Lobna Al AL Juffali Fall 2010

Lobna Al AL Juffali
Fall 2010
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Upper respiratory tract
◦ Nose, oropharynx, and larynx
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Lower respiratory tract
◦ Lower airways and lungs
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Upper and lower airways
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Nose
Passageways that allow
air to reach the
Pharynx
lungs
1. Purify
Larynx (speech)
2. Humidify
Trachea
3. Warm incoming air
Bronchi and their smaller branches
lungs
 Alveoli
Gas exchange
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The major function of the respiratory system
is to supply the body with oxygen and to
dispose of carbon dioxide.
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Hypoxia: Decreased levels of oxygen in the tissues.
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Hypoxemia: Decreased levels of oxygen in arterial blood.
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Hypercapnia: Increased levels of CO2 in the blood.
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Hypocapnia: Decreased levels of CO2 in the blood.
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Dyspnea: Difficulty breathing.
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Tachypnea: Rapid rate of breathing.
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Cyanosis: Bluish discoloration of skin and mucous membranes
due to poor oxygenation of the blood.
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Hemoptysis: Blood in the sputum.
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Pharyngitis is an acute infection of the oropharynx
or nasopharynx that results in 1% to 2% of all
outpatient visits.
The incubation period is 2 to 5 days, and the
illness often occurs in clusters
PHARYNGITIS
viral
causes are most common
rhinovirus, coronavirus, and
adenovirus causes ACUTE
Pharyngitis
Bacterial
Group A β-hemolytic
Streptococcus 15% to 30%
Streptococcus pyogenes
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bacteria or viruses may directly invade the
pharyngeal mucosa, causing a local
inflammatory response.
rhinovirus and coronavirus, can cause
irritation of pharyngeal mucosa secondary to
nasal secretions.
Streptococcal infections are characterized by
local invasion and release of extracellular
toxins and proteases.
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acute rheumatic fever
acute glomerulonephritis
reactive arthritis may occur as a result.
Signs and symptoms
 A sore throat of sudden onset that is mostly selflimited
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Pain on swallowing.
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Fever.
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Headache, nausea, vomiting, and abdominal pain
(especially children).
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Erythema/inflammation of the tonsils and pharynx
with or without patchy exudates.
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Enlarged, tender lymph nodes.
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Red swollen uvula, petechiae on the soft palate
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Several symptoms that are not suggestive of Group
A are cough, conjunctivitis, and diarrhea.
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Streptococcus
Throat swab and culture or rapid antigen
detection testing
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Rhinitis
◦ Inflammation of the nasal mucosa
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Sinusitis
◦ Inflammation of the paranasal sinuses
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that persists beyond 7–14 days
Chronic/recurrent infections occur three to four
times a year and are unresponsive to steam and
decongestants.
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Acute rhinosinusitis
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Subacute rhinosinusitis
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Chronic rhinosinusitis
◦ May be of viral, bacterial, or mixed viral-bacterial
origin
◦ May last from 5 to 7 days up to 4 weeks
◦ Lasts from 4 weeks to less than 12 weeks
◦ Lasts beyond 12 weeks
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Occurrence
◦ Occurs in conjunction with allergic rhinitis
◦ Mucosal changes are the same as allergic rhinitis
Symptoms
◦ Nasal stuffiness, itching and burning of the nose, frequent
bouts of sneezing, recurrent frontal headache, watery nasal
discharge
Treatment
◦ Oral antihistamines, nasal decongestants, and intranasal
cromolyn
Acute
-disease lasts less than 30
days with complete
resolution of symptoms
-S. Pneumoniae and H.
influenzae
Chronic
Bacterial
SINUSITIS
viral
-episodes of inflammation
lasting more than 3 months
with persistence of
respiratory symptoms.
-Polymicrobial
- anaerobes
-gram-negative bacilli
-fungi
condition
Signs and symptoms
Acute
•Nasal discharge/congestion.
•Maxillary tooth pain,
• facial or sinus pain that may radiate (unilateral in
particular) as well as deterioration after initial
improvement.
• Severe or persistent (beyond 7 days) signs and
symptoms are most likely bacterial and should be treated
with antimicrobials.
Children:
•Nasal discharge and cough for greater than 10–14 days
•temperature 39°C (102.2°F)
• facial swelling
•pain
Chronic Symptoms
•are similar to those of acute sinusitis but more
nonspecific.
• Rhinorrhea is associated with acute exacerbations.
•Chronic unproductive cough, laryngitis, and headache
may occur.
Adults:
The common cold is a viral infection of your upper
respiratory tract .
 more than 200 viruses can cause a common cold,
symptoms tend to vary greatly.
 Most adults are likely to have a common cold two
to four times a year.
 Children 6-10 times a year.
 Most people recover from
a common cold in about
a week or two.
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Is a viral infection that can affect the upper or lower
respiratory tract.
 influenza season usually runs from November to April
 Three distinct forms of influenza virus have been
identified: A, B and C.
 Of these three variants, type A is the most common and
causes the most serious illness.
 The influenza virus is a highly transmissible respiratory
pathogen. Because the organism has a high tendency
for genetic mutation, new variants of the virus are
constantly arising in different places around the world.
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Influenza infection can cause marked Inflammation
of the respiratory epithelium leading to acute
tissue damage and a loss of ciliated cells that
protect the respiratory passages from other
organisms.
As a result, influenza infection may lead to coinfection of the respiratory passages with bacteria.
It is also possible for the influenza virus to infect
the tissues of the lung itself to cause a viral
pneumonia.
influenza
cold
onset
sudden
gradual
fever
Charecteristic , high
>38˚C 3-4 days duration
rare
cough
Dry
hacking
headache
prominent
rare
myalgia (muscle
aches/pains)
Usual ; often severe
slight
Tiredness and
weakness
Can last up to 2-3 weeks
Very mild
Extreme exhaustion
Early prominent
never
Chest discomfort
common
Mild to moderate
Stuffy nose
sometimes
common
Sneezing
sometimes
usual
Sore throat
sometimes
common
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Pneumonia is the most common cause of death due
to infectious disease
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Seventh most common cause of death in the USA
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Hospital acquired Pneumonia is the second most
common nosocomial infection(0.6%-1.1%)
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Mortality rates are
 CAP without hospitalization 1%
 CAP with hospitalization about 14%
 Nosocomial about 33-50%
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approximately three million cases are diagnosed
annually at a cost of more than $20 billion to the
healthcare system.
Pneumonia occurs throughout the year, with the
relative prevalence of disease resulting from
different etiologic agents varying with the
seasons.
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It occurs in persons of all ages
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clinical manifestations are most severe in the
very young, the elderly, and the chronically ill.
Pneumonia
Hospital Acquired Pneumonia
Ventilator
Hospital
acquired
Health care
Community
Acquired
Pneumonia
Pneumonia
(depending on
the type of
organism
Typical
Atypical
S. pneumoniae, H. influenzae,
Staphylococcus aureus, and enteric
Gram-negative bacteria
Mycoplasma, Legionella,Chlamydia
Viral and TB
inhaled as
aerosolized
particles
via the bloodstream
from an
extrapulmonary site
of infection
aspiration of
oropharyngeal
contents may
occur.
1.Mechanical
 Epithelial cells are covered with beating cilia
blanketed by a layer of mucus.
 Each cell has about 200 cilia that beat up to 500
times/min, moving the mucus layer upward toward
the larynx.
 The mucus itself contains antimicrobial
compounds such as lysozyme and secretory IgA
antibodies.
 the cough reflex to clear aspirated material
2.Cellualr
 Bacteria that reach the terminal bronchioles,
alveolar ducts, and alveoli are inactivated
primarily by alveolar macrophages and
neutrophils.
3.Humoral
 Opsonization of the microorganism by
complement and antibodies enhances
phagocytosis by these cells.
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Depends on the etiologic agent
Bacterial
An intraalveolar
suppurative exudate
with consolidation
Lobar pneumonia
bronchopneumonia
Viral or Mycoplasma
pneumonia
An interstial inflammation
with accumulation of an
infiltrate in the alveolar
walls
No exudates
No consolidation
Fungal
Patchy distribution of
granulomas
Which undergo caseous
necrosis with the
development of
cavaties
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Age >65
Aspiration of oropharyngeal secretions
Viral respiratory infections
Chronic illness and debilitation
Chronic respiratory disease(COPD,astha,cystic
fibrosis)
Cancer
Prolonged bedrest
Tracheastomy or endotracheal tube
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Abdominal thoracic surgery
Rib fractures
Immunosuppressive therapy
AIDS
Smocking history
Alcoholism
malnutrition
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Acute Infection of the pulmonary parenchyma
accompanied by the presence of an acute
infiltrate on chest radiograph or ausculatory
findings consistent with pneumonia . in
patients who are not hospitalized or in a long
–term care facility for 14 days or more before
symptoms appear
Microbiology
S. pneumoniae
H. Influenzae
S. aures
Gram –ve bacilli
Legionella species
M. Pneumoniae
viral
No diagnosis
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Pneumococci reachs the alveoli in droplets of
mucus or saliva.
The lower lobes of the lungs are frequently
involved because of the effect of gravity.
1.Engorgement
• Serious exudates Pours into the alveoli
from the dilated ,leaking blood vessels
(4-12 hrs)
2. Red hepatization
Next 48 hrs
3.Gray hepatization
3-8 days
4.Resolution
7-11days
• The lung becomes red
As RBCS, fibrin, and PMN leukocytes fill the
alveoli.
• Lung become gray as the leukocytes and
fibrin consolidate in the involved alveoli
• Exudate is lysed and resorbed by
macrophages, restoring the tissue to its
original structure
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Sudden
Chills ,fever
Pleuritic pain
Cough
Rust colored sputum
Hypoxemia
As a result of shunting of blood through the
non ventilated, consolidated area of lung
Consolidation
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Plural effusions
Death
 chronically ill
 elderly
 Bacteremia which leads to ( endocarditis, meningitis and
peritonitis)
Chest radiograph
 Dense lobar or segmental infiltrate
Laboratory examination
 Leukocytosis with a predominance of polymorphonuclear cells
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Sputum examination (gross appearance ,microscopic
examination and culture)
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Blood culture
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Should be done in certain high risk patients (e.g. sever CAP, chronic liver disease).
Low oxygen saturation on arterial blood gas or pulse oximetry
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HAP: Pneumonia that occurs 48 hrs or more
after admission Which was not incubating at
the time of admission
Ventilator- associated Pneumonia that arises
more then 48-72 hrs after endotracheal
intubation
Health care associated Pneumonia:
pneumonia developing in a patient who is
 hospitalized in an acute care hospital for 2 or
more days within 90 days of the infection;
 resides in a nursing home or along-term facility
 received recent IV AB therapy,
 chemotherapy, or wound care within the past 30
days of the current infection ;
 or attended a hospital or hemodialysis clinic
Microorganisms
Gram-negitive
bacilli
S. Aures
Anarobic bacteria
H. Influenzae
Gram-negitive bacilli
Pseudomonas aeruginosa
Acinetobacter Spp.
Enterobacter Spp.
Viral
Cytomegalovirus
Influenza
Respiratory syncytial virus
Fungi
Aspergillus
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Cause extensive damage to the lung
parenchyma
Complications such as lung abscess and
emphysema
Mortality is high 33%
1.
2.
3.
4.
5.
6.
7.
Intubation and mechanical ventilation
Supine patient position
Enteral feeding
pharyngeal colonization
Stress bleeding prophylaxis
Blood transfusion
Hyperglycemia
8.
9.
10.
11.
12.
13.
14.
15.
Immunosuppression/corticosteriods
Surgical procedures :thoracoabdominal,
upperabdominal ,thoracic
Immobilization
Nasogastric tubes
Prior antibiotic therapy
Admission to ICU
Elderly
Underlying chronic lung disease
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Pathological consequences of the entery of
oropharyngeal secretions,particulate matter,or gastric
contents into the lower airway.
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Colonization of oropharynx and gastric plays a critical
role in aspiration pneumonia.
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GM-ve organisms within 48 hrs of hospitalization
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Aspiration of orophyrngeal secretions occurs during
sleep and is enhanced by
1.
2.
3.
4.
nasogastric tube
Altered consciousness
Depressed gag reflex
Delayed gastric emptying
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Bacterial counts rise
Sucrulfate is a medication that heals ulcer
without altering the gastric pH.
Aspiration
of
particulate
matter
Aspiration
pneumonia
Anaerobic
pneumonia
Mendelson’s
pneumonia
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Aspiration of oropharyngeal secretions containing
anerobes
Such as Bacteroids, Fusobacterium,
Peptococcus,and Peptostreptococcus species.
Common among patient with poor hygieneand
chronic alcoholism
Onset of symptoms 1-2 weeks
Most distinguish symptom is productive cough of
foul- smelling sputum
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Related to the regurgitation and aspiration of
the acidic stomach contents.
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May lead to sudden death (obstruction)
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It follows three patterns
1. Rapid recovery (small amount or alkaline)
2. Rapid development of acute respiratory distress
syndrome
3. Bacterial superinfection
If the object is
lodged high in the
trachea complete
obstruction ,apnea,
aphonia and rapid
death
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If the object is
lodged in
smaller airways
Chronic cough
And recurrent
infections
Atypical pneumonia refers to pneumonia caused by
certain bacteria - namely, Legionella pneumophila,
Mycoplasma pneumoniae, and Chlamydophila
pneumoniae or virsus.
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atypical pneumonias are commonly associated with
milder forms of pneumonia, pneumonia due to
Legionella, in particular, can be quite severe and lead to
high mortality rates.
Symptoms
 Confusion (especially with Legionella pneumonia)
 Diarrhea (especially with Legionella pneumonia)
 Muscle stiffness and aching , Rash (especially with
mycoplasma pneumonia)
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