Transcript Breathing regulation

Pulmonary Diseases
Sang-Min Lee
Division of Pulmonary and Critical Care Medicine
Department of Internal Medicine
Seoul National University College of Medicine
Pulmonary Diseases
 Infectious disease
 Airway disease
 Interstitial lung disease
 Pulmonary vascular disease
 Pleural disease
 Malignancy
Pulmonary Diseases
 Infectious disease
 Airway disease
 Interstitial lung disease
 Pulmonary vascular disease
 Pleural disease
 Malignancy
Infectious Disease
 Upper respiratory tract infection
; Common cold
 Lower respiratory tract infection
; Pneumonia
Upper Respiratory Tract Infection (URI)
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Acute
Acute
Acute
Acute
Acute
Acute
Acute
rhinitis
rhinosinusitis
nasopharyngitis (the common cold)
pharyngitis
laryngitis/epiglottitis
layngotracheitis
tracheitis
Common Cold Syndrome
 General term of acute inflammatory disease
of the upper respiratory tracts such as nasal
cavity, tonsils, pharynx and larynx
 Includes rhinitis, tonsilitis, pharyngitis,
laryngitis (including croup), pharyngolaryngitis
Symptom of Common Cold
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Nasal obstruction
Sneezing
Sore throat
Cough
Sputum
Headache
Fever
General malaise
Viruses associated with Common Cold
Seasonal Variation of Pathogens in URI
Treatment of Common Cold
 To keep room warm and humid
 Taking rest
 Enough rehydration
 Taking nourishing food
Symptomatic Treatment of Common Cold
 Antihistamine and/or decongestant
 Antitussive with expectorant
 NSAIDs or Topical anesthetic for sore throat
Role of Antibiotics in Common Cold
 No role in uncomplicated nonspecific URI
• Single course of macrolide can lead to macrolide
resistance among oral streptococci
 Even purulence from the nares and throat
does not confirm bacterial infection
Pneumonia
 Community acquired pneumonia
 Hospital acquired pneumonia
Community Acquired Pneumonia
 an acute infection of the pulmonary
parenchyma in a patient who has acquired
the infection in the community
Diagnosis of CAP
 Symptom : cough,
fever, pleuritic
chest pain,
dyspnea and
sputum production
 Radiographic
abnormality
Pathogens of CAP
Empirical Antibiotic Therapy in CAP
 Outpatient
• ℬ -lactam ± macrolide
– amoxicillin, amoxicillin-clavulanate, cefpodoxime,
cefditoren ± azithromycin, clarithromycin,erythromycin,
roxithromycin
• Respiratory fluoroquinolone
– Gemifloxacin, levofloxacin, moxifloxacin
Empirical Antibiotic Therapy in CAP
 Inpatient (general ward)
• ℬ -lactam + macrolide
– ceftriaxone, cefotaxime
– ampicillin/sulbactam or amoxicillin/clavulanate +
azithromycin, clarithromycin,erythromycin or
roxithromycin
• Respiratory fluroquinolone
– Gemifloxacin, levofloxacin, moxifloxacin
Empirical Antibiotic Therapy in CAP
 Inpatient (ICU, suspected Pseudomonas)
• Antipneumococcal, antipseudomonal ℬ -lactam (cefepime,
piperacillin/tazobactam, imipenem,meropenem) +
ciprofloxacin or levofloxacin
• Antipneumococcal, antipseudomonas ℬ -lactam +
aminoglycoside + azithromycin
• Antipneumococcal, antipseudomonas ℬ -lactam +
aminoglycoside + antipneumococcal fluoroquinolone
(gemifloxacin, levofloxacin, moxifloxacin)
Hospital-Acquired Pneumonia
 Pneumonia not incubating at the time of
hospital admission and occurring 48 hrs
or more after admission
Ventilator-Associated Pneumonia
 Pneumonia occurring >48 hours after
endotracheal intubation
Incidence of HAP
 22% of hospital acquired infection
 10% of intubated patients
 Up to 70% of ARDS patients
 6~20 times higher among mechanically
ventilated patients
Mortality of HAP
 Crude mortality ; 20 ~ 50%
 Highest in
• Bacteremic patients
• Infected with high risk pathogens
• ICU patients
Route of Infection in HAP
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Aspiration of oropharyngeal secretion
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Aspiration of esophageal/gastric contents
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Inhalation of aerosol containing bacteria
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Hematogenous spread
Clinical Manifestations in HAP
 Not so different from community-acquired
 pneumonia
It is important to exclude noninfectious
causescough,
of pulmonary
 Fever,
sputuminfiltrates when
 Dyspnea,
chest
evaluatingpleuritic
a patient
whopain
presents with
 Infiltration
in CXR
possible HAP
!!!
 Hypoxemia
Diagnostic Criteria in HAP
New or progressive
infiltrate on CXR
+
Clinical evidence showing
infectious origin
 Fever
 Leukocytosis
 Purulent sputum
 Decline in oxygenation
Diagnostic Approach
 Physical examination
 Chest radiography
 Bacteriological identification
; sampling of lower respiratory secretion
Sampling Methods
 Endotracheal aspiration
 Bronchoscopic sampling
 Blinded invasive methods
Initial Therapy for HAP
 Most initial Tx for HAP is empirical !!!
 Selection of drugs
• Local bacteriologic patterns
• Local patterns of antimicrobial resistance
• Cost
• Availability
Risk for MDR pathogens
IDSA Guidelines. Clin Infect Dis 2016
Airway Disease
 Bronchial asthma
 Chronic Obstructive Pulmonary Disease
(COPD)
Bronchial asthma
 Clinical manifestation
• Symptoms – breathlessness, cough, wheezing
• Episodic
 Physical Examination
• Wheezing, hyperinflation
Tests for Diagnosis of Asthma
 Lung function test – variable airflow limitation,
reversibility
• Spirometry: FEV1
• Microspirometry PEFR
 Airway hyperresponsiveness
• Airway challenge tests
 Allergic status
• Skin prick tests
• Serum specific IgE
Treatment Strategy for Asthma
Assessment of control level in Asthma
COPD
 Chronic airflow limitation
• Small airway disease
– Obstructive bronchiolitis
– Obstruction of conducting airway
• Parenchymal destruction
– Emphysema
– Loss of elastic recoil
Symptoms of COPD
 Chronic airflow limitation
• Chronic and persistent dyspnea
• Cough
• Sputum
 Slowly progress, persistent
 Chronic bronchitis
• Chronic productive cough for three months in each
of two successive years in a patient in whom
other causes of chronic cough have been
excluded
Diagnosis of COPD
 Symptoms + risk factors + spirometry
 Spirometric diagnostic criteria for COPD
Spirometry:
Post-bronchodilator FEV1/FVC < 70%
Phenotypes of COPD
Spectrum of COPD phenotype
Pharmacotherapy in COPD
Inhalers
Non-Pharmacologic Management of COPD
Table 4.3. Non-Pharmacologic Management of COPD
Patient
Group
A
B-D
Essential
Smoking cessation (can include pharmacologic treatment)
Smoking cessation (can include pharmacologic treatment)
Pulmonary rehabilltation
Recommended
Depending on Local Guidelines
Physical activity
Flu vaccination
Pneumococcal vaccination
Physical activity
Flu vaccination
Pneumococcal vaccination
Classification of Pulmonary Embolism
 Thrombotic Pulmonary Embolism
• Pulmonary (Thrombo)Embolism
 Non-thrombotic Pulmonary Embolism
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Fat embolism
Air embolism
Amniotic fluid embolism
Tumor embolism
Septic embolism
Pulmonary (Thrombo)Embolism
 Definition
• Migration of (a) clot(s) from systemic
veins to the lungs
 Sources of Emboli
• Most pulmonary emboli from deep veins in the legs
• Uncommon but important sources, esp. in women
– pelvic veins
• Rare source – emboli from right heart
• Recently, upper extremities d/t invasive procedures
Pathogenesis of PTE
Risk Factors - Acquired
Clinical Presentation of PTE
CT Pulmonary Angiography
• Primary diagnostic test for pulmonary embolism
• Positive predictive value varies
– 97% with main or lobar
– 68% with segmental
– only 25% with isolated subsegmental pulmonary artery
• CT pulmonary angiography can lead to contrast induced
nephropathy and is associated with substantial radiation
exposure
CT Pulmonary Angiography
Lung Perfusion Scan
Crit Care Clin 2011;27:841
Treatment of PTE
• Anticoagulation
• Thrombolytic therapy
• IVC Filter
• Thromboembolectomy
Anticoagulation of Acute PTE
N Engl J Med 2010;363:266
Thrombolysis
• Significantly accelerated resolution of pulmonary emboli
• In pulmonary embolism with hypotension & shock
• Complications
– significantly higher hemorrhage rates
IVC filter
• Should be reserved for patients with contraindications to
anticoagulant treatment
• Complications
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death
filter migration
filter erosion
IVC obstruction
• Retrievable vena cava filters may be an option for patients
with presumed time-limited contraindications to
anticoagulant therapy
Thank you for your attention !