LUNG DISEASES:

• The respiratory system can be subdivided into :

• an upper respiratory tract (or conducting zone)

and

• lower respiratory tract (respiratory zone), trachea and lungs

Disorders of the respiratory system

• can be classified into four general areas:• Obstructive conditions (e.g., emphysema,

bronchitis, asthma attacks) • Restrictive conditions (e.g., fibrosis, sarcoidosis,

alveolar damage, pleural effusion) • Vascular diseases (e.g., pulmonary edema,

pulmonary embolism, pulmonary hypertension) • Infectious, environmental and other "diseases"

(e.g., pneumonia, tuberculosis, asbestosis, particulate pollutants)

1. UPPER RESPIRATORY TRACT DISEASES:

• Common cold · • Rhinitis ·• Sinusitis · • Pharyngitis (Strep throat)  · • Tonsillitis ·• Laryngitis · • Tracheitis · • Croup · • Epiglottitis • Influenza and Pneumonia

ENT CASES

1.PNEUMONIA

Pneumonia fills the lung's alveoli with fluid, keeping oxygen from reaching the bloodstream. The alveolus on the left is normal, while the alveolus on the right is full of fluid from pneumonia.

Signs and symptoms• People with infectious pneumonia often have a

cough producing greenish or yellow sputum (phlegm) and a high fever accompanied by shaking chills. Shortness of breath, pleuritic chest pain (sharp or stabbing pain) during deep breaths or coughs or worsened by it.

• May cough up blood, headaches, or develop sweaty and clammy skin, loss of appetite, fatigue, blueness of the skin, nausea, vomiting, mood swings, and joint pains or muscle aches

• Pneumonia cause by Legionella cause abdominal pain and diarrhea.

• Pneumonia caused by tuberculosis or Pneumocystis may cause weight loss and night sweats.

• Elderly people may develop confusion or experience unsteadiness, leading to falls.

• Infants are simply sleepy or have a decreased appetite.

• Physical examination by a health care provider may reveal fever or low body temperature, increased respiratory rate, low blood pressure, high heart rate, or low oxygen saturation as indicated by pulse oximetry or blood gas analysis.

• People struggling to breathe, confused, or cyanosis (blue-tinged skin) require immediate attention.

• Physical examination: decreased expansion of the chest on the affected side, bronchial breathing on auscultation with a stethoscope (harsher sounds from the larger airways transmitted through the inflamed and consolidated lung), and rales over the affected area. Percussion: dullness over the affected lung, but increased vocal resonance (which distinguishes it from a pleural effusion).

• these signs are relevant but insufficient to rule out pneumonia.

Diagnosis

• If pneumonia is suspected from symptoms and physical examination, further investigations are - chest X-ray, blood tests,sputum cultures, chest CT scan or other tests to distinguish pneumonia from other illnesses

• Chest x-rays can reveal areas of opacity (white) which represent consolidation. Pneumonia not seen on x-rays, in its initial stages, or involves a part of the lung not easily seen by x-ray.

• Chest CT (computed tomography) can reveal pneumonia that is not seen on chest x-ray.

• X-rays can be misleading. Lung scarring and congestive heart failure, can mimic pneumonia on x-ray.

• Chest x-rays also evaluate complications of pneumonia.

A: Normal chest x-ray. B: Abnormal chest x-ray with shadowing from pneumonia in the right lung (white area, left side of image).

• If antibiotics fail to improve the patient's health, a culture of the sputum are used to confirm sensitivity. A blood culture to look for bacteria.

• A complete blood count show a high white blood cell count, indicating infection or inflammation.

• In people with immune system problems, the white blood cell count may appear deceptively normal.

• Low blood sodium is due to extra anti-diuretic hormone produced in diseased lungs (SIADH).

• Serology tests for other bacteria (Mycoplasma, Legionella and Chlamydophila) and urine test are done for Legionella antigen.

• Respiratory secretions tested for viruses ( influenza, respiratory syncytial virus, adenovirus).

• Liver function tests to test for damage caused by sepsis.

• Combining findings

• Temperature > 37.8 degrees C

• Pulse > 100 beats/min

• Crackles

• Decreased breath sounds

• Absence of asthma

Classification

• Pneumonias can be classified according to the anatomic changes that were found in the lungs during autopsies. Another important system of classification is the combined clinical classification, which combines factors such as age, risk factors for certain microorganisms, the presence of underlying lung disease and underlying systemic disease.

• A lobar pneumonia only involves a single lobe, or section, of a lung due to Streptococcus pneumoniae. Multilobar pneumonia involves more than one lobe.

• Interstitial pneumonia involves the areas in between the alveoli ("interstitial pneumonitis“) caused by viruses or by atypical bacteria.

• Radiological classification. distinguished between typical lobar pneumonia and atypical (e.g. Chlamydophila) or viral pneumonia using the location, distribution, and appearance of the opacities on chest x-rays.

Community-acquired pneumonia

• CAP is infectious pneumonia in a person not recently been hospitalized.. The causes depending on a person's age, but they include Streptococcus pneumoniae, viruses, the atypical bacteria, and Haemophilus influenzae.

• Streptococcus pneumoniae is the most common cause. Gram-negative bacteria cause CAP in certain at-risk populations.

• Hospital-acquired pneumonia (nosocomial pneumonia):

• acquired during or after hospitalization for another illness with onset at least 72 hrs after admission.

• Hospitalized patients have many risk factors including mechanical ventilation, prolonged malnutrition, underlying heart and lung diseases, decreased amounts of stomach acid, and immune disturbances.

• Hospital-acquired microorganisms may include resistant bacteria such as MRSA, Pseudomonas, Enterobacter, and Serratia.

• Ventilator-associated pneumonia (VAP) is a subset of hospital-acquired pneumonia. VAP is pneumonia which occurs after at least 48 hours of intubation and mechanical ventilation.

• Other types of pneumonia• Severe acute respiratory syndrome (SARS)

– highly contagious and deadly caused by the SARS coronavirus.• Bronchiolitis obliterans organizing pneumonia (BOOP)

– caused by inflammation of the small airways of the lungs( cryptogenic organizing pneumonitis -COP).

• Eosinophilic pneumonia – invasion of the lung by eosinophils in response to parasite infection or after

exposure to environmental factors. • Chemical pneumonia

– caused by chemical toxins (pesticides), inhalation or by skin contact. When the toxic substance is an oil, the pneumonia is lipoid pneumonia.

• Aspiration pneumonia – caused by aspirating foreign objects - oral or gastric contentsresulting in

bronchopneumonia. The lung is inflammed since the material aspirated contain anaerobic bacteria. Aspiration - leading cause of death among hospital and nursing home patientsbecause cannot adequately protect their airways and may have impaired defenses.

• Dust pneumonia – caused by excessive exposure to dust storms. Dust settles into the alveoli,

stopping the cilia from moving and clearing the lungs.

Treatment

• oral antibiotics, rest, fluids, and home care are sufficient for complete resolution.

• people with trouble breathing, other medical problems, and the elderly need more advanced treatment.

• If symptoms get worse, the pneumonia not improve,or complications occur, the person have to be hospitalized.

• Antibiotics used depends on the nature of the pneumonia, the microorganisms in the local geographic area, immune status and underlying health of the individual.

• Treatment based on the causative microorganism and known antibiotic sensitivity.

• Empiric treatment is usually started well before laboratory reports are available. (amoxicillin, clarithromycin or erythromycin). are selected for community-acquired pneumonia. Patients allergic to penicillins are given erythromycin instead of amoxicillin. When "atypical" community-acquired pneumonia are common, azithromycin, clarithromycin, and the fluoroquinolones have displaced amoxicillin as first-line treatment. 7-10 days are sufficient.

• Antibiotics for hospital-acquired pneumonia include vancomycin, cephalosporins, carbapenems, fluoroquinolones, and aminoglycosides given intravenously. Multiple antibiotics may be administered in combination.

• People who have difficulty breathing require extra oxygen. Extremely sick individuals may require intensive care treatment, including intubation and artificial ventilation.

• Viral pneumonia caused by influenza A treated with rimantadine or amantadine, while viral pneumonia caused by influenza A or B may be treated with oseltamivir or zanamivir.

• These treatments are beneficial only if they are started within 48 hours of the onset of symptoms.

• Many strains of H5N1 influenza A ( avian influenza or "bird flu“) resistant to rimantadine and amantadine.

• There are no known effective treatments for viral pneumonias caused by SARS coronavirus, adenovirus, hantavirus, or parainfluenza virus.

Complications• Frequently associated with bacterial pneumonia. • Respiratory and circulatory failure

Need non-invasive breathing assistance with a bi-level positive airway pressure machine. Endotracheal tube and a ventilator may be used . Respiratory failure triggering acute respiratory distress syndrome (ARDS) from infection and inflammatory response. The lungs quickly fill with fluid and become stiff, combined with severe difficulties extracting oxygen due to the alveolar fluid, needs mechanical ventilation.

• Sepsis and septic shock - microorganisms enter bloodstream and immune system responds by secreting cytokines. Need hospitalization in intensive care unit. They require intravenous fluids and medications to keep blood pressure from dropping too low. Sepsis can cause liver, kidney, and heart damage, and death.

• Pleural effusion.

• Pleural effusion, empyema, and abscess• fluid build up in the pleural cavity. • If the microorganisms present in the pleural

cavity, fluid collection is empyema. Pleural fluid can be collected with a needle (thoracentesis) and examined. Complete drainage of the fluid necessary, requiring a chest tube.

• In severe empyema, surgery needed. • Rarely, bacteria form a pocket of infected fluid (

abscess) seen with a chest x-ray or chest CT scan. Abscesses occur in aspiration pneumonia contain several types of bacteria. Antibiotics can treat, but sometimes must be drained out.

• Prognosis and mortality• With treatment, most bacterial pneumonia can

be cleared within two to four weeks Viral pneumonia may last longer, and mycoplasmal pneumonia may take four to six weeks to resolve completely.

• The death rate (mortality) depends on the underlying cause of the pneumonia. Mycoplasma is associated with little mortality. However, about half of the people who develop methicillin-resistant Staphylococcus aureus (MRSA) pneumonia while on a ventilator will die. Limited access to clinics and hospitals, limited access to x-rays, limited antibiotic choices, and inability to treat underlying conditions inevitably leads to higher rates of death from pneumonia.

• Prevention• Appropriately treating underlying illnesses decrease risk of

pneumonia.• Smoking cessation limit lung damage since cigarette smoke

interferes with the body's natural defenses against pneumonia.• Testing pregnant women for Group B Streptococcus and Chlamydia

trachomatis, and giving antibiotic treatment reduces pneumonia in infants. Suctioning the mouth and throat of infants with meconium-stained amniotic fluid decreases the rate of aspiration pneumonia.

• Vaccination against Haemophilus influenzae and Streptococcus pneumoniae in the first year of life reduced pneumonia in children. Vaccinating children against Streptococcus pneumoniae. It is currently recommended for all healthy individuals older than 65 and adults with emphysema, congestive heart failure, diabetes mellitus, liver cirrhosis, alcoholism, cerebrospinal fluid leaks, or those who do not have a spleen. A repeat vaccination may also be required after five or ten years.

• Influenza vaccines should be given yearly to individuals who receive vaccination against Streptococcus pneumoniae, health care workers, nursing home residents, and pregnant women.

• In influenza outbreak, amantadine, rimantadine, zanamivir, and oseltamivir can help prevent influenza.

• Pleural effusion. Chest x-ray showing a pleural effusion. The A arrow indicates "fluid layering" in the right chest. The B arrow indicates the width of the right lung. The volume of useful lung is reduced because of the collection of fluid around the lung.

Adenocarcinoma of the lung. This form of non-small cell lung cancer (NSCLC) is now the most common

type. It typically starts in the peripheral region of the lung.

smoker's lung with cystic spaces (emphysema) due to destruction of airsac walls.

lung severely affected by tuberculosis (caused by the bacterium Mycobacterium tuberculosis), resulting in cavity formation, fibrosis and "caseation" (cheesy white areas of necrosis) in the upper lobe.