:

1
??? ???

• ???????
• ?????
• ???

2
??? ???

• ??? ??
• ??? ??
• ?? ?????? / ????
• ????? ???

3
??? ??Upper Respiratory Tract Infection
4
??? ?? ???

• Common cold
• Pharyngitis
• Croup
• Epiglottitis
• Tracheobronchitis
• Influenza

5
?????? ??

• ?? ????? ??? ???
• ??? ???? ??? ????? ??
• ????? ???? ? ? ??
• ??? ?? ?? ?? ??
• ??? ?? ???? ??? ???
• ?? peritonsillar abscess, epiglottitis,
  Ludwigs angina, invasive fungal sinusitis,
  invasive otitis externa

6
Common cold (Coryza)

• Mild, self-limited URI
• Incidence 2-4 /adult/year
• ???
• rhinorrhea sneezing, nasal obstruction
• sore throat, nonproductive cough
• ??? ??, ????? ??
• ?? 5-7?? ??
• ???? ?????? ??
• ??
• rhinovirus 30-40
• coronavirus, respiratory syncytial virus,
  parainfluenza virus?
• ????
• aerosol, secretion(hand to hand)

7
Common cold

• ??
• ??, ??, ??? ??
• ?? ??? ???? ??? ??
• ???
• otitis media, acute sinusitis, pneumonia
• ??
• symptomatic analgesics, nasal decongestant,
  antihistamine,
• antibiotics ??? (?? ???? ????? ??? ??)
• ??? ?? ? 1-2? ?? ?? ??
• ??
• ???

8
Pharyngitis

• ???
• virus gt 60
• rhinovirus (m/c), adenovirus, coronavirus,
  enterovirus, RSV, herpes simplex virus
• bacteria group A streptococcus
• Exudative pharyngitis
• Group A beta-hemolytic streptococcus(20-40),
• Neisseria gonorrhea, Corynebacterium
  diphteriae,
• Mycoplasma, Chlamydia, EBV, etc
• Nonexudative pharyngitis
• RSV, parainfluenza, influenza etc

9
Pharyngitis

• ???
• sore throat, pharyngeal injection,
• hypertrophy of tonsil
• ??
• throat swab
• Group A beta-hemolytic streptococcus? ??
• ??
• ????
• Rest, Adequate fluid, Antipyretic, Gargling with
  warm salt water Local anesthetics
• Antibiotics bacterial
• Group A beta-hemolytic streptococcus? ?? ??
  rheumatic fever? ?? (PCN G)

10
Influenza

• ??
• Influenza virus? ?? ?? ?????
• ?/??? ??? ??? ??? ? ??
• Influenza virus
• Influenza A, B, C
• Influenza A? subtyping (B, C? ?? ??)
• ??????/?? ????/????/????
• Influenza A/Johannesburg/33/94(H3N2)
• Surface hemagglutinin(H), neuraminidase(N)
• Epidemiology(Influenza A)
• Antigenic shift major antigenic variation(????
  ??), A?.
• Antigenic drift minor variation (???? ??),
• ???? 10-15? ???, ???? 1-3? ???

11
???

• ??? 1-3?
• ?? ????? ??? ??
• ??, ??, ??(38-41C), ???, ???
• ????? ????? ??? ??? ?? ??
• ??, ??? ?
• ????? ?? ??, ?? ??? ? ??? ??? ??? ??
• ????, ???, ??? ??? ?? ???? ??? ??
• ?? ??? ?? ???.

12
???

• ??
• primary viral pneumonia least common, most
  severe
• secondary bacterial pneumonia S. pneumoniae, S.
  aureus, H. influenza etc
• mixed pneumonia most common
• Reyes syndrome
• Myositis, rhabdomyolysis, myoglobulinuria
• Myocarditis, pericarditis

13
??

• ??? ??? ??
• antipyretics relief of headache, myalgia,
  fever
• rest hydration
• antiviral agent
• amantadine, rimantadine
• zanamivir, oseltamivir
• antibiotics only secondary bacterial infection
  combined
• ??
• vaccine
• ??? chronic cardiovascular or pulmonary
  disorder
• over 65 years of age
• DM, CRF, other immunosuppressed
  state

14
??
15
?????

• ????, ??, ?? ??? ???? ??? ??? ??

16
Classification of pneumonia

• Pathogenesis Inhalation vs Aspiration vs
  Bacteremia
• Etiology Various
• Anatomy Lobar vs Interstitial
• Diffuse vs Circumscribed
• Epidemiology Community-acquired vs
  Hospital-acquired
• Immunity Immunocompetent vs Immunocompromised
• Time course Acute vs Chronic

17
???? ??

• Air-space consolidation
• Bronchopneumonia
• Interstitial pneumonia
• Hematogenous pneumonia
• Necrotizing pneumonia
• Parapneumonic effusion

18
??? ??

• Mycoplasma
• Chlamydia
• Legionella

19
?????? ??
20
Community-acquired pneumonia

• ??
• ????? ??????? ?? ????
• ???? ??? ?? ??? ?? ??? ???? ??
• ??? ?? 7? ??? ????? ???? ??? ??
• cf. Hospital-acquired pneumonia
• ?? ? 48??? ??? ???? ??

21
CAP ??? ?? ??

• ??? CAP? ????
• ??? CAP? ?? ??? ?????
• ? ??? ?? ?? ?????
• ??? ?? ??
• ???? ??? ?? ???? ??
• ??

22
??? ??
23
Clinical Manifestation

• Onset sudden and dramatic or insidious
• Typical symptom
• fever, chills or rigors
• cough
• sputum productive of purulent or rust-colored
  sputum
• pleuritic chest pain
• shortness of breath
• Atypical symptom
• headache, nausea, vomiting, diarrhea, myalgia,
  arthralgia, fatigue

24
Physical Exam

• Tachypnea, dullness to percussion, egophony,
• increased tactile and vocal fremitus,
  whispering pectoriloquy,
• crackles, and pleural friction rub
• ? 20 of pneumonia
• A diagnosis of pneumonia based on physical
  examination has a sensitivity of 47 to 69 and a
  specificity of 58 to 75

25
??? ??

• Chest PA / lateral
• Consolidation
• not 100 sensitive
• HRCT
• in patients with symptoms and signs suggestive of
  pneumonia in whom chest radiographs are reported
  as not showing pneumonia
• An opacity visible on chest radiograph may not be
  due to pneumonia

26
??? ???? ??? ??
27
?? (Expectorated sputum)

• ??? ??? ??? ?? ???? ?? ??
• ??? ???? ???? ?? ?? ??? 1-5??? ????
• ???? ???? ???? ??? ???
• ?? ?? ??? ? ??? ???? ?? ???? ??
• ???? ??
• ????, ????, ?? ? ??? ??? ??, ?? ???
• ?? PAS ??, Giemsa ??, Penumocystis carinii?
• ?? Silverman methenamine stain ?

28
??? ??? ??

• ??? ?? ??? ??
• Group No. of cells/low-power field
• WBCs SECs
• 5 gt25 lt10
• 4 gt25 10-25
• 3 gt25 gt25
• 2 10-25 gt25
• 1 lt10 gt25

SEC squamous epithelial cell
29
(No Transcript)
30
Severity of Pneumonia

• CURB-65 criteria
• Age gt 65?
• 30 day mortality
• 0? 0.7
• 1? 2.1
• 2? 9.2
• 3? 14.5
• 4? 40
• 5? 57
• 2 more intensive treatment - hospitalization

( 20?/?)
31

• Class I, II ??
• Class III ?? ?? ??, ????
• Class IV ?? ??

32
ICU Admission Decision

• Major
• Minor 3?

ATS 2007
33
Etiologic Diagnosis
34
Etiology of CAP

• Outpatient
• Admittance
• ICU

35
(No Transcript)
36
Underlying conditions related to specific
pathogens in CAP

• Alcoholsim S. pneumoniae, anaerobe, G(-) bacilli
• COPD S. pneumoniae, H. influenzae, M.
  catarrhalis,
• Poor dental hygiene Anaerobe
• HIV infection S. pneumoniae, H. influenzae, M.
  tuberculosis
• Aspiration anaerobe, chemical pneumonitis
• Bronchiectasis Peudomonas Spp., S. aureus
• Drug abuse S. aureus, anaerobe, M. tuberculosis
• Airway obstruction Anaerobe

37
CAP ????

• Outpatient
• Admittance
• ICU

38
????

• ??? ??????
• ?? ????? ?? ???? ????? ??
• ??? ??
• ???

39
CAP? ?? ??
ATS/IDSA (2007)

• Risk factor for DRSP
• Chronic heart, lung, liver or renal disease
• Diabetes mellitus, alcoholism, malignancies
• Asplenia, immunosuppressing conditions, use of
  immunosuppressing drugs
• Use of antimicrobials within the previous 3 months

Risk factors (-) macrolide doxycycline
Risk factors () ?-lactam macrolide or doxy
or respiratory quinolone
(moxifloxacin, gatifloxacin, levofloxacin)
40
CAP? ?? ??
ATS/IDSA (2007)
Respiratory quinolone (moxifloxacin,
gatifloxacin, levofloxacin) or ?-lactam
macrolide
non-ICU
?-lactam (cefotaxime, ceftriaxone, or
ampicillin-sulbactam) either azithromycin or
respiratory quinolone (moxifloxacin,
gatifloxacin, levofloxacin)
ICU
41
Special Concern
ATS/IDSA (2007)

• If Pseudomonas combination treatment
• Risk factor
• structural lung disease (BE)
• repeated exacerbations of COPD (frequent
  steroid, antibiotics)
• prior antibiotics therapy

antipseudomonal ?-lactam (piperacillintazobactam
,cefepime, imipenem, or meropenem)
ciprofloxacin or levofloxacin or antipseudomonal
?-lactam aminoglycoside azithromycin or ant
ipseudomonal ?-lactam aminoglycoside quinolone
42
??? ??? ??? ?? ???
43
???? ??
44
Definition

• Pneumonia occurring ? 48h after admission and
• excluding any infection (incubating at the time
  of admission)
• Definition of VAP (ventilator-associated
  pneumonia)
• Pneumonia occurring ? 48h of MV
• Early onset vs Late onset
• Early onset HAP lt5 d of admission
• Late onset HAP ?5 d of admission

45
Epidemiology

• incidence of HAP
• 5 to 10 cases per 1000 hospital discharges
• second most common nosocomial infection
• up to 30 of all nosocomial infections
• highest morbidity and mortality
• Crude mortality rates for HAP range from 30 to
  70
• incidence among patients in the ICU who are
  undergoing MV
• The incidence of pneumonia 6 to 20 times higher
  
• among MV patients than among other
  hospitalized patients

46
?? ??? ??

• ?? ????? ???? ???
• Cf) CHF, ARDS, atelectasis, underlying disease,
• drug-induced lung disease
• ??? ????
• purulent sputum
• fever
• leukocytosis
• decline oxygenation

ATS/IDSA (2005)
47
Pathogen of HAP

• gram-negative bacilli 64
• P. aeruginosa (21),
• Acinetobacter spp. (6)
• Enterobacter spp. (9)
• K. pneumoniae (8)
• gram-positive pathogen
• S. aureus most common pathogen
• MRSA ??? ?? (2 in 1974 ? 64 in recent)

Harrison
48
Empiric Therapy
ATS/IDSA (2005)

• Onset 5?
• Risk factor
• for MDR pathogen

49
Risk factors for MDR pathogens
ATS/IDSA (2005)
50
Antibiotics therapy for HAP

• Early onset (lt 5?), MDR risk factor (-)

ATS/IDSA (2005)
51
Antibiotics therapy for HAP

• Late onset ( 5?)
• MDR risk factor ()

ATS/IDSA (2005)
52
Etiologic Diagnosis

• Invasive diagnostic testing
• intubated patients with VAP
• endotracheal aspiration
• via a fiberoptic bronchoscope
• PSB
• bronchoalveolar lavage (BAL)

53
Prevention

• Health care providers
• must adhere strictly to hand-washing protocols
• In patients undergoing mechanical ventilation
• extubate rapidly
• reintubation should be avoided
• orao-endotracheal gtgt naso-endotracheal
• minimize ventilator circuit changes
• continuous suctioning of subglottic secretions
• enteral feedings
• elevation of the head of the bed by at least 30
• limiting use of sedatives

54
Opportunistic Infection of the Lung
55
??

• ?? ??
• ?????? ??? ???? ?? ???? ?? ??
• ?? ???? ????? ??
• ???? ??
• ???
• ??? ???, ???, AIDS,
• Malignancy (chemotherapy,
  radiation therapy)
• ????????, CTD (long term steroid)

56
???? ??? ?? ??

• Mucociliary clearance
• ?? gt 2? ??
• Alveolar macrophage
• Surfactants
• Complements
• C3b opsonization
• Lymphocytes
• B-lymphocyte
• CHO ?? ????? ????
• T-lymphocyte peptide ??
• Immunoglobulin
• ????? ???? ?? ????
• ????? ??? IgG? ??
• IgG opsonin?? ??-????? ??.

57
???? ??? ???

• ????? ???
• ????? ?? ???
• CHF, pulmonary infarction, alveolar hemorrhage,
  ARDS, pulmonary edema, leukostasis, spread of
  underlying tumor
• ??? ?? ???
• ????? ????
• ??? ??? ??

58
????? ???? ??

• ???? ??
• ??? ??? ???
• ?? ???
• ???? ???? ?? ??
• ????? ??
• ??? ???? ??

59
Infections a/w specific Immune Defects
60
?? ??

• ??
• ?? ??, ?? ??, ??, ?? ?
• ??? ??
• ????
• ????
• ??? ??
• BAL, TBLB, PCNA, Open lung biopsy etc

61
??? ??
62
?? ??

• Sputum Analysis
• Adequacy lt10 epithelial cells, gt25 WBC (100X)
• Useful in acute bacterial, pneumocystis,
  mycobacterial
• limitation in viral, fungal
• ????
• CMV, herpes simplex, toxoplasma etc
• ???? ??

63
?? ??

• ??? ???
• BAL, PSB, TBLB
• Pneumocystis, Tb, nocardia, fungi
• ?????(PCNA B)
• Nodular or cavitary lesion
• ?????
• Diagnostic standard

64
??? ???
Chest infiltration
Initiate empiric therapy
Normal coagulation
Abnormal coagulation
BAL TBLB
BAL
Nondiagnostic
Diagnostic
Diagnostic
Specific Tx
Specific Tx
OLB
Diagnostic
Nondiagnostic
Continue empiric Tx
Specific Tx
Consider OLB again
65
Bacterial pneumonia

• ?? ??
• ??? ??? ?? ???
• ?????? ??
• ???? / ????
• ??? ????
• ??? ??, ??? ?? Legionella, Pseudomonas
• ??? S. aureus, Stenotrophomonas maltophilia
• ??? ?? Klesiella pneumonia, Pseudomonas
• ?????? Norcadia
• ???? ???? ? ??? ??? ??

66
Cytomegalovirus(CMV)

• ???
• ????? ?? ??
• ?????, ?? ???, AIDS
• ???? ??, ??? ?? ?? ?? ???? ?? ????? ???
• Fever, tachypnea, hypoxia, nonproductive cough,
  fatigue, night sweat
• ??? ??
• Bilateral interstitial or reticulonodular
• ??
• OLB, BAL - virus culture, inclusion body
• Serologic diagnosis
• PCR
• ??
• Gancyclovir
• CMV immunoglobulin
• foscarnet

67
Fungal Infection

• PCP
• Pneumocyctic carinii ? Pneumocystis jiroveci
• Aspergillosis
• Candida

68
Pneumocystis jiroveci (PCP)

• Clinical features
• Insidious onset of fever, dry cough, dyspnea,
  hypoxia in CD4 count lt200 cells/mm3
• tachycardia, tachypnea, cyanosis, few abnormal
  lung sound
• extrapulmonary infection lt 3
• Risk Group
• HIV(), organ TPL, glucocorticoid therapy
• Dx
• sputum exam
• GMS stain for cyst, WG stain for nuclei
• IF stain with monoclonal antibody
• FOB with BAL mainstay of DX
• TBLB OLB

69
PCP

• CXR findings
• Bilateral diffuse opacity, often finely reticular
  to consolidation In the perihilar lesion
• pneumothorax relatively common
• pleural effusion adenopathy rare
• HRCT
• bilateral ground-glass opacity, thickened
  interlobular septa
• sparing subpleural lung
• Tx
• TMP-SMX for 23wk
• Steroid PaO2 lt 70mmHg
• Pentamidine
• clinical response 1wk later

70
(No Transcript)
71
(No Transcript)
72
Aspergillosis

• Risk acute leukemia, organ transplantation,
  steroid
• HIV() CD4T cell lt 50/?
• ??? ??? ??? ?? ??
• Rapidly progressive
• ??? ??, ??? ??, ??, ??? ??
• ?? ??? ?? ???, ???
• ?? OLB, TBLB, PCNB
• ?? amphotericin B

73
66/male, Fever with productive cough

• ?? 2?? ????? ????? ???

74
Candidiasis

• Hematologic malignancy, neutropenia
• Route of infection catheter or GI mucosa
• ???? ???? ??? ?? colonizer
• ?? ?? ??, ??? ??
• ?? amphotericin B, 5-fluorocytosine

75
???? ??? ???

• ??(lt1?)
• ???? ??
• Bacteria(Staph, Strep, E. coli, G(-) rod)
• ??
• ??? ????, ?? ??? ??
• CMV, PCP, Aspergillosis, Legionella
• ??(gt6?)
• Nocardia, Aspergillosis, Mucormycosis

76
Bronchiectasis
77
Definition

• abnormal
• permanent
• dilatation of bronchi

78
??

• ??? ??
• Bacterial
• Pertussis
• P. aeruginosa
• H. influenza
• S. aureus
• Virus
• Measles
• Adenovirus
• influenza
• Mycobacterial
• M. Tb
• NTM

• ??? ??
• Immotile cilia syndrome
• Kartageners syndrome
• ?? ???
• Cystic fibrosis
• Alph-1 antitrypsin deficiency
• ??? ??
• Foreign body
• Neoplasm
• ABPA

79
???

• Cough
• Purulent sputum
• Repeated respiratory infection
• Hemoptysis

80
??

• Simple Chest X-ray
• ???? ? ??? ??? ??
• Tram-track, ring-shadow, signet-ring
• Bronchography
• ?? gold standard
• HRCT

81
????
82
Bronchography
83
(No Transcript)
84
??

• Antibiotics
• Vaccination pneumococcus, influenza
• Chest physiotherapy
• Postural drainage
• Mucolytics
• Bronchodilator Ipratropium, ß agonist
• Surgery
• Hemoptysis BAE (bronchial artery embolization)

85
Lung Abscess
86
Definition

• ???? ?? ????
• ??? ??? ??? ??.
• A cavity containing pus and necrotic debris
• ??? air-fluid level ? ???.

87
??

• ?? ?? ?? ?? ????? ??
• ???? ??, ???
• ???, ????, ????
• ??????, ???? (pulmonary sequestration)
• ?????
• ???? ?? ??? ??
• ??

88
????

• Aspiration (??)
• ??? microaspiration
• Oropharyngeal bacteria anaerobes
• Aerobic or facultative gram negative bacilli
• S. aureus

89
????

• Dependent position? ??
• Supine lower lobe? Sup. segment
• Lateral decubitus upper lobe? post. segment

Supine
Lateral decubitus
90
Organism of lung abscess

• ???? 89
• Prevotella, porphuromonas, Bacterioides,
  Fusobacterium, Peptostreptococcus
• ??? ??
• S. aureus, K. pneumoniae, P. aeruginosa, E. coli
• ???
• ??
• Aspergillus species, Pneumocyctis carinaii

91
????

• aspiration
• alcoholism
• anesthesia
• dysphasia
• trauma
• surgery
• gingivitis

• sinusitis
• obstruction
• bronchiectasis
• embolism
• intubation

92
????

• ??, ????,
• ??? ??? ??? ??? ??
• ?? ??? ??
• ??

93
??

• CPA
• a cavity with an air-fluid level, with or without
  surrounding infiltrate
• CT
• ??? ??, ??, ????? ??

94
????

• Cavitary lung cancer
• Tuberculosis with Tb
• Infected bulla or cyst
• Localized saccular bronchiectasis
• Aspergilloma
• Wegeners granulomatosis
• Cavitated rheumatoid nodule
• Gas-fluid level of diaphragmatic hernia

95
??

• Antimicrobial therapy 8? (??? 2-3?)
• High dose penicillin clindamycin or
  metronidazole
• Postural drainage

96
Thank you for your attention !