Good evening, how are you all doing ? Today we are going to discuss a very important subject which is especially important in preventive healthcare. more specifically for children and senior adults, Which is pneumonia We have discussed a bit about this in the “Old age” video. We said that it is the fourth main reason of death in patients older than 65 years old and it is the main cause of death in children younger than five years old This is why it is very important that we understand what it is, how to prevent it, and It is an important subject since this is one of the real illnesses WHAT IS PNEUMONIA? It is an important subject since this is one of the real illnesses Meaning that is a whole new level of illness Pneumonia has been a terrible scourge of humanity for a long, long time. To the point that in actuality, with the development of antibiotics that have barely been able to slow down this phenomenon We find ourselves with the issue that pneumonia is the fourth main cause of death in the population older than sixty-five. And it is the main cause of death on our little ones, our children Because of this, even though in this video I want to give you the necessary elements for a person to be able to see and diagnose pneumonia and do the right thing, meaning taking the necessary measures to save a life, this video does not constitute a medical consultation I am not making this video so that people start working instead of a medical doctor. This illness, given that it is such a severe and important pathology, needs to be taken care of by a well-qualified medical doctor Now, pneumonia is an invasion of pathogen agents inside of the lung, and this invasion will lead to its malfunction. These pathogen agents, in the majority of cases, are bacteria or are viruses; practically the 90ish per cent of these are either viruses or bacteria. However, there are some parasites, fungi and even some chemical agents exist that can cause pneumonia as well. I won’t focus on those, because epidemiologically, meaning the whole world population, very few cases in the world were actually caused by these agents. Pneumonia is much more common among patients who, in general, have a “weakness” sort to speak, in the lungs or the immune system. And who are, by definition, these patients? They are the children, patients younger than five years old, the elderly, patients older than 65 years old, and patients with lung issues or issues in their immune system, which I’ll mention a bit later. And as I mentioned before, it is the fourth main cause of death in people older than 65 and the first main cause of death in children younger than 5. This is especially important since, due to the increase of resistance to bacteria , in a couple of years, antibiotics won’t be able to help with this, or if we don’t do something about it, antibiotics won’t be able to help with this pathology, and we see an important increase in the amount of deaths and of illness due to this cause What causes this pathology? We already saw this; it is a pathogen agent that enters the lung, and begins to spread. It starts with a bacterium, then there are two, three, four, more each time until they fill a part of the lung; and the body, to defend itself, starts secreting mucus, starts producing pus, among other symptoms. which was to take oxygen and deliver it in the blood to oxygen the body, and at the same time to eliminate the waste products that it can eliminate via the lung, which is basically carbon dioxide. So, these pathogen agents won’t allow for this gas exchange to happen, more specifically for children and senior adults, WHAT IS PNEUMONIA? and they will cause for the patient to have problems in this affected area. What causes it? The main agents that cause this, as I mentioned before, are bacteria and viruses. As from bacteria, the three most important bacteria, the ones that cause more than 80% of all pneumonia worldwide, are: first of all Streptococcus pneumoniae, which is a very resistant and wild bacterium, really tough one. Number two is type B Haemophilus influenzae and number three is Moraxella catarrhalis this is only about bacteria; however, we can also have viruses, as we mentioned before. The most important viruses are going to be this one we can see here, which affects mainly the little ones, which is the Respiratory syncytial virus, affecting children younger than five; and the Influenza virus, which I’ll mention in a bit. However, this means that when we have a patient, or we see or have a family member that has pneumonia, we have to suspect that one of these things here is what is afflicting that person. Moreover, there are some cases in which there are other pathogen agents involved, however, these cases are rare. For example, the influenza virus, which usually hits during winter season Others (unlike the others which can hit at any given time during the year), and the golden staphylococcus or staphylococcus aureus that usually hits accompanied by the influenza virus; meaning first this one attacks, it debilitates the immune system a little, and then this bastard comes, and that can create a very, very severe pneumonia. Also, we have others, like Legionella pneumophila, Mycoplasma pneumonia or “pneumonia” and Mycobacterium tuberculosis, which is obviously the one implied in tuberculosis, which we will talk about in another lesson, because this sole bacterium also causes a great amount of pathology and death. Risk Factors Who are, we already have discussed this a bit, but who are the ones that will be at a higher risk to contract or develop pneumonia? They are the patients older than 65 or younger than 5, both extremes of age. In the case of babies, it’s because they haven’t developed their immune systems completely, and in the case of elders because their immune systems have grown old. And this is in regards to the immune system, which we saw on Theories of Growing Old, that will cause for the patient to be much more likely to contract infections, but the main and most common one will be pneumonia, and urinary tract infections. The second Risk factor, which is very important, is obviously to not be vaccinated. Patients who are not vaccinated have a much higher risk of developing this pathology, and not only develop it, but also, a risk that once the bacteria have already invaded the lung they invade other organs. And then, the case would be much more severe, because then it wouldn’t only be a case of pneumonia, it could also come with meningitis, and other things that are very, very difficult to treat. The third Risk factor is alterations to the immune system, patients that are under medication that debilitates the immune system, like chemotherapy, steroids when have been taken for a long time, etc., patients that just received a transplant, which will cause that the patients are not able to defend themselves against viruses and bacteria, and that they have a higher risk of coming down with a case of pneumonia. Every patient with pulmonary alterations, like asthma, COPD (chronic obstructive pulmonary disease), pulmonary fibrosis, etc., also has a high risk. And of course, patients who have the main functional risk in lung, which also causes immune system alterations, are the patients who are smokers. Meaning that every single patient who is a smoker in general, has a high risk of contracting pneumonia. Signs and symptoms Now, how do we know that a patient is coming down with pneumonia? Meaning, what are we going to see in these patients? The three cardinal signs, that usually appear, even if sometimes are not manifested even if a patient does not show any of these signs, that doesn’t mean he/she doesn’t have a pathology, or this pathology; but what we usually find in a pneumonia patient are these three points at the beginning here. More than 80%, or better the 87% of all patients will have a fever, productive cough, meaning that when they cough up mucus or sputum, and chest pain, a high percentage of patients present it. These I mentioned are the ones called pulmonary symptoms, things that are related to the lungs and that are caused because of the immune reaction of the lung. Moreover, we are going to have some extra-pulmonary data in some patients; these extra-pulmonary data sometimes suggest other types of bacteria, other types of pathologies. these extra-pulmonary data sometimes suggest other types of bacteria, other types of pathologies. are usually advanced in age, and they usually present a different evolution of the illness than the one we would expect from a pneumonia patient. So what are these data of an atypical pneumonia? They are fatigue, mental confusion, headaches, pain in the muscles, the joints, and ears. And, very importantly, a very significant and remarkable sign is coughing blood. Coughing blood can tell us it is either a case of pneumonia that is so advanced it is already destroying the lung tissue, or that it is specifically a case of tuberculosis. And what is what causes all these signs and symptoms? Basically, we already saw it, what happens is that in a normal lung, air comes into a tissue called alveolus, and from there, air enters oxygen into the blood, and travels to the rest of the body to give us oxygen. In the case of pneumonia, bacteria start to conquer or colonize the alveolus, and they start reproducing. The body, to defend itself, starts producing mucus, liquid, it also sends immune cells, like we saw in the Inflammation lesson, which doesn’t allow for oxygen to pass into this blood, and so we can’t have a correct blood oxygenation. As a way for the body to clean this liquid it is producing and to take the bacteria out, it generates the productive cough, it creates the chest pain, and the immune response, the activation of the immune system when these molecules of the immune system called cytosine are entered into the blood, is what causes fever, fatigue, mental confusion, headaches, pains in muscles, joints, and ears, etc. And lastly, as we mentioned, the considerable damage to the lung is what causes the patient to cough up blood. Diagnosis Now, how are we going to be able to diagnose a family member or patient with pneumonia? Evidently, this has to be done by a physician, he/she will check the patient, he/she will determine which parts of the lung, as we said, are filled with liquid, by exploring the lungs, listening, make the percussion, etc., and he/she will listen to rhonchus, which is what it’s called when you can listen to a crackle inside the lungs. Besides that, we are going to require an image study, meaning take x-rays of the patient’s chest cavity, in which we can see that part of the lung is filled with water instead of what normally would be air. By this point we can determine if this patient has pneumonia, or liquid seeping in the lungs and we can start the treatment. What to do? What do we have to do? Since this is such a severe and important illness, first, we have to prevent it. The most important thing we can do, which will also be out most powerful tool is to prevent pneumonia. And to prevent it, the first step is to make sure our vaccinations are up-to-date. Whether it is our little ones, to have them vaccinated for pertussis besides the ones I’ll mention now, or if it is young adults, or elder adults, they all need to be up-to-date in their vaccinations, because this will considerably reduce the risk of developing pneumonia. Now, which specific vaccinations are the ones that’ll prevent pneumonia? The two most important are pneumococcus and the influenza one. The pneumococcus vaccination is divided in 2 types; one that covers against 13 serotypes, 13 types of the pneumococcus bacteria, and the other one that covers against 23. Generally, both can be applied, both are a great defense to prevent pneumonia. . The only difference is that the 13 serotypes one is applied to children between 6 weeks and 5 years old, and patients older than 50. Meanwhile, the 23 serotypes vaccination is applied to children older than 2, and adults older than 50. Now, something that’s very important about the pneumococcus vaccination is that the immunity against pneumococcus is not that strong, so it doesn’t really prevent all of the pneumonias specifically. So, many people might say “Well, I got vaccinated and I still got pneumonia, what the heck?”, but it is very important to say that, even if it doesn’t prevent all the types of pneumonia, , it does prevent in almost a 100% the extrapulmonary infections of this bacterium. Before, it used to be normal that pneumococcus infections would reach the lung, and from there that it passed to the brain, it was very common that it passed to the brain, to meninges, so the patient started with pneumonia, ended up contracting meningitis, and then the patient died, because meningitis caused by pneumococcus is very difficult to treat. And now, with the application of this vaccination, meningitis associated with pneumococcus after pneumonia has almost disappeared. What this vaccination is mainly doing is preventing that this pneumococcus (that reaches the lung and that sometimes does cause pneumonia) infects other parts of the body. Besides the patients in this range of ages, who else is going to get vaccinated against pneumococcus? We have to apply it to people with asthma, people with COPD, that are lung alterations, to people without a spleen, because the spleen is the organ that usually destroy this bacterium, to patients with cardiac insufficiency, because if they get pneumonia, no matter how minor their case is, it’s going to get very complicated, and to patients who have an altered immune system, , patients that receive chemotherapy, that are taking steroids, diabetics, etc. Another very important vaccination is the one against influenza. This vaccine has to be applied from the time children are 6 months old to 8 years old, every single year during the winter, while the pneumococcus one only has to be applied every 5 years, and every 5 years a booster shot. Like I was saying, the influenza shot has to be applied every year, during the winter season, and people older than 50 also have to get it every year. Besides all of the above, the vaccine has to be applied to pregnant women, because of the risk they have of contracting pneumonia, since it could get complicated for her and the baby, to people with asthma and COPD for the same reasons we have already seen, people with cardiac insufficiency and diabetes, and very importantly, to healthcare workers. This last one not only to protect ourselves, but also to protect all those patients we are attending who have pulmonary or immunity alterations, because we could transmit this virus to them which could make things really complicated for them since ultimately, pneumonia in younger people is usually not as severe as it can get for our patients, so it’s not really to protect ourselves, but mainly to protect our patients. Here, as a detail, here I am saying that the influenza vaccination is applied since children are 6 months old, and this is because before 6 months old, in theory, moms are breastfeeding their babies, and by breastfeeding the babies, they pass antibodies to them through the breastmilk; antibodies they have given that when they were pregnant, they were vaccinated against influenza. Now, we are making a lot of assumptions here, we assume the pregnant woman did get the vaccine, that she in fact breastfeeds her child for 6 months, and so for 6 months, the mom’s antibodies are protecting the baby. However, a baby that’s not being breastfed, or a woman that didn’t get the influenza vaccine during her pregnancy, create a situation where the baby in question has an increased risk of developing pneumonia, and that it gets significantly complicated. But, ok, fine, we didn’t prevent for any given reason, or even in spite of the preventive measures, our patient or family member still gets ill. What do we have to do? The first thing we have to do is, given the severity of this infection, since this is really a very mean infection, we need to determine if that person who is ill needs to be hospitalized, or if we can keep calm and just take that person to the doctor to consultation, to a small clinic, or anything. For this purpose, a scale was invented that is very easy to apply, it can be used by medical doctors, general healthcare workers such as nurses, chemists, and everyone in general. What we are going to see here are five parameters, and we’ll remember them easily because we’ll call them CURB65. Each one of these parameters will tell us if any of our patient’s organs is failing for some reason. So, let’s see each one of them. The first one, “C” stands for Confusion. This implies that pneumonia is so severe that it’s attacking the brain, that’s actually causing brain issues, which is causing confusion on our patient. It’s very common in children that they don’t look confused, but that they get really sleepy and can’t wake up. In elder patients it’s blatantly, confusion. The elder patient may believe he’s being attacked or followed, or will stop knowing where he/she is, or won’t be able to recognize people. This doesn’t mean that he/she was normal and now somehow developed Alzheimer’s in a matter of minutes, it means that a pneumonia infection is affecting his/her brain, and this is a very bad prognosis, we need to take this patient to the hospital as soon as possible. The next parameter is “U”. I’ll skip this one for a bit, we’ll come back to this one in a few minutes. Next one is “R” which stands for Respiratory frequency. If the patient takes more than 30 respirations, breaths, in ONE minute, and we’ll see this by checking their tummy, their chest rising, and timing with a watch; and if it’s more than 30 breaths per minute, this will mean that their lung is failing because of pneumonia, and he/she needs to be hospitalized. Parameter “B” stands for “Blood pressure”, in this case, low blood pressure. If he/she has a pressure lower than 90 in high or systolic, and lower than 60 in low or diastolic, it means that the patient’s heart is failing because of pneumonia, and he/she needs to be hospitalized. And if the patient is older than 65 years old, this doesn’t mean anything is failing, but the patient does have a higher risk, because it’s possible that this patient has the Frailty Syndrome, which we have mentioned before in another class, this Frailty; any alteration, no matter how minor this pneumonia case is, if the patient has frailty, this could cause the patient to have great alterations in his/her physiology, or in his/her bodily functions, and this case could get complicated, leading to the death of the patient. Meaning we have to be very attentive of these patients. I go back to parameter “U” now, which stands for Uremia. This uremia has to measure 1 BUN over 7 millimolar per liter. Basically, a BUN is a thing that’s eliminated by the kidney all the time, all time it’s being eliminated, and if the kidney isn’t eliminating this, it’s a sign that the kidney is failing. So basically, this is telling us that the kidney is not working anymore due to pneumonia. Evidently, the BUN cannot be measured by just anyone, it’s a test that has to be ordered by a medical doctor and it has to be analyzed in a laboratory. Which is why, this “U” can only be checked at a clinic, a hospital or a doctor’s office. However, CRB65 can be measured even at home, and it can tell us, if the patient matches more than 2 characteristics or more than 2 parameters are altered in the patient, said patient most probably needs to be hospitalized, and needs to be taken immediately to be attended by a physician, in a specialized center. Also, we have to be aware if the patient has another pathology that has been poorly managed. What type of pathology? For example, cardiac insufficiency that has been badly managed, or it’s a patient with a poorly controlled diabetes, etc. These patients need to be closely observed, and possibly hospitalized to try to manage this pneumonia. And lastly, again in the case of patients older than 65, it would be important in the case of a patient suffering from pneumonia, or who we suspect to be suffering from pneumonia, who also is older than 65, to be checked by a geriatrician doctor. Geriatricians are the experts in elder patients, and they’ll be the ones who’ll be able to tell us if the patient needs to be hospitalized or not. They arrive to the hospital, and then, what’s going to happen to our patient or family member? Basically we need to do 2 things: 1) To make sure that the body is still functioning, and these will be the Life Support measures; and 2) To control the infection. The most urgent and important thing to do, as soon as you reach the scene, meaning the hospital or clinic is, of course, to make sure that the body is still working These are your Life Support measures, so the patient will be immediately administered oxygen if it’s low, hydration via IV if the patient is dehydrated, and some other life support measures. Also, if the doctor suspects there is an infection in the lung or in some other place, and it’s severe, we will probably take a culture study, this can be taken from the secretion that the patient is coughing or even from the blood to see if the bacteria is already in the blood, from where it can get to other tissue. As a comment, usually, culture studies have to be taken before the antibiotic treatment. Furthermore, we are going to have to administer an antimicrobial treatment, meaning something that stops that infection in the lung. And since pneumonia, like most pneumonias are, is generally caused by bacteria, by the bacteria we already mentioned, it generally gets treated with antibiotics. This is one of the few infections that gets treated with antibiotics as a first measure. In the majority of infections, because of the risk of developing resistance, antibiotics are not recommended. Like, for example, in a throat infection, antibiotics are not always prescribed. In a simple flu, even less. In pneumonia, on the other hand, it can actually be indicated since the beginning to prescribe antibiotics, especially in children and elder patients. I won’t get much into what antibiotics have to be prescribed. Basically, the first step is to administer macrolides, in a case that’s not too complicated, these can be erythromycin, clarithromycin, azithromycin, etc. If the patient’s case is more complicated, or depending on the resistance to bacteria of the place, macrolides plus beta-lactams can be administered, for example cephalosporins, or aminopenicillins can also be administered, such as amoxicillin, ampicillin, etc. And if it’s already a very complicated case, we are going to opt for a wider spectrum antibiotic, and we are going to administer fluoroquinolones, specifically those that are designed to treat pulmonary infections. I won’t get much into those, but some examples of them are moxifloxacin, gatifloxacin, etc. Also, if it’s a virus, which is not as common, but it can happen, we have a whole variety of antivirals, such as oseltamivir, sometimes amantadine is prescribed, etc. But again, the antibiotic or antiviral has to be chosen by the attending physician, who will do this based on the epidemiology of that place, how much resistance there is to that antibiotic in that region in which the patient is treated, and also, regarding the patient. We always have to consider what the patient has, what other pathologies are involved, the patient’s allergies, etc. to prescribe to most adequate antibiotic. Lastly, as other preventive measures, once the patient is recovered, we hope the patient does recover from the pneumonia, we are always going to ask the patient to stop smoking, and we are going to pray that he/she actually does, given that that’ll protect not only the immune system but also his/her lungs, and will diminish the risk of having any subsequent pneumonias. Another point that is very important will be to ensure hand hygiene, meaning that we always have to wash our hands properly, after or before shaking hands with anyone, to always wash our hands before touching our face or eyes, to always cover mouth and nose when sneezing or coughing, etc., to avoid one on one transmission of virus. Another preventive measure is to breastfeed babies for at least a year, and if it’s not possible, at least six months would be ideal. And of course, a general recommendation for the health of the immune system and the lungs is to exercise and maintain a healthy body weight, which has also been proven to reduce severity and risk of developing pneumonia. Now here in the image we have just the cause of many cases of transmission of pneumonia, the typical patient that coughs or sneezes, and doesn’t cover his mouth, and these droplets are left floating in the air, where we all can breathe them in, or even worse, the patient coughs or sneezes into his hand, and then goes and shakes our hand. We shake his hand, and then take our hands to our faces or mouths, and we are already infected with influenza or pneumonia in the worst case scenario. SPECIAL THANKS Lastly, so you can read more about this very important subject, you can see these web pages I leave here, , mainly the Guideline for Patient Care of the Infectious Diseases Society of America (IDSA), specifically in the subject of Community-Acquired Pneumonia. I also leave you here the review article of emedicine, at Medscape, and below, the Guidelines for vaccination of the CDC, the Center for Disease Control and Prevention in the United States of America. And remember, all of the images presented, I took from Wikipedia, and therefore I thank Wikipedia because all of its images are copyright free. That would be all. And I repeat once more, if you or anyone you know have any of the symptoms mentioned in this video, please go see your doctor in a timely manner, and have a good communication with your attending physician so that they can give the ideal treatment to your case, and it doesn’t get complicated. Well, that was all; I hope you liked the video. I hope it helps you save lives; helps prevent accidents and grave illnesses. And if you liked it, please share with someone who you think can find this video useful, like it, subscribe to the channel for more videos, and see you next class. Bye! Subtitles and translation by Elizabeth Ochoa Aguilar.