1. INFECTIONS OF THE RESPIRATORY SYSTEM

2. Upper respiratory infection
Lower respiratory infection (pneumonia)
Definition Pneumonia is defined as an acute respiratory illness associated with recently developed radiological pulmonary shadowing which may be segmental, lobar or multilobar.
. pneumonias are usually classified as community- or hospital-acquired; those occurring in immunocompromised hosts. 'Lobar pneumonia' is a radiological and pathological term referring to homogeneous consolidation of one or more lung lobes, often with associated pleural inflammation; bronchopneumonia refers to more patchy alveolar consolidation associated with bronchial and bronchiolar inflammation often affecting both lower lobes.
Classification 1-Community-acquired Pneumonia
2-Hospital-acquired Pneumonia

3. Upper respiratory tract infection
coryza (common cold)is by far the most influenza(Influenza A and Croup -Bronchitis (Rhinoviruses, adenoviruses (influenza A and B) Bronchiolitis Respiratory syncytial virus (parainfluenza 3) infection is the usual cause of acute tonsillitis, otitis media and epiglottis represents a medical emergency, upper respiratory tract infections recover rapidly and specific investigation is rarely warranted.

4. Pneumonia (lower respiratory tract infection)
Pneumonia (inflammation of lung parenchyma )is defined as an acute respiratory illness associated with recently developed radiological pulmonary shadowing which may be segmental, lobar or multilobar. Classification : pneumonias are usually classified as : 1-Community-acquired Pneumonia 2-Hospital-acquired Pneumonia (those occurring in immunocompromised hosts.) ‘

6. Radiological classification:
1-Lobar pneumonia‘ referring to homogeneous consolidation of one or more lung lobes, often with associated pleural inflammation.

7. 2- Bronchopneumonia refers to more patchy alveolar consolidation associated with bronchial and bronchiolar inflammation often affecting both lower lobes

8. Community-acquired pneumonia (CAP)
@accounting for around 5-12% of all lower respiratory tract incidence varies with age, being much higher in the very young and very CAP continues to kill more children than any other pneumonia remains the most common infecting agent, Viral infections are an important cause of CAP in children.

9. PATHOLOGY
Consolidation of lung tissue (which takes on the appearance of liver on a cut surface: phases of red, then grey hepatisation).

10. Most cases are spread by droplet infection
Occur in previously healthy individuals but several factors may predispose to CAP: Factors that predispose to pneumonia Cigarette smoking -Upper respiratory tract infections –Alcohol-Corticosteroid therapy - Old age-Recent influenza infection -Pre- existing lung disease -HIV -Indoor air pollution

11. Clinical features
@Systemic features : fever, rigors, shivering and vomiting predominate . The appetite is usually lost and headache is symptoms : 1-breathlessness –cough(first is characteristically short, painful and dry, but later accompanied by the expectoration of mucopurulent sputum) Rust- colored sputum(Strep. pneumonia infection), S.T with hemoptysis, 2-Pleuritic chest pain

12. Cont.
@Upper abdominal tenderness either due to lower lobe pneumonia or if there is associated hepatitis. 3-clinician may hear bronchial breathing and whispering pectoriloquy . Crackles are often also detected

13. Streptococcus pneumonia
@Most common cause.
@Affects all age groups, particularly young to middle-aged.
@Characteristically rapid onset, high fever and pleuritic chest pain; may be accompanied by herpes labialis and 'rusty' sputum.
@Bacteraemia more common in women and those with diabetes or COPD

14. Mycoplasma pneumonia
@Children and young occur every 3-4 years, usually in complications include hemolytic anemia, Stevens-Johnson syndrome, erythema nodosum, myocarditis, pericarditis, meningoencephalitis, Guillain- Barré syndrome

15. In Stevens-Johnson syndrome

16. Legionella pneumophila
@Middle to old epidemics around contaminated source, e.g. cooling systems in hotels, spread unusual. Some features more common, e.g. headache, confusion, malaise, myalgia, high fever and vomiting and abnormalities include hyponatraemia, elevated liver enzymes, hypoalbuminaemia and elevated creatine corticosteroids, diabetes, chronic kidney disease those in increase risk

17. Chlamydia pneumonia
@Young to epidemics or sporadic; often mild, self-limiting and a longer duration of symptoms before hospital diagnosed on serology

18. Haemophilus influenza
More common in old age and those with underlying lung disease (COPD, bronchiectasis)
Staphylococcus aureus
Associated with debilitating illness and often preceded by influenza.
Radiographic features include multilobar shadowing, cavitation, pneumatocoeles and abscesses.
Dissemination to other organs may cause osteomyelitis, endocarditis or brain abscesses.
Mortality up to 30%

19. Chlamydia psittaci Coxiella burnetii (Q fever, 'querry' fever)
Consider in those in contact with birds, especially recently imported and exotic.
Malaise, low-grade fever, protracted illness, hepatosplenomegaly and occasionally headache with meningism
Coxiella burnetii (Q fever, 'querry' fever)
Consider in workers in dairy farms, abattoirs and hide factories (as amniotic fluid and placenta carry high risk).
Risk of infection increases with age and male sex. Acute illness characterized by severe headache, high fever, hepatitis, myalgia, conjunctivitis. Chronic disease causes endocarditis, hepatomegaly

20. Klebsiella pneumonia (Freidländer's bacillus)
More common in men, alcoholics, diabetics, elderly, hospitalized patients, and those with poor dental hygiene.
Predilection for upper lobes and particularly liable to suppurate and form abscesses.
Actinomyces israelii
Mouth commensal. Cervicofacial, abdominal or pulmonary infection, empyema, chest wall sinuses, pus with sulphur granules

21. Primary viral pneumonias
@Influenza, parainfluenza, measles ,Herpes simplex :May cause pneumonia commonly complicated by secondary bacterial :May cause severe pneumonia. Heals with small nodules that calcify and become visible on chest (CMV) Pneumonia may be a major problem in transplant recipients (particularly bone marrow) and those with (severe acute respiratory distress syndrome) should be suspected if a high fever (> 38°C), malaise, muscle aches, a dry cough and breathlessness follow within 10 days of travel to an area affected by an epidemic

22. Investigations
@Radiological examination usually provides confirmation of the diagnosis. In lobar pneumonia, a homogeneous opacity localized to the affected lobe or segment usually appears within hours of the onset of the illness. Radiological examination is helpful if a complication such as parapneumonic effusion, intrapulmonary abscess formation or empyema is suspected :
@Sputum: direct smear by Gram and Ziehl-Neelsen stains. &Culture and antimicrobial sensitivity testing
@Blood culture: frequently positive in pneumococcal pneumonia
@The white cell count :be normal ,whereas a neutrophil leukocytosis of more than 15 × 109/L favours a bacterial aetiology, A very high (> 20 × 109/l) or low (< 4 × 109/l) white cell count may be seen in severe pneumonia
@Urea and electrolytes and liver function tests should also be checked .

23. Pneumococcal antigen detection in serum or urine
@The C-reactive protein (CRP) is typically elevated
@Serology: for Mycoplasma, Chlamydia, Legionella, and viral infections.
Pneumococcal antigen detection in serum or urine
PCR: IgM for Mycoplasma -Cold agglutinins: positive in 50% of patients with Mycoplasma
@Pleural fluid analysis, Tracheal aspirate.
@Pulse oximetry/An arterial blood gas is important in those with SaO2 < 93%, to identify ventilatory failure or acidosis.

24. Assessment of disease severity
This is best assessed by the CURB- 65 scoring system

25. CURB-65 score one for every one
Any of :
Confusion
Urea>7mmol
Respiratory rate >30/min
Blood pressure(systolic<90+diastolic<60)
age>65y
HOME TREATMENT
OUT PATIENT TREATMENT
> HOSPITAL TREATMENT

26. Differential diagnosis of pneumonia
Pulmonary infarction Pulmonary/pleural TB Pulmonary oedema (can be unilateral) Pulmonary eosinophilia Malignancy: Broncho alveolar cell carcinoma Obliterans organizing pneumonia (COP/BOOP)

27. Management
The most important aspects of management include: 1-Oxygenation 2-Fluid balance 3-Antibiotic therapy. 4-In severe or prolonged illness, nutritional support may be required.

28. High concentrations (≥ 35%), preferably humidified.
Oxygen
should be administered to all patients with tachypnea, hypoxemia, hypotension or acidosis with the aim of maintaining the PaO2 ≥ 8 kPa (60 mmHg) or SaO2 ≥ 92%.
High concentrations (≥ 35%), preferably humidified.
Assisted ventilation should be considered at an early stage in those who remain hypoxemic despite adequate oxygen therapy. .

29. Indications for referral to ITU
1-CURB score 4-5 failing to respond rapidly to initial management
2-Persisting hypoxia (PaO2 < 8 kPa (60 mmHg)) despite high concentrations of oxygen
3-Progressive hypercapnia
4-Severe acidosis
5-Circulatory shock
6-Reduced conscious level

30. Fluid balance
Intravenous fluids should be considered in those with severe illness, in older patients and in those with vomiting. Otherwise, an adequate oral intake of fluid should be encouraged.

31. Treatment of pleural pain: paracetamol, co-codamol or NSAIDs is sufficient. opiates may be required Physiotherapy: Physiotherapy may be helpful to assist expectoration in patients who suppress cough because of pleural pain or when mucus plugging leads to bronchial collapse.

32. Antibiotic treatment
Prompt administration of antibiotics improves outcome. Oral antibiotics are usually adequate patient has severe of swallowing reflex or malabsorption. Uncomplicated CAP Amoxicillin 500 mg 8-hourly orally /If patient is allergic to penicillin Clarithromycin 500 mg 12-hourly orally or Erythromycin 500 mg 6-hourly orally

33. Antibiotic treatment for CAP
@If Mycoplasma or Legionella is suspected
Clarithromycin 500 mg 12-hourly orally or i.v. or Erythromycin 500 mg 6-hourly orally or i.v. plus Rifampicin 600 mg 12-hourly i.v. in severe cases
@If Staphylococcus is cultured or suspected
Flucloxacillin 1-2 g 6-hourly i.v. plus Clarithromycin 500 mg 12-hourly i.v.
@Severe CAP //Clarithromycin 500 mg 12-hourly i.v. or Erythromycin 500 mg 6-hourly i.v. plus
Co-amoxiclav 1.2 g 8-hourly i.v. or Ceftriaxone 1-2 g daily i.v. or Cefuroxime 1.5 g 8-hourly i.v. or Amoxicillin 1 g 6-hourly i.v. plus flucloxacillin 2 g 6-hourly i.v.

34. Complications of pneumonia
$Para-pneumonic effusion-common /Empyema
$Retention of sputum causing lobar collapse
$DVT and pulmonary embolism
$Pneumothorax, particularly with Staph. aureus
$Suppurative pneumonia/lung abscess
$ARDS, renal failure, multi-organ failure
$Ectopic abscess formation (Staph. aureus)
$Hepatitis, pericarditis, myocarditis, meningoencephalitis
$Pyrexia due to drug hypersensitivity
Complications of pneumonia

35. Prognosis
@fever may persist for several days and the chest X-ray often takes several weeks or even months to resolve, especially in old age.
@Delayed recovery suggests either that a complication has occurred or that the diagnosis is incorrect .

36. Prevention
#smokers should be advised to stop. #Influenza and pneumococcal vaccination should be considered in selected Influenza and pneumococcal vaccines in old age '

37. Regarding Community-acquired pneumonia ,all following false except:
1-Staphylococcus bacteria remains the most common infecting agent
2-main presentation are breathlessness and dry painless cough
3- Guillain-Barré syndrome one of Chlamydia pneumoniae; complication
4- CXR used For diagnosis only.
5-Persisting hypoxia give us clue for transfer patient to ITU

38. Thank you