Pulmonology Notes 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