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Pneumonia – Diagnosis, medical management

Diagnostic Evaluation

Physical Examination: may be normal, but often shows decreased expansion of the chest on the affected side, bronchial breathing on auscultation (harsher sounds from the larger airways transmitted through the inflamed and consolidated lung), and rales (or crackles) heard over the affected area during inspiration.

Percussion may be dulled over the affected lung, but increased rather than decreased vocal resonance (which distinguishes it from a pleural effusion).

CT Scan can reveal pneumonia that is not seen on chest x-ray. X-rays can be misleading, because other problems, like lung scarring and congestive heart failure, can mimic pneumonia on x-ray. Chest x-rays are also used to evaluate for complications of pneumonia.

sputum culture

If antibiotics fail to improve the patient’s health, or if the health care provider has concerns about the diagnosis, a sputum culture can be done. Sputum cultures generally take at least two to three days, so they are mainly used to confirm that the infection is sensitive to an antibiotic that has already been started.

 

Chest x ray

An important test for pneumonia in unclear situations is a chest x-ray. Chest x-rays can reveal areas of opacity (seen as white) which represent consolidation. Pneumonia is not always seen on x-rays, either because the disease is only in its initial stages, or because it involves a part of the lung not easily seen by x-ray.

Combining findings

Studies created a prediction rule that found the five following signs best predicted infiltrates on the chest radiograph

  • Temperature > 100 degrees F (37.8 degrees C)
  • Pulse > 100 beats/min
  • Rales/ Crackles
  • Decreased breath sounds
  • Absence of asthma

Management of Pneumonia

1.MEDICAL MANAGMENT

  1. Antibiotics
  2. Support therapy
  3. Therapy of complications

1.Antibiotic therapy

Most cases of pneumonia can be treated without hospitalization. Typically, oral antibiotics, rest, fluids, and home care are sufficient for complete resolution. However, people with pneumonia who are having trouble breathing, people with other medical problems, and the elderly may need more advanced treatment. If the symptoms get worse, the pneumonia does not improve with home treatment, or complications occur, the person will often have to be hospitalized.

Bacterial pneumonia

  • antimicrobial therapy begin promptly because delays in administration of antibiotics have been associated with worse outcomes.
  • Antibiotics are used to treat bacterial pneumonia. In contrast, antibiotics are not useful for viral pneumonia, although they sometimes are used to treat or prevent bacterial infections that can occur in lungs damaged by a viral pneumonia.
  • Because treatment should generally not be delayed in any person with a serious pneumonia, empirical treatment is usually started well before laboratory reports are available
  • Antibiotics for hospital-acquired pneumonia include third- and fourth-generation cephalosporins, carbapenems, fluoroquinolones, aminoglycosides, and vancomycin These antibiotics are usually given intravenously
  • Multiple antibiotics may be administered in combination in an attempt to treat all of the possible causative microorganisms. Antibiotic choices vary from hospital to hospital because of regional differences in the most likely microorganisms, and because of differences in the microorganisms’ abilities to resist various antibiotic treatments.
  • People who have difficulty breathing due to pneumonia may require extra oxygen. Extremely sick individuals may require intensive care often including endotracheal intubation and artificial ventilation
  • Over the counter cough medicine has not been found to be helpful in pneumonia.

Viral pneumonia

Viral pneumonia caused by influenza A may be treated with rimantadin or amantadine, while viral pneumonia caused by influenza A or B may be treated with oseltamivi or zanamivir

These treatments are beneficial only if they are started within 48 hours of the onset of symptoms. Many strains of H5N1 influenza A, also known as avian influenza or “bird flu,” have shown resistance to rimantadine\ and amantadine. There are no known effective treatments for viral pneumonias caused by the SARS coronavirus, adenovirus, hantavirus or parainfluenza virus.

Aspiration pneumonia

There is no evidence to support the use of antibiotics in chemical pneumonitis without bacterial infection. If infection is present in aspiration pneumonia, 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. Corticosteroids are commonly used in aspiration pneumonia, but there is no evidence to support their use either.

2.Supportive measure

Supportive measure are generally used in the initial management of acute pneumo-coccal pneumonia. Such measures include

  • Bed rest
  • Monitoring vital signs and urine output
  • Administering an occasional analgesic to relieve pleuritic pain
  • Replacing fluids, if the patient is dehydrated
  • Correcting electrolytes
  • Oxygen therapy

Management of complications

Empyema develops in appoximately 5% of patients with pneumococcal pneumonia,   although pleural effusion commonly develop in 10%- 20%   patients.

  • Chest X-ray with lateral decubitus films are often useful in the early recognition of pleural effusion, pleural fluid that is removed should be subjected to routing examination
  • If pneumococcal bacteremia occurs, extra pulmonary complications such as arthritis, endocarditis must be excluded, because then therapy requires higher dosages

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