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1. ABDULWAHID KORANE
MBChB III. 218-083011- 11035
ISLAMIC UNIVERSITY IN UGANDA

2. Outlines
• Definition
• Classification of brochopneumonia
• Pathophysiology
• Mode of transmission
• Predisposing factors
• Clinical manifestations
• Investigations
• Differential diagnosis
• Complications
• Treatment
• Preventive measures

3. • Pneumonia is defined as inflammation of the lungs
parenchyma arising as a result of inhalation of infected
aerosols ,haematogenous dissemination or by aspiration
of oropharyngeal secretion and associated flora. It is also
an acute respiratory illness associated with recently
developed radiological pulmunary shadowing which may
be segmental, lobar or multilobar.

4. • Bronchopneumonia, also called lobular pneumonia, is a
type of pneumonia that causes inflammation in the
bronchi and bronchioles (conductive zone). These are
the air passages that feed air into the lungs.
• It also refers to more patchy alveolar consolidation
associated with bronchial and bronchiolar inflammation
often affecting both lower lobes. .

5. • Based on origin
Community acquired, hospital acquired (nosocomial),.
• Based on infecting organism
Bacterial, viral.

6. Sources
• Inhalation of infected aerosols
• Aspiration
• Haematogenous
• Reactivation of Pathogens
• Tuberculosis
• Pneumocystis carinii
• CMV

7. • Many cases of bronchopneumonia are caused by
bacteria. Outside the body, the bacteria are contagious
and can spread between people in close proximity
through sneezes and coughs.
• Common bacterial causes of bronchopneumonia include:
• • Staphylococcus aureus
• • Haemophilus influenza
• • Pseudomonas aeruginosa
• • Escherichia coli
• • Klebsiella pneumoniae
• • Proteus species

8. Other causes include:
• Mycoplasma Pneumoniae`
• Chlamydia Pneumoniae
• Chlamydia Psittaci
• Legionella Species
• Moraxella Catarrhalis
• Viruses
• Mycobacteria
• Causative agent is unidentified in 30 to 50% of cases

9. This refers to a new episode of pneumonia occuring at least 2
days after addmission to the hospital, or pneumonia in a pt
that has spent at least 2 days in the hosp within the last
90days
Causes
• Gram negative bacteria
• Klebsiella -Enterobacteria
• Pseudomonas -Serratia
• Proteus -E coli
• Staph Aureus

10. • Bacteria
Streptococcus pneumoniae, Haemophilus influenzae,
Staphylococcus pyogenes, Streptococcus pyogenes,
Bordetella pertusis, G-ve –Klebsiella, Pseudomonas,
Proteus.
• Viruses - respiratory viruses (infrequent):
RSV, parainfluenzae viruses 1–3, human
metapneumovirus, adenovirus, coronavirus, bocavirus,
rhinovirus, measles virus.

11. • Fungal
Aspergillus spp, Candida spp, Cryptococcus.
• Protozoa
paragonimus westermani
• Others
Mycoplasma pneumoniae, Chlamydia pneumoniae,
Pneumocystis jeruvici, Mycobacterium tuberculosis.

12. • The normal pulmonary host defense system consists of multiple
mechanical barriers, including saliva, nasal hair, the mucociliary
apparatus, the epiglottis, and the cough reflex.
• Humoral immunity, including secretory IgA and serum IgG,
defends against pneumonia, and other airway constituents such
as surfactant, fibronectin, and complement play roles in
microbial killing. Phagocytic cells, including polymorphonuclear
cells and alveolar macrophages, play important defense roles,
and cell-mediated immunity is important in the defense against
certain pathogens, especially viral agents and other intracellular
organisms.

13. • Pneumonia typically follows an upper respiratory tract infection.
LRT is usually sterile.
• Organisms that cause LRTIs usually are transmitted by droplet
spread directly from close personal contact or indirectly by
contaminated fomites.
• Following initial colonization of the nasopharynx, organisms may
be inhaled, leading to a pulmonary focus of infection; less
commonly, bacteremia results from the initial upper airway
colonization, with subsequent seeding of the lung parenchyma.
• Virulence & severity depends on health of the individual,
organism & size of inoculation.

14. • Changes occur in respiratory bronchioles and alveoli.
• Exudation of fibrin, inflammatory cells & organisms --- solid
exudative reaction.
• Destructive necrosis of alveolar walls.
• Confluent involvement of patches throughout lobe/lung
(bronchoPn).
• Red hepatisation.
• Grey hepatisation.
• Normal alveolar architecture restored with removal of dead
blood cells & fibrinous exudates.

15. Ways you can get pneumonia include:
• Bacteria and viruses living in your nose, sinuses,
or mouth may spread to your lungs.
• You may breathe some of these germs directly
into your lungs (droplets infection).
• You breathe in (inhale) food, liquids, vomit, or
fluids from the mouth into your lungs (aspiration
pneumonia).

16. • Extreme of ages. <2yrs of age & >65yrs of age
• Immuno-suppresed patients e.g HIV pts
• Cigarette smoking
• Difficult swallowing (due to stroke, dementia,parkinsons
disease, or other neurological conditions)
• Impaired consciousness ( loss of brain function due to
dementia, stroke, or other neurological conditions)
• Chronic lung disease (COPD, bronchiectasis)
• Frequent suction
• Other serious illness such as heart disease, liver cirrhosis, CKD
and DM
• Recent cold, laryngitis or flu

17. •History taking
•Examination

18. • Acute onset.
• Fever , cough (with or without purulent, blood tinged,
rusty sputum), breathlessness.
• Loss of appetite, low energy, and fatigue
• Stabbing chest pain aggravated by respiration and
coughing (pleurisy)
• Restlessness and cyanosis.
• Lower lobe Pneunonia can present with abdominal pain
as in brochopneumonia
• Muscle aches
• Confusion and delirium

19. • breathless, anxious, restless, febrile, may be cyanosed.
Or dehydrated.
• Tachycardia.
• Tachypnea, retractions (intercostal,subcostal,
suprasternal), wheezing, nasal flaring, and grunting.

20. • Central or displaced trachea.
• Symmetrical or asymmetrical chest.
• Diminished chest expansion over affected lobe.
• Resonant percussion that diminished with increase
severity.
• Tactile fremitus increased over affected site.
• Vocal resonance, egophony, whispering ppectoriloquy,
and brochophony may be heard
• Breath sounds may be diminished or even vesicular.
Brochial breath sounds may be heard in severe BPN.
• Crepitations (fine or coarse).

21. • CX-Ray (multiple patchy areas, mostly at lung bases)
• Culture or PCR of tracheal secretions.
• Blood culture, serology
• Lung puncture
• Culture of pleural effusion
• Viral tissue culture. Rapid test on nasopharyngeal
aspirates by immunoflourescence
• Antigen detection in urine
• Lung biopsy

24. • FBC
• Throat swab MCS(microscopy, culture and sensitivity)
• Sputum MCS
• C- reactive protein
• Arterial blood gas and pulse oximetry
• U/E,Cr
• CT scan

25. • Confusion
• Urea > 7 mmol/L
• Respiratory rate ≥ 30/min
• Blood pressure (systolic < 90 or diastolic ≤ 60 mmHg
• Age > 65 years of age
Score 0–1 – Treat as outpatient
Score 2 – Admit to hospital
Score 3+ – often require ICU care
Mortality rates increase with increasing score
Other markers of severe pneumonia
• ■ Chest X-ray – more than one lobe involved
• ■ Pao2 < 8 kPa
• ■ Low albumin (< 35 g/L)
• ■ White cell count (< 4 × 109/L or > 20 × 109/L)
• ■ Blood culture – positive

26. • Bronchiolitis
• Asthma
• Bronchitis
• Heart failure
• Bronchiectasis
• Lung abscess
• Pulmunary infarction
• Pulmonary oedema
• Atelectasis from foreign body or mucous plug
• Chemical pneumonitis

27. • Heart failure– cor pulmunale
• Pleural effusion/ empyema
• Pneumatocoeles
• Necrotising pneumonia
• Air leak syndromes (pneumothorax,
pneumomediastinum, subcutaneous emphysema
• Embolisation (septicaemia, brain abcess, osteomyelitis,
meningitis, pyomyositis)
• Lung abscess
• Respiratory failure
• Pericarditis and Myocarditis
• ARDS

28. • The treatment of bacterial pneumonia can occur either in
the community or hospital setting depending on the
clinical status.
• In the community, supportive management includes anti-
pyretics and early review by a medical practitioner if there
is deterioration or no response to oral antibiotics within
48 hours.

29. • Elderly
• Hypoxaemia
• Dehydration or malnutrition
• Unable to drink/lethargic/toxic
• Immuno-compromised
• Complications
• Poor compliance with therapy
• Living far from health facility
• Also see CURB-65 above.

30. • The patient is failing to maintain an oxygen saturation
greater than 92% in an FiO2 greater than 0.6.
• The patient is shocked.
• There is a rise in respiratory rate, a rise in pulse rate with
clinical evidence of severe respiratory distress and
exhaustion ± a raised pCO2 on arterial sampling.
• There is recurrent apnoea or slow irregular breathing.
• NB; CURB-65

31. • Patient is propped up in bed and made comfortable
• He is reassured and encouraged to cough if cough is
productive
• Adequate hydration must be ensured; patient is
encouraged to take enough fluids
• Adequate analgesics also given so that pain does
not hamper breathing or coughing
• Oxygen when necessary is also given especially
when patient is in resp distress. Maintain a patent
airway

32. • Use suction if the patient can’t produce a specimen or
excessive secretion so as to clear the airway
• perform chest physiotherapy.

33. • Provide a high calorie, high protein diet of soft
foods.
• To prevent aspiration during nasogastric tube
feedings, check the position of tube, and
administer feedings slowly.
• To control the spread of infection, dispose
secretions properly.

34. • Provide a quiet, calm environment, with frequent rest
periods.
• Monitor the patient’s ABG levels, especially if he’s
hypoxic.
• Assess the patient’s respiratory status. Auscultate breath
sounds at least every 4 hours.
• Evaluate the effectiveness of administered medications.
• Explain all procedures to the patient and family.

35. PRINCIPLE OF ANTIBIOTIC THERAPY
• Start antibiotic treatment as soon as possible but
certainly within 8 hours of presentation
• Select appropriate antibiotics given the underlying
condition, local epidemiology and severity of illness in the
patient.

36. • Community Acquired pneumonia
 Mild cases Amoxicillin plus macrolide
 Or fluoroquinolone
 Levoflox Gatiflox moxiflox
 NB; Resistance is emerging
 Severe cases- Augmentin or Cephalosporin and
macrolide

37. Aspiration pneumonia
• Add metronidazole to 3rd generation Cephalosporin
• Clindamycin useful
Nosocomial pneumonia
• 3rd Generation Cephalosporin and gentamicin
• or an anti-pseudomonial penicillin, Ticarcilln
Piperacillin and Cephalosporin
• Vancomycin, Methicillin for resistant staph

38. • Abscesses occasionally require surgery.
• In addition to antibiotics, empyemas require prompt
insertion of an intercostal drain under ultrasound or CT
guidance. If drainage is inadequate, surgery to clear the
cavity and insertion of a large-bore tube is required.

39. • Prognosis is good in otherwise healthy patients
• Mortality increases with those older than 50, co-existing
disease, bilateral disease, hypotension, Blood urea greater
than 7 mmols, Resp rate greater than 30
• Untreated pneumonia has an overall mortality of more than
30%

40. • Influenza vaccination
• Particularly in immunocompromised and older
patients
• Patients with emphysema and chronic bronchitis
• Pneumococcal vaccines
• Patients older than 65
• Patients with Sickle cell disease
• Immunosuppressed Pts
• Encourage cessation of smoking and excessive use of alcohol

41. • As with any type of infection that is spread by droplet or
contact transmission, good hand washing along with
good personal respiratory hygiene (including wearing a
mask around others and covering one’s mouth and nose
during sneezing and coughing) are important.
• Limiting exposure to ill individuals.

42. • Frequent turning of bed ridden patients and early
ambulation as much as possible.
. Sterilization of respiratory therapy equipment
• Suctioning of secretion in the unconscious who have
poor cough and swallowing reflexes, to prevent
aspiration of secretions and its accumulation.

43. References:
1.Davidson's clinical medicine 23rd edition.
2.Kumar and Clarke's clinical medicine.
3.Uganda Clinical Guidelines 2016.

44. •Thank you.