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COPD.

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Presentation on theme: "COPD."— Presentation transcript:

1 COPD

2 COPD Hallmark symptom - Dyspnea Chronic productive cough
Minor hemoptysis pink puffer blue bloater

3 COPD- pulmonary hyperinflation- the diaphragms are at the level of the eleventh posterior ribs and appear flat.

4 COPD - Physical Findings
Tachypnea Accessory respiratory muscle use Pursed lip exhalation Weight loss due to poor dietary intake and excessive caloric expenditure for work of breathing

5

6 Dominant Clinical Forms of COPD
Pulmonary emphysema Chronic bronchitis Most patients exhibit a mixture of symptoms and signs

7 COPD - Advanced Dx secondary polycythemia cyanosis tremor
somnolence and confusion due to hypercarbia Secondary pulmonary HTN w or w/o cor pulmonale

8 COPD Treatment Strategy
Elimination of extrinsic irritants bronchodilator & glucocorticoid therapy Antibiotics Mobilization of secretions “respiratory vaccines” Oxygen therapy - if oxygen saturation <90% at rest on room air

9 Spirometry

10

11 A-a gradient A-a gradient = predicted pO2 – observed PO2
PAO2 = (FIO2 X 713) – (PaCO2/0.8) at sealevel PAO2 = 150-(PaCO2/0.8) at sealevel on room air Normal range 10-15mm > 30 years of age Normal range 8mm < 30 years of age Increased A-aDO2=diffusion defect Right to left shunt V/Q mismatch

12 Examples A doubel overdose brings two 30 yr old patients to the ED. Both have ingested substantial amounts of barbiturates and diazepam. Blood gases drawn on room air revealed these values: patient 1- pH =7.18, PCO2 = 70mmHg, PO2=50mmHg, HCO3=24mEq/L; patient2- pH =7.31, PCO2=50mmHg, PO2=50mmHg, HCO3=25mEq/L

13 Comment The A-a gradient calculation for patient 1 is as follows:
A-a DO2 = PAO2 – PaO2 PAO2 = 150 – (1.25x PCO2) PAO2 = 150 – (1.25x 70) PAO2 = 62 A-a =62 – 50 A-a = 12

14 Comment The calculation reveals a normal gradient, indicating that the etiology for hypoxemia and hypoventilation is extrinsic to the lung itself.

15 Comment The A-a gradient calculation for patient 2 is as follows:
PAO2 = 150 – (1.25 x PCO2) PAO2 = 150 – (1.25 x 50) PAO2 = 150 – 63 PAO2 = 87 Therefore, A-a = 87 – 50 =37 (an abnormally increased gradient)

16 Comment We can be reasonably confident that patient 1 suffered hypoventilation due to the effect of the ingested drugs on the brain stem. Temporary mechanical ventilation restored this patient’s gas exchange.

17 Comment Patient 2, on the other hand, had an increased A-a gradient, indicating a lung problem in addition to any central cause for hypoventilation. The chest x-ray film revealed that this patient’s overdose was complicated by aspiration pneumonitis and that the patient required treatment with antibiotics in addition to mechanical ventilation.

18 (Chronic Obstructive Pulmonary Disease)
COPD (Chronic Obstructive Pulmonary Disease) Chronic Bronchitis Emphysema

19 Definition A disease state characterized by airflow limitation that is not fully reversible Conditions include: Emphysema: (anatomically defined condition characterized by destruction and enlargement of the lung alveoli) Chronic bronchitis: clinically defined condition with chronic cough and phlegm Small-airways disease: condition in which small bronchioles are narrowed

20 Epidemiology • Affects > 16 million persons in the U.S.
• Fourth leading cause of death in the U.S. • Affects > 16 million persons in the U.S. • Global Initiative for Chronic Obstructive Lung Disease (GOLD) estimates suggest that chronic obstructive lung disease (COLD) will increase from the sixth to the third most common cause of death worldwide by 2020.

21 Epidemiology >70% of COLD-related health care expenditures go to emergency department visits and hospital care (>$10 billion annually in the U.S.).

22 Epidemiology Sex Higher prevalence in men, probably secondary to smoking Prevalence of COLD among women is increasing as the gender gap in smoking rates has diminished.

23 Epidemiology Age Higher prevalence with increasing age
Dose–response relationship between cigarette smoking intensity and decreased pulmonary function

24 Risk Factors Cigarette smoking is a major risk factor.
Cigar and pipe smoking Passive (secondhand) smoking 􀂃 Associated with reductions in pulmonary function 􀂃 Its status as a risk factor for COLD remains uncertain

25 Occupational exposures to dust and fumes (e.g., cadmium)
Likely risk factors The magnitude of these effects appears substantially less important than the effect of cigarette smoking. Ambient air pollution The relationship of air pollution to COLD remains unproven.

26 Genetic factors α1 antitrypsin (α1AT) deficiency
Common M allele: normal levels S allele: slightly reduced levels Z allele: markedly reduced levels Null allele: absence of α1AT (rare) Lowest levels of α1AT are associated with incidence of COLD; α1AT deficiency interacts with cigarette smoking to increase risk.

27 Distributions of forced expiratory volume in 1 s (FEV1)values in a general population sample, stratified by pack-years of smoking

28 Etiology COLD Causal relationship between cigarette smoking and development of COLD has been proven: however, the response varies considerably among individuals.

29 COLD exacerbation Bacterial infections Viral infections (one-third)
􀂃 Streptococcus pneumoniae 􀂃 Haemophilus influenzae 􀂃 Moraxella catarrhalis 􀂃 Mycoplasma pneumoniae or Chlamydia pneumoniae (5–10% of exacerbations) Viral infections (one-third) No specific precipitant identified (20–35%)

30 Symptoms & Signs • 3 most common: Cough Sputum production
Exertional dyspnea, frequently of long duration

31 signs and symptoms Dyspnea at rest
Prolonged expiratory phase and/or expiratory wheezing on lung examination Decreased breath sounds Barrel chest Large lung volumes and poor diaphragmatic excursion, as assessed by percussion Use of accessory muscles of respiration Pursed lip breathing (predominantly emphysema) Characteristic "tripod" sitting position to facilitate the actions of the sternocleidomastoid, scalene, and intercostal muscles Cyanosis, visible in lips and nail beds

32 Paradoxical respiration
Systemic wasting 􀂃 Significant weight loss 􀂃 Bitemporal wasting 􀂃 Diffuse loss of subcutaneous adipose tissue Paradoxical respiration 􀂃 Inward movement of the rib cage with inspiration (Hoover's sign) in some patients "Pink puffers" are patients with predominant emphysema—no cyanosis or edema, with decreased breath sounds. "Blue bloaters" are patients with predominant bronchitis—cyanosis and edema. 􀂃 Most patients have elements of each.

33 Advanced disease: signs of cor pulmonale
􀂃 Elevated jugular venous distention 􀂃 Right ventricular heave 􀂃 Third heart sound 􀂃 Hepatic congestion 􀂃 Ascites 􀂃 Peripheral edema

34 Differential Diagnosis
Congestive heart failure Asthma Bronchiectasis Obliterative bronchiolitis Pneumonia Tuberculosis Atelectasis Pneumothorax Pulmonary embolism

35 Considerations COLD is present only if chronic airflow obstruction occurs. 􀂃 Chronic bronchitis without chronic airflow obstruction is not COLD. Asthma 􀂃 Reduced forced expiratory volume in 1 second (FEV1) in COLD seldom shows large responses (>30%) to inhaled bronchodilators, although improvements up to 15% are common. 􀂃 Asthma patients can also develop chronic (not fully reversible) airflow obstruction.

36 Considerations Problems other than COLD should be suspected when hypoxemia is difficult to correct with modest levels of supplemental oxygen. Lung cancer 􀂃 Clubbing of the digits is not a sign of COLD.In patients with COLD, development of lung cancer is the most likely explanation for newly developed clubbing.

37 Chronic Bronchitis Chronic lower airway inflammation
Increased bronchial mucus production Productive cough Urban male smokers > 30 years old

38 Chronic Bronchitis Blue Bloater
Mucus, swelling interfere with ventilation Increased CO2, decreased 02 Cyanosis occurs early in disease Lung disease overworks right ventricle Right heart failure occurs RHF produces peripheral edema Blue Bloater

39 Emphysema Loss of elasticity in small airways
Destruction of alveolar walls Urban male smokers > years old

40 Emphysema Pink Puffer Lungs lose elastic recoil
Retain CO2, maintain near normal O2 Cyanosis occurs late in disease Barrel chest (increased AP diameter) Thin, wasted Prolonged exhalation through pursed lips Pink Puffer

41 COPD Management Oxygen Assist ventilations as needed Monitor carefully
Some COPD patients may experience respiratory depression on high concentration oxygen Assist ventilations as needed

42 Diagnostic Approach Initial assessment
History and physical examination (Signs & Symptoms) Pulmonary function testing to assess airflow obstruction Radiographic studies

43 Assessment of exacerbation
History 􀂃 Fever 􀂃 Change in quantity and character of sputum 􀂃 ill contacts 􀂃 Associated symptoms 􀂃 Frequency and severity of prior exacerbations

44 Assessment of exacerbation
Physical examination 􀂃 Tachycardia 􀂃 Tachypnea 􀂃 Chest examination 􀂃 Focal findings 􀂃 Air movement 􀂃 Symmetry 􀂃 Presence or absence of wheezing 􀂃 Paradoxical movement of abdominal wall 􀂃 Use of accessory muscles 􀂃 Perioral or peripheral cyanosis 􀂃 Ability to speak in complete sentences 􀂃 Mental status

45 Hospitalization recommended for:
Radiographic studies 􀂃 Chest radiography focal findings (pneumonia, atelectasis) Arterial blood gases 􀂃 Hypoxemia 􀂃 Hypercapnia Hospitalization recommended for: 􀂃 Respiratory acidosis and hypercarbia 􀂃 Significant hypoxemia 􀂃 Severe underlying disease 􀂃 Living situation not conducive to careful observation and delivery of prescribed treatment

46 ABG and oximetry Although not sensitive, they may demonstrate resting or exertional hypoxemia. Blood gases provide additional information about alveolar ventilation and acid–base status by measuring arterial PCO 2 and pH. Change in pH with PCO 2 is 0.08 units/10 mmHg acutely and 0.03 units/10 mmHg in the chronic state. 􀂃

47 Laboratory Tests Elevated hematocrit suggests chronic hypoxemia.
Serum level of α1AT should be measured in some patients. o Presenting at ≤ 50 years of age o Strong family history o Predominant basilar disease o Minimal smoking history o Definitive diagnosis of α1AT deficiency requires PI type determination. 􀂃 Typically performed by isoelectric focusing of serum, which reflects the genotype at the PI locus for the common alleles and many of the rare PI alleles 􀂃 Molecular genotyping can be performed for the common PI alleles (M, S, and Z). Sputum gram stain and culture (for COLD exacerbation)

48 Imaging • Chest radiography • Chest CT
Emphysema: obvious bullae, paucity of parenchymal markings, or hyperlucency Hyperinflation: increased lung volumes, flattening of diaphragm Does not indicate chronicity of changes • Chest CT Definitive test for establishing the diagnosis of emphysema, but not necessary to make the diagnosis

49 Diagnostic Procedures
Pulmonary function tests/spirometry Chronically reduced ratio of FEV1 to forced vital capacity (FVC) In contrast to asthma, the reduced FEV1 in COLD seldom shows large responses (>30%) to inhaled bronchodilators, although improvements up to 15% are common. Reduction in forced expiratory flow rates Increases in residual volume Increases in ratio of residual volume to total lung capacity Increased total lung capacity (late in the disease) Diffusion capacity may be decreased in patients with emphysema. Electrocardiography may detect signs of ventricular hypertroph

50 Classification GOLD stage Classification based on pathologic type

51 GOLD stage I II III IV 􀂃 Severity: at risk
􀂃 Severity: at risk 􀂃 Symptoms: chronic cough, sputum production 􀂃 Spirometry: normal I 􀂃 Severity: mild 􀂃 Symptoms: with or without chronic cough or sputum production 􀂃 Spirometry: FEV1:FVC < 0.7 and FEV1 ≥ 80% predicted II 􀂃 Severity: moderate 􀂃 Spirometry: FEV1:FVC < 0.7 and FEV1 50–80% predicted III 􀂃 Severity: severe 􀂃 Spirometry: FEV1:FVC < 0.7 and FEV1 30–50% predicted IV 􀂃 Severity: very severe 􀂃 Spirometry: FEV1:FVC < 0.7 and FEV1 < 30% predicted or FEV1 < 50% predicted with respiratory failure or signs of right heart failure

52 Treatment Approach General
Only 2 interventions have been demonstrated to influence the natural history. 􀂃 Smoking cessation 􀂃 Oxygen therapy in chronically hypoxemic patients All other current therapies are directed at improving symptoms and decreasing frequency and severity of exacerbations. Therapeutic response should determine continuation of treatment.

53 Specific Treatments Stable-phase COLD, pharmacotherapy
Bronchodilators Used to treat symptoms The inhaled route is preferred. Side effects are less than with parenteral delivery. Theophyllline: various dosages and preparations; typical dose 300–600 mg/d, adjusted based on levels

54 Specific Treatments Stable-phase COLD, pharmacotherapy
Anticholinergic agents Trial of inhaled anticholinergics is recommended in symptomatic patients. Side effects are minor. Improve symptoms and produce acute improvement in FEV Do not influence rate of decline in lung function Ipratropium bromide (short-acting anticholinergic) (Atrovent) 􀂃 Inhaled: 30-min onset of action; 4-h duration 􀂃 Atrovent: metered-dose inhaler; 18 μg per inhalation; 1–2 inhalations qid

55 Specific Treatments Stable-phase COLD, pharmacotherapy
Tiotropium (long-acting anticholinergic) (Spiriva) 􀂃 Spiriva: powder via handihaler; 18 μg per inhalation; 1 inhalation qd Symptomatic benefit Long-acting inhaled β-agonists, such as salmeterol, have benefits similar to ipratropium bromide. 􀂃 More convenient than short-acting agents

56 Specific Treatments Stable-phase COLD, pharmacotherapy
Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefit. Side effects 􀂃 Tremor 􀂃 Tachycardia Salmetrol (Serevent): 􀂃 Powder via diskus; 50-μg inhalation every 12 h Formoterol (Foradil): 􀂃 Powder via aerolizer; 12-μg inhalation every 12 h

57 Specific Treatments Stable-phase COLD, pharmacotherapy
Albuterol (short-acting β-agonist) (Proventil HFA, Ventolin HFA, Ventolin, Proventil) 􀂃 Metered-dose inhaler (or in nebulizer solution); 180-μg inhalation every 4–6 h as needed Combined β-agonist/anticholinergic: albuterol/ipratropium (Combivent) 􀂃 Metered-dose inhaler (also available in nebulizer solution); 120 mcg/21 μg per inhalation 1–2 inhalations qid

58 Inhaled glucocorticoids
Specific Treatments Stable-phase COLD, pharmacotherapy Inhaled glucocorticoids Reduce frequency of exacerbations by 25–30% No evidence of a beneficial effect for the regular use of inhaled glucocorticoids on the rate of decline of lung function, as assessed by FEV1 Consider a trial in patients with frequent exacerbations (≥2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled bronchodilators. Side effects 􀂃 Increased rate of oropharyngeal candidiasis 􀂃 Increased rate of loss of bone density

59 Specific Treatments Stable-phase COLD, pharmacotherapy
Beclomethasone (QVAR): 􀂃 Metered-dose inhaler; 40–80 μg/spray; 40–160 μg bid Budesonide (Pulmicort): 􀂃 Powder via Turbuhaler; 200 μg/spray; 200 μg inhaled bid Fluticasone (Flovent): 􀂃 Metered-dose inhaler; 44, 110 or 220 μg/spray; 88–440 μg inhaled bid Triamcinolone (Azmacort) 􀂃 Metered-dose inhaler via built-in spacer; 100 μg/spray; 100–400 μg inhaled bid

60 Supplemental O2 is the only therapy demonstrated to decrease mortality
Oxygen Supplemental O2 is the only therapy demonstrated to decrease mortality In resting hypoxemia (resting O2 saturation < 88% or < 90% with signs of pulmonary hypertension or right heart failure), the use of O2 has been demonstrated to significantly affect mortality. Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemia. 􀂃 The rationale for supplemental O2 in these settings is physiologically sound, but benefits are not well substantiated.

61 Beclomethasone (QVAR):
􀂃 Metered-dose inhaler; 40–80 μg/spray; 40–160 μg bid Budesonide (Pulmicort): 􀂃 Powder via Turbuhaler; 200 μg/spray; 200 μg inhaled bid Fluticasone (Flovent): 􀂃 Metered-dose inhaler; 44, 110 or 220 μg/spray; 88–440 μg inhaled bid Triamcinolone (Azmacort) 􀂃 Metered-dose inhaler via built-in spacer; 100 μg/spray; 100–400 μg inhaled bid

62 Parenteral corticosteroids
Long-term use of oral glucocorticoids is not recommended. Side effects 􀂃 Osteoporosis, fracture 􀂃 Weight gain 􀂃 Cataracts 􀂃 Glucose intolerance 􀂃 Increased risk of infection Patients tapered off long-term low-dose prednisone (~10 mg/d) did not experience any adverse effect on the frequency of exacerbations, quality of life, or lung function. On average, patients lost ~4.5 kg (~10 lb) when steroids were withdrawn.

63 Theophylline Produces modest improvements in expiratory flow rates and vital capacity and a slight improvement in arterial oxygen and carbon dioxide levels in moderate to severe COPD Side effects 􀂃 Nausea (common) 􀂃 Tachycardia 􀂃 Tremor

64 Specific Treatments Stable-phase COLD, pharmacotherapy
Other agents N-acetyl cysteine 􀂃 Used for its mucolytic and antioxidant (current clinical trials) properties Intravenous α1AT augmentation therapy for patients with severe α1AT deficiency Antibiotics 􀂃 Long-term suppressive or "rotating" antibiotics are not beneficial

65 Specific Treatments Stable-phase COLD, nonpharmacologic therapies
Smoking cessation All patients with COLD should be strongly urged to quit and educated about the benefit of cessation and risks of continuation. Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of successful smoking cessation. 􀂃 Bupropion 􀂃 Nicotine replacement (gum, transdermal, inhaler, nasal spray) 􀂃 The U.S. Surgeon General recommendation is for all smokers considering quitting to be offered pharmacotherapy in the absence of any contraindication.

66 Specific Treatments Stable-phase COLD, nonpharmacologic therapies
General medical care Annual influenza vaccine Polyvalent pneumococcal vaccine is recommended, although proof of efficacy in COLD patients is not definitive.

67 Specific Treatments Stable-phase COLD, nonpharmacologic therapies
Pulmonary rehabilitation Improves health-related quality of life, dyspnea, and exercise capacity Rates of hospitalization are reduced over 6 to 12 months.

68 Specific Treatments Stable-phase COLD, nonpharmacologic therapies
Lung volume reduction surgery Produces symptomatic and functional benefit in selected patients 􀂃 Emphysema 􀂃 Predominant upper lobe involvement Contraindications 􀂃 Significant pleural disease (pulmonary artery systolic pressure >45 mm Hg) 􀂃 Extreme deconditioning 􀂃 Congestive heart failure 􀂃 Other severe comorbid conditions 􀂃 FEV1 < 20% of predicted and diffusely distributed emphysema on CT or diffusing capacity for CO <20% of predicted (due to increased mortality)

69 Specific Treatments Stable-phase COLD, nonpharmacologic therapies
Lung transplantation COLD is the leading indication. Candidates 􀂃 ≤65 years 􀂃 Severe disability despite maximal medical therapy 􀂃 No comorbid conditions, such as liver, renal, or cardiac disease 􀂃 Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindications. Unresolved issues include whether single- or double-lung transplantation is preferred.

70 exacerbation of COPD The goals of emergency therapy
correct tissue oxygenation alleviate reversible bronchospasm treat the underlying etiology of the exacerbation

71 Administer controlled oxygen therapy
correct or prevent life-threatening hypoxemia, PaO2 greater than 60 mm Hg or an SaO2 greater than 90 percent Improvement after administration of supplemental oxygen may take 20 to 30 min to achieve a steady state

72 B 2-Agonists and anticholinergic agents are first-line therapies in the management of acute, severe COPD

73 CORTICOSTEROIDS short course (7 to 14 days) of systemic steroids appears more effective than placebo in improving FEV1 in acute severe exacerbations of COPD, role in mild-to-moderate exacerbations Hyperglycemia is the most common adverse effect

74 ANTIBIOTICS All current guidelines recommend antibiotics if there is evidence of infection, change in volume of sputum and increased purulence of sputum benefits are more apparent in more severe exacerbations Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbation Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis duration of treatment;(3 to 14 days )

75 METHYLXANTHINES theophylline and aminophylline
severe exacerbation when other therapy has failed or in patients already using methylxanthines who have subtherapeutic drug levels The bronchodilation effect of aminophylline is limited, therapeutic range is narrow

76 In patients who regularly use theophylline,
IV loading dose 5 to 6 mg/kg usually required to obtain an initial serum concentration of 8 to 12 macg/mL In patients who regularly use theophylline, a mini-loading dose should be administered: (target concentration–currently assayed concentration) x volume of distribution (i.e., 0.5 times ideal body weight in liters) target concentration should be between 10 and 15 macg/mL. IV maintenance infusion rate is 0.2 to 0.8 mg/kg ideal body weight per h. lower maintenance rates (congestive heart failure or hepatic insufficiency ) raise maintenance rates in patients with higher clearance rates, such as smokers

77 Summary for ED Management
Assess severity of symptom   Administer controlled oxygen therapy   Perform arterial blood gas measurement after 20–30 min if SaO2 remains <90% or if concerned about symptomatic hypercapnia  

78 Administer bronchodilators
B2-agonists and/or anticholinergic agents by nebulization or MDI with spacer   Consider adding intravenous methylxanthine, if needed Add corticosteroids ( Oral or intravenous) Consider antibiotics   If increased sputum volume, change in sputum color, fever, or suspicion of infectious etiology of exacerbation

79 Laboratory evaluation 
 Chest x-ray   CBC with differential   Electrolytes   Arterial blood gases   ECG as needed

80 At all times … Monitor fluid balance
Consider subcutaneous heparin (venous thrombosis prophylaxis)   Identify and treat associated conditions (e.g., heart failure, arrhythmias)   Closely monitor condition of the patient

81 Indications for Invasive Mechanical Ventilation
Severe dyspnea with use of accessory muscles and paradoxical abdominal motion Respiratory frequency >35 breaths per min Life-threatening hypoxemia: PaO2 <50 mm Hg (<5.3 kPa) or PaO2/FIO2 <200 mm Hg  Severe acidosis (pH <7.25) and hypercapnia (PaCO2 >60 mm Hg or >8.0 kPa) Respiratory arrest Somnolence, impaired mental status Cardiovascular complications (hypotension, shock, heart failure) NIPPV failure

82 Indications for ICU Severe dyspnea that responds inadequately to initial emergency therapy Confusion, lethargy, coma Persistent or worsening hypoxemia: PaO2 <50 mm Hg (<6.7 kPa) Severe or worsening hypercapnia: PaCO2 >70 mm Hg (>9.3 kPa) Severe or worsening respiratory acidosis (pH <7.30) despite supplemental oxygen and NIPPV

83 Indications for Hospital Admission
Marked increase in intensity of symptoms, such as sudden development of resting dyspnea Severe background of COPD Onset of new physical signs (e.g., cyanosis, peripheral edema) Failure of exacerbation to respond to initial medical management Significant comorbidities Newly occurring arrhythmias Diagnostic uncertainty Older age Insufficient home support

84 discharge to home adequate supply of home oxygen, if needed
adequate and appropriate bronchodilator treatment short course of oral corticosteroids a follow-up with their physician

85 Spacer Devices for Metered Dose Inhalers
Spacer devices have a chamber that receives the aerosol before it is inhaled.  They serve two functions: a) to overcome difficulties in coordinating the timing of the inhaler actuation and inhalation,  b) to slow down the speed of delivery of the aerosol into the mouth so that less of the drug impacts in the throat.

86 Prevention • Smoking prevention or cessation
• Prevention of exacerbations Long-term suppressive antibiotics are not beneficial. Inhalation glucocorticoids should be considered in patients with frequent exacerbations or in patients with an asthmatic component. • Vaccination against influenza and pneumococcal infection


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