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 elderlyFrequently follows upper airway

infection

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

Pathophysiology

Viral infections damage airway epitelium

Mucous hypersecretionDecreased mucosiliary cleranceActivation of irritating cough

receptorsAirway hyperresponsiveness may

occur

Treatment

SymptomaticRestAntipireticsAntitussives or expectorantsAntibiotics if necessaryİnhaler steroids if bronchial

hyperresponsiveness occurs

Pneumonia

Definition: Acute infectious inflammation of the distal lung paranchyme (Distal to terminal bronchioles) with clinical and radiological signs of consolidation

Pneumonitis: Noninfectious inflammation

Classifications

Community Acquired

Nosocomial (Hospital acquired)

Pneumonia in immuncompromised host

Anatomic Lober Bronchopneumon

ia Interstitial

pneumonia

Etiologic Bacterial** Viral Fungal

The microorganism reaches the lungs by:Inhalation or aspirationHematogenious wayDirect invasion from the neighbouring

tissuesThe amount of the organism

inoculated, the virulance factors and the immunity of the host are important factors

Risk factors:

Smoking, alcohol Viral airway

infections Age COPD Corticosteroids Immunosuppressi

on and drugs

Diabetes mellitus Neurologic

diseases Hypoxemia Toxic gas

inhalations Air polution

Community acquired pneumonia

The symptoms of pneumonia are usually not specific but generaly include:Fever (chills)CoughSputum production (purulent)Thoracic painDyspnea

Most frequent

S. Pneumonia (50%)H. İnfluenzaeMoraxella catarrhalisMycoplasma pneumoniaChlamydia pneumoniaLegionella pneumophiliaVirus (10-20%)

Atypical pn

Typical pneumonia is characterised by abrubt onset high fever, chills, productive cough, thoracic pain, focal clinical signs, lobar or segmental radiographic findings, leukocytosisStrep. PneumoniaH. influenzae

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

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 pneumoniaLegionellaClamydia

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

PercutionNormal sonorityDullness (Matite)

OscultationEnd inspiratory fine cracklesLocal diminished breath soundsBronchial voice

Diagnosis

History and symptomsPhysical examinationPA Chest x-rayMicrobiologic examinationRoutine laboratory testsBlood gas

PA Chest x-ray

Consolidation Lobar or patchy

(Bronchopneumonia) nonhomogenious infiltrations

Air bronchogram Round opacity Fine reticular

density

Complications Pleural effusion Cavitation Abscess Pneumatocell Pneumothorax

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)

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)

Routine Laboratory Tests

CBCESRCRPHepatic enzymesRenal functions

Laboratory in CAP Health Center Policlinic/

emergencyİnpatient

Chest x-ray ± + +

Hemogram ± + +

Biochemistry ± + +

Sputum Gram ± + +

Sputum culture - - +

Blood culture - - +

serology - - ±

Urinary legionella ag

- - ±

Thorasenthesis - - ±

O2 Saturation - + +

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

Risk Factors

Age>65 Comorbid illness Alcoholism Aspiration? Recurrent pneumonia <1year Mental problems Spleenectomy Malnutrition Social problems

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

Intensive Care Indications

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

1 Major or 2 Minor criteria is needed

Bacterial pneumonia

Probable microorganism S. pneumoniae M. pneumoniae Chlamydia

pneumoniae H. influensa Virus Enteric gr (-)

eg:Pseudomonas, klebsiella

MRSA Other

Pneumococ PneumoniaTypical pneumoniaLeucocytosisLober infiltrationRast colored (pink) sputumLabial herpes lesionsPenicilline or macrolide (10-14 days)

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

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

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

Legionella pneumonia

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

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

Prevention

Control of comorbiditiesGood NutritionGeneral hygeneQuit smoking and alcohol abuse Influensa vaccinePneumococ vaccine

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)

NOSOCOMIAL PNEUMONIA

Pathogenesis

Oropharyngeal or gastric aspiration (colonization)**

InhalationHematogenious Contamination (orofecal or from the

hands of the staff) Immunedisturbances of the patient

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)

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 sputumPurulent secretions

Probable microorganisms

Group 1 (Early onset ≤ 4 days) S. Pneumonia H. İnfluenzae M. Catarrhalis S. Aureus

(meticilline sensitive)

High risk, probable multipl resistant bacterial infection P aeruginosa Acinetobacter spp MRSA (S aureus) K pneumonia Group 2

Group 2 (Late onset ≥ 4 days) Enterobacter spp K. pneumonia S. marcescens E coli Other gr (-) Group 1

High risk, probable multipl resistant bacterial infection

Antibiotic use in the previous 3 months (90 days) ≥5 days of hospitalization High antibiotic resistance in the hospital or public Immunsuppressive treatment MV >7 days İntensive care >48 hours Emergency intubation Severe sepsis/septic shock PaO2/FiO2 <250mmHg Bilateral, multilober infiltration, cavitation,

complication,rapid progression

Certain risk-pathogen relations

S aureus Coma Head trauma D. Mellitus Renal failure Past influensa

Legionella Corticosteroid use Kemotherapy Past antibiotic

P aeruginosa Prolonged MV Past antibiotics Tracheostomy CS use Paranchymal lung

disease

Anaerobic pathogens Gastric aspiration Recent thoracic or

abdominal operation

Approach to the patient: Microbiologic Culture

Noninvasive Blood cultures

(obligatory but low sensitivity)

Qualitative culturing of sputum or endotracheal aspirates (high sensitivity but low specificity)

Invasive FOB (lower airway

sampling) Pro-brush BAL TBNA

(Quantitative culturing)

Treatment

Empirically based parentheral antibiotics, can be changed according to the microbiologic culture results

Specific risk factors should be considered

Prevention Staff education (hand washing, gloves) Noninvasive approach when possible Sucralphate for gastric prophylaxis Enteral feeding as much as possible Avoid narcotics Early mobilization Early discharge from IC or hospital

Viral Pneumonia Rare in people with normal immunity

Influensa A >50% B Parainfluensa RSV Herpes Mixed bacteriel infection

İmmunocompromised person CMV Herpes Parainfluensae RSV Varicella 50% bacteria, fungus, protozoa (PCP) superinfection

occurs

Fungal Pneumonia

Endemic Histoplasmosis Blastomycosis Coccidiomycosis Paracoccidiomycosi

s Criptococcosis Sporotricosis

Opportunistic Aspergillosis Candidiasis Mucormycosis

Aspergillosis

Aspergillus fumigatusABPA

AsthmaEosinophylia (>1000 mm3)Central bronchiectasisHigh serum IgEAspergillus specific IgE and IgG (+)

AspergillomaChronic necrotising aspergillosisInvasive aspergillosis

Aspergilloma: Fungus ball in chronic cavity Cause massive hemopthysis

Invasive aspergillosis Seen in immunsuppressive patients

(neutropenia) Inhaled spores cause pneumonia with fever

and cough X ray may be normal in the beginning, focal

infiltrations can be seen later Pleuritic chest pain is common

Pneumonia in immuncompromised host

NeutropeniaNonneutropenia

Organ transplantationCorticosteroid

AIDS

The classic symptoms and signs are commonly absent

Infectious and noninfectious pathologies can be concomitant

Mixed infection with multipl pathogens can be the cause

The general condition of the patient may not allow the invasive diagnostic procedures (BAL, proBAL, TTFNAB)

Opportunistic infections are common with high mortality (45%)

Differential diagnosis of noninfectious pathologies is important

Infectious S. Aureus Gr (-) bacteria Legionella Nocardia CMV Herpes Adenovirus Varicella Aspergillus Criptococcus Candida Tbc PCP Toxoplasmosis

Noninfectious DAH Pulmonary edema Drug reactions Radiation pn Leukostasis Leukemic infiltration Lenfangitis carcin. Lymphoma, lung ca BO BOOP

ARDS Pulmonary embolism

The type of infective agent differs according to the type of immune defect

Physical examination can be nonspecific

Radiologic changes can be late

Common Infectious agents according to the type of immunosuppressionNeutropenia Enteric Gr(-) bct

P. aeruginosa

S aureus

Streptococcus

Enterococcus

Aspergillus

Candida spp.

Humoral immune defect

S pneumonia

H influenzae

Cellular immune defect

Mycobacterium (tb and atipical)

Fungus

Virus (CMV, VZV, HSV, RSV)

P carinii

T gondii

S stercoralis

NONNEUTROPENIC PATIENTS

Solid organ transplantCMVH. influensa, s. pneumoniaLater: Nocardia, tbc and atipical

mycobacteriaBone marrow transplantation

(Stem cell)CMV, PCP (less common due to

allogenic trans and prophylaxis)Later pneumococ pneumonia

AIDS

CD4>500 bacterial pneumoniaCD4 200-499 recurrent bacterial

pneumonia, tuberculosisCD4<200 PCP, disseminated tbCD4<100 CMV, MAC, toxoplasma,

disseminated fungus

PROPHYLAXIS IN IMMUNOCOMPROMISED PATIENTS

Live vaccines are contraindicated Influensa and pneumococ vaccines

should be givenChemoprophylaxis (PCP, CMV)Donor seropositivity in

transplantation

Certain Definitions

Recurrent pneumonia:A second pneumonia that occurs

after the complete healing of a first attack (>1 month). At least 2 times a year.

Late resolution:A pneumonia that resolves <50% in 2

weeks or incomplete regression in 4 weeks

Risk factors for late resolution:

Age COPD Alcoholism Smoking D mellitus Malignancy Renal or cardiac

failure CS use

S pneumonia Legionella Viral H influensae

Complications of pneumonia

Pleural effusion (parapneumonic) Emphyema Bronchopleural fistule Mediastinitis, pericarditis, chest wall infection Necrosis, cavitation Pneumatocel Pneumothorax ARDS Fibrosis Bronchiectasis Late resolution or recurrens

THE END