Respiratory System Disorders 3 Lecture 25 Pathology and Clinical Science 1 (BIOC211) Department of Bioscience Text Reference: Porth s Pathophysiology: Concepts of Altered Health States Sheila C. Grossman & Carol Mattson Porth. Ninth Edition. Copyright 2014 Lippincott, Williams & Wilkins Publishers, Inc. endeavour.edu.au
SESSION LEARNING OUTCOMES o This session explains the aetiology, pathophysiology, clinical features, investigations and management of infections of the respiratory system. o It aims to understand the following respiratory infections Acute Bronchitis Pneumonia Tuberculosis Respiratory diseases caused by Fungi Endeavour College of Natural Health endeavour.edu.au 2
ACUTE BRONCHITIS AND TRACHEITIS Definition Acute inflammation of the trachea and the bronchial tree Aetiology Infection usually bacterial or viral Follows acute coryza Clinical Features Chest tightness, wheezing, breathlessness Coughing & sputum Endeavour College of Natural Health endeavour.edu.au 3
ACUTE BRONCHITIS AND TRACHEITIS Complications Bronchopneumonia Respiratory failure Bronchial asthma Endeavour College of Natural Health endeavour.edu.au 4
ACUTE BRONCHITIS AND TRACHEITIS Investigations X ray throat and chest for trachea and lungs Tracheal / nasopharyngeal swab culture Blood oxygen levels Blood test to determine the cause of infection Treatment ET intubation Analgesics for pain relief Paracetamol for fever Endeavour College of Natural Health endeavour.edu.au 5
TRACHEAL OBSTRUCTION Aetiology Allergic reactions Foreign bodies Throat cancers External tumours pressing on trachea Inflammation of trachea or bronchial tree Clinical Features Stridor Endeavour College of Natural Health endeavour.edu.au 6
TRACHEAL OBSTRUCTION Asphyxia Complications Management Systematic and depending upon the cause Endeavour College of Natural Health endeavour.edu.au 7
TRACHEAL OBSTRUCTION http://www.elsevier.pt/imatges/320/320v21n02/grande/320v21n02-90393307fig3v4.jpg Endeavour College of Natural Health endeavour.edu.au 8
PNEUMONIA o Definition An acute respiratory illness associated with recently developed radiological pulmonary shadowing which may be segmental, lobar or multilobar o Classification Clinical Community acquired Hospital acquired ( nosocomial ) Pneumonia in immuno-compromised hosts Pneumonia in patients with damaged lung (including suppurative and aspirational) Radiological and pathological Lobar Bronchial Endeavour College of Natural Health endeavour.edu.au 9
TYPES OF PNEUMONIA From Pathophysiology for the Health Professions (2nd ed., p. 325), by B Gould, 2002. Philadelphia. W B Saunders Company. Endeavour College of Natural Health endeavour.edu.au 10
PNEUMONIA http://afairgo.net/wp-content/uploads/2014/05/pneumonia.jpg Endeavour College of Natural Health endeavour.edu.au 11
o Epidemiology COMMUNITY ACQUIRED PNEUMONIA (CAP) In UK 5-11/1000 adults per year (5 12% of LRTI) Incidence higher in very young and elderly Pneumonia accounts for 1/5 of childhood death worldwide o Aetiology CAP is usually spread by droplet infection Predisposing factors cigarette smoking, URTI, alcohol, corticosteroid therapy, old age, recent influenza infection, pre-existing lung disease Endeavour College of Natural Health endeavour.edu.au 12
COMMUNITY ACQUIRED PNEUMONIA (CAP) o Bacterial pneumonias are commonly caused by Streptococcus pneumoniae Chlamydia pneumoniae Mycoplasma pneumoniae Legionella pneumoniae o Primary viral pneumonias are caused by influenza, parainfluenza, measles viruses Endeavour College of Natural Health endeavour.edu.au 13
LOBAR OR STREPTOCOCCAL PNEUMONIA Gram (+ve) Diplococci Infiltration of neutrophils in alveoli From Pathophysiology for the Health Professions (2nd ed., p. 326), by B Gould, 2002. Philadelphia. W B Saunders Company. Endeavour College of Natural Health endeavour.edu.au 14
STAGES OF PNEUMONIA Congestion accumulation of bacteria Red hepatisation congestion and increased intraalveolar fluid Gray hepatisation red cells get trapped in parenchyma Resolution enzymatic activity digests exudate coughing From Porth s Pathophysiology: Concepts of Altered Health States. (9 th ed., p. 937), by Sheila C. Grossman & Carol Mattson Porth. Philadelphia, U.S.A. Walters Kluwer Health - Lippincott, Williams & Wilkins Endeavour College of Natural Health endeavour.edu.au 15
COMMUNITY ACQUIRED PNEUMONIA (CAP) Clinical features Acute illness with systemic features such as fever, rigor, shivering, vomiting, loss of appetite, headache Pulmonary symptoms are at first painful and dry cough, later accompanied by mucopurulent sputum Rust colour sputum in patients with Strep. Pneumoniae Endeavour College of Natural Health endeavour.edu.au 16
COMMUNITY ACQUIRED PNEUMONIA (CAP) Investigations Chest X ray Microbiological investigations Sputum microscopy and culture Blood culture Serology Assessment of gas exchange General blood tests Endeavour College of Natural Health endeavour.edu.au 17
COMMUNITY ACQUIRED PNEUMONIA (CAP) student.britannica.com/eb/art-89483/doctors-f... Endeavour College of Natural Health endeavour.edu.au 18
COMMUNITY ACQUIRED PNEUMONIA (CAP) Differential diagnosis Pulmonary infarction Pulmonary TB Pulmonary oedema Malignancy Endeavour College of Natural Health endeavour.edu.au 19
COMMUNITY ACQUIRED PNEUMONIA (CAP) Management Rest, avoid smoking Oxygen Fluid balance Antibiotics Analgesics Physiotherapy Prevention Influenza vaccination to those at high risk Endeavour College of Natural Health endeavour.edu.au 20
HOSPITAL ACQUIRED PNEUMONIA Pneumonia occurring at least 2 days after admission to hospital Aetiology Predisposing factors Reduced host defences Aspiration Bacteria introduced into LRT Bacteraemia Majority caused by gram-negative bacteria (E. coli, Pseudomonas and Klebsiella) and Multidrug Resistant Staphylococcus Aureus Endeavour College of Natural Health endeavour.edu.au 21
HOSPITAL ACQUIRED PNEUMONIA Clinical features and investigations Similar to CAP Management Antibiotics for Gram-negative bacteria Oxygen therapy Fluid support Monitoring ( mortality 30% ) Physiotherapy Endeavour College of Natural Health endeavour.edu.au 22
PNEUMONIA IN THE IMMUNOCOMPROMISED PATIENT o Majority caused by same common pathogens, but gram-negative bacteria are more of a problem o Unusual organisms may become opportunistic pathogens Clinical features Fever, cough, breathlessness and chest X ray changes Patients may develop non-specific symptoms Onset of symptoms less rapid in opportunistic infection Endeavour College of Natural Health endeavour.edu.au 23
PNEUMONIA IN THE IMMUNOCOMPROMISED PATIENT Investigations Similar to other pneumonias Management Initial broad spectrum antibiotics and tailored according to results Endeavour College of Natural Health endeavour.edu.au 24
SUPPURATIVE AND ASPIRATIONAL PNEUMONIA INCLUDING PULMONARY ABSCESS Suppurative pneumonia Pneumonic consolidation with destruction of lung parenchyma by inflammatory process and microabscess formation Pulmonary abscess Lesion with large localised collection of pus Endeavour College of Natural Health endeavour.edu.au 25
SUPPURATIVE AND ASPIRATIONAL PNEUMONIA INCLUDING PULMONARY ABSCESS Aetiology Infection of the previously healthy lung tissue with Staph. aureus or Kleb. Pneumoniae Or inhalation of septic material during operation on nose, mouth or throat under GA or inhalation of vomitus during GA or coma Endeavour College of Natural Health endeavour.edu.au 26
SUPPURATIVE AND ASPIRATIONAL PNEUMONIA INCLUDING PULMONARY ABSCESS Clinical features Cough with large amount of sometimes fetid and blood stained sputum Pleural pain Sudden expectoration of copious amount of foul sputum High fever Endeavour College of Natural Health endeavour.edu.au 27
SUPPURATIVE AND ASPIRATIONAL PNEUMONIA INCLUDING PULMONARY ABSCESS Management Antibiotics ( later modify according to results ) Physiotherapy in pulmonary abscess Endeavour College of Natural Health endeavour.edu.au 28
Pulmonary Abscess http://radiopaedia.org/images/272139 Endeavour College of Natural Health endeavour.edu.au 29
TUBERCULOSIS Epidemiology Caused by infection with Mycobacterium tuberculosis Current estimate 1000 million will become infected between 2002 and 2020 Reasons for re-emergence of TB In developed countries Immigration, HIV, social deprivation, increased elderly, drug resistance In developing countries Ineffective control, lack of access to health care, poverty, civil unrest, HIV, drug resistance Endeavour College of Natural Health endeavour.edu.au 30
TUBERCULOSIS From Porth s Pathophysiology: Concepts of Altered Health States. (9 th ed., p. 940), by Sheila C. Grossman & Carol Mattson Porth. Philadelphia, U.S.A. Walters Kluwer Health - Lippincott, Williams & Wilkins Endeavour College of Natural Health endeavour.edu.au 31
TUBERCULOSIS Predisposing factors Age children, elderly First generation immigrants from high prevalence countries Overcrowding Immunosuppression Type I diabetes X ray evidence of healed TB Endeavour College of Natural Health endeavour.edu.au 32
TUBERCULOSIS Pathogenesis M. tuberculosis spread by droplet inhalation M. bovis from drinking non-sterilised milk of infected cows Bacilli enter lungs engulfed by macrophages helper T cells produce cytokines recruitment of monocytes and formation of granulomas limiting the replication and spread of organism Classical granulomas with central caseous necrosis (primary lesion Ghon focus) Primary lesion with regional lymph node involvement (Ghon complex) Endeavour College of Natural Health endeavour.edu.au 33
TUBERCULOSIS Pathogenesis continued If bacilli spread before immunity established secondary foci in lymph nodes, serous membrane, meninges, bones, liver, kidneys and lungs Or scar tissue then grows around the tubercle (granuloma) completing the isolation of the bacilli generally taking around 10 days to complete Tuberculosis can now remain dormant sometimes for life, however if the immune system is compromised or bacilli escape active disease reoccurs Endeavour College of Natural Health endeavour.edu.au 34
DEVELOPMENT OF TB From Pathophysiology for the Health Professions (2nd ed., p. 328), by B Gould, 2002. Philadelphia. W B Saunders Company. Endeavour College of Natural Health endeavour.edu.au 35
TUBERCULOSIS Clinical features Primary TB Can be asymptomatic with a very gradual onset of the disease, diagnosis not completed until the disease is advanced. Flu like symptoms may be present Miliary TB 2 3 weeks of fever, night sweats, weight loss, dry cough Other symptoms would relate to what parts of the body are affected Endeavour College of Natural Health endeavour.edu.au 36
TUBERCULOSIS Clinical features continued.. Pulmonary TB Dry cough leading to productive haemoptyic sputum Chest pain Shortness of breath Flu like illness Extrapulmonary TB common in HIV patients ( 20 % in HIV negative ) Endeavour College of Natural Health endeavour.edu.au 37
TUBERCULOSIS Investigation for diagnosis Sputum, tissue biopsy (microscopy & culture) Tuberculin test Control and prevention BCG vaccine Identification and contact tracing Treatment Anti TB drugs (multiple drugs to prevent resistance) Endeavour College of Natural Health endeavour.edu.au 38
NATURAL HISTORY AND SPECTRUM OF TB Kumar, V., Cotran, R., & Robbins, S. (1997) Basic Pathology. 6 th ed. P. 426). Philadelphia. W B Saunders Company Endeavour College of Natural Health endeavour.edu.au 39
Secondary TB Primary TB Kumar, V., Cotran, R., & Robbins, S. (1997) Basic Pathology. 6 th ed. P. 423-425). Philadelphia. W B Saunders Company Miliary TB Endeavour College of Natural Health endeavour.edu.au 40
RESPIRATORY DISEASES CAUSED BY FUNGI Aspergillosis Bronchopulmonary aspergillosis caused by Aspergillus fumigatus Allergic bronchopulmonary aspergillosis (ABPA) is hypersensitivity reaction to A. fumigatus involving bronchial wall and periphery of the lungs More common in autumn and winter & associated with asthma Endeavour College of Natural Health endeavour.edu.au 41
ABPA Clinical features Fever, breathlessness, productive cough with bronchial casts and worsening of asthmatic symptoms Chest X ray Skin test Blood test Investigations Management Steroid, physiotherapy Endeavour College of Natural Health endeavour.edu.au 42
ASPERGILLOSIS (cultured) http://www.sciencephoto.com/image/13579/530wm/b2500683- Culture_of_Aspergillus_fumigatus_fungus-SPL.jpg Endeavour College of Natural Health endeavour.edu.au 43
ASPERGILLOSIS (cultured) http://www.sciencephoto.com/image/13579/530wm/b2500683- Culture_of_Aspergillus_fumigatus_fungus-SPL.jpg Endeavour College of Natural Health endeavour.edu.au 44
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LINKS Main classifications of lung diseases are: obstructive, restrictive, ventilation, and perfusion. Classification of common diseases like asthma, emphysema, and pneumonia. Khan Academy. 11.51 minutes https://www.khanacademy.org/science/health-and-medicine/respiratory-systemdiseases/intro-to-pulmonary-diseases/v/types-of-pulmonary-diseases?v=ohlcus7aeu Endeavour College of Natural Health endeavour.edu.au 46
Readings and Resources Resources: o o Set Textbooks: Colledge, N.R., Walker, B.R. & Ralston S.H. (2014). Davidson s Principles and Practice of Medicine, (22nd ed.). Edinburgh. Churchill Livingstone. Grossman, S.C. & Porth, C.M. (2014). Porth s Pathophysiology: concepts of altered health states, (9th ed.). Philadelphia, U.S.A. Walters Kluwer Health - Lippincott, Williams & Wilkins. Additional textbooks: Davies, A. & Moores, C. (2010). The respiratory system: basic science and clinical conditions, (2 nd ed.). Edinburgh. Churchill, Livingstone, Elsevier. Field, M., Pollock, C., Harris, D. (2010). Systems of the Body: The Renal System; Basic Science and Clinical Conditions. (2 nd ed.). United Kingdom: Churchill Livingstone. Jamison, J.R. (2006) Differential Diagnosis for Primary Care: a handbook for health care practitioners. (2 nd ed.). Edinburgh. Churchill Livingstone. Lee, G. & Bishop, P. (2013). Microbiology and Infection Control for Health Professionals, (5th ed.). Frenchs Forest, NSW. Pearson Education. McCance, K.L. & Huether, S.E. (2014). Pathophysiology: the biological basis for disease in adults and children, (7 th ed.). St. Louis, MO. Elsevier. Murphy, K. (2011). Janeway s immunobiology, (8 th ed.). New York. Garland Science. Noble, A., Johnson, R. & Bass, P. (2010). The cardiovascular system: basic science and clinical conditions, (2 nd ed.). Edinburgh. Churchill, Livingstone, Elsevier. Pagana, K.D. & Pagana, T.J. (2013). Mosby s diagnostic and laboratory test reference, (11 th ed.). St. Louis, MO. Elsevier. Smith, M.E. & Morton, D.G. (2010). The digestive system: basic science and clinical conditions, (2 nd ed.). Edinburgh. Churchill, Livingstone, Elsevier. VanMeter, K.C. & Hubert, R. (2014). Gould s pathophysiology for health professions, (5 th ed.). St. Louis, MO. Elsevier. Endeavour College of Natural Health endeavour.edu.au 47
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