A SEMINAR ON LOWER RESPIRATORY TRACT INFECTIONS

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Submitted to: B.P. Satish Kumar Assistant.Professor

Submitted by: P.Deepak Pharm D (P.B) 1st Yr

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Anatomy of bronchi

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ACUTE BRONCHITIS

DEFINITION : Acute bronchitis is a condition that occurs

when the bronchial tubes in the lungs become inflamed. The bronchial tubes swell and produce mucus, which causes a person to cough. Most symptoms of acute bronchitis (chest pain, shortness of breath, etc.) last for up to 2 weeks, but the cough can last for up to 8 weeks in some people.

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Aetiology of acute bronchitis

Common respiratory tract viruses (80%) (in about 20% of cases):

Pneumococci ( in 2 - 30%)? Haemophilus ( in 2 - 8%)? Mycoplasma (in 0.5 - 11%) Chlamydia (in 0 -18%) (Pertussis (in 0 - 7%))
20.6.2000 4/12/12 5

Bacteria

Epidemiology:

Cough is the most frequent reason. the UK, acute bronchitis affects 44 out of every 1000 adults over the age of 16 years, with most episodes (82%) occurring in autumn or winter. in the US it has been estimated that almost 5% of the general population develops acute bronchitis each year

In

While

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PATHOGENESIS
Acute bronchitis is a self limiting illness. Infection of trachea and bronchi produce hyperemic and edematous mucous membranes with an increase in bronchial secretions which can become thick and tenacious impairing mucociliary activity. Recurrent respiratory infections may be associated with increase airway hyperreactivity and leads to pathogenesis of asthma and COPD.

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CLINICAL PRESENTATION
Signs and Symptoms :

Cough persisting > 5 days to weeks Coryza,sore throat,malaise,headache Fever rarely > 39c

Physical examination :

Rhonchi or coarse Purulent sputum in 50% of patients

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PHARMACOLOGICAL THERAPY
Mild

analgesic or antipyretics therapy is helpful in removal of malaise,lethargy and fever. 650 mg in adults or 10-15 mg/kg in children 200-800 mg in adults or 10 mg/kg in children. Common antibiotics used in these cases are: Erythromycin, ampicillin/clavulanic acid ( Augmentin), azithromycin (Zithromax) or 4/12/12

Aspirin

Ibuprofen

Chronic Bronchitis

Definition:
Chronic bronchitis is defined as chronic cough and expectoration. Excessive tracheo bronchial mucus production sufficient to cause cough with expectoration for most days of at least 3 months of the year for 2 consecutive years.
The most important etiologic factor in the development of chronic bronchitis is cigarette smoking.
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Etiology:

CHRONIC BRONCHITIS
PATHOPHYSIOLOGY :

Chronic inflammation Hypertrophy & hyperplasia of bronchial glands that secrete mucus Increase number of goblet cells Bronchospasm End result
Hypoxemia Polycythemia (increase

RBCs)

Chronic Bronchitis: Clinical Manifestations

In early stages
Productive cough

Bronchospasm

Frequent respiratory infections Advanced stages

Dyspnea on exertion Dyspnea at rest Hypoxemia & hypercapnea Polycythemia Cyanosis
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Goals of Treatment:

Improved ventilation Remove secretions complications progression of signs & symptoms

Prevent Slow

Promote

patient comfort and participation in treatment includes omission of the causative 4/12/12 agent, antiobiotic therapy, and

Treatment

Acute exacerbation of chronic bronchitis

Management in primary care

Antibiotic. e.g. doxycycline or amoxicillin Bronchodilator inhalers Short course of steroids in some cases

Refer

to hospital if

Evidence of respiratory failure Not coping at home

A.J.France 2010

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Pulmonary function test:

Decrease Prolonged

vital capacity expiratory flow

Spirometry peak

flow meter blood gas (ABG)

Arterial x-ray

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TREATMENT
drugs

Oral
dose 0.25-0.5 .5 .5-75 dose .5

dose schedule(dose/dail y)

ampicillin amoxicillin ciprofloxacin drugs Tetracycline HCL

azithromycin erythromycin

antibiotics commonly used4 3 2 dose 4 .25 .5

schedule(dose/dai ly 1 4/12/12 16 4

BRONCHIOLITIS
Its an acute viral infection of lower respiratory tract infection affecting
nearly 50% of children during 1st year of life and 100% by age of 3 years.

Respiratory syncytial virus is the most common cause of bronchiolitis accounting for 70 % of cases.

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INFLUENZA
Influenza

is an acute, viral respiratory

infection.
Fever,

chills, headache, aches and pains throughout the body, sore throat which may lead to bronchitis or pneumonia.

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SYMPTOMS
FEVER HEADACHE MYALGIA COUGH RHINITIS

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NON-PULMONARY COMPLICATIONS
myositis (rare, > in children, > with type B) cardiac complications liver and CNS
Reye syndrome

peripheral nervous system

Guillian-Barr syndrome

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Signs and symptoms

Chills Body aches, especially throat and joints Coughing and sneezing Extreme fever Fatigue, headache, and nasal congestion

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Although four antiviral agents are commercially available, for treatment of influenza disease in infants and children oseltamivir (Tamiflu), zanamivir (Relenza), amantidine and rimantidine. Oseltamivir is given for the treatment and prophylaxis of influenza for those aged 1 year and older.

Pharmacotherapy of influenza

Zanamivir is labeled for use in ages 7 years for treatment and for ages 5 years for prophylaxis.

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PNEUMONIA

DEFINITION : An inflammation of the lung caused by bacteria, viruses, or mycoplasms. Radiographs reveal patchy alveolar infiltrates, or pulmonary densities The alveolar air spaces are filled with fluid or cells If the infection is bacterial, treatment includes antiobiotics

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Community-acquired pneumonia
Epidemiology

Community-acquired pneumonia (CAP) is a serious illness. 85% of cases of CAP are caused by the typical bacterial pathogens, namely, Streptococcus pneumoniae,Haemophilus influenzae, and Moraxella catarrhalis. remaining 15% are caused by atypical pathogens, namely Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella species. Unusual aerobic gram-negative bacilli (for 4/12/12 example, Pseudomonas

The

Clinical features

headache malaise diarrhea confusion decreased appetite

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Signs and Symptoms

Fever or hypothermia Cough with or without sputum, hemoptysis Pleuritic chest pain Myalgia, malaise, fatigue GI symptoms Dyspnea Rales, rhonchi, wheezing Bronchial breath sounds

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Risk Factors for pneumonia

age alcoholism smoking asthma Immuno suppression COPD dementia

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Hospital-acquired pneumonia

Hospital-acquired pneumonia, also called nosocomial pneumonia, is a lung infection acquired after hospitalization for another illness or procedure. Hospitalized patients have a variety of risk factors for pneumonia, including mechanical ventilation, prolonged malnutrition, underlying cardiac and pulmonary diseases, achlorhydria. These pathogens include resistant aerobic gram-negative rods, such as Pseudomonas , Enterobacter and Serratia, resistant g Antibiotics used for hospital-acquired pneumonia include aminoglycosides, fluoroquinolones, carbapenems, and 4/12/12

Pathogenesis

Inhalation, aspiration and hematogenous spread are the 3 main mechanisms by which bacteria reaches the lungs When organisms bypass normal respiratory defense mechanisms or when the Pt inhales aerobic GN organisms that colonize the upper respiratory tract or respiratory support equipment.

Primary inhalation:

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Aspiration Pneumonia

This type of pneumonia can occur if you inhale food, drink, vomit, or saliva from your mouth into your lungs. This may happen if something disturbs your normal gag reflex, such as a brain injury, swallowing problem, or excessive use of alcohol or drugs. Aspiration pneumonia can cause pus to form in a cavity in the lung. When this happens, it's called a lung abscess (AB-ses) Atypical Pneumonia Several types of bacteriaLegionella pneumophila , mycoplasma pneumonia, and Chlamydophila pneumoniaecause atypical pneumonia, a type of CAP.
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TYPES OF ATYPICAL PNEUMONIA

Legionella

pneumophila pneumonia :

Mycoplasma This It

is a common type of pneumonia that usually affects people younger than 40 years old. may be associated with a skin rash and hemolysis (the breakdown of red blood cells). pneumoniae : This type of pneumonia can occur all year and often is mild. The infection is most common in people 65 to 79 years old. 4/12/12

Chlamydophila

A lobar pneumonia is an infection that involves, and is limited to, a single lobe of a lung (generally due to Streptococcus pneumoniae). In contrast, multilobar pneumonia involves more than one lobe. Ventilator-associated pneumonia can be considered a subset of hospital-acquired pneumonia; and in hospitalized or recently discharged patients . Pneumococcal pneumonia is due to S. pneumoniae (around half of all pneumonias). Finally, atypical pneumonia is due to either Mycoplasma, Chlamydia,or Legionella.

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Lobar Pneumonia

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Pathophysiologic process and manifestations.

Organisms may enter the respiratory tract through inspiration

or aspiration of oral secretions; staphylococcus and Gramnegative bacilli may reach the lungs through circulation in the bloodstream.

Normal pulmonary defense mechanisms (cough reflex,

mucocilliary transport, and pulmonary macrophages) usually protect against infection.

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Pathogenesis
The invading organism multiplies and releases

damaging toxins, causing inflammation and edema of the lung parenchyma;

This results in accumulation of cellular debris and exudates.

Lung tissue fills with exudates and fluid, In viral pneumonia, the ciliated epithelial cells

become damaged.

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Streptococcus pneumonia

Most common cause of CAP Gram positive diplococci Typical symptoms (e.g. malaise, shaking chills, fever, rusty sputum, pleuritic hest pain, cough) Suppressed host 25% bacteremic

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Viral Pneumonia

More common cause in children

RSV, influenza, para influenza

Influenza

most important viral cause in adults, especially during winter months pneumonia (secondary bacterial infection)
S. pneumo, Staph aureus

Post-influenza

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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 beta-lactamase inhibitor, with a macrolide.

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AMOXICILLIN

Capsules: 250 mg (as trihydrate), 500 mg (as trihydrate) Class: Antibiotic/Penicillin Action Inhibits bacterial cell wall mucopeptide synthesis. Clavulanic acid inactivates a wide range of beta-lactam enzymes found in bacteria resistant to penicillins and cephalosporins. Lower Respiratory Tract Infections ADULTS AND CHILDREN WEIGHING AT LEAST 40 KG: PO 875 mg q 12 hr or 500 mg q 8 hr. CHILDREN (OLDER THAN 3 MO AND WEIGHING LESS THAN 40 KG): PO 45 mg/kg/day in divided doses q 12 hr or 40 mg/kg/day in divided doses q 8 hr. Adverse Reactions: CNS: Dizziness; fatigue; insomnia; GI: Gastritis; anorexia; nausea; vomiting;HEPA: Transient hepatitis; cholestatic jaundice;GU: Interstitial nephritis
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OSELTAMIVIR PHOSPHATE
Class:

Anti-infective/Antiviral

Action:

Inhibition of influenza virus neuraminidase with possible alteration of virus particle aggregation and release. : Treatment of uncomplicated acute illness caused by influenza infection in patients > 1 yr who have been symptomatic for 2 days; prophylaxis of influenza in 4/12/12

Indications

Diphenhydramine
Trade One

name: Benadryl

of the oldest anti-histamines

Action:

Antagonizes the effects of histamine at the H1 receptor sites. Effects: Significant CNS depressant: drowsiness, dizziness, hypotension, dry mouth.
Onset: immediate to 60 minutes Peak: 1-4 hours Duration: 4-8 hours
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Adverse

TRIMETHOPRIMSULFAMETHOXAZOLE(COTRIMOXAZOLE)

Action: Sulfamethoxazole (SMZ) inhibits bacterial synthesis of dihydrofolic acid by competing with PABA. Trimethoprim (TMP) blocks production of tetrahydrofolic acid by inhibiting the enzyme dihydrofolate reductase. This combination blocks two consecutive steps in bacterial biosynthesis of essential nucleic .
Pneumocystis Carinii Pneumonitis ADULTS: PO 20 mg/kg TMP/100 mg/kg SMZ daily in divided doses q 6 hr for 14 days. IV 1520 mg/kg/day (based on TMP) in 34 divided doses for up to 14 days. Exacerbation of Chronic Bronchitis ADULTS: PO 160 mg TMP/800 mg SMZ q 12 hr for 14 days. acids and proteins and is usually bactericidal.

Adverse Reactions;CNS: Headache; depression; seizures;GI: Nausea; 4/12/12

Azithromycin

Action : Interferes with microbial protein synthesis. Zithromax Tablets: 250 mg (as dihydrate) Tablets: 500 mg (as dihydrate) Class: Antibiotic, Macrolide Indications ADULTS: Treatment of infections of the respiratory tract, chronic obstructive pulmonary disease (COPD), community-acquired pneumonia, CHILDREN: community-acquired pneumonia Bacterial Infections Adults: PO 500 mg as single dose on first day, then 250 mg/day on days 2 through 5. Community-Acquired Pneumonia
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References

Joseph .T. Dipiro; Pharmacotherapy- A Pathophysiolgic Approach; 7th

edition; Page.no.1945-50.

Bestpractice.bmj.com/bestpractice/monograph/135/.../epidemiology.html

Hueston WJ (March 1997). "Antibiotics: neither cost effective nor 'cough' effective". The Journal of Family Practice 44 (3): 2615. A to Z drug facts 4/12/12 44