Pleural Diseases, Bronchial Asthma, and Pneumonia PDF

Pleural diseases Treatment ❖ Thoracocentesis: Indicated mainly for pleural effusion Removal of fluid from pleural space through a needle inserted on the upper border of rib below at scapular line under 10th rib Should be done under complete aseptic conditions May be complicated by h...

Pleural diseases Treatment ❖ Thoracocentesis: Indicated mainly for pleural effusion Removal of fluid from pleural space through a needle inserted on the upper border of rib below at scapular line under 10th rib Should be done under complete aseptic conditions May be complicated by hemothorax, pneumothorax, neurogenic shock or pulmonary edema ❖ Intercostal chest tube (under water seal) : Indicated for Pneumothorax (open, bilateral or tension) Empyema, hemothorax ❖ Tension pneumothorax is a medical emergency treated by: Immediate insertion of wide-bore needle in 2nd space for decompression Insertion of intercostal chest tube Oxygen & analgesics Bronchial Asthma Definition  Aetiology: Bronchial narrowing caused by: ❖ Spasm of bronchial smooth muscles (bronchospasm) ❖ Inflammatory infiltrate (mainly eosinophils) & oedema of bronchial mucosa ❖ Thick mucus in lumen of bronchi (mucus plug) Pathophysiology: bronchial narrowing is due to either: ❑ Allergy: ( Extrinsic or Atopic asthma) ❑ Bronchial hyper-reactivity: (Intrinsic asthma)  Clinical picture:- ❖ In-between the attacks, the patient is usually free of symptoms & signs Symptoms:- - The onset of attacks usually at night & early morning - Triad of wheeze, non productive cough & dyspnea - At the end of the attack, a small viscid sputum (mucous pellets) may be expectorated. Signs (during attack): ▪ Inspection: Restricted respiratory movement (bilateral). ▪ Palpation: central trachea, palpable rhonchi (rhonchus fremitus) ▪ Percussion: Bilateral hyper-resonance. ▪ Auscultation: harsh vesicular breathing with prolonged expiration & generalized rhonchi COMPLICATIONS 1- Respiratory: - Status asthmaticus: the most severe form of asthma - Respiratory failure. 2- General: - Complications of treatment e.g. steroids cause DM, HTN..etc 3- Complications of chronic cough: a) Thoracic: myositis, rib fractures, pneumothorax, hemoptysis b) Extra-thoracic: puffy eye lids & hernia Investigations: ❖ Sputum examination: ↑Eosinophils ❖ Blood picture: Eosinophilia ❖ Serum IgE :- increased in extrinsic asthma. ❖ Skin prick test:- Intradermal injection of multiple antigens to identify the causative antigen in extrinsic asthma. ❖ Chest X-ray: signs of hyperinflation during the attack ❖ Pulmonary Function tests by spirometry: Obstructive hypoventilation Skin prick test  Treatment: ❖ Inhaled short-acting B2-agonists (SABA) e.g: Salbutamol PRN ❖ Inhaled corticosteroids (ICS) e.g: Beclomethasone or Budesonide ❖ Inhaled long-acting B-agonists (LABA) e.g: Salmeterol ❖ Oral leukotriene receptor antagonists (LTRA) e.g: Montelukast ❖ Oral or parenteral steroids e.g: prednisolone ❖ IgE monoclonal antibodies e.g: Omalizumab - SABA are reliever & symptomatic treatment during the attacks (bronchodilators). So, they are the best initial treatment of asthma. - All other drugs are controller medications (anti-inflammatory) used during & between the attacks. Pneumonia Clinical picture: ❑ Symptoms: Constitutional: fever, anorexia, headache, malaise Chest: cough, dyspnea, expectoration of rusty sputum ❑ Signs: Inspection: limited respiratory movements on the affected side Palpation: increased tactile vocal fremitus (TVF) Percussion: dullness Auscultation: bronchial breathing with crepitations Special types of pneumonia: ❖ Staphylococcal pneumonia: - Caused by staph. Aureus (gram-positive cocci in clusters) - Treated by nafcillin or vancomycin ❖ Fridlander's pneumonia: - Caused by Klebsiella in immunosuppressed patients e.g. diabetics - Mainly in apical parts of lungs & treated by ceftriaxone ❖ Pneumocystis carinii (jiroveci) pneumonia - Caused by the fungus pneumocystis jiroveci in AIDS patients - Treated by Septrin or pentamidine ❖ Mycoplasma pneumonia (atypical pneumonia) - Caused by mycoplasma pneumonia mostly in children & young adults - Cause other systemic infections: encephalitis, meningitis, gastroenteritis, myocarditis & hemolytic anemia - Diagnosed by cold agglutination test &treated by macrolides e.g: erythromycin ❖ Legionella pneumonia (Legionnaire disease): atypical pneumonia - Pneumonia caused by legionella pneumophila mostly from contaminated water supplies from showers or humidified air conditions - Cause hyponatremia with atypical pneumonia - Diagnosed by urine antigen test & treated with macrolides Viral pneumonia - Atypical pneumonia caused by influenza virus (including H1N1, H5N1 viruses), CMV, EBV, RSV, measles, CORONA or SARS viruses. - Treatment: - Preventive: by annual vaccination against influenza virus - Specific : for influenza pneumonia, must be within 48 hours of symptoms, give Oseltamivir (Tamiflu) or Zanamivir. - Treatment of Corona virus pneumonia is mainly supportive. (Remedesivir for COVID-19). Nosocomial Pneumonia Definition: - Pneumonia developing two or more days after hospital admission in immuno- compromized patients Aetiology: - Causative agents: by resistant organisms either gram-positive (e.g Staph. Aureus), gram-negative (e.g: E-Coli, Pseudomonas), or anaerobes (e.g Bacteroids) Clinical picture: severe pneumonia with rapid progress to respiratory failure Treatment: - The best initial empirical antibiotic is IV 3rd generation cephalosporin with anti- pseudomonas activity e.g ceftazidim Thank You