Acute Bronchitis and Pneumonia PDF

Acute Bronchitis Acute bronchitis is an acute and self-limited viral inflammation of the trachea and major bronchi without evidence of pneumonia, generally characterized by cough lasting 1 to 3 weeks without evidence of bronchial consolidation or underlying cardiopulmonary disease. Starts as a...

Acute Bronchitis Acute bronchitis is an acute and self-limited viral inflammation of the trachea and major bronchi without evidence of pneumonia, generally characterized by cough lasting 1 to 3 weeks without evidence of bronchial consolidation or underlying cardiopulmonary disease. Starts as an URI and moves down to bronchi A lower respiratory infection of the large airways (bronchi) with no evidence of pneumonia (high fever, chills, productive cough, green-rust sputum, pleuritic chest pain with cough). Usually self limited. Highest incidence in late fall and winter. Causes include adenovirus, flu, covid, RSV, parainfluenza, and human metapneumovirus. The patient presents with a persistent cough for at least 5 days for it to be acute bronchitis and must resolve within 3 weeks. If cough persists for 2 months, it is chronic Low grade fever or no fever, whereas pneumonia will have high fevers Causes/Incidence: Viral causes for 90% cases commonly Influenza A and B viruses, Rhinovirus, Corona virus, Adenovirus Bacterial causes (5-10%): Streptococcus pneumoniae, Hemophilus influenzae (most common), Atypical causes: Mycoplasma pneumoniae and M. pertussis Increased incidence in smokers Most common in patients >50 years old  Clinical Presentation of Acute Bronchitis p. 487, 202 Signs and Symptoms Cough- with or without light colored sputum production that affects sleep is the most common symptom reported with acute bronchitis. Characterized as dry and nonproductive, but progresses to productive as illness evolves. Cough may also produce a burning, substernal pain with inspiration. Headache Wheezing in bronchitis and pneumonia, rhonchi, coarse rales may persist Common prodromal symptoms: rhinorrhea, sore throat, malaise, low grade fever Will have normal vital signs High grade fever is uncommon and warrants further evaluation of pneumonia *cough and normal vital signs (in the absence of tachypnea, tachycardia, crackles, and egophony), are strongly suggestive of acute bronchitis and minimize likelihood of pneumonia. Physical Exam of Acute Bronchitis No evidence of lung consolidation Breath sounds clear to auscultation Resonance to percussion Upper airway rhonchi clear with coughing Afebrile to low-grade temperature (viral) Elevated temperature (bacterial) Labs & Diagnostics of Acute Bronchitis Usually none indicated If diagnosis is unclear (suggestive of pneumonia, cold asthma, or COPD exacerbation) CXR useful with possibility of Community Acquired Pneumonia (CAP) if there is a high fever, tachycardia, tachypnea. Only when egophony/fremitus seen on xray, heart rate is greater than 100, respiratory rate greater than 24 and temperature greater than 100.4 Sputum C&S not helpful C-reactive protein – elevated >10 mcg/dl indicates likelihood of pneumonia Differential Diagnosis of Acute Bronchitis Acute Bronchitis if cough > 7 days If cough lasts > 3 weeks: Asthma & bronchiolitis (acute but is present < 3 weeks inflammations of small airway and present with wheezing, Consider Acute Bronchitis is cough and tachypnea, respiratory distress, and hypoxemia), sinusitis, sputum production on most days of COPD, GERD, HF, Flu, Pertussis (paroxysmal, intermittent the month for three months of the year for two consecutive years cough > 2 weeks), Pneumonia, PE, viral pharyngitis Chronic Bronchitis Upper Respiratory Infection (URI) Bronchiectasis- bronchial dilation and chronic cough  Treatment of Acute Bronchitis Supportive: Humidifiers, antipyretics, increase fluid intake. Should resolve within a couple weeks Smoking cessation Use cough suppressant judiciously (antitussives): Promethazine, Mucinex, Benzonatate or dextromethorphan PRN Analgesics (Tylenol) for fever, chest soreness B2 adrenergic agonists for wheezing (albuterol) if history of asthma Antibiotics for bacterial infections only (like pertussis): Macrolides, Doxycycline, Trimethoprim-sulfamethoxazole. Avoid Azithromycin in: QT prolongation, torsade's de pointes, bradyarrhythmia's, uncompensated HF, those taking drugs known to prolong QT (antiarrhythmics), those with hypokalemia, hypomagnesemia No antibiotic prescription is recommended for immunocompetent adults for a productive cough attributed to acute bronchitis Need for hospitalization when: progressive dyspnea, oxygen saturation < 90%, or signs of sepsis Need for reevaluation: Do not respond to symptomatic treatment and symptoms last > 3 weeks (get a chest xray) Pneumonia A leading cause of morbidity and mortality in the US, especially in older adults and those with underlying chronic disease. Pneumonia is the 2nd leading cause of death in children younger than 5 years Pneumonia is classified as typical and atypical. Typical pneumonia caused by Streptococcus pneumoniae accounts for 60 to 70% of all bacterial Community Acquired Pneumonia (CAP). Atypical pneumonia organisms are not detectable on Gram stain, caused by Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella species and respiratory viruses.  Pneumonia Clinical presentation In CAP, diagnosis is made by H&P exam, identification of causative agent is usually NOT necessary. CAP is most common cause of focal infiltrate on CXR Clinical manifestations include: Fever, chills or rigors, malaise, cough with or without sputum production May report hemoptysis, dyspnea, pleuritic chest symptoms, temp > 100.4, RR > 24, HR > 100 Upon auscultation crackles/rales do not clear with cough Consolidation, including dullness to percussion Bronchial breath sounds Egophony (E-to-A changes) Chest X-ray may be normal in early disease Headache and Sore throat Fatigue, lethargy, decreased appetite Increase in falls, altered mental status change(confusion, stupor, coma) Bacterial Pneumonia Syndrome Gram Positive Strep pneumonaie is the leading cause in any age group Abrupt onset with high fever, shaking chills, productive cough, pleuritic chest pains, green-rust colored sputum Upon exam: sign of consolidation (egophony, increased fremitus, rales, rhonchi) Gram Negative Hemophilus influenzae another cause of CAP is a small gram negative rod. There are 6 serotypes. Type B is the most severe and invasive causing meningitis and sepsis. Older adults with underlying causes (COPD) most susceptible. Abrupt onset with fever, chills, cough, pleuritic pain, and consolidation. Bronchopneumonia seen on CXR, ground glass opacities, bronchial wall thickening, confluent areas of consolidation, and centrilobular nodules Mortality rates relatively high with gram negative pneumonias  Atypical Pneumonia (Walking Pneumonia) Atypical Pneumonias caused by nonbacterial organisms Mycoplasma pneumonaie one of most common causes of atypical pneumonaie in US (less common are chlamydia and legionella) Infection rates highest among younger: school-age children, military recruits, college students Gradual onset characterized by low grade fever, headache, fatigue, myalgias, dry, nonproductive cough Physical exam reveals fine cackles/rales with no signs of consolidation, clear mucus Maculopapular eruptions, painful (TM) bullous myringitis CXR reveals bilateral patchy alveolar densities or segmental lobar infiltrates, atelectasis and small pleural effusions WBC count is normal or slightly elevated Gold diagnostic: PCR or sputum swab Full recovery expected without residual effects, however can be severe in those with Sickle cell disease or those in immunosuppression Treatment: Azithromycin 5 days or Clarithromycin 500 mg BID 7-10 days Doxycycline 100 BID 7-10 days Levofloxacin 750 mg 5-7 days Antitussives PRN  Pneumonia Essential Diagnostics CXR- Posteroanterior and lateral views to confirm new infiltrates. Gold standard for pneumonia diagnosis Bacterial: lobar consolidation (typical), cavitation, large pleural effusions, bilateral, diffuse infiltrates (atypical) May have a normal CXR- does not rule out pneumonia Pulse Oximetry Sputum analysis useful to identify causative organism (not for outpatient CAP but inpatient MRSA or P. aeruginosa) Culture and gram stain of a sputum sample from bronchial tree For CAP, do not get culture, obtain CXR Labs: CBC with differential, Blood chemistry, Arterial Blood gases, Liver function tests (likely to have bacteriemia with CAP in chronic liver disease) Blood cultures if hospitalized with CAP, MRSA or P. aeruginosa, or hospitalized/got parenteral antibiotics in last 90 days Other: Bronchoscopy CT Scan  Pneumonia Differential Diagnosis Pneumonia: Fever, tachypnea, tachycardia, productive cough. CXR shows lobar consolidation. May have pleuritic chest pain with cough Pulmonary Embolus: New onset of dyspnea, hemoptysis, pleuritic chest pain. Vital signs show tachycardia and tachypnea. May have signs of DVT Heart failure: SOB/dyspnea that worsens with exertion or exercise, pitting edema, and dry cough. Physical exam may show S3, elevated JVD Inflammatory lung disease (systemic vasculitis, sarcoidosis) Foreign body aspiration (especially in young children) Tuberculosis: fever, anorexia, fatigue, night sweats, productive cough with blood stained sputum and weight loss Pulmonary tumors (lung cancer): Cough in a person with risk factors (cigarette smoker long term), weight loss COVID-19 symptoms A fever, a dry cough, and shortness of breath are common early signs of COVID-19. Fatigue, Chills Nausea or vomiting Diarrhea Belly pain Muscle or body aches A headache Loss of smell or taste A sore throat Congestion or a runny nose Pinkeye Skin rashes CXR- infiltrates COVID-19 Pneumonia People who get COVID-19 pneumonia may also develop acute respiratory distress syndrome (ARDS) and require mechanical ventilation. The new coronavirus causes severe inflammation in the lungs. It damages the cells and tissue that line the alveoli in the lungs, where oxygen is delivered to blood. The damage causes tissue to break off and damage the lungs. The walls of the alveoli can thicken, making it very hard to breathe.  Types of COVID-19 tests COVID-19 tests are available that can test for current infection or past infection. A viral test indicates a current infection. Two types of viral tests can be used: nucleic acid amplification tests (NAATs) and antigen tests. An antibody test (also known as a serology test) might tell you if you had a past infection. Antibody tests should not be used to diagnose a current infection. Authorized and Recommended Vaccines in the US to prevent COVID-19 Pfizer-BioNTech People 12 years and older 2 shots Given 3 weeks (21 days) apart *Fully vaccinated after 2 weeks after your second shot Moderna People 18 years and older 2 shots Given 4 weeks (28 days) apart *Fully vaccinated after 2 weeks after your second shot Johnson & Johnson/Janssen People 18 years and older 1 shot- *Fully vaccinated after 2 weeks after your shot COVID-19 Vaccine Recent Information CDC Monitoring Reports of Myocarditis and Pericarditis CDC has received increased reports of myocarditis and pericarditis in adolescents and young adults after COVID-19 vaccination. The known and potential benefits of COVID-19 vaccination outweigh the known and potential risks, including the possible risk of myocarditis or pericarditis. CDC continues to recommend COVID-19 vaccination for individuals 12 years of age and older as of this date 6/11/2021. Lobar/Bacterial Pneumonia: Grayish to white areas on a lobe or lobes of lung (consolidation) from purulent fluid  Pharmacologic Treatment for Typical Pneumonia Healthy patients 60 years, no recent antibiotic use in 90 days Combination therapy (beta lactam + macrolide or doxycycline): Amoxicillin Clavulanate 875/125 mg BID, macrolide (azithromycin 500 mg first day then 250 mg daily or clarithromycin 500 mg BID) or doxycycline 100 mg BID Fluoroquinolones such as levofloxacin (Levaquin) 750 mg daily, Gemifloxacin (Factive) 320 mg daily or moxifloxacin (Avelox) 400 mg daily Pharmacologic Treatment Atypical Pneumonia A macrolide, such as azithromycin (Zithromax), clarithromycin (Biaxin), erythromycin, fluoroquinolones or doxycycline Outpatient who are low risk for death are treated at outpatient settings Treatment of Pneumonia include use of severity assessment tools (CURB-65 criteria) and Pneumonia Severity Index to assist in determining patient who require hospitalization.  Pneumonia Patient and Family Education and Health Promotion Provide directions for use of antibiotics and information of potential side effects of the drug Follow up in 24-48 hours by telephone or visit in office Drink adequate fluids and use of antipyretic to control fever and myalgias prn Use of cough medicines are avoided because it will prevent removal of secretions Use of codeine at night allows more restorative sleep, avoid cough medicines due to thick secretions and cough reflex Patients at risk should receive pneumonia vaccine, influenza vaccine annually Institute respiratory hygiene measures (hand sanitizer, masks, social distancing) Daily exercise and healthy diet plan, including vitamins, nutrients and fiber COVID patients at higher risk for DVT/PE