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Tracheobronchitis and pneumonia
Sevda Özdoğan MD, Prof.Chest Diseases
Tracheobronchitis
It is the inflammation of tracheobronchial tree
Rhynovirus, Influensa virus are the most common causes
Frequent in children and elderlyFrequently follows upper airway
infection
Clinical signs and symptoms
Cough Sputum Substernal cough related pain (Tracheitis) Fever not so frequent Crackles that change or diminish after
coughing can be detected on chest oscultation (A. Bronchitis)
Ronchus can be detected (A. Bronchitis) Physical examination can be normal Chest x-ray is normal
Pathophysiology
Viral infections damage airway epitelium
Mucous hypersecretionDecreased mucosiliary cleranceActivation of irritating cough
receptorsAirway hyperresponsiveness may
occur
Treatment
SymptomaticRestAntipireticsAntitussives or expectorantsAntibiotics if necessaryİnhaler steroids if bronchial
hyperresponsiveness occurs
Pneumonia
Definition: Acute infectious inflammation of the distal lung paranchyme (Distal to terminal bronchioles) with clinical and radiological signs of consolidation
Pneumonitis: Noninfectious inflammation
Classifications
Community Acquired
Nosocomial (Hospital acquired)
Pneumonia in immuncompromised host
Anatomic Lober Bronchopneumon
ia Interstitial
pneumonia
Etiologic Bacterial** Viral Fungal
The microorganism reaches the lungs by:Inhalation or aspirationHematogenious wayDirect invasion from the neighbouring
tissuesThe amount of the organism
inoculated, the virulance factors and the immunity of the host are important factors
Risk factors:
Smoking, alcohol Viral airway
infections Age COPD Corticosteroids Immunosuppressi
on and drugs
Diabetes mellitus Neurologic
diseases Hypoxemia Toxic gas
inhalations Air polution
Community acquired pneumonia
The symptoms of pneumonia are usually not specific but generaly include:Fever (chills)CoughSputum production (purulent)Thoracic painDyspnea
Most frequent
S. Pneumonia (50%)H. İnfluenzaeMoraxella catarrhalisMycoplasma pneumoniaChlamydia pneumoniaLegionella pneumophiliaVirus (10-20%)
Atypical pn
Typical pneumonia is characterised by abrubt onset high fever, chills, productive cough, thoracic pain, focal clinical signs, lobar or segmental radiographic findings, leukocytosisStrep. PneumoniaH. influenzae
Confusion, tachypnea, hypotermia can be the presenting symptom in old age groups
Atypical pneumonias are characterised by progressive onset, fever without chills, a cough without sputum, headache, myalgia, diffuse crackles, modest leukocytosis, interstitial infiltrates on chest radiographs.Mycoplasma pneumoniaLegionellaClamydia
Physical examination
High fever, tachicardia, tachypnea, (hypotension, confusion, drowsiness, altered mental status)
Respiratory system: Inspection:
Normal Respiratory disstress Ortopnea Cyanosis
Palpation İncreased Vibration thoracic (local) Decreased hemithoracal movement
PercutionNormal sonorityDullness (Matite)
OscultationEnd inspiratory fine cracklesLocal diminished breath soundsBronchial voice
Diagnosis
History and symptomsPhysical examinationPA Chest x-rayMicrobiologic examinationRoutine laboratory testsBlood gas
PA Chest x-ray
Consolidation Lobar or patchy
(Bronchopneumonia) nonhomogenious infiltrations
Air bronchogram Round opacity Fine reticular
density
Complications Pleural effusion Cavitation Abscess Pneumatocell Pneumothorax
Microbiologic examination(identification of the causative pathogen)
The causative pathogen can not be isolated in 30-50% of CAP
Sputum Gram Staining (more specific than culture but
less sensitive)
In microscopic examination sputum shoud show <10 epithelial cell , and >25 PNL Culture
Blood culture (Hospitalised patients) Pleural fluid analysis (If present)
Serology (Urine, sputum or blood: pneumococcal antigen, urine: Legionella antigen, 4 fold increase in specific antibody titers (cold agglutinins) between acute and covalescent period
İnvasive techniques (FOB, BAL, Protected-brush, TBB, PCFNA)
Routine Laboratory Tests
CBCESRCRPHepatic enzymesRenal functions
Laboratory in CAP Health Center Policlinic/
emergencyİnpatient
Chest x-ray ± + +
Hemogram ± + +
Biochemistry ± + +
Sputum Gram ± + +
Sputum culture - - +
Blood culture - - +
serology - - ±
Urinary legionella ag
- - ±
Thorasenthesis - - ±
O2 Saturation - + +
Approach to the patient
Is it an infection? Pulmonary edema Pulmonary embolism Interstitial fibrosis Atelectasis Malignancy
How severe is the illness? (Hospitalization?) Risk factors Severe condition
Risk Factors
Age>65 Comorbid illness Alcoholism Aspiration? Recurrent pneumonia <1year Mental problems Spleenectomy Malnutrition Social problems
Signs of Severe condition Respiratory rate >30/min BP <90/60 mmHg Fever>38,3 C Extrapulmonary disease (menegitis, artritis,
myocarditis etc) WBC <4000 or >30000 / mm3 Htc <30% or Hb<9 gr/dl ABG PaO2<60 mmHg
PCO2>50 mmHg BUN >20 mg/dl Multilober infiltration, cavity, effusion, rapid
progression Sepsis or multisystem disfunction
Intensive Care Indications
Major PaO2/FiO2 <200 Septic Shock
Minor PaO2/FiO2 <300 Confusion BP<90/60 mm Hg RR>30 Urine <20 ml/st,
ARF Bilateral,
multilober infiltration or progression >50% in 48 hrs
1 Major or 2 Minor criteria is needed
Bacterial pneumonia
Probable microorganism S. pneumoniae M. pneumoniae Chlamydia
pneumoniae H. influensa Virus Enteric gr (-)
eg:Pseudomonas, klebsiella
MRSA Other
Pneumococ PneumoniaTypical pneumoniaLeucocytosisLober infiltrationRast colored (pink) sputumLabial herpes lesionsPenicilline or macrolide (10-14 days)
Gr (-) pneumonia
Frequent in alcoholic, diabetic, nursing home residents old age group
E coli, Klebsiella pneumonia Necrose, cavitation is frequent, upper lobe enlargement
in klebsiella
Pseudomonas chronic lung disease, (Bronchiectasis, C. Fibrozis) nebulisator, ventilator use, recent antibiotic use (>7 days in the previous month) Steroid (>10 mg/day) Malnutrition
Pneumonia of anaerobic bacteria
Probability of aspiration (alcoholism, epileptic atack, gingivitis, esophageal obstruction
Fusobacterium, bacteroides, peptostreptococcus, actinomyces
Sputum with bad smell, fever, leucocytosis
Multipl necrotic area on chest x ray, lung abscess, emphyema
H. influenzae Smoking COPD
Legionella pneumophila Age >65 Malignancy COPD Steroid treat. Smoking Recent travel (hotel) Water supply system
reconstruction
C. psittachi Recent bird contact At risk occupation
Legionella pneumonia
Fatigue, myalgia in the first 24 hours Abrubt high fever Patchy infiltrations Bradicardia Confusion Hyponatremia Ekstrapulmonary signs Contaminated water system (Air condition)
Staphlococcic pneumonia (MRSA)
Follow a viral upper airway infection High complication and mortality Rapid progression to cavity, pneumatocell,
emphyema (Changes in 24 hours) SA is found in upper airway flora; skin
wounds; iv port Iv drug addicts! and nursing home
residents are the risk group
Prevention
Control of comorbiditiesGood NutritionGeneral hygeneQuit smoking and alcohol abuse Influensa vaccinePneumococ vaccine
A new pulmonary infiltrate and signs of pneumonia that occur after 48 hours of hospitalization or within 48 hours of discharge
VAP (ventilator associated pneumonia): A pneumona that occurs after 48 hours of entubation
The second most common nosocomial infection after urinary tract infection (mortality %25-70)
NOSOCOMIAL PNEUMONIA
Pathogenesis
Oropharyngeal or gastric aspiration (colonization)**
InhalationHematogenious Contamination (orofecal or from the
hands of the staff) Immunedisturbances of the patient
Risk Factors
MV (>48 hours)increases the risk by 6-20 times.
Invasive procedures (Catheters, intubation etc)
Duration of hospitalization, antibiotic use, the severity of the underlying disease. (chronic respiratory or immunosuppressive)
Increased gastric ph (antiacid drugs)
Diagnosis
A new infiltration on chest x-ray that (was apsent before) can not be explained by an another pathology
Fever >38,3 or <36 C, Leucocytosis or PNL>25 in sputumPurulent secretions
Probable microorganisms
Group 1 (Early onset ≤ 4 days) S. Pneumonia H. İnfluenzae M. Catarrhalis S. Aureus
(meticilline sensitive)
High risk, probable multipl resistant bacterial infection P aeruginosa Acinetobacter spp MRSA (S aureus) K pneumonia Group 2
Group 2 (Late onset ≥ 4 days) Enterobacter spp K. pneumonia S. marcescens E coli Other gr (-) Group 1
High risk, probable multipl resistant bacterial infection
Antibiotic use in the previous 3 months (90 days) ≥5 days of hospitalization High antibiotic resistance in the hospital or public Immunsuppressive treatment MV >7 days İntensive care >48 hours Emergency intubation Severe sepsis/septic shock PaO2/FiO2 <250mmHg Bilateral, multilober infiltration, cavitation,
complication,rapid progression
Certain risk-pathogen relations
S aureus Coma Head trauma D. Mellitus Renal failure Past influensa
Legionella Corticosteroid use Kemotherapy Past antibiotic
P aeruginosa Prolonged MV Past antibiotics Tracheostomy CS use Paranchymal lung
disease
Anaerobic pathogens Gastric aspiration Recent thoracic or
abdominal operation
Approach to the patient: Microbiologic Culture
Noninvasive Blood cultures
(obligatory but low sensitivity)
Qualitative culturing of sputum or endotracheal aspirates (high sensitivity but low specificity)
Invasive FOB (lower airway
sampling) Pro-brush BAL TBNA
(Quantitative culturing)
Treatment
Empirically based parentheral antibiotics, can be changed according to the microbiologic culture results
Specific risk factors should be considered
Prevention Staff education (hand washing, gloves) Noninvasive approach when possible Sucralphate for gastric prophylaxis Enteral feeding as much as possible Avoid narcotics Early mobilization Early discharge from IC or hospital
Viral Pneumonia Rare in people with normal immunity
Influensa A >50% B Parainfluensa RSV Herpes Mixed bacteriel infection
İmmunocompromised person CMV Herpes Parainfluensae RSV Varicella 50% bacteria, fungus, protozoa (PCP) superinfection
occurs
Fungal Pneumonia
Endemic Histoplasmosis Blastomycosis Coccidiomycosis Paracoccidiomycosi
s Criptococcosis Sporotricosis
Opportunistic Aspergillosis Candidiasis Mucormycosis
Aspergillosis
Aspergillus fumigatusABPA
AsthmaEosinophylia (>1000 mm3)Central bronchiectasisHigh serum IgEAspergillus specific IgE and IgG (+)
AspergillomaChronic necrotising aspergillosisInvasive aspergillosis
Aspergilloma: Fungus ball in chronic cavity Cause massive hemopthysis
Invasive aspergillosis Seen in immunsuppressive patients
(neutropenia) Inhaled spores cause pneumonia with fever
and cough X ray may be normal in the beginning, focal
infiltrations can be seen later Pleuritic chest pain is common
Pneumonia in immuncompromised host
NeutropeniaNonneutropenia
Organ transplantationCorticosteroid
AIDS
The classic symptoms and signs are commonly absent
Infectious and noninfectious pathologies can be concomitant
Mixed infection with multipl pathogens can be the cause
The general condition of the patient may not allow the invasive diagnostic procedures (BAL, proBAL, TTFNAB)
Opportunistic infections are common with high mortality (45%)
Differential diagnosis of noninfectious pathologies is important
Infectious S. Aureus Gr (-) bacteria Legionella Nocardia CMV Herpes Adenovirus Varicella Aspergillus Criptococcus Candida Tbc PCP Toxoplasmosis
Noninfectious DAH Pulmonary edema Drug reactions Radiation pn Leukostasis Leukemic infiltration Lenfangitis carcin. Lymphoma, lung ca BO BOOP
ARDS Pulmonary embolism
The type of infective agent differs according to the type of immune defect
Physical examination can be nonspecific
Radiologic changes can be late
Common Infectious agents according to the type of immunosuppressionNeutropenia Enteric Gr(-) bct
P. aeruginosa
S aureus
Streptococcus
Enterococcus
Aspergillus
Candida spp.
Humoral immune defect
S pneumonia
H influenzae
Cellular immune defect
Mycobacterium (tb and atipical)
Fungus
Virus (CMV, VZV, HSV, RSV)
P carinii
T gondii
S stercoralis
NONNEUTROPENIC PATIENTS
Solid organ transplantCMVH. influensa, s. pneumoniaLater: Nocardia, tbc and atipical
mycobacteriaBone marrow transplantation
(Stem cell)CMV, PCP (less common due to
allogenic trans and prophylaxis)Later pneumococ pneumonia
AIDS
CD4>500 bacterial pneumoniaCD4 200-499 recurrent bacterial
pneumonia, tuberculosisCD4<200 PCP, disseminated tbCD4<100 CMV, MAC, toxoplasma,
disseminated fungus
PROPHYLAXIS IN IMMUNOCOMPROMISED PATIENTS
Live vaccines are contraindicated Influensa and pneumococ vaccines
should be givenChemoprophylaxis (PCP, CMV)Donor seropositivity in
transplantation
Certain Definitions
Recurrent pneumonia:A second pneumonia that occurs
after the complete healing of a first attack (>1 month). At least 2 times a year.
Late resolution:A pneumonia that resolves <50% in 2
weeks or incomplete regression in 4 weeks
Risk factors for late resolution:
Age COPD Alcoholism Smoking D mellitus Malignancy Renal or cardiac
failure CS use
S pneumonia Legionella Viral H influensae
Complications of pneumonia
Pleural effusion (parapneumonic) Emphyema Bronchopleural fistule Mediastinitis, pericarditis, chest wall infection Necrosis, cavitation Pneumatocel Pneumothorax ARDS Fibrosis Bronchiectasis Late resolution or recurrens
THE END