Respiratory Tract Infections, Neoplasms & Childhood Disorders (Ch. 30)-- Definition First Flashcards by Hannah Hinckley

Most common cause of bacterial pneumonia

S. pneumoniae
Immune response
- Humoral (B-cell) response
- Reticuloendothelial system
  - Macrophages from spleen
    - Asplenic = Highly susceptible
Pathology (4 stages)
- Edema
  - Alveoli fill with protein-rich fluid
- Red hepatization
  - Lungs look like liver (red & congested)
    - Capillary congestion
    - Movement of leukocytes into blood vessel
- Grey hepatization
  - >2 days
  - Macrophages phagocytose leukocytes
  - Lung is firm, but congestion is diminished
- Resolution
  - Removal of alveolar exudate
  - Scarring (sometimes)

Pneumococcal Pneumonia

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Humoral immunity defects
- B-cells
  - Bacterial infection
Cellular immunity defects
- T-cells
  - Viral, fungal, mycobacterial, & protozoal
Neutropenia & impaired granulocyte function
- Bacterial
  - S. aureus
- Fungal
  - Aspergillus
  - Candida albicans
Time course hints to infectious agent
- Fulminant (fast onset, severe) → Bacterial
- Insidious (slow onset) → Viral, fungal, mycobacterial, & protozoal

Pneumonia in Immunocompromised

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Embryonic (4-6 wks)
- Bronchial buds
Pseudoglandular (5-16 wks)
- Conducting airways formed
Canalicular (17-27 wks)
- Primitive alveoli
- Respiration is possible
Saccular (27-35 wks)
- Terminal alveolar ducts & air sacs
  - Gas exchange is possible
- Surfactant available
  - Required to inhale/exhale
Mature alveoli form after birth
- First 3 months
  - Slowing of alveolar growth
- First year
  - Rapid increase in alveoli #
Alvolar

5 Stages of Lung Development

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Bronchopneumonia
- Legionella pneumophila
Consolidation of lung tissue
Impaired gas exchange
S/S (onset 2-10 days after infection)
- Malaise
- Weakness
- Lethargy
- Fever
- Dry cough
- CNS & GI tract disturbances

Diagnosis– Chest x-ray, Urine antigen test for Legionella bacteria

Treatment– Antibiotics (Azithromycin, Ciprofloxacin…)

Legionnaire’s Disease (Typical Pneumonia)

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Larynx, trachea, & bronchi

Parainfluenza virus
- 3 months- 5 y.o
  - Follow symptoms of a cold
  - Stridor
  - Wet, barking cough
  - Occurs @ night
  - Relieved by exposure to cold or most air
  - May resolve
  - Cyanotic
    - EMERGENCY!
      - Any larynx manipulation can lead to respiratory failure
        Ex: tongue depressor

Treatment– Humidifier, Mist tent, Nebulization, Most air oxygen

Croup

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Respiratory syncytial virus
- Impaired gas exchange → Risk for respiratory distress
  - <2 y.o.
    - Most severe in <6 months
      - Preceded by stuffy nose
      - Breathlessness
      - Rapid
      - Shallow breathing
      - Wheezing w/ expiration
      - Cough
      - Retractions during inspiration
        Lower ribs & sternum

Treatment– Supportive treatment, possibly nebulization or intubation

Bronchiolitis

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Squamous cell lung carcinoma
Adenocarcinoma
Small cell carcinoma
Large cell carcinoma

4 Major Categories of Lung Cancer

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Pulmonary immaturity + Surfactant deficiency → Alveolar collapse

S/S
- Respiratory distress 24 hrs. after birth
- Central cyanosis
- Retraction
- Grunting w/ expiration
- Increased RR
- Fatigue
- Patent ductus arteriosis

Treatment– Supportive care, Incubation, Monitoring (BG & O₂), Supplemental O₂, CPAP, Ventilation, Exogenous surfactant therapy

Respiratory Distress Syndrome

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Primary
- Unsensitized individuals
- Latent infection
Primary progressive
- Immunocompromised people
  - Disorders of cell-mediated immunity
    - HIV
- Reinfection or reactivation
  - Bacteria never die
- Aggravation by cell-mediated hypersensitivity
  - Cavitation (holes) w/i lungs
  - Bronchial dissemination
  - Pleural effusion
  - Empyema
Secondary
- Reactivated latent infection

Tuberculosis Clinical Manifestations

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Facial pain
Headache
Purulent nasal discharge
Decreased sense of smell
Fever
Maxillary–
- Pain w/ bending over
- Unilateral pain behind the eyes
- Pain in teeth
Acute Viral–
- 5-7 days
Acute Bacterial–
- Worse after 5-7 days
- Symptoms
Chronic–
- Persistent sinus pressure
- Nasal congestion
- Constant, dull HA
Immunocompromised–
- Rhinorrhea
  - Runny nose
- Facial edema
- Lack of purulent discharge/signs of inflammation

Rhinosinusitis Clinical Manifestations

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Limited vs. Extensive Staging
- TNM staging NOT used
Small, round to oval cells
- Arise from neuroendocrine cells of bronchial epithelium
Highly malignant
- Brain metastasis often provides first evidence
Strong association w/ smoking cigarettes
Associated w/ paraneoplastic syndrome
- SIADH
- Cushing syndrome
  - Hypercortisolism
- Eaton-Lambert syndrome
  - Neuromuscular

Small Cell Lung Cancer (SCLC)

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Fetal lung
- Secretes fluid into potential air spaces
  - Alveoli development stimulated
  - Fluid cleared from lungs during birth

Fetal Breathing

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Bacteria multiply extracellularly in the alveoli
Inflammation
- Exudate in air-filled spaces of alveoli

Risk factors

Loss of cough reflex
- Brain lesions
- NG tube
- Sedation
Damage to ciliated epithelium
- Loss of mucociliary blanket
  - Removed mucus, microorganisms, & particles from RT
    - Chemical irritants
    - Smoking
Immunodeficiency
- loss of IgA & IgG w/i secretions
- Impaired cell-mediated immunity
Bacterial adherence
- Loss of epithelial surface function
  - Flu
Antibiotic therapy
- Alters normal flora
DM
Chronic bronchitis
Viral infection

Typical Pneumonia

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Conducting air
Gas exchange

2 Major Functions of the Respiratory Tract

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Pneumonia + Diarrhea + Hyponatremia + Confusion

Legionnaire’s Disease Clinical Manifestations

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Diagnosed w/i 48 hrs. after admission to hospital
- Bacterial
  - S. pneumonia (most common)
- Viral
  - Influenza virus

Diagnosis– History, Chest x-ray (infiltrate present), Public health information

Treatment– Antibiotics (bacterial), Hospitilzation/ICU

Community-Acquired Pneumonia

Diagnosed >48 hrs. after admission to the hospital

30-50% Mortality rate
- Ventilator-Associated (VAP)
  - Intubation
  - Tracheotomy
- Immunocompromised
- Chronic lung disease
Usually bacterial
- P. aeuruginosa
- Klebsiella sp
- E. coli

Nosocomial Pneumonia

Upper Respiratory Tract (URT)
- Nose
- Oropharynx
- Larynx
Lower Respiratory Tract (LRT)
- Lower airways
- Lungs
Conducting Airways (conduct air)
- Nasal passages
- Mouth
- Pharynx
- Larynx
- Trachea
- Bronchi
- Bronchioles
Respiratory Airways (gas exchange)
- Lungs
- Alveoli

The Respiratory Tract

Rhinotracheitis
- Uncomplicated URTI
- Targets & kills epithelial cells w/i RT lining
  - ECF escape → Nasal discharge
Viral pneumonia
- Shedding of bronchial & alveolar cells
Viral to bacterial RTI
- Compromise of RT natural defenses
  - Bacterial adhesion & infection → PNA
    - Secondary RTI

Influenza Pathogenesis

LRTI that leads to inflammation of parenchymal structure (alveoli and bronchioles)

8th leading cause of death
- Elderly & immunocompromised
Classifications
- Setting
  - Community-acquired
  - Hospital-acquired
    - Nosocomial
- Infectious agent
  - Typical
  - Atypical
- Pattern of distribution
  - Lobar
    - Localized to one lung lobe
  - Bronchopneumonia
    - Dispersed

Pneumonia

Typially URTI

Mycobacterium tuberculosis
- Strict aerobic, acid-fast bacilli
Transmission
- Airborne transmission of droplet nuclei
  - Coughing, sneezing, talking…
  - Crowded, confined conditions

Diagnosis–

Tuberculin skin test (PPD)
- Type IV hypersensitivity reaction
Chest x-ray
- Active vs. latent
Diagnosis of active
- Culture
  - Takes weeks to get results
- Nucleic acid amplification
- Acid-fast staining of sputum

Treatment– Multi-drug therapy (INH, Rifampin, Pyrazinamide, Ethambutol, Streptomycin), Prophylactic treatment (latent infection)

Tuberculosis

URTI
- Haemophilius influenzae Type B
- 2-7 y.o
  - Sudden onset
  - Mouth open
  - Chin thrust forward
  - Low-pitched stridor w/ inspiration
  - Dysphagia
  - Fever
  - Drooling
  - Anxiety
  - Asphyxia
    - Airway obstruction

Treatment– Hospitalization (intubation or tracheotomy), Antibiotic therapy

Epiglottitis

S/S
- Anorexia
- Weight loss
- Similar to chronic bronchitis
  - Chronic cough
  - SOB
  - Wheezing
- Hemoptysis
  - Blood in sputum
- Dull, poorly localized retrosternal pain
  - Tumors of mediastinum
- Persistant, localized, severe pain
  - Pleura
Metastasis
- Brain
- Bone
- Liver

Diagnosis– History, PE, Chest x-ray, Bronchoscopy, Cytology of sputum or bronchial washings, Needle biopsy, Lymph node biopsy, CT scan, MRI, Ultrasound

Lung Cancer Clinical Manifestations

Influenza virus unrecognized by immune system d/t new HA & NA surface proteins

Antigenic Shift

* Viral and *Mycoplasma* **infections of the alveolar septum and interstitium surrounding alveoli** * Mild, low mortality rate * “Walking pneumonia” * **Lack of lung consolidation** * Elevation of WBCs * Damage to epithelium * Predispose to secondary bacterial infections * ***Mycoplasma pneumoniae*** * Viruses * **Influenza, RSV, adenovirus, rhinoviruses, rubeola, varicella**

Atypical Pneumonia

* Trivalent inactivated influenza virus **(TIIV)** * **Injection** * Live, attenuated influenza vaccine **(LAIV)** * **Intranasal** * Not given to elderly or immunocompromised

Types of Influenza Vaccines

Pathogenesis based on hypersensitive immune response * **Cell-mediated (T-cells)** * Macrophage infection (primarily) * Droplet deposited in alveoli → Bacteria phagocytosed → **Macrophages unable to kill** (d/t cell wall virulence factors) → T-cells contain infection * **Infected macrophages** degrade & present antigen to T-cells → Stimulation of macrophage production of **lytic enzyme** → **Lung tissue damage** * **Ghon focus** formation * Primary granulomatous lesions w/i lungs * Soft tissue necrosis * **Caseous granulomas** * lymph node granuloma * **Ghon complex** * Ghon focus + Caseous granulomas * Fibrous scarring & calcification * **Visible on chest x-ray** * Indicated history of TB infection * Laten TB (viable tubercle bacilli) → Secondary infection

Tuberculosis Pathogenesis

Diagnosis-- * **Rapid diagnostic test** * **Immunoassay** * Type A or B Treatment-- * Rest * Keep warm * Manage fever * Hydrate * **Analgesic** cough medication * **Antiviral drugs** * **Decrease duration** of course of infection Prevention * **Immunization** * \>6 months old * New formulation every year **(October)** * Antigenic changes

Influenza Treatment & Prevention

* 4 week long sinus infection * Viral, bacterial, or mixed * Haemophilus influenzae * Streptococcus pneumoniae * Ostiomeatal complex (OMC) blockage * d/t-- barotrauma or nasal polyps

Acute Rhinosinusitis

* \>12 week long sinus infection * Bacterial and fungal infection * Anaerobes (alone or in combo w/ aerobes) * Pseudomonas aeuriginosa

Chronic Rhinosinusitis

* **Upper airways, diaphragm, & intercostal muscles** used * Diaphragm more horizontal * Highly compliant chest wall and lungs * **Retractions** * **Airway obstruction** * **Atelectasis**

Neonatal Breathing

Changes to influenza virus minor * **Virus still recognized** by immune system * More common w/ Influenza B & C

Antigenic Drift

* **Acute URTI** * Common among children & 65+ y.o. * Orthomyxoviridae * ssRNA * Surface proteins * **Hemagglutinin (HA)** * Virus enters cells * **Neuraminidase (NA)** * Virus replicates * Type A * Mammalian & avian species infected * New HA & NA subtypes can develop * Type B & C * Only infects mammals

Influenza

* **Epiglottitis** * **Croup** * **Broncholitis** Respiratory failure S/S * Rapid breathing * Exaggerated use of **accessory muscles** * **Chest & abdominal muscles** * **Retractions** * **Intercostal muscles** * **Nasal flaring** * **Grunting** during expiration

Respiratory Infections in Children

* **TNM Staging** * Tumor, node, metastasis * Bioactive products * Paraneoplastic syndrome * **Squamous cell carcinomas** * **Most common in men w/ smoking history** * Originate in central bronchi * Early detection in sputum * Paraneoplasm * **Hypercalcemia** * **Adenocarcinomas** * Most common type * **Women & nonsmokers** * Originate in bronchiolar or alveolar tissue * More peripheral than squamous * Associated w/ lung scarring * Large cell carcinomas * Poor prognosis * Large, polygonal cells

Non-Small Cell Lung Cancer (NSCLC)

**Droplet** transmission * **More contagious than bacterial** RTIs * Incubation * 1-4 days * Infectious * 1 day prior to S/S onset * \>1 week after S/S subside * **Viral shedding** * **3 weeks**

Influenza Transmission

* Early * **Type A or B** * Abrupt onset of fever * Chills * Rigors * Malaise * Muscle ache * HA * Profuse watery nasal discharge * Nonproductive cough * Sore throat * **Type C** * Common cold * Milder * Complications * **Viral PNA** * 1 day after flu onset * Rapid progression * **Hypoxemia** * **Death** * **Diffuse pulmonary fibrosis** * **Secondary** complications * **Sinusitis** * **Otitis media** * **Bronchitis** * **Bacterial PNA** * Croup * Young children * Parotitis * Rare * Tracheitis * Rare * Reye syndrome * ASA used to treat S/S in children

Influenza Clinical Manifestations

**Inflammation of the nasal sinuses** due to infection d/t-- Blockage of ostia, Viral RTI, Nasal polyps, Barotrauma

Rhinosinusitis

Respiratory Tract Infections, Neoplasms & Childhood Disorders (Ch. 30)-- Definition First Flashcards

Exam 2