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4/12/12

A SEMINAR ON LOWER RESPIRATORY

TRACT INFECTIONS

Submitted to:

B.P. Satish KumarAssistant.Professor

Submitted by:P.DeepakPharm D (P.B) 1st Yr

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Anatomy obronchi

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ACUTE BRONCHITIS

DEFINITION: Acute bronchitis is a condition that occurswhen the bronchial tubes in the lungs become inflamed.

The bronchial tubes swell and produce mucus, which causesa person to cough.

Most symptoms of acute bronchitis (chest pain, shortness ofbreath, etc.) last for up to 2 weeks, but the cough can lastfor up to 8 weeks in some people.

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Aetiology of acute bronchitis

Common respiratory tract viruses(80%)

Bacteria (in about 20% of cases): Pneumococci ( in 2 - 30%)?

Haemophilus ( in 2 - 8%)?

Mycoplasma (in 0.5 - 11%)

Chlamydia (in 0 -18%)

(Pertussis (in 0 - 7%))

20.6.20005

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Epidemiology:

Cough is the most frequent reason.

In the UK, acute bronchitis affects 44 out ofevery 1000 adults over the age of 16 years,

with most episodes (82%) occurring inautumn or winter.

While in the US it has been estimated thatalmost 5% of the general population develops

acute bronchitis each year

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PATHOGENESIS

Acute bronchitis is a self limiting illness.

Infection of trachea and bronchi produce hyperemic andedematous mucous membranes with an increase in bronchialsecretions which can become thick and tenacious impairingmucociliary activity.

Recurrent respiratory infections may be associated with increaseairway hyperreactivity and leads to pathogenesis of asthma andCOPD.

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CLINICAL PRESENTATION

Signs and Symptoms :

Cough persisting > 5 days to weeks

Coryza,sore throat,malaise,headache

Fever rarely > 39c

Physical examination :

Rhonchi or coarse

Purulent sputum in 50% of patients

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PHARMACOLOGICAL THERAPY

Mild analgesic or antipyretics therapy ishelpful in removal of malaise,lethargy andfever.

Aspirin 650 mg in adults or 10-15 mg/kgin children

Ibuprofen 200-800 mg in adults or 10 mg/kg

in children. Common antibiotics used in these cases are:

Erythromycin, ampicillin/clavulanic acid (

Augmentin), azithromycin (Zithromax) or

http://www.medtogo.com/antibiotics.htmlhttp://www.medtogo.com/erythromycin.htmlhttp://www.medtogo.com/ampicillin.htmlhttp://www.medtogo.com/augmentin.htmlhttp://www.medtogo.com/zithromax.htmlhttp://www.medtogo.com/biaxin.htmlhttp://www.medtogo.com/zithromax.htmlhttp://www.medtogo.com/augmentin.htmlhttp://www.medtogo.com/ampicillin.htmlhttp://www.medtogo.com/erythromycin.htmlhttp://www.medtogo.com/antibiotics.html

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Chronic Bronchitis

Definition: Chronic bronchitis is defined as chronic cough and

expectoration.Excessive tracheo bronchial mucus production sufficient to

cause cough with expectoration for most days of at least 3months of the year for 2 consecutive years.

Etiology:The most important etiologic factor in the development of chronic

bronchitis is cigarette smoking.

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CHRONIC BRONCHITIS

PATHOPHYSIOLOGY : Chronic inflammation

Hypertrophy &hyperplasia of bronchialglands that secrete mucus

Increase number of gobletcells

Bronchospasm End result

Hypoxemia

Polycythemia (increase

RBCs)

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Chronic Bronchitis:

Clinical Manifestations In early stages

Productive cough

Bronchospasm Frequent respiratory infections

Advanced stages

Dyspnea on exertion Dyspnea at rest

Hypoxemia & hypercapnea

Polycythemia

Cyanosis

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Goals of Treatment:

Improved ventilation

Remove secretionsPrevent complications

Slow progression of signs & symptoms

Promote patient comfort and participation intreatment

Treatment includes omission of the causativea ent antiobiotic thera and

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Acute exacerbation of chronicbronchitis

Management in primary care

Antibiotic. e.g. doxycycline or amoxicillin

Bronchodilator inhalers Short course of steroids in some cases

Refer to hospital if

Evidence of respiratory failure

Not coping at home

A.J.France 2010

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TREATMENT

Oral

antibiotics

commonlyused-16

drugs dose dose

schedule(dose/daily)

ampicillin 0.25-0.5 4

amoxicillin .5 3

ciprofloxacin .5-75 2

Tetracycline HCL .5 4drugs dose dose

schedule(dose/daily

azithromycin .25 1

er throm cin .5 4

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Its an acute viral infection of lower respiratory tract infection affectingnearly 50% of children during 1st year of life and 100% by age of 3 years.

Respiratory syncytial virus is the most common cause of bronchiolitisaccounting for 70 % of cases.

BRONCHIOLITIS

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INFLUENZA

Influenza is an acute, viral respiratoryinfection.

Fever, chills, headache, aches andpains throughout the body, sorethroat which may lead to bronchitisor pneumonia.

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SYMPTOMS

FEVER

HEADACHE

MYALGIACOUGH

RHINITIS

19

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NON-PULMONARY COMPLICATIONS

myositis (rare, > in children, > with type B)

cardiac complications

liver and CNS Reye syndrome

peripheral nervous system

Guillian-Barr syndrome

20

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Signs and symptoms

Chills

Body aches, especially throat andjoints

Coughing and sneezing

Extreme fever

Fatigue, headache, and nasal

congestion

h h f

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Pharmacotherapy ofinfluenza

Although four antiviral agents are commercially available, fortreatment of influenza disease in infants and children oseltamivir (Tamiflu), zanamivir (Relenza), amantidine andrimantidine.

Oseltamivir is given for the treatment and prophylaxis ofinfluenza for those aged 1 year and older.

Zanamivir is labeled for use in ages 7 years for treatment and forages 5 years for prophylaxis.

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PNEUMONIA

DEFINITION : An inflammation of the lung caused by bacteria,viruses, or mycoplasms.

Radiographs reveal patchy alveolar infiltrates, or pulmonarydensities

The alveolar air spaces are filled with fluid or cells

If the infection is bacterial, treatment includes antiobiotics

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Clinical features

headache

malaise

diarrhea

confusion

decreased appetite

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Signs and Symptoms

Fever or hypothermia

Cough with or without sputum, hemoptysis

Pleuritic chest pain

Myalgia, malaise, fatigue

GI symptoms

Dyspnea

Rales, rhonchi, wheezing Bronchial breath sounds

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Risk Factors for pneumonia

age

alcoholism

smoking

asthma

Immuno suppression

COPD

dementia

osp a acqu re

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osp a -acqu repneumonia

Hospital-acquired pneumonia, also called nosocomialpneumonia, is a lung infection acquired after hospitalization for

another illness or procedure.Hospitalized patients have a variety ofrisk factorsfor

pneumonia, including mechanical ventilation, prolongedmalnutrition, underlying cardiac and pulmonary diseases,

achlorhydria. These pathogens include resistant aerobic gram-negative rods,

such as Pseudomonas, EnterobacterandSerratia, resistant g

Antibiotics used for hospital-acquired pneumonia include

aminoglycosides, fluoroquinolones, carbapenems, and

http://people.theiapolis.com/http://people.theiapolis.com/http://people.theiapolis.com/

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Pathogenesis

Inhalation, aspiration and hematogenous spread are the 3 mainmechanisms by which bacteria reaches the lungs

Primary inhalation:

When organisms bypass normal respiratory defensemechanisms or when the Pt inhales aerobic GN organisms thatcolonize the upper respiratory tract or respiratory supportequipment.

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Aspiration Pneumonia

This type of pneumonia can occur if you inhale food, drink,vomit, or saliva from your mouth into your lungs.

This may happen if something disturbs your normal gag reflex,such as a brain injury, swallowing problem, or excessive use ofalcohol or drugs.

Aspiration pneumonia can cause pus to form in a cavity in thelung. When this happens, it's called a lung abscess (AB-ses)

Atypical Pneumonia Several types of bacteriaLegionella

pneumophila ,mycoplasma pneumonia, and Chlamydophilapneumoniaecause atypical pneumonia, a type of CAP.

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TYPES OF ATYPICAL PNEUMONIA

Legionella pneumophila

Mycoplasma pneumonia :

This is a common type of pneumonia that usually affectspeople younger than 40 years old.

It may be associated with a skin rash and hemolysis (thebreakdown of red blood cells).

Chlamydophila pneumoniae : This type of pneumonia canoccur all year and often is mild. The infection is most

common in people 65 to 79 years old.

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Alobar pneumonia is an infection that involves, and is limitedto, a single lobe of a lung (generally due to Streptococcus

pneumoniae).

In contrast, multilobar pneumonia involves more than one lobe.

Ventilator-associated pneumonia can be considered a subset ofhospital-acquired pneumonia; and in hospitalized or recentlydischarged patients .

Pneumococcal pneumonia is due to S. pneumoniae (aroundhalf of all pneumonias). Finally, atypical pneumonia is due toeither Mycoplasma,Chlamydia,orLegionella.

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Lobar Pneumonia

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Pathophysiologic process

and manifestations.

Organisms may enter the respiratory tract through inspirationor aspiration of oral secretions;staphylococcus and Gram-negative bacilli may reach the lungs through circulation inthe bloodstream.

Normal pulmonary defense mechanisms (cough reflex,mucocilliary transport, and pulmonary macrophages) usuallyprotect against infection.

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Pathogenesis

The invading organism multiplies and releasesdamaging toxins, causing inflammation andedema of the lung parenchyma;

This results in accumulation of cellular debrisand exudates.

Lung tissue fills with exudates and fluid,

In viral pneumonia, the ciliated epithelial cells

become damaged.

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Streptococcus pneumonia

Most common cause of CAP

Gram positive diplococci

Typical symptoms (e.g. malaise, shaking chills, fever, rusty

sputum, pleuritic hest pain, cough) Suppressed host

25% bacteremic

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Viral Pneumonia

More common cause in children

RSV, influenza, para influenza

Influenza most important viral cause in adults,especially during winter months

Post-influenza pneumonia (secondary bacterialinfection)

S. pneumo, Staph aureus

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Treatment

Outpatient: doxycycline, newer macrolide orfluoroquinolone

Hospitalized:

Evidence indicates that early administration (within8 hrs of presentation) leads to lower mortality rateand hospital stay, therapy should be initiated with2-3rd generation cephalosporin or beta-lactamaseinhibitor, with a macrolide.

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AMOXICILLIN

Capsules: 250 mg (as trihydrate), 500 mg (as trihydrate)

Class: Antibiotic/Penicillin

Action Inhibits bacterial cell wall mucopeptide synthesis. Clavulanic acidinactivates a wide range of beta-lactam enzymes found in bacteria resistantto penicillins and cephalosporins.

Lower Respiratory Tract Infections

ADULTS AND CHILDREN WEIGHING AT LEAST 40 KG: PO 875 mgq 12 hr or 500 mg q 8 hr. CHILDREN (OLDER THAN 3 MO ANDWEIGHING LESS THAN 40 KG): PO 45 mg/kg/day in divided doses q 12hr or 40 mg/kg/day in divided doses q 8 hr.

Adverse Reactions:

CNS: Dizziness; fatigue; insomnia; GI: Gastritis; anorexia; nausea;vomiting;HEPA: Transient hepatitis; cholestatic jaundice;GU: Interstitialnephritis

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Diphenhydramine

Trade name: Benadryl

One of the oldest anti-histamines

Action: Antagonizes the effects of histamine

at the H1 receptor sites.

Adverse Effects: Significant CNS depressant:drowsiness, dizziness, hypotension, dry

mouth. Onset: immediate to 60 minutes

Peak: 1-4 hours

Duration: 4-8 hours

TRIMETHOPRIM

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TRIMETHOPRIM-SULFAMETHOXAZOLE(COTRIMOXAZOLE)

Action: Sulfamethoxazole (SMZ) inhibits bacterial synthesis of dihydrofolic

acid by competing with PABA.

Trimethoprim (TMP) blocks production of tetrahydrofolic acid by inhibitingthe enzyme dihydrofolate reductase.

This combination blocks two consecutive steps in bacterial biosynthesis of

essential nucleic .

Pneumocystis Carinii Pneumonitis

ADULTS: PO 20 mg/kg TMP/100 mg/kg SMZ daily in divided doses q 6 hr for14 days.IV1520 mg/kg/day (based on TMP) in 34 divided doses for up to 14days.

Exacerbation of Chronic Bronchitis

ADULTS: PO 160 mg TMP/800 mg SMZ q 12 hr for 14 days.

acids and proteins and is usually bactericidal.

Adverse Reactions;CNS: Headache; depression; seizures;GI: Nausea;-

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Azithromycin

Action : Interferes with microbial protein synthesis. Zithromax

Tablets: 250 mg (as dihydrate)

Tablets: 500 mg (as dihydrate)

Class: Antibiotic, Macrolide Indications

ADULTS: Treatment of infections of the respiratory tract, chronicobstructive pulmonary disease (COPD), community-acquired pneumonia,

CHILDREN: community-acquired pneumonia Bacterial Infections

Adults:PO 500 mg as single dose on first day, then 250 mg/day on days 2through 5.

Community-Acquired Pneumonia

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References

Joseph .T. Dipiro; Pharmacotherapy- A Pathophysiolgic Approach; 7thedition; Page.no.1945-50.

Bestpractice.bmj.com/best-

practice/monograph/135/.../epidemiology.html

Hueston WJ (March 1997). "Antibiotics: neither cost effective nor'cough' effective". The Journal of Family Practice44 (3): 2615.