Transcript Bronchitis, Pneumonia, and Pleural Empyema

Bronchitis, Pneumonia, and
Pleural Empyema
Katay Bouttamy DO
Tintinalli Chapter 63
Acute Bronchitis



Definition: an acute respiratory tract
infection with cough being the
predominant feature
Usually lasts 1 to 3 weeks, peaks
between October and March
Viruses cause the vast majority of
cases: Influenza A and B, parainfluenza,
and RSV are the most common
Acute Bronchitis


Bordetella pertussis, Mycoplasma
pneumoniae, Chlamydia pneumoniae,
and Legionella species are reported in
5-25% of cases
Clinical features: cough and wheezing
are the strongest positive predictors,
less than 10% of patients are febrile
Acute Bronchitis


Diagnosis: (1) acute cough less than 1-2
weeks (2) no prior lung disease (3) no
auscultatory abnormalities that suggest
pneumonia
Treatment: studies have failed to show
significant improvement with Abx therapy and
at best may decrease duration of cough,
decrease purulent sputum production and
return patients to work < 1 day each
Acute Exacerbation of Chronic
Bronchitis




Two-thirds are bacterial in origin (H. flu, Strep
pneumo, M. Catarrhalis)
High risk patients are the elderly and those
with poor lung function and with comorbid
conditions
Characterized by increased dyspnea,
increased cough and sputum production and
purulence with underlying COPD
Treatment includes doxycycline, extended
spectrum cephalosporin, macrolide,
augmentin or fluoroquinolone
Pneumonia


CAP is 6th leading cause of death
Studies of both inpatients and
outpatients with CAP fail to identify a
specific pathogen in 40-60% of patients
but when found pneumococcus is still
the most common
Pneumonia


Typical presentation of pneumococcal
pneumonia is sudden onset of fever,
rigors, dyspnea, bloody sputum
production, chest pain, tachycardia,
tachypnea and abnormal findings on
lung exam
Some of the atypicals are associated
with headache and GI illness
Other bacterial pneumonia

Staph aureus is a consideration in
patients with chronic lung disease,
laryngeal CA, immunosuppressed
patients, NH patients; chest Xray
usually shows extensive disease with
empyema, effusion or multiple areas of
infiltrate
Other bacterial pneumonia


Klebsiella occurs in patients at risk at
aspiration, alcoholics, elderly and other
patients with chronic disease; may develop
abscesses but often have lobar infiltrates
Pseudomonas not a typical cause of CAP and
usually associated in patients who have
prolonged hospitalization, have been on
broad-spectrum Abx, high-dose steroids,
structural lung disease or NH patients
Other bacterial pneumonia


H. flu seen in elderly and should be
considered in patients with COPD, sickle
cell disease or immunocompromised
disorders
M. catarrhalis similar to H. flu
Atypical Pneumonia


Legionella should be considered in cigarette
smokers, persons with COPD, transplant
patients and immunosuppressed patients;
commonly complicated by GI symptoms
including abdominal pain, vomiting and
diarrhea
Chlamydia usually causes a mild subacute
illness with sore throat, mild fever, and NP
cough
Atypical Pneumonia

Mycoplasma occurs year round and
causes a subacute respiratory illness
and occasionally causes extrapulmonary
symptoms including bullous myringitis,
rash, neurologic symptoms, arthritis,
hematologic abnormalities and rarely
renal failure
Pneumonia in Special
populations



Alcoholics: Strep pneumo still most
common but Klebsiella and H. flu are
important pathogens
Diabetics: patients between 25-64 are 4
times more likely to have pneumonia
Pregnancy: more likely to experience
preterm labor, preterm delivery and
deliver a low birthweight infant
Pneumonia in Special
populations

Elderly: 3 times more likely to have
pneumococcal bacteremia, mortality is
3-5 times greater than those younger
than 65, have atypical symptoms
(afebrile, c/o weakness, falling, GI
symptoms, delirium, confusion) and up
to 1/3 will not manifest leukocytosis
Nursing-Home acquired
Pneumonia


Patients are less likely to have productive
cough or pleuritic chest pain and more likely
to be confused and have poorer functional
status and more severe disease
8 independent predictors of pneumonia:
increased pulse, RR>30, T>100.4,
somnalence or decreased alertness, acute
confusion, lung crackles, absence of wheezes
and increased WBC
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 PCN plus betalactamase inhibitor, with a macrolide.
Coverage can also be provided with newer
fluoroquinolone.
Disposition


Estimated 75% of patients with CAP do
not require hospitalization, many factors
influence prognosis and outcome
Fine’s prediction rules can be used to
estimate risk of death and ICU
placement (does not include patients
from NH or hospital setting and HIV
patients)
Disposition


PSI score of I, II, III generally have low
mortality and mortality jumps between III
and IV
Forest study looked at clinical judgement vs
PSI alone to determine need for
hospitalization: many people with low PSI
need to be admitted for other reasons
(noncompliance, inability to eat or drink,
unmet social needs, failed outpatient Tx)
Empyema


Pleural effusions are present on X-ray of
20-60% of patients with bacterial
pneumonia and often resolve with
antibiotic therapy
Risk factors: aspiration,
immunocompromised patients with
gram neg bacteria, fungal infections, TB
or malignancy
Empyema



Exudative stage: free flowing pleural fluid,
very amenable to treatment with closed tube
drainage
Fibrinopurulent stage: formation of fibrin
strands through the pleural fluid resulting in
loculations, makes adequate drainage with
single chest tube unlikely
Organizational stage: fibrosis is much more
extensive forming a pleural peel that restricts
expansion even if fluid can be evacuated
Empyema


Decub films will be helpful in
determining if fluid is free flowing or
loculated
Pleural fluid that is gross pus with
positive cultures or gram stain is
considered empyema along with other
findings: pH<7.1, glucose<40 and
LDH>1000
Empyema

Treatment: drainage of pus by chest
tube, reexpansion of lung and
eradication of the infection. Treatment
of organizational stage requires surgical
intervention with removal of the fibrous
peel
Questions

1. All are true of Acute Bronchitis
except:
a. Peaks from October and March
b. Viruses are the majority of cause
c. Strep pneumo is a major cause if it is
bacterial in etiology
d. Less than 10% of patients are febrile
Questions

2. A 45 yo male presents with sudden
onset of fever, rigors, shortness of
breath and rust colored sputem. The
most likely cause is:
a. H. Flu
b. Legionella
c. Strep pneumo
d. M. catarrhalis
Questions

3. The most common cause of CAP in
an HIV patient is:
a. Strep pneumo
b. Tuberculosis
c. H. Flu
d. Pneumoncystis carinii
Questions


4. T or F: Klebsiella is the most common
cause of CAP in alcoholics.
5. A 57 yo male presents with nonproductive
cough, fever of 102, dyspnea and diarrhea.
His labs show a WBC of 18,000 and Na of
129. The most likely cause is:
a. H. Flu
b. Strep pneumo
c. Mycoplasma
d. Legionella
Answers





1.
2.
3.
4.
5.
C
C
A
False
D