pneumonia (pulmonya)
DESCRIPTION
Community Acquired Pneumonia and Respiratory Tract Infections lecture (RHU Quezon, Quezon Lecture Series) for RHU Quezon, Quezon staff.TRANSCRIPT
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PNEUMONIA(Pulmonya)RHU Quezon Lecture Series # 2
January 30, 2011
Paolo Victor N. Medina MDMunicipal Health Officer
Quezon, Quezon
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Mga Pinagkunang Sipi:
• Philippine Community Acquired Pneumonia (CAP) Guidelines 2010
• Integrated Management of Childhood Illness (IMCI)
• Integrated Management of Childhood Illness (IMCI) Technical Update 2007
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Mga Layunin• Ipakilala sa RHU staff ang madalas na ginagamit
na grading ng antas ng ebidensiya sa tinatawag na Evidence Based Medicine
• Mabilisang pagbabalik-aral sa anatomiya ng Daanang Hangin (respiratory tract) ng katawan
• Balikan ang depinisyon ng Pneumonia/Pulmonya– Ano ang pulmonya?– Papaanong masasabing may pulmonya ang isang tao?
• Matutunan ang kahalagahan ng kaalaman ukol sa pulmonya bilang mga primary health worker sa Rural Health Unit/BHS– Diagnosis
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Mga Layunin
• Matutunan ang basic na gamutan ng Pulmonya– 2010 Clinical Practice Guidelines (para sa
matatanda)– IMCI 2007 Technical Update (para sa mga bata)
• Matutunan ang tamang pagpapayo sa mga pasyenteng may pulmonya– Pag-iwas sa pulmonya
• Mga paalala
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Grading System for the Strength of the Recommendations and Quality of Evidence
Grade DefinitionStrength of Recommendation
A Good evidence to support a recommendation for or against use
B Moderate evidence to support a recommendation for or against use
C Poor evidence to support a recommendation for or against use
Quality of Evidence
Level I Evidence from ≥ 1 randomized control trial
Level II Evidence from >1 well-designed clinicaltrial, without randomization; fromcohort or case-control analytic studies(preferably from >1 center); from multipletime series; or from dramatic results ofuncontrolled experiments
Level III Evidence from opinions of respectedauthorities, based on clinical experience,descriptive studies, or reports from expertcommittees
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Ang Daanang Hangin ng Katawan
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Ano ang Pulmonya/Pneumonia?
• Pinakasimple: Impeksyon ng lower respiratory tract (ibabang bahagi ng daanang hangin) – mula trachea hanggang alveoli
• Sa ating pang araw-araw na karanasan, ang pinakamahalagang matutunan at maintindihan ay ang community acquired pneumonia (CAP)– “community-acquired” dahil nakukuha ang
impeksyon na ito sa community
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Ano ang Pulmonya/Pneumonia?
• Community Acquired Pneumonia (CAP)– Impeksyong nakukuha sa community sa loob ng 24 na
oras hanggang 2 linggo– Karaniwang sintomas (adult):
• Ubo (24 hours < 2 weeks)• Tachypnea (RR > 20 breaths per minute)• Tachycardia (HR > 100 beats per minute)• Fever (T > 37.8 C)• WITH at least one abnormal chest finding:
– Decreased breath sounds– Rhonchi– Crackles– Wheeze
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Ano ang Pulmonya/Pneumonia?• Community Acquired Pneumonia (CAP)– Karaniwang sintomas (pediatric):
• Ubo (24 hours < 2 weeks)• Fever (T > 37.8 C)• Fast Breathing:
– RR > 50 per minute (2 to 12 months)– RR > 40 per minute (12 months to 5 years)
• SEVERE: chest indrawing or stridor in a calm child
– WITH at least one abnormal chest finding:• Decreased breath sounds• Rhonchi• Crackles• Wheeze
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Ano ang Pulmonya/Pneumonia?
• PERO kahit may mga nakitang sintomas at senyales gaya ng mga naunang nabanggit, hindi pa rin siguradong CAP ang diagnosis
• Pero pwede pa ring gumawa ng presumptive diagnosis ng CAP na ang batayan ay history at P.E. (Grade B Evidence)
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Ano ang Pulmonya/Pneumonia?
• Kung may history ng admission sa ospital o long-term health facility sa loob ng 2 linggo, hindi pwedeng maging CAP ang diagnosis
• Dapat ding tandaan na kapag elderly ang pasyente, malaki ang posibilidad na wala sila ng mga tinatawag na “classical symptoms” gaya ng lagnat, ubo, dyspnea, etc.
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Anong Diagnosic/Laboratory Procedure ang Mahalaga sa Diagnosis ng Pulmonya?
• Hangga’t maari, DAPAT may chest x-ray ang bawat pasyenteng pinaghihinalaang may pneumonia (Grade A Evidence) – CAP CPG 2010– Matutukoy kung gaano kalala ang pulmonya– Masisiguro ang diagnosis ng pulmonya– Makikita kung may ibang sakit ang pasyente na
maipapaliwanag ang kanyang mga sintomas
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Anong Diagnosic/Laboratory Procedure ang Mahalaga sa Diagnosis ng Pulmonya?• Subalit para sa mga lugar o sitwasyong walang sapat
na resources o mga pasilidad, pwede nang hindi gawin ang X-ray sa mga sumusunod na kundisyon:– Mga relatively malusog na tao na may “stable co-morbid
conditions”– Normal/Stable vital signs and assuring PE findings– AND nakakasisiguro tayo sa follow-up ng pasyente at
pagsunod sa payo• Hindi na rin kailangan ang CXR kung susundin ang IMCI
guidelines (para sa mga 0-5)• Kung magpapagawa ng CXR para sa pasyente, kung
gumaganda naman ang lagay nito sa loob ng 2 araw, hindi kailangang ulitin ang CXR (Grade B Evidence)
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Kailan Dapat I-refer ang Pasyente sa Ospital (Adult)?• Kailangang pagbasehan ang mga sumusunod
sa pagdedesisyon kung sa ospital ba dapat gamutin ang pasyente o pwedeng outpatient (Grade A Evidence)– Kondisyon ng pasyente sa oras ng pagkonsulta– Kung ang kanyang ibang sakit (co-morbid
condition) ay hindi stable– CXR Findings– Base sa mga ito, mayroong management-oriented
risk stratification na mabubuo (categories ng CAP)
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Kailan Dapat I-refer ang Pasyente sa Ospital (Adult)?• Ang mga pasyenteng mapapabilang sa
kategoryang Low-risk ang maaaring gamutin bilang outpatient (Grade A Evidence)
• Kung ang pasyente ay nasa categoryang Moderate-risk o High-risk kinakailangang ma-ospital ang pasyente para sa mas tutukang pagbabantay at gamot na padadaanin sa swero (Grade A Evidence)
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Clinical Features of Patients with CAP According to Risk Categories (CAP CPG 2010)
• LOW-RISK CAP– Presence of:
• Stable vital signs: RR < 30 breaths/min, PR < 125 beats/min• Temp > 36 C or < 40 C• SBP ≥ 90mmHg, DBP > 60mmHg
– No altered mental state of acute onset– No suspected aspiration– No OR stable comorbid conditions– CXR
• Localized infiltrates• No evidence of pleural effusion or abscess
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Clinical Features of Patients with CAP According to Risk Categories (CAP CPG 2010)
• MODERATE-RISK CAP – ANY of the following:• Unstable vital signs: RR ≥ 30 breaths/min, PR ≥ 125
beats/min• Temp ≥ 40 C or ≤ 36 C• SBP < 90, DBP ≤ 60• Altered mental state of acute onset• Suspected aspiration• Decompensated co-morbid condition• CXR
– Multilobar infiltrates– Pleural effusion or abscess
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Clinical Features of Patients with CAP According to Risk Categories (CAP CPG 2010)
• HIGH-RISK CAP– ANY of the criteria under moderate risk CAP
category PLUS Severe Sepsis and Septic Shock– Need for mechanical ventilation
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Kailan Dapat I-refer ang Pasyente sa Ospital (Pedia)?• Based on IMCI Guidelines:– Presence of ANY Danger Signs• Hindi makasuso/dede o makainom• Isinusuka ang lahat• Ang bata ay nagkombulsyon• Tingnan kung ang bata ay lethargic (sobrang tamlay) o
walang malay
– (+) Chest Indrawing OR– (+) Stridor in a CALM child
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Pediatric Risk Classification of Pneumonia (based on Pediatric Pneumonia CPG)
Variables PCAP A Minimal Risk
PCAP B Low Risk
PCAP C Moderate Risk
PCAP D High Risk
Co-morbid Illness None Present Present Present
Compliant Caregiver Yes Yes No No
Ability to Follow-up Possible Possible Not Possible Not Possible
Presence of Dehydration
None Mild Moderate Severe
Ability to Feed Able Able Unable Unable
Age > 11 mos > 11 mos < 11 mos < 11 mos
Respiratory Rate 2-12 mos 1-5 years > 5 years
50/min40/min30/min
>50/min>40/min>30/min
>60/min>50/min>35/min
>70/min>50/min>35/min
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Pediatric Risk Classification of Pneumonia (based on Pediatric Pneumonia CPG)
Variables PCAP A Minimal Risk
PCAP B Low Risk
PCAP C Moderate Risk
PCAP D High Risk
Signs of Respiratory Failure a. Retraction b. Head bobbing c. Cyanosis d. Grunting e. Apnea f. Sensorium
NoneNoneNoneNoneNone
Awake
NoneNoneNoneNoneNone
Awake
Intercostal/SubcostalPresentPresent
NoneNone
Irritable
Supraclavicular/Intercostal/Subcostal
PresentPresentPresentPresent
Lethargic/Stuporous/Comatose
Complication (effusion, pneumothorax)
None None Present Present
Action Plan OPD Follow up at the end of treatment
OPD Follow up after 3 days
Admit to regular ward
Admit to ICU (refer to
specialist)
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Ano ang Gamutan Para sa Pneumonia?
• ADULT:– Low-risk CAP without comorbid illness, amoxicillin
remains the standard drug of choice (Grade A).• Amoxicillin 500mg TID x 7 days• 5 to 7 days for low risk uncomplicated pneumonia (Grade B)
– In our setting (dito sa Quezon RHU), we can still try using cotrimoxazole but IT IS NOT RECOMMENDED (dahil sa resistance sa gamot)
– For Low-risk CAP with stable comorbid illness – REFER TO RHU MD =)• Co-amoxiclav• Cefuroxime
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Ano ang Gamutan Para sa Pneumonia?
• PEDIA:– IMCI Technical Update 2007:• Non-severe Pneumonia:
– 3 days Oral Amoxicillin or Cotrimoxazole– Where resistance to Cotrimoxazole is high, Amoxicillin IS
preferred– DOSE: Amoxicillin 25mg/kg/dose BID x 3 days
• Severe Pneumonia:– Ideally hospitalization– But if not feasible due to lack of resources/logistics, oral
amoxicillin may be given
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Ano ang Gamutan Para sa Pneumonia?
– Pediatric Pneumonia CPG:• For a patient PCAP A or PCAP B:
– Oral Amoxicillin 40-50 mg/kg/day TID x 7 days
– Cotrimoxazole:• 40 mg/kg sulfamethoxazole per day (BID) x 7 days• IMCI 4mg/kg trimethoprim per dose BID
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Paano Masasabing Gumagaling ang Pasyenteng May Pneumonia?• ADULT:– Assess: Temperature, RR, HR, BP, Sensorium, O2
Saturation, Inspired O2 concentration– Dapat gumaganda na ang lagay ng pasyente sa
loob ng 24 hanggang 72 oras. (Average: 2 days). Kung hindi gumaganda ang lagay ng pasyente matapos ang 72 oras, dapat ulitin (o magpa) CXR (Grade A)
– Kung hindi gumaganda ang lagay ng pasyente – REFER to MD!
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Paano Masasabing Gumagaling ang Pasyenteng May Pneumonia?• PEDIA:– Gumagandang lagay ng Pasyente (lalung-lalo na
ang pagbagal ng “fast breathing”) sa loob ng 72 oras (ave. 2 days) matapos umpisahan ang antibiotic
– Kung hindi gumaganda ang lagay ng pasyente, REFER!
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Pag-iwas sa Pneumonia
• ADULT:– Ang bakuna laban sa influenza ay inirerekomenda
para sa pag-iwas sa Pulmonya (Grade A)– Ang bakunang tinatawag na pneumococcal
vaccine ay inirerekomenda para maiwasan ang invasive pneumococcal disease (Grade A)
– SMOKING CESSATION is recommended for all patients with CAP who smoke (Grade A)
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Pag-iwas sa Pneumonia
• Recommendations for Pneumococcal Vaccination (one time vaccination):– > 60 years old– Persons with chronic illnesses– Immunocompromised persons (mahina ang
resistensiya, depensa ng katawan)– Mga nakatira sa nursing home o iba pang long
term care facilities– Mga naninigarilyo o may hika edad 19 to 64
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Pag-iwas sa Pneumonia• ≥ 50 years old• Chronic illness• Immunosuppression (HIV, CA, etc)• Buntis na nasa 2nd or 3rd trimester• Mga nakatira sa nursing home o iba pang katulad na
pasilidad• Health care personnel• Household contacts and caregivers of children < 5
years and adults ≥ 50• Household contacts (including children) and caregivers
of persons with medical conditions that put them at high risk for severe complications from influenza
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THE ENDMay mga tanong ba kayo???