is a CT so again in this patient we ended up getting a chest x-ray they had an interesting type of kind of consolidation involving like they're right up or low but even getting into a little bit of their middle lobe but primarily kind of like their right upper lobe was really getting hit and what we're concerned about is kind of like the way it looks so what I wanted to do is I wanted to show you something really interesting on the CT why it's so good it really is like the best for pneumonia but we try to just reserve it if we're kind of unclear we don't have enough from our chest x-ray they're not getting better with antibiotics or they're immunocompromised when I look at the CT here look at the right lung you can already kind of see here in this right hemithorax here you can see kind of this hazy opacities in comparison to the left one looks nice and aerated and as I go down it's getting worse more opacities more opacities more opacities more opacities and boom you see something really interesting you see how here's like a bronchus that's kind of coming off here and it's moving into this consolidation and it's open there's a lot of air move moving into and then it stops it's like a cut off here these are called air bronchograms this is very characteristic of pneumonia so if you see a consolidation and you see these opened up air kind of filled cavities moving into the consolidation that is called a air bronchogram pretty consistent with a patient having pneumonia okay so that would be a right kind of lobe pneumonia generally it's kind of if you kind of look here you can see it's actually hitting more of in this patient's case it's definitely involving more of their upper lobe all right my friends let's not talk about the treatment of pneumonia so we're going to talk about this in particularly focusing on the antibiotics that we're going to use to treat the infection it's an infection of the actual lung tissue right so the primary focus should be treating the actual infection there's a lot of supportive measures that come into it as well obviously treating potentially the hypoxemia that they may have the work of breathing we're not going to go into that we talked about that with the acute respiratory failure of the lecture but what I really want us to focus on is here the antibiotics but the antibiotics are really really kind of dependent upon what kind of pneumonia we have and that's really dependent upon how we stratify these patients and determine their need for outpatient care in hospital care but not in the ICU and then ICU level care or they've been in the hospital for a couple days more than two days more than 48 hours and they've developed pneumonia so they have a hap right so let's talk about this really quickly so you have a patient come in and this is really only applying to What's called the community acquired pneumonias so this is really trying to determine is this a community quiet pneumonia that can go home to the floor or to the ICU the way that we do this that they will likely ask you on the exam something called the curb 65 score and so really what this to consists of is confusion so you're probably like wait Zach where did confusion come into play remember I told you that if a patient gets pneumonia one of the complications is the bacteria can seed into the bloodstream cause Inc a decrease in their main opportunity or perfusion they don't perfuse the brain as well they don't perfuse the kidney don't perfuse the liver they develop multi-system organ failure one of the first things for elderly individuals is that they develop confusion or altered mental status and this is due to kind of the septic feature so if they're already presenting with sepsis isn't that a concerning sign Absa stink and lutely it is so confusion is a very concerning sign the next thing here is uremia now uremia wait is that uremia wasn't that what the you know the increase in the urea off of the patient's uh particularly their BMP and whenever we say the uremia is present we say greater than like 20. so we're saying like greater than like 20 in this situation that would be concerning what that would tell me that there were an acute kidney injury telling me that they're decreasing the perfusion to their kidneys potentially so they have an acute kidney injury yeah that's a concerning sign that means that they need to be hospitalized it's like what if their respiratory rate is like really high it's like greater than 30 breasts per minute they're like breathing super super fast they're super Technic their work of breathing is very scary when I feel comfortable sending that patient home no that's a very concerning sign and that is another big one the next thing is blood pressure blood pressure plus blood pressure well that was the thing with the map right the meaner to your pressure that's dropping of their hypotensive is that the problem absolutely so if their blood pressure is low and what I mean by low is we're talking about two particular parameters that their systolic blood pressure is less than 90 millimeters of mercury or if they're diastolic blood pressure is less than 60 millimeters Mercury this is a concerning sign and the last thing is patients who are greater than 65 years of age they're obviously a higher risk of worse outcomes and so because of that it's worth assuming that as you get older your immune system is becoming compromised you have an impaired mucous ciliary clearance and also you likely have other comorbidities that put you at higher risk and we don't feel comfortable sending those patients home sometimes and so if you are 65 years of age or greater you are at high risk and what we do is we sum up all the points so if you have one of these you obviously get a point and what we do is we kind of risk stratify based upon their score if their score is between zero or one that's a patient that I feel relatively confident that does not have sepsis multi-system organ failure and can decompensate I can send these patients home so this would be a cap outpatient okay if their score is two okay then I'm a little bit more concerned for this patient this is a patient that could potentially decompensate and they need just a little bit more observation maybe not an ICU level care but they need some observation so this is a cap but this is going to be a non-icu admission okay and the last one is they have three plus this is a patient that you're very concerned with they have a very high mortality rate and we should not send them to a home we should not send them to a non-icu they need a very close observation and very aggressive care these are patients that have a community acquired pneumonia and require ICU level care so that's how we should re-stratify these patients okay but I want you to understand why we use the curb 65 and what's the purpose of looking at these parameters not just memorizing it okay now we've wrist stratified we've determined those with high mortality low mortality intermediate mortality and then we say okay now that I have kind of a sequence I can treat these patients accordingly to cap outpatient cap9 ICU cap ICU and then what else hap Hospital acquired doing let's talk about that all right so when we talk about these patients we now can kind of group them into the cap outpatient cap inpatient cap ICU and then we'll talk about the haps right greater than two days in the hospital and then we'll briefly briefly talk about aspiration money we won't spend a lot of time on it now with cap outpatient what I want you to remember is in these particular populations you're really kind of thinking about the atypicals that's the big big one possibly even strep pneumonia as well so for that what really covers the strep pneumonia covers the atypicals pretty well the first option that I would consider in these patients would be your macrolides so azithromycin would be kind of the one or doxycycline which is one of those particular I'm going to put doxy which is one of the actual tetracycles that we can consider as well so doxycycline would be a pretty good one as well as a macrolide is the other alternative option there okay either one the second option here would really be a respiratory fluoroquinolone and the reason we would consider this don't do this one first is because of high resistance I would really only do this if a patient has an underlying comorbidity that puts them at high risk or they've gotten antibiotics in less than the past 90 days if they have then you can consider that they may have a little bit higher resistance and so because of that I would then say Okay a respiratory fluoroquinolone may work well if they've had antibiotics in the last 90 days or a comorbidity they're present okay all right so that would be that situation there next one if a patient has community acquired pneumonia and they're actually in the hospital but they're an observation not in an ICU setting you can do some of the same thing here we could still do a respiratory fluoroquinolone that's definitely an option here as a monotherapy the other option here is I would consider doing same thing up here a macrolide or doxy Plus a beta-lactin and the preferred beta lactam is obviously dependent upon where you are in the world in the hospital but oftentimes the most preferred agent is Ceftriaxone okay Ceftriaxone is one that I would definitely consider all right for a patient who is in the ICU they have community acquired pneumonia they're in the ICU and that situation you could do somewhat of the same thing but unfortunately we kind of get rid of the doxycycline and so all that changes here is we can do two options here one is we can do a macrolide so azithromycin or we could do a respiratory fluoroquinolone the only thing that's different is I add a beta-lactin to one of these particular regimens it doesn't matter which one you pick okay so you can pick either one of these as an option so this would be how we would start cap outpatient macrolite or doxy just by itself or a fluorine loan only if you meet this criteria cap in the hospital it's a little bit different you can do respiratory fluoroquinone by itself or you could do macrolide or doxy plus beta-lactin when you get into the ICU you don't use doxy it's usually macrolide plus a beta-lactin or respiratory fluoroquinolone plus a betalactum that's it preferred Ceftriaxone doesn't mean lacking of choice sometimes you can do Augmentin which is amoxicillin clavulani is another option as well or ampicillin sulbactum which is also known a Unison but this is usually the easy one to remember hap this is generally greater than two days in the hospital right so whether this is with a tube down your Airway or not you're in the hospital for two days or more and you have pneumonia it is now a hap you're covering a different type of bug what is the bugs that I told you to not forget the first one is don't forget about MRSA so generally you treat with Vancomycin another option is called linasalid okay pseudomonas originosa in this situation what are we covering with there's so many of these so I'm going to abbreviate what we call this piperacillin tazobactum sometimes piptazo or zosin the other one is called cefepime and the other one that would also potentially consider here is your aminoglycosides so Tobramycin Gentamicin Amy casein I would really avoid these though they're really harsh on the kidneys so I'm going to put Amino glycosides but I would really try to avoid these as an option in the test question as well as in real life okay the other thing that I would also consider here is if a patient is HIV positive let's see if you guys remember this HIV positive and their CD4 count is less than 200. I suspect PJP what should I treat them with because PJP is really really nasty one and this one I treat them with what's called Bactrim trimethoprim sulfamethoxazole the only other thing that would add on is is that sometimes you can add on a fluoroquinolone a respiratory fluoroquinoline like levofloxacin or amoxifloxacin if you think that the patient has lesionella if they do have Legionella you can add on respiratory fluoroquinolone but let's not get too far down that rabbit hole these are the big things that I really want you to remember that you may get on the exam the last one is aspiration I don't want you to get too locked up on this just because I don't think that it's actually super correct to be honest with you according to what you'll need to know for the boards in comparison to True Life aspiration pneumonia think about it what kind of pathogens ana rose is the big one what is the lung is it aerated very very aerobic or is it anaerobic the lung is filled with oxygen so it's going to be hard for an anaerobe to be able to survive in the lungs right so therefore unless the patient has a lung abscess or unless they have an impiema we don't really treat for anaerobic infections with these particular bugs but on the exam you do but in real life you don't so what are these think about clindamycin clindamycin would be one potential option here another one may be what's called um Augmentin so Augmentin so we call that amoxicillin clavulanate it's called Augmentin and the third option that you may consider again I really don't think that this is worth mentioning but metronidazole plus a beta atom but these are things that they may see on the exam if you had to pick between one I pick clindamycin if they really ask you but oftentimes because the lung is so aerated we don't treat aspiration pneumonia with these types of pathogens we just treat it as though it's a half or a cap same treatment unless they have a lung abscess or an empyema then we treat with the clindamycin or the Augmentin or the beta lactam and then the metronidazole all right my friends the only thing I would actually tell you guys to remember potentially for the treatment of pneumonia is just remember prevention how do we prevent this we'll talk about it more in the vaccinations lecture but are going to be talking about your pneumococcal vaccination so PCV 13 generally at 2 4 16 2 4 6 and 12 to 15 months of age and then the ppsv 23 vaccinations you get at 65 years of age or older or if you have a lot of underlying conditions that make you at risk in patients 2 to 64 years of age but that'd be a good prevention that they could ask you all right that covers pneumonia all right my friends let's do another case study here so here we have a 72 year old male presented to the ninja Clinic with purlin cough dyspnea rigors and Progressive confusion past medical space program for COPD diabetes and HIV so we know this patient's gonna have pneumonia but some of the features here that are suggestive of pneumonia and are concerning is because she has a purling cough so she's got a purulent speed in production she has nistia so Disney could be indicative of a lot of the consolidation causing hypoxemia to some degree she's got rigors which could be due to the fevers from a bacterial type of source here and she's got Progressive confusion maybe kind of suggesting to some degree that she has some type of organ dysfunction she may not be kind of allowing for proper perfusion of the brain and so especially in elderly individuals we can see that so concerning finding there but her past medical issues also kind of supportive of worst and kind of lung problems COPD can cause a lot of nasty bugs there diabetes makes her a little bit more of immunocompromised plus she's HIV positive that also makes her superimino compromised so she's got a lot of risk factors here for increasing the risk of her having some type of pneumonia COPD again a lot of thickening secretions a lot of bronchospasm and again because of the not being able to beat the mucosiliar apparatus that's a problem diabetics she's also kind of immunocompromised HIV Amino compromise may not be able to have the immune system response that she needs to fight off any kind of normal pathogens in her Airway so very concerning findings here so and she's 72 which makes her a little bit more elderly and again reduces the amount of cilia reduces that up kind of like process there so concerning findings here oh vitals are not very good at all she's in big trouble so vitals BP is 80 over 50 so she is hypotensive she's a slightly attacker cardic so heart rate's 110 respiratory rate is 32 shows you slightly to kipnik as well and there are temp is elevated so she's got a temperature of 101 degree Fahrenheit so she's febrile to kipnik tachycardic and mildly hypotensive and on top of that her spo2 is dookie so she's on 84 percent and she's already on fio2 of 60 so she must be on some type of supplemental oxygen source that's giving her 60 fio2 so maybe some type of like high Flonase of cannula or you know Etc so in general this is a concerning finding for this patient so she's hypoxemic on oxygen supplementation February tachycardic and hypotensive so very concerning signings now when we go to the chest and we go to examine this patient we want to think about signs of consolidation so things that are going to actually alter the kind of like process of auscultating altering the process of tactile fremitus auscultating the process of like these sounds or Whispers um and percussion so how do we find concerning findings of consolidation so if we hear bronchial brass sounds that means that there's a consolidation as the bronchus is actually trying to run into the smaller bronchials it's running into a consolidative area so we're going to hear the breath sounds proximal to that consolidation such as bronchial breast sounds when we're percussing generally anything that's more fluid filled or pus filled in this kind of case is going to give a more dull type of percussion and it's going to be louder on tactile fremitus too so they'll have an increased tactile fremitus they'll also have a positive bronchophony egophony and Whisper pectiloquy on their specialized tests okay so that's important as well so these are all findings that are supportive of consolidation here for this patient so how do we go about diagnosing pneumonia well there's a lot of different things that we can do we can get a bunch of different Labs we can get a bunch of different Imaging I mean obviously starting off with like a CBC wouldn't be a bad idea in the CMP um so what we would see with the CBC in this patient is that she has a leukocytosis so she has an elevated white count may be supportive of an infectious etiology sure CMP shows a bun of 30. so she's got an elevated bu in her creatinine was also elevated slightly her lfts are normal her sodium is normal again this is important when it comes to Legionella her blood cultures when we actually tested her and then she ended up going to the floor um well actually we'll see where where she'll be able to go but she goes somewhere in the hospital um her blood cultures actually came back positive for hemophilus influenza and streptococcus pneumonia and then her sputum cultures were positive for PJP H flu and streptococcus pneumonia her CD4 count because she is HIV positive we wanted to check is less than 200 and her Imaging on chest X ratios bilateral patchy consolidations so this woman has got a lot of different problems here so what we're seeing is she has a bacterial infection right both bacteremic and mnemonic she has HIV with a very very low CD4 count and she's definitely got bilateral patchy consolidation supporting more of like a Broncho pneumonia type of finding so she's got a leukocytosis she has potential uh signs of acute kidney dysfunction bacteremia positive sputum cultures and the source of her bacteremia probably from her lungs and she's got a low CD4 count putting her at high risk of PJP which she's positive for and her lungs are supportive of Consolidated findings here so she's definitely got a really really bad pneumonia secondary to strep pneumo and age flu and then she's also got a little bit of PJP due to her CD4 HIV less than 200. okay so what are the three types of radiographic pneumonia I talked about Broncho pneumonia but what are the different types so there's lobar Broncho and interstitial pneumonia so low Barn ammonia is when it's usually like a socked in pneumonia it's Consolidated to potentially usually one lobe or two lobes so generally it'd be like a right middle low bar pneumonia right low lower lobe kind of like low bar pneumonia so it's usually kind of socked up usually we very commonly see this in pneumococcal pneumonia Bronco to moon is more scattered bilateral patchy and usually we see that kind of involving like the smaller bronchioles and alveolar tissue as well usually you can see a lot of different bugs that cause this one and then the last one here is interstitial pneumonia so you see a lot of kind of like interstitial infiltrates and usually like this reticular reticular nodular kind of opacification and we usually see this with like the mycoplasma the chlamydia Legionella so that's important to remember here whereas the Bronco you see things with like staff and strap and haemophilus and klebsiella a lot of different bacteria all right so we have a patient who we're definitely concerned has pneumonia I think the question that we have to ask ourselves is is this a community choir pneumonia or Hospital acquired pneumonia well she just got into the hospital she just arrived she's not even been in the hospital for more than 48 hours so because of that I would say that this is a community acquired pneumonia she acquired this in the community she hasn't even been in the hospital for very long at all so what level of care is another great question to ask that this patient may require and how does actually one go about determining what level of care so remember I told you about the curb 65 score so what out of these does she have and then based upon that what puts her at high risk so you see here her curb 65 score she has confusion we actually see that in her HPI she does have uremia her urea was greater than 20 it was actually 30. her respiratory rate was 34 I believe so she's got tachypnea that kind of supports that her BP's are soft so she had an 80 over like 50 so she kind of fulfills that and she's 72 so she's hidden 65 years of age she has all of those findings and so generally when someone has like findings that potentially high like three or more that's very concerning and they require ICU level care so this patient needs to go to the ICU now when we send her to the ICU we're going to start her on antibiotics because obviously the core the source of this is a bacterial pneumonia there's so many different types of bacteria that can cause pneumonia but likely hers is again because she's 72 and the most common cause of community acquired pneumonia and elderly individuals is streptococcus pneumonia and on top of that she has COPD and diabetes puts her at high risk for homophilus influenza and she's got HIV which puts her at risk of her PJP she's got a multi-bacterial type of polymicrobial pneumonia here and with evidence of sepsis too my friends so she's also septic so with that being said if we were to kind of treat let's say that we didn't we excluded sepsis at this point in time and we were only treating the pneumonia we were not treating the sepsis what kind of antibiotics would we put her on based upon her curb 65 score putting her in the ICU level care we would do a beta-lactin and a macroli generally is going to be the first thing that we'll do here or we can do a fluoroquinolone and a beta-lactin of some type right but these these would generally be what you would start a patient on so you would do this and get them started on this and then when their cultures come back as we already have them now we would narrow down according to what we think is best but again I think a beta lachim and a macrolide or a beta-lactam and a chloroquinolone would put her in this kind of ICU level category now if we had her becoming septic we could potentially change the antibiotics up a little bit oftentimes patients just get put on something like vancomycin and Piper silentezobactum but I think the best thing here is that she would be appropriate with a beta-lactum antibiotic such as Ceftriaxone and a macrolides such as something as we've talked about before like azithromycin in this particular situation if that wasn't appropriate you could do a beta lactum like Ceftriaxone and a fluoroquinolone if there was concerns that she had MRSA which she does not have MRSA because our cultures came back with no MRSA we would treat her with Vancomycin if her cultures came back positive for pseudomonas originosa or we had concerns for that then we put her on something like piperacylentazobactin or sethupine but she doesn't have that so we're going to treat her for what we would suspect based upon what the guidelines are and that we talked about on the Whiteboard and what her sputum cultures and blood cultures came back positive 4. beta lactam and a macrolide or beta-lactam and a fluoroquinolone would be appropriate here there's one other thing that she did test positive for which is PJP and PJP generally we should treat these patients with bactrim so I would also add on Bactrim in this particular situation which is the trimethoprim sulfamethoxazole the next question okay that I actually did kind of lead into this is that when you have demonium one of the complications of pneumonia obviously you can get things like ards you can get peritonemonic effusions that can lead to empyemas there's a lot of different things that can happen with this potential disease but one of the worst case scenarios that we can see here is that the patient can actually kind of seed some of the bacteria into their circulation their systemic circulation which can cause worsening features of hypotension tachycardia severe fevers and then sometimes becoming refractory to fluids and vasopresses we can see the patient becoming septic and going into septic shock so right now the patient does have features of sepsis and some degree of septic shock because they are lower on the blood pressures and we're seeing organ dysfunction now so I would say that this patient is in the point of septic shock which is concerning and again we would treat the patient accordingly for septic shock such as putting them on vasopressors uh fluids up you know with a minimal kind of fluid approach and then on top of that considering things such as um you know antibiotics obviously that we would already have this patient on for their pneumonia so treating them pneumonia vasopressors to support their blood pressure plus or minus a little bit of fluids just being careful not to fluid overload them but anyway that's how we would go about this patient now getting back to the actual Concepts here that I need you guys to remember for the exam is remembering these buzzword terms and so if thinking about the microbe can really come Acro across on the clinical vignette so if they kind of use the term strep pneumonia or you think that it's strep pneumonia which one of these would be more of a support of strep pneumonia and I want you to think that it's the most common cause of community acquired pneumonia and elderly individuals that's streptococcus pneumonia all right staph aureus I want you to think about post influenza and IV drug abuse and again think about MRSA as a hospital acquired pneumonia type of pathogen that's very very dangerous um part of me the next one is hflu and marxella so for H flu marxella I want you to think about COPD ears and even some degree bronchiectasis the next one here is klebsiella think about alcoholics and CNS disease and depression anything that increases the risk of aspiration would be klebsiella and then pseudomonas definitely think about immunocompromised or immunosuppressed in cystic fibrosis is a Harbinger for pseudomonas as well mycoplasma think about young healthy and close quarter living especially dormitories Alicia now you want to think about contaminated water sources their smoker they're elderly they're immunocompromised that's the big one there PJP think about HIV AIDS CD4 count less than 200 coccidiomycosis is the fungus in the southwestern United States so California and then you have the next one here which is histoplasmosis this is the bird or bat droppings that you see during the spelunking kind of events in the Ohio and Mississippi River Valley and then blastomycosis think about the yeast from the East all right so Eastern United States think about blastomycosis and then lastly anaerobic bacteria I think about in situations of aspiration events all right my friends that covers pneumonia I hope that it made sense I hope that you guys enjoyed it as always love you thank you and until next time [Music]

Channel: Ninja Nerd

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Keywords: Ninja Nerd Lectures, Ninja Nerd, Ninja Nerd Science, education, whiteboard lectures, medicine, science

Id: lzyUVVOqyS0

Length: 89min 23sec (5363 seconds)

Published: Tue Apr 18 2023