Lower Respiratory Infection
Lower Respiratory Infection
Lower Respiratory Infection
Agus Widiyatmoko
Lower Respiratory Tract
Definition
• History collection
• Physical examination
• Chest x- rays
• Sputum cultures
• Pulmonary function test
• Spirometer excercises
• Bronchoscopy
Pharmacologic Antibiotics - these are effective for
bacterial infections, but not for viral
management infections. They may also prevent
secondary infections.
Cough medicine - one must be careful not
to completely suppress the cough, for it is
an important way to bring up mucus and
remove irritants from the lungs.
Bronchodilators - these open the bronchial
tubes and clear out mucus.
Management, cont...
01 02 03
Mucolytics - these Anti-inflammatory Pulmonary
thin or loosen mucus medicines and rehabilitation
in the airways, glucocorticoid program - this
making it easier to steroids - these are includes work with a
cough up sputum. for more persistent respiratory therapist
symptoms. to help breathing.
Pneumonia
Pneumonia - Definition
• Pneumonia is an
abnormal inflammatory condition of
the lung. It is often characterized as
including inflammation of
the parenchyma of the lung (that is,
the alveoli) and abnormal alveolar
filling with fluid
(consolidation and exudation)
• Community acquired PNA (CAP)
• Infection of lung parenchyma in pt who is not
hospitalized or living in a long-term care facility for
≥2 weeks
• Community-acquired
pneumonia develops in people
with limited or no contact with
medical institutions or settings.
• CAP occurs throughout the
world and is a leading cause of
illness and death
• Risk Factors for pneumonia
• age
• alcoholism
Community • smoking
Acquired • asthma
• Immuno suppression
Pneumonia • institutionalization
• COPD
• dementia
Several Microbes can
cause CAP
• The most commonly identified pathogens are
Streptococcus pneumoniae, Haemophilus
influenzae, and atypical organisms (i.e.,
Chlamydia pneumoniae, Mycoplasma
pneumoniae, Legionella sp).
• Typical pneumonia usually is caused by
bacteria such as Streptococcus pneumoniae.
Typical x • Atypical pneumonia usually is caused by the
influenza virus, mycoplasma, Chlamydia,
Atypical Legionella, adenovirus, or other unidentified
microorganism.
etiological • The patient's age is the main differentiating
agents factor between typical and atypical pneumonia;
young adults are more prone to atypical
causes, and very young and older persons are
more predisposed to typical causes.
• CAP is usually acquired via
inhalation or aspiration of
pulmonary pathogenic organisms
into a lung segment or lobe.
• Less commonly, CAP results from
Pathophysiology secondary bacteraemia from a
distant source, such as Escherichia
coli urinary tract infection and/or
bacteraemia.
• CAP due to aspiration of
Oropharyngeal contents is the
only form of CAP involving
multiple pathogens.
• Symptoms:
• Cough (typically productive)
• Fever with chills and sweats
• Shortness of breath
• Chest pain
CAP:
Clinical Presentation • Signs:
• Fever, tachycardia,
tachypnea
• Crackles/rhonchi on lung
exam
• Leukocytosis
• Infiltrate on Cxray (or other imaging) required
for the diagnosis of pneumonia
CAP: • If clinically suspect CAP, but negative Cxray
Diagnosis – consider:
• Chest CT
Imaging • Empiric treatment and repeat Cxray in 24-48
hrs
X ray chest gives the
leading clues in Diagnosis
Lobar Infiltrate Interstitial Infiltrate
CAP: Diagnosis – Sputum Gram Stain/Culture
• CURB-65 criteria
• Confusion
• Urea >19 mg/dL
Severity of PNA • Respiratory rate ≥30
• Blood pressure (SBP <90 or DBP ≤60)
• ≥65 year old
• ≥2 criteria then needs hospital
admission and ≥3 criteria may need
ICU level of care
Risk Score
II < 70
III 71-90
IV 91-130
V > 130
PSI Index Mortality Rate
I 0.1-0.5%
Consider
II 0.4-0.9%
Outpt Tx
III 0-2.8%
IV 8.2-12.5% Needs Inpt
V 27-31% Tx
• CURB-65 criteria
• Confusion
• Uremia (BUN >20)
• Respiratory rate (RR >30)
• Blood pressure (SBP <90 or DBP < 60)
• Age 65 years or greater
CAP:
CURB-65
[Magill SS, Edwards JR, Fridkin SK; Emerging Infections Program Healthcare-Associated Infections
Antimicrobial Use Prevalence Survey Team. Survey of healthcare-associated infections. N Engl J Med
2014; 370:2542–3.]
2005 ATS/IDSA guidelines
Pneumonia* Definition
VAP Patients receiving mechanical ventilation for at least 24 h with first positive bacterial† respiratory
culture finding after ventilator start date.
HAP Patients with a first positive bacterial† respiratory culture finding >2 days from admission who do
not meet VAP definition.
HCAP Patients with a first positive bacterial† respiratory culture finding within 2 days of admission and
any of the following:
(1) admission source indicates a transfer from another health-care facility;
(2)receiving long-term hemodialysis (ICD-9-CMcodes); and
(3) prior hospitalization within 30 days who do not meet VAP definition
CAP Patients with a first positive bacterial† respiratory culture finding who do not meet VAP or HCAP
definition.
All pneumonia cases with primary or secondary ICD-9-CM codes for pneumonia and positive respiratory culture finding treated in a hospital that collected at least 5 days
of culture data.†Eligible bacteria include: Acinetobacter, Bacillus, Bacteroides, Bordetella,Brucella, Chlamydia, Enterobacter, Escherichia, Haemophilus, Klebsiella,
Legionella, Listeria, MRSA, Mycoplasma, Proteus, Pseudomonas, Salmonella, Serratia, Shigella, S aureus, Streptobacillus, Streptococcus A, Streptococcus B,
Streptococcus C, Streptococcus D, Streptococcus F, Streptococcus G, Streptococcus nongroup, S pneumoniae, Yersinia.(2)
• Definition – not amended . Same as
2005 guidelines.
HAP/VAP ATS/IDSA • All recommendations were labeled as
2016 Practice either “strong” or “weak” (conditional)
guidelines according to the GRADE approach. The
words “we recommend” indicate strong
recommendations and “we suggest”
indicate weak recommendations.
Threshold values for cultured specimens used in the
diagnosis of pneumonia
• Values and preferences: Targeting the specific pathogens and to assure adequate
treatment.
• Remarks: The frequency with which the distribution of pathogens and their
antimicrobial susceptibilities are updated should be determined by the institution.
Considerations should include their rate of change, resources, and the amount of
data available for analysis.
What Antibiotics Are Recommended for Empiric
Treatment of Clinically Suspected VAP?
• Coverage for S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli in all empiric regimens (strong
recommendation, low-quality evidence).
• i. We suggest including an agent active against MRSA for the empiric treatment of suspected VAP only in patients
with any of the following:
• a risk factor for antimicrobial resistance (Table 2),
• patients being treated in units where >10%–20% of S. aureus isolates are methicillin resistant, and
• patients in units where the prevalence of MRSA is not known (weak recommendation, very low-quality evidence).
• ii. We suggest including an agent active against methicillin sensitive S. aureus (MSSA) (and not MRSA) for the
empiric treatment of suspected VAP in patients without risk factors for antimicrobial resistance, who are being
treated in ICUs where <10%–20% of S. aureus isolates are methicillin resistant (weak recommendation, very low-
quality evidence).
• 2. If empiric coverage for MRSA - vancomycin or linezolid (strong recommendation, moderate-quality evidence).
• 3. empiric coverage for MSSA (and not MRSA) - piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or
meropenem (weak recommendation, very low-quality evidence). Oxacillin, nafcillin, or cefazolin are preferred
agents for treatment of proven MSSA, but are not necessary for the empiric treatment of VAP if one of the above
agents is used.
• 4. Two antipseudomonal antibiotics from different classes for the empiric treatment of
suspected VAP only in patients with any of the following:
• a risk factor for antimicrobial resistance,
• patients in units where >10% of gram-negative isolates are resistant to an agent being
considered for monotherapy, and
• patients in an ICU where local antimicrobial susceptibility rates are not available (weak
recommendation, low-quality evidence).
• 5. We suggest prescribing one antibiotic active against P. aeruginosa for the empiric
treatment of suspected VAP in patients without risk factors for antimicrobial resistance
who are being treated in ICUs where ≤10% of gram-negative isolates are resistant to the
agent being considered for monotherapy (weak recommendation, low-quality evidence).
• 6. In patients with suspected VAP, we suggest avoiding Colistin / aminoglycosides if alternative agents
with adequate gram-negative activity are available (weak recommendation, low-quality evidence).
• Values and Preferences: These recommendations are a compromise between the competing goals of
providing early appropriate antibiotic coverage and avoiding superfluous treatment that may lead to
adverse drug effects, Clostridium difficile infections, antibiotic resistance, and increased cost.
• Remarks: The 10%–20% threshold for deciding whether or not to target MRSA and the 10% threshold
for deciding whether or not to prescribe 1 antipseudomonal agent or 2 were chosen by the panel with a
goal of trying to assure that ≥95% of patient receive empiric therapy active against their likely
pathogens; when implementing these recommendations, individual ICUs may elect to modify these
thresholds.
• If patient has structural lung disease increasing the risk of gram-negative infection (ie, bronchiectasis or
cystic fibrosis), 2 antipseudomonal agents are recommended.
Should Patients With VAP Receive 7 Days or
8–15 Days of Antibiotic Therapy?
Mutation Mutation
#1 #2
Mutation #1
Result
of Mutation #2
ANTIGENIC DRIFT
Antigenic drift
Human influenza
Influenza virion virion
from an animal
Reassortment
of genome
segments
Host cell
Antigenic
ANTIGENIC SHIFT shift Only for A
Prevention and Treatment
• C. Traction from
adjacent fibrosis
• Many conditions may lead to bronchial wall
injury.These include infections like
Mechanisms • Recurrent infections
of • Impaired host defense leading to infection
• Exaggerated immune response
development • Congenital structural defects of the
of bronchial wall
• And extrinsic insults damaging the airway
Bronchiectasis wall
• Symptoms
1. Persistent and recurrent cough with purulent
and sputum production.
2. Repeated respiratory tract infection.
Clinical 3. Haemoptysis 50-70% of cases.
• Sputum analysis
when sputum is allowed to settle may reveal Dittrich plugs, small, white or yellow concretions.
Gram’s stain may reveal Pseudomonas and E-coli suggestive of CF but not diagnostic.
Presence of non-mucoid sputum is suggestive of pseudomonas aeruginosa, while presence of
eosinophilia and golden plugs containing hyphae is suggestive of aspergillous species.
• Routine bacterial, fungal, and mycobacterial cultures may reveal other organisms.
Types of bronchiectasis
Cylindrical bronchiectasis
Varicose bronchiectasis
Cystic bronchiectasis
Supportive Treatment
• Cessation of smoking
• Avoidance of second-hand smoking
• Adequate nutritional intake
• Immunizations for influenza and pneumococcal pneumonia
• Conformation of immunizations for measles, rubella and pertusis
• Oxygen therapy is reserved for patients with hypoxemia and end stage complications such as cor-
pulmonale
1. Treatment of infection
2. Clearance of the secretion
3. Reduction of the inflammation
4. Treatment of the underlying problem
• Antibiotics- Initially during the acute phase amoxicillin,TMP or levofloxacin
should be started and later proper antibiotic should be chosen accordingly to the
Sputum culture and Gram’s stain.
• When pseudomonas is the organism oral Quinolone or parentral therapy with
aminoglycosides, carbapenam or third generation cephalosporins should be
given.
• There is no firm guidelines for therapy and hence should be continued for 10-14
days.
• Aerosolized antibiotics
It delivers relatively high concentration of drugs with relatively lesser
systemic side-effects.
It is beneficial in treating Pseudomonas infection.
Currently, inhaled Tobramycin is most widely used. Gentamycin and Colistin
have also been used
• Bronchial hygiene
Proper mechanical and devices with proper positioning of the patient can
help the patients with copious secretions.
Postural drainage with percussion and vibration helps in effective clearance.
Devices like Flutter device, Intrapulmonic percussive ventilation device and
incentive spirometry are available.
Newest device is the ‘Vest’ system wherein a pneumatic compression vest is
worn by the patient periodically throughout the day.
Tapping of the chest wall to
dislodge the secretions
Positional drainage and
physiotherapy
Use of mucolytics can help thinning out the thick mucous secretions.
Use of recombinant DNAse which help in the destruction of the DNA released by
the neutrophiles has shown improvement in the PF in case of CF.
Bronchodilators help in the obstruction and clearance e of the bronchus.
Use of nebulizations concentrated with 7% NaCl have shown beneficial in
CF-related Bronchiectasis.
• Anti-inflammatory therapy
Reduce the inflammation caused by the organisms and subsequently reduce the
tissue damage.
Inhaled corticosteroids, Leucotriene inhibitors and NSAID can be given.
Studies have shown use of inhaled corticosteroids have shown qualitative
improvement in the quality of life.
Azithromycin has known anti-inflammatory properties and its long term use has
shown ,marked improvement in CF and non-CF bronchiectasis.
• Surgical resection
Helpful in advanced or complicated disease.
Indications :
1.Patients who have focal disease that is poorly controlled by anti-biotics.
2.Reduction of acute infective episodes
3.Massive haemoptysis(Alternatively bronchial artery embolization may be
attempted)
4. Foreign body or tumor removal
5. Consideration in the treatment of MAC or Aspergillus specific infections
• Complications :
empyema, haemmorrhage, prolonged air leak and persistent atelectasis.
Mortality is <1 %.
• Lung transplantation
Single or double lung transplantation for severe bronchiectasis,
predominantly related to CF. FEV1 < 30
and in younger patients it may be considered.
ALHAMDULILLAH