Pneumopathies, diagnosis and treatment

Definition

Inflammation of the lungs induced by pathogen (infectious).
Distinguished from pneumonia which is instead a phlogistic reaction induced by physical noxes (eg rays) and chemical (eg, drugs, irritating gases, gastric juices).
- Etiological: primary and secondary pneumopathy, respectively with and without previous cardiopulmonary disease
-patiological-anatomical: alveolar and interstitial pneumopathy.
- Epidemiological: pneumopathy acquired in the hospital and in the clinic.
-Not more in use: clinical or radiological subdivision in typical [lobate] and atypical pneumopathy.

Etiology

Pneumopathy acquired in outpatients: pneumococci, streptococci, Haemophilus influenzae, anaerobes, viruses, mycoplasmas, Rickettsias (eg, Q fever), Clamydia (eg, ornithosis), Legionellae.
Hospital acquired pneumopathy (manifestation> 72 hours after patient admission): Staphylococcus aureus, gram negative germs (Klebsielle, Pseudomonas, Serratia, Proteus).
Pneumopathies for reduced immune defenses (eg, in leukemia, malignant lymphomas, AIDS) or immunsuppression (eg, in the course of immunosuppressive / cytostatic therapy): viruses (varicella zoster, herpes simplex), bacteria, nosocomial pathogens, see above, mycobacteria), mycetes (Candida, Aspergillus, Cryptococcus neoformans), Pneumocystis carinii.
Predisposition also for alcohol abuse, advanced age, cardiopulmonary primary disease, other infections.

CLINIC

Typical findings (eg, pneumococcal pneumopathy): acute onset, chills, high fever, cough with reddish-purulent sputum, dyspnea, tachypnea,
possible cyanosis, chest pains related to breathing (concomitant pleurisy).
Auscultation marked wheezes, enhanced vocal thrill, attenuated percussion sound.
-Pneumopathy But also silent beginning (eg, chlamydial pneumopathy, mycoplasmas, Legionella, virus) with light fever, myalgias, headaches and poorly productive cough, despite partially marked changes in radiological examination, finding with little or no auscultation .
Special features of certain forms of pneumopathy:
viral: in otherwise healthy subjects, severe courses particularly in bacterial superinfection
- Mycoplasma patients: frequent in young people
-Legionellosis (frequent transmission through purification and air humification plants): moreover abdominal discomfort with nausea and diarrhea
-Ornitosis (transmitted by chickens and pigeons), Psittacosis (transmitted by parrots, budgerigars): high fever, otherwise symptoms as above
-Febbre Q (mainly transmitted by pets): acute beginning with high fever, chills, headaches, possibly hepatitis, endo- / myocarditis etc.

Diagnostics - Differential diagnosis

Anamnesis: basic diseases, voluntary consumption, profession, contact with animals.
Clinical, alone often scarcely useful for diagnosis (differential diagnosis with influenza-like infection).
Radiograph of the thorax in two projections = important examination to ascertain a pneumopathy.
finds:
- Lobe or segmental opacity, often clearly defined, possible positive bronchogram, eg, in pneumococcal pneumopathy
- Stain-like, reticular or homogeneous opacity, localized on both sides, for example, in mopoplasmas pneumopathy

Laboratory exams

- Acceleration of the ESR
- Hemogram: leukocytosis, left deviation, granulation and lymphopenia, especially in bacterial pneumopathy
- Blood gas analysis: hypoxia, hypocapnia, global respiratory failure, indicating a severe course (artificial respiration required?)
- Detection of the pathogen agent:
• Blood culture: particularly indicated in cases of chills and fever
• Spit: suitable only in case of purulent sputum, often contamination
• Tracheal / bronchial secret in patients under artificial respiration by tube
• Withdrawal of material by bronchoscopy (bronchoalveolar lavage, previously suspending antibiotics) in case of severe pneumopathy acquired in hospital, with resistance to therapy or with reduced immune defenses (eg, especially from Pneumocystis carinii), possibly also transbronchial biopsy
• A pleural point in case of payment formation
• Indirect detection of the pathogen by means of serological research methods: detection of antibodies, 4-fold increase in the titer of two serum samples within 2 weeks (generally not useful for deciding the therapy)
• In the presence of Legionelle, proceed also to check the antigen in the urine.
- Differential diagnosis: think mainly of
- Tuberculosis
- Pneumopathy (poststenotica) in bronchial carcinoma
- Pulmonary embolism with infarct pneumopathy
- Aspiration in patients with difficulty swallowing as a result of neuropathies (eg, after stroke).

Complications

Complication of complications especially in bacterial genetics pneumopathies.

- Bacterial septicemia: eg, otitis media, meningitis, endocarditis, brain abscess.
- Pulmonary abscess, pleural effusion or pleural empyema.
- Global respiratory insufficiency
Thromboembolic complications following entrapment and dehydration (spe cies in elderly patients).
Cardiovascular insufficiency: toxic and / or intense fluid displacements
as well as for hypoxemia and high fever. > - Acute renal failure: especially in elderly patients with dehydration.
Relapse.

Therapy

In severe form (respiratory rate> 30 / min., Po2 <60 mmHg, hypotension) always treatment in hospital, initially entrapment and prophylaxis of thromboembolism. In the case of a non-severe course, outpatient treatment may be sufficient, using precautionary measures at a physical level.
Initial antibiotic therapy generally not targeted, according to the presumed etiology. Previously collection of material for the diagnosis of the pathogen (see above): at least blood culture, in the case of severe pneumopathies acquired in the hospital, of pneumopathy acquired with artificial respiration as well as of patients with immunosuppression, bronchocavular bronchoscopy.
Sufficient intake of fluids, possibly injecting.
Antipyretics (eg, paracetamol 4 x 500 mg / day) and / or sural packs.
Inhalation treatment (eg, with 0.9% NaCl and), mucolytic.
Respiratory gymnastics, percussion massages.
In case of hypoxia, administration of oxygen with control of blood gases. With no improvement in symptoms and progressive global respiratory failure, proceed with artificial respiration promptly.
Possible treatment of a bronchial obstruction.
After receiving the sensitivity results, replace the antibiotic if necessary.
Pneumocystis carinii pneumopathy therapy: cotrimoxazole (20 mg / kg / w / day of trimethoprim + 100 mg / kg / w / day of sulfamethoxazole) for 3 weeks.

Prognosis

Negative prognostic symptoms:
- Patients> 60 years
- Cardiopathies / pneumopathies in progress
- Chronic renal failure
- Reduced immune defenses
- Complications.

Primary antibiotic therapy of pneumopathies

Pneumopathy acquired in the clinic:
- without primary pathology
Macrolides: eg, clarithromycin 2 x 0.25 g / day p.o. erythromycin
4 x 500 mg / day p.o., e.v. roxithromycin 2 x 0.15 g / day p.
- with primary internology pathology:
Amoxicillin clavulanic acid
3 x 2.2 g e. v.
or ampicillin / sulbactam 3 x 1.5 g e.v.

Pneumopathy acquired in the hospital
Second generation cephalosporin (e.g., cefuroxim 3 x 1.5 g / day, cefotiam 2x2 gZday) + aminoglycoside (e.g., gentamicin 1 x 240-360 mg / day)

Intensive care unit,
Artificial respiration therapy
Cephalosporin of the 3rd generation (eg, cefotaxim 3x2 g / day, ceftriaxone 1 x 2 g / day), + aminoglycoside or piperacillin / tazobactam
3 x 4.5 g / day + aminoglycoside

Aspiration bronchopneumonia
Clindamycin
3 x 600 mg / day With a severe course: imipeneme / cilastatin 3 x 1 g / day

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