Dr Niharika Jain
Dr Neeta Jain
INTRODUCTION –The word “pneumonia” originates from the ancient Greek word “pneumon,” which means “lung,” so the word “pneumonia” becomes “lung disease.” Medically it is an inflammation of lung parenchyma that is more often, but not always, caused by infections. The many causes of pneumonia include bacteria, viruses, fungi, and parasites (1).
‘Lobar pneumonia’ is a radiological and pathological term referring to homogeneous consolidation of one or more lung lobes, often with pleural inflammation.
Bronchopneumonia refers to more patchy alveolar consolidation with bronchial and bronchiolar inflammation, often affecting both lower lobes (2)
According to the new classification of pneumonia, there are four categories: community-acquired (CAP), hospital-acquired (HAP), healthcare-associated (HCAP), and ventilator-associated pneumonia (VAP).
TYPES OF BACTERIAL PNEUMONIA
- CAP: The acute infection of lung tissue in a patient who has acquired it from the community or within 48 hours of the hospital admission.
- HAP: The acute infection of lung tissue in a non-intubated patient that develops after 48 hours of hospitalization.
- VAP: A type of nosocomial infection of lung tissue that usually develops 48 hours or longer after intubation for mechanical ventilation.
- HCAP: The acute infection of lung tissue acquired from healthcare facilities such as nursing homes, dialysis centers, outpatient clinics, or a patient with a history of hospitalization within the past three months.
Some articles include both HAP and VAP under the category of HCAP, so defining HCAP is problematic and controversial.
Bacteria have classically been categorized into two divisions based on etiology, “typical” and “atypical” organisms. Typical organisms can be cultured on standard media or seen on Gram stain, but “atypical” organisms do not have such properties.
- Typical pneumonia refers to pneumonia caused by Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, Group A streptococci, Moraxella catarrhalis, anaerobes, and aerobic gram-negative bacteria.
- Atypical pneumonia is mostly caused by Legionella, Mycoplasma pneumoniae, Chlamydia pneumoniae, and Chlamydia psittaci.
Pathologically, lobar pneumonia is the acute exudative inflammation of a lung lobe. It has the following four advanced stages if left untreated:
- Congestion: In this stage, pulmonary parenchyma is not fully consolidated, and microscopically, the alveoli have serous exudates, pathogens, few neutrophils, and macrophages.
- Red hepatization: In this stage, the lobe becomes consolidated, firm, and liver-like. Microscopically, there is fibrin and serous exudate, pathogens, neutrophils, and macrophages. The capillaries are congested, and the alveolar walls are thickened.
- Gray hepatization: The lobe is still liver-like in consistency but gray in color due to suppurative and exudate-filled alveoli.
- Resolution: After a week, it starts resolving as lymphatic drainage or a productive cough clears the exudate.
A)Risks of Aspiration: Patients with an increased risk of aspiration are more prone to develop pneumonia secondary to aspiration. Associated risks are:
- Altered mentation
- Drug abuse
- Gastroesophageal reflux disease (GERD)
- Seizure disorder
- B) Exposure: A detailed history of possible exposures should be sought as it can help in establishing the potential etiologies. The following are some associations of exposures and etiologies of bacterial pneumonia:
- Contaminated air-conditioning and water systems may cause Legionella pneumonia.
- Crowded places, such as jails, shelters, etc., expose a person to Streptococcus pneumonia, Mycobacteria, Mycoplasma, and Chlamydia.
- Exposures to several animals, such as cats, sheep, and cattle, may lead to infection with Coxiella burnetii
- Some birds, such as chickens, turkeys, and ducks, can expose a person to Chlamydia psittaci.
SIGN AND SYMPTOMS
The presence of productive cough is the most common and significant presenting symptom. Some bacterial causes have particular manifestation, such as:
- S. pneumoniae – Rust-colored sputum
- Pseudomonas, Hemophilus – Green sputum
- Klebsiella – Red currant-jelly sputum
- Anaerobes – foul-smelling and bad-tasting sputum
Atypical pneumonia presents with pulmonary and extra-pulmonary manifestations, such as Legionella pneumonia, which often presents with altered mentation and gastrointestinal symptoms.
Some examination findings are specific for certain etiologies, such as:
- Bradycardia – Legionella
- Dental illnesses – Anaerobes
- Impaired gag reflex – Aspiration pneumonia
- Cutaneous nodules – Nocardiosis
- Bullous myringitis – Mycoplasma
MANAGEMENT OF PATIENT
The approach to evaluate and diagnose pneumonia depends on the clinical status, laboratory parameters, and radiological evaluation.
- Clinical Evaluation: It includes taking a careful patient history and performing a thorough physical examination to judge the clinical signs and symptoms mentioned above.
- Laboratory Evaluation: This includes lab values such as complete blood count with differentials, inflammatory biomarkers like ESR and C-reactive protein, blood cultures, sputum analysis or Gram staining and/or urine antigen testing, or polymerase chain reaction for nucleic acid detection of certain bacteria.
- An arterial blood gas may reveal hypoxia and respiratory acidosis.
- Pulse oximetry of less than 92% indicates severe hypoxia, and elevated CRP predicts a serious infection.
- Blood cultures should be obtained before administering antibiotics. Unfortunately, they are only positive in 40% of cases.
- If good quality, sputum evaluation may reveal more than 25 WBC per low-power field and less than 10 squamous epithelial cells.
- Some bacterial causes present with specific biochemical evidence, such as Legionella, may present with hyponatremia and microhematuria.
- Radiological Evaluation: It includes a chest X-ray as an initial imaging test, and the finding of pulmonary infiltrates on plain film is considered as a gold standard for diagnosis when the lab and clinical features are supportive.
- The chest x-ray may reveal a consolidation or parapneumonic effusion.
- Chest CT is done for complex cases where the cause is not known.
- Bronchoalveolar lavage is done in patients who are intubated and can provide samples for culture.
An expanded CURB-65 pneumonia severity score can be used for risk quantification. It includes C = Confusion, U = Uremia (BUN greater than 20 mg/dL), R = Respiratory rate (greater than 30 per min), B = B.P (BP less than 90/60 mmHg) and age greater than 65 years. One point is scored for each of these risk factors. For a score of 0-1, outpatient treatment is advised. If the total score is 2 or more, it indicates medical ward admission. If the total score is 3 or more, it indicates ICU admission.
Distinguishing pneumonia from other pulmonary diseases can be a daunting task, particularly in patients with co-existing pulmonary pathology. The differential diagnoses are different for children and adults, as mentioned below:
Differential Diagnosis in Children
- Asthma or reactive airway disease
- Respiratory distress syndrome
Differential Diagnosis in Adults
- Acute and chronic bronchitis
- Aspiration of a foreign body
- Chronic obstructive pulmonary disease
- Respiratory failure
MANAGEMENT WITH HOMOEOPATHY
ACONITUM NAPELLUS – first stage caused by chill in COLD ,DRY AIR. Chill more or less pronounced in the beginning of an attack promptly followed by intense fever , with dry burning .hot skin quick & hard pulse with violent thirst anxiety ,restlessness ,shortness of breath & perhaps fear of death .constant pressure on left chest, lobored breathing. whistling cough worse from every inspiration, at night, drinking; grasps the throat.
Cough better lying on back. Shortness of breath during sleep. Violent congestion of blood in the chest. Pneumonia. Oppression of the chest on least motion. Lungs feel hot.
ANTIMONIUM TARTARICUM –best remedy for pneumonia of right lung associated with jaundice cough of elderly patients ,especially in the winter months with weak chest & feeble powers of expulsion.
Difficult respiration ,ameliorated by expectoration. respiratory difficulties of neonates.& marked respiratory distress .children with Rattling chest.
BRYONIA ALBA -Cough;DRY, HARD, VERY PAINFUL, at night as of from stomach, must sit up worse eating and drinking. Wantsto take deep breath, but cannot or it excites cough. Expectoration; rusty blood streaked or tough. Pneumonia.SHARP STITCHES IN CHEST or at right scapula, worse deep breathing and coughing. Pleurisy. Coming into warm room excites cough. Holds chest, or pressesthe sternum when coughing.
BROMIUM -lower lobe of the right lung affected. sensation as if he could not get sufficient air into chest. stitches in right side of chest
CARBO VEGETABILIS – Pneumonia advanced esp in third stage .Dyspnea& must sit up in bed .dyspnea from flatus or over eating ,better eructation, fanning .Breath of foul smell. great irritability especially directed at the family.
CHELIDONIUM – Right-sided pneumonia with pain through to the back ,desire for warm drinks ,painful cough. hemoptysis .Right-sided intercostal neurolagia ,worse from motions .
Bilious pneumonia. Respiratory symptoms with liver symptoms. Short breath and tight chest. Dyspnoea worse urinating. they usually have right sided complaints. aggravation from motions .& ameliorates after lunch.
CALCAERA CARBONICA – short of breath. Tickling cough as from dust or feather in throat. Cough; worse inspiratio. Purulent, loose, sweet, expectoration. Chest very sensitive to touch.despair of recovery.strong sense of duty & responsibility.nightmares or night terrors at any age.
DROSERAROTUNDIFOLIA violent paroxysm of coughing ,sometimes so severe the patient cant catch his breath or becomes cyanotic.cough worse after midnight ,eating ,immediately upon lying on night. Cough so severe as to produce epistaxis. vomiting from the cough. painful cough.
DULCAMARA -cough which on in cold ,damp weather. pneumonia. domineering about & preoccupied with family matters ; spends the entire interview discussing family controversies. anxiety about family.
FERRUM PHOSPHORICUM -best medicine for first stage also beginning of second stage that of exudation .pneumonia often right sided. Pleurisy First stage of all inflammatory affections. Congestions of lungs. Hard, dry cough. Hoarseness. Expectoration of pure blood in pneumonia .Cough better at night.the patient is generally thin,often with light flush.he is open natured ,alert & has abundant ideas.
KALIUM CARBONICUM -cough worse night especially 2 to 4 AM ,worse morning on waking .cough with thick ,purulent sputum with a cheesy taste.Pneumonia often left-sided but also right lower lobe s.Pneumonia in children ,stitching pains on inspiring ,cant eat & drink, cant sleep.
KALI IODATUM -Sputa frothy ,profuse , purulent & green .when HEPATIZATION has commenced .great difficulty of breathing.
LACHESIS MUTUS- in late stage of pneumonia when it assumes a typhoid form esp when abscess in lungs. HEPATIZATION MOSTLY IN LEFT LUNGS. Great difficulty in breathing
OPIUM– Pneumonia of old topers.deep snoring breathing with wide open mouth. Hot sweat all over body. bed feels too hot .
SANGUINARIA CANADENSIS -Second & third stage for pneumonia.in second stage tough & rusty colour sputa , difficult to raise. In third stage sputa pus like &offensive ,smelling very badly even to the patients. Difficulty in breathing very distressing.
SULPHUR -after acon has played its role at the onset sulphur often abort the disease. Much rattling of phlegm in chest .frequent ,weak, fainting spells, & flushes of heat. Wants doors & windows open.
IN LATER STAGES OF PNEUMONIA WHEN THERE IS NO TENDENCY TO RESOLUTION OFTEN REQUIRED AFTER BRYONIA.
VERATRUM VIRIDE -it is service in the congestive stage of pneumonia , the temperature is high , pulse is hard, full & rapid.
RUBRICS FROM DIFFERENT REPEROTRIES
- CHEST & LUNGS, PNEUMONIA, NEGLECTED, UNRESOLVED (7)
- SLEEPINESS, PNEUMONIA, IN (4)
- NEVER WELL SINCE, PNEUMONIA (1)
- CHEST & LUNGS, PNEUMONIA, INFANTS, IN (1)
- FEAR, DISEASE OF, PNEUMONIA (1)
- LUNGS, INFLAMMATION, CROUPOUS PNEUMONIA (47
- LUNGS, INFLAMMATION, BRONCHO-PNEUMONIA (17)
- ENTERIC, PNEUMONIA, BRONCHIAL SYMPTOMS (13)
- ENTERIC, PUTRESCENT PNEUMONIA (2)
- NEPHRITIS, PNEUMONIA, WITH (2)
- BÖNNINGHAUSEN REPERTORY
- PNEUMONIA: PURULENT EXPECTORATION, WITH: (16)
- PNEUMONIA: CEREBRAL TYPE: (14)
- PNEUMONIA: CATARRHAL: (12)
- PNEUMONIA: ASTHENIC TYPE (SENILE): (10)
- CONVALESCENCE, ailments during pneumonia, after (10)
- INFLAMMATION Lungs pleura pneumonia (19)
- DIFFICULT pneumonia, in (11)
- DELIRIUM pneumonia in (5)
- SLEEPINESS pneumonia, in (4)
- HEMORRHAGE pneumonia, results of (2)
- UNCONSCIOUSNESS, coma pneumonia, in (2)
- RAGE, fury pneumonia, after
- MUTTERING pneumonia, in (1)
- FEAR pneumonia, of (1)
- DIFFICULT pneumonia, in chronic (1)
- TALK, sleep in pneumonia, in
- PNEUMONIA, infection, (104)
- PNEUMONIA, infants, (13)
- PAIN, pneumonia, after (7)
- PNEUMONIA, congestive stage (7)
- PNEUMONIA, consolidation stage
- PNEUMONIA, left, lung (8)
- PNEUMONIA, left, lung lower lobe (3)
- PNEUMONIA, resolution stage (15)
- PNEUMONIA, infection, consolidation stage (8)
- PNEUMONIA, right, lung (15)
- PNEUMONIA, right, lung lower lobe (3)
- PNEUMONIA, right, lung upper lobe (2)
- FAST, pulse pneumonia, in (4)
- QUICK, pulse pneumonia, in (5)
- INSOMNIA, pneumonia, in (10)
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Dr. Niharika Jain ,MD (Scholar)
Department of Practice Of Medicine , GHMC ,Bhopal , MP
Dr. Neeta Jain, MD (Medicine)
Founder of Prabha Multi speciality Homoeopathic clinic, Indore, MP