Infectious Pulmonary Diseases--An Overview

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Infectious Pulmonary Diseases--An Overview

• Al Heuer, PhD, MBA, RRT, RPFT
• Professor
• Rutgers- School of Health Related Professions

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Learning Objectives

• 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

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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.

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Key Terms in Pulmonary Infectious Disease

• 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

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Diseases Well Focus on Today

• Pediatric Respiratory Disease
• Croup
• Epiglottitis
• Bronchiolititis- respiratory syncytial virus
• Adult Diseases
• TB
• Pneumonia Viral Bacterial
• PCP
• SARS
• Others Pulmonic Plague

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Croup--Etiology

• Viral Infection
• Parainfluenza
• Influenza
• RSV
• Adenovirus
• Gradual onset
• Affects children 6 months to 3 years-old

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Croup--Pathophysiology

• Swelling and inflammation of subglottic
  structures.
• Larynx
• Trachea
• Larger Bronchi
• Can affect mid-sized and smaller airways

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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

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Steeple Sign-Often Found in Croup
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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.

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Epiglottitis--Etiology

• Bacterial infection
• Most common microorganisms
• Staphylococcus Aureus
• Group A B Streptococci
• Strep Pneumoniae
• Other causes
• thermal injury
• caustic ingestion
• radiation exposure

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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

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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

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Lateral Neck X-RayThumb Sign
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Epiglottitis-Treatment

• Minimal patient stimulation-keep patient calm!
• Cool mist aerosol w/suppl O2
• Antibiotics and fluids (steroids generally not
  effective)
• If severe obstruction, intubation shouldnt be
  attempted in ER
• Intubate patient in OR as trach may be necessary
  and patient may need to be paralyzed

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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

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Bronchiolititis

• EtiologyCaused 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 infants
• Treatment
• 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.

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Adult Infectious Pulmonary Diseases

• TB
• Pneumonia
• Viral
• Bacterial
• PCP
• SARS
• Others
• Pulmonic Plague

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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

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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.

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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.

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TB Lesion in Right Apex
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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

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HIV/TB--Treatment

• First Two-Months
• Isoniazid-INH
• Rifampin
• Pyrazinomide
• Ethambutal
• Next Five-Six Months
• INH
• Rifampin

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Pneumonia--Etiology

• Community Acquired vs nosocomial
• Pathogens
• Bacterial
• Viral
• Other--fungal, rickettesia

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Pneumonia--Pathophysiology

• Route - Often Inhalation of microbes or
  aspiration of stomach contents or other
  substances
• Microbes
• Bacteria
• Viral
• Other-Fungus-coccidiodes valley fever

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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

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Types of Bacterial Pneumonia

• Gram positive - aerobic
• Gram negative - aerobic
• Anaerobic
• Mycobateria

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Gram stain will showBacilli (rods) or Cocci
(round)Positive (blue) or Negative (red)
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Gram Stain - E. coli
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Lower Lobe pneumonia
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Pneumonia--Treatment

• Supportive
• Oxygen therapy
• Rest
• Proper hydration nutrition
• Isolate the microbe - Sputum CS
• Antibiotics/antimicrobials
• CPT
• Bronchodilators

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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 lt 600/ml.
• Opportunistic Infections take hold
• Pneumocystis Carinii PCP Now renamed as
  pneumocystis jirrevecii pneumonia and it is a
  protozoal-like microbe.

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PCP--Pathophysiology

• PCP-An opportunistic Protozoal Infection
• Generally only affects immunosuppressed
• HIV
• Chemotherapy
• Organ Transplantation/Immunosuppressant Drugs

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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)

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PCP--DX Clinical Manifestations (cont.)

• Fever/Chills
• Malaise
• Weight loss
• Lymphadenopathy
• Dyspnea/SOB
• CXR
• Early-Ground Glass Appearance
• Later-Diffuse infiltrates, lymph node enlargement

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Initial Treatment

• Oxygen for Hypoxemia
• Bronchodilators for bronchoconstriction
• Mucolytics, for mucous plugging
• Supportive Therapy
• Nutrition, hydration, rest
• Monitoring
• Vital signs
• Pulse oximetry
• Is Os
• Chart review for Relevant Orders and Advanced
  Directive and/or DNR

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PCP--Treatment

• Prophylaxis
• 1st choice--Daily administration of SMX-TMP
  (Triamethoprim-Sulfomethoxazole)
• 2nd choice--Pantamidine (if cant tolerate sulfa)
• Active Disease
• 1st Choice--TMP-SMX
• 2nd choice--Pantamidine
• 90 recovery rate

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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.
  

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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.

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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 (gt 75) with late diagnosis.
• Diagnosis Gram stain, CS, Immunoassay for
  capsulated antigen
• Treatment Streptomycin 30 mg/kg/day IM. Oral
  Doxycycline or Ciprofloxin. No vaccine.

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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 lt 5
  days) and supportive care.

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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.

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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 downdont 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)

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Take Home Messages- Avoiding Ethical Problems

• 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.
• Dont let your ego get in the way.
• If you have questionsor need addl infoAsk!

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Selected References

• Guideline for Hand Hygiene in Health-care
  Settings. MMWR 2002 vol. 51.
• The Centers of Disease Control and Prevention --
  httpwww.cdc.gov
• Egans Fundamentals of Respiratory Care, ed 10
  2012.
• Clinical Assessment in Respiratory Care, ed. 5,
  2010.
• AARC www.aarc.org/education/aarc
• Pubmed
• Medline