Understanding Asthma and Pneumonia: Symptoms and Treatments
Azma Etio:
-SG |
Th1-Th2-Ig2-Cytokines(IL3-4-5-9), GM-CSF, TNF-alpha-ADAM33 |
-SG =-EF: ^Triggers:^Px:
I: (intermittent) -ASx [N] PEF Night Sx (2x/Month) FEV1PEF 80% Prediction | II: (mild persist) -1+Week less 1 day -Nocturnal 2+Month |
III: Mod Persist -Daily Sx -1+ Week nocturnal Variable 20-30% | IV: Severe Persistence -Continuous Sx -Frequent Nocturnal |
Sx:
excess muscle-Wheezing-Expiration ↑-paradoxical pulse ^^Lab: (PFT/Spir/FVL/Provo)
^Exacerbation:
***Az Tx: GOAL/Achieve/Trigger
I-<-B->:
II-CSD:
III-Mast Cell Stabilizer IV-LKT Modified:
V-Methylxanthine:
![]() |
1-Control x & stabilize 2-Attack–Albuterol/SABA -Inhaled <-B->=emergency -Systemic CSD -O2 (Hypoxia) -Monitor -Hospital (4h no improvement) ***B-Tis: Dx & Tx
^^Dx:
^^Tx:
^^X:
**Pn: Etiology/Px/Class: ^^Etio:
^^Px:
– inflammatory mediators IL-1 & TNF=FEVER)- Chemokines IL8+ G-CSF —->Neutrophil release—-> ↑ purulent secretion-Infl mediators —-> capillary leak- leading to hypoxemia, ↑Resp Drive & secretion 4-Stages: (E/R/G/R):
^^Class:
***Pn: CF + Radio:
History | CF & PE | X-ray (consolidation) |
Pul Edema ↑ Carcinoma | 1-Cough, NP—->P Mucoid (RED=Strep Pn /Jelly= Klebsiella/Bad smell=O2(-) 2-Dyspnea 3-Chest pain 4-Fever/Chills/sweat PE: -RR ↑ -excess muscle/ -Crackle -Bronchial breath | GOLD #1 Lobar: Bronchial: consolidation in several lobes -Int: -Miliary: Discrete lesions hematogenous spread |
History | CF & PE | X-ray |
Pul Edema ↑ Carcinoma | 1-Cough, NP—->P Mucoid (RED=Strep Pn /Jelly= Klebsiella/Bad smell=O2(-) 2-Dyspnea 3-Chest pain 4-Fever/Chills/sweat PE: RR ↑ /excess muscle/Crackle /Bronchial breath | GOLD #1 Lobar/ Bronchial/Int/Miliary |
CAP | VAP | HAP |
1-Sputum Stain & Culture-25WBC & 10 squamous cells per high -Gram stain organisms 2-Blood culture+ve = Worst Prognosis 3-Antigen TestUrine antigen Step Pn & Legionella | Quantitative culture, True infection & colonization HAP hardest | hardest |
Site of Care | Ax |
I-PSI (severity) class 4+5 –> Hospital Class 3—->observation II-CURB 65: confusion (C); urea >7 mmol/L (U);-RR ≥ 30/min (R);-BP: S ≤ 90 mmHg /DS ≤ 60 mmHg (B);-age ≥ 65 years (65).Score:0 —> Tx @ Home 2 —->Hospital 3—->ICU | I-outpatient: 1-No Ax use in 3 M: —–> Macrolide [[Clarithromycin (500 mg PO bid)] Doxycycline (100 mg PO bid]2-Comorbidities of Ax use: ——>Fluoroquinolone + B-LactamII-Inpatient, non ICU-Resp Fluoroquinolone-B lactamIII-Inpatient ICU:B-Lactam!IV-Pseudomonas:– antipseudomonas X-B Lactam plus aminoglycoside (Piper) |
Site of Care | Ax |
I-PSI (severity) class 4+5 –> Hospital Class 4—->observation II-CURB 65: confusion (C); urea >7 mmol/L (U);-RR ≥ 30/min (R);-BP: S ≤ 90 mmHg /DS ≤ 60 mmHg (B);-age ≥ 65 years (65).Score:0 —> Tx @ Home 2 —->Hospital 3—->ICU | I-outpatient: -No Ax use in 3 M:——->Give Macrolide [[Clarithromycin (500 mg PO bid)] Doxycycline (100 mg PO bid] -Comorbidities of Ax use: ——>Give Fluoroquinolone + B-Lactam II-Inpatient, non ICU-Resp Fluoroquinolone-B lactam III-Inpatient ICU:B-Lactam! IV-Pseudomonas:- antipseudomonas X-B Lactam plus aminoglycoside |
***Nosocomial Pn:^^Empirical therapy:-Start TX once the Dx Specimen is obtained-Most patients without MDR can be Tx with a single Agent, The difference from CAP is lower incidence of atypical pathogens in VAPfor MDR infection 3 Ax: 2 P aeruginosa + 1 MRSA
^^ NO RF for MDR pathogen | RF for MDR pathogens |
-Ceftriaxone – Moxifloxacin – Ciprofloxacin – Levofloxacin – Ampicillin/sulbactam – Ertapenem (1 g IV q24h) | 1-A β-lactam: – Ceftazidime (2 g IV q8h) or – Cefepime (2 g IV q8–12h) or – Piperacillin/tazobactam (4.5 g IV) – Meropenem (1 g IV q8h) + 2-Second agent against G(-): -Gentamicin or Tobramycin – Amikacin or – Ciprofloxacin – Levofloxacin 3-Agents Against G(+ Bacteria): -Linezolid – Vancomycin |
***PE: Etio /Px/Class^^Def:
Initial | Non-Invasive | Invasive |
-Pulse oximetry (Hypoxia) -X-ray (atelectasis, Focal infiltrates) -ECG (HR ↑, ST-T ↑) (new RBBB rise in RV pressure) -ABD (Arterial O2) | -D-Dimer: ↑ -V/Q: V ↑, P ↓ -US (S) & specific thrombi Iliac Vein -CT angiography (To see Blockage) ( High (S) for PE in lobar or segmental Vessels) -ECG Detect Right ventricular dysfunction!!McConnell sign!!( -Cardiac marker testing : elevated troponin levels in Right ventricular Strain | Pulmonary angiography: when Risk of PE is High |
0 | Chronic cough Sputum | [N] |
1 (mild) | Chronic Cough & Sputum | Ratio=70% FEV1>80% |
2 (Moderate) | +/- Chronic Cough & sputum | Ratio <70% 50% |
3 (severe) | +/-… | Ratio<70 30% |
4 (V Severe) | +/-… | +Chronic Resp Failure |
Pink Puffers (emphysema) | Blue Bloaters (Chronic Bronchitis) |
-↑ Alveolar Ventilation -PaO2 [N] -PaCO2 [N] /↓ -Breath ↓ -Not cyanosis | ↓ Alveolar Ventilation- ↓PO2- ↓ PaCO2-Cyanosis not breath may lead to Cor Pul |
^^History & physical Exam:-Chronic PC that almost always produces large volumes of thick, tenacious, purulent sputum – Dyspnea- Hemoptysis, due to neovascularization of the airways – Low-grade fever may present- Halitosis- Abnormal breath sounds (including crackles, rhonchi, and wheezing)- Finger clubbing may present.- In advanced cases, hypoxemia and signs of pulmonary hypertension | |
^^Chest X-ray :-Scattered Irregular opacities-Honeycombing-Ring & tram lines | -Scattered Irregular opacities-Honeycombing-Ring & tram lines |
^^High Resolution CT :-For confirmation & extend of Bronchiectasis | -For confirmation & extend of Bronchiectasis |
^^PFT baseline :baseline function and progression of Disease over Time | baseline function and progression of Disease over Time |
^^Specific test:To Determine cause:1- Sputum evaluation : culture mycobacterium (M tB or avium)2-Rh factor 3- transmission electron microscopy4- Alpha antitrypsin Deficiency! | To Determine cause:1- Sputum evaluation : culture mycobacterium (M tB or avium)2-Rh factor 3- transmission electron microscopy4- Alpha anti |
***Lung Abscess: Etiology, Px, And dx^^ Def:NLI ———–>Purulent Pus^^Etiology:gingivitis / poor oral hygiene /aspiration (vomiting) or Hematogenous Seeding in Lung 1-Pathogens (Anaerobic bacteria Actinomyces) 2-Aerobic: Streptococcus & Staphylococcus 3-Immuno(-) Patient^^Dx:
I- History :
| -Aspiration prone history -Anaerobic Infection | ||
II-Sx:-PC-Fever-Sweat-↓KG-TiredSx of abscess due to Anaerobic bacteria develop more acutely and resemble Bacterial Pn | -PC-Fever-Sweat-↓KG-Tired Sx of abscess due to Anaerobic bacteria develop more acutely and resemble Bacterial Pn! | ||
III-Sign:-↓ Breath sound-T >38 -Crackles (affected area)-Echophony-Dullness-Chest X-ray: consolidation with single cavity containing air fluid level in portion to lung-Sputum Culture: for fungi & Mycobacteria-Bronchoscopy: To exclude cancer |
I- History : | -Aspiration prone history -Anaerobic Infection |
II-Sx | -PC-Fever-Sweat-↓KG-Tired Sx of abscess due to Anaerobic bacteria develop more acutely and resemble Bacterial Pn! |
III-Sign | -↓ Breath sound-T >38 -Crackles (affected area)-Echophony-Dullness-Chest X-ray: consolidation with single cavity containing air fluid level in portion to lung-Sputum Culture: for fungi & Mycobacteria-Bronchoscopy: To exclude cancer |
I-Prevent Exacerbation, Ax + Regular Vaccination:-Daily prophylactic oral Ax (Ciprofloxacin 500 mg)-Chronic therapy: azithromycin 500 mg OP x 3/wk has .-Diffuse bronchiectasis: aerosolized Gentamicin (40 mg bid) Yearly vaccine: influenza /Pneumococcal | -Daily prophylactic oral Ax (Ciprofloxacin 500 mg)-Chronic therapy: azithromycin 500 mg OP x 3/wk has .-Diffuse bronchiectasis: aerosolized Gentamicin (40 mg bid) Yearly vaccine: influenza /Pneumococcal |
Measures to help clear secretions:-Postural drainage-Chest percussion- +expiratory pressure devices- Intrapulmonary percussive ventilators- Pneumatic vests- Autogenic drainage | -Postural drainage-Chest percussion- +expiratory pressure devices- Intrapulmonary percussive ventilators- Pneumatic vests- Autogenic drainage |
Ax for Acute Exacerbation :-Tx exacerbation with Ax to clear sputum from airways with use of bronchodilatorsAx selection for CF by sputum culture -childhood, (S. aureus and H. influenzae )—–> quinolone antibiotics as ciprofloxacin & levofloxacin -Later stages (gram-negative organisms including P.aeruginosa, Burkholderia)—–>Tx is x Ax (Tobramycin,Aztreonam, Ticarcillin-Clavulanate, Ceftazidime, Cefepime).-Superinfection with mycobacterial organisms IV infusion :◦ Clarithromycin 500 mg po bid or Azithromycin 250 mg 1/day; ◦ Rifampin 600 mg po 1/day or Rifabutin 300 mg po 1/day;◦ Ethambutol 25 mg/kg po 1/day for 2 mo followed by 15 mg/kg 1/day.X taken till sputum is -ve | -Tx exacerbation with Ax to clear sputum from airways with use of bronchodilatorsAx selection for CF by sputum culture -childhood, (S. aureus and H. influenzae )—–> quinolone antibiotics as ciprofloxacin & levofloxacin -Later stages (gram-negative organisms including P.aeruginosa, Burkholderia)—–>Tx is x Ax (Tobramycin, Aztreonam, Ticarcillin-Clavulanate, Ceftazidime, Cefepime). -Superinfection with mycobacterial organisms IV infusion :◦ Clarithromycin 500 mg po bid or Azithromycin 250 mg 1/day; ◦ Rifampin 600 mg po 1/day or Rifabutin 300 mg po 1/day;◦ Ethambutol 25 mg/kg po 1/day for 2 mo followed by 15 mg/kg 1/day.X taken till sputum is -ve |
Surgical Resection :-bronchial artery Embolization (Severe Hemoptysis)-Surgical resection for localized Bronchiectasis (Sx v strong) | -bronchial artery Embolization (Severe Hemoptysis)-Surgical resection for localized Bronchiectasis (Sx v strong) |
Additional Tx: Depends on the cause:-Alpha 1 antitrypsin def Replacement therapy-ABPA is Tx with CSD-Management of Cystic Fibrosis | Depends on the cause:-Alpha 1 antitrypsin def Replacement therapy-ABPA is Tx with CSD-Management of Cystic Fibrosis |
IV Ax for severeOP Ax, less severe-CLindamycin 600 mg IV /6-8H or-B lactam / B lactamase (-) When Fever ↓ IV —-> OP | -CLindamycin 600 mg IV /6-8H or-B lactam / B lactamase (-) When Fever ↓ IV —-> OP |
Percutaneous Drainage or Surgery in case of:-if we have Empyema-No Response to Ax->6cmwhat surgery?-Lobectomy is most common-surgical resection-Pnctomy in case of X abscess | what surgery?-Lobectomy is most common-surgical resection-Pnctomy in case of X abscess |