well welcome to the MedCram lecture we're going to talk about pneumonia
which is a pretty big topic today pneumonia is very common so you do have
to know about it and you do see it quite a bit in the inpatient setting and you
also see it in the outpatient setting pneumonia globally affects about 450
million people a year that's a huge amount of people that's about seven
percent of the population it turns out that out of those 450 million people who
develop pneumonia there's only about four million deaths so we do treat these
things especially men with antibiotics and specifically with vaccines which
we'll talk about a little bit today we're going to talk about the diagnosis
the symptoms signs and how we treat pneumonia and some key things that may
come up on tests that you'll be able to use for your advantage okay so the first
thing you got to know is what is a pneumonia and you see know the lungs
kind of look like this got the right upper lobe you've got the right middle
lobe the right lower lobe and the left side as well and they branch off to all
these things keep branching and branching and branching finally what
you're going to do is you're going to get to this part where you have these
alveolar sacs okay it looks like a little grapes and that's where the air
exchange occurs so if you were to look at a cross-section of that here's the
alveolar sac and here is the blood vessel associated with that what happens
is this area gets filled up with infection and mucus and white blood
cells and so what happens is that the air coming in is not able to exchange
and put oxygen into the red blood cells okay so you've got an infection there so
what you should see is number one you should see a fever
although not always number two you should have an elevated white-blood-cell
count and then finally number three you should see an infiltrate on the x-ray
well the fever we get from taking the temperature a WBC we get from ordering
something called the complete blood count and an infiltrate we get by
ordering a chest x-ray but what are the other signs that we'll see well people
will have fevers we'll have chills they will feel if they're young they're gonna
have pulmonary symptoms so that's one thing that you should know is in the
young population and in the old population what do we see in the young
population you're more likely to see things like shortness of breath cough in
other words respiratory symptoms pain in the chest okay whereas the old might
just be confused sleepy so in other words more nonspecific symptoms in the
elderly population whereas more respiratory specific in the younger
population okay the other thing that you've got to know that's just really
important is where these patients coming from so there's something called
community and then there's something that's called healthcare acquired the
reason why this is important is because there are different bacteria that are
associated with each of these there's bacteria that's associated with the
community which we'll talk about and there's bacteria associated with
healthcare for instance Pseudomonas and Mrs A which require completely different
antibiotics generally speaking the thing that's
going to divide this is if the patient has come from a health care facility
into your Hospital then it's going to be a healthcare acquired infection if on
the other hand it's from a community then they would be coming in from like
from their home or from their and complex if the patient is already
admitted to the hospital and they're developing an infection in the lung
after 72 hours then that would be a healthcare acquired okay so let's go
through some key points here to kind of read through this so we've already
decided that an infection in the lung is a pneumonia let's look at a little bit
more of the history of the patient okay so if you see a patient who has been bed
bound I want you to think of an infection with Klebsiella that's a
Klebsiella pneumoniae is a specific type of bacteria if your patient has COPD
then I want you to think of Hamas influenza that's the classic one if the
patient's been exposed to sheep in the field then I want you to think about Q
fever hey these are associations that I want you to have if the patient is a
bird handler then I want you to think about psittacosis psittacosis is a
condition that's associated with Birds chlamydia psittacosis if you are a
hunter specifically a rabbit hunter from Arkansas but it could be any kind of
hunter I want you to think of tularemia if there's something about bat caves in
the question stem then I want you to think about histoplasmosis okay if the
patient is in the Central Valley of California or they mentioned something
about California the thing I want you to think about is coccidia mycosis which is
a fungus and then if they mentioned something about Chicago or the
Mississippi Valley I want you to think of blasto
mycosis okay so these are again histories that you might get in the
patients who are coming in with these symptoms that we've already talked about
something else that you might see on history is the onset okay if it's abrupt
think about typical pneumonia that's typically what happens if it however is
insidious I want you to think of atypical now epical typically it has an
infection that comes on dramatically it comes on fast you have fevers chills and
you're sick very quickly atypical on the other hand is not as
severe comes on gradually and that type of onset is associated with different
bacterial organisms atypical organisms versus typical organisms now the typical
organism as you'll know is the streptococcal pneumonia and that one has
actually gone down quite a bit in the last few years and that's because
of what's been going on with the vaccine so let's talk about that a little bit so
there are two different vaccines in the United States that we're using currently
it's the the polyvalent 23 which has been around for some time and the
Prevnar 13 polyvalent 23 is also known as the ppsv23 and the Prevnar 13 is also
known as PCV 13 so the polyvalent 23 I think you should know that it's used as
a polysaccharide and because of that it's not a protein protein is what's
required to make memory cells so there's no memory cells here with the
polysaccharide vaccine it's currently FDA approved United States to be used in
all adults who are 65 and older and for people who are 2 years or older and at
high risk or two plus and high-risk what do I mean
by high-risk these are people who are high-risk at having pneumococcal disease
such as people with sickle cell disease HIV infection or other conditions which
can make them immunocompromised now the ppsv23 or the polyvalent 23 is
also recommended for people who are 19 plus it's a 64 okay so before they get
to 65 years of age if they do a couple of things if they smoke or if they have
asthma okay so there still is a role for the polyvalent vaccine now the Prevnar
has a dipteroid protein in it and what that means is you get memory cells so
that's pretty good and it's currently recommended for all children younger
than five years old so from zero to five years of age and all adults 65 plus and
this has been a recent thing here in 2014 is that anyone 65 years or older
get it and people who are six to 64 if they have certain medical conditions
and what they found is this Prevnar 13 has really done an amazing job at
reducing the invasive pneumococcal rates so they started looking at the
prevalence of invasive pneumococcal disease in the United States and they
tracked it from 1997 and they wanted to see exactly what happened so they looked
at these kids who were less than five years of age and they started around the
80 or so mark and right as soon as PCV 7 which is the the forerunner if you will
of the pren mar 13 in its started to just dive in terms of the
prevalence of invasive pneumococcal disease so this is really encouraging
because this was a protein derived vaccine and it pretty much stayed low
until finally printing 413 was introduced back in 2009 in the pediatric
population it continued to decline now interestingly enough if you looked at
the adults in the same category they hate derive some some benefit so
like in 2000 their rate started to go down and then kind of plateaued and then
when prent of our 13 was introduced after 2009 they started to go down and
it wasn't until way out here in 2014 was it finally approved for them and we're
hoping that we'll see a even bigger decline so it looks as though the
decline in adults adults over than 65 years of age so the red here is greater
than 65 and the blue is less than 5 it looks as though there was some herd
effect so we talked about what pneumonia is what the symptoms are and some of the
specific ideologies and how to tell them in the history and then we went over a
little bit about the vaccines for invasive pneumococcal disease when we
come back we'll talk about the specific entities and how they look again with
clinical findings thanks for joining us
you