1. Upper and Lower Respiratory infections
Lobna Al AL Juffali
Spring 2010

2. Respiratory system

3. Areas Involved in Respiratory Tract Infections
Upper respiratory tract
Nose, oropharynx, and larynx
Lower respiratory tract
Lower airways and lungs
Upper and lower airways

4. Anatomy of the Respiratory system
Nose
Pharynx
Larynx (speech)
Trachea
Bronchi and their smaller branches
lungs
Alveoli Gas exchange
Passageways that allow air to reach the lungs
Purify
Humidify
Warm incoming air

5. Functions of the respiratory system
The major function of the respiratory system is to supply the body with oxygen and to dispose of carbon dioxide.

6. Functions of the respiratory system
Breathing
Gas exchange between the pulmonary blood and alveoli must take place
Respiratory gas transport via the bloodstream to the tissue cells
Internal respiration at systemic capillaries between the blood and tissue cells

7. General Symptoms of Respiratory Disease
Hypoxia: Decreased levels of oxygen in the tissues.
Hypoxemia: Decreased levels of oxygen in arterial blood.
Hypercapnia: Increased levels of CO2 in the blood.
Hypocapnia: Decreased levels of CO2 in the blood.
Dyspnea: Difficultybreathing.
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.

8. Upper Respiratory infection

9. PHARYNGITIS
Pharyngitis is an acute infection of the oropharynx or nasopharynx that results in 1% to 2% of all outpatient visits.
The incubation period is 2 to 5 days, and the illness often occurs in clusters

10. PHARYNGITIS
rhinovirus, coronavirus, and adenovirus causes ACUTE Pharyngitis
causes are most common
viral
Streptococcus pyogenes
Group A β-hemolytic Streptococcus 15% to 30%
Bacterial

11. Pathopyisiology
bacteria or viruses may directly invade the pharyngeal mucosa, causing a local inflammatory response.
rhinovirus and coronavirus, can cause irritation of pharyngeal mucosa secondary to nasal secretions.
Streptococcal infections are characterized by local invasion and release of extracellular toxins and proteases.

12. Complications of pharyngitis with Group A Streptococcus
acute rheumatic fever
acute glomerulonephritis
reactive arthritis may occur as a result.

13. CLINICAL PRESENTATION
Signs and symptoms
A sore throat of sudden onset that is mostly self- limited
Pain on swallowing.
Fever.
Headache, nausea, vomiting, and abdominal pain (especially children).

14. CLINICAL PRESENTATION
Erythema/inflammation of the tonsils and pharynx with or without patchy exudates.
Enlarged, tender lymph nodes.
Red swollen uvula, petechiae on the soft palate
Several symptoms that are not suggestive of Group A are cough, conjunctivitis, and diarrhea.

15. Laboratory tests
Streptococcus Throat swab and culture or rapid antigen detection testing

16. Rhinitis and Sinusitis
Inflammation of the nasal mucosa
Sinusitis
Inflammation of the paranasal sinuses
that persists beyond 7–14 days
Chronic/recurrent infections occur three to four times a year and are unresponsive to steam and decongestants.

17. The sinuses are surrounded by bone and cartilage and lined with a mucous membrane. Sinusitis occurs when the membranes becomes inflamed and painful, which may be a result of a blocked sinus opening.
Chronic sinusitis is often caused by inflammation and blockage due to physical obstruction such as a deviated septum, misformed bone or cartilage structures such as the nasal conchae (turbinates), or blockage by nasal cysts or polyps.

18. Classifications of Rhinosinusitis
Acute rhinosinusitis
May be of viral, bacterial, or mixed viral-bacterial origin
May last from 5 to 7 days up to 4 weeks
Subacute rhinosinusitis
Lasts from 4 weeks to less than 12 weeks
Chronic rhinosinusitis
Lasts beyond 12 weeks

19. Allergic Rhinosinusitis
Occurrence
Occurs in conjunction with allergic rhinitis
Mucosal changes are the same as allergic rhinitis
Symptoms
Nasal stuffiness, itching and burning of the nose, frequent bouts of sneezing, recurrent frontal headache, watery nasal discharge
Treatment
Oral antihistamines, nasal decongestants, and intranasal cromolyn

20. SINUSITIS
Bacterial
Acute
-disease lasts less than 30 days with complete resolution of symptoms
-S. Pneumoniae and H. influenzae
Chronic
-episodes of inflammation lasting more than 3 months with persistence of respiratory symptoms.
-Polymicrobial
- anaerobes
-gram-negative bacilli
-fungi
viral

21. Signs and symptoms
condition
Nasal discharge/congestion.
Maxillary tooth pain,
facial or sinus pain that may radiate (unilateral in particular) as well as deterioration after initial improvement.
Severe or persistent (beyond 7 days) signs and symptoms are most likely bacterial and should be treated with antimicrobials.
Acute
Adults:
Nasal discharge and cough for greater than 10–14 days
temperature 39°C (102.2°F)
facial swelling
pain
Children:
are similar to those of acute sinusitis but more nonspecific.
Rhinorrhea is associated with acute exacerbations.
Chronic unproductive cough, laryngitis, and headache may occur.
Chronic Symptoms

22. Common cold
The common cold is a viral infection of your upper respiratory tract .
more than 200 viruses can cause a common cold, symptoms tend to vary greatly.
Most adults are likely to have a common cold two to four times a year.
Children 6-10 times a year.
Most people recover from
a common cold in about
a week or two.

23. Influenza
Is a viral infection that can affect the upper or lower respiratory tract.
influenza season usually runs from November to April
Three distinct forms of influenzavirus have been
identified: A, B and C.
Of these three variants, type A is the most common and causes the most serious illness.
The influenza virus is a highly transmissible respiratory pathogen. Because the organism has a high tendency for genetic mutation, new variants of the virus are constantly arising in different places around the world.

24. Influenza
Influenza infection can cause marked Inflammation of the respiratory epithelium leading to acute tissue damage and a loss of ciliated cells that protect the respiratory passages from other organisms.
As a result, influenza infection may lead to co- infection of the respiratory passages with bacteria.
It is also possible for the influenza virus to infect the tissues of the lung itself to cause a viral pneumonia.

25. Differentiating the symptoms of cold and influenza
gradual
sudden
onset
rare
Charecteristic , high
>38˚C 3-4 days duration
fever
hacking
Dry
cough
prominent
headache
slight
Usual ; often severe
myalgia (muscle aches/pains)
Very mild
Can last up to 2-3 weeks
Tiredness and weakness
never
Early prominent
Extreme exhaustion
Mild to moderate
common
Chest discomfort
sometimes
Stuffy nose
usual
Sneezing
Sore throat

26. Lower respiratory infection

27. Pneumonia
Pneumonia is the most common cause of death due to infectious disease
Seventh most common cause of death in the USA
Hospital acquired Pneumonia is the second most common nosocomial infection(0.6%-1.1%)
Mortality rates are
CAP without hospitalization 1%
CAP with hospitalization about 14%
Nosocomial about 33-50%

28. Pneumonia
approximately three million cases are diagnosed annually at a cost of more than $20 billion to the healthcare system.
Pneumonia occurs throughout the year, with the relative prevalence of disease resulting from different etiologic agents varying with the seasons.
It occurs in persons of all ages
clinical manifestations are most severe in the very young, the elderly, and the chronically ill.

29. The environmental setting in which it developed:
Pneumonia
Hospital Acquired Pneumonia
Ventilator
Hospital acquired
Health care
Community Acquired Pneumonia

30. (depending on the type of organism
Pneumonia
(depending on the type of organism
Typical
S. pneumoniae, H. influenzae, Staphylococcus aureus, and enteric Gram-negative bacteria
Atypical
Mycoplasma, Legionella,Chlamydia
Viral and TB

31. Microorganisms gain access to the lower respiratory tract by three routes:
inhaled as aerosolized particles
via the bloodstream from an extrapulmonary site of infection
aspiration of oropharyngeal contents may occur.

33. Host defense mechanisms
1.Mechanical
Epithelial cells are covered with beating cilia blanketed by a layer of mucus.
Each cell has about 200 cilia that beat up to 500 times/min, moving the mucus layer upward toward the larynx.
The mucus itself contains antimicrobial compounds such as lysozyme and secretory IgA antibodies.
the cough reflex to clear aspirated material

34. Host defense mechanisms
2.Cellualr
Bacteria that reach the terminal bronchioles, alveolar ducts, and alveoli are inactivated primarily by alveolar macrophages and neutrophils.
3.Humoral
Opsonization of the microorganism by complement and antibodies enhances phagocytosis by these cells.

35. Pathological Picture Depends on the etiologic agent Bacterial
An intraalveolar suppurative exudate with consolidation
Lobar pneumonia
bronchopneumonia
Viral or Mycoplasma pneumonia
An interstial inflammation with accumulation of an infiltrate in the alveolar walls
No exudates
No consolidation
Patchy distribution of granulomas
Which undergo caseous necrosis with the development of cavaties

36. Risk factors for pneumonia
Age >65
Aspiration of oropharyngeal secretions
Viral respiratory infections
Chronic illness and debilitation
Chronic respiratory disease(COPD,astha,cystic fibrosis)
Cancer
Prolonged bedrest
Tracheastomy or endotracheal tube

37. Risk factors for pneumonia
Abdominal thoracic surgery
Rib fractures
Immunosuppressive therapy
AIDS
Smocking history
Alcoholism
malnutrition

38. Community Acquired Pneumonia CAP
Acute Infection of the pulmonary parenchyma accompanied by the presence of an acute infiltrate on chest radiograph or ausculatory findings consistent with pneumonia . in patients who are not hospitalized or in a long –term care facility for 14 days or more before symptoms appear

39. Microbiology of community acquired pneumonia

40. Pneumococcal pneumonia
Pneumococci reachs the alveoli in droplets of mucus or saliva.
The lower lobes of the lungs are frequently involved because of the effect of gravity.

41. Pneumococcus in the alveoli
1.Engorgement
(4-12 hrs)
Serious exudates Pours into the alveoli from the dilated ,leaking blood vessels
2. Red hepatization
Next 48 hrs
The lung becomes red
As RBCS, fibrin, and PMN leukocytes fill the alveoli.
3.Gray hepatization
3-8 days
Lung become gray as the leukocytes and fibrin consolidate in the involved alveoli
4.Resolution
7-11days
Exudate is lysed and resorbed by macrophages, restoring the tissue to its original structure

42. Clinical presentation
Sudden
Chills ,fever
Pleuritic pain
Cough
Rust colored sputum
Hypoxemia
As a result of shunting of blood through the non ventilated, consolidated area of lung

43. Consolidation
Pleural Effusion

44. Complications Plural effusions Death chronically ill elderly
Bacteremia which leads to ( endocarditis, meningitis and peritonitis)

45. Diagnostic test Chest radiograph Dense lobar or segmental infiltrate
Laboratory examination
Leukocytosis with a predominance of polymorphonuclear cells
Sputum examination (gross appearance ,microscopic examination and culture)
Blood culture
Should be done in certain high risk patients (e.g. sever CAP, chronic liver disease).
Low oxygen saturation on arterial blood gas or pulse oximetry

46. Hospital Aquired Pneumonia HAP
HAP: Pneumonia that occurs 48 hrs or more after admission Which was not incubating at the time of admission
Ventilator- associated Pneumonia that arises more then hrs after endotracheal intubation

47. Hospital Aquired Pneumonia HAP
Health care associated Pneumonia:
pneumonia developing in a patient who is
hospitalized in an acute care hospital for 2 or more days within 90 days of the infection;
resides in a nursing home or along-term facility
received recent IV AB therapy,
chemotherapy, or wound care within the past 30 days of the current infection ;
or attended a hospital or hemodialysis clinic

48. Gram-negitive bacilli
Pseudomonas aeruginosa
Acinetobacter Spp.
Enterobacter Spp.
Viral
Cytomegalovirus
Influenza
Respiratory syncytial virus
Fungi
Aspergillus

49. Complications of HAP Cause extensive damage to the lung parenchyma
Complications such as lung abscess and emphysema
Mortality is high 33%

50. Risk factors for Hospital-acquired pneumonia
Intubation and mechanical ventilation
Supine patient position
Enteral feeding
pharyngeal colonization
Stress bleeding prophylaxis
Blood transfusion
Hyperglycemia

51. Risk factors for Hospital-acquired pneumonia
Immunosuppression/corticosteriods
Surgical procedures :thoracoabdominal, upperabdominal ,thoracic
Immobilization
Nasogastric tubes
Prior antibiotic therapy
Admission to ICU
Elderly
Underlying chronic lung disease

52. Aspiration pnemonia
Pathological consequences of the entery of oropharyngeal secretions,particulate matter,or gastric contents into the lower airway.
Colonization of oropharynx and gastric plays a critical role in aspiration pneumonia.
GM-ve organisms within 48 hrs of hospitalization
Aspiration of orophyrngeal secretions occurs during sleep and is enhanced by
nasogastric tube
Altered consciousness
Depressed gag reflex
Delayed gastric emptying

53. What happens when patients take medications that raise the gastric pH
What happens when patients take medications that raise the gastric pH? (H2 blockers)
Bacterial counts rise
Sucrulfate is a medication that heals ulcer without altering the gastric pH.

54. Aspiration of particulate matter Mendelson’s pneumonia
Aspiration pneumonia
Aspiration of particulate matter
Mendelson’s pneumonia
Anaerobic pneumonia

55. Anaerobic pneumonia
Aspiration of oropharyngeal secretions containing anerobes
Such as Bacteroids, Fusobacterium, Peptococcus,and Peptostreptococcus species.
Common among patient with poor hygieneand chronic alcoholism
Onset of symptoms 1-2 weeks
Most distinguish symptom is productive cough of foul- smelling sputum

56. Mendelson’s Pneumonia
Related to the regurgitation and aspiration of the acidic stomach contents.
May lead to sudden death (obstruction)
It follows three patterns
Rapid recovery (small amount or alkaline)
Rapid development of acute respiratory distress syndrome
Bacterial superinfection

57. Aspiration of particulate matter
If the object is lodged high in the trachea complete obstruction ,apnea, aphonia and rapid death
If the object is lodged in smaller airways
Chronic cough
And recurrent infections

58. Atypical Pneumonia
Atypical pneumonia refers to pneumonia caused by certain bacteria - namely, Legionella pneumophila, Mycoplasma pneumoniae, and Chlamydophila pneumoniae or virsus.
atypical pneumonias are commonly associated with milder forms of pneumonia, pneumonia due to Legionella, in particular, can be quite severe and lead to high mortality rates.
Symptoms
Confusion (especially with Legionella pneumonia)
Diarrhea (especially with Legionella pneumonia)
Muscle stiffness and aching , Rash (especially with mycoplasma pneumonia)