Understanding Asthma and Pneumonia: Symptoms and Treatments

Azma Etio:

Def:
(Airway Infl(+)<—Trigger)—-> Partial /Complete Obstruction
TH2
Etiology
xFactorial : EF + SG
-SG
Th1-Th2-Ig2-Cytokines(IL3-4-5-9), GM-CSF, TNF-alpha-ADAM33

-SG =-EF: ^Triggers:^Px:

1-Infl/Edema/Ovst/remodel
2-SG / TH2/ (+)allergen
3-Sensitization/TH2/Cytokine
4-Short Term: BC/Mucous/VD
5-Long: MAST/chemokine/
6-Repeated: Remodel
Stages:
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


***Az Dx:
^Clinical: H+ PE
H:
1-Mild–>ASx
2-Severe: Chest Tight/Dyspnea/Wheezing/Cough

Sx:

HR ↑, RR ↑

excess muscle-Wheezing-Expiration ↑-paradoxical pulse ^^Lab: (PFT/Spir/FVL/Provo)

-DLo (Azma vs COPD)
-X-ray (diff Dx & causE)
-PEF: Monitor & therapy

^Exacerbation:

1-Pulse oximetry
2-PEF
3-FEV1
4-X-ray
5-ABG

***Az Tx: GOAL/Achieve/Trigger

G: Exacerbation/Sx/Pulmonary Function/Fun/ADR
A: Exacerbation/X therapy/educate/trigger
T: Home allergen/work/Wine/URI

I-<-B->:

B Agonist + Anti-Cholinergic

II-CSD:

Inflammation
(-)Cytokine release
reverse B-Receptors

III-Mast Cell Stabilizer IV-LKT Modified:

(-) Histamine release
Long control & prevention

V-Methylxanthine:

-Bronchodilation
I (intermittent): SABA
II (Mild Persistence): LI -CSD/LKT(-)
III (Moderate persistence): …+LAGA
IV (Severe P): SABA/LABA/LKT(-)/I-CSD!/Anti-IGE therapy
Asthma Podcast

***Azma exacerbation:

1-Control x & stabilize 2-Attack–Albuterol/SABA -Inhaled <-B->=emergency -Systemic CSD -O2 (Hypoxia) -Monitor -Hospital (4h no improvement) ***B-Tis: Dx & Tx

-Infl URT—>LRT
-Viral > Bacteria

^^Dx:

CF:
-Cough 5 days
-NP—->P
-[N]/ Bloody /purulent
4-Mild Fever
5-X-ray (suspect Pn)

^^Tx:

-Self Limiting
-Sx: (Prednisolone & H2O)
-Antitussive: (Cough) Sleep
-<-B-> (Wheezing)
-OP Ax, COPD

^^X:

Amoxicillin mg OP/7days
Doxy 100mg…
Azithromycin 500 mg/1/day

**Pn: Etiology/Px/Class: ^^Etio:

CAP/HAP/VAP/MDR (Strep/E. coli/G(-)/MSSA)

^^Px:

1-Bacteria At level Alveoli
2-How it gets there
3-Alv Macrophage—>Infl—>Pn CF

– 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):

E: Prt Exudate & Bacteria in Alveoli
R: RBC & Neut in Intraalveolar space
G: RBC ↓, Neut ↑
R: Macrophage ↑, inflammation ends

^^Class:

CAP (48H -, outside)
HAP (48H +, nursing)
VAP (48-72 H)

***Pn: CF + Radio:

HistoryCF & PEX-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
HistoryCF & PEX-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
**Pn DX Lab
CAPVAPHAP
1-Sputum Stain & Culture-25WBC & 10 squamous cells per high
-Gram stain organisms
2-Blood culture
+ve = Worst Prognosis
3-Antigen Test
Urine antigen Step Pn & Legionella
Quantitative culture, True infection & colonization

HAP hardest
hardest
**Pn CAP Tx:
Site of CareAx
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)
– Antipseudomonal β-lactam [Piperacillin/Tazobactam (4.5 g IV q6h), +Ciprofloxacin/Levofloxacin
– β-lactams + Aminoglycoside + antipneumococcal Fluoroquinolone
If CA-MRSA is a consideration
^Extra: H2O, Oxygenation, Ventilation
Site of CareAx
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
**Tx Nosocomial Pn:

***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 pathogenRF 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:
PA <—Obst—>Distant Origin
^^Etiology:
-DVT
-High emboli, Thrombosis lower Calf vein
-TE upper extremity
-Risk (DVT + PE):
1-Endothelial damage
2-Hypercoagulation
3-↓venous Return
^^Px:
-DVT
-Emboli detaches leaves venous system
-Sticks in PA
-Size of occlusion = Sx severity
1-Small: disintegrates hours–>Days
2-Large: Atelectasis, ↑ Vascular pressure, Hypoxia, Tachypnea
^^ Class:
Small
Submassive
Massive
***PE Dx:
InitialNon-InvasiveInvasive
-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
^^Probability
6+ = High
2-6= Moderate
2(-)= Low
***PE Tx:
-suspected —hospitalized & monitor
I-Initial Tx with:
-O2 /IV saline / Vasopressors (HBP) /Anticoagulants
II-Anticoagulants:
1-Heparin (unfractionated / Subcutaneous)
2-Warfarin (not in pregnant)
III-IVC filter when anticoagulation (-)
IV-Clot elimination (Thrombolytic therapy) for Massive emboli :-Embolectomy or dissolution by IV thrombolytic therapy ***PE prophylaxis:^^X: 1-LDUH (low dose unfractionated Heparin) 2-LMWH (Fondaparinux 2.5 mg /day) 3-WARFARIN :(2-5 mg ) 4-Aspirin only better than placebo but worse than other X ^^ Devices:1-IVC Filters : (+) helps prevent PE in patients with lower extremity DVT (-) long term complications such as anticoagulants2- IPC (intermittent Pneumatic Compression)-Rhythmic external Compression to Legs or to legs & Thigh -Better for preventing Calf than proximal DVT -Not given for obese patients3-Graded Elastic compression stocking : -less used in favor of external Pn leg compression ***Cor Pul:
-RVH(Failure)<—-P-HBP, 2nd Disease
^^Etiology:
-Acute (PE/Injury due to Mechanical Ventilation/ARDS)
-Chronic (COPD/Sclerosis/NM/Obesity + HBP)
NOT (LVF, Congenital or valve disorder)
^^Px:
Lung disorder—->P-HBP:
1-Distal Alveolar Capillary Bed
2- ↑ Alveolar Pressure
3-Hypertrophy
4—>V<–, due to Hypoxia hypercapnia
PHNP—> ↑P-VR—> ↑Afterload (RV)
—>ED and Central pressure ↑
—>Ventricle Hypertrophy & Dilation
**Cor, Dx:
-Sign & Sx:
1-Asx (start)
—>Left parasternal Lift
2-S2 ↑
3-X-ray: RV and PA size ↑
4-ECG: RV size ↑
5-Echocardiogram: RV/LV assessment
***Cor Tx:
-Early the better
-Diuretic (Peripheral edema)
-Bosentan (endothelin Receptor blocker, 1 Pulmonary HBP)
-Digoxin (concomitant LV dysfunction)
-Phlebotomy (hypoxia Cor Pul)
-Anticoag (Chronic cor P)
-Pulmonary Vasodilators (Hydralazine)
(not effective in 1 HBP)
***Chronic Obstructive Pulmonary Disease: Def/ Etiopathogenesis ^^Def:PRAL <———Toxin (SMOKE)
Irreversible Obstruction
I-COPD: PC, 3M, 2Y
II-Emphysema: (x) Lung Parenchyma—> ↓alveolar septa & Elastic Recoil
^^Px::
Causes:
1-Inhalation:—->smoking or pollution smoke 2-GF:———->alpha1 antitrypsin Deficiency! STEPS 1-Inflammation: (Inhaled, Toxin) 2-Infection: (in conjunction with smoking) 3-Airflow limitation: (obstruction /Loss of elastic recoil—–> Hyperinflation) ^^Complication : 1-P-HBP—>Cor Pul(Hypoxemia & ↑ Vascular Tone)
2-Resp infection :(Viral / bacteria in conjunction with COPD patients)
3-Weight loss ***COPD: Dx & Class: I-History: -smoking being primary RF II-Sx & Signs:-Productive cough: initial sx (40’s and 50’s)-Dyspnea: -Morning headache (more advanced Disease) III-PFT-FEV1 / FVC & Ratio is the hallmark of airflow limitation FEV1 < 1L, = Dyspnea IV-Imaging: 1-X-ray: emphysema (hyperinflation) -Widening of retrosternal airspace
-changes due to alpha anti-Trypsin Deficiency
2-CT scan 3-α 1 -Antitrypsin levels-Non-smokers with COPD V-other tests: -↑TLC/FRC/RV-↓ vital capacity ^^Class: St 0 —>(Chronic Cough/Sputum) —>[N]St1—->(+/- Chronic Cough + sputum) —->Ratio=70 ,FEV1>80 St 2
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
****COPD: Prophylaxis & Tx I-Aim: prevent Exacerbation & improve Lung/physical function II-Smoking cessation:-Slow doesn’t HALT the Rate of FEV decline (Does Not Stop) III-Drug therapy:-Inhaled are important and include X like: 1-B agonist 2-Anticholinergics 3-CS (inhaled): 4-Theophylline IV-Oxygen therapy:-COPD + PaO2 <55mmHg.-Indication: 1-PaO2 <55mmHg or SaO2 <88 % 2-PaO2 =55-59 or SaO2 <89% 3-PaO2 >60mmHg SaO2 >90% V-Vaccination:-need annual Influenza Vaccine VI-Nutrition:COPD patients are prone to Weight Loss PUL Rehab! VII-Surgery: 1-Lung Volume reduction Surgery:-Resecting emphysematous Areas-improves Exercise tolerance & mortality 2-Single Lung Transplantation: -Age <60-65 & FEV1 <25% after bronchodilation
All Stages—->Avoid RF (Smoking) Influenza Vaccine
St 1 (Mild) —->Tx only when Sx, SABA
St 2 (Moderate)—->Tx with 1+ <–B–>+ Rehab
St 3 (Severe)—–>…. + Inhaled CS when Bronchodilators Fail
St 4 (V Severe) ——>Bronchodilators 1+/Inhaled CS. Rehab. Long term O2 therapy
                                      Surgery considered
***COPD Exacerbation :
In Case of Exacerbation (restore O2, normalize pH, Tx the cause) I-O2:-immediately-Prior minimize V/Q mismatch by ↓perfusion of the most poorly ventilated areas ,II-Ventilation assistance
:for intubation / Hospital Stay / mortality
III-Drug therapy:1- Beta agonist (acute exacerbation) 2-CS (All but mild Exacerbation) 3- Ax (exacerb + purulent sputum) ***Bronchiectasis: Etiology & pathogenesis: ^^Def:
<—B—> large bronchi <——chronic infection + Inflammation
(dilation of Large Airways)!! (impairment to Clear mucous) (Infection—>destruction—->impairment) W-IC-I ^^Etiology P47 TABLE !!!
1-infection (bacteria/Fungi/Myco/viral)
3-congenital disorder (Alpha 1 antitrypsin def/Cystic Fibrosis/)
3-immuno(-) (Gammaglobulinemia and HIV)
4-Airway obstruction (Cancer=Endotracheal Lesion/Tumor mass)
5-CT & systemic disorder (RA/Sjogren/SLE)
6-Congenital Structural Defect (Ammonia/Cl/Nit)
7-Toxic inhalation (Transplantation)
-All causative agents (-) clearance & host defenses —->inability to clear secretion  ———> predisposing chronic infection & inflammation!
-Frequent infection——> Airway thickening with viscous mucous containing mediators,
Slowly become dilated, scarred & deformed!!
-Histological Bronchial wall are thickened by Edema / Inflammation & Neovascularization!!
***Bronchiectasis Dx:
Criteria: Chronic cough + Sputum production /CT(+)
^^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

-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


***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-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
***Purulent Lung Disease (abscess, Bronchiectasis) Principles of Management:
^^Bronchiectasis -Tx:
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
^^Lung abscess Tx:
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