Acute bronchitis Pneumonia in Adult

Question 1

Acute bronchitis definition, etiology and clinical features?

Answer 1

Definition:
It is an acute inflammatory condition affecting the bronchi

Etiology:
1) Viral (commonest cause) : Influenza and measles.
2) Bacterial as: H influenza, streptococcal pneumonia, staph. aureus especially after influenza infection) and other bacterial organisms.
3) Chemical as: ammonia inhalation,nitrogen dioxide (with saw wood - wood burns and silofillors), hydrogen chloride, sulphur dioxide exposure in fumigants, chlorine exposure as in chemical and plastic industry, phosgen (war
gas).
4) Allergic as : some fumes, dusts and pine pollens.
5) Physical as: in temperature changes.

Clinical features:
- Any age can be affected especially children and elders.
- Cough, firstly dry then become productive of mucoid or mucopurulent sputum, sometimes streaked with blood, fever is less common in adults.
- Breathlessness and cyanosis do not occur unless the patient has coexisting cardiopulmonary disease.
- Physical examination may reveal no signs but occasionally has low pitched wheeze and coarse crackles due to secretions.

Question 2

Acute bronchitis diagnosis and ttt?

Answer 2

Diagnosis:
- Is based on the history and the self limiting nature of the disease.
- Attention should be paid to detail and if the cough lasts longer than 2 weeks, so chest X-ray should be obtained.
- Bronchoscopy should be done for every patient with haemoptysis especially those over 35 years and cigarette smoker.
- Culture for the mucopurulent sputum.

Treatment:
- Rest and hydration especially for febrile patients.
- Antitussive especially for dry irritating cough.
- Proper antibiotic therapy as amoxicillin or erythromycin, azithromycin in bacterial infection
- Antiallergic, O2, bronchodilators and even corticosteroids in severe cases.

Question 3

Community acquired pneumonia definition and risk factors

Answer 3

Definition: Pneumonia is an inflammatory condition of the lung affecting primarily the microscopic air sacs known as alveoli.

Risk factors include:
* Other lung diseases such as cystic fibrosis, COPD, and asthma.
* Diabetes
* Heart failure.
* Smoking.
* Stroke
* Old age
* Weak immune system
* Chronic kidney disease, and liver disease.
* blockers 2H pump inhibitors or-Proton

Question 4

Diagnosis of Pneumonia

Answer 4

People with infectious pneumonia often have:

-Productive cough
-Fever
-Shortness of breath
-Sharp or stabbing chest pain
-Increased rate of breathing
-In the elderly, confusion may be the most prominent sign.
-Legionella pneumonia may occur with abdominal pain, diarrhea, or confusion.
-Streptococcus pneumoniae is associated with rusty-colored sputum.
-Klebsiella pneumoniae may have bloody sputum often described as “currant jelly.”
- Bloody sputum (hemoptysis) may also occur with tuberculosis, Gram-negative pneumonia, and lung abscesses, as well as more commonly with acute bronchitis.
- Mycoplasma may occur in association with pneumonia, lymph node swelling in the neck, joint pain, or a middle ear infection.

Physical exam:
Physical examination may sometimes reveal:
- Low blood pressure, high heart rate, or low oxygen saturation.
- Decreased chest expansion on the affected side.
- Percussion may be dulled over the affected lung, and increased, rather than decreased, vocal resonance distinguishes pneumonia from a pleural effusion.
- On auscultation, bronchial breathing and crackles may be heard.

Imaging:
- X-ray presentations of pneumonia may be classified as lobar pneumonia, bronchopneumonia (also known as lobular pneumonia), and interstitial pneumonia.
- Bacterial, community-acquired pneumonia classically shows consolidation of one lung lobe, which is known as lobar pneumonia. However, findings may vary, and other patterns are common in other types of pneumonia.
- CT scan can give additional information in indeterminate cases.

Microbiology:
- Pretreatment Gram stain and culture of expectorated sputum should be performed.
- Sputum culture should be considered.
- Viral infections can be confirmed via detection of either the virus or its antigen with culture or polymerase chain reaction (PCR), among other techniques.
- Pleural fluid (if present) for M, C, & S and pH to exclude empyema.
- The causative agent is determined in only 15% of cases with routine microbiological tests.

Blood tests:
- CBC: A white cell count (WCC) >15 x 10^9 suggests bacterial (particularly pneumococcal) infection. Counts of >20 or <4 indicate severe infection.
- Deranged renal and liver function tests can be indicative of severe infection or point to the presence of underlying disease. LFTs may be abnormal, particularly with right lower lobe pneumonia. A raised urea level is a marker of more severe pneumonia.
- Metabolic acidosis is associated with severe illness.
- C-reactive protein (CRP) may be useful in management. Serial CRP measures may be useful in assessing response to treatment.

Question 5

General management of pneumonia

Answer 5

General management
1. Oxygen Hypoxia is due to V/Q mismatching, as blood flows through unventilated lung. Aim for oxygen saturation >92%. If there is severe concomitant COPD, controlled oxygen therapy and close monitoring of blood gases are mandatory.
2. non-invasive ventilatory support NIV may have a place in the management of severe CAP, but should only be used in a high dependency setting, with very close observation.
3. Fluids Assessment of volume status by JVP (with or without central venous access) and blood pressure is paramount. Encourage oral fluids. Intravenous fluids may be needed if volume depleted and severely unwell. Monitor urine output
4. Analgesia Paracetamol or NSAIDs initially if required. Paracetamol also has an antipyretic role
5. Nutritional status is important to the outcome, and nutritional supplements may be of benefit in prolonged illness. Poor nutritional status may increase the risk of acquiring pneumonia
6. Physiotherapy is of no proven benefit in acute pneumonia

Question 6

Where to treat pneumonia

Answer 6

• Outpatient
  *Inpatient ( non ICU )
  *Inpatient ( ICU )

The answer come from severity index eg (C U R B - 65)
*Confusion
*Urea >_ 7 mmol/liter
*RR raised >_ 30 /min
*BP systolic BP <_ 90 and/or diastolic <_ 60
*Age >_ 65

Criteria for severe community-acquired pneumonia.
Minor criteria:
*Respiratory rate >_ 30 breaths/min
*PaO2/FiO2 ratio <_ 250
*Multilobar infiltrates
*Confusion/disorientation
*Uremia (BUN level, >_ 20 mg/dL)
*Leukopenia (WBC count, <_ 4000 cells/mm3)
*Thrombocytopenia (platelet count, <_ 100,000 cells/mm3)
*Hypothermia (core temperature, <_ 36C)
*Hypotension requiring aggressive fluid resuscitation
Major criteria:
*Invasive mechanical ventilation
*Septic shock with the need for vasopressors

Question 7

antibiotics

Answer 7

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