Chapter 3: Management of Patients with Chest and Lower Respiratory Tract Disorders (Part 2)

Bronchopneumonia

lung involvement: patchy areas of consolidation

Lobar pneumonia

lung involvement: consolidation of an entire lobe

Prevention of pneumonia

- Pneumococcal conjugate vaccine (PCV13)

- Pneumococcal polysaccharide vaccine (PPSV23)

Pneumococcal conjugate vaccine (PCV13)

- protects against 13 types of pneumococcal bacteria

- recommended for all adults 65 years of age or older as well as adults 19 years or older with conditions that weaken the immune system (HIV, organ transplant, leukemia)

Pneumococcal polysaccharide vaccine (PPSV23)

- newer vaccine and protects against 23 types of pneumococcal bacteria.

- recommended for all adults 65 years of age or older and for those adults 19 through 64 years of age who smoke cigarettes or who have chronic heart, lung, or liver disease, or alcoholism

Management of Pneumonia

- no known multidrug resistance: monotherapy

- With known multidrug resistance: a three-drug combination therapy

- Bacterial pneumonia: antibiotic

- Antibiotics: indicated with a viral respiratory infection only if a secondary bacterial pneumonia, bronchitis, or rhinosinusitis is present

- Viral pneumonia: supportive regimen

Monotherapy drugs for pneumonia

- Ceftriaxone

- Ampicillin/Sulbactam

- Levofloxacin

- Ertapenem

drugs for 3-drug combination therapy for pneumonia

Cephalosporin or Ceftazidime, Carbapenem or Piperacillin-Tazobactam

+

fluoroquinolone or aminoglycoside

+

linezolid or vancomycin

Supportive regimen for viral pneumonia

- Hydration: due to fever, tachypnea (insensible loss)

- Antipyretic agents (fever)

- Antitussive agents (cough suppresants)

- Antihistamines (reduce sneezing and rhinorhea)

- Nasal decongestants

- Hypoxemia (O2 therapy)

Pulmonary tuberculosis

leading cause of death from infectious disease in the world

airborne

- mode of transmission for pulmonary tuberculosis

- an infected person releases droplet nuclei (usually particles 1 to 5 mcm in diameter) through talking, coughing, sneezing, laughing, or singing

- smaller droplets remain suspended in the air and are inhaled by a susceptible person

Pathophysiology of Pulmonary Tuberculosis

Susceptible person (inhales mycobacteria) and become infected

↓

Deposited in alveoli and begin to multiply

↓

Inflammatory reaction

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Phagocytes engulfs the bacteria and TB-specific lymphocytes lyse (destroy) the bacilli and normal tissue

↓

Accumulation of exudates in alveoli (bronchopneumonia)

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2-10 weeks after exposure: Ghon tubercle formation

↓

Ghon tubercle becomes necrotic, forming a cheesy mass

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Calcified and form a collagenous scar

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Bacteria becomes dormant- no further progression

Activation of Pulmonary Tuberculosis

immunocompromised

↓

May also occur in reinfection and activation of dormant bacteria

↓

Ghon tubercle ulcerates (releasing cheesy material in the bronchi)

↓

Bacteria become airborne

↓

Ghon tubercle heals and forms scar tissue

↓

Bronchopneumonia and further tubercle formation

Signs and Symptoms of Pulmonary Tuberculosis

- usually insidious

- low grade fever

- cough (may be productive or nonproductive)

- night sweats

- fatigue

- weight loss

- hemoptysis

Tuberculin skin test/Mantoux test

diagnostic test for Pulmonary Tuberculosis that involves injection a PPD ID

Purified protein derivative

substance injected ID for Mantoux test

48-72 hours

test result for Mantoux test is read after this much time has passed after injection

induration and erythema

both of these indicators will be present if a patient will test positive for pulmonary TB

induration

raised hard area or swelling

0-4 mm

size of wheal for Mantoux test that would indicate test results are not significant

5 mm and above

size of wheal for Mantoux test indicating patient is

- considered to be at risk

- positive for pts with HIV

- Positive for who are close contacts with active TB

- Chest xray results consitent with TB

10 mm and above

size of wheal indicating

- Mildly impaired immunity

- Past exposure to TB or vaccinated with BCG

positive reaction for Mantoux test

- does not necessarily mean that active disease is present in the body

- More than 90% of people who are tuberculin significant reactors do not develop clinical TB

- all significant reactors are candidates for active TB

- the more intense the reaction, the greater the likelihood of an active infection

QuantiFERON-TB Gold Plus and T-SPOT

- diagnostic tests for TB

- available only in US (blood test)

- results are available 24-36 hours

Sputum Culture

presence of AFB on a sputum smear may indicate disease but does not confirm the diagnosis of TB because some AFB are not M. tuberculosis

anti-TB agents for 6-12 months

management of pulmonary TB

multidrug resistant TB

- resistant to isoniazid and rifampin

- At risk: HIV +, homeless, institutionalized

Extensively drug resistant TB

- Resistance to isoniazid and rifampin, in addition to any fluroquinolone, and at least one of three injectable second-line agents (i.e., amikacin, kanamycin, or capreomycin)

- At risk: HIV+ and other immunocompromised conditions

initial and continuation

2 phases of treatment guidelines of pulmonary TB

initial treatment

RIPE + Vit B6 50 mg- all taken once a daily for 8 weeks

Continuation phase

RI or Isoniazid and Rifapentine for the next 4-7 months

2-3 weeks

after this time has passed of continuous medication therapy, Patients are considered noninfectious

1 hour before meals

when to take TB medications?

tyramine rich foods/processed foods

- type of food to avoid during isoniazid therapy

- to avoid having headache, flushing, hypotension, lightheadedness, palpitations, diaphoresis

hepatotoxic

reason why alcohol is avoided during intake of TB meds

Miliary TB

- dissemination of TB infection to nonpulmonary sites of the body

- invasion of the bloodstream by the tubercle bacillus.

Lung Abscess

- localized collection of pus caused by microbial infection

- found in areas of the lung that may be affected by aspiration

aspiration of anaerobic bacteria

general cause of lung abscess

signs and symptoms of lung abscess

- fever

- prod cough

- moderate to copious amounts of foul-smelling, sometimes bloody, sputum

Diagnostic tests for Lung Abscess

- Chest X-ray

- Sputum culture

- Bronchoscopy

Prevention of Lung Abscess

- adequate oral and dental hygiene

- antibiotic therapy before dental procedures in patients who must have teeth extracted while their gums and teeth are infected

Management of Lung Abscess

- clindamycin, ampicillin-sulbactam, or carbapenem (standard for anaerobic infection)

- offer emotional support: abscess may take a long time to resolve

Pleural Disorders

- Pleurisy

- Pleural effusion

- Empyema

Pleurisy/Pleuritis

- refers to inflammation of both layers of the pleurae (parietal and visceral)

- may develop in conjunction with pneumonia, URTI, TB, trauma

severe, sharp, knifelike pain

- results when the inflamed pleural membranes rub together during respiration (intensified on inspiration)

- Taking a deep breath, coughing, or sneezing worsens the pain.

- hallmark sign of pleuritis

Management of Pleuritis

discover the underlying condition causing the pleurisy and to relieve the pain

Pleural Effusion

- a collection of fluid in the pleural space

- rarely a primary disease process; it is usually secondary to other diseases

- may be a complication of heart failure, TB, pneumonia, pulmonary infections (particularly viral infections), nephrotic syndrome connective tissue disease

5-15 mL

- normal amount of fluid in the pleural space

- acts as a lubricant that allows the pleural surfaces to move without friction

Bronchogenic carcinoma

The most common malignancy associated with a pleural effusion

Lung assessment results of pleural effusion

- decreased or absent breath sounds

- decreased fremitus

- a dull, flat sound on percussion

Management of Pleural Effusion

- discover the underlying cause of the pleural effusion; to prevent reaccumulation of fluid; and to relieve discomfort