Download CM 32- Acute Obstructive Pulmonary Disease Acute Bronchitis Self

CM 32- Acute Obstructive Pulmonary Disease
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Acute Bronchitis
Self limited inflammation of the bronchi due to upper airway infection
One of the most common conditions encountered in clinical practice
Presents with a cough lasting more than 5 days(typically 1-3 weeks)
Distinguished from chronic bronchitis, a condition in patients with COPD by a cough of at least 3 months in 2
successive years
Generally cause by a virus
• Influenza A and B
• Para influenza*
*What Dr Myles worries about
• Coronavirus
• Rhinovirus
• Respiratory syncytial virus*
• Human metapneumovirus
Other Pathogens:
• Mycoplasma pneumoniae-pharyngitis, constitutional symptoms and cough. (Common case)
• Chamydophilia pneumoniae-pharyngitis, laryngitis and bronchitis, hoarseness and low grade fever.( 5%
of cases)
• Pertussis-1% of cases in US
Clincial Features
• Cough that may have sputum production
• Consider when cough lasts more than 5 days
• Chest wall tenderness
• Wheezing
• Important to distinguish from pneumonia
• If patients have cough, fever, sputum production and constitutional symptoms strongly consider
influenza or pneumonia
• Purulent sputum is reported in 50% of patients
• DOES NOT signify a bacterial infection
Physical exam:
• Wheezing
• Rhonchi that clear with coughing
• If you have any of the following, consider pneumonia
• Dullness to percussion
• Decreased breath sounds
• Rales
• Egophony
• Bronchophony
• Pleural rub(pleural inflammation)
Chest x-ray: nonspecific
WBC: normal or slightly elevated
Consider Chest X-ray only if needed to exclude pneumonia
Abnormal vital signs
Rales or signs of consolidation
Age > 75
Decreased oxygen saturation
Consider influenza swab because of morbidity
Treatment:
• Symptomatic
• Nonsteroidal anti-inflammatory drugs
• Cough suppressants – limited
• Beta 2 agonists – no difference
CM 32- Acute Obstructive Pulmonary Disease
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• OTC’s no evidence for or against
• Antibiotics – multiple studies no significant benefit.
Mycoplasma pneumoniae or Chlamydophila pneumoniae
• Suspect with prolonged cough and URI symptoms
• Treatment: tetracyclines, macrolides and fluoroquinolones
Pertussis: Treatment: erythromycin or clarithromycin
Influenza: Consider treatment of neuraminidase inhibitors if symptoms onset within 48 hours
Case 1
• A 23 year old female presents with a c/c of cough for several days. It is productive of green sputum.
• What questions should you ask?
• Do you need an x-ray?
• Do you need labs?
• Should you give antibiotics?
Acute Exacerbation of COPD
COPD: characterized by airflow limitation that is usually progressive and associated with an enhanced
inflammatory response in the airways and the lungs to noxious particles or gases.
It affects more than 5% of the population
It is the third ranked cause of death in the US
It causes frequent doctor visits and hospitalizations for due to acute exacerbations.
Acute exacerbation defined as:
• An increase in symptoms beyond normal day to day variation
• An increase in one or more of the cardinal symptoms
• -cough increase in frequency and severity
• -sputum production increases in volume and or character
• -dyspnea increases
70-80% of COPD exacerbations are due to respiratory infections.
• -viral and bacterial infections
• -atypical bacteria are uncommon
20-30% due to environmental pollution or have an unknown etiology(consider CHF, MI, PE)
Risk factors:
• -advanced age
• -productive cough
• -duration of COPD
• -history of antibiotic therapy
• -COPD related hospitalization within the previous year
• -Chronic mucous hyper secretion
• -theophylline therapy
• -having one or more comorbidities(ischemic heart disease, CHF, DM)
• -GERD
GOLD guidelines(global initiative for COPD): uses FEV1 and history of exacerbations to assess the exacerbation
risk
• -Low risk = GOLD 1 or 2 = mild to moderate airflow limitation and/or 0 to 1 exacerbations per year
• -High risk = GOLD 3 or 4 = severe or very severe airflow limitation and/or > 2 exacerbations per year
History
Physical
Chest x-ray
Labs
ABG ?
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Treatment
• Oxygen -how much?-Is hypercapnia a problem
• Bronchodilators -beta adrenergic agents – (albuterol)-anticholinergic agents (ipratropium)
• Steroids -IV solumedrol(60-125mg)vs PO prednisone(30-60mg)
• Antibiotics?
• When do you consider Bipap or intubation? Bipap (like CPAP): positive pressure air forced into lung****
In alert and oriented pts (border b/t CAO and AMS) do well
Cut down on intubation
Intubation: can get infection from ventilators (common in hospitals)
Admission
• Inadequate response to treatment
• Marked increase in dyspnea
• Inability to eat or sleep due to symptoms
• Worsening hypoxemia
• Worsening hypercapnia
• Changes in mental status
• Inability to care for oneself
• High risk comorbidities including pneumonia, cardiac arrhythmia, CHF, DM, renal failure or liver failure
• Uncertain diagnosis
Prognosis
• 14% of patients admitted for acute exacerbation of COPD will die within 3 months of admission
• PaCO2 of 50mmHg 6 month mortality is 33%
• One year mortality was 28% in one study of 260 patients
Case 2
• A 56 year old male with a PMHx of COPD presents with a c/c of increasing cough and sputum
production. What questions should you ask?
• Do you need a chest x-ray? Yes, always for COPD
• Do you need labs or an ABG? If low sat yes
• Do you give antibiotics? Yes
• When should you admit this patient? If feel bad, look bad, ask the pt and decide
URI in Adults
Benign self limited syndrome representing a group of diseases caused by members of several families of viruses
It is the most frequent acute illness in the US
Common cold refers to a mild upper respiratory viral illness
Important because of enormous economic burden
40% of all lost time from jobs
Incidence in children is 5-7 episodes per year
Incidence in adults is 2-3 episodes per year
Over 200 subtypes of viruses
• Rhinovirus which includes more than 100 serotypes is the most common(30-50%)
• Coronaviruses responsible for 10-15%
• Influenza virus responsible for 5-15%
• Respiratory syncytial virus(RSV) responsible for 5%
• Most are capable of reinfection
Seasonal Patterns:
• -Rhinoviruses and Para influenza types typically cause outbreaks in fall and late spring
• -RSV and coronaviruses typically produce epidemics in the winter and spring
• -Enteroviruses cause illness in the summer
• -Adenoviruses are usually not seasonal but outbreaks occur in military facilities, daycare centers and
hospital wards
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Transmission
• Three mechanisms:
• 1. Hand contact(person or surface)
• 2. Small particle droplets(airborne from sneezing or coughing)
• 3. Large particle droplets(close contact with infected person)
• Cold-inducing viruses may remain viable on human skin for up to 2 hours
• Droplet transmission is most common in both influenza and RSV
• Fomites may harbor Rhinoviruses for several hours. Porous materials such as tissues and cotton
handkerchiefs to not appear to support virus survival.
Fact or Fiction?
• 1. Antibacterial home cleaning products are better than standard cleaning products--FALSE
• 2. Recirculating air in commercial airliners will increase common cold transmission-- FALSE
• 3. Saliva is an efficient means of spread of most cold viruses-- FALSE
Period of infectivity
• -peak viral shedding can occur on the 2nd or 3rd day of illness
• -low level shedding may persist for up to two weeks
Risk Factors
• Exposure to children in daycare
• Psychological stress
• Decreased sleep
• Underlying chronic disease
• Cigarette smoking
• malnutrition
• Moderate physical exercise decreases the risk
Clinical Features
• Largely due to immune response
• rhinitis and nasal congestion(most common)
• sore throat
• Cough
• malaise
• Incubation period is typically 24-72 hours
• Colds last normally 3-10 days, but can persist for 2 weeks
Diagnosis
• Clinical
• X-ray not needed unless abnormal vital signs or patient appears sick
Complications
• Acute rhino sinusitis
• Lower respiratory tract disease
• Asthma exacerbation
• Acute otitis media
Treatment
• Symptomatic therapy
• -ipratropium bromide nasal spray
• -cromolyn sodium nasal spray
• -antihistamines
• -antitussives
• -expectorants-not helpful
• -decongestants
• -Zinc-not recommended
CM 32- Acute Obstructive Pulmonary Disease
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Case 3
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Vitamins and herbal remedies:
• -Vitamin C – Not helpful
• -Echinacea – no benefit
• -antiviral therapy ?
• -antibiotic therapy – causes more harm than benefit due to adverse effects
A 50 year old female presents with a c/c of cough and congestion for a few days
What questions do you ask?
Do you need an x-ray or labs? Nah
How would you treat this patient? Fluids, relax, 3 weeks go away