Pneumonia, Asthma, and COPD

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Pneumonia, Asthma, and COPD
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Pneumonia

• An acute lower respiratory tract dx due to
  infection with fever, focal chest symptoms,
  shadowing on CXR
• Classification
• Community acquired pneumonia
• Occur within 48 hrs of admission or in patients
  who havent been hospitalized in the last 2 wks
• Strep pneumonia, mycoplasma pneumonia, influenza
  A, Haemophilus influenza, and Legionella are more
  common pathogens
• Patients with chronic diseases are more prone to
  Klebsiella and other gram negative organisms
• Hospital acquired (nosocomial)
• Develops 2 or more days after admission
• Gram negative bacilli (Klebsiella, Pseudomonas, E
  coli, Proteus) or Staphylococcus are more common
  pathogens
• Aspiration around an ETT/reduced consciousness or
  difficulty swallowing allows pathogens in the
  oropharynx to colonize the lungs
• Ventilator-associated in patients on
  ventilators
• Aspiation follows aspiration of gastric
  contents
• Immunosuppression chemotherapy/bone marrow
  transplant/HIV patients susceptible to fungi and
  viral infections as well as other pathogens
• Recurrent CF and bronchiectasis patients have
  organisms that constantly colonize

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Pneumonia

• Risk Factors
• Specific occupational, environmental,
  geographical, or localized
• Seasonal pneumonia is more common in the
  winterthere are also seasonal peaks in different
  organisms
• Diagnosis
• Can be difficult because fever, leukocytosis, and
  CXR features of pneumonia are common to many
  other dx

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Pneumonia

• Symptoms
• Dyspnea
• Pleurisy
• Cough
• Discolored sputum
• Signs
• Cyanosis
• Tachycardia
• Tachypnea
• Dull percussion
• Crepitus
• Bronchial breath sounds
• Pleural rub
• Non-respiratory features
• HA, confusion
• diarrhea

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Pneumonia

• Complications
• Sinus infection
• Respiratory failure
• Hemoptysis (Klebsiella)
• Pneumatoceles (Staph)
• Pleural effusion/empyema
• Jaundice (Legionella)
• Septicemia
• Meningitis (Strep)
• Lung abscess
• Pericardial infection
• Myocarditis/hypotension
• Cerebral symptoms (Mycoplasma)

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Pneumonia

• Increased mortality associated with
• Age gt60
• RR gt30
• Diastolic BP lt60
• New atrial fib
• Confusion
• Multilobar involvement
• Albumin lt35
• Hypoxemia
• Leucopenia
• bacteremia

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Pneumonia

• Investigation
• No microorganism is isolated in almost half of
  patients because of ATB therapy or inadequate
  specimens
• Routine blood tests
• hemolysis/agglutination suggests Mycoplasma,
• abnormal liver fx tests suggest
  Legionalla/Mycoplasma
• ABG
• Microbiology
• Blood cultures, sputum cultures, BAL to ID
  organism and sensitivity
• Serology
• IDs mycoplasma
• Can detect Legionella antigen in urine and
  pneumococcal antigen in serum, pleural fluid, and
  urine
• Radiology
• CXR
• CT

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Pneumonia

• Management
• Supportive O2, IV
• Ventilatory support if resp failure exists
• Bronchoscopy sputum clearanceID organism
• CPT sputum clearance
• ATB initially use broad spectrum that covers
  your best guess as to causitive agentchange to
  specific once organism has been IDd
• Community acquired Erythromycin alone or
  combined with cefuroxime
• Hospital acquired cephalosporin, quinolone,
  antistaphylococcal
• Other pneumonias
• Aspiration cover anaerobes
• Immunocompromised antifungal/antiviral/broad
  spectrumsteroids and cotrimoxazole used for PCP

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Asthma

• A reversible obstruction of inflamed,
  hyperreactive airways causing wheezing, coughing,
  and dyspnea
• Airway inflammation is central to asthma usually
  its an allergic reaction
• Airway changes include accumulation of
  inflammatory cells, mediator release, epithelial
  denudation, edema, submucosal fibrosis, goblet
  cell hyperplasia, submucosal gland enlargement,
  mucus hypersecretion, and hypertrophied
  hyperresponsive smooth muscle

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Asthma

• Pathophysiology
• Triggers upper respiratory infections,
  inhalation of allergens, inhalation of irritants,
  environmental change, drugs, food additives,
  changes in weather, exercise, emotional upset,
  hormonal factors
• Patient struggles to breathe, using accessory
  musclesWOB is high from increased airway
  resistance
• Hypoxic vasoconstriction and pulmonary capillary
  compression increase deadspace and cause
  pulmonary hypertension
• Increased RV afterload and right heart failure
  can push septum to the left, decreasing LV end
  diastolic volume, so systolic volume may
  decrease, especially during inspiration causing
  pulsus paradoxus
• Eventually the respiratory muscles exhaust
  leading to respiratory failurearrestdeath

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Asthma

• Clinical Features
• Wheeze, cough, and nocturnal waking with
  breathlessness are typical
• May be a seasonal pattern or may be triggered
• PE
• Wheeze
• Prolonged expiration
• Signs of hyperinflation
• Severe asthma
• Marked decrease in peak expiratory flow rate
• Difficulty completing sentences
• Agitation
• RR gt25
• Sweating
• Accessory muscle use
• Pulsus paradoxus
• Life-threatening asthma
• Confusion and drowsiness
• Silent chest
• PEFR lt33 of predicted

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Asthma

• Investigation
• ABG
• Initially show respiratory alkalosis with
  hypoxemia
• Respiratory muscle fatigue eventually causes ABG
  to shift to respiratory acidosis with hypoxemia
• CXR
• May show hyperinflation
• Used to rule out other pathlogies
• EKG
• See signs of RV strain/hypertrophy
• FEV1 or PEFR
• Assess severity of attack
• Monitor effectiveness of therapy

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Asthma

• Management
• Primary pharmacological therapy
• Short acting B2 agonists
• Intravenous steroids
• Secondary pharmacological therapy
• Warranted if primary agents dont cause
  improvement within 24 hours
• Ipratropium
• Magnesium sulfate
• Aminophylline
• Respiratory therapy
• Oxygen
• NIV
• BAL to remove mucus plugs
• Mechanical ventilation
• Deep sedation
• Permissive hypercapnia

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COPD

• Irreversible expiratory airflow obstruction and
  increased work of breathing
• Risk factors
• Smoking
• Agegt50
• Childhood chest infections
• Airway hyperreactivity
• Alpha-1 antitrypsin deficiency
• Heavy metal exposure (cadmium)
• Atmospheric pollution
• Smoking and other risk factors accelerate the
  decline in lung function seen with aging

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COPD

• Pathophysiology
• Emphysema destroys alveolar septa and
  capillariesmay be due to inadequate antiprotease
  defences
• Smoking causes centrilobular emphysema with
  mainly upper lobe involvement
• Alpha-1 causes panacinar emphysema which affects
  the lower lobes
• Lung tissue loss results in bullae, reduced
  elastic recoil, and impaired diffusion capacity
• Airway obstruction is caused by distal airway
  collapse during exhalation leading to
  hyperinflation
• This puts the inspiratory muscles at a
  disadvantage
• Chronic bronchitis causes airway obstruction from
  chronic mucosal inflammation, mucus gland
  hypertrophy with hypersecretion, and bronchospasm
  but lung parenchyma is not affected
• Most patients have characteristics of both
  emphysema and bronchitis

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COPD

• Diagnosis
• PFT
• airflow obstruction which is irreversible with
  bronchodilators
• Increased RV, FRC, TLC
• ABG resting is normal with pure emphysema
  (because alveoli and capillaries are destroyed in
  equal proportion) but exercise causes hypoxemia
  from reduced diffusion capacity
• CXR
• Hyperinflation
• Pure bronchitis would have normal lung volumes
  and diffusing capacity, but be hypoxemic from V/Q
  mismatchCXR shows increased vascular markings
  but not hyperinflation

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COPD

• Emphysema pink puffer
• Tend to be breathless and tachypneic
• Signs of hyperinflation and malnutrition
• Barrel chest, pursed lip breathing, accessory
  muscle use, distant breath sounds, prolonged
  expiration with wheeze
• Chronic Bronchitis blue bloater
• Daily morning cough with mucus production
• Less breathless despite hypoxemia potential
• CO2 retention (bounding pulse, vasodilation,
  confusion, HA, tremor, papilloedema)
• Hypoxemia induced renal fluid retention and right
  heart failure leading to cor pulmonale
• Pulmonary hypertension from hypoxic pulmonary
  vasoconstriction

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COPD

• Management
• Smoking cessation
• Wont reverse COPD
• Will slow down disease progression and minimize
  symptoms
• Pharmacological therapy
• Inhaled beta agonists
• Anticholinergics
• Theophyllines
• Steroids
• Mucolytics
• Pulmonary rehab
• Strengthens muscles
• Increases exercise tolerance
• Improves quality of life
• Reduces hospitalizations
• Home oxygen
• Prophylaxis pneumococcal and flu vaccines
• Volume reduction surgery

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COPD

• Acute exacerbations
• Infection, PE, IHD, arrhythmias, medications, and
  metabolic disturbances may all cause
• General
• Fluid management
• Electrolyte correction/nutrition
• Thromboembolytic prophylaxis
• Oxgyen
• Pharmacologic therapy high dose aerosolized
  beta agonists/anticholinergics, oral
  corticosteroids, ATB
• Respiratory therapy for secretion clearance
• Mechanical ventilation/NIV

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COPD

• Problems with mechanical ventilation
• Prolonged weaning
• Dynamic hyperinflation (autoPEEP)
• Increased WOB
• Patient-ventilatory dyssynchrony
• Used long Et, low Ve, bronchodilators, and
  setting ventilator PEEP to autoPEEP level to
  reduce hyperinflation