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Tracheobronchitis and pneumonia

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 elderly Frequently follows upper airway infection.

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Tracheobronchitis and pneumonia

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  1. Tracheobronchitis and pneumonia Sevda Özdoğan MD, Prof. Chest Diseases

  2. Tracheobronchitis • It is the inflammation of tracheobronchial tree • Rhynovirus, Influensa virus are the most common causes • Frequent in children and elderly • Frequently follows upper airway infection

  3. 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

  4. Pathophysiology • Viral infections damage airway epitelium • Mucous hypersecretion • Decreased mucosiliary clerance • Activation of irritating cough receptors • Airway hyperresponsiveness may occur

  5. Treatment • Symptomatic • Rest • Antipiretics • Antitussives or expectorants • Antibiotics if necessary • İnhaler steroids if bronchial hyperresponsiveness occurs

  6. Pneumonia • Definition: Acute infectious inflammation of the distal lung paranchyme (Distal to terminal bronchioles) with clinical and radiological signs of consolidation • Pneumonitis: Noninfectious inflammation

  7. Community Acquired Nosocomial (Hospital acquired) Pneumonia in immuncompromised host Anatomic Lober Bronchopneumonia Interstitial pneumonia Etiologic Bacterial** Viral Fungal Classifications

  8. The microorganism reaches the lungs by: • Inhalation or aspiration • Hematogenious way • Direct invasion from the neighbouring tissues • The amount of the organism inoculated, the virulance factors and the immunity of the host are important factors

  9. Smoking, alcohol Viral airway infections Age COPD Corticosteroids Immunosuppression and drugs Diabetes mellitus Neurologic diseases Hypoxemia Toxic gas inhalations Air polution Risk factors:

  10. Community acquired pneumonia • The symptoms of pneumonia are usually not specific but generaly include: • Fever (chills) • Cough • Sputum production (purulent) • Thoracic pain • Dyspnea

  11. Most frequent • S. Pneumonia (50%) • H. İnfluenzae • Moraxella catarrhalis • Mycoplasma pneumonia • Chlamydia pneumonia • Legionella pneumophilia • Virus (10-20%) Atypical pn

  12. Typical pneumonia is characterised by abrubt onset high fever, chills, productive cough, thoracic pain, focal clinical signs, lobar or segmental radiographic findings, leukocytosis • Strep. Pneumonia • H. influenzae

  13. Confusion, tachypnea, hypotermia can be the presenting symptom in old age groups

  14. 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 pneumonia • Legionella • Clamydia

  15. 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

  16. Percution • Normal sonority • Dullness (Matite) • Oscultation • End inspiratory fine crackles • Local diminished breath sounds • Bronchial voice

  17. Diagnosis • History and symptoms • Physical examination • PA Chest x-ray • Microbiologic examination • Routine laboratory tests • Blood gas

  18. Consolidation Lobar or patchy (Bronchopneumonia) nonhomogenious infiltrations Air bronchogram Round opacity Fine reticular density Complications Pleural effusion Cavitation Abscess Pneumatocell Pneumothorax PA Chest x-ray

  19. 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)

  20. 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)

  21. Routine Laboratory Tests • CBC • ESR • CRP • Hepatic enzymes • Renal functions

  22. Laboratory in CAP

  23. 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

  24. Risk Factors • Age>65 • Comorbid illness • Alcoholism • Aspiration? • Recurrent pneumonia <1year • Mental problems • Spleenectomy • Malnutrition • Social problems

  25. 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

  26. 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 Intensive Care Indications 1 Major or 2 Minor criteria is needed

  27. Probable microorganism S. pneumoniae M. pneumoniae Chlamydia pneumoniae H. influensa Virus Enteric gr (-) eg:Pseudomonas, klebsiella MRSA Other Bacterial pneumonia

  28. Pneumococ Pneumonia • Typical pneumonia • Leucocytosis • Lober infiltration • Rast colored (pink) sputum • Labial herpes lesions • Penicilline or macrolide (10-14 days)

  29. 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

  30. 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

  31. 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

  32. Legionella pneumonia • Fatigue, myalgia in the first 24 hours • Abrubt high fever • Patchy infiltrations • Bradicardia • Confusion • Hyponatremia • Ekstrapulmonary signs • Contaminated water system (Air condition)

  33. 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

  34. Prevention • Control of comorbidities • Good Nutrition • General hygene • Quit smoking and alcohol abuse • Influensa vaccine • Pneumococ vaccine

  35. Break

  36. NOSOCOMIAL PNEUMONIA • 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)

  37. Pathogenesis • Oropharyngeal or gastric aspiration (colonization)** • Inhalation • Hematogenious • Contamination (orofecal or from the hands of the staff) • Immunedisturbances of the patient

  38. 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)

  39. 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 sputum • Purulent secretions

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