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Pneumonia

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What is pneumonia?

WorldPneumoniaDay

WORLD HEALTH ORGANIZATION

Pneumonia is an infection of lungs that is most commonly caused by viruses or bacteria. These infections are generally spread by direct contact with infected people.

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  • Integrated global action plan for the prevention and control of pneumonia and diarrhoea (GAPPD) 12 April 2013
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    肺炎

    肺炎是一种影响肺部的急性呼吸道感染,可由病毒、细菌或真菌引起。肺炎一般通过与感染者直接接触传播。

    在世界范围内,肺炎是儿童死亡的首要原因。通过免疫、充分的营养以及通过处理环境因素,可预防肺炎。

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    Neumonía

    La neumonía es un tipo de infección respiratoria aguda que afecta a los pulmones. Se transmite generalmente por contacto directo con personas infectadas.

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    Pneumonie

    La pneumonie se définit comme une infection respiratoire aiguë affectant les poumons. Elle est causée par un certain nombre d’agents infectieux, bactéries, virus ou champignons.

    Elle se transmet généralement lors d'un contact direct avec une personne infectée.

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    Пневмония

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    أنواع العدوى الناجمة عن المكورات الرئوية

    تتيح هذه الصفحة روابط إلى صفحات تتضمن تفاصيل عن الأنشطة والتقارير والأخبار والتظاهرات، وإلى نقاط الاتصال والشركاء المتعاونين مع المنظمة في مختلف برامجها ومكاتبها التي تعمل في هذا المجال. وثمة أيضاً روابط إلى مواقع ومواضيع أخرى ذات صلة.

    MeSH scope note: Infections with bacteria of the species STREPTOCOCCUS PNEUMONIAE.

     روابط ذات صلة

     

     

    PNEUMONIA

    Source: wikipedia

    Pneumonia

    Classification and external resources


    A chest X-ray showing a very prominent wedge-shaped bacterial pneumonia in the right lung.

    ICD-10

    J12, J13, J14, J15, J16, J17, J18, P23

    ICD-9

    480-486, 770.0

    DiseasesDB

    10166

    MedlinePlus

    000145

    eMedicine

    topic list

    MeSH

    D011014

    Pneumonia is an inflammatory condition of the lung—affecting primarily the microscopic air sacs known as alveoli.[1][2] It is usually caused by infection with viruses or bacteria and less commonly other microorganisms, certain drugs and other conditions such as autoimmune diseases.[1][3]

    Typical symptoms include a cough, chest pain, fever, and difficulty breathing.[4] Diagnostic tools include x-rays and culture of the sputum. Vaccines to prevent certain types of pneumonia are available. Treatment depends on the underlying cause. Presumed bacterial pneumonia is treated with antibiotics. If the pneumonia is severe, the affected person is generally admitted to hospital.

    Annually, pneumonia affects approximately 450 million people, seven percent of the world's total, and results in about 4 million deaths. Although pneumonia was regarded by William Osler in the 19th century as "the captain of the men of death",[5] the advent of antibiotic therapy and vaccines in the 20th century has seen improvements in survival.[6] Nevertheless, in developing countries, and among the very old, the very young and the chronically ill, pneumonia remains a leading cause of death.[6][7]

    Signs and symptoms

    Symptoms frequency[8]

    Symptom

    Frequency

    Cough

    79–91%

    Fatigue

    90%

    Fever

    71–75%

    Shortness of breath

    67–75%

    Sputum

    60–65%

    Chest pain

    39–49%

     

     

    Main symptoms of infectious pneumonia

    People with infectious pneumonia often have a productive cough, fever accompanied by shaking chills, shortness of breath, sharp or stabbing chest pain during deep breaths, and an increased respiratory rate.[9] In the elderly, confusion may be the most prominent sign.[9] The typical signs and symptoms in children under five are fever, cough, and fast or difficult breathing.[10]

    Fever is not very specific, as it occurs in many other common illnesses, and may be absent in those with severe disease or malnutrition. In addition, a cough is frequently absent in children less than 2 months old.[10] More severe signs and symptoms may include: blue-tinged skin, decreased thirst, convulsions, persistent vomiting, extremes of temperature, or a decreased level of consciousness.[10][11]

    Bacterial and viral cases of pneumonia usually present with similar symptoms.[12] Some causes are associated with classic, but non-specific, clinical characteristics. Pneumonia caused by Legionella may occur with abdominal pain, diarrhea, or confusion,[13] while pneumonia caused by Streptococcus pneumoniae is associated with rusty colored sputum,[14] and pneumonia caused by Klebsiella may have bloody sputum often described as "currant jelly".[8] Bloody sputum (known as hemoptysis) may also occur with tuberculosis, Gram-negative pneumonia, and lung abscesses as well as more commonly with acute bronchitis.[11] Mycoplasma pneumonia may occur in association with swelling of the lymph nodes in the neck, joint pain, or a middle ear infection.[11] Viral pneumonia presents more commonly with wheezing than does bacterial pneumonia.[12]

    Cause

    The bacterium Streptococcus pneumoniae, a common cause of pneumonia, imaged by an electron microscope.

    Pneumonia is primarily due to infections caused by bacteria or viruses and less commonly by fungi and parasites. Although there are more than 100 strains of infectious agents identified, only a few are responsible for the majority of the cases. Mixed infections with both viruses and bacteria may occur in up to 45% of infections in children and 15% of infections in adults.[6] A causative agent may not be isolated in approximately half of cases despite careful testing.[15]

    The term pneumonia is sometimes more broadly applied to any condition resulting in inflammation of the lungs (caused for example by autoimmune diseases, chemical burns or drug reactions); however, this inflammation is more accurately referred to as pneumonitis.[16][17] Infective agents were historically divided into "typical" and "atypical" based on their presumed presentations, but the evidence has not supported this distinction, thus it is no longer emphasized.[18]

    Conditions and risk factors that predispose to pneumonia include: smoking, immunodeficiency, alcoholism, chronic obstructive pulmonary disease, chronic kidney disease, and liver disease.[11] The use of acid-suppressing medications -such as proton-pump inhibitors or H2 blockers- is associated with an increased risk[19] of pneumonia. Old age also predisposes pneumonia.[11]

    Bacteria

    Main article: Bacterial pneumonia

    Bacteria are the most common cause of community-acquired pneumonia (CAP), with Streptococcus pneumoniae isolated in nearly 50% of cases.[20][21] Other commonly isolated bacteria include: Haemophilus influenzae in 20%, Chlamydophila pneumoniae in 13%, and Mycoplasma pneumoniae in 3% of cases;[20] Staphylococcus aureus; Moraxella catarrhalis; Legionella pneumophila and Gram-negative bacilli.[15] A number of drug-resistant versions of the above infections are becoming more common, including drug-resistant Streptococcus pneumoniae (DRSP) and methicillin-resistant Staphylococcus aureus (MRSA).[11]

    The spreading of organisms is facilitated when risk factors are present.[15] Alcoholism is associated with Streptococcus pneumoniae, anaerobic organisms and Mycobacterium tuberculosis; smoking facilitates the effects of Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Legionella pneumophila. Exposure to birds is associated with Chlamydia psittaci; farm animals with Coxiella burnetti; aspiration of stomach contents with anaerobic organisms; and cystic fibrosis with Pseudomonas aeruginosa and Staphylococcus aureus.[15]Streptococcus pneumoniae is more common in the winter,[15] and should be suspected in persons who aspirate a large amount anaerobic organisms.[11]

    Viruses

    Main article: Viral pneumonia

    In adults, viruses account for approximately a third[6] and in children for about 15% of pneumonia cases.[22] Commonly implicated agents include: rhinoviruses, coronaviruses, influenza virus, respiratory syncytial virus (RSV), adenovirus, and parainfluenza.[6][23] Herpes simplex virus rarely causes pneumonia, except in groups such as: newborns, persons with cancer, transplant recipients, and people who have significant burns.[24] People following organ transplantation or those who are otherwise immunocompromised present high rates of cytomegalovirus pneumonia.[22][24] Those with viral infections may be secondarily infected with the bacteria Streptococcus pneumoniae, Staphylococcus aureus, or Haemophilus influenzae, particularly when other health problems are present.[11][22] Different viruses predominate at different periods of the year, for example during influenza season influenza may account for over half of all viral cases.[22] Outbreaks of other viruses also occasionally occur, including hantaviruses and coronavirus.[22]

    Fungi

    Main article: Fungal pneumonia

    Fungal pneumonia is uncommon, but occur more commonly in individuals with weakened immune systems due to AIDS, immunosuppressive drugs, or other medical problems.[15][25] It is most often caused by Histoplasma capsulatum, blastomyces, Cryptococcus neoformans, Pneumocystis jiroveci, and Coccidioides immitis. Histoplasmosis is most common in the Mississippi River basin, and coccidioidomycosis is most common in the Southwestern United States.[15] The number of cases have been increasing in the later half of the 20th century due to increasing travel and rates of immunosuppression in the population.[25]

    Parasites

    Main article: Parasitic pneumonia

    A variety of parasites can affect the lungs, including: Toxoplasma gondii, Strongyloides stercoralis, Ascaris lumbricoides, and Plasmodium malariae.[26] These organisms typically enter the body through direct contact with the skin, ingestion, or via an insect vector.[26] Except for Paragonimus westermani, most parasites do not specifically affect the lungs but involve the lungs secondarily to other sites.[26] Some parasites, particularly those belonging to the Ascaris and Strongyloides genera, stimulate a strong eosinophilic reaction, which may result in eosinophilic pneumonia.[26] In other infections, such as malaria, lung involvement is primarily due to cytokine-induced systemic inflammation.[26] In the developed world these infections are most common in people returning from travel or in immigrants.[26] Globally these infections are most common in those who are immunodeficient.[27]

    Idiopathic

    Main article: Idiopathic interstitial pneumonia

    Idiopathic interstitial pneumonia or noninfectious pneumonia[28] are a class of diffuse lung diseases. They include: diffuse alveolar damage, organizing pneumonia, nonspecific interstitial pneumonia, lymphocytic interstitial pneumonia, desquamative interstitial pneumonia, respiratory bronchiolitis interstitial lung disease, and usual interstitial pneumonia.[29]

    Pathophysiology

    Pneumonia fills the lung's alveoli with fluid, hindering oxygenation. The alveolus on the left is normal, whereas the one on the right is full of fluid from pneumonia.

    Pneumonia frequently starts as an upper respiratory tract infection that moves into the lower respiratory tract.[30]

    Viral

    Viruses may reach the lung by a number of different routes. Respiratory syncytial virus is typically contracted when people touch contaminated objects and then they touch their eyes or nose.[22] Other viral infections occur when contaminated airborne droplets are inhaled through the mouth or nose.[11] Once in the upper airway the viruses may make their way in the lungs, where they invade the cells lining the airways, alveoli, or lung parenchyma.[22] Some viruses such as measles and herpes simplex may reach the lungs via the blood.[31] The invasion of the lungs may lead to varying degrees of cell death.[22] When the immune system responds to the infection, even more lung damage may occur.[22] White blood cells, mainly mononuclear cells, primarily generate the inflammation.[31] As well as damaging the lungs, many viruses simultaneously affect other organs and thus disrupt other body functions. Viruses also make the body more susceptible to bacterial infections; in this way bacterial pneumonia can arise as a co-morbid condition.[23]

    Bacterial

    Most bacteria enter the lungs via small aspirations of organisms residing in the throat or nose.[11] Half of normal people have these small aspirations during sleep.[18] While the throat always contains bacteria, potentially infectious ones reside there only at certain times and under certain conditions.[18] A minority of types of bacteria such as Mycobacterium tuberculosis and Legionella pneumophila reach the lungs via contaminated airborne droplets.[11] Bacteria can spread also via the blood.[12] Once in the lungs, bacteria may invade the spaces between cells and between alveoli, where the macrophages and neutrophils (defensive white blood cells) attempt to inactivate the bacteria.[32] The neutrophils also release cytokines, causing a general activation of the immune system.[33] This leads to the fever, chills, and fatigue common in bacterial pneumonia.[33] The neutrophils, bacteria, and fluid from surrounding blood vessels fill the alveoli resulting in the consolidation seen on chest X-ray.[34]

    Diagnosis

    Pneumonia is typically diagnosed based on a combination of physical signs and a chest X-ray.[35] However, the underlying cause can be difficult to confirm, as there is no definitive test able to distinguish between bacterial and non-bacterial origin.[6][35] The World Health Organization has defined pneumonia in children clinically based on either a cough or difficulty breathing and a rapid respiratory rate, chest indrawing, or a decreased level of consciousness.[36] A rapid respiratory rate is defined as greater than 60 breaths per minute in children under 2 months old, 50 breaths per minute in children 2 months to 1 year old, or greater than 40 breaths per minute in children 1 to 5 years old.[36] In children, increased respiratory rate and lower chest indrawing are more sensitive than hearing chest crackles with a stethoscope.[10]

    In adults, investigations are generally not needed in mild cases[37]: there is a very low risk of pneumonia if all vital signs and auscultation are normal.[38] In persons requiring hospitalization, pulse oximetry, chest radiography and blood tests—including a complete blood count, serum electrolytes, C-reactive protein level and possibly liver function tests—are recommended.[37] The diagnosis of influenza-like illness can be made based on the signs and symptoms; however, confirmation of an influenza infection requires testing.[39] Thus, treatment is frequently based on the presence of influenza in the community or a rapid influenza test.[39]

    Physical exam

    Physical examination may sometimes reveal low blood pressure, high heart rate or low oxygen saturation.[11] The respiratory rate may be faster than normal and this may occur a day or two before other signs.[11][18] Examination of the chest may be normal, but may show decreased chest expansion on the affected side. Harsh breath sounds from the larger airways that are transmitted through the inflamed lung are termed bronchial breathing, and are heard on auscultation with a stethoscope.[11] Crackles (rales) may be heard over the affected area during inspiration.[11] Percussion may be dulled over the affected lung, and increased, rather than decreased, vocal resonance distinguishes pneumonia from a pleural effusion.[9]

    Imaging

    CT of the chest demonstrating right sided pneumonia (left side of the image).

    A chest radiograph is frequently used in diagnosis.[10] In people with mild disease, imaging is needed only in those with potential complications, those who have not improved with treatment, or those in which the cause in uncertain.[10][37] If a person is sufficiently sick to require hospitalization, a chest radiograph is recommended.[37] Findings do not always correlate with the severity of a disease and do not reliably distinguish between bacterial infection and viral infection.[10]

    X-ray presentations of pneumonia may be classified as lobar pneumonia, bronchopneumonia (also known as lobular pneumonia), and interstitial pneumonia.[40] Bacterial, community-acquired pneumonia, classically show lung consolidation of one lung segmental lobe which is known as lobar pneumonia.[20] However, findings may vary, and other patterns are common in other types of pneumonia.[20] Aspiration pneumonia may present with bilateral opacities primarily in the bases of the lungs and on the right side.[20] Radiographs of viral pneumonia may appear normal, hyper-inflated, have bilateral patchy areas, or present similar to bacterial pneumonia with lobar consolidation.[20] Radiologic findings may not be present in the early stages of the disease, especially in the presence of dehydration; or may be difficult to be interpreted in those who are obese or have a history of lung disease.[11] A CT scan can give additional information in indeterminate cases.[20]

    Microbiology

    In patients managed in the community, determining the causative agent is not cost effective and typically does not alter management.[10] For people who do not respond to treatment, sputum culture should be considered, and culture for Mycobacterium tuberculosis should be carried out in persons with a chronic productive cough.[37] Testing for other specific organisms may be recommended during outbreaks, for public health reasons.[37] In those who are hospitalized for severe disease, both sputum and blood cultures are recommended,[37] as well as testing the urine for antigens to Legionella and Streptococcus.[41] Viral infections can be confirmed via detection of either the virus or its antigens with culture or polymerase chain reaction (PCR), among other techniques.[6] The causative agent is determined in only 15% of cases with routine microbiological tests.[9]

    Classification

    Main article: Classification of pneumonia

    Pneumonitis refers to lung inflammation; pneumonia refers to pneumonitis, usually due to infection but sometimes non-infectious, that has the additional feature of pulmonary consolidation.[42] Pneumonia is most commonly classified by where or how it was acquired: community-acquired, aspiration, healthcare-associated, hospital-acquired, and ventilator-associated pneumonia.[20] It may also be classified by the area of lung affected: lobar pneumonia, bronchial pneumonia and acute interstitial pneumonia;[20] or by the causative organism.[43] Pneumonia in children may additionally be classified based on signs and symptoms as non-severe, severe, or very severe.[44]

    Differential diagnosis

    Several diseases can present with similar signs and symptoms to pneumonia, such as: chronic obstructive pulmonary disease (COPD), asthma, pulmonary edema, bronchiectasis, lung cancer, and pulmonary emboli.[9] Unlike pneumonia, asthma and COPD typically present with wheezing, pulmonary edema presents with an abnormal electrocardiogram, cancer and bronchiectasis present with a cough of longer duration, and pulmonary emboli presents with acute onset sharp chest pain and shortness of breath.[9]

    Prevention

    Prevention includes vaccination, environmental measures, and appropriate treatment of other health problems.[10] It is believed that if appropriate preventive measures were instituted globally, mortality among children could be reduced by 400,000 and if proper treatment were universally available, childhood deaths could be decreased by another 600,000.[12]

    Vaccination

    Vaccination prevents against certain bacterial and viral pneumonias both in children and adults. Influenza vaccines are modestly effective against influenza A and B.[6][45] The Center for Disease Control and Prevention (CDC) recommends yearly vaccination for every person 6 months and older.[46] Immunizing health care workers decreases the risk of viral pneumonia among their patients.[41] When influenza outbreaks occur, medications such as amantadine or rimantadine may help prevent the condition.[47] It is unknown if zanamivir or oseltamivir are effective due to the fact that the company that manufactures oseltamivir has refused to release the trial data for independent analysis.[48]

    Vaccinations against Haemophilus influenzae and Streptococcus pneumoniae have good evidence to support their use.[30] Vaccinating children against Streptococcus pneumoniae has led to a decreased incidence of these infections in adults, because many adults acquire infections from children. A Streptococcus pneumoniae vaccine is available for adults, and has been found to decrease the risk of invasive pneumococcal disease.[49] Other vaccines for which there to support for a protective effect against pneumonia include: pertussis, varicella, and measles.[50]

    Other

    Smoking cessation[37] and reducing indoor air pollution, such as that from cooking indoors with wood or dung, are both recommended.[10][12] Smoking appears to be the single biggest risk factor for pneumococcal pneumonia in otherwise healthy adults.[41] Hand hygiene and coughing into ones sleeve may also be effective preventative measures.[50] Wearing surgical masks by those who are sick may also prevent illness.[41]

    Appropriately treating underlying illnesses (such as HIV/AIDS, diabetes mellitus, and malnutrition) can decrease the risk of pneumonia.[12][50][51] In children less than 6 months of age exclusive breast feeding reduces both the risk and severity of disease.[12] In those with HIV/AIDS and a CD4 count of less than 200 cells/uL the antibiotic trimethoprim/sulfamethoxazole decreases the risk of Pneumocystis pneumonia[52] and may also be useful for prevention in those who are immunocomprised but do not have HIV.[53]

    Testing pregnant women for Group B Streptococcus and Chlamydia trachomatis, and administering antibiotic treatment, if needed, reduces rates of pneumonia in infants;[54][55] preventive measures for HIV transmission from mother to child may also be efficient.[56] Suctioning the mouth and throat of infants with meconium-stained amniotic fluid has not been found to reduce the rate of aspiration pneumonia and may cause potential harm,[57] thus this practice is not recommended in the majority of situations.[57] In the frail elderly good oral health care may lower the risk of aspiration pneumonia.[58]

    Management

    CURB-65

    Symptom

    Points

    Confusion

    1

    Urea>7 mmol/l

    1

    Respiratory rate>30

    1

    SBP<90mmHg, DBP<60mmHg

    1

    Age>=65

    1

    Typically, oral antibiotics, rest, simple analgesics, and fluids suffice for complete resolution.[37] However, those with other medical conditions, the elderly, or those with significant trouble breathing may require more advanced care. If the symptoms worsen, the pneumonia does not improve with home treatment, or complications occur, hospitalization may be required.[37] Worldwide, approximately 7–13% of cases in children result in hospitalization[10] while in the developed world between 22 and 42% of adults with community-acquired pneumonia are admitted.[37] The CURB-65 score is useful for determining the need for admission in adults.[37] If the score is 0 or 1 people can typically be managed at home, if it is 2 a short hospital stay or close follow-up is needed, if it is 3–5 hospitalization is recommended.[37] In children those with respiratory distress or oxygen saturations of less than 90% should be hospitalized.[59] The utility of chest physiotherapy in pneumonia has not yet been determined.[60] Non-invasive ventilation may be beneficial in those admitted to the intensive care unit.[61] Over-the-counter cough medicine has not been found to be effective[62] nor has the use of zinc in children.[63] There is insufficient evidence for mucolytics.[62]

    Bacterial

    Antibiotics improve outcomes in those with bacterial pneumonia.[64] Antibiotic choice depends initially on the characteristics of the person affected, such as age, underlying health, and the location the infection was acquired. In the UK, empiric treatment with amoxicillin is recommended as the first line for community-acquired pneumonia, with doxycycline or clarithromycin as alternatives.[37] In North America, where the "atypical" forms of community-acquired pneumonia are more common, macrolides (such as azithromycin or erythromycin), and doxycycline have displaced amoxicillin as first-line outpatient treatment in adults.[21][65] In children with mild or moderate symptoms amoxicillin remains the first line.[59] The use of fluoroquinolones in uncomplicated cases is discouraged due to concerns about side effects and generating resistance in light of there being no greater clinical benefit.[21][66] The duration of treatment has traditionally been seven to ten days, but increasing evidence suggests that shorter courses (three to five days) are similarly effective.[67] Recommended for hospital-acquired pneumonia include third- and fourth-generation cephalosporins, carbapenems, fluoroquinolones, aminoglycosides, and vancomycin.[68] These antibiotics are often given intravenously and used in combination.[68] In those treated in hospital more than 90% improve with the initial antibiotics.[18]

    Viral

    Neuraminidase inhibitors may be used to treat viral pneumonia caused by influenza viruses (influenza A and influenza B).[6] No specific antiviral medications are recommended for other types of community acquired viral pneumonias including SARS coronavirus, adenovirus, hantavirus, and parainfluenza virus.[6] Influenza A may be treated with rimantadine or amantadine, while influenza A or B may be treated with oseltamivir, zanamivir or peramivir.[6] These are of most benefit if they are started within 48 hours of the onset of symptoms.[6] Many strains of H5N1 influenza A, also known as avian influenza or "bird flu," have shown resistance to rimantadine and amantadine.[6] The use of antibiotics in viral pneumonia is recommended by some experts as it is impossible to rule out a complicating bacterial infection.[6] The British Thoracic Society recommends that antibiotics be withheld in those with mild disease.[6] The use of corticosteroids is controversial.[6]

    Aspiration

    In general, aspiration pneumonitis is treated conservatively with antibiotics indicated only for aspiration pneumonia.[69] The choice of antibiotic will depend on several factors, including the suspected causative organism and whether pneumonia was acquired in the community or developed in a hospital setting. Common options include clindamycin, a combination of a beta-lactam antibiotic and metronidazole, or an aminoglycoside.[70] Corticosteroids are sometimes used in aspiration pneumonia, but there is limited evidence to support their effectiveness.[69]

    Prognosis

    With treatment, most types of bacterial pneumonia will stabilize in 3–6 days.[71] It often takes a few weeks before most symptoms resolve.[71] X-ray finding typically clear within four weeks and mortality is low (less than 1%).[11][72] In the elderly or people who have other lung problems recovery may take more than 12 weeks. In persons who require hospitalization mortality may be as high as 10% and in those who require intensive care it may reach 30–50%.[11] Pneumonia is the most common hospital-acquired infection that causes death.[18] Before the advent of antibiotics, mortality was typically 30% in those who were hospitalized.[15]

    Complications may occur particularly in the elderly and those with underlying health problems.[72] This may include, among others: empyema, lung abscess, bronchiolitis obliterans, acute respiratory distress syndrome, sepsis, and worsening of underlying health problems.[72]

    Clinical prediction rules

    Clinical prediction rules have been developed to more objectively predict outcomes of pneumonia.[18] These rules are often used in deciding whether or not to hospitalize the person.[18]

     

     

    Pleural effusion, empyema, and abscess

    A pleural effusion: as seen on chest x-ray. The A arrow indicates fluid layering in the right chest. The B arrow indicates the width of the right lung. The volume of the lung is reduced because of the collection of fluid around the lung.

    In pneumonia, a collection of fluid may form in the space that surrounds the lung.[74] Occasionally, microorganisms will infect this fluid, causing an empyema.[74] To distinguish an empyema from the more common simple parapneumonic effusion, the fluid may be collected with a needle (thoracentesis), and examined.[74] If this shows evidence of empyema, complete drainage of the fluid is necessary, often requiring a drainage catheter.[74] In severe cases of empyema, surgery may be needed.[74] If the infected fluid is not drained, the infection may persist, because antibiotics do not penetrate well into the pleural cavity. If the fluid is sterile, it needs to be drained only if it is causing symptoms or remains unresolved.[74]

    Rarely, bacteria in the lung will form a pocket of infected fluid called a lung abscess.[74] Lung abscesses can usually be seen with a chest X-ray but frequently require a chest CT scan to confirm the diagnosis.[74] Abscesses typically occur in aspiration pneumonia, and often contain several types of bacteria. Long term antibiotics are usually adequate to treat a lung abscess, but sometimes the abscess must be drained by a surgeon or radiologist.[74]

    Respiratory and circulatory failure

    Pneumonia can cause respiratory failure by triggering acute respiratory distress syndrome (ARDS), which results from a combination of infection and inflammatory response. The lungs quickly fill with fluid and become stiff. This stiffness, combined with severe difficulties extracting oxygen due to the alveolar fluid, may require long periods of mechanical ventilation for survival.[22]

    Sepsis is a potential complication of pneumonia but occurs typically only in people with poor immunity or hyposplenism. The organisms most commonly involved are Streptococcus pneumoniae, Haemophilus influenzae and Klebsiella pneumoniae. Other causes of the symptoms should be considered such as a myocardial infarction or a pulmonary embolism.[75]

    Epidemiology

    Main article: Epidemiology of pneumonia

    Age-standardized death rate: lower respiratory tract infections per 100,000 inhabitants in 2004.[76]

      no data

      <100

      100–700

      700–1400

      1400–2100

      2100–2800

      2800–3500

      3500–4200

      4200–4900

      4900–5600

      5600–6300

      6300–7000

      >7000

    Pneumonia is a common illness affecting approximately 450 million people a year and occurring in all parts of the world.[6] It is a major cause of death among all age groups resulting in 4 million deaths (7% of the world's total death) yearly.[6][64] Rates are greatest in children less than five, and adults older than 75 years.[6] It occurs about five times more frequently in the developing world than in the developed world.[6] Viral pneumonia accounts for about 200 million cases.[6] In the United States, as of 2009, pneumonia is the 8th leading cause of death.[11]

    Children

    In 2008, pneumonia occurred in approximately 156 million children (151 million in the developing world and 5 million in the developed world).[6] It resulted in 1.6 million deaths, or 28–34% of all deaths in those under five years, of which 95% occurred in the developing world.[6][10] Countries with the greatest burden of disease include: India (43 million), China (21 million) and Pakistan (10 million).[77] It is the leading cause of death among children in low income countries.[6][64] Many of these deaths occur in the newborn period. The World Health Organization estimates that one in three newborn infant deaths is due to pneumonia.[78] Approximately half of these deaths can theoretically be prevented, as they are caused by the bacteria for which an effective vaccine is available.[79]

    History

    WPA poster, 1936/1937

    Pneumonia has been a common disease throughout human history.[80] The symptoms were described by Hippocrates (c. 460 BC – 370 BC):[80] "Peripneumonia, and pleuritic affections, are to be thus observed: If the fever be acute, and if there be pains on either side, or in both, and if expiration be if cough be present, and the sputa expectorated be of a blond or livid color, or likewise thin, frothy, and florid, or having any other character different from the common... When pneumonia is at its height, the case is beyond remedy if he is not purged, and it is bad if he has dyspnoea, and urine that is thin and acrid, and if sweats come out about the neck and head, for such sweats are bad, as proceeding from the suffocation, rales, and the violence of the disease which is obtaining the upper hand."[81] However, Hippocrates referred to pneumonia as a disease "named by the ancients." He also reported the results of surgical drainage of empyemas. Maimonides (1135–1204 AD) observed: "The basic symptoms that occur in pneumonia and that are never lacking are as follows: acute fever, sticking pleuritic pain in the side, short rapid breaths, serrated pulse and cough."[82] This clinical description is quite similar to those found in modern textbooks, and it reflected the extent of medical knowledge through the Middle Ages into the 19th century.

    Edwin Klebs was the first who observed bacteria in the airways of persons who died of pneumonia in 1875.[83] Initial work identifying the two common bacterial causes, Streptococcus pneumoniae and Klebsiella pneumoniae, was performed by Carl Friedländer[84] and Albert Fränkel[85] in 1882 and 1884, respectively. Friedländer's initial work introduced the Gram stain, a fundamental laboratory test still used today to identify and categorize bacteria. Christian Gram's paper describing the procedure in 1884 helped to differentiate the two bacteria, and showed that pneumonia could be caused by more than one microorganism.[86]

    Sir William Osler, known as "the father of modern medicine," appreciated the death and disability caused by pneumonia, describing it as the "captain of the men of death" in 1918, as it had overtaken tuberculosis as one of the leading causes of death in this time. This phrase was originally coined by John Bunyan in reference to "consumption" (tuberculosis).[87][88] Osler also described pneumonia as "the old man's friend" as death was often quick and painless when there were many slower more painful ways to die.[15]

    Several developments in the 1900s improved the outcome for those with pneumonia. With the advent of penicillin and other antibiotics, modern surgical techniques, and intensive care in the 20th century, mortality from pneumonia, had approached 30%, dropped precipitously in the developed world. Vaccination of infants against Haemophilus influenzae type B began in 1988 and led to a dramatic decline in cases shortly thereafter.[89] Vaccination against Streptococcus pneumoniae in adults began in 1977, and in children in 2000, resulting in a similar decline.[90]

    Society and culture

    See also: List of notable pneumonia cases

    Due to the high burden of disease in developing countries and a relatively low awareness of the disease in developed countries, the global health community has declared 12th November as World Pneumonia Day, a day for concerned citizens and policy makers to take action against the disease.[91] The global economic cost of community-acquired pneumonia has been estimated at $17 billion.[11]

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    Bibliography

     

    • Murray and Nadel's textbook of respiratory medicine (5th ed.). Philadelphia, PA: Saunders/Elsevier. 2010. ISBN 1416047107.
    • Edited by Burke A. Cunha (2010). Pneumonia essentials (3rd ed.). Sudbury, MA: Physicians' Press. ISBN 0763772208.

     

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    Pneumonia

       

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    D011014

    Mise en garde médicale

    Une pneumonie franche lobaire aiguë (PFLA), est une pneumopathie bactérienne.

    La PFLA peut atteindre des personnes de tout âge, mais le plus grand risque concerne les jeunes enfants, les personnes âgées, et les patients immunodéficients. Pour traiter les pneumonies, on utilise souvent des agents antimicrobiens.

    Épidémiologie

    En France

    Selon les différents établissements de santé, l'incidence des pneumonies serait de 400 à 600 000 nouveaux cas par an. Les pneumonies seraient responsables de 16 000 décès par an1. Il semblerait que les pneumonies soient la deuxième cause d'infections nosocomiales, derrière les infections urinaires2.

    Charlemagne serait mort d'une affection aiguë qui semble avoir été une pneumonie3.

    Aux États-Unis

    Chaque année, le nombre de nouveaux cas serait d'environ 2 millions et le nombre de décès compris entre 40 000 et 70 0004 (sixième maladie en nombre de décès causés). Elle représente l'infection nosocomiale la plus fréquente4.

    Streptococcus pneumoniae

    Étiologie

    Les causes de pneumonie franche lobaire aiguë sont nombreuses et variées, et diverses sources peuvent additionner leurs effets :

     

    • infections bactériennes ou virales, les plus fréquentes (80 à 90 %). Les germes les plus souvent identifiés sont, par ordre décroissant, le Streptococcus pneumoniae, l'Haemophilus influenzae, Legionella pneumophila, Mycoplasma pneumoniae et le virus Influenzae A ;
    • les pneumopathies atypiques (10 à 20 %) : Mycoplasma pneumoniae, Legionella pneumophila et Chlamydiae pneumoniae ;
    • l'air pollué, notamment par les véhicules, est aussi un facteur de risque et d'aggravation des pneumonies. Un excès significatif de morts par pneumonie a été constaté au Royaume-Uni, chez des Britanniques plus exposés aux émissions de pots d'échappement (surmortalité mesurée en croisant les données de pollution et les autres causes de décès observées et attendues pour 352 collectivités locales anglaises de 1996 à 2004) ; les pneumonies, mais aussi les maladies cardiaques et les cancers de l'estomac ont pu être statistiquement corrélées à certaines émissions polluantes, au tabagisme et/ou à une consommation élevée d’alcool. Les morts par pneumonie étaient le plus fortement corrélables aux fumées d’échappement des véhicules (avec également une surmortalité par d'autres maladies pulmonaires et cardites rhumatismales). Selon cette étude, le taux de mortalité annuel lié à la pollution dans ces 352 collectivités est comparable à celui entraîné par le smog de Londres de 1952 («great London smog»)5, bien que les manifestations de la pollution ne soient plus aujourd'hui aussi visibles. Les nanoparticules des échappements pourraient être aujourd'hui en cause, alors que les suies l'étaient sans doute dans les années 1950 et depuis l'avènement du charbon au XIXe siècle ;
    • les pneumonies acquises sous ventilation mécanique (ou PAVM, souvent infections nosocomiales) sont contractées chez des patients dépendant d'un respirateur, généralement intubés ou trachéotomisés de réanimation. Multifactorielles, ces pneumonies résultent de l'inhalation du contenu gastrique et/ou oropharyngé via le ballonnet de la sonde trachéale ou canule.

     

    Diagnostic

    Le diagnostic repose sur :

     

     

    Dans environ 50 % des cas, le germe responsable n'est pas identifié, en effet, celui-ci est identifié grâce à la mise en culture des crachats, qui sont souvent contaminés par la flore oropharyngée normale.

    Sémiologie chez l'adulte

    Les signes cliniques suivants sont à rechercher en suspicion de pneumonie (conférence de consensus 2006), ils varient en fonction de l'agent bactérien en cause :

     

     

    Chez la personne âgée, la sémiologie peut être plus fruste : confusion, tachypnée, dyspnée, aggravation de pathologie préexistante.

    Elle donne une forte fièvre, une grande fatigue et cela dure au minimum pendant 7 jours.
    La maladie se caractérise par l'accumulation de pus et de sécrétions dans les alvéoles pulmonaires. Ces dernières ne peuvent plus assurer de manière optimale l'oxygénation du sang. Ce manque d'oxygénation du sang peut entraîner un dysfonctionnement ou même la mort des cellules.

    Signes permettant d'éliminer le diagnostic d'une PFLA

    Selon la conférence de consensus 2006, l'association des 3 signes suivants permet d'éliminer le diagnostic de pneumonie aiguë communautaire (PAC), c'est la valeur prédictive négative :

    1. Fréquence cardiaque < 100/min
    2. Fréquence respiratoire < 30/min
    3. Température centrale < 37,9 °C

    Examens complémentaires

    Selon la conférence de consensus 2006 :

     

     

    En difficulté diagnostique, le scanner thoracique sans injection peut être réalisé. En cas de doute diagnostique, l'angioscanner thoracique permet d'éliminer l'embolie pulmonaire.

    Autres examens réalisables (consensus 2006) :

     

    • antigène urinaire du Streptoccocus pneumoniae. Sensibilité de 77-89 % en bactériémie, 44-64 % sans bactériémie. Les faux positifs sont rares chez l'adulte ;
    • antigène urinaire de la légionellose. 80 % des pneumonies aiguës communautaires à Légionelle sérotype 1 excrètent cet antigène après 1 à 3 jours, et ce peut durer 1 an. La sensibilité du test est de 86 %, spécificité 93 %.

     

    Prise en charge thérapeutique

    Un traitement de fond par antibiothérapie est nécessaire. Si le germe a préalablement été identifié, l'antibiothérapie sera adaptée à celui-ci, sinon, il s'agira d'une antibiothérapie probabiliste. En ce qui concerne les symptômes, une oxygénothérapie peut être nécessaire devant une hypoxie ; lorsqu'une hospitalisation est nécessaire, la kinésithérapie respiratoire et la ventilation non invasive faciliteront l'hématose. En cas d'échec de ces mesures, un transfert en réanimation et parfois une intubation seront nécessaires.

    PFLA non sévère en ambulatoire

     

    • Origine bactérienne. Aucun examen microbiologique n'est recommandé. Le traitement est probabiliste.

     

    Patient sans comorbidité

    Amoxicilline 1 g x 3 / J PO (per os)
    ou Pristinamycine 1 g x 3 / J PO
    ou Télithromycine 800 mg / J PO

    Patient avec comorbidité

    Augmentin 1 g x 3 / J PO

    Patient âgé en institution

    Augmentin 1 g x 3 / J PO
    ou Ceftriaxone 1 g / J IM/IV/SC
    ou FQAP (Levofloxacine 500 mg / J PO ou Moxifloxacine 400 mg / J PO)

    Ces traitements nécessitent une réévaluation clinique au 2e-3e jour.
    En absence de défervescence thermique et d'aggravation, un macrolide sera ajouté au traitement, ou la substance sera remplacée par les substances alternatives proposées ci-dessus.

    PFLA non sévère à l'hôpital

    Pas d'examens microbiologiques réalisés

    Arguments pour le pneumocoque

    Amoxicilline 1 g x 3 / J PO/IV

    Pas d'arguments pour le pneumocoque

    Patient sans comorbidité

    Amoxicilline 1 g x 3 / J PO/IV
    ou Pristinamycine 1 g x 3 / J PO
    ou Télithromycine 800 mg / J PO

    Patient âgé et/ou comorbidité

    Augmentin 1 g x 3 / J PO/IV
    ou Céfotaxime 1 g x 3/J IV
    ou Ceftriaxone 1 g / J IV
    ou FQAP (Levofloxacine 500 mg x1-2 / J PO ou Moxifloxacine 400 mg / J PO)

    Complications

     

     

    Autres pneumopathies

     

     

    [...]

    Prévention

    Chez les patients fragiles (âgés de plus de 65 ans, insuffisants respiratoires chroniques ou immunodéprimés), il est possible de réaliser des actions de prévention des pneumopathies communautaires par la vaccination contre le pneumocoque et l'haemophilus.

    Notes et références

    1. [PDF] Omédit région Centre Infections à Streptococcus pneumoniae [archive], Fiche Bon Usage, mise en ligne le 2 mars 2010, consulté le 6 juin 2012.
    2. Cahier des ECN de pneumologie, éditions Masson
    3. Les morts mystérieuses de l'histoire Volume 1 du docteur Augustin Cabanès
    4. a et b Manuel Merck
    5. (en) E G Knox, « Atmospheric pollutants and mortalities in English local authority areas », Journal of epidemiology and community health, vol. 62, no 5, mai 2008, p. 442-447 (ISSN 1470-2738) [texte intégral [archive], lien PMID [archive], lien DOI [archive] (pages consultées le 6 juin 2012)]

    Sources

     

     

    Voir aussi

    Articles connexes

     

     

    Liens externes

     

     

    Catégories :

     

     

    Neumonía


    Rayos X de tórax donde se evidencia neumonía complicada en el lóbulo inferior izquierdo con efusión.

    Clasificación y recursos externos

    CIE-10

    J12, J13, J14, J15, J16, J17, J18, P23

    CIE-9

    480-486, 770.0

    CIAP-2

    R81

    DiseasesDB

    10166

    MedlinePlus

    000145

    Sinónimos

    Pulmonía

     Aviso médico 

    La neumonía o pulmonía es una enfermedad del sistema respiratorio que consiste en la inflamación de los espacios alveolares de los pulmones.1 La mayoría de las veces la neumonía es infecciosa, pero no siempre es así. La neumonía puede afectar a un lóbulo pulmonar completo (neumonía lobular), a un segmento de lóbulo, a los alvéolos próximos a los bronquios (bronconeumonía) o al tejido intersticial (neumonía intersticial). La neumonía hace que el tejido que forma los pulmones se vea enrojecido, hinchado y se torne doloroso. Muchos pacientes con neumonía son tratados por médicos de cabecera y no ingresan en los hospitales. La neumonía adquirida en la comunidad (NAC) o neumonía extrahospitalaria es la que se adquiere fuera de los hospitales, mientras que la neumonía nosocomial (NN) es la que se adquiere durante la estancia hospitalaria transcurridas 48 horas o dos semanas después de recibir el alta.

    La neumonía puede ser una enfermedad grave si no se detecta a tiempo, y puede llegar a ser mortal, especialmente entre personas de edad avanzada y entre los inmunodeprimidos. En particular los pacientes de sida contraen frecuentemente la neumonía por Pneumocystis. Las personas con fibrosis quística tienen también un alto riesgo de padecer neumonía debido a que continuamente se acumula fluido en sus pulmones.

    Puede ser altamente contagiosa, ya que el virus se disemina rápidamente en el aire, por medio de estornudos, tos y mucosidad; un paciente que ha padecido neumonía puede quedar con secuelas de esta en su organismo por mucho tiempo, esto lo hace potencialmente contagioso y las personas más propensas a contraerla son las que estén en curso de una gripe, un cuadro asmático, entre otras enfermedades del aparato respiratorio.

    Fisiopatología

    NEUMONÍA

     

     

     

    Neumonías infeccciosas

    Neumonías causadas por agentes infecciosos o no infecciosos

    Neumonías no infecciosas

    Los enfermos de neumonía infecciosa a menudo presentan una tos que produce un esputo herrumbroso o de color marrón o verde, o flema y una fiebre alta que puede ir acompañada de escalofríos febriles. La disnea también es habitual, al igual que un dolor torácico pleurítico, un dolor agudo o punzante, que aparece o empeora cuando se respira hondo. Los enfermos de neumonía pueden toser sangre, sufrir dolores de cabeza o presentar una piel sudorosa y húmeda. Otros síntomas posibles son falta de apetito, cansancio, cianosis, náuseas, vómitos, cambios de humor y dolores articulares o musculares. Las formas menos comunes de neumonía pueden causar otros síntomas, por ejemplo, la neumonía causada por Legionella puede causar dolores abdominales y diarrea2 , mientras que la neumonía provocada por tuberculosis o Pneumocystis puede causar únicamente pérdida de peso y sudores nocturnos. En las personas mayores, la manifestación de la neumonía puede no ser típica. Pueden desarrollar una confusión nueva o más grave, o experimentar desequilibrios, provocando caídas3 . Los niños con neumonía pueden presentar muchos de los síntomas mencionados, pero en muchos casos simplemente están adormecidos o pierden el apetito.

    Los síntomas de la neumonía requieren una evaluación médica inmediata. La exploración física por parte de un asistente sanitario puede revelar fiebre o a veces una temperatura corporal baja, una velocidad de respiración elevada, una presión sanguínea baja, un ritmo cardíaco elevado, o una baja saturación de oxígeno, que es la cantidad de oxígeno en la sangre revelada o bien por pulsioximetría o bien por gasometría arterial. Los enfermos que tienen dificultades para respirar, están confundidos o presentan cianosis (piel azulada) necesitan atención inmediata.

    La exploración física de los pulmones puede ser normal, pero a menudo presenta una expansión mermada del tórax en el lado afectado, respiración bronquial auscultada con fonendoscopio (sonidos más ásperos provenientes de las vías respiratorias más grandes, transmitidos a través del pulmón inflamado y consolidado) y estertores perceptibles en el área afectada durante la inspiración. La percusión puede ser apagada sobre el pulmón afectado, pero con una resonancia aumentada y no mermada (lo que la distingue de un embalse pleural). Aunque estos signos son relevantes, resultan insuficientes para diagnosticar o descartar una neumonía; de hecho, en estudios se ha demostrado que dos médicos pueden llegar a diferentes conclusiones sobre el mismo paciente.

    Virus

    Los virus necesitan invadir las células para su reproducción. Normalmente los virus llegan al pulmón a través del aire, siendo inhalados por la boca o la nariz, o al ingerir un alimento. Una vez en el pulmón, los virus invaden las células de revestimiento de las vías aéreas y los alvéolos. Esta invasión a menudo conduce a la muerte celular, ya sea directamente o por medio de apoptosis. Cuando el sistema inmune responde a la infección viral provoca más daño pulmonar. Las células blancas, principalmente los linfocitos, activan una variedad de mediadores químicos de inflamación ―como son las citoquinas, que aumentan la permeabilidad de la pared bronquio alveolar permitiendo el paso de fluidos―. La combinación de destrucción celular y el paso de fluidos al alvéolo empeora el intercambio gaseoso.

    Además del daño pulmonar, muchos virus favorecen a otros órganos y pueden interferir múltiples funciones. La infección viral también puede hacer más susceptible al huésped a la infección bacteriana4 5 .

    Las neumonías virales son causadas principalmente por el virus de la influenza, virus sincitial respiratorio, adenovirus. El virus del herpes es una causa rara de neumonía excepto en recién nacidos. El citomegalovirus puede causar neumonía en inmunodeprimidos6 .

    Clasificación

    Las neumonías puede clasificarse:

     

    • En función del agente causal:
    • neumocócica,
    • neumonía estafilocócica,
    • Neumonía por Klebsiella,
    • Neumonía por Legionella, entre otros.
    • Por la localización anatómica macroscópica:
    • Neumonía lobar,
    • Neumonía multifocal o bronconeumonía y
    • Neumonía intersticial.
    • En función de la reacción del huésped:
    • Neumonía supurada
    • Neumonía fibrinosa.7
    • En función del ámbito de adquisición:
    • Adquiridas en la comunidad (o extrahospitalarias). Las más típicas son la neumonía neumocócica, la neumonía por Mycoplasma y la neumonía por Chlamydia. Se da en 3 a 5 adultos por 1000/año, con una mortalidad de entre el 5 y el 15 %.
    • Neumonías hospitalarias o nosocomiales. Presentan mayor mortalidad que la neumonía adquirida en la comunidad. En el hospital se da la conjunción de una población con alteración de los mecanismos de defensas, junto a la existencia de unos gérmenes muy resistentes a los antibióticos, lo que crea dificultades en el tratamiento de la infección.

     

    Clasificación pronóstica

    Existen dos clasificaciones pronósticas de la neumonía o pulmonía:

     

    • Clasificación de Fine (pneumonia severity index o PSI).
    • Clasificación FALTA.

     

    Causas

    La neumonía puede ser causada por varios agentes etiológicos:

     

    • Múltiples bacterias, como neumococo (Streptococcus pneumoniae), Mycoplasmas pneumoniae, Chlamydias pneumoniae8 .
    • Distintos virus.
    • Hongos, como Pneumocystis jiroveci, cándida.
    • En recién nacidos las neumonías suelen ser causadas por: Streptococcus pneumoniae, Staphylococcus áureus y ocasionalmente bacilos gram negativos.
    • En lactantes (niños de 1 mes a 2 años) y preescolares (niños de 2 años a 5 años): el principal patógeno bacteriano es el Streptococcus pneumoniae, además ocasionalmente es causada por la Chlamydia trachomatis y por el Mycoplasma pneumoniae.
    • En niños mayores de 5 años: Streptococcus pneumoniae y Mycloplasma pneumoniae.
    • En inmunocomprometidos: bacterias gram negativas, Pneumocystis jiroveci, citomegalovirus (CMV), hongos, y Micobacterium tuberculosis6 .
    • En ocasiones se puede presentar neumonías por bacterias anaeróbicas, en el caso de personas que tienen factores de riesgo para aspirar contenido gástrico a los pulmones, existe un riesgo significativo de aparición de abscesos pulmonares.
    • En las neumonías nosocomiales: Pseudomonas aeruginosa, hongos y Staphylococcus áureus.
    • En personas adultas: Streptococcus pneumoniae y virus influenza.
    • En los casos de neumonía atípica: virus, Mycoplasma pneumoniae y Chlamydia pneumoniae.

     

    Diversos agentes infecciosos ―virus, bacterias y hongos― causan neumonía, siendo los más comunes los siguientes:

     

    • Streptococcus pneumoniae: la causa más común de neumonía bacteriana en niños;
    • Haemophilus influenzae de tipo b (Hib): la segunda causa más común de neumonía bacteriana;
    • El virus sincitial respiratorio es la causa más frecuente de neumomía vírica.
    • Pneumocystis jiroveci es una causa importante de neumonía en niños menores de seis meses con VIH/sida, responsable de al menos uno de cada cuatro fallecimientos de lactantes seropositivos al VIH.

     

    Signos y síntomas

    Los siguientes síntomas pueden estar relacionados con la enfermedad:

     

    • Generalmente, es precedida por una enfermedad como la gripe o el catarro común.
    • Fiebre prolongada por más de tres días, en particular si es elevada.
    • La frecuencia respiratoria aumentada:
    • recién nacidos hasta menos de 3 meses: más de 60 por minuto,
    • lactantes: más de 50 por minuto,
    • preescolares y escolares: más de 40 por minuto,
    • adultos: más de 20 por minuto.
    • Se produce un hundimiento o retracción de las costillas con la respiración, que se puede observar fácilmente con el pecho descubierto.
    • Las fosas nasales se abren y se cierran como un aleteo rápido con la respiración. (Esto se da principalmente en niños).
    • Quejido en el pecho como asmático al respirar.
    • Las personas afectadas de neumonía a menudo tienen tos que puede producir una expectoración de tipo mucopurulento (amarillenta), fiebre alta que puede estar acompañada de escalofríos. Limitación respiratoria también es frecuente así como dolor torácico de características pleuríticas (aumenta con la respiración profunda y con la tos). También pueden tener hemoptisis (expectoración de sangre por la boca durante episodios de tos) y disnea. Suele acompañarse de compromiso del estado general (anorexia, astenia y adinamia).
    • Al examen físico general es probable encontrar taquicardia, taquipnea y baja presión arterial, ya sea sistólica o diastólica.
    • Al examen físico segmentario, el síndrome de condensación pulmonar es a menudo claro;
    • a la palpación: disminución de la expansión y de la elasticidad torácica y aumento de las vibraciones vocales;
    • a la percusión: matidez.
    • a la auscultación: disminución del murmullo pulmonar, crepitaciones y/o soplo tubario.
    • El paciente infantil tiene la piel fría, tose intensamente, parece decaído, apenas puede llorar y puede tener convulsiones, se pone morado cuando tose, no quiere comer (afagia), apenas reacciona a los estímulos. El cuadro clínico es similar en el paciente adulto.
    • En adultos sobre 65 años es probable una manifestación sintomática muchísimo más sutil que la encontrada en personas jóvenes.

     

    Tratamiento

    Principal antibiótico por agente bacteriano

    Subtipo histológico

    Frecuencia (%).

    Antibiótico

    Streptococcus pneumoniae9

    31.1

    En adultos sanos:

    Comorbilidades:

    Staphylococcus áureus

    0.4

    Oxacilina o

    Cefuroxima o
    Cefazolina o
    Amoxicilina y ácido clavulánico

    Moraxella catarrhalis

    0.4

    Cefuroxima o

    Trimetoprim-sulfametoxazol o
    Cefotaxima o
    Ceftriaxone o
    Ceftazidima o
    Ciprofloxacino o
    Levofloxacina o
    Azitromicina

    Streptococcus pyogenes

    0.4

    Clindamicina o

    Penicilina G o
    Vancomicina o

    Neisseria meningitidis

    0.4

    Penicilina G o

    Ceftriaxone o
    Cefotaxima o
    Ceftriaxone o
    Cloranfenicol o
    Ciprofloxacino o
    Rifampina o
    Eritromicina o

    Klebsiella pneumoniae

    0.4

    Cefotaxima o

    Ceftriaxone o
    Gentamicina o
    Amikacina o
    Piperacilina o
    Imipenem o
    Ciprofloxacino o
    Trimetoprim-sulfametoxazol o

    Haemophilus influenzae

    0.4

    * Azitromicina o

    Cefotaxima o
    Ceftriaxone o
    Amoxicilina o
    Ampicilina o
    Cloranfenicol o

    Neumonía atípica

    Legionella pneumophila

     

    23.2

     

    Mycoplasma pneumoniae

     

    3.0

     

    Chlamydophila pneumoniae

     

    1.2

     

    Pneumocystis jiroveci

    10.7

     

    Tuberculosis

    0.4

     

    La mayoría de los casos de neumonía puede ser tratada sin hospitalización. Normalmente, los antibióticos orales, reposo, líquidos, y cuidados en el hogar son suficientes para completar la resolución. Sin embargo, las personas con neumonía que están teniendo dificultad para respirar, las personas con otros problemas médicos, y las personas mayores pueden necesitar un tratamiento más avanzado. Si los síntomas empeoran, la neumonía no mejora con tratamiento en el hogar, o se producen complicaciones, la persona a menudo tiene que ser hospitalizada.

    Los antibióticos se utilizan para tratar la neumonía bacteriana. En contraste, los antibióticos no son útiles para la neumonía viral, aunque a veces se utilizan para tratar o prevenir las infecciones bacterianas que pueden ocurrir en los pulmones dañados por una neumonía viral. La elección de tratamiento antibiótico depende de la naturaleza de la neumonía, los microorganismos más comunes que causan neumonía en el área geográfica local, y el estado inmune subyacente y la salud del individuo.

    El tratamiento de la neumonía debe estar basada en el conocimiento del microorganismo causal y su sensibilidad a los antibióticos conocidos. Sin embargo, una causa específica para la neumonía se identifica en solo el 50% de las personas, incluso después de una amplia evaluación. En el Reino Unido, la amoxicilina y la claritromicina o la eritromicina son los antibióticos seleccionados para la mayoría de los pacientes con neumonía adquirida en la comunidad; a los pacientes alérgicos a las penicilinas se les administra la eritromicina en vez de amoxicilina. En Estados Unidos, donde las formas atípicas de neumonía adquiridas en la comunidad son cada vez más comunes, la azitromicina, la claritromicina y las fluoroquinolonas han desplazado a amoxicilina como tratamiento de primera línea. La duración del tratamiento ha sido tradicionalmente de siete a diez días, pero cada vez hay más pruebas de que los cursos más cortos (tan corto como tres días) son suficientes10 .

    Entre los antibióticos para la neumonía adquirida en el hospital se pueden incluir la vancomicina, la tercera y cuarta generación de cefalosporinas, las carbapenemas, las fluoroquinolonas y los aminoglucósidos. Estos antibióticos se suelen administrar por vía intravenosa. Múltiples antibióticos pueden ser administrados en combinación, en un intento de tratar todos los posibles microorganismos causales. La elección de antibióticos varía de un hospital a otro, debido a las diferencias regionales en los microorganismos más probables, y debido a las diferencias en la capacidad de los microorganismos a resistir a diversos tratamientos antibióticos.

    Las personas que tienen dificultad para respirar debido a la neumonía puede requerir oxígeno extra. Individuos extremadamente enfermos pueden requerir de cuidados intensivos de tratamiento, a menudo incluyendo intubación y ventilación artificial.

    La neumonía viral causada por la influenza A pueden ser tratados con amantadina o rimantadina, mientras que la neumonía viral causada por la influenza A o B puede ser tratado con oseltamivir o zanamivir. Estos tratamientos son beneficiosos solo si se inició un plazo de 48 horas de la aparición de los síntomas. Muchas cepas de influenza A H5N1, también conocida como influenza aviar o «gripe aviar», han mostrado resistencia a la amantadina y la rimantadina. No se conocen tratamientos eficaces para las neumonías virales causadas por el coronavirus del SRAS, el adenovirus, el hantavirus o el parainfluenza virus.

    Diagnóstico

    El diagnóstico de neumonía se fundamenta tanto en la clínica del paciente como en resultado de Rx. Generalmente se usan la Rx de tórax (posteroanterior y lateral), analítica sanguínea y cultivos microbiológicos de esputo y sangre11 . La radiografía de tórax es el diagnóstico estándar en hospitales y clínicas con acceso a rayos x.

    En personas afectadas de otras enfermedades (como sida o Enfisema) que desarrollan neumonía, la Rx de tórax puede ser difícil de interpretar. Un TAC u otros test son a menudo necesarios en estos pacientes para realizar un diagnóstico diferencial de neumonía.

    Referencias

    $11.                              pneumonia en el Diccionario de eMedicine

    $12.                              Varios autores. Brote epidémico de neumonia por Legionella pneumophila en niños cubanos Hospital Pediátrico Universitario “William Soler”. Consultado el 10 de mayo de 2013.

    $13.                              Rigoberto Marcano Pasquier. Las neumonías Medicina Preventiva Santa Fe. Consultado el 10 de mayo de 2013.

    $14.                              Neumonía viral Medline Plus. Consultado el 10 de marzo de 2013.

    $15.                              Neumonía viral Allina Health. Consultado el 10 de marzo de 2013.

    $16.                              ↑ a b G. Pérez Chica. Infecciones respiratorias en el paciente inmundodeprimido Neumosur. Consultado el 10 de mayo de 2013.

    $17.                              Cotran, Kumar, Robbins (1995). «15». En Schoen, FJ (en español). Patología Estructural y Funcional (5a edición). pp. 767. ISBN 84-486-0113-0.

    $18.                              Neumonía atípica Medline Plus. Consultado el 10 de marzo de 2013.

    $19.                              Pneumococcal infections

    $110.                          Tratamiento de la neumonía News Medical. Consultado el 10 de mayo de 2013.

    $111.                          Diagnóstico de Neumonía News Medical. Consultado el 10 de mayo de 2013.

    Véase también

     

     

    Enlaces externos

     

     

    Pneumonia

     

    A radiografia de tórax mostrando uma pneumonia muito proeminente no pulmão direito.

    Classificação e recursos externos

    CID-10

    J12, J13, J14, J15, J16, J17, J18, P23

    CID-9

    480-486, 770.0

    DiseasesDB

    10166

    eMedicine

    lista de tópicos

    MeSH

    C08.381.677

    Aviso médico

     

    • Neumonía, gráfico interactivo en el diario El Mundo (Madrid).

     

    Categoría:

     

     

    Pneumonia

    Pneumonia é uma doença inflamatória no pulmão—afetando especialmente os sacos de ar microscópicos (alvéolos)—associada a febre, sintomas no peito e falta de espaço aéreo (consolidação) em uma radiografia de tórax.1 2 A pneumonia é geralmente causada por uma infecção, mas há uma série de outras causas.1 Os agentes infecciosos são: bactérias, vírus, fungos e parasitas.3

    Os sintomas típicos incluem tosse, dor torácica, febre e dificuldade para respirar.4 As ferramentas de diagnóstico incluem raios-X e exame de escarro. Vacinas para prevenir alguns tipos de pneumonia estão disponíveis. O tratamento depende da causa fundamental com presunção de pneumonia bacteriana podendo ser tratada com antibióticos.

    Embora a pneumonia tenha sido considerada por William Osler, no século XIX, "a capitã da morte dos homens", o advento da terapia com antibióticos e vacinas, no século XX, tem trazido melhores resultados no que se refere a sobrevivência. Entretanto, no terceiro mundo e entre os muito idosos, os muito jovens e os doentes crônicos, a pneumonia continua a ser uma das principais causas de morte.5

    Classificação

    Pneumonite refere-se a inflamação pulmonar, pneumonia refere-se a pneumonia infecciosa, geralmente devido à infecção, mas às vezes não, que tem a característica adicional de consolidação pulmonar.6 Pneumonia pode ser classificada de várias maneiras. É mais comumente classificada por onde ou como ela foi adquirida (adquirida na comunidade, aspiração, associada com cuidados de saúde, hospital e por ventilação),7 mas também pode ser classificada pela área do pulmão afetada (pneumonia lobar, broncopneumonia e pneumonia intersticial aguda) ou pelo organismo causador.8 Pneumonia em crianças pode ainda ser classificadas com base em sinais e sintomas como não-graves, graves ou muito graves.9

    Sinais e Sintomas

    Sintomas frequentes em pneumonias10

    Sintoma

    Frequência

    Tosse

    79–91%

    Fadiga

    90%

    Febre

    71–75%

    Falta de ar

    67–75%

    Expectoração

    60–65%

    Dor no peito

    39–49%

     

     

    Principais sintomas da pneumonia

    Os sintomas mais comuns da pneumonia são febre de 39°C a 40°C11 ,suor frio, calafrios, respiração rápida e curta, tosse com catarro amarela ou esverdeada, sendo que em alguns tipos de pneumonia, a tosse pode vir seca ou sem catarro, dores no peito ou no tórax,12 além de problemas para respirar,13 diarreias, vômitos, náuseas e fadiga.11 Febre, no entanto, não é muito específica, já que ocorre em muitas outras doenças comuns, e podem estar ausentes em pacientes com doença grave ou desnutrição. Além disso, uma tosse é frequentemente ausente em crianças com menos de 2 meses de idade.14 Sintomas mais graves podem incluir: cianose central, diminuição de sede, convulsões, vômitos persistentes, ou uma diminuição do nível de consciência.14

    Algumas causas de pneumonia estão associados com clássicas, mas não específicas, características clínicas. Pneumonia causada pela Legionella pode ocorrer com dor abdominal, diarreia ou confusão,15 enquanto a pneumonia causada por Streptococcus pneumoniae está associada com expectoração com cor enferrujada,16 e a pneumonia causada por Klebsiella pode ter expectoração com sangue, muitas vezes descrita como "geleia de groselha".10

    Fatores de risco

    As pessoas que tem mais tendência em pegar pneumonia são idosos com mais de 65 anos, bebês, crianças pequenas, pessoas que tem outros problemas de saúde, como diabetes, doença hepática crônica, estado mental alterado, desnutrição, alcoolismo,17 pessoas que tem o sistema imunológico frágil por causa da aids, transplante de órgãos ou quimioterapia. Também correm risco de pegar pneumonia pessoas com doenças pulmonares, como asma, enfisema e também pessoas que têm dificuldade de tossir, sofreram derrames, fizeram ou fazem uso de sedativos e pessoas com mobilidade limitada.18

    Tratamento

    A pneumonia bacteriana é tratada por antibióticos e, dependendo do caso, pode ser tratado com internação. Em casos mais graves, uma internação é necessária na Unidade de Tratamento Intensivo, conhecida como UTI. As medicações podem ser tanto via oral ou por injeções, aplicadas na veia ou no músculo.19

    Além das medicações, como auxiliar no tratamento, pode ser usada a fisioterapia respiratória. Os fisioterapeutas podem utilizar vibradores no tórax, exercícios respiratórios e tapotagem, que é a percussão do tórax com os punhos, para retirar as secreções que estão dentro dos pulmões e fazendo com que o paciente possa ser curado mais rapidamente.19

    Em caso de pneumonias virais, o tratamento é só de suporte. Ela é tratada com dieta adequada, oxigênio, caso seja necessário e medicações para dor e febre. Em casos de pneumonias causadas por fungos, antimicrobianos específicos são utilizados.19

    Prevenção

    A prevenção inclui vacinação, medidas ambientais, e o tratamento de outras doenças de forma adequada.14

    Vacinação

    Vacinação é eficaz para prevenir certos tipos de pneumonias bacterianas e virais em crianças e adultos.

    Vacinas contra a gripe são modestamente eficazes contra influenza A e B.20 21 O Centro de Controle e Prevenção de Doenças (CDC) recomenda que todos que tem seis meses de idade ou mais se vacinarem anualmente.22 Quando um surto de gripe está ocorrendo, medicamentos, tais como amantadina, rimantadine, zanamivir, e oseltamivir pode ajudar a prevenir a gripe.23 24

    Vacinações contra a Haemophilus influenzae e Streptococcus pneumoniae têm boas evidências para apoio do seu uso. Vacinação de crianças contra a Streptococcus pneumoniae também leva a uma diminuição da incidência destas infecções em adultos, pois muitos adultos adquirem infecções das crianças. A vacina contra a Streptococcus pneumoniae também está disponível para adultos, e ela foi encontrada para diminuir o risco de doença invasiva pneumocócica.25

    Meio ambiente

    Redução da poluição do ar em lugares fechados é recomendada14 tal como parar de fumar.26

    Outros

    Adequadamente o tratamento de doenças subjacentes (como AIDS) pode diminuir o risco de ter pneumonia.

    Existem várias maneiras de prevenir pneumonia em recém-nascidos. Testes para mulheres grávidas encontrarem Streptococcus do grupo B e Chlamydia trachomatis, e dando o tratamento com antibióticos, se necessário, reduz a pneumonia em crianças. Aspiração da boca e da garganta de recém-nascidos com líquido amniótico diminui a taxa de pneumonia por aspiração.

    Epidemiologia

     

     

    Número de mortes a cada 100.000 habitantes, em 2004.27

      no data

      <100

      100-700

      700-1400

      1400-2100

      2100-2800

      2800-3500

      3500-4200

      4200-4900

      4900-5600

      5600-6300

      6300-7000

      >7000

    A pneumonia é uma doença comum que afeta aproximadamente 450 milhões de pessoas por ano e ocorre em todas as partes do mundo.20 É uma das principais causas de morte entre todas as faixas etárias, resultando em 4 milhões de mortes (7% do total anual do mundo).20 28 As taxas são maiores em crianças menores de cinco anos, e adultos com mais de 75 anos de idade.20 Ocorre cerca de cinco vezes mais frequentemente em países em desenvolvimento em relação aos países desenvolvidos.20 A pneumonia viral atinge cerca de 200 milhões de pessoas.20

    Crianças

    Em 2008, pneumonia ocorreu em, aproximadamente, 156 milhões de crianças (151 milhões nos países em desenvolvimento e 5 milhões nos países desenvolvidos).20 Isso resultou em 1,6 milhões de mortes, ou 28-34% de todas as mortes em menores de cinco anos de idade, dos quais 95% ocorreram nos países em desenvolvimento.14 20 Países com o maior fardo da doença incluem: Índia (43 milhões), China (21 milhões) e Paquistão (10 milhões).29 É a principal causa de morte entre crianças em países de baixa renda.20 28 Muitas dessas mortes ocorrem no período neonatal. A Organização Mundial da Saúde estima que, uma em cada três mortes de bebês recém-nascidos, são devido à pneumonia.30 Cerca de metade destas mortes são evitáveis​​, teoricamente, já que elas são causadas ​​pelas bactérias para as quais existe uma vacina eficaz disponível.31

    Sociedade e cultura

    Devido ao grande número de pessoas infectadas nos países em desenvolvimento, a comunidade global de saúde declarou que o 12 de novembro é o Dia Mundial da Pneumonia, um dia dedicado ao combate à doença.32

    Ver também

     

     

    Referências

    1. a b A. McLuckie. Respiratory disease and its management. [S.l.: s.n.], 2009. 51 p. ISBN 9781848820944
    2. Leach, Richard E.. Acute and Critical Care Medicine at a Glance. 2 ed. [S.l.]: Wiley-Blackwell, 2009. ISBN 1-4051-6139-6
    3. Jeffrey C. Pommerville. Alcamo's Fundamentals of Microbiology. 9 ed. Sudbury, Mass: Jones & Bartlett Publishers, 2010. p. 323. ISBN 0-7637-6258-X
    4. Ashby, Bonnie; Turkington, Carol. The encyclopedia of infectious diseases. 3 ed. New York: Facts on File, 2007. p. 242. ISBN 0-8160-6397-4
    5. Causes of death in neonates and children under five in the world (2004). World Health Organization. (2008).
    6. Stedman's medical dictionary.. 28th ed. Philadelphia: Lippincott Williams & Wilkins, 2006. ISBN 9780781764506
    7. Sharma, S; Maycher, B, Eschun, G. (2007 May). "Radiological imaging in pneumonia: recent innovations". Current opinion in pulmonary medicine 13 (3): 159–69. DOI:10.1097/MCP.0b013e3280f3bff4. PMID 17414122.
    8. Dunn, L. (2005 Jun 29-Jul 5). "Pneumonia: classification, diagnosis and nursing management". Nursing standard (Royal College of Nursing (Great Britain) : 1987) 19 (42): 50–4. PMID 16013205.
    9. organization, World health. Pocket book of hospital care for children : guidelines for the management of common illnesses with limited resources.. Geneva: World Health Organization, 2005. p. 72. ISBN 9789241546706
    10. a b Tintinalli, Judith E.. Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies, 2010. 480 p. ISBN 0-07-148480-9
    11. a b SINTOMAS PNEUMONIA. Cria Saúde. Página visitada em 8 de janeiro de 2012.
    12. Sintomas da pneumonia. Banco de Saúde. Página visitada em 8 de janeiro de 2012.
    13. O que é pneumonia?. Boa Saúde. Página visitada em 8 de janeiro de 2012.
    14. a b c d e Singh, V; Aneja, S. (2011 Mar). "Pneumonia - management in the developing world". Paediatric respiratory reviews 12 (1): 52–9. DOI:10.1016/j.prrv.2010.09.011. PMID 21172676.
    15. Darby, J; Buising, K. (2008 Oct). "Could it be Legionella?". Australian family physician 37 (10): 812–5. PMID 19002299.
    16. Ortqvist, A; Hedlund, J, Kalin, M. (2005 Dec). "Streptococcus pneumoniae: epidemiology, risk factors, and clinical features.". Seminars in respiratory and critical care medicine 26 (6): 563–74. PMID 16388428.
    17. Pneumonia nos idosos – Fatores de risco. Medicina Geriátrica. Página visitada em 9 de janeiro de 2012.
    18. GRUPOS DE RISCO PNEUMONIA. Cria Saúde. Página visitada em 9 de janeiro de 2012.
    19. a b c PNEUMONIA. ABC da Saúde. Página visitada em 9 de janeiro de 2012.
    20. a b c d e f g h i Ruuskanen, O; Lahti, E, Jennings, LC, Murdoch, DR. (2011 Apr 9). "Viral pneumonia". Lancet 377 (9773): 1264–75. DOI:10.1016/S0140-6736(10)61459-6. PMID 21435708.
    21. Jefferson, T; Di Pietrantonj, C, Rivetti, A, Bawazeer, GA, Al-Ansary, LA, Ferroni, E. (2010 Jul 7). "Vaccines for preventing influenza in healthy adults". Cochrane database of systematic reviews (Online) (7): CD001269. DOI:10.1002/14651858.CD001269.pub4. PMID 20614424.
    22. Seasonal Influenza (Flu). Center for Disease Control and Prevention. Página visitada em 29 June 2011.
    23. Jefferson T; Deeks JJ, Demicheli V, Rivetti D, Rudin M. (2004). "Amantadine and rimantadine for preventing and treating influenza A in adults". Cochrane Database Syst Rev (3): CD001169. DOI:10.1002/14651858.CD001169.pub2. PMID 15266442.
    24. Hayden FG; Atmar RL, Schilling M, et al.. (October 1999). "Use of the selective oral neuraminidase inhibitor oseltamivir to prevent influenza" (PDF). N. Engl. J. Med. 341 (18): 1336–43. DOI:10.1056/NEJM199910283411802. PMID 10536125.
    25. Moberley, SA; Holden, J, Tatham, DP, Andrews, RM. (2008 Jan 23). "Vaccines for preventing pneumococcal infection in adults". Cochrane database of systematic reviews (Online) (1): CD000422. DOI:10.1002/14651858.CD000422.pub2. PMID 18253977.
    26. Lim, WS; Baudouin, SV, George, RC, Hill, AT, Jamieson, C, Le Jeune, I, Macfarlane, JT, Read, RC, Roberts, HJ, Levy, ML, Wani, M, Woodhead, MA, Pneumonia Guidelines Committee of the BTS Standards of Care, Committee. (2009 Oct). "BTS guidelines for the management of community acquired pneumonia in adults: update 2009". Thorax 64 Suppl 3: iii1–55. DOI:10.1136/thx.2009.121434. PMID 19783532.
    27. WHO Disease and injury country estimates. World Health Organization (WHO) (2004). Página visitada em 11 November 2009.
    28. a b Kabra SK; Lodha R, Pandey RM. (2010). "Antibiotics for community-acquired pneumonia in children". Cochrane Database Syst Rev 3 (3): CD004874. DOI:10.1002/14651858.CD004874.pub3. PMID 20238334.
    29. Rudan, I; Boschi-Pinto, C, Biloglav, Z, Mulholland, K, Campbell, H. (2008 May). "Epidemiology and etiology of childhood pneumonia". Bulletin of the World Health Organization 86 (5): 408–16. DOI:10.2471/BLT.07.048769. PMID 18545744.
    30. Garenne M; Ronsmans C, Campbell H. (1992). "The magnitude of mortality from acute respiratory infections in children under 5 years in developing countries". World Health Stat Q 45 (2–3): 180–91. PMID 1462653.
    31. WHO. (1999). "Pneumococcal vaccines. WHO position paper". Wkly. Epidemiol. Rec. 74 (23): 177–83. PMID 10437429.
    32. World Pneumonia Day Official Website. World Pneumonia Day Official Website. Fiinex. Página visitada em 13 August 2011.

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