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415 PHCL
Upper and Lower
Respiratory TractInfections
Raniah A. Al-Jaizani
Lecturer
Clinical Pharmacy Dept.
415 PHCL
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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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