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Bronchitis, Pneumonia, and Pleural Empyema

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Bronchitis, Pneumonia, and Pleural Empyema Katay Bouttamy DO Tintinalli Chapter 63 Acute Bronchitis Definition: an acute respiratory tract infection with cough being ... – PowerPoint PPT presentation

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Title: Bronchitis, Pneumonia, and Pleural Empyema


1
Bronchitis, Pneumonia, and Pleural Empyema
  • Katay Bouttamy DO
  • Tintinalli Chapter 63

2
Acute Bronchitis
  • Definition an acute respiratory tract infection
    with cough being the predominant feature
  • Usually lasts 1 to 3 weeks, peaks between October
    and March
  • Viruses cause the vast majority of cases
    Influenza A and B, parainfluenza, and RSV are the
    most common

3
Acute Bronchitis
  • Bordetella pertussis, Mycoplasma pneumoniae,
    Chlamydia pneumoniae, and Legionella species are
    reported in 5-25 of cases
  • Clinical features cough and wheezing are the
    strongest positive predictors, less than 10 of
    patients are febrile

4
Acute Bronchitis
  • Diagnosis (1) acute cough less than 1-2 weeks
    (2) no prior lung disease (3) no auscultatory
    abnormalities that suggest pneumonia
  • Treatment studies have failed to show
    significant improvement with Abx therapy and at
    best may decrease duration of cough, decrease
    purulent sputum production and return patients to
    work lt 1 day each

5
Acute Exacerbation of Chronic Bronchitis
  • Two-thirds are bacterial in origin (H. flu, Strep
    pneumo, M. Catarrhalis)
  • High risk patients are the elderly and those with
    poor lung function and with comorbid conditions
  • Characterized by increased dyspnea, increased
    cough and sputum production and purulence with
    underlying COPD
  • Treatment includes doxycycline, extended spectrum
    cephalosporin, macrolide, augmentin or
    fluoroquinolone

6
Pneumonia
  • CAP is 6th leading cause of death
  • Studies of both inpatients and outpatients with
    CAP fail to identify a specific pathogen in
    40-60 of patients but when found pneumococcus is
    still the most common

7
Pneumonia
  • Typical presentation of pneumococcal pneumonia is
    sudden onset of fever, rigors, dyspnea, bloody
    sputum production, chest pain, tachycardia,
    tachypnea and abnormal findings on lung exam
  • Some of the atypicals are associated with
    headache and GI illness

8
Other bacterial pneumonia
  • Staph aureus is a consideration in patients with
    chronic lung disease, laryngeal CA,
    immunosuppressed patients, NH patients chest
    Xray usually shows extensive disease with
    empyema, effusion or multiple areas of infiltrate

9
Other bacterial pneumonia
  • Klebsiella occurs in patients at risk at
    aspiration, alcoholics, elderly and other
    patients with chronic disease may develop
    abscesses but often have lobar infiltrates
  • Pseudomonas not a typical cause of CAP and
    usually associated in patients who have prolonged
    hospitalization, have been on broad-spectrum Abx,
    high-dose steroids, structural lung disease or NH
    patients

10
Other bacterial pneumonia
  • H. flu seen in elderly and should be considered
    in patients with COPD, sickle cell disease or
    immunocompromised disorders
  • M. catarrhalis similar to H. flu

11
Atypical Pneumonia
  • Legionella should be considered in cigarette
    smokers, persons with COPD, transplant patients
    and immunosuppressed patients commonly
    complicated by GI symptoms including abdominal
    pain, vomiting and diarrhea
  • Chlamydia usually causes a mild subacute illness
    with sore throat, mild fever, and NP cough

12
Atypical Pneumonia
  • Mycoplasma occurs year round and causes a
    subacute respiratory illness and occasionally
    causes extrapulmonary symptoms including bullous
    myringitis, rash, neurologic symptoms, arthritis,
    hematologic abnormalities and rarely renal failure

13
Pneumonia in Special populations
  • Alcoholics Strep pneumo still most common but
    Klebsiella and H. flu are important pathogens
  • Diabetics patients between 25-64 are 4 times
    more likely to have pneumonia
  • Pregnancy more likely to experience preterm
    labor, preterm delivery and deliver a low
    birthweight infant

14
Pneumonia in Special populations
  • Elderly 3 times more likely to have pneumococcal
    bacteremia, mortality is 3-5 times greater than
    those younger than 65, have atypical symptoms
    (afebrile, c/o weakness, falling, GI symptoms,
    delirium, confusion) and up to 1/3 will not
    manifest leukocytosis

15
Nursing-Home acquired Pneumonia
  • Patients are less likely to have productive cough
    or pleuritic chest pain and more likely to be
    confused and have poorer functional status and
    more severe disease
  • 8 independent predictors of pneumonia increased
    pulse, RRgt30, Tgt100.4, somnalence or decreased
    alertness, acute confusion, lung crackles,
    absence of wheezes and increased WBC

16
Treatment
  • Outpatient doxycycline, newer macrolide or
    fluoroquinolone
  • Hospitalized evidence indicates that early
    administration (within 8 hrs of presentation)
    leads to lower mortality rate and hospital stay,
    therapy should be initiated with 2-3rd generation
    cephalosporin or PCN plus beta-lactamase
    inhibitor, with a macrolide. Coverage can also be
    provided with newer fluoroquinolone.

17
Disposition
  • Estimated 75 of patients with CAP do not require
    hospitalization, many factors influence prognosis
    and outcome
  • Fines prediction rules can be used to estimate
    risk of death and ICU placement (does not include
    patients from NH or hospital setting and HIV
    patients)

18
Disposition
  • PSI score of I, II, III generally have low
    mortality and mortality jumps between III and IV
  • Forest study looked at clinical judgement vs PSI
    alone to determine need for hospitalization many
    people with low PSI need to be admitted for other
    reasons (noncompliance, inability to eat or
    drink, unmet social needs, failed outpatient Tx)

19
Empyema
  • Pleural effusions are present on X-ray of 20-60
    of patients with bacterial pneumonia and often
    resolve with antibiotic therapy
  • Risk factors aspiration, immunocompromised
    patients with gram neg bacteria, fungal
    infections, TB or malignancy

20
Empyema
  • Exudative stage free flowing pleural fluid, very
    amenable to treatment with closed tube drainage
  • Fibrinopurulent stage formation of fibrin
    strands through the pleural fluid resulting in
    loculations, makes adequate drainage with single
    chest tube unlikely
  • Organizational stage fibrosis is much more
    extensive forming a pleural peel that restricts
    expansion even if fluid can be evacuated

21
Empyema
  • Decub films will be helpful in determining if
    fluid is free flowing or loculated
  • Pleural fluid that is gross pus with positive
    cultures or gram stain is considered empyema
    along with other findings pHlt7.1, glucoselt40 and
    LDHgt1000

22
Empyema
  • Treatment drainage of pus by chest tube,
    reexpansion of lung and eradication of the
    infection. Treatment of organizational stage
    requires surgical intervention with removal of
    the fibrous peel

23
Questions
  • 1. All are true of Acute Bronchitis except
  • a. Peaks from October and March
  • b. Viruses are the majority of cause
  • c. Strep pneumo is a major cause if it is
    bacterial in etiology
  • d. Less than 10 of patients are febrile

24
Questions
  • 2. A 45 yo male presents with sudden onset of
    fever, rigors, shortness of breath and rust
    colored sputem. The most likely cause is
  • a. H. Flu
  • b. Legionella
  • c. Strep pneumo
  • d. M. catarrhalis

25
Questions
  • 3. The most common cause of CAP in an HIV patient
    is
  • a. Strep pneumo
  • b. Tuberculosis
  • c. H. Flu
  • d. Pneumoncystis carinii

26
Questions
  • 4. T or F Klebsiella is the most common cause of
    CAP in alcoholics.
  • 5. A 57 yo male presents with nonproductive
    cough, fever of 102, dyspnea and diarrhea. His
    labs show a WBC of 18,000 and Na of 129. The most
    likely cause is
  • a. H. Flu
  • b. Strep pneumo
  • c. Mycoplasma
  • d. Legionella

27
Answers
  • 1. C
  • 2. C
  • 3. A
  • 4. False
  • 5. D
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