Transcript Symptoms and Signs of chronic bronchitis

Pharmacotherapy of
pulmonary disease
Pneumonia
is acute inflammation of the lungs caused by infection
An estimated 2 to 3 million people in the US develop
pneumonia each year, of whom about 45,000 die.
Pneumonia is the most common fatal hospital-acquired
infection and the most common overall cause of death
in developing countries.
Classification of pneumonia
Hospital-acquired pneumonia (HAP)
develops at least 48 h after hospital admission.
HAP includes
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ventilator-associated pneumonia (VAP)
postoperative pneumonia
pneumonia that develops in unventilated but
otherwise moderately or critically ill hospitalized
inpatientsIt
new category healthcare-associated pneumonia
(HCAP), which refers to pneumonia acquired by
patients in healthcare facilities such as chronic
care facilities, dialysis centers, and infusion
centers
Etiology
The most common cause is microaspiration of bacteria that colonize
the oropharynx and upper airways in seriously ill patients.
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The most important pathogen is Pseudomonas aeruginosa, which is
especially common in pneumonias acquired in intensive care
settings and in patients with cystic fibrosis, neutropenia, advanced
AIDS, and bronchiectasis.
Other important pathogens are gram-negative bacteria
(Enterobacter sp, Klebsiella pneumoniae, Escherichia coli, Serratia
marcescens, Proteus sp, Acinetobacter) and both methicillinsensitive and methicillin-resistant Staphylococcus aureus.
S. aureus, Streptococcus pneumoniae, and Haemophilus influenzae
are most commonly implicated when pneumonia develops within 4
to 7 days of hospitalization
High-dose corticosteroids increase the risk of Legionella and
Pseudomonas infections.
Risk factors of HAP
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Endotracheal intubation with mechanical ventilation
poses the greatest overall risk. Endotracheal intubation
breaches airway defenses, impairs cough and
mucociliary clearance, and facilitates microaspiration of
bacteria-laden secretions that pool above the inflated
endotracheal tube cuff.
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In nonintubated patients, risk factors include previous
antibiotic treatment, high gastric pH (due to stress ulcer
prophylaxis or therapy), and coexisting cardiac,
pulmonary, hepatic, or renal insufficiency.
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Major risk factors for postoperative pneumonia are age >
70, abdominal or thoracic surgery, and dependent
functional status.
Symptoms and Signs
in nonintubated patients are generally the same
as those for community-acquired pneumonia:
 Malaise
 Cough typically is productive
in adults and dry in the elderly
 Dyspnea usually is mild and exertional and is
rarely present at rest
 Chest pain is pleuritic and is adjacent to the
infected area
 Pneumonia may manifest as upper
abdominal pain when lower lobe infection
irritates the diaphragm.
Symptoms and Signs
also include
fever (may be frequently absent in the elderly),
tachypnea, tachycardia,
bronchial breath sounds,
egophony, and dullness to percussion.
Signs of pleural effusion may also be present
Pneumonia in critically ill, mechanically
ventilated patients more typically causes fever
and increased respiratory rate or heart rate or
changes in respiratory parameters, such as an
increase in purulent secretions or worsening
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Pharmacotherapy
Treatment may begin with initial use of broad-spectrum drugs,
which are replaced by the most specific drug available for the
pathogens identified by culture. Multiple regimens exist, but
all should include antibiotics that are effective against both
resistant gram-negative and gram-positive organisms
Antibiotics
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Carbapenem
Imipenem/cilastatin 500 mg IV q 6 h
or 1 g q 8 h
Meropenem
1 g IV q 8 h
Monobactam
Aztreonam
1 to 2 g IV q 8 h
Piperacillin/tazobactam 4.5 g q 6 h
Antibiotics
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Cephalosporines
Ceftazidime 2 g IV q 8 h
Cefepime
1 to 2 g q 8 to 12 h
These drugs are given alone or combined with
vancomycin 15 mg/kg q 12 h
Linezolid 600 mg IV q 12 h may be used for
some pulmonary infections involving
methicillin-resistant S. aureus.
Bronchitis
is characterized by inflammation of the bronchial
tubes (or bronchi), the air passages that extend from
the trachea into the small airways and alveoli
Acute bronchitis
is inflammation of the
upper airways,
commonly following a URI
Chronic bronchitis
is defined clinically as cough with sputum
expectoration for at least 3 months a year during a
period of 2 consecutive years.
Etiology
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Acute bronchitis
is frequently a component of a URI caused by rhinovirus,
parainfluenza, influenza A or B, respiratory syncytial
virus, coronavirus, or human metapneumovirus. Less
common causes may be Mycoplasma pneumoniae,
Bordetella pertussis,Chlamydia pneumoniae,
Streptococcus pneumoniae, Moraxella catarrhalis, and
Haemophilus influenzae
Cigarette smoking is indisputably
the predominant cause
of chronic bronchitis.
Common risk factors for
acute exacerbations of
chronic bronchitis are advanced age and low forced
expiratory volume in one second
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Symptoms and Signs of acute bronchitis
Cough generally lasts from 10-20 days
 Sputum production is reported in half the patients, it is
may be clear, yellow, green, purulent (50%) or even
blood-tinged
 Fever is a relatively unusual sign and, when
accompanied by cough, suggests either influenza or
pneumonia
 Severe cases may cause
general malaise and chest pain
 With severe tracheal involvement,
symptoms include burning,
substernal chest pain
associated with respiration, and coughing.
 Other symptoms are following:
•Sore throat, Runny or stuffy nose,
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Symptoms and Signs of chronic
bronchitis
When a stable patient experiences sudden
clinical deterioration with increased sputum
volume, sputum purulence, and/or worsening
of shortness of breath,
this is referred to as an
exacerbation of
chronic bronchitis, as long as
conditions other than
acute tracheobronchitis are ruled out
Treatment of acute bronchaitis
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Symptom relief (acetaminophen, hydration,
possibly antitussives)
Inhaled β-agonist or anticholinergic for
wheezing
Sometimes oral antibiotics for patients with
COPD
Antitussives
should be used only if the cough is interfering with sleep
Dextromethorphan use as tablet or syrup at a
dose of 15 to 30 mg po 1 to 4 times/day
Codeine 10 to 20 mg po q 4 to 6 h
Benzonatate 100 to 200 mg po tid
Expectorants
Guaifenesin 200 to 400 mg po q 4 h in syrup
or tablet form
 Multiple expectorants
bromhexine, ipecac, and saturated
solution of K iodide (SSKI)
 Aerosolized expectorants such as N-acetylcysteine
are generally reserved for hospital-based treatment
of cough in patients with bronchiectasis or cystic
fibrosis
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Topical treatments
such as acacia, licorice, glycerin, honey, and wild
cherry cough drops or syrups (demulcents), are
locally and perhaps emotionally soothing, but their
use is not supported by scientific evidence.
beta2-agonist bronchodilators may be useful in patients
who have associated wheezing with cough and
underlying lung disease (albuterol) or an
anticholinergic (ipratropium) for ≤ 7 days
Oral antibiotics
are typically not used
except in patients with pertussis or in patients
with COPD who have at least 2 of the following:
 Increased cough
 Increased dyspnea
 Increase in sputum purulence
Oral antibiotocs for pharmaconherapy
of acute bronchitis
amoxicillin 500 mg po tid for 7 days
doxycycline 100 mg po bid for 7 days
azithromycin 500 mg po once/day for 4 days,
trimethoprim/sulfamethoxazole
160/800 mg po bid for 7 days
influenza vaccine
may reduce the incidence of upper respiratory tract
infections and, subsequently, reduce the incidence
of acute bacterial bronchitis.
Pharmaconherapy of chronic bronchitis
For patients with an acute exacerbation of chronic
bronchitis, therapy with
 short-acting B-agonists (Albuterol, Metaproterenol
sulfate, Salmrterol, Formoterol) or
 anticholinergic bronchodilators (Ipratropium,
Tiotropium)
should be administered during the acute exacerbation
In addition, a short course of systemic corticosteroid
(Fluticasone, Beclomethasone) therapy may be
given and has been proven to be effective
Pharmaconherapy of chronic bronchitis
Antibiotics,
are recommended in patients older than 65 years with acute cough if
they have had a hospitalization in the past year, have diabetes
mellitus or congestive heart failure, or are on steroids
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Amoxicillin and clavulanate is a good alternative
antibiotic for patients allergic to or intolerant of the
macrolide class
Eryhtromicin, Azithtromicyn is indicated for
staphylococcal, streptococcal, chlamydial, and
mycoplasmal infections. Azithromycin treats mild-tomoderate microbial infections.
Tetracycline is less effective than erythromycin.
Cefditoren (400-mg daily) is indicated for acute
exacerbation of chronic bronchitis caused by susceptible
strains of S pyogenes