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Al Heuer, PhD, MBA, RRT, RPFTProfessor
Rutgers- School of Health Related Professions
• Describe the etiology and pathophysiology of pulmonary infectious diseases– Children– Adults
• Review the manifestations of such diseases. • Discuss the treatment of such diseases• Provide resources & how to find additional
information
Brief History & Evolution of Infectious Disease
• Over 100 years ago, there were little to no knowledge of infectious disease.
• The prevailing belief was that disease was caused by “bad air” or “night air”; known as the miasma theory .
• In 1676, Antonie van Leeuwenhoek discovered bacteria, but he did not know it caused disease
• However, in 1928, Alexander Fleming discovered penicillin.
• Virus-RNA/DNA, Protein Coat and a Lipid Envelope
• Bacteria-Cells which can independently multiply• Other microbes: Protozoa• Pathogenic-Ability to cause disease• Virulence-Ability to cause severe disease• Transmission-Route of spreading• Sterilization Vs. Disinfection
Diseases We’ll Focus on Today• Pediatric Respiratory Disease
– Croup– Epiglottitis– Bronchiolititis- respiratory syncytial virus
• Adult Diseases:– TB– Pneumonia Viral & Bacterial– PCP– SARS – Others: Pulmonic Plague
Croup--Etiology
• Viral Infection: – Parainfluenza– Influenza– RSV– Adenovirus
• Gradual onset
• Affects children 6 months to 3 years-old
Croup--Pathophysiology
• Swelling and inflammation of subglottic structures.– Larynx– Trachea– Larger Bronchi
• Can affect mid-sized and smaller airways
Croup--Clinical Manifestations
• Slow onset, like a “cold”• Brassy/barking cough• Horseness & Audible stridor• Neck X-Ray: Steeple Sign• If Severe:
– Tachycardia/tachypnea– Retractions– Decrease in SPO2– ABG: Hypoxemia & Respiratory Acidosis
Steeple Sign-Often Found in Croup
Croup--Treatment• Cool Mist w/oxygen via tent or face mask
• Reassurance--Parental presence
• Racemic Epinephrine via SVN or IPPB
– 6 Y.O. or less: 0.25 mls of 2.25% w/NSS
– More than 6 Y.O. 0.5mls w/NSS
• Systemic Steroids: Dextramethasone
– 0.3 to 0.6 mg/KG
• Intubation: Mainly if respiratory failure present: e.g., muscle fatigue, change in sensorium, cyanosis, ABG results.
Epiglottitis--Etiology
• Bacterial infection
• Most common microorganisms:– Staphylococcus Aureus– Group A & B Streptococci– Strep Pneumoniae
• Other causes:– thermal injury– caustic ingestion– radiation exposure
Epiglottitis--Pathophysiology
• Supra-glottic swelling
• Epigottis turns bright, cherry red & swollen
• Inflamation leads to a/w narrowing and dysphagia
• If severe, a/w can become completely obstructed
Epiglottitis--Clinical Manifestations
• Patient appears acutely ill• Rapid Onset• Affects mainly children 1 - 5 years old• Drooling, sore throat, dysphagia• Stridor & hoarseness w/diminished breath
sounds in lung regions• High fever• Lateral neck x-ray: Balloon-shaped
epiglottis/”thumb sign”
Lateral Neck X-Ray—Thumb Sign
Epiglottitis-Treatment
• Minimal patient stimulation-keep patient calm!• Cool mist aerosol w/supp’l O2• Antibiotics and fluids (steroids generally not effective)
• If severe obstruction, intubation shouldn’t be attempted in ER
• Intubate patient in OR as trach may be necessary and patient may need to be paralyzed
Epiglottitis Vs. Croup
• Epiglottitis– Bacterial– Rapid On-set– Profound illness– Hospitalization common
required.– Pt. may be drooling and
leaning forward with compromised speech
– May need emergent care and airway management.
• Croup– Viral– More gradual onset– Mild to moderate illness– Occasionally requires
hospitalization– Mainly supportive care
17
Bronchiolititis
Etiology—Caused by respiratory syncytial virus (RSV)Pathophysiology: Inflamed upper and lower airways, excessive
mucus.Clinical manifestations
– Usually follows a URI– Slight fever and cough worsen to dyspnea, tachypnea – Inspiratory and expiratory wheezing may develop– Radiograph shows hyperinflation and consolidation
Prophylaxis: Immunization recommended BPD infantsTreatment:
– Supportive: Hydration, nutrition, rest, monitoring– Humidified supplemental oxygen, HF nasal cannula– Bronchodilators and mucous clearance (CPT, mucolytics)– If severe: Intubation and mechanical ventilation with prolonged
expiration time.
Adult Infectious Pulmonary Diseases
TB
Pneumonia
Viral
Bacterial
PCP
SARS
Others:
Pulmonic Plague
Tuberculosis--Etiology
• Microorganism- Mycobacterium “family”
• Airborne transmission of droplet nuclei
• Droplet nuclei settle into the lungs and can start the infection
• Risk of infection is determined by many factors:– Length of exposure– Immune status
Tuberculosis-Pathophysiology
• Acid-fast bacilli are inhaled and begin to multiply• Bacilli may migrate to kidneys, brain and bones• 6-8 weeks after infection-immune system often
localizes and contains infection.
• TB Infection Vs TB Disease – TB Infection: Bacilli become inactive but
remain– TB Disease: Active bacilli are not stopped by
immune system and continue to multiply.
TB-Clinical Manifestations• Positive Mantoux Test (PPD)-5mm,10mm,15mm
• CXR-Lesion in apical or posterior upper lobe. Affinity for higher oxygen environment
• Positive sputum culture. • Laboratory data: Increased bands, elevated
alkaline phosphate• Signs/Symptoms--Productive Cough, chest
pain, hemoptisis, weakness, weight loss, fever/chills, night sweats.
TB Lesion in Right Apex
TB-Treatment
• Antibiotics: Cure most cases– 6-month: Isoniazid, Rifampin and initially,
pyrazinamide– 9-month: Isoniazid and Rifampin – Other ABX combinations for multiple drug
resistant (MDR) strains.
• Supportive– Proper rest and nutrition– Avoid high risk activities
HIV/TB--Treatment
• First Two-Months– Isoniazid-INH– Rifampin– Pyrazinomide– Ethambutal
• Next Five-Six Months– INH– Rifampin
Pneumonia--Etiology
• Community Acquired vs nosocomial
• Pathogens– Bacterial– Viral– Other--fungal, rickettesia
Pneumonia--Pathophysiology
• Route - Often Inhalation of microbes or aspiration of stomach contents or other substances
• Microbes– Bacteria– Viral– Other-Fungus-coccidiodes = “valley fever”
Pneumonia-Clinical Findings
• Acutely ill patient
• Hypoxemia & possible cyanosis
• CXR-Consolidation
• Unilateral Chest expansion
• Dull percussion note
• Decreased breath sounds &/or rhonchi
• Cough-Productive or non-productive
• Sputum- Green, yellow, brown, red
Types of Bacterial Pneumonia
• Gram positive - aerobic
• Gram negative - aerobic
• Anaerobic
• Mycobateria
Gram stain will showBacilli (rods) or Cocci (round)
Positive (blue) or Negative (red)
Gram Stain - E. coli
Lower LobeLower Lobepneumoniapneumonia
Pneumonia--Treatment
• Supportive– Oxygen therapy– Rest– Proper hydration & nutrition
• Isolate the microbe - Sputum C&S
• Antibiotics/antimicrobials
• CPT
• Bronchodilators
HIV/PCP--Etiology • HIV- Viral infection via bodily fluid exchange
• Helper T-Cells are invaded and destroyed– Helper T-Cells have the CD-4 antigen on the
surface.
• Immune system is compromised: Helper T-cell count of 800-1200/ml drops < 600/ml.
• Opportunistic Infections take hold– Pneumocystis Carinii PCP: Now renamed as
pneumocystis jirrevecii pneumonia and it is a protozoal-like microbe.
PCP--Pathophysiology
• PCP-An opportunistic Protozoal Infection
• Generally only affects immunosuppressed– HIV– Chemotherapy– Organ Transplantation/Immunosuppressant
Drugs
PCP--DX & Clinical Manifestations• High Index of Suspicion
– HX of:• IVDA or other “high risk” behavior• Immunosuppression due to other causes (Chemo, organ
transplantation)
• DX via Sputum staining– Silver staining– Obtained via BAL
• Review of Labs– Positive HIV antibodies (HIV positive)– Reduced CD 4 Count (w/AIDS)
PCP--DX & Clinical Manifestations (cont.)
• Fever/Chills• Malaise• Weight loss• Lymphadenopathy• Dyspnea/SOB• CXR
– Early-Ground Glass Appearance– Later-Diffuse infiltrates, lymph node enlargement
Initial Treatment• Oxygen for Hypoxemia• Bronchodilators for bronchoconstriction• Mucolytics, for mucous plugging• Supportive Therapy
– Nutrition, hydration, rest
• Monitoring– Vital signs– Pulse oximetry– I’s & O‘s
• Chart review for Relevant Orders and Advanced Directive and/or DNR
PCP--Treatment
• Prophylaxis– 1st choice--Daily administration of SMX-TMP
(Triamethoprim-Sulfomethoxazole)– 2nd choice--Pantamidine (if can’t tolerate
sulfa)
• Active Disease– 1st Choice--TMP-SMX– 2nd choice--Pantamidine– 90% recovery rate
Severe Acute Respiratory Syndrome (SARS)
• Occurrence: 2003 Outbreak, 8,000 cases Worldwide, Several Hundred in N. America.– 23 % of victims were healthcare workers.
• Etiology/Pathophysiology: Airborne transmission via respiratory droplets of Coronavirus (SARS-CoV).
• Clinical Manifestations: High Fever, body aches, dry cough progressing to pneumonia.
• Diagnosis: Sputum, nasal secretions analysis.• Treatment: Antiviral Meds and supportive therapy. •
Hantavirus• Natural Occurrence: 3-4,000 cases/Yr. in US.
• Etiology/Pathophysiology: Virus found in the urine and feces of rodents, mainly mice. Does not make the mouse sick. Humans get sick if they inhale dust containing mouse excrement. 2 – 5 day incubation period.
• Clinical Manifestations: Flu-like symptoms, rapid progression to Respiratory Failure. Approx. 50% mortality.
• Diagnosis: Blood tests for antigen or virus.
• Treatment: Ribavirin, Supportive care.
Pulmonic Plague (Yersinia Pestis)
• Natural Occurrence: 5 - 15 cases/Yr. in US.
• Etiology/Pathophysiology: Bacteria commonly spread by aerosol droplets. 1 – 6 day incubation period.
• Clinical Manifestations: High fever, chills, hemoptysis, shock, stridor, B/S crackles, ARF. High mortality (> 75%) with late diagnosis.
• Diagnosis: Gram stain, C&S, Immunoassay for capsulated antigen
• Treatment: Streptomycin 30 mg/kg/day IM. Oral Doxycycline or Ciprofloxin. No vaccine.
Smallpox (Variola Major)• Natural Occurrence: Last case in Somalia, 1977.
• Etiology: Viral infection with an incubation period of 7 – 17 days– Most contagious in “early rash” phase.
• Clinical Manifestations: Fever, back pain, vomiting, malaise, headache, rigors; papules to pustular vessicles face/ extremities.
• Diagnosis: Modified silver stain, PCR and viral isolation IHC
• Treatment: Immediate vaccination (if exposure < 5 days) and supportive care.
Inhaled Anthrax (Bacillus Anthraxis)• Etiology:
– Natural Occurrence: Few via Inhalation.– Mostly transmitted via livestock. No Known Human-to-
Human Transmission
• Clinical Manifestations: Fever, malaise, cough, mild chest discomfort; later dyspnea, diaphoresis, stridor, cyanosis, hypotension, hemorrhagic meningitis. 50% Mortality, with treatment.
• Diagnosis: Mediastinal widening w/o infiltrates on CXR, Serology, Gram stain, PCR
• Treatment: Supportive care, Doxycycline 200 mg IV
then 100 mg IV Q12 hr. Vaccine - high risk groups.
What RTs and other Healthcare Professionals Can and Should Do
• Protect Thy Self and Patient.– Proper use of Protective Equipment: Seal mask from bridge of
nose down…don’t pinch nose.– Get Vaccinated– Handwashing!!!
• Get Educated: Understand Prevention and Disease Identification.
• Educate homecare patients: Disease Recognition, Vaccination, Prevention, Infection Control and Contingency Planning.
• Be Aware: If It Seems Unusual, Maybe it Is!!!• Report suspicious cases per plan or protocol.• Consider joining the US Dept of Health & Human
Services Disaster Response Team (Visit: HHS website)
• Use proper Infection Control Techniques• Maintain and index of suspicion• If it does not look right, take special
precautions and communicate with other members of the health care team.
• Identify and utilize practical resources• Participate in all appropriate training • Exercise common sense and good judgment.• Don’t let your ego get in the way. • If you have questions…or need add’l info…
Ask!
• Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51.
• The Centers of Disease Control and Prevention -- http:www.cdc.gov
• Egan’s Fundamentals of Respiratory Care, ed 10 2012.• Clinical Assessment in Respiratory Care, ed. 5, 2010.• AARC: www.aarc.org/education/aarc • Pubmed• Medline