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General Symptoms of Respiratory

Disease Hypoxia: Decreased levels of oxygen in the tissues.

Hypoxemia: Decreased levels of oxygen in arterialblood.

Hypercapnia: Increased levels of CO2 in the blood.

Hypocapnia: Decreased levels of CO2 in the blood.

Dyspnea: Difficulty breathing.

Tachypnea: Rapid rate of breathing.

Cyanosis: Bluish discoloration of skin and mucous

membranes due to poor oxygenation of the blood. Hemoptysis: Blood in the sputum.

Respiratory infections

Infections of the respiratory tract canoccur in the upper or lower respiratorytract, or both.

Organisms capable of infecting respiratorystructures include bacteria, viruses andfungi.

Depending on the organism and extent ofinfection, the manifestations can rangefrom mild to severe and even life-threatening.


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Infections of the upper

respiratory tract

The common cold

The majority of upper respiratory tractinfections are caused by viruses.

The most common viral pathogens for the

common cold are rhinovirus, parainfluenzavirus, respiratory syncytial virus, adenovirus andcoronavirus.

These viruses tend to have seasonalvariations in their peak incidence.

Spread from person to person viarespiratory secretions.


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The common cold

Manifestations of the common cold include:

Rhinitis: Inflammation of the nasal mucosa.

Sinusitis: Inflammation of the sinus

mucosa.

Pharyngitis: Inflammation of the pharynx

and throat.

Headache.

Nasal discharge and congestion.

Influenza

Is a viral infection that can affect the upper orlower respiratory tract.

Three distinct forms ofinfluenza virus have beenidentified: A, B and C.

Of these three variants, type A is the mostcommon and causes the most serious illness.

The influenza virus is a highly transmissiblerespiratory pathogen. Because the organism has ahigh tendency for genetic mutation, new variantsof the virus are constantly arising in differentplaces around the world.


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Influenza

Symptoms ofinfluenza infection:

Headache.

Fever.

Chills.

Muscle aches.

Nasal discharge. Unproductive cough.

Sore throat.

Influenza

Influenza infection can cause markedinflammation of the respiratory epitheliumleading to acute tissue damage and a loss of

ciliated cells that protect the respiratorypassages from other organisms.

As a result, influenza infection may lead toco-infection of the respiratory passages withbacteria.

It is also possible for the influenza virus toinfect the tissues of the lung itself to cause aviral pneumonia.


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Infections of the lower

respiratory tract

Pneumonia

The word pneumonia is of Greek origin,

meaning a condition about the lung.

Pneumonia is defined as an infection orinflammation of the lung parenchyma

caused most often by microbial

pathogens.

Noninfectious pneumonia or pneumonitis

results from exposure to drugs, fluids, or

chemicals.


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Pneumonia

Despite major advances in diagnosis and treatment, however,

mortality associated with pneumonia remains high, especially

in the elderly.

Pneumonia has often been classified by:

The environmental setting in which it developed:

1. Community-acquired pneumonia (CAP).

2. Hospital-acquired pneumonia (HAP).

o Specific structures of the lung that the organisms infect:1.Typical.

2. Atypical.

Community-acquired pneumonia

(CAP)

In a person who has not recently beenhospitalized.

The most common causes of CAP include:Streptococcus pneumoniae, viruses, the atypicalbacteria, and Haemophilus influenzae.

Viral agents account for 2% to 15% of all casesof CAP. Influenza A and B, adenovirus, andparainfluenza virus are most commonlyreported in adults, whereas respiratory syncytialvirus is most common in the pediatricpopulation.


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Microbiology of Community-Acquired Pneumonia Microbial Agent Percentage

Bacteria

S. pneumoniae 2060

H. influenzae 310

S. aureus 35

Gram-negative bacilli 310

Atypical Agents

Legionella species 28

M. pneumoniae 1

6C. pneumoniae 46

Viral 215

No diagnosis 3060

Mortality Rates by Pathogen for Community-Acquired

Pneumonia

Pathogen Mortality Rate (%)

S. pneumoniae 12

H. influenzae 7.4

S. aureus 31.8

K. pneumoniae 35.7

P. aeruginosa 61

Legionella 14.7

C. pneumoniae 9.8

M. pneumoniae 1.4
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Hospital-acquired pneumonia

(HAP) Is pneumonia acquired during or after hospitalization for another

illness or procedure with onset at least 72 hrs after admission.

Hospitalized patients may have many risk factors for pneumonia,

including mechanical ventilation, prolonged malnutrition,

underlying heart and lung diseases, decreased amounts of

stomach acid, and immune disturbances. Additionally, the

microorganisms a person is exposed to in a hospital are often

different from those at home .

Ventilator-associated pneumonia (VAP):is pneumonia which

occurs after at least 48 hours of intubation and mechanical

ventilation.

Term nosocomial pneumonia is a broader term that

incorporates HAP and VAP and the more recently established

entity healthcare- associated pneumonia (HCAP).

Healthcare- associated pneumonia

(HCAP) HCAP is included within the spectrum of HAP and VAP.

HCAP was coined to include patients who may be atgreater risk of being infected with resistant nosocomialorganisms but who may have developed the infection byexposure to the healthcare system but outside of ahospital.

By definition, HCAP includes patients hospitalized in anacute care hospital for 2 or more days within 90 days ofthe infection; those who lived in a nursing home or long-term care facility; those who received recent intravenousantibiotic therapy, chemotherapy, or wound care within thepast 30 days of the current infection; or those whoattended a hospital or hemodialysis clinic.


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Host defense Mechanical:

The hairs lining the nasal passages, ciliated epithelial

cells on mucosal surfaces, production of mucus, salivary

enzymes, and the mechanical process of swallowing

minimize the passage of foreign material into the lower

respiratory tract.

Cough/gag reflex.

Normal oropharyngeal flora.

Cellular: The pulmonary macrophages residing within the alveoli,

polymorphonuclear leukocytes.

Humoral/ Molecular/ Inflammatory:

Immunoglobulin and complement present in lung tissue.

Conditions That Diminish Key Host Defenses

Overwhelm or Bypass Mechanical Barriers, Predisposing Patients to Aspiration

Alcohol or drug abuse Anesthesia

Seizures Head trauma

Stroke Parkinson's disease

Multiple sclerosis Dysphagia

Neurologic disorders Esophageal cancer

Vomiting Gastroesophageal reflux disorder

Diminished Mucociliary Transport of Cellular and Bacterial Debris

Tracheostomy Nasogastric or endotracheal tube

Bronchoscopy

Smoking Chronic lung diseases

Immotile cilia syndrome Cystic fibrosis

Viral infections Aging

Hyperoxia Inhalation of toxic substances

Diminished Alveolar Macrophage Activity and Chemotaxis

Alcohol ingestion Advanced age

Diabetes mellitus Sickle cell diseases

Malnutrition Immunosuppressive therapy

Hypogammaglobulinemia

Viral infection

Chronic obstructive pulmonary disease

AIDS Malignancy

Cystic fibrosis Bacterial endotoxin

Hypoxemia Metabolic acidosis

Pulmonary edema Uremia

Hyperoxia Mechanical obstruction
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Risk Factors The elderly.

The immunosuppressed patients.

Smokers.

Individuals with chronic medical conditions such as chronic

obstructive lung disease, congestive heart failure, coronary artery

disease, diabetes, alcoholism, renal failure, malignancy, dementia,

chronic neurologic disease, seizure disorders, and chronic liver

disease.

Patients who have previously had pneumonia or recently had

influenza are also at increased risk for developing pneumonia.

Hospitalized patients receiving mechanical ventilation are 20 times

more likely to develop pneumonia than nonventilated hospitalized

patients.

Risk Factors Contd Retrograde movement of bacteria living in gastric contents into the

upper respiratory tract, with eventual aspiration into the lung may

be important cause of VAP.

Supine positioning seems to be a risk factor for aspiration

pneumonia.

Growth of bacteria in the gastric environment is enhanced in

situations of hypoacidity. Medications such as H2-receptor

antagonists and proton-pump inhibitors (PPIs) reduce gastric

acidity. Many ventilated patients receive these agents for stress-

ulcer prophylaxis. Use of these agents has been identified as a risk

factor for developing VAP.

Enteral feeding of ventilated patients has also been associated with

higher rates of VAP. The increased risk may be explained by the fact

that these formulations typically promote alkalinization of the

gastric environment and may increase the risk of aspiration.


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Clinical Presentation

Cough (with or without sputum

production).

Tachypnea.

Fever.

Diagnostic test Chest radiograph revealing consolidation in one or

more areas of the lung.

Pneumonia as seen on chest x-ray.

A: Normal chest x-ray.

B: Abnormal chest x-ray with

shadowing from pneumonia in the right

lung (white area, left side of image).
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Diagnostic test

Determination of Etiologic Agent:

Adequately and appropriately

collected sputum that is Gram stained

and cultured remain the mainstays in

identifying the etiologic organisms of

acute pneumonias.

Diagnostic test

Blood culture:

Only 5-14% cultures of blood are +ve.

No longer considered necessary for allhospitalized CAP patients.

Should be done in certain high risk

patients (e.g. sever CAP, chronic liver

disease).

CAP : Community-acquired pneumonia.


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Aspiration Pneumonia

Is a pneumonic process that results from abnormal entry ofsignificant volumes (macroaspiration) of oropharyngeal orgastrointestinal contents into the lower respiratory tract.

The term aspiration pneumonia is best applied toaspiration from an oropharyngeal source.

The term aspiration pneumonitis is best applied topulmonary sequelae that arise from aspiration of sterilegastric contents. This usually noninfectious inflammatoryprocess results from chemical injury by gastric acid or fromexposure to particulate material (e.g., food).

Patients experiencing noninfectious or chemical pneumonitismay present clinically like those with infectious pneumonia.

The specific effect of the aspirated material on the lungsdepends on the quantity and quality of the material aspirated.The latter can be categorized into three types: directpulmonary toxin, particulate matter, and infected inoculum.

Predisposing Conditions in Aspiration Pneumonia

Alterations of Consciousness

Alcoholism

Seizure disorders

General anesthesia

Cerebrovascular accident

Drug intoxication

Head injury

Severe illness with obtundation

Impaired Swallowing Mechanism

Neurologic disorders

Esophageal dysfunction

NasogastricFeeding

Tracheotomy

EndotrachealTube

Periodontal Disease

Reprinted with permission from Klein RS, Steigbigel NH. Seminars in

Infectious Disease. New York: Thieme Medical Publishers, 1983;5.
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Atypical Pneumonia

The term atypical originated from the observation thatthese organisms were associated with pneumonic infectionswhose clinical presentation was different than that observedfor the more classic pneumococcal pneumonia presentationof high fever, chills, pleuritic chest pain, lobar consolidation,purulent sputum, and often toxic appearance.

Symptoms of pneumonia secondary to pathogens such as S.pneumoniae,H. influenzae,Staphylococcus aureus, and entericGram-negative bacteria (typical) is different from thatobserved for Mycoplasma, Legionella, and Chlamydia(atypical).

The atypical pneumonia syndrome was often associatedwith a more subacute or gradual illness, a nonproductivecough, and extrapulmonary symptoms such as headache,hoarseness, pharyngitis, myalgias, and gastrointestinalcomplaints.

415 PHCL

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