By Adem Lewis / in , , , , , , , , , , , , , , , , , , , , , , , , , , , , , /


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


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