Bronchitis, Bronchiectasis, Asthma, and Pneumonia PDF

BRONCHITIS Inflammation of the bronchial tree Acute /chronic Acute Bronchitis Acute infection of mucous membrane of trachea, bronchi- virus, bacteria, external irritants Causes Infection- bacteria, virus, descending infection from nasal sinuses/throat Physical/chemical irritants- inhaled du...

BRONCHITIS Inflammation of the bronchial tree Acute /chronic Acute Bronchitis Acute infection of mucous membrane of trachea, bronchi- virus, bacteria, external irritants Causes Infection- bacteria, virus, descending infection from nasal sinuses/throat Physical/chemical irritants- inhaled dust, steam, gases Diseases- measles, whooping cough Allergic- pollens, organic dust Symptoms Toxemic- malaise, fever, palpitation Irritative – cough + expectoration, scanty first later mucopurulent, substernal pain Obstructive- choked up feeling, paroxysms of dyspnoea- following cough , relieved by expectoration Signs Occasional ronchi After 2-3days- diffuse b/l ronchi Prolonged expiration + expiratory wheeze Chronic Bronchitis Productive cough due to excess mucus secretion in bronchial tree not caused by local broncho –pulmonary disease on most of the days -3months of the year- last 2consecutive years Causes Infection- acute bronchitis, URT, sinusitis, tonsillitis Smoking Air pollution Alcoholism, obesity, chronic renal disease Symptoms Cough- constant paroxysmal, winter, cold winds, sudden change in temperature Expectoration – thin/thick, mucoid/froathy Dyspnoea- quick breathing, wheezing at rest Fever- absent , except in acute exacerbation Haemoptyosis – streaks of blood Signs Prolonged expiration, pursed lip breathing Widespread wheeze on expiration, crackles at lung base- alters with coughing Investigations Chest X ray DC  BRONCHIECTASIS Destructive lung disease- chronic dilatation of bronchi ass. With persistent inflammatory process in lungs- lung bases Causes Immunodeficiency HIV Leukemia Lung transplantation Cystic fibrosis Inhalation of foreign body Tuberculosis Pneumonia Whooping cough Adenovirus Gastric aspiration Inflammatory bowel disease RA Systemic vasculitis Symptoms Bronchitic – recurrent bronchitis- winter Haemorrhagic- recurrent hemoptyosis Suppurative- chronic cough, copious purulent expectoration, dyspnoea, wheeze(75%), pleuritic chest pain(50%) Rapid onset of symptoms- early stages paroxysmal cough+ occasional offensive sputum – change in position, later stages- large foetid sputum Signs Early stages- crackles/ronchi, slight alteration in character of breath sounds Late stages- bronchial breathing, coarse creps, sharp metallic leathery rales, clubbing Investigations Sputum Chest X ray HRCT IgA  BRONCHIAL ASTHMA Syndrome of variable airflow obstruction Physiologically- bronchial hyperactivity Pathologically - bronchial inflammation + eosinophil infiltration Clinically- variable cough, chest tightness, wheeze Types Extrinsic asthma- excessive IgE production –allergens Intrinsic asthma- excessive IgE production cannot be demonstrated Causes Infections- viral –childhood Smoking – parents - 1st 2yrs of Childs life Allergens- genetic, environmental factors- 1. aero-allergens(inhalants)- house dust, mites, pollens, feathers, paint, smoke, animal dander, moulds 2. ingestants- milk, eggs, nuts, chocolates, fish, shellfish, strawberries etc. Triggers Night/early morning Exercise-running Cold air, fog Viral respiratory tract infection Allergens Drugs- bets blockers, aspirin, NSAID Emotion/stress Occupational exposure Asthmatic attack Premonitory symptoms- sneezing, flatulence, drowsiness/restlessness, irritability, dry irritant cough may accompany wheezy breathlessness Paroxysm- sudden in middle night, anxiety, cyanosis, perspiration, cold extremities, wheezing heard at a distance examination- auscultation- short inspiration, prolonged expiration+ wheeze, crackles at base of lungs towards the end of an attack Termination – spontaneous/therapy- due to decreased bronchial spasm- pt is able to cough- viscid mucofibrin  Duration of attack – few mins- several hours/continuous paroxysms- status asthamaticus Extrinsic asthma Intrinsic asthma Young pt- child/teenager Adults>35yrs h/o eczema in childhood No h/o eczema in childhood Family h/o asthma, eczema, Negative family h/o hay fever Attacks related to specific Attacks related to infection, antigens exercise etc Intermittent attacks Persistent asthma Attacks are acute- self limiting Attacks are fulminant , severe Not aspirin sensitive, Aspirin sensitive, nasal polyps occasional polyps Skin test +ve Skin test –ve IgE increased Normal/low IgE Good prognosis Poor prognosis Investigations CBC- eosinophilia Skin test IgE chest X ray – normal/segmental/lobar collapse  PNEUMONIA Accumulation of secretions & inflammatory cells in alveolar spaces of the lungs caused by infection Pathology – infecting organism & inflammatory response- disturbance in gas exchange- alveolar involvement Causes – Bacterial- streptococcus pneumoniae, mycoplasma pneumoniae, chlaymydia pneumoniae, H.influenzaetc Viral- measles, influenz a , c yt om e ga l ovi rus, adenovirus, varicella, herpes zoaster Protozoal- entamoeba histolytica- Fungi- actinomycosis, aspergillosis, histoplasmosis  Chemicals- aspiration of vomit, pharyngeal diverticulum, achalasia cardia, hiatus hernia, kerosone, paraffin, petroleum, toxic gases , smoke Radiation Types Community acquired pneumonia(CAP) Hospital acquired pneumonia( nosocomial) Aspiration pneumonia Pneumonia in immunocompromised patients Recurrent pneumonia Unusual pneumonia Clinical symptoms Onset often sudden followed by minor respiratory infection of few days duration Infection- malaise, fever, rigors, night sweats, vomiting, elderly- confusion, disorientation Pulmonary – dyspnoea, cough, blood stained sputum- difficult to expectorate Pleural- pain aggravated by cough/deep breath/movement usually localised at the site of inflammation Signs General- tachycardia, rapid respiratory rate, high fever, flushed dry skin, herpes labialis, confusion, hypotension Pulmonary- early signs- prolonged expiration, fine rales, impaired percussion note signs of consolidation on 2nd/3rd day, resolution- most signs disappear by the end of 2nd week but fine rales, impaired percussion persists longer Investigations WBC count Chest X Ray Sputum ,blood, urine culture Serology CRP LFT, serum urea, electrolytes, arterial blood gas level  Emphysema Abnormal permanent enlargement of the airspaces distal to terminal bronchioles Pathology –combination of mechanical obstruction in the small airways from inflammation, later scarring, loss of elastic recoil of the lungs- collapse during expiration Clinical features h/o slowly increasing exertional dyspnoea Use of accessory muscle for respiration Barrel shaped chest, hyperesonant Cough with scanty mucoid sputum Recurrent respiratory infections are not frequent Weight loss Right heart failure Chest x ray- small heart, hyperinflated lungs Classification Centralacinar /central lobar- upper, apex, lower lobes, smokers Panacinar/panlobular entire acinus- alpha1 antitrypsin deficiency- lower lobes Paraseptal/distalacinar Irregular Mixed Features Pink Blue puffer/emphysema bloater/bronchitis Onset Dyspnoea & cough Cough without dyspnoea Built/weight loss Thin Obese Sputum Scanty Profuse, mucopurulent Dyspnoea Intense+ purse lip Mild breathing Cough After dyspnoea Before dyspnoea Bronchial infections Less More Location Acinus Bronchus Age Adults Adulta Pulmonary Mild Moderate- severe hypertension Pathology Deficiency of alpha1 Impaired ciliary COPD – Chronic Obstructive Pulmonary Disease air flow limitation that is not fully reversible- progressive, abnormal inflammatory response of the lungs to noxious particles/gases Risk factors Tobacco smoke Recurrent bronchopulmonary infection Environmental pollution Occupational- coal, gold mining, cement & cotton industries, grain handling, farming Low socioeconomic status genetic factors-alpha1 antitrypsin Birth weight, childhood respiratory illness Diagnosis h/o chronic progressive symptoms- cough, wheeze, breathlessness Ratio of FEV/FVC of less than 70% after using bronchodilater COPD- Chronic bronchitis Emphysema Bronchial asthma Bronchectiasis Small airway disease(bronhiolitis) Clinical features Persistent cough + copious expectoration of long duration- initially beginning in a heavy smoker – morning catarrh/ throat clearing which worsens in winter recurrent respiratory infections Dyspnoea at exertion Pts are called- blue bloaters- cyanosis, edema Cor pulmonale/right heart failure Chest x ray- enlarged heart+ prominent vessels  Pulmonary Tuberculosis Risk factors- Close contact with sputum smear +ve individual Environmental factors- malnutrition, poor/overcrowded housing, alcoholism, drug addiction, smoking, corticosteroid therapy Relation to other diseases- DM, liver cirrhosis, pneumoconiosis, partial gastrectomy Immunosuppression- drugs, autoimmune deificency syndrome Renal failure, family history Route of infection – inhalation of air borne affected droplet nuclei- sputum of an adult with cavitary pulmonary tuberculosis Clinical types Primary pulmonary tuberculosis Post primary tuberculosis Miliary tuberculosis 1.Primary Pulmonary Tuberculosis Invasion of tubercle bacilli- inhalation into lungs Primary complex- inhaled bacilli deposits in the alveoli- subpleural inflammatory lesion- reaches regional lymph nodes- infected- tuberculin test becomes +ve within 6weeks of infection- resolve/local calcification Progression Hematogenous dissemination- about 3months after primary infection acute - miliary tuberculosis, TB meningitis chronic- local manifestations- kidney, joints, bones etc  Progress of lung component- adolescents, young children after 6months of initial infection- lung focus- cavity, pleural involvement- pleural effusion Progress of lymph node component – pressure on trachea/ main bronchi- severe paroxysmal cough, dyspnoea, stridor/wheeze – mimics asthma Bronchial involvement – - partial bronchial obstruction- obstructive emphysema - complete bronchial obstruction – middle/lower lobes- pneumonia, collapse, lesions- permanent collapse, broncheictasis, obstructive emphysema - Middle lobe syndrome – vulnerable bronchiectasis, recurrent middle lobe infection 2. Post primary tuberculosis Causes – progressive primary lesion, reactivation of primary lesion, subsequent exogenous infection a. Acute pulmonary tuberculosis - Pneumonic tuberculosis- upper lobe, acute lobar pneumonia, irregular temperature, rapid breathing, signs of cavitation, leucopenia, failure to respond to antibiotics 2. Bronchopneumonic tuberculosis – abrupt onset, infleunza/measles(children), whooping cough- signs of diffuse bronchits in early stage, later- areas of consolidation at apex, rapid wasting X ray- scattered foci thought lung 3. Miliary tuberculosis onset- gradual, vague ill health, loss of weight, fever Fever – irregular, wide variation b/w morning , evening Hepatosplenomegaly- 20-30% cases  Respiratory symptoms- dyspnoea, cyanosis,, slight dry cough, scattered wheeze, occasional creps CNS – severe headache, signs of meningial irritation in early stages CVS- tachycardia Skin – miliary lesions- macules, papules, purpuric lesions Investigations Mantoux test Chest x ray – scattered opacities throughout lung fields- snow storm appearance 4. Acute disseminated heamtogenous tuberculosis - Pyrexia of unknown origin- few weeks, sudden disorientation- immunocompromised pts , absent/ scanty sputum,ARDS, tachypnoea, multiple organ dysfunction Chest x ray – miliary/scatterd shadows Brocnhoscopy- AFB culture, granuloma Liver cell dysfunction  Chronic pulmonary tuberculosis Symptom free- diagnosis by routine Xray Insidious malaise, fatigue, weight loss, pyrexia of unknown origin, cough(Persistent/smokers cough), repeated attacks of cold Hemoptysis – sudden, large- artery erosion(cavity), recurrent small quantity Non resolving pneumonia Hoarseness of voice Pleural- pleurisy- dry/with effusion, spontaneous pneumothorax Symptoms Asymptomatic Cough Expectoration- mucoid- purulent Hemoptysis Fever , sweats Malaise, fatigue Chest wall pain Dyspnoea Anorexia Signs Localised wheeze Apical crackles Non resolving pneumonia Diagnosis Sputum Chest xray- opacity- upper zone, patchy nodules, cavitation, calcification, cold abscess CT of thorax ESR Tuberculin test/mantoux test Biopsy ELISA